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Clinical diagnosis of ICU-acquired pneumonia after cardiothoracic surgery is challenging. Johanson criteria (chest radiograph infiltrate, purulent tracheal secretions, fever, and leukocytosis) fail in half the cases. A high Clinical Pulmonary Infection Score (CPIS) and ≥ 2-point increase in Sequential Organ Failure Assessment (SOFA) score (SOFA↑ ≥ 2) may improve diagnosis. The aim of the study was to evaluate whether CPIS or SOFA↑ ≥ 2 contributes to predict ICU-acquired pneumonia in subjects after cardiothoracic surgery.We used a prospective observational design. Spiegelhalter-Knill-Jones scoring systems including CPIS or SOFA↑ ≥ 2, together with other clinical and laboratory variables, were developed in a derivation cohort. A positive quantitative pulmonary sample culture was required to confirm ICU-acquired pneumonia. Area under the receiver operating characteristic curve (AUROC) was computed for each of the 2 scoring systems. The best system was evaluated in a validation cohort.Derivation and validation cohorts included 172 and 108 subjects, with 410 and 216 suspected ICU-acquired pneumonia episodes, respectively. AUROC was 0.53 ± 0.03 for CPIS (A clinical scoring system including at least SOFA↑ ≥ 2 increase barely improved ICU-acquired pneumonia prediction in subjects after cardiothoracic surgery.

BACKGROUND: Obesity may increase the risk of respiratory failure after cardiothoracic surgery. A recruitment maneuver followed by PEEP might decrease the risk of respiratory failure in obese subjects. We hypothesized that the routine use after heart surgery of a recruitment maneuver followed by high or low PEEP level would decrease the frequency of respiratory failure in obese subjects. METHODS: In a pragmatic, randomized controlled trial, we assigned obese subjects (ie, with body mass index [BMI] ≥ 30 kg/m(2)) in the immediate postoperative period of cardiothoracic surgery to either volume control ventilation with 5 cm H(2)O of PEEP (control group) or a recruitment maneuver followed by 5 or 10 cm H(2)O of PEEP in the intervention arms (RM5 and RM10 groups, respectively). The primary outcome was the proportion of subjects with postextubation respiratory failure, defined as the need for re-intubation, bi-level positive airway pressure, or high-flow nasal cannula within the first 48 h. RESULTS: The study included 192 subjects: 65 in the control group (BMI 33.5 ± 3.2 kg/m(2)), 66 in the RM5 group (BMI 34.5 ± 3.2 kg/m(2), and 61 in RM10 group (BMI 33.8 ± 4.8 kg/m(2)). Postextubation respiratory failure occurred in 14 subjects in the control group (21.5% [95% CI 13.3–35.3]), 21 subjects in the RM5 group (31.8% [95% CI 21.2–44.6]), and 9 subjects in the RM10 group (14.7% [95% CI 7.4–26.7]) (P = .07). The recruitment maneuver was stopped prematurely due to severe hypotension in 8 (12.1%) RM5 subjects and in 4 (6.6%) RM10 subjects (P = .28). There were no significant differences between the 3 groups for the frequencies of atelectasis, pneumonia, and death in the ICU. CONCLUSIONS: The routine use after heart surgery of a recruitment maneuver followed by 5 or 10 cm H(2)O of PEEP did not decrease the frequency of respiratory failure in obese subjects. A recruitment maneuver followed by 5 cm H(2)O of PEEP is inappropriate.

Extracorporeal membrane oxygenation (ECMO) is a standard treatment for refractory hypoxaemia (veno-venous ECMO, VV-ECMO) and cardiogenic shock (veno-arterial ECMO, VA-ECMO). Severe hypoxaemia may persist despite ECMO. Prone positioning (PP) can improve outcomes of acute respiratory distress syndrome (ARDS)(1,2). However, few data exist on PP in hypoxaemic patients receiving VV-ECMO or VA-ECMO, particularly after cardio-thoracic surgery. Here, we evaluated oxygenation and complications seen with PP during ECMO.

