Biblio du mois – Juin 2018
6 juillet 2018
Quand les grandes revues parlent d’anesthésie et de réanimation, la biblio de l’AJAR ne peut passer à côté !
Et c’est pour cela que l’on vous livre le best of biblio du mois !
Biblio du mois exhaustive avec les revues de notions sur différents thèmes publiés dans ICM mais bien d’autres très intéressantes qui vous donneront de quoi lire pour l’été !
Ce mois-ci l’accent est mis sur les facteurs et les scores pronostiques ainsi que des études sur les catécholamines (à débattre).
N’oubliez pas que si vous voulez quelques astuces pour en profiter au mieux, nos conseils sur notre site : https://www.ajar-online.fr/biblio-du-mois-le-tuto-pour-se-maintenir-informe/
Pour mieux répondre à vos attentes, nous vous proposons de répondre à ce court sondage pour qu’on améliore ensemble notre biblio !
Evaluation d’une stratégie de soutien des proches de patients en réanimation : une meilleure communication et une durée de séjour réduite pour les patients ?
Douglas B. White, et al., N Engl J Med 2018; 378:2365-2375
https://www.nejm.org/doi/full/10.1056/NEJMoa1802637
DOI: 10.1056/NEJMoa1802637
Abstract
Background
Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients’ preferences.
Methods
We conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates’ mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates’ mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician–family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay.
Results
A total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates’ mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, −0.34; 95% confidence interval [CI], −1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, −1.66 to 3.47; P=0.49). The surrogates’ mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, −0.15; 95% CI, −0.26 to −0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P<0.001).
Conclusions
Among critically ill patients and their surrogates, a family-support intervention delivered by the interprofessional ICU team did not significantly affect the surrogates’ burden of psychological symptoms, but the surrogates’ ratings of the quality of communication and the patient- and family-centeredness of care were better and the length of stay in the ICU was shorter with the intervention than with usual care. (Funded by the UPMC Health System and the Greenwall Foundation; PARTNER ClinicalTrials.gov number, NCT01844492.)
Fin du Synto au frigo : avènement du Pabal au chaud ?
Widmer et al., NEJM, 2018
DOI: 10.1056/NEJMoa1805489
Background
Postpartum hemorrhage is the most common cause of maternal death. Oxytocin is the standard therapy for the prevention of postpartum hemorrhage, but it requires cold storage, which is not available in many countries. In a large trial, we compared a novel formulation of heat-stable carbetocin with oxytocin.
Methods
We enrolled women across 23 sites in 10 countries in a randomized, double-blind, noninferiority trial comparing intramuscular injections of heat-stable carbetocin (at a dose of 100 μg) with oxytocin (at a dose of 10 IU) administered immediately after vaginal birth. Both drugs were kept in cold storage (2 to 8°C) to maintain double-blinding. There were two primary outcomes: the proportion of women with blood loss of at least 500 ml or the use of additional uterotonic agents, and the proportion of women with blood loss of at least 1000 ml. The noninferiority margins for the relative risks of these outcomes were 1.16 and 1.23, respectively.
Results
A total of 29,645 women underwent randomization. The frequency of blood loss of at least 500 ml or the use of additional uterotonic agents was 14.5% in the carbetocin group and 14.4% in the oxytocin group (relative risk, 1.01; 95% confidence interval [CI], 0.95 to 1.06), a finding that was consistent with noninferiority. The frequency of blood loss of at least 1000 ml was 1.51% in the carbetocin group and 1.45% in the oxytocin group (relative risk, 1.04; 95% CI, 0.87 to 1.25), with the confidence interval crossing the margin of noninferiority. The use of additional uterotonic agents, interventions to stop bleeding, and adverse effects did not differ significantly between the two groups.
Conclusions
Heat-stable carbetocin was noninferior to oxytocin for the prevention of blood loss of at least 500 ml or the use of additional uterotonic agents. Noninferiority was not shown for the outcome of blood loss of at least 1000 ml; low event rates for this outcome reduced the power of the trial.
Revue sur la prévention des hémorragies digestives hautes
Deborah Cook, M.D. and Gordon Guyatt, M.D., N Engl J Med 2018; 378:2506-2516
https://www.nejm.org/doi/full/10.1056/NEJMra1605507?query=featured_home
DOI: 10.1056/NEJMra1605507
Traitement par albumine au long court chez le patient cirrhotique avec ascite non compliquée : augmentation de la survie ?
Caraceni et al., Lancet, 2018
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30840-7/fulltext
DOI: https://doi.org/10.1016/S0140-6736(18)30840-7
Background
Evidence is scarce on the efficacy of long-term human albumin (HA) administration in patients with decompensated cirrhosis. The human Albumin for the treatmeNt of aScites in patients With hEpatic ciRrhosis (ANSWER) study was designed to clarify this issue.
Methods
We did an investigator-initiated multicentre randomised, parallel, open-label, pragmatic trial in 33 academic and non-academic Italian hospitals. We randomly assigned patients with cirrhosis and uncomplicated ascites who were treated with anti-aldosteronic drugs (≥200 mg/day) and furosemide (≥25 mg/day) to receive either standard medical treatment (SMT) or SMT plus HA (40 g twice weekly for 2 weeks, and then 40 g weekly) for up to 18 months. The primary endpoint was 18-month mortality, evaluated as difference of events and analysis of survival time in patients included in the modified intention-to-treat and per-protocol populations. This study is registered with EudraCT, number 2008–000625–19, and ClinicalTrials.gov, number NCT01288794.
Findings
From April 2, 2011, to May 27, 2015, 440 patients were randomly assigned and 431 were included in the modified intention-to-treat analysis. 38 of 218 patients died in the SMT plus HA group and 46 of 213 in the SMT group. Overall 18-month survival was significantly higher in the SMT plus HA than in the SMT group (Kaplan-Meier estimates 77% vs 66%; p=0·028), resulting in a 38% reduction in the mortality hazard ratio (0·62 [95% CI 0·40–0·95]). 46 (22%) patients in the SMT group and 49 (22%) in the SMT plus HA group had grade 3–4 non-liver related adverse events.
Interpretation
In this trial, long-term HA administration prolongs overall survival and might act as a disease modifying treatment in patients with decompensated cirrhosis.
Dabigatran diminue la mortalité chez les patients avec une troponite en post-opératoire de chirurgie non cardiaque ?
Devereaux et al., Lancet, 2018
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30832-8/fulltext
DOI: https://doi.org/10.1016/S0140-6736(18)30832-8
Background
Myocardial injury after non-cardiac surgery (MINS) increases the risk of cardiovascular events and deaths, which anticoagulation therapy could prevent. Dabigatran prevents perioperative venous thromboembolism, but whether this drug can prevent a broader range of vascular complications in patients with MINS is unknown. The MANAGE trial assessed the potential of dabigatran to prevent major vascular complications among such patients.
