Bibliographie de Médecine d'Urgence

Mois de septembre 2017

American Heart Journal

Protocol changes to the TRIUMPH study.
Webster R | Am Heart J. 2017 Sep;191:e1
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Letter to the Editor

Editorial : Finally, given increasing calls for fixed-dose combi- nation therapy to be recommended as first-line treatment for hypertension, a subgroup analysis defined by whether or not patients were treated with blood pressure lowering therapy prior to randomiza- tion has been added to the prespecified statistical analysis plan.

Conclusion : -

Commentaire : TRIple pill vs Usual care Management for Patients with mild-to-moderate Hypertension (TRIUMPH): Study protocol  .
Salam A, Webster R, Singh K, Kallakuri S, Rodgers A, Prabhakaran D, Maulik PK, Jan S, Thom S, Naik N, Guggilla R, Selak V, Patel A.
Am Heart J. 2014 Feb;167(2):127-32

Critical Care Medicine

Technologic Distractions (Part 1): Summary of Approaches to Manage Alert Quantity With Intent to Reduce Alert Fatigue and Suggestions for Alert Fatigue Metrics.
Kane-Gill SL , O'Connor MF, Rothschild JM, Selby NM, McLean B, Bonafide CP, Cvach MM, Hu X, Konkani A, Pelter MM, Winters BD. | Crit Care Med. 2017 Sep;45(9):1481-1488
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Review Articles

Introduction : To provide ICU clinicians with evidence-based guidance on tested interventions that reduce or prevent alert fatigue within clinical decision support systems.

Méthode : Systematic review of PubMed, Embase, SCOPUS, and CINAHL for relevant literature from 1966 to February 2017.
PATIENTS: Focus on critically ill patients and included evaluations in other patient care settings, as well.
INTERVENTIONS: Identified interventions designed to reduce or prevent alert fatigue within clinical decision support systems.

Résultats : Study selection was based on one primary key question to identify effective interventions that attempted to reduce alert fatigue and three secondary key questions that covered the negative effects of alert fatigue, potential unintended consequences of efforts to reduce alert fatigue, and ideal alert quantity. Data were abstracted by two reviewers independently using a standardized abstraction tool. Surveys, meeting abstracts, "gray" literature, studies not available in English, and studies with non-original data were excluded. For the primary key question, articles were excluded if they did not provide a comparator as key question 1 was designed as a problem, intervention, comparison, and outcome question. We anticipated that reduction in alert fatigue, including the concept of desensitization may not be directly measured and thus considered interventions that reduced alert quantity as a surrogate marker for alert fatigue. Twenty-six articles met the inclusion criteria.

Conclusion : Approaches for managing alert fatigue in the ICU are provided as a result of reviewing tested interventions that reduced alert quantity with the anticipated effect of reducing fatigue. Suggested alert management strategies include prioritizing alerts, developing sophisticated alerts, customizing commercially available alerts, and including end user opinion in alert selection. Alert fatigue itself is studied less frequently, as an outcome, and there is a need for more precise evaluation. Standardized metrics for alert fatigue is needed to advance the field. Suggestions for standardized metrics are provided in this document.

Conclusion (proposition de traduction) : Les approches de gestion de la fatigue occasionnées par les alarmes dans l'USI sont fournies à la suite de l'examen d'interventions testées qui ont réduit la quantité d'alarmes avec l'effet escompté pour réduire la fatigue. Les stratégies de gestion des alarmes suggérées comprennent la hiérarchisation des alarmes, l'élaboration d'alarmes sophistiquées, la personnalisation des alarmes disponibles dans le commerce et l'inclusion de l'opinion de l'utilisateur final dans la sélection des alarmes. La fatigue occasionnée par les alarmes elle-même est moins souvent étudiée, en tant que résultat, et il est nécessaire de procéder à une évaluation plus précise. Des mesures normalisées de la fatigue occasionnée par les alarmes sont nécessaires pour faire progresser le domaine. Des suggestions de mesures normalisées sont fournies dans ce document.

