Biblio du mois : Juillet 2017

Voilà l’été ! et la biblio du mois de Juillet ! Profitez-en avec une étude qui modère l’étude qui avait montré la surmortalité en période de vacances et WE 😉

Au programme, de l’hypothermie post-ACR, de l’infectieux avec BMR et du microbiote, de l’anesthésiologie avec de la kétamine, de l’ALR et surtout de la physiologie notamment sur la Pression artérielle !

Enfin pour compléter cette biblio, un certain nombre de méta-analyses intéressantes qui pourront vous faire réfléchir sur votre pratique.

Encore une biblio du mois qui montre que l’Anesthésie-Réanimation, ce n’est pas « que » du travail au bloc opératoire mais une prise en charge globale !

N’oubliez pas les astuces pour profiter au mieux de la biblio du mois : ici

 

 

 

 

Edito : L’allergie aux pénicillines : « Not Necessarily Forever » ?

 

Trubiano et al., JAMA, 2017

http://jamanetwork.com/journals/jama/article-abstract/2635615

doi:10.1001/jama.2017.6510

 

Hypothermie thérapeutique post-ACR: 48h versus 24h

 

Kirkegaard et al., JAMA, 2017

http://jamanetwork.com/journals/jama/article-abstract/2645105

doi:10.1001/jama.2017.8978

 

 

Importance  International resuscitation guidelines recommend targeted temperature management (TTM) at 33°C to 36°C in unconscious patients with out-of-hospital cardiac arrest for at least 24 hours, but the optimal duration of TTM is uncertain.

Objective  To determine whether TTM at 33°C for 48 hours results in better neurologic outcomes compared with currently recommended, standard, 24-hour TTM.

Design, Setting, and Participants  This was an international, investigator-initiated, blinded-outcome-assessor, parallel, pragmatic, multicenter, randomized clinical superiority trial in 10 intensive care units (ICUs) at 10 university hospitals in 6 European countries. Three hundred fifty-five adult, unconscious patients with out-of-hospital cardiac arrest were enrolled from February 16, 2013, to June 1, 2016, with final follow-up on December 27, 2016.

Interventions  Patients were randomized to TTM (33 ± 1°C) for 48 hours (n = 176) or 24 hours (n = 179), followed by gradual rewarming of 0.5°C per hour until reaching 37°C.

Main Outcomes and Measures  The primary outcome was 6-month neurologic outcome, with a Cerebral Performance Categories (CPC) score of 1 or 2 used to define favorable outcome. Secondary outcomes included 6-month mortality, including time to death, the occurrence of adverse events, and intensive care unit resource use.

Results  In 355 patients who were randomized (mean age, 60 years; 295 [83%] men), 351 (99%) completed the trial. Of these patients, 69% (120/175) in the 48-hour group had a favorable outcome at 6 months compared with 64% (112/176) in the 24-hour group (difference, 4.9%; 95% CI, −5% to 14.8%; relative risk [RR], 1.08; 95% CI, 0.93-1.25; P = .33). Six-month mortality was 27% (48/175) in the 48-hour group and 34% (60/177) in the 24-hour group (difference, −6.5%; 95% CI, −16.1% to 3.1%; RR, 0.81; 95% CI, 0.59-1.11; P = .19). There was no significant difference in the time to mortality between the 48-hour group and the 24-hour group (hazard ratio, 0.79; 95% CI, 0.54-1.15; P = .22). Adverse events were more common in the 48-hour group (97%) than in the 24-hour group (91%) (difference, 5.6%; 95% CI, 0.6%-10.6%; RR, 1.06; 95% CI, 1.01-1.12; P = .04). The median length of intensive care unit stay (151 vs 117 hours; P < .001), but not hospital stay (11 vs 12 days; P = .50), was longer in the 48-hour group than in the 24-hour group.

Conclusions and Relevance  In unconscious survivors from out-of-hospital cardiac arrest admitted to the ICU, targeted temperature management at 33°C for 48 hours did not significantly improve 6-month neurologic outcome compared with targeted temperature management at 33°C for 24 hours. However, the study may have had limited power to detect clinically important differences, and further research may be warranted.

 

 

Surmortalité le week-end et périodes de vacances : pas tant que ça ?

 

Walker et al., Lancet, 2017

http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)30782-1.pdf

http://dx.doi.org/10.1016/S0140-6736(17)30782-1

 

 

Background

Weekend hospital admission is associated with increased mortality, but the contributions of varying illness severity and admission time to this weekend effect remain unexplored.

Methods

We analysed unselected emergency admissions to four Oxford University National Health Service hospitals in the UK from Jan 1, 2006, to Dec 31, 2014. The primary outcome was death within 30 days of admission (in or out of hospital), analysed using Cox models measuring time from admission. The primary exposure was day of the week of admission. We adjusted for multiple confounders including demographics, comorbidities, and admission characteristics, incorporating non-linearity and interactions. Models then considered the effect of adjusting for 15 common haematology and biochemistry test results or proxies for hospital workload.

Findings

257 596 individuals underwent 503 938 emergency admissions. 18 313 (4·7%) patients admitted as weekday energency admissions and 6070 (5·1%) patients admitted as weekend emergency admissions died within 30 days (p<0·0001). 9347 individuals underwent 9707 emergency admissions on public holidays. 559 (5·8%) died within 30 days (p<0·0001 vs weekday). 15 routine haematology and biochemistry test results were highly prognostic for mortality. In 271 465 (53·9%) admissions with complete data, adjustment for test results explained 33% (95% CI 21 to 70) of the excess mortality associated with emergency admission on Saturdays compared with Wednesdays, 52% (lower 95% CI 34) on Sundays, and 87% (lower 95% CI 45) on public holidays after adjustment for standard patient characteristics. Excess mortality was predominantly restricted to admissions between 1100 h and 1500 h (pinteraction=0·04). No hospital workload measure was independently associated with mortality (all p values >0·06).

