Biblio du mois : Décembre 2015
Pour la dernière biblio de l’année, je vous souhaite de très bonnes fêtes ! Avec au programme, une étude pour se rassurer avec les repas de fin d’année sur le surpoids et la survie en réanimation. Plus sérieusement, vous pourrez découvrir enfin une étude randomisée contrôlée sur le mode d’administration des beta-lactamines, une étude sur le massage cardiaque, de nombreuses études en péri-opératoire mais également un article du NEJM dédié au récit des Attentats de Paris.
Petit cadeau et sondage sur la biblio parfaite à la fin, déroulez 😉
ACR extra-hospitalier : Massage continu versus interrompu pour ventilation
Graham et al., NEJM 2015, DOI: 10.1056/NEJMoa1509139
During cardiopulmonary resuscitation (CPR) in patients with out-of-hospital cardiac arrest, the interruption of manual chest compressions for rescue breathing reduces blood flow and possibly survival. We assessed whether outcomes after continuous compressions with positive-pressure ventilation differed from those after compressions that were interrupted for ventilations at a ratio of 30 compressions to two ventilations.
This cluster-randomized trial with crossover included 114 emergency medical service (EMS) agencies. Adults with non–trauma-related cardiac arrest who were treated by EMS providers received continuous chest compressions (intervention group) or interrupted chest compressions (control group). The primary outcome was the rate of survival to hospital discharge. Secondary outcomes included the modified Rankin scale score (on a scale from 0 to 6, with a score of ≤3 indicating favorable neurologic function). CPR process was measured to assess compliance.
Of 23,711 patients included in the primary analysis, 12,653 were assigned to the intervention group and 11,058 to the control group. A total of 1129 of 12,613 patients with available data (9.0%) in the intervention group and 1072 of 11,035 with available data (9.7%) in the control group survived until discharge (difference, −0.7 percentage points; 95% confidence interval [CI], −1.5 to 0.1; P=0.07); 7.0% of the patients in the intervention group and 7.7% of those in the control group survived with favorable neurologic function at discharge (difference, −0.6 percentage points; 95% CI, −1.4 to 0.1, P=0.09). Hospital-free survival was significantly shorter in the intervention group than in the control group (mean difference, −0.2 days; 95% CI, −0.3 to −0.1; P=0.004).
In patients with out-of-hospital cardiac arrest, continuous chest compressions during CPR performed by EMS providers did not result in significantly higher rates of survival or favorable neurologic function than did interrupted chest compressions.
Le récit médical des Attentats de Paris
par Charlotte Haug
Utilisation de l’EPO chez les traumatisés crâniens
Nichol, et al., Lancet, 2015, DOI: http://dx.doi.org/10.1016/S0140-6736(15)00386-4
Erythropoietin might have neurocytoprotective effects. In this trial, we studied its effect on neurological recovery, mortality, and venous thrombotic events in patients with traumatic brain injury.
Erythropoietin in Traumatic Brain Injury (EPO-TBI) was a double-blind, placebo-controlled trial undertaken in 29 centres (all university-affiliated teaching hospitals) in seven countries (Australia, New Zealand, France, Germany, Finland, Ireland, and Saudi Arabia). Within 24 h of brain injury, 606 patients were randomly assigned by a concealed web-based computer-generated randomisation schedule to erythropoietin (40 000 units subcutaneously) or placebo (0·9% sodium chloride subcutaneously) once per week for a maximum of three doses. Randomisation was stratified by severity of traumatic brain injury (moderate vs severe) and participating site. With the exception of designated site pharmacists, the site dosing nurses at all sites, and the pharmacists at the central pharmacy in France, all study personnel, patients, and patients’ relatives were masked to treatment assignment. The primary outcome, assessed at 6 months by modified intention-to-treat analysis, was improvement in the patients’ neurological status, summarised as a reduction in the proportion of patients with an Extended Glasgow Outcome Scale (GOS-E) of 1–4 (death, vegetative state, and severe disability). Two equally spaced preplanned interim analyses were done (after 202 and 404 participants were enrolled). This study is registered with ClinicalTrials.gov, number NCT00987454.
