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Background: The delayed diagnosis of the presence of Candida in severe intra-abdominal infections exposes patients to an increased risk of mortality. The prevalence of intra-abdominal candidiasis (IAC) varies with the type of intra-abdominal infection, the underlying conditions and the presence of risk factors for Candida infection. This study aims to evaluate the interest of the measure of 1.3-β-D-glucan (BDG) in the peritoneal fluid for the early diagnosis of IAC. Methods and analysis: This is a prospective multicenter (n = 5) non-interventional study, focusing on all critically ill patients with an intra-abdominal infection requiring intra-abdominal surgery. The primary objective is to assess the diagnostic performance of the BDG measured in the peritoneal fluid for the early detection of IAC using the Candida culture as the gold standard. The secondary objective is to report the prevalence of IAC in the selected population. This study aims to enroll 200 patients within 48 months. By estimating the prevalence of IAC in the selected population at 30%, 50 patients with IAC (cases) are expected. These 50 IAC cases will be matched with 50 non-IAC patients (as a control group). The peritoneal BDG will be measured a posteriori in all of these 100 selected patients. This article presents the protocol and the current status of the study. Only the prevalence of IAC is reported as preliminary result.

Background Little is known about the outcomes of elderly patients admitted to the intensive care unit (ICU) with severe acute cholangitis (SAC). The objectives were to describe the 6-month mortality in patients with SAC ≥75 years and to identify factors associated with this mortality. Methods Bi-center retrospective study of critically ill elderly patients with SAC conducted between 2013 and 2017. Demographic and clinical variables of ICU and hospital stays with a 6-month follow-up were analyzed. Results 85 patients, with a median [Q1–Q3] age of 83 [80–89] years were enrolled of whom 51 (60%) were men. SAC was due to choledocholithiasis in 72 (85%) patients. Median [Q1–Q3] ICU length of stay was 3 [2–6] days. Median [Q1–Q3] admission SAPS II was 50 [42–70]. The ICU and 6-month mortality rates were 18% and 48% respectively. Multivariate analysis showed that malnutrition (OR = 34.5, 95% CI [1.4–817.9]) and a decrease in SOFA score at 48 h (OR by unit 0.7, 95% CI [0.5–0.9]) were associated with higher 6-month mortality. Conclusion In their decision-making process, ICU physicians and hepato-pancreato-biliary surgeons could use these data to estimate the probability of survival of an elderly patient presenting with SAC and to offer time-limited trials of intensive care. Trial registration NCT03831529.

Objectives To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children. Design A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion. Results The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations. Conclusion Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.

Background : Accurate risk stratification of critically ill patients with coronavirus disease 2019 (COVID-19) is essential for optimizing resource allocation, delivering targeted interventions, and maximizing patient survival probability. Machine learning (ML) techniques are attracting increased interest for the development of prediction models as they excel in the analysis of complex signals in data-rich environments such as critical care. Methods : We retrieved data on patients with COVID-19 admitted to an intensive care unit (ICU) between March and October 2020 from the RIsk Stratification in COVID-19 patients in the Intensive Care Unit (RISC-19-ICU) registry. We applied the Extreme Gradient Boosting (XGBoost) algorithm to the data to predict as a binary outcome the increase or decrease in patients’ Sequential Organ Failure Assessment (SOFA) score on day 5 after ICU admission. The model was iteratively cross-validated in different subsets of the study cohort. Results : The final study population consisted of 675 patients. The XGBoost model correctly predicted a decrease in SOFA score in 320/385 (83%) critically ill COVID-19 patients, and an increase in the score in 210/290 (72%) patients. The area under the mean receiver operating characteristic curve for XGBoost was significantly higher than that for the logistic regression model {0.86 vs. 0.69, P

Background Patients with obesity are at increased risk of severe COVID-19, requiring mechanical ventilation due to acute respiratory failure. However, conflicting data are obtained for intensive care unit (ICU) mortality. Objective To analyze the relationship between obesity and in-hospital mortality of ICU patients with COVID-19. Subjects/methods Patients admitted to the ICU for COVID-19 acute respiratory distress syndrome (ARDS) were included retrospectively. The following data were collected: comorbidities, body mass index (BMI), the severity of ARDS assessed with PaO2/FiO2 (P/F) ratios, disease severity measured by the Simplified Acute Physiology Score II (SAPS II), management and outcomes. Results For a total of 222 patients, there were 34 patients (15.3%) with normal BMI, 92 patients (41.4%) who were overweight, 80 patients (36%) with moderate obesity (BMI:30–39.9 kg/m2), and 16 patients (7.2%) with severe obesity (BMI ≥ 40 kg/m2). Overall in-hospital mortality was 20.3%. Patients with moderate obesity had a lower mortality rate (13.8%) than patients with normal weight, overweight or severe obesity (17.6%, 21.7%, and 50%, respectively; P = 0.011. Logistic regression showed that patients with a BMI ≤ 29 kg/m2 (odds ratio [OR] 3.64, 95% CI 1.38–9.60) and those with a BMI > 39 kg/m2 (OR 10.04, 95% CI 2.45–41.09) had a higher risk of mortality than those with a BMI from 29 to 39 kg/m2. The number of comorbidities (≥2), SAPS II score, and P/F

Background Critically ill patients with severe intra-abdominal infections (IAIs) requiring surgery may undergo several pharmacokinetic (PK) alterations that can lead to β-lactam underdosage. Objectives To measure serum and peritoneal exudate concentrations of β-lactams after high doses and optimal administration schemes. Methods This observational prospective study included critically ill patients with suspicion of IAI who required surgery and a β-lactam antibiotic as empirical therapy. Serum and peritoneal exudate concentrations were measured during surgery and after a 24 h steady-state period. The PK/pharmacodynamic (PD) target was to obtain serum β-lactam concentrations of 100% fT>4×MIC based on a worst-case scenario (based on the EUCAST highest epidemiological cut-off values) before bacterial documentation (a priori) and redefined following determination of the MIC for the isolated bacteria (a posteriori). Registered with ClinicalTrials.gov (NCT03310606). Results Forty-eight patients were included with a median (IQR) age of 64 (53–74) years and a SAPS II of 40 (32–65). The main diagnosis was secondary nosocomial peritonitis. Piperacillin/tazobactam was the most administered β-lactam antibiotic (75%). The serum/peritoneal piperacillin/tazobactam ratio was 0.88 (0.64–0.97) after a 24 h steady-state period. Prior to bacterial documentation, 16 patients (33.3%) achieved the a priori PK/PD target. The identification of microorganisms was available for 34 patients (71%). Based on the MIC for isolated bacteria, 78% of the patients achieved the serum PK/PD target. Conclusions In severe IAIs, high doses of β-lactams ensured 100% fT>4×MIC in the serum for 78% of critically ill patients with severe IAIs within the first 24 h. In order to define optimal β-lactam dosing, the PK/PD target should take into account the tissue penetration and local ecology.

