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Supplemental digital content is available in the text., Introduction Avoiding coronavirus disease 2019 (COVID-19) work-related infection in frontline healthcare workers is a major challenge. A massive training program was launched in our university hospital for anesthesia/intensive care unit and operating room staff, aiming at upskilling 2249 healthcare workers for COVID-19 patients' management. We hypothesized that such a massive training was feasible in a 2-week time frame and efficient in avoiding sick leaves. Methods We performed a retrospective observational study. Training focused on personal protective equipment donning/doffing and airway management in a COVID-19 simulated patient. The educational models used were in situ procedural and immersive simulation, peer-teaching, and rapid cycle deliberate practice. Self-learning organization principles were used for trainers' management. Ordinary disease quantity in full-time equivalent in March and April 2020 were compared with the same period in 2017, 2018, and 2019. Results A total of 1668 healthcare workers were trained (74.2% of the target population) in 99 training sessions over 11 days. The median number of learners per session was 16 (interquartile range = 9–25). In the first 5 days, the median number of people trained per weekday was 311 (interquartile range = 124–385). Sick leaves did not increase in March to April 2020 compared with the same period in the 3 preceding years. Conclusions Massive training for COVID-19 patient management in frontline healthcare workers is feasible in a very short time and efficient in limiting the rate of sick leave. This experience could be used in the anticipation of new COVID-19 waves or for rapidly preparing hospital staff for an unexpected major health crisis.

Objectives Patients on venoarterial extracorporeal membrane oxygenation have many risk factors for pulmonary complications in addition to their heart failure. Optimal positive end-expiratory pressure is unknown in these patients. The aim was to evaluate the ability of electrical impedance tomography to help the physician to select the optimal positive end-expiratory pressure in venoarterial extracorporeal membrane oxygenation treated and mechanically ventilated patients during a positive end-expiratory pressure trial. Design Observational prospective monocentric. Setting University hospital. Patients Patients (n = 23) older than 18 years old, on mechanical ventilation and venoarterial extracorporeal membrane oxygenation. Interventions A decreasing positive end-expiratory pressure trial (20-5 cm H2O) in increments of 5 cm H2O was performed and monitored by a collection of clinical parameters, ventilatory and ultrasonographic (cardiac and pulmonary) to define an optimal positive end-expiratory pressure according to respiratory criteria (optimal positive end-expiratory pressure selected by physician with respiratory parameters), and then adjusted according to hemodynamic and cardiac tolerances (optimal positive end-expiratory pressure selected by physician with respiratory, hemodynamic, and echocardiographic parameters). At the same time, electrical impedance tomography data (regional distribution of ventilation, compliance, and overdistension collapse) were recorded and analyzed retrospectively to define the optimal positive end-expiratory pressure. Measurements and main results The median of this optimal positive end-expiratory pressure was 10 cm H2O in our population. Electrical impedance tomography showed that increasing positive end-expiratory pressure promoted overdistention of ventral lung, maximum at positive end-expiratory pressure 20 cm H20 (34% [interquartile range, 24.5-40]). Decreasing positive end-expiratory pressure resulted in collapse of dorsal lung (29% [interquartile range, 21-45.8]). The optimal positive end-expiratory pressure selected by physician with respiratory parameters was not different from the positive end-expiratory pressure chosen by the electrical impedance tomography. However, there is a negative impact of a high level of intrathoracic pressure on hemodynamic and cardiac tolerances. Conclusions Our results support that electrical impedance tomography appears predictive to define optimal positive end-expiratory pressure on venoarterial extracorporeal membrane oxygenation , aided by echocardiography to optimize hemodynamic assessment and management.

Purpose Ultra-protective ventilation with low tidal volume is used in severe acute respiratory distress syndrome (ARDS) patients under extracorporeal membrane oxygenation (ECMO). However, the optimal positive end-expiratory pressure (PEEP) is unknown. The aim of our study was to assess electrical impedance tomography's (EIT) ability to choose the best PEEP for these patients. Materials and methods A recruitment maneuver and after a decremental PEEP trial from 20 to 5 cmH20 were monitored by EIT, with lung images divided into four ventral-to-dorsal horizontal regions of interest. For each patient, three EIT-based PEEP were defined: PEEP ODCLmin (lowest pressure with the least EIT-based collapse lung [CL] and overdistension [OD]), PEEP ODCL15 (lowest pressure able to limit EIT-based collapse to less than or equal to 15% with the least overdistension) and PEEP Comp (PEEP with the highest EIT-based compliance). Results High PEEP levels were significantly associated with more overdistension while decreasing PEEP led to more collapsed zones. PEEP ODCL15 and PEEP Comp were in complete agreement with the reference Pulmonary PEEP (chosen according to usual respiratory clinical and ultrasound criteria), PEEP ODCLmin was in average agreement with the Pulmonary PEEP. Conclusion EIT may be a useful real-time monitoring technique to optimize the PEEP level in severe ARDS patients under ECMO. Take-home message Ultra-protective ventilation with low tidal volume is used in severe acute respiratory distress syndrome patients under extracorporeal membrane oxygenation (ECMO), but the optimal positive end-expiratory pressure is unknown. This trial shows that electrical impedance tomography may be an interesting non-invasive bedside tool to provide real-time monitoring of PEEP impact in severe ARDS patients under ECMO. The Pulmovista® electrical impedance tomography was provided by Drager (Lubeck, Germany) during the study period. Drager had no role in the study design, collection, analysis and interpretation of the data, writing the article, or the decision to submit the article for publication.

Supplemental Digital Content is available in the text., Objectives: Recovery from coma might critically depend on the structural and functional integrity of frontoparietal networks. We aimed to measure this integrity in traumatic brain injury and anoxo-ischemic (cardiac arrest) coma patients by using an original multimodal MRI protocol. Design: Prospective cohort study. Setting: Three Intensive Critical Care Units affiliated to the University in Toulouse (France). Patients: We longitudinally recruited 43 coma patients (Glasgow Coma Scale at the admission < 8; 29 cardiac arrest and 14 traumatic brain injury) and 34 age-matched healthy volunteers. Exclusion criteria were disorders of consciousness lasting more than 30 days and focal brain damage within the explored brain regions. Patient assessments were conducted at least 2 days (5 ± 2 d) after complete withdrawal of sedation. All patients were followed up (Coma Recovery Scale-Revised) 3 months after acute brain injury. Interventions: None. Measurements and Main Results: Functional and structural MRI data were recorded, and the analysis was targeted on the posteromedial cortex, the medial prefrontal cortex, and the cingulum. Univariate analyses and machine learning techniques were used to assess diagnostic and predictive values. Coma patients displayed significantly lower medial prefrontal cortex–posteromedial cortex functional connectivity (area under the curve, 0.94; 95% CI, 0.93–0.95). Cardiac arrest patients showed specific structural disturbances within posteromedial cortex. Significant cingulum architectural disturbances were observed in traumatic brain injury patients. The machine learning medial prefrontal cortex–posteromedial cortex multimodal classifier had a significant predictive value (area under the curve, 0.96; 95% CI, 0.95–0.97), best combination of subregions that discriminates a binary outcome based on Coma Recovery Scale-Revised). Conclusions: This exploratory study suggests that frontoparietal functional disconnections are specifically observed in coma and their structural counterpart provides information about brain injury mechanisms. Multimodal MRI biomarkers of frontoparietal disconnection predict 3-month outcome in our sample. These findings suggest that fronto-parietal disconnection might be particularly relevant for coma outcome prediction and could inspire innovative precision medicine approaches.

