Épanchements pleuraux en réanimation

Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries

Pleural Effusions in Hospitalized Patients Receiving Long-term Hemodialysis

HomeRadiology: Cardiothoracic ImagingVol. 2, No. 3 Previous Letters to the EditorFree AccessClarification on Pleural Effusions in COVID-19Avinash Aujayeb Avinash Aujayeb Author AffiliationsDepartment of Respiratory and Acute Medicine, Northumbria Healthcare NHS Foundation Trust, Northumbria Way, Cramlington NE23 6NZ, Englande-mail: [email protected]Avinash Aujayeb Published Online:Jun 11 2020https://doi.org/10.1148/ryct.2020200330MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack Citations ShareShare onFacebookTwitterLinked In Editor:We thank Dr Tabatabaei and colleagues for their recent article in the April 2020 issue of Radiology: Cardiothoracic Imaging on CT characteristics of 120 patients with coronavirus disease 2019 (COVID-19) with a wide range of clinical outcomes (1). A total of 12.5% (19 of 96) of ward patients, 45% (nine of 11) of those in intensive care, and 23% (three of 13) of those deceased had pleural effusions. The authors rightly mention that the incidence of pleural effusions is out of keeping with other published studies and that pleural effusions are uncommon in COVID-19 (2). Therefore, we must dispute this finding in the absence of further explanations. It would be important to know if the effusions were unilateral or bilateral, whether those patients had any coexisting comorbidities such as concurrent heart, renal, or liver failure, or any disseminated malignancies which are by far the most common cause of pleural effusions, and more importantly whether any of those effusions were sampled and what were the resultant biochemical and microbiologic characteristics. So far, in the literature, there is only one report of pleural effusions in deceased COVID-19 patients being positive for the virus (3). However, patient characteristics in that study are also not described. We run a large pleural service in the North East of England, and this would greatly inform local and national practice (4). Current British Thoracic Society guidance suggests that all pleural procedures are potentially aerosol generating and could spread the virus, but the statement mentions that the evidence is poor (5). We believe the case series will be greatly enhanced if the details above are provided. If they cannot be provided, perhaps a note of caution should be added to the article by way of reply to this letter? We would also welcome any chance of international collaboration on the matter.Disclosures of Conflicts of Interest: A.A. disclosed no relevant relationships.

Psychiatric management of Patients in intensive care units.

The purpose of this study was to investigate the relationship between pleural temperature and pneumothorax or pleural effusion after radiofrequency (RF) ablation of lung tumors. The pleural temperature was measured immediately outside the lung surface nearest to the tumor with a fiber-type thermocouple during 25 ablation procedures for 34 tumors in 22 patients. The procedures were divided into two groups depending on the highest pleural temperature: P-group I and P-group II, with highest pleural temperatures of <40 degrees C and >/=40 degrees C, respectively. The incidence of pneumothorax or pleural effusion was compared between the groups. Multiple variables were compared between the groups to determine the factors that affect the pleural temperature. The overall incidence of pneumothorax and pleural effusion was 56% (14/25) and 20% (5/25), respectively. Temperature data in five ablation procedures were excluded from the analyses because these were affected by the pneumothorax. P-group I and P-group II comprised 10 procedures and 10 procedures, respectively. The incidence of pleural effusion was significantly higher in P-group II (4/10) than in P-group I (0/10) (p = 0.043). However, the incidence of pneumothorax did not differ significantly (p = 0.50) between P-group I (4/10) and P-group II (5/10). Factors significantly affecting the pleural temperature were distance between the electrode and the pleura (p < 0.001) and length of the lung parenchyma between the electrode and the pleura (p < 0.001). We conclude that higher pleural temperature appeared to be associated with the occurrence of pleural effusion and not with that of pneumothorax.