Resume La microcirculation represente l’ensemble des vaisseaux de moins de 200 microns classes en arterioles, capillaires et veinules. Ses caracteristiques anatomiques et fonctionnelles la rendent tres differente de la macrocirculation. Le couplage macro- versus microcirculation n’est donc pas constant du fait du role majeur de l’endothelium, des differences d’architecture d’un organe a l’autre, et de l’etat inflammatoire local et systemique. Les techniques d’explorations possibles en clinique font l’objet de recherches intenses et leur apport respectif chez l’homme et leur utilite sont discutes dans cet article. Elles peuvent evaluer : l’oxygenation tissulaire (spectrometrie en proche infrarouge), la perfusion microcirculatoire (laser Doppler) ou l’hypercapnie tissulaire stagnante ; la densite capillaire et la qualite du flux microcirculatoire (Dark Side Streaming). Si une insuffisance circulatoire systemique engendre une anomalie microcirculatoire, la correction n’ameliore pas forcement la microperfusion tissulaire en presence d’une inflammation. Cela definit la coherente ou la non-coherente avec la macrocirculation. Ce constat peut amener a guider la reanimation sur les aspects microcirculatoires, en dehors de la circulation systemique.

International audience; Background: In patients with severe COVID-19, no data are available on the longitudinal evolution of biochemical abnormalities and their ability to predict disease outcomes.Methods: Using a retrospective, longitudinal cohort study design on consecutive patients with severe COVID-19, we used an extensive biochemical dataset of serial data and time-series design to estimate the occurrence of organ dysfunction and the severity of the inflammatory reaction and their association with acute respiratory failure (ARF) and death.Findings: On the 162 studied patients, 1151 biochemical explorations were carried out for up to 59 biochemical markers, totaling 15,260 biochemical values. The spectrum of biochemical abnormalities and their kinetics were consistent with a multi-organ involvement, including lung, kidney, heart, liver, muscle, and pancreas, along with a severe inflammatory syndrome. The proportion of patients who developed an acute kidney injury (AKI) stage 3, increased significantly during follow-up (0·9%, day 0; 21·4%, day 14; P250 iterations), only CRP >90 mg/L (odds ratio [OR] 6·87, 95% CI, 2·36-20·01) and urea nitrogen >0·36 g/L (OR 3·91, 95% CI, 1·15-13·29) were independently associated with the risk of ARF. Urea nitrogen >0·42 g/L was the only marker associated with the risk of COVID-19 related death.Interpretation: Our results point out the lack of the association between the inflammatory markers and the risk of death but rather highlight a significant association between renal dysfunction and the risk of COVID-19 related acute respiratory failure and death.

Background Coronavirus disease 2019 (COVID-19) is associated with a high disease burden with 10% of confirmed cases progressing towards critical illness. Nevertheless, the disease course and predictors of mortality in critically ill patients are poorly understood. Methods Following the critical developments in ICUs in regions experiencing early inception of the pandemic, the European-based, international RIsk Stratification in COVID-19 patients in the Intensive Care Unit (RISC-19-ICU) registry was created to provide near real-time assessment of patients developing critical illness due to COVID-19. Findings As of April 22, 2020, 639 critically ill patients with confirmed SARS-CoV-2 infection were included in the RISC-19-ICU registry. Of these, 398 had deceased or been discharged from the ICU. ICU-mortality was 24%, median length of stay 12 (IQR, 5-21) days. ARDS was diagnosed in 74%, with a minimum P/F-ratio of 110 (IQR, 80-148). Prone positioning, ECCO2R, or ECMO were applied in 57%. Off-label therapies were prescribed in 265 (67%) patients, and 89% of all bloodstream infections were observed in this subgroup (n = 66; RR=3·2, 95% CI [1·7-6·0]). While PCT and IL-6 levels remained similar in ICU survivors and non-survivors throughout the ICU stay (p = 0·35, 0·34), CRP, creatinine, troponin, d-dimer, lactate, neutrophil count, P/F-ratio diverged within the first seven days (p

Background In patients with severe coronavirus disease 2019 (COVID-19), data are scarce and conflicting regarding whether chronic use of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) influences disease outcomes. In patients with severe COVID-19, we assessed the association between chronic ACEI/ARB use and the occurrence of kidney, lung, heart, and liver dysfunctions and the severity of the inflammatory reaction as evaluated by biomarkers kinetics, and their association with disease outcomes. Methods We performed a retrospective longitudinal cohort study on consecutive patients with newly diagnosed severe COVID-19. Independent predictors were assessed through receiver operating characteristic analysis, time-series analysis, logistic regression analysis, and multilevel modeling for repeated measures. Results On the 149 patients included in the study 30% (44/149) were treated with ACEI/ARB. ACEI/ARB use was independently associated with the following biochemical variations: phosphorus >40 mg/L (odds ratio [OR], 3.35, 95% confidence interval [CI], 1.83–6.14), creatinine >10.1 mg/L (OR, 3.22, 2.28–4.54), and urea nitrogen (UN) >0.52 g/L (OR, 2.65, 95% CI, 1.89–3.73). ACEI/ARB use was independently associated with acute kidney injury stage ≥1 (OR, 3.28, 95% CI, 2.17–4.94). The daily dose of ACEI/ARB was independently associated with altered kidney markers with an increased risk of +25 to +31% per each 10 mg increment of lisinopril-dose equivalent. In multivariable multilevel modeling, UN >0.52 g/L was independently associated with the risk of acute respiratory failure (OR, 3.54, 95% CI, 1.05–11.96). Conclusions Patients chronically treated with ACEI/ARB who have severe COVID-19 are at increased risk of acute kidney injury. In these patients, the increase in UN associated with ACEI/ARB use could predict the development of acute respiratory failure., The present retrospective longitudinal cohort study on consecutive patients with newly diagnosed severe COVID-19 provides new evidence on the potentially harmful effect of chronic ACEI/ARB use on kidney outcomes and their possible interaction with the occurrence of acute respiratory failure.

BACKGROUND: COVID-19 can induce pulmonary and systemic inflammation and subsequent multi-organ dysfunction In patients with severe COVID-19, no data are availa

Plasma neutrophil gelatinase-associated lipocalin (pNGAL) has been used as a biomarker in acute kidney injury (AKI). AKI is a common postoperative complication of aortic surgery. We sought to evaluate the performance of the immediately postoperative pNGAL level in comparison with the serum creatinine (SCr) level in predicting AKI and the need for renal replacement therapy (RRT).Prospective non-interventional study in a university hospital. Fifty patients undergoing elective or emergent major intra-abdominal aortic surgery were included. Comparisons between groups of patients with or without postoperative AKI, according to KDIGO staging, were made. Performance of NGAL was determined by examining the area under receiver operating characteristic (AUROC) curve.The incidence of AKI was 36%. At H+2, pNGAL values in AKI and non-AKI patients, respectively, were 221 [133-278] versus 50 [50-90] ng/mL (P0.0001), and SCr values were 115 [96-178] versus 90 [72-99] μmol/L (P0.0008). The AUROC of pNGAL for prediction of AKI was 0.90 (95% CI: 0.81-0.98) with an optimal cutoff of 112ng/mL, a sensitivity of 83%, specificity of 84%, and positive and negative predictive values of 75% and 90%, respectively. SCr produced an AUROC curve of 0.79 (0.65-0.92) at a cutoff of 110μmol/L. The diagnostic performance of pNGAL was significantly better than that of SCr (P=0.039). PNGAL at H+2 better predicted the RRT requirement [0.96 (0.90-1.0)] compared to SCr [0.86 (0.73-0.98)], but this difference was not statistically significant.A 2-hour postoperative determination of pNGAL outperformed SCr level in predicting postoperative AKI after major aortic surgery.

