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Objectives: Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH). Materials and Methods: A scoping review was conducted on Medline database from inception to September 2021. Results: The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D). Conclusion: This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.

Introduction To date, there is no evidence concerning the emergency surgical management of severe trauma patients (STP) with severe traumatic brain injury (STBI) presenting a life-threatening intracranial hematoma and a concomitant extra-cranial noncompressible active bleeding. Current guidelines recommend stopping the extra-cranial bleeding first. Nevertheless, the long-term outcome of STP with STBI mainly depends from intracranial lesions. Thus, we propose a combined damage-control surgical strategy aiming to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. The main objective of the study is to evaluate the benefits of combined cranial and extra-cranial surgery of STP on the long-term outcome. Materials and Methods We retrospectively searched through the database of STBI of a level 1 trauma center facility (Sainte-Anne Military Teaching Hospital, Toulon, France) from 2007 until 2021 looking for patients who benefited from combined cranial and extra-cranial surgery in an acute setting. Results The research yielded 8 patients. The mean age was 35 years old (±14) and the male to female sex ratio was 1.7/1. The trauma mechanism was a fall in 50% of the cases and a traffic accident in 50% of the cases. The median Glasgow coma scale score was 8 (IQR 4) before intubation. The median Injury Severity Score was 41 (IQR 16). Seven patients (88%) presented hypovolemic shock upon admission. Six patients (75%) benefited from damage-control laparotomy among, whom 4 (67%) underwent hemostatic splenectomy. One patient benefited from drainage of tension pneumothorax, and one patient benefited from external fixator of multiple limb fractures. Seven patients (88%) benefited from decompressive craniectomy for acute subdural hematoma (5 patients) or major brain contusion (2 patients). One patient (12%) benefited from craniotomy for epidural hematoma. Three patients presented intraoperative profound hypovolemic shock. Six patients (75%) presented a favorable neurologic outcome with minor complications from extra-cranial surgeries and 2 patients died (25%). Conclusion Performing combined life-saving cranial and extra-cranial surgery is feasible and safe as long as the trauma teams are trained according to the principles of damage control. It may be beneficial for the neurologic prognostic of STP with STBI requiring cranial and extra-cranial surgery.

International audience; Rationale: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown.Objectives: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2

Background The death rate in intensive care units (ICUs) can reach 20%. More than half occurs after a decision of care withholding/withdrawal. We aimed at describing and evaluating the experience of ICU physicians and nurses involved in the end-of-life (EOL) procedure. Primary objective was the evaluation of the experience of EOL assessed by the CAESAR questionnaire. Secondary objectives were to describe factors associated with a low or high score and to examine the association between Numeric Analogic Scale and quality of EOL. Methods Consecutive adult patients deceased in 52 ICUs were included between April and June 2018. Characteristics of patients and caregivers, therapeutics and care involved after withdrawal were recorded. CAESAR score included 15 items, rated from 1 (traumatic experience) to 5 (comforting experience). The sum was rated from 15 to 75 (the highest, the best experience). Numeric Analogic Scale was rated from 0 (worst EOL) to 10 (optimal EOL). Results Five hundred and ten patients were included, 403 underwent decision of care withholding/withdrawal, and among them 362 underwent effective care withdrawal. Among the 510 patients, mean CAESAR score was 55/75 (± 6) for nurses and 62/75 (± 5) for physicians (P P = 0.06). CAESAR score and Numeric Analogic Scale were significantly but weakly correlated. They were significantly higher for both nurses and physicians if the patient died after a decision of withholding/withdrawal. In multivariable analysis, among the 362 patients with effective care withdrawal, disagreement on the intensity of life support between caregivers, non-invasive ventilation and monitoring and blood tests the day of death were associated with lower score for nurses. For physicians, cardiopulmonary resuscitation the day of death was associated with lower score in multivariable analysis. Conclusion Experience of EOL was better in patients with withholding/withdrawal decision as compared to those without. Our results suggest that improvement of nurses’ participation in the end-of-life process, as well as less invasive care, would probably improve the experience of EOL for both nurses and physicians. Registration: ClinicalTrial.gov: NCT03392857.