JAMA Internal Medicine

Comparison of Early versus Late Orthostatic Hypotension Assessment Times in Middle-Age Adults.
Juraschek SP , Daya N, Rawlings AM, Appel LJ, Miller ER III, Windham BG, Griswold ME, Heiss G, Selvin E. | JAMA Intern Med. 2017 Sep 1;177(9):1316-1323
DOI:  | Télécharger l'article au format  
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Original Investigation

Introduction : Importance: Guidelines recommend assessing orthostatic hypotension (OH) 3 minutes after rising from supine to standing positions. It is not known whether measurements performed immediately after standing predict adverse events as strongly as measurements performed closer to 3 minutes.
Objective: To compare early versus later OH measurements and their association with history of dizziness and longitudinal adverse outcomes.

Méthode : Design, Setting, and Participants: Middle-aged (range 44 to 66 years) participants in the Atherosclerosis Risk in Communities Study (1987–1989).
Exposures: OH, defined as a drop in blood pressure (systolic ≥20 mmHg or diastolic ≥10 mmHg) from the supine to standing position, was measured up to five times at 25 seconds intervals.
Main Outcomes and Measures: We determined the association of each of the five OH measurements with history of dizziness upon standing (logistic regression) and risk of fall, fracture, syncope, motor vehicle accidents, and all-cause mortality (Cox regression) over a median of 23 years of follow-up (through December 31, 2013).

Résultats : In 11 429 participants (mean age, 54 years; 6220 [54%] were women; 2934 [26%] were black) with at least 4 OH measurements after standing, after adjustment OH assessed at measurement 1 (mean [SD], 28 [5.4] seconds; range, 21-62 seconds) was the only measurement associated with higher odds of dizziness (odds ratio [OR], 1.49; 95% CI, 1.18-1.89). Measurement 1 was associated with the highest rates of fracture, syncope, and death at 18.9, 17.0, and 31.4 per 1000 person-years. Measurement 2 was associated with the highest rate of falls and motor vehicle crashes at 13.2 and 2.5 per 1000 person-years. Furthermore, after adjustment measurement 1 was significantly associated with risk of fall (hazard ratio [HR], 1.22; 95% CI, 1.03-1.44), fracture (HR, 1.16; 95% CI, 1.01-1.34), syncope (HR, 1.40; 95% CI, 1.20-1.63), and mortality (HR, 1.36; 95% CI, 1.23-1.51). Measurement 2 (mean [SD], 53 [7.5] seconds; range, 43-83 seconds) was associated with all long-term outcomes, including motor vehicle crashes (HR, 1.43; 95% CI, 1.04-1.96). Measurements obtained after 1 minute were not associated with dizziness and were inconsistently associated with individual long-term outcomes.

Conclusion : In contrast to prevailing recommendations, OH measurements performed within 1 minute of standing were the most strongly related to dizziness and individual adverse outcomes, suggesting that OH be assessed within 1 minute of standing.

Conclusion (proposition de traduction) : Contrairement aux recommandations en vigueur, les mesures d'hypotension orthostatique effectuées sur 1 minute de repos étaient les plus fortement liées aux étourdissements et aux résultats indésirables individuels, suggérant que l'hypotension orthostatique soit évalué dans la minute suivant le repos.

Commentaire : Pour rappel, le test de Shellong, recherche d’une hypotension orthostatique, se fait en mesurant la pression artérielle et le pouls dans les conditions suivantes :
- au repos, puis après un lever rapide sur 3 minutes, avec des mesures tensionnelles et de fréquence à 0, 1 et 3 minutes ;
- ou bien sur 10 minutes avec des mesures à 0, 2, 4, 6, 8 et 10 minutes.
Le diagnostic est positif si la pression artérielle systolique chute de plus de 20 mmHg dans les 3 minutes suivant le lever, qu’il y ait ou non des signes cliniques ou que la pression artérielle diastolique chute de plus de 10 mmHg dans les 3 minutes suivant le lever, qu’il y ait ou non des signes cliniques. Bien sûr, c’est sur un test de trois minutes.
Pour ce qui est de la mesure de la fréquence cardiaque, elle est faite pour aider à déterminer la cause ; en particulier la survenue d’une bradycardie est en faveur d’une origine vagale, une accélération notable de la fréquence cardiaque sans baisse tensionnelle peut être en rapport avec un syndrome de tachycardie orthostatique posturale.
L’objectif de cette étude de cohorte prospective était de déterminer l’association entre une version plus courte du test de Shellong, c’est-à-dire 5 mesures pendant 2 minutes, et le risque de survenue d’effets secondaires ou d’événements secondaires comme la survenue de chutes, de fractures, de syncopes, d’accidents de voiture ou de décès durant 23 ans de suivi médian.

