Adverse Events With Ketamine Versus Ketofol for Procedural Sedation on Adults: A Double-blind, Randomized Controlled Trial.
Lemoel F , Contenti J, Giolito D, Boiffier M, Rapp J, Istria J, Fournier M, Ageron FX, Levraut J. | Acad Emerg Med. 2017 Dec;24(12):1441-1449
Introduction : The goal of our study was to compare the frequency and severity of recovery reactions between ketamine and ketamine-propofol 1:1 admixture (“ketofol”).
Méthode : We performed a multicentric, randomized, double-blind trial in which adult patients received emergency procedural sedations with ketamine or ketofol. Our primary outcome was the proportion of unpleasant recovery reactions. Other outcomes were frequency of interventions required by these recovery reactions, rates of respiratory or hemodynamic events, emesis, and satisfaction of patients as well as providers.
Résultats : A total of 152 patients completed the study, 76 in each arm. Compared with ketamine, ketofol determined a 22% reduction in recovery reactions incidence (p < 0.01) and less clinical and pharmacologic interventions required by these reactions. There was no serious adverse event in both groups. Rates in hemodynamic or respiratory events as well as satisfaction scores were similar. Significantly fewer patients experienced emesis with ketofol, with a threefold reduction in incidence compared with ketamine.
Conclusion : We found a significant reduction in recovery reactions and emesis frequencies among adult patients receiving emergency procedural sedations with ketofol, compared with ketamine.
Conclusion (proposition de traduction) : Nous avons constaté une réduction significative de la fréquence des réactions de réveil et des vomissements chez les patients adultes recevant une sédation en urgence avec du kétofol, comparativement à la kétamine.
Early initiation of low-dose hydrocortisone treatment for septic shock in adults: A randomized clinical trial.
Lv QQ , Gu XH, Chen QH, Yu JQ, Zheng RQ.. | Am J Emerg Med. 2017 Dec;35(12):1810-1814
Keywords: Hydrocortisone; Mortality; Septic shock
Introduction : Physiologic dose hydrocortisone is part of the suggested adjuvant therapies for patients with septic shock. However, the association between the corticosteroid therapy and mortality in patients with septic shock is still not clear. Some authors considered that the mortality is related to the time frame between development of septic shock and start of low dose hydrocortisone. Thus we designed a placebo-controlled, randomized clinical trial to assess the importance of early initiation of low dose hydrocortisone for the final outcome.
Méthode : A total of 118 patients with septic shock were recruited in the study. All eligible patients were randomized to receive hydrocortisone (n = 58) or normal saline (n = 60). The study medication (hydrocortisone and normal saline) was initiated simultaneously with vasopressors. The primary end-point was 28-day mortality. The secondary end-points were the reversal of shock, in-hospital mortality and the duration of ICU and hospital stay.
Résultats : The proportion of patients with reversal of shock was similar in the two groups (P = 0.602); There were no significant differences in 28-day or hospital all-cause mortality; length of stay in the ICU or hospital between patients treated with hydrocortisone or normal saline.
Conclusion : The early initiation of low-dose of hydrocortisone did not decrease the risk of mortality, and the length of stay in the ICU or hospital in adults with septic shock.
Conclusion (proposition de traduction) : L'initiation précoce d'une faible dose d'hydrocortisone n'a pas diminué le risque de mortalité et la durée de séjour en soins intensifs ou à l'hôpital chez les adultes présentant un choc septique.
Commentaire : Encore une étude qui confirme l'absence de bénéfice des corticoïdes dans le sepsis
The impact of the BLUE protocol ultrasonography on the time taken to treat acute respiratory distress in the ED.
Seyedhosseini J , Bashizadeh-Fakhar G, Farzaneh S, Momeni M, Karimialavijeh E. | Am J Emerg Med. 2017 Dec;35(12):1815-1818
DOI: https://dx.doi.org/10.1016/j.ajem.2017.06.007 | Télécharger l'article au format
Keywords: Acute dyspnea; BLUE protocol; Time-to-treatment; Ultrasound
Editorial : Respiratory distress is one of the most common complaints in the emergency department (ED). In extreme scenarios, during which respiratory distress becomes respiratory failure, the survival of the patients will significantly drop. For instance, a recent cohort study showed that the mortality rate among hospitalized patients with respiratory distress was as much as 10%.
Conclusion : Our findings showed that utilizing the BLUE protocol in cases of acute respiratory distress in the ED will significantly shorten the time taken to manage patients and decrease the gap in delivering definite therapies.
Conclusion (proposition de traduction) : Nos résultats ont montré que l'utilisation du protocole BLEU dans les cas de détresse respiratoire aiguë aux urgences a raccourci considérablement le temps nécessaire pour prendre en charge les patients et réduire l'écart dans la mise en place des traitements nécessaires.
Commentaire : Cette publication confirme la place de l'échographie dans le diagnostic étiologique d'une décompensation respiratoire aigüe aux urgences. A noter : Bedside Lung Ultrasound in Emergency (BLUE) protocol.
The Revised Trauma Score plus serum albumin level improves the prediction of mortality in trauma patients.
Kim SC , Kim DH, Kim TY, Kang C, Lee SH, Jeong JH, Park YJ, Lee SB, Lim D. | Am J Emerg Med. 2017 Dec;35(12):1882-1886
Keywords: Albumin; Mortality; Revised Trauma Score; The emergency trauma score; Trauma and Injury Severity Score
Introduction : The Revised Trauma Score (RTS) is used worldwide in prehospital practice and in the emergency department (ED) settings to triage trauma patients. The main purpose of this study was to evaluate the value of the RTS plus serum albumin (RTS-A) and to compare it with other existing trauma scores as well as to compare the predictive performance of the Trauma and Injury Severity Score with the RTS-A (TRISS-A) with the original TRISS.
Méthode : This was a single center, trauma registry based observational cohort study. Data were collected from consecutive patients with blunt or penetrating injuries who presented to the emergency department of a tertiary referral hospital, between January 2012 and June 2016. 3145 and 2447 patients were assigned to the derivation group and validation group, respectively. Main outcome was in-hospital mortality.
Résultats : Among patients in the derivation group, the median [interquartile range] age was 59 [43–73] years, and 66.7% were male. The area under the receiver operating characteristic curves (AUC) of the RTS-A (0.948; 95% CI: 0.939–0.955) was higher than that of the RTS (0.919; 95% CI: 0.909–0.929). In patients with blunt trauma, the AUC of the TRISS-A (0.960; 95% CI: 0.952–0.967) was significantly higher than that of the original TRISS (0.949; 95% CI: 0.941–0.957).
Conclusion : The value of the RTS-A predicts the in-hospital mortality of trauma patients better than the RTS, and the TRISS-A is a better mortality predictor compared to the original TRISS in patients with blunt trauma.
Conclusion (proposition de traduction) : La valeur du RTS-A prédit mieux la mortalité à l'hôpital des patients traumatisés que le RTS, et le TRISS-A est un meilleur prédicteur de la mortalité par rapport au TRISS initial chez les patients présentant un traumatisme contondant.
Fifty Years of Research in ARDS. Vt Selection in Acute Respiratory Distress Syndrome..
Sahetya SK , Mancebo J, Brower RG. | Am J Respir Crit Care Med. 2017 Dec 15;196(12):1519-1525
Keywords: acute respiratory distress syndrome; mechanical ventilation; tidal volume
Concise Clinical Review
Editorial : Mechanical ventilation (MV) is critical in the management of many patients with acute respiratory distress syndrome (ARDS). However, MV can also cause ventilator-induced lung injury (VILI). The selection of an appropriate Vt is an essential part of a lung-protective MV strategy. Since the publication of a large randomized clinical trial demonstrating the benefit of lower Vts, the use of Vts of 6 ml/kg predicted body weight (based on sex and height) has been recommended in clinical practice guidelines. However, the predicted body weight approach is imperfect in patients with ARDS because the amount of aerated lung varies considerably due to differences in inflammation, consolidation, flooding, and atelectasis. Better approaches to setting Vt may include limits on end-inspiratory transpulmonary pressure, lung strain, and driving pressure. The limits of lowering Vt have not yet been established, and some patients may benefit from Vts that are lower than those in current use. However, lowering Vts may result in respiratory acidosis. Tactics to reduce respiratory acidosis include reductions in ventilation circuit dead space, increases in respiratory rate, higher positive end-expiratory pressures in patients who recruit lung in response to positive end-expiratory pressure, recruitment maneuvers, and prone positioning. Mechanical adjuncts such as extracorporeal carbon dioxide removal may be useful to normalize pH and carbon dioxide levels, but further studies will be necessary to demonstrate benefit with this technology.
Conclusion : The optimal method for setting VT for patients with ARDS remains unknown. The use of smaller VTs has been accepted by many since the publication of the National Institutes of Health ARDS Network study (15, 60). However, some patients remain at risk for overdistention injury even when small VTs are used, because their aerated lung volumes are greatly reduced (20, 25). As PBW does not correlate well with aerated lung volume, better approaches to setting VT may involve limiting lung stress, strain, or driving pressure as potential surrogates for VILI from parenchymal overdistention injury. Whatever method is initially used, for patients with moderate to severe ARDS or more severely impaired respiratory mechanics, we suggest the careful, continued further reduction of VT in a stepwise manner until a patient begins to exhibit physiologic signs of intolerance or the DP or Pplat is in a safer range (Table 1). As is frequently the case, this intervention will have competing effects that must be balanced on a patient-by-patient basis. Higher levels of PEEP may be necessary to prevent atelectasis that may result from the smaller VTs. However, higher PEEP may cause overdistention or hemodynamic instability (61). The need for strict control of PaCO2, as in intracranial hypertension, may outweigh the need to lower VT to protect the lung. Nevertheless, we recommend keeping VT at the lowest possible value as dictated by patient tolerance and appropriateness of respiratory mechanics, gas exc
Conclusion (proposition de traduction) : La méthode optimale de réglage du volume courant pour les patients atteints du syndrome de détresse respiratoire aiguë reste inconnue. L'utilisation de plus petits volumes courant a été génréalement validée depuis la publication de l'étude du National Institutes of Health sur le syndrome de détresse respiratoire aiguë. Cependant, certains patients demeurent à risque de barotraumatisme même lorsqu'on utilise de petits volumes courant, parce que leur volume pulmonaire résiduel est grandement réduit. Comme le poids corporel prévu ne correspond pas bien au volume pulmonaire résiduel, de meilleures approches pour établir le volume couran tpeuvent impliquer de limiter le stress pulmonaire, la tension ou la pression de ventilation en tant que substituts potentiels pour les lésions pulmonaires induites par la ventilation à la suite d'une blessure de surdistension parenchymateuse. Quelle que soit la méthode utilisée au départ, pour les patients présentant un syndrome de détresse respiratoire aiguë modérée à sévère ou des troubles respiratoires plus graves, nous suggérons une réduction continue et prudente du volume courant jusqu'à ce qu'un patient commence à présenter des signes physiologiques d'intolérance ou que la pression de pointe ou le plateau de Pression se situedans une plage plus sûre. Comme c'est souvent le cas, cette intervention aura des effets secondaires qui doivent être équilibrés au cas par cas. Des niveaux plus élevés de PEP peuvent être nécessaires pour prévenir l'atélectasie qui peut résulter des plus petits volumes courant. Cependant, une PEEP plus élevée peut causer une distension excessive ou une instabilité hémodynamique. La nécessité d'un contrôle strict de la PaCO2, comme dans le cas de l'hypertension intracrânienne, peut l'emporter sur la nécessité de réduire le volume courant pour protéger les poumons. Néanmoins, nous recommandons de maintenir le volume courant au niveau le plus bas possible en fonction de la tolérance du patient et de l'adéquation de la mécanique respiratoire, de l'échange gazeux et des paramètres hémodynamiques. Comme la technologie de l'élimination extracorporelle du dioxyde de carbone continue d'évoluer, les limites de la ventilation minute avec un faible volume courant comme stratégie de protection des poumons devraient continuer d'être testées. D'autres études sont nécessaires pour déterminer si le fait de repousser les limites de la réduction du volume courant améliorera les résultats cliniques.
A comparison of balanced and unbalanced crystalloid solutions in surgery patient outcomes.
Kuca T , Butler MB, Erdogan M, Green RS. | Anaesth Crit Care Pain Med. 2017 Dec;36(6):371-376
Keywords: Balanced; Crystalloid; Intravenous; Outcome; Saline; Vascular
Introduction : The objective of this study was to evaluate adverse patient outcomes associated with the choice of intravenous fluid administered during general anaesthesia.
Méthode : This study was a retrospective chart review of vascular surgery patients at a Canadian tertiary care hospital. Patients were separated into three groups: those who were intraoperatively administered normal saline (NS), balanced crystalloids, or a combination of both solutions. Multivariate analysis was performed to determine association between volume of each fluid type administered and adverse outcomes including in-hospital mortality, prolonged intensive care unit admission, vasopressor requirement, ventilator requirement, hemodialysis requirement, and a composite endpoint of any of these adverse events occurring.
Résultats : Overall, 796 vascular surgery patients were included in the analysis. There were 425 patients who received balanced crystalloids, 158 patients who received NS, and 213 patients received both balanced crystalloids and NS. Groups were similar in age (P=0.06), but varied in gender (P<0.001) and overall health (ASA≥2; P=0.027). The most common adverse event was ventilator requirement (NS: 27.9%, balanced: 7.5%, both: 38.0%; P<0.001). Mortality was lowest in the group that received balanced fluids (NS: 12.0%, balanced: 5.9%, both: 10.8%; P=0.018). Patients who were administered NS or both fluids were more likely to reach the composite endpoint than patients receiving balanced crystalloid alone.
Conclusion : The administration of an unbalanced crystalloid solution was associated with poor patient outcomes in our study population.
Conclusion (proposition de traduction) : L'administration d'une solution cristalloïde non balancée était associée à de mauvais résultats chez les patients de notre étude.
Commentaire : Confirme l'intérêt des cristalloïdes balancés
The clinical impact and prevalence of emergency point-of-care ultrasound: A prospective multicenter study.
Bobbia X , Zieleskiewicz L, Pradeilles C, Hudson C, Muller L, Claret PG, Leone M, de La Coussaye JE; Winfocus France Group. | Anaesth Crit Care Pain Med. 2017 Dec;36(6):383-389
Keywords: Emergency medicine; Point-of-care systems; Ultrasonography
Introduction : The main objectives of our study were to evaluate the prevalence of emergency point-of-care ultrasound (POCUS) use and to assess the impact of POCUS on: diagnostic, therapeutic, patient orientation and imaging practices.
Méthode : This was a one-day, prospective, observational study carried out across multiple centers. Fifty emergency departments (EDs) recorded all POCUS performed over a 24h period. The prevalence of POCUS was defined as the number of POCUS/number of patients seen in all units. The “diagnostic impact” was defined as a POCUS-induced confirmation or change to the initial clinical diagnosis. The “therapeutic impact” was defined as a POCUS-induced change in treatment. The “orientation impact” was defined as an ultrasound-induced confirmation or change in the initial orientation. The “imaging change” was defined as a radiologic imaging prescription modification.
Résultats : Two hundred and twenty-nine (5%) POCUS were performed on 192 patients (4%) from among the 4671 patients seen on the study day in the 50 EDs. No ultrasound procedural guidance was given during the study day. The diagnostic, therapeutic and orientation impacts were respectively 82%, 47% and 85%. In 101 cases (44%), POCUS led to at least one imaging change. The clinical value of POCUS, i.e. considering at least one impact and/or imaging change, was assessed at 95%.
Conclusion : This study shows that POCUS is used on a minority of emergency patients. However, when used, it significantly affects diagnostic and therapeutic practices in the emergency setting.
Conclusion (proposition de traduction) : Cette étude montre que l'échographie au point d'intervention est utilisé sur une minorité de patients des urgences. Cependant, lorsqu'il est utilisé, il modifie significativement les pratiques diagnostiques et thérapeutiques dans les situations d'urgence.
Editorial : À partir de ce numéro des Annales Françaises de Médecine d’Urgence, le Cochrane PEC publiera désormais régulièrement un nouveau format de connaissance adapté à votre pratique : les Practical Evidence About Real Life Situations (PEARLS).
Conclusion : -
Conclusion (proposition de traduction) : -
Commentaire : A suivre…
, L. Aigle et C. Landy. | Ann Fr Med Urgence. 2017 Dec;7:375-382
Introduction : En mission extérieure, l’activité du médecin généraliste militaire (MGM) se partage entre les soins de premier recours et la prise en charge des blessés de guerre. Des techniques d’anesthésie locorégionale (ALR) peuvent être utiles dans ces deux cas. L’objectif principal de l’étude était de faire l’état des lieux sur l’utilisation de l’ALR par les MGM et de dépister les facteurs limitant la pratique.
Méthode : Une étude observationnelle multicentrique a été réalisée sur la base d’un questionnaire portant sur l’expérience, la formation et la pratique de l’ALR lors de la dernière mission extérieure. Étaient inclus les MGM d’active exerçant en France métropolitaine et ayant réalisé au moins une mission extérieure.
Résultats : Durant leur dernière mission extérieure, 23 % des praticiens avaient réalisé au moins un geste d’ALR, concernant moins de cinq patients dans 92 % des cas, sans aide au guidage dans 97 % des cas. Parmi tous les répondants, 22 % estimaient que des gestes d’ALR auraient pu être réalisés, mais ne l’ont pas été par manque de maîtrise des techniques (38 %), de matériel (20 %), de temps (15 %) ou de conditions d’hygiène (12 %). Aucun facteur étudié n’était statistiquement associé à une pratique plus importante de l’ALR.
Conclusion (proposition de traduction) : Le faible taux de pratique de l’ALR est probablement multifactoriel. Les facteurs environnementaux, le manque de maîtrise des gestes et le recrutement semblent être les éléments principaux. Le développement de ces techniques doit passer par une formation adaptée aux conditions opérationnelles. L’utilisation de l’échographie est envisageable dans ce cadre et permettrait de sécuriser la pratique.
Commentaire : Les mêmes conclusions ont été faites lors du congrès FORUM de l'URGENCE pour l'activité des urgences
Posttraumatic Stress Disorder in Emergency Medicine Residents.
Vanyo L , Sorge R, Chen A, Lakoff D. | Ann Emerg Med. 2017 Dec;70(6):898-903
DOI: https://doi.org/10.1016/j.annemergmed.2017.07.010 | Télécharger l'article au format
Conclusion : Physicians are at higher risk for PTSD than nonphysicians. Emergency physicians in particular are exposed to trauma, violence, and death, beginning primarily in their residency training. The DSM-5 clearly delineates through the A4 exposure type that regularly witnessing patient illness, trauma, and death may cause PTSD. It is likely that unrecognized and untreated PTSD exists in emergency medicine resident physicians. The dangers of untreated PTSD affect physicians personally, with significantly higher rates of suicide, depression, anxiety, and burnout, and professionally, with increased errors and inefficiency.Overall, there are many ways the management of PTSD symptoms can be approached for emergency medicine residents. The first step is awareness; that is, to consider PTSD a diagnosis in addition to burnout or depression, and to allow a safe environment in which to provide help. The next step is to consider applying strategies based on the aforementioned research, both those specifically studied in physicians and in PTSD populations. A combination of preventive and treatment measures may be necessary. Residents should be aware of the symptoms of PTSD and take steps to address it should they see worrisome signs in themselves or their peers.