Methods
In this international, randomised, placebo-controlled trial, we recruited patients from 84 hospitals in 19 countries. Eligible patients were aged at least 45 years, had undergone non-cardiac surgery, and were within 35 days of MINS. Patients were randomly assigned (1:1) to receive dabigatran 110 mg orally twice daily or matched placebo for a maximum of 2 years or until termination of the trial and, using a partial 2-by-2 factorial design, patients not taking a proton-pump inhibitor were also randomly assigned (1:1) to omeprazole 20 mg once daily, for which results will be reported elsewhere, or matched placebo to measure its effect on major upper gastrointestinal complications. Research personnel randomised patients through a central 24 h computerised randomisation system using block randomisation, stratified by centre. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary efficacy outcome was the occurrence of a major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism. The primary safety outcome was a composite of life-threatening, major, and critical organ bleeding. Analyses were done according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, number NCT01661101.
Findings
Between Jan 10, 2013, and July 17, 2017, we randomly assigned 1754 patients to receive dabigatran (n=877) or placebo (n=877); 556 patients were also randomised in the omeprazole partial factorial component. Study drug was permanently discontinued in 401 (46%) of 877 patients allocated to dabigatran and 380 (43%) of 877 patients allocated to placebo. The composite primary efficacy outcome occurred in fewer patients randomised to dabigatran than placebo (97 [11%] of 877 patients assigned to dabigatran vs 133 [15%] of 877 patients assigned to placebo; hazard ratio [HR] 0·72, 95% CI 0·55–0·93; p=0·0115). The primary safety composite outcome occurred in 29 patients (3%) randomised to dabigatran and 31 patients (4%) randomised to placebo (HR 0·92, 95% CI 0·55–1·53; p=0·76).
Interpretation
Among patients who had MINS, dabigatran 110 mg twice daily lowered the risk of major vascular complications, with no significant increase in major bleeding. Patients with MINS have a poor prognosis; dabigatran 100 mg twice daily has the potential to help many of the 8 million adults globally who have MINS to reduce their risk of a major vascular complication.
Contre une évaluation subjective en pré-opératoire de chirurgie cardiaque ?
#FacteurHumain
Duminda N Wijeysundera,et al., Lancet, 2018
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31131-0/fulltext
DOI: https://doi.org/10.1016/S0140-6736(18)31131-0
Background
Functional capacity is an important component of risk assessment for major surgery. Doctors’ clinical subjective assessment of patients’ functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complications after major elective non-cardiac surgery.
Methods
We did a multicentre, international, prospective cohort study at 25 hospitals: five in Canada, seven in the UK, ten in Australia, and three in New Zealand. We recruited adults aged at least 40 years who were scheduled for major non-cardiac surgery and deemed to have one or more risk factors for cardiac complications (eg, a history of heart failure, stroke, or diabetes) or coronary artery disease. Functional capacity was subjectively assessed in units of metabolic equivalents of tasks by the responsible anaesthesiologists in the preoperative assessment clinic, graded as poor (<4), moderate (4–10), or good (>10). All participants also completed the DASI questionnaire, underwent CPET to measure peak oxygen consumption, and had blood tests for measurement of NT pro-BNP concentrations. After surgery, patients had daily electrocardiograms and blood tests to measure troponin and creatinine concentrations until the third postoperative day or hospital discharge. The primary outcome was death or myocardial infarction within 30 days after surgery, assessed in all participants who underwent both CPET and surgery. Prognostic accuracy was assessed using logistic regression, receiver-operating-characteristic curves, and net risk reclassification.
Findings
Between March 1, 2013, and March 25, 2016, we included 1401 patients in the study. 28 (2%) of 1401 patients died or had a myocardial infarction within 30 days of surgery. Subjective assessment had 19·2% sensitivity (95% CI 14·2–25) and 94·7% specificity (93·2–95·9) for identifying the inability to attain four metabolic equivalents during CPET. Only DASI scores were associated with predicting the primary outcome (adjusted odds ratio 0·96, 95% CI 0·83–0·99; p=0·03).
Interpretation
Subjectively assessed functional capacity should not be used for preoperative risk evaluation. Clinicians could instead consider a measure such as DASI for cardiac risk assessment.
Revue sur l’antibiorésistance chez les migrants
Nellums et al., Lancet, 2018
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30219-6/fulltext
DOI: https://doi.org/10.1016/S1473-3099(18)30219-6
Mandrin souple versus rigide pour les intubations difficiles en urgence
Driver et al., JAMA, 2018
https://jamanetwork.com/journals/jama/article-abstract/2681717
Importance The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear.
Objective To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet.
Design, Setting, and Patients The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection.
Interventions Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376).
Main Outcomes and Measures The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia.
Results Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups.
Conclusions and Relevance In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings.
Méta-analyse sur l’impact de l’oxygénothérapie chez les prématurés
Askie et al., JAMA, 2018
https://jamanetwork.com/journals/jama/article-abstract/2683220
Question For extremely preterm infants, is targeting a lower oxygen saturation (85%-89%) compared with a higher saturation (91%-95%) associated with a difference in death or major disability by a corrected age of 24 months?
Findings In a prospectively designed meta-analysis of individual participant data from 4965 infants in 5 randomized clinical trials, there was no significant difference in the primary composite outcome of death or major disability between those treated with lower vs higher oxygen saturations (53.5% vs 51.6%, respectively). Lower oxygen targets were associated with increased death and necrotizing enterocolitis but reduced retinopathy of prematurity treatment.
Meaning Among extremely preterm infants, there was no significant difference between lower and higher oxygen saturation targets on a composite of death or major disability; secondary end points may need to be considered in decision making.
Validation du qSOFA dans les pays en voie de développement
Rudd et al., JAMA, 2018
https://jamanetwork.com/journals/jama/article-abstract/2681801
Revue sur le management des endocardites
WAng et al., JAMA, 2018
https://jamanetwork.com/journals/jama/article-abstract/2686799
Biomarqueurs du SDRA (sous-étude LIPS-A)
https://www.atsjournals.org/
https://doi.org/10.1164/rccm.201712-2530OC
Faut-il changer les seuils de Pa02/FiO2 dans les critères de Berlin ?
Giorgia Maiolo et al., AJRCCM, 2018
https://www.atsjournals.org/
https://doi.org/10.1164/rccm.201709-1804OC
L’adrénaline associée à un risque de mortalité x3 dans le choc cardiogénique ?
Leopold et al., ICM, 2018
Objective
Catecholamines have been the mainstay of pharmacological treatment of cardiogenic shock (CS). Recently, use of epinephrine has been associated with detrimental outcomes. In the present study we aimed to evaluate the association between epinephrine use and short-term mortality in all-cause CS patients.
Design
We performed a meta-analysis of individual data with prespecified inclusion criteria: (1) patients in non-surgical CS treated with inotropes and/or vasopressors and (2) at least 15% of patients treated with epinephrine administrated alone or in association with other inotropes/vasopressors. The primary outcome was short-term mortality.
