Bibliographie de Médecine d'Urgence

Mois de février 2021


Academic Emergency Medicine

Rapid Administration of Methoxyflurane to Patients in the Emergency Department (RAMPED) Study: A Randomized Controlled Trial of Methoxyflurane Versus Standard Care.
Brichko L, Gaddam R, Roman C, O'Reilly G, Luckhoff C, Jennings P, Smit V, Cameron P, Mitra B. | Acad Emerg Med. 2021 Feb;28(2):164-171
DOI: https://doi.org/10.1111/acem.14144
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : The objective was to evaluate the effectiveness of methoxyflurane versus standard care for the initial management of severe pain among adult emergency department (ED) patients.

Méthode : This randomized parallel-group open-label phase IV trial of methoxyflurane was conducted in a tertiary hospital ED setting in Australia. Inclusion criteria required adult patients to have an initial pain score ≥ 8 on the 11-point Numerical Rating Scale (NRS). Patients were randomized 1:1 to receive either inhaled methoxyflurane (3 mL) or standard analgesic treatment at ED triage. The primary outcome was the proportion of patients achieving clinically substantial pain reduction, defined as a ≥50% drop in the pain score at 30 minutes. Secondary outcomes included the pain score at multiple time points (15, 30, 60, 90 minutes) and the difference in the proportion of patients achieving a >2-point reduction on the NRS.

Résultats : There were 120 patients randomized and analyzed between September 4, 2019, and January 16, 2020. The primary outcome was achieved in six (10%) patients in the methoxyflurane arm and three (5%) in the standard care arm (p = 0.49). A higher proportion of patients in the methoxyflurane arm reported a >2-point drop on the NRS at all time points (17% vs. 5% at 15 minutes, 25% vs. 9% at 30 minutes, 30% vs. 10% at 60 minutes, and 33% vs. 13% at 90 minutes). Methoxyflurane use was also associated with lower median pain scores at all time points.

Conclusion : Initial management with inhaled methoxyflurane in the ED did not achieve the prespecified substantial reduction in pain, but was associated with clinically significant lower pain scores compared to standard therapy.

Conclusion (proposition de traduction) : La prise en charge initiale avec du méthoxyflurane inhalé aux urgences n'a pas permis d'obtenir la réduction substantielle prédéfinie de la douleur, mais a été associée à des scores de douleur plus faibles cliniquement significatifs par rapport au traitement standard.

Machine Learning Versus Usual Care for Diagnostic and Prognostic Prediction in the Emergency Department: A Systematic Review.
Kareemi H, Vaillancourt C, Rosenberg H, Fournier K, Yadav K. | Acad Emerg Med. 2021 Feb;28(2):184-196.
DOI: https://doi.org/10.1111/acem.14190
Keywords: Aucun

Original contribution

Introduction : Having shown promise in other medical fields, we sought to determine whether machine learning (ML) models perform better than usual care in diagnostic and prognostic prediction for emergency department (ED) patients.

Méthode : In this systematic review, we searched MEDLINE, Embase, Central, and CINAHL from inception to October 17, 2019. We included studies comparing diagnostic and prognostic prediction of ED patients by ML models to usual care methods (triage-based scores, clinical prediction tools, clinician judgment) using predictor variables readily available to ED clinicians. We extracted commonly reported performance metrics of model discrimination and classification.

Résultats : The search yielded 1,656 unique records, of which 23 studies involving 16,274,647 patients were included. In all seven diagnostic studies, ML models outperformed usual care in all performance metrics. In six studies assessing in-hospital mortality, the best-performing ML models had better discrimination (area under the receiver operating characteristic curve [AUROC] =0.74-0.94) than any clinical decision tool (AUROC =0.68-0.81). In four studies assessing hospitalization, ML models had better discrimination (AUROC =0.80-0.83) than triage-based scores (AUROC =0.68-0.82). Clinical heterogeneity precluded meta-analysis. Most studies had high risk of bias due to lack of external validation, low event rates, and insufficient reporting of calibration.

Conclusion : Our review suggests that ML may have better prediction performance than usual care for ED patients with a variety of clinical presentations and outcomes. However, prediction model reporting guidelines should be followed to provide clinically applicable data. Interventional trials are needed to assess the impact of ML models on patient-centered outcomes.

Conclusion (proposition de traduction) : Notre étude suggère que l'apprentissage automatique (Machine learning) pourrait avoir de meilleures performances prédictive que les soins habituels pour les patients des services d'urgence présentant une variété de présentations et de résultats cliniques. Toutefois, il faut suivre les lignes directrices relatives à la présentation de rapports sur les modèles de prévision pour fournir des données cliniquement applicables. Des essais interventionnels sont nécessaires pour évaluer l'impact des modèles d'apprentissage automatique sur les résultats centrés sur le patient.

Commentaire : « Machine learning » traduit par « apprentissage automatique » (ou apprentissage statistique) est un champ d'étude de l'intelligence artificielle qui se fonde sur des approches statistiques pour donner aux ordinateurs la capacité d'apprendre à partir de données, c'est-à-dire d'améliorer leurs performances à résoudre des tâches sans être explicitement programmés pour chacune.

Outpatient Treatment of Low-risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review.
Maughan BC, Frueh L, McDonagh MS, Casciere B, Kline JA. | Acad Emerg Med. 2021 Feb;28(2):226-239
DOI: https://doi.org/10.1111/acem.14108
Keywords: Aucun

SYSTEMATIC REVIEWS (WITH OR WITHOUT META‐ANALYSES)

Introduction : Clinical guidelines have supported outpatient treatment of low-risk pulmonary embolism (PE) since 2014, but adoption of this practice has been slow. Direct oral anticoagulant (DOAC) therapy for venous thromboembolism (VTE) is now as common as vitamin K antagonist treatment, but data are sparse regarding outcomes for patients with low-risk PE treated with DOACs as outpatients. We conducted a systematic review of literature on outcomes of outpatient management for PE, including comparisons to inpatient treatment and differences by anticoagulant class.

Méthode : We searched Medline, Embase, PubMed, CENTRAL, clinicaltrials.gov, and ICTRN for studies published from January 1980 through February 2019 using a predefined strategy developed with a medical librarian. We included English-language randomized controlled trials (RCTs) and prospective nonrandomized trials (NRTs) of adult patients diagnosed with acute, symptomatic PE, and discharged from the emergency department or within 48 hours. Our primary outcome included four major adverse outcomes (all-cause mortality, PE-related mortality, recurrent VTE, and major bleeding) within 30 and 90 days. A preplanned subanalysis of high-quality studies assessed outcomes associated with different anticoagulation treatment classes.

Résultats : Our initial search identified 6,818 records, of which 12 studies (four RCT, eight NRT) with a total of 3,191 patients were included in the review. All RCTs and six NRTs were determined to have low to moderate risk of bias and were classified as high quality. Outpatients in these studies (n = 1,814) had rates of 90-day major adverse outcomes below 1%, including all-cause mortality (0.7%, 95% confidence interval [CI] = 0.4% to 1.2%), PE-related mortality (0.06%, 95% CI = 0.01% to 0.3%), recurrent VTE (0.8%, 95% CI = 0.5% to 1.4%), and major bleeding (0.8%, 95% CI = 0.5% to 1.4%). Exploratory analysis revealed no association between anticoagulant treatment class and rates of major adverse outcomes.

Conclusion : Among patients with low-risk pumonary embolism treated as outpatients, few patients experienced major adverse outcomes such as mortality, recurrent venous thromboembolism, or major bleeding within 90 days.

Conclusion (proposition de traduction) : Parmi les patients présentant une embolie pulmonaire à faible risque traités en ambulatoire, peu de patients ont présenté des effets indésirables majeurs tels que mortalité, thrombophlébite veineuse récurrente ou des saignements majeurs dans les 90 jours.

Commentaire : Les AOD (niveau de preuve I) sont désormais le traitement de 1er choix de l'embolie pulmonaire chez les patients à risque faible ou intermédiaire-faible.
Il est recommandé d’utiliser un score clinique pronostique (PESI  , sPESI, critères HESTIA) pour identifier ces patients à faible risque des patients à risque intermédiaire de mortalité précoce (grade 1+).
Consulter les : Recommandations de bonne pratique pour la prise en charge de la maladie veineuse thromboembolique chez l’adulte. Version courte. In: Rev Mal Respir. 2019 February;36(2):249—283    Français.

Effect of Tight Glycemic Control on Patients With Ischemic Stroke.
Long B, Gottlieb M. | Acad Emerg Med. 2021 Feb;28(2):255-257
DOI: https://doi.org/10.1111/acem.14017  | Télécharger l'article au format  
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Hyperglycemia in the setting of acute ischemic strokeis associated with increased mortality and worse neuro-logic outcome.1Multiple mechanisms exist by whichhyperglycemia may worsen ischemic brain injury,including increased inflammatory stress, calciumimbalance, accumulation of reactive oxygen species,and decreased blood perfusion, but it is unclear iftreating hyperglycemia can reduce brain injury.

Conclusion : This meta-analysis suggests tight glycemic control inpatients with acute ischemic stroke increases severe or symptomatic hypoglycemia but does not improve survival or functional outcome.
Despite some limitations, this analysis suggests tight glycemic control targeting serum glucose levels of 70 to 135 mg/dL with IV insulin therapy is associated with hypoglycemia and no discernible benefit. Wehave thus assigned a color recommendation of black(harm> benefits).

Conclusion (proposition de traduction) : Cette méta-analyse suggère qu'un contrôle glycémique strict chez les patients présentant un AVC ischémique aigu augmente le risque d'hypoglycémie sévère ou symptomatique mais n'améliore pas la survie ou les résultats fonctionnels.
Malgré certaines limites, cette analyse suggère qu'un contrôle glycémique strict ciblant des taux de glycémie de 0,7 à 1,35 g/L par une insulinothérapie IV est associé à une hypoglycémie et aucun bénéfice perceptible. Nous avons donc attribué une recommandation de couleur de noir (dommage > bénéfices).

Atraumatic Versus Conventional Needles for Lumbar Puncture.
Gottlieb M, Long B. | Acad Emerg Med. 2021 Feb;28(2):258-259
DOI: https://doi.org/10.1111/acem.14061  | Télécharger l'article au format  
Keywords: Aucun

The Brass Tacks: Concise Reviews Of Published Evidence

Editorial : Post–dural puncture headache (PDPH) is one of the most common complications after an LP, occurring in approximately 11% of patients, with one study report-ing an occurrence rate of up to 36%. While PDPH has been attributed to multiple factors, needle tip design has been frequently investigated as a potential cause. It has been suggested that conventional needles may cause larger lacerations in the dural fibers compared to atraumatic needles, increasing the degree of cerebrospinal fluid leakage. However, it is important to determine whether needle tip design influences the rate of PDPH.

Conclusion : Based on the above data, atraumatic needles wereassociated with a reduced rate of PDPH with no differ-ence in failure rates. We have therefore assigned acolor recommendation of green (benefits outweighharms) to this intervention overall, with recognitionthat randomized trials from acute care environmentsare needed.

Conclusion (proposition de traduction) : Sur la base des données ci-dessus, les aiguilles atraumatiques ont été associées à un taux réduit de syndrome post-PL sans différence dans les taux d'échec. Nous avons donc attribué une recommandation de couleur verte (les avantages l'emportent sur les dommages) à cette intervention dans son ensemble, en reconnaissant que des essais randomisés provenant d'environnements de soins de courte durée sont nécessaires.

Commentaire : La SFAR et la HAS, recommandent d’utiliser une aiguille atraumatique « à extrémité non tranchante », avec introducteur, quelle que soit l’indication de la ponction lombaire réalisée, et ce chez l’adulte comme en pédiatrie.
Consulter le texte : Prévention et prise en charge des effets indésirables pouvant survenir après une ponction lombaire  . Fiche mémo. Juin 2019

American Journal of Respiratory and Critical Care Medicine

Cardiopulmonary Resuscitation-associated Lung Edema (CRALE). A Translational Study.
Magliocca A, Rezoagli E, Zani D, Manfredi M, De Giorgio D, Olivari D, Fumagalli F, Langer T, Avalli L, Grasselli G, Latini R, Pesenti A, Bellani G, Ristagno G. | Am J Respir Crit Care Med. 021 Feb 15;203(4):447-457
DOI: https://doi.org/10.1164/rccm.201912-2454oc
Keywords: acute lung injury; cardiac arrest; cardiopulmonary resuscitation; chest compression; intrathoracic pressure.

Critical Care

Introduction : Cardiopulmonary resuscitation is the cornerstone of cardiac arrest (CA) treatment. However, lung injuries associated with it have been reported.Objectives: To assess 1) the presence and characteristics of lung abnormalities induced by cardiopulmonary resuscitation and 2) the role of mechanical and manual chest compression (CC) in its development.

Méthode : This translational study included 1) a porcine model of CA and cardiopulmonary resuscitation (n = 12) and 2) a multicenter cohort of patients with out-of-hospital CA undergoing mechanical or manual CC (n = 52). Lung computed tomography performed after resuscitation was assessed qualitatively and quantitatively along with respiratory mechanics and gas exchanges.

Résultats : The lung weight in the mechanical CC group was higher compared with the manual CC group in the experimental (431 ± 127 vs. 273 ± 66, P = 0.022) and clinical study (1,208 ± 630 vs. 837 ± 306, P = 0.006). The mechanical CC group showed significantly lower oxygenation (P = 0.043) and respiratory system compliance (P < 0.001) compared with the manual CC group in the experimental study. The variation of right atrial pressure was significantly higher in the mechanical compared with the manual CC group (54 ± 11 vs. 31 ± 6 mm Hg, P = 0.001) and significantly correlated with lung weight (r = 0.686, P = 0.026) and respiratory system compliance (r = -0.634, P = 0.027). Incidence of abnormal lung density was higher in patients treated with mechanical compared with manual CC (37% vs. 8%, P = 0.018).

Conclusion : This study demonstrated the presence of cardiopulmonary resuscitation-associated lung edema in animals and in patients with out-of-hospital CA, which is more pronounced after mechanical as opposed to manual CC and correlates with higher swings of right atrial pressure during CC.