Microvesicles (MVs) have previously been shown to exert profibrinolytic capacity, which is increased in patients with septic shock (SS) with a favorable outcome. We, therefore, hypothesized that the plasmin generation capacity (PGC) could confer to MVs a protective effect supported by their capacity to lyse a thrombus, and we investigated the mechanisms involved. Using an MV-PGC kinetic assay, ELISA, and flow cytometry, we found that granulocyte MVs (Gran-MVs) from SS patients display a heterogeneous PGC profile driven by the uPA (urokinase)/uPAR system. In vitro, these MVs lyse a thrombus according to their MV-PGC levels in a uPA/uPAR-dependent manner, as shown in a fluorescent clot lysis test and a lysis front retraction assay. Fibrinolytic activators conveyed by MVs contribute to approximately 30% of the plasma plasminogenolytic capacity of SS patients. In a murine model of SS, the injection of high PGC Gran-MVs significantly improved mouse survival and reduced the number of thrombi in vital organs. This was associated with a modification of the mouse coagulation and fibrinolysis properties toward a more fibrinolytic profile. Interestingly, mouse survival was not improved when soluble uPA was injected. Finally, using a multiplex array on plasma from SS patients, we found that neutrophil elastase correlates with the effect of high-PGC-capacity plasma and modulates the Gran-MV plasmin generation capacity by cleaving uPA-PAI-1 complexes. In conclusion, we show that the high PGC level displayed by Gran-MVs reduces thrombus formation and improves survival, conferring to Gran-MVs a protective role in a murine model of sepsis.

IntroductionAn amphibious assault ship was deployed on 22 March in Corsica to carry out medical evacuation of 12 critical patients infected with COVID-19. The ship has on-board hospital capacity and is the first time that an amphibious assault ship is engaged in this particular condition. The aim is to evaluate the feasibility and safety of prolonged medical evacuation of critical patients with COVID-19.MethodsWe included 12 patients with confirmed COVID-19 infection: six ventilated patients with acute respiratory distress syndrome and six non-ventilated patients with hypoxaemia. Transfer on an amphibious assault ship lasted 20 hours. We collected patients’ medical records: age, comorbidities, COVID-19 history and diagnosis, ventilation supply and ventilator settings, and blood gas results. We calculated oxygen consumption (OC).ResultsAll patients had a medical history. The median delay from onset of symptoms to hospitalisation was 8 (7–10) days. The median Sequential Organ Failure Assessment score on admission was 3 (2–5). There was no significant increase in oxygen during ship transport and no major respiratory complication. There was no significant increase in arterial oxygen pressure to fractional inspired oxygen ratio among ventilated patients during ship transport. Among ventilated patients, the median calculated OC was 255 L (222–281) by hours and 5270 L (4908–5616) during all ship transport. Among non-ventilated patients, the median calculated OC was 120 L (120–480) by hours and 2400 L (2400–9600) during all ship transport.ConclusionThe present work contributes to assessing the feasibility and safety condition of critical COVID-19 evacuation on an amphibious assault ship during an extended transport. The ship needs to prepare a plan and a specialised intensive team and conduct patient screening for prolonged interhospital transfers.

Hypocapnia induces cerebral vasoconstriction leading to a decrease in cerebral blood flow, which might precipitate cerebral ischemia. Hypocapnia can be intentional to treat intracranial hypertension or unintentional due to a spontaneous hyperventilation (SHV). SHV is frequent after subarachnoid hemorrhage. However, it is understudied in patients with severe traumatic brain injury (TBI). The objective of this study was to describe the incidence and consequences on outcome of SHV after severe TBI. We conducted a retrospective, observational study including all intubated TBI patients admitted in the trauma center and still comatose 24 h after the withdrawal of sedation. SHV was defined by the presence of at least one arterial blood gas (ABG) with both PaCO2 7.45. Patient characteristics and outcome were extracted from a prospective registry of all intubated TBI admitted in the intensive care unit. ABG results were retrieved from patient files. A multivariable logistic regression model was developed to determine factors independently associated with unfavorable outcome (defined as a Glasgow Outcome Scale between 1 and 3) at 6-month follow-up. During 7 years, 110 patients fully respecting inclusion criteria were included. The overall incidence of SHV was 69.1% (95% CI [59.9–77]). Patients with SHV were more severely injured (median head AIS score (5 [4–5] vs. 4 [4–5]; p = 0.016)) and exhibited an elevated morbidity during their stay. The proportion of patients with an unfavorable functional neurologic outcome was significantly higher in patients with SHV: 40 (52.6%) versus 6 (17.6%), p = 0.0006. After adjusting for confounders, SHV remains an independent factor associated with unfavorable outcome at the 6-month follow-up (OR 4.1; 95% CI [1.2–14.4]). SHV is common in patients with a persistent coma after a severe TBI (overall rate: 69%) and was independently associated with unfavorable outcome at 6-month follow-up.

