Search

There are currently no data regarding characteristics of critically ill patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) variant of concern (VOC) 20H/501Y.V2. We therefore aimed to describe changes of characteristics in critically ill patients with Covid-19 between the first and the second wave when viral genome sequencing indicated that VOC was largely dominant in Mayotte Island (Indian Ocean). Consecutive patients with Covid-19 and over 18 years admitted in the unique intensive care unit (ICU) of Mayotte during wave 2 were compared with an historical cohort of patients admitted during wave 1. We performed a LR comparing wave 1 and wave 2 as outcomes. To complete analysis, we built a Random Forest model (RF), that is, a machine learning classification tool- using the same variable set as that of the LR. We included 156 patients, 41 (26.3%) and 115 (73.7%) belonging to the first and second waves respectively. Univariate analysis did not find difference in demographic data or in mortality. Our multivariate LR found that patients in wave 2 had less fever (absence of fever aOR 5.23, 95% confidence interval (CI) 1.89-14.48, p = .001) and a lower simplified acute physiology score (SAPS II) (aOR 0.95, 95% CI 0.91-0.99, p = .007) at admission; at 24 hours, the need of invasive mechanical ventilation was higher (aOR 3.49, 95% CI 0.98-12.51, p = .055) and pO2/FiO2 ratio was lower (aOR 0.99, 95 % CI 0.98-0.99, p = .03). Patients in wave 2 had also an increased risk of ventilator-associated pneumonia (VAP) (aOR 4.64, 95% CI 1.54-13.93, p = .006). Occurrence of VAP was also a key variable to classify patients between wave 1 and wave 2 in the variable importance plot of the RF model. Our data suggested that VOC 20H/501Y.V2 could be associated with a higher severity of respiratory failure at admission and a higher risk for developing VAP. We hypothesized that the expected gain in survival brought by recent improvements in critical care management could have been mitigated by increased transmissibility of the new lineage leading to admission of more severe patients. The immunological role of VOC 20H/501Y.V2 in the propensity for VAP requires further investigations.

Background: The incidence of ventilator-associated pneumonia caused by Stenotrophomonas maltophilia (SM-VAP) is on the rise. This pathology is associated with increased morbidity and mortality in intensive care unit (ICU), notably due to intrinsic resistance and ineffective probabilistic antibiotic therapy. Our study aimed to determine the risk factors for a first episode of SM-VAP in ICU.Methods: This single center retrospective study was conducted from 2010 to 2018 in the polyvalent ICU of Félix Guyon University Hospital in Reunion Island. All patients who developed ventilator-associated pneumonia (VAP) during their ICU stay were consecutively evaluated. Patients with a first episode of SM-VAP were compared to those with a first episode of VAP caused by another microorganism. Results: A total of 89 patients developed a first episode of SM-VAP over the study period. In the group of patients with SM-VAP, infection was polymicrobial in 43.8% of cases and ICU mortality was 49.4%. After multivariate logistic regression analysis, the risk factors for a first episode of SM-VAP were: chronic respiratory failure (Odds Ratio (OR): 4.212; 95% Confidence Interval (CI): 1.776 – 9.989; p = 0.001), chronic renal failure (OR: 2.693; 95% CI: 1.356 – 5.352; p = 0.05), use of third-generation cephalosporins active against Pseudomonas aeruginosa (OR 2.862; 95% CI: 1.505 – 5.442; p = 0.001), and female sex (OR: 2.646; 95% CI: 1.458 – 4.808; p = 0.001). Conclusion: In our study, chronic respiratory failure, chronic renal failure, use of third-generation cephalosporins active against P. aeruginosa, and female sex were identified as risk factors for a first episode of SM-VAP.

