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Background Among patients successfully resuscitated after an out-of-hospital cardiac arrest (OHCA), 10% to 15% evolve toward brain death (BD), thus becoming potential organ donors. Research Question Is it possible to establish a score for early estimation of BD risk after OHCA? Study Design and Methods The BD after cardiac arrest (BDCA) score was developed from data available within 24 hours after OHCA from two OHCA trials: Cyclosporine in Cardiac Arrest Resuscitation and Erythropoietin After OHCA. The BDCA score was then validated in another large prospective multicenter data set. The main outcome was the occurrence of BD. Independent prognostic covariates for BD were identified using a binomial two-stage adaptive least absolute shrinkage and selection operator procedure. Results The development cohort included 569 patients alive 24 hours after OHCA, among whom 84 (14.8%) experienced BD. Independent predictors of BD used to build the BDCA score were being female (4 points), nonshockable rhythm (24 points), cardiac cause of OHCA (−6 points), neurological cause of OHCA (45 points), natremia at 24 hours (natremia in millimoles per liter minus 140 points), and vasoactive drug at admission (4 points) and at 24 hours (6 points). The area under the curve (AUC) of the BDCA score was 0.82 (95% CI, 0.77-0.86), and the discrimination value in the validation cohort (n = 487) was consistent (AUC, 0.81; 95% CI, 0.76-0.86). In the validation cohort, BD occurred in 4.0%, 20.4%, and 67.7% of patients with scores of 50, respectively. Interpretation The BDCA score allows early detection of patients with a high probability of experiencing BD, which may help increase organ donation after OHCA. Clinical Trial Registration ClinicalTrials.gov; No.: NCT01595958, and ClinicalTrials.gov ; No.: NCT00999583; URL: www.clinicaltrials.gov

Introduction Septic shock (SS) is characterized by low blood pressure resulting in organ failure and poor prognosis. Among SS treatments, in hospital studies reported a beneficial effect of early hemodynamic resuscitation on mortality rate. This study aims to investigate the relationship between prehospital hemodynamic optimisation and 30-day mortality in patients with SS. Methods From April 6th, 2016 to December 31th, 2019, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (mICU) were included. Prehospital hemodynamic optimisation was defined as a arterial blood pressure of >65 mmHg, or >75 mmHg if previous hypertension history, at the end of the prehospital stage. Results Three hundred thirty-seven patients were retrospectively analysed. The mean age was 69 ± 15 years, and 226 patients (67%) were male. One hundred and thirty-six patients (40%) had previous hypertension history. Pulmonary, digestive and urinary infections were the suspected cause of the SS in respectively 46%, 23% and 15% of the cases. 30-day overall mortality was 30%. Prehospital hemodynamic optimisation was complete for 204 patients (61%). Cox regression analysis reports a significant association between prehospital hemodynamic optimisation and 30-day mortality (HRa = 0.52 95%CI [0.31–0.86], p = 0.01). Conclusion In this study, we report that prehospital hemodynamic optimisation is associated with a decrease in 30-day mortality in patients with SS cared for by a mICU in the prehospital setting. An individualized mean arterial pressure target, based on previous hypertension history, may be considered from the prehospital stage of SS resuscitation.

Resume La pandemie COVID-19 qui a atteint la France au 1er semestre 2020 a constitue pour le Service d’aide medicale urgente (SAMU) un veritable « stress test » afin de pouvoir faire face, d’une part, a la demande de soins de la population, et d’autre part, a la doctrine evolutive des autorites de sante. Cette situation sanitaire exceptionnelle (SSE), inedite de par son amplitude et sa duree, a necessite de la part des differents centres de regulation et de reception des appels (CRRA) de multiples adaptations tant quantitatives que qualitatives, sur les plans : humain, logistique, materiel, et technique. Alors que la premiere phase de l’epidemie COVID-19 s’est terminee, et dans l’incertitude d’une eventuelle reprise dans les jours ou semaines a venir, les progres majeurs realises a marche forcee au niveau des SAMU pour faire face a cette crise extreme doivent devenir perennes et constituer une nouvelle base de notre systeme de sante, tant pour le quotidien que pour de futures nouvelles situations sanitaires exceptionnelles.

Objective For mechanically ventilated patients, the best predictors of fluid responsiveness are dynamic parameters. Many methods that reflect cardiopulmonary interactions have been proposed to evaluate the preload dependency. In this study, we describe the interchangeability between respiratory variations of the subclavian (ΔSCV) vein and pulse pressure variation (PPV) in sedated and mechanically ventilated patients benefiting from kidney transplantation. Methods The ΔSCV via infraclavicular transthoracic echocardiography and PPV measurements were recorded simultaneously by a single operator. The Bland-Altman method assessed the interchangeability between ΔSCV and PPV. Results A total of 27 patients were prospectively included in the study. The Bland-Altman analysis showed a bias of +1.6 % for ΔSCV measurements vs. PPV. The limit of agreements was, respectively, -4% and 8%. The agreement between PPV >13% and ΔSCV >13% was 100%, and the agreement between PPV 13% [0%]) was observed. Conclusion ΔSCV and PPV are interchangeable when assessing preload dependency in mechanically ventilated patients benefiting from kidney transplantation. ΔSCV appears to be a suitable tool because it is non-invasive, simple, easy and almost always available.

