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Objective: Assess whether elevated oxygen partial arterial pressure (PaO2) measured after the initiation of extra-corporeal cardiopulmonary resuscitation (eCPR), is associated with mortality in patients suffering from refractory out-of-hospital cardiac arrest (rOHCA).Methods: Retrospective cohort study including rOHCA admitted to the ICU. Patients were divided into 3 groups, defined according to the PaO2 measured from arterial blood gas analysis 30 min after the initiation of eCPR. Hyperoxemia was defined as PaO2 ≥ 300 mmHg, hypoxemia as PaO2 ≤ 60 mmHg and normoxemia, as 60 < PaO2 < 300 mmHg. The main outcome was the mortality rate on day 28 after hospital admission.Results: Sixty-six consecutive rOHCA, 77% male, with a mean age of 51 ± 14 years, were admitted to the ICU. rOHCA were mainly due to acute coronary syndrome (67%), hypertrophic cardiomyopathy (8%) and cardiotoxic overdose (8%). Mortality at day 28 reached 61%. In the overall population, the mean PaO2 was 227 ± 124 mmHg. An association between mortality and PaO2 was observed (OR = 1.01 [1.01-1.02]). The AUC for PaO2 after starting eCPR was 0.77 [0.65-0.89]. After adjustment for witnessed arrest, bystander's CPR, location, no-flow, low-flow, lactate and pH, age, and PaCO2, hyperoxemia had an ORa of 1.89 (CI95 [1.74-2.07]).Conclusion: We found an association between mortality and hyperoxemia in patients admitted to the ICU for rOHCA requiring eCPR. These data underline the potential toxicity of high dose of oxygen and suggest that controlled oxygen administration for these patients is crucial. [ABSTRACT FROM AUTHOR]

Background: Epinephrine is recommended for the treatment of non-shockable out of hospital cardiac arrest (OHCA) to obtain return of spontaneous circulation (ROSC). Epinephrine efficiency and safety remain under debate.Objective: We propose to describe the association between the cumulative dose of epinephrine and the failure of ROSC during the first 30 min of advanced life support (ALS).Methodology: A retrospective observational cohort study using the Paris SAMU 75 registry including all non-traumatic OHCA. All OHCA receiving epinephrine during the first 30 min of ALS were enrolled. Cumulative epinephrine dose given during ALS to ROSC was retrieved from medical reports.Results: Among 1532 patients with OHCA, 776 (51%) had initial non-shockable rhythm. Fifty-four patients were excluded for missing data. The mean value of cumulative dose of epinephrine was 10 ± 4 mg in patients who failed to achieve ROSC (ROSC-) and 4 ± 3 mg (p = 0.04) for those who achieved ROSC. ROC curve analysis indicated a cut-off point of 7 mg total cumulative epinephrine associated with ROSC- (AUC = 0.89 [0.86-0.92]). Using propensity score analysis including age, sex and no-flow duration, association with ROSC- only remained significant for epinephrine > 7 mg (p ≤10-3, OR [CI95] = 1.53 [1.42-1.65]).Conclusion: An association between total cumulative epinephrine dose administered during OHCA resuscitation and ROSC- was reported with a threshold of 7 mg, best identifying patients with refractory OHCA. We suggest using this threshold in this context to guide the termination of ALS and early decide on the implementation of extracorporeal life support or organ harvesting in the first 30 min of ALS. [ABSTRACT FROM AUTHOR]

