mercredi 5 février 2020 

14h10 - 15h10


 
Forum 4

Hémodynamique I

MODÉRATEUR(S) :  Hafid AIT-OUFELLA (Paris), Michel SLAMA (Amiens)  
  

A Systematic Echography During Intubation Procedure to Predict Cardiovascular Collapse (EPIC)

Orateur(s) :   Vanessa JEAN-MICHEL (Tourcoing) 

Auteur(s) :  Gwenael PRAT (Brest)   Pierre BAILLY (Brest)   James BENIS (Quimper)   Montaine LEFEVRE (Morlaix)   Pierre-yves EGRETEAU (Morlaix)   Christophe GIACARDI (Brest)   Cécile AUBRON (Brest)   Erwan L'HER (Brest)  

14h10 - 14h18
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
A Systematic Echography During Intubation Procedure to Predict Cardiovascular Collapse (EPIC)

Introduction / Rationale :
Emergency endotracheal intubation (ETI) in the Intensive Care Unit (ICU) often concerns hypoxemic patients with hemodynamic instability. A cardiovascular collapse (CVC) after ETI is a life-threatening complication. 2018 French guidelines suggested systematic fluid loading prior to ETI. Our study aimed to predict CVC after ETI, while using echocardiography, and to evaluate the impact of fluid loading.

Méthodes / Patients and Methods :
A prospective study of 70 consecutive intubations was performed from June 2017 to November 2018 in three ICUs. Patients were selected if mean blood pressure measurements ≥ 60 mmHg before ETI. CVC was defined as mean blood pressure < 60 mmHg within 15 minutes following ETI. Four echocardiographic examinations were performed: 1- 30 min before and 2- 30 min after ETI (or when a CVC occurred); 3- after passive leg raising; 4- 3 hours following ETI. Patients were classified as fluid responders when the left ventricular outflow tract velocity-time integral increased by at least 10% compared with baseline.

Résultats / Results :
269 echocardiographic examinations were performed. CVC occurred in 32/70 procedures (46%). In CVC group, mean dose of Diprivan, used for fast sequence induction, was higher (2.8 ± 1 mg/kg vs 1.3 ± 0.7 mg/kg, p = 0.02). In the CVC group, fluid responsiveness was considered in 44% patients and left ventricular (LV) systolic dysfunction 13%. LV diastolic dysfunction did not concern any patient in the CVC group. Systolic blood pressure (SBP) < 120 mmHg was the sole independent risk factor for CVC occurrence in multivariate analysis: OR 5.9 CI 95% 1.7 – 21.2, p = 0.02. Fluid responsiveness independent risk factors for CVC patients was SBP < 120 mmHg (OR 8.7, CI 95% 1.1 – 65.1, p = 0.01) and tidal volume > 7 ml/kg IBW (OR 7.8 ICI 5% 1.02 – 60.3, p = 0.048).

Discussion / Discussion :


Conclusion / Conclusion :
CVC frequently occurs following ETI. Fluid loading doesn’t seem to be mandatory for all patients to prevent CVC during the ETI procedure.
 

Heart rate variability as an indicator of outcome in the ICU ? A prospective cohort

Orateur(s) :   Laetitia BODENES (Brest) 

Auteur(s) :  Victoire PATEAU (Brest)   Julien DOLOU (Brest)   Quang-thang N'GUYEN (Brest)   Erwan L'HER (Brest)  

14h18 - 14h26
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
Heart rate variability as an indicator of outcome in the ICU ? A prospective cohort

Introduction / Rationale :
The autonomic nervous system is highly adaptable and allows the organism to maintain its balance when experiencing stress. Heart rate variability (HRV) is a mean to evaluate cardiac effects of autonomic nervous system activity and a relation between HRV and outcome has been proposed in various types of patients. We attempted to evaluate the best determinants of such variation in survival prediction using a physiological data-warehousing program (ReaSTOC ClinicalTrials identifier NCT 02893462).

