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 1^er 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    .

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

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. 2021 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.

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 1^st of January 2017, through the 31^st 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.

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.

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.

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.

Effects of Intravenous Lipid Emulsion on Tramadol-Induced Seizure; a Randomized Clinical Trial.
Kazemifar AM, Yazdi Z, Bedram A, Mahmoudi J, Ziaee M. | Arch Acad Emerg Med. 2021 Feb 20;9(1):e20
DOI: https://doi.org/10.22037/aaem.v9i1.1070  | Télécharger l'article au format  
Keywords: Clinical trial; Poisoning; Seizure; Tramadol; phospholipid emulsion; soybean oil.

Original/Research Article

Introduction : There are numerous studies on the efficacy of intralipid emulsion (ILE) in various xenobiotic toxicities. This study aimed to evaluate the potential role of ILE as an antidote in tramadol-induced seizure.

Méthode : A single-blind clinical trial was undertaken to establish the efficacy and safety of ILE in patients with acute tramadol intoxication, who referred to Booali Hospital in Qazvin. Patients were randomly assigned to 2 groups. The Control group received standard care while the intervention group received intralipid emulsion (ILE) 20% in addition to the standard care. The occurrence of in-hospital seizure was compared between the groups.

Résultats : 80 patients who abused tramadol and met the study criteria were randomly assigned to either the intervention (40 cases) or the control (40 cases) group. Seizure occurred in 44 (56%) patients before admission to the emergency department. There were not any statistical differences between the groups regarding sex distribution (p=0.513) and mean age (p=0.19), presenting vital signs (p < 0.05), laboratory findings (p < 0.05), and mean abused dose of tramadol (p = 0.472) as well as occurrence of prehospital seizure (p = 0.7). In-hospital seizure occurred in 15 (18.75%) cases (all in the control group; p < 0.001). The mean duration of admission was 2.01 ± 1.13 days in the control group and 2.15 ± 1.04 days in the intervention group (p = 0.6). The number needed to treat for ILE to prevent tramadol-induced seizure was 2.7 (37.5% absolute risk reduction).

Conclusion : The findings of this study supported ILE administration, as an adjunct to standard antidote protocols, in tramadol intoxication to prevent tramadol-induced seizures.

Conclusion (proposition de traduction) : Les résultats de cette étude ont soutenu l'administration d'émulsion intralipidique, en complément des protocoles d'antidote standard, dans l'intoxication au tramadol pour prévenir les crises induites par le tramadol.

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.

Association between antihypertensive treatment and adverse events: systematic review and meta-analysis.
Albasri A, Hattle M, Koshiaris C, Dunnigan A, Paxton B, Fox SE, Smith M, Archer L, Levis B, Payne RA, Riley RD, Roberts N, Snell KIE, Lay-Flurrie S, Usher-Smith J, Stevens R, Hobbs FDR, McManus RJ, Sheppard JP; STRATIFY investigators. | BMJ. 2021 Feb 10;372:n189
DOI: https://doi.org/10.1136/bmj.n189  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : To examine the association between antihypertensive treatment and specific adverse events.
Design: Systematic review and meta-analysis.
Eligibility criteria: Randomised controlled trials of adults receiving antihypertensives compared with placebo or no treatment, more antihypertensive drugs compared with fewer antihypertensive drugs, or higher blood pressure targets compared with lower targets. To avoid small early phase trials, studies were required to have at least 650 patient years of follow-up.
Information sources: Searches were conducted in Embase, Medline, CENTRAL, and the Science Citation Index databases from inception until 14 April 2020.

Méthode : The primary outcome was falls during trial follow-up. Secondary outcomes were acute kidney injury, fractures, gout, hyperkalaemia, hypokalaemia, hypotension, and syncope. Additional outcomes related to death and major cardiovascular events were extracted. Risk of bias was assessed using the Cochrane risk of bias tool, and random effects meta-analysis was used to pool rate ratios, odds ratios, and hazard ratios across studies, allowing for between study heterogeneity (τ²).

Résultats : Of 15 023 articles screened for inclusion, 58 randomised controlled trials were identified, including 280 638 participants followed up for a median of 3 (interquartile range 2-4) years. Most of the trials (n=40, 69%) had a low risk of bias. Among seven trials reporting data for falls, no evidence was found of an association with antihypertensive treatment (summary risk ratio 1.05, 95% confidence interval 0.89 to 1.24, τ²=0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ²=0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ²=0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ²=0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ²=0.050, n=16). The heterogeneity between studies assessing acute kidney injury and hyperkalaemia events was reduced when focusing on drugs that affect the renin angiotensin-aldosterone system. Results were robust to sensitivity analyses focusing on adverse events leading to withdrawal from each trial. Antihypertensive treatment was associated with a reduced risk of all cause mortality, cardiovascular death, and stroke, but not of myocardial infarction.

Conclusion : This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function.

Conclusion (proposition de traduction) : Cette méta-analyse n'a trouvé aucune preuve suggérant qu'un traitement antihypertenseur était associé à des chutes, mais a trouvé des preuves d'une association avec des événements indésirables légers (hyperkaliémie, hypotension) et sévères (lésion rénale aiguë, syncope). Ces données pourraient être utilisées pour éclairer la prise de décision partagée entre les médecins et les patients concernant l'initiation et la poursuite du traitement antihypertenseur, en particulier chez les patients à haut risque de survenue d'évènements indésirables en raison de la survenue antérieure d'événements indésirables ou de leur mauvaise fonction rénale.

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.

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.

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.

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.

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.

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.

Impact of videolaryngoscopy introduction into prehospital emergency medicine practice: a quality improvement project.
Steel A, Haldane C, Cody D. | Emerg Med J. 2021 Feb 15:emermed-2020-209944
DOI: https://doi.org/10.1136/emermed-2020-209944
Keywords: airway; pre-hospital.

QUALITY IMPROVEMENT REPORT

Introduction : Advanced airway management is necessary in the prehospital environment and difficult airways occur more commonly in this setting. Failed intubation is closely associated with the most devastating complications of airway management. In an attempt to improve the safety and success of tracheal intubation, we implemented videolaryngoscopy (VL) as our first-line device for tracheal intubation within a UK prehospital emergency medicine (PHEM) setting.

Méthode : An East of England physician-paramedic PHEM team adopted VL as first line for undertaking all prehospital advanced airway management. The study period was 2016-2020. Statistical process control charts were used to assess whether use of VL altered first-pass intubation success, frequency of intubation-related hypoxia and laryngeal inlet views. A survey was used to collect the team's views of VL introduction.

