Biblio du mois : Août 2018

 

 

 

Et oui malgré la fin de l’été 2018, le soleil de la Biblio du mois de l’AJAR Paris continue de vous tenir informé !

Encore une biblio exhaustive entre Revue sur le delirium ou sur la gestion analgésique des toxicomanes et du sepsis, beaucoup de sepsis !

On touchera un mot sur la revue sur les corticoïdes dans le sepsis (l’équipe d’Annane continue de publier), l’intérêt du paracétamol dans les palus graves, il y a surtout enfin la publication de l’étude contre la Tazocilline dans les infections à BLSE !

Et puis quand les grands journaux discutent de remplissage vasculaire, de masques laryngés ou de tester l’intérêt de l’Adrénaline dans les ACRs, on ne peut pas rater ça !

Vive l’Anesthésie-Réanimation !

 

 

 

 

Pas d’intérêt de l’acide tranexamique systématique après accouchement par voie basse dans la prévention de l’hémorragie de la délivrance ?

 

Tranexamic Acid for the Prevention of Blood Loss after Vaginal Delivery

Loïc Sentilhes, M.D., Ph.D., Norbert Winer, M.D., Ph.D., Elie Azria, M.D., Ph.D., Marie-Victoire Sénat, M.D., Ph.D., Camille Le Ray, M.D., Ph.D., Delphine Vardon, M.D., Franck Perrotin, M.D., Ph.D., Raoul Desbrière, M.D., Florent Fuchs, M.D., Ph.D., Gilles Kayem, M.D., Ph.D., Guillaume Ducarme, M.D., Ph.D., Muriel Doret-Dion, M.D., Ph.D.,

et al., for the Groupe de Recherche en Obstétrique et Gynécologie*

 

August 23, 2018
N Engl J Med 2018; 379:731-742
DOI: 10.1056/NEJMoa1800942

 

Abstract

BACKGROUND

The use of tranexamic acid reduces mortality due to postpartum hemorrhage. We investigated whether the prophylactic administration of tranexamic acid in addition to prophylactic oxytocin in women with vaginal delivery would decrease the incidence of postpartum hemorrhage.

METHODS

In a multicenter, double-blind, randomized, controlled trial, we randomly assigned women in labor who had a planned vaginal delivery of a singleton live fetus at 35 or more weeks of gestation to receive 1 g of tranexamic acid or placebo, administered intravenously, in addition to prophylactic oxytocin after delivery. The primary outcome was postpartum hemorrhage, defined as blood loss of at least 500 ml, measured with a collector bag.

RESULTS

Of the 4079 women who underwent randomization, 3891 had a vaginal delivery. The primary outcome occurred in 156 of 1921 women (8.1%) in the tranexamic acid group and in 188 of 1918 (9.8%) in the placebo group (relative risk, 0.83; 95% confidence interval [CI], 0.68 to 1.01; P=0.07). Women in the tranexamic acid group had a lower rate of provider-assessed clinically significant postpartum hemorrhage than those in the placebo group (7.8% vs. 10.4%; relative risk, 0.74; 95% CI, 0.61 to 0.91; P=0.004; P=0.04 after adjustment for multiple comparisons post hoc) and also received additional uterotonic agents less often (7.2% vs. 9.7%; relative risk, 0.75; 95% CI, 0.61 to 0.92; P=0.006; adjusted P=0.04). Other secondary outcomes did not differ significantly between the two groups. The incidence of thromboembolic events in the 3 months after delivery did not differ significantly between the tranexamic acid group and the placebo group (0.1% and 0.2%, respectively; relative risk, 0.25; 95% CI, 0.03 to 2.24).

CONCLUSIONS

Among women with vaginal delivery who received prophylactic oxytocin, the use of tranexamic acid did not result in a rate of postpartum hemorrhage of at least 500 ml that was significantly lower than the rate with placebo. (Funded by the French Ministry of Health; TRAAP ClinicalTrials.gov number, NCT02302456.)

 

 

Enfin un essai évaluant les bolus d’adrénaline dans la réanimation des arrêts cardio-circulatoires extra-hospitaliers !

–> Plus de survie globale mais plus de handicap neurologique sévère ?

 

 

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest

Gavin D. Perkins, M.D., Chen Ji, Ph.D., Charles D. Deakin, M.D., Tom Quinn, M.Phil., Jerry P. Nolan, M.B., Ch.B., Charlotte Scomparin, M.Sc., Scott Regan, B.A., John Long, Anne Slowther, Ph.D., Helen Pocock, M.Sc., John J.M. Black, M.B., B.S., Fionna Moore, M.B., B.S., et al., for the PARAMEDIC2 Collaborators

 

August 23, 2018
N Engl J Med 2018; 379:711-721
DOI: 10.1056/NEJMoa1806842

 

Abstract

BACKGROUND

Concern about the use of epinephrine as a treatment for out-of-hospital cardiac arrest led the International Liaison Committee on Resuscitation to call for a placebo-controlled trial to determine whether the use of epinephrine is safe and effective in such patients.

METHODS

In a randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest in the United Kingdom, paramedics at five National Health Service ambulance services administered either parenteral epinephrine (4015 patients) or saline placebo (3999 patients), along with standard care. The primary outcome was the rate of survival at 30 days. Secondary outcomes included the rate of survival until hospital discharge with a favorable neurologic outcome, as indicated by a score of 3 or less on the modified Rankin scale (which ranges from 0 [no symptoms] to 6 [death]).