Méthodes / Patients and Methods :
Physiological tracings were recorded at 125 Hz from the standard monitoring system (Intelliview Philips MP70) using the Synapse Software (LTSI INSERM UMR 1099), for a 2 hours period, during the 24 hours following ICU admission.
All measurements were recorded while patients were laying in bed, with the head at 30° and without any medical intervention. Physiological data were associated with metadata collection by a dedicated research assistant. HRV was derived using Kubios HRV, in either temporal ((SDNN), (RMSSD) and triangular index (TI)), frequency ((LF), (HF)), non-linear domains (Poincaré plotting) and entropy.

Résultats / Results :
540 consecutives patients were recorded between May 2014 and April 2019 . A lower LF/HF ( < 0,9) and SD2/SD1 ( < 1,3) ratios on admission were associated with a higher ICU mortality. Multivariate analysis enabled to develop a mortality predictive model (BICUS) associating SpO2/FiO2 and HRV parameters (LF/HF and Shannon entropy) with an AUC = 0,73 (p < 0,0001) for a BICUS value > 1 (Figure 1).

Discussion / Discussion :


Conclusion / Conclusion :
HRV measured on admission enables to predict prognosis in the ICU, independently of the admission diagnosis, treatment and MV requirements. BICUS may help predict prognosis on a real time basis, using parameters derived from standard routine monitoring.
 

A mouse model of ischemic stroke in impaired glucose tolerance condition induced by chronical exposure of High Fat Diet

Orateur(s) :   Coline GRISOTTO (Saint-Pierre) 

Auteur(s) :  David COURET (Saint Pierre)  

14h26 - 14h34
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
A mouse model of ischemic stroke in impaired glucose tolerance condition induced by chronical exposure of High Fat Diet

Introduction / Rationale :
Stroke, in context of type 2 diabetes (T2D) is associated with a worse outcome than in non-diabetic conditions, reflected by an increased ischemic volume and more intracerebral hemorrhage. An unbalanced diet is one of major risk for developing T2D . We aimed at creating a reproducible mouse model of stroke in impaired glucose tolerance condition induced by high fat diet.

Méthodes / Patients and Methods :
Adult C57BL6mice (28 male and 28 female) were fed for 2 months with either High Fat Diet (HFD, 43% lipids, 21% proteins, 35% carbohydrates) or a normal diet (ND, 8,4% lipids, 19,3% proteins, 72,4% carbohydrates). We used a model of Middle Cerebral Artery Occlusion by a monofilament for 90 minutes. Oral Glucose Tolerance Test and Insulin Tolerance Test were used for evaluating the pre-diabetic state. Mice were euthanatized 20h after reperfusion. Systemic inflammation, cerebral infarct volume and hemorrhagic transformation were determined.

Résultats / Results :
HFD was associated with an increased glycaemia following the Oral Glucose Tolerance Test . Plasma leptinlevels in stroke conditions were significantly higher in HFD vs ND group. The HFD group presented a significant increase of infarct volume (HFD: 51.86 ± 4.46 mm3 vs ND: 33.23 ± 4.29 mm3 p=0.016) and hemorrhagic transformation (HFD: 2.67 ± 0.66 vs ND: 0.73 ± 0.28 p= 0.012) (figure 1) compared to ND group.

Discussion / Discussion :
In human, one of the mechanisms leading to insulin resistance is low-grade inflammation. HFD increases gut permeability , which leads microbiota dysbiosis, thereby promoting metabolic endotoxaemia and a low-grade inflammation state. Experimental mouse models available for diabetes studies use leptin receptor deficient mice which develop T2D or destruction of pancreatic beta cells by streptozotocine injection (T1D). Studies using diet-induced insulin resistance models generally feed the mice for twelve weeks or more. However, metabolic disorders could appear earlier such as increase inflammatory markers. In our model, a short exposition to HFD (8 weeks) leads to an increase of the pro-inflammatory markers as plasma leptin and a more severe stroke status (infarct and hemorrhagic transformation).

Conclusion / Conclusion :
Two months of HFD in adult mice altered hyperglycemia control. This metabolic disorder was associated with significantly higher leptin production, increased infarct volume and hemorrhagic complications than in normal-fed mice. This new model is particularly relevant to study stroke under pre-diabetic conditions induced by HFD.
 

