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Objectives: Micronutrient supplementation in critically ill adults remains controversial. In the pediatric setting, the impact of oxidative stress on the overall micronutrient status has been poorly explored, due to the limited number of studies and to confounding factors (i.e., malnutrition or extra losses). In order to better understand this phenomenon, we aim to describe micronutrient status, focusing on seven micronutrients, in well-nourished critically ill children presenting with severe oxidative stress. Design: Prospective, transversal, observational, single-center study. Setting: PICU, and anesthesiology department, Lyon, France. Patients: Three groups of patients were clinically defined: severe oxidative stress PICU group (at least two organ dysfunctions), moderate oxidative stress PICU group (single organ dysfunction), and healthy control group (prior to elective surgery); oxidative stress intensity was controlled by measuring plasma levels of glutathione peroxidase and glutathione. Children presenting any former condition leading to micronutrient deficiency were excluded (malnutrition, external losses). Interventions: Plasma levels of selenium, zinc, copper, vitamin A, vitamin E, vitamin C, and -carotene were measured in PICU oxidative stress conditions and compared with those of healthy children. Measurements and Main Results: Two hundred one patients were enrolled (51, 48, and 102 in severe, moderate, and healthy control groups, respectively). Median age was 7.1 years (interquartile range, 2.1-13.8 yr). There was a significant trend (p \textless 0.02) toward plasma level decrease of six micronutrients (selenium, zinc, copper, vitamin E, vitamin C, and -carotene) while oxidative stress intensity increased. Biological markers of oxidative stress (glutathione peroxidase and glutathione) were in accordance with the clinical definition of the three groups. Conclusions: A multiple micronutrient deficiency or redistribution occurs in critically ill children presenting with severe oxidative stress. These findings will help to better identify children who might benefit from micronutrient supplementation and to design adapted supplementation trials in this particular setting.

An intraoperative automated closed-loop system for goal-directed fluid therapy has been successfully tested in silico, in vivo and in a clinical case-control matching. This trial compared intraoperative cardiac output (CO) in patients managed with this closed-loop system versus usual practice in an academic medical center. The closed-loop system was connected to a CO monitoring system and delivered automated colloid fluid boluses. Moderate to high-risk abdominal surgical patients were randomized either to the closed-loop or the manual group. Intraoperative final CO was the primary endpoint. Secondary endpoints were intraoperative overall mean cardiac index (CI), increase from initial to final CI, intraoperative fluid volume and postoperative outcomes. From January 2014 to November 2015, 46 patients were randomized. There was a lower initial CI (2.06 vs. 2.51 l min-1 m-2, p = 0.042) in the closed-loop compared to the control group. No difference in final CO and in overall mean intraoperative CI was observed between groups. A significant relative increase from initial to final CI values was observed in the closed-loop but not the control group (+ 28.6%, p = 0.006 vs. + 1.2%, p = 0.843). No difference was found for intraoperative fluid management and postoperative outcomes between groups. There was no significant impact on the primary study endpoint, but this was found in a context of unexpected lower initial CI in the closed-loop group.Trial registry number ID-RCB/EudraCT: 2013-A00770-45. ClinicalTrials.gov Identifier NCT01950845, date of registration: 17 September 2013.

Introduction L’anesthesie generale en obstetrique est une situation a risque d’inhalation pulmonaire du contenu gastrique. L’echographie antrale permet d’evaluer le contenu gastrique chez l’adulte. Un seuil de 340 mm 2 d’aire antrale a ete decrit pour detecter un estomac vide avec une excellente performance [1] . L’aspect de l’antre en decubitus dorsal (DD) et lateral droit (DLD) permet un classement en trois grades : grade 0 : antre vide en DD et DLD, grade 1 : contenu liquide en DLD, grade 2 : contenu liquide en DLD et DD [2] . Cette evaluation qualitative a egalement ete decrite en obstetrique [3] . Neanmoins, l’installation des parturientes en DLD lors du travail est parfois inconfortable et surtout n’est pas souhaitable en cas d’urgence obstetricale. L’objectif de notre travail etait donc de definir un seuil de surface antrale mesuree en DD predictif d’un estomac vide (Perlas 0) chez des parturientes en travail. Materiel et methodes Cette etude prospective observationnelle a ete realisee en salle d’accouchement de notre etablissement (HFME, Lyon), chez des parturientes en travail apres recueil du consentement eclaire. Les mesures echographiques etaient realisees sur une coupe sagittale epigastrique passant par l’aorte et le lobe gauche du foie, associant la mesure de l’aire antrale et l’evaluation qualitative du contenu gastrique, en DD et DLD, afin de classer les parturientes en fonction des grades de Perlas. Une courbe ROC a ete construite pour determiner la performance de la mesure de l’aire antrale pour predire un grade de Perlas = 0 correspondant a un estomac vide. Resultats Soixante-sept parturientes en travail ont ete incluses. Les caracteristiques demographiques sont resumees dans le Tableau 1 . Il y eu 6 echecs de visualisation de l’antre en DLD (9 %), 10 (15 %) d’echecs de visualisation en DD et DLD, et 1 seul echec de visualisation en DD seul. La qualite des images etait consideree comme bonne dans 60 % des cas. Sur les 50 femmes chez qui l’antre etait visualisable en DD et DLD, 25 (50 %) etaient classees Perlas 0, 7 (14 %) perlas 1 et 18 (36 %) Perlas 2. Nous avons pu determiner un seuil d’aire antrale de 389 mm 2 , mesuree en DD, permettant de predire un grade de Perlas 0, avec une sensibilite de 78 %, une specificite de 79 %, une valeur predictive positive de 78 % et negative de 79 %. Selon ce seuil, 27 des 56 mesures realisables en DD montraient un estomac « vide » ( Fig. 1 ). Discussion La mesure echographique de l’aire antrale en decubitus dorsal permet de predire avec une bonne performance l’absence de contenu gastrique correspondant a un grade 0 selon le score de Perlas. Le seuil d’aire antrale de 389 mm 2 pourrait etre utilise en contexte d’urgence obstetricale afin d’adapter la technique anesthesique au risque d’inhalation pulmonaire du contenu gastrique.