Interpretation

Adjustment for routine test results substantially reduced excess mortality associated with emergency admission at weekends and public holidays. Adjustment for patient-level factors not available in our study might further reduce the residual excess mortality, particularly as this clustered around midday at weekends. Hospital workload was not associated with mortality. Together, these findings suggest that the weekend effect arises from patient-level differences at admission rather than reduced hospital staffing or services.

 

 

La kétamine per-opératoire : kétamine bonne mine ?

 

 

Avidan et al., Lancet, 2017

http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)31467-8.pdf

DOI: http://dx.doi.org/10.1016/S0140-6736(17)31467-8

 

 

Background

Delirium is a common and serious postoperative complication. Subanaesthetic ketamine is often administered intraoperatively for postoperative analgesia, and some evidence suggests that ketamine prevents delirium. The primary purpose of this trial was to assess the effectiveness of ketamine for prevention of postoperative delirium in older adults.

Methods

The Prevention of Delirium and Complications Associated with Surgical Treatments [PODCAST] study is a multicentre, international randomised trial that enrolled adults older than 60 years undergoing major cardiac and non-cardiac surgery under general anaesthesia. Using a computer-generated randomisation sequence we randomly assigned patients to one of three groups in blocks of 15 to receive placebo (normal saline), low-dose ketamine (0·5 mg/kg), or high dose ketamine (1·0 mg/kg) after induction of anaesthesia, before surgical incision. Participants, clinicians, and investigators were blinded to group assignment. Delirium was assessed twice daily in the first 3 postoperative days using the Confusion Assessment Method. We did analyses by intention-to-treat and assessed adverse events. This trial is registered with clinicaltrials.gov, number NCT01690988.

Findings

Between Feb 6, 2014, and June 26, 2016, 1360 patients were assessed, and 672 were randomly assigned, with 222 in the placebo group, 227 in the 0·5 mg/kg ketamine group, and 223 in the 1·0 mg/kg ketamine group. There was no difference in delirium incidence between patients in the combined ketamine groups and the placebo group (19·45% vs 19·82%, respectively; absolute difference 0·36%, 95% CI −6·07 to 7·38, p=0·92). There were more postoperative hallucinations (p=0·01) and nightmares (p=0·03) with increasing ketamine doses compared with placebo. Adverse events (cardiovascular, renal, infectious, gastrointestinal, and bleeding), whether viewed individually (p value for each >0·40) or collectively (36·9% in placebo, 39·6% in 0·5 mg/kg ketamine, and 40·8% in 1·0 mg/kg ketamine groups, p=0·69), did not differ significantly across groups.

Interpretation

A single subanaesthetic dose of ketamine did not decrease delirium in older adults after major surgery, and might cause harm by inducing negative experiences.

 

 

Body-TDM post-mortem versus Autopsie

 

Rutty et al., Lancet, 2017

http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)30333-1.pdf

http://dx.doi.org/10.1016/S0140-6736(17)30333-1

 

Background

England and Wales have one of the highest frequencies of autopsy in the world. Implementation of post-mortem CT (PMCT), enhanced with targeted coronary angiography (PMCTA), in adults to avoid invasive autopsy would have cultural, religious, and potential economic benefits. We aimed to assess the diagnostic accuracy of PMCTA as a first-line technique in post-mortem investigations.

Methods

In this single-centre (Leicester, UK), prospective, controlled study, we selected cases of natural and non-suspicious unnatural death referred to Her Majesty’s (HM) Coroners. We excluded cases younger than 18 years, known to have had a transmittable disease, or who weighed more than 125 kg. Each case was assessed by PMCTA, followed by autopsy. Pathologists were masked to the PMCTA findings, unless a potential risk was shown. The primary endpoint was the accuracy of the cause of death diagnosis from PMCTA against a gold standard of autopsy findings, modified by PMCTA findings only if additional substantially incontrovertible findings were identified.

Findings

Between Jan 20, 2010, and Sept 13, 2012, we selected 241 cases, for which PMCTA was successful in 204 (85%). Seven cases were excluded from the analysis because of procedural unmasking or no autopsy data, as were 24 cases with a clear diagnosis of traumatic death before investigation; 210 cases were included. In 40 (19%) cases, predictable toxicology or histology testing accessible by PMCT informed the result. PMCTA provided a cause of death in 193 (92%) cases. A major discrepancy with the gold standard was noted in 12 (6%) cases identified by PMCTA, and in nine (5%) cases identified by autopsy (because of specific findings on PMCTA). The frequency of autopsy and PMCTA discrepancies were not significantly different (p=0·65 for major discrepancies and p=0·21 for minor discrepancies). Cause of death given by PMCTA did not overlook clinically significant trauma, occupational lung disease, or reportable disease, and did not significantly affect the overall population data for cause of death (p≥0·31). PMCTA was better at identifying trauma and haemorrhage (p=0·008), whereas autopsy was better at identifying pulmonary thromboembolism (p=0·004).

Interpretation

For most sudden natural adult deaths investigated by HM Coroners, PMCTA could be used to avoid invasive autopsy. The gold standard of post-mortem investigations should include both PMCT and invasive autopsy.

