Bibliographie de Médecine d'Urgence

Mois d'octobre 2017

American Journal of Emergency Medicine

A prospective study of ketamine as primary therapy for prehospital profound agitation.
Cole JB, Klein LR, Nystrom PC, Moore JC, Driver BE, Fryza BJ, Harrington J, Ho JD. | Am J Emerg Med. 2017 Oct 7. pii: S0735-6757(17)30820-3
DOI: https://doi.org/10.1016/j.ajem.2017.10.022
Keywords: Agitation; EMS; Excited delirium syndrome; Intubation; Ketamine; Sedation

Original article

Introduction : We investigated the effectiveness of ketamine as a primary therapy for prehospital profound agitation.

Méthode : This was a prospective observational study of patients receiving 5mg/kg of intramuscular ketamine for profound agitation, defined as a score of +4 on the Altered Mental Status Scale (AMSS), a validated ordinal scale of agitation from -4 (unresponsive) to +4 (most agitated). The primary outcome was time to adequate sedation (AMSS<+1). Secondary outcomes included need for additional sedatives, intubation frequency, complications associated with ketamine, and mortality.

Résultats : Forty-nine patients were enrolled. Median age was 29years (range 18-66); 76% (37/49) were male. Median time to adequate sedation was 4.2min (95% CI: 2.5-5.9, range 1-25min) and 90% (44/49) had adequate sedation prehospital. Seven patients (14%) received a second sedative prehospital. Intubation occurred in 57% (28/49) of patients. Mechanical ventilation lasted <24h in 82% (23/28) of patients, and <48h in 96% (27/28) of patients. A single physician intubated 36% (10/28) of the patients. Complications related to ketamine included hypersalivation (n=9, 18%), vomiting (n=3, 6%), and emergence reaction (n=2, 4%). One patient died from complications of septic shock on hospital day 29, likely unrelated to ketamine.

Conclusion : In patients with prehospital profound agitation, ketamine provides rapid effective sedation when used as a primary therapy. Intubation was common but accompanied by a short duration of mechanical ventilation and appears to have been subject to individual physician practice variation.

Conclusion (proposition de traduction) : Chez les patients en été d'agitation majeure en préhospitalier, la kétamine permet une sédation efficace et rapide lorsqu'elle est utilisée en première intention.
Le besoin d'intubation était fréquente mais accompagnée d'une courte ventilation mécanique et semble avoir été sujette à des variations individuelles de la pratique médicale.

Commentaire : 57 % des patients intubé pour une agitation !

Annals of Emergency Medicine

High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Emergency Department Patients With Cardiogenic Pulmonary Edema: A Randomized Controlled Trial.
Makdee O, Monsomboon A, Surabenjawong U, Praphruetkit N, Chaisirin W, Chakorn T, Permpikul C, Thiravit P, Nakornchai T. | Ann Emerg Med. 2017 Oct;70(4):465-472.e2
DOI: https://doi.org/10.1016/j.annemergmed.2017.03.028
Keywords: Aucun

Original research

Introduction : High-flow nasal cannula is a new method for delivering high-flow supplemental oxygen for victims of respiratory failure. This randomized controlled trial compares high-flow nasal cannula with conventional oxygen therapy in emergency department (ED) patients with cardiogenic pulmonary edema.

Méthode : We conducted an open-label randomized controlled trial in the ED of Siriraj Hospital, Bangkok, Thailand. Patients aged 18 years or older with cardiogenic pulmonary edema were randomly assigned to receive either conventional oxygen therapy or high-flow nasal cannula. The primary outcome was the respiratory rate 60 minutes postintervention.

Résultats : We enrolled 128 participants (65 in the conventional oxygen therapy and 63 in the high-flow nasal cannula groups). Baseline high-flow nasal cannula and conventional oxygen therapy mean respiratory rates were 28.7 breaths/min (SD 3.2) and 28.6 breaths/min (SD 3.5). Mean respiratory rates at 60 minutes postintervention were lower in the high-flow nasal cannula group (21.8 versus 25.1 breaths/min; difference 3.3; 95% confidence interval 1.9 to 4.6). No significant differences were found in the admission rate, ED and hospital lengths of stay, noninvasive ventilation, intubation, or mortality.

Conclusion : In patients with cardiogenic pulmonary edema in the ED, high-flow nasal cannula therapy may decrease the severity of dyspnea during the first hour of treatment.