RESULTS

At 30 days, 130 patients (3.2%) in the epinephrine group and 94 (2.4%) in the placebo group were alive (unadjusted odds ratio for survival, 1.39; 95% confidence interval [CI], 1.06 to 1.82; P=0.02). There was no evidence of a significant difference in the proportion of patients who survived until hospital discharge with a favorable neurologic outcome (87 of 4007 patients [2.2%] vs. 74 of 3994 patients [1.9%]; unadjusted odds ratio, 1.18; 95% CI, 0.86 to 1.61). At the time of hospital discharge, severe neurologic impairment (a score of 4 or 5 on the modified Rankin scale) had occurred in more of the survivors in the epinephrine group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90 patients [17.8%]).

CONCLUSIONS

In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group. (Funded by the U.K. National Institute for Health Research and others; Current Controlled Trials number, ISRCTN73485024.)

 

 

Efficacité de la thrombolyse guidée par le mismatch perfusion/FLAIR pour les AVC ischémiques de délai inconnu ?

MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset

Götz Thomalla, M.D., Claus Z. Simonsen, M.D., Ph.D., Florent Boutitie, Ph.D., Grethe Andersen, M.D., D.M.Sc., Yves Berthezene, M.D., Bastian Cheng, M.D., Bharath Cheripelli, M.D., Tae-Hee Cho, M.D., Franz Fazekas, M.D., Jens Fiehler, M.D., Ian Ford, Ph.D., Ivana Galinovic, M.D., et al., for the WAKE-UP Investigators*

August 16, 2018
N Engl J Med 2018; 379:611-622
DOI: 10.1056/NEJMoa1804355

Abstract

BACKGROUND

Under current guidelines, intravenous thrombolysis is used to treat acute stroke only if it can be ascertained that the time since the onset of symptoms was less than 4.5 hours. We sought to determine whether patients with stroke with an unknown time of onset and features suggesting recent cerebral infarction on magnetic resonance imaging (MRI) would benefit from thrombolysis with the use of intravenous alteplase.

METHODS

In a multicenter trial, we randomly assigned patients who had an unknown time of onset of stroke to receive either intravenous alteplase or placebo. All the patients had an ischemic lesion that was visible on MRI diffusion-weighted imaging but no parenchymal hyperintensity on fluid-attenuated inversion recovery (FLAIR), which indicated that the stroke had occurred approximately within the previous 4.5 hours. We excluded patients for whom thrombectomy was planned. The primary end point was favorable outcome, as defined by a score of 0 or 1 on the modified Rankin scale of neurologic disability (which ranges from 0 [no symptoms] to 6 [death]) at 90 days. A secondary outcome was the likelihood that alteplase would lead to lower ordinal scores on the modified Rankin scale than would placebo (shift analysis).

RESULTS

The trial was stopped early owing to cessation of funding after the enrollment of 503 of an anticipated 800 patients. Of these patients, 254 were randomly assigned to receive alteplase and 249 to receive placebo. A favorable outcome at 90 days was reported in 131 of 246 patients (53.3%) in the alteplase group and in 102 of 244 patients (41.8%) in the placebo group (adjusted odds ratio, 1.61; 95% confidence interval [CI], 1.09 to 2.36; P=0.02). The median score on the modified Rankin scale at 90 days was 1 in the alteplase group and 2 in the placebo group (adjusted common odds ratio, 1.62; 95% CI, 1.17 to 2.23; P=0.003). There were 10 deaths (4.1%) in the alteplase group and 3 (1.2%) in the placebo group (odds ratio, 3.38; 95% CI, 0.92 to 12.52; P=0.07). The rate of symptomatic intracranial hemorrhage was 2.0% in the alteplase group and 0.4% in the placebo group (odds ratio, 4.95; 95% CI, 0.57 to 42.87; P=0.15).

CONCLUSIONS

In patients with acute stroke with an unknown time of onset, intravenous alteplase guided by a mismatch between diffusion-weighted imaging and FLAIR in the region of ischemia resulted in a significantly better functional outcome and numerically more intracranial hemorrhages than placebo at 90 days. (Funded by the European Union Seventh Framework Program; WAKE-UP ClinicalTrials.gov number, NCT01525290; and EudraCT number, 2011-005906-32.)

 

 

 

 

 

Quand Nature parle de remplissage vasculaire :

 

Simon Finfer, John Myburgh & Rinaldo Bellomo

Nature Reviews Nephrology, 2018

https://www.nature.com/articles/s41581-018-0044-0

 

 

 

 

Revue sur les corticoides lors du sepsis pour être a la page sur le sujet

 

Nicholas Heming1,2, Sivanthiny Sivanandamoorthy1, Paris Meng1, Rania Bounab1 and Djillali Annane1,2

https://www.frontiersin.org/articles/10.3389/fimmu.2018.01736/full

 

 

 

Masque laryngé versus Intubation dans les ACR extra-hospitaliers

 

1) Etude AIRWAYS-2 : pas de supériorité du masque laryngé

https://jamanetwork.com/journals/jama/article-abstract/2698493

JAMA. 2018;320(8):779-791. doi:10.1001/jama.2018.11597

Importance  The optimal approach to airway management during out-of-hospital cardiac arrest is unknown.

Objective  To determine whether a supraglottic airway device (SGA) is superior to tracheal intubation (TI) as the initial advanced airway management strategy in adults with nontraumatic out-of-hospital cardiac arrest.

Design, Setting, and Participants  Multicenter, cluster randomized clinical trial of paramedics from 4 ambulance services in England responding to emergencies for approximately 21 million people. Patients aged 18 years or older who had a nontraumatic out-of-hospital cardiac arrest and were treated by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017; follow-up ended in February 2018.

Interventions  Paramedics were randomized 1:1 to use TI (764 paramedics) or SGA (759 paramedics) as their initial advanced airway management strategy.

Main Outcomes and Measures  The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred sooner. Modified Rankin Scale score was divided into 2 ranges: 0-3 (good outcome) or 4-6 (poor outcome; 6 = death). Secondary outcomes included ventilation success, regurgitation, and aspiration.

