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Copyright of Annales Françaises de Médecine d'Urgence is the property of John Libbey Eurotext Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Author(s): S. Gaudry [sup.1] [sup.2], C. Verney [sup.1], D. Hajage [sup.3] [sup.4] [sup.5], J. D. Ricard [sup.1] [sup.6], Didier Dreyfuss [sup.1] [sup.6] [sup.7] Author Affiliations: (1) 0000 0001 0273 556X, [...]

Nicolas Dufour,1 Fouad Fadel,1 Bruno Gelée,1 Jean-Louis Dubost,1 Sophie Ardiot,2 Pascal Di Donato,2 Jean-Damien Ricard3,4 1Medical and Surgical Intensive Care Unit, Centre Hospitalier René Dubos, Pontoise 95300, France; 2Agence Nationale de Sécurité du Médicament et des Produits de Santé, Direction des Dispositifs Médicaux, des Cosmétiques et des Dispositifs de Diagnostic in vitro, Saint-Denis Cedex 93285, France; 3Medical and Surgical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, 92700 Colombes, France; 4Infection, Antimicrobials, Modelling and Evolution, Université de Paris, IAME UMR 1137 Institut National de la Santé et de la Recherche Médicale, Paris 75018, FranceCorrespondence: Nicolas DufourCentre Hospitalier René Dubos, 6, Avenue de l’île de France, Pontoise 95300, FranceTel +33 130754341Email nicolas.dufour@ght-novo.frBackground: Complexity and functions of automated medical devices used to support life (eg, ventilators, dialysis machines, monitors, insulin pump with continuous blood glucose monitoring system, etc.) increase over time. Until recently, devices were partially automated by very simple feedback loops, with no or few software dependence (such as the simplest home thermostat). For the last two decades, devices have been increasingly driven by complex algorithms devoted to improve patient’s treatment and monitoring as well as users experience.Methods: We report the unexpected and inappropriate operation of two recent ventilators, associated to potential harmful consequences. We provide both a description of the clinical situations (five ICU patients, archetypal situations) and a test bench analysis.Results: While set in volume mode, these ventilators activated an algorithm dedicated to limit airway pressure when an increase in airway resistance occurred. In such situations, a pressure-like mode was activated (with decelerating inspiratory flow and set pressure, with target of volume). The main consequences observed were that the tidal volume was no longer guaranteed or delivered and that the pressure limitation operated by the algorithm prevented the airway pressure from reaching the high-pressure alarm threshold.Conclusion: This led to the silent takeover of commands by the ventilator without clinicians or nurses being aware of it and without any warnings or alarms emission adapted to the severity of the event. Generally speaking, such an algorithm questions the place of automation and its limit when users are not aware of its presence as well as the need for regulation and additional tests before its implementation. Intensivists and respiratory care specialists should remain vigilant regarding the risk of rare but critical events related to unexpected functioning or insufficiently tested equipment during the pre-clinical development phases. They should not neglect misunderstood critical events without having performed sufficient investigations.Keywords: mechanical ventilation, algorithm, dual mode, automation, material vigilance, case report

Summary Traumatic pancreatic injuries are rare: their severity correlates with main pancreatic duct involvement. We report the case of a 5-year-old child who presented with complete disruption of the main pancreatic duct, treated successfully with an endoscopically inserted double pigtail stent. [ABSTRACT FROM AUTHOR]

Abstract: Amniotic fluid embolism is a relatively rare clinical entity and with difficult medical recognition. However, it is the second leading cause of maternal mortality. We report here the case of a 32-year-old patient who underwent elective caesarean section complicated by an amniotic fluid embolism with cardiac arrest. The presence of a major disseminated intravascular coagulation favored the occurrence of a retroperitoneal hematoma of iatrogenic origin on attempt of femoral venous catheterization and that of hemoperitoneum on bleeding of an hepatic adenoma. The diagnostic of amniotic fluid embolism was confirmed by the presence of amniotic cells in the bronchoalveolar lavage. The patient survived without sequelae. [Copyright &y& Elsevier]