A recent case report described the radiological features of a suspected COVID-19 necrotising haemorrhagic encephalopathy.1 We present here a description of clinical, biological, radiological and immunological features of a COVID-19 patient case, evocative of virus-associated acute necrotising encephalopathy (ANE) possibly mediated by antibodies. Patient’s representative consent has been obtained in agreement with the journal’s policy. A 51-year-old man without personal or family history of neurological disease was hospitalised after 10 days of fever and cough. COVID-19 was diagnosed by reverse-transcriptase PCR on nasal swab and bilateral ground-glass opacities on thoracic CT scan. At day 12, he was admitted in intensive care unit (ICU) for non-invasive ventilation. The result of the neurological examination was normal. At day 21, while the patient had been weaned off oxygen, he became unresponsive and rapidly comatose (Glasgow Coma Scale 6: E1, V1, M4) with a disconjugated gaze. The patient was groaning and showing rhythmic movements of the right upper limb. An urgent brain MRI, including diffusion-weighted imaging (DWI) and MR angiogram, ruled out vertebrobasilar ischaemic stroke; gradient echo T2*-weighted images excluded haemorrhage and thrombus in the venous system. It revealed only subtle hyperintensities in bilateral thalami on FLAIR sequence (figure 1). Consciousness impairment required tracheal intubation. He was hyperthermic (39°C) without shock. Blood and cerebrospinal fluid (CSF) samples revealed thrombopenia and lymphopenia, mild inflammatory response (C reactive protein, ferritin and fibrinogen), CSF albumin-cytological dissociation with increased CSF IgG antibodies (91.9 mg/L, normal 10–30 mg/L) and altered blood–brain barrier integrity (CSF/serum albumin index=17.3, normal

Linezolid is an antibiotic used against gram-positive bacteria, including methicillin-resistant Staphylococcus aureus. Its primary adverse effect is haematotoxicity. The objective of this study was to analyse the risk factors for onset of thrombocytopenia in critically ill patients treated with linezolid. This was a retrospective, single-centre study of 72 patients. Platelets were measured from D0 to D20 after the start of treatment. The risk factors for thrombocytopenia were identified using a multivariate logistic regression analysis following a Monte Carlo simulation. Following ROC curve analysis, a baseline platelet count lower than 108 × 109/L and a Cmin higher than 4 mg/L, with respective odds ratios of 117 (95% CI [97-206]) and 3 (95% CI [1.5-6.2]) in the simulated population, were identified as risk factors. Among the source population patients combining these 2 factors, a significantly higher number developed thrombocytopenia (66.7% vs. 33.3%, p = 0.0042). A baseline platelet count lower than 108 × 109/L and a Cmin higher than 4 mg/L are risk factors for the onset of thrombocytopenia in critically ill patients treated with linezolid.

The emergence of carbapenemases in gram-negative aerobes is worrying. The aim of this prospective study was to estimate the incidence of acquisition of carbapenem-resistance during treatment in ICU and to identify the risk factors. This was a prospective, observational, cohort study. This study was conducted at intensive care unit, academic medical center, Toulouse Rangueil University Hospital. Patients were included if they received antibiotic treatment with carbapenem for more than 48 h. Biological samples were taken in accordance with current practice in the unit. The main endpoint was the occurrence of bacterial resistance to carbapenems occurring between the onset of treatment and the patient’s exit from the ICU. Uni- and multi-variate analyses were carried out. Of the 364 patients admitted to the unit between May and November 2014, 78 were included in our study and 16 (20.51%) developed resistance. The two main risk factors were a length of stay in ICU of more than 29 days (HR = 3.61, p = 0.01) and the presence of Pseudomonas aeruginosa in the samples taken before the start of treatment (HR = 5.31, p = 0.002). No resistance due to carbapenemase production was observed in this study. The prescription of carbapenems in the ICU setting must adhere to the expert guidelines. In light of our results, special attention must be paid to patients whose stay in intensive care is prolonged, and those in whom Pseudomonas aeruginosa is isolated from bacteriological samples taken before the beginning of antibiotic therapy.

Central venous catheter (CVC) insertion is a common practice for anesthetists, but this invasive procedure generates anxiety and pain in patients that are often underestimated. We compared target-controlled infusion of remifentanil and local lidocaine infiltration with placebo and local lidocaine infiltration to decrease pain scores during CVC placement.We included conscious, adult patients without contraindication to remifentanil or lidocaine. We excluded pregnant women, emergency situations, and opioid abuse. Patients requiring CVC were randomly assigned, using computer-generated allocation numbers stored in sealed envelopes, to receive target-controlled infusion of remifentanil or placebo-all patients received local anesthesia with lidocaine. All patients were hospitalized in a recovery room or intensive care unit, monitored, and received 4 L/min of oxygen.The primary outcome was global pain (Verbal Numeric Rating Pain Scale) during the procedure. Secondary outcomes were pain perceived at every stage of the procedure, anxiety, patient satisfaction, operational ease, and side effects.In this double-blind study, we included 90 patients (split into 2 groups of 45 patients). Global pain was significantly reduced in the remifentanil group: 20 of 100 (95% confidence interval, 16-40) versus 50 of 100 (95% confidence interval, 40-60) in the placebo group; P=0.0009. No major adverse events were observed during this study, and there were no significant differences between both groups regarding side effects.Target-controlled infusion of remifentanil is an effective drug to reduce pain during CVC insertion in association with lidocaine-based local anesthesia, in conscious patients.

Recent European Society of Parenteral and Enteral Nutrition guidelines highlighted the interest of prevention, diagnosis and treatment of malnutrition in the management of coronavirus disease 19 (COVID-19) patients. The aim of our study was to evaluate the prevalence of malnutrition in patients hospitalised for COVID-19. In a prospective observational cohort study malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition (GLIM) two-step approach. Patients were divided into two groups according to the diagnosis of malnutrition. Covariate selection for the multivariate analysis was based on P n 46, 57·5 %) was similar in the two groups. Three patients who died (3·75 %) were malnourished. Multivariate analysis exhibited that low BMI (OR 0·83, 95 % CI 0·73, 0·96, P = 0·0083), dyslipidaemia (OR 29·45, 95 % CI 3·12, 277·73, P = 0·0031), oral intake reduction P = 0·0422) and glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration; CKD-EPI) at admission (OR 0·979, 95 % CI 0·96, 0·998, P = 0·0297) were associated with the occurrence of malnutrition. We demonstrate the existence of a high prevalence of malnutrition in a general cohort of COVID-19 inpatients according to GLIM criteria. Nutritional support in COVID-19 care seems an essential element.