Conclusion (proposition de traduction) : Cette étude a démontré la présence d'un œdème pulmonaire associé à la réanimation cardio-pulmonaire chez les animaux et chez les patients souffrant d'un arrêt cardiaque extra-hospitalier, qui est plus prononcé après une compression thoracique mécanique par opposition à une compression thoracique manuelle et est en corrélation avec des oscillations plus élevées de la pression auriculaire droite pendant la compression thoracique.

Anaesthesia Critical Care & Pain Medicine

National incidence rate and related mortality for acute respiratory distress syndrome in France.
Papazian L, Pauly V, Hamouda I, Daviet F, Orleans V, Forel JM, Roch A, Hraiech S, Boyer L. | Anaesth Crit Care Pain Med. 2021 Feb;40(1):100795
DOI: https://doi.org/10.1016/j.accpm.2020.100795  | Télécharger l'article au format  
Keywords: ARDS; Age; Database; Epidemiology; Incidence; Mortality.

Research article

Introduction : Despite many efforts to improve mechanical ventilation strategies and the use of rescue strategies, ARDS-related mortality remains high. The primary objective of this study was to determine the incidence and 90-day mortality of ARDS patients admitted to all French ICUs following the introduction of the Berlin definition of ARDS.

Méthode : The data source for this nationwide cohort study was the French national hospital database (Programme de Médicalisation des Systèmes d'Information (PMSI)), which systematically collects administrative and medical information related to all patients hospitalised and hospital stays. Patient-level data were obtained from the PMSI database for all patients admitted to an ICU from the 1st of January 2017, through the 31st of December 2017. The inclusion criteria were as follows: ICU patients ≥ 18 years old with at least one International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) diagnosis code of J80 (ARDS), either as a primary diagnosis or a secondary diagnosis, during their ICU stay.

Résultats : A total of 12,846 ICU adult patients with ARDS were included. The crude incidence of ARDS was 24.6 per 100,000 person-years, varying with age from 6.7 per 100,000 person-years for those 18 through 40 years of age to 51.9 per 100,000 person-years for those 68 through 76 years of age. The in-hospital mortality rate was 51.1%. Day-90 mortality (day-1 being the ICU admission) was 51.2% and increased with age from 29.0% for patients 18 through 40 years of age to 69.3% for patients 77 years of age or older (p < 0.001). Only 53.9% of the survivors were transferred home directly after hospital discharge.

Conclusion : The incidence and mortality of ARDS in adults in France are higher than that generally reported in other countries.

Conclusion (proposition de traduction) : L'incidence et la mortalité du SDRA chez l'adulte en France sont plus élevées que celles généralement rapportées dans les autres pays.

The benefit of adding lidocaine to ketamine during rapid sequence endotracheal intubation in patients with septic shock: A randomised controlled trial.
Fathy S, Hasanin A, Mostafa M, Ramzy E, Sarhan K, Almenesey T, Safina AG, Hosny O, Hamden GA, Gado AA, Mokhtar A. | Anaesth Crit Care Pain Med. 2021 Feb;40(1):100731
DOI: https://doi.org/10.1016/j.accpm.2020.06.017
Keywords: Anaesthesia; Endotracheal intubation; Ketamine; Lidocaine; Septic shock.

Research article

Introduction : Patients with septic shock commonly require endotracheal intubation under general anaesthesia in the operating theatre, the emergency department, and the intensive care unit. Hypotension is a serious complication after induction of general anaesthesia, especially in patients with circulatory failure. No randomised controlled trials had previously investigated protocols for induction of anaesthesia in septic shock patients. The aim of the current work is to compare two protocols, lidocaine-ketamine combination versus ketamine full-dose for rapid-sequence endotracheal intubation in patients with septic shock.

Méthode : Forty-four adult patients, with septic shock, scheduled for emergency surgical intervention were enrolled in this randomised, double-blinded, controlled study. Patients were randomised to receive either 1 mg/kg ketamine (ketamine group, n = 22) or 0.5 mg/kg ketamine plus 1 mg/kg lidocaine (ketamine-lidocaine group, n = 22) for induction of anaesthesia in addition to 0.05 mg/kg midazolam (in both groups). Our primary outcome was the mean arterial pressure (MAP). Other outcomes included frequency of post-induction hypotension, heart rate, and cardiac output.

Résultats : Forty-three patients were available for final analysis. The average MAP reading in the first 5 min post-induction was higher in ketamine-lidocaine group than in the ketamine group {82.8 ± 5.6 mmHg and 73 ± 10.2 mmHg, P < 0.001}. Furthermore, the incidence of post-intubation hypotension was lower in the ketamine-lidocaine group than in the ketamine group {1 patient (5%) versus 17 patients (77%), P < 0.001}. The ketamine-lidocaine group showed higher MAP in almost all the readings after induction compared to ketamine group. Other haemodynamic variables including cardiac output and heart rate were comparable between both study groups.

Conclusion : Lidocaine-ketamine combination showed less incidence of hypotension compared to ketamine full-dose when used for rapid-sequence endotracheal intubation in patients with septic shock.

Conclusion (proposition de traduction) : L'association lidocaïne-kétamine a montré une incidence moindre d'hypotension par rapport à la kétamine à dose complète lorsqu'elle est utilisée pour l'intubation endotrachéale à séquence rapide chez les patients présentant un choc septique.

Anesthesia & Analgesia

Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management.
Kornas RL, Owyang CG, Sakles JC, Foley LJ, Mosier JM; Society for Airway Management’s Special Projects Committee. | Anesth Analg. 2021 Feb 1;132(2):395-405
DOI: https://doi.org/10.1213/ane.0000000000005233
Keywords: Aucun

Review Article

Editorial : Multiple international airway societies have created guidelines for the management of the difficult airway. In critically ill patients, there are physiologic derangements beyond inadequate airway protection or hypoxemia. These risk factors contribute to the "physiologically difficult airway" and are associated with complications including cardiac arrest and death. Importantly, they are largely absent from international guidelines. Thus, we created management recommendations for the physiologically difficult airway to provide practical guidance for intubation in the critically ill. Through multiple rounds of in-person and telephone conferences, a multidisciplinary working group of 12 airway specialists (Society for Airway Management's Special Projects Committee) over a time period of 3 years (2016-2019) reviewed airway physiology topics in a modified Delphi fashion. Consensus agreement with the following recommendations among working group members was generally high with 80% of statements showing agreement within a 10% range on a sliding scale from 0% to 100%. We limited the scope of this analysis to reflect the resources and systems of care available to out-of-operating room adult airway providers. These recommendations reflect the practical application of physiologic principles to airway management available during the analysis time period.

Conclusion : The multidisciplinary approach of Society for Airway Management provides an avenue for discourse that transcends subspecialty and cultural barriers. Because the various recommen- dations from the Committee are diverse and expan- sive in breadth, the top 10 recommendations from the multidisciplinary group are summarized in the Table. By highlighting themes in the context of a physiologic approach, these Society for Airway Management guidelines for the physiologi- cally difficult airway define principles that extend beyond a single practice environment and highlight areas where research is needed.

Conclusion (proposition de traduction) : L’approche multidisciplinaire de la Society for Airway Management offre une voie de discussion qui transcende les barrières culturelles et les sous-spécialités. Étant donné que les diverses recommandations du Comité sont variées et étendues, les dix principales recommandations du groupe multidisciplinaire sont résumées dans un tableau. En mettant l’accent sur des thèmes dans le contexte d’une approche physiologique, ces lignes directrices de la Society for Airway Management pour les voies respiratoires physiologiquement difficiles définissent des principes qui vont au-delà d’un milieu de pratique unique et mettent en évidence les domaines où des recherches sont nécessaires.

Commentaire :  Les dix principales recommandations du groupe multidisciplinaire.
Hypoxémie
1. La préoxygénation doit être effectuée en utilisant de l’oxygène à haut débit pendant au moins 3 min, ou 8 respirations de capacité vitale.
2. La désaturation est le plus grand facteur de risque d’arrêt cardiopulmonaire.
3. Si la patiente présente un shunt physiologique importante ou une capacité fonctionnelle résiduelle réduite (p. ex. grossesse, obésité, SDRA), une préoxygénation doit être effectuée avec PEEP à l’aide d’une ventilation à pression positive non invasive.
4. Dans la mesure du possible, les patients doivent être préoxygénés en position assise.
5. L’intubation en séquence retardée est une option pour les patients qui ne peuvent tolérer une préoxygénation avec ventilation à pression positive non invasive ou une oxygénation nasale à haut débit.
Hypotension
6. Les facteurs de risque de décompensation comprennent les effets vasculaires et cardiaques des agents d’induction et les effets d’une ventilation sous pression positive.
7. L’hypotension péri-intubation est associée de façon indépendante à de mauvais résultats, notamment la mortalité, la durée d’hospitalisation et une défaillance multiviscérale.
8. Les patients doivent faire l’objet d’un dépistage du risque élevé de collapsus hémodynamique lors de l’intubation. Ceux dont le « Shock Index » est > 0,7 courent un risque accru.
9. Les patients qui répondent et tolèrent un remplissage doivent être réanimés avant l’intubation, ou au moins pendant la tentative d’intubation.
10. Dans la mesure du possible, les perfusions de vasopresseur doivent être initiées avant l’intubation chez les patients qui ne répondent pas ou qui ne tolèrent pas le remplissage.

Annals of Emergency Medicine

Use of Machine Learning to Develop a Risk-Stratification Tool for Emergency Department Patients With Acute Heart Failure.
Sax DR, Mark DG, Huang J, Sofrygin O, Rana JS, Collins SP, Storrow AB, Liu D, Reed ME. | Ann Emerg Med. 2021 Feb;77(2):237-248
DOI: https://doi.org/10.1016/j.annemergmed.2020.09.436
Keywords: Aucun

Cardiology

Introduction : We use variables from a recently derived acute heart failure risk-stratification rule (STRATIFY) as a basis to develop and optimize risk prediction using additional patient clinical data from electronic health records and machine-learning models.

Méthode : Using a retrospective cohort design, we identified all emergency department (ED) visits for acute heart failure between January 1, 2017, and December 31, 2018, among adult health plan members of a large system with 21 EDs. The primary outcome was any 30-day serious adverse event, including death, cardiopulmonary resuscitation, balloon-pump insertion, intubation, new dialysis, myocardial infarction, or coronary revascularization. Starting with the 13 variables from the STRATIFY rule (base model), we tested whether predictive accuracy in a different population could be enhanced with additional electronic health record-based variables or machine-learning approaches (compared with logistic regression). We calculated our derived model area under the curve (AUC), calculated test characteristics, and assessed admission rates across risk categories.

Résultats : Among 26,189 total ED encounters, mean patient age was 74 years, 51.7% were women, and 60.7% were white. The overall 30-day serious adverse event rate was 18.8%. The base model had an AUC of 0.76 (95% confidence interval 0.74 to 0.77). Incorporating additional variables led to improved accuracy with logistic regression (AUC 0.80; 95% confidence interval 0.79 to 0.82) and machine learning (AUC 0.85; 95% confidence interval 0.83 to 0.86). We found that 11.1%, 25.7%, and 48.9% of the study population had predicted serious adverse event risk of less than or equal to 3%, less than or equal to 5%, and less than or equal to 10%, respectively, and 28% of those with less than or equal to 3% risk were admitted.

Conclusion : Use of a machine-learning model with additional variables improved 30-day risk prediction compared with conventional approaches.

Conclusion (proposition de traduction) : L'utilisation d'un modèle d'apprentissage automatique avec des variables supplémentaires a amélioré la prédiction des risques sur 30 ours par rapport aux approches conventionnelles.

Annals of Intensive Care

Non-invasive ventilation alternating with high-flow nasal oxygen versus high-flow nasal oxygen alone after extubation in COPD patients: a post hoc analysis of a randomized controlled trial.
Thille AW, Coudroy R, Nay MA, Gacouin A, Decavèle M, Sonneville R, Beloncle F, Girault C, Dangers L, Lautrette A, Levrat Q, Rouzé A, Vivier E, Lascarrou JB, Ricard JD, Razazi K, Barberet G, Lebert C, Ehrmann S, Massri A, Bourenne J, Pradel G, Bailly P, Terzi N, Dellamonica J, Lacave G, Robert R, Ragot S, Frat JP; HIGH-WEAN Study Group, for the REVA Research Network.. | Ann Intensive Care. 2021 Feb 9;11(1):30
DOI: https://doi.org/10.1186/s13613-021-00823-7  | Télécharger l'article au format  
Keywords: Airway extubation; Chronic obstructive pulmonary disease; High-flow nasal oxygen; Non-invasive ventilation; Weaning.

Research

Introduction : Several randomized clinical trials have shown that non-invasive ventilation (NIV) applied immediately after extubation may prevent reintubation in patients at high-risk of extubation failure. However, most of studies included patients with chronic respiratory disorders as well as patients without underlying respiratory disease. To date, no study has shown decreased risk of reintubation with prophylactic NIV after extubation among patients with chronic obstructive pulmonary disease (COPD). We hypothesized that prophylactic NIV after extubation may decrease the risk of reintubation in COPD patients as compared with high-flow nasal oxygen.

Méthode : We performed a post hoc subgroup analysis of COPD patients included in a multicenter, randomized, controlled trial comparing prophylactic use of NIV alternating with high-flow nasal oxygen versus high-flow nasal oxygen alone immediately after extubation.

Résultats : Among the 651 patients included in the original study, 150 (23%) had underlying COPD including 86 patients treated with NIV alternating with high-flow nasal oxygen and 64 patients treated with high-flow nasal oxygen alone. The reintubation rate was 13% (11 out of 86 patients) with NIV and 27% (17 out of 64 patients) with high-flow nasal oxygen alone [difference, - 14% (95% CI - 27% to - 1%); p = 0.03]. Whereas reintubation rates were significantly lower with NIV than with high-flow nasal oxygen alone at 72 h and until ICU discharge, mortality in ICU did not differ between groups: 6% (5/86) with NIV vs. 9% (6/64) with high-flow nasal oxygen alone [difference - 4% (95% CI - 14% to 5%); p = 0.40].