Results  A total of 9296 patients (4886 in the SGA group and 4410 in the TI group) were enrolled (median age, 73 years; 3373 were women [36.3%]), and the modified Rankin Scale score was known for 9289 patients. In the SGA group, 311 of 4882 patients (6.4%) had a good outcome (modified Rankin Scale score range, 0-3) vs 300 of 4407 patients (6.8%) in the TI group (adjusted risk difference [RD], −0.6% [95% CI, −1.6% to 0.4%]). Initial ventilation was successful in 4255 of 4868 patients (87.4%) in the SGA group compared with 3473 of 4397 patients (79.0%) in the TI group (adjusted RD, 8.3% [95% CI, 6.3% to 10.2%]). However, patients randomized to receive TI were less likely to receive advanced airway management (3419 of 4404 patients [77.6%] vs 4161 of 4883 patients [85.2%] in the SGA group). Two of the secondary outcomes (regurgitation and aspiration) were not significantly different between groups (regurgitation: 1268 of 4865 patients [26.1%] in the SGA group vs 1072 of 4372 patients [24.5%] in the TI group; adjusted RD, 1.4% [95% CI, −0.6% to 3.4%]; aspiration: 729 of 4824 patients [15.1%] vs 647 of 4337 patients [14.9%], respectively; adjusted RD, 0.1% [95% CI, −1.5% to 1.8%]).

Conclusions and Relevance  Among patients with out-of-hospital cardiac arrest, randomization to a strategy of advanced airway management with a supraglottic airway device compared with tracheal intubation did not result in a favorable functional outcome at 30 days.

 

2) Meilleur survie à 72h ?

JAMA. 2018;320(8):769-778. doi:10.1001/jama.2018.7044

Importance  Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown.

Objective  To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA.

Design, Setting, and Participants  Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017.

Interventions  Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals.

Main Outcomes and Measures  The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score ≤3), and key adverse events.

Results  Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%).

Conclusions and Relevance  Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted.

 

 

 

Etude contre l’utilisation de Tazocilline dans les infections à BLSE

 

 

for the MERINO Trial Investigators and the Australasian Society for Infectious Disease Clinical Research Network (ASID-CRN)
JAMA. 2018;320(10):984-994. doi:10.1001/jama.2018.12163

 

Importance  Extended-spectrum β-lactamases mediate resistance to third-generation cephalosporins (eg, ceftriaxone) in Escherichia coli and Klebsiella pneumoniae. Significant infections caused by these strains are usually treated with carbapenems, potentially selecting for carbapenem resistance. Piperacillin-tazobactam may be an effective “carbapenem-sparing” option to treat extended-spectrum β-lactamase producers.

Objectives  To determine whether definitive therapy with piperacillin-tazobactam is noninferior to meropenem (a carbapenem) in patients with bloodstream infection caused by ceftriaxone-nonsusceptible E coli or K pneumoniae.

Design, Setting, and Participants  Noninferiority, parallel group, randomized clinical trial included hospitalized patients enrolled from 26 sites in 9 countries from February 2014 to July 2017. Adult patients were eligible if they had at least 1 positive blood culture with E coli or Klebsiella spp testing nonsusceptible to ceftriaxone but susceptible to piperacillin-tazobactam. Of 1646 patients screened, 391 were included in the study.

Interventions  Patients were randomly assigned 1:1 to intravenous piperacillin-tazobactam, 4.5 g, every 6 hours (n = 188 participants) or meropenem, 1 g, every 8 hours (n = 191 participants) for a minimum of 4 days, up to a maximum of 14 days, with the total duration determined by the treating clinician.

Main Outcomes and Measures  The primary outcome was all-cause mortality at 30 days after randomization. A noninferiority margin of 5% was used.

Results  Among 379 patients (mean age, 66.5 years; 47.8% women) who were randomized appropriately, received at least 1 dose of study drug, and were included in the primary analysis population, 378 (99.7%) completed the trial and were assessed for the primary outcome. A total of 23 of 187 patients (12.3%) randomized to piperacillin-tazobactam met the primary outcome of mortality at 30 days compared with 7 of 191 (3.7%) randomized to meropenem (risk difference, 8.6% [1-sided 97.5% CI, −∞ to 14.5%]; P = .90 for noninferiority). Effects were consistent in an analysis of the per-protocol population. Nonfatal serious adverse events occurred in 5 of 188 patients (2.7%) in the piperacillin-tazobactam group and 3 of 191 (1.6%) in the meropenem group.

Conclusions and relevance  Among patients with E coli or K pneumoniae bloodstream infection and ceftriaxone resistance, definitive treatment with piperacillin-tazobactam compared with meropenem did not result in a noninferior 30-day mortality. These findings do not support use of piperacillin-tazobactam in this setting.

 

 

 

 

 

Comment éviter les complications liées aux VVP ?

 

 

Rickard et al., Lancet, 2018

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)31380-1.pdf

DOI:https://doi.org/10.1016/S0140-6736(18)31380-1

 

Background

Two billion peripheral intravenous catheters (PIVCs) are used globally each year, but optimal dressing and securement methods are not well established. We aimed to compare the efficacy and costs of three alternative approaches to standard non-bordered polyurethane dressings.

Methods

We did a pragmatic, randomised controlled, parallel-group superiority trial at two hospitals in Queensland, Australia. Eligible patients were aged 18 years or older and required PIVC insertion for clinical treatment, which was expected to be required for longer than 24 h. Patients were randomly assigned (1:1:1:1) via a centralised web-based randomisation service using random block sizes, stratified by hospital, to receive tissue adhesive with polyurethane dressing, bordered polyurethane dressing, a securement device with polyurethane dressing, or polyurethane dressing (control). Randomisation was concealed before allocation. Patients, clinicians, and research staff were not masked because of the nature of the intervention, but infections were adjudicated by a physician who was masked to treatment allocation. The primary outcome was all-cause PIVC failure (as a composite of complete dislodgement, occlusion, phlebitis, and infection [primary bloodstream infection or local infection]). Analysis was by modified intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000769987.