BackgroundThere are currently no data regarding characteristics of critically ill patients with SARS-CoV-2 Variant of Concern (VOC) 20H/501Y.V2. We therefore aimed to describe changes of characteristics in critically ill patients with Covid-19 between the first and the second wave when viral genome sequencing indicated that VOC was largely dominant in Mayotte Island (Indian Ocean).MethodsConsecutive patients with Covid-19 and over 18 years admitted in the unique Intensive Care Unit (ICU) of Mayotte during wave 2 were compared with an historical cohort of patients admitted during wave 1. We performed a Logistic Regression (LR) comparing wave 1 and wave 2 as outcomes. To complete analysis of changes in characteristics and outcomes, we built a Random Forest model (RF) -i.e., a machine learning classification tool- using the same variable set as that of the LR.ResultsWe included 156 patients, 41 (26.3%) and 115 (73.7%) belonging to the first and second waves respectively. Univariate analysis did not find difference in demographic data or in mortality. Our multivariate LR found that patients in wave 2 had less fever (absence of fever aOR 5.23, 95% CI 1.89 – 14.48, p=0.001) and a lower SAPS II (aOR 0.95, 95% CI 0.91 – 0.99, p=0.007) at admission; at 24 hours, the need of invasive mechanical ventilation was higher (aOR 3.49, 95% CI 0.98 – 12.51, p=0.055) and pO2/FiO2 ratio was lower (aOR 0.99, 95 % CI 0.98-0.99, p=0.03). Patients in wave 2 had also an increased risk of VAP (aOR 4.64, 95% CI 1.54-13.93, p=0.006). Occurrence of VAP was also a key variable to classify patients between wave 1 and wave 2 in the variable importance plot of the RF model.ConclusionOur data suggested that VOC 20H/501Y.V2 could be associated with a higher severity of respiratory failure at admission and a higher risk for developing VAP. We hypothesized that the expected gain in survival brought by recent improvements in critical care management could have been mitigated by increased transmissibility of the new lineage leading to admission of more severe patients. The immunological role of VOC 20H/501Y.V2 in the propensity for VAP requires further investigations.

Background Ventilator-associated pneumonia (VAP) caused by Stenotrophomonas maltophilia is poorly described in the literature. However, it has been shown to be associated with increased morbidity and mortality. Probabilistic antibiotic therapy against S. maltophilia is often ineffective as this pathogen is resistant to many antibiotics. There is no consensus at present on the best therapeutic strategy to adopt (class of antibiotics, antibiotic combination, dosage, treatment duration). The aim of this study was to evaluate the effect of antibiotic therapy strategy on the prognosis of patients with VAP caused by S. maltophilia. Results This retrospective study evaluated all consecutive patients who developed VAP caused by S. maltophilia between 2010 and 2018 while hospitalized in the intensive care unit (ICU) of a French university hospital in Reunion Island, in the Indian Ocean region. A total of 130 patients with a median Simplified Acute Physiology Score II of 58 [43–73] had VAP caused by S. maltophilia after a median duration of mechanical ventilation of 12 [5–18] days. Ventilator-associated pneumonia was polymicrobial in 44.6% of cases, and ICU mortality was 50.0%. After multivariate Cox regression analysis, the factors associated with increased ICU mortality were older age (hazard ratio (HR): 1.03; 95% CI 1.01–1.04, p = 0.001) and high Sequential Organ Failure Assessment score on the day of VAP onset (HR: 1.08; 95% CI 1.03–1.14, p = 0.002). Appropriate antibiotic therapy, and in particular trimethoprim–sulfamethoxazole, was associated with decreased ICU mortality (HR: 0.42; 95% CI 0.24–0.74, p = 0.003) and decreased hospital mortality (HR: 0.47; 95% CI 0.28–0.79, p = 0.04). Time to start of appropriate antibiotic therapy, combination therapy, and duration of appropriate antibiotic therapy had no effect on ICU mortality (p > 0.5). Conclusion In our study, appropriate antibiotic therapy, and in particular trimethoprim–sulfamethoxazole, was associated with decreased ICU and hospital mortality in patients with VAP caused by S. maltophilia.

RATIONALE Whereas non-invasive ventilation (NIV) may prevent reintubation in patients at high-risk of extubation failure in intensive care units (ICUs), this oxygenation strategy has not been specifically assessed in obese patients. OBJECTIVES We hypothesized that NIV may decrease the risk of reintubation in obese patients compared with high-flow nasal oxygen (HFNO). METHODS Post-hoc analysis of a multicenter, randomized, controlled trial (not pre-specified) comparing NIV alternating with HFNO versus HFNO alone after extubation, with the aim of assessing NIV effects according to patient body-mass index (BMI). MEASUREMENTS AND MAIN RESULTS Among 623 patients at high-risk of extubation failure, 206 (33%) were obese (BMI≥30 kg/m2), 204 (33%) were overweight (25≤BMI