Conclusion (proposition de traduction) : Les médecins présentent un risque plus élevé de syndrome de trouble de stress post-traumatique que les non-médecins. Les médecins d’urgence en particulier sont exposés aux traumatismes, à la violence et à la mort, en commençant principalement par leur internat. Le DSM-5 délimite clairement à travers le type d'exposition A4 que l'observation régulière de la maladie, du traumatisme et de la mort du patient peut entraîner un syndrome de trouble de stress post-traumatique. Il est probable que le syndrome de trouble de stress post-traumatique non reconnu et non traité existe chez les internes en médecine d'urgence. Les dangers du syndrome de trouble de stress post-traumatique non traité affectent personnellement les médecins, avec des taux de suicide, de dépression, d'anxiété et d'épuisement professionnel significativement plus élevés, avec des erreurs et des inefficacités accrues.
La première étape est la prise de conscience; c'est-à-dire considérer le syndrome de trouble de stress post-traumatique comme un diagnostic en plus de l'épuisement professionnel ou de la dépression, et permettre un environnement sûr dans lequel fournir de l'aide.
L'étape suivante consiste à envisager d'appliquer des stratégies basées sur les recherches susmentionnées, à la fois celles spécifiquement étudiées chez les médecins et dans les populations souffrant de syndrome de trouble de stress post-traumatique. Une combinaison de mesures préventives et thérapeutiques peut être nécessaire. Les internes doivent être conscients des symptômes du syndrome de trouble de stress post-traumatique et prendre des mesures pour y remédier s'ils constatent des signes inquiétants chez eux ou chez leurs pairs.
Commentaire : Un problématique d'actualité !
Stormy weather: a retrospective analysis of demand for emergency medical services during epidemic thunderstorm asthma.
Andrew E , Nehme Z, Bernard S, Abramson MJ, Newbigin E, Piper B, Dunlop J, Holman P, Smith K. | BMJ. 2017 Dec 13;359:j5636
Introduction : To describe the demand for emergency medical assistance during the largest outbreak of thunderstorm asthma reported globally, which occurred on 21 November 2016.
Méthode : A time series analysis was conducted of emergency medical service caseload between 1 January 2015 and 31 December 2016. Demand during the thunderstorm asthma event was compared to historical trends for the overall population and across specific subgroups.
Résultats : On 21 November 2016, the emergency medical service received calls for 2954 cases, which was 1014 more cases than the average over the historical period. Between 6 pm and midnight, calls for 1326 cases were received, which was 2.5 times higher than expected. A total of 332 patients were assessed by paramedics as having acute respiratory distress on 21 November, compared with a daily average of 52 during the historical period. After adjustment for temporal trends, thunderstorm asthma was associated with a 42% (95% confidence interval 40% to 44%) increase in overall caseload for the emergency medical service and a 432% increase in emergency medical attendances for acute respiratory distress symptoms. Emergency transports to hospital increased by 17% (16% to 19%) and time critical referrals from general practitioners increased by 47% (21% to 80%). Large increases in demand were seen among patients with a history of asthma and bronchodilator use. The incidence of out-of-hospital cardiac arrest increased by 82% (67% to 99%) and pre-hospital deaths by 41% (29% to 55%).
Conclusion : An unprecedented outbreak of thunderstorm asthma was associated with substantial increase in demand for emergency medical services and pre-hospital cardiac arrest. The health impact of future events may be minimised through use of preventive measures by patients and predictive early warning systems.
Conclusion (proposition de traduction) : Une épidémie sans précédent d’asthme pendant un orage a été associée à une augmentation substantielle de la demande de soins médicaux d’urgence et d’arrêts cardiaques préhospitaliers. L'impact sur la santé des événements (météorologiques) futurs peut être minimisé en ayant recours à des mesures préventives pour les patients et par des systèmes prédictifs d'alerte précoce (de ces événements météorologiques).
Commentaire : Phénomène connu et décrit par d'autres auteurs en France. Notamment l'article de Denis Caillaud. Tempête et asthme. Revue Française d'Allergologie et d'Immunologie Clinique, January 2005;45:29-32 (https://doi.org/10.1016/j.allerg.2004.10.010)
The full moon and motorcycle related mortality: population based double control study.
Redelmeier DA , Shafir E. | BMJ. 2017 Dec 11;359:j5367
Introduction : To test whether a full moon contributes to motorcycle related deaths.
Méthode : Population based, individual level, double control, cross sectional analysis. Main outcome measure Motorcycle fatalities during a full moon.
Résultats : 13 029 motorcyclists were in fatal crashes during 1482 relevant nights. The typical motorcyclist was a middle aged man (mean age 32 years) riding a street motorcycle with a large engine in a rural location who experienced a head-on frontal impact and was not wearing a helmet. 4494 fatal crashes occurred on the 494 nights with a full moon (9.10/night) and 8535 on the 988 control nights without a full moon (8.64/night). Comparisons yielded a relative risk of 1.05 associated with the full moon (95% confidence interval 1.02 to 1.09, P=0.005), a conditional odds ratio of 1.26 (95% confidence interval 1.17 to 1.37, P<0.001), and an absolute increase of 226 additional deaths over the study interval. The increase extended to diverse types of motorcyclists, vehicles, and crashes; was accentuated during a supermoon; and replicated in analyses from the United Kingdom, Canada, and Australia.
Conclusion : The full moon is associated with an increased risk of fatal motorcycle crashes, although potential confounders cannot be excluded. An awareness of the risk might encourage motorcyclists to ride with extra care during a full moon and, more generally, to appreciate the power of seemingly minor distractions at all times.
Conclusion (proposition de traduction) : La pleine lune est associée à un risque accru d'accidents de la route mortels, bien que les facteurs de confusion potentiels ne puissent être exclus. Une prise de conscience du risque peut encourager les motocyclistes à faire preuve de prudence pendant la pleine lune et, plus généralement, à apprécier le pouvoir des distractions apparemment mineures à tout moment.
Commentaire : Comme le concluent les auteurs, peut-être y a-t-il des biais... sinon, les gardes de pleines lunes risquent d'être chargées !
Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis.
No authors listed | BMJ. 2017 Dec 4;359:j5631
DOI: https://doi.org/10.1136/bmj.j5631 | Télécharger l'article au format
Introduction : To compare the efficacy, safety, and cost effectiveness of direct acting oral anticoagulants (DOACs) for patients with atrial fibrillation.
Méthode : Systematic review, network meta-analysis, and cost effectiveness analysis.
Résultats : 23 randomised trials involving 94 656 patients were analysed: 13 compared a DOAC with warfarin dosed to achieve a target INR of 2.0-3.0. Apixaban 5 mg twice daily (odds ratio 0.79, 95% confidence interval 0.66 to 0.94), dabigatran 150 mg twice daily (0.65, 0.52 to 0.81), edoxaban 60 mg once daily (0.86, 0.74 to 1.01), and rivaroxaban 20 mg once daily (0.88, 0.74 to 1.03) reduced the risk of stroke or systemic embolism compared with warfarin. The risk of stroke or systemic embolism was higher with edoxaban 60 mg once daily (1.33, 1.02 to 1.75) and rivaroxaban 20 mg once daily (1.35, 1.03 to 1.78) than with dabigatran 150 mg twice daily. The risk of all-cause mortality was lower with all DOACs than with warfarin. Apixaban 5 mg twice daily (0.71, 0.61 to 0.81), dabigatran 110 mg twice daily (0.80, 0.69 to 0.93), edoxaban 30 mg once daily (0.46, 0.40 to 0.54), and edoxaban 60 mg once daily (0.78, 0.69 to 0.90) reduced the risk of major bleeding compared with warfarin. The risk of major bleeding was higher with dabigatran 150 mg twice daily than apixaban 5 mg twice daily (1.33, 1.09 to 1.62), rivaroxaban 20 mg twice daily than apixaban 5 mg twice daily (1.45, 1.19 to 1.78), and rivaroxaban 20 mg twice daily than edoxaban 60 mg once daily (1.31, 1.07 to 1.59). The risk of intracranial bleeding was substantially lower for most DOACs compared with warfarin, whereas the risk of gastrointestinal bleeding was higher with some DOACs than warfarin. Apixaban 5 mg twice daily was ranked the highest for most outcomes, and was cost effective compared with warfarin.
Conclusion : The network meta-analysis informs the choice of DOACs for prevention of stroke in patients with atrial fibrillation. Several DOACs are of net benefit compared with warfarin. A trial directly comparing DOACs would overcome the need for indirect comparisons to be made through network meta-analysis.
Conclusion (proposition de traduction) : La méta-analyse du réseau informe sur le choix des anticoagulants oraux directs (AOD) pour la prévention des accidents vasculaires cérébraux chez les patients présentant une fibrillation auriculaire. Plusieurs AOD présentent un avantage net par rapport à la warfarine. Un essai comparant directement les AOD permettrait de surmonter le besoin de faire des comparaisons indirectes par le biais d'une méta-analyse de réseau.
Commentaire : Méta-analyse qui va dans le sens des recommandations actuelles sur le traitement de la fibrillation atriale par les AOD (Anticoagulants Oraux Directs, ex NACO).
Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry .
Froehler MT , STRATIS Investigators. | Circulation. 2017 Dec 12;136(24):2311-2321
DOI: https://doi.org/10.1161/CIRCULATIONAHA.117.028920 | Télécharger l'article au format
ORIGINAL RESEARCH ARTICLE
Introduction : Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation.
Méthode : STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0-2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass.
Résultats : A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (P<0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06-1.79; P=0.02). Likewise, excellent outcome (modified Rankin Score 0-1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13-1.92; P=0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P=0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier.
Conclusion : In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes.
Conclusion (proposition de traduction) : Dans cette vaste étude en situation réelle, le transfert interhospitalier était associé à des retards importants dans le traitement et à un risque moindre de résultats positifs. Les stratégies visant à faciliter une identification plus rapide de l'occlusion des gros vaisseaux et l'acheminement direct vers les centres de traitement des maladies endovasculaires pour les patients ayant subi un AVC grave peuvent améliorer les résultats.
Commentaire : A confirmer, pour adapter nos pratiques régionale.
2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.
Olasveengen TM , ILCOR Collaborators. | Circulation. 2017 Dec;136:e424-e440
DOI: https://doi.org/10.1161/CIR.0000000000000541 | Télécharger l'article au format
CLINICAL STATEMENTS AND GUIDELINES
Editorial : The International Liaison Committee on Resuscitation has initiated a near-continuous review of cardiopulmonary resuscitation science that replaces the previous 5-year cyclic batch-and-queue approach process. This is the first of an annual series of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations summary articles that will include the cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation in the previous year. The review this year includes 5 basic life support and 1 pediatric Consensuses on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Each of these includes a summary of the science and its quality based on Grading of Recommendations, Assessment, Development, and Evaluation criteria and treatment recommendations. Insights into the deliberations of the International Liaison Committee on Resuscitation task force members are provided in Values and Preferences sections. Finally, the task force members have prioritized and listed the top 3 knowledge gaps for each population, intervention, comparator, and outcome question...
Conclusion : Guideline
Conclusion (proposition de traduction) : Recommandations
Commentaire : Mise à jour des recommandations de 2015 en ce qui concerne trois points : Adult and Pediatric Basic Life Support et Cardiopulmonary Resuscitation Quality...
Durability and Long-term Clinical Outcomes of Fecal Microbiota Transplant Treatment in Patients With Recurrent Clostridium difficile Infection.
Mamo Y , Woodworth MH, Wang T, Dhere T, Kraft CS. | Clin Infect Dis. 2017 Dec 19
Introduction : Fecal microbiota transplant (FMT) appears safe and effective for treatment of recurrent Clostridium difficile infection (RCDI). However, durability, long-term clinical outcomes of FMT for RCDI, and patient satisfaction after FMT are not well described.
Méthode : Eligible patients who received FMT for RCDI at Emory Hospital between July 1, 2012 and December 31, 2016 were contacted via telephone for a follow up survey. Of 190 eligible patients, 137 (72%) patients completed the survey.
Résultats : Median time from last FMT to follow up was 22 months. Overall, 82% (113/137) of patients at follow up had no recurrence of C. difficile infection (CDI) post-FMT (non-RCDI group) and 18% (24/137) of patients had CDI post-FMT (RCDI group). Antibiotic exposure for non-CDI infections after FMT was more common in the RCDI group compared to the non-RCDI group, 75% vs 38%, p=0.0009, respectively. Overall, 11% of patients reported improvement or resolution of diagnoses not related to CDI post-FMT and 33% reported development of a new medical condition or symptom post-FMT. Ninety-five percent of patients (122/128) indicated that they would undergo FMT again, and 70% of these 122 reported that they would prefer FMT to antibiotics as initial treatment if they were to have a CDI recurrence.
Conclusion : In this follow up survey of outcomes after FMT at median 22 months' follow-up, 82% of patients had durable cure of CDI. Patients with recurrence had more post-FMT antibiotic exposure, underscoring the need for thoughtful antibiotic use and a potential role for prophylactic microbiome enrichment to reduce recurrence.
Commentaire : La TMF pourrait être envisagée raisonnablement dès la 2ème récidive d'infection à Clostridium difficile, avec un faible taux de complications et une perception très positive de la part des patients.
Des doutes subsistent cependant sur la tolérance à très long terme de la TMF et il convient de rester prudent quant à son utilisation.
Elevation of the head during intensive care management in people with severe traumatic brain injury.
Alarcon JD , Rubiano AM, Okonkwo DO, Alarcón J, Martinez-Zapata MJ, Urrútia G, Bonfill Cosp X. | Cochrane Database Syst Rev. 2017 Dec 28;12:CD009986
Introduction : To assess the clinical and physiological effects of HBE during intensive care management in people with severe TBI.
Méthode : Search methods.We searched the following electronic databases from their inception up to March 2017: Cochrane Injuries' Specialised Register, CENTRAL, MEDLINE, Embase, three other databases and two clinical trials registers. The Cochrane Injuries' Information Specialist ran the searches.Selection criteria.We selected all randomised controlled trials (RCTs) involving people with TBI who underwent different HBE or backrest positions. Studies may have had a parallel or cross-over design. We included adults and children over two years of age with severe TBI (Glasgow Coma Scale (GCS) less than 9). We excluded studies performed in children of less than two years of age because of their unfused skulls. We included any therapeutic HBE including supine (flat) or different degrees of head elevation with or without knee gatch or reverse Trendelenburg applied during the acute management of the TBI.Data collection and analysis.Two review authors independently checked all titles and abstracts, excluding references that clearly didn't meet all selection criteria, and extracted data from selected studies on to a data extraction form specifically designed for this review. There were no cases of multiple reporting. Each review author independently evaluated risk of bias through assessing sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias.
Résultats : We included three small studies with a cross-over design, involving a total of 20 participants (11 adults and 9 children), in this review. Our primary outcome was mortality, and there was one death by the time of follow-up 28 days after hospital admission. The trials did not measure the clinical secondary outcomes of quality of life, GCS, and disability. The included studies provided information only for the secondary outcomes intracranial pressure (ICP), cerebral perfusion pressure (CPP), and adverse effects.We were unable to pool the results as the data were either presented in different formats or no numerical data were provided. We included narrative interpretations of the available data.The overall risk of bias of the studies was unclear due to poor reporting of the methods. There was marked inconsistency across studies for the outcome of ICP and small sample sizes or wide confidence intervals for all outcomes. We therefore rated the quality of the evidence as very low for all outcomes and have not included the results of individual studies here. We do not have enough evidence to draw conclusions about the effect of HBE during intensive care management of people with TBI.
Conclusion : The lack of consistency among studies, scarcity of data and the absence of evidence to show a correlation between physiological measurements such as ICP, CCP and clinical outcomes, mean that we are uncertain about the effects of HBE during intensive care management in people with severe TBI.Well-designed and larger trials that measure long-term clinical outcomes are needed to understand how and when different backrest positions can affect the management of severe TBI.
Conclusion (proposition de traduction) : Le manque de cohérence entre les études, la rareté des données et l'absence de preuves démontrant une corrélation entre les mesures physiologiques telles que la pression intracrânienne, la pression de perfusion cérébrale et les résultats cliniques signifient que nous ne sommes pas certains des effets de la surélévation de la tête au cours de la prise en charge intensive des TCC sévères. Des essais bien conçus et plus vastes qui mesurent les résultats cliniques à long terme sont nécessaires pour comprendre comment et quand différentes positions du dossier peuvent affecter la prise en charge des lésions cérébrales traumatiques graves.
Commentaire : Les auteurs ne peuvent pas conclure (ni proposer ni exclure), sans des études supplémentaires et d'une durée supérieure, quant au bénéfice de surélever de la tête chez le traumatisé crânien grave.
Ultrasound-guided central venous catheter placement: first things first.
Saugel B , Saugel B, Schulte-Uentrop L, Scheeren TWL, Teboul JL. | Crit Care. 2017 Dec 29;21(1):331
Editorial : We thank Drs. Gawda and Czarnik for their comments regarding our article on ultrasound (US)-guided central venous catheter (CVC) placement.We recommended a “six-step-approach”. Because US is still used infrequently for CVC insertion we aimed to provide a basic, pragmatic, and evidence-based concept applicable in clinical routine rather than making the approach unnecessarily complicated.We discussed that a disadvantage of the short-axis/out-of-plane approach is that not the entire needle but only an echogenic point (that must not be the needle tip) is visualized.
Conclusion : Guideline
Conclusion (proposition de traduction) : Nous remercions les Drs. Gawda et Czarnik pour leurs commentaires concernant notre article sur la mise en place de cathéters veineux centraux guidés par échographie.
Nous avons recommandé une "approche en six étapes". Étant donné que les États-Unis ont encore peu recours à lamine en place de cathéter centraux veineux, nous avons cherché à fournir un concept de base, pragmatique et fondé sur des preuves, applicable en routine clinique, plutôt que de compliquer inutilement l'approche. L'approche dans le plan ne correspond pas à l'aiguille entière, mais seulement à un point échogène (qui ne doit pas être la pointe de l'aiguille).
Commentaire : L'article original est très intéressant (août 2017) et propose un protocole en six points pour le placement échoguidé d'un cathéter veineux central (https://doi.org/10.1186/s13054-017-1814-y).
Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury – a multicentre prospective cohort study and systematic review.
Asehnoune K , ATLANREA group; COBI group. | Crit Care. 2017 Dec 28;21(1):328
DOI: https://doi.org/10.1186/s13054-017-1918-4 | Télécharger l'article au format
Introduction : Intracranial hypertension (ICH) is a major cause of death after traumatic brain injury (TBI). Continuous hyperosmolar therapy (CHT) has been proposed for the treatment of ICH, but its effectiveness is controversial. We compared the mortality and outcomes in patients with TBI with ICH treated or not with CHT.
Méthode : We included patients with TBI (Glasgow Coma Scale ≤ 12 and trauma-associated lesion on brain computed tomography (CT) scan) from the databases of the prospective multicentre trials Corti-TC, BI-VILI and ATLANREA. CHT consisted of an intravenous infusion of NaCl 20% for 24 hours or more. The primary outcome was the risk of survival at day 90, adjusted for predefined covariates and baseline differences, allowing us to reduce the bias resulting from confounding factors in observational studies. A systematic review was conducted including studies published from 1966 to December 2016.