 

 

Effet nocebo : exemple des statines

 

Gupta et al., Lancet, 2017

http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)31075-9.pdf

 

 

Background

In blinded randomised controlled trials, statin therapy has been associated with few adverse events (AEs). By contrast, in observational studies, larger increases in many different AEs have been reported than in blinded trials.

Methods

In the Lipid-Lowering Arm of the Anglo-Scandinavian Cardiac Outcomes Trial, patients aged 40–79 years with hypertension, at least three other cardiovascular risk factors, and fasting total cholesterol concentrations of 6·5 mmol/L or lower, and who were not taking a statin or fibrate, had no history of myocardial infarction, and were not being treated for angina were randomly assigned to atorvastatin 10 mg daily or matching placebo in a randomised double-blind placebo-controlled phase. In a subsequent non-randomised non-blind extension phase (initiated because of early termination of the trial because efficacy of atorvastatin was shown), all patients were offered atorvastatin 10 mg daily open label. We classified AEs using the Medical Dictionary for Regulatory Activities. We blindly adjudicated all reports of four prespecified AEs of interest—muscle-related, erectile dysfunction, sleep disturbance, and cognitive impairment—and analysed all remaining AEs grouped by system organ class. Rates of AEs are given as percentages per annum.

Results

The blinded randomised phase was done between February, 1998, and December, 2002; we included 101 80 patients in this analysis (5101 [50%] in the atorvastatin group and 5079 [50%] in the placebo group), with a median follow-up of 3·3 years (IQR 2·7–3·7). The non-blinded non-randomised phase was done between December, 2002, and June, 2005; we included 9899 patients in this analysis (6409 [65%] atorvastatin users and 3490 [35%] non-users), with a median follow-up of 2·3 years (2·2–2·4). During the blinded phase, muscle-related AEs (298 [2·03% per annum] vs 283 [2·00% per annum]; hazard ratio 1·03 [95% CI 0·88–1·21]; p=0·72) and erectile dysfunction (272 [1·86% per annum] vs 302 [2·14% per annum]; 0·88 [0·75–1·04]; p=0·13) were reported at a similar rate by participants randomly assigned to atorvastatin or placebo. The rate of reports of sleep disturbance was significantly lower among participants assigned atorvastatin than assigned placebo (149 [1·00% per annum] vs 210 [1·46% per annum]; 0·69 [0·56–0·85]; p=0·0005). Too few cases of cognitive impairment were reported for a statistically reliable analysis (31 [0·20% per annum] vs 32 [0·22% per annum]; 0·94 [0·57–1·54]; p=0·81). We observed no significant differences in the rates of all other reported AEs, with the exception of an excess of renal and urinary AEs among patients assigned atorvastatin (481 [1·87%] per annum vs 392 [1·51%] per annum; 1·23 [1·08–1·41]; p=0·002). By contrast, during the non-blinded non-randomised phase, muscle-related AEs were reported at a significantly higher rate by participants taking statins than by those who were not (161 [1·26% per annum] vs 124 [1·00% per annum]; 1·41 [1·10–1·79]; p=0·006). We noted no significant differences between statin users and non-users in the rates of other AEs, with the exception of musculoskeletal and connective tissue disorders (992 [8·69% per annum] vs 831 [7·45% per annum]; 1·17 [1·06–1·29]; p=0·001) and blood and lymphatic system disorders (114 [0·88% per annum] vs 80 [0·64% per annum]; 1·40 [1·04–1·88]; p=0·03), which were reported more commonly by statin users than by non-users.

Interpretation

These analyses illustrate the so-called nocebo effect, with an excess rate of muscle-related AE reports only when patients and their doctors were aware that statin therapy was being used and not when its use was blinded. These results will help assure both physicians and patients that most AEs associated with statins are not causally related to use of the drug and should help counter the adverse effect on public health of exaggerated claims about statin-related side-effects.

 

 

 

Transplantation fécale pour lutter contre les BMR ?

 

Bilinsky et al., CID, 2017

https://academic.oup.com/cid/article-abstract/65/3/364/3088486/Fecal-Microbiota-Transplantation-in-Patients-With?redirectedFrom=fulltext

 

Background.

Patients with blood disorders colonized with antibiotic-resistant bacteria (ARB) are prone to systemic infections that are difficult to treat. Reintroduction of commensal bacteria in a murine model of enterococcal colonization of the gut can lead to eradication of enterococci. We hypothesized that fecal microbiota transplantation (FMT) could be used to eradicate ARB in humans.

Methods.

Participants colonized with ARB were treated with intraduodenal FMT according to a prospective protocol (NCT02461199). The primary endpoint was complete ARB decolonization at 1 month after FMT. Secondary endpoints included safety assessment and partial ARB decolonization. Microbiome sequencing was performed to investigate the influence of microbial composition of the transplanted material on the outcome of FMT.

Results.

Twenty-five FMTs were performed in 20 participants (including 40% who had neutropenia) who were colonized by a median of 2 (range, 1–4) strains of ARB. The primary endpoint was reached in 15/25 (60%) of the FMTs and more frequently in cases in which there was no periprocedural use of antibiotics (79% vs 36%, P < .05). Among participants, 15/20 (75%) experienced complete ARB decolonization. There were no severe adverse events, and partial ARB decolonization was observed in 20/25 (80%) of the FMTs. The microbiota composition analysis revealed higher abundance of Barnesiella spp., Bacteroides, and Butyricimonas and greater bacterial richness in the fecal material, resulting in eradication of Klebsiella pneumoniae compared with nonresponders.

Conclusions.

FMT in patients with blood disorders is safe and promotes eradication of ARB from the gastrointestinal tract.