Background: The aim of this study was to compare the prognosis of patients with acute respiratory failure (ARF) due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant 501Y.V2 to that of patients with ARF due to the original strain. Methods: This retrospective matched cohort study included all consecutive patients who were hospitalized for ARF due to SARS-CoV-2 in Reunion Island University Hospital between March 2020 and March 2021. Twenty-eight in hospital mortality was evaluated before and after matching.Results: A total of 218 patients with ARF due to SARS-CoV-2 were enrolled in the study. Of these, 83 (38.1%) were infected with the 501Y.V2 variant. During intensive care unit stay, 104 (47.7%) patients received invasive mechanical ventilation and 20 (9.2%) patients were supported by venovenous extracorporeal membrane oxygenation. Patients infected with the 501Y.V2 variant were younger (58 [51-68] vs. 67 [56-74] years old, P=0.003), had less hypertension (54.2% vs 68.1%, P=0.04), and had less chronic kidney disease (13.3% vs. 31.9%, P=0.002) than patients infected with the original strain. After controlling for confounding variables (62 matched patients in each group), 28-day mortality was higher in the group of patients infected with the 501Y.V2 variant (30.6%) than in the group of patients infected with the original strain (19.4%, P=0.04).Conclusion: In Reunion Island, where SARS-CoV-2 incidence remained low until February 2021 and the health care system was never saturated, mortality was higher in patients with ARF infected with the 501Y.V2 variant than in patients infected with the original strain.

In February 2021, an explosion of cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia overwhelmed the only hospital in Mayotte. To report a case series of patients with acute respiratory failure (ARF) due to SARS-CoV-2 who were evacuated by air from Mayotte to Reunion Island.This retrospective observational study evaluated all consecutive patients with ARF due to SARS-CoV-2 who were evacuated by air from Mayotte Hospital to the intensive care unit (ICU) of Félix Guyon University Hospital in Reunion Island between February 2, and March 5, 2021.A total of 43 patients with SARS-CoV-2 pneumonia were evacuated by air, for a total flight time of 2 hours and a total travel time of 6 hours. Of these, 38 patients (88.4%) with a median age of 55 (46-65) years presented with ARF and were hospitalized in our ICU. Fifteen patients were screened for the SARS-CoV-2 501Y.V2 variant, all of whom tested positive. Thirteen patients (34.2%) developed an episode of severe hypoxemia during air transport, and the median paO2/FiO2 ratio was lower on ICU admission (140 [102-192] mmHg) than on departure (165 [150-200], P = .022). Factors associated with severe hypoxemia during air transport was lack of treatment with curare (P = .012) and lack of invasive mechanical ventilation (P = .003). Nine patients (23.7%) received veno-venous extracorporeal membrane oxygenation support in our ICU. Seven deaths (18.4%) occurred in hospital.Emergency air evacuation of patients with ARF due to SARS-CoV-2 was associated with severe hypoxemia but remained feasible. In cases of ARF due to SARS-CoV-2 requiring emergency air evacuation, sedated patients receiving invasive mechanical ventilation and curare should be prioritized over nonintubated patients. It is noteworthy that patients with SARS-CoV-2 pneumonia related to the 501Y.V2 variant were very severe despite their young age.

Background Spontaneous breathing trial (SBT) using a T-piece remains the most frequently performed trial before extubation in ICUs. Research Question We aimed at determining whether initial SBT using pressure-support ventilation (PSV) could increase successful extubation rates among patients at high risk of extubation failure. Study Design and Methods Post hoc analysis of a multicenter trial focusing on reintubation in patients at high-risk of extubation failure. The initial SBT was performed using PSV or T-piece according to the physician/center decision. The primary outcome was the proportion of patients successfully extubated 72 hours after initial SBT, that is, extubated after initial SBT and not reintubated within the following 72 hours. Results Among the 641 patients included in the original study, initial SBT was performed using PSV (7.0 cm H2O in median without positive end-expiratory pressure) in 243 patients (38%) and using a T-piece in 398 patients (62%). The proportion of patients successfully extubated 72 hours after initial SBT was 67% (162/243) using PSV and 56% (223/398) using T-piece (absolute difference 10.6%; 95% CI, 2.8 to 28.1; P = .0076). The proportion of patients extubated after initial SBT was 77% (186/283) using PSV and 63% (249/398) using T-piece (P = .0002), whereas reintubation rates within the following 72 hours did not significantly differ (13% vs 10%, respectively; P = .4259). Performing an initial SBT using PSV was independently associated with successful extubation (adjusted OR, 1.60; 95% CI, 1.30 to 2.18; P = .0061). Interpretation In patients at high risk of extubation failure in the ICU, performing an initial SBT using PSV may hasten extubation without an increased risk of reintubation.