Background To compare patients hospitalised in the intensive care unit (ICU) after surgery for community-acquired intra-abdominal infection (CA-IAI) and hospital-acquired intra-abdominal infection (HA-IAI) in terms of mortality, severity and complications. Methods Retrospective study including all patients admitted to 2 ICUs within 48 h of undergoing surgery for peritonitis. Results Two hundred twenty-six patients were enrolled during the study period. Patients with CA-IAI had an increased 28-day mortality rate compared to those with HA-IAI (30% vs 15%, respectively (p = 0.009)). At 90 days, the mortality rates were 36.7 and 37.5% in the CA-IAI group and HA-IAI group, respectively, with a similar APACHE II score on admission (median: 21 [15–25] vs. 21 [15–24] respectively, p = 0.63). The patients with HA-IAI had prolonged ICU and hospital stays (median: 17 [7–36] vs. 6[3–12] days, p p = 0.001), and experienced more complications (reoperation and reintubation) than those with CA-IAI. Conclusion CA-IAI group had higher 28-day mortality rate than HA-IAI group. Mortality was similar at 90 days but those with HA-IAI had a prolonged ICU and hospital stay. In addition, they developed more complications.

International audience; Purpose: The 4-point score is the corner stone of brain death (BD) confirmation using computed tomography angiography (CTA). We hypothesized that considering the superior petrosal veins (SPVs) may improve CTA diagnosis performance in BD setting. We aimed at comparing the diagnosis performance of three revised CTA scores including SPVs and the 4-point score in the confirmation of BD.Methods: In this retrospective study, 69 consecutive adult-patients admitted in a French University Hospital meeting clinical brain death criteria and receiving at least one CTA were included. CTA images were reviewed by two blinded neuroradiologists. A first analysis compared the 4-point score, considered as the reference and three non-opacification scores: a "Toulouse score" including SPVs and middle cerebral arteries, a "venous score" including SPVs and internal cerebral veins and a "7-score" including all these vessels and the basilar artery. Psychometric tools, observer agreement and misclassification rates were assessed. A second analysis considered clinical examination as the reference.Results: Brain death was confirmed by the 4-score in 59 cases (89.4 %). When compared to the 4-score, the Toulouse score displayed a 100 % positive predictive value, a substantial observer agreement (0.77 [0.53; 1]) and the least misclassification rate (3.03 %). Results were similar in the craniectomy subgroup. The Toulouse score was the only revised test that combined a sensitivity close to that of the 4-score (86.4 % [75.7; 93.6] and 89.4 % [79.4; 95.6], p-value < 0.001, respectively) and a substantial observer agreement.Conclusions: A score including SPVs and middle cerebral arteries is a valid method for BD confirmation using CTA even in patients receiving craniectomy.

Study objective To assess incidence and predicting factors of awake craniotomy complications. Design Retrospective cohort study. Setting Operating room and Post Anesthesia Care unit. Patients 162 patients who underwent 188 awake craniotomy procedures for brain tumor, ASA I to III, with monitored anesthesia care. Measurements We classified procedures in 3 groups: major event group, minor event group, and no event group. Major events were defined as respiratory failure requiring face mask or invasive ventilation; hemodynamic instability treated by vasoactive drugs, or bradycardia treated by atropine, bleeding >500 ml, transfusion, gaseous embolism, cardiac arrest; seizure, cerebral edema, or any events leading to stopping of the cerebral mapping. Minor event was defined as any complication not classified as major. Multivariate logistic regression was used to determine predicting factors of major complication, adjusted for age and ASA score. Main results 45 procedures (24%) were classified in major event group, 126 (67%) in minor event group, and 17 (9%) in no event group. Seizure was the main complication (n = 13). Asthma (odds ratio: 10.85 [1.34; 235.6]), Remifentanil infusion (odds ratio: 2.97 [1.08; 9.85]) and length of the operation after the brain mapping (odds ratio per supplementary minute: 1.01 [1.01; 1.03]) were associated with major events. Conclusions Previous medical history of asthma, remifentanil infusion and a long duration of neurosurgery after cortical mapping appear to be risk factors for major complications during AC.

BackgroundTo explore risk factors for unfavorable outcome (death or requiring invasive mechanical ventilation at 28 days from ICU admission) of critically ill COVID-19 patients hospitalized in the Toulouse regionMethodsRetrospective cohort of critically ill COVID-19 patients sequentially admitted to 12 ICUs in Toulouse region (March 9, 2020, to April 8, 2020). All patients had laboratory confirmed SARS-CoV-2 infection and required invasive mechanical ventilation. Baseline characteristics, pathophysiological respiratory data, clinical outcomes, viral shredding, and chest CT scan were collected.ResultsA total of 150 patients were included (median age, 68 years (interquartile range, (IQR), 58-72; 81% male). The most common comorbidities were hypertension (77, 51%) and obesity (42, 28%). At ICU admission, the median PaO2/FiO2 ratio was 138 (IQR,112-178). During hospitalization, the rate of ventilator-acquired pneumonia (VAP) was 61% and 51 (34%) patients had acute kidney injury (AKI) with a Kidney Disease Improving Global Outcomes (KDIGO) score > 1. The 28-day mortality was 15.3%, and 50 (33%) patients had unfavorable outcome. We found that VAP (5.91; 2.10-10.03; p value = 0.002) and AKI with a KDIGO score > 1 (4.71; 1.69-14.41; p value = 0.004) were associated with increased odds of unfavorable outcome. Neither, chest CT scan data on admission, nor pathophysiological respiratory data during ICU stay were associated to patient’s outcome.ConclusionThe potential risk factors of AKI and VAP could help clinicians to identify patients with poor prognosis at an early stage. Targeted care of these factors might have a significant impact on COVID-19 patient’s outcome.

Extracerebral complications, especially pulmonary and cardiovascular, are frequent in brain-injured patients and are major outcome determinants. Two major pathways have been described: brain-lung and brain-heart interactions. Lung injuries after acute brain damages include ventilator-associated pneumonia (VAP), acute respiratory distress syndrome (ARDS) and neurogenic pulmonary œdema (NPE), whereas heart injuries can range from cardiac enzymes release, ECG abnormalities to left ventricle dysfunction or cardiogenic shock. The pathophysiologies of these brain-lung and brain-heart crosstalk are complex and sometimes interconnected. This review aims to describe the epidemiology and pathophysiology of lung and heart injuries in brain-injured patients with the different pathways implicated and the clinical implications for critical care physicians.

BackgroundDue to time limitations, the preanesthetic consultation (PAC) is not the best time for patients to integrate information specific to their perioperative care pathway.ObjectiveThe main objectives of this study were to evaluate the effectiveness of a digital companion on patients' knowledge of anesthesia and their satisfaction after real-life implementation.MethodsWe conducted a prospective, monocentric, comparative study using a before-and-after design. In phase 1, a 9-item self-reported anesthesia knowledge test (Delphi method) was administered to patients before and after their PAC (control group: PAC group). In phase 2, the study was repeated immediately after the implementation of a digital conversational agent, MyAnesth (@+PAC group). Patients’ satisfaction and their representations for anesthesia were also assessed using a Likert scale and the Abric method of hierarchized evocation.ResultsA total of 600 tests were distributed; 205 patients and 98 patients were included in the PAC group and @+PAC group, respectively. Demographic characteristics and mean scores on the 9-point preinformation test (PAC group: 4.2 points, 95% CI 3.9-4.4; @+PAC: 4.3 points, 95% CI 4-4.7; P=.37) were similar in the two groups. The mean score after receiving information was better in the @+PAC group than in the PAC group (6.1 points, 95% CI 5.8-6.4 points versus 5.2 points, 95% CI 5.0-5.4 points, respectively; PConclusionsThe implementation of our digital conversational agent in addition to the PAC improved patients' knowledge about their perioperative care pathway. This innovative audiovisual support seemed clear, adapted, easily accessible, and reassuring. Future studies should focus on adapting both the content and delivery of a digital conversational agent for the PAC in order to maximize its benefit to patients.