Between May 3, 2010, and Nov 1, 2014, 606 patients were enrolled and randomly assigned to erythropoietin (n=308) or placebo (n=298). Ten of these patients (six in the erythropoietin group and four in the placebo group) were lost to follow up at 6 months; therefore, data for the primary outcome analysis was available for 596 patients (302 in the erythropoietin group and 294 in the placebo group). Compared with placebo, erythropoietin did not reduce the proportion of patients with a GOS-E level of 1–4 (134 [44%] of 302 patients in the erythropoietin group vs 132 [45%] of 294 in the placebo group; relative risk [RR] 0·99 [95% CI 0·83–1·18], p=0·90). In terms of safety, erythropoietin did not significantly affect 6-month mortality versus placebo (32 [11%] of 305 patients had died at 6 months in the erythropoietin group vs 46 [16%] of 297 [16%] in the placebo group; RR 0·68 [95% CI 0·44–1·03], p=0·07) or increase the occurrence of deep venous thrombosis of the lower limbs (48 [16%] of 305 vs 54 [18%] of 298; RR 0·87 [95% CI 0·61–1·24], p=0·44).
Following moderate or severe traumatic brain injury, erythropoietin did not reduce the number of patients with severe neurological dysfunction (GOS-E level 1–4) or increase the incidence of deep venous thrombosis of the lower limbs. The effect of erythropoietin on mortality remains uncertain.
Beta-lactamines : Administration continue versus intermittente
Dulhunty et al., AJRCCM, 2015, doi: 10.1164/rccm.201505-0857OC
Continuous infusion of β-lactam antibiotics may improve outcomes because of time-dependent antibacterial activity compared with intermittent dosing.
To evaluate the efficacy of continuous versus intermittent infusion in patients with severe sepsis.
We conducted a randomized controlled trial in 25 intensive care units (ICUs). Participants commenced on piperacillin–tazobactam, ticarcillin–clavulanate, or meropenem were randomized to receive the prescribed antibiotic via continuous or 30-minute intermittent infusion for the remainder of the treatment course or until ICU discharge. The primary outcome was the number of alive ICU-free days at Day 28. Secondary outcomes were 90-day survival, clinical cure 14 days post antibiotic cessation, alive organ failure–free days at Day 14, and duration of bacteremia.
Measurements and Main Results
We enrolled 432 eligible participants with a median age of 64 years and an Acute Physiology and Chronic Health Evaluation II score of 20. There was no difference in ICU-free days: 18 days (interquartile range, 2–24) and 20 days (interquartile range, 3–24) in the continuous and intermittent groups (P = 0.38). There was no difference in 90-day survival: 74.3% (156 of 210) and 72.5% (158 of 218); hazard ratio, 0.91 (95% confidence interval, 0.63–1.31; P = 0.61). Clinical cure was 52.4% (111 of 212) and 49.5% (109 of 220); odds ratio, 1.12 (95% confidence interval, 0.77–1.63; P = 0.56). There was no difference in organ failure–free days (6 d; P = 0.27) and duration of bacteremia (0 d; P = 0.24).
In critically ill patients with severe sepsis, there was no difference in outcomes between β-lactam antibiotic administration by continuous and intermittent infusion.
Hypotension & Infarctus du myocarde en Chirurgie vasculaire
van Waes et al., Anesthesiology, 2015, doi: 10.1097/ALN.0000000000000922
Postoperative myocardial injury occurs frequently after noncardiac surgery and is strongly associated with mortality. Intraoperative hypotension (IOH) is hypothesized to be a possible cause. The aim of this study was to determine the association between IOH and postoperative myocardial injury.
This cohort study included 890 consecutive patients aged 60 yr or older undergoing vascular surgery from two university centers. The occurrence of myocardial injury was assessed by troponin measurements as part of a postoperative care protocol. IOH was defined by four different thresholds using either relative or absolute values of the mean arterial blood pressure based on previous studies. Either invasive or noninvasive blood pressure measurements were used. Poisson regression analysis was used to determine the association between IOH and postoperative myocardial injury, adjusted for potential clinical confounders and multiple comparisons.
