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Background Therapeutic head positioning plays a role in the management of patients with acute brain injury. Although intracranial pressure (ICP) is typically lower in an upright posture than in a flat position, limited data exist concerning the effect of upright positioning on brain oxygenation and circulation. We sought to determine the impact of supine (0°) and semirecumbent (15° and 30°) postures on ICP, brain oxygenation, and brain circulation. Methods An observational cohort study was conducted between February 2012 and September 2015. Twenty-three patients with severe acute brain injury were successively observed at head elevations of 30°, 15°, and 0°. Postural-induced changes in ICP, cerebral perfusion pressure, brain tissue oxygenation pressure, and transcranial Doppler findings were simultaneously measured during three repeated experiments: 24 h after admission to the intensive care unit (exp1), 24 h later (exp2), and 96 h later (exp3). Cerebral perfusion pressure, arterial blood gases, hemoglobin content, and body temperature remained unchanged during the three experiments. Results Using linear random-slope mixed models, we found that during the early phase of acute brain injury (exp1), lowering the head posture from 30° to 15°, and then to 0°, was associated with a gradual mean ICP increase of 2.6 mm Hg (1.4–3.7 mm Hg; P

Objective Muscle atrophy is frequent in critically ill patients and is associated with increased mortality and long-lasting alteration in quality of life. Muscle ultrasound has not been clearly validated in intensive care unit patients. The aim of this study was to compare the level of agreement between ultrasound and computed tomography scan for the measurement of quadriceps muscle thickness. Design A prospective observational study. Patients Forty-two consecutive patients admitted to a neurological intensive care unit. Methods Quadriceps thickness was measured 15 cm above the upper edge of the patella. Iterative brain computed tomography scans were associated with a quadriceps-centred acquisition sequence. Concomitantly, an ultrasound of the quadriceps was performed. The position of the studied leg was standardized for ultrasound and computed tomography. Results A total of 73 measurements of ultrasound and computed tomography quadriceps thickness were compared. The correlation between both measures was 0.93 (95% confidence interval (95% CI) 0.84-1.02). Intra-rater reliability of ultrasound measurements and inter-rater reliability were excellent, with an ICC of 0.98 (95% CI 0.97-0.99) and 0.96 (95% CI 0.92-0.98), respectively. Conclusion A specific ultrasound set-up for measurement of quadriceps thickness is reliable and reproducible in an intensive care unit population.

BACKGROUND Transcranial color duplex ultrasound (TCCD) is becoming an important tool for cerebral monitoring of brain-injured patients. To date, TCCD reproducibility has been studied in healthy volunteers or patients with subarachnoid hemorrhage and its efficiency in many brain injuries has not been proved. Our aim was to evaluate TCCD interobserver agreement in different brain injuries. PATIENTS AND METHODS We performed a prospective monocentric trial conducted from January 2014 to September 2014 in intensive care unit (ICU) of Saint-Etienne university teaching hospital, France.Brain-damaged patients admitted in ICU were included, excluding those with decompressive craniectomy. Two randomized operators among the ICU medical staff consecutively performed measurements of cerebral blood flow velocities with TCCD. RESULTS One hundred measurements were obtained from 42 patients. Hemodynamic and end-tidal CO2 pressure were similar between both measurement set. The results obtained with the Bland-Altman method showed bias at 0.52 (95% confidence interval [CI], -4.19 to 3.16), 0.53 (95% CI, -1.86 to 2.92), and 0.002 (95% CI, -0.06 to 0.06) for mean velocity, diastolic velocity, and pulsatility index, respectively. The limits of agreement were (-32.4; 31.4), (-20.4; 21.4), (-0.5; 0.5) for mean velocity, diastolic velocity, and pulsatility index, respectively. The Passing and Bablok regression have shown a quasilinear relationship between measurements. CONCLUSIONS We reported the reliability of TCCD interobserver agreement in brain-damaged patients.

Introduction L’echo-doppler transcrânien (EDTC) est devenu un outil incontournable dans le monitorage de l’hemodynamique cerebrale des patients cerebroleses dans les services de reanimation. Son accessibilite, sa facilite d’utilisation et son innocuite en fond un examen de choix pour la surveillance des ces patients en l’absence de moyens de monitorages plus invasifs. Son utilisation est egalement recommandee dans l’hemorragie meningee et la surveillance du vasospasme arteriel. L’EDTC existe depuis 30 ans et seulement quelques etudes ont evaluees sa reproductibilite. La plupart de ses etudes ont ete realisees chez un nombre limite de volontaires sains. Seule une etude recente a evalue sa reproductibilite dans le contexte de l’hemorragie meningee. L’objectif de ce travail etait d’evaluer la reproductibilite de l’EDTC dans plusieurs situations d’agression cerebrale chez des patients admis en service de reanimation. Patients et methodes Tous les patients admis en reanimation pour des tableaux d’agressions cerebrales a l’exclusion des patients mineurs et ayant subi une craniectomie de decompression ont ete inclus. Le protocole a ete accepte par le comite d’ethique local. Cinq medecins reanimateurs seniors ont participe a l’etude. Pour chaque patient, deux praticiens etaient randomises. Les mesures etaient realisees de chaque cote. La tension arterielle, la pression intracrânienne (en cas de monitorage invasif) et le CO2 expire (ETCO2) etaient releves. La reproductibilite des mesures a ete evaluee par un test de Passing-Bablok et un test de Bland-Altman. Resultats Cent mesures ont ete obtenues chez 42 patients. Trente et un pour cent des patients ont ete admis pour hemorragie meningee. Il n’existait pas de difference significative sur les parametres de pression arterielle, de pression intracrânienne et d’ETCO2 entre les deux temps des mesures. Nous avons observe une tres bonne reproductibilite des mesures. Les coefficients de pente obtenus avec la methode de Passing-Bablok pour les vitesses diastoliques, moyennes et l’index de pulsatilite (IP) etaient de 0,94 (IC 95 % [0,84 a 1,05]), 0,96 (IC 95 % [0,87 a 1,1]), 0,92 (IC 95 % [0,81 a 1,03]) respectivement. Les constantes etaient de 1,3 (IC 95 % [−3,6 a 5,6]), 2,4 (IC 95 % [−5,7 a 8,6]) et 0,1 (IC 95 % [−0,01 a 0,2]) pour les vitesses diastoliques, moyennes et l’IP respectivement ( Fig. 1 A–B). Ces resultats etaient confirmes par l’aspect du graphique de Bland-Altman ( Fig. 1 C–D). Discussion Nos resultats confirment la fiabilite de L’EDTC pour la mesure des differents parametres de l’hemodynamique cerebrale dans des situations d’agressions cerebrales diverses. L’etape ulterieure serait d’evaluer l’integration de l’EDTC au sein d’algorithmes therapeutiques et son impact sur le devenir des malades.