Résultats : 919 patients underwent advanced airway management during the study period. The introduction of VL did not improve first-pass intubation success, view of laryngeal inlet or intubation-associated hypoxia. VL improved situational awareness and opportunities for training but performed poorly in some environments.

Conclusion : Despite the lack of objective improvement in care, subjective improvements meant that overall PHEM clinicians wanted to retain VL within their practice.

Conclusion (proposition de traduction) : Malgré l'absence d'amélioration objective des soins, les améliorations subjectives signifiaient que les cliniciens en médecine d'urgence préhospitalier dans l'ensemble voulaient conserver la vidéolaryngoscopie dans leur pratique.

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.

Survival and quality of life after early discharge in low-risk pulmonary embolism.
Barco S, Schmidtmann I, Ageno W, Anušić T, Bauersachs RM, Becattini C, Bernardi E, Beyer-Westendorf J, Bonacchini L, Brachmann J, Christ M, Czihal M, Duerschmied D, Empen K, Espinola-Klein C, Ficker JH, Fonseca C, Genth-Zotz S, Jiménez D, Harjola VP, Held M, Iogna Prat L, Lange TJ, Lankeit M, Manolis A, Meyer A, Münzel T, Mustonen P, Rauch-Kroehnert U, Ruiz-Artacho P, Schellong S, Schwaiblmair M, Stahrenberg R, Valerio L, Westerweel PE, Wild PS, Konstant. | Eur Respir J. 2021 Feb 4;57(2):2002368
DOI: https://doi.org/10.1183/13993003.02368-2020
Keywords: Aucun

Pulmonary vascular disease

Introduction : Early discharge of patients with acute low-risk pulmonary embolism requires validation by prospective trials with clinical and quality-of-life outcomes.

Méthode : The multinational Home Treatment of Patients with Low-Risk Pulmonary Embolism with the Oral Factor Xa Inhibitor Rivaroxaban (HoT-PE) single-arm management trial investigated early discharge followed by ambulatory treatment with rivaroxaban. The study was stopped for efficacy after the positive results of the predefined interim analysis at 50% of the planned population. The present analysis includes the entire trial population (576 patients). In addition to 3-month recurrence (primary outcome) and 1-year overall mortality, we analysed self-reported disease-specific (Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire) and generic (five-level five-dimension EuroQoL (EQ-5D-5L) scale) quality of life as well as treatment satisfaction (Anti-Clot Treatment Scale (ACTS)) after pulmonary embolism.

Résultats : The primary efficacy outcome occurred in three (0.5%, one-sided upper 95% CI 1.3%) patients. The 1-year mortality was 2.4%. The mean±sd PEmb-QoL decreased from 28.9±20.6% at 3 weeks to 19.9±15.4% at 3 months, a mean change (improvement) of -9.1% (p<0.0001). Improvement was consistent across all PEmb-QoL dimensions. The EQ-5D-5L was 0.89±0.12 at 3 weeks after enrolment and improved to 0.91±0.12 at 3 months (p<0.0001). Female sex and cardiopulmonary disease were associated with poorer disease-specific and generic quality of life; older age was associated with faster worsening of generic quality of life. The ACTS burden score improved from 40.5±6.6 points at 3 weeks to 42.5±5.9 points at 3 months (p<0.0001).

Conclusion : Our results further support early discharge and ambulatory oral anticoagulation for selected patients with low-risk pulmonary embolism. Targeted strategies may be necessary to further improve quality of life in specific patient subgroups.

Conclusion (proposition de traduction) : Nos résultats soutiennent en autre une sortie précoce et une anticoagulation orale ambulatoire pour certains patients présentant une embolie pulmonaire à faible risque. Des stratégies ciblées peuvent être nécessaires pour améliorer encore la qualité de vie dans des sous-groupes de patients spécifiques.

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.

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.

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.

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.

The incidence of pulmonary thromboembolism in COVID-19 patients admitted to the intensive care unit: a meta-analysis and meta-regression of observational studies.
Ng JJ, Liang ZC, Choong AMTL. | J Intensive Care. 2021 Feb 22;9(1):20
DOI: https://doi.org/10.1186/s40560-021-00535-x  | Télécharger l'article au format  
Keywords: COVID-19; Coronavirus disease 2019; Critical care; Intensive care unit; Pulmonary thromboembolism.

Research

Introduction : Coronavirus disease 2019 (COVID-19) infection is associated with a prothrombotic state. We performed a meta-analysis of proportions to estimate the weighted average incidence of pulmonary thromboembolism (PTE) in COVID-19 patients who were admitted to the intensive care unit (ICU).

Méthode : We searched various medical databases for relevant studies from 31 December 2019 till 30 September 2020. We included observational studies that reported the incidence of PTE in COVID-19 patients admitted to the ICU. We extracted data related to study characteristics, patient demographics, and the incidence of PTE. Risk of bias was assessed by using the ROBINS-I tool. Statistical analysis was performed with R 3.6.3.

Résultats : We included 14 studies with a total of 1182 patients in this study. Almost all patients in this meta-analysis received at least prophylactic anticoagulation. The weighted average incidence of PTE was 11.1% (95% CI 7.7% to 15.7%, I2 = 78%, Cochran's Q test P < 0.01). We performed univariate and multivariate meta-regression, which identified the proportion of males as a significant source of heterogeneity (P = 0.03, 95% CI 0.00 to - 0.09).

Conclusion : The weighted average incidence of PTE remains high even after prophylactic anticoagulation. PTE is a significant complication of COVID-19 especially in critically ill patients in the ICU.

Conclusion (proposition de traduction) : L'incidence moyenne pondérée de l'embolie pulmonaire reste élevée même après une anticoagulation prophylactique. l'embolie pulmonaire est une complication importante de la COVID-19, en particulier chez les patients gravement malades en réanimation.

Oxygen administration for patients with ARDS.
Ohshimo S | J Intensive Care. 2021 Feb 6;9(1):17
DOI: https://doi.org/10.1186/s40560-021-00532-0  | Télécharger l'article au format  
Keywords: Acute respiratory failure; Complication; Extracorporeal membrane oxygenation; High-flow nasal cannula; Mechanical ventilation; Non-invasive positive pressure ventilation; Prognosis.