The optimal dose of cefoxitin for antibiotic prophylaxis in obese patients remains uncertain. We evaluated the adequacy of a 4-g dosing regimen of cefoxitin against the most common pathogens that infect patients undergoing bariatric surgery. This observational prospective study included obese patients who required bariatric surgery and a 4-g dose of cefoxitin as an antibiotic prophylaxis. Serum concentrations were measured during surgery (incision, wound closure, and in case of reinjection). The pharmacokinetic/pharmacodynamic (PK/PD) target was to obtain free cefoxitin concentrations above 4× MIC, from incision to wound closure (100% fT>4×MIC). The targeted MIC was based on the worst-case scenario (the highest ECOFF value of Staphylococcus aureus, Enterobacteriaceae, and anaerobic bacteria). The secondary outcomes were the factors related to underdosage. A total of 200 patients were included. The mean age of the patients was 46 ± 12 years old, and the mean body mass index (BMI) was 45.8 ± 6.9 kg/m(2). Bypass surgery was the preferred technique (84%). The percentages of patients who met the PK/PD target (100% fT>4×MIC) of cefoxitin were 37.3, 1.1, and 0% for S. aureus, Enterobacteriaceae and anaerobic bacteria, respectively. BMIs below 50 kg/m(2) (odds ratio [OR] = 0.29, 95% confidence interval [CI] = 0.11 to 0.75, P = 0.0107) and a shorter duration of surgery (OR = 0.97, 95% CI = 0.95 to 0.99, P = 0.004) were associated with reaching the target concentrations. In obese patients undergoing bariatric surgery, a regimen of 4 g of cefoxitin led to an inadequate coverage for most common pathogens. A longer surgery duration and a BMI of >50 kg/m(2) increase the risk of underdosage. (This study was registered on ClinicalTrials.gov under identifier NCT03306290.)

Background Smartphone to-do list app was hypothesized to be more efficient than a paper-based list in the management of workflow and to provide additional benefits. Purpose To analyze the impact of a mobile task-management application on the workflow of an ICU medical staff. Methods Superiority by a margin test, quasi-experimental study comparing the use of a smartphone application versus standard practice regarding tasks management in an academic ICU. Superiority margin was set at 8 % based on a pilot study. During two periods of 20 working days each (October 2018 and January 2019), medical staff managed tasks with both methods on a weekly rotation basis. Primary outcome was the proportion of daily tasks completed. Secondary outcomes assessed users’ satisfaction and the impact of the app in terms of changes in clinical practice. Results 25 ICU physicians were enrolled. A total of 1983 tasks were recorded. The proportion of completed tasks per day was higher when using the smartphone app (99 % [96–100] versus 95 % [93–98] for the standard group, p = 0.006), but did not reach the superiority margin. Smartphone application was perceived as positive experience, as participants felt that they forgot fewer tasks (p = 0.02), were more aware of their progress on ongoing or remaining tasks (p = 0.03) and observed an improvement in communication among the medical staff (p = 0.03). Conclusion This study failed to demonstrate the superiority of a smartphone app over paper-based lists regarding the proportion of daily tasks completed. However, positive feedback regarding the application was received from the medical staff.

Resume Le Kayexalate®, dont le principe actif est le polystyrene sulfonate de sodium indique dans le traitement des hyperkaliemies, est un produit largement prescrit dans la pratique medicale quotidienne. Une complication rare et peu connue de son administration est la necrose colique. Nous rapportons le cas d’une patiente de 48 ans, decedee a j16 d’une chirurgie de derivation urinaire dans les suites d’une peritonite stercorale revelant une perforation colique gauche induite par l’administration de Kayexalate®.

Resume Nous rapportons un cas rare d’anevrisme mycotique de l’aorte thoracique secondaire a un corps etranger alimentaire et revele par une fistule aorto-œsophagienne responsable d’une hematemese inaugurale. Malgre deux traitements endovasculaires, ayant permis d’exclure l’anevrisme, la patiente decedera d’un accident vasculaire cerebral. Une fistule aorto-œsophagienne doit etre evoquee devant toute hematemese sans etiologie evidente et necessite une prise en charge reanimatoire et chirurgicale urgente.

BACKGROUND Decision to start an anti-fungal therapy in intra-abdominal candidiasis (IAC) is complex. Yeast culture, considered the gold standard, suffers from a delayed response time and exposes the patient to delayed introduction of anti-fungal therapy. We sought to evaluate the performance and feasibility of measuring 1,3-β-D-glucan (1,3-BDG) in the peritoneal fluid (PF) for the diagnosis of IAC. METHODS We analyzed retrospectively all PF obtained during abdominal surgery for critically ill adult patients presenting intra-abdominal infections. For each PF sample, direct examination, bacterial and fungal culture, fungal PCR and 1,3-BDG measurements were performed. The diagnostic performance of each technique and the Peritonitis score were calculated considering the positive yeast culture as the reference. The levels of 1,3-BDG were compared between IAC and non-IAC patients. RESULTS During an 8-month period in 2016, 33 PF samples were recovered. Median (interquartile range) SAPS 2 and SOFA scores were 44 (9-94) and 9 (4-15), respectively. There were seven cases of IAC, 14 of bacterial peritonitis and 12 of undocumented peritonitis. All IAC cases were secondary peritonitis, with a 1,3-BDG level of 1461 (325-5000) versus 224 (68-1357) pg/mL in the non-IAC group (P=0.03). When the 1,3-BDG level was ≤310 pg/mL, its negative predictive value was 100%. CONCLUSIONS In secondary peritonitis, a peritoneal measurement of 1,3-BDG ≤310 pg/mL could rule out IAC.

Resume Objectifs Etude de l’acceptabilite des risques associes a la realisation d’une analgesie peridurale obstetricale, comparee entre parturientes et medecins anesthesistes-reanimateurs. Type d’etude Etude prospective, transversale, monocentrique. Patients et methodes Evaluation de l’acceptabilite des complications associees a l’analgesie peridurale obstetricale a partir de 6 cas cliniques proposes dans deux populations : des parturientes suivies a la maternite regionale de Nancy et des anesthesistes-reanimateurs lorrains. Les parturientes etaient interrogees par un anesthesiste, et les medecins via Internet. L’acceptabilite absolue etait evaluee au moyen d’une echelle visuelle numerique et l’acceptabilite relative par classement des scenarii par ordre croissant d’acceptabilite. Resultats Cent quarante-six parturientes et 87 anesthesistes-reanimateurs ont evalue l’acceptabilite des differents scenarii. Les trois scenarii les moins graves (hypotension arterielle, echec, breche durale) etaient juges acceptables par les deux populations. Seul l’hematome perimedullaire etait juge inacceptable par les parturientes. Trois cas (echec, breche, lesion plexique sequellaire) etaient juges significativement moins acceptables par les parturientes que par les medecins (acceptabilite 5,9 vs 7,9 [ p p p = 0,035]). L’analyse multivariee ne retrouvait pas de facteur predictif d’une variation d’acceptabilite dans les deux populations. Conclusion Dans cette etude, l’acceptabilite globale des complications inherentes a l’analgesie perimedullaire etait bonne dans les deux populations, celle-ci etant essentiellement basee sur la notion de gravite et d’evitabilite. Une grande variabilite interindividuelle etait observee ainsi qu’une meilleure acceptabilite de la part des medecins anesthesistes.