BACKGROUND: Severe poisoning due to the overdosing of cardiac drugs can lead to cardiovascular failure. In order to decrease the mortality rate, the most severe patients should be transferred as quickly as possible to an extracorporeal membrane oxygenation (ECMO) center. However, the predictive factors showing the need for venous-arterial ECMO (VA-ECMO) had never been evaluated. METHODS: A retrospective, descriptive, and single-center cohort study. All consecutive patients admitted in the largest ICU of Reunion Island (Indian Ocean) between January 2013 and September 2018 for beta-blockers (BB), calcium channel blockers (CCB), renin-angiotensin-aldosterone system blockers, digoxin or anti-arrythmic intentional poisonings were included. ECMO implementation was the primary outcome. RESULTS: A total of 49 consecutive admissions were included. Ten patients had ECMO, 39 patients did not have ECMO. Three patients in ECMO group died, while no patients in the conventional group died. The most relevant ECMO-associated factors were pulse pressure and heart rate at first medical contact and pulse pressure, heart rate, arterial lactate concentration, liver enzymes and left ventricular ejection fraction (LVEF) at ICU-admission. Only pulse pressure at first medical contact and LVEF were significant after logistic regression. CONCLUSION: A transfer to an ECMO center should be considered for a pulse pressure < 35 mmHg at first medical contact or LVEF < 20% on admission to ICU.

Introduction : The incidence of ventilator associated pneumonia due to Stenotrophomonas maltophilia (SM-VAP) is increasing. This pathology is related with an increase in mortality and morbidity in intensive care, in particular due to unsuitable probabilist antibiotherapy and intrinsic resistance of this bacteria. The aim of this study was to identify risk factors for developping a first episod of SM-VAP, in order to adapt probabilist antibiotherapy as early as possible.Materials and methods : This is a retrospective monocentric study, carried out between 2010 and 2018 in a general intensive care unit (ICU) in the University Hospital of Réunion Island, France. All consecutive patients with a first episod of VAP were included. Patients with SM-VAP and patients with VAP due to other germs were comparated.Results : 89 patients developped a SM-VAP among which 43.8% were polymicrobial. Mortality in ICU was 49,4%. Multivariate logistic regression analysis found that risk factors for developping a first episod of SM-VAP were : chronic respiratory failure (OR4.212 ; CI95% : 1.776 – 9.989 ; p=0.001), chronic kidney failure (OR 2.693 ; CI95% : 1.356 – 5.352 ; p=0.005), prior exposure to third generation cephalosporins active on Pseudomonas Aeruginosa (OR 2.862 ; CI95% : 1.505 – 5.442 ; p = 0.001) and female gender (OR 2.646 ; CI95% : 1.458 – 4.808 ; p = 0.001).Conclusion : In our study, chronic respiratory and kidney failure, prior exposure to third generation cephalosporins active on Pseudomonas aeruginosa and female gender were identify as risk factors for developping a first episod of SM-VAP.; Introduction: L’incidence des pneumopathies acquises sous ventilation mécanique (PAVM) à Stenotrophomonas maltophilia (SM) est en augmentation. Cette pathologie est associée à une augmentation de la morbi-mortalité en réanimation notamment du fait d’une antibiothérapie probabiliste inadaptée et des résistances intrinsèques de ce germe. Le but de cette étude était de déterminer les facteurs de risque de survenue d’un premier épisode de PAVM à SM. Méthode: Etude rétrospective monocentrique réalisée de 2010 à 2018 dans une réanimation polyvalente du CHU de La Réunion. Ont été comparés les patients présentant un premier épisode de PAVM documenté à SM à ceux présentant un premier épisode de PAVM à un autre germe. Résultats: Pendant la période 89 patients ont développé une première PAVM à SM dont 43.8% étaient polymicrobiennes. La mortalité en réanimation était de 49.4%. Après analyse multivariée par régression logistique les facteurs de risque de survenue d’une première PAVM à SM étaient : l’insuffisance respiratoire chronique (OR 4.212 ; IC à 95% : 1.776 – 9.989 ; p = 0.001), l’insuffisance rénale chronique (OR 2.693 ; IC à 95% : 1.356 – 5.352 ; p = 0.005), l’exposition préalable aux céphalosporines de troisième génération actives sur Pseudomonas aeruginosa (OR 2.862 ; IC à 95% : 1.505 – 5.442 ; p = 0.001) et le sexe féminin (OR 2.646 ; IC à 95% : 1.458 – 4.808 ; p = 0.001). Conclusion: L’insuffisance respiratoire et rénale chronique, l’exposition préalable aux céphalosporines de troisième génération actives sur Pseudomonas aeruginosa et le sexe féminin ont été identifiés comme facteurs de risque de développer un premier épisode de PAVM à SM.