Conclusion : In COPD patients, prophylactic NIV alternating with high-flow nasal oxygen significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone.

Conclusion (proposition de traduction) : Chez les patients BPCO, la VNI prophylactique en alternance avec l'oxygène nasal à haut débit a significativement réduit le risque de réintubation par rapport à l'oxygène nasal à haut débit seul.

Predicting fluid responsiveness in non-intubated COVID-19 patients: two methods are better than one.
Caplan M, Howsam M, Favory R, Preau S. | Ann Intensive Care. 2021 Feb 15;11(1):34
DOI: https://doi.org/10.1186/s13613-021-00826-4  | Télécharger l'article au format  
Keywords: Aucun

Letter to the Editor

Conclusion : In summary, both collapsibility index of the inferior vena cava and passive leg raising display significant limitations to predict fluid responsiveness in non-intubated COVID-19 patients. Moreover, while echography skills and ultrasound materials are required to assess both collapsibility index of the inferior vena cava and passive leg raising-induced changes in the velocity time integral of the aortic blood flow, specialized devices are required to track passive leg raising-induced changes in stroke volume or surrogates. Notwithstanding these technical challenges, we are firmly of the opinion that both methods are viable approaches, and that their pragmatic and complementary use remains a useful strategy in assessing whether patients with acute respiratory failure may benefit from rapid volume expansion in the presence of hypoperfusion.

Conclusion (proposition de traduction) : En résumé, l'indice de collapsibilité de la veine cave inférieure et la levée passive de la jambe présentent des limitations significatives pour prédire la réactivité hydrique chez les patients COVID-19 non intubés. De plus, alors que les compétences en échographie et les matériaux à ultrasons sont nécessaires pour évaluer à la fois l'indice de collapsibilité de la veine cave inférieure et les changements induits par l'élévation passive de la jambe dans l'intégrale de temps de vitesse du flux sanguin aortique, des dispositifs spécialisés sont nécessaires pour suivre les changements induits par l'élévation passive de la jambe. en volume systolique ou substituts. Malgré ces défis techniques, nous sommes fermement convaincus que les deux méthodes sont des approches viables et que leur utilisation pragmatique et complémentaire reste une stratégie utile pour évaluer si les patients atteints d'insuffisance respiratoire aiguë peuvent bénéficier d'une expansion rapide du volume en présence d'hypoperfusion.

Intensive care management of patients with COVID-19: a practical approach.
Hajjar LA, Costa IBSDS, Rizk SI, Biselli B, Gomes BR, Bittar CS, de Oliveira GQ, de Almeida JP, de Oliveira Bello MV, Garzillo C, Leme AC, Elena M, Val F, de Almeida Lopes M, Lacerda MVG, Ramires JAF, Kalil Filho R, Teboul JL, Landoni G. | Ann Intensive Care. 2021 Feb 18;11(1):36
DOI: https://doi.org/10.1186/s13613-021-00820-w  | Télécharger l'article au format  
Keywords: Aucun

Review

Editorial : SARS-CoV-2, the causative agent of coronavirus disease 2019 (COVID-19), is responsible for the largest pandemic facing humanity since the Spanish flu pandemic in the early twentieth century. Since there is no specific antiviral treatment, optimized support is the most relevant factor in the patient's prognosis. In the hospital setting, the identification of high-risk patients for clinical deterioration is essential to ensure access to intensive treatment of severe conditions in a timely manner. The initial management of hypoxemia includes conventional oxygen therapy, high-flow nasal canula oxygen, and non-invasive ventilation. For patients requiring invasive mechanical ventilation, lung-protective ventilation with low tidal volumes and plateau pressure is recommended. Cardiovascular complications are frequent and include myocardial injury, thrombotic events, myocarditis, and cardiogenic shock. Acute renal failure is a common complication and is a marker of poor prognosis, with significant impact in costs and resources allocation. Regarding promising therapies for COVID-19, the most promising drugs until now are remdesivir and corticosteroids although further studies may be needed to confirm their effectiveness. Other therapies such as, tocilizumab, anakinra, other anti-cytokine drugs, and heparin are being tested in clinical trials. Thousands of physicians are living a scenario that none of us have ever seen: demand for hospital exceed capacity in most countries. Until now, the certainty we have is that we should try to decrease the number of infected patients and that an optimized critical care support is the best strategy to improve patient's survival.

Commentaire : 

High flow nasal oxygen therapy to avoid invasive mechanical ventilation in SARS-CoV-2 pneumonia: a retrospective study.
Bonnet N, Martin O, Boubaya M, Levy V, Ebstein N, Karoubi P, Tandjaoui-Lambiotte Y, Van Der Meersch G, Oziel J, Soulie M, Ghalayini M, Winchenne A, Zahar JR, Ahmed P, Gaudry S, Cohen Y. | Ann Intensive Care. 2021 Feb 27;11(1):37
DOI: https://doi.org/10.1186/s13613-021-00825-5  | Télécharger l'article au format  
Keywords: Acute respiratory failure; COVID-19; High flow nasal canula; Intensive care unit.

Research

Introduction : The efficacy of high flow nasal canula oxygen therapy (HFNO) to prevent invasive mechanical ventilation (IMV) is not well established in severe coronavirus disease 2019 (COVID-19). The aim of this study was to compare the risk of IMV between two strategies of oxygenation (conventional oxygenation and HFNO) in critically ill COVID 19 patients.

Méthode : This was a bicenter retrospective study which took place in two intensive care units (ICU) of tertiary hospitals in the Paris region from March 11, to May 3, 2020. We enrolled consecutive patients hospitalized for COVID-19 and acute respiratory failure (ARF) who did not receive IMV at ICU admission. The primary outcome was the rate of IMV after ICU admission. Secondary outcomes were death at day 28 and day 60, length of ICU stay and ventilator-free days at day 28. Data from the HFNO group were compared with those from the standard oxygen therapy (SOT) group using weighted propensity score.

Résultats : Among 138 patients who met the inclusion criteria, 62 (45%) were treated with SOT alone, and 76 (55%) with HFNO. In HFNO group, 39/76 (51%) patients received IMV and 46/62 (74%) in SOT group (OR 0.37 [95% CI, 0.18-0.76] p = 0.007). After weighted propensity score, HFNO was still associated with a lower rate of IMV (OR 0.31 [95% CI, 0.14-0.66] p = 0.002). Length of ICU stay and mortality at day 28 and day 60 did not significantly differ between HFNO and SOT groups after weighted propensity score. Ventilator-free days at days 28 was higher in HNFO group (21 days vs 10 days, p = 0.005). In the HFNO group, predictive factors associated with IMV were SAPS2 score (OR 1.13 [95%CI, 1.06-1.20] p = 0.0002) and ROX index > 4.88 (OR 0.23 [95%CI, 0.008-0.64] p = 0.006).

Conclusion : High flow nasal canula oxygen for ARF due to COVID-19 is associated with a lower rate of invasive mechanical ventilation.

Conclusion (proposition de traduction) : L'oxygènothérapie nasale à haut débit dans le SDRA due à la COVID-19 est associée à un taux plus faible de ventilation mécanique invasive.

BMC Emergency Medicine

Testing mechanical chest compression devices of different design for their suitability for prehospital patient transport - a simulator-based study.
Jörgens M, Königer J, Kanz KG, Birkholz T, Hübner H, Prückner S, Zwissler B, Trentzsch H. | BMC Emerg Med. 2021 Feb 4;21(1):18
DOI: https://doi.org/10.1186/s12873-021-00409-3  | Télécharger l'article au format  
Keywords: Cardio-pulmonary resuscitation; Device stability; Mechanical chest compressions; Pre-hospital emergency medical services; Transport.

Research article

Introduction : Mechanical chest compression (mCPR) offers advantages during transport under cardiopulmonary resuscitation. Little is known how devices of different design perform en-route. Aim of the study was to measure performance of mCPR devices of different construction-design during ground-based pre-hospital transport.

Méthode : We tested animax mono (AM), autopulse (AP), corpuls cpr (CC) and LUCAS2 (L2). The route had 6 stages (transport on soft stretcher or gurney involving a stairwell, trips with turntable ladder, rescue basket and ambulance including loading/unloading). Stationary mCPR with the respective device served as control. A four-person team carried an intubated and bag-ventilated mannequin under mCPR to assess device-stability (displacement, pressure point correctness), compliance with 2015 ERC guideline criteria for high-quality chest compressions (frequency, proportion of recommended pressure depth and compression-ventilation ratio) and user satisfaction (by standardized questionnaire).

Résultats : All devices performed comparable to stationary use. Displacement rates ranged from 83% (AM) to 11% (L2). Two incorrect pressure points occurred over 15,962 compressions (0.013%). Guideline-compliant pressure depth was > 90% in all devices. Electrically powered devices showed constant frequencies while muscle-powered AM showed more variability (median 100/min, interquartile range 9). Although physical effort of AM use was comparable (median 4.0 vs. 4.5 on visual scale up to 10), participants preferred electrical devices.

Conclusion : All devices showed good to very good performance although device-stability, guideline compliance and user satisfaction varied by design. Our results underline the importance to check stability and connection to patient under transport.

Conclusion (proposition de traduction) : Tous les appareils ont montré de bonnes à très bonnes performances, bien que la stabilité de l'appareil, la conformité aux directives et la satisfaction des utilisateurs varient selon la conception. Nos résultats soulignent l'importance de vérifier la stabilité et la connexion au patient pendant le transport.

Chest

Effect of Early Balanced Crystalloids Before ICU Admission on Sepsis Outcomes.
Jackson KE, Wang L, Casey JD, Bernard GR, Self WH, Rice TW, Semler MW; SMART Investigators and the Pragmatic Critical Care Research Group. | Chest. 2021 Feb;159(2):585-595
DOI: https://doi.org/10.1016/j.chest.2020.08.2068
Keywords: balanced crystalloids; critical care; sepsis.

Original Research

Introduction : Studies suggest that using balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) rather than saline (0.9% sodium chloride) may improve outcomes for patients with sepsis in the ED and ICU.
Research question: What is the relative impact on sepsis outcomes of fluid composition during early resuscitation in the ED vs after ICU admission?

Méthode : We performed a secondary analysis of the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) data set, examining medical ICU patients with a diagnosis of sepsis (n = 1,641). SMART was a cluster-crossover trial comparing balanced crystalloids vs saline among critically ill adults. During the first 7 months of SMART, fluid choice was controlled only in the ICU ("ICU-only period"). In the final 15 months, fluid choice was coordinated between the ED and ICU ("ED and ICU period"). We performed logistic regression modeling for 30-day in-hospital mortality with an interaction term between randomized group (balanced crystalloids vs saline) and study period (ICU-only period vs ED and ICU period).

Résultats : Three hundred and sixty-seven patients with sepsis were enrolled during the ICU-only period and 1,274 were enrolled during the ED and ICU period. Thirty-day in-hospital mortality occurred in 47 of 142 patients (33.1%) in the balanced crystalloid group vs 74 of 225 patients (32.9%) in the saline group during the ICU-only period (OR, 1.14; 95% CI, 0.70-1.88) and in 170 of 682 patients (24.9%) in the balanced crystalloid group vs 181 of 592 patients (30.6%) in the saline group in the ED and ICU period (OR, 0.68; 95% CI, 0.52-0.89) (P value for interaction, .07), consistent with a beneficial effect of balanced crystalloid primarily in the ED and ICU period.

Conclusion : Among patients with sepsis, the effect of balanced crystalloids vs saline on mortality was greater among patients for whom fluid choice was controlled starting in the ED compared with starting in the ICU.

Conclusion (proposition de traduction) : Chez les patients présentant une septicémie, l'effet des cristalloïdes balancés par rapport au sérum physiologique sur la mortalité était plus important chez les patients pour lesquels le choix du liquide était initié à partir des urgences par rapport à celui de l'USI.

Circulation

Gender-Based Differences in Outcomes Among Resuscitated Patients With Out-of-Hospital Cardiac Arrest.
Mody P, Pandey A, Slutsky AS, Segar MW, Kiss A, Dorian P, Parsons J, Scales DC, Rac VE, Cheskes S, Bierman AS, Abramson BL, Gray S, Fowler RA, Dainty KN, Idris AH, Morrison L. . | Circulation. 2021 Feb 16;143(7):641-649
DOI: https://doi.org/10.1161/circulationaha.120.050427
Keywords: out-of-hospital cardiac arrest; outcome assessment, health care; sex characteristics.

Original Research Article

Introduction : Studies examining gender-based differences in outcomes of patients experiencing out-of-hospital cardiac arrest have demonstrated that, despite a higher likelihood of return of spontaneous circulation, women do not have higher survival.

Méthode : Patients successfully resuscitated from out-of-hospital cardiac arrest enrolled in the CCC trial (Trial of Continuous or Interrupted Chest Compressions during CPR) were included. Hierarchical multivariable logistic regression models were constructed to evaluate the association between gender and survival after adjustment for age, gender, cardiac arrest rhythm, witnessed status, bystander cardiopulmonary resuscitation, episode location, epinephrine dose, emergency medical services response time, and duration of resuscitation. Do not resuscitate (DNR) and withdrawal of life-sustaining therapy (WLST) order status were used to assess whether differences in postresuscitation outcomes were modified by baseline prognosis. The analysis was replicated among ALPS trial (Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest) participants.

Résultats : Among 4875 successfully resuscitated patients, 1825 (37.4%) were women and 3050 (62.6%) were men. Women were older (67.5 versus 65.3 years), received less bystander cardiopulmonary resuscitation (49.1% versus 54.9%), and had a lower proportion of cardiac arrests that were witnessed (55.1% versus 64.5%) or had shockable rhythm (24.3% versus 44.6%, P<0.001 for all). A significantly higher proportion of women received DNR orders (35.7% versus 32.1%, P=0.009) and had WLST (32.8% versus 29.8%, P=0.03). Discharge survival was significantly lower in women (22.5% versus 36.3%, P<0.001; adjusted odds ratio, 0.78 [95% CI, 0.66-0.93]; P=0.005). The association between gender and survival to discharge was modified by DNR and WLST order status such that women had significantly reduced survival to discharge among patients who were not designated DNR (31.3% versus 49.9%, P=0.005; adjusted odds ratio, 0.74 [95% CI, 0.60-0.91]) or did not have WLST (32.3% versus 50.7%, P=0.002; adjusted odds ratio, 0.73 [95% CI, 0.60-0.89]). In contrast, no gender difference in survival was noted among patients receiving a DNR order (6.7% versus 7.4%, P=0.90) or had WLST (2.8% versus 2.4%, P=0.93). Consistent patterns of association between gender and postresuscitation outcomes were observed in the secondary cohort.