Context In the prehospital setting, early identification of septic shock (SS) with high risk of mortality aims to initiate early treatments and to decide delivery unit (emergency department (ED) or intensive care unit (ICU)). In this context, there is a need for a prognostic measure of severity and death in order to early detect patients with a higher risk of pejorative evolution. In this study, we describe the association between prehospital shock index (SI) and mortality at day 28 of patients with SS initially cared for in the prehospital setting by a mobile intensive care unit (MICU). Methods Patients with SS cared for by a MICU between January 2016 and May 2019 were retrospectively analyzed. Using propensity score, the association between SI and mortality was assessed by Odd Ratio (OR) with 95 percent confidence interval [95 CI]. Results One-hundred and fourteen patients among which 78 males (68%) were analysed. The mean age was 71 ± 14 years old. SS was mainly associated with pulmonary (55%), digestive (20%) or urinary (11%) infection. Overall mortality reached 33% (n = 38) at day 28. Median SI [interquartile range] differed between alive and deceased patients: 0.73 [0.61–1.00] vs 0.80 [0.66–1.10], p 0.9 was 1.17 [1.03–1.32]. Conclusion In this study, we report an association between prehospital SI and mortality of patients with prehospital SS. A SI > 0.9 is a readily available tool correlated with increased mortality of patients with SS initially cared for in the prehospital setting.

Objective Septic shock results in a decreased blood pressure (BP) leading to organ failure. The haemodynamic resuscitation aims at restoring the BP to allow efficient tissue perfusion. The aim of the present study was to evaluate the association between the mean BP (MBP) reached after haemodynamic resuscitation in patients with septic shock cared for in the prehospital setting by a mobile intensive care unit (MICU) and mortality at 28 days after intensive care unit (ICU) admission. Methods Patients with septic shock managed by a mobile intensive care unit (MICU) and admitted in the ICU were retrospectively analysed. The association between mortality and MBP after prehospital resuscitation was studied. Results A total of 85 patients with septic shock were included in the study. The origin of sepsis was mainly pulmonary (64%). Mortality reached 35%. Haemodynamic resuscitation was performed using crystalloids (98%) with a mean infused volume indexed on a body weight of 16±11 mL kg−1 in the prehospital setting. No patient received catecholamine or antibiotic prior to hospital admission. Final prehospital MBP was 64±8 mm Hg in the overall population and 66±8 mm Hg versus 62±8 mm Hg in alive and deceased patients, respectively (p=0.02). After adjustment, final prehospital MBP [odds ratio adjusted (ORa) (95% confidence interval (CI)]=0.89 (0.80–0.99), MBP 65 mmHg [ORa (95% CI)=0.06 (0.01–0.25)] were associated with mortality. Conclusion Persistent low MBP after prehospital initial resuscitation measures in patients with septic shock managed in the prehospital setting is associated with increased mortality. Further studies are needed to evaluate the impact of prehospital haemodynamic management in septic shock to further optimise prehospital care and improve outcome.

Septic shock (SS) is associated with high morbidity and mortality rate. Early antibiotic therapy administration in septic patients was shown to reduce mortality but its impact on mortality in a prehospital setting is still under debate. To clarify this point, we performed a retrospective analysis on patients with septic shock who received antibiotics in a prehospital setting.

Objective In the pre-hospital setting, the assessment of septic shock severity is essential when determining the optimal initial in-hospital level of care. As clinical signs can be faulted, there is a need for an additional component to enhance the severity assessment and to decide on in-hospital admission in the intensive care unit (ICU) or in the emergency department (ED). Point-of-care medical devices by yielding blood lactate value since the pre-hospital setting may give an easy and valuable component for the severity assessment and decision-making. The aim of this study is to provide clinical evidence that the pre-hospital blood lactate level predicts the 30-day mortality in patients with septic shock. Methods This trial is a prospective, observational, non-randomised controlled study. A total of 1,000 patients requiring a mobile ICU intervention for septic shock in the pre-hospital setting will be included. Pre-hospital blood lactate levels will not be taken into account to decide patients’ treatments and/or ED or ICU admission. In the pre-hospital setting, each patient will benefit from two measurements of the blood lactate level: initial measurement at the first contact, and final measurement at the hospital admission with a specific point-of-care medical device. Conclusion This study could provide clinical evidence that the pre-hospital blood lactate level predicts the 30-day mortality of patients with septic shock. The results from this study could also prove the utility of the pre-hospital blood lactate level for the triage and early orientation of patients with septic shock.