OBJECTIVES To determine the regional cerebral oxygen saturation of hemoglobin (rcSO2) in severe preeclamptic parturients exhibiting neurologic symptoms compared with healthy pregnant women (control) and to describe the effects of MgSO4 infusion on rcSO2 and cerebral and systemic hemodynamic variables. DESIGN Prospective, observational study. SETTING Obstetric critical care unit in a university-affiliated hospital. PATIENTS Twenty severe preeclamptic parturients presenting with neurologic signs before any administration of MgSO4, and 20 control parturients. INTERVENTION Infusion of MgSO4 in severe preeclamptic patients. MEASUREMENTS AND MAIN RESULTS We measured rcSO2 using near-infrared spectroscopy, blood flow velocities of the middle cerebral artery, and cardiac output at baseline, 5 minutes, 1 hour, and 6 hours after the MgSO4 bolus (4 g), followed by continuous MgSO4 infusion (1 g/h). These measurements were also obtained in 20 control parturients at baseline and 6 hours. Baseline rcSO2 was significantly lower in the severe preeclamptic group: 61% (56-69) vs 66% (63-71) (p = 0.037). At inclusion, blood pressures were significantly higher in the severe preeclamptic group compared with the control group, whereas cardiac output and transcranial Doppler readings were similar. Five minutes after the MgSO4 bolus infusion, a median increase of 8.6% (3.2-18.1) in rcSO2 was observed (p = 0.007), reaching values of the control group that were maintained up to 6 hours. Blood pressures and systolic velocities of the middle cerebral artery significantly decreased (p < 0.01) after the MgSO4 bolus, whereas cardiac output did not change. The percentage increase in rcSO2 was negatively correlated to the mean blood pressure (r = 0.60, p < 0.0001). CONCLUSION Cerebral oxygenation impairment can be detected by near-infrared spectroscopy monitoring in severe preeclamptic parturients. These results suggested the presence of disorders in cerebral microcirculation and/or changes in cerebral oxygenation. MgSO4 infusion in patients with severe preeclampsia restored rcSO2 to control levels with no systemic side effects. Further studies are needed to confirm the usefulness of near-infrared spectroscopy monitoring in patients with preeclampsia and to assess the action of other antihypertensive therapies on rcSO2.

Summary Background & aims Nutrition therapy is a cornerstone of burn care from the early resuscitation phase until the end of rehabilitation. While several aspects of nutrition therapy are similar in major burns and other critical care conditions, the patho-physiology of burn injury with its major endocrine, inflammatory, metabolic and immune alterations requires some specific nutritional interventions. The present text developed by the French speaking societies, is updated to provide evidenced-based recommendations for clinical practice. Methods A group of burn specialists used the GRADE methodology (Grade of Recommendation, Assessment, Development and Evaluation) to evaluate human burn clinical trials between 1979 and 2011. The resulting recommendations, strong suggestions or suggestions were then rated by the non-burn specialized experts according to their agreement (strong, moderate or weak). Results Eight major recommendations were made. Strong recommendations were made regarding, 1) early enteral feeding, 2) the elevated protein requirements (1.5–2 g/kg in adults, 3 g/kg in children), 3) the limitation of glucose delivery to a maximum of 55% of energy and 5 mg/kg/h associated with moderate blood glucose (target ≤ 8 mmol/l) control by means of continuous infusion, 4) to associated trace element and vitamin substitution early on, and 5) to use non-nutritional strategies to attenuate hypermetabolism by pharmacological (propranolol, oxandrolone) and physical tools (early surgery and thermo-neutral room) during the first weeks after injury. Suggestion were made in absence of indirect calorimetry, to use of the Toronto equation (Schoffield in children) for energy requirement determination (risk of overfeeding), and to maintain fat administration ≤ 30% of total energy delivery. Conclusion The nutritional therapy in major burns has evidence-based specificities that contribute to improve clinical outcome.

International audience; Herpes simplex Virus (HSV) hepatitis is a rare complication of HSV-1 primary infection, with a delayed diagnosis, affecting mainly immunocompromised patients. We describe a case of HSV-1 hepatitis after primary infection occurring in the postoperative days after a pancreas-kidney transplantation. The patient presented with an unusual evolution of a persistent severe hepatitis associated with a persistent viremia (Quantitative Polymerase Chain Reaction) despite an adequate intravenous (iv) antiviral treatment. Abdominal computed tomography scan showed a miliary hepatitis. The diagnosis of HSV-1 hepatitis was confirmed by immuno-chemistry on liver biopsy. The donor was negative for anti-HSV antibodies, excluding contamination by the graft. This case report emphasizes a rather seldom risk of care-associated viral infections, predominantly in immunocompromised patients.

BACKGROUND This prospective observational study aimed to assess the relevance of serial postoperative plasma neutrophil gelatinase-associated lipocalin (NGAL) measurements on prediction of early renal transplant function. METHODS Plasma NGAL (pNGAL) was measured (Triage NGAL Test; Biosite Inc., Inverness Medical) in 41 patients scheduled for kidney transplantation from deceased or living donors, immediately before and after surgery, and at 12 hr, day 1, day 3, and day 7. A delayed graft function (DGF) was defined as the need for dialysis during the first week. The results were expressed as median (Q1, Q3). RESULTS Of the 41 consecutive patients enrolled, all had a high preoperative pNGAL level: 453 ng/mL (382, 595). Fifteen (36.6%) presented a DGF. In patients with DGF, pNGAL was significantly higher at 12 hr (571 [467, 634] vs. 242 [158, 299] ng/mL, P

Continuous positive airway pressure (CPAP) is a useful treatment for patients with acute cardiogenic pulmonary oedema (CPE). However, its usefulness in the out-of-hospital setting has been poorly investigated and only by small and single-centre studies. We designed a multicentre randomised study to assess the benefit of CPAP initiated out of hospital. A total of 207 patients with CPE were randomly allocated by emergency mobile medical units to receive either standard treatment alone or standard treatment plus CPAP. CPAP was maintained after admission to the intensive care unit (ICU). Inclusion criteria were orthopnoea, respiratory rate greater than 25 breaths/min, pulse oximetry less than 90% in room air and diffuse crackles. The primary end point was assessed during the first 48 h and combined: death, presence of intubation criteria, persistence of either all inclusion criteria or circulatory failure at the second hour or their reappearance before 48 h. Absence of all criteria defined successful treatment. CPAP was used for 60 min [40, 65] (median [Q1, Q3]) in the pre-hospital setting and 120 min [60, 242] in ICU and was well tolerated in all patients. Treatment was successful in 79% of patients in the CPAP group and 63% in the control group (p = 0.01), especially for persistence of inclusion criteria after 2 h (12 vs. 26%) and for intubation criteria (4 vs. 14%). CPAP was beneficial irrespective of the initial PaCO2 or left ventricular ejection fraction. Immediate use of CPAP in out-of-hospital treatment of CPE and until CPE resolves after admission significantly improves early outcome compared with medical treatment alone.

