Biblio du mois : Juin-Juillet 2019

22 juillet 2019Formation • La Biblio du mois

 

Revue sur le coup de chaleur en été en cette période de canicule !

Mais aussi de plus en plus d’études sur le machine learning pour éventuellement vous libérer du temps pour le prochain Afterbloc ? ou goûter le nouvel ingrédient de médecine traditionnelle chinoise contre les PAVM ?

Pour les plus studieux, voici une biblio du mois bien remplie avec de la hépato/chir dig avec de l’évaluation du TIPS ou du traitement chirurgical des péritonites

Du débat sur l’intérêt de manoeuvres de recrutement sur les complications respiratoires post-opératoires : il semblerait qu’une PEEP seule suffise. Bref, de quoi alimenter vos débats lors de la prochaine pétanque !

Sinon du classique avec de l’infectio (impact des DDS pour relancer le débat), de l’ACR et du pronostic, de la physio avec microcirculation…

Un petit point sur les allergies vu le retard de la pollenisation cette année 😉

Et parce qu’il faut rester en forme l’été, une étude « kétamine bonne mine » en tant qu’anti-dépresseur !

Et n’oubliez pas de participer et de partager notre sondage sur vos déclarations (ou non) des AES : https://fr.surveymonkey.com/r/6QF6NH8

Détection d’activité cérébrale par EEG+machine learning chez les traumatisés crâniens ?

Jan Claassen,et al. N Engl J Med 2019; 380:2497-2505

https://www.nejm.org/doi/full/10.1056/NEJMoa1812757?query=TOC
DOI: 10.1056/NEJMoa1812757

Background

Brain activation in response to spoken motor commands can be detected by electroencephalography (EEG) in clinically unresponsive patients. The prevalence and prognostic importance of a dissociation between commanded motor behavior and brain activation in the first few days after brain injury are not well understood.

Methods

We studied a prospective, consecutive series of patients in a single intensive care unit who had acute brain injury from a variety of causes and who were unresponsive to spoken commands, including some patients with the ability to localize painful stimuli or to fixate on or track visual stimuli. Machine learning was applied to EEG recordings to detect brain activation in response to commands that patients move their hands. The functional outcome at 12 months was determined with the Glasgow Outcome Scale–Extended (GOS-E; levels range from 1 to 8, with higher levels indicating better outcomes).

Results

A total of 16 of 104 unresponsive patients (15%) had brain activation detected by EEG at a median of 4 days after injury. The condition in 8 of these 16 patients (50%) and in 23 of 88 patients (26%) without brain activation improved such that they were able to follow commands before discharge. At 12 months, 7 of 16 patients (44%) with brain activation and 12 of 84 patients (14%) without brain activation had a GOS-E level of 4 or higher, denoting the ability to function independently for 8 hours (odds ratio, 4.6; 95% confidence interval, 1.2 to 17.1).

Conclusions

A dissociation between the absence of behavioral responses to motor commands and the evidence of brain activation in response to these commands in EEG recordings was found in 15% of patients in a consecutive series of patients with acute brain injury.

Comment guider la prise en charge avec la Troponine Ultra-sensible ?

https://www.nejm.org/doi/full/10.1056/NEJMoa1803377?query=TOC

Neumann, et al., N Engl J Med 2019; 380:2529-2540
DOI: 10.1056/NEJMoa1803377

Background

Data regarding high-sensitivity troponin concentrations in patients presenting to the emergency department with symptoms suggestive of myocardial infarction may be useful in determining the probability of myocardial infarction and subsequent 30-day outcomes.

Methods

In 15 international cohorts of patients presenting to the emergency department with symptoms suggestive of myocardial infarction, we determined the concentrations of high-sensitivity troponin I or high-sensitivity troponin T at presentation and after early or late serial sampling. The diagnostic and prognostic performance of multiple high-sensitivity troponin cutoff combinations was assessed with the use of a derivation–validation design. A risk-assessment tool that was based on these data was developed to estimate the risk of index myocardial infarction and of subsequent myocardial infarction or death at 30 days.

Results

Among 22,651 patients (9604 in the derivation data set and 13,047 in the validation data set), the prevalence of myocardial infarction was 15.3%. Lower high-sensitivity troponin concentrations at presentation and smaller absolute changes during serial sampling were associated with a lower likelihood of myocardial infarction and a lower short-term risk of cardiovascular events. For example, high-sensitivity troponin I concentrations of less than 6 ng per liter and an absolute change of less than 4 ng per liter after 45 to 120 minutes (early serial sampling) resulted in a negative predictive value of 99.5% for myocardial infarction, with an associated 30-day risk of subsequent myocardial infarction or death of 0.2%; a total of 56.5% of the patients would be classified as being at low risk. These findings were confirmed in an external validation data set.

Conclusions

A risk-assessment tool, which we developed to integrate the high-sensitivity troponin I or troponin T concentration at emergency department presentation, its dynamic change during serial sampling, and the time between the obtaining of samples, was used to estimate the probability of myocardial infarction on emergency department presentation and 30-day outcomes.

Epidémie actuelle d’Ebola en RDC

Kalenga et al. The Ongoing Ebola Epidemic in the Democratic Republic of Congo, 2018–2019. N Engl J Med 2019;epublished May 29th

Revue sur le « coup de chaud »

https://www.nejm.org/doi/full/10.1056/NEJMra1810762?query=pulmonary

Revue sur la prise en charge des brûlés

https://www.nejm.org/doi/full/10.1056/NEJMra1807442?query=pulmonary

Bolus IV de NaCl 0.9% ou d’Albumine associés à plus de morbi-mortalité en réa péd ?

 Levin et al., Lancet, 2019

DOI:https://doi.org/10.1016/S2213-2600(19)30114-6

Background

Methods

Findings

Interpretation

Méta-analyse sur l’extension de la thrombolyse d’AVC à 9h ou au réveil avec l’IRM de perfusion

Campbell et al.  Lancet 2019;epublished May 21st

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31053-0/fulltext

DOI:https://doi.org/10.1016/S0140-6736(19)31053-0

Bénéfice du TIPS précoce chez le patient cirrhotique + rupture de VO ?