Background The typical sign of intracranial hypotension (IH) is postural headache. However, IH can be associated with a large diversity of clinical or radiological signs leading to difficult diagnosis especially in case of coma. The association of cerebral venous thrombosis (CVT) and subdural hemorrhage is rare but should suggest the diagnosis of IH. Methods Case report. Case description We report here a case of comatose patient due to spontaneous IH complicated by CVT and subdural hemorrhage. The correct diagnosis was delayed due to many confounding factors. IH was suspected after subdural hemorrhage recurrence and confirmed by magnetic resonance imaging (MRI). After 2 epidural patches with colloid, favorable outcome was observed. Discussion The most common presentation of IH is postural orthostatic headaches. In the present case report, the major clinical signs were worsening of consciousness and coma, which are a rare presentation. Diagnosis of IH is based on the association of clinical history, evocative symptomatology, and cerebral imaging. CVT occurs in 1-2% of IH cases and the association between IH, CVT, and subdural hemorrhage is rare. MRI is probably the key imaging examination. In the present case, epidural patch was performed after confounding factors for coma had been treated. Benefit of anticoagulation had to be balanced in this case with potential hemorrhagic complications, especially within the brain. Conclusion Association of CVT and subdural hemorrhage should lead to suspect IH. Brain imaging can help and find specific signs of IH.

In urgent situations, preoperative full stomach assessment mostly relies on clinical judgment. Our primary objective was to assess the diagnostic performance of clinical judgment for the preoperative assessment of full stomach in urgent patients compared to gastric point-of-care ultrasound (PoCUS). Our secondary objective was to identify risk factors associated with PoCUS full stomach in urgent patients.We led a prospective observational study at our Hospital, between January and July 2016. Adult patients admitted for urgent surgery were eligible. Patients with altered gastric sonoanatomy, interventions reducing stomach content, impossible lateral decubitus were excluded. Clinical judgment and risk factors of full stomach were collected before gastric PoCUS measurements. Ultrasonographic full stomach was defined by solid contents or liquid volume ≥ 1.5 ml kgThe prevalence of clinical and PoCUS full stomach in 196 included patients was 29% and 27%, respectively. Positive and negative predictive values were 42% (95% CI: 32.3-52.6%) and 79% (95% CI: 74.9-83.4%), respectively. Patients with PoCUS full stomach were clinically misdiagnosed in 55% of cases. PoCUS full stomach was associated with abdominal or gynaecological-obstetrical surgery (OR 3.6, 95% CI: 1.5-8.8, P 0.01) but not with fasting durations. Positive solid intake after illness onset with respect to 6-h solid fasting rule was associated with PoCUS low-risk gastric content (OR 0.4, 95% CI: 0.2-0.9, P = 0.03).Clinical judgment showed poor-to-moderate performance in urgent surgical patients for the diagnosis of full stomach. Gastric PoCUS should be used to assess risk of full stomach in this population.

Background: Extracorporeal life support (ECLS) holds the promise of significant improvement of the survival of patient in refractory cardiogenic shock (CS) or cardiac arrest (CA). Nevertheless, it remains to be shown to which extent these highly invasive supportive techniques could improve long-term patient's outcome. Methods: The outcomes of 82 adult ECLS patients at our institution between January 2012 and December 2013 were retrospectively analyzed. Results: Patients were essentially men (64.7%) and are 54 years old. Preexisting ischemic (53.7%) and dilated cardiomyopathy (14.6%) were frequent. ECLS indications were shared equally between CA and CS. ECLS-specific adverse effects as hemorrhage (30%) and infection (50%) were frequent. ECLS was effective for 43 patients (54%) with recovery for 35 (43%), 5 (6%) heart transplant, and 3 (4%) left ventricular assist device support. Mortality rate at 30 days was 59.8%, but long-term and 3-month survival rates were similar of 31.7%. Initial plasma lactate levels >5.3 mmol/L and glomerular filtration rate

Background: Reversible cerebral vasoconstriction syndrome (RCVS) is a rare cause of intracerebral hemorrhage (ICH) causing intracranial hypertension. Methods: Case report. Results: We report a case of RCVS-related ICH leading to refractory intracranial hypertension. A decompressive craniectomy was performed to control intracranial pressure. We discuss here the management of RCVS with intracranial hypertension. Decompressive craniectomy was preformed to avoid the risky option of high cerebral perfusion pressure management with the risk of bleeding, hemorrhagic complications, and high doses of norepinephrine. Neurological outcome was good. Conclusion: RCVS has a complex pathophysiology and can be very difficult to manage in cases of intracranial hypertension. Decompressive craniectomy should probably be considered.

Background The objective of this study was to determine the main risk factors of Pseudomonas aeruginosa mutation as well as the mechanisms of acquired resistance. Methods We conducted a 2-year prospective study in patients who were carriers of a Pseudomonas aeruginosa strain and who had been admitted to a medical/surgical ICU. Results Of the 153 patients who were included, 34 had a mutation in their strain. In a multivariate analysis, a duration of ventilation > 24 days was a risk factor for mutation (risk ratio 4.29; CI 95% 1.94–9.49) while initial resistance was a protective factor (RR 0.36; CI 95% 0.18–0.71). In a univariate analysis, exposure of P. aeruginosa to ceftazidime was associated with an over-production of AmpC cephalosporinase and exposure to meropenem was associated with impermeability. A segmentation method based on the duration of ventilation (> 24 days), initial resistance, and exposure of strains to ceftazidime made it possible to predict at 83% the occurrence of mutation. Conclusion The duration of ventilation and the presence of resistance as soon as P. aeruginosa is identified are predictive factors of mutation in ICU patients.

Graph theory has been playing an increasingly important role in understanding the organizational properties of brain networks, subsequently providing new tools for the search of neural correlates of consciousness, particularly in the context of patients recovering from severe brain injury. However, this approach is not without challenges, as it usually relies on arbitrarily fixing a threshold in order to retain the strongest connections proportionally equal across subjects. This method increases the comparability between individuals or groups but it risks the inclusion of false positive and therefore spurious connections, especially in the context of brain disorders. Resting state data acquired in 25 coma patients and 22 healthy subjects was compared. We obtained a representative fixed density of significant connections by first applying a p-value-based threshold on healthy subjects' networks and then choosing a threshold at which all individuals exhibited meaningful connections. The obtained threshold (i.e. 10%) was used to construct graphs in the patient group. The findings showed that coma patients have lower number of significant connections with approximately 50% of them not fulfilling the criteria of the fixed density threshold. The remaining patients with relatively preserved global functional connectivity had sufficient significant connections between regions, but showed signs of major whole-brain network reorganization. These results warrant careful consideration in the construction of functional connectomes in patients with disorders of consciousness and set the scene for future studies investigating potential clinical implications of such an approach.

Glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1), and matrix metalloproteinase 9 (MMP-9) are potential biomarkers of traumatic brain injury (TBI) but also of secondary insults to the brain. The aim of this study was to describe the cerebral distribution of GFAP, UCH-L1, and MMP-9 in a rat model of diffuse TBI associated with standardized hypoxia-hypotension (HH). Adult male Sprague-Dawley rats were allocated to Sham (n = 10), TBI (n = 10), HH (n = 10), and TBI+HH (n = 10) groups. After 4 hours, brains were rapidly removed and immunostaining of GFAP, UCH-L1, and MMP-9 was performed. Areas of interest that have been described as particularly sensitive to hypoxic insults were analyzed. For GFAP, in the neocortex, immunostaining revealed a significant decrease in strong staining for HH and TBI+HH groups compared with TBI group ( P

Hypotension frequently occurs during spinal anesthesia (SA), especially in the elderly. Phenylephrine is effective to prevent SA-induced hypotension during cesarean delivery. The objective of this study was to evaluate the efficacy and safety of prophylactic infusion of phenylephrine after SA for orthopedic surgery in the elderly.This prospective, randomized, double-blind, and placebo-controlled study included 54 patients older than 60 years undergoing elective lower limb surgery under SA (injection of 10 mg of isobaric bupivacaine with 5 μg of sufentanyl).Patients were randomized to group P (100-μg/mL solution of phenylephrine solution at 1 mL/min after placement of SA) or the control group C (0.9% isotonic sodium chloride solution). The flow of the infusion was stopped if the mean arterial blood pressure (MAP) was higher than the baseline MAP and maintained or restarted at 1 mL/min if MAP was equal to or lower than the baseline MAP. Heart rate and MAP were collected throughout the case.Hypotension was defined by a 20% decrease and hypertension as a 20% increase from baseline MAP. Bradycardia was defined as a heart rate lower than 50 beats per minute.Twenty-eight patients were randomized to group P and 26 patients to group C. MAP was higher in group P than in group C (92 ± 2 vs 82 ± 2 mm Hg, mean ± SD, P.001). The number of hypotensive episodes per patient was higher in group C compared with group P (9 [0-39] vs 1 [0-10], median [extremes], P.01), but the number of hypotensive patients was similar between groups (19 [73%] vs 20 [71%], P= 1). The time to onset of the first hypotension was shorter in group C (3 [1-13] vs 15 [1-95] minutes, P= .004). The proportion of patients without hypotension (cumulative survival) was better in group P (P= .04). The number of hypertensive episodes per patient and the number of bradycardic episodes per patient were similar between groups (P= not significant).Prophylactic phenylephrine infusion is an effective method of reducing SA-induced hypotension in the elderly. Compared with a control group, it delays the time to onset of hypotension and decreases the number of hypotensive episodes per patient. More data are needed to evaluate clinical outcomes of such a strategy.

Hypothermia, along with acidosis and coagulopathy, is part of the lethal triad that worsen the prognosis of severe trauma patients. While accidental hypothermia is easy to identify by a simple measurement, it is no less pernicious if it is not detected or treated in the initial phase of patient care. It is a multifactorial process and is a factor of mortality in severe trauma cases. The consequences of hypothermia are many: it modifies myocardial contractions and may induce arrhythmias; it contributes to trauma-induced coagulopathy; from an immunological point of view, it diminishes inflammatory response and increases the chance of pneumonia in the patient; it inhibits the elimination of anaesthetic drugs and can complicate the calculation of dosing requirements; and it leads to an over-estimation of coagulation factor activities. This review will detail the pathophysiological consequences of hypothermia, as well as the most recent principle recommendations in dealing with it.

The post-traumatic brain vulnerability suggests that after traumatic brain injury (TBI), the brain may be more susceptible to posttraumatic hypoxic insults. This concept could be extended to ‘peripheral’ organs, as non-neurologic organ failure is common after TBI. This study aims to characterize and quantify cerebral and extracerebral tissue hypoxia with pimonidazole resulting from a standardized hypoxia-hypotension (HH) phase occurring after a diffuse experimental TBI in rats. Rats were allocated to Sham (n=5), TBI (n=7), HH (n=7) and TBI+HH (n=7) groups. Then, pimonidazole was injected and brain, liver, heart and kidneys were analysed. In the cerebral cortex, post-treatment hypoxia was higher in TBI+HH group than Sham group (p=0.003), HH group (p=0.003) and TBI group (p=0.002). Large trends in thalamus, hippocampus and striatum for the TBI+HH group compared to the other groups were observed. For the heart and liver, the 4 groups were comparable. For the kidneys, post-treatment hypoxia was higher in the TBI group compared to the Sham and HH groups, but not more than TBI+HH group. This study reveals that a posttraumatic hypoxic insult occurring after a severe TBI has major hypoxic consequences on brain structures. However, TBI by itself appears to induce renal hypoxia that is not enhanced by posttraumatic hypoxic insult.

Summary Background Acute acidaemia is frequently observed during critical illness. Sodium bicarbonate infusion for the treatment of severe metabolic acidaemia is a possible treatment option but remains controversial, as no studies to date have examined its effect on clinical outcomes. Therefore, we aimed to evaluate whether sodium bicarbonate infusion would improve these outcomes in critically ill patients. Methods We did a multicentre, open-label, randomised controlled, phase 3 trial. Local investigators screened eligible patients from 26 intensive care units (ICUs) in France. We included adult patients (aged ≥18 years) who were admitted within 48 h to the ICU with severe acidaemia (pH ≤7·20, PaCO2 ≤45 mm Hg, and sodium bicarbonate concentration ≤20 mmol/L) and with a total Sequential Organ Failure Assessment score of 4 or more or an arterial lactate concentration of 2 mmol/L or more. We randomly assigned patients (1:1), by stratified randomisation with minimisation via a restricted web platform, to receive either no sodium bicarbonate (control group) or 4·2% of intravenous sodium bicarbonate infusion (bicarbonate group) to maintain the arterial pH above 7·30. Our protocol recommended that the volume of each infusion should be within the range of 125–250 mL in 30 min, with a maximum of 1000 mL within 24 h after inclusion. Randomisation criteria were stratified among three prespecified strata: age, sepsis status, and the Acute Kidney Injury Network (AKIN) score. The primary outcome was a composite of death from any cause by day 28 and the presence of at least one organ failure at day 7. All analyses were done on data from the intention-to-treat population, which included all patients who underwent randomisation. This study is registered with ClinicalTrials.gov, number NCT02476253. Findings Between May 5, 2015, and May 7, 2017, we enrolled 389 patients into the intention-to-treat analysis in the overall population (194 in the control group and 195 in the bicarbonate group). The primary outcome occurred in 138 (71%) of 194 patients in the control group and 128 (66%) of 195 in the bicarbonate group (absolute difference estimate −5·5%, 95% CI −15·2 to 4·2; p=0·24). The Kaplan-Meier method estimate of the probability of survival at day 28 between the control group and bicarbonate group was not significant (46% [95% CI 40–54] vs 55% [49–63]; p=0·09. In the prespecified AKIN stratum of patients with a score of 2 or 3, the Kaplan-Meier method estimate of survival by day 28 between the control group and bicarbonate group was significant (37% [95% CI 28–48] vs 54% [45–65]; p=0·0283). Metabolic alkalosis, hypernatraemia, and hypocalcaemia were observed more frequently in the bicarbonate group than in the control group, with no life-threatening complications reported. Interpretation In patients with severe metabolic acidaemia, sodium bicarbonate had no effect on the primary composite outcome. However, sodium bicarbonate decreased the primary composite outcome and day 28 mortality in the a-priori defined stratum of patients with acute kidney injury. Funding French Ministry of Health and the Societe Francaise d'Anesthesie Reanimation.