BACKGROUND Early transfusion of high ratio of fresh frozen plasma (FFP) and red blood cells (RBC) is associated with mortality reduction. However, time to reach high ratio is limited by the need to thaw the FFP. French lyophilized plasma (FLYP) used by French army and available in military teaching hospital does not need to be thawed and is immediately available. We hypothesize that the use of FLYP may reduce time to reach a plasma/RBC ratio of 1:1. METHODS A retrospective study performed in a Level 1 trauma center between January 2012 and December 2015. Severe trauma patients who received 2 U of RBC in the emergency room were included and assigned to two groups according to first plasma transfused: FLYP group and FFP group. RESULTS Forty-three severe trauma patients in the FLYP group and 29 in the FFP group were included. The time until first plasma transfusion was shorter in the FLYP group than in the FFP group, respectively 15 min (10-25) versus 95 min (70-145) (p < 0.0001). Time until a 1:1 ratio was shorter in the FLYP group than in the FFP group. There were significantly fewer cases of massive transfusion in the FLYP group than in the FFP group with respectively 7% vs. 45% (p < 0.0001). CONCLUSION The use of FLYP provided significantly faster plasma transfusions than the use of FFP as well as a plasma and RBC ratio superior to 1:2 that was reached more rapidly in severe trauma patients. These results may explain the less frequent need for massive transfusion in the patients who received FLYP. These positive results should be confirmed by a prospective and randomized evaluation. LEVEL OF EVIDENCE Therapeutic, level IV.

Background: Cocaine is one of the most widely used illicit drugs, and it is the most common cause of drug-related death. The association of cocaine use with acute heart failure is a rare occurrence. Case Report: We report the case of a 31 years-old woman who presented Takotsubo cardiomyopathy with severe cardiogenic shock after cocaine abuse. That required the use of high doses of positive inotropic amines and mechanical ventilation. The evolution was quickly favorable after the cessation of cocaine. Discussion: Takotsubo cardiomyopathy is often related to a stressful trigger, and several cases have been described with the use of several psychostimulants. As such, it is not surprising that cocaine use can be associated with the development of Takotsubo cardiomyopathy when it results in excess release of catecholamines and excitation of adrenergic receptors. Conclusion: In critical care unit, Takotsubo cardiomyopathy is a rare complication of cocaine abuse. This etiological diagnosis can be difficult especially in the absence of the concept of toxic intake as it was initially the case for our patient, but the treatment does not differ from other causes of cardiomyopathy and Cessation of cocaine use has been associated with improvement in cardiac function.

To the Editor: We read with interest the comments from Sarc et al[1][1] about our previous study on ![Formula][2] delivered by noninvasive ventilation (NIV) compared with long-term oxygen therapy at the same flow.[2][3] We want to give some precision in response to their comments. Sarc et al

Background Blood clot formation is a multifactorial process and has been related many times in intensive care units. Here is presented a multiple thrombosis formation in a rewarming patient. Case description A 68-year-old patient was admitted to our intensive care unit after lying on the floor for an unknown time. She presented a severe hypothermia at 26° and a severe cardiogenic shock. Because she was confused and was hypoxemic, she had been intubated at her admission. After intravascular warming, we could stop sedative medications. She presented a right hemiparesis and acute left leg ischemia. Computed tomography (CT) scan revealed a constituted left Sylvian stroke and a massive clot along the aorta. She required a surgical embolectomy and fasciotomy. She died after she presented a severe bowel ischemia on the third day after her admission. Conclusion Relevant hypothesis for blood clot formation in this patient may include prolonged lying position or blood temperature variation. Hypothermia and rewarming responsibilities may explain multiple thrombosis development. How to cite this article Schmitt J, Esnault P, Sartre M, Cungi PJ, Meaudre E. Severe Aortic Thrombosis and Profound Hypothermia: A Case Report. Indian J Crit Care Med 2021;25(5):588–589.