Yong Lv, et al., Lancet Gastro 2019

https://www.thelancet.com/journals/langas/article/PIIS2468-1253(19)30090-1/fulltext

DOI:https://doi.org/10.1016/S2468-1253(19)30090-1

Background

Methods

Findings

Interpretation

Hartman ou anatomose en 1 temps pour les péritonites diverticulaires ?

Echec de la stratégie haute PEP + manoeuvres de recrutement sur les complications respiratoires post-opératoires chez la patient obèse ?

Importance  An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain.

Objective  To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP.

Design, Setting, and Participants  Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018.

Interventions  Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H₂O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H₂O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight.

Main Outcomes and Measures  The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with Spo₂ ≤92% for >1 minute).

Results  Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, −2.3% [95% CI, −5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, −8.6% [95% CI, −11.1% to 6.1%]; P < .001).

Conclusions and Relevance  Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications.

Epreuve de VS versus CPAP avant extubation

Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial.

Subirà et al.  JAMA 2019;321(22):2175-2182

DOI : 10.1001/jama.2019.7234

Importance  Daily spontaneous breathing trials (SBTs) are the best approach to determine whether patients are ready for disconnection from mechanical ventilation, but mode and duration of SBT remain controversial.

Objective  To evaluate the effect of an SBT consisting of 30 minutes of pressure support ventilation (an approach that is less demanding for patients) vs an SBT consisting of 2 hours of T-piece ventilation (an approach that is more demanding for patients) on rates of successful extubation.

Design, Setting, and Participants  Randomized clinical trial conducted from January 2016 to April 2017 among 1153 adults deemed ready for weaning after at least 24 hours of mechanical ventilation at 18 intensive care units in Spain. Follow-up ended in July 2017.

Interventions  Patients were randomized to undergo a 2-hour T-piece SBT (n = 578) or a 30-minute SBT with 8-cm H₂O pressure support ventilation (n = 557).

Main Outcome and Measures  The primary outcome was successful extubation (remaining free of mechanical ventilation 72 hours after first SBT). Secondary outcomes were reintubation among patients extubated after SBT; intensive care unit and hospital lengths of stay; and hospital and 90-day mortality.

Results  Among 1153 patients who were randomized (mean age, 62.2 [SD, 15.7] years; 428 [37.1%] women), 1018 (88.3%) completed the trial. Successful extubation occurred in 473 patients (82.3%) in the pressure support ventilation group and 428 patients (74.0%) in the T-piece group (difference, 8.2%; 95% CI, 3.4%-13.0%; P = .001). Among secondary outcomes, for the pressure support ventilation group vs the T-piece group, respectively, reintubation was 11.1% vs 11.9% (difference, −0.8%; 95% CI, −4.8% to 3.1%; P = .63), median intensive care unit length of stay was 9 days vs 10 days (mean difference, −0.3 days; 95% CI, −1.7 to 1.1 days; P = .69), median hospital length of stay was 24 days vs 24 days (mean difference, 1.3 days; 95% CI, −2.2 to 4.9 days; P = .45), hospital mortality was 10.4% vs 14.9% (difference, −4.4%; 95% CI, −8.3% to −0.6%; P = .02), and 90-day mortality was 13.2% vs 17.3% (difference, −4.1% [95% CI, −8.2% to 0.01%; P = .04]; hazard ratio, 0.74 [95% CI, 0.55-0.99]).

Conclusions and Relevance  Among patients receiving mechanical ventilation, a spontaneous breathing trial consisting of 30 minutes of pressure support ventilation, compared with 2 hours of T-piece ventilation, led to significantly higher rates of successful extubation. These findings support the use of a shorter, less demanding ventilation strategy for spontaneous breathing trials.

Double AAP après revascularisation coronaire : OK 1 mois versus 1 an ?

Effect of 1-Month Dual Antiplatelet Therapy Followed by Clopidogrel vs 12-Month Dual Antiplatelet Therapy on Cardiovascular and Bleeding Events in Patients Receiving PCIThe STOPDAPT-2 Randomized Clinical Trial.

Watanabe et al. JAMA 2019;321(24):2414-2427

doi : 10.1001/jama.2019.8145

Importance  Very short mandatory dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with a drug-eluting stent may be an attractive option.

Objective  To test the hypothesis of noninferiority of 1 month of DAPT compared with standard 12 months of DAPT for a composite end point of cardiovascular and bleeding events.

Design, Setting, and Participants  Multicenter, open-label, randomized clinical trial enrolling 3045 patients who underwent PCI at 90 hospitals in Japan from December 2015 through December 2017. Final 1-year clinical follow-up was completed in January 2019.

Interventions  Patients were randomized either to 1 month of DAPT followed by clopidogrel monotherapy (n=1523) or to 12 months of DAPT with aspirin and clopidogrel (n=1522).

Main Outcomes and Measures  The primary end point was a composite of cardiovascular death, myocardial infarction (MI), ischemic or hemorrhagic stroke, definite stent thrombosis, or major or minor bleeding at 12 months, with a relative noninferiority margin of 50%. The major secondary cardiovascular end point was a composite of cardiovascular death, MI, ischemic or hemorrhagic stroke, or definite stent thrombosis and the major secondary bleeding end point was major or minor bleeding.

Results  Among 3045 patients randomized, 36 withdrew consent; of 3009 remaining, 2974 (99%) completed the trial. One-month DAPT was both noninferior and superior to 12-month DAPT for the primary end point, occurring in 2.36% with 1-month DAPT and 3.70% with 12-month DAPT (absolute difference, −1.34% [95% CI, −2.57% to −0.11%]; hazard ratio [HR], 0.64 [95% CI, 0.42-0.98]), meeting criteria for noninferiority (P < .001) and for superiority (P = .04). The major secondary cardiovascular end point occurred in 1.96% with 1-month DAPT and 2.51% with 12-month DAPT (absolute difference, −0.55% [95% CI, −1.62% to 0.52%]; HR, 0.79 [95% CI, 0.49-1.29]), meeting criteria for noninferiority (P = .005) but not for superiority (P = .34). The major secondary bleeding end point occurred in 0.41% with 1-month DAPT and 1.54% with 12-month DAPT (absolute difference, −1.13% [95% CI, −1.84% to −0.42%]; HR, 0.26 [95% CI, 0.11-0.64]; P = .004 for superiority).