Conclusion : Among patients resuscitated after experiencing out-of-hospital cardiac arrest, discharge survival was significantly lower in women than in men, especially among patients considered to have a favorable prognosis.

Conclusion (proposition de traduction) : Parmi les patients réanimés après un arrêt cardiaque extra-hospitalier, la survie à la sortie était significativement plus faible chez les femmes que chez les hommes, en particulier chez les patients considérés comme ayant un pronostic favorable.

Clinical Infectious Diseases

Dose, Timing, and Spectrum of Prenatal Antibiotic Exposure and Risk of Childhood Asthma.
Turi KN, Gebretsadik T, Ding T, Abreo A, Stone C, Hartert TV, Wu P. | Clin Infect Dis. 2021 Feb 1;72(3):455-462
DOI: https://doi.org/10.1093/cid/ciaa085
Keywords: prenatal antibiotic exposure; antibiotic course timing; childhood asthma; dose-response relationship; genetic predisposition.

MAJOR ARTICLES AND COMMENTARIES

Introduction : The potential for prenatal antibiotic exposure to influence asthma risk is not clear. We aimed to determine the effect of timing, dose, and spectrum of prenatal antibiotic exposure on the risk of childhood asthma.

Méthode : We conducted a population-based cohort study of 84 214 mother-child dyads to examine the association of prenatal antibiotic exposure and childhood asthma using multivariable logistic regression models.

Résultats : Sixty-four percent of pregnant women received antibiotics. Prenatal antibiotic exposure was associated dose-dependently with increased odds of childhood asthma (adjusted odds ratio [aOR] for interquartile increase of 2 courses [interquartile range, 0-2], 1.26 [95% confidence interval {CI}, 1.20-1.33]). Among children exposed to at least 1 course in utero, the effect of timing at the first course was moderated by total maternal courses. Among pregnant women receiving a single antibiotic course, timing of exposure had no effect on childhood asthma risk. Among women receiving > 1 course, early exposure of the first course was associated with greater childhood asthma risk. Compared to narrow spectrum-only antibiotic use, broad spectrum-only antibiotic exposure was associated with increased odds of asthma (aOR, 1.14 [95% CI, 1.05-1.24]). There were effect modifications (P < .001) by maternal asthma on total courses, and on timing of the first course, significant only among those without maternal asthma.

Conclusion : Increased cumulative dose, early pregnancy first course, and broad-spectrum antibiotic exposure were associated with childhood asthma risk. Our study provides important evidence supporting judicious prenatal antibiotic use, particularly timing of use and choice of antibiotics, in preventing subsequent childhood asthma.

Conclusion (proposition de traduction) : L’augmentation de la dose cumulative, la prise précoce au cours de la grossesse et l’antibiothérapie à large spectre ont été associés au risque d’asthme chez l’enfant. Notre étude fournit des preuves importantes à l’appui d’une utilisation judicieuse des antibiotiques prénataux, particulièrement en ce qui concerne le moment de leur utilisation et le choix de l'antibiotique, dans la prévention de l'asthme infantile ultérieur.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : La prise d’antibiotiques pendant la grossesse est associée à un risque majoré d’asthme chez l’enfant  . Rédigé par le Pr Pierre Tattevin, le 30 mars 2021.
Cette étude suggère l’importance du microbiote sur l’état de santé, bien au-delà des maladies infectieuses classiques. Même si cette étude, purement observationnelle, est à risque de biais, elle apporte de nouveaux arguments – s’il en fallait – en faveur d’un usage plus raisonné des antibiotiques.

Critical Care

Incidence and management of metabolic acidosis with sodium bicarbonate in the ICU: An international observational study.
Fujii T, Udy AA, Nichol A, Bellomo R, Deane AM, El-Khawas K, Thummaporn N, Serpa Neto A, Bergin H, Short-Burchell R, Chen CM, Cheng KH, Cheng KC, Chia C, Chiang FF, Chou NK, Fazio T, Fu PK, Ge V, Hayashi Y, Holmes J, Hu TY, Huang SF, Iguchi N, Jones SL, Karumai T, Katayama S, Ku SC, Lai CL, Lee BJ, Liaw WJ, Ong CTW, Paxton L, Peppin C, Roodenburg O, Saito S, Santamaria JD, Shehabi Y, Tanaka A, Tiruvoipati R, Tsai HE, Wang AY, Wang CY, Yeh YC, Yu CJ, Yuan. | Crit Care. 2021 Feb 2;25(1):45
DOI: https://doi.org/10.1186/s13054-020-03431-2  | Télécharger l'article au format  
Keywords: Intensive care unit; Metabolic acidosis; Mortality; Observational study; Sodium bicarbonate; Vasopressor.

Research

Introduction : Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood.

Méthode : This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < -4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model.

Résultats : We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality.

Conclusion : Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

Conclusion (proposition de traduction) : L'acidose métabolique précoce est fréquente chez les patients de réanimation. Le bicarbonate de sodium est administré précocement par les cliniciens à des patients de réanimation, mais sans correction du poids ou de la gravité de l'acidose. Le traitement par bicarbonate chez les patients en acidose dépendants de vasopresseurs peut être bénéfique et justifie une étude plus approfondie.

High-flow nasal oxygen in patients with COVID-19-associated acute respiratory failure.
Mellado-Artigas R, Ferreyro BL, Angriman F, Hernández-Sanz M, Arruti E, Torres A, Villar J, Brochard L, Ferrando C; COVID-19 Spanish ICU Network. | Crit Care. 2021 Feb 11;25(1):58
DOI: https://doi.org/10.1186/s13054-021-03469-w  | Télécharger l'article au format  
Keywords: Acute hypoxemic respiratory failure; COVID-19; High-flow nasal oxygen; Ventilator-free days.

Research

Introduction : Whether the use of high-flow nasal oxygen in adult patients with COVID-19 associated acute respiratory failure improves clinically relevant outcomes remains unclear. We thus sought to assess the effect of high-flow nasal oxygen on ventilator-free days, compared to early initiation of invasive mechanical ventilation, on adult patients with COVID-19.

Méthode : We conducted a multicentre cohort study using a prospectively collected database of patients with COVID-19 associated acute respiratory failure admitted to 36 Spanish and Andorran intensive care units (ICUs). Main exposure was the use of high-flow nasal oxygen (conservative group), while early invasive mechanical ventilation (within the first day of ICU admission; early intubation group) served as the comparator. The primary outcome was ventilator-free days at 28 days. ICU length of stay and all-cause in-hospital mortality served as secondary outcomes. We used propensity score matching to adjust for measured confounding.

Résultats : Out of 468 eligible patients, a total of 122 matched patients were included in the present analysis (61 for each group). When compared to early intubation, the use of high-flow nasal oxygen was associated with an increase in ventilator-free days (mean difference: 8.0 days; 95% confidence interval (CI): 4.4 to 11.7 days) and a reduction in ICU length of stay (mean difference: - 8.2 days; 95% CI - 12.7 to - 3.6 days). No difference was observed in all-cause in-hospital mortality between groups (odds ratio: 0.64; 95% CI: 0.25 to 1.64).

Conclusion : The use of high-flow nasal oxygen upon ICU admission in adult patients with COVID-19 related acute hypoxemic respiratory failure may lead to an increase in ventilator-free days and a reduction in ICU length of stay, when compared to early initiation of invasive mechanical ventilation. Future studies should confirm our findings.

Conclusion (proposition de traduction) : L'utilisation de l'oxygènothérapie nasal à haut débit lors de l'admission à l'USI chez des patients adultes atteints d'insuffisance respiratoire hypoxémique aiguë liée à la COVID-19 peut entraîner une augmentation des jours sans ventilateur et une réduction de la durée de séjour en unité de soins intensifs, par rapport à l'initiation précoce du traitement ventilation. Les études futures devraient confirmer nos résultats.

Epinephrine's effects on cerebrovascular and systemic hemodynamics during cardiopulmonary resuscitation: metabolic changes may limit the persistence of the effect.
Jouffroy R, Vivien B. | Crit Care. 2021 Feb 16;25(1):67
DOI: https://doi.org/10.1186/s13054-020-03378-4  | Télécharger l'article au format  
Keywords: Aucun

Letter

Conclusion : In conclusion, we fully agree with Mavroudis et al., that, despite the exact mechanisms of epinephrine’s effects on CBF and cerebral oxygenation, CPR methods, including epinephrine administration, aim to maintain CBF in order to limit cerebral hypoperfusion and neu- rologic injury. Moreover, even if CPR methods allow to maintain CBF, pending cardiac arrest etiological treat- ment, short and long-term survival increase requires a true bundle of care, including, CPR methods and cerebral protection, implemented complementarily to the chain of survival.

Conclusion (proposition de traduction) : En conclusion, nous sommes entièrement d'accord avec Mavroudis et al., que, malgré les mécanismes exacts des effets de l'épinéphrine sur le flux sanguin cérébral et l'oxygénation cérébrale, les méthodes de RCP, y compris l'administration d'épinéphrine, visent à maintenir le flux sanguin cérébral afin de limiter l'hypoperfusion cérébrale et l'atteinte neurologique. De plus, même si les méthodes de RCP permettent de maintenir le flux sanguin cérébral, en attendant le traitement étiologique de l'arrêt cardiaque, l'augmentation de la survie à court et à long terme nécessite un véritable faisceau de soins, y compris les méthodes de RCP et la protection cérébrale, mis en œuvre en complément de la chaîne de survie.

Commentaire : Mavroudis CD, Ko TS, Morgan RW, Volk LE, Landis WP, Smood B, Xiao R, Hefti M, Boorady TW, Marquez A, Karlsson M, Licht DJ, Nadkarni VM, Berg RA, Sutton RM, Kilbaugh TJ. Epinephrine's effects on cerebrovascular and systemic hemodynamics during cardiopulmonary resuscitation. Crit Care. 2020 Sep 29;24(1):583  .

Helmet CPAP to treat hypoxic pneumonia outside the ICU: an observational study during the COVID-19 outbreak.
Coppadoro A, Benini A, Fruscio R, Verga L, Mazzola P, Bellelli G, Carbone M, Mulinacci G, Soria A, Noè B, Beck E, Di Sciacca R, Ippolito D, Citerio G, Valsecchi MG, Biondi A, Pesci A, Bonfanti P, Gaudesi D, Bellani G, Foti G. | Crit Care. 2021 Feb 24;25(1):80
DOI: https://doi.org/10.1186/s13054-021-03502-y  | Télécharger l'article au format  
Keywords: Coronavirus pneumonia; Covid-19; Helmet continuous positive airways pressure CPAP; Noninvasive ventilation; Positive end expiratory pressure PEEP.

Research

Introduction : Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may overwhelm health care systems, due to the surge of patients requiring advanced respiratory support. Shortage of intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe gas exchange impairment. Helmet is an effective interface to provide continuous positive airway pressure (CPAP) noninvasively. We report data about the usefulness of helmet CPAP during pandemic, either as treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI).

Méthode : In this observational study we collected data regarding patients failing standard oxygen therapy (i.e., non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients' data were recorded before, at initiation of CPAP treatment and once a day, thereafter. CPAP failure was defined as a composite outcome of intubation or death.

Résultats : A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full treatment and 28% of the DNI patients (P < 0.001). With helmet CPAP, PaO2/FiO2 ratio doubled from about 100 to 200 mmHg (P < 0.001); respiratory rate decreased from 28 [22-32] to 24 [20-29] breaths per minute, P < 0.001). C-reactive protein, time to oxygen mask failure, age, PaO2/FiO2 during CPAP, number of comorbidities were independently associated with CPAP failure. Helmet CPAP was maintained for 6 [3-9] days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wards.

Conclusion : Helmet CPAP treatment is feasible for several days outside the ICU, despite persistent impairment in gas exchange. It was used, without escalating to intubation, in the majority of full treatment patients after standard oxygen therapy failed. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival.

Conclusion (proposition de traduction) : Le traitement CPAP avec casque est possible pendant plusieurs jours en dehors de l'unité de soins intensifs, malgré une altération persistante des échanges gazeux. Il a été utilisé, sans passer par l'intubation, chez la majorité des patients en traitement complet après l'échec de l'oxygénothérapie standard. Les patients en limitations de soins pourraient bénéficier de la CPAP avec casque en tant que traitement de secours pour améliorer leur survie.

Critical Care Medicine

Is Cardiopulmonary Resuscitation Futile in Coronavirus Disease 2019 Patients Experiencing In-Hospital Cardiac Arrest?.
Shah P, Smith H, Olarewaju A, Jani Y, Cobb A, Owens J, Moore J, Chenna A, Hess D. | Crit Care Med. 2021 Feb 1;49(2):201-208
DOI: https://doi.org/10.1097/ccm.0000000000004736  | Télécharger l'article au format  
Keywords: Aucun

Feature Article

Introduction : There is limited data regarding outcomes after in-hospital cardiac arrest among coronavirus disease 2019 patients. None of the studies have reported the outcomes of in-hospital cardiac arrest in coronavirus disease 2019 patients in the United States. We describe the characteristics and outcomes of in-hospital cardiac arrest in coronavirus disease 2019 patients in rural Southwest Georgia.

Méthode : Retrospective cohort study.
Setting: Single-center, multihospital.
Patients: Consecutive coronavirus disease 2019 patients who experienced in-hospital cardiac arrest with attempted resuscitation.
Interventions: Attempted resuscitation with advanced cardiac life support.