BACKGROUND: Hypercapnia has been reported to modify liver circulation. The vascular regulations implicated in this response remain partly unknown. METHODS: Using anesthetized and ventilated rabbits, we designed this study to evaluate the hepatic artery and portal vein blood flow velocity adjustments (20 MHz pulsed Doppler) after changes in Paco 2 (by varying the inspiratory fraction of CO 2 ) and to assess the proper role of pH, independent of Paco 2 changes, the role of portal vein CO 2 , and the effect of nitric oxide synthase inhibition on CO 2 -induced modifications of hepatic hemodynamics. RESULTS: Increasing Paco 2 from 30.9 ± 5 mm Hg to 77 ± 11 mm Hg increased arterial blood pressure by 20% (P < 0.01) and hepatic artery blood flow velocity by 90% (P < 0.05) and decreased aortic blood flow velocity by 15% and portal vein blood flow velocity by 40% (both P < 0.05). Changes in pH (1 mL of 0.1 N hydrochloric acid infusion) or isolated changes in portal vein CO 2 at constant Paco 2 induced by CO 2 insufflation in an open abdomen had no effect on hepatic hemodynamics. Pretreatment with a nitric oxide synthase inhibitor, N ω -nitro- L -arginine (2.5 mg/kg), blunted the systemic response to hypercapnia, whereas the portal modifications persisted, with a largely attenuated hepatic artery blood flow increase. CONCLUSIONS: CO 2 per se acts on hepatic blood flow by its systemic effect, probably via chemoreflexes. Nitric oxide does not mediate hepatosplanchnic hemodynamic modifications to acute changes in Paco 2 but may play a permissive role by regulating the amplitude of hepatic vascular response.

A 79-year-old man with atherosclerosis presented blue toes and livedo reticularis. The patient had eroded aortic atheromatous plaques, and cholesterol embolization syndrome was suspected. An endovascular technique to exclude sources of cholesterol emboli was however performed. The patient immediately presented with severe muscle pain and total functional disability of lower limbs, new ischemic lesions of toes, anal and genital necrosis, and a livedo extended up to the abdomen. A massive rhabdomyolysis occurred associated with acute kidney injury and hyperkaliemia treated by continuous renal replacement therapy with regional citrate anticoagulation. Steroids have been introduced and renal function improved. Cholesterol crystals were also found on a skin biopsy, performed before endovascular procedure.

Background and Purpose— Attempts to reverse cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage (aSAH) rely on a limited number of treatments. Calcium channel blockers have proven a benefit but their vasodilating effect on spastic cerebral arteries is relatively modest. Milrinone, a phosphodiesterase inhibitor, combines vasodilating and inotropic properties, but limited data exist to support its use for the treatment of CVS. We assessed the efficacy and tolerance of milrinone in patients with CVS secondary to aSAH. Methods— Twenty-two consecutive patients with angiographically-proven CVS (arterial diameter reduction >40%) have been studied. Intraarterial milrinone was infused in the cerebral territory(ies) involved and followed by continuous intravenous infusion until Day 14 after initial bleeding. We evaluated angiographic reversal of CVS, hemodynamic tolerance, and neurological outcome 1 year after aSAH. Results— Thirty-four selective intraarterial infusions of milrinone were required to treat 72 vasospastic territories. Intraarterial milrinone resulted in 53±37% increase in arterial diameter ( P Conclusion— This study suggests that milrinone is effective and safe for reversal of CVS after aSAH and should be tested in a large randomized trial.

Fluid loading is an essential part of cardiovascular resuscitation in septic shock. We hypothesized that fluid administration increases blood flow velocity and thus endothelial shear stress, causing the release of nitric oxide by the vascular endothelium. Because of endothelial dysfunction in sepsis, this mechanism would be less effective in septic animals. Fluid loading may have different effects in septic compared with control animals.Prospective, randomized, controlled study.Animal research laboratory.Male Sprague-Dawley rats.We tested the involvement of nitric oxide in the fluid-induced cardiovascular response after administration of lipopolysaccharide (5 mg/kg, n = 10) or vehicle (control, n = 10) in rats subsequently randomized after 165 mins to receive L-N(G)-nitroarginine (7.5 mg/kg) or saline (n = 5 in each group). At 180 mins, all animals received hydroxyethyl starch (fluid loading, 15 mL/kg in 15 mins). Reversal of L-N(G)-nitroarginine was studied with an intravenous bolus of L-arginine (300 mg/kg).Lipopolysaccharide injection induced a hypokinetic shock (low blood pressure: -30% +/- 9%, p.05), low cardiac output (aortic pulsed-Doppler probe: -20% +/- 8, p.05), and unchanged systemic conductance, which turned into a hyperkinetic shock by fluid loading. Pretreatment with L-N(G)-nitroarginine totally abolished this fluid loading-induced vasodilation in control rats but only partially in lipopolysaccharide-treated rats, suggesting an altered endothelial response after lipopolysaccharide injection. Maximal aortic blood flow acceleration was used as an index of left ventricular systolic function. The improvement of maximal aortic blood flow acceleration observed during fluid loading in lipopolysaccharide-treated or control animals was blunted by L-N(G)-nitroarginine pretreatment, suggesting the involvement of nitric oxide in the myocardial response to fluid loading.These results suggest that the endothelium participates in the hemodynamic response to fluid loading in control rats, but less in rats with septic shock, secondary to an altered nitric oxide-dependent vasodilation.

Nocardia farcinica is an emerging pathogen in immunosuppressed patients causing both localized and disseminated infections. Many strains of this species are multidrug-resistant and require long-term antibiotic therapy, and consequently the choice of an oral treatment can be problematic. We report here the first case of successful treatment of N. farcinica brain abscess in a renal transplant recipient with an extended-spectrum fluoroquinolone, moxifloxacin.

To determine the regional cerebral oxygen saturation of hemoglobin (rcSO2) in severe preeclamptic parturients exhibiting neurologic symptoms compared with healthy pregnant women (control) and to describe the effects of MgSO4 infusion on rcSO2 and cerebral and systemic hemodynamic variables.Prospective, observational study.Obstetric critical care unit in a university-affiliated hospital.Twenty severe preeclamptic parturients presenting with neurologic signs before any administration of MgSO4, and 20 control parturients.Infusion of MgSO4 in severe preeclamptic patients.We measured rcSO2 using near-infrared spectroscopy, blood flow velocities of the middle cerebral artery, and cardiac output at baseline, 5 minutes, 1 hour, and 6 hours after the MgSO4 bolus (4 g), followed by continuous MgSO4 infusion (1 g/h). These measurements were also obtained in 20 control parturients at baseline and 6 hours. Baseline rcSO2 was significantly lower in the severe preeclamptic group: 61% (56-69) vs 66% (63-71) (p = 0.037). At inclusion, blood pressures were significantly higher in the severe preeclamptic group compared with the control group, whereas cardiac output and transcranial Doppler readings were similar. Five minutes after the MgSO4 bolus infusion, a median increase of 8.6% (3.2-18.1) in rcSO2 was observed (p = 0.007), reaching values of the control group that were maintained up to 6 hours. Blood pressures and systolic velocities of the middle cerebral artery significantly decreased (p0.01) after the MgSO4 bolus, whereas cardiac output did not change. The percentage increase in rcSO2 was negatively correlated to the mean blood pressure (r = 0.60, p0.0001).Cerebral oxygenation impairment can be detected by near-infrared spectroscopy monitoring in severe preeclamptic parturients. These results suggested the presence of disorders in cerebral microcirculation and/or changes in cerebral oxygenation. MgSO4 infusion in patients with severe preeclampsia restored rcSO2 to control levels with no systemic side effects. Further studies are needed to confirm the usefulness of near-infrared spectroscopy monitoring in patients with preeclampsia and to assess the action of other antihypertensive therapies on rcSO2.