Résultats : Among the 1086 included patients, 545 (51.7%) developed ICH (143 treated and 402 not treated with CHT). In patients with ICH, the relative risk of survival at day 90 with CHT was 1.43 (95% CI, 0.99-2.06, p = 0.05). The adjusted hazard ratio for survival was 1.74 (95% CI, 1.36-2.23, p < 0.001) in propensity-score-adjusted analysis. At day 90, favourable outcomes (Glasgow Outcome Scale 4-5) occurred in 45.2% of treated patients with ICH and in 35.8% of patients with ICH not treated with CHT (p = 0.06). A review of the literature including 1304 patients from eight studies suggests that CHT is associated with a reduction of in-ICU mortality (intervention, 112/474 deaths (23.6%) vs. control, 244/781 deaths (31.2%); OR 1.42 (95% CI, 1.04-1.95), p = 0.03, I 2 = 15%).
Conclusion : CHT for the treatment of posttraumatic ICH was associated with improved adjusted 90-day survival. This result was strengthened by a review of the literature.
Conclusion (proposition de traduction) : Une perfusion de soluté hyperosmolaire continue (NaCl 20% pendant 24 heures ou plus) pour le traitement d’une hypertension intracrânienne post-traumatique était associée à une amélioration de la survie ajustée à 90 jours. Ce résultat a été renforcé par une revue de la littérature.
Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment.
Brogi E , Gargani L, Bignami E, Barbariol F, Marra A, Forfori F, Vetrugno L. | Crit Care. 2017 Dec 28;21(1):325
DOI: https://doi.org/10.1186/s13054-017-1897-5 | Télécharger l'article au format
Editorial : Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF. Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.
Conclusion : Lung ultrasound is a simple non-invasive bedside procedure, with better sensitivity and specificity than chest radiography, for the diagnosis of PLEFF. It is not only crucial for visualizing the effusion, but can also help distinguish between different forms of PLEFF. The use of ultrasound to guide thoracentesis and to insert chest tubes has recently been advocated to increase the safety of this invasive procedure, especially in ventilated ICU patients, or for small, loculated effusions. Furthermore, TUS is also essential to monitor the volume of PLEFF drained, and to decide when to remove the drainage.
Conclusion (proposition de traduction) : L'échographie pulmonaire est une procédure au lit du malade, non invasive, simple, avec une sensibilité et une spécificité meilleures que la radiographie thoracique, pour le diagnostic d'un épanchement pleural. Cela est non seulement crucial pour visualiser l'épanchement, mais peut également aider à distinguer différentes formes d'épanchement pleural. L’utilisation de l'échographie pour guider la thoracentèse et insérer les drains thoraciques a récemment été préconisée pour accroître la sécurité de cette procédure invasive, en particulier chez les patients en USI ventilés ou pour les petits épanchements localisés. De plus, une échographie thoracique est également essentielle pour surveiller le volume de l'épanchement pleural drainé et pour décider du moment opportun pour retirer le drainage.
The effect of angiotensin II on blood pressure in patients with circulatory shock: a structured review of the literature.
Busse LW , McCurdy MT, Ali O, Hall A, Chen H, Ostermann M. | Crit Care. 2017 Dec 28;21(1):324
DOI: https://doi.org/10.1186/s13054-017-1896-6 | Télécharger l'article au format
Introduction : Circulatory shock is a common syndrome with a high mortality and limited therapeutic options. Despite its discovery and use in clinical and experimental settings more than a half-century ago, angiotensin II (Ang II) has only been recently evaluated as a vasopressor in distributive shock. We examined existing literature for associations between Ang II and the resolution of circulatory shock.
Méthode : We searched PubMed, MEDLINE, Ovid, and Embase to identify all English literature accounts of intravenous Ang II in humans for the treatment of shock (systolic blood pressure [SBP] ≤ 90 mmHg or a mean arterial pressure [MAP] ≤ 65 mmHg), and hand-searched the references of extracted papers for further studies meeting inclusion criteria. Of 3743 articles identified, 24 studies including 353 patients met inclusion criteria. Complete data existed for 276 patients. Extracted data included study type, publication year, demographics, type of shock, dosing of Ang II or other vasoactive medications, and changes in BP, lactate, and urine output. BP effects were grouped according to type of shock, with additional analyses completed for patients with absent blood pressure. Shock was distributive (n = 225), cardiogenic (n = 38), or from other causes (n = 90). Blood pressure as absent in 18 patients.
Résultats : For the 276 patients with complete data, MAP rose by 23.4% from 63.3 mmHg to 78.1 mmHg in response to Ang II (dose range: 15 ng/kg/min to 60 mcg/min). SBP rose by 125.2% from 56.9 mmHg to 128.2 mmHg (dose range: 0.2 mcg/min to a 1500 mcg bolus). A total of 271 patients with complete data were determined to exhibit a BP effect which was directly associated with Ang II. Subgroups (patients with cardiogenic, septic, and other types of shock) exhibited similar increases in BP. In patients with absent BP, deemed to be cardiac arrest, return of spontaneous circulation (ROSC) was achieved, and BP increased by an average of 107.3 mmHg in 11 of 18 patients. The remaining seven patients with cardiac arrest did not respond.
Conclusion : Intravenous Ang II is associated with increased BP in patients with cardiogenic, distributive, and unclassified shock. A role may exist for Ang II in restoring circulation in cardiac arrest.
Conclusion (proposition de traduction) : L'administration intraveineuse d'angiotensine II est associée à une augmentation de la pression artérielle chez les patients présentant un choc cardiogénique, distributif et non classifié. Angiotensine II peut avoir une place dans la restauration de la circulation lors d'un arrêt cardiaque.
Initial blood pH during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients: a multicenter observational registry-based study.
Shin J , Lim YS, Kim K, Lee HJ, Lee SJ, Jung E, You KM, Yang HJ, Kim JJ, Kim J, Jo YH, Lee JH, Hwang SY. | Crit Care. 2017 Dec 21;21(1):322
DOI: https://doi.org/10.1186/s13054-017-1893-9 | Télécharger l'article au format
Introduction : When an out-of-hospital cardiac arrest (OHCA) patient receives cardiopulmonary resuscitation (CPR) in the emergency department (ED), blood laboratory test results can be obtained by using point-of-care testing during CPR. In the present study, the relationship between blood laboratory test results during CPR and outcomes of OHCA patients was investigated.
Méthode : This study was a multicenter retrospective analysis of prospective registered data that included 2716 OHCA patients. Data from the EDs of three university hospitals in different areas were collected from January 2009 to December 2014. Univariate and multivariable analyses were conducted to elucidate the factors associated with survival to discharge and neurological outcomes. A final analysis was conducted by including patients who had no prehospital return of spontaneous circulation and those who underwent rapid blood laboratory examination during CPR.
Résultats : Overall, 2229 OHCA patients were included in the final analysis. Among them, the rate of survival to discharge and a good Cerebral Performance Categories Scale score were 14% and 4.4%, respectively. The pH level was independently related to survival to hospital discharge (adjusted OR 6.287, 95% CI 2.601-15.197; p < 0.001) and good neurological recovery (adjusted OR 15.395, 95% CI 3.439-68.911; p < 0.001). None of the neurologically intact patients had low pH levels (< 6.8) or excessive potassium levels (> 8.5 mEq/L) during CPR.
Conclusion : Among the blood laboratory test results during CPR of OHCA patients, pH and potassium levels were observed as independent factors associated with survival to hospital discharge, and pH level was considered as an independent factor related to neurological recovery.
Conclusion (proposition de traduction) : Parmi les résultats des tests sanguin de laboratoire effectués pendant la RCP chez des patients en arrêt cardiaque extrahospitalier, le pH et les taux de potassium ont été considérés comme des facteurs indépendants associés à la survie à la sortie de l'hôpital.
Comparison of the efficacy of three topical antiseptic solutions for the prevention of catheter colonization: a multicenter randomized controlled study.
Yasuda H , for Japanese Society of Education for Physicians and Trainees in Intensive Care (JSEPTIC) Clinical Trial Group. | Crit Care. 2017 Dec 21;21(1):320
DOI: https://doi.org/10.1186/s13054-017-1890-z | Télécharger l'article au format
Introduction : To compare the efficacy of three antiseptic solutions [0.5%, and 1.0% alcohol/chlorhexidine gluconate (CHG), and 10% aqueous povidone-iodine (PVI)] for the prevention of intravascular catheter colonization, we conducted a randomized controlled trial in patients from 16 intensive care units in Japan.
Méthode : Adult patients undergoing central venous or arterial catheter insertions were randomized to have one of three antiseptic solutions applied during catheter insertion and dressing changes. The primary endpoint was the incidence of catheter colonization, and the secondary endpoint was the incidence of catheter-related bloodstream infections (CRBSI).
Résultats : Of 1132 catheters randomized, 796 (70%) were included in the full analysis set. Catheter-tip colonization incidence was 3.7, 3.9, and 10.5 events per 1000 catheter-days in 0.5% CHG, 1% CHG, and PVI groups, respectively (p = 0.03). Pairwise comparisons of catheter colonization between groups showed a significantly higher catheter colonization risk in the PVI group (0.5% CHG vs. PVI: hazard ratio, HR 0.33 [95% confidence interval, CI 0.12-0.95], p = 0.04; 1.0% CHG vs. PVI: HR 0.35 [95% CI 0.13-0.93], p = 0.04). Sensitivity analyses including all patients by multiple imputations showed consistent quantitative conclusions (0.5% CHG vs. PVI: HR 0.34, p = 0.03; 1.0% CHG vs. PVI: HR 0.35, p = 0.04). No significant differences were observed in the incidence of CRBSI between groups.
Conclusion : Both 0.5% and 1.0% alcohol CHG are superior to 10% aqueous PVI for the prevention of intravascular catheter colonization.
Conclusion (proposition de traduction) : Le gluconate de chlorhexidine à 0,5 % et 1,0 % d'alcool est supérieur à la povidone-iode aqueuse (Bétadine) à 10 % pour la prévention de la colonisation des cathéter intravasculaire.
Commentaire : Confirme (heureusement) les recommandations françaises de mai 2016 (Recommandations pour la pratique clinique de la Société Française d’Hygiène Hospitalière : Antisepsie de la peau saine avant un geste invasif chez l’adulte).
Effects of High-Flow Nasal Cannula on the Work of Breathing in Patients Recovering From Acute Respiratory Failure.
Delorme M , Bouchard PA, Simon M, Simard S, Lellouche F. | Crit Care Med. 2017 Dec;45(12):1981-1988
Introduction : High-flow nasal cannula is increasingly used in the management of respiratory failure. However, little is known about its impact on respiratory effort, which could explain part of the benefits in terms of comfort and efficiency. This study was designed to assess the effects of high-flow nasal cannula on indexes of respiratory effort (i.e., esophageal pressure variations, esophageal pressure-time product/min, and work of breathing/min) in adults.
Méthode : DESIGN: A randomized controlled crossover study was conducted in 12 patients with moderate respiratory distress (i.e., after partial recovery from an acute episode, allowing physiologic measurements). SETTING: Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada. SUBJECTS: Twelve adult patients with respiratory distress symptoms were enrolled in this study. INTERVENTIONS: Four experimental conditions were evaluated: baseline with conventional oxygen therapy and high-flow nasal cannula at 20, 40, and 60 L/min. The primary outcomes were the indexes of respiratory effort (i.e., esophageal pressure variations, esophageal pressure-time product/min, and work of breathing/min). Secondary outcomes included tidal volume, respiratory rate, minute volume, dynamic lung compliance, inspiratory resistance, and blood gases.
Résultats : Esophageal pressure variations decreased from 9.8 (5.8-14.6) cm H2O at baseline to 4.9 (2.1-9.1) cm H2O at 60 L/min (p = 0.035). Esophageal pressure-time product/min decreased from 165 (126-179) to 72 (54-137) cm H2O • s/min, respectively (p = 0.033). Work of breathing/min decreased from 4.3 (3.5-6.3) to 2.1 (1.5-5.0) J/min, respectively (p = 0.031). Respiratory pattern variables and capillary blood gases were not significantly modified between experimental conditions. Dynamic lung compliance increased from 38 (24-64) mL/cm H2O at baseline to 59 (43-175) mL/cm H2O at 60 L/min (p = 0.007), and inspiratory resistance decreased from 9.6 (5.5-13.4) to 5.0 (1.0-9.1) cm H2O/L/s, respectively (p = 0.07).
Conclusion : High-flow nasal cannula, when set at 60 L/min, significantly reduces the indexes of respiratory effort in adult patients recovering from acute respiratory failure. This effect is associated with an improvement in respiratory mechanics.
Conclusion (proposition de traduction) : L'oxygénothérapie nasale à haut débit , lorsqu'elle est réglée à 60 L/min, réduit de manière significative les indices d'effort respiratoire chez les patients adultes en convalescence après une insuffisance respiratoire aiguë. Cet effet est associé à une amélioration de la mécanique respiratoire.
Diagnostic Accuracy of Point-of-Care Ultrasound Performed by Pulmonary Critical Care Physicians for Right Ventricle Assessment in Patients With Acute Pulmonary Embolism..
Filopei J , Acquah SO, Bondarsky EE, Steiger DJ, Ramesh N, Ehrlich M, Patrawalla P.. | Crit Care Med. 2017 Dec;45(12):2040-2045
Introduction : Risk stratification for acute pulmonary embolism using imaging presence of right ventricular dysfunction is essential for triage; however, comprehensive transthoracic echocardiography has limited availability. We assessed the accuracy and timeliness of Pulmonary Critical Care Medicine Fellow's performance of goal-directed echocardiograms and intensivists' interpretations for evaluating right ventricular dysfunction in acute pulmonary embolism.
Méthode : DESIGN: Prospective observational study and retrospective chart review. SETTING: Four hundred fifty bed urban teaching hospital. PATIENTS: Adult in/outpatients diagnosed with acute pulmonary embolism. INTERVENTIONS: Pulmonary critical care fellows performed and documented their goal-directed echocardiogram as normal or abnormal for right ventricular size and function in patients with acute pulmonary embolism. Gold standard transthoracic echocardiography was performed on schedule unless the goal-directed echocardiogram showed critical findings. Attending intensivists blinded to the clinical scenario reviewed these exams at a later date.
Résultats : Two hundred eighty-seven consecutive patients were evaluated for acute PE. Pulmonary Critical Care Medicine Fellows performed 154 goal-directed echocardiograms, 110 with complete cardiology-reviewed transthoracic echocardiography within 48 hours for comparison. Pulmonary Critical Care Medicine Fellow's area under the curve for size and function was 0.83 (95% CI, 0.75-0.90) and 0.83 (95% CI, 0.75-0.90), respectively. Intensivists' 1/2 area under the curve for size and function was (1) 0.87 (95% CI, 0.82-0.94), (1) 0.87 (95% CI, 0.80-0.93) and (2) 0.88 (95% CI, 0.82-0.95), (2) 0.88 (95% CI, 0.82-0.95). Median time difference between goal-directed echocardiogram and transthoracic echocardiography was 21 hours 18 minutes.
Conclusion : This is the first study to evaluate pulmonary critical care fellows' and intensivists' use of goal-directed echocardiography in diagnosing right ventricular dysfunction in acute pulmonary embolism. Pulmonary Critical Care Medicine Fellows and intensivists made a timely and accurate assessment. Screening for right ventricular dysfunction using goal-directed echocardiography can and should be performed by pulmonary critical care physicians in patients with acute pulmonary embolism.
Conclusion (proposition de traduction) : Il s'agit de la première étude visant à évaluer les soins intensifs pulmonaires en équipe et par le réanimateur par l'approche échocardiographique dans le diagnostic du dysfonctionnement du ventricule droit dans l'embolie pulmonaire aiguë. Les équipes en soins intensifs pulmonaires et les réanimateurs ont effectué une évaluation précise et en temps opportun. Le dépistage de la dysfonction ventriculaire droite par l'approche échocardiographique peut et doit être effectué par des médecins de soins intensifs pulmonaires chez les patients atteints d'embolie pulmonaire aiguë.
Point-of-care transcranial Doppler by intensivists..
Lau VI , Arntfield RT. | Crit Ultrasound J. 2017 Dec 13;9(1):21
DOI: https://doi.org/10.1186/s13089-017-0077-9 | Télécharger l'article au format
Editorial : In the unconscious patient, there is a diagnostic void between the neurologic physical exam, and more invasive, costly and potentially harmful investigations. Transcranial color-coded sonography and two-dimensional transcranial Doppler imaging of the brain have the potential to be a middle ground to bridge this gap for certain diagnoses. With the increasing availability of point-of-care ultrasound devices, coupled with the need for rapid diagnosis of deteriorating neurologic patients, intensivists may be trained to perform point-of-care transcranial Doppler at the bedside. The feasibility and value of this technique in the intensive care unit to help rule-in specific intra-cranial pathologies will form the focus of this article. The proposed scope for point-of-care transcranial Doppler for the intensivist will be put forth and illustrated using four representative cases: presence of midline shift, vasospasm, raised intra-cranial pressure, and progression of cerebral circulatory arrest. We will review the technical details, including methods of image acquisition and interpretation. Common pitfalls and limitations of point-of-care transcranial Doppler will also be reviewed, as they must be understood for accurate diagnoses during interpretation, as well as the drawbacks and inadequacies of the modality in general.
Conclusion : The advent of intensivist-performed ultrasound and availability of ultrasound machines now provides a unique climate where point-of-care TCD is a reality. Intensivists with this skill are able to provide immediate, 24/7 bedside assessment for midline shift, elevated ICP, vasospasm and intra-cranial hypertension progression. Barriers to training do still exist, but despite these pitfalls and limitations, intensivists performing limited point-of-care TCD as a screening tool to rule-in certain indications is feasible. Reaching competence is attainable, without extensive formal radiology training for diagnostic TCD. Much like many other POC modalities, to rule in various pathologies where prompt bedside diagnosis could be invaluable to the expedition of patient care. We support the use of TCD as a complementary adjunct to routine investigations (formal TCD, CT/MRI, ICP monitors).
Conclusion (proposition de traduction) : L'avènement de l'échographie réalisée par les réanimateurs et la disponibilité d'appareils d'échographie offrent désormais un climat unique où le doppler transcrânien au point d'intervention est une réalité. Les réanimateurs possédant cette compétence sont en mesure de fournir une évaluation immédiate, 24 h/24 et 7 j/7 au décochage, de la pression intra-crânienne invasive élevée, du vasospasme et de la progression de l'hypertension intra-cranienne. Les obstacles à la formation existent toujours, mais malgré ces pièges et limitations, les réanimateurs pratiquant un doppler transcrânien limité au lieu du traitement en tant qu'outil de dépistage permettant de contrôler certaines indications sont possibles. Atteindre la compétence est réalisable sans une formation approfondie en radiologie formelle pour le diagnostic Doppler transcrânien. À l'instar de nombreuses autres modalités au d'intervention, utilisé dans diverses pathologies où un diagnostic rapide au chevet du patient pourrait s'avérer précieux pour la dispensation de soins aux patients. Nous soutenons l'utilisation du doppler transcrânien en complément des examens de routine (doppler transcrânien formel, TDM/IRM, moniteurs de pression intra-crânienne invasifs).
Commentaire : Mise au point intéressante. La pratique en pré-hospitalier est faisable et semble pertinente (NDLR, non démontré ici).
Minimal training sufficient to diagnose pediatric wrist fractures with ultrasound.
Hedelin H , Tingström C, Hebelka H, Karlsson J. | Crit Ultrasound J. 2017 Dec;9(1):11
DOI: https://doi.org/10.1186/s13089-017-0066-z | Télécharger l'article au format
Introduction : In children, non-fractured wrists generally need no treatment and those that are fractured may only require a 3-week cast without any clinical follow-up. The ability to perform a point-of-care triage decision if radiographs are needed could improve patient flow and decrease unnecessary radiographs. The aim of this study was to evaluate the role of ultrasound (US) as a point-of-care triage tool for pediatric wrist injuries with limited training.