Journal of the American Medical Association

Medical Students Fall Short on Blood Pressure Check Challenge.
Abbasi J | JAMA. 2017 Sep 19;318(11):991-992
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Medical News & Perspectives

Editorial : Athird of US adults have hypertension, a major risk factor for heart disease, which is the leading cause of death in the country. Additionally, more than a quarter of the population has higher than normal blood pressure (BP), or prehypertension. With stats like that, one might assume checking BP would be at the top of the list of medical student proficiencies. Yet a recent report suggests otherwise. Only 1 out of 159 medical students correctly performed all 11 elements in a BP check challenge with simulated patients, and the average number of steps performed properly was an abysmal.

Conclusion : -

Le Praticien en Anesthésie Réanimation

Fuchs-Buder T , Schmartz D. | Prat Anesth Reanim. 2017 Septembre;21(4):212-215
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Rubrique pratique

Editorial : Les curares permettent d’améliorer les conditions d’intubation et d’intervention de façon significative. Leur usage comporte des risques comme celui lié à la curarisation résiduelle qui peut conduire à des complications respiratoires. Pour éviter ce risque, il est nécessaire de monitorer systématiquement la curarisation avec des moniteurs quantitatifs et d’antagoniser les patients ayant un rapport T4/T1 < 0,9.

Conclusion : -

The New England Journal of Medicine

Oxygen Therapy in Suspected Acute Myocardial Infarction.
Hofmann R , and al; DETO2X–SWEDEHEART Investigators.. | N Engl J Med. 2017 Sep 28;377(13):1240-1249
Keywords: Aucun

Original article

Introduction : The clinical effect of routine oxygen therapy in patients with suspected acute myocardial infarction who do not have hypoxemia at baseline is uncertain.

Méthode : In this registry-based randomized clinical trial, we used nationwide Swedish registries for patient enrollment and data collection. Patients with suspected myocardial infarction and an oxygen saturation of 90% or higher were randomly assigned to receive either supplemental oxygen (6 liters per minute for 6 to 12 hours, delivered through an open face mask) or ambient air.

Résultats : A total of 6629 patients were enrolled. The median duration of oxygen therapy was 11.6 hours, and the median oxygen saturation at the end of the treatment period was 99% among patients assigned to oxygen and 97% among patients assigned to ambient air. Hypoxemia developed in 62 patients (1.9%) in the oxygen group, as compared with 254 patients (7.7%) in the ambient-air group. The median of the highest troponin level during hospitalization was 946.5 ng per liter in the oxygen group and 983.0 ng per liter in the ambient-air group. The primary end point of death from any cause within 1 year after randomization occurred in 5.0% of patients (166 of 3311) assigned to oxygen and in 5.1% of patients (168 of 3318) assigned to ambient air (hazard ratio, 0.97; 95% confidence interval [CI], 0.79 to 1.21; P=0.80). Rehospitalization with myocardial infarction within 1 year occurred in 126 patients (3.8%) assigned to oxygen and in 111 patients (3.3%) assigned to ambient air (hazard ratio, 1.13; 95% CI, 0.88 to 1.46; P=0.33). The results were consistent across all predefined subgroups.

Conclusion : Routine use of supplemental oxygen in patients with suspected myocardial infarction who did not have hypoxemia was not found to reduce 1-year all-cause mortality.

Conclusion (proposition de traduction) : L'utilisation systématique d'oxygène de confort chez les patients présentant une suspicion d'infarctus du myocarde qui ne présentent pas d'hypoxémie n'a pas permis de réduire la mortalité toutes causes confondues à un an.

Commentaire : Voir l'Interêt de l'oxygénothérapie en cas de suspicion d'infarctus du myocarde   par Mariama Akodad le mardi 12 septembre 2017.