International audience; The choice of volume expander for fluid resuscitation in hemorrhagic shock is still debated. Changes in plasma viscosity (PV) are barely investigated while PV modulates functional capillary density, microcirculation and organ function. The present study evaluated the impact of 2 strategies of fluid resuscitation in hemorrhagic shock in pigs. Ten pigs were subjected to hemorrhagic shock and randomly assigned to a low viscosity fluid regimen (Lactated Ringer's, LR) group or a high viscosity regimen (hypertonic-hydroxyethyl starch, HES) for volume resuscitation. Sublingual microcirculatory flow and tissue oxygen tension were assessed together with macro-and microcirculatory, biochemical and rheological variables at baseline, 30 minutes after hemorrhagic shock, immediately after reaching resuscitation endpoints (R-0), and 60 minutes after resuscitation (R-60). PV decreased similarly in both groups following resuscitation (from 1.36 [ 1.32-1.38] to 1.21 [ 1.21-1.23] for LR, and from 1.32 [ 1.31-1.32] to 1.20 [ 1.17-1.21] mPa. s for HES). No differences were found between the groups for other rheological variables, microcirculatory flow or tissue oxygen tension at R-0 and R-60. Despite a 6-fold difference in the volumes required to achieve blood flow endpoints, commercially available volume expanders had similar effects on rheological and microcirculatory variables, irrespective of their viscosity. Our findings are consistent with the absence of clinically relevant differences between crystalloid and colloid resuscitation of hemorrhagic shock.

Objective. Inhaled nitric oxide (NO) can be delivered continuouslyor sequentially (= during inspiration) at different locations of theventilation circuit. We have tested the influence of locations, modes of NOadministration and the ratio of the inspiratory time over the respiratorycycle time (I/I + E ratio) on the accuracy of NO fractions, delivered by 2devices: Opti-NO and Flowmeter. Methods.We used a simplified lungmodel consisting of a ventilation circuit with a Y piece, a tracheal tube, a150 ml dead-space volume and a 5 liter balloon. Three fractions (3, 6, 9 ppm)were administered continuously or sequentially, in controlled volume, in 4different sites on the inspiratory branch above the Y piece:i) justafter the water trap, ii) just before the Y piece; below the Y piece:iii) just after the Y piece, iv) into the endotracheal tube. In addition,different I/I + E ratios (25, 33, 50, 80%) were studied. The delivered NOfractions were measured in the balloon by chemiluminescence (CLD 700,Ecophysics). A linear regression analysis was used to test the relationshipbetween administered and measured NO fractions for the 3 fractions (3, 6 and9 ppm) in sequential and continuous modes. Intercept values were compared tozero and slopes to the identity line. Results.When NO was administeredin the continuous mode upstream the Y piece, NO fractions measured in theballoon corresponded to the administered fractions. In contrast, below the Ypiece, the measured NO fractions were significantly lower than theadministered NO fractions. In the sequential mode, above and below the Ypiece, the delivered NO fractions were within the manufacturer's range.Conclusions.For the continuous NO delivery, locations above the Ypiece are mandatory. However, locations below the Y piece imposes a sequentialsystem, which can also be used for the sites located above the Y piece.

Introduction Le nombre de nouveaux patients en attente de greffes d’organes augmente d’annees en annees. L’opposition des proches elevee (33,5 % en 2014), la diminution des deces lies a la traumatologie routiere et une meilleure prevention de la pathologie vasculaire cerebrale limitent le nombre de donneurs dits « classiques ». Pour faire face a cette situation, le recours a des donneurs a criteres elargis (ECD) est l’un des moyens envisages. Ainsi, des donneurs de plus en plus âges sont recenses et proposes au prelevement. Le but de ce travail est d’evaluer le recours aux donneurs tres âges (≥ 75 ans) et la pertinence de cette strategie. Materiel et methodes Etude retrospective multicentrique realisee a partir de la base de donnees Cristal de l’Agence de la biomedecine. Recueil des donnees du 01/01/2002 au 31/12/2011. Resultats Au cours de la periode etudiee, 2461 donneurs potentiels âges de plus de 75 ans ont ete recenses dont 953 (38,7 %) preleves. En 2011, ces donneurs representaient 14,7 % des recensements, 13,3 % des prelevements et 7,2 % du total des greffes realisees en France (7,3 % des greffes renales, 12,1 % des greffes hepatiques). Sur l’ensemble de la periode, ce ratio preleves/recenses (38,7 %) etait inferieur dans cette tranche d’âge par rapport a celui de l’ensemble de la population (49,2 %). Neanmoins, en 2011, ce ratio tendait a s’en approcher (44,8 % vs 49,5 %). Il est de 42,6 % pour les donneurs de plus de 80 ans. Parmi les donneurs recenses, 884 avaient plus de 80 ans, dont 307 preleves (34,7 %). 79,7 % des donneurs preleves decedent de cause vasculaire. Le delai entre l’admission et le passage en mort encephalique etait le plus souvent court (39 % Discussion Le prelevement de reins et de foies chez des patients âges de plus de 75 ans contribue de maniere significative a la greffe d’organes. Les resultats a un an sont satisfaisants. Le developpement de techniques dynamiques de conservation des greffons va permettre d’ameliorer encore la qualite de ces greffons.