Méthode : Physicians with no previous US experience attended a 1.5 h course in the use of US to diagnose distal radius fractures at the Emergency Department (ED). The physicians firstly used US to diagnose a potential fracture and, if the patient had a fracture, grouped the patient according to how they wanted him/her to be treated based on US. The physician then interpreted the subsequent radiographs and decided on a treatment based on this information. Consultant traumatologists and a senior radiologist established a gold standard for correct treatment and radiological diagnosis, respectively.
Résultats : One hundred and sixteen injuries in 115 patients were included. The ED physician identified 75 fractures on radiographs. With the exception of a minimal buckle fracture, all were identified on US. US had a tendency to interpret complete fractures on radiographs as incomplete (n = 7) leading to incorrect treatment decisions.
Conclusion : In the hands of an US novice, US examination is comparable with radiographs as a point-of-care tool to distinguish a fractured wrist from a non-fractured one. US is not, however, as good as radiographs for placing fractured wrists into the correct treatment group.
Conclusion (proposition de traduction) : Dans les mains d'un novice en échographie, l'examen par ultrasons est comparable aux radiographies en tant qu'outil de prise en charge au point d'intervention pour distinguer un poignet fracturé d'un poignet non fracturé. Cependant, l'échographie n'est pas aussi efficace que les radiographies pour placer les poignets fracturés dans le groupe de traitement approprié.
Commentaire : L'échographie remplacera-t-elle la radiographie dans un avenir proche ?
Systematic review and meta-analysis for the use of ultrasound versus radiology in diagnosing of pneumonia.
Alzahrani S , Alzahrani SA, Al-Salamah MA, Al-Madani WH, Elbarbary MA. | Crit Ultrasound J. 2017 Dec;9(1):6
DOI: https://doi.org/10.1186/s13089-017-0059-y | Télécharger l'article au format
Introduction : Physicians are increasingly using point of care lung ultrasound (LUS) for diagnosing pneumonia, especially in critical situations as it represents relatively easy and immediately available tool. They also used it in many associated pathological conditions such as consolidation, pleural effusion, and interstitial syndrome with some reports of more accuracy than chest X-ray. This systematic review and meta-analysis are aimed to estimate the pooled diagnostic accuracy of ultrasound for the diagnosis of pneumonia versus the standard chest radiological imaging.
Résultats : A systematic literature search was conducted for all published studies comparing the diagnostic accuracy of LUS against a reference Chest radiological exam (C X-ray or Chest computed Tomography CT scan), combined with clinical criteria for pneumonia in all age groups. Eligible studies were required to have a Chest X-ray and/or CT scan at the time of clinical evaluation. The authors extracted qualitative and quantitative information from eligible studies, and calculated pooled sensitivity and specificity and pooled positive/negative likelihood ratios (LR). Twenty studies containing 2513 subjects were included in this meta-analysis. The pooled estimates for lung ultrasound in the diagnosis of pneumonia were, respectively, as follows: Overall pooled sensitivity and specificity for diagnosis of pneumonia by lung ultrasound were 0.85 (0.84-0.87) and 0.93 (0.92-0.95), respectively. Overall pooled positive and negative LRs were 11.05 (3.76-32.50) and 0.08 (0.04-0.15), pooled diagnostic Odds ratio was 173.64 (38.79-777.35), and area under the pooled ROC (AUC for SROC) was 0.978.
Conclusion : Point of care lung ultrasound is an accurate tool for the diagnosis of pneumonia. Considering being easy, readily availability, low cost, and free from radiological hazards, it can be considered as important diagnostic strategy in this condition.
Conclusion (proposition de traduction) : L'échographie pulmonaire au point d'intervention est un outil précis pour le diagnostic de la pneumopathie. Considérant qu’elle est facile, facilement disponible, peu coûteuse et exempte de risques radiologiques, elle peut être considérée comme une stratégie de diagnostic importante dans cette situation.
Commentaire : La radiographie du thorax comparée à l'échographie semble moins performante dans plusieurs articles récents. L'échographie remplacera-t-elle la radiographie dans un avenir proche ?
Novel concepts for damage control resuscitation in trauma.
Van PY , Holcomb JB, Schreiber MA. | Curr Opin Crit Care. 2017 Dec;23(6):498-502
Editorial : PURPOSE OF REVIEW: Traumatic injuries are a major cause of mortality worldwide. Damage control resuscitation or balanced transfusion of plasma, platelets, and red blood cells for the management of exsanguinating hemorrhage after trauma has become the standard of care. We review the literature regarding the use of alternatives to achieve the desired 1 : 1:1 ratio as availability of plasma and platelets can be problematic in some environments. RECENT FINDINGS: Liquid and freeze dried plasma (FDP) are logistically easier to use and may be superior to fresh frozen plasma. Cold storage platelets (CSPs) have improved hemostatic properties and resistance to bacterial contamination. Low titer type O whole blood can be transfused safely in civilian patients. SUMMARY: In the face of hemorrhagic shock from traumatic injury, resuscitation should be initiated with 1 : 1 : 1 transfusion of plasma, platelets, and red blood cells with limited to no use of crystalloids. Availability of plasma and platelets is limited in some environments. In these situations, the use of low titer type O whole blood, thawed or liquid plasma, cold stored platelets or reconstituted FDP can be used as substitutes to achieve optimal transfusion ratios. The hemostatic properties of CSPs may be superior to room temperature platelets.
Conclusion : Mortality from major trauma continues to be a worldwide problem, and massive haemorrhage remains a major cause in 40% of potentially preventable trauma deaths. Development of trauma-induced coagulopathy challenges 25-35% of the patients further increasing trauma mortality. The pathophysiology of coagulopathy in trauma reflects at least two distinct mechanisms: Acute traumatic coagulopathy, consisting of endogenous heparinization, activation of the protein C pathway, hyperfibrinolysis and platelet dysfunction, and resuscitation associated coagulopathy. Clear fluid resuscitation with crystalloids and colloids is associated with dilutional coagulopathy and poor outcome in trauma. Haemostatic resuscitation is now the backbone of trauma resuscitation using a ratio-driven strategy aiming at 1:1:1 of red blood cells, plasma and platelets while applying goal-directed therapy early and repeatedly to control trauma-induced coagulopathy.
Conclusion (proposition de traduction) : La mortalité due à un traumatisme majeur reste un problème mondial et une hémorragie massive reste une cause majeure dans 40 % des décès traumatisants potentiellement évitables. Le développement de la coagulopathie induite par un traumatisme impacte 25 à 35 % des patients, augmentant encore la mortalité par traumatisme. La physiopathologie de la coagulopathie dans les traumatismes reflète au moins deux mécanismes distincts : la coagulopathie traumatique aiguë, consistant en une héparinisation endogène, une activation de la voie de la protéine C, une hyperfibrinolyse et une dysfonction plaquettaire et une coagulopathie associée à la réanimation. La réanimation liquidienne avec les cristalloïdes et les colloïdes est associée à une coagulopathie de dilution et à un résultat médiocre dans le trauma. La réanimation hémostatique est maintenant la colonne vertébrale de la réanimation des traumatisés en utilisant une stratégie basée sur les ratios visant à atteindre 1:1:1 des globules rouges, du plasma et des plaquettes tout en appliquant un traitement ciblé précoce et répété pour contrôler la coagulopathie induite par le traumatisme.
Early haemorrhage control and management of trauma-induced coagulopathy: the importance of goal-directed therapy.
Stensballe J , Henriksen HH, Johansson PI. | Curr Opin Crit Care. 2017 Dec;23(6):503-510
Introduction : The aim of this study was to discuss the recent developments in trauma-induced coagulopathy and the evolvement of goal-directed therapy.
Conclusion : Trauma resuscitation should focus on early goal-directed therapy with use of viscoelastic haemostatic assays while initially applying a ratio 1:1:1 driven transfusion therapy (with red blood cells, plasma and platelets) in order to sustain normal haemostasis and control further bleeding.
Conclusion (proposition de traduction) : La réanimation traumatique devrait se concentrer sur un traitement ciblé précoce avec utilisation de tests hémostatiques viscoélastiques tout en appliquant initialement un traitement transfusionnel basé sur le ratio 1:1:1 (globules rouges, plasma et plaquettes) afin de maintenir l'hémostase.
Current trends in the management of hemodynamically unstable pelvic ring injuries.
Stahel PF , Burlew CC, Moore EE. | Curr Opin Crit Care. 2017 Dec;23(6):511-519
Introduction : Complex traumatic pelvic ring disruptions are associated with a high mortality rate due to associated retroperitoneal hemorrhage, traumatic-hemorrhagic shock, and postinjury coagulopathy. The present review provides an update on current management strategies to improve survival rates form hemodynamically unstable pelvic ring injuries.
Discussion : Recently published international consensus guidelines have attempted to standardize the classification of hemodynamically unstable pelvic ring injuries and provided classification-based management algorithms for acute resuscitation and pelvic ring stabilization.
Conclusion : Acute management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta for patients 'in extremis' in conjunction with point-of-care guided resuscitation for postinjury coagulopathy. Recent data indicate that a protocol of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from retroperitoneal exsanguinating hemorrhage in at-risk patients with historic mortality rates as high as 50-60%.
Conclusion (proposition de traduction) : Les stratégies de prise en charge en urgence des ruptures de l'anneau pelvien associées à un choc hémorragique incluent une embolisation endovasculaire de sauvetage de l'aorte par ballonnet chez les patients « in extremis » en conjonction avec une réanimation prodiguée au point d'intervention en cas de coagulopathie post-lésion. Des données récentes indiquent qu'un protocole de fixation externe pelvienne précoce associé à un compactage pelvien prépéritonéal direct et à une angioembolisation ultérieure chez des patients présentant une hémorragie en cours entraînent une amélioration significative de la survie après hémorragie rétropéritonéale chez des patients à risque présentant des taux de mortalité de 50 à 60 %
The crashing patient: hemodynamic collapse.
Gidwani H , Gómez H. | Curr Opin Crit Care. 2017 Dec;23(6):533-540
EMERGENCIES IN CRITICAL CARE
Introduction : Rapid restoration of tissue perfusion and oxygenation are the main goals in the resuscitation of a patient with circulatory collapse. This review will focus on providing an evidence based framework of the technological and conceptual advances in the evaluation and management of the patient with cardiovascular collapse.
Discussion : The initial approach to the patient in cardiovascular collapse continues to be based on the Ventilate-Infuse-Pump rule. Point of care ultrasound is the preferred modality for the initial evaluation of undifferentiated shock, providing information to narrow the differential diagnosis, to assess fluid responsiveness and to evaluate the response to therapy. After the initial phase of resuscitative fluid administration, which focuses on re-establishing a mean arterial pressure to 65 mmHg, the use of dynamic parameters to assess preload responsiveness such as the passive leg raise test, stroke volume variation, pulse pressure variation and collapsibility of the inferior vena cava in mechanically ventilated patients is recommended.
Conclusion : The crashing patient remains a clinical challenge. Using an integrated approach with bedside ultrasound, dynamic parameters for the evaluation of fluid responsiveness and surrogates of evaluation of tissue perfusion have made the assessment of the patient in shock faster, safer and more physiologic.
Conclusion (proposition de traduction) : Le patient accidenté reste un défi clinique. En utilisant une approche systémique intégrant l’échographie déportée, le recueil de paramètres hémodynamiques pour l'évaluation de la réponse au remplissage (EtCO2...) et des paramètres d'évaluation de la perfusion tissulaire (Pression artérielle moyenne...) ont rend l'évaluation du patient en état de choc plus rapide, plus sûre et plus physiologique.
Early management of acute cerebrovascular accident.
Manners J , Steinberg A, Shutter L. | Curr Opin Crit Care. 2017 Dec;23(6):556-560
EMERGENCIES IN CRITICAL CARE
Introduction : Stroke is common and often presents as a neurologic emergency that requires rapid evaluation and treatment to minimize debilitation. Recent advances in therapy expanded time windows for intra-arterial thrombectomy in ischemic stroke, and surgical interventions for clot evacuation in large intracranial hemorrhage have recently proven feasible. This review discusses recent data regarding new therapeutic options in both ischemic and hemorrhagic stroke, notably in scenarios in which therapy was previously limited to supportive care.
Discussion : Recent data show that intra-arterial therapy in ischemic stroke provides both benefit in outcomes and potential for further advancements in care. Therapeutic windows for endovascular treatment of a cerebral vessel occlusion now extend to 6 h, and recent data suggest this may increase further to 24 h. Intervention in hemorrhagic stroke remains limited to reversal of coagulopathy and hypertension; however, surgical techniques are underway and may prove beneficial in some cases.
Conclusion : Advancing therapeutics in ischemic and hemorrhagic stroke are changing acute care intervention and broadening potential candidates for what were once thought to be nonintervenable conditions. Execution of best practices in stroke will continue to evolve and will require understanding advanced imaging techniques, as well as selection criteria for procedural and surgical interventions.
Conclusion (proposition de traduction) : Les progrès thérapeutiques dans la prise en charge des accidents vasculaires cérébraux ischémiques et hémorragiques modifient les interventions en soins de courte durée et élargit le champ des candidats potentiels pour ce que l'on croyait autrefois être des affections ou il ne fallait pas intervenir. L'application des meilleures pratiques en matière d'AVC continuera d'évoluer et nécessitera la compréhension des techniques d'imagerie de pointe, ainsi que les critères de sélection pour les interventions et procédures chirurgicales.
Septic shock resuscitation in the first hour.
Simpson N , Lamontagne F, Shankar-Hari M. | Curr Opin Crit Care. 2017 Dec;23(6):561-566
EMERGENCIES IN CRITICAL CARE
Introduction : We reviewed the recent advances in the initial approach to resuscitation of sepsis and septic shock patients.
Discussion : Sepsis and septic shock are life-threatening emergencies. Two key interventions in the first hour include timely antibiotic therapy and resuscitation. Before any laboratory results, the need for resuscitation is considered if a patient with suspected infection has low blood pressure (BP) or impaired peripheral circulation found at clinical examination. Until now, this early resuscitation in sepsis and septic shock was supported by improvements in outcome seen with goal-directed therapy. However, three recent, goal-directed therapy trials failed to replicate the originally reported mortality reductions, prompting a debate on how this early resuscitation should be performed. As resuscitation is often focussed on macrociculatory goals such as optimizing central venous pressure, the discordance between microcirculatory and macrocirculatory optimization during resuscitation is a potential argument for the lack of outcome benefit in the newer trials. Vasoactive drug dose and large volume resuscitation-associated-positive fluid balance, are independently associated with worse clinical outcomes in critically ill sepsis and septic shock patients. As lower BP targets and restricted volume resuscitation are feasible and well tolerated, should we consider a lower BP target to reduce the adverse effects of catecholamine' and excess resuscitation fluids. Evidence guiding fluids, vasopressor, and inotrope selection remains limited.
Conclusion : Though the early resuscitation of sepsis and septic shock is key to improving outcomes, ideal resuscitation targets are elusive. Distinction should be drawn between microcirculatory and macrocirculatory changes, and corresponding targets. Common components of resuscitation bundles such as large volume resuscitation and high-dose vasopressors may not be universally beneficial. Microcirculatory targets, individualized resuscitation goals, and reassessment of completed trials using the updated septic shock criteria should be focus areas for future research.
Conclusion (proposition de traduction) : Bien que la réanimation précoce du sepsis et du choc septique soit essentielle pour améliorer les résultats, les cibles de réanimation idéales ne sont pas connues. Il convient d'établir une distinction entre les changements microcirculatoires et macrocirculatoires et les cibles correspondantes. Les composants communs des protocoles de réanimation tels que la réanimation à grand volume et les vasopresseurs à forte dose peuvent ne pas être universellement bénéfiques. Les cibles microcirculatoires, les objectifs de réanimation individualisés et la réévaluation des essais terminés utilisant les critères du choc septique mis à jour devraient constituer des domaines de recherche pour les recherches futures.
| Douleur analg. 2017 Dec;30:205–216
Mise Au Point
Editorial : Le syndrome de l’intestin irritable est un trouble fonctionnel digestif fréquent, associant douleurs abdominales et troubles du transit, qui concerne 5 % de la population générale. La maladie, bien que bénigne, peut être responsable d’une altération de la qualité de vie, qui est notamment fonction de la sévérité de la maladie et de la réponse au traitement de première intention. L’amélioration des connaissances de la physiopathologie a parfois été à l’origine de nouveaux traitements et d’une amélioration de la prise en charge. Parmi les différents traitements, on compte des recommandations hygiénodiététiques, des traitements classiques ou alternatifs et l’éducation thérapeutique.
Conclusion : -
Conclusion (proposition de traduction) : Le SII est une pathologie fonctionnelle fréquente, à la phy- siopathologie complexe, qui peut altérer la qualité de vie, notamment dans les formes sévères et en cas d’efficacité insuffisante des traitements prescrits. Les progrès réalisés ces dernières années sur les mécanismes physiopatholo- giques ont parfois permis de développer de nouvelles straté- gies thérapeutiques. Malheureusement, on ne peut aujour- d’hui deviner a priori quels sont chez un patient donné les mécanismes en cause et prédire ainsi les chances de succès d’un traitement avant de l’avoir essayé. Aussi, outre le déve- loppement de nouveaux traitements, c’est sûrement d’un meilleur phénotypage des patients en fonction des mécanis- mes que viendra une amélioration notable de la prise en charge de cette pathologie complexe.
Predicting outcomes in traumatic out-of-hospital cardiac arrest: the relevance of Utstein factors.
Beck B , Bray JE, Cameron P, Straney L, Andrew E, Bernard S, Smith K. | Emerg Med J. 2017 Dec;34(12):786-792
Introduction : Given low survival rates in cases of traumatic out-of-hospital cardiac arrest (OHCA), there is a need to identify factors associated with outcomes. We aimed to investigate Utstein factors associated with achieving return of spontaneous circulation (ROSC) and survival to hospital in traumatic OHCA.
Méthode : The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify cases of traumatic OHCA that received attempted resuscitation and occurred between July 2008 and June 2014. We excluded cases aged <16 years or with a mechanism of hanging or drowning.
Résultats : Of the 660 traumatic OHCA patients who received attempted resuscitation, ROSC was achieved in 159 patients (24%) and 95 patients (14%) survived to hospital (ROSC on hospital handover). Factors that were positively associated with achieving ROSC in multivariable logistic regression models were age ≥65 years (adjusted OR (AOR)=1.56, 95% CI: 1.01 to 2.43) and arresting rhythm (shockable (AOR=3.65, 95% CI: 1.64 to 8.11) and pulseless electrical activity (AOR=2.15, 95% CI: 1.36 to 3.39) relative to asystole). Similarly, factors positively associated with survival to hospital were arresting rhythm (shockable (AOR=3.92, 95% CI: 1.64 to 9.41) relative to asystole), and the mechanism of injury (falls (AOR=2.16, 95% CI: 1.03 to 4.54) relative to motor vehicle collisions), while trauma type (penetrating (AOR=0.27, 95% CI: 0.08 to 0.91) relative to blunt trauma) and event region (rural (AOR=0.39, 95% CI: 0.19 to 0.80) relative to urban) were negatively associated with survival to hospital.
Conclusion : Few patient and arrest characteristics were associated with outcomes in traumatic OHCA. These findings suggest there is a need to incorporate additional information into cardiac arrest registries to assist prognostication and the development of novel interventions in these trauma patients.