Resume L’hypothermie fait partie, avec l’acidose et la coagulopathie, de la triade letale aggravant le pronostic des traumatises graves. Si l’hypothermie accidentelle est facile a reconnaitre par une simple mesure, elle n’en reste pas moins deletere si elle n’est pas prevenue ou traitee des la phase initiale de la prise en charge du patient. Elle est multifactorielle et est un facteur de risque de mortalite chez le traumatise grave. Les consequences de l’hypothermie sont multiples : elle modifie la contractilite myocardique et favorise les arythmies. Elle participe a la coagulopathie traumatique. Du point de vue immunologique, elle diminue la reponse inflammatoire et augmente le taux de pneumopathies chez le traumatise. Elle diminue l’elimination des medicaments utilises pour l’anesthesie et la sedation et perturbe l’interpretation des dosages biologiques en particulier, elle entraine une surestimation de l’activite des facteurs de la coagulation. Cette mise au point se propose de detailler les consequences physiopathologiques de l’hypothermie, ainsi que les principales recommandations recemment formulees sur ce theme.

Background Takotsubo cardiomyopathy can occur at the early phase of severe acute brain injuries. In the case of cardiac output decrease or shock, the optimal treatment is still a matter of debate. Due to massive stress hormone release, the infusion of catecholamines may have limited effects and may even aggravate cardiac failure. Other inotropic agents may be an option. Levosimendan has been shown to have potential beneficial effects in this setting, although milrinone has not been studied. Methods We report a case of a young female presenting with inverted Takotsubo cardiomyopathy syndrome after severe traumatic brain injury. Results Due to hemodynamic instability and increasing levels of infused norepinephrine, dobutamine infusion was begun but rapidly stopped due to tachyarrhythmia. Milrinone infusion stabilized the patient's hemodynamic status and improved cardiac output without deleterious effects. Conclusion Milrinone could be a good alternative when inotropes are required in Takotsubo cardiomyopathy and when dobutamine infusion is associated with tachyarrhythmia.

Veno-venous ECMO is increasingly used for the management of refractory ARDS. In this context, acute kidney injury (AKI) is a major and frequent complication, often associated with poor outcome. We aimed to identify characteristics associated with severe renal failure (Kidney Disease Improving Global Outcome (KDIGO) 3) and its impact on 3-month outcome.Between May 2009 and April 2016, 60 adult patients requiring VV-ECMO in our University Hospital were prospectively included.AKI occurrence was frequent (75%; n=45), 51% of patients (n=31) developed KDIGO 3 - predominantly prior to ECMO insertion - and renal replacement therapy was required in 43% (n=26) of cases. KDIGO 3 was associated with a lower mechanical ventilation weaning rate (24% vs 68% for patients with no AKI or other stages of AKI; p0.001) and a higher 90-day mortality rate (72% vs 32%, p=0.002). Multivariate logistic regression suggested that KDIGO 3 occurrence prior to ECMO insertion, as well as PaCO257mmHg and mSOFA12 were independent risks factors for 90-day mortality.KDIGO 3 AKI occurrence is correlated with the severity of patients' clinical condition prior to ECMO insertion and is negatively associated with 90-day survival.

Background Recent studies suggest that isolated sonographic assessment of the respiratory, cardiac, or neuromuscular functions in mechanically ventilated patients may assist in identifying patients at risk of postextubation distress. The aim of the present study was to prospectively investigate the value of an integrated thoracic ultrasound evaluation, encompassing bedside respiratory, cardiac, and diaphragm sonographic data in predicting postextubation distress. Methods Longitudinal ultrasound data from 136 patients who were extubated after passing a trial of pressure support ventilation were measured immediately after the start and at the end of this trial. In case of postextubation distress (31 of 136 patients), an additional combined ultrasound assessment was performed while the patient was still in acute respiratory failure. We applied machine-learning methods to improve the accuracy of the related predictive assessments. Results Overall, integrated thoracic ultrasound models accurately predict postextubation distress when applied to thoracic ultrasound data immediately recorded before the start and at the end of the trial of pressure support ventilation (learning sample area under the curve: start, 0.921; end, 0.951; test sample area under the curve: start, 0.972; end, 0.920). Among integrated thoracic ultrasound data, the recognition of lung interstitial edema and the increased telediastolic left ventricular pressure were the most relevant predictive factors. In addition, the use of thoracic ultrasound appeared to be highly accurate in identifying the causes of postextubation distress. Conclusions The decision to attempt extubation could be significantly assisted by an integrative, dynamic, and fully bedside ultrasonographic assessment of cardiac, lung, and diaphragm functions.

Handovers during anaesthesia are common, and failures in communication may lead to morbidity and mortality. We hypothesised that intraoperative handover training and display of a checklist would improve communication during anaesthesia care transition in the operating room. Interventional cohort study. Single-centre tertiary care university hospital. A total of 204 random observations of handovers between anaesthesia providers (residents and nurse anaesthetists) over a 6-month period in 2016. Two geographically different hospital sites were studied simultaneously (same observations, but no training/checklist at the control site): first a 2-week 'baseline' observation period; then handover training and display of checklists in each operating room (at the intervention site only) followed by an 'immediate' second and finally a third (3 months later) observation period. A 22-item checklist was created by a modified DELPHI method and a checklist score calculated for each handover by adding the individual scores for each item as follows: -1, if error in communicating item; 0, unreported item; 0.5, if partly communicated item; 1, if correctly communicated item. Before training and display of the checklist, the scores in the interventional and the control groups were similar. There was no improvement in the control group's scores over the three observation periods. In the interventional group, the mean (95% confidence interval) score increased by 43% [baseline 7.6 (6.7 to 8.4) n = 42; 'immediate' 10.9 (9.4 to 12.4) n = 27, P

International audience; AbstractIntroductionAfter elective craniotomy for brain tumour surgery, patients are usually admitted to an intensive care unit (ICU) for monitoring. Our goal was to evaluate the incidence and timing of neurologic and non-neurologic postoperative complications after brain tumour surgery, to determine factors associated with neurologic events and to evaluate the timing and causes of ICU readmission.Patients and methodsThis prospective, observational and analytic study enrolled 188 patients admitted to the ICU after brain tumour surgery. All postoperative clinical events during the first 24 hours were noted and classified. Readmission causes and timing were also analysed.ResultsTwenty-one (11%) of the patients were kept sedated after surgery; the remaining 167 patients were studied. Thirty one percent of the patients presented at least one complication (25% with postoperative nausea and vomiting (PONV), 16% with neurologic complications). The occurrence of neurological complications was significantly associated with the absence of preoperative motor deficit and the presence of higher intraoperative bleeding. Seven patients (4%) were readmitted to the ICU after discharge; 43% (n = 3) of them had a posterior fossa surgery.ConclusionPostoperative complications, especially PONV, are frequent after brain tumour surgery. Moreover, 16% of patients presented a neurological complication, probably justifying the ICU postoperative stay for early detection. The absence of preoperative motor deficit and intraoperative bleeding seems to predict postoperative neurologic complications. Finally, patients may present complications after ICU discharge, especially patients with fossa posterior surgery, suggesting that ICU hospitalization may be longer in this type of surgery.