 

 

Colonisation gastro-intestinale à Klebsiella pneumoniae associée aux infections en Réa ?

 

Gorrie et al., CID, 2017

Lien vers pdf

 

Background.

Klebsiella pneumoniae is an opportunistic pathogen and leading cause of hospital-associated infections. Intensive care unit (ICU) patients are particularly at risk. Klebsiella pneumoniae is part of the healthy human microbiome, providing a potential reservoir for infection. However, the frequency of gut colonization and its contribution to infections are not well characterized.

Methods.

We conducted a 1-year prospective cohort study in which 498 ICU patients were screened for rectal and throat carriage of K. pneumoniae shortly after admission. Klebsiella pneumoniae isolated from screening swabs and clinical diagnostic samples were characterized using whole genome sequencing and combined with epidemiological data to identify likely transmission events.

Results.

Klebsiella pneumoniae carriage frequencies were estimated at 6% (95% confidence interval [CI], 3%–8%) among ICU patients admitted direct from the community, and 19% (95% CI, 14%–51%) among those with recent healthcare contact. Gut colonization on admission was significantly associated with subsequent infection (infection risk 16% vs 3%, odds ratio [OR] = 6.9, P < .001), and genome data indicated matching carriage and infection isolates in 80% of isolate pairs. Five likely transmission chains were identified, responsible for 12% of K. pneumoniae infections in ICU. In sum, 49% of K. pneumoniae infections were caused by the patients’ own unique strain, and 48% of screened patients with infections were positive for prior colonization.

Conclusions.

These data confirm K. pneumoniae colonization is a significant risk factor for infection in ICU, and indicate ~50% of K. pneumoniae infections result from patients’ own microbiota. Screening for colonization on admission could limit risk of infection in the colonized patient and others.

 

 

 

Méta-analyse sur le « pre-operative Goal-Directed Therapy »

 

Michard et al., BJA, 2017

Lien vers pdf

L’index de perfusion sur oxymètre pour prédire l’efficacité d’un bloc supraclaviculaire ?

Abdelnasser et al., BJA, 2017

Background.

Supraclavicular nerve block is a popular approach for anaesthesia for upper limb surgeries. Conventional methods for evaluation of block success are time consuming and need patient cooperation. The aim of this study was to evaluate whether the perfusion index (PI) can be used to predict and provide a cut-off value for ultrasound-guided supraclavicular nerve block success.

Methods.

The study included 77 patients undergoing elective orthopaedic procedures under ultrasound-guided supraclavicular nerve block. After local anaesthetic injection, sensory block success was assessed every 3 min by pinprick, and motor block success was assessed every 5 min by the ability to flex the elbow and the hand against resistance. The PI was recorded at baseline and at 10, 20, and 30 min after anaesthetic injection in both blocked and non-blocked limbs. The PI ratio was calculated as the PI after 10 min divided by the PI at the baseline. Receiver operating characteristic curves were constructed for the accuracy of the PI in detection of block success.

Results.

The PI was higher in the blocked limb at all time points, and this was paralleled by a higher PI ratio compared with the unblocked limb. Both the PI and the PI ratio at 10 min after injection showed a sensitivity and specificity of 100% for block success at cut-off values of 3.3 and 1.4, respectively.

Conclusions.

The PI is a useful tool for evaluation of successful supraclavicular nerve block. A PI ratio of > 1.4 is a good predictor for block success.

 

 

La différence entre PaCO2 et PvcCO2 comme facteur pronostique dans le choc septique ?

 

 

Muller et al., BJA, 2017

https://academic.oup.com/bja/article-abstract/119/2/239/3965679/Prognostic-significance-of-central-venous-to?redirectedFrom=fulltext

Objective

To investigate the prognostic significance of central venous-to-arterial carbon dioxide difference (cv-art CO2 gap) during septic shock in patients with and without impaired cardiac function.

Methods

We performed a prospective cohort study in 10 French intensive care units. Patients suffering from septic shock were assigned to the impaired cardiac function group (‘cardiac group’, n=123) if they had atrial fibrillation (AF) and/or left ventricular ejection fraction (LVEF) <50% at study entry and to the non-cardiac group (n=240) otherwise.

Results

Central venous and arterial blood gases were sampled every 6 h during the first 24 h to calculate cv-art CO2 gap. Patients in the cardiac group had a higher cv-art CO2 gap [at study entry and 6 and 12 h (all P<0.02)] than the non-cardiac group. Patients in the cardiac group with a cv-art CO2 gap >0.9 kPa at 12 h had a higher risk of day 28 mortality (hazard ratio=3.18; P=0.0049). Among the 59 patients in the cardiac group with mean arterial pressure (MAP) ≥65 mm Hg, central venous pressure (CVP) ≥8 mm Hg and central venous oxygen saturation (ScvO2) ≥70% at 12 h, those with a high cv-art CO2 gap (>0.9 kPa; n=19) had a higher day 28 mortality (37% vs. 13%; P=0.042). In the non-cardiac group, a high cv-art CO2 gap was not linked to a higher risk of day 28 death, whatever the threshold value of the cv-art CO2 gap.

Conclusion

Patients with septic shock and with AF and/or low LVEF were more prone to a persistent high cv-art CO2 gap, even when initial resuscitation succeeded in normalizing MAP, CVP, and ScvO2. In these patients, a persistent high cv-art CO2 gap at 12 h was significantly associated with higher day 28 mortality.

 

4mg de Dexa per-opératoire : pas si anodin sur le système immunitaire ?