Does metformin act as a protective drug after a massive ischemia reperfusion induced by cardiac arrest? A survival study.

Orateur(s) :   Amélie ROLLE (Les Abymes) 

Auteur(s) :  Barthélémy VALLEE (Les Abymes)   Romain ROZIER (Nice)   Frédéric MARTINO (Les Abymes)   Jean-ehrland RICCI (Nice)   Bertrand PONS (Les Abymes)   Michel CARLES (Les Abymes)  

14h34 - 14h42
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
Does metformin act as a protective drug after a massive ischemia reperfusion induced by cardiac arrest? A survival study.

Introduction / Rationale :
Cardiac arrest (CA), as massive ischemia reperfusion (IR), is an universal health issue. Medication taken at the time of the CA could have prognosis consequences. No medication has proven its benefit on CA prognosis.
Pharmacological pre- or postconditioning aims to reduce IR injury but with disappointing results. Metformin (MET) is a worldwide-prescribed antidiabetic drug, and several clinical reports plead for a potential protective effect in various settings of sterile and non sterile inflammation, including IR. Our hypothesis is that MET act as a preconditioning drug against CA-induced IR.

Méthodes / Patients and Methods :
Retrospective single academic medical center survival study (French West Indies) on resuscitated CA in ICU (institutional ethical committee approval). Data were extracted from medical charts, PMSI, and laboratory DBSYNERGY™ software. Anonymized data were entered on a Excel™ and transferred to IBM® – SPSS® software (v 24.0.0.0) for analysis. Univariate study (Chi-2, Fisher exact tests, Student-t test, Mann Whitney U-test if required) was followed by a multivariate model (Odd ratio OR and 95%CI : Kaplan Meier estimator and non parametric Logrank test - Mantel Cox model). Assuming an overall in-hospital mortality for CA in ICU of 80% with an expected mortality decrease of 15% by MET, the number of patients to be included is 510.

Résultats / Results :
The inclusion period was 2012 to 2018, with 555 included patients (36% of diabetic patients, n=202 among which 62 taking MET).
The D28 mortality was 67% in MET+ patients (n=62) versus 82% in NoMET patients (n=493), p<0.01. Comparing alive (n=115) versus deceased (n=440) at D28 in univariate then multivariate analysis, asystole on the first EKG, number of iterative cardiac arrest, SOFA, No-Flow, lactate, Low-flow and SAPSII appear as independent criteria associated with D28 mortality. Conversely, MET intake showed up as a protective criterion (OR 0.477, CI95 0.237-0.957). The survival curve, including a strata of Low-Flow duration at the cut-off 20 minutes, is reported on the figure.
Among diabetic patients (n=202), the mortality of patients in the MET+ (n=62) was 67% versus 80% in the NoMET (n=140), p=0.04.

Discussion / Discussion :


Conclusion / Conclusion :
In diabetic patients suffering of massive IR related to a resuscitated CA, a current treatment by MET is associated with a better survival. These results support a protective effect of MET and are important to initiate prospective evaluations, because of millions diabetic people around the world and the potential benefit of MET. The potential benefit in non diabetic patients and in sterile as well as non sterile inflammation should be addressed.
 

Ischemic and hemorrhagic complications of patients on venoarterial-extracorporeal membrane for cardiogenic shock post myocardial infarction.

Orateur(s) :   Paul MASI (Paris) 

Auteur(s) :  Maxence LE GUYADER (Paris)   Charles-Edouard LUYT (Paris)   Guillaume FRANCHINEAU (Paris)   Loïc LE GUENNEC (Paris)   Simon BOURSIER (Paris)   Nicolas BRECHOT (Paris)   Matthieu SCHMIDT (Paris)   Alain COMBES (Paris)   Guillaume HEKIMIAN (Paris)  

14h42 - 14h50
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
Ischemic and hemorrhagic complications of patients on venoarterial-extracorporeal membrane for cardiogenic shock post myocardial infarction.