Purpose: A couple of scoring systems have been developed for risk stratification of septic patients. Their performance in the management of out-of-hospital initial care delivery is not documented. This study try to evaluate the predictive ability of Quick Sequential Organ Failure Assessment (qSOFA), Robson Screening Tool (RST), Modified Early Warning Score (MEWS) and Prehospital Early Sepsis Detection (PRESEP) scores on out of-hospital triage of septic patients, to predict intensive care unit (ICU) admission.Methods: A retrospective study using call records received by the SAMU 15 regulation call centre including all patients with presumed septic shock was performed. The primary outcome was the admission to the ICU.Results: Among the 47 000 reports received, 37 patients with presumed septic shock were included. Twenty-two patients (59%) were admitted to ICU. AUCs of qSOFA, RST, MEWS and PRESEP scores were respectively 0.40 [0.22-0.59], 0.60 [0.43-0.78], 0.66 [0.47-0.85] and 0.67 [0.51-0.84]. RST outperformed PRESEP, MEWS and qSOFA for sensitivity (1, 0.92, 0.85 and 0.62 respectively). MEWS showed better specificity than PRESEP, MRST and qSOFA (0.33, 0.29, 0.16 and 0.16). MEWS showed comparable positive predictive value than PRESEP and outperformed MRST and qSOFA (0.41, 0.41, 0.39 and 0.29 respectively). Negative predictive value of MRST outperformed PRESEP, MEWS and qSOFA (1, 0.88, 0.80 and 0.44 respectively).Conclusion: Our findings suggest that screening patients at SAMU 15 regulation call centre using qSOFA, MRST, MEWS and PRESEP scores to predict ICU admission is irrelevant. Development of a specific scoring system for out-of-hospital triage of septic patients is needed. [ABSTRACT FROM AUTHOR]

Purpose: One of the major prognostic factors in the management of sepsis is the early initiation of appropriate treatment. To serve this purpose, early identification and triage of patients are crucial steps, which are still not optimal. The objective of this study was to determine whether the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score is an accurate method for prehospital triaging of septic patients. We evaluated whether the use of qSOFA criteria collected by the ServiceMobile d'Urgence et de Réanimation 15 (SAMU 15) regulation call center during prehospital care would facilitate appropriate intensive care unit (ICU) admission of patients with septic syndromes. Methods: We conducted a retrospective observational register-based study using data collected between April 01 and May 31 2011. These data are based on call registry reports of calls received by the Paris Emergency regulation call centre during prehospital management of patients. All patients with suspected infection were included in the study and evaluated using qSOFA and systemic inflammatory response syndrome (SIRS) criteria. The primary outcome was Intensive Care Unit (ICU) admission. Results: Among the 30 642 reports received, 141 patients with presumed sepsis were included. Twenty-two patients were admitted to an ICU. The qSOFAand SIRS scores were the same in predicting admission to an ICU (p = 0.26). The qSOFA had a sensitivity of 75% and a specificity of 68% for ICU admission whereas the SIRS had a sensitivity of 87% and a specificity of 43%. At day 28, 12 patients (9%) had died, 5 of them in the ICU. The negative predictive value reached 93% and 94% for pre-hospital qSOFA and SIRS respectively. Pre-hospital systolic blood pressure (SBP) ≤100 mmHg was significantly associated with ICU admission (OR = 4.19 [1.89-9.84]), while all other criteriawere not. Conclusion: The current study reports no difference between the SIRS and the qSOFA scores for prehospital triage of septic patients to predict ICU admission. Both scores have comparable, pertinent, negative predictive value for ICU admission. Nevertheless, an improved score for pre-hospital triaging is needed to predict ICU admission of septic patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: The effects of acute respiratory versus metabolic acidosis on the myocardium and their consequences on adrenoceptor stimulation remain poorly described. We compared the effects of metabolic