Review

Editorial : Acute respiratory distress syndrome (ARDS) is a fatal condition with insufficiently clarified etiology. Supportive care for severe hypoxemia remains the mainstay of essential interventions for ARDS. In recent years, adequate ventilation to prevent ventilator-induced lung injury (VILI) and patient self-inflicted lung injury (P-SILI) as well as lung-protective mechanical ventilation has an increasing attention in ARDS.Ventilation-perfusion mismatch may augment severe hypoxemia and inspiratory drive and consequently induce P-SILI. Respiratory drive and effort must also be carefully monitored to prevent P-SILI. Airway occlusion pressure (P0.1) and airway pressure deflection during an end-expiratory airway occlusion (Pocc) could be easy indicators to evaluate the respiratory drive and effort. Patient-ventilator dyssynchrony is a time mismatching between patient's effort and ventilator drive. Although it is frequently unrecognized, dyssynchrony can be associated with poor clinical outcomes. Dyssynchrony includes trigger asynchrony, cycling asynchrony, and flow delivery mismatch. Ventilator-induced diaphragm dysfunction (VIDD) is a form of iatrogenic injury from inadequate use of mechanical ventilation. Excessive spontaneous breathing can lead to P-SILI, while excessive rest can lead to VIDD. Optimal balance between these two manifestations is probably associated with the etiology and severity of the underlying pulmonary disease.High-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NPPV) are non-invasive techniques for supporting hypoxemia. While they are beneficial as respiratory supports in mild ARDS, there can be a risk of delaying needed intubation. Mechanical ventilation and ECMO are applied for more severe ARDS. However, as with HFNC/NPPV, inappropriate assessment of breathing workload potentially has a risk of delaying the timing of shifting from ventilator to ECMO. Various methods of oxygen administration in ARDS are important. However, it is also important to evaluate whether they adequately reduce the breathing workload and help to improve ARDS.

Conclusion : I have discussed the recent advances in the oxygen ad- ministration for patients with ARDS. Lung-protective ventilation remains the mainstay of respiratory manage- ment in ARDS, whereas the benefit of recruitment man- euver or high PEEP is not confirmed. Although ECMO has the potential to be a new procedure of oxygen ad- ministration for patients with ARDS, each physician should also become proficient in managing complica- tions and troubles for improving patient outcome.

Conclusion (proposition de traduction) : Dans cet article, j'ai discuté des progrès récents dans l'administration de l'oxygène chez les patients en SDRA. La ventilation de protection pulmonaire reste le pilier de la prise en charge respiratoire dans le SDRA, alors que le bénéfice de la manœuvre de recrutement ou de la PEP élevée n'est pas confirmé. Bien que l'ECMO ait le potentiel d'être une nouvelle procédure d'administration de l'oxygène pour les patients en SDRA, chaque médecin devrait également devenir compétent dans la gestion des complications et des problèmes pour améliorer les résultats des patients.

Effects of Inotropes on the Mortality in Patients With Septic Shock.
Sato R, Ariyoshi N, Hasegawa D, Crossey E, Hamahata N, Ishihara T, Nasu M, Devendra G. | J Intensive Care Med. 2021 Feb;36(2):211-219
DOI: https://doi.org/10.1177/0885066619892218
Keywords: cardiogenic shock; dobutamine; epinephrine; inotropes; milrinone; sepsis; septic shock.

Original Research

Introduction : Although surviving sepsis campaign guidelines recommend the use of inotropes in the presence of myocardial dysfunction, the effects of inotropes, including epinephrine, dobutamine, and milrinone, on in-hospital mortality in patients with septic shock remains unclear.

Méthode : We conducted an international,2-center, retrospective cohort study. The Cox proportional hazards regression model with time-varying covariates was used to investigate whether epinephrine, milrinone, or dobutamine reduces in-hospital mortality in patients with septic shock. Sensitivity analysis was performed using propensity score matching. The primary outcome was in-hospital mortality. The secondary outcome included atrial fibrillation (Afib) with a rapid ventricular response (RVR) in the intensive care unit (ICU) and ICU-free days.

Résultats : A total of 417 patients with septic shock were included, 72 (17.3%) of whom received inotropes. The use of epinephrine and dobutamine was associated with significantly higher in-hospital mortality (epinephrine, hazard ratio [HR]: 4.79, 95% confidence interval [CI]: 2.12-10.82, P = .001; dobutamine, HR: 2.53, 95% CI: 1.30-4.95, P = .046). The effects of epinephrine and dobutamine were time- and dose-dependent. The use of milrinone was not associated with increased mortality (HR: 1.07, 95% CI: 0.42-2.68, P = .345). The use of epinephrine, dobutamine, and milrinone was associated with significantly increased odds of Afib with RVR (epinephrine, odds ratio [OR]: 3.88, 95% CI: 1.11-13.61, P = .034; dobutamine, OR: 3.95, 95% CI: 1.14-13.76; and milrinone, OR: 3.77, 95% CI: 1.05-13.59). On the other hand, the use of epinephrine, dobutamine, and milrinone was not associated with less ICU-free days (epinephrine, adjusted OR: 0.30, 95% CI: 0.09-1.01, P = .053; dobutamine, adjusted OR: 0.91, 95% CI: 0.29-2.84; and milrinone, adjusted OR: 0.60, 95% CI: 0.19-1.87).

Conclusion : The present study showed that the use of epinephrine and dobutamine was associated with significantly increased in-hospital mortality in patients with septic shock. These effects were both time- and dose-dependent. On the other hand, the use of milrinone was not associated with increased in-hospital mortality.

Conclusion (proposition de traduction) : La présente étude a montré que l'utilisation d'adrénaline et de dobutamine était associée à une mortalité hospitalière significativement accrue chez les patients en choc septique. Ces effets étaient à la fois dépendants du temps et de la dose. En revanche, l'utilisation de la milrinone n'a pas été associée à une augmentation de la mortalité hospitalière.

Commentaire : Le choix du traitement vasoconstricteur dans les recommandations françaises sont les suivantes :
Traitement vasoconstricteur
Les médicaments vasoconstricteurs doivent être utilisés si le remplissage vasculaire ne permet pas d’obtenir une PAM > 65 mmHg (grade B). L’utilisation précoce de ces agents est recommandée car elle permet de limiter la survenue des défaillances viscérales (grade E).
La noradrénaline étant la plus puissante des amines vasoconstritrices, elle doit être utilisée en première intention (grade E).
La vasopressine (0,01 à 0,04 U/min) ou la terlipressine (bolus de 1 à 2 mg) peut être utilisée dans les chocs réfractaires (grade E).
Traitement inotrope positif
L’adjonction systématique des inotropes n’est pas recommandée (grade E).
L’indication des inotropes, chez un patient ayant bénéficié d’un traitement bien conduit (optimisation de la volémie, administration de vasopresseurs et correction d’une anémie), ne peut pas se justifier par une valeur isolée de débit cardiaque. Il est recommandé qu’elle soit toujours associée à une valeur de la SvcO₂ inférieure à 70 % (grade B).
Il est recommandé d’évaluer l’efficacité du traitement inotrope sur l’amélioration de la SvcO₂, la baisse de la lactatémie et la surveillance des paramètres évaluant la fonction myocardique (grade E).
L’association de la dobutamine à la noradrénaline permet d’adapter de façon séparée les composantes α et ß-adrénergiques, elle est recommandée en première intention (grade E). L’adrénaline apparaît aussi efficace mais ses effets métaboliques peuvent restreindre son utilisation.