Findings

Between March 18, 2013, and Sept 9, 2014, we randomly assigned 1807 patients to receive tissue adhesive with polyurethane (n=446), bordered polyurethane (n=454), securement device with polyurethane (n=453), or polyurethane (n=454); 1697 patients comprised the modified intention-to-treat population. 163 (38%) of 427 patients in the tissue adhesive with polyurethane group (absolute risk difference −4·5% [95% CI −11·1 to 2·1%], p=0·19), 169 (40%) of 423 of patients in the bordered polyurethane group (–2·7% [–9·3 to 3·9%] p=0·44), 176 (41%) of 425 patients in the securement device with poplyurethane group (–1·2% [–7·9% to 5·4%], p=0·73), and 180 (43%) of 422 patients in the polyurethane group had PIVC failure. 17 patients in the tissue adhesive with polyurethane group, two patients in the bordered polyurethane group, eight patients in the securement device with polyurethane group, and seven patients in the polyurethane group had skin adverse events. Total costs of the trial interventions did not differ significantly between groups.

Interpretation

Current dressing and securement methods are commonly associated with PIVC failure and poor durability, with simultaneous use of multiple products commonly required. Cost is currently the main factor that determines product choice. Innovations to achieve effective, durable dressings and securements, and randomised controlled trials assessing their effectiveness are urgently needed.

Méta-analyse sur les traitements des colites à Clostridium difficile

Beinortas et al., Lancet ID, 2018

Paracétamol en tant que néphroprotecteur dans les crises palustres graves ?

Background

Acute kidney injury independently predicts mortality in falciparum malaria. It is unknown whether acetaminophen’s capacity to inhibit plasma hemoglobin-mediated oxidation is renoprotective in severe malaria.

Methods

This phase 2, open-label, randomized controlled trial conducted at two hospitals in Bangladesh assessed effects on renal function, safety, pharmacokinetic (PK) properties and pharmacodynamic (PD) effects of acetaminophen. Febrile patients (>12 years) with severe falciparum malaria were randomly assigned to receive acetaminophen (1 g 6–hourly for 72 hours) or no acetaminophen, in addition to intravenous artesunate. Primary outcome was the proportional change in creatinine after 72 hours stratified by median plasma hemoglobin.

Results

Between 2012 and 2014, 62 patients were randomly assigned to receive acetaminophen (n = 31) or no acetaminophen (n = 31). Median (interquartile range) reduction in creatinine after 72 hours was 23% (37% to 18%) in patients assigned to acetaminophen, versus 14% (29% to 0%) in patients assigned to no acetaminophen (P = .043). This difference in reduction was 37% (48% to 22%) versus 14% (30% to −71%) in patients with hemoglobin ≥45000 ng/mL (P = .010). The proportion with progressing kidney injury was higher among controls (subdistribution hazard ratio, 3.0; 95% confidence interval, 1.1 to 8.5; P = .034). PK–PD analyses showed that higher exposure to acetaminophen increased the probability of creatinine improvement. No patient fulfilled Hy’s law for hepatotoxicity.

Conclusions

In this proof-of-principle study, acetaminophen showed renoprotection without evidence of safety concerns in patients with severe falciparum malaria, particularly in those with prominent intravascular hemolysis.

 

 

 

Impact du don d’organes sur le deuil des familles

 

 

,et al., AJRCCM, 2018

https://www.atsjournals.org/doi/full/10.1164/rccm.201709-1899OC

https://doi.org/10.1164/rccm.201709-1899OC

 

 

Rationale: Studies show that the quality of end-of-life communication and care have a significant impact on the living long after the death of a relative and have been implicated in the burden of psychological symptoms after the ICU experience. In the case of organ donation, the patient’s relatives are centrally involved in the decision-making process; yet, few studies have examined the impact of the quality of communication on the burden of psychological symptoms after death.

Objectives: To assess the experience of the organ donation process and grief symptoms in relatives of brain-dead patients who discussed organ donation in the ICU.

Methods: We conducted a multicenter longitudinal study in 28 ICUs in France. Participants were the relatives of brain-dead patients who were approached to discuss organ donation. Relatives were followed-up by phone at three time points: at 1 month, to complete a questionnaire describing their experience of the organ donation process; at 3 months, to complete the Hospital Anxiety and Depression Scale and the Impact of Event Scale–Revised; and at 9 months, to complete the Impact of Event Scale–Revised and the Inventory of Complicated Grief.

Measurements and Main Results: In total, 202 relatives of 202 patients were included, of whom 158 consented to and 44 refused organ donation. Interviews were conducted at 1, 3, and 9 months with 78%, 68%, and 58% of relatives, respectively. The overall experience of the organ donation process was significantly more burdensome for relatives of nondonors. They were more dissatisfied with communication (27% vs. 10%; P = 0.021), more often shocked by the request (65% vs. 19%; P < 0.0001), and more often found the decision difficult (53% vs. 27%; P = 0.017). However, there were no significant differences in grief symptoms measured at 3 and 9 months between the two groups. Understanding of brain death was associated with grief symptoms; our results show a higher prevalence of complicated grief symptoms among relatives who did not understand the brain death process than among those who did (75% vs. 46.1%; P = 0.026).

Conclusions: Experience of the organ donation process varied between relatives of donor versus nondonor patients, with relatives of nondonors experiencing lower-quality communication, but the decision was not associated with subsequent grief symptoms. Importantly, understanding of brain death is a key element of the organ donation process for relatives.