Critical Care Medicine

BackgroundPrevious studies have indicated that C-C class chemokine ligand 22 (CCL22) is involved in the pathogenesis of tuberculous pleural effusion and malignant pleural effusion. However, the diagnostic role of pleural fluid CCL22 levels in patients with undiagnosed pleural effusions remains to be elucidated.MethodsWe prospectively recruited patients with undiagnosed pleural effusion who visited two centres (Hohhot and Changshu) in China. Pleural biopsy, microbiological culture and effusion cytology were used to verify the cause of pleural effusion. Pleural fluid CCL22 levels were measured using an ELISA. The diagnostic accuracy of CCL22 for identifying heart failure (HF) was evaluated using a receiver operating characteristic (ROC) curve, and the net benefit of CCL22 was evaluated using decision curve analysis (DCA). Net benefit was defined as the benefit associated with true positives minus the harms associated with false positives at various threshold probabilities.ResultsWe enrolled 153 and 58 patients in the Hohhot and Changshu cohorts, respectively. The cohort included 28 patients with HF and 183 patients with non-HF. Patients with HF had significantly lower pleural fluid CCL22 levels than non-HF patients. The area under the ROC curve (AUC) of CCL22 was 0.85 (95% CI: 0.77 to 0.93) in the Hohhot cohort and 0.87 (95% CI: 0.75 to 0.98) in the Changshu cohort. The AUC in the combined cohort was 0.85 (95% CI: 0.79 to 0.92), with a sensitivity of 0.82 (95% CI: 0.68 to 0.93) and a specificity of 0.73 (95% CI: 0.67 to 0.79) at the threshold of 150 ng/mL. DCA revealed a potential net benefit of pleural CCL22 determination in patients with undiagnosed pleural effusions.ConclusionsPleural fluid CCL22 may be a potential diagnostic marker for HF-related pleural effusion. Owing to the small sample size of this study, further studies with larger sample sizes are needed to validate our findings.

The management of pleural effusion usually involves the drainage of the effusion, identification, and treatment of the underlying cause (s). Studies have shown that the initial diagnostic techniques do not give conclusive diagnosis in some cases of pleural effusion. This group of patients described as patients with indeterminate or undiagnosed pleural effusion constitutes a significant proportion of patients with pleural effusion in clinical practice. In this study, we examined the role of video-assisted thoracoscopy (VAT) in the diagnostic work-up of these patients. To determine the diagnostic outcome of VAT in the management of indeterminate pleural effusion in our center. Consecutive patients who presented with pleural effusions and who met the inclusion criteria had video-assisted thoracoscopy for diagnostic purposes. Outcome measures including the diagnostic yield, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VAT in patients with indeterminate pleural effusion, duration of the procedure, duration of hospitalization after the procedure, and complications for all the patients were documented and analyzed. Of the 22 patients with indeterminate pleural effusion, conclusive diagnosis was obtained in 18 (81.8%) with a sensitivity of 91.7% [95% confidence interval (CI); 61.5-99.8%], specificity of 100% (95% CI; 69.1-100%), PPV of 100% (95% CI; 0-100%), and NPV of 90.9% (95% CI; 60.5-98.5%) for malignancy and a sensitivity of 78% (95% CI; 40-97%), a specificity of 100% (95% CI; 75.3-100%), PPV of 100% (95% CI; 0-100%), and NPV of 86.7% (95% CI; 65.7-95.7%) for tuberculosis. Our results show that video-assisted thoracoscopy plays a useful role in our center in obtaining diagnosis in patients with indeterminate pleural effusion.

Background: Although Epicutaneo cava catheters (ECCs) are being routinely used for intravenous access for long-term parenteral nutrition and prolonged medication administration in neonates, ECC use can be associated with rare but acute life-threatening events such as pleural effusion (PE). It is important to identify and maintain the ECC tip in a central location for preventing complications. Recently, intracavitary electrocardiogram (IC-ECG) has been developed for the real-time monitoring and verification of ECC tip position.Objective: To investigate the causes and preventive measures of ECC-related PE in neonates.Methods: This prospective cohort study was conducted between January 2013 and December 2017. We observed and analyzed the clinical characteristics and causes of ECC-related PE. From January to December 2017, all ECCs were guided by IC-ECG. The incidence of ECC-related PE and first-attempt success rates were analyzed before and after the introduction of IC-ECG. Additionally, the sensitivity and specificity of IC-ECG were evaluated.Results: ECC-related PE was identified in 14 infants. Catheters were malpositioned in three cases; in the other 11 cases, catheters were located centrally on insertion but had migrated to non-central locations at the time of PE. After the introduction of IC-ECG, the incidence of PE was zero (P < 0.05). The incidence of ECC-related PE was lower when veins of the lower extremities were selected as the insertion site (P < 0.05). The first-attempt success rate was significantly higher in the group with IC-ECG-guided ECC placement than in the group without (P < 0.05). The sensitivity and specificity of IC-ECG were 97.9 and 84.6%, respectively.Conclusion: ECC-related PE can be associated with either primary malposition or migration of the catheter tip. IC-ECG can help detect malposition and migration of catheter tips and improve the first-attempt success rate. Choosing a lower extremity insertion site may help decrease the rate of ECC-related PE. In neonates, IC-ECG is a reliable positioning method for ECCs with superior sensitivity and specificity.