Prise en charge hémodynamique du sepsis sévère (nouveau-né exclu)   - Avec la participation de l’Association des Anesthésistes Réanimateurs Pédiatriques d’Expression Française, du Groupe Francophone de Réanimation et Urgences Pédiatriques et de la Société Francophone de Médecine d’Urgence. Jeudi 13 octobre 2005.

Prone Positioning in Moderate to Severe Acute Respiratory Distress Syndrome Due to COVID-19: A Cohort Study and Analysis of Physiology.
Shelhamer MC, Wesson PD, Solari IL, Jensen DL, Steele WA, Dimitrov VG, Kelly JD, Aziz S, Gutierrez VP, Vittinghoff E, Chung KK, Menon VP, Ambris HA, Baxi SM. | J Intensive Care Med. 2021 Feb;36(2):241-252
DOI: https://doi.org/10.1177/0885066620980399  | Télécharger l'article au format  
Keywords: acute respiratory distress syndrome; coronavirus disease 2019; prone position; respiratory failure; severe acute respiratory syndrome coronavirus 2.

Original Research

Introduction : Coronavirus disease 2019 (COVID-19) can lead to acute respiratory distress syndrome (ARDS) but it is unknown whether prone positioning improves outcomes in mechanically ventilated patients with moderate to severe ARDS due to COVID-19.

Méthode : A cohort study at a New York City hospital at the peak of the early pandemic in the United States, under crisis conditions. The aim was to determine the benefit of prone positioning in mechanically ventilated patients with ARDS due to COVID-19. The primary outcome was in-hospital death. Secondary outcomes included changes in physiologic parameters. Fine-Gray competing risks models with stabilized inverse probability treatment weighting (sIPTW) were used to determine the effect of prone positioning on outcomes. In addition, linear mixed effects models (LMM) were used to assess changes in physiology with prone positioning.

Résultats : Out of 335 participants who were intubated and mechanically ventilated, 62 underwent prone positioning, 199 met prone positioning criteria and served as controls and 74 were excluded. The intervention and control groups were similar at baseline. In multivariate-adjusted competing risks models with sIPTW, prone positioning was significantly associated with reduced mortality (SHR 0.61, 95% CI 0.46-0.80, P < 0.005). Using LMM to evaluate the impact of positioning maneuvers on physiological parameters, the oxygenation-saturation index was significantly improved during days 1-3 (P < 0.01) whereas oxygenation-saturation index (OSI), oxygenation-index (OI) and arterial oxygen partial pressure to fractional inspired oxygen (PaO2: FiO2) were significantly improved during days 4-7 (P < 0.05 for all).

Conclusion : Prone positioning in patients with moderate to severe ARDS due to COVID-19 is associated with reduced mortality and improved physiologic parameters. One in-hospital death could be averted for every 8 patients treated. Replicating results and scaling the intervention are important, but prone positioning may represent an additional therapeutic option in patients with ARDS due to COVID-19.

Conclusion (proposition de traduction) : Le décubitus ventral chez les patients atteints de SDRA modéré à sévère dû à la COVID-19 est associé à une mortalité réduite et à une amélioration des paramètres physiologiques. Un décès à l'hôpital pourrait être évité pour 8 patients traités. S'il est important de reproduire ces résultats et de protocoler la technique, il n'en demeure pas moins que le décubitus ventral peut représenter une option thérapeutique supplémentaire chez les patients atteints de SDRA en raison de la COVID-19.

Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia: The REALITY Randomized Clinical Trial.
Ducrocq G, Gonzalez-Juanatey JR, Puymirat E, Lemesle G, Cachanado M, Durand-Zaleski I, Arnaiz JA, Martínez-Sellés M, Silvain J, Ariza-Solé A, Ferrari E, Calvo G, Danchin N, Avendaño-Solá C, Frenkiel J, Rousseau A, Vicaut E, Simon T, Steg PG; REALITY Investigators. | JAMA. 2021 Feb 9;325(6):552-560
DOI: https://doi.org/10.1001/jama.2021.0135
Keywords: Aucun

Original Investigation

Introduction : The optimal transfusion strategy in patients with acute myocardial infarction and anemia is unclear. Objective: To determine whether a restrictive transfusion strategy would be clinically noninferior to a liberal strategy.

Méthode : Open-label, noninferiority, randomized trial conducted in 35 hospitals in France and Spain including 668 patients with myocardial infarction and hemoglobin level between 7 and 10 g/dL. Enrollment could be considered at any time during the index admission for myocardial infarction. The first participant was enrolled in March 2016 and the last was enrolled in September 2019. The final 30-day follow-up was accrued in November 2019. Interventions: Patients were randomly assigned to undergo a restrictive (transfusion triggered by hemoglobin ≤8; n = 342) or a liberal (transfusion triggered by hemoglobin ≤10 g/dL; n = 324) transfusion strategy. Main outcomes and measures: The primary clinical outcome was major adverse cardiovascular events (MACE; composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia) at 30 days. Noninferiority required that the upper bound of the 1-sided 97.5% CI for the relative risk of the primary outcome be less than 1.25. The secondary outcomes included the individual components of the primary outcome.

Résultats : Among 668 patients who were randomized, 666 patients (median [interquartile range] age, 77 [69-84] years; 281 [42.2%] women) completed the 30-day follow-up, including 342 in the restrictive transfusion group (122 [35.7%] received transfusion; 342 total units of packed red blood cells transfused) and 324 in the liberal transfusion group (323 [99.7%] received transfusion; 758 total units transfused). At 30 days, MACE occurred in 36 patients (11.0% [95% CI, 7.5%-14.6%]) in the restrictive group and in 45 patients (14.0% [95% CI, 10.0%-17.9%]) in the liberal group (difference, -3.0% [95% CI, -8.4% to 2.4%]). The relative risk of the primary outcome was 0.79 (1-sided 97.5% CI, 0.00-1.19), meeting the prespecified noninferiority criterion. In the restrictive vs liberal group, all-cause death occurred in 5.6% vs 7.7% of patients, recurrent myocardial infarction occurred in 2.1% vs 3.1%, emergency revascularization prompted by ischemia occurred in 1.5% vs 1.9%, and nonfatal ischemic stroke occurred in 0.6% of patients in both groups.