BACKGROUND: Long-term home mechanical ventilation is increasingly used by patients with chronic respiratory failure. Storage of medical data in the cloud is expanding, and ventilation can be monitored remotely. The aim of this bench study was to determine whether tidal volume (VT) can be affected by the location of supplemental oxygen placement. METHODS: We tested 4 home ventilators in a bench test using a dual-chamber test lung to test the addition of supplemental oxygen placement via a connector in the circuit (ie, front intake port) versus via the manufacturer9s rear intake port, with different oxygen supply flows of 2, 4, 6, and 8 L/min. We compared the effectively delivered VT as measured with a pneumotachograph (ie, measured VT) versus the VT reported by each home ventilator (ie, monitored VT). RESULTS: For all of the home ventilators, the monitored VT and measured VT were comparable when the rear oxygen intake was used, regardless of oxygen flow. However, when the front oxygen intake was used, the monitored VT as measured by the ventilators was significantly lower than the measured VT, with the greatest difference reaching 29% for the highest oxygen flow tested (8 L/min). CONCLUSIONS: The monitored VT may be inaccurate if oxygen is added with a connector in the circuit, which may have consequences on both the individual level and collective level (ie, big data analysis). Physicians who analyze data from home ventilators should be aware of the site of oxygen supplementation and promote use of only the rear oxygen intake.

International audience; No abstract available

BACKGROUND: Nocturnal noninvasive ventilation is recommended for patients with hypercapnic COPD. Long-term oxygen therapy improves survival in patients with hypoxemic disease. However, leaks during noninvasive ventilation are likely to reduce the fraction of inspired oxygen. OBJECTIVES: To compare nocturnal inspired O2 fractions during noninvasive ventilation with daytime pharyngeal inspired O2 fractions during nasal cannula oxygen therapy (with the same O2 flow) in patients with COPD at home (ie, real-life conditions). METHODS: This single-center prospective observational study included 14 subjects with COPD who received long-term O2 therapy. We analyzed pharyngeal inspired O2 fractions in the evening, with a nasopharyngeal probe (sidestream gas analyzer). The O2 flow was measured with a precision flow meter, at the usual flow. Then, the same O2 flow was implemented for noninvasive ventilation with a study’s home ventilator. The all-night noninvasive ventilation parameters were delivered in pressure mode with a single-limb leaking circuit. Daytime and nighttime inspired O2 fractions were compared. RESULTS: The mean ± SD daytime pharyngeal inspired O2 fraction, measured with normobaric basal O2 flow, 0.308 ± 0.026%, was significantly higher than the mean ± SD nighttime inspired O2 fraction, measured during noninvasive ventilation (0.251 ± 0.011; P CONCLUSIONS: The nighttime inspired O2 fraction decreased with a modern noninvasive ventilation pattern, pressure target, and intentional leaks. This partial lack of O2 therapy is likely to be harmful. It might explain the poor results in all but 2 randomized controlled trials on long-term noninvasive ventilation in COPD. (ClinicalTrials.gov registration NCT02599246.)

The concept of damage control (DC) is based on a sequential therapeutic strategy that favors physiological restoration over anatomical repair in patients presenting acutely with hemorrhagic trauma. Initially described as damage control surgery (DCS) for war-wounded patients with abdominal penetrating hemorrhagic trauma, this concept is articulated in three steps: surgical control of lesions (hemostasis, sealing of intestinal spillage), physiological restoration, then surgery for definitive repair. This concept was quickly adapted for intensive care management under the name damage control resuscitation (DCR), which refers to the modalities of hospital resuscitation carried out in patients suffering from traumatic hemorrhagic shock within the context of DCS. It is based mainly on specific hemodynamic resuscitation targets associated with early and aggressive hemostasis aimed at prevention or correction of the lethal triad of hypothermia, acidosis and coagulation disorders. Concomitant integration of resuscitation and surgery from the moment of admission has led to the concept of an integrated DCR-DCS approach, which enables initiation of hemostatic resuscitation upon arrival of the injured person, improving the patient's physiological status during surgery without delaying surgery. This concept of DC is constantly evolving; it stresses management of the injured person as early as possible, in order to initiate hemorrhage control and hemostatic resuscitation as soon as possible, evolving into a concept of remote DCR (RDCR), and also extended to diagnostic and therapeutic radiological management under the name of radiological DC (DCRad). DCS is applied only to the most seriously traumatized patients, or in situations of massive influx of injured persons, as its universal application could lead to a significant and unnecessary excess-morbidity to injured patients who could and should undergo definitive treatment from the outset. DCS, when correctly applied, significantly improves the survival rate of war-wounded.