Measurements and results
Fourteen published cohorts and two unpublished data sets were included. We studied 2583 patients. Across all cohorts of patients, the incidence of epinephrine use was 37% (17–76%) and short-term mortality rate was 49% (21–69%). A positive correlation was found between percentages of epinephrine use and short-term mortality in the CS cohort. The risk of death was higher in epinephrine-treated CS patients (OR [CI] = 3.3 [2.8–3.9]) compared to patients treated with other drug regimens. Adjusted mortality risk remained striking in epinephrine-treated patients (n = 1227) (adjusted OR = 4.7 [3.4–6.4]). After propensity score matching, two sets of 338 matched patients were identified and epinephrine use remained associated with a strong detrimental impact on short-term mortality (OR = 4.2 [3.0–6.0]).
Conclusions
In this very large cohort, epinephrine use for hemodynamic management of CS patients is associated with a threefold increase of risk of death.
L’échographie trans-thoracique associée à une meilleure survie chez les patients septiques ?
Feng et al., ICM, 2018
Purpose
While the use of transthoracic echocardiography (TTE) in the ICU is rapidly expanding, the contribution of TTE to altering patient outcomes among ICU patients with sepsis has not been examined. This study was designed to examine the association of TTE with 28-day mortality specifically in that population.
Methods and results
The MIMIC-III database was employed to identify patients with sepsis who had and had not received TTE. The statistical approaches utilized included multivariate regression, propensity score analysis, doubly robust estimation, the gradient boosted model, and an inverse probability-weighting model to ensure the robustness of our findings. Significant benefit in terms of 28-day mortality was observed among the TTE patients compared to the control (no TTE) group (odds ratio = 0.78, 95% CI 0.68–0.90, p < 0.001). The amount of fluid administered (2.5 vs. 2.1 L on day 1, p < 0.001), use of dobutamine (2% vs. 1%, p = 0.007), and the maximum dose of norepinephrine (1.4 vs. 1 mg/min, p = 0.001) were significantly higher for the TTE patients. Importantly, the TTE patients were weaned off vasopressors more quickly than those in the no TTE group (vasopressor-free days on day 28 of 21 vs. 19, p = 0.004).
Conclusion
In a general population of critically ill patients with sepsis, use of TTE is associated with an improvement in 28-day mortality.
Hypotension en réanimation : Augmentation de 4% du risque de mortalité toutes les 2h de PAM en dessous de 65mmHg
Maheshwari et al., ICM, 2018
https://link.springer.com/content/pdf/10.1007/s00134-018-5218-5
Purpose:
Methods:
Results:
Conclusions:
Faut-il réévaluer le diagnostic de SDRA à J2 ?
Madotto et al., ICM, 2018
Purpose
To evaluate patients with resolved versus confirmed ARDS, identify subgroups with substantial mortality risk, and to determine the utility of day 2 ARDS reclassification.
Methods
Our primary objective, in this secondary LUNG SAFE analysis, was to compare outcome in patients with resolved versus confirmed ARDS after 24 h. Secondary objectives included identifying factors associated with ARDS persistence and mortality, and the utility of day 2 ARDS reclassification.
Results
Of 2377 patients fulfilling the ARDS definition on the first day of ARDS (day 1) and receiving invasive mechanical ventilation, 503 (24%) no longer fulfilled the ARDS definition the next day, 52% of whom initially had moderate or severe ARDS. Higher tidal volume on day 1 of ARDS was associated with confirmed ARDS [OR 1.07 (CI 1.01–1.13), P = 0.035]. Hospital mortality was 38% overall, ranging from 31% in resolved ARDS to 41% in confirmed ARDS, and 57% in confirmed severe ARDS at day 2. In both resolved and confirmed ARDS, age, non-respiratory SOFA score, lower PEEP and P/F ratio, higher peak pressure and respiratory rate were each associated with mortality. In confirmed ARDS, pH and the presence of immunosuppression or neoplasm were also associated with mortality. The increase in area under the receiver operating curve for ARDS reclassification on day 2 was marginal.
Conclusions
ARDS, whether resolved or confirmed at day 2, has a high mortality rate. ARDS reclassification at day 2 has limited predictive value for mortality. The substantial mortality risk in severe confirmed ARDS suggests that complex interventions might best be tested in this population.
ARA II ou IEC post insuffisance rénale aiguë en réanimation : diminution de la mortalité à 1 an
Gayat et al., ICM, 2018
Purpose
Acute kidney injury (AKI) is associated with the activation of the renin–angiotensin system. Whether angiotensin-converting enzyme inhibitors (ACEi) or angiotensin-receptor blockers (ARB) improve outcome in patients recovering from AKI remains unexplored. The purpose was to investigate the association between prescription of ACEi/ARB at intensive care unit (ICU) discharge and 1-year outcome in patients recovering from AKI.
Methods
Association between ACEi/ARB and 1-year mortality rate was explored in 1551 patients discharged from 21 European ICUs in an observational cohort. One-year all-cause mortality after ICU discharge was the primary endpoint. AKI was defined using the kidney disease improvement global outcome definition. Propensity score matching was used to consider the probability to receive ACEi/ARB at ICU discharge and included chronic heart failure, ACEi/ARB on ICU admission, Charlson Comorbidity Index, age, diabetes mellitus, chronic kidney disease, estimated glomerular filtration rate and arterial blood pressure at ICU discharge vasopressors and renal replacement therapy.
Results
Overall, 1-year mortality was 28 and 15% in patients with AKI (n = 611, 39%) and without AKI (n = 940), respectively. In patients with AKI, unadjusted, adjusted and propensity-score matched 1-year mortality rates were lower in patients treated with ACEi/ARB at ICU discharge [HR of 0.55 (0.35–0.89), HR of 0.45 (0.27–0.75), and HR of 0.48 (0.27–0.85, p < 0.001), respectively]. These results were consistent across sensitivity analysis. No association was observed in patients without AKI.
Conclusions
In patients discharged alive from the ICU after experiencing AKI, ACEi/ARB prescription at discharge is associated with a decrease in 1-year mortality.
Quelques courts rappels :
-Sur l’insuffisance surrénale aiguë
– Sur les objectifs de température après un arrêt cardio-respiratoire
– Sur la tamponnade
– Sur le changement physiologique cardiaque du sujet âgé
– Sur la pression artérielle
-Sur les alternatives au Catéthérisme droit
– Sur les agents vasopresseurs et ionotropes :
Pharmacologie et algorithme de prise en charge
Le cœur droit : diagnostic et management en 10 points
Antoine Vieillard-Baron et al., ICM, 2018
La survenue d’une hypotension <65mmHg en per-opératoire de chirurgie cardiaque augmente le risque d’AVC ischémique
Defining an Intraoperative Hypotension Threshold in Association with Stroke in Cardiac Surgery
Louise Y. Sun, M.D., S.M.; Amy M. Chung, M.D., M.Sc.; Michael E. Farkouh, M.D., M.Sc.; Sean van Diepen, M.D., M.Sc.; Jesse Weinberger, M.D.; et al
Anesthesiology Newly Published on June 7, 2018. doi:10.1097/ALN.0000000000002298
Abstract
Background: Stroke is a leading cause of morbidity, mortality, and disability in patients undergoing cardiac surgery. Identifying modifiable perioperative stroke risk factors may lead to improved patient outcomes. The association between the severity and duration of intraoperative hypotension and postoperative stroke in patients undergoing cardiac surgery was evaluated.