Conclusion (proposition de traduction) : Peu de patient et de caractéristiques de l'arrêt étaient associées à des résultats dans l'arrêt cardiaque extrahospitalier traumatique. Ces résultats suggèrent qu'il est nécessaire d'intégrer des informations supplémentaires dans les registres sur l'arrêt cardiaque pour faciliter le pronostic et le développement de nouvelles interventions chez ces patients traumatisés.
Sacral fractures: classification and management.
Beckmann NM , Chinapuvvula NR. | Emerg Radiol. 2017 Dec;24(6):605-617
Editorial : Sacral fractures are a common component of pelvic fracture patterns and are an increasingly diagnosed injury both due to increased utilization of CT in trauma evaluation as well as an increasing rate of sacral fragility fractures as a result of an increase in general population age. Innovations in minimally invasive surgical techniques have also resulted in an increasing number of sacral fractures undergoing surgical management. It is vital that physicians practicing in an emergency setting are aware of the injury patterns and management of this increasingly injured and treated component of the bony pelvis. This article reviews the sacral anatomy as well as discusses the role of imaging and imaging appearance of sacral fractures. Sacral fracture patterns are described along with both historic and newer classification systems for sacral fractures and current management of sacral fracture.
Conclusion : Sacral fractures are an increasingly recognized pathology in patients presenting with pelvic trauma, and these injuries are important for both the structural instability and neurologic com- plications that can result. Management of sacral fractures re- mains a challenge as significant variability exists regarding what constitutes an unstable sacral fracture and which neuro- logic injuries require surgical intervention. The lumbosacral injury classification system represents the first attempt to create a specific classification system to guide management of sacral fractures and may find utility in treating complex sacral frac- tures in the future. However, this classification system is novel and requires further validation before gaining widespread use.
Conclusion (proposition de traduction) : Les fractures du sacrum sont une pathologie de plus en plus reconnue chez les patients présentant un traumatisme pelvien. Ces lésions sont importantes à la fois pour l'instabilité structurelle et les complications neurologiques pouvant en résulter. La prise en charge des fractures sacrées reste un défi car une variabilité significative existe en ce qui concerne ce qui constitue une fracture sacrée instable et les lésions neurologiques nécessitant une intervention chirurgicale. Le système de classification des lésions lombo-sacrées représente la première tentative de création d'un système de classification spécifique pour guider la gestion des fractures du sacrum et pourrait trouver une utilité dans le traitement des fractures sacrée complexes à l'avenir. Cependant, ce système de classification est nouveau et nécessite une validation supplémentaire avant de généraliser son utilisation.
Prognosis of patients with syncope seen in the emergency room department: an evaluation of four different risk scores recommended by the European Society of Cardiology guidelines.
Barón-Esquivias G , Fernández-Cisnal A, Arce-León Á, Toro R, Cantero-Pérez E, Parejo-Matos J, Romero-Rodriguez N, Montero E, Martinez A. | Eur J Emerg Med. 2017 Dec;24(6):428-434
Introduction : To apply, analyze, and evaluate the four syncope risk scores recommended by the 2009 European guidelines and the different parameters that they use to predict death, syncope recurrence, and hospital readmission in the population seen in the emergency room department (ERD) for syncope.
Résultats : A total of 323 patients aged older than 14 years [mean age 59 (32-75) years] and seen in ERD for syncope over a 2-month period were included in the study; 50.7% were women. Patients were evaluated using the four risk scores and were followed up for at least 2 years. In all, 275 patients (85.2%) were discharged directly from ERD after evaluation. During 28±5 months of follow-up, 8% died, 18.3% presented a further syncopal episode, and 18.6% were readmitted to hospital. Only two of the four risk scores were useful in risk discrimination, but no statistically significant differences were detected between predicted risk and observed risk. Multivariate analysis indicated relationships between age and death, a history of cardiovascular disease and syncope recurrence, and between presyncopal palpitations and hospital readmission.
Conclusion : Although a large number of events occur after syncope, the risk scores recommended by guidelines overestimate risk, but there were no statistically significant differences between observed and predicted risk.
Conclusion (proposition de traduction) : Bien qu'un grand nombre d'événements surviennent après une syncope, les scores de risque recommandés par les directives surestiment le risque, mais il n'y avait pas de différence statistiquement significative entre le risque observé et le risque prédit.
Intranasal fentanyl for the prehospital management of acute pain in children.
Murphy AP , Hughes M, Mccoy S, Crispino G, Wakai A, O'Sullivan R. | Eur J Emerg Med. 2017 Dec;24(6):450-454
Introduction : Acute pain is the most common symptom in the emergency setting and its optimal management continues to challenge prehospital emergency care practitioners, particularly in the paediatric population. Difficulty in establishing vascular access and fear of opiate administration to small children are recognized reasons for oligoanalgesia. Intranasal fentanyl (INF) has been shown to be as safe and effective as intravenous morphine in the treatment of severe pain in children in the Emergency Department setting. This study aimed to describe the clinical efficacy and safety of INF when administered by advanced paramedics in the prehospital treatment of acute severe pain in children.
Méthode : A 1-year prospective cross-sectional study was carried out of children (>1 year, <16 years) who received INF as part of the prehospital treatment of acute pain by the statutory national emergency medical services in Ireland.
Résultats : Ninety-four children were included in the final analysis [median age 11 years (interquartile range 7-13)]; 53% were males and trauma was implicated in 86% of cases. A clinically effective reduction in the pain score was found in 78 children [83% (95% confidence interval: 74-89%)]. The median initial pain rating score was 10. Pain assessment at 10 min after INF administration indicated a median pain rating of 5 (interquartile range 2-7). No patient developed an adverse event as a result of INF.
Conclusion : INF at a dose of 1.5 µg/kg appears to be a safe and effective analgesic in the prehospital management of acute severe pain in children and may be an attractive alternative to both oral and intravenous opiates.
Conclusion (proposition de traduction) : Le fentanyl intranasal à la dose de 1,5 µg/kg semble être un analgésique sûr et efficace dans la prise en charge préhospitalière de la douleur aiguë sévère chez les enfants et peut être une alternative séduisante aux opiacés oraux et intraveineux.
Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC).
Kneyber MCJ , section Respiratory Failure of the European Society for Paediatric and Neonatal Intensive Care. | Intensive Care Med. 2017 Dec;43(12):1764-1780
DOI: https://doi.org/10.1007/s00134-017-4920-z | Télécharger l'article au format
Conference Reports and Expert Panel
Introduction : Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children.
Méthode : The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms.
Résultats : The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement.
Conclusion : These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research.
Conclusion (proposition de traduction) : Ces recommandations devraient aider à harmoniser l'approche de la ventilation mécanique en pédiatrie et peuvent être proposées en tant que normes de soins applicables à la pratique clinique quotidienne et à la recherche clinique.
Predicting vasopressor needs using dynamic parameters.
Monge García MI , Pinsky MR, Cecconi M. | Intensive Care Med. 2017 Dec;43(12):1841-1843
What's New in Intensive Care
Editorial : This paper adds to the growing literature around Eadyn (dynamic arterial elastance).Importantly, although the reliability of Eadyn relies on the robustness of how SVV and PVV are calculated, validation of this parameter has now come from different monitors and in different clinical situations. Current practice shows that fluids are often given in large quantities to increase MAP in hypotensive patients.The decision to start a vasopressor could also be guided by Eadyn, potentially sparing the amount of fluids given. The fact that spontaneous breathing does not affect Eadyn accuracy makes Eadyn a particularly attractive parameter in the context of de-escalation of vasopressor therapy as well when patients are breathing spontaneously, no longer hypotensive, and are being weaned off pressor support.Importantly, Eadyn has the potential to be an important tool for the bedside clinician to individualize fluid and vasopressor therapy and while minimizing fluid infusion in non-volume-responsive patients and keeping vasopressor therapy at an acceptable minimum.
Conclusion : Importantly, Eadyn tool for the bedside clinician to individualize fluid and vasopressor therapy and while minimizing fluid infusion in non-volume-responsive patients and keeping vasopressor therapy at an acceptable minimum.
Conclusion (proposition de traduction) : Il est important de noter que l’élastance artérielle dynamique est un outil permettant au clinicien d’individualiser la thérapeutique par remplissage vasculaire et en besoins de vasopresseur tout en minimisant la perfusion de liquide de perfusion chez les patients ne répondant pas au volume de remplissage et en maintenant la thérapeutique par vasopresseur à un minimum acceptable.
Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study).
Robert R | Intensive Care Med. 2017 Dec;43(12):1793-1807
Introduction : The relative merits of immediate extubation versus terminal weaning for mechanical ventilation withdrawal are controversial, particularly regarding the experience of patients and relatives.
Méthode : This prospective observational multicentre study (ARREVE) was done in 43 French ICUs to compare terminal weaning and immediate extubation, as chosen by the ICU team. Terminal weaning was a gradual decrease in the amount of ventilatory assistance and immediate extubation was extubation without any previous decrease in ventilatory assistance. The primary outcome was posttraumatic stress symptoms (Impact of Event Scale Revised, IES-R) in relatives 3 months after the death. Secondary outcomes were complicated grief, anxiety, and depression symptoms in relatives; comfort of patients during the dying process; and job strain in staff.
Résultats : We enrolled 212 (85.5%) relatives of 248 patients with terminal weaning and 190 relatives (90.5%) of 210 patients with immediate extubation. Immediate extubation was associated with airway obstruction and a higher mean Behavioural Pain Scale score compared to terminal weaning. In relatives, IES-R scores after 3 months were not significantly different between groups (31.9 ± 18.1 versus 30.5 ± 16.2, respectively; adjusted difference, -1.9; 95% confidence interval, -5.9 to 2.1; p = 0.36); neither were there any differences in complicated grief, anxiety, or depression scores. Assistant nurses had lower job strain scores in the immediate extubation group.
Conclusion : Compared to terminal weaning, immediate extubation was not associated with differences in psychological welfare of relatives when each method constituted standard practice in the ICU where it was applied. Patients had more airway obstruction and gasps with immediate extubation.
Conclusion (proposition de traduction) : Comparé au sevrage terminal, l'extubation immédiate n'était pas associée à des différences dans la perception psychologique des parents lorsque chaque méthode constituait une pratique standard dans l'unité de soins intensifs où elle était appliquée. Les patients présentaient plus d'obstruction des voies respiratoires et de gasps avec l'extubation immédiate.
2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways.
Tomaselli GF , Mahaffey KW, Cuker A, Dobesh PP, Doherty JU, Eikelboom JW, Florido R, Hucker W, Mehran R, Messé SR, Pollack CV Jr, Rodriguez F, Sarode R, Siegal D, Wiggins BS.. | J Am Coll Cardiol. 2017 Dec 19;70(24):3042-3067
DOI: https://doi.org/10.1016/j.jacc.2017.09.1085 | Télécharger l'article au format
EXPERT CONSENSUS DECISION PATHWAY
Editorial : The guidance in this document is designed to address the clinical problem of bleeding management of patients treated with anticoagulants and will consider both DOACs and VKAs used for any indication. The decision pathway considered the severity of the bleed (major vs. nonmajor), acute medical and surgical management, the need for reversal, the appropriateness and time of restarting anticoagulation, and the impact of pertinent comorbid- ities and concomitant drug therapy. At each step in the decision pathway algorithms, patient specific factors should be considered.
Conclusion : Guideline
Conclusion (proposition de traduction) : Recommandation
Percutaneous Closure of Patent Foramen Ovale in Patients With Migraine: The PREMIUM Trial.
Tobis JM , Charles A, Silberstein SD, Sorensen S, Maini B, Horwitz PA, Gurley JC. | J Am Coll Cardiol. 2017 Dec 5;70(22):2766-2774
Original research article
Introduction : Migraine is a prevalent and disabling disorder. Patent foramen ovale (PFO) has been associated with migraine, but its role in the disorder remains poorly understood.
Méthode : This study examined the efficacy of percutaneous PFO closure as a therapy for migraine with or without aura. METHODS: The PREMIUM (Prospective, Randomized Investigation to Evaluate Incidence of Headache Reduction in Subjects With Migraine and PFO Using the AMPLATZER PFO Occluder to Medical Management) was a double-blind study investigating migraine characteristics over 1 year in subjects randomized to medical therapy with a sham procedure (right heart catheterization) versus medical therapy and PFO closure with the Amplatzer PFO Occluder device (St. Jude Medical, St. Paul, Minnesota). Subjects had 6 to 14 days of migraine per month, had failed at least 3 migraine preventive medications, and had significant right-to-left shunt defined by transcranial Doppler. Primary endpoints were responder rate defined as 50% reduction in migraine attacks and adverse events. Secondary endpoints included reduction in migraine days and efficacy in patients with versus without aura.
Résultats : Of 1,653 subjects consented, 230 were enrolled. There was no difference in responder rate in the PFO closure (45 of 117) versus control (33 of 103) groups. One serious adverse event (transient atrial fibrillation) occurred in 205 subjects who underwent PFO closure. Subjects in the PFO closure group had a significantly greater reduction in headache days (-3.4 vs. -2.0 days/month, p = 0.025). Complete migraine remission for 1 year occurred in 10 patients (8.5%) in the treatment group versus 1 (1%) in the control group (p = 0.01).
Conclusion : PFO closure did not meet the primary endpoint of reduction in responder rate in patients with frequent migraine. (Prospective, Randomized Investigation to Evaluate Incidence of Headache Reduction in Subjects With Migraine and PFO Using the AMPLATZER PFO Occluder to Medical Management [PREMIUM]).
Conclusion (proposition de traduction) : La fermeture du foramen ovale ne correspondait pas au critère d'évaluation principal de la réduction du taux de réponse chez les patients présentant une migraine fréquente. (Étude prospective randomisée pour évaluer l'incidence de la réduction des céphalées chez les sujets souffrant de migraine et du foramen ovale breveté à l'aide du foramen ovale AMPLATZER Patent foramen ovale Occluder à la gestion médicale [Etude PREMIUM]).
Commentaire : La fin d'un mythe ?
Abdominal Obesity Is Associated With an Increased Risk of All-Cause Mortality in Patients With HFpEF.
Tsujimoto T , Kajio H. | J Am Coll Cardiol. 2017 Dec 5;70(22):2739-2749
Introduction : There is a lack of studies that evaluate the association between abdominal obesity and subsequent outcomes in patients with heart failure with preserved ejection fraction (HFpEF)
Méthode : The present study aimed to assess the association between abdominal obesity and risk of all-cause mortality in patients with HFpEF. METHODS: The present study used data from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial. The primary outcome was all-cause mortality. We analyzed and compared the hazard ratios (HRs) in patients with abdominal obesity and those without abdominal obesity using multivariable Cox proportional hazard models. Abdominal obesity was defined as a waist circumference of ≥102 cm in men and ≥88 cm in women.
Résultats : The present study included 3,310 patients with HFpEF: 2,413 patients with abdominal obesity and 897 without abdominal obesity. The mean follow-up was 3.4 ± 1.7 years. During follow-up, 500 patients died. All-cause mortality rates in patients with and without abdominal obesity were 46.1 and 40.7 events per 1,000 person-years, respectively. After multivariable adjustment, the risk of all-cause mortality was significantly higher in patients with abdominal obesity than in those without abdominal obesity (adjusted HR: 1.52; 95% confidence interval [CI]: 1.16 to 1.99; p = 0.002). The risk of cardiovascular and noncardiovascular mortality was also significantly higher in patients with abdominal obesity than in those without abdominal obesity (adjusted HR: 1.50; 95% CI: 1.08 to 2.08; p = 0.01 and adjusted HR: 1.58; 95% CI: 1.00 to 2.51; p = 0.04, respectively).
Conclusion : The risk of all-cause mortality was significantly higher in patients with HFpEF with abdominal obesity than in those without abdominal obesity.
Conclusion (proposition de traduction) : Le risque de mortalité toutes causes confondues était significativement plus élevé chez les patients présentant une insuffisance cardiaque avec une fraction d'éjection conservée avec obésité abdominale que chez ceux sans obésité abdominale.
| Prat Anesth reanim. 2017 Dec;21: 308-314
Editorial : L’hypotension artérielle (HAPA) est un événement fréquent pendant l’anesthésie. L’estimation de son incidence dépend des valeurs de pression artérielle utilisées pour définir l’HAPA. Des travaux récents ont mis en évidence une relation statistique entre l’HAPA et la morbidité/mortalité postopératoires. Ces travaux ont été à l’origine des recommandations de pratique clinique concernant la prévention et la gestion de l’HAPA. Cet article a pour objectifs d’améliorer le raisonnement clinique concernant les définitions de l’HAPA, sa gestion et sa correction en proposant : (i) un modèle physiologique/phyiopathologique hémodynamique permettant de mieux comprendre la problématique de l’HAPA ; (ii) des algorithmes décisionnels qui peuvent faciliter le diagnostic, la prévention et la gestion de l’HAPA ; (iii) une réflexion sur la correction de l’HAPA.
Conclusion : -
Conclusion (proposition de traduction) : La communauté d’anesthésie-réanimation a été confrontée en moins d’une dizaine d’années au passage entre « l’anesthésie n’a pas d’effets mesurables sur les complications postopératoires raquo; à « l’anesthésie est statistiquement associée à la morbi-mortalité postopératoires ». Ce passage n’est pas un miracle, mais le simple résultat d’un gain de puissance statistique permis par l’analyse de bases de données avec plusieurs dizaines de milliers de patients. Cette transition est reflétée maintenant dans des recommandations de pratique clinique comme celles de l’ESC/ESA de 2014 adoptées par la SFAR concernant plusieurs aspects de gestions de l’anesthésie dont l’ HAPA.
L’implémentation de ces recommandations est confrontée à des problèmes pratiques de raisonnement clinique qui ont été l’objet de ce texte. La complexité des phénomènes physiologiques et physiopathologiques rend indispensable plusieurs éléments :
• un modèle physiologique hémodynamique adapté à la complexité ; • un monitorage hémodynamique tel qu’il est recommande par les sociétés savantes dont la SFAR ;
• la connaissance de la pharmacologie des catécholamines.
Des études prospectives interventionnelles seront nécessaires pour apporter la preuve que la correction de l’HAPA, de préférence fondée sur un raisonnement clinique individualisé, atténue ses effets néfastes sur la morbidité/mortalité postopératoires.
Risk Factors for Admission and Prolonged Length of Stay in Pediatric Isolated Skull Fractures.
Williams DC , Selassie AW, Russell WS, Borg KT, Basco WT Jr. | Pediatr Emerg Care. 2017 Dec;33(12):e146-e151
Introduction : This study aimed to assess management of pediatric isolated skull fracture (ISF) patients by determining frequency of admission and describing characteristics associated with patients admitted for observation compared with patients discharged directly from the emergency department (ED) and those requiring a prolonged hospitalization.
Méthode : We evaluated children younger than 5 years who presented with ISF using the South Carolina Traumatic Brain Injury Surveillance and Registry System data from 2001 to 2011. Outcomes analyzed included discharged from ED, admitted for less than 24 hours, and admitted for more than 24 hours (prolonged hospitalization). Bivariate analyses and a polytomous logistic regression model identified factors associated with patient disposition.
Résultats : Five hundred twenty-seven patients met the study criteria (ED discharge = 283 [53%]; inpatient <24 hours = 156 [29%]; inpatient >24 hours = 88 [18%]). The mean length of stay for admissions was 1.9 (SD, 1.5) days. In the regression model, ED discharges had greater odds of presenting to levels 2 to 3 hospitals (level 2: odds ratio [OR], 6.16; 95% confidence interval [CI], 3.66-10.39; level 3: OR, 30.98; 95% CI, 10.92-87.91) and lower odds of a high poverty status (OR, 0.20; 95% CI, 0.10-0.40). Prolonged hospitalizations had greater odds of concomitant injuries (OR, 2.21; 95% CI, 1.12-4.36).