Conclusions and Relevance  Among patients undergoing PCI, 1 month of DAPT followed by clopidogrel monotherapy, compared with 12 months of DAPT with aspirin and clopidogrel, resulted in a significantly lower rate of a composite of cardiovascular and bleeding events, meeting criteria for both noninferiority and superiority. These findings suggest that a shorter duration of DAPT may provide benefit, although given study limitations, additional research is needed in other populations.

Double AAP après revascularisation coronaire : OK 3 mois versus 1 an ?

Effect of P2Y12 Inhibitor Monotherapy vs Dual Antiplatelet Therapy on Cardiovascular Events in Patients Undergoing Percutaneous Coronary InterventionThe SMART-CHOICE Randomized Clinical Trial.

Hahn et al. JAMA 2019;321(24):2428-2437

doi:10.1001/jama.2019.8146

Importance  Data on P2Y12 inhibitor monotherapy after short-duration dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention are limited.

Objective  To determine whether P2Y12 inhibitor monotherapy after 3 months of DAPT is noninferior to 12 months of DAPT in patients undergoing PCI.

Design, Setting, and Participants  The SMART-CHOICE trial was an open-label, noninferiority, randomized study that was conducted in 33 hospitals in Korea and included 2993 patients undergoing PCI with drug-eluting stents. Enrollment began March 18, 2014, and follow-up was completed July 19, 2018.

Interventions  Patients were randomly assigned to receive aspirin plus a P2Y12 inhibitor for 3 months and thereafter P2Y12 inhibitor alone (n = 1495) or DAPT for 12 months (n = 1498).

Main Outcomes and Measures  The primary end point was major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke) at 12 months after the index procedure. Secondary end points included the components of the primary end point and bleeding defined as Bleeding Academic Research Consortium type 2 to 5. The noninferiority margin was 1.8%.

Results  Among 2993 patients who were randomized (mean age, 64 years; 795 women [26.6%]), 2912 (97.3%) completed the trial. Adherence to the study protocol was 79.3% of the P2Y12 inhibitor monotherapy group and 95.2% of the DAPT group. At 12 months, major adverse cardiac and cerebrovascular events occurred in 42 patients in the P2Y12 inhibitor monotherapy group and in 36 patients in the DAPT group (2.9% vs 2.5%; difference, 0.4% [1-sided 95% CI, –∞% to 1.3%]; P = .007 for noninferiority). There were no significant differences in all-cause death (21 [1.4%] vs 18 [1.2%]; hazard ratio [HR], 1.18; 95% CI, 0.63-2.21; P = .61), myocardial infarction (11 [0.8%] vs 17 [1.2%]; HR, 0.66; 95% CI, 0.31-1.40; P = .28), or stroke (11 [0.8%] vs 5 [0.3%]; HR, 2.23; 95% CI, 0.78-6.43; P = .14) between the 2 groups. The rate of bleeding was significantly lower in the P2Y12 inhibitor monotherapy group than in the DAPT group (2.0% vs 3.4%; HR, 0.58; 95% CI, 0.36-0.92; P = .02).

Conclusions and Relevance  Among patients undergoing percutaneous coronary intervention, P2Y12 inhibitor monotherapy after 3 months of DAPT compared with prolonged DAPT resulted in noninferior rates of major adverse cardiac and cerebrovascular events. Because of limitations in the study population and adherence, further research is needed in other populations.

Nouveau score de mortalité à long terme dans le sepsis ?

Risk Factors at Index Hospitalization Associated With Longer-term Mortality in Adult Sepsis Survivors

Shankar-Hari et al. JAMA Netw Open 2019;2(5):e194900

doi:10.1001/jamanetworkopen.2019.4900

Atention à ne pas ultrafiltrer trop vite les patients en réa sous CVVHDF ?

Association of Net Ultrafiltration Rate With Mortality Among Critically Ill Adults With Acute Kidney Injury Receiving Continuous Venovenous HemodiafiltrationA Secondary Analysis of the Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy Trial.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2735468

Importance  Net ultrafiltration (NUF) is frequently used to treat fluid overload among critically ill patients, but whether the rate of NUF affects outcomes is unclear.

Objective  To examine the association of NUF with survival among critically ill patients with acute kidney injury being treated with continuous venovenous hemodiafiltration.

Design, Setting, and Participants  The Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy trial was conducted between December 30, 2005, and November 28, 2008, at 35 intensive care units in Australia and New Zealand among critically ill adults with acute kidney injury who were being treated with continuous venovenous hemodiafiltration. This secondary analysis began in May 2018 and concluded in January 2019.

Exposures  Net ultrafiltration rate, defined as the volume of fluid removed per hour adjusted for patient body weight.

Main Outcomes and Measures  Risk-adjusted 90-day survival.

Results  Of 1434 patients, the median (interquartile range) age was 67.3 (56.9-76.3) years; 924 participants (64.4%) were male; median (interquartile range) Acute Physiology and Chronic Health Evaluation III score was 100 (84-118); and 634 patients (44.2%) died. Using tertiles, 3 groups were defined: high, NUF rate greater than 1.75 mL/kg/h; middle, NUF rate from 1.01 to 1.75 mL/kg/h; and low, NUF rate less than 1.01 mL/kg/h. The high-tertile group compared with the low-tertile group was not associated with death from day 0 to 6. However, death occurred in 51 patients (14.7%) in the high-tertile group vs 30 patients (8.6%) in the low-tertile group from day 7 to 12 (adjusted hazard ratio [aHR], 1.51; 95% CI, 1.13-2.02); 45 patients (15.3%) in the high-tertile group vs 25 patients (7.9%) in the low-tertile group from day 13 to 26 (aHR, 1.52; 95% CI, 1.11-2.07); and 48 patients (19.2%) in the high-tertile group vs 29 patients (9.9%) in the low-tertile group from day 27 to 90 (aHR, 1.66; 95% CI, 1.16-2.39). Every 0.5-mL/kg/h increase in NUF rate was associated with increased mortality (3-6 days: aHR, 1.05; 95% CI, 1.00-1.11; 7-12 days: aHR, 1.08; 95% CI, 1.02-1.15; 13-26 days: aHR, 1.11; 95% CI, 1.04-1.18; 27-90 days: aHR, 1.13; 95% CI, 1.05-1.22). Using longitudinal analyses, increase in NUF rate was associated with lower survival (β = .056; P < .001). Hypophosphatemia was more frequent among patients in the high-tertile group compared with patients in the middle-tertile group and patients in the low-tertile group (high: 308 of 477 patients at risk [64.6%]; middle: 293 of 472 patients at risk [62.1%]; low: 247 of 466 patients at risk [53.0%]; P < .001). Cardiac arrhythmias requiring treatment occurred among all groups: high, 176 patients (36.8%); middle: 175 patients (36.5%); and low: 147 patients (30.8%) (P = .08).