Résultats : Out of 1,094 patients hospitalized for coronavirus disease 2019 during the study period, 63 patients suffered from in-hospital cardiac arrest with attempted resuscitation and were included in this study. The median age was 66 years, and 49.2% were males. The majority of patients were African Americans (90.5%). The most common comorbidities were hypertension (88.9%), obesity (69.8%), diabetes (60.3%), and chronic kidney disease (33.3%). Eighteen patients (28.9%) had a Charlson Comorbidity Index of 0-2. The most common presenting symptoms were shortness of breath (63.5%), fever (52.4%), and cough (46%). The median duration of symptoms prior to admission was 14 days. During hospital course, 66.7% patients developed septic shock, and 84.1% had acute respiratory distress syndrome. Prior to in-hospital cardiac arrest, 81% were on ventilator, 60.3% were on vasopressors, and 39.7% were on dialysis. The majority of in-hospital cardiac arrest (84.1%) occurred in the ICU. Time to initiation of advanced cardiac life support protocol was less than 1 minute for all in-hospital cardiac arrest in the ICU and less than 2 minutes for the remaining patients. The most common initial rhythms were pulseless electrical activity (58.7%) and asystole (33.3%). Although return of spontaneous circulation was achieved in 29% patients, it was brief in all of them. The in-hospital mortality was 100%.

Conclusion : In our study, coronavirus disease 2019 patients suffering from in-hospital cardiac arrest had 100% in-hospital mortality regardless of the baseline comorbidities, presenting illness severity, and location of arrest.

Conclusion (proposition de traduction) : Dans notre étude, les patients atteints de la Covid 2019 faisant un arrêt cardiaque à l'hôpital présentaient une mortalité hospitalière de 100 %, quels que soient les comorbidités de base, la gravité de la maladie et le lieu de l'arrêt cardiaque.

Current Opinion in Critical Care

Noninvasive ventilation and high-flow nasal oxygen for acute respiratory failure: is less more?.
Thille AW, Coudroy R, Frat JP. | Curr Opin Crit Care. 2021 Feb 1;27(1):60-65
DOI: https://doi.org/10.1097/mcc.0000000000000785
Keywords: Aucun

RESPIRATORY SYSTEM

Introduction : High-flow nasal oxygen and noninvasive ventilation (NIV) are two strategies representing an alternative to standard oxygen in the management of respiratory failure.

Résultats : Although high-flow nasal oxygen has shown promising results in patients with de-novo acute respiratory failure, further large clinical trials are needed to determine the best oxygenation strategy. As NIV may have deleterious effects, especially in patients generating strong inspiratory efforts, protective NIV using higher levels of positive-end expiratory pressure, more prolonged sessions and additional interfaces such as helmets should be assessed in the future. Whereas NIV is the first-line ventilation strategy in patients with acute exacerbation of chronic lung diseases, high-flow nasal oxygen could be an alternative to NIV after partial reversal of respiratory acidosis. To prevent severe hypoxemia during intubation of hypoxemic patients or to prevent postextubation respiratory failure in patients at high-risk of reintubation, NIV is the best strategy for preoxygenation or immediately after extubation in ICUs.

Conclusion : New large-scale clinical trials are needed to compare high-flow nasal oxygen with standard oxygen in patients with de-novo acute respiratory failure to determine the reference treatment. After which, more protective NIV could be assessed among the more severe patients.

Conclusion (proposition de traduction) : De nouveaux essais cliniques à grande échelle sont nécessaires pour comparer l'oxygènothérapie nasal à haut débit avec l'oxygènothérapie standard chez les patients présentant une insuffisance respiratoire aiguë de novo afin de déterminer le traitement de référence. Après quoi, une VNI plus protectrice pourrait être évaluée parmi les patients les plus sévères.

Emergency Radiology

Ultra-low dose CT abdomen and pelvis for the detection of acute abdominal pathology in the emergency room: initial experience from an academic hospital.
Gavrielli S, Yan C, Rogalla P, Anconina R, Metser U. | Emerg Radiol. 2021 Feb;28(1):15-21
DOI: https://doi.org/10.1007/s10140-020-01804-2
Keywords: Abdominal pain; Bowel obstruction; CT abdomen; Ultra low dose.

Original Article

Introduction : The aim of this study is to describe our initial experience using ULDCT performed in the emergency room in the evaluation of acute abdominal pathology.

Méthode : Data from consecutive patients who underwent ULDCT for assessment of bowel obstruction, free intraperitoneal air, unexplained abdominal pain, or fecal loading for constipation between June 1, 2016 and March 31, 2017 was retrospectively assessed. Demographic data, radiation dose, CT findings, and clinical outcomes including performance of full dose contrast-enhanced CT (CECT), hospitalization, and surgery was collected. Concordance of ULDCT to CECT was calculated.

Résultats : ULDCT was performed in 325 patients (188 women and 137 men; mean age, 65.1 years). ULDCT detected acute abdominal pathology in 134/325 (41.2%), and in 89/134 (66.4%) it was concordant with the clinical working diagnosis. The average dose length product (DLP) was 101.6 mGy cm (range 51.7-614; median, 82.6). CECT was performed in 44/325 patients (13.5%). In 7/44 (15.9%), CECT identified discordant findings which likely impacted management. A greater proportion of patients were admitted to hospital after a positive ULDCT 99/137 (72.3%), compared to those with a negative study 81/188 (43.1%); p < 0.0001(Chi2, 27.30). Of those admitted to hospital, 11/99 (11.1%) with positive ULDCT had surgery compared to 1/81 (1.2%) with a negative ULDCT; p < 0.008 (Chi2, 6.98).

Conclusion : With its high clinical yield and similar radiation dose, ULDCT appears as a suitable alternative to abdominal radiography for the detection of select acute abdominal pathology in the emergency room.

Conclusion (proposition de traduction) : Avec son rendement clinique élevé et sa dose de rayonnement similaire, la tomodensitométrie à ultra-faible dose apparaît comme une alternative appropriée à la radiographie abdominale pour la détection de certaines pathologies abdominales aiguës aux urgences.

Imaging review of sickle cell disease for the emergency radiologist.
Gilyard SN, Hamlin SL, Johnson JO, Herr KD. | Emerg Radiol. 2021 Feb;28(1):153-164
DOI: https://doi.org/10.1007/s10140-020-01828-8
Keywords: Acute chest; Moya-Moya; Sickle cell; Splenic sequestration.

Review Article

Editorial : Sickle cell disease (SCD), one of the most common inherited genetic syndromes in the USA, is characterized by recurring episodes of acute illness and progressive multisystem organ injury. Individuals with SCD frequently present to the emergency department for a spectrum of complications, such as vaso-occlusive crises, infection, cholecystitis, and stroke. Imaging correlates for most of these presentations exist, positioning the emergency radiologist to play a pivotal role in facilitating patient care. Using a systems-based approach, we describe the acute and chronic imaging manifestations of SCD that an emergency radiologist can expect to encounter in most practice settings, highlighting the unique pathophysiology of this disorder that typically underlies the imaging findings.

Conclusion : SCD is a relatively common inherited hemoglobinopathy that presents with a spectrum of manifestations that can impact any number organ systems, particularly the lungs, cardiovascular system, abdominal viscera, musculoskeletal system, neurological system, and neurovasculature. Its protean effects on these organs are attributable to both acute and cumulative effects of microvascular ischemia. Hospital resource utilization for individuals with SCD is high and includes frequent medical imaging to assist in the diagnosis of complications from an early age. Since much of the imaging of SCD occurs out of the emergency department, the emergency radiologist should have an understanding of the relationship between the unique pathophysiology of SCD as well as a familiarity of the range of imaging appearances in the acute and chronic setting, some of which are rare in the general population, but notably distinctive for this population.

Conclusion (proposition de traduction) : La drépanocytose est une hémoglobinopathie héréditaire relativement courante qui se manifeste par un éventail de manifestations qui peuvent avoir une incidence sur un certain nombre de systèmes organiques, en particulier les poumons, le système cardiovasculaire, les viscères abdominaux, le système musculo-squelettique, le système neurologique et le système neurovasculaire. Ses effets protéiques sur ces organes sont attribuables à la fois aux effets aigus et cumulatifs de l'ischémie microvasculaire. L'utilisation des ressources hospitalières pour les personnes atteintes de drépanocytose est élevée et comprend des images médicales fréquentes pour aider au diagnostic des complications dès le plus jeune âge. Étant donné que la plupart des imagerie de la drépanocytose se font en dehors du service des urgences, le radiologue d'urgence devrait comprendre la relation entre la physiopathologie particulière de la drépanocytose et être familiarisé avec la gamme d'apparences d'imagerie dans les situations aiguës et chroniques, dont certaines sont rares dans la population générale, mais distinctives pour cette population.

International Journal of Emergency Medicine

Implementation of isopropyl alcohol (IPA) inhalation as the first-line treatment for nausea in the emergency department: practical advantages and influence on the quality of care.
Veldhuis P, Melse M, Mullaart N. | Int J Emerg Med. 2021 Feb 24;14(1):15
DOI: https://doi.org/10.1186/s12245-021-00334-z  | Télécharger l'article au format  
Keywords: Emergency department; Implementation outcome measures; Isopropyl alcohol inhalation; Nausea; Quality of care.

Original Research

Introduction : Nasal inhalation of isopropyl alcohol (IPA) seems an effective anti-emetic for the symptomatic treatment of nausea in the emergency department (ED) compared to conventional anti-emetics (Ondansetron and Metoclopramide). However, it is not yet known what the practical consequences are related to the use of IPA in the ED.
Objectives: The purpose of this study was to assess the practical implications for patient care associated with IPA use and to evaluate the viability of permanent implementation of IPA inhalation as a first-line therapy for nausea in the ED.

Méthode : We conducted a prospective, single-center implementation study comparing ED-based care for nauseated patients before (n=106) and after (n=104) the introduction of IPA. We evaluated the treatment process and cost and assessed implementation using a survey based on recommended implementation outcome measures.

Résultats : Comparing baseline phase to implementation phase, we found a significant increase in the percentage of patients receiving nausea treatment (66.0% versus 97.1%; p<0.001) and a reduction in time to treatment initiation (7 versus 1 min, p<0.001). Additionally, IPA introduction was associated with a decrease in the administration of conventional anti-emetics (0.52 versus 0.23 administrations per patient, p<0.001) and a notable drop in treatment cost (€1.33 versus €0.67 per patient). Nurses were content with IPA implementation and regarded definitive implementation as feasible and sustainable.

Conclusion : Implementation of IPA as the first-line nausea treatment in the ED can increase the quality of care and improve care efficiency. Definitive implementation of IPA as a first-line treatment in the ED is both viable and practically feasible.

Conclusion (proposition de traduction) : La mise en œuvre de l'inhalation d'alcool isopropylique comme traitement de première intention des nausées au service des urgences peut augmenter la qualité et améliorer l'efficacité des soins. La mise en œuvre définitive de l'inhalation d'alcool isopropylique en tant que traitement de première intention au service des urgences est à la fois viable et faisable en pratique.

JAMA Network Open

Single vs Serial Measurements of Cardiac Troponin Level in the Evaluation of Patients in the Emergency Department With Suspected Acute Myocardial Infarction.
Wassie M, Lee MS, Sun BC, Wu YL, Baecker AS, Redberg RF, Ferencik M, Shen E, Musigdilok V, Sharp AL. | JAMA Netw Open. 2021 Feb 1;4(2):e2037930
DOI: https://doi.org/10.1001/jamanetworkopen.2020.37930  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : Chest pain is among the most common reasons for emergency department (ED) presentations. However, most patients are at low risk for acute coronary syndrome (ACS), with low cardiac adverse outcomes rates. Biomarker testing with troponin levels is key in the initial assessment for ACS. Although serial troponin testing can improve the diagnosis of ACS in clinical practice, some patients deemed to be low risk are discharged after a single negative troponin test result.
Objective: To report the clinical outcomes of patients discharged after a single negative troponin test result compared with patients discharged after serial troponin measurements.

Méthode : This is a retrospective cohort study of ED encounters from May 5, 2016, to December 1, 2017, across 15 community EDs within an integrated health care system in southern California. The study cohort includes 27 918 adult ED encounters in which patients were evaluated for suspected ACS with a HEART (history, electrocardiogram, age, risk factors, and troponin) score and an initial conventional troponin-I measurement below the level of detection (<0.02 ng/mL). Statistical analysis was performed from December 1, 2019, to December 1, 2020.
Exposure : Single troponin test vs multiple troponin tests.
Main outcomes and measures: The primary outcome was acute myocardial infarction or cardiac mortality; secondary outcomes included coronary artery bypass graft, percutaneous coronary intervention, invasive coronary angiography, and unstable angina within 30 days of discharge. A multivariable logistic regression model was performed to evaluate the association between testing strategies and clinical outcomes.

Résultats : A total of 27 918 patient encounters (16 212 women [58.1%]; mean [SD] age, 58.7 [15.2] years) were included in the study. Of patients with an initial troponin measurement below the level of detection, 14 459 (51.8%) were discharged after a single troponin measurement, and 13 459 (48.2%) underwent serial troponin tests. After adjustment for cardiac risk factors and comorbidities, there was no statistically significant difference in the primary outcome of acute myocardial infarction or cardiac mortality within 30 days between the 2 groups (single troponin, 56 [0.4%] vs serial troponin, 52 [0.4%]; adjusted odds ratio, 1.41 [95% CI, 0.96-2.07]). Patients discharged after a single troponin test had lower rates of coronary artery bypass graft (adjusted odds ratio, 0.24 [95% CI, 0.11-0.48]) and invasive coronary angiography (adjusted odds ratio, 0.46 [95% CI, 0.38-0.56]).

Conclusion : This study suggests that patients are routinely discharged from the ED after a single negative troponin test result, and when compared with serial troponin testing, a single troponin test appears safe based on current physician decision-making, with no difference in rates of 30-day cardiac mortality and acute myocardial infarction, which are low in both groups.