Etiology of Pleural Effusions: Analysis of More Than 3,000 Consecutive Thoracenteses

To assess the incidence, risk factors, and outcome of active cytomegalovirus (CMV) infection in nonimmunosuppressed intensive care unit (ICU) patients. Prospective epidemiologic study. A medical ICU in a university hospital. Two hundred forty-two nonimmunosuppressed ICU patients mechanically ventilated for >or=2 days. Routine pp65 antigenemia and serology for CMV were performed at admission, and then weekly. Bronchoalveolar lavage viral cultures were done when pneumonia was suspected. Thirty-nine of the 242 ICU patients (16.1%, confidence interval 11.5% to 20.7%) developed an active CMV infection, as diagnosed by positive antigenemia (85%) and/or positive rapid viral culture in bronchoalveolar lavage (26%). Antiviral treatment was initiated in 21 (54%) patients. ICU mortality (54% vs. 37%, p = 0.082) and in-hospital mortality (59% vs. 41%, p = 0.058) were increased in patients with active CMV infection, as compared with those without active CMV infection. Active CMV infection and Simplified Acute Physiology Score II at admission were associated with ICU death on multivariate analysis. The patients with active CMV infection had longer mechanical ventilation and longer ICU stay and were significantly more prone to developing bacterial nosocomial infections (p < 0.001). Logistic regression analysis showed that prior admission to other wards (p = 0.043; odds ratio [OR], 2.49), blood transfusions (p = 0.04; OR, 3.31), enteral feeding (p = 0.005; OR, 3.00), recent corticosteroid use before ICU admission (p = 0.08; OR, 2.26), and age (p = 0.07; OR, 1.026) were associated with the occurrence of active CMV infection. : Active CMV infection is common among previously healthy patients under mechanical ventilation in a medical ICU. Further studies are needed to evaluate the role of antiviral treatments to reduce both the incidence and the outcome impact of active CMV infection.