Conclusions and Relevance  Among critically ill patients, NUF rates greater than 1.75 mL/kg/h compared with NUF rates less than 1.01 mL/kg/h were associated with lower survival. Residual confounding may be present from unmeasured risk factors, and randomized clinical trials are required to confirm these findings.

Impact de l’utilisation de l’ETT dans la prise en charge d’IDM ?

Pack et al., JAMA Intern Med.

doi:10.1001/jamainternmed.2019.1051

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2735988

Importance  Guidelines recommend that patients with acute myocardial infarction (AMI) undergo echocardiography for assessment of cardiac structure and ejection fraction, but little is known about the association between echocardiography as used in routine clinical management of AMI and patient outcomes.

Objective  To examine the association between risk-standardized hospital rates of transthoracic echocardiography and outcomes.

Design, Setting, and Participants  This retrospective cohort study of data from 397 US hospitals that contributed to the Premier Healthcare Informatics inpatient database from January 1, 2014, to December 31, 2014, used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify 98 999 hospital admissions for patients with AMI. Data were analyzed between October 2017 and January 2019.

Exposures  Rates of transthoracic echocardiography.

Main Outcomes and Measures  Inpatient mortality, length of stay, total inpatient costs, and 3-month readmission rate.

Results  Among the 397 hospitals with more than 25 admissions for AMI in 2014, a total of 98 999 hospital admissions for AMI were identified for analysis (38.2% women; mean [SD] age, 66.5 [13.6] years), of which 69 652 (70.4%) had at least 1 transthoracic echocardiogram performed. The median (IQR) hospital risk-standardized rate of echocardiography was 72.5% (62.6%-79.1%). In models that adjusted for hospital and patient characteristics, no difference was found in inpatient mortality (odds ratio [OR], 1.02; 95% CI, 0.88-1.19) or 3-month readmission (OR, 1.01; 95% CI, 0.93-1.10) between the highest and lowest quartiles of echocardiography use (median risk-standardized echocardiography use rates of 83% vs 54%, respectively). However, hospitals with the highest rates of echocardiography had modestly longer mean lengths of stay (0.23 days; 95% CI, 0.04-0.41; P = .01) and higher mean costs ($3164; 95% CI, $1843-$4485; P < .001) per admission compared with hospitals in the lowest quartile of use. Multiple sensitivity analyses yielded similar results.

Conclusions and Relevance  In patients with AMI, hospitals in the quartile with the highest rates of echocardiography showed greater hospital costs and length of stay but few differences in clinical outcomes compared with hospitals in the quartile with the lowest rates of echocardiography. These findings suggest that more selective use of echocardiography might be used without adversely affecting clinical outcomes, particularly in hospitals with high rates of echocardiography use.

Choc septique = Noradrénaline précoce ?

https://www.atsjournals.org/doi/full/10.1164/rccm.201806-1034OC?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed

Rationale: Recent retrospective evidence suggests the efficacy of early norepinephrine administration during resuscitation; however, prospective data to support this assertion are scarce.

Objectives: To conduct a phase II trial evaluating the hypothesis that early low-dose norepinephrine in adults with sepsis with hypotension increases shock control by 6 hours compared with standard care.

Methods: This single-center, randomized, double-blind, placebo-controlled clinical trial was conducted at Siriraj Hospital, Bangkok, Thailand. The study enrolled 310 adults diagnosed with sepsis with hypotension. The patients were randomly divided into two groups: early norepinephrine (n = 155) and standard treatment (n = 155). The primary outcome was shock control rate (defined as achievement of mean arterial blood pressure ≥65 mm Hg, with urine flow ≥0.5 ml/kg/h for 2 consecutive hours, or decreased serum lactate ≥10% from baseline) by 6 hours after diagnosis.

Measurements and Main Results: The patients in both groups were well matched in background characteristics and disease severity. Median time from emergency room arrival to norepinephrine administration was significantly shorter in the early norepinephrine group (93 vs. 192 min; P < 0.001). Shock control rate by 6 hours was significantly higher in the early norepinephrine group (118/155 [76.1%] vs. 75/155 [48.4%]; P < 0.001). The 28-day mortality was not different between groups: 24/155 (15.5%) in the early norepinephrine group versus 34/155 (21.9%) in the standard treatment group (P = 0.15). The early norepinephrine group was associated with lower incidences of cardiogenic pulmonary edema (22/155 [14.4%] vs. 43/155 [27.7%]; P = 0.004) and new-onset arrhythmia (17/155 [11%] vs. 31/155 [20%]; P = 0.03).

Conclusions: Early norepinephrine was significantly associated with increased shock control by 6 hours. Further studies are needed before this approach is introduced in clinical resuscitation practice.

Impact des paramètres de ventilation chez le spatients sous ECMO

Mechanical Ventilation Management during ECMO for ARDS: An International Multicenter Prospective Cohort (LIFEGARDS Study).

Schmidt et al. Am J Respir Crit Care Med 2019;epublished May 30th

https://doi.org/10.1164/rccm.201806-1094OC

Objectives: To report current practices regarding mechanical ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) and their association with 6-month outcomes.

