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Background: Haemodynamically unstable patients often require arterial and venous catheter insertion urgently. We hypothesised that ultrasound-guided arterial and venous catheterisation would reduce mechanical complications., Methods: We performed a prospective RCT, where patients requiring both urgent arterial and venous femoral catheterisation were randomised to either ultrasound-guided or landmark-guided catheterisation. Complications and characteristics of catheter insertion (procedure duration, number of punctures, and procedure success) were recorded at the time of insertion (immediate complications). Late complications were investigated by ultrasound examination performed between the third and seventh days after randomisation. Primary outcome was the proportion of patients with at least one mechanical complication (immediate or late), by intention-to-treat analysis. Secondary outcomes included success rate, procedure time, and number of punctures., Results: We analysed 136 subjects (102 [75%] male; age range: 27-62 yr) by intention to treat. The proportion of subjects with one or more complications was lower in 22/67 (33%) subjects undergoing ultrasound-guided catheterisation compared with landmark-guided catheterisation (40/69 [58%]; odds ratio: 0.35 [95% confidence interval: 0.18-0.71]; P=0.003). Ultrasound-guided catheterisation reduced both immediate (27%, compared with 51% in the landmark approach group; P=0.004) and late (10%, compared with 23% in the landmark approach group; P=0.047) complications. Ultrasound guidance also reduced the proportion of patients who developed deep vein thrombosis (4%, compared with 22% following landmark approach; P=0.012), and achieved a higher procedural success rate (96% vs 78%; P=0.004)., Conclusions: An ultrasound-guided approach reduced mechanical complications after urgent femoral arterial and venous catheterisation, while increasing procedural success., Clinical Trial Registration: NCT02820909., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objective: To compare management of injured children in an adult trauma center (TC) with competencies in pediatric trauma care (2005-2007) and in a pediatric-only trauma center (2010-2012)., Study Design: A before-after retrospective study., Patients and Methods: Fifty-nine children between 1 and 15 years of age admitted to the adult TC (2005-2007) were compared to 56 children admitted to the pediatric TC (2010-2012). Epidemiological data, severity scores, early outcome, and care duration in trauma resuscitation before whole-body CT were collected and compared between the two periods., Results: This study found no significant differences between the two periods in terms of care duration before the whole-body CT scan (28 min [18-40] vs 26.5 min [21-36], P=0.89) and early mortality (eight children [13.5%] vs ten children [17.8%], P=0.35)., Conclusion: With no differences in early management of injured children demonstrated, this study validates the organization within our pediatric trauma center. The effectiveness of management of children between 1 and 15 years of age with severe trauma seems to be similar in the two contexts., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Metabolic phenotyping consists in the identification of subtle and coordinated metabolic variations associated with various pathophysiological stimuli. Different analytical methods, such as nuclear magnetic resonance, allow the simultaneous quantification of a large number of metabolites. Statistical analyses of these spectra thus lead to the discrimination between samples and the identification of a metabolic phenotype corresponding to the effect under study. This approach allows the extraction of candidate biomarkers and the recovery of perturbed metabolic networks, driving to the generation of biochemical hypotheses (pathophysiological mechanisms, diagnostic tests, therapeutic targets…). Metabolic phenotyping could be useful in anaesthesiology and intensive care medicine for the evaluation, monitoring or diagnosis of life-threatening situations, to optimise patient managements. This review introduces the physical and statistical fundamentals of NMR-based metabolic phenotyping, describes the work already achieved by this approach in anaesthesiology and intensive care medicine. Finally, potential areas of interest are discussed for the perioperative and intensive management of patients, from newborns to adults., (Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Angiotensin-converting enzyme (ACE) inhibitor-related angioedema (AE) may be fatal in the absence of specific treatment. No consensus for this side effect currently exists. Also, the French national reference centre for angioedema (CREAK) decided to establish recommendations, developed by an expert group and proposed at a national meeting. A scientific committee conducted a comprehensive literature review and worked out with proposals. These proposals were submitted to a vote to the expert panel of CREAK at a national meeting. Proposals that had received the majority were retained. Diagnosis of ACE inhibitor-related AE is based on clinical events. Regarding the severity of the disease, this diagnosis has to be put forward in any patient currently treated with or who has been treated with ACE inhibitors in the previous 6 months. The diagnosis is important because AE does not respond to usual treatment of histamine-induced AE (antihistamines, corticosteroids, and epinephrine), but only to specific treatment of bradykinin-induced AE, as antagonists of bradykinin or concentrates of C1 inhibitor. The subsequent use of ACE is strictly contra-indicated. A report to pharmacovigilance centres of every case is essential. These recommendations should improve the standardization of the management of ACE inhibitor-related AE., (Copyright © 2013 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Purpose: Amongst trauma patients, early coagulopathy is common on hospital admission. No studies have evaluated the initial coagulation status in the pre-hospital setting. We hypothesise that the coagulopathic process begins at the time of trauma. We studied the on-scene and on hospital arrival coagulation profile of trauma patients., Methods: Prospective, observational study investigating the on-scene coagulation profile and its time course. We studied 45 patients at the scene of the accident, before fluid administration, and on hospital admission and classified their coagulopathy using the International Society on Thrombosis and Haemostasis score during a 2-month period. Prothrombin time, activated partial thromboplastin time, fibrinogen concentration, factors II, V and VII activity, fibrin degradation products, antithrombin and protein C activities, platelet counts and