title: Interest of a therapeutic optimization strategy in severe ARDS.
abstract: OBJECTIVE
  Evaluate the interest of the response to a therapeutic optimization as a predictor of prognosis in ARDS.
  
  
  METHODS
  Prospective study.
  
  
  METHODS
  ICU of a University Hospital.
  
  
  METHODS
  Thirty-six consecutive patients with severe ARDS addressed for extracorporeal carbon dioxide removal (ECCO2R).
  
  
  METHODS
  We studied the response during the first 2 days after arrival to the therapeutic optimization strategy consisting in a combination of the following: (1) decrease in extravascular lung water (diuretics or hemofiltration); (2) selection of the best ventilatory mode; (3) permissive hypercarbia; and (4) correction of hypoxemia by alveolar recruitment, additional continuous oxygen insufflation, body position changes (prone position), inhaled nitric oxide, enhancement of hypoxic pulmonary vasoconstriction with almitrine, and drainage of pleural or mediastinal effusions. In patients remaining severely hypoxemic despite these modalities, ECCO2R was then proposed.
  
  
  RESULTS
  Thirty-six patients were addressed after 8.3+/-5.5 days of mechanical ventilation. On arrival, mean simplified acute physiologic score was 46.8+/-14.2, multiple system organ failure score was 1.8+/-1.6, Murray score was 3.4+/-0.4, PaO2 was 75.3+/-31.3 (fraction of inspired oxygen [FIO2]=1) for a positive end-expiratory pressure level of 12.3+/-3.4 cm H2O. Nineteen of 36 patients improved their gas exchange within 2 days and their mortality was 21%. The seventeen remaining patients did not improve PaO2/FIO2; PaCO2 and airway pressures remained high and their mortality was 88%. This different response to therapeutic optimization appeared using stepwise logistic regression as the most predictive factor for mortality (p<0.05).
  
  
  CONCLUSIONS
  In patients with severe ARDS, the response to an early performed therapeutic optimization used to improve hypoxemia appeared to be a highly discriminant factor distinguishing deceased from surviving patients.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Hôpital Universitaire Lariboisière, Paris, France.
authors.forename: N
authors.initials: N
authors.lastname: Guinard
authors.forename: S
authors.initials: S
authors.lastname: Beloucif
authors.forename: C
authors.initials: C
authors.lastname: Gatecel
authors.forename: J
authors.initials: J
authors.lastname: Mateo
authors.forename: D
authors.initials: D
authors.lastname: Payen
mesh_terms: D000293:Adolescent; D000328:Adult; D015765:Almitrine / Q000627:therapeutic use; D000704:Analysis of Variance; D004232:Diuretics / Q000627:therapeutic use; D004322:Drainage; D005260:Female; D006440:Hemofiltration; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010347:Patient Care Planning; D010996:Pleural Effusion; D011187:Posture; D011379:Prognosis; D011446:Prospective Studies; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000401:mortality / Q000628:therapy*; D014692:Ventilation-Perfusion Ratio
chemical_list: D004232:Diuretics; D015765:Almitrine