Conclusion (proposition de traduction) : Chez des patients présentant un œdème pulmonaire cardiogénique aux urgences, l'utilisation de l'oxygénothérapie à haut débit peut diminuer la gravité de la dyspnée pendant la première heure du traitement.

The Journal of the American Medical Association

Effect of an Early Resuscitation Protocol on In-hospital Mortality Among Adults With Sepsis and Hypotension: A Randomized Clinical Trial.
Andrews B, Semler MW, Muchemwa L, Kelly P, Lakhi S, Heimburger DC, Mabula C, Bwalya M, Bernard GR. | JAMA. 2017 Oct 3;318(13):1233-1240
DOI: https://doi.org/10.1001/jama.2017.10913  | Télécharger l'article au format  
Keywords: Aucun

Original investigation

Introduction : The effect of an early resuscitation protocol on sepsis outcomes in developing countries remains unknown.
OBJECTIVE: To determine whether an early resuscitation protocol with administration of intravenous fluids, vasopressors, and blood transfusion decreases mortality among Zambian adults with sepsis and hypotension compared with usual care.

Méthode : Randomized clinical trial of 212 adults with sepsis (suspected infection plus ≥2 systemic inflammatory response syndrome criteria) and hypotension (systolic blood pressure ≤90 mm Hg or mean arterial pressure ≤65 mm Hg) presenting to the emergency department at a 1500-bed referral hospital in Zambia between October 22, 2012, and November 11, 2013. Data collection concluded December 9, 2013.
INTERVENTIONS: Patients were randomized 1:1 to either (1) an early resuscitation protocol for sepsis (n = 107) that included intravenous fluid bolus administration with monitoring of jugular venous pressure, respiratory rate, and arterial oxygen saturation and treatment with vasopressors targeting mean arterial pressure (≥65 mm Hg) and blood transfusion (for patients with a hemoglobin level <7 g/dL) or (2) usual care (n = 105) in which treating clinicians determined hemodynamic management.
MAIN OUTCOMES AND MEASURES: The primary outcome was in-hospital mortality and the secondary outcomes included the volume of intravenous fluid received and receipt of vasopressors.

Résultats : Among 212 patients randomized to receive either the sepsis protocol or usual care, 3 were ineligible and the remaining 209 completed the study and were included in the analysis (mean [SD] age, 36.7 [12.4] years; 117 men [56.0%]; 187 [89.5%] positive for the human immunodeficiency virus). The primary outcome of in-hospital mortality occurred in 51 of 106 patients (48.1%) in the sepsis protocol group compared with 34 of 103 patients (33.0%) in the usual care group (between-group difference, 15.1% [95% CI, 2.0%-28.3%]; relative risk, 1.46 [95% CI, 1.04-2.05]; P = .03). In the 6 hours after presentation to the emergency department, patients in the sepsis protocol group received a median of 3.5 L (interquartile range, 2.7-4.0 L) of intravenous fluid compared with 2.0 L (interquartile range, 1.0-2.5 L) in the usual care group (mean difference, 1.2 L [95% CI, 1.0-1.5 L]; P < .001). Fifteen patients (14.2%) in the sepsis protocol group and 2 patients (1.9%) in the usual care group received vasopressors (between-group difference, 12.3% [95% CI, 5.1%-19.4%]; P < .001).

Conclusion : Among adults with sepsis and hypotension, most of whom were positive for HIV, in a resource-limited setting, a protocol for early resuscitation with administration of intravenous fluids and vasopressors increased in-hospital mortality compared with usual care. Further studies are needed to understand the effects of administration of intravenous fluid boluses and vasopressors in patients with sepsis across different low- and middle-income clinical settings and patient populations.

Conclusion (proposition de traduction) : Parmi les adultes atteints de sepsis et d'hypotension, dont la plupart étaient séropositifs au VIH, dans un contexte de ressources limitées, un protocole de réanimation précoce avec administration de liquides intraveineux et de vasopresseurs augmentait la mortalité à l'hôpital par rapport aux soins habituels. Des études complémentaires sont nécessaires pour comprendre les effets de l'administration de bolus de liquide et de vasopresseurs par voie intraveineuse chez les patients atteints de sepsie dans différents contextes cliniques et groupes de patients à revenus faibles et moyens.

Commentaire : Voir l'analyse de l'article sur le site de la SRLF : Protocole de réanimation hémodynamique précoce du sepsis : le mieux est le mortel ennemi du bien  . Commenté par le Pr. Armand Mekontso Dessap, Réanimation médicale, AP-HP, CHU Henri Mondor, Créteil, France. Publié le 02/05/2019.