Objective To compare the respiratory workload using the diaphragm thickening fraction (DTf) determined by sonography during high-flow nasal oxygen (HFNO), standard oxygen therapy (SOT), and noninvasive bilevel positive airway pressure support (BIPAP) in patients with acute respiratory failure (ARF) after cardiothoracic surgery. Design Prospective controlled clinical trial. Setting A French 23-bed cardiothoracic surgical intensive care unit. Participants Nonintubated patients with ARF after cardiothoracic surgery or while awaiting lung transplantation. Interventions HFNO (50 L/min), SOT via a standard facemask, and BIPAP (pressure support, 4 cmH2O; positive end-expiratory pressure [PEEP], 4 cmH2O), with FIO2 kept constant were successively applied and compared. With BIPAP, pressure support or PEEP increments up to 8 cmH2O were compared with baseline settings. Each measurement was made after stable breathing for 5 minutes. Measurements and Main Results Fifty patients aged 60.0 ± 12.2 years were enrolled, including 14 (28%) with obesity. Mean PaO2/FIO2 was 153 ± 55 mmHg. DTf was lower with HFNO and BIPAP than with SOT (respectively 21.2% ± 15.1% v 30.9% ± 21.1% and 17.8% ± 19.1% v 30.9% ± 21.1%, p Conclusion HFNO provides a comparable respiratory workload decrease compared with BIPAP at lower levels of pressure support and PEEP compared with SOT. Increasing BIPAP pressure support may provide higher levels of assistance but carries a risk of overdistension.

BACKGROUND Whether train-of-four (TOF) monitoring is more effective than clinical monitoring to guide neuromuscular blockade (NMB) in patients with acute respiratory distress syndrome (ARDS) is unclear. We compared clinical monitoring alone or with TOF monitoring to guide atracurium dosage adjustment with respect to drug dose and respiratory parameters. METHODS From 2015 to 2016, we conducted a randomized controlled trial comparing clinical assessments every 2 hours with or without corrugator supercilii TOF monitoring every 4 hours in patients who developed ARDS (Pao2/Fio2

Introduction Une certaine proportion de patients sous ECMO demeurent hypoxemiques par persistance d’un shunt pulmonaire significatif. Le recours au decubitus ventral (DV) chez ces patients pourrait ameliorer leur oxygenation et accelerer le sevrage d’ECMO. La reserve principale des reanimateurs est la crainte de complications graves liees au retournement pour cette population particuliere. Materiel et methodes Nous avons analyse les donnees de 6 patients hypoxemiques positionnes en DV durant leur traitement par ECMO. Les patients etaient en ventilation assistee controlee, avec des reglages du respirateur conformes aux recommandation de ventilation du SDRA. Les parametres demographiques consignes etaient l’age, le sexe, l’index de masse corporelle (IMC), le score SAPS 2 a l’admission, le motif d’admission, et l’etiologie de recours a l’ECMO ainsi que sa conformation veinoarterielle ou veinoveineuse et sa duree. Nous avons releve le nombre et la duree des seances de DV, les parametres ventilatoires et la FiO 2 de l’ECMO avant et apres l’ensemble des seances de DV, l’evolution du rapport PaO 2 /FiO 2 sur le respirateur, le delai de sevrage de l’ECMO apres premiere mise en DV, les complications eventuelles liees au DV et la mortalite en reanimation. Resultats Cinq hommes et une femme ont ete inclus dans l’analyse. L’âge moyen etait de 56,7 ± 13,8 ans, l’IMC moyen etait de 27,1 ± 7,0 et le score SAPS 2 de 43,6 ± 7,3. Le motif d’admission en reanimation etait la prise en charge postoperatoire de chirurgie thoracique sous CEC dans 3 cas, de transplantation bipulmonaire dans 2 cas, et un choc cardiogenique sur cardiomyopathie obstructive dans un cas. Les ECMO etaient veinoarterielles dans 4 cas et veinoveineuses dans 2 cas, pour une duree moyenne de 18,5 ± 6,0 j. Les patients ont ete positionnes 2,3 ± 0,5 fois en DV, pour une duree moyenne de 18,9 ± 0,9 h par seance. Le rapport PaO 2 /FiO 2 a constamment augmente, entre les mesures realisees avant et apres l’ensemble des cycles de DV. Les autres parametres ventilatoires n’ont pas ete modifies par les seances de DV. La FiO 2 de l’ECMO a pu etre diminuee. (cf. Tableau 1 ). Le delai de sevrage etait de 8,3 ± 5,8 j en moyenne apres premiere mise en DV, mais deux patients ont pu etre sevres a J2 apres la premiere seance. Il n’y a pas eu de variation hemodynamique significative lors des retournement sauf dans un cas. Les complications rencontrees ont ete une desunion de la cicatrice sternale, et une baisse de debit d’ECMO lors du retournement ayant necessite plusieurs repositionnements du patient. Nous n’avons pas observe de decanulation ou d’extubation accidentelles. Un seul patient est decede en reanimation (16,7 %). Discussion Le placement en DV semble une solution envisageable pour la prise en charge de patients hypoxemiques sous ECMO. Nous n’avons pas observe de complications graves liees au retournement. Un interet pour la facilitation du sevrage de certains patients pourrait etre suggere par nos donnees, mais est a preciser sur une population plus importante.