Conclusion : Among patients with acute myocardial infarction and anemia, a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of MACE after 30 days. However, the CI included what may be a clinically important harm.

Conclusion (proposition de traduction) : Chez les patients présentant un infarctus aigu du myocarde et une anémie, une stratégie transfusionnelle restrictive par rapport à une stratégie transfusionnelle libérale a entraîné un taux non inférieur d'événements cardiovasculaires indésirables majeurs après 30 jours. Cependant, l'intervalle de confiance comprenait ce qui pourrait être un préjudice cliniquement important.

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.

What defines an efficacious COVID-19 vaccine? A review of the challenges assessing the clinical efficacy of vaccines against SARS-CoV-2.
Hodgson SH, Mansatta K, Mallett G, Harris V, Emary KRW, Pollard AJ. | Lancet Infect Dis. 2021 Feb;21(2):e26-e35
DOI: https://doi.org/10.1016/s1473-3099(20)30773-8  | Télécharger l'article au format  
Keywords: Aucun

Review

Editorial : The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused more than 1 million deaths in the first 6 months of the pandemic and huge economic and social upheaval internationally. An efficacious vaccine is essential to prevent further morbidity and mortality. Although some countries might deploy COVID-19 vaccines on the strength of safety and immunogenicity data alone, the goal of vaccine development is to gain direct evidence of vaccine efficacy in protecting humans against SARS-CoV-2 infection and COVID-19 so that manufacture of efficacious vaccines can be selectively upscaled. A candidate vaccine against SARS-CoV-2 might act against infection, disease, or transmission, and a vaccine capable of reducing any of these elements could contribute to disease control. However, the most important efficacy endpoint, protection against severe disease and death, is difficult to assess in phase 3 clinical trials. In this Review, we explore the challenges in assessing the efficacy of candidate SARS-CoV-2 vaccines, discuss the caveats needed to interpret reported efficacy endpoints, and provide insight into answering the seemingly simple question, "Does this COVID-19 vaccine work?"

Conclusion : The development of SARS-CoV-2 vaccines is under great political and media scrutiny. In keeping with the development of any novel medical intervention, but particularly so in this context, it is imperative that efficacy outcomes for a SARS-CoV-2 vaccine are critically appraised with scientific rigour to understand their generalisability and clinical significance.

Conclusion (proposition de traduction) : Le développement des vaccins contre le SRAS-CoV-2 fait l'objet d'un grand examen politique et médiatique. Conformément au développement de toute nouvelle intervention médicale, mais particulièrement dans ce contexte, il est impératif que les résultats d'efficacité d'un vaccin contre le SRAS-CoV-2 soient évalués de manière critique avec une rigueur scientifique afin de comprendre leur généralisabilité et leur signification clinique.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Cet article sous forme de revue développe les différents aspects de l’efficacité d’un vaccin dans le contexte de la pandémie COVID19  . Rédigé par le Dr Jacques Gaillat, le 21 avril 2021.

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.

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.

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.

Differences between manual CPR and corpuls cpr in regard to quality and outcome: study protocol of the comparing observational multi-center prospective registry study on resuscitation (COMPRESS).
Seewald S, Dopfer S, Wnent J, Jakisch B, Heller M, Lefering R, Gräsner JT. | Scand J Trauma Resusc Emerg Med. 2021 Feb 25;29(1):39
DOI: https://doi.org/10.1186/s13049-021-00855-9  | Télécharger l'article au format  
Keywords: Corpuls cpr; GS Elektromedizinische Geräte G. Stemple GmbH; German resuscitation registry; Mechanical CPR.

Study protocol

Introduction : The effect of mechanical CPR is diversely described in the literature. Different mechanical CPR devices are available. The corpuls cpr is a new generation of piston-driven devices and was launched in 2015. The COMPRESS-trial analyzes quality of chest compression and CPR-related injuries in cases of mechanical CPR by the corpuls cpr and manual CPR.

Méthode : This article describes the design and study protocol of the COMPRESS-trial. This observational multi-center study includes all patients who suffered an out-of-hospital cardiac arrest (OHCA) where CPR is attempted in four German emergency medical systems (EMS) between January 2020 and December 2022. EMS treatment, in-hospital-treatment and outcome are anonymously reported to the German Resuscitation Registry (GRR). This information is linked with data from the defibrillator, the feedback system and the mechanical CPR device for a complete dataset. Primary endpoint is chest compression quality (complete release, compression rate, compression depth, chest compression fraction, CPR-related injuries). Secondary endpoint is survival (return of spontaneous circulation (ROSC), admission to hospital and survival to hospital discharge). The trial is sponsored by GS Elektromedizinische Geräte G. Stemple GmbH.

Discussion : This observational multi-center study will contribute to the evaluation of mechanical chest compression devices and to the efficacy and safety of the corpuls cpr.

Conclusion (proposition de traduction) : Cette étude observationnelle multicentrique contribuera à l'évaluation des dispositifs de compression thoracique mécaniques ainsi qu'à l'efficacité et à l'innocuité du Corpuls CPR.

Association Between Intravenous Fluid Resuscitation and Hospital Mortality in Post Cardiac Arrest Patients: A Retrospective Study.
Gul F, Peterson E, Dejoy R, Albano J, Chaudhary S, Valestra P, Azmaiparashvili Z, Lo KB, Rangaswami J, Patarroyo-Aponte G. | Shock. 2021 Feb 1;55(2):224-229
DOI: https://doi.org/10.1097/shk.0000000000001617
Keywords: Aucun

linical Science Aspects

Introduction : To assess the role for intravenous fluid (IVF) resuscitation in the postarrest state. Primary outcome was survival to hospital discharge and 30-day mortality. Secondary outcomes were associations with amount of vasopressor use and mechanical ventilation days.

Méthode : Retrospective study design.
Setting: Single-center tertiary hospital in Philadelphia, Pennsylvania.
Patients: All patients admitted to the intensive care unit between 2018 and 2019.
Interventions: Patients were divided into two groups based on amount of IVF received within 24 h <30 mL/kg (restricted) and over 30 mL/kg (liberal).