 

 

Atrophie diaphragmatique à cause de la PEP ?

 

 

 

, et al., AJRCCM, 2018

https://www.atsjournals.org/doi/full/10.1164/rccm.201709-1899OC

https://doi.org/10.1164/rccm.201709-1917OC

 

 

Rationale: Diaphragm weakness in critically ill patients prolongs ventilator dependency and duration of hospital stay and increases mortality and healthcare costs. The mechanisms underlying diaphragm weakness include cross-sectional fiber atrophy and contractile protein dysfunction, but whether additional mechanisms are at play is unknown.

Objectives: To test the hypothesis that mechanical ventilation with positive end-expiratory pressure (PEEP) induces longitudinal atrophy by displacing the diaphragm in the caudal direction and reducing the length of fibers.

Methods: We studied structure and function of diaphragm fibers of mechanically ventilated critically ill patients and mechanically ventilated rats with normal and increased titin compliance.

Measurements and Main Results: PEEP causes a caudal movement of the diaphragm, both in critically ill patients and in rats, and this caudal movement reduces fiber length. Diaphragm fibers of 18-hour mechanically ventilated rats (PEEP of 2.5 cm H2O) adapt to the reduced length by absorbing serially linked sarcomeres, the smallest contractile units in muscle (i.e., longitudinal atrophy). Increasing the compliance of titin molecules reduces longitudinal atrophy.

Conclusions: Mechanical ventilation with PEEP results in longitudinal atrophy of diaphragm fibers, a response that is modulated by the elasticity of the giant sarcomeric protein titin. We postulate that longitudinal atrophy, in concert with the aforementioned cross-sectional atrophy, hampers spontaneous breathing trials in critically ill patients: during these efforts, end-expiratory lung volume is reduced, and the shortened diaphragm fibers are stretched to excessive sarcomere lengths. At these lengths, muscle fibers generate less force, and diaphragm weakness ensues.

 

 

Impact du DV précoce en réanimation ?

 

 

, et al., AJRCCM, 2018

https://www.atsjournals.org/doi/full/10.1164/rccm.201708-1728OC

https://doi.org/10.1164/rccm.201708-1728OC

 

 

Rationale: It remains unclear how prone positioning improves survival in acute respiratory distress syndrome. Using serial computed tomography (CT), we previously reported that “unstable” inflation (i.e., partial aeration with large tidal density swings, indicating increased local strain) is associated with injury progression.

Objectives: We prospectively tested whether prone position contains the early propagation of experimental lung injury by stabilizing inflation.

Methods: Injury was induced by tracheal hydrochloric acid in rats; after randomization to supine or prone position, injurious ventilation was commenced using high tidal volume and low positive end-expiratory pressure. Paired end-inspiratory (EI) and end-expiratory (EE) CT scans were acquired at baseline and hourly up to 3 hours. Each sequential pair (EI, EE) of CT images was superimposed in parametric response maps to analyze inflation. Unstable inflation was then measured in each voxel in both dependent and nondependent lung. In addition, five pigs were imaged (EI and EE) prone versus supine, before and (1 hour) after hydrochloric acid aspiration.

Measurements and Main Results: In rats, prone position limited lung injury propagation and increased survival (11/12 vs. 7/12 supine; P = 0.01). EI–EE densities, respiratory mechanics, and blood gases deteriorated more in supine versus prone rats. At baseline, more voxels with unstable inflation occurred in dependent versus nondependent regions when supine (41 ± 6% vs. 18 ± 7%; P < 0.01) but not when prone. In supine pigs, unstable inflation predominated in dorsal regions and was attenuated by prone positioning.

Conclusions: Prone position limits the radiologic progression of early lung injury. Minimizing unstable inflation in this setting may alleviate the burden of acute respiratory distress syndrome.

 

 

 

IPP ou anti-H2 dans la prévention de l’ulcère de stress ?

Lilly et al., Chest, 2018
https://journal.chestnet.org/article/S0012-3692(18)30795-5/fulltext
DOI: https://doi.org/10.1016/j.chest.2018.05.015

Background

Proton pump inhibitors (PPIs) and histamine type 2 receptor blockers (H2Bs) are used for stress ulcer prophylaxis. Although the PPIs have greater potency for acid suppression, their relative effectiveness for preventing clinically important GI bleeding (CIGIB) has not been established. The goal of this study was to determine whether prophylactic PPIs were associated with lower risk of CIGIB than H2Bs among critically ill adults.

Methods

This retrospective cohort study included adults with critical illness from January 1, 2008, to June 30, 2012, who had at least one stress ulcer risk factor and received a PPI or H2B for ≥ 3 days. Cox proportional hazards regression propensity score matching and instrumental variable analyses were used to control for selection bias and confounding by unmeasured factors. The Acute Physiology and Chronic Health Evaluation Score version IV score was used to adjust for differences of acuity. The main outcome and exposure was CIGIB.

Results

Among 70,093 patients at risk, 49,576 (70.7%) received prophylaxis for at least 3 days, and 424 patients (0.6%) met the definition for experiencing CIGIB. The hazard for CIGIB was two times greater for PPI users compared with H2B users (adjusted hazard ratio, 1.82 [95% CI, 1.19-2.78]; hazard ratio, 2.37 [95% CI, 1.61-3.5]). Sensitivity analyses failed to detect any plausible scenario in which PPIs were superior to H2Bs for the prevention of CIGIB.

Conclusions

H2Bs were robustly and consistently associated with significantly lower CIGIB risk compared with PPIs in this population.