Methods: International, multi-center, prospective cohort study of patients undergoing ECMO for ARDS during a one-year period in 23 international intensive care units (ICUs).

Measurements and Main Results: We collected demographics, daily pre- and per-ECMO mechanical ventilation settings and use of adjunctive therapies, ICU- and 6-month–outcome data for 350 patients (median ± standard deviation pre-ECMO PaO2/FiO2 71±34 mmHg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. Tidal volume (6.4±2.0 vs 3.7±2.0 ml/kg), plateau pressure (32±7 vs 24±7cmH2O), driving pressure (20±7 vs. 14±4 cmH2O), respiratory rate (26±8 vs 14±6 breaths/min) and mechanical power (26.1±12.7 vs. 6.6±4.8 J/min) were markedly reduced after ECMO initiation. Six-month survival was 61%. No association was found between ventilator settings during the first 2 days of ECMO and survival in multivariable analysis. A time-varying Cox model retained older age, higher fluid balance, higher lactate, and more need for renal replacement therapy along the ECMO course as being independently associated with 6-month mortality. A higher tidal volume and lower driving pressure (likely markers of static compliance improvement) across the ECMO course were also associated with better outcomes.

Conclusion: Ultra-protective lung ventilation on ECMO was largely adopted across medium to high case-volume ECMO centers. In contrast with previous observations, mechanical ventilation settings during ECMO did not impact patients’ prognosis in this context.

La dyspnée, sous diagnostiquée et sous traitée ?

Underdetection and Undertreatment of Dyspnea in Critically Ill Patients.

Gentzler et al. Am J Respir Crit Care Med 2019;199(11):1377–1384

https://doi.org/10.1164/rccm.201805-0996OC

ROX = Indice (SpO2/FiO2)  mieux que la FR pour prédire l’échec d’Optiflow ?

An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy.

Roca et al. Am J Respir Crit Care Med 2019;199(11):1368–1376

https://doi.org/10.1164/rccm.201803-0589OC

Rationale: One important concern during high-flow nasal cannula (HFNC) therapy in patients with acute hypoxemic respiratory failure is to not delay intubation.

Objectives: To validate the diagnostic accuracy of an index (termed ROX and defined as the ratio of oxygen saturation as measured by pulse oximetry/Fi_O2 to respiratory rate) for determining HFNC outcome (need or not for intubation).

Methods: This was a 2-year multicenter prospective observational cohort study including patients with pneumonia treated with HFNC. Identification was through Cox proportional hazards modeling of ROX association with HFNC outcome. The most specific cutoff of the ROX index to predict HFNC failure and success was assessed.

Measurements and Main Results: Among the 191 patients treated with HFNC in the validation cohort, 68 (35.6%) required intubation. The prediction accuracy of the ROX index increased over time (area under the receiver operating characteristic curve: 2 h, 0.679; 6 h, 0.703; 12 h, 0.759). ROX greater than or equal to 4.88 measured at 2 (hazard ratio, 0.434; 95% confidence interval, 0.264–0.715; P = 0.001), 6 (hazard ratio, 0.304; 95% confidence interval, 0.182–0.509; P < 0.001), or 12 hours (hazard ratio, 0.291; 95% confidence interval, 0.161–0.524; P < 0.001) after HFNC initiation was consistently associated with a lower risk for intubation. A ROX less than 2.85, less than 3.47, and less than 3.85 at 2, 6, and 12 hours of HFNC initiation, respectively, were predictors of HFNC failure. Patients who failed presented a lower increase in the values of the ROX index over the 12 hours. Among components of the index, oxygen saturation as measured by pulse oximetry/Fi_O2 had a greater weight than respiratory rate.

Conclusions: In patients with pneumonia with acute respiratory failure treated with HFNC, ROX is an index that can help identify those patients with low and those with high risk for intubation.

Outcomes chez les patients ayant eu une ventilation mécanique prolongée

Long-Term Outcome after Prolonged Mechanical Ventilation. A Long-Term Acute-Care Hospital Study.

Jubran et al. Am J Respir Crit Care Med 2019;199(12):1508–1516

https://doi.org/10.1164/rccm.201806-1131OC

Stop aux antigénuries Légionnelle et Pneumocoque systématiques ?

https://academic.oup.com/cid/article-abstract/68/12/2026/5108546?redirectedFrom=fulltext

VRS plus grave chez la personne âgée que la grippe ?

PBR chez le patient en réanimation : diagnostic et traitement

de Chambrun, et al., CCM, 2019

https://journals.lww.com/ccmjournal/Citation/2019/03000/Transvenous_Renal_Biopsy_of_Critically_Ill.11.aspx

doi: 10.1097/CCM.0000000000003634

Le retour du Pentho ?

https://read.qxmd.com/read/31228006/comparison-between-hemodynamic-effects-of-propofol-and-thiopental-during-general-anesthesia-induction-with-remifentanil-infusion-a-double-blind-age-stratified-randomized-study

Taux d’intubation au 1er coup : impact du sexe de l’opérateur ?

https://read.qxmd.com/read/31227421/does-physician-gender-have-a-significant-impact-on-first-pass-success-rate-of-emergency-endotracheal-intubation

De la médecine traditionnelle chinoise pour avancer sur les pneumonies communautaires sévères ?

Objectives: To investigate whether XueBiJing injection improves clinical outcomes in critically ill patients with severe community-acquired pneumonia.

Design: Prospective, randomized, controlled study.

Setting: Thirty-three hospitals in China.

Patients: A total of 710 adults 18–75 years old with severe community-acquired pneumonia.

Interventions: Participants in the XueBiJing group received XueBiJing, 100 mL, q12 hours, and the control group received a visually indistinguishable placebo.