 

Corcoran et al., BJA, 2017

https://academic.oup.com/bja/article-abstract/119/2/221/3939716/Intraoperative-dexamethasone-alters-immune-cell?redirectedFrom=fulltext

 

Background

Anaesthetists use dexamethasone principally for its anti-emetic effect. The purpose of this study was to characterize the effects of a single intraoperative dose of dexamethasone on cellular and metabolic components of the immune system in patients undergoing laparoscopic surgical procedures.

Methods

In this prospective double-blind trial, female patients undergoing elective major laparoscopic surgery were randomized to receive saline (Control group, n=16) or dexamethasone 4 mg (Dexamethasone group, n=16) i.v. after the induction of anaesthesia. Inflammatory markers and immune cell counts were examined at 24 and 48 h and 6 weeks after surgery. The changes from baseline preoperative values were compared between groups using a Mann–Whitney U-test, and linear mixed models were used to validate the findings.

Results

No differences in concentrations of serum glucose and interleukin-6 were observed between groups after surgery. The increase in C-reactive protein concentration at 24 h after surgery was greater in the control group [median (interquartile range), 33 (25–65) vs 17 (7–26) mg dl−1; P=0.018]. Extensive changes in the counts of white cells, including most lymphocyte subsets, were observed 24 h after surgery, and dexamethasone appeared to attenuate most of these changes. Changes at 48 h and 6 weeks did not differ between groups.

Conclusions

In female patients undergoing elective laparoscopic gynaecological surgery, dexamethasone administration appears to attenuate inflammation and to alter immune cell counts at 24 h, with no effects identified after this time. The importance of these changes for postoperative immune function is unknown.

 

Méta-analyse sur la Dexamethasone systémique versus périnerveuse en ALR

 

Baeriswyl et al., BJA, 2017

lien vers pdf

L’avènement des check-lists dynamiques ?

 

De Bie et al., BJA, 2017

https://academic.oup.com/bja/article-abstract/119/2/231/3897319/Intelligent-dynamic-clinical-checklists-improved?redirectedFrom=fulltext

 

Background

Checklists can reduce medical errors. However, the effectiveness of checklists is hampered by lack of acceptance and compliance. Recently, a new type of checklist with dynamic properties has been created to provide more specific checklist items for each individual patient. Our purpose in this simulation-based study was to investigate a newly developed intelligent dynamic clinical checklist (DCC) for the intensive care unit (ICU) ward round.

Methods

Eligible clinicians were invited to participate as volunteers. Highest achievable scores were established for six typical ICU scenarios to determine which items must be checked. The participants compared the DCC with the local standard of care. The primary outcomes were the caregiver satisfaction score and the percentages of checked items overall and of critical items requiring a direct intervention.

Results

In total, 20 participants were included, who performed 116 scenarios. The median percentage of checked items was 100.0% with the DCC and 73.6% for the scenarios completed with local standard of care (P<0.001). Critical items remained unchecked in 23.1% of the scenarios performed with local standard of care and 0.0% of the scenarios where the DCC was available (P<0.001). The mean satisfaction score of the DCC was 4.13 out of 5.

Conclusions

This simulation study indicates that an intelligent DCC significantly increases compliance with best practice by reducing the percentage of unchecked items during ICU ward rounds, while the user satisfaction rate remains high. Real-life clinical research is required to evaluate this new type of checklist further.

 

Etudes PK-PD sur la Dex : vers de l’AIVOC de Dexmedetomidine ?

 

 

Colin et al., BJA, 2017

1 : https://academic.oup.com/bja/article-abstract/119/2/200/3970833/Dexmedetomidine-pharmacokinetic-pharmacodynamic?redirectedFrom=fulltext

DOI:https://doi.org/10.1093/bja/aex085

2 : https://academic.oup.com/bja/article-abstract/119/2/211/4049133/Dexmedetomidine-pharmacodynamics-in-healthy?redirectedFrom=fulltext

Effets des corticoïdes à long terme : risque infectieux x 2 ?

Chaudhary et al., CC, 2017
https://doi.org/10.1186/s13054-017-1767-1

Background

Prior studies associate steroid use with infection risk but were limited to select populations and short follow-up periods. The association of steroid use with long-term risk of community-acquired infections is unknown. We sought to determine the association of steroid risk with long-term risks of community- acquired infections and sepsis.

Methods

We used data on 30,239 adults aged ≥ 45 years old from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. The primary exposure was oral or injectable steroid use, determined from medication inventory obtained at baseline in-home visit. The primary outcome was time to first infection event during 2003–2012, determined through adjudicated review of hospital records. We determined associations between baseline steroid use and first infection hospitalization events using Cox proportional hazards models, adjusting for demographics, health behaviors, chronic medical conditions, and medication adherence. Among the first infection hospitalization events, we also determined the association between baseline steroid use and sepsis.

Results

Steroid use was reported in 2.24% (n = 677) of the study population. There were 2593 incident infection events during the 10-year follow-up period. Infection incidence rates were higher for steroid than non-steroid users (37.99 vs. 13.79 per 1000 person-years). Steroid use was independently associated with increased risk of infection (adjusted HR 2.10, 95% CI: 1.73–2.56). Among first-infection events, steroid use was associated with increased odds of sepsis (adjusted OR 2.11, 95% CI: 1.33–3.36). The associations persisted in propensity matched analyses as well as models stratified by propensity score and medication adherence.

Conclusions

In this population-based cohort study, baseline steroid use was associated with increased long-term risks of community-acquired infections and sepsis.

L’EIT pour prédire le sevrage ventilatoire ?

