Pierre Damas

Platelets have been involved in both immune surveillance and host defense against severe infection. To date, whether platelet phenotype or other hemostasis components could be associated with predisposition to sepsis in critical illness remains unknown. The aim of this work was to identify platelet markers that could predict sepsis occurrence in critically ill injured patients. This single-center, prospective, observational, 7-month study was based on a cohort of 99 non-infected adult patients admitted to ICUs for elective cardiac surgery, trauma, acute brain injury, and post-operative prolonged ventilation and followed up during ICU stay. Clinical characteristics and severity score (SOFA) were recorded on admission. Platelet activation markers, including fibrinogen binding to platelets, platelet membrane P-selectin expression, plasma soluble CD40L, and platelet-leukocytes aggregates were assayed by flow cytometry at admission and 48 h later, and then at the time of sepsis diagnosis (Sepsis-3 criteria) and 7 days later for sepsis patients. Hospitalization data and outcomes were also recorded. Of the 99 patients, 19 developed sepsis after a median time of 5 days. These patients had a higher SOFA score at admission; levels of fibrinogen binding to platelets (platelet-Fg) and of D-dimers were also significantly increased compared to the other patients. Levels 48 h after ICU admission no longer differed between the two patient groups. Platelet-Fg % was an independent predictor of sepsis (P = 0.0031). By ROC curve analysis, cutoff point for Platelet-Fg (AUC = 0.75) was 50%. In patients with a SOFA cutoff of 8, the risk of sepsis reached 87% when Platelet-Fg levels were above 50%. Patients with sepsis had longer ICU and hospital stays and higher death rate. Platelet-bound fibrinogen levels assayed by flow cytometry within 24 h of ICU admission help identifying critically ill patients at risk of developing sepsis.

Surv Anesthesiol 2016;60(2):51–53 The implementation of ventilator-associated pneumonia (VAP) bundles in intensive care units (ICUs) has led to a reduction in VAP rate, but the discrepancy between VAP rates in ICUs in the United States and Europe merits further investigation. Focusing on ventilator-associated events involving quantitative evidence of deteriorating respiration (worsening oxygenation) has been proposed to obtain fast and reliable surveillance definitions of VAP.

Detecting impaired glomerular filtration rate (GFR) is important in intensive care units (ICU) in order to diagnose acute kidney injuries and adjust the dose of renally excreted drugs. Whether serum Cystatin C (SCysC) may better reflect glomerular filtration rate than serum creatinine (SCr) in the context of intensive care medicine is uncertain.

Much controversy exists about pneumonia in intensive care—especially, ventilator-associated pneumonia (VAP)—about its diagnosis and its attributable mortality. A better consensus exists about its prevention and its treatment. VAP occurs in already critically ill patients, and the relationship between preexisting organ dysfunction or failures and the severity of VAP has been recently highlighted. The role of the underlying disease should be considered as dominant, and this fact explains the paradox that exists between the high mortality of VAP and the relative minor effect of prevention measures on mortality.

Le diagnostic de la pneumopathie acquise sous ventilation mécanique (PAVM) se base sur un ensemble de signes peu spécifiques. Plusieurs indicateurs ont été testés pour améliorer la performance de ce diagnostic. Aucun ne démontre, à l’heure actuelle, un apport substantiel, que ce soit la quantification des paramètres cliniques par un score tentant de globaliser l’ensemble des informations, le score clinique d’infection pulmonaire (CPIS) ou les marqueurs biologiques recherchés tant dans le sérum comme la procalcitonine ou la protéine C réactive (CRP), que dans le liquide de lavage bronchoalvéolaire (LLBA), comme le soluble Triggering Receptor Expressed on Myeloid Cells 1 (s-TREM 1), l’endotoxine, les fibres d’élastine, la protéine 10 des cellules Clara ou les cytokines pro-inflammatoires. L’examen direct des prélèvements endotrachéaux, et surtout du LLBA, par la mise en évidence de cellules contenant des bactéries apporterait, seul, une information utile. On ne peut donc pas se passer de la microbiologie. Diagnosis of ventilator-associated pneumonia (VAP) is based on non-specific clinical signs. Several indicators have been tested in order to improve the accuracy of VAP diagnosis. The quantification of clinical parameters by using the clinical pulmonary infection score (CPIS), however, failed to improve the specificity of the diagnosis. This was the same for all the biomarkers tested either in the serum (procalcitonin, C-reactive protein) or in the bronchoalveolar lavage (BAL) fluid [soluble triggering receptor expressed on myeloid cells 1 (sTREM 1), elastin fibers, endotoxin, pro-inflammatory cytokines, Clara cell protein 10]. The microscopic examination of endotracheal samples alone, especially of the BAL fluid, may provide useful information for the detection of infected cells. Thus, microbiology is still needed.