Methods
A retrospective cohort study was conducted of adult patients who underwent cardiac surgery requiring cardiopulmonary bypass at a tertiary center between November 1, 2009, and March 31, 2015. The primary outcome was postoperative ischemic stroke. Intraoperative hypotension was defined as the number of minutes spent within mean arterial pressure bands of less than 55, 55 to 64, and 65 to 74 mmHg before, during, and after cardiopulmonary bypass. The association between stroke and hypotension was examined by using logistic regression with propensity score adjustment.
Results
Among the 7,457 patients included in this analysis, 111 (1.5%) had a confirmed postoperative diagnosis of stroke. Stroke was strongly associated with sustained mean arterial pressure of less than 64 mmHg during cardiopulmonary bypass (adjusted odds ratio 1.13; 95% CI, 1.05 to 1.21 for every 10 min of mean arterial pressure between 55 and 64 mmHg; adjusted odds ratio 1.16; 95% CI, 1.08 to 1.23 for every 10 min of mean arterial pressure less than 55 mmHg). Other factors that were independently associated with stroke were older age, hypertension, combined coronary artery bypass graft/valve surgery, emergent operative status, prolonged cardiopulmonary bypass duration, and postoperative new-onset atrial fibrillation.
Conclusions
Hypotension is a potentially modifiable risk factor for perioperative stroke. The study’s findings suggest that mean arterial pressure may be an important intraoperative therapeutic hemodynamic target to reduce the incidence of stroke in patients undergoing cardiopulmonary bypass.
Le bloc suprascapulaire antérieur > le bloc inster-scalénique : pour préserver la fonction diaphragmatique ?
Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial
David B. Auyong, M.D.; Neil A. Hanson, M.D.; Raymond S. Joseph, M.D.; Brian E. Schmidt, M.D.; April E. Slee, M.S.; et al
Anesthesiology 7 2018, Vol.129, 47-57.
doi:10.1097/ALN.0000000000002208
Abstract
Background
The interscalene nerve block provides analgesia for shoulder surgery, but is associated with diaphragm paralysis. One solution may be performing brachial plexus blocks more distally. This noninferiority study evaluated analgesia for blocks at the supraclavicular and anterior suprascapular levels, comparing them individually to the interscalene approach.
Methods
One hundred-eighty-nine subjects undergoing arthroscopic shoulder surgery were recruited to this double-blind trial and randomized to interscalene, supraclavicular, or anterior suprascapular block using 15 ml, 0.5% ropivacaine. The primary outcome was numeric rating scale pain scores analyzed using noninferiority testing. The predefined noninferiority margin was one point on the 11-point pain scale. Secondary outcomes included opioid consumption and pulmonary assessments.
Results
All subjects completed the study through the primary outcome analysis. Mean pain after surgery was: interscalene = 1.9 (95% CI, 1.3 to 2.5), supraclavicular = 2.3 (1.7 to 2.9), suprascapular = 2.0 (1.4 to 2.6). The primary outcome, mean pain score difference of supraclavicular–interscalene was 0.4 (–0.4 to 1.2; P = 0.088 for noninferiority) and of suprascapular–interscalene was 0.1 (–0.7 to 0.9; P = 0.012 for noninferiority). Secondary outcomes showed similar opioid consumption with better preservation of vital capacity in the anterior suprascapular group (90% baseline [P < 0.001]) and the supraclavicular group (76% [P = 0.002]) when compared to the interscalene group (67%).
Conclusions
The anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared to the interscalene approach for major arthroscopic shoulder surgery. Pulmonary function is best preserved with the anterior suprascapular nerve block.
Une stratégie de prise en charge hémodynamique précoce des grands brulés
Early Hemodynamic Management of Critically Ill Burn Patients
Sabri Soussi, M.D.; François Dépret, M.D.; Mourad Benyamina, M.D.; Matthieu Legrand, M.D., Ph.D.
Anesthesiology Newly Published on June 28, 2018.
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2686991
doi:10.1097/ALN.0000000000002314
Pas d’effet mis en évidence du fibrinogène précoce dans l’hémorragie traumatique dans un essai pilote…Administration trop tardive ?
Early fibrinogen concentrate therapy for major haemorrhage in trauma (E-FIT 1): results from a UK multi-centre, randomised, double blind, placebo-controlled pilot trial
Nicola Curry, Claire Foley, Henna Wong, Ana Mora, Elinor Curnow, Agne Zarankaite, Renate Hodge, Valerie Hopkins, Alison Deary, James Ray, Phil Moss, Matthew J. Reed, Suzanne Kellett, Ross Davenport and Simon Stanworth
Critical Care 201822:164
https://doi.org/10.1186/s13054-018-2086-x
Abstract
Background
There is increasing interest in the timely administration of concentrated sources of fibrinogen to patients with major traumatic bleeding. Following evaluation of early cryoprecipitate in the CRYOSTAT 1 trial, we explored the use of fibrinogen concentrate, which may have advantages of more rapid administration in acute haemorrhage. The aims of this pragmatic study were to assess the feasibility of fibrinogen concentrate administration within 45 minutes of hospital admission and to quantify efficacy in maintaining fibrinogen levels ≥ 2 g/L during active haemorrhage.
Methods
We conducted a blinded, randomised, placebo-controlled trial at five UK major trauma centres with adult trauma patients with active bleeding who required activation of the major haemorrhage protocol. Participants were randomised to standard major haemorrhage therapy plus 6 g of fibrinogen concentrate or placebo.
Results
Twenty-seven of 39 participants (69%; 95% CI, 52–83%) across both arms received the study intervention within 45 minutes of admission. There was some evidence of a difference in the proportion of participants with fibrinogen levels ≥ 2 g/L between arms (p = 0.10). Fibrinogen levels in the fibrinogen concentrate (FgC) arm rose by a mean of 0.9 g/L (SD, 0.5) compared with a reduction of 0.2 g/L (SD, 0.5) in the placebo arm and were significantly higher in the FgC arm (p < 0.0001) at 2 hours. Fibrinogen levels were not different at day 7. Transfusion use and thromboembolic events were similar between arms. All-cause mortality at 28 days was 35.5% (95% CI, 23.8–50.8%) overall, with no difference between arms.
Conclusions
In this trial, early delivery of fibrinogen concentrate within 45 minutes of admission was not feasible. Although evidence points to a key role for fibrinogen in the treatment of major bleeding, researchers need to recognise the challenges of timely delivery in the emergency setting. Future studies must explore barriers to rapid fibrinogen therapy, focusing on methods to reduce time to randomisation, using ‘off-the-shelf’ fibrinogen therapies (such as extended shelf-life cryoprecipitate held in the emergency department or fibrinogen concentrates with very rapid reconstitution times) and limiting the need for coagulation test-based transfusion triggers.