and respiratory acidosis on inotropy and lusitropy in rat myocardium and their effects on the responses to [alpha]- and [beta]-adrenoceptor stimulations. METHODS: The effects of acute respiratory and metabolic acidosis (pH 7.10) and their interactions with [alpha] and [beta]-adrenoceptor stimulations were studied in isolated rat left ventricular papillary muscle (n=8 per group). Intracellular pH was measured using confocal microscopy and a pH-sensitive fluorophore in isolated rat cardiomyocytes. Data are mean percentages of baseline±SD. RESULTS: Respiratory acidosis induced more pronounced negative inotropic effects than metabolic acidosis did both in isotonic (45±3 versus 63±6%, P<0.001) and isometric (44±5 versus 64±3%, P<0.001) conditions concomitant with a greater decrease in intracellular pH (6.85±0.07 versus 7.12±0.07, P<0.001). The response to [alpha]-adrenergic stimulation was not modified by respiratory or metabolic acidosis. The inotropic response to [beta]-adrenergic stimulation was impaired only in metabolic acidosis (137±12 versus 200±33%, P<0.001), but this effect was not observed with administration of forskolin or dibutiryl-cyclic adenosine monophosphate. This effect might be explained by a change in transmembrane pH gradient only observed with metabolic acidosis. The lusitropic response to [beta]-adrenergic stimulation was not modified by respiratory or metabolic acidosis. CONCLUSION: Acute metabolic and respiratory acidosis induce different myocardial effects related to different decreases in intracellular pH. Only metabolic acidosis impairs the positive inotropic effect of [beta]-adrenergic stimulation. [ABSTRACT FROM AUTHOR]

Background: The resuscitative endovascular balloon occlusion of the aorta (REBOA) technique controls abdominal, pelvic, junctional, and postpartum hemorrhage via aortic endoclamping. There are no protocols or clear indications guiding REBOA use in a two-tiered prehospital emergency medical system, as found in France. We conducted a Delphi study to clarify the indications and contraindications for REBOA application in such a system., Methods: We performed a Delphi study in three rounds with an international group of doctors with REBOA expertise and clinical experience (members of the EndoVascular and Trauma Management Society). Based on the consensus answers, complemented by existing data in the literature, we developed a protocol for REBOA use in a medicalized prehospital setting., Results: We identified 10 questions that were not answered in the literature and submitted them to 21 experts. Over three rounds, consensus was reached on these 10 questions. The most important ones were "In your opinion, in a hemorrhagic patient, vascularly well-filled and whose hemodynamics remain unstable with 3mg/h of norepinephrine, should we inflate a REBOA to prevent the patients death and get them to the operating room alive?" and "In the case of REBOA placement (zone I) in the prehospital setting, would you agree that the maximum occlusion duration is approximately 30 minutes, with a partial or intermittent occlusion when possible?", Conclusion: We propose a protocol for REBOA use in a medicalized prehospital setting. This protocol clarifies that hemorrhagic shock, despite a noradrenaline (also known as norepinephrine) dose of 0.6µg/kg/min, is considered too serious for the patient to be transported to the trauma center without REBOA. Moreover, it clarifies that a zone 1 REBOA should be inflated for maximum 30 minutes and with a partial occlusion strategy, if possible. This protocol should be updated based on feedback following the establishment of prehospital REBOA and large randomized studies., Competing Interests: The authors have no conflict of interests to disclose., (2024.)