base deficit were measured., Results: The median injury severity score was 25 (13-35). On-scene, coagulation status was abnormal in 56% of patients. Protein C activities were decreased in the trauma-associated coagulopathy group (p=.02). Drops in protein C activities were associated with changes in activated partial thromboplastin time, prothrombin time, fibrinogen concentration, factor V and antithrombin activities. Only factor V levels decreased significantly with the severity of the trauma. On hospital admission, coagulation status was abnormal in 60% of patients. The on-scene coagulopathy was spontaneously normalised only in 2 patients whereas others had the same or a poorer coagulopathy status. All parameters of coagulation were significantly abnormal comparing to the on-scene phase. Decreases in protein C activities were related to the coagulation status (p<.0001) and changes in other coagulation parameters. Patients with base deficit ≤-6 mmol/L had changes in antithrombin, factor V and protein C activities but no significant coagulopathy., Conclusion: Coagulopathy occurs very early after injury, before fluid administration, at the site of accident. Coagulation and fibrinolytic systems are activated early. The incidence of coagulopathy is high and its severity is related to the injury and not to hypoperfusion., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Lemierre's syndrome is a classical presentation of human necrobacillosis. It is characterized by a primary infection in the face including a septic thrombophlebitis of the internal jugular vein and disseminated metastatic abcesses. Fusobacterium necrophorum is the main pathogen found in that syndrome. The diagnosis is based on clinical features, then on the microbiology with positive anaerobic blood cultures as key role and finally on the computed tomography. Most of the time a well-chosen antibiotic treatment against anaerobic pathogens and Gram negative bacilli is efficient but surgery can be useful. We report a case of a 73 years old man, which seems to be unique because it is the first case reported of a Lemierre's syndrome characterized by a parotitis infected by F. necrophorum., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objectives: Present the clinical signs of bradykinin-mediated angioedema, a disease little known to intensive care anaesthesiologists, and develop their scientific basis with recent data on management in emergency and perioperative care., Data Sources: International recommendations and recent general reviews. Data collection was performed using the Medline database with the keyword: angioedema., Study Selection and Data Extraction: Research studies published during the last 10 years were reviewed. Relevant clinical information was extracted and discussed., Data Synthesis: Angioedema is a clinical syndrome characterized by episodes of transitory recurrent submucosal and subcutaneous oedema, called attacks. During an attack, the oedema may be localized at the level of the skin and/or ENT and digestive tract mucosa. This syndrome is not due to an allergic reaction. It is related to a C1 complement inhibitor deficiency or an increase in factor XII resulting in the excessive release of bradykinin, which leads to capillary permeability. There are hereditary and acquired forms, notably associated with the use of ACE inhibitors and sartans. This rare disease should be recognized by anaesthesiologists and intensive care and emergency physicians because, in the absence of specific treatment, it can be life-threatening due to the appearance of laryngeal oedema. In addition, there is a risk that the patient may have an attack during the perioperatory period, due to surgical trauma. International recommendations exist, and there are new molecules available in France. For moderate attacks, treatment is based on tranexamic acid. For hereditary forms, according to the localization and gravity of the attacks, emergency treatment is based on the use of Icatibant, a bradykinin B2 receptor inhibitor, and C1 inhibitor concentrate. For pregnant women and acquired forms, C1 inhibitor concentrate is the treatment of reference. Antalgic and perfusion treatments should not be neglected, and should be modified as a function of clinical signs. High-risk situations (perioperatory period, birthing, dental care) should be identified and short-term prophylaxis put in place before any procedure that may trigger an attack. Algorithms are proposed for the diagnosis, treatment and prevention of attacks. Recommendations exist for during childbirth, in which case C1 inhibitor concentrate should be used., Conclusion: Bradykinin-mediated angioedema should be evoked in the case of recurrent and transitory oedema. Emergency management has evolved thanks to the commercialization of new molecules. Prevention of attacks during surgery and for during childbirth is important. The availability of C1 inhibitor concentrate in sufficient doses should be verified prior to the procedure. A multi-site reference centre (CREAK) has been created to help clinicians manage this disease. Patients with this disease should be identified in emergency departments. Health establishments, which cannot all have emergency stocks, should set up procedures for rapid provision or the transfer of patients to reference sites., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objectives: The aim of this bibliographic review is to evaluate the usefulness of the measurement of HLA-DR expression on circulating monocytes (mHLA-DR) in predicting the development of nosocomial infections and unfavourable outcome in critically ill patients., Data Source: References obtained from the medical database PubMed in English and in French were reviewed. The keywords included separately or in combination were: HLA-DR antigens, sepsis, trauma, injuries, wounds, burns, stroke, pancreatitis, postoperative, prognostic, immunity, monocytic., Data Extraction: Data in selected articles were reviewed, clinical and basic science research relevant information were extracted., Data Synthesis: Low mHLA-DR expression appears as a marker for monocytic dysfunctions and immunosuppression, temporarily present in the majority of critically ill patients admitted to the ICU (sepsis, trauma injuries, postoperative, burns, pancreatitis and stroke). The decrease in mHLA-DR expression is a predictor of septic complications in all these clinical conditions. However, no predictive threshold value could be determined regarding unfavourable outcome., Conclusion: The monitoring of mHLA-DR expression could be a biomarker to detect ICU patients at high risk of developing secondary nosocomial infections. Those patients could probably benefit of preemptive strategies to prevent these infections., (Copyright 2010 Elsevier Masson SAS. All rights reserved.)