Evaluation échographique de la perfusion rénale pendant le choc septique : une étude observationnelle
Acute kidney injury is associated with a decrease in cortical renal perfusion during septic shock
Anatole Harrois, Nicolas Grillot, Samy Figueiredo and Jacques Duranteau
Critical Care 2018 22:161
https://doi.org/10.1186/s13054-018-2067-0
Background
Renal perfusion status remains poorly studied at the bedside during septic shock. We sought to measure cortical renal perfusion in patients with septic shock during their first 3 days of care using renal contrast enhanced ultrasound (CEUS).
Methods
We prospectively included 20 ICU patients with septic shock and 10 control patients (CL) without septic shock admitted to a surgical ICU. Cortical renal perfusion was evaluated with CEUS during continuous infusion of Sonovue (Milan, Italy) within the first 24 h (day 0), between 24 and 48 h (day 1) and after 72 h (day 3) of care. Each measurement consisted of three destruction replenishment sequences that were recorded for delayed analysis with dedicated software (Vuebox). Renal perfusion was quantified by measuring the mean transit time (mTT) and the perfusion index (PI), which is the ratio of renal blood volume (rBV) to mTT.
Results
Cortical renal perfusion was decreased in septic shock as attested by a lower PI and a higher mTT in patients with septic shock than in patients of the CL group (p = 0.005 and p = 0.03). PI values had wider range in patients with septic shock (median (min-max) of 74 arbitrary units (a.u.) (3–736)) than in patients of the CL group 228 a.u. (67–440)). Renal perfusion improved over the first 3 days with a PI at day 3 higher than the PI at day 0 (74 (22–120) versus 160 (88–245) p = 0.02). mTT was significantly higher in patients with severe acute kidney injury (AKI) (n = 13) compared with patients with no AKI (n = 7) over time (p = 0.005). The PI was not different between patients with septic shock with severe AKI and those with no AKI (p = 0.29).
Conclusions
Although hemodynamic macrovascular parameters were restored, the cortical renal perfusion can be decreased, normal or even increased during septic shock. We observed an average decrease in cortical renal perfusion during septic shock compared to patients without septic shock. The decrease in cortical renal perfusion was associated with severe AKI occurrence. The use of renal CEUS to guide renal perfusion resuscitation needs further investigation.
Revue sur l’évaluation pronostique après ACR
Prognostication after cardiac arrest
Claudio Sandroni Sonia D’Arrigo and Jerry P. Nolan
Critical Care 2018 22:150
https://doi.org/10.1186/s13054-018-2060-7
Abstract
Hypoxic–ischaemic brain injury (HIBI) is the main cause of death in patients who are comatose after resuscitation from cardiac arrest. A poor neurological outcome—defined as death from neurological cause, persistent vegetative state, or severe neurological disability—can be predicted in these patients by assessing the severity of HIBI. The most commonly used indicators of severe HIBI include bilateral absence of corneal and pupillary reflexes, bilateral absence of N2O waves of short-latency somatosensory evoked potentials, high blood concentrations of neuron specific enolase, unfavourable patterns on electroencephalogram, and signs of diffuse HIBI on computed tomography or magnetic resonance imaging of the brain. Current guidelines recommend performing prognostication no earlier than 72 h after return of spontaneous circulation in all comatose patients with an absent or extensor motor response to pain, after having excluded confounders such as residual sedation that may interfere with clinical examination. A multimodal approach combining multiple prognostication tests is recommended so that the risk of a falsely pessimistic prediction is minimised.
sPD-1 et sPD-L1 comme marqueurs d’immunoparalysie chez les patients septiques ?
Soluble programmed cell death protein-1 and programmed cell death ligand-1 in sepsis
Debasree Banerjee, Sean Monaghan, Runping Zhao, Thomas Walsh, Amy Palmisciano, Gary S. Phillips, Steven Opal and Mitchell M. Levy
Critical Care 2018 22:146
https://doi.org/10.1186/s13054-018-2064-3
Pharmacologie des anti-épileptiques à l’usage du réanimateur
Antiepileptic drugs in critically ill patients
Salia Farrokh, Pouya Tahsili-Fahadan, Eva K. Ritzl, John J. Lewin and Marek A. Mirski
Critical Care201822:153
https://doi.org/10.1186/s13054-018-2066-1
Abstract
Background
The incidence of seizures in intensive care units ranges from 3.3% to 34%. It is therefore often necessary to initiate or continue anticonvulsant drugs in this setting. When a new anticonvulsant is initiated, drug factors, such as onset of action and side effects, and patient factors, such as age, renal, and hepatic function, should be taken into account. It is important to note that the altered physiology of critically ill patients as well as pharmacological and nonpharmacological interventions such as renal replacement therapy, extracorporeal membrane oxygenation, and target temperature management may lead to therapeutic failure or toxicity. This may be even more challenging with the availability of newer antiepileptics where the evidence for their use in critically ill patients is limited.
Main body
This article reviews the pharmacokinetics and pharmacodynamics of antiepileptics as well as application of these principles when dosing antiepileptics and monitoring serum levels in critically ill patients. The selection of the most appropriate anticonvulsant to treat seizure and status epileptics as well as the prophylactic use of these agents in this setting are also discussed. Drug-drug interactions and the effect of nonpharmacological interventions such as renal replacement therapy, plasma exchange, and extracorporeal membrane oxygenation on anticonvulsant removal are also included.
Conclusion
Optimal management of antiepileptic drugs in the intensive care unit is challenging given altered physiology, polypharmacy, and nonpharmacological interventions, and requires a multidisciplinary approach where appropriate and timely assessment, diagnosis, treatment, and monitoring plans are in place.
Le BAT score pour prédire l’évolution des hématomes intra-cérébraux ?
Morotto et al., Stroke, 2018
http://stroke.ahajournals.org/content/49/5/1163.long
https://doi.org/10.1161/STROKEAHA.117.020138
Background and Purpose—Although the computed tomographic angiography spot sign performs well as a biomarker for hematoma expansion (HE), computed tomographic angiography is not routinely performed in the emergency setting. We developed and validated a score to predict HE-based on noncontrast computed tomography (NCCT) findings in spontaneous acute intracerebral hemorrhage.
Methods—After developing the score in a single-center cohort of patients with intracerebral hemorrhage (n=344), we validated it in a large clinical trial population (n=954) and in a multicenter intracerebral hemorrhage cohort (n=241). The following NCCT markers of HE were analyzed: hypodensities, blend sign, hematoma shape and density, and fluid level. HE was defined as hematoma growth >6 mL or >33%. The score was created using the estimates from multivariable logistic regression after final predictors were selected from bootstrap samples.