Bickenbach et al., CC, 2017

Background

Spontaneous breathing trials (SBTs) on a T-piece can be difficult in patients with prolonged weaning because of remaining de-recruitment phenomena and/or insufficient ventilation. There is no clinically established method existent other than experience for estimating whether an SBT is most probably beneficial. Electrical impedance tomography (EIT) is a clinical useful online monitoring technique during mechanical ventilation, particularly because it enables analysis of effects of regional ventilation distribution. The aim of our observational study was to examine if EIT can predict whether patients with prolonged weaning will benefit from a planned SBT.

Methods

Thirty-one patients were examined. Blood gas analysis, vital parameter measurements, and EIT recordings were performed at three time points: (1) baseline with pressure support ventilation (PSV) (t0), (2) during a T-piece trial (t1), and (3) after resumption of PSV (t2). Calculation of EIT parameters was performed, including the impedance ratio (IR), the tidal variation of impedance (TIV), the changes in end-expiratory lung impedance (ΔEELI), the global inhomogeneity index (GI), and the regional ventilation delay (RVD) index with use of different thresholds of the percentage inspiration time (RVD40, RVD60, RVD80). The predictive power of the baseline GI with regard to clinical impairment of an SBT was analyzed by means of ROC curves. Clinical deterioration was assumed when tidal volume was decreased by at least 20 ml after the T-piece trial, measured at t2.

Results

Partial pressure of arterial oxygen significantly decreased at t1 (71 ± 15 mmHg) compared with t0 (85 ± 17 mmHg, p < 0.05) and t2 (82 ± 18 mmHg, p < 0.05). The IR trended toward higher values during t1. At t1, TIV and ΔEELI significantly decreased. The GI was significantly increased at t1 (t0 59.3 ± 46.1 vs t1 81.5 ± 62.5, p = 0.001), as were all RVD indexes. Assuming a GI cutoff value of >40, sensitivity of 85% and specificity of 50% were reached for predicting an increased future tidal volume.

Conclusions

EIT enables monitoring of regional ventilation distribution during SBTs and is suitable to estimate whether an SBT probably will be beneficial for an individual patient. Therefore, the application of EIT can support clinical decisions regarding patients in the phase of prolonged weaning.

Profils métabolomiques différents selon le niveau de vitamine D

 

Lasky-Su et al., CC, 2017
https://doi.org/10.1186/s13054-017-1794-y

Background

Metabolic homeostasis is substantially disrupted in critical illness. Given the pleiotropic effects of vitamin D, we hypothesized that metabolic profiles differ between critically ill patients relative to their vitamin D status.

Methods

We performed a metabolomics study on biorepository samples collected from a single academic medical center on 65 adults with systemic inflammatory response syndrome or sepsis treated in a 20-bed medical ICU between 2008 and 2010. To identify key metabolites and metabolic pathways related to vitamin D status in critical illness, we first generated metabolomic data using gas and liquid chromatography mass spectroscopy. We followed this by partial least squares-discriminant analysis to identify individual metabolites that were significant. We then interrogated the entire metabolomics profile using metabolite set enrichment analysis to identify groups of metabolites and pathways that were differentiates of vitamin D status. Finally we performed logistic regression to construct a network model of chemical-protein target interactions important in vitamin D status.

Results

Metabolomic profiles significantly differed in critically ill patients with 25(OH)D ≤ 15 ng/ml relative to those with levels >15 ng/ml. In particular, increased 1,5-anhydroglucitol, tryptophan betaine, and 3-hydroxyoctanoate as well as decreased 2-arachidonoyl-glycerophosphocholine and N-6-trimethyllysine were strong predictors of 25(OH)D >15 ng/ml. The combination of these five metabolites led to an area under the curve for discrimination for 25(OH)D > 15 ng/ml of 0.82 (95% CI 0.71–0.93). The metabolite pathways related to glutathione metabolism and glutamate metabolism are significantly enriched with regard to vitamin D status.

Conclusion

Vitamin D status is associated with differential metabolic profiles during critical illness. Glutathione and glutamate pathway metabolism, which play principal roles in redox regulation and immunomodulation, respectively, were significantly altered with vitamin D status.

Méta-analyse sur l’IOT pré-hospitalière chez les polytraumatisés

 

 

Fevang et al., CC, 2017
https://doi.org/10.1186/s13054-017-1787-x

Revue sur le monitorage continu de la glycémie

 

Krinsley et al., CC, 2017
https://doi.org/10.1186/s13054-017-1784-0

Méta-analyse : Optiflow vs VNI vs O2

Zhao et al., CC, 2017
https://doi.org/10.1186/s13054-017-1760-8

Revue sur le « Subsyndromal delirium »

Serafim et al., CC, 2017
https://doi.org/10.1186/s13054-017-1765-3

Arrêter les ATB si prélèvements respiratoires négatifs

 

Lascarrou et al., CCM, 2017
doi: 10.1097/CCM.0000000000002525

Objectives

To determine the proportion of patients with documented bacterial aspiration pneumonia among comatose ICU patients with symptoms suggesting either bacterial aspiration pneumonia or non-bacterial aspiration pneumonitis.

Design

Prospective observational study.

Setting

University-affiliated 30-bed ICU.

Patients

Prospective cohort of 250 patients admitted to the ICU with coma (Glasgow Coma Scale score ≤ 8) and treated with invasive mechanical ventilation.

Interventions

None.