Conclusion (proposition de traduction) : Cette étude suggère que les patients sont systématiquement renvoyés du service des urgences après un seul résultat négatif de troponine et que, comparé au cycle de troponine, un dosage unique de troponine semble sécuritaire d’après les décisions actuelles du médecin, sans différence entre les taux de mortalité cardiaque à 30 jours et d’infarctus aigu du myocarde, qui sont faibles dans les deux groupes.

JAMA Neurology

Thrombectomy for Primary Distal Posterior Cerebral Artery Occlusion Stroke: The TOPMOST Study.
Meyer L, Stracke CP, Jungi N, Wallocha M, Broocks G, Sporns PB, Maegerlein C, Dorn F, Zimmermann H, Naziri W, Abdullayev N, Kabbasch C, Behme D, Jamous A, Maus V, Fischer S, Möhlenbruch M, Weyland CS, Langner S, Meila D, Miszczuk M, Siebert E, Lowens S, Krause LU, Yeo LLL, Tan BY, Anil G, Gory B, Galván J, Arteaga MS, Navia P, Raz E, Shapiro M, Arnberg F, Zelenák K, Martinez-Galdamez M, Fischer U, Kastrup A, Roth C, Papanagiotou P, Kemmling A, Gralla J, . | JAMA Neurol. 2021 Feb 22:e210001
DOI: https://doi.org/10.1001/jamaneurol.2021.0001
Keywords: Aucun

Original Investigation

Introduction : Clinical evidence of the potential treatment benefit of mechanical thrombectomy for posterior circulation distal, medium vessel occlusion (DMVO) is sparse.
Objective: To investigate the frequency as well as the clinical and safety outcomes of mechanical thrombectomy for isolated posterior circulation DMVO stroke and to compare them with the outcomes of standard medical treatment with or without intravenous thrombolysis (IVT) in daily clinical practice.

Méthode : This multicenter case-control study analyzed patients who were treated for primary distal occlusion of the posterior cerebral artery (PCA) of the P2 or P3 segment. These patients received mechanical thrombectomy or standard medical treatment (with or without IVT) at 1 of 23 comprehensive stroke centers in Europe, the United States, and Asia between January 1, 2010, and June 30, 2020. All patients who met the inclusion criteria were matched using 1:1 propensity score matching.
Interventions: Mechanical thrombectomy or standard medical treatment with or without IVT.
Main outcomes and measures: Clinical end point was the improvement of National Institutes of Health Stroke Scale (NIHSS) scores at discharge from baseline. Safety end point was the occurrence of symptomatic intracranial hemorrhage and hemorrhagic complications were classified based on the Second European-Australasian Acute Stroke Study (ECASSII). Functional outcome was evaluated with the modified Rankin Scale (mRS) score at 90-day follow-up.

Résultats : Of 243 patients from all participating centers who met the inclusion criteria, 184 patients were matched. Among these patients, the median (interquartile range [IQR]) age was 74 (62-81) years and 95 (51.6%) were female individuals. Posterior circulation DMVOs were located in the P2 segment of the PCA in 149 patients (81.0%) and in the P3 segment in 35 patients (19.0%). At discharge, the mean NIHSS score decrease was -2.4 points (95% CI, -3.2 to -1.6) in the standard medical treatment cohort and -3.9 points (95% CI, -5.4 to -2.5) in the mechanical thrombectomy cohort, with a mean difference of -1.5 points (95% CI, 3.2 to -0.8; P = .06). Significant treatment effects of mechanical thrombectomy were observed in the subgroup of patients who had higher NIHSS scores on admission of 10 points or higher (mean difference, -5.6; 95% CI, -10.9 to -0.2; P = .04) and in the subgroup of patients without IVT (mean difference, -3.0; 95% CI, -5.0 to -0.9; P = .005). Symptomatic intracranial hemorrhage occurred in 4 of 92 patients (4.3%) in each treatment cohort.

Conclusion : This study suggested that, although rarely performed at comprehensive stroke centers, mechanical thrombectomy for posterior circulation DMVO is a safe, and technically feasible treatment option for occlusions of the P2 or P3 segment of the PCA compared with standard medical treatment with or without IVT.

Conclusion (proposition de traduction) : Cette étude suggére que, bien que rarement réalisée dans les UNV, la thrombectomie mécanique pour occlusion distale et moyenne de la circulation postérieure est une option thérapeutique sûre et techniquement réalisable pour les occlusions du segment P2 ou P3 de l'artère cérébrale postérieure, comparativement au traitement médical standard avec ou sans thrombolyse intraveineuse.

Commentaire : Voir l'analyse de l'article sur le site Univadis from Medscape : La thrombectomie améliore l’issue de l’AVC lié à une occlusion distale de l’ACP  . Rédigé par le Dr Susan London, le 2 mars 2021.

Journal of Critical Care

Vasopressor dose equivalence: A scoping review and suggested formula.
Goradia S, Sardaneh AA, Narayan SW, Penm J, Patanwala AE. | J Crit Care. 2021 Feb;61:233-240
DOI: https://doi.org/10.1016/j.jcrc.2020.11.002
Keywords: Blood pressure; Clinical trials; Intensive care; Scoping review; Shock; Vasopressor.

Review article

Introduction : Calculating equipotent doses between vasopressor agents is necessary in clinical practice and research pertaining to the management of shock. This scoping review summarizes conversion ratios between vasopressors and provides a formula to incorporate into study designs.

Méthode : Medline, Embase and Web of Science databases were searched from inception to 21st October 2020. Additional papers were obtained through bibliography searches of retrieved articles. Two investigators assessed articles for eligibility. Clinical trials comparing the potency of at least two intravenous vasopressors (norepinephrine, epinephrine, dopamine, phenylephrine, vasopressin, metaraminol or angiotensin II), with regard to an outcome of blood pressure, were selected.

Résultats : Of 16,315 articles, 21 were included for synthesis. The range of conversion ratios equivalent to one unit of norepinephrine were: epinephrine (0.7-1.4), dopamine (75.2-144.4), metaraminol (8.3), phenylephrine (1.1-16.3), vasopressin (0.3-0.4) and angiotensin II (0.07-0.13). The following formula may be considered for the calculation of norepinephrine equivalents (NE) (all in mcg/kg/min, except vasopressin in units/min): NE = norepinephrine + epinephrine + phenylephrine/10 + dopamine/100 + metaraminol/8 + vasopressin*2.5 + angiotensin II*10.

Conclusion : A summary of equipotent ratios for common vasopressors used in clinical practice has been provided. Our formula may be considered to calculate NE for studies in the intensive care unit.

Conclusion (proposition de traduction) : Un résumé des rapports d'équivalence pour les vasopresseurs courants utilisés en pratique clinique a été fourni. Notre formule peut être utilisée pour calculer les équivalents de la noradrénaline dans les études en unité de soins intensifs.

The effects of arterial CO2 on the injured brain: Two faces of the same coin.
Godoy DA, Rovegno M, Lazaridis C, Badenes R. | J Crit Care. 2021 Feb;61:207-215
DOI: https://doi.org/10.1016/j.jcrc.2020.10.028
Keywords: CO(2) physiology; Cerebral blood flow; Hypercapnia; Hyperventilation; Hypocapnia; Intracranial hypertension.

Review article

Editorial : Serum levels of carbon dioxide (CO2) closely regulate cerebral blood flow (CBF) and actively participate in different aspects of brain physiology such as hemodynamics, oxygenation, and metabolism. Fluctuations in the partial pressure of arterial CO2 (PaCO2) modify the aforementioned variables, and at the same time influence physiologic parameters in organs such as the lungs, heart, kidneys, and the gastrointestinal tract. In general, during acute brain injury (ABI), maintaining normal PaCO2 is the target to be achieved. Both hypercapnia and hypocapnia may comprise secondary insults and should be avoided during ABI. The risks of hypocapnia mostly outweigh the potential benefits. Therefore, its therapeutic applicability is limited to transient and second-stage control of intracranial hypertension. On the other hand, inducing hypercapnia could be beneficial when certain specific situations require increasing CBF. The evidence supporting this claim is very weak. This review attempts providing an update on the physiology of CO2, its risks, benefits, and potential utility in the neurocritical care setting.

Conclusion : The injured brain is highly vulnerable to primary and secondary insults. CO2 levels markedly influence CBF through changes in the diameter of the resistance vessels. Oscillations of these levels modify hemodynamics, metabolism and cerebral oxygenation. Hypocapnia and hypercapnia are secondary insults with cerebral and systemic impacts. In general, it is recommended to maintain normocapnia. The potential benefits of hypercapnia or hypocapnia require further evidence. Hypocapnia is recommended in short duration as a measure to emergently control ICP, while hypercapnia could increase CBF improving perfusion in specific situations. Brain-lung interactions and consequent PaCO2 levels must always be considered during acute brain injury.

Conclusion (proposition de traduction) : Le cerveau blessé est très vulnérable aux agressions primaires et secondaires. Les taux de CO2 influencent nettement le débit sanguin cérébral en modifiant le diamètre de résistance des vaisseaux. Les oscillations de ces taux modifient l'hémodynamique, le métabolisme et l'oxygénation cérébrale. L'hypocapnie et l'hypercapnie sont des agressions secondaires avec des impacts cérébraux et systémiques. En général, il est recommandé de maintenir la normocapnie.
Les avantages potentiels de l'hypercapnie ou de l'hypocapnie nécessitent des preuves supplémentaires. L'hypocapnie est recommandée de courte durée comme mesure pour contrôler de façon urgente la pression intracrânienne, tandis que l'hypercapnie pourrait augmenter le débit sanguin cérébral améliorant la perfusion dans des situations spécifiques. Les interactions cerveau-poumon et les niveaux de PaCO2 qui en découlent doivent toujours être pris en compte lors d'une lésion cérébrale aiguë.

Safety and efficacy of vasopressor administration through midline catheters.
Prasanna N, Yamane D, Haridasa N, Davison D, Sparks A, Hawkins K. | J Crit Care. 2021 Feb;61:1-4
DOI: https://doi.org/10.1016/j.jcrc.2020.09.024
Keywords: CLABSI; Central lines; Midlines; Peripheral IV access; Safety; Vasoactive medications; Vasopressors.

Research article

Introduction : Vasopressors are commonly administered through Central Venous Catheters (CVCs) as it is considered unsafe to administer them via peripheral IVs, mainly due to the concern of local tissue injury. Unlike peripheral IVs, midline catheters provide a wider lumen with the catheter tip ending in a large peripheral vein. The use of vasopressors through midline catheters has not yet been evaluated.
Objective: The primary objective of this study is to determine the safety and efficacy of long term administration of vasopressors through a midline catheter.

Méthode : This is a retrospective study between 2016 and 2019 looking at the outcomes of midline catheters.
Setting : 45 bed Tertiary level ICU in a 600-bed teaching hospital.
Patients: A total of 248 patients received vasopressors via midline catheters.

Résultats : The average midline dwell time was 14.7 ± 12.8 days and the average duration of continuous vasopressor infusion was 7.8 ± 9.3 days. Vasopressors used with their average dose (AD) were norepinephrine (n = 165, 16.8 CE ± 10.7 μg/min), epinephrine (n = 56, 9.1 CE ± 6.0 μg/min), vasopressin (n = 123, 0.05 CE ± 0.02 units/min), phenylephrine (n = 158, 91.4 CE ± 64.7 μg/min) and Angiotensin II (50 CE ± 27.6 ng/kg/min). Early Complication rate was 3.6% due to Bloodstream infection (n = 6), drug extravasation (n = 1), thrombophlebitis (n = 1) and arterial puncture (n = 1). Late Complication rate was 0.8% (n = 2) due to midline-associated DVTs. There were no complications related to ineffective drug delivery or limb endangerment.

Conclusion : Many medical centers are attempting to limit the use of central venous catheters (CVCs) to avoid central line-associated bloodstream infections (CLABSIs). This study demonstrates that midline catheters are a safe alternative to CVCs, for the safe and efficacious administration of vasopressors for prolonged periods of time.

Conclusion (proposition de traduction) : De nombreux centres médicaux tentent de limiter l'utilisation des cathéters veineux centraux (CVC) pour éviter les infections de la circulation sanguine associées à la ligne centrale (CLABSI). Cette étude démontre que les cathéters Midlines sont une alternative sûre aux cathéters veineux centraux, pour l'administration sûre et efficace de vasopresseurs pendant des périodes prolongées.

Commentaire : Les cathéters Midline sont des cathéters veineux périphériques insérés au dessus du pli du coude dans une veine du bras jusqu’à la ligne axillaire pour des traitements prolongés de plus de 8 jours et peuvent rester en place jusqu’à 30 jours.
Consulter le documents de l'OMEDIT Centre-Val de Loire :
Différences entre cathéters émergeant au dessus du pli du coude du patient  .

Temperature control in critically ill patients with fever: A meta-analysis of randomized controlled trials.
Sakkat A, Alquraini M, Aljazeeri J, Farooqi MAM, Alshamsi F, Alhazzani W.. | J Crit Care. 2021 Feb;61:89-95
DOI: https://doi.org/10.1016/j.jcrc.2020.10.016
Keywords: Acetaminophen; Critical illness; Fever; Mortality; Non-steroidal anti-inflammatory drugs; Physical cooling; Sepsis.

Reviews and Meta-Analysis

Introduction : Fever is frequently encountered in ICU. It is unclear if targeted temperature control is beneficial in critically ill patients with suspected or confirmed infection. We conducted a systemic review and meta-analysis to answer this question.

Méthode : We systematically reviewed major databases before January 2020 to identify randomized controlled trials (RCTs) that compared antipyretic with placebo for temperature control in non-neurocritical ill adult patients with suspected or confirmed infection. Outcomes of interest were 28-day mortality, temperature level, hospital mortality, length of stay, shock reversal, and patient comfort.

Résultats : 13 RCTs enrolling 1963 patients were included. No difference in 28-day mortality between antipyretic compared with placebo (risk ratio [RR] 1.03; 95% CI 0.79-1.35). Lower temperature levels were achieved in the antipyretic group (MD [mean difference] -0.41; 95% CI -0.66 to -0.16). Antipyretic use did not affect the risk of hospital mortality (RR 0.97; 95% CI 0.73-1.30), ICU length of stay (MD -0.07; 95% CI -0.70 to 0.56), or shock reversal (RR 1.11; 95% CI 0.76-1.62).