Measurements and Main Results: The primary outcome was 8-day improvement in the pneumonia severity index risk rating. Secondary outcomes were 28-day mortality rate, duration of mechanical ventilation and total duration of ICU stay. Improvement in the pneumonia severity index risk rating, from a previously defined endpoint, occurred in 203 (60.78%) participants receiving XueBiJing and in 158 (46.33%) participants receiving placebo (between-group difference [95% CI], 14.4% [6.9–21.8%]; p < 0.001). Fifty-three (15.87%) XueBiJing recipients and 84 (24.63%) placebo recipients (8.8% [2.4–15.2%]; p = 0.006) died within 28 days. XueBiJing administration also decreased the mechanical ventilation time and the total ICU stay duration. The median mechanical ventilation time was 11.0 versus 16.5 days for the XueBiJing and placebo groups, respectively (p = 0.012). The total duration of ICU stay was 12 days for XueBiJing recipients versus 16 days for placebo recipients (p = 0.004). A total of 256 patients experienced adverse events (119 [35.63%] vs 137 [40.18%] in the XueBiJing and placebo groups, respectively [p = 0.235]).

Conclusions: In critically ill patients with severe community-acquired pneumonia, XueBiJing injection led to a statistically significant improvement in the primary endpoint of the pneumonia severity index as well a significant improvement in the secondary clinical outcomes of mortality, duration of mechanical ventilation and duration of ICU stay.

Deep learning sur EEG pour prédire le pronostic neurologique post-ACR

Outcome Prediction in Postanoxic Coma With Deep Learning.

Tjepkema-Cloostermans et al. Crit Care Med 2019;epublished June 3rd

DOI: 10.1097/CCM.0000000000003854

Objectives:Visual assessment of the electroencephalogram by experienced clinical neurophysiologists allows reliable outcome prediction of approximately half of all comatose patients after cardiac arrest. Deep neural networks hold promise to achieve similar or even better performance, being more objective and consistent.

Design:Prospective cohort study.Setting:Medical ICU of five teaching hospitals in the Netherlands.

Patients:Eight-hundred ninety-five consecutive comatose patients after cardiac arrest.Interventions:None.

Measurements and Main Results:Continuous electroencephalogram was recorded during the first 3 days after cardiac arrest. Functional outcome at 6 months was classified as good (Cerebral Performance Category 1–2) or poor (Cerebral Performance Category 3–5). We trained a convolutional neural network, with a VGG architecture (introduced by the Oxford Visual Geometry Group), to predict neurologic outcome at 12 and 24 hours after cardiac arrest using electroencephalogram epochs and outcome labels as inputs. Output of the network was the probability of good outcome. Data from two hospitals were used for training and internal validation (n = 661). Eighty percent of these data was used for training and cross-validation, the remaining 20% for independent internal validation. Data from the other three hospitals were used for external validation (n = 234). Prediction of poor outcome was most accurate at 12 hours, with a sensitivity in the external validation set of 58% (95% CI, 51–65%) at false positive rate of 0% (CI, 0–7%). Good outcome could be predicted at 12 hours with a sensitivity of 48% (CI, 45–51%) at a false positive rate of 5% (CI, 0–15%) in the external validation set.

Conclusions:Deep learning of electroencephalogram signals outperforms any previously reported outcome predictor of coma after cardiac arrest, including visual electroencephalogram assessment by trained electroencephalogram experts. Our approach offers the potential for objective and real time, bedside insight in the neurologic prognosis of comatose patients after cardiac arrest.

L’insuffisance rénale aigue + SDRA = surmortalité

Impact of Early Acute Kidney Injury on Management and Outcome in Patients With Acute Respiratory Distress Syndrome. A Secondary Analysis of a Multicenter Observational Study (LUNG-SAFE).

McNicholas et al. Crit Care Med 2019;epublished May 31st

DOI: 10.1097/CCM.0000000000003832

Objectives:To understand the impact of mild-moderate and severe acute kidney injury in patients with acute respiratory distress syndrome.

Design:Secondary analysis of the “Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure”, an international prospective cohort study of patients with severe respiratory failure.Setting:Four-hundred fifty-nine ICUs from 50 countries across five continents.

Subjects:Patients with a glomerular filtration rate greater than 60 mL/min/1.73 m2 prior to admission who fulfilled criteria of acute respiratory distress syndrome on day 1 and day 2 of acute hypoxemic respiratory failure.Interventions:Patients were categorized based on worst serum creatinine or urine output into: 1) no acute kidney injury (serum creatinine < 132 µmol/L or urine output ≥ 0.5 mL/kg/hr), 2) mild-moderate acute kidney injury (serum creatinine 132–354 µmol/L or minimum urine output between 0.3 and 0.5mL/kg/hr), or 3) severe acute kidney injury (serum creatinine > 354 µmol/L or renal replacement therapy or minimum urine output < 0.3 mL/kg/hr).Measurements and Main

Results:The primary outcome was hospital mortality, whereas secondary outcomes included prevalence of acute kidney injury and characterization of acute respiratory distress syndrome risk factors and illness severity patterns, in patients with acute kidney injury versus no acute kidney injury. One-thousand nine-hundred seventy-four patients met inclusion criteria: 1,209 (61%) with no acute kidney injury, 468 (24%) with mild-moderate acute kidney injury, and 297 (15%) with severe acute kidney injury. The impact of acute kidney injury on the ventilatory management of patients with acute respiratory distress syndrome was relatively limited, with no differences in arterial CO2 tension or in tidal or minute ventilation between the groups. Hospital mortality increased from 31% in acute respiratory distress syndrome patients with no acute kidney injury to 50% in mild-moderate acute kidney injury (p ≤ 0.001 vs no acute kidney injury) and 58% in severe acute kidney injury (p ≤ 0.001 vs no acute kidney injury and mild-moderate acute kidney injury). In multivariate analyses, both mild-moderate (odds ratio, 1.61; 95% CI, 1.24–2.09; p < 0.001) and severe (odds ratio, 2.13; 95% CI, 1.55–2.94; p < 0.001) acute kidney injury were independently associated with mortality.

Conclusions:The development of acute kidney injury, even when mild-moderate in severity, is associated with a substantial increase in mortality in patients with acute respiratory distress syndrome.

La PEEP seule suffit à diminuer les atélectasies ?

Positive End-expiratory Pressure and Postoperative Atelectasis: A Randomized Controlled Trial.

Östberg et al. Anesthesiology 2019;epublished May 14th

DOI:10.1097/ALN.0000000000002764

BACKGROUND:

Various methods for protective ventilation are increasingly being recommended for patients undergoing general anesthesia. However, the importance of each individual component is still unclear. In particular, the perioperative use of positive end-expiratory pressure (PEEP) remains controversial. The authors tested the hypothesis that PEEP alone would be sufficient to limit atelectasis formation during nonabdominal surgery.