Measurements and Main Results

The primary outcome was the proportion of patients with microbiologically documented bacterial aspiration pneumonia. Patients meeting predefined criteria for aspiration syndrome routinely underwent telescopic plugged catheter sampling during bronchoscopy before starting probabilistic antibiotic treatment. When cultures were negative, the antibiotic treatment was stopped. Of 250 included patients, 98 (39.2%) had aspiration syndrome, including 92 before mechanical ventilation discontinuation. Telescopic plugged catheter in these 92 patients showed bacterial aspiration pneumonia in 43 patients (46.7%). Among the remaining 49 patients, 16 continued to receive antibiotics, usually for infections other than pneumonia; of the 33 patients whose antibiotics were discontinued, only two subsequently showed signs of lung infection. In the six patients with aspiration syndrome after mechanical ventilation, and therefore without telescopic plugged catheter, antibiotic treatment was continued for 7 days. Mechanical ventilation duration, ICU length of stay, and mortality did not differ between the 43 patients with bacterial aspiration pneumonia and the 49 patients with non-bacterial aspiration pneumonitis. The 152 patients without aspiration syndrome did not receive antibiotics.

Conclusions

Among comatose patients receiving mechanical ventilation, those without clinical, laboratory, or radiologic evidence of bacterial aspiration pneumonia did not require antibiotics. In those with suspected bacterial aspiration pneumonia, stopping empirical antibiotic therapy when routine telescopic plugged catheter sampling recovered no microorganisms was nearly always effective. This strategy may be a valid alternative to routine full-course antibiotic therapy. Only half the patients with suspected bacterial aspiration pneumonia had this diagnosis confirmed by telescopic plugged catheter sampling.

 

 

Evaluation des fonctions cognitives pré-op et delirium post-op : Pour prédire la démence à 5 ans post-opératoire de chirurgie cardiaque ?

 

Lingehall et al., CCM, 2017

http://journals.lww.com/ccmjournal/Fulltext/2017/08000/Preoperative_Cognitive_Performance_and.5.aspx

doi: 10.1097/CCM.0000000000002483

 

Objective

To investigate if postoperative delirium was associated with the development of dementia within 5 years after cardiac surgery.

Design

Longitudinal cohort study.

Setting

Cardiothoracic Division, Umeå University Hospital, Sweden.

Patients

Patients aged 70 years old or older (n = 114) scheduled for routine cardiac procedures with cardiopulmonary bypass without documented dementia were enrolled in 2009.

Intervention

Structured assessments were performed preoperatively, 1 and 4 days after extubation, and 1, 3, and 5 years postoperatively.

Measurements and Main Results

Patients were assessed comprehensively, including cognitive and physical function, coexisting medical conditions, demographic characteristics, and medications. Diagnoses of delirium, depression, and dementia were made according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criteria. During the 5-year period, 30 of 114 participants (26.3%) developed dementia. Postoperative delirium had occurred in 87% of those who later developed dementia. A multivariable logistic regression model showed a lower preoperative Mini-Mental State Examination score (p < 0.001; odds ratio, 0.68; 95% CI, 0.54–0.84) and the occurrence of postoperative delirium (p = 0.002; odds ratio, 7.57; 95% CI, 2.15–26.65) were associated with dementia occurrence.

Conclusions

Our findings suggest that older patients with reduced preoperative cognitive functions or who develop postoperative delirium are at risk of developing dementia within 5 years after cardiac surgery. Cognitive functions should be screened for preoperatively, those who develop postoperative delirium should be followed up to enable early detection of dementia symptoms, and management should be implemented.

 

 

 

Explorations à faire chez les patients ayant eu une insuffisance respiratoire hypercapnique

 

Adler et al., CCM, 2017

http://www.atsjournals.org/doi/full/10.1164/rccm.201608-1666OC

https://doi.org/10.1164/rccm.201608-1666OC

 

 

Rationale

No methodical assessment of the lung, cardiac, and sleep function of patients surviving an acute hypercapnic respiratory failure episode requiring admission to the intensive care unit (ICU) has been reported in the literature.

Objectives

To prospectively investigate the prevalence and impact of comorbidities in patients treated by mechanical ventilator support (invasive or noninvasive) for acute hypercapnic respiratory failure in the ICU.

Methods

Seventy-eight consecutive patients admitted for an episode of acute hypercapnic respiratory failure underwent an assessment of lung, cardiac, and sleep function by pulmonary function tests, transthoracic echocardiography, and polysomnography 3 months after ICU discharge.

Measurements and Main Results

Sixty-seven percent (52 of 78) of patients exhibited chronic obstructive pulmonary disease (COPD), although only 19 had been previously diagnosed. Patients without COPD were primarily obese. Prevalence of severe obstructive sleep apnea was 51% (95% confidence interval, 34–69) in patients with COPD and 81% (95% confidence interval, 54–96) in patients without COPD. Previously undiagnosed cardiac dysfunction with preserved ejection fraction was highly prevalent (44%), as was hypertension (67%). More than half of the population demonstrated at least three major comorbidities known to precipitate acute hypercapnic respiratory failure. Multimorbidity was associated with longer time to hospital discharge. Hospital readmission or death occurred in 46% of patients over an average of 3.5 months after discharge.

Conclusions

Severe hypercapnic respiratory failure requiring ICU admission resulted primarily from COPD or obesity. Major comorbidities are highly prevalent in both cases and most often ignored. Surviving acute hypercapnic respiratory failure should be an opportunity to systematically evaluate lung, heart, and sleep functions to improve poor outcomes.

 

 

Un score spécifique prédictif dans l’heure de la mortalité en réanimation pédiatrique

Schlapbach et al., ICM, 2017

http://icmjournal.esicm.org/journals/abstract.html?v=43&j=134&i=8&a=4701_10.1007_s00134-017-4701-8&doi=

 

Purpose

The definitions of sepsis and septic shock have recently been revised in adults, but contemporary data are needed to inform similar approaches in children.