Results—Presence of blend sign (odds ratio, 3.09; 95% confidence interval [CI],1.49–6.40; P=0.002), any intrahematoma hypodensity (odds ratio, 4.54; 95% CI, 2.44–8.43; P<0.0001), and time from onset to NCCT <2.5 hours (odds ratio, 3.73; 95% CI, 1.86–7.51; P=0.0002) were predictors of HE. A 5-point score was created (BAT score: 1 point for blend sign, 2 points for any hypodensity, and 2 points for timing of NCCT <2.5 hours). The c statistic was 0.77 (95% CI, 0.70–0.83) in the development population, 0.65 (95% CI 0.61–0.68) and 0.70 (95% CI, 0.64–0.77) in the 2 validation cohorts. A dichotomized score (BAT score ≥3) predicted HE with 0.50 sensitivity and 0.89 specificity.
Conclusions—An easy to use 5-point prediction score can identify subjects at high risk of HE with good specificity and accuracy. This tool requires just a baseline NCCT scan and may help select patients with intracerebral hemorrhage for antiexpansion clinical trials.
Intérêt de l’Angiotensine II chez les patients en insuffisance rénale aiguë nécessitant une épuration extra-rénale (étude ATHOS-3)
Tumlin et al., CCM, 2018
doi: 10.1097/CCM.0000000000003092
Objective
Acute kidney injury requiring renal replacement therapy in severe vasodilatory shock is associated with an unfavorable prognosis. Angiotensin II treatment may help these patients by potentially restoring renal function without decreasing intrarenal oxygenation. We analyzed the impact of angiotensin II on the outcomes of acute kidney injury requiring renal replacement therapy.
Design
Post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial.
Setting
ICUs.
Patients
Patients with acute kidney injury treated with renal replacement therapy at initiation of angiotensin II or placebo (n = 45 and n = 60, respectively).
Interventions
IV angiotensin II or placebo.
Measurements and Main Results
Primary end point: survival through day 28; secondary outcomes included renal recovery through day 7 and increase in mean arterial pressure from baseline of ≥ 10 mm Hg or increase to ≥ 75 mm Hg at hour 3. Survival rates through day 28 were 53% (95% CI, 38%–67%) and 30% (95% CI, 19%–41%) in patients treated with angiotensin II and placebo (p = 0.012), respectively. By day 7, 38% (95% CI, 25%–54%) of angiotensin II patients discontinued RRT versus 15% (95% CI, 8%–27%) placebo (p = 0.007). Mean arterial pressure response was achieved in 53% (95% CI, 38%–68%) and 22% (95% CI, 12%–34%) of patients treated with angiotensin II and placebo (p = 0.001), respectively.
Conclusions
In patients with acute kidney injury requiring renal replacement therapy at study drug initiation, 28-day survival and mean arterial pressure response were higher, and rate of renal replacement therapy liberation was greater in the angiotensin II group versus the placebo group. These findings suggest that patients with vasodilatory shock and acute kidney injury requiring renal replacement therapy may preferentially benefit from angiotensin II.
Le niveau de sédation dans les 48 premières heures de ventilation mécanique a-t-il un impact sur la survie à long terme ? (étude SPICE)
Plus grande mortalité en réanimation chez les consommateurs réguliers d’opioïdes
Épidémiologie des PAVM en France entre 2007 et 2014 (résultats du réseau REA-Raisin)
La mortalité globale est-elle un bon critère de jugement dans les études sur le SDRA ?
La diversité des manifestations cliniques du sepsis a-t-elle une explication moléculaire ?
Revue sur l’hypothermie thérapeutique en neuro-réanimation
Méta-analyse sur l’effet de l’hyperoxie et l’incidence des infections du site opératoire
Cohen et al., BJA, 2018
https://bjanaesthesia.org/
Revue Cochrane sur l’utilisation ou non de curares pour l’intubation
L.H. Lundstrøm et al., BJA, 2018
https://bjanaesthesia.org/
Gestion de la pression artérielle et pronostic neurologique lors des thrombectomies d’AVC
Rasmussen et al., BJA, 2018
https://bjanaesthesia.org/
Beta-bloquant et BPCO : Pas de majoration des troubles ventilatoires
Maltais et al., Chest, 2018
https://journal.chestnet.org/article/S0012-3692(18)30080-1/fulltext
DOI: https://doi.org/10.1016/j.chest.2018.01.008
Background
Cardiovascular disease is a frequent comorbidity in patients with COPD. Many physicians, particularly pulmonologists, are reluctant to use β-adrenoceptor blocking agents (β-blockers) in patients with COPD, despite their proven effectiveness in preventing cardiovascular events.
Methods
The large (5,162 patients) phase III TONADO 1 and 2 studies assessed lung function and patient-reported outcomes in patients with moderate to very severe COPD receiving long-acting bronchodilator treatment across 1 year. This post hoc analysis characterized lung-function changes, patient-reported outcomes, and safety in the subgroup of patients receiving β-blockers in the studies.
Results
In total, 557 of 5,162 patients (11%) received β-blockers at baseline. Postbronchodilator FEV1 at baseline was higher in the β-blocker group (1.470 L) compared with that in the no β-blocker group (1.362 L). As expected, patients receiving β-blockers had a more frequent history of cardiovascular comorbidities and medications. Lung function improved from baseline in patients with or those without β-blocker treatment, and no relevant between-group differences were observed in trough FEV1 or trough FVC at 24 or 52 weeks. No relevant differences were observed for St. George’s Respiratory Questionnaire results and Transition Dyspnea Index in patients with β-blockers compared with those in patients without. Safety findings were comparable between groups.
Conclusions
Lung function, overall respiratory status, and safety of tiotropium/olodaterol were not influenced by baseline β-blocker treatment in patients with moderate to very severe COPD. Results from this large patient cohort support the cautious and appropriate use of β-blockers in patients with COPD and cardiovascular comorbidity.
SDRA et PID : Un pronostic sévère
Gannon et al., Chest, 2018
https://journal.chestnet.org/article/S0012-3692(18)30078-3/fulltext
DOI: https://doi.org/10.1016/j.chest.2018.01.006
Background
We aimed to examine short- and long-term mortality in a mixed population of patients with interstitial lung disease (ILD) with acute respiratory failure, and to identify those at lower vs higher risk of in-hospital death.
Methods
We conducted a single-center retrospective cohort study of 126 consecutive adults with ILD admitted to an ICU for respiratory failure at a tertiary care hospital between 2010 and 2014 and who did not undergo lung transplantation during their hospitalization. We examined associations of ICU-day 1 characteristics with in-hospital and 1-year mortality, using Poisson regression, and examined survival using Kaplan-Meier curves. We created a risk score for in-hospital mortality, using a model developed with penalized regression.
Results
In-hospital mortality was 66%, and 1-year mortality was 80%. Those with connective tissue disease-related ILD had better short-term and long-term mortality compared with unclassifiable ILD (adjusted relative risk, 0.6; 95% CI, 0.3-0.9; and relative risk, 0.6; 95% CI, 0.4-0.9, respectively). Our prediction model includes male sex, interstitial pulmonary fibrosis diagnosis, use of invasive mechanical ventilation and/or extracorporeal life support, no ambulation within 24 h of ICU admission, BMI, and Simplified Acute Physiology Score-II. The optimism-corrected C-statistic was 0.73, and model calibration was excellent (P = .99). In-hospital mortality rates for the low-, moderate-, and high-risk groups were 33%, 65%, and 96%, respectively.