Blunt cerebrovascular injuries (BCVI) have been increasingly recognized in the past decade due to the initiation of different screening protocols. We present the case of an anterior cerebral artery rupture with free contrast extravasation following a severe traumatic brain injury. Epidemiology, modalities of screening and treatment of BCVI are discussed. This report reminds that the screening of BCVI may be essential after a severe traumatic brain injuries (TBI). How to cite this article Mathais Q, Esnault P, Joubert C, Dragone C, Meaudre E. Post-traumatic Anterior Cerebral Artery Rupture after a Severe Traumatic Brain Injury. Indian Journal of Critical Care Medicine, January 2019;23(1):54-55.

Purpose Experimental animal models of acute respiratory distress syndrome (ARDS) have shown that the updated airway pressure release ventilation (APRV) methodologies may significantly improve oxygenation, maximize lung recruitment, and attenuate lung injury, without circulatory depression. This led us to hypothesize that early application of APRV in patients with ARDS would allow pulmonary function to recover faster and would reduce the duration of mechanical ventilation as compared with low tidal volume lung protective ventilation (LTV). Methods A total of 138 patients with ARDS who received mechanical ventilation for

Background: Long term oxygen therapy improves survival in hypoxemic patients with chronic obstructive pulmonary disease (COPD). Because pressure support ventilation with a home care ventilator is largely unsupervised, there is considerable risk of leakage occurring, which could affect delivered FiO2. We have therefore conducted a bench study in order to measure the effect of different levels of O2 supply and degrees of leakage on delivered FiO2. Ventilator tested: Legendair W (Airox™, Pau, France). Thirty-six measures were performed in each four ventilators with zero, 5 and 10 l.min-1 leakage and 1,2,4 and 8 l O2 flow. Findings: FiO2 decreased significantly with 5 l.min-1 leakage for all O2 flow rates, and with 10 l.min-1 at 4 and 8 l. min-1 O2. Conclusion: During application of NIV on home ventilators, leakage can dramatically decrease inspired FiO2 making it less effective. It is important to know the FiO2 dispensed when NIV is used for COPD at home. We would encourage industry to develop methods for FiO2 regulation Chronic use of NIV for COPD with controlled FiO2 or SpO2 requires further studys.

Pholcodine is a commonly used antitussive medication. In France, its use is limited because of the risk of an allergic cross-reaction with curare. Here we report the case of a 52-year-old man who ingested 750 mg of pholcodine syrup. An emergency medical team found him at home in nonshockable cardiac arrest. Orotracheal intubation was impossible because of instantaneous rigor associated with trismus, so an emergency cricothyrotomy was performed. Return of spontaneous circulation was obtained 5 min later. Cardiac arrest recurred upon arrival at the intensive care unit, leading to death. Toxicological analysis showed a pholcodine blood level of 2500 ng ml−1 (a lethal dose is >1000 ng ml−1, extrapolated from animal studies). Pholcodine is an opioid derivate with a central antitussive effect that is indicated for unproductive cough in adults. No case of fatal intoxication has ever been reported. We hypothesize that cardiac arrest was the result of hypoxia due to respiratory arrest connected to the opioid nature of pholcodine. Interestingly, instantaneous rigor occurred, which should be not confused with rigor mortis. Instantaneous rigor is a rarely reported condition that persists until rigor mortis and disappears in the stage of secondary flaccidity. Instantaneous rigor can lead to trismus, making orotracheal intubation impossible and necessitating emergency cricothyrotomy. This case shows that pholcodine overdose can be lethal and can lead to instantaneous rigor.