To observe the early change in plasma brain natriuretic peptide (BNP) level in burn patients with long delayed fluid resuscitation of burn shock and its clinical significance. Thirty-six burn patients with second and third degree of burn covering 32%-92% total body surface area were enrolled for the study, among them 10 patients were complicated with serious heart failure (heart failure group), and 26 patients rallied from shock after delayed fluid resuscitation without heart failure (stable group). The level of plasma BNP, lactate dehydrogenase (LDH), MB isoenzyme of creatine kinase (CK-MB), and left ventricle ejection fraction (LVEF) were determined at admission and 3 hours after hospitalization, and 24, 48, 72, 168 hours after the injury in both groups with electrochemiluminescence (ECL). Compared with stable group, the plasma BNP level (ng/L) of heart failure group at 3 hours after hospitalization, and 24, 48, 72 hours after the burn injury increased significantly (3 hours after hospitalization: 1 521.38+/-121.11 vs. 391.36+/-63.27, 24 hours after burn: 2 516.86+/-193.25 vs. 360.79+/-146.56, 48 hours after burn: 1 587.76+/-169.23 vs. 398.92+/-77.46, 72 hours after burn: 974.45+/-166.33 vs. 283.43+/-68.15, all P<0.01), the level of LVEF lowered significantly (3 hours after hospitalization : 0.33+/-0.03 vs. 0.58+/-0.09, 24 hours after burn: 0.36+/-0.09 vs. 0.60+/-0.10, 48 hours after burn: 0.35+/-0.08 vs. 0.62+/-0.11, 72 hours after burn: 0.39+/-0.10 vs. 0.64+/-0.10, all P<0.05). The levels of LDH (micromolxs(-1) xL(-1)) in stable group were 2.87+/-0.50 at admission, 3.02+/-0.43 3 hours after hospitalization, 4.02+/-0.87 24 hours after burn, 6.90+/-0.87 48 hours after burn, 3.64+/-0.75 72 hours after burn, 2.67+/-0.45 168 hours after burn while in heart failure group, they were 2.97+/-1.40, 3.84+/-0.37, 4.29+/-0.45, 8.50+/-0.38, 3.84+/-0.62, 2.30+/-0.38, respectively; and CK-MB (U/L) in stable group were 59.12+/-13.75 at admission, 70.39+/-10.72 3 hours after hospitalization, 79.29+/-17.27 24 hours after burn, 67.44+/-12.77 48 hours after burn, 30.28+/-7.13 72 hours after burn, 21.44+/-3.15 168 hours after burn while in heart failure group, they were 65.76+/-16.38, 81.46+/-7.92, 86.43+/-14.19, 72.53+/-11.27, 36.39+/-6.18, 22.85+/-7.26, respectively. No statistically significant difference was found in changes in both LDH and CK-MB between two groups (all P>0.05). Determination of the plasma BNP is a simple and useful method in detecting heart failure during resuscitation of shock after a serious burn injury.

Purpose: To determine multi-drug resistant (MDR) and metallo β-lactamase (MBL)-resistant genes from Pseudomonas aeruginosa isolated from intensive care unit (ICU) patients under mechanical ventilation and respiratory support.Methods: P. aeruginosa was isolated from 387 purulent tracheobronchial secretions collected from ICU patients who were intubated and mechanically ventilated for at least 48 h. Antibiotic resistance was determined by minimum inhibitory concentration (MIC) assay while MDR genes, viz, blaTEM, blaOXA, blaVIM, blaCTX-M-15 were determined by polymerase chain reaction (PCR).Results: A total of 144 (37.2 %) P. aeruginosa were isolated from the purulent tracheobronchial secretions. A majority of the isolates (51.4 %) were resistant to gentamicin. Meropenem-gentamicin was the predominant (35.4 %) resistant combination. Out of the 144 isolates, 102 (70.8 %) were positive for blaTEM gene, 51 (35.4 %) for were positive for blaOXA gene, 22 (15.3 %) were positive for blaVIM gene, while 19 (13.2 %) were positive for blaCTX-M gene.Conclusion: The high prevalence of MDR P. aeruginosa indicates the need for continued monitoring of MDR P. aeruginosa especially in ICU patients who are under mechanical respiratory support.Keywords: Multi-drug resistance genes, Mechanical ventilator, Respiratory support, Pseudomonas aeruginosa