Conclusion : Admission after ISF is high despite a low risk of deterioration. High-poverty patients presenting to high-acuity medical centers are more commonly admitted for observation. Only presence of concomitant injuries was clinically predictive of prolonged hospitalization. The ability to better stratify risk after pediatric ISF would help providers make more informed decisions regarding ED disposition.
Conclusion (proposition de traduction) : L'admission après une fracture du crâne isolée est élevée malgré un faible risque de détérioration. Les patients très pauvres qui se présentent dans des centres hospitaliers d'urgence sont plus souvent admis en observation. Seule la présence de lésions concomitantes était cliniquement prédictive d'une hospitalisation prolongée. La capacité de mieux stratifier le risque après les fractures pédiatriques isolées du crâne aiderait les urgentistes à prendre des décisions plus éclairées concernant l'organisation du service des urgences.
Benefits of Manometer in Non-Invasive Ventilatory Support.
Lacerda RS , de Lima FCA, Bastos LP, Fardin Vinco A, Schneider FBA, Luduvico Coelho Y, Fernandes HGC, Bacalhau JMR, Bermudes IMS, da Silva CF, da Silva LP, Pezato R. | Prehosp Disaster Med. 2017 Dec;32(6):615-620
Introduction : Effective ventilation during cardiopulmonary resuscitation (CPR) is essential to reduce morbidity and mortality rates in cardiac arrest. Hyperventilation during CPR reduces the efficiency of compressions and coronary perfusion. Problem How could ventilation in CPR be optimized? The objective of this study was to evaluate non-invasive ventilator support using different devices.
Méthode : The study compares the regularity and intensity of non-invasive ventilation during simulated, conventional CPR and ventilatory support using three distinct ventilation devices: a standard manual resuscitator, with and without airway pressure manometer, and an automatic transport ventilator. Student's t-test was used to evaluate statistical differences between groups. P values <.05 were regarded as significant.
Résultats : Peak inspiratory pressure during ventilatory support and CPR was significantly increased in the group with manual resuscitator without manometer when compared with the manual resuscitator with manometer support (MS) group or automatic ventilator (AV) group.
Conclusion : The study recommends for ventilatory support the use of a manual resuscitator equipped with manometer support or automatic ventilators, due to the risk of reduction in coronary perfusion pressure and iatrogenic thoracic injury during hyperventilation found using manual resuscitator without manometer.
Conclusion (proposition de traduction) : L’étude recommande, pour le support ventilatoire, l’utilisation d’un ballon auto remplisseur à valve unidirectionnelle (BAVU) manuel équipé d’un manomètre ou de ventilateurs automatiques, en raison du risque de réduction de la pression de perfusion coronarienne et des lésions thoraciques iatrogènes lors d’une hyperventilation à l’aide d’un ballon auto remplisseur à valve unidirectionnelle (BAVU) manuel sans manomètre.
Assessing and Improving Hospital Mass-Casualty Preparedness: A No-Notice Exercise.
Waxman DA , Chan EW, Pillemer F, Smith TW, Abir M, Nelson C. | Prehosp Disaster Med. 2017 Dec;32(6):662-666
Editorial : In recent years, mass-casualty incidents (MCIs) have become more frequent and deadly, while emergency department (ED) crowding has grown steadily worse and widespread. The ability of hospitals to implement an effective mass-casualty surge plan, immediately and expertly, has therefore never been more important. Yet, mass-casualty exercises tend to be highly choreographed, pre-scheduled events that provide limited insight into hospitals' true capacity to respond to a no-notice event under real-world conditions. To address this gap, the US Department of Health and Human Services (Washington, DC USA), Office of the Assistant Secretary for Preparedness and Response (ASPR), sponsored development of a set of tools meant to allow any hospital to run a real-time, no-notice exercise, focusing on the first hour and 15 minutes of a hospital's response to a sudden MCI, with the goals of minimizing burden, maximizing realism, and providing meaningful, outcome-oriented metrics to facilitate self-assessment. The resulting exercise, which was iteratively developed, piloted at nine hospitals nationwide, and completed in 2015, is now freely available for anyone to use or adapt. This report demonstrates the feasibility of implementing a no-notice exercise in the hospital setting and describes insights gained during the development process that might be helpful to future exercise developers. It also introduces the use of ED “immediate bed availability (IBA)” as an objective, dynamic measure of an ED’s physical capacity for new arrivals.
Conclusion : This work demonstrates that hospitals can implement a no-notice, mass-casualty exercise and introduces dynamic measurements of immediate bed availability (IBA) as an objective way to assess preparedness. The product of this work is an exercise toolkit that is available for download and use or for others to further refine or develop. The lack of notice and real-time pace enhances realism, while the step-by-step instructions, easy-to-use data collection features, and analytics built into the Excel tools limit the costs of running the exercise and ensures that players receive quick and objective feedback on their performance. While this exercise tests only a narrow slice of preparedness, the model of developing and refining widely applicable tools in this manner holds great promise for enhancing readiness.
Conclusion (proposition de traduction) : Ce travail démontre que les hôpitaux peuvent mettre en œuvre un exercice sans préavis et faire de nombreuses victimes et introduit des mesures dynamiques sur la disponibilité immédiate des lits en tant que moyen objectif d'évaluer la préparation. Le produit de ce travail est une boîte à outils d’exercices qui peut être téléchargée et utilisée ou que d’autres peuvent affiner ou développer. L'absence de préavis et le rythme en temps réel augmentent le réalisme, tandis que les instructions pas à pas, les fonctionnalités de collecte de données faciles à utiliser et les analyses intégrées aux outils Excel limitent les coûts d'exécution de l'exercice et garantissent aux joueurs une réponse rapide et des commentaires objectifs sur leurs performances. Bien que cet exercice ne teste qu'une petite tranche de préparation, le modèle de développement et de perfectionnement d'outils largement applicables de cette manière est très prometteur pour l'amélioration de la préparation.
Observational Study on Safety of Prehospital BLS CPAP in Dyspnea.
Sahu N , Matthews P, Groner K, Papas MA, Megargel R. | Prehosp Disaster Med. 2017 Dec;32(6):610-614
Introduction : Continuous positive airway pressure (CPAP) improves outcomes in patients with respiratory distress. Additional benefits are seen with CPAP application in the prehospital setting. Theoretical safety concerns regarding Basic Life Support (BLS) providers using CPAP exist. In Delaware's (USA) two-tiered Emergency Medical Service (EMS) system, BLS often arrives before Advanced Life Support (ALS). Hypothesis This study fills a gap in literature by evaluating the safety of CPAP applied by BLS prior to ALS arrival.
Méthode : This was a retrospective, observational study using Quality Assurance (QA) data collected from October 2009 through December 2012 throughout a state BLS CPAP pilot program; CPAP training was provided to BLS providers prior to participation. Collected data include pulse-oximetry (spO2), respiratory rate (RR), heart rate (HR), skin color, and Glasgow Coma Score (GCS) before and after CPAP application. Pre-CPAP and post-CPAP values were compared using McNemar's and t-tests. Advanced practitioners evaluated whether CPAP was correctly applied and monitored and whether the patient condition was "improved," "unchanged," or "worsened."
Résultats : Seventy-four patients received CPAP by BLS; CPAP was correctly indicated and applied for all 74 patients. Respiratory status and CPAP were appropriately monitored and documented in the majority of cases (98.6%). A total of 89.2% of patients improved and 4.1% worsened; CPAP significantly reduced the proportion of patients with SpO224, and cyanosis (P<.01). The GCS improved from mean (standard deviation [SD]) 13.9 (SD=1.9) to 14.1 (SD=1.9) after CPAP (mean difference [MD]=0.17; 95% CI, -0.49 to 0.83; P=.59). The HR decreased from 115.7 (SD=53) to 105.1 (SD=37) after CPAP (MD=-10.9; 95% CI, -3.2 to -18.6; P<.01). The SpO2 increased from 80.8% (SD=11.4) to 96.9% (SD=4.2) after CPAP (MD=17.8; 95% CI, 14.2-21.5; P<.01).
Conclusion : The BLS providers were able to determine patients for whom CPAP was indicated, to apply it correctly, and to appropriately monitor the status of these patients. The majority of patients who received CPAP by BLS providers had improvement in their clinical status and vital signs. The findings suggest that CPAP can be safely used by BLS providers with appropriate training.
Conclusion (proposition de traduction) : Les dispensateurs de gestes élémentaires de survie (GES) ont pu déterminer les patients pour lesquels la CPAP était indiqué, les appliquer correctement et surveiller de manière appropriée le statut de ces patients. La majorité des patients qui ont reçu un traitement par CPAP par des dispensateurs de gestes élémentaires de survie (GES) ont amélioré leur état clinique et leurs signes vitaux. Les résultats suggèrent que la CPAP peut être utilisé en toute sécurité par les dispensateurs de gestes élémentaires de survie (GES) avec une formation appropriée.
The accuracy of the Broselow tape as a weight estimation tool and a drug-dosing guide - A systematic review and meta-analysis.
Wells M , Wells M, Goldstein LN, Bentley A, Basnett S, Monteith I. | Resuscitation. 2017 Dec;121:9-33
Introduction : The Broselow tape is widely used as a weight-estimation device and drug-dosing guide aid, but concerns about its accuracy and its efficacy have emerged in the last decade. The aim of this study was to systematically review the literature to analyse the accuracy of the Broselow tape as a weight estimation device and review evidence of its utility as a drug-dosing guide.
Méthode : This was a MOOSE-driven systematic review and meta-analysis, which focused on studies evaluating the accuracy of the Broselow tape and studies reviewing its use as a drug-dosing aid.
Résultats : The tape has undergone substantial changes over the years, but there was no evidence to show that the changes have improved weight-estimation performance. The weight-estimation accuracy of the tape was suboptimal in all populations, with just over 50% of children receiving an estimation within 10% of their actual weight. The overestimation of weight in low- and middle-income countries was often extreme. This indicated a significant potential for potentially harmful medication errors. The limited available evidence on the value of the tape as a drug-dosing guide indicated that the tape was frequently used incorrectly and contained insufficient information to function without additional resources.
Conclusion : The Broselow tape lacked sufficient accuracy as a weight estimation and drug-dosing tool when compared to other available techniques. In addition, the Broselow tape contains insufficient drug-dosing information to function as a complete resuscitation aid without additional material. The frequent rate of incorrect usage of the tape indicated that appropriate training with the tape is mandatory to reduce errors.
Conclusion (proposition de traduction) : La réglette de Broselow manquait de précision en tant qu'outil d'estimation du poids et du dosage des médicaments par rapport aux autres techniques disponibles. De plus, la réglette Broselow contient des informations insuffisantes sur la posologie pour fonctionner comme une aide complète à la réanimation sans matériel supplémentaire.
Le taux fréquent d'utilisation incorrecte de la réglette indique qu'une formation appropriée avec la réglette est obligatoire pour réduire les erreurs.
Prognostic significance of spontaneous shockable rhythm conversion in adult out-of-hospital cardiac arrest patients with initial non-shockable heart rhythms: A systematic review and meta-analysis.
Luo S , Luo S1, Zhang Y, Zhang W, Zheng R, Tao J, Xiong Y. | Resuscitation. 2017 Dec;121:1-8
Introduction : There remains controversy over the prognostic significance of spontaneous shockable rhythm conversion in out-of-hospital cardiac arrest (OHCA) patients with initial non-shockable heart rhythms (pulseless electrical activity [PEA] or asystole). The aim of this study was to examine the association of shockable rhythm conversion with multiple OHCA outcomes, and to explore effect modifiers.
Méthode : A dual-reviewer search was conducted in PubMed and EMBASE databases in March 2017. Data on study design, patient characteristics, outcomes, adjusting and stratifying variables were extracted. Estimates were combined using random-effects models.
Résultats : Twelve studies involving 1,108,281 OHCA patients with initial non-shockable heart rhythms were identified using pre-specified eligibility criteria. Combined adjusted estimates showed that shockable rhythm conversion was associated with higher odds of pre-hospital return of spontaneous circulation (ROSC) (odds ratio [OR]=1.47, 95% confidence interval [CI] 1.40-1.55). Although shockable rhythm conversion was not associated with survival to hospital discharge (OR=1.36, 95% CI 0.77-2.38), it was associated with higher odds of one-month survival (OR=1.96, 95% CI 1.66-2.31), and one-month favourable neurological outcome (OR=2.69, 95% CI 2.00-3.62). Subgroup analyses found that shockable rhythm conversion from asystole, but not PEA, was associated with pre-hospital ROSC and survival to hospital discharge, and that earlier shockable rhythm conversions, compared to those occurring later during cardiopulmonary resuscitation, were associated with higher odds of one-month favourable neurological outcome.
Conclusion : Shockable rhythm conversion from initial non-shockable heart rhythms was associated with better OHCA outcomes, depending on the type of initial heart rhythm, and time of rhythm conversion.
Conclusion (proposition de traduction) : La conversion d'un rythme choquable à partir d'un rythme cardiaque non choquable initial était associée à de meilleurs résultats dans l'arrêt cardiaque extrahospitalier, en fonction du type de rythme cardiaque initial et du temps de conversion du rythme.
Predictors of favourable outcome after in-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation: A systematic review and meta-analysis.
D'Arrigo S , Cacciola S, Dennis M, Jung C, Kagawa E, Antonelli M, Sandroni C. | Resuscitation. 2017 Dec;121:62-70
Introduction : To identify the predictors of survival to discharge in adults resuscitated with extracorporeal cardiopulmonary resuscitation (ECPR) following in-hospital cardiac arrest (IHCA).
Méthode : MEDLINE and ISI Web of Science were searched for eligible studies. Pooled Odds Ratio (OR) and Pooled Mean Difference (PMD) for each predictor were calculated. The quality of evidence (QOE) was evaluated according to the GRADE guidelines.
Résultats : Eleven studies were included totalling 856 patients. Of these, 324 (37.9%) survived to discharge. Good neurological outcome (Cerebral Performance Category 1 or 2) occurred in 222/263 (84.4%) survivors. Survival was associated with significantly higher odds of an initial shockable rhythm (OR 1.65; 95% confidence interval [95%CI] 1.05-2.61; p=0.03), shorter low-flow time (PMD -17.15 [-20.90, -13.40]min; p<0.00001), lower lactate levels both immediately before ECPR start (PMD -4.12 [-6.0,-2.24]mmol/L; p<0.0001) and on ICU admission (PMD -4.13 [-6.38, -1.88]mmol/L; p<0.0003), lower SOFA score (PMD -1.71 [-2.93, -0.50]; p=0.006) and lower creatinine levels within 24h after ICU admission (PMD -0.37 [-0.54, -0.19]mg/dl; p<0.00001). No significant association was found between survival and age, gender, or cardiac vs. non-cardiac aetiology. The overall QOE was low or very low.
Conclusion : In adult IHCA treated with ECPR a shockable initial rhythm, a lower low-flow time, lower blood lactate levels before ECPR start or on ICU admission, and a lower SOFA score or creatinine levels in the first 24h after ICU admission were associated with a higher likelihood of survival. These factors could help identifying patients who are eligible for ECPR. Copyright © 2017 Elsevier B.V. All rights reserved.
Conclusion (proposition de traduction) : Chez les adultes en arrêt cardiaque à l'hôpital traités par réanimation cardiopulmonaire extracorporelle (ECPR), un rythme initial choquable, un low-flow court, des taux de lactate sanguin plus faibles avant le début de la réanimation cardiopulmonaire extracorporelle (ECPR) ou à l'admission à l'USI, et un score SOFA ou des taux de créatinine plus faibles dans les 24 heures suivant l'admission à l'USI étaient associés à une probabilité de survie plus élevée. Ces facteurs pourraient aider à identifier les patients candidats à la réanimation cardiorespiratoire extracorporelle.
Comparative effectiveness of antiarrhythmics for out-of-hospital cardiac arrest: A systematic review and network meta-analysis.
McLeod SL , Brignardello-Petersen R, Worster A, You J, Iansavichene A, Guyatt G, Cheskes S. | Resuscitation. 2017 Dec;121:90-97
Introduction : Despite their wide use in the prehospital setting, randomized control trials (RCTs) have failed to demonstrate that any antiarrhythmic agent improves survival to hospital discharge following out-of-hospital cardiac arrest.
Méthode : To assess the use of antiarrhythmic drugs for patients experiencing out-of-hospital cardiac arrest (OHCA).
METHODS: Electronic searches of Medline, EMBASE and Cochrane Central Register of Controlled Trials were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) investigating the use of antiarrhythmic agents administered during resuscitation for adult (≥18years) patients suffering non-traumatic OHCA were included. Direct and indirect evidence were combined in a network meta-analysis (NMA) using a frequentist approach with fixed-effects models and reported as relative risks (RR) with 95% confidence intervals (CIs). For each pairwise comparison, the certainty of direct, indirect, and network evidence was assessed using the GRADE approach.
Résultats : 8 RCTs involving 4464 patients were combined to compare the effectiveness of 5 antiarrhythmic agents and placebo administered during resuscitation following OHCA. Lidocaine was associated with a statistically significant increase in ROSC compared to placebo (1.15; 95% CI: 1.03-1.28) and was also superior to bretylium (1.61; 95% CI: 1.00-2.60) for ROSC. When compared to placebo, both amiodarone (1.18; 95% CI: 1.08-1.30) and lidocaine (1.18; 95% CI: 1.07-1.30) were associated with a statistically significant increase in survival to hospital admission. However, no antiarrhythmic was statistically more effective than placebo for survival to hospital discharge or neurologically intact survival, and no antiarrhythmic was convincingly superior to any other for any outcome.
Conclusion : Amiodarone and lidocaine were the only agents associated with improved survival to hospital admission in the NMA. For the outcomes most important to patients, survival to hospital discharge and neurologically intact survival, no antiarrhythmic was convincingly superior to any other or to placebo.
Conclusion (proposition de traduction) : L'amiodarone et la lidocaïne étaient les seuls agents associés à une meilleure survie à l'admission à l'hôpital dans les méta-analyses. Pour les résultats les plus importants pour les patients, la survie à la sortie de l'hôpital et la survie intacte sur le plan neurologique, aucun antiarythmique n'était supérieur de manière convaincante à un autre ou au placebo.
The use of trained volunteers in the response to out-of-hospital cardiac arrest - the GoodSAM experience.
Smith CM , Wilson MH, Ghorbangholi A, Hartley-Sharpe C, Gwinnutt C, Dicker B, Perkins GD. | Resuscitation. 2017 Dec;121:123-126
Commentary and Concepts
Editorial : In England, fewer than 1 in 10 out-of-hospital cardiac arrest victims survive to hospital discharge. This could be substantially improved by increasing bystander cardiopulmonary resuscitation and Automated External Defibrillator use. GoodSAM is a mobile-phone, app-based system alerting trained individuals to nearby cardiac arrests. 'Responders' can be notified by bystanders using the GoodSAM 'Alerter' function. In London, when a 999 call-handler identifies cardiac arrest, in addition to dispatching the usual professional resources, London Ambulance Service automatically activates nearby GoodSAM responders. This article discusses the development of GoodSAM, its integration with London Ambulance Service, and the plans for future expansion.