Acute pancreatitis is frequently associated with electrocardiographic abnormalities, including arrhythmias and repolarization. We briefly describe a male patient with a severe acute pancreatitis who presented several bradycardias during his hospitalization in our intensive care unit. The aim of this case report is to underline the probability of severe arrhythmias during acute pancreatitis, which can increase morbidity of this pathology. Despite many publications or reports, causes of increased EKG abnormalities during severe pancreatitis remained unclear and are probably multifactorial. To prevent accidents or complications, patients with severe acute pancreatitis should have a continuous EKG monitoring., (Copyright (c) 2009 Elsevier Masson SAS. All rights reserved.)

Thoracic aortic mural thrombus is a rare entity and potential source of serious systemic emboli. The progress of computed tomography (CT) angiography and the current use of transesophageal echocardiography (TEE) after any embolic event have considerably increased the frequency of diagnostic and there is a growing interest about the etiopathogenesis, which is still widely misunderstood. Therapeutic management remains controversial. We present a case of floating thrombus in the thoracic aorta detected by contrast-enhanced CT scan. This thrombus was responsible for two close major embolic events and was therefore managed surgically. Finally, outcome was favorable.

Background: Blood loss and uncontrollable bleeding are major factors affecting survival in trauma patients. Because treatment with antifibrinolytic drugs may be effective, early detection of hyperfibrinolysis with rotation thrombelastography (ROTEM may be beneficial., Methods: Eighty-seven trauma patients were included in this prospective observational study. Blood samples were collected at admission. After in vitro activation with tissue factor (EXTEM) and inhibition with aprotinin (APTEM), ROTEM parameters including maximal clot firmness (MCF) and clot lysis index at 30 min (CLI(30)) were determined. Hyperfibrinolysis was defined as a euglobulin lysis time (ELT) <90 min. Threshold for ROTEM parameters were determined with receiver-operating characteristic curves (ROC) analysis according to the ELT results., Results: ELT was determined in a subgroup of 23 patients. In this group of patients, ROC analysis showed that for a threshold of 18 mm (MCF-EXTEM), 71% (CLI(30)) and 7% (increase of MCF-APTEM), sensitivity was, respectively, 100%, 75%, and 80% with a specificity of 100%. With the application of these thresholds to the whole trauma cohort, ROTEM analysis detected hyperfibrinolysis in five patients [6%, 95% confidence interval (CI): 2-13%]. As expected, patients with hyperfibrinolysis were more severely injured (median Injury Severity Score: 75 vs 20, P<0.05), had greater coagulation abnormalities [international normalized ratio (INR): 8.2 vs 1.3, P<0.05; fibrinogen: 0.0 vs 2.2 g litre(-1), P<0.05], and a higher mortality rate (100%, CI: 48-100% vs 11% CI: 5-20%, P<0.05)., Conclusions: ROTEM provided rapid and accurate detection of hyperfibrinolysis in severely injured trauma patients.

Penetrating non-lethal injuries to the distal extra-cranial internal carotid artery are often a surgical challenge, because of the difficulty of direct exposure and repair of the internal carotid artery at the skull base. We describe a case of a successful emergency treatment, with an endovascular procedure using a PTFE covered-stent, of an internal carotid artery haemorrhagic pseudoaneurysm following penetrating trauma to the neck by single gunshot.