Résultats : A total of 264 patients were included in the study, with 200 included in the restrictive (<30 mL/kg) group and 64 included in the liberal (>30 mg/kg) group. There was no difference in 30-day mortality between the two groups with 146 (73%) deaths in the restrictive groups and 44 (69%) deaths in the liberal group (P = 0.53). There was also no significant difference between those who survived to hospital discharge in the liberal and restrictive groups on Kaplan-Meier analysis (Log-rank = 1.476 P = 0.224). However, there was a significant difference between restrictive and liberal groups with the duration of mechanical ventilation (4 ± 6 days vs. 6 ± 9 days; P = 0.03) and in the rates of two or more vasopressor use (38% vs. 59%; P = 0.002). End-stage renal disease (ESRD) (OR = 2.39; P = 0.03) and volume of fluids in mL/kg/24 h (OR = 1.025; P < 0.0001) were independently associated with higher vasopressor need. Volume of fluid in mL/kg/24 h (P = 0.01), ESRD (P = 0.015), and chronic obstructive pulmonary disease (P = 0.04) were significantly associated with duration of mechanical ventilation, even after adjusting for demographic factors, comorbidities, and mortality.

Conclusion : A liberal strategy of IVF used in resuscitation after cardiac arrest is not associated with higher mortality. However, it predicts higher vasopressor use and duration of mechanical ventilation.

Conclusion (proposition de traduction) : Une stratégie libérale de remplissage utilisé en réanimation après un arrêt cardiaque n'est pas associée à une mortalité plus élevée. Cependant, il prédit une utilisation plus élevée des vasopresseurs et la durée de la ventilation mécanique.

Female Stroke: Sex Differences in Acute Treatment and Early Outcomes of Acute Ischemic Stroke.
Bonkhoff AK, Karch A, Weber R, Wellmann J, Berger K. | Stroke. 2021 Jan;52(2):406-415
DOI: https://doi.org/10.1161/strokeaha.120.032850
Keywords: comorbidity; ischemic stroke; mortality; odds ratio; sex differences.

Clinical and Population Sciences

Introduction : Men and women are differently affected by acute ischemic stroke (AIS) in many aspects. Prior studies on sex disparities were limited by moderate sample sizes, varying years of data acquisition, and inconsistent inclusions of covariates leading to controversial findings. We aimed to analyze sex differences in AIS severity, treatments, and early outcome and to systematically evaluate the effect of important covariates in a large German stroke registry.

Méthode : Analyses were based on the Stroke Registry of Northwestern Germany from 2000 to 2018. We focused on admission-stroke severity and disability, acute recanalization treatment, and early stroke outcomes. Potential sex divergences were investigated via odds ratio (OR) using logistic regression models. Covariates were introduced in 3 steps: (1) base models (age and admission year), (2) partially adjusted models (additionally corrected for acute stroke severity and recanalization treatment), (3) fully adjusted models (additionally adjusted for onset-to-admission time interval, prestroke functional status, comorbidities, and stroke cause). Models were separately fitted for the periods 2000 to 2009 and 2010 to 2018.

Résultats : Data from 761 106 patients with AIS were included. In fully adjusted models, there were no sex differences with respect to treatment with intravenous thrombolysis (2000-2009: OR, 0.99 [95% CI, 0.94-1.03]; 2010-2018: OR, 1.0 [0.98-1.02]), but women were more likely to receive intraarterial therapy (2010-2018: OR, 1.12 [1.08-1.15]). Despite higher disability on admission (2000-2009: OR, 1.10 [1.07-1.13]; 2010-2018: OR, 1.09 [1.07-1.10]), female patients were more likely to be discharged with a favorable functional outcome (2003-2009: OR, 1.05 [1.02-1.09]; 2010-2018: OR, 1.05 [1.04-1.07]) and experienced lower in-hospital mortality (2000-2009: OR, 0.92 [0.86-0.97]; 2010-2018: OR, 0.91 [0.88-0.93]).

Conclusion : Female patients with AIS have a higher chance of receiving intraarterial treatment that cannot be explained by clinical characteristics, such as age, premorbid disability, stroke severity, or cause. Women have a more favorable in-hospital recovery than men because their higher disability upon admission was followed by a lower in-hospital mortality and a higher likelihood of favorable functional outcome at discharge after adjustment for covariates.

Conclusion (proposition de traduction) : Les patientes ayant présenté un AVC ischémique aigu ont un risque plus élevé de recevoir un traitement intra-artériel qui ne peut pas être expliqué par des caractéristiques cliniques, telles que l'âge, les co-morbidités, la gravité ou la cause de l'AVC. Les femmes ont une récupération à l'hôpital plus favorable que les hommes parce que leur invalidité plus élevée à l'admission était suivie d'une mortalité à l'hôpital plus faible et d'une probabilité plus élevée de résultats fonctionnels favorables à la sortie après ajustement pour les covariables.

Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation and Prior Gastrointestinal Bleeding.
Kwon S, Lee SR, Choi EK, Lee E, Jung JH, Han KD, Cha MJ, Oh S, Lip GYH. | Stroke. 2021 Jan;52(2):511-520
DOI: https://doi.org/10.1161/strokeaha.120.030761
Keywords: anticoagulants; atrial fibrillation; gastrointestinal hemorrhage; stroke; warfarin.

Original Contributions

Introduction : Limited data support the benefits of non-vitamin K oral anticoagulants (NOACs) among atrial fibrillation patients with prior gastrointestinal bleeding (GIB). We aimed to evaluate the effectiveness and safety of NOACs compared with those of warfarin among atrial fibrillation patients with prior GIB.

Méthode : Oral anticoagulant-naive individuals with atrial fibrillation and prior GIB between January 2010 and April 2018 were identified from the Korean claims database. NOAC users were compared with warfarin users by balancing covariates using the inverse probability of treatment weighting method. The primary outcomes were ischemic stroke, major bleeding, and the composite outcome (combined ischemic stroke and major bleeding). Fatal events from each outcome were evaluated as secondary outcomes.

Résultats : A total of 42 048 patients were included (24 781 in the NOAC group and 17 267 in the warfarin group). The mean time from prior GIB to the initiation of oral anticoagulant was 3.1±2.6 years. After inverse probability of treatment weighting, baseline characteristics were balanced between the two groups (mean age, 72 years; men, 56.8%; and mean CHA2DS2-VASc score, 3.7). Lower risks of ischemic stroke, major bleeding, and the composite outcome were associated with NOAC use than with warfarin use (weighted hazard ratio, 0.608 [95% CI, 0.543-0.680]; hazard ratio, 0.731 [95% CI, 0.642-0.832]; and hazard ratio, 0.661 [95% CI, 0.606-0.721], respectively). For all secondary outcomes, NOACs showed greater risk reductions compared with warfarin.