Introduction La reactivation des herpesviridae survient frequemment chez les patients de reanimation immunocompetents et pourrait etre associee a une duree de sejour et une mortalite plus elevees [1,2] . L’objectif de cette etude etait de decrire l’incidence de survenue, les facteurs de risque et les complications de la reactivation de 4 herpesviridae (CMV, EBV, HSV et VZV) chez le patient brule grave. Materiel et methodes Etude prospective observationnelle incluant les patients brules sur plus de 20 % de la surface cutanee totale (SCT) ou plus de 10 % de la SCT en association avec des lesions d’inhalation de fumees, admis dans le Centre de Traitement des Grands Brules du CHR Metz-Thionville entre avril 2013 et mai 2014. Le statut serologique des patients etait determine a l’admission. Les reactivations virales etaient definies par la presence d’une replication virale sanguine detectee par PCR chez un patient prealablement expose. Les patients etaient repartis en 2 groupes : « reactivation virale » et « pas de reactivation virale » puis compares. Les donnees sont exprimees en mediane (extremes). Resultats Vingt patients âges de 50 (20–74) ans, ont ete inclus (17 hommes/3 femmes). La surface cutanee brulee totale etait de 26 % (11–72) dont une surface brulee au 3 e degre de 20 % (0–60). Au total, 14 reactivations virales sont survenues chez 11 patients (55 %) d’âge moyen de 51 ± 17 ans contre 42 ± 17 ans pour le groupe sans reactivation. La surface cutanee brulee n’etait pas differente entre les deux groupes. L’ADN de VZV n’a ete detecte chez aucun patient. Un seul patient a presente une reactivation d’HSV, alors qu’une eruption peribuccale a ete observee chez quatre patients. Dix patients (50 %) ont presente une reactivation d’EBV dans les trois premieres semaines d’hospitalisation, une lyse de greffe de peau a ete constatee chez un seul patient. La presence de l’ADN de CMV a ete detectee chez 4 patients (20 %), dont 3 reactivations et une primo-infection. Toutes les reactivations d’HSV et CMV sont survenues pendant la 3 e semaine d’hospitalisation. La seule primo-infection a CMV est apparue dans la 8 e semaine apres l’admission. Dans le groupe reactivation virale 3 patients (27 %) presentaient une candidemie contre aucun dans le groupe sans reactivation. Il y avait deux fois plus de reactivations virales en cas de traitement par allogreffe cutanee. Le nombre moyen de culots globulaires transfuses n’etait pas different entre les deux groupes. La reactivation d’herpesviridae n’avait pas d’influence sur la duree de ventilation mecanique qui etait de 38 j en moyenne dans les deux groupes et la duree moyenne de sejour en reanimation 48 ± 26 j dans le groupe sans reactivation vs. 52 ± 25 j dans le groupe reactivation. Discussion La reactivation d’herpesviridae est frequente chez le patient brule grave. Elle touche des patients plus âges, concerne plus souvent les patients ayant beneficie d’allogreffes cutanees et pourrait etre un signe avant-coureur d’une infection nosocomiale fongique. Son depistage systematique pourrait permettre de la diagnostiquer precocement et d’eviter la survenue de complications pouvant mettre en jeu le pronostic fonctionnel ou vital des patients infectes.

Ex vivo cytokine production by circulating lymphocytes and monocytes is reduced in patients with infectious or noninfectious systemic inflammatory response syndrome. Very few studies have addressed the reactivity of polymorphonuclear cells (PMN). To analyze further the relative contribution of systemic inflammatory response syndrome alone or in combination with infection we studied the interleukin-8 (IL-8) production by PMN isolated from patients who had undergone cardiac surgery with cardiopulmonary bypass (CPB) and patients with sepsis. Cells were activated with either lipopolysaccharide (LPS) or heat-killed streptococci. Compared with healthy controls, the release of IL-8 by PMN in both groups of patients was significantly reduced whether activated by LPS, independently of its concentration and origin, or by heat-killed streptococci. These observations suggest that stressful conditions related to inflammation, independently of infection, rapidly dampened the reactivity of circulating PMN. We investigated whether the observed diminished reactivity of PMN might reflect an endotoxin tolerance phenomenon. Our in vitro experiments with PMN from healthy controls indicated that PMN could not be rendered tolerant stricto sensu. However, our data suggested that LPS-induced mediators such as IL-10 may be responsible for the observed anergy in patients.

The balance between proinflammatory cytokines and their inhibitors has rarely been investigated in pleural effusions of nonmalignant or noninfectious origin. To evaluate the impact of a lung and/or intrathoracic infection in such a circumstance, we compared the levels of proinflammatory cytokines (interleukin-8 [IL-8]); tumor necrosis factor-alpha (TNF-alpha); the cytokine antagonists and inhibitors (IL-1 receptor antagonist [IL-1ra]) and soluble TNF receptors Types I and II (sTNFRI, sTNFRII); and antiinflammatory cytokines (transforming growth factor-beta [TGF-beta]) in pleural effusion and plasma from septic (n = 15) and nonseptic (n = 9) patients. In addition, we analyzed the levels of IL-6 and its soluble receptor (sIL-6R). Bronchoalveolar lavage fluids (BALFs) were also studied in a few septic patients. High and nonsignificantly different levels of cytokines and inhibitors were detected in both groups of patients. The levels of IL-6 and sTNFRI and sTNFRII in pleural effusion were higher than in plasma, whereas the levels of IL-1ra and sIL-6R were higher in plasma. The levels of sIL-6R influenced the bioactivity of IL-6. There was no correlation between the levels of cytokines in plasma and in pleural effusion. In contrast, a significant correlation was observed for the soluble receptors sIL-6R (r = 0.67, p < 0.001), sTNFRI (r = 0.76, p < 0.001) and sTNFRII (r = 0.66, p = 0.001). Furthermore, a high correlation was found between the levels of both forms of sTNFRs in plasma (r = 0.95, p < 0.001) and in pleural effusion (r = 0.79, p < 0.001). In addition, a correlation was observed between the levels of TGF-beta in pleural effusion and in BALF. The highest levels of some markers in plasma and of others in pleura argue in favor of both a systemic and a compartmentalized response, independently of the presence of infection. Because cytokines can be trapped by the surrounding cells in their environment, measurable levels of cytokines in biologic fluids represent the "tip of the iceberg," which is not the case for soluble receptors. The correlations of these latter markers between plasma and pleura strongly suggest that exchanges between both compartments can occur in both directions.

Losser, Marie-Reine, Catherine Bernard, Jean-Louis Beaudeux, Christophe Pison, and Didier Payen. Glucose modulates hemodynamic, metabolic, and inflammatory responses to lipopolysaccharide in rabbits. J. Appl. Physiol. 83(5): 1566–1574, 1997.—Glucose is important for vascular and immunocompetent cell functions. We hypothesized that modifications in glucose metabolism (normal feeding, 24-h fasting, glucose loading) may influence the hemodynamic, metabolic, and inflammatory responses to lipopolysaccharide administration (LPS; 600 μg/kg iv) in rabbits. Aortic (ABFV), hepatic artery (HABFV), and portal vein blood flow velocities (PVBFV) (pulsed Doppler), plasma tumor necrosis factor (TNF) and nitrites were measured. Fasting depleted hepatic glycogen content, and intraportal glucose load (2 g/kg) partially restored it. LPS induced a similar hypotension (−20%, P < 0.05) in three groups of animals. In fed animals, systemic vasoconstriction occured with low ABFV and PVBFV (−40%, P < 0.05), together with lactacidemia and hyperglycemia. In fasted animals, ABFV and PVBFV were maintained, without metabolic acidosis or hyperglycemia. Glucose loading induced hemodynamic and metabolic patterns comparable to those observed in fed animals, although significantly more severe. TNF release was amplified fourfold by glucose loading, with no impact on nitrite levels. In conclusion, glucose metabolism interferes with hemodynamic, metabolic, and inflammatory responses to LPS.