Background: Ultra-trail running races pose appreciable physiological challenges, particularly for glucose metabolism. Previous studies that yielded divergent results only measured glycaemia at isolated times., Objectives: We aimed to explore the impact of an ultra-endurance race on continuously measured glycaemia and to understand potential physiological mechanisms, as well as the consequences for performance and behavioural alertness., Methods: Fifty-five athletes (78% men, 43.7 ± 9.6 years) ran a 156-km ultra-trail race (six 26-km laps, total elevation 6000 m). Participants wore a masked continuous glucose monitoring sensor from the day before the race until 10 days post-race. Blood was taken at rest, during refuelling stops after each lap, and after 24-h recovery. Running intensity (% heart rate reserve), performance (lap times), psychological stress, and behavioural alertness were explored. Linear mixed models and logistic regressions were carried out., Results: No higher risk of hypo- or hyperglycaemia was observed during the exercise phases of the race (i.e. excluding stops for scientific measurements and refuelling) compared with resting values. Laps comprising a greater proportion of time spent at maximal aerobic intensity were nevertheless associated with more time > 180 mg/dL (P = 0.021). A major risk of hyperglycaemia appeared during the 48-h post-race period compared with pre-race (P < 0.05), with 31.9% of the participants spending time with values > 180 mg/dL during recovery versus 5.5% during resting. Changes in circulating insulin, cortisol, and free fatty acids followed profiles comparable with those usually observed during traditional aerobic exercise. However, creatine phosphokinase, and to a lesser extent lactate dehydrogenase, increased exponentially during the race (P < 0.001) and remained high at 24-h post-race (P < 0.001; respectively 43.6 and 1.8 times higher vs. resting). Glycaemic metrics did not influence physical performance or behavioural alertness., Conclusion: Ultra-endurance athletes were exposed to hyperglycaemia during the 48-h post-race period, possibly linked to muscle damage and inflammation. Strategies to mitigate muscle damage or subsequent inflammation before or after ultra-trail races could limit recovery hyperglycaemia and hence its related adverse health consequences., Trial Registration Number: NCT05538442 2022-09-21 retrospectively registered., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: Respiratory dysfunction is one of the most frequent symptoms observed during sepsis reflecting hypoxemia and/or acidosis that may be assessed by the ROX index (ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate). This study aimed to describe the relationship between the prehospital ROX index and 30-day mortality rate among septic shock patients cared for in the prehospital setting by a mobile intensive care unit (MICU)., Methods: From May 2016 to December 2021, 530 septic shock patients cared for by a prehospital MICU were retrospectively analysed. Initial ROX index value was calculated at the first contact with MICU. A Cox regression analysis after propensity score matching was performed to assess the relationship between 30-day mortality rate and a ROX index ≤ 10., Results: Pulmonary, digestive and urinary sepsis were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality reached 31%. Cox regression analysis showed a significant association between 30-day mortality and a ROX index ≤ 10: adjusted hazard ratio of 1.54 [1.08-2.31], p < 0.05., Conclusions: During the prehospital stage of septic shock patients cared for by a MICU, ROX index is significantly associated with 30-day mortality. A prehospital ROX ≤ 10 value is associated with a 1.5-fold 30-day mortality rate increase. Prospective studies are needed to confirm the ability of prehospital ROX to predict sepsis outcome since the prehospital setting., (© 2024. The Author(s).)

Acute kidneys injuries (AKIs) have been described in marathon and trail running. The currently available data allows assessment of before/after comparisons but does not allow an analysis of what happens during the race. A multidisciplinary assessment protocol was performed during the first trail of Clécy (Normandy France) in November 2021. This allowed an initial assay to be carried out, then at the end of each of the 6 loops of 26 km, and finally after 24 h of recovery. The race extends over 156 km in hilly terrain and 6000 m of elevation gain (D+). The level of impairment according to the RIFLE classification was defined for each runner at each assay. Fifty-five runners were at the start, and the per protocol analysis involved 36 runners (27 men and 9 women, 26 finishers). Fifteen (41.7%) of the riders presented at least one result corresponding to a "RIFLE risk" level. After 24 h of rest, only one runner still had a "RIFLE Risk". The distance around the marathon seems to be the moment of greatest risk. For the first time, we find an association between this renal risk and the probability of abandonment. Many runners are vulnerable to kidney damage during long-duration exercise, which is why it's important to limit risk situations, such as the use of potentially toxic drugs or hydration disorders. The consumption of NSAIDs (nonsteroidal anti-inflammatory drugs) before or during an ultra-distance race should therefore be prohibited. Attention should be paid to hydration disorders., (© 2024 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

This article describes the structures and processes involved in healthcare delivery for sepsis, from the prehospital setting until rehabilitation. Quality improvement initiatives in sepsis may reduce both morbidity and mortality. Positive outcomes are more likely when the following steps are optimized: early recognition, severity assessment, prehospital emergency medical system activation when available, early therapy (antimicrobials and hemodynamic optimization), early orientation to an adequate facility (emergency room, operating theater or intensive care unit), in-hospital organ failure resuscitation associated with source control, and finally a comprehensive rehabilitation program. Such a trajectory of care dedicated to sepsis amounts to a chain of survival and rehabilitation for sepsis. Implementation of this chain of survival and rehabilitation for sepsis requires full interconnection between each link. To date, despite regular international recommendations updates, the adherence to sepsis guidelines remains low leading to a considerable burden of the disease. Developing and optimizing such an integrated network could significantly reduce sepsis related mortality and morbidity., (© 2024. The Author(s).)