Depending on the definition used, IOH occurred in 12 to 81% of the patients. Postoperative myocardial injury occurred in 131 (29%) patients with IOH as defined by a mean arterial pressure less than 60 mmHg, compared with 87 (20%) patients without IOH (P = 0.001). After adjustment for potential confounding factors including mean heart rates, a 40% decrease from the preinduction mean arterial blood pressure with a cumulative duration of more than 30 min was associated with postoperative myocardial injury (relative risk, 1.8; 99% CI, 1.2 to 2.6, P < 0.001). Shorter cumulative durations (less than 30 min) were not associated with myocardial injury. Postoperative myocardial infarction and death within 30 days occurred in 26 (6%) and 17 (4%) patients with IOH as defined by a mean arterial pressure less than 60 mmHg, compared with 12 (3%; P= 0.08) and 15 (3%; P = 0.77) patients without IOH, respectively.
In elderly vascular surgery patients, IOH defined as a 40% decrease from the preinduction mean arterial blood pressure with a cumulative duration of more than 30 min was associated with postoperative myocardial injury.
Surmortalité de l’anesthésie volatile versus anesthésie intra-veineux ?
Wigmore, Anesthesiology, 2015, doi:10.1097/ALN.0000000000000936
Surgical resection remains the best option for long-term survival in many solid tumors. Surgery can, however, lead to tumor cell release into the circulation. Data have suggested differential effects of anesthetic agents on cancer cell growth. This retrospective analysis investigated the association of anesthetic technique with long-term survival in patients presenting for elective surgery in a comprehensive cancer center over 3 yr.
All patients undergoing elective surgery between June 2010 and May 2013 were included. Patients were grouped according to whether they had received volatile inhalational (INHA) or total IV anesthesia (TIVA). After excluding those who received both forms of anesthesia during the study period, Kaplan–Meier survival curves were constructed from the date of surgery to death. After propensity matching, univariate and multivariable regression models were used to compare hazard ratios for death.
A total of 11,395 anesthetics using INHA or TIVA were delivered in the study period. After exclusions, 3,316 patients (796 deaths, 24%) remained in the INHA group and 3,714 (504 deaths, 13.5%) in the TIVA group. After propensity matching, 2,607 patients remained in each group (597 deaths, 22.8%, in INHA group vs. 407, 15.6%, in TIVA group). Volatile inhalational anesthesia was associated with a hazard ratio of 1.59 (1.30 to 1.95) for death on univariate analysis and 1.46 (1.29 to 1.66) after multivariable analysis of known confounders in the matched group.
This retrospective analysis demonstrates an association between type of anesthetic delivered and survival. This analysis alongside biological plausibility should lead to urgent prospective work exploring the effect of anesthetic technique on survival.
Evaluation du Protoxyde d’Azote sur la mortalité à long terme
Leslie et al., Anesthesiology, 2015, doi:10.1097/ALN.0000000000000908
Effet anti-inflammatoire du Cisatracurium sur le poumon ?
Fanelli et al., Anesthesiology, 2016, doi:10.1097/ALN.0000000000000907
Neuromuscular blocking agents (NMBAs) bind the nicotinic acetylcholine receptor α1 (nAChRα1) that also contributes to inflammatory signaling. Thus, the author hypothesized that the use of NMBA mitigates lung injury by improving ventilator synchrony and decreasing inflammatory responses.
Lung injury was induced by intratracheal instillation of hydrogen chloride in rats that were randomized to receive no NMBA with evidence of asynchronous ventilation (noNMBA/aSYNC, n = 10); no NMBA with synchronous ventilation (noNMBA/SYNC, n = 10); cisatracurium (CIS, n = 10); or pancuronium (PAN, n = 10). Mechanical ventilation was set at a tidal volume of 6 ml/kg and positive end-expiratory pressure 8 cm H2O for 3 h. Human lung epithelial, endothelial, and CD14+ cells were challenged with mechanical stretch, lipopolysaccharide, lung lavage fluids (bronchoalveolar lavage fluid), or plasma obtained from patients (n = 5) with acute respiratory distress syndrome, in the presence or absence of CIS or small-interfering RNA and small hairpin RNA to attenuate the cell expression of nAChRα1.