Conclusion : NOACs were associated with lower risks of ischemic stroke and major bleeding than warfarin among atrial fibrillation patients with prior GIB.

Conclusion (proposition de traduction) : Les AOD ont été associés à des risques plus faibles d'accident vasculaire cérébral ischémique et de saignement majeur que la warfarine chez les patients atteints de fibrillation auriculaire avec des saignements gastro-intestinaux.

Commentaire : Pour mémoire :
Les anticoagulants oraux directs (AOD) inhibent de façon spécifique et directe (en opposition aux AVK qui exercent une inhibition « indirecte » des facteurs vitamine-K dépendants) les facteurs de la coagulation activés qui sont soit la thrombine (facteur IIa) (seul représentant de la classe : dabigatran [-gatran]), soit le facteur de Stuart activé (facteur Xa [-xabans]).

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.

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.

Causes of early mortality in pediatric trauma patients.
Theodorou CM, Galganski LA, Jurkovich GJ, Farmer DL, Hirose S, Stephenson JT, Trappey AF. | J Trauma Acute Care Surg. 2021 Mar 1;90(3):574-581
DOI: https://doi.org/10.1097/ta.0000000000003045
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Trauma is the leading cause of death in children, and most deaths occur within 24 hours of injury. A better understanding of the causes of death in the immediate period of hospital care is needed.

Méthode : Trauma admissions younger than 18 years from 2009 to 2019 at a Level I pediatric trauma center were reviewed for deaths (n = 7,145). Patients were stratified into ages 0-6, 7-12, and 13-17 years old. The primary outcome was cause of death, with early death defined as less than 24 hours after trauma center arrival.

Résultats : There were 134 (2%) deaths with a median age of 7 years. The median time from arrival to death was 14.4 hours (interquartile range, 0.5-87.8 hours). Half (54%) occurred within 24 hours. However, most patients who survived initial resuscitation in the emergency department died longer than 24 hours after arrival (69%). Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%). Deaths from hemorrhage were most often in patients sustaining gunshot wounds (73% vs. 11% of all other deaths, p < 0.0001), more likely to occur early (100% vs. 50% of all other deaths, p = 0.0009), and all died within 6 hours of arrival. Death from hemorrhage was more common in adolescents (21.4% of children aged 13-17 vs. 6.3% of children aged 0-6, and 0% of children aged 7-12 p = 0.03). The highest case fatality rates were seen in hangings (38.5%) and gunshot wounds (9.6%).

Conclusion : Half of pediatric trauma deaths occurred within 24 hours. Death from hemorrhage was rare, but all occurred within 6 hours of arrival. This is a critical time for interventions for bleeding control to prevent death from hemorrhage in children. Analysis of these deaths can focus efforts on the urgent need for development of new hemorrhage control adjuncts in children.

Conclusion (proposition de traduction) : La moitié des décès par traumatisme en pédiatrie sont survenus dans les 24 heures. Les décès par hémorragie étaient rares, mais tous sont survenus dans les 6 heures suivant l'arrivée. Il s'agit d'un moment critique pour les interventions de contrôle des saignements afin de prévenir la mort par hémorragie chez les enfants. L'analyse de ces décès peut concentrer les efforts sur le besoin urgent de développer de nouveaux adjuvants de contrôle des hémorragies chez les enfants.

Antiplatelet and anticoagulant agents have minimal impact on traumatic brain injury incidence, surgery, and mortality in geriatric ground level falls: A multi-institutional analysis of 33,710 patients.
Fakhry SM, Morse JL, Garland JM, Wilson NY, Shen Y, Wyse RJ, Watts DD. | J Trauma Acute Care Surg. 2021 Feb 1;90(2):215-223
DOI: https://doi.org/10.1097/ta.0000000000002985
Keywords: Aucun

AAST 2020 PODIUM PAPERS

Introduction : Falls are the leading cause of traumatic brain injury (TBI) and TBI-related deaths for older persons (age, ≥65 years). Antiplatelet and/or anticoagulant therapy (antithrombotics [ATs]) is generally felt to increase this risk, but the literature is inconsistent. The purpose of this study was to determine the impact of AT use on the rate, severity, and outcomes of TBI in older patients following ground level falls.

Méthode : Ground level fall patients from 90 hospitals' trauma registries were selected. Patients were excluded if younger than 65 years or had an Abbreviated Injury Scale score of >2 in a region other than head. Electronic medical record data for preinjury AT therapy were obtained. Patients were grouped by regimen for no AT, single, or multiple agents. Groups were compared on rates of diagnosed TBI, TBI surgery, and mortality.

Résultats : There were 33,710 patients (35% male; mean age, 80.5 years; mean Glasgow Coma Scale, 14.6), with 47.6% on single or combination AT therapy. The proportion of patients with TBI diagnoses did not differ between those on no AT (21.25%) versus AT (21.61%; p = 0.418). Apixaban (15.7%; p < 0.001) and rivaroxaban (13.19%; p = 0.011) were associated with lower rates of TBI, and acetylsalicylic acid-clopidogrel was associated with a higher TBI rate (24.34%; p = 0.002) versus no AT. acetylsalicylic acid-clopidogrel was associated with a higher cranial surgery rate (2.9%; p = 0.006) versus no AT (1.96%), but surgery rates were similar for all other regimens. No regimen was associated with higher mortality.

Conclusion : In this large multicenter study, the intake of ATs in older patients with ground level falls was associated with inconsistent effects on risk of TBI and no significant increases in mortality, indicating that AT use may have negligible impact on patient clinical management. A large, confirmatory, prospective study is needed because the commonly held belief that ATs uniformly increase the risk of traumatic intracranial bleeding and mortality is not supported.

Conclusion (proposition de traduction) : Dans cette vaste étude multicentrique, la prise d'antithrombotiques chez les patients âgés présentant des chutes a été associée à des résultats contradictoires sur le risque de traumatisme crânien et à aucune augmentation significative de la mortalité, ce qui indique que l'utilisation d'antithrombotiques peut avoir un impact négligeable sur la prise en charge clinique des patients. Une vaste étude prospective de confirmation est nécessaire car la croyance communément admise que les antithrombotiques augmentent uniformément le risque d'hémorragie intracrânienne traumatique et de mortalité n'est pas étayée.