Background: The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU)., Methods: Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports., Results: Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39-3.95], 2.08 [1.33-3.25] and 2.22 [1.38-3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively., Conclusion: A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis., (© 2024. The Author(s).)

Background: There are few publications regarding manifestations of vestibular disorders (VDs) following BNT162b2 mRNA COVID-19 vaccination., Purpose: We describe cases of VD potentially related to BNT162b2 vaccination and calculate its reporting rate, in order to enlarge knowledge about this adverse effect., Methods: A retrospective analysis of cases of VD following BNT162b2 vaccination reported to the pharmacovigilance centre of Georges-Pompidou European Hospital (France), in 2021 was performed. In order to identify these cases from the pharmacovigilance database containing all our registered cases, we used the Standardised MedDRA Query (SMQ) 'vestibular disorders'. Then we analysed cases with vestibular symptoms, based on the association of typical manifestations. The reporting rate was calculated based on the number of VD cases and the number of vaccinated patients., Results: Among 6608 cases reported to our centre related to COVID-19 vaccines during 2021, 34 VDs associated with BNT162b2 administration were included. They were mainly reported in females (79%), 62% occurred after the first dose and 32% were serious. Symptoms had completely resolved in 13 cases (38%). Vertigo was the most common symptom followed by balance disorders. Three patients received second dose without reappearance of VD. The final diagnosis was reported in 10 patients (six cases of vestibular neuritis, two cases of central VD, two cases of benign paroxysmal positional vertigo). The regional reporting rate was 26 [95% CI: 17-34] cases of VD per 1 million persons vaccinated., Conclusion: Although the relationship between vaccination and VD cannot be established, clinicians should be aware of this rare adverse effect., (© 2023 Société Française de Pharmacologie et de Thérapeutique Published by John Wiley & Sons Ltd.)

Background: In order to reduce septic shock mortality, international guidelines recommend early treatment implementation, antibiotic therapy (ABT) and hemodynamic optimisation, within 1-h. This retrospective multicentric study aims to investigate the relationship between prehospital ABT delivered within 1st hour and mean blood pressure (MAP) ≥ 65 mmHg at the end of the prehospital stage, and 30-day mortality among patients with septic shock., Methods: From May 2016 to December 2021, patients with septic shock requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To assess the relationship between 30-day mortality and prehospital ABT delivered within 1st hour and/or MAP ≥ 65 mmHg at the end of the prehospital stage, Inverse Probability Treatment Weighting (IPTW) propensity score method was performed., Results: Among the 530 patients included, 341 were male gender (64%) with a mean age of 69 ± 15 years. One-hundred and thirty-two patients (25%) patients received prehospital ABT, among which 98 patients (74%) were treated with 3rd generation cephalosporin. Suspected pulmonary, urinary and digestive infections were the cause of sepsis in respectively 43%, 25% and 17%. The 30-day overall mortality was 31%. A significant association was observed between 30-day mortality rate and (i) ABT administration within the first hour: RRa = 0.14 [0.04-0.55], (ii) ABT administration within the first hour associated with a MAP ≥ 65 mmHg: RRa = 0.08 [0.02-0.37] and (iii) ABT administration within the first hour in the prehospital setting associated with a MAP < 65 mmHg at the end of the prehospital stage: RRa = 0.75 [0.45-0.85]. Patients who received prehospital ABT after the first hour have also a 30-day mortality rate decrease: RRa = 0.87 [0.57-0.99], whereas patients who did not received ABT had an increased 30-day mortality rate: RRa = 2.36 [1.89-2.95]., Conclusion: In this study, we showed that pre-hospital ABT within the first hour and MAP≥65 mmHg at the end of prehospital stage are both associated with 30-day mortality decrease among patients suffering from septic shock cared for by a MICU. Further