Novel oral anticoagulants (NOAs) which directly inhibit thrombin (dabigatran) or factor Xa (rivaroxaban and apixaban) have recently been developed. We report the first case of perioperative management of a patient treated with dabigatran requiring haemodialysis before emergency surgery. A 62-yr-old woman visited the emergency department for a left bi-malleolar ankle fracture; she had a past medical history of severe ischaemic cardiomyopathy, alcoholic cirrhosis Child B, and moderate chronic renal insufficiency. The patient was treated with dabigatran for a left ventricular aneurysm with thrombus. Cutaneous manifestation of a voluminous haematoma required emergency surgery. Blood tests revealed dabigatran anticoagulant activity of 123 ng ml(-1) (therapeutic values: 85-200 ng ml(-1)), activated partial thromboplastin time of 63 s, and a prothrombin ratio of 68%, indicating that dabigatran disturbed coagulation. We decided to perform emergency haemodialysis before surgery. After 2 h, the anticoagulant activity of dabigatran was 11 ng ml(-1), allowing surgery. Surgery proceeded without any problems and the postoperative period was unremarkable. This case highlights the difficulties for the anaesthesiologist regarding emergency perioperative management of patients treated with NOAs and confirms the efficacy of haemodialysis in cases of dabigatran treatment. NOAs should be prescribed with caution, especially for patients with renal or hepatic disease, at least as long as no antagonist is available. In cases of deferred operative urgency in haemodynamically stable patients treated with dabigatran, haemodialysis should be considered to reverse dabigatran's anticoagulant effects.

Introduction Although aneurysmal subarachnoid hemorrhage (SAH) is often complicated by myocardial injury, whether this neurogenic cardiomyopathy is associated with the modification of cardiac metabolism is unknown. This study sought to explore, by positron emission tomography/computed tomography, the presence of altered cardiac glucose metabolism after SAH. Methods During a 16-month period, 30 SAH acute phase patients underwent myocardial 18 F- fluorodesoxyglucose positron emission tomography (18F-FDGPET), 99mTc-tetrofosmin and 123I-meta-iodobenzylguanidine (123I-mIBG) scintigraphy, respectively, assessing glucose metabolism, cardiac perfusion, and sympathetic innervation. Patients with initial abnormalities were followed monthly for two months for 18F-FDG, and six months later for 123I-mIBG. Results In this SAH population, acute cardiac metabolic disturbance was observed in 83% of patients (n = 25), and sympathetic innervation disturbance affected 90% (n = 27). Myocardial perfusion was normal for all patients. The topography and extent of metabolic defects and innervation abnormalities largely overlapped. Follow-up showed rapid improvement of glucose metabolism in one or two months. Normalization of sympathetic innervation was slower; only 27% of patients (n = 8) exhibited normal 123I-mIBG scintigraphy after six months. Presence of initial altered cardiac metabolism was not associated with more unfavorable cardiac or neurological outcomes. Conclusions These findings support the hypothesis of neurogenic myocardial stunning after SAH. In hemodynamically stable acute phase SAH patients, cardiomyopathy is characterized by diffuse and heterogeneous 18F-FDG and 123I-mIBG uptake defect. Trial registration Clinicaltrials.gov NCT01218191. Registered 6 October 2010.

We read with great interest the study by de Waard and colleagues highlighting interest in continuous peritoneal lavage (PL) to induce mild therapeutic hypothermia (MTH) in unconscious patients after resuscitated cardiac arrest [1]. It is now quite well established that MTH improves outcome [2]. Compared with cooled intravenous infusion and cooled blankets, the authors showed that the target temperature was reached faster (30 minutes vs. 150 minutes) and had a lower coefficient of variation during the maintenance phase (0.5% vs. 1.5%) in the PL group [1]. However, using this PL method in daily practice seems difficult to us and this device must be used by experimented operators (usually surgeons) to limit the complications. In our unit, we have used an intravascular device consisting of a central venous catheter (Icy™ catheter; ALSIUS Corporation, Irvine, CA, USA) associated with an external heat exchange system (CoolGard 3000™; ALSIUS Corporation). This device acts as a thermostat for core body temperature control. This system replaces the triple-lumen central venous catheter, whose efficacy is proven [3,4]. The CoolGard 3000™ allows fast cooling, stability of the temperature and controlled progressive reheating. Few complications have been reported and have been essentially related to the central venous access (placement errors, catheter-related thrombosis, infection) [5]. The system's main limitation is its accessibility and its cost. To conclude, although PL is interesting to obtain MTH in post-resuscitation patients, we believe that the use of an endovascular device seems to have a better benefit/risk ratio.