BACKGROUND:It has been suggested that the complementary use of echocardiography could improve the diagnostic accuracy of lung ultrasonography (LUS) in patients with acute respiratory failure (ARF). Nevertheless, the additional diagnostic value of echocardiographic data when coupled with LUS is still debated in this setting. The aim of the current study was to compare the diagnostic accuracy of LUS and an integrative cardiopulmonary ultrasound approach (thoracic ultrasonography [TUS]) in patients with ARF. METHODS:We prospectively recruited patients consecutively admitted for ARF to the ICU of a university teaching hospital over a 12-month period. Inclusion criteria were age ≥ 18 years and the presence of criteria for severe ARF justifying ICU admission. We compared both LUS and TUS approaches and the final diagnosis determined by a panel of experts using machine learning methods to improve the accuracy of the final diagnostic classifiers. RESULTS:One hundred thirty-six patients were included (age, 68 ± 15 years; sex ratio, 1). A three-dimensional partial least squares and multinomial logistic regression model was developed and subsequently tested in an independent sample of patients. Overall, the diagnostic accuracy of TUS was significantly greater than LUS (P CONCLUSIONS:This study demonstrated for the first time to our knowledge a significantly better performance of TUS than LUS in the diagnosis of ARF. The value of the TUS approach was particularly important to disambiguate cases of hemodynamic pulmonary edema and pneumonia. We suggest that the bedside use of artificial intelligence methods in this setting could pave the way for the development of new clinically relevant integrative diagnostic models.

Transcutaneous oxygen pressure (PtcO2) value in response to an increase of FiO2 or oxygen challenge test (OCT) in ventilated patients has been reported to be related to peripheral perfusion and outcome during septic shock. However, patients with sepsis-related acute respiratory distress syndrome could demonstrate compromised arterial oxygenation with OCT impairment decoupled to circulatory failure. The aims of this study were to confirm the prognostic value of OCT and to explore the influence of respiratory status on OCT results. This was a prospective study set in an intensive care unit of a tertiary teaching hospital. Fifty-six mechanically ventilated patients with septic shock criteria were studied. Transcutaneous oxygen pressure was measured at baseline and after OCT, at intensive care unit admittance (T0), and 24 h later (T24). Survival at day 28 and hemodynamic and respiratory parameters were analyzed and compared according to outcome and respiratory status. Central hemodynamic parameters or static transcutaneous data did not differ between survivors and nonsurvivors at enrollment. The OCT was statistically different at T24 according to outcome (P < 0.001), but sensitivity was low (53%). Moreover, patients with low OCT results at T24 exhibited more severe respiratory failure (P < 0.01). The OCT at T24 is related to outcome but is influenced by the severity of respiratory failure. Our results suggest considering with caution hemodynamic management based on OCT in septic shock patients with altered pulmonary function.

The purpose of this study was to determine the best estimate of glomerular filtration rate (GFR) to adjust vancomycin (VAN) dosage in critically ill patients. Seventy-eight adult intensive care unit patients received a 15 mg/kg loading dose of VAN plus a 30 mg/kg/day continuous infusion. Steady-state concentration was measured 48 hours later and the dose was adjusted to obtain a target concentration ranging from 20 to 25 mg/1. GFR was estimated by measured creatinine clearance (CLCR), Cockcroft, Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. The required dose providing the target concentration was 36±17 mg/kg/day. The first dosage had to be increased in 51% of all patients and in 84% of trauma patients (highest GFR), but had to be decreased in 17% of patients. The closest relationship between clearances of vancomycin was observed with CKD-EPI to GFR. The correlation between clearances of vancomycin and measured CLCR was significant but was rather poor with Cockcroft and Modification of Diet in Renal Disease equation. On the Bland and Altman plots, measured CLCR provided a lower bias but a larger confidence interval and a weaker precision than CKD-EPI. For VAN dose adjustments in intensive care unit patients, Cockcroft formula and Modification of Diet in Renal Disease should be used with caution. In clinical practice, the physician does not have at their disposal the patient's measured CLCR when prescribing. The CKD-EPI appears to be the best predictor of clearances of vancomycin for calculation of a therapeutic VAN regimen.

The technology of anesthesia ventilators has substantially progressed during last years. The choice of a pediatric anesthesia ventilator needs to be led by multiple parameters: requirement, technical (pneumatic performance, velocity of halogenated or oxygen delivery), cost (purchase, in operation, preventive and curative maintenance), reliability, ergonomy, upgradability, and compatibility. The demonstration of the interest of pressure support mode during maintenance of spontaneous ventilation anesthesia makes this mode essential in pediatrics. In contrast, the financial impact of target controlled inhalation of halogenated has not be studied in pediatrics. Paradoxically, complex and various available technologies had not been much prospectively studied. Anesthesia ventilators performances in pediatrics need to be clarified in further clinical and bench test studies.

To evaluate the feasibility of guidewire detection in right cardiac cavities by transthoracic echocardiography (TTE) in order to detect catheter misplacement and to optimize central venous catheter (CVC) positioning. Ultrasonic control for catheter tip positioning was compared to that by chest X-ray (CXR). We conducted a monocentric prospective observational study (January–November 2010). All consecutive patients undergoing CVC insertion were included. The puncture was performed using the landmark method or ultrasound guidance. TTE was performed during the procedure to follow the arrival of the guidewire in the right cardiac cavities. Catheter misplacement was defined as an aberrant position on the postprocedural CXR (catheter positioning in ipsilateral or contralateral veins). The primary endpoint was the prediction of catheter misplacement by guidewire detection in the cardiac cavities. The secondary endpoint was the optimization of the catheter tip placement in the superior vena cava. A total of 98 patients received 101 CVC. The guidewire was visualized in 92 cases. In five cases, the guidewire was not seen in the right cardiac cavities and CXR showed catheter misplacement. In four cases, poor echogenicity led to the ultrasound examination being abandoned. Catheter misplacement was detected by TTE with a sensitivity of 96 % (CI 90–98 %), a specificity of 83 % (CI 44–97 %), a positive predictive value of 98 %, and a negative predictive value of 55 %. Likelihood ratios were LR+ 5.7 (CI 0.96–34.4) and LR− 0.05 (CI 0.02–0.14). Guidewire removal under TTE avoided an excessively distal position of the catheter tip in all cases. TTE is a reliable tool to detect catheter misplacement and to optimize catheter tip positioning during the procedure of CVC insertion.

This study investigated the clinical relevance of early general chest ultrasonography (ie, heart and lung recordings) in patients in the ICU with acute respiratory failure (ARF).We prospectively compared this diagnostic approach (ultrasound) to a routine evaluation established from clinical, radiologic, and biologic data (standard). Subjects were patients consecutively admitted to the ICU of a university teaching hospital during a 1-year period. Inclusion criteria were age ≥ 18 years and the presence of severe ARF criteria to justify ICU admission. We compared the diagnostic approaches and the final diagnosis determined by a panel of experts.Seventy-eight patients were included (age, 70 ± 18 years; sex ratio, 1). Three patients given two or more simultaneous diagnoses were subsequently excluded. The ultrasound approach was more accurate than the standard approach (83% vs 63%, respectively; Plt; .02). Receiver operating characteristic curve analysis showed greater diagnostic performance of ultrasound in cases of pneumonia (standard, 0.74 ± 0.12; ultrasound, 0.87 ± 0.14; Plt; .02), acute hemodynamic pulmonary edema (standard, 0.79 ± 0.11; ultrasound, 0.93 ± 0.08; Plt; .007), decompensated COPD (standard, 0.8 ± 0.09; ultrasound, 0.92 ± 0.15; Plt; .05), and pulmonary embolism (standard, 0.65 ± 0.12; ultrasound, 0.81 ± 0.17; Plt; .04). Furthermore, we found that the use of ultrasound data could have significantly improved the initial treatment.The use of cardiothoracic ultrasound appears to be an attractive complementary diagnostic tool and seems able to contribute to an early therapeutic decision based on reproducible physiopathologic data.