Conclusions
We created a risk score that classifies patients with ILD with acute respiratory failure from low to high risk for in-hospital mortality. The score could aid providers in counseling these patients and their families.
Thrombopénie induite par l’héparine : Forte performance diagnostic du test de libération de la sérotonine radio-marquée
Warkentin et al., Chest, 2018
https://journal.chestnet.org/article/S0012-3692(18)30066-7/fulltext
DOI: https://doi.org/10.1016/j.chest.2018.01.001
Background
Heparin-induced thrombocytopenia (HIT) is a prothrombotic drug reaction caused by platelet-activating antibodies that recognize platelet factor 4 (PF4)/heparin complexes. It is unknown whether platelet-activating antibodies are detectable at the onset of the HIT-related platelet count fall.
Methods
Available blood samples from 18 patients obtained at onset of HIT were tested using the serotonin-release assay (SRA), a test for platelet-activating antibodies, and a PF4-dependent enzyme-linked immunosorbent assay (ELISA). Patient samples showing a delay of > 2 days between ELISA and SRA seroconversion were tested for subthreshold levels of platelet-activating antibodies using two modifications of the SRA that amplify detection of HIT antibodies. We also estimated SRA sensitivity and specificity in two postorthopedic surgery clinical trials (633 samples), including assessing whether a positive SRA influenced platelet count recovery in the absence of thrombocytopenia.
Results
Platelet-activating HIT antibodies were detected in all 18 patients at the beginning of the HIT-related platelet count fall. Although ELISA seroconversion usually preceded SRA seroconversion by only 1 day (median), subthreshold levels of platelet-activating antibodies were detected in both patients who exhibited a lag between ELISA and SRA seroconversion. SRA sensitivity was 100% (18/18), and its specificity was 97% (597/615). Nonthrombocytopenic SRA-positive patients with ongoing heparin treatment exhibited blunted platelet count recovery vs control subjects, suggesting even higher SRA specificity for detecting abnormal platelet count profiles.
Conclusions
Platelet-activating HIT antibodies are detectable at the onset of the HIT-related platelet count fall. The SRA has high sensitivity and specificity for HIT, and indicates that presence of HIT antibodies can blunt postoperative platelet count recovery.
Revue sur le management de la ventilation après un arrêt cardiaque
Johnson et al., Chest, 2018
https://journal.chestnet.org/article/S0012-3692(17)33123-9/fulltext
Sepsis pré-ACR intra-hospitalier de moins bon pronostic ?
Koivikko, Pia*; Arola, Olli*,†; Inkinen, Outi*,†; Tallgren, Minna*,†,‡
Shock: July 2018 – Volume 50 – Issue 1 – p 38–43
doi: 10.1097/SHK.0000000000001024
Aim: Cardiac arrest is not a common complication of sepsis, although sepsis has been recognized as one condition behind cardiac arrest. Our aim was to evaluate the prevalence of sepsis among patients with inhospital cardiac arrest (IHCA), and to determine if sepsis is associated with inferior outcome after IHCA.
Methods: All consecutive emergency team dispatches in Turku University Hospital in 2011 to 2014 (n = 607) were retrospectively reviewed to identify the patients undergoing cardiopulmonary resuscitation (CPR) for IHCA (n = 301). The patient records were reviewed for the criteria of severe sepsis, organ dysfunction, and chronic comorbidities before IHCA. Outcome was followed for 1 year.
Results: The criteria for prearrest severe sepsis were met by 83/301 (28%) of the patients, and 93/301 (31%) had multiorgan dysfunction (3 or more organ systems). The patients with severe sepsis had higher mortality than those without severe sepsis, increasing from 30-day mortalities of 63/83 (76%) and 151/218 (69%), respectively (P = 0.256), to 1-year mortalities of 72/83 (87%) and 164/218 (75%), respectively (P = 0.030). Emergency admission, age, immunosuppression, DM, multiorgan dysfunction, and a nonshockable rhythm were independent predictors of 1-year mortality by multivariate logistic regression analysis. Six out of 83 patients with severe sepsis before IHCA (7%) survived 1 year with good neurological outcome (CPC scale 1).
Conclusions: A high proportion of patients with IHCA have sepsis and multiorgan dysfunction, and their prognosis is worse than the prognosis of patients with IHCA in general.
L’albuminémie comme marqueur précoce de routine pour détecter l’endothéliopathie du traumatisé ?
Early Identification of the Patient with Endotheliopathy of Trauma by Arrival Serum Albumin
Gonzalez Rodriguez, Erika*; Cardenas, Jessica, C.*; Lopez, Ernesto*; Cotton, Bryan, A.*; Tomasek, Jeffrey, S.*; Ostrowski, Sisse, R.†; Baer, Lisa, A.*; Stensballe, Jakob†,‡; Holcomb, John, B.*; Johansson, Pär, I.*,†; Wade, Charles, E.*
Shock: July 2018 – Volume 50 – Issue 1 – p 31–37
doi: 10.1097/SHK.0000000000001036
Objective: Traumatic endotheliopathy (EoT) is associated with glycocalyx breakdown and capillary leak resulting in the extravasation of proteins. We hypothesized that lower serum albumin levels are associated with EoT, poor outcomes, and can be used for early EoT screening in trauma patients.
Methods: We enrolled severely injured trauma patients with serum albumin levels available on admission. Syndecan-1 and soluble thrombomodulin were quantified from plasma by ELISA. Demographic and clinical data were obtained. We evaluated the association of serum albumin and EoT+ (syndecan-1 level ≥40 ng/mL), followed by dichotomization by serum albumin level, and subgroup comparisons.
Results: Of the 258 patients enrolled 92 (36.0%) were EoT+ (syndecan-1 ≥ 40 ng/mL). Median albumin levels in the EoT+ group were 3.4 g/dL, and 3.8 g/dL in EoT− patients, P < 0.05. In a multifactorial analysis, lower albumin levels were inversely associated with the likelihood of EoT+. With receiver characteristic curve analysis, we determined a cutoff albumin level < 3.6 g/dL for EoT+ prediction (area under the curve 0.70; 95% CI: 0.63, 0.77). After dichotomizing by albumin <3.6 or ≥3.6 g/dL, 51.5% of patients had low albumin. Low albumin patients were more likely to have EoT+, as well as higher soluble thrombomodulin (both P < 0.05). Furthermore, they required more frequently blood transfusions, had fewer hospital-free days and higher mortality rate than those with normal albumin.
Conclusions: EoT is a syndrome associated with leakage of albumin from the intravascular compartment, which re-emphasizes that arrival albumin may be a novel and timely approach to the identification of patients needing endothelial rescue therapy.