We read with great interest the study by Chen and colleagues highlighting interest in hydroxyethyl starch (HES) 130/0.4 in treatment after hemorrhagic shock to ameliorate oxidative stress and the inflammatory response in a rat model. Compared with HES 200/0.5 and succinylated gelatin, the authors showed that infusions of HES 130/0.4 significantly reduced malondialdehyde levels and myeloperoxidase activity and also inhibited about 50% of TNF-α production in the intestine [1]. However, we regret the lack of assessment of another resuscitative fluid: the hypertonic saline solution (HTS). In our level 1 trauma center, we chose to use HTS because we have some concerns about HES safety. Indeed, HES may induce coagulopathy and increase risk of renal-replacement therapy [2]. HTS has several advantages due to its osmotic effects. Firstly, it leads to restoration of circulating volume with a smaller volume of fluid. Secondly, it reduces intracranial pressure in case of associated traumatic brain injury [3]. In addition, HTS attenuates the increase in plasma concentration of IL-1β, IL-6, IFN-γ and TNF-α, suggesting that HTS may also limit the inflammatory response to hemorrhage and reperfusion [4]. One of its inconveniences may be the increased risk of acute kidney injury due to hyperchloremic metabolic acidosis decreasing renal blood flow; however, this effect was especially demonstrated when using large amounts of 0.9% saline solution [5]. We suggest that, in 2013, studies on fluid resuscitation should compare all the available resuscitative fluids, and not just HES, currently under concern for safety reasons. Abbreviations HES: hydroxyethyl starch; HTS: hypertonic saline solution; IFN: interferon; IL: interleukin; TNF: tumor necrosis factor. Competing interests The authors declare that they have no competing interests.

Potential lung transplants are lost because of hypoxemia after apnea test. Marie Paries and collaborators evaluated the positive effect of a single recruitment maneuver after the apnea test. Mascia and collaborators perform the apnea test with CPAP with better result on PaO2/FiO2 than classical apnea test. We think that recruitment maneuver will not be necessary if apnea test is performed with CPAP.

Dialysis disequilibrium syndrome (DDS) is a brain disease characterized by neurological symptoms due to cerebral edema after hemodialysis (HD). However, a direct measurement of intracranial pressure (ICP) rarely objectifi ed this edema [1]. We report the case of a patient whose DDS was diagnosed by an increase of ICP. A 51-year-old man was admitted for severe traumatic brain injury. At admission, an extradural hematoma was evacuated. After surgery, ICP monitoring guided the treatment. At day 4, toxic acute renal failure appeared. Fearing the occurrence of a DDS, we used continuous veno-venous hemofi ltration (CVVH), which allowed a gradual reduction in urea without an intracranial hypertension (ICH) episode. Later, after a resumption of diuresis, we stopped CVVH. At day 11, urea increased to 35.6 mmol/L and creatininemia to 452 mol/L. Serum sodium was 145 mmol/L. Because the trauma had occurred several days before, we decided to perform HD. One hour after the start of HD, an ICH appeared (ICP = 37 mm Hg). Urea was 22.3 mmol/L and serum sodium was 144 mmol/L (unchanged). DDS was diagnosed. After HD was stopped, osmotherapy was administered, and neurosedation was increased, ICP returned to normal (Figure 1). Afterward, we successfully used CVVH

We agree with the letter from Scala and Esquinas [1] in response to the article by Schortgen and colleagues [2], who emphasised the use of non-invasive ventilation in the ICU as the best ventilatory treatment for ‘do not intubate’ octogenarian patients. Scala and Esquinas argued that ICU beds are scarce and that the ICU environ ment alters contact between the patient and family. We do not, however, entirely accept the views of Schortgen and colleagues. Use of the non-invasive ventilation mask for palliative care patients with acute respiratory distress prevents the patient from eating and talking, and the patient’s experience can be that of being smothered. When the major indication is hypoxemia, a trea tment option is the administration of high-fl ow oxygen using up to 60 l/minute heated and humidifi ed oxygen through a nasal cannula [3] Th e mouth is thus freed and the patient is able to eat and talk with his family. Th e cost to effi ciency ratio is favourable because the Optifl ow® oxygenation system (Fischer and Paykel™, Auckland, New Zealand) costs €4,000 versus €15,600 for the V60® ventilation system (Philips™, Amsterdam, Th e Netherlands). Non-invasive ventilation appears preferable in chronic obstructive pulmonary disease patients with hypercapnia. We tested high-fl ow oxygen administration in 10 ‘do not intubate’ patients receiving palliative cancer care in whom a high oxygen concentration mask failed to relieve dyspnoea (abstract accepted for the Societe Francaise