Early anticoagulant reversal after trauma: A Western Trauma Association critical decisions algorithm.
Peck KA, Ley EJ, Brown CV, Moore EE, Sava JA, Ciesla DJ, Sperry JL, Rizzo AG, Rosen NG, Brasel KJ, Kozar R, Inaba K, Martin MJ. | J Trauma Acute Care Surg. 2021 Feb 1;90(2):331-336
DOI: https://doi.org/10.1097/ta.0000000000002979
Keywords: Aucun

WTA 2020 ALGORITHM

Editorial : This is a recommended evaluation and management algorithm from the Western Trauma Association (WTA) Algorithms Committee addressing the management of adult patients who are taking anticoagulant medications at the time of injury and potentially require reversal of anticoagulation. Given the paucity of published prospective randomized clinical trials that have generated class I data, these recommendations are based primarily on data from published prospective and retrospective cohort studies and the expert opinion of WTA members. The final algorithm is the result of an iterative process including an initial internal review and revision by the WTA Algorithms Committee members followed by revisions based on input during and after presentation of the algorithm to the full WTA membership.

Conclusion : This algorithm was designed to guide clinicians in the management of severely injured patients who are taking anticoag- ulant medications at the time of injury and have potentially life- threatening bleeding. Early identification of those patients with severe injury or bleeding will determine the need for urgent reversal of anticoagulation. Reversal or correction of the anticoagulated state can be quickly accomplished using the provided informa- tion. Further study is needed to more clearly define the risks and benefits of reversal, to develop evidence-based guidelines for reversal protocols, and to determine the optimal circumstances for re-initiating anticoagulation.

Conclusion (proposition de traduction) : Cet algorithme a été conçu pour guider les cliniciens dans la prise en charge des patients gravement blessés qui prennent des médicaments anticoagulants au moment du traumatisme et qui présentent des saignements potentiellement mortels. L'identification précoce de ces patients présentant des blessures graves ou des saignements déterminera la nécessité d'une réversion urgente de l'anticoagulation. L'inversion ou la correction de l'anticoagulation peut être rapidement accomplie à l'aide des informations fournies. Une étude plus approfondie est nécessaire pour définir plus clairement les risques et les avantages de la réversion, pour développer des lignes directrices fondées sur des preuves pour les protocoles de réversion complète et pour déterminer les circonstances optimales pour la reprise de l'anticoagulation.

Hypocalcemia in trauma patients: A systematic review.
Vasudeva M, Mathew JK, Groombridge C, Tee JW, Johnny CS, Maini A, Fitzgerald MC. | J Trauma Acute Care Surg. 2021 Feb 1;90(2):396-402
DOI: https://doi.org/10.1097/ta.0000000000003027  | Télécharger l'article au format  
Keywords: Aucun

SYSTEMATIC REVIEW

Introduction : During hemorrhagic shock and subsequent resuscitation, pathways reliant upon calcium such as platelet function, intrinsic and extrinsic hemostasis, and cardiac contractility are disrupted. The objective of this systematic review was to examine current literature for associations between pretransfusion, admission ionized hypocalcemia, and composite outcomes including mortality, blood transfusion requirements, and coagulopathy in adult trauma patients.

Méthode : This review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. We searched Ovid MEDLINE and grey literature from database inception till May 3, 2020. Case series and reports were excluded. Reference lists of appraised studies were also screened for articles that the aforementioned databases might not have captured. The Newcastle-Ottawa Scale was used to assess study quality.

Résultats : A total of 585 abstracts were screened through database searching and alternative sources. Six unique full-text studies were reviewed, of which three were excluded. Admission ionized hypocalcemia was present in up to 56.2% of the population in studies included in this review. Admission ionized hypocalcemia was also associated with increased mortality in all three studies, with increased blood transfusion requirements in two studies, and with coagulopathy in one study.

Conclusion : Hypocalcemia is a common finding in shocked trauma patients. While an association between admission ionized hypocalcemia and mortality, blood transfusion requirements, and coagulopathy has been identified, further prospective trials are essential to corroborating this association.

Conclusion (proposition de traduction) : L'hypocalcémie est une constatation courante chez les patients traumatisés choqués. Bien qu'une association entre l'hypocalcémie ionisée à l'admission et la mortalité, les besoins en transfusion sanguine et la coagulopathie ait été identifiée, d'autres essais prospectifs sont essentiels pour corroborer cette association.

Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: A systematic review.
Fuller G, Pandor A, Essat M, Sabir L, Buckley-Woods H, Chatha H, Holt C, Keating S, Turner J. | J Trauma Acute Care Surg. 2021 Feb 1;90(2):403-412
DOI: https://doi.org/10.1097/ta.0000000000003039
Keywords: Aucun

SYSTEMATIC REVIEW

Introduction : Older adults with major trauma are frequently undertriaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to evaluate the diagnostic performance of prehospital triage tools to identify suspected elderly trauma patients in need of specialized trauma care.

Méthode : Several electronic databases (including MEDLINE, EMBASE, and the Cochrane Library) were searched from inception to February 2019. Prospective or retrospective diagnostic studies were eligible if they examined prehospital triage tools as index tests (either scored theoretically using observed patient variables or evaluated according to actual paramedic transport decisions) compared with a reference standard for major trauma in elderly adults who require transport by paramedics following injury. Selection of studies, data extraction, and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarize the findings.

Résultats : Fifteen studies met the inclusion criteria, with 11 studies examining theoretical accuracy, three evaluating real-life transport decisions, and one assessing both (of 21 individual index tests). Estimates for sensitivity and specificity were highly variable with sensitivity estimates ranging from 19.8% to 95.5% and 57.7% to 83.3% for theoretical accuracy and real life triage performance, respectively. Specificity results were similarly diverse ranging from 17.0% to 93.1% for theoretical accuracy and 46.3% to 78.9% for actual paramedic decisions. Most studies had unclear or high risk of bias and applicability concerns. There were no obvious differences between different triage tools, and findings did not appear to vary systematically with major trauma prevalence, age, alternative reference standards, study designs, or setting.

Conclusion : Existing prehospital triage tools may not accurately identify elderly patients with serious injury. Future work should focus on more relevant reference standards, establishing the best trade-off between undertriage and overtriage, optimizing the role prehospital clinician judgment, and further developing geriatric specific triage variables and thresholds.

Conclusion (proposition de traduction) : Les outils de triage préhospitalier existants peuvent ne pas identifier avec précision les patients âgés souffrant de blessures graves. Les travaux futurs devraient se concentrer sur des normes de référence plus pertinentes, en établissant le meilleur compromis entre la sous-triage et le surtriage, en optimisant le rôle du jugement du clinicien préhospitalier et en développant davantage les variables et les seuils de triage spécifiques à la gériatrie.

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.

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.