OBJECTIVES: Randomized controlled trials of partial liquid ventilation in acute respiratory distress syndrome have been negative. Reasons for this failure may reside in the use of too large doses of perfluorocarbon. The objective was to evaluate whether various doses of perflubron affect ventilation-induced injury in edematous lungs in different ways. DESIGN: Prospective, controlled animal study. SETTING: Research laboratory of a university. SUBJECTS: Male Wistar rats weighing 300+/-20 g. INTERVENTIONS: Separate groups of rats were injected with alpha-naphtylthiourea to produce mild permeability pulmonary edema. They were then given 0, 7 (low), 13 (moderate), or 20 mL/kg (near functional residual capacity) perflubron doses and mechanically ventilated with a large (33 mL/kg) tidal volume for 15 mins. MEASUREMENTS AND MAIN RESULTS: 125I-albumin distribution space was used to assess lung microvascular permeability. Quasi-static respiratory system pressure-volume curves were analyzed. Administration of low and moderate perflubron doses significantly improved respiratory mechanics and reduced the ventilator-induced permeability alterations to the level observed in rats that were not ventilated. By contrast, a perflubron dose that was near functional residual capacity increased end-inspiratory plateau pressure and aggravated the permeability alterations due to high tidal volume ventilation. CONCLUSIONS: Near functional residual capacity but not low perflubron dose worsens ventilation-induced lung injury of preinjured lungs. This may provide some explanation for the negative results of the recent clinical trials, and it stresses the importance of the amount of perflubron used for partial liquid ventilation. [ABSTRACT FROM AUTHOR]

Rationale and objectives: The respective influence on the incidence of ventilator-associated pneumonia of currently available systems used for warming and humidifying the gases delivered to mechanically ventilated patients, that is, heated humidifiers and heat and moisture exchanger filters, remains controversial.Methods: We addressed this question in a multicenter randomized study comparing heated humidifiers (with heated circuits) and filters in an unselected population of 369 intensive care patients receiving mechanical ventilation for more than 48 h.Main Measurements and Results: The diagnosis of pneumonia was confirmed according to strict microbiologic criteria. There was no difference in pneumonia rate between the two groups (53 of 184 [28.8%] versus 47 of 185 [25.4%] for humidifiers versus filters; p = 0.48), or in the incidence density of pneumonia (27.4/1,000 ventilatory days versus 25.3/1,000 ventilatory days for humidifiers versus filters; p = 0.76). The mean duration of mechanical ventilation did not differ between the two groups (14.9 +/- 15.1 versus 13.5 +/- 16.3 days for humidifiers versus filters, p = 0.36). Endotracheal tube occlusion occurred, respectively, in five patients and one patient in the humidifier and filter groups (p = 0.12). Intensive care mortality was identical in the two groups (about 33%).Conclusion: These results suggest that both heated humidifiers and heat and moisture exchanger filters can be used with no significant impact on the incidence of ventilator-associated pneumonia and that other criteria may justify their choice. [ABSTRACT FROM AUTHOR]

Purpose. – The aim of this study was to evaluate the change in ureteropelvic junction management, from surgical correction to observation of the hydronephrosis. We checked wether or not it was deleterious for kidney.Materials and methods. – We retrospectively reviewed 96 charts between 1988 and 1998. Initial ultrasonography, and voiding cystourethrogram were available for all cases. Intravenous urography and diuretic renography were studied when available. Minimal follow-up of patients was one year. Patients were divided into three groups: surgery right away, surgery after observation, and observation only.Results. – Later was the diagnosis, more significant were the hydronephrosis and impairment of renal function (p < 0.01). In group operated on right away (69 cases), drainage improved, hydronephrosis decreased, but renal function did not improve significantly (p = 0.37). Sixteen patients were operated on after observation without deleterious effect for kidney. Eleven patients were only observed: hydronephrosis progressively decreased. Initial radiological results were not different between the last two groups (p > 0.05), and were not predictive of their course.Conclusion. – Initial non operative management of hydronephrosis was not dangerous for renal function. It is advisable to detect at the earliest all signs of obstruction, because surgery improves renal drainage but not renal function. [Copyright &y& Elsevier]