Conclusion : Antipyretic therapy effectively reduces temperature in non-neurocritical ill patients but does not reduce mortality or impact other outcomes.

Conclusion (proposition de traduction) : Le traitement antipyrétique réduit efficacement la température chez les patients malades non neurocritiques, mais ne réduit pas la mortalité et n'affecte pas les autres résultats.

Lancet

Azithromycin in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial.
RECOVERY Collaborative Group | Lancet. 2021 Feb 13;397(10274):605-612
DOI: https://doi.org/10.1016/s0140-6736(21)00149-5  | Télécharger l'article au format  
Keywords: Aucun

ARTICLE

Introduction : Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatory actions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.

Méthode : In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospital with COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients were randomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once per day by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatment groups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment and were twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants and local study staff were not masked to the allocated treatment, but all others involved in the trial were masked to the outcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treat population.

Résultats : Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) were eligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was 65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomly allocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall, 561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days (rate ratio 0·97, 95% CI 0·87-1·07; p=0·50). No significant difference was seen in duration of hospital stay (median 10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days (rate ratio 1·04, 95% CI 0·98-1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, no significant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilation or death (risk ratio 0·95, 95% CI 0·87-1·03; p=0·24).

Conclusion : In patients admitted to hospital with COVID-19, azithromycin did not improve survival or other prespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restricted to patients in whom there is a clear antimicrobial indication.

Conclusion (proposition de traduction) : Chez les patients admis à l'hôpital pour COVID-19, l'azithromycine n'a pas amélioré la survie ou d'autres résultats cliniques prédéfinis. L'utilisation de l'azithromycine chez les patients admis à l'hôpital pour COVID-19 doit être limitée aux patients pour lesquels il existe une indication antimicrobienne claire.

Pediatric Emergency Care

Trends in Imaging Findings, Interventions, and Outcomes Among Children With Isolated Head Trauma.
Coon ER, Newman TB, Hall M, Wilkes J, Bratton SL, Schroeder AR. | Pediatr Emerg Care. 2021 Feb 1;37(2):55-61
DOI: https://doi.org/10.1097/pec.0000000000001475
Keywords: Aucun

Original Article

Introduction : The aim was to analyze the impact of decreased head computed tomography (CT) imaging on detection of abnormalities and outcomes for children with isolated head trauma.

Méthode : The study involves a multicenter retrospective cohort of patients younger than 19 years presenting for isolated head trauma to emergency departments in the Pediatric Health Information System database from 2003 to 2015. Patients directly admitted or transferred to another facility and those with a discharge diagnosis code for child maltreatment were excluded. Outcomes were ascertained from administrative and billing data. Trends were tested using mixed effects logistic regression, accounting for clustering within hospitals and adjusted for age, sex, insurance type, race, presence of a complex chronic condition, and hospital-level case mix index.

Résultats : Between 2003 and 2015, 306,041 children presented for isolated head trauma. The proportion of children receiving head CT imaging was increasing until 2008, peaking at just under 40%, before declining to 25% by 2015. During the recent period of decreased head CT imaging, the detection of skull fractures (odds ratio [OR]/year, 0.96; 95% confidence interval [CI], 0.95-0.97) and intracranial bleeds (OR/year, 0.96; 95% CI, 0.94-0.97), hospitalization (OR/year, 0.96; 95% CI, 0.95-0.96), neurosurgery (OR/year, 0.91; 95% CI, 0.87-0.95), and revisit (OR/year, 0.98; 95% CI, 0.96-1.00) also decreased, without significant changes in mortality (OR/year, 0.93; 95% CI, 0.84-1.04) or persistent neurologic impairment (OR/year, 1.03; 95% CI, 0.92-1.15).

Conclusion : The recent decline in CT scanning in children with isolated head trauma was associated with a reduction in detection of intracranial abnormalities, and a concomitant decrease in interventions, without measurable patient harm.

Conclusion (proposition de traduction) : Le déclin récent de la tomodensitométrie chez les enfants présentant un traumatisme crânien isolé était associé à une réduction de la détection des anomalies intracrâniennes et à une diminution concomitante des interventions, sans préjudice mesurable pour les patients.

Prehospital and Disaster Medicine

The Effects of Positional Change on Hemodynamic Parameters in Spinal Immobilization.
Gökçen E, Demir V. | Prehosp Disaster Med. 2021 Feb;36(1):67-73
DOI: https://doi.org/10.1017/s1049023x20001338
Keywords: cervical collar; inferior vena cava diameter; left ventricular outflow tract velocity time integral; long backboard; spinal immobilization.

Origina research

Introduction : The use of a long backboard and cervical collar are commonly recommended by international guidelines for spinal immobilization, but both devices may cause several side effects. In a recent study, it was reported that spinal immobilization at 20° eliminated the decrease in pulmonary function secondary to spinal immobilization performed at 0°. Spinal immobilization at 20° is a new recommendation, but other potential effects need to be explored before it can be implemented in clinical use.
Study objective: Hemodynamic observation is important in the management of trauma patients. The aim of this study was to investigate the effect of spinal immobilization at a 20° position instead of 0° on hemodynamic parameters.

Méthode : This study included 53 healthy volunteers who underwent spinal immobilization in the supine position (00) and in an elevated position (200). Systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), left ventricular outflow tract velocity time integral (LVOT-VTI), left ventricular stroke volume (LVSV), cardiac output (CO), inferior vena cava diameter inspiration (IVC diameter insp), IVC diameter expiration (IVC diameter exp), and inferior vena cava collapsibility index (IVC-CI) were measured at the 0th and 30th minutes of spinal immobilization in both positions. The data were compared for demonstrating the efficiency of both positions in spinal immobilization.

Résultats : A statistically significant difference was found in the parameters of the IVC diameter (exp), IVC diameter (insp), LVOT-VTI, LVSV, and CO through the measurements starting in the 0th minute of the transition from 0° to 20° (P <.001). Delta values (∆) of hemodynamic parameters (∆IVC diameter [exp], ∆IVC diameter [insp], ∆LVOT-VTI, ∆SV, ∆CO, ∆IVC-CI, ∆MAP, ∆SAP, ∆DAP, and ∆HR) were similar in spinal immobilization at 0° and 20°.

Conclusion : The findings obtained from this study illustrate that spinal immobilization at 20° does not cause clinically significant hemodynamic changes in healthy subjects compared to spinal immobilization at 0°.

Conclusion (proposition de traduction) : Les résultats de cette étude illustrent que l'immobilisation de la colonne vertébrale à 20 ° ne provoque pas de changements hémodynamiques cliniquement significatifs chez les sujets sains par rapport à l'immobilisation de la colonne vertébrale à 0 °.

Prehospital Tourniquets in Civilians: A Systematic Review.
Eilertsen KA, Winberg M, Jeppesen E, Hval G, Wisborg T. | Prehosp Disaster Med. 2021 Feb;36(1):86-94
DOI: https://doi.org/10.1017/s1049023x20001284
Keywords: first responder; hemorrhage; penetrating wounds; tourniquet.

Systematic Review

Introduction : Objectives: Terrorist attacks and civilian mass-casualty events are frequent, and some countries have implemented tourniquet use for uncontrollable extremity bleeding in civilian settings. The aim of this study was to summarize current knowledge on the use of prehospital tourniquets to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities.
Design : Systematic literature review in Medline (Ovid), Embase (Ovid), Cochrane Library, and Epistemonikos was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. The search was performed in January 2019.

Méthode : Setting: All types of studies that examined use of tourniquets in a prehospital setting published after January 1, 2000 were included.
Primary/secondary outcomes: The primary outcome was mortality with and without tourniquet, while adverse effects of tourniquet use were secondary outcomes.

Résultats : Among 3,460 screened records, 55 studies were identified as relevant. The studies were highly heterogeneous with low quality of evidence. Most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. Most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use.

Conclusion : Despite relatively low evidence, the studies consistently suggested that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage seemed to be associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects.

Conclusion (proposition de traduction) : Malgré des preuves relativement faibles, les études ont systématiquement suggéré que l'utilisation de garrots commerciaux dans un cadre civil pour contrôler l'hémorragie des extrémités potentiellement mortelle semblait être associée à une amélioration de la survie, à une réduction du besoin de transfusion sanguine et à des effets indésirables peu nombreux et transitoires.

Resuscitation

Clinical evaluation of intravenous alone versus intravenous or intraosseous access for treatment of out-of-hospital cardiac arrest.
Tan BKK, Chin YX, Koh ZX, Md Said NAZB, Rahmat M, Fook-Chong S, Ng YY, Ong MEH. | Resuscitation. 2021 Feb;159:129-136
DOI: https://doi.org/10.1016/j.resuscitation.2020.11.019
Keywords: Adrenaline; EMS; Intraosseous; Intravenous; Out-of-hospital cardiac arrest; Prehospital; Resuscitation.

Clinical Paper

Introduction : Obtaining vascular access during out-of-hospital cardiac arrest (OHCA) is challenging. The aim of this study was to determine if using intraosseous (IO) access when intravenous (IV) access fails improves outcomes.

Méthode : This was a prospective, parallel-group, cluster-randomised study that compared 'IV only' against 'IV + IO' in OHCA patients, where if 2 IV attempts failed or took more than 90 s, paramedics had 2 further attempts of IO. Primary outcome was any return of spontaneous circulation (ROSC). Secondary outcomes were insertion success rate, adrenaline administration, time to adrenaline and survival outcome.

Résultats : A total of 1007 patients were included in the analysis. An Intention To Treat analysis showed a significant difference in success rates of obtaining vascular access in the IV + IO arm compared to the IV arm (76.6% vs 61.1% p = 0.001). There were significantly more patients in the IV + IO arm than the IV arm being administered prehospital adrenaline (71.3% vs 55.4% p = 0.001). The IV + IO arm also received adrenaline faster compared to the IV arm in terms of median time from emergency call to adrenaline (23 min vs 25 min p = 0.001). There was no significant difference in ROSC (adjusted OR 0.99 95%CI: 0.75-1.29), survival to discharge or survival with CPC 2 or better in both groups. A Per Protocol analysis also showed there was higher success in obtaining vascular access in the IV + IO arm, but ROSC and survival outcomes were not statistically different.

Conclusion : Using IO when IV failed led to a higher rate of vascular access, prehospital adrenaline administration and faster adrenaline administration. However, it was not associated with higher ROSC, survival to discharge, or good neurological outcome.

Conclusion (proposition de traduction) : L'utilisation de le voie intra-osseuse en cas d'échec de la voie intraveineux a entraîné un taux d'accès vasculaire plus élevé, une administration préhospitalière d'adrénaline et une administration plus rapide d'adrénaline. Cependant, il n'était pas associé à une RACS plus élevé, à une survie à la sortie ou à un bon résultat neurologique.

Improving post-cardiac arrest cerebral perfusion pressure by elevating the head and thorax.
Duhem H, Moore JC, Rojas-Salvador C, Salverda B, Lick M, Pepe P, Labarere J, Debaty G, Lurie KG. | Resuscitation. 2021 Feb;159:45-53
DOI: https://doi.org/10.1016/j.resuscitation.2020.12.016
Keywords: Active compression-decompression CPR; Advanced cardiac life support; Cardiac arrest; Cardiopulmonary resuscitation; Cerebral perfusion pressure; Head Up CPR; Head and thorax elevation; Heart arrest; Impedance threshold device; Intracranial pressure; Medical device; Patient positioning; Posture; Return of spontaneous circulation.

Experimental

Introduction : The optimal head and thorax position after return of spontaneous circulation (ROSC) following cardiac arrest (CA) is unknown. This study examined whether head and thorax elevation post-ROSC is beneficial, in a porcine model.

Méthode : Protocol A: 40 kg anesthetized pigs were positioned flat, after 7.75 min of untreated CA the heart and head were elevated 8 and 12 cm, respectively, above the horizontal plane, automated active compression decompression (ACD) plus impedance threshold device (ITD) CPR was started, and 2 min later the heart and head were elevated 10 and 22 cm, respectively, over 2 min to the highest head up position (HUP). After 30 min of CPR pigs were defibrillated and randomized 10 min later to four 5-min epochs of HUP or flat position. Multiple physiological parameters were measured. In Protocol B, after 6 min of untreated VF, pigs received 6 min of conventional CPR flat, and after ROSC were randomized HUP versus Flat as in Protocol A. The primary endpoint was cerebral perfusion pressure (CerPP). Multivariate analysis-of-variance (MANOVA) for repeated measures was used. Data were reported as mean ± SD.

Résultats : In Protocol A, intracranial pressure (ICP) (mmHg) was significantly lower post-ROSC with HUP (9.1 ± 5.5) versus Flat (18.5 ± 5.1) (p < 0.001). Conversely, CerPP was higher with HUP (62.5 ± 19.9) versus Flat (53.2 ± 19.1) (p = 0.004), respectively. Protocol A and B results comparing HUP versus Flat were similar.

Conclusion : Post-ROSC head and thorax elevation in a porcine model of cardiac arrest resulted in higher CerPP and lower ICP values, regardless of VF duration or CPR method.

Conclusion (proposition de traduction) : L'élévation post-RACS de la tête et du thorax dans un modèle porcin d'arrêt cardiaque a entraîné une pression de perfusion cérébrale plus élevée et des valeurs de pression intracrânienne plus faibles, quelle que soit la durée de la fibrillation ventriculaire ou la méthode de RCP.

The American Journal of Emergency Medicine

Is the use of greater than 1 L of intravenous crystalloids associated with worse outcomes in trauma patients?.
Zitek T, Ataya R, Farino L, Mohammed S, Miller G. | Am J Emerg Med. 2021 Feb;40:32-36
DOI: https://doi.org/10.1016/j.ajem.2020.12.013
Keywords: Crystalloids; Resuscitation; Trauma.