Cytomegalovirus (CMV) reactivation has been widely documented in the past 10 years in critically ill patients [1]. Conversely, few data are available on burn patients despite experimental studies showing that these patients are predisposed to herpes virus infections [2]. To our knowledge, only two studies reported the incidence of CMV infection in burn patients using a modern technique, such as PCR, which has become the gold standard [3,4]. These two studies demonstrated a high rate of CMV reactivation, 55% and 71%, respectively. Moreover, CMV reactivation in burn patients has been proven to be intense. Indeed, in the study of Bordes and colleagues [4], 67% of patients who reactivated CMV experienced viremia greater than 1,000 copies/ml, and 33% viremia greater than 10,000 copies/ml. These results may reflect the severe immunosuppression that characterizes thermally injured patients. Consequently, severe burn patients could be considered as a model for CMV reactivation in critically ill patients. However, the precise kinetics of CMV DNA load in these patients is still poorly documented. That is why we would like to briefly present data from longitudinal monitoring of CMV infection by real-time PCR (RT-PCR) in four severe burn patients during their ICU stay (Figure ​(Figure11). Figure 1 Cytomegalovirus plasma load measurements during ICU stay of four severe burn patients. All the patients were CMV IgG seropositive on admission. They were monitored for CMV reactivation once to twice a week. Detection of CMV DNA in blood samples was performed by quantitative RT-PCR on whole blood. The patients' characteristics are described in Table ​Table1.1. Patient 2 presented a CMV-associated hemophagocytic syndrome and was treated by ganciclovir for a duration of 21 days. DNAemia became undetectable in patients 3 and 4 spontaneously. These examples demonstrate that critically ill patients may experience several episodes of CMV reactivation during their ICU stay, and that CMV viral load can be very changeable. Furthermore, CMV viremia may be highly variable over a short period. Table 1 Patient characteristics In our opinion, CMV reactivation in critically ill patients should be monitored with quantitative methods of detection, such as RT-PCR. Indeed, we hypothesize that the potential role of CMV on patient outcome is mostly due to the intensity of CMV reactivation rather than the CMV reactivation per se. That is why we suggest that studies aimed at determining the role of CMV reactivation as a contributor to outcome in critically ill patients should use quantitative methods of detection. Consequently, a CMV viremia threshold could be determined to guide preemptive therapy in these patients. Written consent for publication was obtained from the patients or patients' relatives.

International audience; Abstract Background The COVID-19 pandemic is a heavy burden in terms of health care resources. Future decision-making policies require consistent data on the management and prognosis of the older patients (> 70 years old) with COVID-19 admitted in the intensive care unit (ICU). Methods Characteristics, management, and prognosis of critically ill old patients (> 70 years) were extracted from the international prospective COVID-ICU database. A propensity score weighted-comparison evaluated the impact of intubation upon admission on Day-90 mortality. Results The analysis included 1199 (28% of the COVID-ICU cohort) patients (median [interquartile] age 74 [72–78] years). Fifty-three percent, 31%, and 16% were 70–74, 75–79, and over 80 years old, respectively. The most frequent comorbidities were chronic hypertension (62%), diabetes (30%), and chronic respiratory disease (25%). Median Clinical Frailty Scale was 3 (2–3). Upon admission, the PaO 2 /FiO 2 ratio was 154 (105–222). 740 (62%) patients were intubated on Day-1 and eventually 938 (78%) during their ICU stay. Overall Day-90 mortality was 46% and reached 67% among the 193 patients over 80 years old. Mortality was higher in older patients, diabetics, and those with a lower PaO 2 /FiO 2 ratio upon admission, cardiovascular dysfunction, and a shorter time between first symptoms and ICU admission. In propensity analysis, early intubation at ICU admission was associated with a significantly higher Day-90 mortality (42% vs 28%; hazard ratio 1.68; 95% CI 1.24–2.27; p