 

Revue sur le choc vasoplégique réfractaire

Jacob C. Jentzer, et al., Chest, 2018

Association entre le risque de bactériémie et la carence martiale

Randi Marie Mohus, et al., ICM, 2018
https://link.springer.com/article/10.1007/s00134-018-5320-8

Purpose

As iron is essential for both immune function and microbial growth, alterations in iron status could influence the risk of infections. We assessed the associations of iron status with risk of bloodstream infections (BSIs) and BSI mortality.

Methods

We measured serum iron, transferrin saturation (Tsat) and total iron-binding capacity (TIBC) in 61,852 participants in the population-based HUNT2 study (1995–97). Incident BSIs (1995–2011) were identified through linkage with the Mid-Norway Sepsis Register, which includes prospectively registered information on BSI from local and regional hospitals. We assessed the risk of a first-time BSI and BSI mortality with the iron indices using Cox proportional hazards regression analysis.

Results

During a median follow-up of 14.8 years, 1738 individuals experienced at least one episode of BSI, and 370 died within 30 days after a BSI. In age- and sex-adjusted analyses, BSI risk was increased among participants with indices of iron deficiency, serum iron ≤ 2.5th percentile (HR 1.72, 95% CI 1.34–2.21), Tsat ≤ 2.5th percentile (HR 1.48, 95% CI 1.12–1.96) or TIBC ≥ 97.5th percentile (HR 1.46, 95% CI 1.06–2.01). The associations remained similar after adjusting for comorbidities and exclusion of BSI related to cancer, rheumatic illnesses and inflammatory bowel disease. BSI mortality showed similar associations.

Conclusion

Indices of severe iron deficiency are associated with an increased risk of a future BSI.

Rôle de la réponse immunitaire dans les candidoses invasives

Jigar V. Desai, Frank L. van de Veerdonk, Michail S. Lionakis

ICM, 2018

https://link.springer.com/article/10.1007/s00134-017-4988-5

Qualité de vie après la réanimation : Impact du sepsis ?

Kelly Thompson et al., ICM, 2018
https://link.springer.com/article/10.1007/s00134-018-5274-x

Purpose

To determine differences in health-related quality of life (HRQoL), survival and healthcare resource use of critically ill adults with and without sepsis.

Methods

We conducted a primary propensity score matched analysis of patients with and without sepsis enrolled in a large multicentre clinical trial. Outcomes included HRQoL at 6 months, survival to 2 years, length of ICU and hospital admission and cost of ICU and hospital treatment to 2 years.

Results

We obtained linked data for 3442 (97.3%) of 3537 eligible patients and matched 806/905 (89.0%) patients with sepsis with 806/2537 (31.7%) without. After matching, there were no significant differences in the proportion of survivors with and without sepsis reporting problems with mobility (37.8% vs. 38.7%, p = 0.86), self-care (24.7% vs. 26.0%, p = 0.44), usual activities (44.5% vs. 46.8%, p = 0.28), pain/discomfort (42.4% vs. 41.6%, p = 0.54) and anxiety/depression (36.9% vs. 37.7%, p = 0.68). There was no significant difference in survival at 2 years: 482/792 (60.9%) vs. 485/799 (60.7%) (HR 1.01, 95% CI 0.86–1.18, p = 0.94). The initial ICU and hospital admission were longer for patients with sepsis: 10.1 ± 11.9 vs. 8.0 ± 9.8 days (p < 0.0001) and 22.8 ± 21.2 vs. 19.1 ± 19.0 days, (p = 0.0003) respectively. The cost of ICU admissions was higher for patients with sepsis: A$43,345 ± 46,263 (€35,109 ± 35,043) versus 34,844 ± 38,281 (€28,223 ± 31,007), mean difference $8501 (€6885), 95% CI $4342–12,660 (€3517 ± 10,254), p < 0.001 as was the total cost of hospital treatment to 2 years: A$74,120 ± 60,750 (€60,037 ± 49,207) versus A$65,806 ± 59,856 (€53,302 ± 48,483), p = 0.005.

Conclusions

Critically ill patients with sepsis have higher healthcare resource use and costs but similar survival and HRQoL compared to matched patients without sepsis.

Impact de la Pression motrice dans SDRA chez l’obèse : NS

De Jong, et al., ICM, 2018
https://link.springer.com/article/10.1007/s00134-018-5241-6

Purpose

The relation between driving pressure (plateau pressure-positive end-expiratory pressure) and mortality has never been studied in obese ARDS patients. The main objective of this study was to evaluate the relationship between 90-day mortality and driving pressure in an ARDS population ventilated in the intensive care unit (ICU) according to obesity status.

Methods

We conducted a retrospective single-center study of prospectively collected data of all ARDS patients admitted consecutively to a mixed medical-surgical adult ICU from January 2009 to May 2017. Plateau pressure, compliance of the respiratory system (Crs) and driving pressure of the respiratory system within 24 h of ARDS diagnosis were compared between survivors and non-survivors at day 90 and between obese (body mass index ≥ 30 kg/m2) and non-obese patients. Cox proportional hazard modeling was used for mortality at day 90.

Results

Three hundred sixty-two ARDS patients were included, 262 (72%) non-obese and 100 (28%) obese patients. Mortality rate at day 90 was respectively 47% (95% CI, 40–53) in the non-obese and 46% (95% CI, 36–56) in the obese patients. Driving pressure at day 1 in the non-obese patients was significantly lower in survivors at day 90 (11.9 ± 4.2 cmH2O) than in non-survivors (15.2 ± 5.2 cmH2O, p < 0.001). Contrarily, in obese patients, driving pressure at day 1 was not significantly different between survivors (13.7 ± 4.5 cmH2O) and non-survivors (13.2 ± 5.1 cmH2O, p = 0.41) at day 90. After three multivariate Cox analyses, plateau pressure [HR = 1.04 (95% CI 1.01–1.07) for each point of increase], Crs [HR = 0.97 (95% CI 0.96–0.99) for each point of increase] and driving pressure [HR = 1.07 (95% CI 1.04–1.10) for each point of increase], respectively, were independently associated with 90-day mortality in non-obese patients, but not in obese patients.