Purpose To estimate the agreement between radial or femoral, and ascending aortic invasive blood pressure values. Patients and methods Prospective study on 32 patients who underwent an aortic endografting under general anesthesia. After deploying the prosthesis under controlled hypotension, a catheter was introduced in the aorta to measure the staged systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures, in particular at the level of ascending aorta and femoral artery. Results No differences were observed between SAP, DAP or MAP measured in the aorta versus femoral or radial arteries. A better agreement was observed between the aortic and femoral MAP (bias of 1 mmHg, limits of agreement between: –8.8 mmHg and +10.8 mmHg) than between the aortic and the radial MAP (bias of 1.7 mmHg, limits of agreement between: –14.1 mmHg and +17.5 mmHg). The comparison between radial and femoral MAP was not satisfying (bias of –4.7 mmHg and limits of agreement between –19.1 mmHg and +9.7 mmHg). Conclusion The femoral MAP is more accurate to predict value of the aortic MAP than the radial MAP in a hypotensive setting. The clinician should be aware of these discrepancies in conditions of hemodynamic impairment to optimize the treatment.

Objective Pulmonary embolism remains a leading cause of maternal death in France and in other developed countries. Prevention is well codified, but management remains complex both for diagnosis and therapeutics. The objective of this review was to update the knowledge on diagnosis and treatment of pulmonary embolism during pregnancy.

Postoperative pain management is a clinical challenge that can be complicated by opioid-induced hyperalgesia (OIH). Kinin receptors could mediate both the acute and chronic phases of inflammation and pain. A few recent studies suggest that dynorphin A could maintain neuropathic pain by activating the bradykinin (BK) receptor. Thus, the effect of a single administration of sufentanil (a μ-opioid receptor agonist) was investigated in a model of carrageenan-induced inflammatory pain using three strains of mice, i.e., knockout mice for one kinin receptor, B1R or B2R (B1KO, B2KO), and wild-type C57/BL6J mice (WT) treated with either a B1R (R954) or a B2R antagonist (HOE140) or a KKS inhibitor (aprotinin). Pain was assessed and compared between the different groups using two behavioral tests exploring mechanical (von Frey filaments) and thermal (Hargreaves test) sensitivity. Pretreatment with sufentanil induced a sustained increase in pain sensitivity with a delayed return to baseline values characterizing an OIH in carrageenan-injected mice only. Sufentanil-induced OIH was not observed in B2KO but persisted in B1KO and was blunted by aprotinin and the B2R antagonist only. Collectively, our data indicate that the B2R receptor and BK synthesis or availability are essential peripheral steps in the mechanism leading to OIH in a pain context.

Resume But Comparer la perception de l’hypertrophie benigne de la prostate (HBP) du patient et du medecin generaliste (MG) en termes de severite et d’evolution des symptomes et d’observance. Materiel Une etude observationnelle transversale a ete conduite en France aupres d’un echantillon de MG ayant inclus des patients pour lesquels un traitement de l’HBP etait prescrit. Les donnees recueillies concernaient le profil des MG et des patients, le diagnostic, la prise en charge, la severite et l’evolution des symptomes et l’observance. Resultats Au total, 1098 patients ont ete inclus par 247 MG. Dans 87,4 % des cas, le diagnostic etait etablit par le MG. Parmi les patients, 82,7 % etaient traites par monotherapie. Le choix d’un traitement reposait principalement sur son efficacite, l’avis du patient etait pris en compte dans ce choix par 5 % des MG. La severite des symptomes ressentie par le patient concordait avec l’estimation du MG dans 53,9 % des cas. Une aggravation des symptomes etait rapportee significativement plus souvent par le patient (18,5 %) que par le MG (8,8 %). Parmi les patients ayant rapporte une faible observance ( n = 94), les medecins estimaient que, pour 77 % d’entre eux ( n = 72), l’observance etait au contraire bonne. Conclusion Il existait une discordance entre le medecin et le patient dans la perception des symptomes de l’HBP et l’evaluation du niveau d’observance. L’avis du patient a ete peu pris en compte lors du choix therapeutique temoignant d’un deficit en matiere de partage de la decision, partage qui aiderait le medecin a optimiser la prise en charge globale.

Background The cecal ligation and puncture (CLP) model, a gold standard in sepsis research, is associated with an important variability in mortality. While the number of punctures and needle size is well described in CLP animal studies, the length of cecal ligation is often not. The relationship between cecal ligation and survival in mice is briefly reported in the literature; therefore, we devised an investigation in mice of the consequences of three standardized cecal ligation lengths on mortality and the severity of the ensued sepsis. Methods Male C57BL/6J mice underwent standardized CLP. The cecum was ligated at 5, 20, or 100 % of its total length and further perforated by a single 20-G puncture. Mortality was analyzed. We assessed blood lactate, serum creatinine levels, and serum cytokines (TNF-α, IL-1β, IL-6, and IL-10) after procedure in a control group and in ligated mice. Results Mortality was directly related to ligation length: median survival was 24 h for the “100 %” group and 44 h for the “20 %” group. Blood lactate increased proportionally with the ligation length. At 6 h post-procedure, pro-inflammatory cytokines significantly increased in the ligated group with significantly higher serum levels of IL-6 in the 100 % group compared to the other ligated groups. The 20 % group exhibited the characteristics of septic shock with hypotension below 65 mmHg, pro-inflammatory balance, organ dysfunction, and hyperlactatemia. Conclusions Cecal ligation length appears to be a major limiting factor in the mouse CLP model. Thus, this experimental model should be performed with high consistency in future protocol designs.

Background Intracardiac shunts are rare but very serious lesions after non-penetrating chest trauma. Their diagnosis is difficult. This pathology often goes unrecognized in the context of multiple trauma. Case Report We report the case of a 21-year-old man involved in a motor vehicle crash who presented with multiple injuries including myocardial contusion, severe brain injury, multiple pelvic fractures, closed femur fracture, bilateral lung contusion with a right pneumothorax, and intra-abdominal injuries. Three days after the initial event, a new cardiac murmur and complete heart block appeared. Transthoracic echocardiography (echo) followed by transesophageal echo revealed a high-velocity flow communication between the left ventricle and the right atrium. The patient underwent delayed cardiac surgery due to other unstable injuries. The hospital course was prolonged but favorable, and the patient left the hospital 1 month later without any neurologic or cardiologic after-effect. Conclusion This case highlights the potential for cardiac complications to occur in any patient with serious thoracic trauma. Transesophageal echo should be performed on any trauma patient with electrocardiographic abnormalities.