The use of CIS and PAN improved respiratory compliance (7.2 ± 0.7 in noNMBA/aSYNC, 6.6 ± 0.5 in noNMBA/SYNC, 5.9 ± 0.3 in CIS, and 5.8 ± 0.4 cm H2O/l in PAN; P < 0.05), increased Pao2 (140 ± 54, 209 ± 46, 269 ± 31, and 269 ± 54 mmHg, respectively, P < 0.05), and decreased the plasma levels of tumor necrosis factor-α (509 ± 252 in noNMBA, 200 ± 74 in CIS, and 175 ± 84 pg/ml in PAN;P < 0.05) and interleukin-6 (5789 ± 79, 1608 ± 534, and 2290 ± 315 pg/ml, respectively; P < 0.05). The use of CIS and PAN or silencing the receptor nAChRα1 resulted in decreased cytokine release in the human cells in response to a variety of stimuli mentioned earlier.
The use of NMBA is lung protective through its antiinflammatory properties by blocking the nAChRα1.
Effets des beta-bloquants en pré-opératoire pour les Pontages coronariens
Kohsaka et al., Anesthesiology, 2015, doi:10.1097/ALN.0000000000000901
The authors evaluated the effect of preoperative β-blocker use on early outcomes in patients undergoing coronary artery bypass grafting (CABG) in Japan.
The authors analyzed 34,980 cases of isolated CABGs, performed between 2008 and 2011, at the 333 sites recorded in the Japanese Cardiovascular Surgical Database. In addition to the use of multivariate models, a one-to-one matched analysis, based on estimated propensity scores for patients with or without preoperative β-blocker use, was performed.
The study population (mean age, 68 yr) comprised 20% women, and β-blockers were used in 10,496 patients (30%), who were more likely to have risk factors and comorbidities than patients in whom β-blockers were not used. In the β-blocker and non-β-blocker groups, the crude in-hospital mortality rate was 1.7 versus2.5%, whereas the composite complication rate was 9.7 versus11.6%, respectively. However, after adjustment, preoperative β-blocker use was not a predictor of in-hospital mortality (odds ratio, 1.00; 95% CI, 0.82 to 1.21) or complications (odds ratio, 0.99; 95% CI, 0.91 to 1.08). When the outcomes of the two propensity-matched patient groups were compared, differences were not seen in the 30-day operative mortality (1.6 vs. 1.5%, respectively; P = 0.49) or postoperative complication (9.8 vs. 9.7%; P = 1.00) rates. The main findings were broadly consistent in a subgroup analysis of low-risk and high-risk groups.
In this nationwide registry, the use of preoperative β-blockers did not affect short-term mortality or morbidity in patients undergoing CABG.
Analgésie post-opératoire en AIVOC de Morphine
Jeleazcov et al., Anesthesiology, 2015, doi:10.1097/ALN.0000000000000937
Patient-controlled analgesia (PCA) is a common method for postoperative pain therapy, but it is characterized by large variation of plasma concentrations. PCA with target-controlled infusion (TCI-PCA) may be an alternative. In a previous analysis, the authors developed a pharmacokinetic model for hydromorphone. In this secondary analysis, the authors investigated the feasibility and efficacy of TCI-PCA for postoperative pain therapy with hydromorphone.
Fifty adult patients undergoing cardiac surgery were enrolled in this study. Postoperatively, hydromorphone was applied intravenously during three sequential periods: (1) as TCI with plasma target concentrations of 1 to 2 ng/ml until extubation; (2) as TCI-PCA with plasma target concentrations between 0.8 and 10 ng/ml during the following 6 to 8 h; and (3) thereafter as PCA with a bolus dose of 0.2 mg until the next morning. During TCI-PCA, pain was regularly assessed using the 11-point numerical rating scale (NRS). A pharmacokinetic/pharmacodynamic model was developed using ordinal logistic regression based on measured plasma concentrations.
Data of 43 patients aged 40 to 81 yr were analyzed. The hydromorphone dose during TCI-PCA was 0.26 mg/h (0.07 to 0.93 mg/h). The maximum plasma target concentration during TCI-PCA was 2.3 ng/ml (0.9 to 7.0 ng/ml). The NRS score under deep inspiration was less than 5 in 83% of the ratings. Nausea was present in 30%, vomiting in 9%, and respiratory insufficiency in 5% of the patients. The EC50 of hydromorphone for NRS of 4 or less was 4.1 ng/ml (0.6 to 12.8 ng/ml).
TCI-PCA with hydromorphone offered satisfactory postoperative pain therapy with moderate side effects.