Conclusion : The ultimate aim of GoodSAM, and other similar systems to alert volunteer first-responders, is to increase the number of people who survive after OHCA. Its strength is that it uses existing technolo- gies, requires little capital investment and is easily adaptable to the needs of different EMS across the UK and worldwide. With proper evaluation and optimisation of the GoodSAM system it could have a significant impact on OHCA survival.
Conclusion (proposition de traduction) : Le but final de GoodSAM et d’autres systèmes similaires pour alerter les premiers intervenants volontaires est d’augmenter le nombre de personnes qui survivent après un arrêt cardiaque extrahospitalier. Sa force réside dans le fait qu’il utilise les technologies existantes, nécessite peu d’investissements et s’adapte facilement aux besoins de différents systèmes de gestion de l’environnement au Royaume-Uni et dans le monde. Avec une évaluation et une optimisation appropriées du système GoodSAM, cela pourrait avoir un impact significatif sur la survie de l'arrêt cardiaque extrahospitalier.
Commentaire : Pour plus d'information sur le programme consulter le site
En France, plusieurs organisations similaires sont accessibles :
La communauté des citoyens sauveteurs , Permis de sauver , Staying Alive …
Ideal (i) CPR: Looking beyond shadows in a cave.
Segal N , Youngquist S, Lurie K. | Resuscitation. 2017 Dec;121:81-83
DOI: https://dx.doi.org/10.1016/j.resuscitation.2017.10.009 | Télécharger l'article au format
Commentary and Concepts
Editorial : Survival rates after cardiac arrest have shown minimal improvement in the last 60 years. However, in some forward-thinking cities and hospitals, out-of and in-hospital cardiac arrest survival rates exceed 20% and 40% respectively. These beacons of hope can enlighten us, providing a clearer vision of what it takes to provide Ideal cardiopulmonary resuscitation. To make progress in a field that has seemingly stagnated for too many decades, we must be open to new ideas and develop bundles of care that work in communities with varying EMS systems and various existing infrastructure to bring the best practices to the rest of the country.
Conclusion : -
Conclusion (proposition de traduction) : -
A user-friendly risk-score for predicting in-hospital cardiac arrest among patients admitted with suspected non ST-elevation acute coronary syndrome - The SAFER-score.
Faxén J , Hall M, Gale CP, Sundström J, Lindahl B, Jernberg T, Szummer K. | Resuscitation. 2017 Dec;121:41-48
Introduction : To develop a simple risk-score model for predicting in-hospital cardiac arrest (CA) among patients hospitalized with suspected non-ST elevation acute coronary syndrome (NSTE-ACS).
Méthode : Using the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART), we identified patients (n=242 303) admitted with suspected NSTE-ACS between 2008 and 2014. Logistic regression was used to assess the association between 26 candidate variables and in-hospital CA. A risk-score model was developed and validated using a temporal cohort (n=126 073) comprising patients from SWEDEHEART between 2005 and 2007 and an external cohort (n=276 109) comprising patients from the Myocardial Ischaemia National Audit Project (MINAP) between 2008 and 2013.
Résultats : The incidence of in-hospital CA for NSTE-ACS and non-ACS was lower in the SWEDEHEART-derivation cohort than in MINAP (1.3% and 0.5% vs. 2.3% and 2.3%). A seven point, five variable risk score (age ≥60 years (1 point), ST-T abnormalities (2 points), Killip Class >1 (1 point), heart rate <50 or ≥100bpm (1 point), and systolic blood pressure <100mmHg (2 points) was developed. Model discrimination was good in the derivation cohort (c-statistic 0.72) and temporal validation cohort (c-statistic 0.74), and calibration was reasonable with a tendency towards overestimation of risk with a higher sum of score points. External validation showed moderate discrimination (c-statistic 0.65) and calibration showed a general underestimation of predicted risk.
Conclusion : A simple points score containing five variables readily available on admission predicts in-hospital CA for patients with suspected NSTE-ACS.
End-tidal carbon dioxide and defibrillation success in out-of-hospital cardiac arrest..
Savastano S , Baldi E, Raimondi M, Palo A, Belliato M, Cacciatore E, Corazza V, Molinari S, Canevari F, Danza AI, De Ferrari GM, Iotti GA, Visconti LO. | Resuscitation. 2017 Dec;121:71-75
Introduction : Basing on the relationship between the quality of cardiopulmonary resuscitation (CPR) and the responsiveness of VF to the defibrillation we aimed to assess whether the values of ETCO2 in the minute before defibrillation could predict the effectiveness of the shock.
Méthode : We retrospectively evaluated the reports generated by the manual monitor/defibrillator (Corpuls by GS Elektromedizinische Geräte G. Stemple GmbH, Germany) used for cases of VF cardiac arrest from January 2015 to December 2016. The mean ETCO2 value of the minute preceding the shock (METCO260) was computed. A blind evaluation of the effectiveness of each shock was provided by three cardiologists.
Résultats : A total amount of 207 shocks were delivered for 62 patients. When considering the three tertiles of METCO260 (T1:METCO260 ≤ 20mmHg; T2: 20mmHg < METCO260 ≤ 31mmHg and T3: METCO260 > 31mmHg) a statistically significant difference between the percentages of shock success was found (T1: 50%; T2: 63%; T3: 78%; Chi square p=0.003; p for trend <0.001). When the METCO260 was lower than 7mmHg no shock was effective and when the METCO260 was higher than 45mmHg no shock was ineffective. Shocks followed by ROSC were preceded by higher values of METCO260 as compared either to ineffective shocks or effective ones without ROSC.
Conclusion : This is the first demonstration of the relation between ETCO2 and defibrillation effectiveness. Our findings stress the pivotal role of High Quality CPR, monitored via ETCO2, and suggest ETCO2 monitoring as an additional weapon to guide defibrillation.
Factors and outcomes associated with inpatient cardiac arrest following emergent endotracheal intubation.
Wardi G , Villar J, Nguyen T, Vyas A, Pokrajac N, Minokadeh A, Lasoff D, Tainter C, Beitler JR, Sell RE. | Resuscitation. 2017 Dec;121:76-80
Original research article
Introduction : Inpatient peri-intubation cardiac arrest (PICA) following emergent endotracheal intubation (ETI) is an uncommon but potentially preventable type of cardiac arrest (CA). Limited published data exist describing factors associated with inpatient PICA and patient outcomes. This study identifies risk factors associated with PICA among hospitalized patients emergently intubated out of the operating room and compares PICA to other types of inpatient CA.
Méthode : Retrospective case-control study of patients at our institution over a five-year period. Cases were defined as inpatients emergently intubated outside of the operating room that experienced cardiac arrest within 20min after ETI. The control group consisted of inpatients emergently intubated out of the operating room without CA. Predictors of PICA were identified through univariate and multivariate analysis. Clinical outcomes were compared between PICA and other inpatient CAs, identified through a prospectively enrolled CA registry at our institution.
Résultats : 29 episodes of PICA occurred over 5 years, accounting for 5% of all inpatient arrests. Shock index ≥1.0, intubation within one hour of nursing shift change, and use of succinylcholine were independently associated with PICA. Sustained ROSC, survival to discharge, and neurocognitive outcome did not differ significantly between groups.
Conclusion : Patients outcomes following PICA were comparable to other causes of inpatient CA. Potentially modifiable factors were associated with PICA. Hemodynamic resuscitation, optimized staffing strategies, and possible avoidance of succinylcholine were associated with decreased risk of PICA. Clinical trials testing targeted strategies to optimize peri-intubation care are needed to identify effective interventions to prevent this potentially avoidable type of CA.
Early coronary angiography in patients resuscitated from out of hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis.
Khan MS , Khan MS, Shah SMM, Mubashir A, Khan AR, Fatima K, Schenone AL, Khosa F, Samady H, Menon V. | Resuscitation. 2017 Dec;121:127-134
Original research article
Introduction : A meta-analysis of published studies was performed to determine the impact of performing early versus delayed or no coronary angiography in patients without ST-segment elevation myocardial infarction following out of hospital cardiac arrest.
Méthode : A structured search was conducted using Medline, Embase and Ovid by two independent investigators using a variety of keywords. The primary outcome was short term (at discharge) and long term (at 6-14 months follow-up) mortality whereas the secondary end-point was good neurological outcome (defined as a Cerebral Performance Category Score of 1 or 2), at discharge and follow up. Random-effects model was utilized to pool the data, whilst publication bias was assessed using funnel plot.
Résultats : A total of 8 studies (7 observational studies and 1 randomized control trial) were identified and incorporated into the meta-analysis. The use of early angiography was associated with decreased short term (OR=0.46, 95% CI=0.36-0.56, P<0.001) and long term (OR=0.59, 95%CI=0.44-0.74, P<0.001) mortality. Early angiography was also shown to be associated with improved neurological outcomes on discharge (OR=2.00, 95% CI=1.50-2.49, P<0.001) as well as on follow-up (OR=1.48, 95% CI=1.06-1.90, P<0.001).
Conclusion : The results of our meta-analysis support the use of early coronary angiography in out of hospital cardiac-arrest patients presenting without ST-segment elevation on the post-resuscitation electrocardiogram. However, given the low level of evidence of available studies, future guideline changes should be directed by the results of large-scale randomized clinical trials on the subject matter.
Four-year experience of providing mobile extracorporeal life support to out-of-center patients within a suprainstitutional network-Outcome of 160 consecutively treated patients.
Aubin H , Petrov G, Dalyanoglu H, Richter M, Saeed D, Akhyari P, Kindgen-Milles D, Albert A, Lichtenberg A. | Resuscitation. 2017 Dec;121:151-157
Original research article
Introduction : Mobile extracorporeal life support (ECLS) may soon be on the verge to become a fundamental part of emergency medicine. Here, we report on our four-year experience of providing advanced mechanical circulatory support for out-of-center patients within the Düsseldorf ECLS Network (DELSN).
Méthode : This retrospective cohort study analyses the outcome of 160 patients with refractory circulatory failure consecutively treated with mobile veno-arterial extracorporeal membrane oxygenation (vaECMO) between July 2011 and October 2015 within the DELSN.
Résultats : Out of the 160 patients (56±16years, vaECMO initiation under CPR 68%), 59 patients (36%) survived to primary discharge, with 50 patients (31%) still alive after a median follow-up of 1.74 years. Time-discrete mortality was highest during the first 24h. There was no difference between survivors and non-survivors regarding age, etiology of circulatory failure, presence of CPR during implantation or distance to implantation site. Incidence of kidney injury requiring dialysis (61% vs. 24%, p<0.0001), shock liver (27% vs. 12%, p=0.031) and visceral ischemia (19% vs. 3%, p=0.013) were the only complications increased in non-survivors. Subgroup analysis showed no significant outcome difference for ECPR vs. non-ECPR patients. Outcome was significantly impaired with initial neuron-specific enolase ≥45.4μg/L (AUC 0.75, p<0.0001) and lactate ≥5.5mmol/L (AUC 0.70, p<0.0001). Program-year-dependent in-center mortality showed an increasing trend, while program-year-dependent follow-up mortality decreased over time.
Conclusion : This study illustrates that regional mobile ECLS rescue therapy can be provided with encouraging outcomes, although patient selection criteria and early outcome parameters reflecting on therapy success or futility still need to be refined.
Recurrent out-of-hospital cardiac arrest.
Nehme Z , Andrew E, Nair R, Bernard S, Smith K. | Resuscitation. 2017 Dec;121:158-165
Original research article
Introduction : Little is known about the burden of recurrent out-of-hospital cardiac arrest (OHCA) episodes in initial survivors of OHCA. We sought to investigate the frequency of recurrent OHCA, describe time-to-event trends, and establish baseline predictors of occurrence.
Méthode : Between January 2000 and June 2015, we included consecutive OHCA survivors to hospital discharge from the Victorian Ambulance Cardiac Arrest Registry. Patient identifiers were used to match index and recurrent episodes of OHCA, and death records from a government database. Kaplan-Meier curves and a Cox proportional-hazards model were used to estimate the long-term risk of recurrent OHCA and identify index characteristics associated with their occurrence.
Résultats : Among 3581 survivors, 214 (6.0%) experienced a recurrent OHCA over a median time-at-risk of 5.0 years (interquartile range [IQR]: 2.0, 8.1). The median age at recurrent OHCA was 69 years, 72.9% were male, and 92.0% of events were fatal. Fatal recurrent OHCA episodes accounted for more than one-quarter of all deaths at follow-up. The probability of recurrent OHCA at 1, 5, 10 and 15 years was 2.4% (95% CI: 2.0%, 3.0%), 6.0% (95% CI: 5.2%, 6.9%), 8.4% (95% CI: 7.3%, 9.8%), and 11.2% (95% CI: 9.1%, 13.8%), respectively. In the multivariable model, the following baseline predictors were significantly associated with recurrent OHCA: respiratory (HR 1.88, 95% CI: 1.02, 3.47; p=0.045) or overdose/poisoning aetiology (HR 2.47, 95% CI: 1.08, 5.62; p=0.03), diabetes (HR 1.92, 95% CI: 1.17, 3.14, p=0.01), heart failure (HR 2.22, 95% CI: 1.28, 3.85; p=0.005), and renal insufficiency (HR 2.43, 95% CI: 1.23, 4.82; p=0.01). The risk of recurrent OHCA did not decline over the study period (per year increase: HR 0.97, 95% CI: 0.93, 1.01; p=0.13).
Conclusion : Recurrent OHCA episodes occur frequently in OHCA survivors, and could account for as many as one-quarter of all deaths at follow-up. Index characteristics may help to identify at-risk patients.
Prehospital cooling to improve successful targeted temperature management after cardiac arrest: A randomized controlled trial..
Scales DC , Cheskes S, Verbeek PR, Pinto R, Austin D, Brooks SC, Dainty KN, Goncharenko K, Mamdani M, Thorpe KE, Morrison LJ; Strategies for Post-Arrest Care SPARC Network. | Resuscitation. 2017 Dec;121:187-194
DOI: https://doi.org/10.1016/j.resuscitation.2017.10.002 | Télécharger l'article au format
Original research article
Introduction : argeted temperature management (TTM) improves survival with good neurological outcome after out-of-hospital cardiac arrest (OHCA), but is delivered inconsistently and often with delay.
Méthode : To determine if prehospital cooling by paramedics leads to higher rates of 'successful TTM', defined as achieving a target temperature of 32-34°C within 6h of hospital arrival. METHODS: Pragmatic RCT comparing prehospital cooling (surface ice packs, cold saline infusion, wristband reminders) initiated 5min after return of spontaneous circulation (ROSC) versus usual resuscitation and transport. The primary outcome was rate of 'successful TTM'; secondary outcomes were rates of applying TTM in hospital, survival with good neurological outcome, pulmonary edema in emergency department, and re-arrest during transport.
Résultats : 585 patients were randomized to receive prehospital cooling (n=279) or control (n=306). Prehospital cooling did not increase rates of 'successful TTM' (30% vs 25%; RR, 1.17; 95% confidence interval [CI] 0.91-1.52; p=0.22), but increased rates of applying TTM in hospital (68% vs 56%; RR, 1.21; 95%CI 1.07-1.37; p=0.003). Survival with good neurological outcome (29% vs 26%; RR, 1.13, 95%CI 0.87-1.47; p=0.37) was similar. Prehospital cooling was not associated with re-arrest during transport (7.5% vs 8.2%; RR, 0.94; 95%CI 0.54-1.63; p=0.83) but was associated with decreased incidence of pulmonary edema in emergency department (12% vs 18%; RR, 0.66; 95%CI 0.44-0.99; p=0.04).
Conclusion : Prehospital cooling initiated 5min after ROSC did not increase rates of achieving a target temperature of 32-34°C within 6h of hospital arrival but was safe and increased application of TTM in hospital.
Head and thorax elevation during active compression decompression cardiopulmonary resuscitation with an impedance threshold device improves cerebral perfusion in a swine model of prolonged cardiac arrest.
Moore JC , Segal N, Lick MC, Dodd KW, Salverda BJ, Hinke MB, Robinson AE, Debaty G, Lurie KG. | Resuscitation. 2017 Dec;121:195-200
Original research article
Introduction : As most cardiopulmonary resuscitation (CPR) efforts last longer than 15min, the aim of this study was to compare brain blood flow between the Head Up (HUP) and supine (SUP) body positions during a prolonged CPR effort of 15min, using active compression-decompression (ACD) CPR and impedance threshold device (ITD) in a swine model of cardiac arrest.
Méthode : Ventricular fibrillation (VF) was induced in anesthetized pigs. After 8min of untreated VF followed by 2min of ACD-CPR+ITD in the SUP position, pigs were randomized to 18min of continuous ACD-CPR+ITD in either a 30° HUP or SUP position. Microspheres were injected before VF and then 5 and 15min after start of CPR.
Résultats : The mean blood flow (ml/min/g, mean±SD) to the brain after 15min of CPR was 0.42±0.05 in the HUP group (n=8) and 0.21±0.04 SUP (n=10), respectively, (p<0.01). The HUP group also had statistically significantly lower intracranial pressures and higher calculated cerebral perfusion pressures after 5, 15, 19 (before adrenaline) and 20 (after adrenaline) minutes of HUT versus SUP CPR.
Conclusion : After prolonged ACD-CPR+ITD in the HUP position, brain blood flow was 2-fold higher versus the SUP position. These positive findings provide strong pre-clinical support to proceed with a clinical evaluation of elevation of the head and thorax during ACD-CPR+ITD in humans in cardiac arrest.
Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections.
Gerber JS , Ross RK, Bryan M, Localio AR, Szymczak JE, Wasserman R, Barkman D, Odeniyi F, Conaboy K, Bell L, Zaoutis TE, Fiks AG. | JAMA. 2017 Dec 19;318(23):2325-2336
Introduction : Acute respiratory tract infections account for the majority of antibiotic exposure in children, and broad-spectrum antibiotic prescribing for acute respiratory tract infections is increasing. It is not clear whether broad-spectrum treatment is associated with improved outcomes compared with narrow-spectrum treatment.
To compare the effectiveness of broad-spectrum and narrow-spectrum antibiotic treatment for acute respiratory tract infections in children.
Méthode : A retrospective cohort study assessing clinical outcomes and a prospective cohort study assessing patient-centered outcomes of children between the ages of 6 months and 12 years diagnosed with an acute respiratory tract infection and prescribed an oral antibiotic between January 2015 and April 2016 in a network of 31 pediatric primary care practices in Pennsylvania and New Jersey. Stratified and propensity score-matched analyses to account for confounding by clinician and by patient-level characteristics, respectively, were implemented for both cohorts. Broad-spectrum antibiotics vs narrow-spectrum antibiotics. In the retrospective cohort, the primary outcomes were treatment failure and adverse events 14 days after diagnosis. In the prospective cohort, the primary outcomes were quality of life, other patient-centered outcomes, and patient-reported adverse events.
Résultats : Of 30 159 children in the retrospective cohort (19 179 with acute otitis media; 6746, group A streptococcal pharyngitis; and 4234, acute sinusitis), 4307 (14%) were prescribed broad-spectrum antibiotics including amoxicillin-clavulanate, cephalosporins, and macrolides. Broad-spectrum treatment was not associated with a lower rate of treatment failure (3.4% for broad-spectrum antibiotics vs 3.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 0.3% [95% CI, -0.4% to 0.9%]). Of 2472 children enrolled in the prospective cohort (1100 with acute otitis media; 705, group A streptococcal pharyngitis; and 667, acute sinusitis), 868 (35%) were prescribed broad-spectrum antibiotics. Broad-spectrum antibiotics were associated with a slightly worse child quality of life (score of 90.2 for broad-spectrum antibiotics vs 91.5 for narrow-spectrum antibiotics; score difference for full matched analysis, -1.4% [95% CI, -2.4% to -0.4%]) but not with other patient-centered outcomes. Broad-spectrum treatment was associated with a higher risk of adverse events documented by the clinician (3.7% for broad-spectrum antibiotics vs 2.7% for narrow-spectrum antibiotics; risk difference for full matched analysis, 1.1% [95% CI, 0.4% to 1.8%]) and reported by the patient (35.6% for broad-spectrum antibiotics vs 25.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 12.2% [95% CI, 7.3% to 17.2%]).