Perfusion prophylactique de noradrénaline lors de la césarienne programmée pour la prévention des hypotensions
doi: 10.1213/ANE.0000000000002243
BACKGROUND: The use of norepinephrine for maintaining blood pressure (BP) during spinal anesthesia for cesarean delivery has been described recently. However, its administration by titrated manually controlled infusion in this context has not been evaluated.
METHODS: In a double-blinded, randomized controlled trial, 110 healthy women having spinal anesthesia for elective cesarean delivery were randomly allocated to 1 of 2 groups. In group 1, patients received an infusion of 5 µg/mL norepinephrine that was started at 30 mL/h (2.5 µg/min) immediately after intrathecal injection and then manually adjusted within the range 0–60 mL/h (0–5 µg/min), according to values of systolic BP measured noninvasively at 1-minute intervals until delivery, with the objective of maintaining values near baseline. In group 2, no prophylactic vasopressor was given, and a bolus of 1 mL norepinephrine 5 µg/mL (5 µg) was given whenever systolic BP decreased to <80% of the baseline value. The study protocol was continued until delivery. The primary outcomes of the study were the incidence of hypotension and the overall stability of systolic BP control versus baseline compared using performance error calculations. In addition, the incidence and timing of hypotension were further compared using survival analysis.
RESULTS: Three patients were excluded from the analysis. Nine patients (17%) in group 1 had 1 or more episodes of hypotension versus 35 (66%) in group 2 (P < .001). Performance error calculations showed that on average, systolic BP was maintained closer to baseline (P < .001) in group 1. Survival curve analysis showed a significant difference between groups (log-rank test P < .001). Four patients in each group had a recorded heart rate <60 beats/min (P = .98). Despite a much greater rate of administration of norepinephrine in group 1 (median, 61.0 [interquartile range, 47.0–72.5] µg) versus group 2 (5.0 [0–18.1] µg) (P < .001), there was no difference in neonatal outcome as assessed by Apgar scores and umbilical cord blood gas analysis.
CONCLUSIONS: In patients having spinal anesthesia for elective cesarean delivery, a manually titrated infusion of 5 µg/mL of norepinephrine was effective for maintaining BP and decreasing the incidence of hypotension, with no detectable detrimental effect on neonatal outcome. Further investigation of the use of dilute norepinephrine infusions for routine use in obstetric patients is suggested.
Tachycardie (>100/min) et hypotension péri-opératoires (<100mmHg) sont associées avec des lésions myocardiques post-opératoires
doi: 10.1213/ANE.0000000000002560
BACKGROUND: The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS).
METHODS: Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR <55 beats per minute (bpm); maximum SBP >160 mm Hg or minimum SBP <100 mm Hg. Secondary outcomes were myocardial infarction and mortality within 30 days after surgery.
RESULTS: After excluding missing data, 1197 of 15,109 patients (7.9%) sustained MINS, 454 of 16,031 (2.8%) sustained myocardial infarction, and 315 of 16,061 patients (2.0%) died within 30 days after surgery. Maximum intraoperative HR >100 bpm was associated with MINS (odds ratio [OR], 1.27 [1.07–1.50]; P < .01), myocardial infarction (OR, 1.34 [1.05–1.70]; P = .02), and mortality (OR, 2.65 [2.06–3.41]; P < .01). Minimum SBP <100 mm Hg was associated with MINS (OR, 1.21 [1.05–1.39]; P = .01) and mortality (OR, 1.81 [1.39–2.37]; P < .01), but not myocardial infarction (OR, 1.21 [0.98–1.49]; P = .07). Maximum SBP >160 mm Hg was associated with MINS (OR, 1.16 [1.01–1.34]; P = .04) and myocardial infarction (OR, 1.34 [1.09–1.64]; P = .01) but, paradoxically, reduced mortality (OR, 0.76 [0.58–0.99]; P = .04). Minimum HR <55 bpm was associated with reduced MINS (OR, 0.70 [0.59–0.82]; P < .01), myocardial infarction (OR, 0.75 [0.58–0.97]; P = .03), and mortality (OR, 0.58 [0.41–0.81]; P < .01). Minimum SBP <100 mm Hg with maximum HR >100 bpm was more strongly associated with MINS (OR, 1.42 [1.15–1.76]; P < .01) compared with minimum SBP <100 mm Hg alone (OR, 1.20 [1.03–1.40]; P = .02).
CONCLUSIONS: Intraoperative tachycardia and hypotension are associated with MINS. Further interventional research targeting HR/blood pressure is needed to define the optimum strategy to reduce MINS.
Facteurs de risque d’échec de masques laryngés
doi: 10.1213/ANE.0000000000002659
BACKGROUND: Extraglottic airway device (EGA) failure can be associated with severe complications and adverse patient outcomes. Prior research has identified patient- and procedure-related predictors of EGA failure. In this retrospective study, we assessed the incidence of perioperative EGA failure at our institution and identified modifiable factors associated with this complication that may be the target of preventative or mitigating interventions.
METHODS: We performed a 5-year retrospective analysis of adult general anesthesia cases managed with EGAs in a single academic center. Univariable and multivariable logistic regressions were used to identify clinically modifiable and nonmodifiable factors significantly associated with 3 different types of perioperative EGA failure: (1) “EGA placement failure,” (2) “EGA failure before procedure start,” and (3) “EGA failure after procedure start.”
RESULTS: A total of 19,693 cases involving an EGA were included in the analysis dataset. EGA failure occurred in 383 (1.9%) of the cases. EGA placement failure occurred in 222 (1.13%) of the cases. EGA failure before procedure start occurred in 76 (0.39%) of the cases. EGA failure after procedure start occurred in 85 (0.43%) of the cases. Factors significantly associated with each type of failure and controllable by the anesthesia team were as follows: (1) EGA placement failure: use of desflurane (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.23–2.25) and EGA size 4 or 5 vs 2 or 3 (OR, 0.07; 95% CI, 0.05–0.10); (2) EGA failure before procedure start: use of desflurane (OR, 2.05; 95% CI, 1.23–3.40) and 3 or more placement attempts (OR, 4.69; 95% CI, 2.57–8.56); and (3) EGA failure after procedure start: 3 or more placement attempts (OR, 2.06; 95% CI, 1.02–4.16) and increasing anesthesia time (OR, 1.35; 95% CI, 1.17–1.55).
CONCLUSIONS: The overall incidence of EGA failure was 1.9%, and EGA placement failure was the most common type of failure. We also found that use of desflurane and use of smaller EGA sizes in adult patients were factors under the direct control of anesthesia clinicians associated with EGA failure. An increasing number of attempts at EGA placement was associated with later device failures. Our findings also confirm the association of EGA failure with previously identified patient- and procedure-related factors such as increased body mass index, male sex, and position other than supine.
Pose d’un cathéter sous-clavier : Orienter la tête 30° vers le côté de la pose ?
Hyerim et al., Anesthesia & Analgesia: June 2018 – Volume 126 – Issue 6 – p 1946–1948
doi: 10.1213/ANE.0000000000002446
Revue et méta-analyse sur l’impact de la musique sur l’anxiété et la douleur
Étiquettes :