Objective To investigate the risk factors and prognosis of blood stream infection in patients of intensive care unit (ICU). Methods Clinical data of all patients with culture-positive sepsis were collected from all ICUs of Guangdong General Hospital from October 12th, 2012 to December 1st, 2014 for retrospective study. Physiological characteristics and laboratory data were compared between patients with blood culture-positive sepsis group and patients without sepsis of control group. Logistic regression analysis was made to identify the risk factors for blood stream infection. Patients with blood culture-positive sepsis group were further divided into survivor and non-survivor groups according to the clinical outcomes. Physiological and laboratory data were compared between two groups. Logistic regression analysis was also performed to identify the risk factors for mortality. Results There were 299 patients with positive blood culture sepsis admitted in the ICUs in two years. Of them, 250 patients infected with Gram positive cocci including staphylococcus haemolyticus, staphylococcus epidermidis, staphylococcus capitis and staphylococcusaureus accounting for the majority. There were 174 patients infected with Gram negative bacilli including acinetobacter baumannii, Escherichia coli and Klebsiella pneumoniaesubsp. pneumoniae accounting for the majority. A univariate analysis demonstrated that there were significant differences in hypertension (P =0.001) , diabetes (P=0.01) , coronary heart diseases and heart failure (P=0.000) , chronic renal insufficiency (P=0.000) , prolonged mechanical ventilation (P=0.000) , pre-admission intravenous administration of antibiotics (P=0.000) , and hypoalbuminemia (P=0.008) between culture positive group and control group. A logistic regression analysis demonstrated that diabetes [ OR=2.158, 95% CI(1.230, 3.787) , P=0.007] , chronic renal insufficiency [ OR=13.410, 95% CI (1.715, 104.879) , P=0.013] , pre-admission intravenous administration of antibiotics [ OR=8.375, 95% CI (5.267, 13.317) , P=0.000] were independent risk factors for bloodstream infections in ICU. In patients with positive blood culture, the non-survivor group had patients with higher advance of old age, higher rate of hypertension, coronary heart diseases or congestive heart failure, tumor and chronic renal insufficiency, prolonged mechanical ventilation and higher incidence of surgery and pre-admission intravenous administration of antibiotics compared with the survivor group. The advance of old age [ OR=1.023, 95% CI (1.008-1.037) , P=0.002] , prolonged mechanical ventilation [ OR=1.055, 95% CI (1.024, 1.088) , P=0.000] and hypoalbuminemia [ OR=0.933, 95% CI (0.898, 0.971) , P=0.001] were independently associated with mortality of bloodstream infection in ICU. Conclusions Diabetes, chronic renal insufficiency and pre-admission intravenous administration of antibiotics were associated with the development of blood stream infection in ICU. The advance of old age, prolonged mechanical ventilation and hypoalbuminemia were independent risk factors for mortality in patients with culture-positive sepsis in ICU. Key words: Descriptive retrospective study; Logistic regression analysis; Blood stream infection; Culture-positive sepsis; Intensive care unit; Risk factor; Prognosis; Mortality

To quantify the mean daily cost of intensive care, identify key factors associated with increased cost, and determine the incremental cost of mechanical ventilation during a day in the intensive care unit. Retrospective cohort analysis using data from NDCHealth's Hospital Patient Level Database. A total of 253 geographically diverse U.S. hospitals. The study included 51,009 patients >/=18 yrs of age admitted to an intensive care unit between October 1, 2002, and December 31, 2002. None. Days of intensive care and mechanical ventilation were identified using billing data, and daily costs were calculated as the sum of daily charges multiplied by hospital-specific cost-to-charge ratios. Cost data are presented as mean (+/-sd). Incremental daily cost of mechanical ventilation was calculated using log-linear regression, adjusting for patient and hospital characteristics. Approximately 36% of identified patients were mechanically ventilated at some point during their intensive care unit stay. Mechanically ventilated patients were older (63.5 yrs vs. 61.7 yrs, p < .0001) and more likely to be male (56.1% vs. 51.8%, p < 0.0001), compared with patients who were not mechanically ventilated, and required mechanical ventilation for a mean duration of 5.6 days +/- 9.6. Mean intensive care unit cost and length of stay were 31,574 +/- 42,570 dollars and 14.4 days +/- 15.8 for patients requiring mechanical ventilation and 12,931 +/- 20,569 dollars and 8.5 days +/- 10.5 for those not requiring mechanical ventilation. Daily costs were greatest on intensive care unit day 1 (mechanical ventilation, 10,794 dollars; no mechanical ventilation, 6,667 dollars), decreased on day 2 (mechanical ventilation:, 4,796 dollars; no mechanical ventilation, 3,496 dollars), and became stable after day 3 (mechanical ventilation, 3,968 dollars; no mechanical ventilation, 3,184 dollars). Adjusting for patient and hospital characteristics, the mean incremental cost of mechanical ventilation in intensive care unit patients was 1,522 dollars per day (p < .001). Intensive care unit costs are highest during the first 2 days of admission, stabilizing at a lower level thereafter. Mechanical ventilation is associated with significantly higher daily costs for patients receiving treatment in the intensive care unit throughout their entire intensive care unit stay. Interventions that result in reduced intensive care unit length of stay and/or duration of mechanical ventilation could lead to substantial reductions in total inpatient cost.