La mise à jeûn inutile pour l’anesthésie hors bloc en pédiatrie ?
Beach, Anesthesiology, 2016, doi:10.1097/ALN.0000000000000933
Le Surpoids, facteur indépendant de survie en Réanimation ?
Sakr, et al., CCM, 2015, doi: 10.1097/CCM.0000000000001310
To assess the effect of body mass index on ICU outcome and on the development of ICU-acquired infection.
A substudy of the Intensive Care Over Nations audit.
Seven hundred thirty ICUs in 84 countries.
All adult ICU patients admitted between May 8 and 18, 2012, except those admitted for less than 24 hours for routine postoperative monitoring (n = 10,069). In this subanalysis, only patients with complete data on height and weight (measured or estimated) on ICU admission in order to calculate the body mass index were included (n = 8,829).
Measurements and Main Results
Underweight was defined as body mass index less than 18.5 kg/m2, normal weight as body mass index 18.5–24.9 kg/m2, overweight as body mass index 25–29.9 kg/m2, obese as body mass index 30–39.9 kg/m2, and morbidly obese as body mass index greater than or equal to 40 kg/m2. The mean body mass index was 26.4 ± 6.5 kg/m2. The ICU length of stay was similar among categories, but overweight and obese patients had longer hospital lengths of stay than patients with normal body mass index (10 [interquartile range, 5–21] and 11 [5–21] vs 9 [4–19] d; p < 0.01 pairwise). ICU mortality was lower in morbidly obese than in normal body mass index patients (11.2% vs 16.6%; p = 0.015). In-hospital mortality was lower in morbidly obese and overweight patients and higher in underweight patients than in those with normal body mass index. In a multilevel Cox proportional hazard analysis, underweight was independently associated with a higher hazard of 60-day in-hospital death (hazard ratio, 1.32; 95% CI, 1.05–1.65; p = 0.018), whereas overweight was associated with a lower hazard (hazard ratio, 0.79; 95% CI, 0.71–0.89; p < 0.001). No body mass index category was associated with an increased hazard of ICU-acquired infection.
In this large cohort of critically ill patients, underweight was independently associated with a higher hazard of 60-day in-hospital death and overweight with a lower hazard. None of the body mass index categories as independently associated with an increased hazard of infection during the ICU stay.
Baisse du lactate chez les patients sous beta-bloquants aux Urgences
Contenti et al. CCM, 2015, doi: 10.1097/CCM.0000000000001308
Measurement of blood lactate concentration in the early management of sepsis is an important step in severity assessment. High blood lactate levels in the early phase of sepsis have classically been thought to be related to tissue hypoxia, but other factors could intervene. We hypothesized that the activation of glycolysis through β-adrenergic stimulation by endogenous catecholamines plays an important role in lactate production and that long-term β-blocker therapy could affect the lactate concentration in patients with severe sepsis and septic shock.
Retrospective cohort study.
Two hundred sixty patients with severe sepsis or septic shock were included. Twenty-five percent were previously treated with β-blockers.
Measurements and Main Results
We recorded initial vital signs, the source of infection, mortality at 28 days, blood lactate concentration, and Predisposition Insult Response of Organ failure and Sequential Organ Failure Assessment scores using an electronic database. Blood lactate concentration was significantly lower in patients previously treated with β-blockers (3.9 ± 2.3 mmol/L vs 5.6 ± 3.6 mmol/L; p < 0.001). This difference was still significant after controlling for mortality (p < 0.005), for the level of the Predisposition Insult Response of Organ failure (p < 0.05) and Sequential Organ Failure Assessment (p < 0.05) scores, and for the source of infection (p < 0.05). Nearly four times more patients treated with β-blockers had normal blood lactate levels (p< 0.001). Only two factors were significantly and independently associated with normal blood lactate concentration during severe sepsis and septic shock: survival (p = 0.03) and β-blocker therapy (p = 0.01).
Long-term β-blocker therapy decreases blood lactate concentration of severely ill septic patients at presentation. We conclude that the use of blood lactate measurement as a triage tool in the initial assessment of septic patients with β-blocker therapy may underestimate the severity of the sepsis.
Cadeau dans la revue Nature : La colonisation et le bactériome de nos machines Nespresso adorées…