Introduction / Rationale :
Short-term ischemic and hemorrhagic complications of patients on venoarterial-extracorporeal membrane (VA-ECMO) for cardiogenic shock post myocardial infarction (MI) have not yet been reported. Our objective was to describe frequencies, outcomes and risk factors for ischemic and hemorrhagic complications.

Méthodes / Patients and Methods :
From 2015 to 2019, we conducted a retrospective observational study in a single tertiary care center on patients who developed a cardiogenic shock post MI and required VA-ECMO.

Résultats / Results :
During this period, 177 patients were implanted with VA-ECMO for cardiogenic shock post MI. Mean age was 56 years and 78% were male gender. MI was complicated by cardiac arrest in 61%. Culprit lesion was respectively the left main coronary artery for 23 patients (14.6%), left anterior descending artery for 82 patients (46%), circumflex artery for 14 patients (8.9%) and right coronary artery for 36 patients (22.9%). Intraaortic balloon pump or Impella were implanted respectively for 89 patients (50.9%) and 8 patients (4.6%). 108 (61%) patients died in intensive care, 76 (43.4%) patients had a hemorrhagic complication, 46 patients (26%) had a severe hemorrhagic complication defined by dead or/and massive transfusion or/and hemostatic procedure (surgery or endoscopy), 87 (49%) patients had thrombopenia < 100 G/L, 50 (28%) patients had thrombopenia < 50 G/L, 53 patients (30.1%) and 43 patients (24.6%) required antiaggregation and anticoagulation withdrawal. 9 (5.6%) patients died secondary to bleeding. VA-ECMO membranes thrombosis occurred in 6 (3.5%) patients. A coronary angiography check was performed for 27 (15.6%) patients, 8 (4.6%) patients had stent thrombosis.

Discussion / Discussion :


Conclusion / Conclusion :
Ischemic and hemorrhagic complications are frequent in patients on VA-ECMO for cardiogenic shock post MI. The main findings of our study were an high rate of severe bleeding complications and thrombopenia requiring antiaggregation withdrawal associated with a very high prevalence of stent thrombosis.
 

The endoplasmic reticulum stress expression under cardiopulmonary bypass : the relationship with organ failure.

Orateur(s) :   Zoé DEMAILLY (Rouen) 

Auteur(s) :  Thomas CLAVIER (Rouen)   Vincent RICHARD (Rouen)   Fabienne TAMION (Rouen)  

14h50 - 14h58
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
The endoplasmic reticulum stress expression under cardiopulmonary bypass : the relationship with organ failure.

Introduction / Rationale :
During systemic inflammation, the accumulation of misfolded proteins in the endoplasmic reticulum (ER) induces ER stress (ERS). In animal models, the inhibition of ERS reduces inflammatory response and organ failure. Cardiopulmonary bypass (CPB) induces a significant systemic inflammatory response but ERS expression has never been described in cardiac surgery patients. Our objective was to describe the variations of the Glucose Related Protein of 78 kDa (GRP78), the final effector of the ERS, during CPB.

Méthodes / Patients and Methods :
We conducted a prospective monocenter study including patients undergoing cardiac surgery with CPB. Two samples (PAXGene® tube + EDTA tube) were taken at three times: before CPB, 2 hours after the end of CPB (H2-CPB) and 24 hours after (H24-CPB). After RNA isolation and reverse transcription, we performed a quantitative polymerase chain reaction to evaluate the expression of gene encoding for GRP78 and determined the plasma level of GRP78 using Enzyme-Linked Immunosorbent Assay. Our main objective was to study the variation of GRP78 between pre-CPB and H2-CPB samples. Our secondary objectives were to evaluate the association of ERS with morbi-mortality: organ failure at 24 hours (catecholamines and/or invasive ventilation and/or acute renal failure), troponinemia and PaO2/FiO2 ratio (lung damage control).