Conclusions

Contrary to non-obese ARDS patients, driving pressure was not associated with mortality in obese ARDS patients.

Management periopératoire du patiente toxicomane aux opoides

Ward, et al. Anesthesia & Analgesia: August 2018

doi: 10.1213/ANE.0000000000003477
https://journals.lww.com/anesthesia-analgesia/Fulltext/2018/08000/Opioid_Use_Disorders___Perioperative_Management_of.37.aspx?utm_source=newsletter_416&utm_medium=email&utm_campaign=critical-care-reviews-newsletter-348

Délirium post-opératoire : une revue de la littérature

Evered, Lisbeth A., PhD*,†; Silbert, Brendan S., MB, BS*,†

Anesthesia & Analgesia: August 2018
doi: 10.1213/ANE.0000000000003514
https://journals.lww.com/anesthesia-analgesia/Fulltext/2018/08000/Postoperative_Cognitive_Dysfunction_and_Noncardiac.32.aspx?utm_source=newsletter_416&utm_medium=email&utm_campaign=critical-care-reviews-newsletter-348

Variation de l’INR induite par la transfusion de PFC

Warner, et al. Anesthesia & Analgesia: August 2018

doi: 10.1213/ANE.0000000000003336
https://journals.lww.com/anesthesia-analgesia/Abstract/2018/08000/Changes_in_International_Normalized_Ratios_After.11.aspx

Anaphylaxie : Intérêt du rapport (Tryptase pendant l’allergie/Tryptase basale) ?

Gastaminza, et al. Anesthesia & Analgesia: August 2018

doi: 10.1213/ANE.0000000000002656
 https://journals.lww.com/anesthesia-analgesia/Abstract/2018/08000/Improvement_of_the_Elevated_Tryptase_Criterion_to.19.aspx

 

 

 

Devenir fonctionnel des patients admis pour tuberculose méningée : effet délétère de l’hyperprotéinorrachie et de l’hydrocéphalie, protecteur de la corticothérapie adjuvante

 

Functional outcomes in adults with tuberculous meningitis admitted to the ICU: a multicenter cohort study

Marie Cantier, Adeline Morisot, Emmanuel Guérot, Bruno Megarbane, Keyvan Razazi, Damien Contou, Eric Mariotte, Emmanuel Canet, Etienne De Montmollin, Vincent Dubée, Eric Boulet, Stéphane Gaudry, Guillaume Voiriot, Julien Mayaux, Frédéric Pène, Mathilde Neuville, Bruno Mourvillier, Stéphane Ruckly, Lila Bouadma, Michel Wolff, Jean-François Timsit, Romain Sonneville and ENCEPHALITICA study group

Critical Care201822:210

https://doi.org/10.1186/s13054-018-2140-8

 

 

Un BMI < 22kg/m2 et une balance hydrique positive sont des facteurs prédicteurs d’un pic d’amikacine insuffisnat chez les patients sous ECMO

 

Predictors of insufficient peak amikacin concentration in critically ill patients on extracorporeal membrane oxygenation

Cyril Touchard, Alexandra Aubry, Philippine Eloy, Nicolas Bréchot, Guillaume Lebreton, Guillaume Franchineau, Sebastien Besset, Guillaume Hékimian, Ania Nieszkowska, Pascal Leprince, Charles-Edouard Luyt, Alain Combes and Matthieu Schmidt

Critical Care201822:199

https://doi.org/10.1186/s13054-018-2122-x

Abstract

Background

Amikacin infusion requires targeting a peak serum concentration (Cmax) 8–10 times the minimal inhibitory concentration, corresponding to a Cmax of 60–80 mg/L for the least susceptible bacteria to theoretically prevent therapeutic failure. Because drug pharmacokinetics on extracorporeal membrane oxygenation (ECMO) are challenging, we undertook this study to assess the frequency of insufficient amikacin Cmax in critically ill patients on ECMO and to identify relative risk factors.

Methods

This was a prospective, observational, monocentric study in a university hospital. Patients on ECMO who received an amikacin loading dose for suspected Gram-negative infections were included. The amikacin loading dose of 25 mg/kg total body weight was administered intravenously and Cmax was measured 30 min after the end of the infusion. Independent predicators of Cmax < 60 mg/L after the first amikacin infusion were identified with mixed-model multivariable analyses. Various dosing simulations were performed to assess the probability of reaching 60 mg/L < Cmax < 80 mg/L.

Results

A total of 106 patients on venoarterial ECMO (VA-ECMO) (68%) or venovenous-ECMO (32%) were included. At inclusion, their median (1st; 3rd quartile) Sequential Organ-Failure Assessment score was 15 (12; 18) and 54 patients (51%) were on renal replacement therapy. Overall ICU mortality was 54%. Cmax was < 60 mg/L in 41 patients (39%). Independent risk factors for amikacin under-dosing were body mass index (BMI) < 22 kg/m2 and a positive 24-h fluid balance. Using dosing simulation, increasing the amikacin dosing regimen to 30 mg/kg and 35 mg/kg of body weight when the 24-h fluid balance is positive and the BMI is ≥ 22 kg/m2 or < 22 kg/m2 (Table 3), respectively, would have potentially led to the therapeutic target being reached in 42% of patients while reducing under-dosing to 23% of patients.

Conclusions

ECMO-treated patients were under-dosed for amikacin in one third of cases. Increasing the dose to 35 mg/kg of body weight in low-BMI patients and those with positive 24-h fluid balance on ECMO to reach adequate targeted concentrations should be investigated.