prospective studies are needed to confirm these preliminary results., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: A relative hypovolemia occurs during septic shock (SS); the early phase is clinically reflected by tachycardia and low blood pressure. In the prehospital setting, simple objective tools to assess hypovolemia severity are needed to optimize triaging., Objective: The aim of this study was to evaluate the relationship between shock index (SI), diastolic SI (DSI), modified SI (MSI), and age SI (ASI) and 28-day mortality of patients with SS initially cared for in a prehospital setting of a mobile intensive care unit (MICU)., Methods: From April 6, 2016 through December 31, 2021, 530 patients with SS cared for at a prehospital MICU were analyzed retrospectively. Initial SI, MSI, DSI, and ASI values, that is, first measurement after MICU arrival to the scene were calculated. A propensity score analysis with inverse probability of treatment weighting (IPTW) method was used to assess the relationship between SI, DSI, MSI, and ASI and 28-day mortality., Results: SS resulted mainly from pulmonary, digestive, and urinary infections in 44%, 25%, and 17% of patients. The 28-day overall mortality was 31%. IPTW propensity score analysis indicated a significant relationship between 28-day mortality and SI (adjusted odds ratio [aOR] 1.13; 95% CI 1.01-1.26; p = 0.04), DSI (aOR 1.16; 95% CI 1.06-1.34; p = 0.03), MSI (aOR 1.03; 95% CI 1.01-1.17; p = 0.03), and ASI (aOR 3.62; 95% CI 2.63-5.38; p < 10 -6 )., Conclusions: SI, DSI, MSI, and ASI were significantly associated with 28-day mortality among patients with SS cared for at a prehospital MICU. Further studies are needed to confirm the usefulness of SI and SI derivates for prehospital SS optimal triaging., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background:  The presence of dextran sulfate (DS) in reagents and the type of blood collection tube (citrate/citrated-theophylline-adenosine-dipyridamole [CTAD]) can lead to discrepancies between unfractionated heparin (UFH) anti-Xa levels., Objectives:  To evaluate the extent of the effect (1) of different reagents containing or not containing DS and (2) of the blood collection tubes, on UFH anti-Xa levels, in various clinical situations (NCT04700670)., Methods:  We prospectively included patients from eight centers: group (G)1, cardiopulmonary bypass (CPB) after heparin neutralization ( n  = 39); G2, cardiothoracic intensive care unit (ICU) after CPB ( n  = 35); G3, medical ICU ( n  = 53); G4, other medical inpatients ( n  = 38). Blood was collected into citrated and CTAD tubes. Chromogenic anti-Xa assays were centrally performed, using seven reagent/analyzer combinations including two without DS. The association between anti-Xa levels and covariates was tested using a linear mixed-effects model., Results:  We analyzed 4,546 anti-Xa values from 165 patients. Median anti-Xa levels were systematically higher with reagents containing DS, whatever the patient group, with the greatest effect observed in G1 (0.32 vs . 0.05 IU/mL). Anti-Xa levels were slightly higher in CTAD than in citrate samples, irrespective of the assay. The model showed: (1) a significant dextran-patient group interaction ( p  < 0.0001), the effect of DS on anti-Xa levels varying from 30.9% in G4 to 296% in G1, and (2) a significant effect of CTAD, varying between patient groups ( p  = 0.0302)., Conclusion:  The variability of anti-Xa levels with a great overestimation of the values, using a reagent containing DS, can lead to different treatment decisions, especially after heparin neutralization by protamine. Clinical consequences of these differences remain to be demonstrated., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Over 300 000 cases of out-of-hospital cardiac arrests (OHCAs) occur each year in the USA and Europe. Despite decades of investment and research, survival remains disappointingly low. We report the trends in survival after a ventricular fibrillation/pulseless ventricular tachycardia OHCA, over a 13-year period, in a French urban region, and describe the simultaneous evolution of the rescue system., Methods: We investigated four 18-month periods between 2005 and 2018. The first period was considered baseline and included patients from the randomised controlled trial 'DEFI 2005'. The