Résultats / Results :
We included 46 patients with a median age of 70[63;75] years and a median CPB duration of 117[92;139] min. We showed an increase in GRP78 gene expression (p<0.0001) and a decrease in its plasma level at H2-CPB (4540[2519;7575] ng/mL vs. 1902[939;3133] ng/mL; p<0.0001). H24-CPB GRP78 plasma levels were lower than baseline in patients with persistent organ failure at 24 hours but returned to baseline in patients without persistent organ failure (-37[-61;-18] % vs. 0.33[-29;43] %; p<0.01; cf. Fig.1). We found an inverse correlation between GRP78 plasma level and troponinemia at H2 (r=-0.31; 95% CI[-0.56;-0.10] ; p=0.037) and a correlation between the PaO2/FiO2 ratio and GRP78 plasma level at H2 (r = 0.37 ; 95% CI[0.10 ; 0.59] ; p = 0.0064).

Discussion / Discussion :


Conclusion / Conclusion :
We showed a significant relationship between the variation in plasma concentration of GRP78 and post-operative organ failure after CPB. Further studies are needed to better understand the molecular mechanisms of ERS in acute inflammatory organ failure in humans.
 

Acute mesenteric ischemia in patients under mechanical support by veno-arterial ECMO

Orateur(s) :   Quentin DE ROUX (Créteil) 

Auteur(s) :  Marie RENAUDIER (Créteil)   Wulfran BOUGOUIN (Massy)   Johanna BOCCARA (Créteil)   Baptiste DUBOST (Créteil)   Antonio FIORE (Créteil)   Aurélien AMIOT (Créteil)   Olivier LANGERON (Créteil)   Nicolas MONGARDON (Créteil)  

14h58 - 15h06
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
Acute mesenteric ischemia in patients under mechanical support by veno-arterial ECMO

Introduction / Rationale :
Acute mesenteric ischemia is a dramatic complication in critically ill patients. However, acute mesenteric ischemia has never been evaluated in patients under veno-arterial ExtraCorporeal Membrane Oxygenation (VA-ECMO). This study was designed to determine the incidence of acute mesenteric ischemia in this population and to evaluate its risk factors, therapeutic modalities and outcome.

Méthodes / Patients and Methods :
In a retrospective monocentric study (01/2013-01/2017) conducted in cardio-vascular surgical ICU in Henri Mondor teaching hospital, all consecutive adult patients who underwent peripheral VA-ECMO were included, with exclusion of those dying in the first 24 hours. Diagnostic of acute mesenteric ischemia was performed using digestive endoscopy, abdominal CT-scan or fist-line laparotomy. Significative results in univariate analysis were analyzed in multivariate analysis using logistic regression.

Résultats / Results :
150 VA-ECMO were implanted. Median age was 58 (48-69) years and median SAPS II 54 (38-70). VA-ECMO was implanted after a cardiotomy in 43% of the cases and for a medical reason in 57% of the cases including 26% of refractory cardiac arrest. Patients characteristics are reported in the table. Acute mesenteric ischemia was suspected in 38 patients, with a delay of 4 (2-7) days after ECMO implantation. Digestive endoscopy was performed in 33 patients, CT-scan in 5 patients and first-line laparotomy in 3 patients. Acute mesenteric ischemia was confirmed in 14 patients, i.e. an incidence of 9%. Laparotomy was performed in 6 of the 14 patients, 2 having a stage I colitis ischemitis with stable conditions and 6 being considered too severe to undergo futile surgery. Overall mortality was 56%. All the patients with acute mesenteric ischemia died in ICU. Independent risk factors of developing acute mesenteric ischemia were renal replacement therapy (OR 4.5 (95%CI 1.3-15.7, p=0.02)) and onset of a second shock state within the first 5 days of ICU stay (OR 7.8 (95%CI 1.5-41.3, p=0.02)). Conversely, early enteral nutrition was negatively associated with acute mesenteric ischemia (OR 0.15 (95%CI 0.03-0.69), p 0.02).

Discussion / Discussion :


Conclusion / Conclusion :
Acute mesenteric ischemia is a relatively frequent condition among patients under VA-ECMO for cardiogenic shock. Its extremely poor prognosis requires low threshold of suspicion.