Perforation of the abdominal oesophagus from blunt trauma is an extremely rare injury. We report a case of an initially unrecognized oesophageal injury. The patient underwent an immediate laparotomy for haemorrhagic shock. The diagnosis was made by tomodensitometry and was delayed by modified radiological interpretation secondary to laparotomy. Finally, the outcome was favourable.

The biphasic waveform (BPW) is an abnormality of the optical transmission waveform obtained during measurement of the activated partial thromboplastin time on a specific photometric haemostasis autoanalyzer. This abnormality is related to calcium-dependent formation of complexes between C reactive protein and very low density lipoprotein. Biphasic waveform had a high sensitivity and negative predictive value for the identification of patients with severe sepsis and septic shock. On day 3, the time course of the biphasic waveform is a marker for the prognosis of sepsis-related mortality. The BPW is not a surrogate marker for C-reactive protein or procalcitonin and provides additional information. Further trials should be necessary using BPW for diagnostic and management procedures. Compared with other laboratory markers such as C reactive protein or procalcitonin, activated partial thromboplastin time waveform analysis is a tool that is rapid, inexpensive, effective and available 24 hours a day. When the analyzer is locally available, waveform analysis of this routine coagulation test provides information for the diagnosis of severe sepsis and the prognosis of septic patients.

Background: Reagent-supported thromboelastometry with the rotation thrombelastography (e.g. ROTEM) is a whole blood assay that evaluates the visco-elastic properties during blood clot formation and clot lysis. A hemostatic monitor capable of rapid and accurate detection of clinical coagulopathy within the resuscitation room could improve management of bleeding after trauma., Objectives: The goals of this study were to establish whether ROTEM correlated with standard coagulation parameters to rapidly detect bleeding disorders and whether it can help to guide transfusion., Methods: Ninety trauma patients were included in the study. At admission, standard coagulation assays were performed and ROTEM parameters such as clot formation time (CFT) and clot amplitude (CA) were obtained at 15 min (CA(15)) with two activated tests (INTEM, EXTEM) and at 10 min (CA(10)) with a test analyzing specifically the fibrin component of coagulation (FIBTEM)., Results: Trauma induced significant modifications of coagulation as assessed by standard assays and ROTEM. A significant correlation was found between prothrombin time (PT) and CA(15)-EXTEM (r = 0.66, P < 0.0001), between activated partial thromboplastin time and CFT-INTEM (r = 0.91, P < 0.0001), between fibrinogen level and CA(10)-FIBTEM (r = 0.85, P < 0.0001), and between platelet count and CA(15)-INTEM (r = 0.57, P < 0.0001). A cutoff value of CA(15)-EXTEM at 32 mm and CA(10)-FIBTEM at 5 mm presented a good sensitivity (87% and 91%) and specificity (100% and 85%) to detect a PT > 1.5 of control value and a fibrinogen less than 1 g L(-1), respectively., Conclusions: ROTEM is a point-of-care device that rapidly detects systemic changes of in vivo coagulation in trauma patients, and it might be a helpful device in guiding transfusion.

Bacteremic pasteurellosis is an uncommon form of Pasteurella multocida infection, usually involved in local infections. This systemic infection often occurs in immuno-compromised patient such as cirrhotic or alcoholic patients, with a high mortality rate (up to 60%). Septic shock may occur and neurological disorders or coma are frequent. We report such a case. Treatment associated local care, antibiotics (beta-lactam antibiotics plus fluoroquinolone) during 14 days and resuscitation of septic shock. Owing these therapies, septic shock was successfully treated without complications.

The present report describes a simple method to selectively extract free fatty acids and analyze them by capillary gas-liquid chromatography. The procedure is based on the use of fumed silicon dioxide. In the presence of plasma, this material induces a rapid rise in the viscosity of the mixture and presents the ability to trap large particles such as emulsified lipids and lipoproteins. Albumin-bound fatty acids are thus left in the aqueous media. We present applications of our procedure for the analysis of free fatty acids in 0.2 ml of plasma from rat or human. By comparison with the method utilizing thin-layer chromatography for the separation of fatty acids and gas chromatography analysis, the present method has been found to be reliable and simple. The recovery of linoleic acid was 92.1 +/- 8.2%, a value which is about twice better than that obtained with the procedure using thin-layer chromatography. In particular, long-chain polyunsaturated fatty acids were better preserved. Our procedure does not require the use of organic solvents and its simplicity and reproducibility make it suitable for routine specific determination of the composition of free fatty acids in biological samples.