Original contribution

Introduction : Advanced Trauma Life Support guidelines recommend only 1 L of intravenous (IV) crystalloid before transitioning to blood products. We sought to determine if receiving >1 L of IV crystalloid during the initial resuscitation is associated with worse outcomes. We also sought to determine if receiving no crystalloids is associated with better outcomes.

Méthode : We performed a single center retrospective study using trauma registry data, which was supplemented by manual chart review. We only included patients who had an initial heart rate ≥ 100 beats/min or a systolic blood pressure ≤ 90 mmHg. For each patient, we determined the total amount of IV crystalloid administered in the first 3 h after arrival to the hospital plus prehospital crystalloid. We performed multivariate regression analyses to determine if there is an association between the administration of >1 L of crystalloids or no crystalloids with in-hospital mortality, hospital length of stay (LOS), or packed red blood cells (PRBCs) transfused.

Résultats : Between January 1, 2018 and September 30, 2019, there were 878 who met criteria for enrollment. Among those, 55.0% received ≤1 L of IV crystalloids, and 45.0% received >1 L. Multivariate analyses showed no significant association between receiving >1 L and mortality (p = 0.61) or PRBCs transfused (p = 0.29), but patients who received >1 L had longer hospital LOS (p = 0.04). We found no association between receiving no crystalloids and mortality, PRBCs transfused, or LOS.

Conclusion : On a multivariate analysis of trauma patients, we did not find an association between the administration of >1 L of IV crystalloid and in-hospital mortality or the volume of PRBCs transfused. However, receiving >1 L of crystalloids was associated with a longer hospital LOS. We found no benefit to completely withholding crystalloids.

Conclusion (proposition de traduction) : Lors d'une analyse multivariée de patients traumatisés, nous n'avons pas trouvé d'association entre l'administration de > 1 L de cristalloïde IV et la mortalité à l'hôpital ou le volume de concentrés de globules rouges transfusés. Cependant, recevoir > 1 L de cristalloïdes était associé à une durée d'hospitalisation plus longue. Nous n'avons trouvé aucun avantage à retenir complètement les cristalloïdes.

Time to first defibrillation and survival outcomes of out-of-hospital cardiac arrest with refractory ventricular fibrillation.
Lee SGW, Park JH, Ro YS, Hong KJ, Song KJ, Shin SD. | Am J Emerg Med. 2021 Feb;40:96-102
DOI: https://doi.org/10.1016/j.ajem.2020.12.019
Keywords: Electric countershock; Emergency medical services; Out-of-hospital cardiac arrest; Tachycardia; Ventricular fibrillation.

Original contribution

Introduction : Timely defibrillation is associated with increased survival in out-of-hospital cardiac arrest (OHCA) cases. This study aimed to determine whether the time to first defibrillation was associated with good neurological outcomes in OHCA patients with refractory ventricular fibrillation.

Méthode : Bystander-witnessed adult OHCA patients with presumed cardiac etiology who presented with ventricular fibrillation and received ≥2 successive prehospital defibrillations from emergency medical services between 2013 and 2018 were included. The times from collapse to first defibrillation were categorized into Group 1 (0-5 min), Group 2 (6-10 min), Group 3 (11-15 min), and Group 4 (16-60 min). The primary outcome was a good neurological recovery (cerebral performance category 1-2). Multivariable logistic regression analysis was performed to calculate the adjusted odd ratios (AORs) and 95% confidence intervals (CIs) for outcomes according to time group (Group 1 as the reference) and per 1-min delay.

Résultats : The study included 5753 patients, with overall rates of 34.4% for survival to discharge and 27.2% for good neurological recovery. The median number of prehospital defibrillations was 3 (interquartile range 2-5). Relative to Group 1, the AORs for good neurological recovery were 0.58 in Group 2 (95% CI: 0.41-0.82), 0.42 in Group 3 (95% CI: 0.29-0.60), and 0.19 in Group 4 (95% CI: 0.13-0.29). When time from collapse to first EMS defibrillation was analyzed as a continuous variable, each 1-min delay was associated with a significant decrease in the likelihood of good neurological recovery (AOR: 0.93, 95% CI: 0.91-0.94).

Conclusion : A short time from collapse to first defibrillation was associated with good neurological recovery among patients with OHCA and refractory ventricular fibrillation. This result suggests that a failed first shock still has a positive effect if it is delivered quickly.

Conclusion (proposition de traduction) : Un court laps de temps entre l'effondrement et la première défibrillation était associé à une bonne récupération neurologique chez les patients présentant un arrêt cardiaque extrahospitalier et une fibrillation ventriculaire réfractaire. Ce résultat suggère qu'un premier choc raté a toujours un effet positif s'il est délivré rapidement.

The optimal peripheral oxygen saturation may be 95-97% for post-cardiac arrest patients: A retrospective observational study.
Zhou DW, Li ZM, Zhang SL, Wu L, Li YY, Zhou JX, Shi GZ. | Am J Emerg Med. 2021 Feb;40:120-126
DOI: https://doi.org/10.1016/j.ajem.2020.01.038
Keywords: Mortality; Oxygen titration; PaO(2); Post-cardiac arrest care; SpO(2)

Original contribution

Introduction : Current post-resuscitation guidelines recommend oxygen titration in adults with the return of spontaneous circulation after cardiac arrest. However, the optimal peripheral oxygen saturation (SpO2) is still unclear for post-cardiac arrest care.

Méthode : We conducted a retrospective observational study of prospectively collected data of all cardiac arrest patients admitted to the intensive care units between 2014 and 2015. The main exposure was SpO2, which were interfaced from bedside vital signs monitors as 1-min averages, and archived as 5-min median values. The proportion of time spent in different SpO2 categories was included in separate multivariable regression models along with covariates. The primary outcome measure was hospital mortality and the proportion of discharged home as the secondary outcome was reported.

Résultats : 2836 post-cardiac arrest patients in ICUs of 156 hospitals were included. 1235 (44%) patients died during hospitalization and 818 (29%) patients discharged home. With multivariate regression analysis, the proportion of time spent in SpO2 of ≤89%, 90%, 91%, and 92% were associated with higher hospital mortality. The proportion of time spent in SpO2 of 95%, 96%, and 97% were associated with a higher proportion of discharged home outcome, but not associated with hospital mortality.

Conclusion : In this retrospective observational study, the optimal SpO2 for patients admitted to the intensive care unit after cardiac arrest may be 95-97%. Further investigation is warranted to determine if targeting SpO2 of 95-97% would improve patient-centered outcomes after cardiac arrest.

Conclusion (proposition de traduction) : Dans cette étude observationnelle rétrospective, la SpO2 optimale pour les patients admis en unité de soins intensifs après un arrêt cardiaque serait de 95 à 97 %. Une enquête plus approfondie est justifiée pour déterminer si le ciblage d'une SpO2 de 95 à 97 % améliorerait les résultats centrés sur le patient après un arrêt cardiaque.

The Journal of Emergency Medicine

Utilization of Prophylactic Antibiotics After Nasal Packing for Epistaxis.
Hu L, Gordon SA, Swaminathan A, Wu T, Lebowitz R, Lieberman S. | J Emerg Med. 2021 Feb;60(2):144-149
DOI: https://doi.org/10.1016/j.jemermed.2020.10.011  | Télécharger l'article au format  
Keywords: acute sinusitis; epistaxis; nasal packing; prophylactic antibiotics; toxic shock syndrome.

Origial Contribution

Introduction : There have been few investigations examining the benefits, consequences, and patterns of use for prophylactic antibiotics for nasal packing in the emergency department setting. Given the frequency of epistaxis in the emergency department, it is an ideal setting to study the efficacy and utilization patterns of prophylactic antibiotics in nasal packing.
Objective: Our aim was to assess both rates of utilization and evidence of benefit for prophylactic antibiotics in patients with nasal packing for epistaxis.

Méthode : A single-institution retrospective review of 275 cases of anterior nasal packing in an urban emergency department between September 2013 and April 2017 was performed. Chi-square statistical analysis was used to evaluate results.

Résultats : Among 275 cases studied, there were no instances of toxic shock syndrome. Roughly 73% of patients with nonabsorbable packing received prophylactic antibiotics. Only one (1.1%) case of sinusitis was noted among the nonabsorbable packing with prophylaxis group, with no such complication in the nonprophylaxis group. In contrast, 95% of patients with absorbable nasal packing were not given prophylactic antibiotics. Analysis of all cases given prophylactic antibiotics vs. no prophylaxis, regardless of packing type, revealed no statistically significant difference in the development of acute sinusitis (1% vs. 0.56%; p = 0.6793).

Conclusion : There was no observed advantage or disadvantage to using prophylactic antibiotics in anterior nasal packing in the emergency department, regardless of whether patients received absorbable or nonabsorbable packing. However, patients who receive nonabsorbable nasal packing were more likely to receive antibiotic prophylaxis.

Conclusion (proposition de traduction) : On n’a observé aucun avantage ou inconvénient à utiliser l'antibioprophylacxie dans le méchage nasal antérieur au service des urgences, que les patients aient bénéficié d'un méchage absorbable ou non. Cependant, les patients qui reçoivent un méchage nasal non absorbable étaient plus susceptibles de bénéficier d'une prophylaxie antibiotique.

The New England Journal of Medicine

Dexamethasone in Hospitalized Patients with Covid-19.
RECOVERY Collaborative Group, Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, Staplin N, Brightling C, Ustianowski A, Elmahi E, Prudon B, Green C, Felton T, Chadwick D, Rege K, Fegan C, Chappell LC, Faust SN, Jaki T, Jeffery K, Montgomery A, Rowan K, Juszczak E, Baillie JK, Haynes R, Landray MJ. | N Engl J Med. 2021 Feb 25;384(8):693-704
DOI: https://doi.org/10.1056/nejmoa2021436  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Coronavirus disease 2019 (Covid-19) is associated with diffuse lung damage. Glucocorticoids may modulate inflammation-mediated lung injury and thereby reduce progression to respiratory failure and death.

Méthode : In this controlled, open-label trial comparing a range of possible treatments in patients who were hospitalized with Covid-19, we randomly assigned patients to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days or to receive usual care alone. The primary outcome was 28-day mortality. Here, we report the final results of this assessment.

Résultats : A total of 2104 patients were assigned to receive dexamethasone and 4321 to receive usual care. Overall, 482 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.001). The proportional and absolute between-group differences in mortality varied considerably according to the level of respiratory support that the patients were receiving at the time of randomization. In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.92 to 1.55).

Conclusion : In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support.

Conclusion (proposition de traduction) : Chez les patients hospitalisés pour une pneumopathie Covid-19, l'administration de dexaméthasone a permis une baisse de la mortalité à 28 jours chez ceux qui bénéficiaient lors de la randomisation, soit d'une ventilation mécanique invasive, soit d'une oxygènothérapie uniquement, mais pas parmi ceux qui ne recevaient aucune assistance respiratoire.

Commentaire : Voir l'analyse de l'article sur le site Univadis from Medscape : COVID-19 : un bénéfice de survie est observé avec la dexaméthasone dans le cadre de la forme sévère de la maladie  . Rédigé par le Dr Liz Scherer, le 3 mars 2021.

The Ultrasound Journal

Bedside lung ultrasonography by emergency department residents as an aid for identifying heart failure in patients with acute dyspnea after a 2-h training course.
Msolli MA, Sekma A, Marzouk MB, Chaabane W, Bel Haj Ali K, Boukadida L, Bzeouich N, Gannoun I, Trabelssi I, Laaouiti K, Grissa MH, Beltaief K, Dridi Z, Belguith A, Methamem M, Bouida W, Boukef R, Boubaker H, Nouira S; GREAT Network. | Ultrasound J. 2021 Feb 9;13(1):5
DOI: https://doi.org/10.1186/s13089-021-00207-9  | Télécharger l'article au format  
Keywords: Accuracy; B-lines; Congestive heart failure; Diagnosis; Lung ultrasonography; Reproducibility.

ORIGINAL ARTICLE

Introduction : Ultrasonographic B-lines have recently emerged as a bedside imaging tool for the differential diagnosis of acute dyspnea in the Emergency Department (ED). However, despite its simplicity, LUS has not fully penetrated emergency department. This study aimed to assess the accuracy and reproducibility of ultrasonographic B-lines performed by emergency medicine (EM) residents for the diagnosis of congestive heart failure (CHF) in patients admitted to ED for acute dyspnea.

Méthode : This is a cross-sectional prospective study conducted between January 2016 and October 2017 including patients aged over 18 years admitted to ED for acute dyspnea. At admission, two consecutive bedside LUS study were performed by a pair of EM residents who received a 2-h course for recognition of sonographic B-lines to determine independently B-lines score and B-profile pattern. All participating sonographers were blinded to patients' clinical data. B-lines score ≥ 15 or a B-profile pattern was considered as suggestive of CHF. The final leading diagnosis was assessed by two expert sonographers, who were blinded to the residents' interpretations, based on clinical findings, chest X-ray, brain natriuretic peptide, cardiac and lung ultrasound testing. Accuracy and agreement of B-lines score and B-profile pattern were calculated.

Résultats : We included 700 patients with a mean age of 68 ± 12.6 years and a sex ratio (M/F) of 1.43. The diagnosis of CHF was recorded in 371 patients (53%). The diagnostic performance of B-lines score at a cut-off 15 and B-profile pattern was, respectively, 88% and 82.5% for sensitivity, 75% and 84% for specificity, 80% and 85% for positive predictive value, 84% and 81% for negative predictive value. The area under receiver operating characteristic curve was 0.86 [0.83-0.89] and 0.83 [0.80-0.86], respectively, for B-lines score and B-profile pattern. There was an excellent agreement between residents for the diagnosis of CHF using both scores (kappa = 0.81 and 0.85, respectively, for ordinal scale B-lines score and B-profile pattern).

Conclusion : Lung ultrasound B-lines assessment has a good accuracy and an excellent reproducibility in the diagnosis of CHF in the hand of EM residents following a short training program.

Conclusion (proposition de traduction) : L'évaluation des lignes B par échographie pulmonaire a une bonne précision et une excellente reproductibilité dans le diagnostic de l'insuffisance cardiaque congestive dans la main des internes en médecine d'urgence suite à un programme de formation court.


Mois de février 2021