Purpose To assess the severity of intensive care unit (ICU)-acquired pneumonia (ICUAP) according to the bacteria involved, classified into seven groups: third-generation cephalosporin-resistant non-fermenting Gram-negative bacilli (resistant C3NF); sensitive C3NF; methicillin-resistant Staphylococcus aureus; methicillin-sensitive Staphylococcus aureus; extended-spectrum beta-lactamase-producing Enterobacteriaceae; Enterobacteriaceae not producing extended-spectrum beta-lactamase; Haemophilus influenzae and Streptococcus pneumoniae. Methods Over a 4-year period, sequential organ failure assessment (SOFA) score was prospectively measured daily in 453 adult patients with ICUAP. ICUAP severity was evaluated by the severity of sepsis and by the occurrence of new organ dysfunctions or failures (OD/F) during ICUAP. Results Septic shock occurred in 21% of all cases of ICUAP. The occurrence of new OD/F during ICUAP was similar regardless of the identified microorganism. These new OD/F represented less than 11% of SOFAmax, defined as the sum of all OD/F occurring at any time during the ICU stay. There was a significant association between SOFApreICUAP, defined as the sum of all the OD/F occurring before ICUAP, and ICUAP severity. In the multivariate analysis, the type of bacteria was not a risk factor (RF) for occurrence of septic shock and mortality. Age and SOFApreICUAP were RF for the sepsis severity. The ICUAP severity was an RF for ICU mortality. Conclusions ICUAP was responsible for a minor proportion of OD/F occurring during the ICU stay. Severity of ICUAP was related to clinical status prior to ICUAP, but not to the type of bacteria. ICU mortality depended on the severity of ICUAP.

Introduction: Outcome studies in patients with acute kidney injury (AKI) have focused on differences between modalities of renal replacement therapy (RRT). The outcome of conservative treatment, however, has never been compared with RRT. Methods: Nine Belgian intensive care units (ICUs) included all adult patients consecutively admitted with serum creatinine >2 mg/dl. Included treatment options were conservative treatment and intermittent or continuous RRT. Disease severity was determined using the Stuivenberg Hospital Acute Renal Failure (SHARF) score. Outcome parameters studied were mortality, hospital length of stay and renal recovery at hospital discharge. Results: Out of 1,303 included patients, 650 required RRT (58% intermittent, 42% continuous RRT). Overall results showed a higher mortality (43% versus 58%) as well as a longer ICU and hospital stay in RRT patients compared to conservative treatment. Using the SHARF score for adjustment of disease severity, an increased risk of death for RRT compared to conservative treatment of RR = 1.75 (95% CI: 1.4 to 2.3) was found. Additional correction for other severity parameters (Acute Physiology And Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA)), age, type of AKI and clinical conditions confirmed the higher mortality in the RRT group. Conclusions: The SHARF study showed that the higher mortality expected in AKI patients receiving RRT versus conservative treatment can not only be explained by a higher disease severity in the RRT group, even after multiple corrections. A more critical approach to the need for RRT in AKI patients seems to be warranted.

To assess the temporal relationship between ICU-acquired infection (IAI) and the prevalence and severity of organ dysfunction or failure (OD/F).