three following periods were based on the Paris Sudden Death Expertise Center Registry (France). Inclusion criteria were non-traumatic cardiac arrests treated with at least one external electric shock with an automated external defibrillator from the basic life support team and resuscitated by a physician-staffed ALS team. Primary outcome was survival at hospital discharge with a good neurological outcome., Results: Of 21 781 patients under consideration, 3476 (16%) met the inclusion criteria. Over all study periods, survival at hospital discharge increased from 12% in 2005 to 25% in 2018 (p<0.001), and return of spontaneous circulation at hospital admission increased from 43% to 58% (p=0.004).Lay-rescuer cardiopulmonary resuscitation (CPR) and telephone CPR (T-CPR) rates increased significantly, but public defibrillator use remained limited., Conclusion: In a two-tiered rescue system, survival from OHCA at hospital discharge doubled over a 13-year study period. Concomitantly, the system implemented an OHCA patient registry and increased T-CPR frequency, despite a consistently low rate of public defibrillator use., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Septic shock medical treatment relies on a bundle of care including antibiotic therapy and hemodynamic optimisation. Hemodynamic optimisation consists of fluid expansion and norepinephrine administration aiming to optimise cardiac output to reach a mean arterial pressure of 65mmHg. In the prehospital setting, direct cardiac output assessment is difficult because of the lack of invasive and non-invasive devices. This study aims to assess the relationship between 30-day mortality and (i) initial pulse pressure (iPP) as (ii) pulse pressure variation (dPP) during the prehospital stage among patients cared for SS by a prehospital mobile intensive care unit (MICU)., Methods: From May 09th, 2016 to December 02nd, 2021, septic shock patients requiring MICU intervention were retrospectively analysed. iPP was calculated as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the first contact between the patient and the MICU team prior to any treatment and, dPP as the difference between the final PP (the difference between SBP and DBP at the end of the prehospital stage) and iPP divided by prehospital duration. To consider cofounders, the propensity score method was used to assess the relationship between (i) iPP < 40mmHg, (ii) positive dPP and 30-day mortality., Results: Among the 530 patients analysed, pulmonary, digestive, and urinary infections were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality rate reached 31%. Cox regression analysis showed an association between 30-day mortality and (i) iPP < 40mmHg; aHR of 1.61 [1.03-2.51], and (ii) a positive dPP; aHR of 0.56 [0.36-0.88]., Conclusion: The current study reports an association between 30-day mortality rate and iPP < 40mmHg and a positive dPP among septic shock patients cared for by a prehospital MICU. A negative dPP could be helpful to identify septic shock with higher risk of poor outcome despite prehospital hemodynamic optimization., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Purpose: Out-of-hospital cardiac arrest (OHCA) has a poor prognosis, with an overall survival rate of about 5% at discharge. Shockable rhythm cardiac arrests (ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have a better prognosis. In case of shockable rhythm, treatment is based on defibrillation, and thereafter, in case of failure of 3 external electric shocks (EES), on direct intravenous administration of 300 mg amiodarone, or lidocaine when amiodarone is unavailable or inefficient. During surgical procedures under extracorporeal circulation, a high potassium cardioplegia solution is administered to interrupt cardiac activity and facilitate surgical procedure. By extension, direct intravenous administration of potassium chloride (KCl) has been shown to convert VF, resulting in return to a hemodynamically efficient organized heart rate within a few minutes. The aim of this study is to provide clinical evidence that direct intravenous injection of KCl, into a patient presenting with OHCA due to refractory VF although 3 EES, should interrupt this VF and then allow rapid restauration of an organized heart rhythm, and thus return of spontaneous circulation (ROSC)., Methods: A multicenter, prospective, single group, phase 2 study will be conducted on 81 patients presenting with refractory VF. After failure of 3 EES, each patient will receive direct intravenous injection of 20 mmol KCl instead of amiodarone. The primary outcome will be survival rate at hospital admission. Major secondary outcomes will include ROSC and time to ROSC in the prehospital setting, number of VF recidivism after KCl injection, survival rate at hospital discharge with a good neurologic prognostic, and survival rate 3 months after hospital discharge with a good neurologic prognostic., Results: No patient is currently included in the study., Discussion: Conventional guideline strategy based on antiarrhythmic drug administration, i.e. amiodarone or lidocaine, for OHCA due to shockable rhythm, has not yet demonstrated an increase in survival at hospital admission or at hospital discharge. This may be related to the major cardiodepressant effect of those drugs., Trial Registration: ClinicalTrials.gov Identifier: NCT04316611. Registered on March 2020. AP-HP180577 / N° EUDRACT: 2019-002544-24. Funded by the French Health Ministry. https://clinicaltrials.gov/ct2/show/NCT04316611., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Jouffroy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Vancomycin is a reference antibiotic against methicillin-resistant staphylococci. Its administration is associated with infusion-related local complications (IRLC). To reduce this risk, it has been proposed to increase vancomycin dilution in the IV bag and to perform continuous infusion using the volumetric pump. The aim of our study was to assess the safety of peripheral infusion of vancomycin with the volumetric pump., Objectives: To compare the frequency of IRLC between patients receiving vancomycin and those receiving β-lactam (BL) antibiotics. Our secondary objective was to assess factors associated with the occurrence of IRLC., Patients and Methods: We conducted a prospective observational study in a French tertiary hospital. Between February 2021 and November 2021, we included all patients receiving continuous infusions of vancomycin or BL through a peripherally inserted venous catheter (PIVC). The primary endpoint was the occurrence of IRLC on Day 1 (D1)., Results: We included 168 patients (56 vancomycin, 112 BL). At D1, 14 patients (25%) presented IRLC in the vancomycin group versus 11 patients (10%) in the BL group (P = 0.01). There was significantly more IRLC in the group receiving vancomycin at an infused concentration above 5 mg/mL than those receiving BL (8/15, 53.3% versus 11/112, 10%, respectively, P < 0.01). However, no significant difference was observed between patients receiving infused vancomycin concentration ≤5 mg/mL and patients receiving BL (P = 0.4)., Conclusion: Our data support safe administration of vancomycin if infused at a concentration under 5 mg/mL, through the volumetric pump on PIVC., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Point of care testing (POCT) tests are needed to assess severity and to help for triage in hospital and in prehospital settings. Before their use, the analytical performances of POCTs have to be compared with central laboratory reference methods. In this study, we describe the comparability of results obtained by either the Abbott i-STAT® System POCT handheld device or the blood gases analyzer of the central laboratory of our hospital., Methods: Sample blood from 37 septic patients admitted to the intensive care unit (ICU) were assayed by Abbott i-STAT® System POCT and Radiometer ABL800 Flex® lab analyzer. Studied parameters were as follows: pH, pO2, pCO2, base excess (BE), HCO3- and lactate. Comparability was evaluated using Bland-Altman method. The clinical value for possible mismatch issued of values differences was also assessed., Results: Quite acceptable correlations in results of POCT and laboratory analyzer were observed with R² most of time above 0.85. Bland-Altman analysis showed a bias of 1.26% for Abbott i-STAT® System POCT vs laboratory., Conclusion: Abbott i-STAT® System POCT handheld device is comparable to Radiometer ABL800 Flex® lab analyzer and concordant with laboratory analysis. Abbott i-STAT® System POCT handled device could be used in the prehospital settings in order to evaluate the severity of sepsis.