Introduction La severite de l’atteinte cerebrale au cours de la preeclampsie severe est difficile a monitorer et a prevenir [1] . La spectrometrie de proche infra-rouge (NIRS) permet de mesurer la saturation regionale en O 2 au niveau de la microcirculation cerebrale (rcSO 2 ) de maniere non invasive. Cette etude evalue la rcSO 2 de patientes preeclamptiques severes presentant des signes neurologiques et examine l’impact du traitement de reference par MgSO 4 [2] . Materiel et methodes Etude prospective, observationnelle menee a la Maternite de NANCY entre janvier 2012 et mai 2013. Apres accord du comite d’ethique (MRU-12-06) et information orale, 20 patientes preeclamptiques severes (SP) presentant des signes neurologiques etaient incluses avant administration de MgSO 4 . Vingt femmes enceintes en bonne sante servaient de groupe temoin. Des mesures non invasives de la pression arterielle (PA), de la rcSO 2 par NIRS (INVOS, 5100c, Covidien), du debit cardiaque (echocardiographie) et des velocites au niveau de l’artere cerebrale moyenne par Doppler transcranien (sonde P10 × 5-1 MHz, EDGE, Sonosite) etaient effectuees a l’etat basal, 5 minutes apres un bolus intraveineux de 4 g MgSO 4 , puis 1H et 6H apres le bolus associe a une perfusion continue a 1 g/H. Dans le groupe temoin, ces mesures etaient effectuees a H-0 et H + 6, sans administration de MgSO 4 . Resultats Les donnees demographiques etaient similaires entre les 2 groupes. A l’inclusion, la PA moyenne etait de 119 [114–125] vs. 81 [76–90] mmHg ( p 0,0001), la proteinurie a 3,40 g/L (1,6–4,7) vs. 0,25 g/L (0,15–0,3) ( p 0,0001), la rcSO 2 a 61 % [56–69] vs. 66 % [63–71] ( p = 0,037) dans le groupe SP et controle respectivement. La frequence et le debit cardiaque etaient similaires. Concernant les velocites cerebrales, il n’etait pas note de difference significative. Administration de MgSO4 5 minutes apres le bolus, une augmentation significative de la rcSO 2 etait observee ( p = 0,007) ( Fig. 1 ). La ΔrcSO 2 etait de 8,6 % [3,2–18,1] entre Baseline et H + 6. Les PA diminuaient significativement apres le bolus ( p 0,0001). Douze patientes necessitaient de la nicardipine pour controler efficacement la PA a partir de H + 1. Les parametres hemodynamiques macrocirculatoires (frequence et debit cardiaque, SpO 2 ) restaient inchanges. Une correlation negative significative existait entre le pourcentage de diminution de la PA moyenne et la ΔrcSO 2 entre H-0 et H + 6 ( r 2 = 0,60, p 0,0001). Une faible correlation entre le debit cardiaque et la rcSO 2 etait constatee ( r 2 = 0,23, p = 0,03). Concernant l’hemodynamique cerebrale, seule la velocite systolique etait significativement plus basse apres le bolus de MgSO 4 sans modification des autres velocites ou des index derives. Il n’existait pas de correlation entre les velocites dans l’artere cerebrale moyenne et la rcSO 2 ( r 2 = 0,04, p = 0,59, Fig. 1 ). Discussion Cette etude est la premiere a demontrer des anomalies de l’oxygenation cerebrale chez des patientes preeclamptiques severes presentant des signes neurologiques. Ces resultats suggerent des anomalies de la microcirculation cerebrale et/ou des changements dans la consommation ou la delivrance de l’oxygene. La perfusion de MgSO 4 , traitement de reference dans la prevention et le traitement de l’eclampsie, permet de restaurer une valeur de rcSO 2 similaire a celle de femmes enceintes ne presentant pas de pathologie. D’autres etudes sont necessaires pour confirmer l’interet de la NIRS cerebrale dans la prise en charge de patientes preeclamptiques mais egalement pour evaluer l’impact d’autres therapeutiques antihypertensives.

Introduction Les interventions de chirurgie digestive carcinologique sont a risque de transfusion sanguine postoperatoire. Celle-ci est associee a une morbidite ayant un impact sur l’evolution postoperatoire et de la maladie. Les facteurs associes a la transfusion sanguine perioperatoire sont representes par l’anemie preoperatoire. Le deficit en fer est la premiere cause d’anemie. L’objectif de notre etude est d’evaluer l’impact d’un protocole d’evaluation et de traitement du deficit en fer en periode postoperatoire immediate de chirurgie carcinologique sur la transfusion sanguine postoperatoire et de rechercher les facteurs associes a la transfusion sanguine postoperatoire. Patients et methodes Il s’agit d’une etude monocentrique comparant deux populations de patients operes de chirurgie carcinologique sus-mesocolique. La premiere serie (S1) de patients, retrospective, beneficiait de ces interventions de janvier 2011 a decembre 2012, avant la mise en place d’un algorithme d’evaluation et de traitement du deficit en fer par carboxymaltose ferrique (CF). La deuxieme serie (S2), prospective, beneficiait de ces interventions de janvier 2013 a juillet 2013, apres la mise en place de cet algorithme. L’objectif de principal de cette etude etait de mettre en evidence une reduction significative du nombre de patients transfuses en periode postoperatoire par l’application de cet algorithme. L’objectif secondaire etait de determiner les facteurs associes a la transfusion sanguine postoperatoire. Resultats Cent quarante-sept patients etaient inclus, 111 pour la serie S1 et 36 pour la serie S2. Les deux series etaient comparables concernant l’âge, le sexe, l’indice de masse corporelle, les comorbidites, le type histologique et la prise en charge perioperatoire. Six patients de la serie S2 presentaient un deficit en fer et cinq d’entre eux etaient traites par CF. Il existait une difference significative entre les deux series concernant la proportion de patients transfuses en postoperatoire (35 % pour S1 versus 11 % pour S2, p = 0,009). En analyse bivariee, le fait de beneficier de l’algorithme etait un facteur de protection vis-a-vis de la transfusion sanguine postoperatoire (OR = 0,2 [0,1–0,7], p = 0,002). En analyse bivariee, un pourcentage de globules rouges hypochromes preoperatoire superieur a 10 %, la duree d’intervention et la transfusion peroperatoire etaient des facteurs de risque de transfusion postoperatoire. Aucune complication liee au traitement par CF n’etait notee ( Tableau 1 , Fig. 1 ). Discussion Notre etude met en evidence l’interet de l’evaluation et du traitement du deficit en fer pour reduire les besoins transfusionnels, et ce d’autant plus qu’il apparait que le deficit en fer est un facteur associe a la transfusion sanguine postoperatoire. D’autres etudes sont necessaire pour evaluer l’impact du traitement du deficit en fer sur l’evolution postoperatoire, et son integration dans une strategie de traitement global de l’anemie preoperatoire.

Background Totally implanted ports (TIP) have become a standard part of patient care, providing long-term central venous access for treatment administration and other procedures. Despite overall the safety and effectiveness of TIP, complications still occur. Negative pressure created during needle withdrawal induces blood reflux and subsequent catheter occlusion. Application of positive pressure during needle withdrawal is thought to largely prevent such reflux, but supporting data are limited. Purpose of Research To quantify the role of positive pressure, using a test model designed to simulate physiological conditions. Methods Reflux associated with needle withdrawal with and without applied positive pressure was tested using various TIP models from different manufacturers mounted on a specially designed test bench. In addition to the presence or absence of positive pressure during needle withdrawal, study variables comprised of needle type (safety and standard), needle gauge and port septum diameter. Results Application of positive pressure during needle withdrawal reduced the incidence of reflux during needle withdrawal by nearly 80% (22% vs. 99%, pConclusion The results of this study support the use of positive pressure during needle withdrawal to prevent blood reflux potentially leading to catheter tip occlusion.