METHODS:

This was a randomized controlled evaluator-blinded study. Twenty-four healthy patients undergoing general anesthesia were randomized to receive either mechanical ventilation with PEEP 7 or 9 cm H2O depending on body mass index (n = 12) or zero PEEP (n = 12). No recruitment maneuvers were used. The primary outcome was atelectasis area as studied by computed tomography in a transverse scan near the diaphragm, at the end of surgery, before emergence. Oxygenation was evaluated by measuring blood gases and calculating the ratio of arterial oxygen partial pressure to inspired oxygen fraction (PaO2/FIO2 ratio).

RESULTS:

At the end of surgery, the median (range) atelectasis area, expressed as percentage of the total lung area, was 1.8 (0.3 to 9.9) in the PEEP group and 4.6 (1.0 to 10.2) in the zero PEEP group. The difference in medians was 2.8% (95% CI, 1.7 to 5.7%; P = 0.002). Oxygenation and carbon dioxide elimination were maintained in the PEEP group, but both deteriorated in the zero PEEP group.

CONCLUSIONS:

During nonabdominal surgery, adequate PEEP is sufficient to minimize atelectasis in healthy lungs and thereby maintain oxygenation. Thus, routine recruitment maneuvers seem unnecessary, and the authors suggest that they should only be utilized when clearly indicated.

Haldol prophylactique sur la qualité de vie à long terme chez les patients en réa à haut risque de Delirium ?

Prophylactic Haloperidol Effects on Long-term Quality of Life in Critically Ill Patients at High Risk for Delirium: Results of the REDUCE Study.

doi:10.1097/ALN.0000000000002812

Background: Delirium incidence in intensive care unit patients is high and associated with impaired long-term outcomes. The use of prophylactic haloperidol did not improve short-term outcome among critically ill adults at high risk of delirium. This study evaluated the effects of prophylactic haloperidol use on long-term quality of life in this group of patients and explored which factors are associated with change in quality of life.

Methods: A preplanned secondary analysis of long-term outcomes of the pRophylactic haloperidol usE for DeliriUm in iCu patients at high risk for dElirium (REDUCE) study was conducted. In this multicenter randomized clinical trial, nondelirious intensive care unit patients were assigned to prophylactic haloperidol (1 or 2 mg) or placebo (0.9% sodium chloride). In all groups, patients finally received study medication for median duration of 3 days [interquartile range, 2 to 6] until onset of delirium or until intensive care unit discharge. Long-term outcomes were assessed using the Short Form-12 questionnaire at intensive care unit admission (baseline) and after 1 and 6 months. Quality of life was summarized in the physical component summary and mental component summary scores. Differences between the haloperidol and placebo group and factors associated with changes in quality of life were analyzed.

Results: Of 1,789 study patients, 1,245 intensive care unit patients were approached, of which 887 (71%) responded. Long-term quality of life did not differ between the haloperidol and placebo group (physical component summary mean score of 39 ± 11 and 39 ± 11, respectively, and P = 0.350; and mental component summary score of 50 ± 10 and 51 ± 10, respectively, and P = 0.678). Age, medical and trauma admission, quality of life score at baseline, risk for delirium (PRE-DELIRIC) score, and the number of sedation-induced coma days were significantly associated with a decline in long-term quality of life.

Conclusions: Prophylactic haloperidol use does not affect long-term quality of life in critically ill patients at high risk for delirium. Several factors, including the modifiable factor number of sedation-induced coma days, are associated with decline in long-term outcomes.

ACR extra-hospitalier = Masser et seulement masser !

Survival in out-of-hospital cardiac arrest after standard cardiopulmonary resuscitation or chest compressions only before arrival of emergency medical services: nationwide study during three guideline periods.

Riva et al. Circulation 2019;139:2600–2609

https://doi.org/10.1161/CIRCULATIONAHA.118.038179

Doppler Transcranien pour le pronostic précoce post-ACR extrahospitalier ?

Pression intracrânienne normale mais troubles de compliance cérébrale en cas de lésions ischémiques post-ACR ?

Intracranial pressure and compliance in hypoxic ischemic brain injury patients after cardiac arrest.

Sekhon et al.  Resuscitation 2019;epublished June 8th

DOI: https://doi.org/10.1016/j.resuscitation.2019.05.036

Des soins intensifs pour les patients avec un infarctus

Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study.

https://www.bmj.com/content/bmj/365/bmj.l1927.full.pdf

Valley et al. BMJ 2019;365:l1927

Oligurie per-op : associée à l’IRA mais mauvaise prédiction

Importance of intraoperative oliguria during major abdominal surgery: findings of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery trial.

Myles et al. Br J Anaesth 2019;122(6):726–733

Surtout pas de manoeuvre de recrutement pour les patients en SDRA choqués sur une pneumonie ? Résultats de machine learning

Zampieri et al. Br J Anaesth 2019;123(1):88–95

Heterogeneous effects of alveolar recruitment in acute respiratory distress syndrome: a machine learning reanalysis of the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial.

Réactions d’hypersenbilité péri-opératoire

– Revue de ce qui se fait dans le Monde :

Mertes et al. Br J Anaesth 2019;123(1):e16–e28

-Recommendations internationales :

 – Gestion type du patient « allergique à la pénicilline »

Méta-analyse : baisse de la mortalité en onco-réanimation sauf chez les patients allogreffés de moelle ?

Intérêt de l’ETO continue dans la gestion des états de choc en Réa ?

Impact écologique de la DDS

In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission.

Abe et al.  Critical Care 2019;23:202

Remplissage en débit libre versus débit lent : pas plus de fuite capillaire ?

Albumin infusion rate and plasma volume expansion: a randomized clinical trial in postoperative patients after major surgery.

Statkevicius et al. Critical Care 2019;23:191

Background

Optimal infusion rate of colloids in patients with suspected hypovolemia is unknown, and the primary objective of the present study was to test if plasma volume expansion by 5% albumin is greater if fluid is administered slowly rather than rapidly.