Conclusion : Among children with acute respiratory tract infections, broad-spectrum antibiotics were not associated with better clinical or patient-centered outcomes compared with narrow-spectrum antibiotics, and were associated with higher rates of adverse events. These data support the use of narrow-spectrum antibiotics for most children with acute respiratory tract infections.
Conclusion (proposition de traduction) : Chez les enfants atteints d'infections respiratoires aiguës, les antibiotiques à large spectre n'étaient pas associés à de meilleurs résultats cliniques ou meilleurs taux améliorations comparativement aux antibiotiques à spectre étroit et étaient associés à des taux plus élevés d'effets indésirables. Ces données appuient l'utilisation d'antibiotiques à spectre étroit pour la plupart des enfants souffrant d'infections respiratoires aiguës.
Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.
Cifu AS , Davis AM. | JAMA. 2017 Dec 5;318(21):2132-2134
Editorial : Hypertension is a leading risk factor for mortality and disability. Recent estimates are that 874 million adults worldwide have an SBP of 140 mm Hg or higher. With its association with CVD, stroke (cerebrovascular accident [CVA]), heart failure, and chronic kidney disease (CKD), hypertension is second only to cigarette smoking as a preventable cause of death in the United States. Given demographic trends and the increasing prevalence of hypertension with increasing age (79% of men and 85% of women >75 years old have hypertension), the consequences of hypertension are expected to increase.
Conclusion : Guideline
Conclusion (proposition de traduction) : -
Valproic acid decreases brain lesion size and improves neurologic recovery in swine subjected to traumatic brain injury, hemorrhagic shock, and polytrauma.
Nikolian VC , Georgoff PE, Pai MP, Dennahy IS, Chtraklin K, Eidy H, Ghandour MH, Han Y, Srinivasan A, Li Y, Alam HB. | J Trauma Acute Care Surg. 2017 Dec;83(6):1066-1073
Introduction : We have previously shown that treatment with valproic acid (VPA) decreases brain lesion size in swine models of traumatic brain injury (TBI) and controlled hemorrhage. To translate this treatment into clinical practice, validation of drug efficacy and evaluation of pharmacologic properties in clinically realistic models of injury are necessary. In this study, we evaluate neurologic outcomes and perform pharmacokinetic analysis of a single dose of VPA in swine subjected to TBI, hemorrhagic shock, and visceral hemorrhage.
Méthode : Yorkshire swine (n = 5/cohort) were subjected to TBI, hemorrhagic shock, and polytrauma (liver and spleen injury, rib fracture, and rectus abdominis crush). Animals remained in hypovolemic shock for 2 hours before resuscitation with isotonic sodium chloride solution (ISCS; volume = 3× hemorrhage) or ISCS + VPA (150 mg/kg). Neurologic severity scores were assessed daily for 30 days, and brain lesion size was measured via magnetic resonance imaging on postinjury days (PID) 3 and 10. Serum samples were collected for pharmacokinetic analysis.
Résultats : Shock severity and response to resuscitation were similar in both groups. Valproic acid-treated animals demonstrated significantly less neurologic impairment between PID 1 to 5 and smaller brain lesions on PID 3 (mean lesion size ± SEM, mm: ISCS = 4,956 ± 1,511 versus ISCS + VPA = 828 ± 279; p = 0.047). No significant difference in lesion size was identified between groups at PID 10 and all animals recovered to baseline neurologic function during the 30-day observation period. Animals treated with VPA had faster neurocognitive recovery (days to initiation of testing, mean ± SD: ISCS = 6.2 ± 1.6 vs ISCS + VPA = 3.6 ± 1.5; p = 0.002; days to task mastery: ISCS = 7.0 ± 1.0 vs ISCS + VPA = 4.8 ± 0.5; p = 0.03). The mean ± SD maximum VPA concentrations, area under the curve, and half-life were 145 ± 38.2 mg/L, 616 ± 150 hour·mg/L, and 1.70 ± 0.12 hours.
Conclusion : In swine subjected to TBI, hemorrhagic shock, and polytrauma, VPA treatment is safe, decreases brain lesion size, and reduces neurologic injury compared to resuscitation with ISCS alone. These benefits are achieved at clinically translatable serum concentrations of VPA.
Outcome differences in adolescent blunt severe polytrauma patients managed at pediatric versus adult trauma centers.
Rogers AT , Gross BW, Cook AD, Rinehart CD, Lynch CA, Bradburn EH, Heinle CC, Jammula S, Rogers FB. | J Trauma Acute Care Surg. 2017 Dec;83(6):1082-1087
Introduction : Previous research suggests adolescent trauma patients can be managed equally effectively at pediatric and adult trauma centers. We sought to determine whether this association would be upheld for adolescent severe polytrauma patients. We hypothesized that no difference in adjusted outcomes would be observed between pediatric trauma centers (PTCs) and adult trauma centers (ATCs) for this population.
Méthode : All severely injured adolescent (aged 12-17 years) polytrauma patients were extracted from the Pennsylvania Trauma Outcomes Study database from 2003 to 2015. Polytrauma was defined as an Abbreviated Injury Scale (AIS) score ≥3 for two or more AIS-defined body regions. Dead on arrival, transfer, and penetrating trauma patients were excluded from analysis. ATC were defined as adult-only centers, whereas standalone pediatric hospitals and adult centers with pediatric affiliation were considered PTC. Multilevel mixed-effects logistic regression models assessed the adjusted impact of center type on mortality and total complications while controlling for age, shock index, Injury Severity Score, Glasgow Coma Scale motor score, trauma center level, case volume, and injury year. A generalized linear mixed model characterized functional status at discharge (FSD) while controlling for the same variables.
Résultats : A total of 1,606 patients met inclusion criteria (PTC: 868 [54.1%]; ATC: 738 [45.9%]), 139 (8.66%) of which died in-hospital. No significant difference in mortality (adjusted odds ratio [AOR]: 1.10, 95% CI 0.54-2.24; p = 0.794; area under the receiver operating characteristic: 0.89) was observed between designations in adjusted analysis; however, FSD (AOR: 0.38, 95% CI 0.15-0.97; p = 0.043) was found to be lower and total complication trends higher (AOR: 1.78, 95% CI 0.98-3.32; p = 0.058) at PTC for adolescent polytrauma patients.
Conclusion : Contrary to existing literature on adolescent trauma patients, our results suggest patients aged 12-17 presenting with polytrauma may experience improved overall outcomes when managed at adult compared to pediatric trauma centers.
Parathyroid hormone as a marker for hypoperfusion in trauma: A prospective observational study.
Fligor SC , Love KM, Collier BR, Lollar DI, Hamill ME, Benson AD, Bradburn EH. | J Trauma Acute Care Surg. 2017 Dec;83(6):1142-1147
Introduction : Hyperparathyroidism is common in critical illness. Intact parathyroid hormone has a half-life of 3 minutes to 5 minutes due to rapid clearance by the liver, kidneys, and bone. In hemorrhagic shock, decreased clearance may occur, thus making parathyroid hormone a potential early marker for hypoperfusion. We hypothesized that early hyperparathyroidism predicts mortality and transfusion in trauma patients.
Méthode : A prospective observational study was performed at a Level I trauma center in consecutive adult patients receiving the highest level of trauma team activation. Parathyroid hormone and lactic acid were added to the standard laboratory panel drawn in the trauma bay on arrival, before the administration of any blood products. The primary outcomes assessed were transfusion in 24 hours and mortality.
Résultats : Forty-six patients were included. Median age was 47 years, 82.6% were men, 15.2% suffered penetrating trauma, and 21.7% died. Patients who were transfused in the first 24 hours (n = 17) had higher parathyroid hormone (182.0 pg/mL vs. 73.5 pg/mL, p < 0.001) and lactic acid (4.6 pg/mL vs. 2.3 pg/mL, p = 0.001). Patients who did not survive to discharge (n = 10) also had higher parathyroid hormone (180.3 pg/mL vs. 79.3 pg/mL, p < 0.001) and lactic acid (5.5 mmol/L vs. 2.5 mmol/L, p = 0.001). For predicting transfusion in the first 24 hours, parathyroid hormone has an area under the receiver operating characteristic curve of 0.876 compared with 0.793 for lactic acid and 0.734 for systolic blood pressure. Parathyroid hormone has an area under the receiver operating characteristic curve of 0.875 for predicting mortality compared with 0.835 for lactic acid and 0.732 for systolic blood pressure.
Conclusion : Hyperparathyroidism on hospital arrival in trauma patients predicts mortality and transfusion in the first 24 hours. Further research should investigate the value of parathyroid hormone as an endpoint for resuscitation.
The trauma center is too late: Major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock.
Scerbo MH , Holcomb JB, Taub E, Gates K, Love JD, Wade CE, Cotton BA. | J Trauma Acute Care Surg. 2017 Dec;83(6):1165-1172
Introduction : To date, no civilian studies have demonstrated that pre-hospital (PH) tourniquets improve survival. We hypothesized that late, trauma center (TC) tourniquet use would increase death from hemorrhagic shock compared to early (PH) placement.
Méthode : All patients arriving to a Level 1, urban TC between October 2008 and January 2016 with a tourniquet placed before (T-PH) or after arrival to the TC (T-TC) were evaluated. Cases were assigned the following designations: indicated (absolute indication [vascular injury requiring repair/ligation, operation within 2 hours for extremity injury, or traumatic amputation] or relative indication [major musculoskeletal/soft tissue injury requiring operation 2-8 hours after arrival, documented large blood loss]) or non-indicated. Outcomes were death from hemorrhagic shock, physiology upon arrival to the TC, and massive transfusion requirements. After univariate analysis, logistic regression was carried out to assess independent predictors of death from hemorrhagic shock.
Résultats : A total of 306 patients received 326 tourniquets for injuries to 157 upper and 147 lower extremities. Two hundred eighty-one (92%) had an indication for placement. Seventy percent of patients had a blunt mechanism of injury. T-TC patients arrived with a lower systolic blood pressure (SBP, 101 [86, 123] vs. 125 [100, 145] mm Hg, p < 0.001), received more transfusions in the first hour of arrival (55% vs. 34%, p = 0.02), and had a greater mortality from hemorrhagic shock (14% vs. 3.0%, p = 0.01). When controlling for year of admission, mechanism of injury and shock upon arrival (SBP ≤90 mm Hg or HR ≥120 bpm or base deficit ≤ 4) indicated T-TC had a 4.5-fold increased odds of death compared to T-PH (OR 4.5, 95% CI 1.23-16.4, p = 0.02).
Conclusion : Waiting until TC arrival to control hemorrhage with a tourniquet was associated with worsened blood pressure and increased transfusion within the first hour of arrival. In routine civilian trauma patients, delaying to T-TC was associated with 4.5-fold increased odds of mortality from hemorrhagic shock.
Commentaire : Confirmation s'il en était besoin de l'intérêt d'arrêter une hémorragie... même en pré-hospitalier !
Big for small: Validating brain injury guidelines in pediatric traumatic brain injury.
Azim A , Jehan FS, Rhee P, O'Keeffe T, Tang A, Vercruysse G, Kulvatunyou N, Latifi R, Joseph B. | J Trauma Acute Care Surg. 2017 Dec;83(6):1200-1204
Introduction : Brain injury guidelines (BIG) were developed to reduce overutilization of neurosurgical consultation (NC) as well as computed tomography (CT) imaging. Currently, BIG have been successfully applied to adult populations, but the value of implementing these guidelines among pediatric patients remains unassessed. Therefore, the aim of this study was to evaluate the established BIG (BIG-1 category) for managing pediatric traumatic brain injury (TBI) patients with intracranial hemorrhage (ICH) without NC (no-NC).
Méthode : We prospectively implemented the BIG-1 category (normal neurologic examination, ICH ≤ 4 mm limited to one location, no skull fracture) to identify pediatric TBI patients (age, ≤ 21 years) that were to be managed no-NC. Propensity score matching was performed to match these no-NC patients to a similar cohort of patients managed with NC before the implementation of BIG in a 1:1 ratio for demographics, severity of injury, and type as well as size of ICH. Our primary outcome measure was need for neurosurgical intervention.
Résultats : A total of 405 pediatric TBI patients were enrolled, of which 160 (NC, 80; no-NC, 80) were propensity score matched. The mean age was 9.03 ± 7.47 years, 62.1% (n = 85) were male, the median Glasgow Coma Scale score was 15 (13-15), and the median head Abbreviated Injury Scale score was 2 (2-3). A subanalysis based on stratifying patients by age groups showed a decreased in the use of repeat head CT (p = 0.02) in the no-NC group, with no difference in progression (p = 0.34) and the need for neurosurgical intervention (p = 0.9) compared with the NC group.
Discussion : The BIG can be safely and effectively implemented in pediatric TBI patients. Reducing repeat head CT in pediatric patients has long-term sequelae. Likewise, adhering to the guidelines helps in reducing radiation exposure across all age groups.
Conclusion : The brain injury guidelines (BIG) can be safely and effectively implemented in pediatric traumatic brain injury patients. Pediatric patients with mild traumatic brain injury can be safely and independently managed by acute care surgeons. Furthermore, implementation of the brain injury guidelines guidelines is associated with a significant decrease in repeat head computed tomography scans without impacting clinical outcomes. Reducing repeat head computed tomography in pediatric patients has long-term sequelae. In effect, adherence to these guidelines helps in reducing radiation exposure across all age groups and also limits the injudicious use of hospital resources.
Conclusion (proposition de traduction) : Les recommandations sur les lésions cérébrales peuvent être mises en œuvre de manière sûre et efficace chez les patients pédiatriques traumatisés cérébraux. Les patients pédiatriques présentant une lésion cérébrale traumatique légère peuvent être pris en charge de manière sûre et indépendante par des chirurgiens en soins de courte durée. En outre, la mise en œuvre des recommandations sur les lésions cérébrales est associée à une diminution significative du nombre de tomodensitométries répétées sans incidence sur les résultats cliniques. Réduire la répétition de la tomodensitométrie chez les patients pédiatriques a des séquelles à long terme. En effet, le respect de ces directives contribue à réduire l'exposition aux rayonnements dans tous les groupes d'âge et limite également l'utilisation peu judicieuse des ressources hospitalières.
The French emergency medical services after the Paris and Nice terrorist attacks: what have we learnt?.
Carli P , Pons F, Levraut J, Millet B, Tourtier JP, Ludes B, Lafont A, Riou B. | Lancet. 2017 Dec 16;390(10113):2735-2738
Editorial : An appropriate medical response does not only save lives but can improve the resilience of the population. It breaks the vicious circle between attacks and repression, provides a positive message of hope and strength, and mobilises the whole country. The medical response is an essential component of the response to terrorist attacks and is in fundamental opposition to terrorism’s main objectives of aggression, fear, and panic. The medical community promotes organisation and quality of care for all victims, as close as those provided for a unique victim and including care providers and even terrorists. Because the war against terrorism is an international war, the medical response must be also international and we must share our experience and emergency plans to be able to better serve all of humanity.
Conclusion : -
Conclusion (proposition de traduction) : -
Sécurité de l'imagerie par résonance magnétique chez les patients porteurs de dispositifs cardiaques.
Nazarian S , Hansford R, Rahsepar AA, Weltin V, McVeigh D, Gucuk Ipek E, Kwan A, Berger RD, Calkins H, Lardo AC, Kraut MA, Kamel IR, Zimmerman SL, Halperin HR. | N Engl J Med. 2017 Dec 28;377(26):2555-2564
Introduction : Patients who have pacemakers or defibrillators are often denied the opportunity to undergo magnetic resonance imaging (MRI) because of safety concerns, unless the devices meet certain criteria specified by the Food and Drug Administration (termed
Méthode : We performed a prospective, nonrandomized study to assess the safety of MRI at a magnetic field strength of 1.5 Tesla in 1509 patients who had a pacemaker (58%) or an implantable cardioverter-defibrillator (42%) that was not considered to be MRI-conditional (termed a
Résultats : No long-term clinically significant adverse events were reported. In nine MRI examinations (0.4%; 95% confidence interval, 0.2 to 0.7), the patient's device reset to a backup mode. The reset was transient in eight of the nine examinations. In one case, a pacemaker with less than 1 month left of battery life reset to ventricular inhibited pacing and could not be reprogrammed; the device was subsequently replaced. The most common notable change in device parameters (>50% change from baseline) immediately after MRI was a decrease in P-wave amplitude, which occurred in 1% of the patients. At long-term follow-up (results of which were available for 63% of the patients), the most common notable changes from baseline were decreases in P-wave amplitude (in 4% of the patients), increases in atrial capture threshold (4%), increases in right ventricular capture threshold (4%), and increases in left ventricular capture threshold (3%). The observed changes in lead parameters were not clinically significant and did not require device revision or reprogramming.
Conclusion : We evaluated the safety of MRI, performed with the use of a prespecified safety protocol, in 1509 patients who had a legacy pacemaker or a legacy implantable cardioverter-defibrillator system. No long-term clinically significant adverse events were reported.
Conclusion (proposition de traduction) : Nous avons évalué la sécurité de l'IRM, réalisée avec l'utilisation d'un protocole de sécurité prédéfini, chez 1509 patients qui étaient porteur d’un stimulateur cardiaque ou d’un défibrillateur implantable. Aucun événement indésirable, cliniquement significatif à long terme, n'a été rapporté.
Comparison of extracorporeal and conventional cardiopulmonary resuscitation: A meta-analysis of 2 260 patients with cardiac arrest.
Wang GN , Chen XF, Qiao L, Mei Y, Lv JR, Huang XH, Shen B, Zhang JS. | World J Emerg Med. 2017 Dec;8(1):5-11
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2017.01.001 | Télécharger l'article au format
Introduction : This meta-analysis aimed to determine whether extracorporeal cardiopulmonary resuscitation (ECPR), compared with conventional cardiopulmonary resuscitation (CCPR), improves outcomes in adult patients with cardiac arrest (CA).
Méthode : PubMed, EMBASE, Web of Science, and China Biological Medicine Database were searched for relevant articles. The baseline information and outcome data (survival, good neurological outcome at discharge, at 3-6 months, and at 1 year after CA) were collected and extracted by two authors. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using Review Manager 5.3.
Résultats : In six studies 2 260 patients were enrolled to study the survival rate to discharge and long-term neurological outcome published since 2000. A significant effect of ECPR was observed on survival rate to discharge compared to CCPR in CA patients (RR 2.37, 95%CI 1.63-3.45, P<0.001), and patients who underwent ECPR had a better long-term neurological outcome than those who received CCPR (RR 2.79, 95%CI 1.96-3.97, P<0.001). In subgroup analysis, there was a significant difference in survival to discharge favoring ECPR over CCPR group in OHCA patients (RR 2.69, 95%CI 1.48-4.91, P=0.001). However, no significant difference was found in IHCA patients (RR 1.84, 95%CI 0.91-3.73, P=0.09).
Conclusion : ECPR showed a beneficial effect on survival rate to discharge and long-term neurological outcome over CCPR in adult patients with CA.