Methods

Multicenter cohort study including children <16 years admitted with sepsis or septic shock to ICUs in Australia and New Zealand in the period 2012–2015. We assessed septic shock criteria at ICU admission to define sepsis severity, using 30-day mortality as outcome. Through multivariable logistic regression, a pediatric sepsis score was derived using variables available within 60 min of ICU admission.

Results

Of 42,523 pediatric admissions, 4403 children were admitted with invasive infection, including 1697 diagnosed as having sepsis/septic shock on admission. Mortality was 8.5% (144/1697) and 50.7% of deaths occurred within 48 h of admission. The presence of septic shock as defined by the 2005 consensus was sensitive but not specific in predicting mortality (AUC = 0.69; 95% CI 0.65–0.72). Combinations of hypotension, vasopressor therapy, and lactate >2 mmol/l discriminated poorly (AUC <0.60). Multivariate models showed that oxygenation markers, ventilatory support, hypotension, cardiac arrest, serum lactate, pupil responsiveness, and immunosuppression were the best-performing predictors (0.843; 0.811–0.875). We derived a pediatric sepsis score (0.817; 0.779–0.855), and every one-point increase was associated with a 28.5% (23.8–33.2%) increase in the odds of death. Children with a score ≥6 had 19.8% mortality and accounted for 74.3% of deaths. The sepsis score performed comparably when applied to all children admitted with invasive infection (0.810; 0.781–0.840).

Conclusions

We observed mortality patterns specific to pediatric sepsis that support the need for specialized definitions of sepsis severity in children. We demonstrated the importance of lactate, cardiovascular, and respiratory derangements at ICU admission for the identification of children with substantially higher risk of sepsis mortality.

 

 

Facteurs modifiables pour réduire l’encéphalopathie septique ?

 

Sonneville et al., ICM, 2017

http://icmjournal.esicm.org/journals/abstract.html?v=43&j=134&i=8&a=4807_10.1007_s00134-017-4807-z&doi=$

 

Purpose

Identifying modifiable factors for sepsis-associated encephalopathy may help improve patient care and outcomes.

Methods

We conducted a retrospective analysis of a prospective multicenter database. Sepsis-associated encephalopathy (SAE) was defined by a score on the Glasgow coma scale (GCS) <15 or when features of delirium were noted. Potentially modifiable risk factors for SAE at ICU admission and its impact on mortality were investigated using multivariate logistic regression analysis and Cox proportional hazard modeling, respectively.

Results

We included 2513 patients with sepsis at ICU admission, of whom 1341 (53%) had sepsis-associated encephalopathy. After adjusting for baseline characteristics, site of infection, and type of admission, the following factors remained independently associated with sepsis-associated encephalopathy: acute renal failure [adjusted odds ratio (aOR) = 1.41, 95% confidence interval (CI) 1.19–1.67], hypoglycemia <3 mmol/l (aOR = 2.66, 95% CI 1.27–5.59), hyperglycemia >10 mmol/l (aOR = 1.37, 95% CI 1.09–1.72), hypercapnia >45 mmHg (aOR = 1.91, 95% CI 1.53–2.38), hypernatremia >145 mmol/l (aOR = 2.30, 95% CI 1.48–3.57), and S. aureus (aOR = 1.54, 95% CI 1.05–2.25). Sepsis-associated encephalopathy was associated with higher mortality, higher use of ICU resources, and longer hospital stay. After adjusting for age, comorbidities, year of admission, and non-neurological SOFA score, even mild alteration of mental status (i.e., a score on the GCS of 13–14) remained independently associated with mortality (adjusted hazard ratio = 1.38, 95% CI 1.09–1.76).

Conclusions

Acute renal failure and common metabolic disturbances represent potentially modifiable factors contributing to sepsis-associated encephalopathy. However, a true causal relationship has yet to be demonstrated. Our study confirms the prognostic significance of mild alteration of mental status in patients with sepsis.

 

 

 

 

Comparaison d’une mesure invasive versus non invasive de la PA dans le choc septique

 

Riley et al., Blood Pressure Monitoring, 2017

lien vers pdf

doi: 10.1097/MBP.0000000000000258

 

Objective

In the critically ill, the insertion of peripheral arterial catheters to monitor hemodynamics is a low-risk procedure, but carries the potential for complications. This study was designed to compare invasive and noninvasive blood pressure measurements in patients with septic shock in a medical ICU.

Patients and methods

We carried out a prospective observational study of patients admitted with septic shock and a radially inserted peripheral arterial catheter in the medical ICU with 31 adult patients who underwent four pairs of simultaneous noninvasive and invasive blood pressure measurements (124 comparisons), with the invasive blood pressure taken as the gold standard. Agreements between invasive and noninvasive blood pressure methods were assessed using Bland–Altman analysis, and clinical significance was determined by the European Society of Hypertension criteria.

Results

In all patients, noninvasive systolic (P=0.0385), diastolic (P<0.0001), and mean arterial pressures (P<0.0001) did correlate statistically with invasive measurements; however, all noninvasive pressure measurements did not correlate clinically according to the European Society of Hypertension criteria.

Conclusion

In our patients admitted to the medical ICU with septic shock, noninvasive blood pressure monitoring did not clinically correlate with invasive blood pressure measurements.

 

 

 

La fin du « PAM > 65mmHg » pour tous ?

 

Saugel et al., Current Opinion in Critical Care, 2017

lien vers pdf

 

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