Methods

Patients with signs of hypoperfusion after major abdominal surgery were randomized to intravenous infusion of 5% albumin at a dose of 10 ml/kg (ideal body weight) either rapidly (30 min) or slowly (180 min). Plasma volume was measured using radiolabeled albumin at baseline, at 30 min, and at 180 min after the start of infusion. Primary outcome was change in plasma volume from the start of infusion to 180 min after the start of infusion. Secondary outcomes included the change in the area under the plasma volume curve and transcapillary escape rate (TER) for albumin from 180 to 240 min after the start of albumin infusion.

Results

A total of 33 and 31 patients were included in the analysis in the slow and rapid groups, respectively. The change in plasma volume from the start of infusion to 180 min did not differ between the slow and rapid infusion groups (7.4 ± 2.6 vs. 6.5 ± 4.1 ml/kg; absolute difference, 0.9 ml/kg [95%CI, − 0.8 to 2.6], P = 0.301). Change in the area under the plasma volume curve was smaller in the slow than in the rapid infusion group and was 866 ± 341 and 1226 ± 419 min ml/kg, respectively, P < 0.001. TER for albumin did not differ and was 5.3 ± 3.1%/h and 5.4 ± 3%/h in the slow and in the rapid infusion groups, respectively, P = 0.931.

Conclusions

This study does not support our hypothesis that a slow infusion of colloid results in a greater plasma volume expansion than a rapid infusion. Instead, our result of a smaller change in the area under the plasma volume curve indicates that a slow infusion results in a less efficient plasma volume expansion, but further studies are required to confirm this finding. A rapid infusion has no effect on vascular leak as measured after completion of the infusion.

Le Mottling score (score de marbrures) : bonnes capacités prédictives

Mottling score is a strong predictor of 14-day mortality in septic patients whatever vasopressor doses and other tissue perfusion parameters.

Dumas et al. Critical Care 2019;23:211

PCT : pas d’intérêt pour différencier les bactériémies des candidémies

Procalcitonin levels in candidemia versus bacteremia: a systematic review.

Cortegiani et al. Critical Care 2019;23:190

Revue et méta-analyse du choc septique dans les pays occidentaux

Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis.

Vincent et al. Critical Care 2019;23:196

https://ccforum.biomedcentral.com/articles/10.1186/s13054-019-2478-6

Echec de l’écho diaphragmatique pour prédire l’echec d’extubation

Inability of Diaphragm Ultrasound to Predict Extubation Failure. A Multicenter Study.

https://journal.chestnet.org/article/S0012-3692(19)30694-4/pdf

DOI: https://doi.org/10.1016/j.chest.2019.03.004

Quand le patient n’est pas d’accord sur son traitement en réa…

Prevalence of Disagreement About Appropriateness of Treatment Between ICU Patients/Surrogates and Clinicians.

Antibiothérapie guidée par la PCT : vers la fin du débat ?

Levosimendan vs Milrinone en post-op de chirurgie cardiaque pédiatrique ?

Thorlacius et al., Ped CCM, 2019

https://insights.ovid.com/crossref?an=00130478-900000000-98211

DOI: 10.1097/PCC.0000000000002017

Objectives:It has been shown that, in contrast to other inotropic agents, levosimendan improves glomerular filtration rate after adult cardiac surgery. The aim of this study was to investigate the efficacy of levosimendan, compared with milrinone, in preventing acute kidney dysfunction in infants after open-heart surgery with cardiopulmonary bypass.

Design:Two-center, double-blinded, prospective, randomized clinical trial.

Setting:The study was performed in two tertiary pediatric centers, one in Sweden (Gothenburg) and one in Finland (Helsinki).

Patients:Infants between 1 and 12 months old, diagnosed with Tetralogy of Fallot, complete atrioventricular septal defect or nonrestrictive ventricular septal defect, undergoing total corrective cardiac surgery with cardiopulmonary bypass.

Interventions:Seventy-two infants were randomized to receive a perioperative infusion of levosimendan (0.1 µg/kg/min) or milrinone (0.4 µg/kg/min). The infusion was initiated at the start of cardiopulmonary bypass and continued for 26 hours.

Measurements and Main Results:The primary outcome variable was the absolute value of serum creatinine data on postoperative day 1. Secondary outcomes included the following: 1) acute kidney injury according to the serum creatinine criteria of the Kidney Diseases: Improving Global Outcomes; 2) acute kidney injury with serum creatinine corrected for fluid balance; 3) plasma neutrophil gelatinase-associated lipocalin; 4) cystatin C; 5) urea; 6) lactate; 7) hemodynamic variables; 8) use of diuretics in the PICU; 9) need of dialysis; 10) length of ventilator therapy; and 11) length of PICU stays. There was no significant difference in postoperative serum creatinine between the treatment groups over time (p = 0.65). The occurrence rate of acute kidney injury within 48 hours was 46.9% in the levosimendan group and 39.5% in the milrinone group (p = 0.70). There were no significant differences in other secondary outcome variables between the groups.

Conclusions:Levosimendan compared with milrinone did not reduce the occurrence rate of acute kidney injury in infants after total corrective heart surgery for atrioventricular septal defect, ventricular septal defect, or Tetralogy of Fallot.

Triage des patients pour la réa :

– Impact du délai du tri

Impact of triage-to-admission time on patient outcome in European intensive care units: A prospective, multi-national study.

Stohl et al. J Crit Care 2019;53:11-17

https://doi.org/10.1016/j.jcrc.2019.05.013

– Chez les patients d’onco-réa

Variability in triage practices for critically ill cancer patients: A randomized controlled trial.

https://doi.org/10.1016/j.jcrc.2019.05.012

Recommendations USA pour l’EP

https://journals.sagepub.com/doi/full/10.1177/1076029619853037?utm_source=newsletter_464&utm_medium=email&utm_campaign=critical-care-reviews-newsletter-392&

Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practicefrom the PERT Consortium.

Rivera-Lebron et al. Clinical and Applied Thrombosis/Hemostasis 2019;25:1-16

Kétamine comme anti-dépressif