 

 

 

Une revue sur la douleur chronique post-opératoire :

 

Persistent Postsurgical Pain: Pathophysiology and Preventative Pharmacologic Considerations

Philippe Richebé, M.D., Ph.D.Xavier Capdevila, M.D., Ph.D.Cyril Rivat, Ph.D.

 

Anesthesiology 9 2018, Vol.129, 590-607. doi:10.1097/ALN.0000000000002238

 

Abstract

The development of chronic pain is considered a major complication after surgery. Basic science research in animal models helps us understand the transition from acute to chronic pain by identifying the numerous molecular and cellular changes that occur in the peripheral and central nervous systems. It is now well recognized that inflammation and nerve injury lead to long-term synaptic plasticity that amplifies and also maintains pain signaling, a phenomenon referred to as pain sensitization. In the context of surgery in humans, pain sensitization is both responsible for an increase in postoperative pain via the expression of wound hyperalgesia and considered a critical factor for the development of persistent postsurgical pain. Using specific drugs that block the processes of pain sensitization reduces postoperative pain and prevents the development of persistent postoperative pain. This narrative review of the literature describes clinical investigations evaluating different preventative pharmacologic strategies that are routinely used by anesthesiologists in their daily clinical practices for preventing persistent postoperative pain. Nevertheless, further efforts are needed in both basic and clinical science research to identify preclinical models and novel therapeutics targets. There remains a need for more patient numbers in clinical research, for more reliable data, and for the development of the safest and the most effective strategies to limit the incidence of persistent postoperative pain.

 

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 9 2018, Vol.129, 583-589. doi:10.1097/ALN.0000000000002314

 

Burn injury is associated with early profound hypovolemia followed by a systemic inflammatory response with a subsequent hyperdynamic state.1  Hemodynamic management has long been identified as a key factor impacting burn patients’ prognosis.2  Because both under- and over-resuscitation may potentially negatively impact outcome, anesthesiologists and intensivists caring for burn patients will have to face the challenge of fluid balance in these patients.3,4  The aim of this review is to provide an overview of the hemodynamic consequences of burn injury and to propose strategies for the initial hemodynamic management of severe burn patients using the available evidence-based medicine combined with a physiologic approach.

 

Bloc ilio-fascial pour la chirurgie arthroscopique de la hanche : Gain analgésique et/ou risque de chute ?

 

Preoperative Fascia Iliaca Block Does Not Improve Analgesia after Arthroscopic Hip Surgery, but Causes Quadriceps Muscles Weakness: A Randomized, Double-blind Trial

Matthias Behrends, M.D.Edward N. Yap, M.D.Alan L. Zhang, M.D.Kerstin Kolodzie, M.D., Ph.D.Sakura Kinjo, M.D.; et al

 

Anesthesiology 9 2018, Vol.129, 536-543. doi:10.1097/ALN.0000000000002321

 

Abstract

What We Already Know about This Topic:

Hip arthroscopy is a surgical procedure growing in popularity

The optimal approach to postoperative analgesia has not been identified

What This Article Tells Us That Is New:

The addition of preoperative fascia iliaca block using ropivacaine to the intraarticular injection of ropivacaine did not improve early postoperative pain scores

The fascia iliaca blocks also did not improve most secondary endpoints, although they did cause quadriceps weakness

Background: Ambulatory hip arthroscopy is associated with postoperative pain routinely requiring opioid analgesia. The potential role of peripheral nerve blocks for pain control after hip arthroscopy is controversial. This trial investigated whether a preoperative fascia iliaca block improves postoperative analgesia.

Methods: In a prospective, double-blinded trial, 80 patients scheduled for hip arthroscopy were randomized to receive a preoperative fascia iliaca block with 40 ml ropivacaine 0.2% or saline. Patients also received an intraarticular injection of 10-ml ropivacaine 0.2% at procedure end. Primary study endpoint was highest pain score reported in the recovery room; other study endpoints were pain scores and opioid use 24 h after surgery. Additionally, quadriceps strength was measured to identify leg weakness.

Results: The analysis included 78 patients. Highest pain scores in the recovery room were similar in the block group (6 ± 2) versus placebo group (7 ± 2), difference: −0.2 (95% CI, −1.1 to 0.7), as was opioid use (intravenous morphine equivalent dose: 15 ± 7mg [block] vs. 16 ± 9 mg [placebo]). Once discharged home, patients experienced similar pain and opioid use (13 ± 7 mg [block] vs. 12 ± 8 mg [placebo]) in the 24 h after surgery. The fascia iliaca block resulted in noticeable quadriceps weakness. There were four postoperative falls in the block group versus one fall in the placebo group.

Conclusions: Preoperative fascia iliaca blockade in addition to intraarticular local anesthetic injection did not improve pain control after hip arthroscopy but did result in quadriceps weakness, which may contribute to an increased fall risk. Routine use of this block cannot be recommended in this patient population.

 

 

Une hypotension, même modérée, pendant plus de 10min est associée à un risqué d’AVC ischémique en chirurgie cardiaque

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 9 2018, Vol.129, 440-447. doi:10.1097/ALN.0000000000002298

 

Abstract

What We Already Know about This Topic:

Ischemic stroke after cardiac surgery is a devastating complication affecting approximately 2% of patients

The relationship between hypotension occurring before, during, and after cardiopulmonary bypass and stroke remains unclear

What This Article Tells Us That Is New:

Mean arterial pressure less than 65 mmHg for 10 or more min during cardiopulmonary bypass is associated with an increased risk of stroke

Even mild relative hypotension, defined as a less than 10% decrease from preinduction baseline during bypass, was also associated with an increased risk of stroke

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.

 

 

 

 

Share This:

© 2014 - AJAR Paris – IDF. Tous droits réservés. Wordpress & We Create Web Designs