Biblio du mois : Janvier 2016
Voici la 1ère biblio exhaustive de l’année 2016 qui est chargée de petites études très intéressantes sur la ventilation agrémentées d’études sur les nausées/vomissements et la congélation de selles de transplantation… Bon appétit bien sûr !
On peut noter des études sur l’effet de la TCC en ligne sur le risque suicidaire des Internes en médecine et sur l’application du taylorisme en médecine.
D’après le sondage précédent, certains d’entre vous préféreraient une biblio en français, ce que je vous propose, la solution la plus simple, c’est la traduction de page par Google Traduction.
Intégration à Google Chrome : https://chrome.google.com/webstore/detail/google-translate/aapbdbdomjkkjkaonfhkkikfgjllcleb?hl=fr
Intégration à Firefox : https://addons.mozilla.org/fr/firefox/addon/google-translator-for-firefox/
L’AG pas plus néfaste que l’ALR pour le développement neurologique du nourrisson ?
Davidson et al, Lancet, 2015; DOI: http://dx.doi.org/10.1016/S0140-6736(15)00608-X
Preclinical data suggest that general anaesthetics affect brain development. There is mixed evidence from cohort studies that young children exposed to anaesthesia can have an increased risk of poor neurodevelopmental outcome. We aimed to establish whether general anaesthesia in infancy has any effect on neurodevelopmental outcome. Here we report the secondary outcome of neurodevelopmental outcome at 2 years of age in the General Anaesthesia compared to Spinal anaesthesia (GAS) trial.
In this international assessor-masked randomised controlled equivalence trial, we recruited infants younger than 60 weeks postmenstrual age, born at greater than 26 weeks’ gestation, and who had inguinal herniorrhaphy, from 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand. Infants were randomly assigned (1:1) to receive either awake-regional anaesthesia or sevoflurane-based general anaesthesia. Web-based randomisation was done in blocks of two or four and stratified by site and gestational age at birth. Infants were excluded if they had existing risk factors for neurological injury. The primary outcome of the trial will be the Wechsler Preschool and Primary Scale of Intelligence Third Edition (WPPSI-III) Full Scale Intelligence Quotient score at age 5 years. The secondary outcome, reported here, is the composite cognitive score of the Bayley Scales of Infant and Toddler Development III, assessed at 2 years. The analysis was as per protocol adjusted for gestational age at birth. A difference in means of five points (1/3 SD) was predefined as the clinical equivalence margin. This trial is registered with ANZCTR, number ACTRN12606000441516 and ClinicalTrials.gov, number NCT00756600.
Between Feb 9, 2007, and Jan 31, 2013, 363 infants were randomly assigned to receive awake-regional anaesthesia and 359 to general anaesthesia. Outcome data were available for 238 children in the awake-regional group and 294 in the general anaesthesia group. In the as-per-protocol analysis, the cognitive composite score (mean [SD]) was 98·6 (14·2) in the awake-regional group and 98·2 (14·7) in the general anaesthesia group. There was equivalence in mean between groups (awake-regional minus general anaesthesia 0·169, 95% CI −2·30 to 2·64). The median duration of anaesthesia in the general anaesthesia group was 54 min.
For this secondary outcome, we found no evidence that just less than 1 h of sevoflurane anaesthesia in infancy increases the risk of adverse neurodevelopmental outcome at 2 years of age compared with awake-regional anaesthesia.
Les AINS ne réduisent pas l’efficacité des pleurodèses ?
Rahman et al., JAMA, 2016; doi:10.1001/jama.2015.16840
For treatment of malignant pleural effusion, nonsteroidal anti-inflammatory drugs (NSAIDs) are avoided because they may reduce pleurodesis efficacy. Smaller chest tubes may be less painful than larger tubes, but efficacy in pleurodesis has not been proven.
To assess the effect of chest tube size and analgesia (NSAIDs vs opiates) on pain and clinical efficacy related to pleurodesis in patients with malignant pleural effusion.
Design, Setting, and Participants
A 2×2 factorial phase 3 randomized clinical trial among 320 patients requiring pleurodesis in 16 UK hospitals from 2007 to 2013.
Patients undergoing thoracoscopy (n = 206; clinical decision if biopsy was required) received a 24F chest tube and were randomized to receive opiates (n = 103) vs NSAIDs (n = 103), and those not undergoing thoracoscopy (n = 114) were randomized to 1 of 4 groups (24F chest tube and opioids [n = 28]; 24F chest tube and NSAIDs [n = 29]; 12F chest tube and opioids [n = 29]; or 12F chest tube and NSAIDs [n = 28]).
Main Outcomes and Measures
Pain while chest tube was in place (0- to 100-mm visual analog scale [VAS] 4 times/d; superiority comparison) and pleurodesis efficacy at 3 months (failure defined as need for further pleural intervention; noninferiority comparison; margin, 15%).
Pain scores in the opiate group (n = 150) vs the NSAID group (n = 144) were not significantly different (mean VAS score, 23.8 mm vs 22.1 mm; adjusted difference, −1.5 mm; 95% CI, −5.0 to 2.0 mm; P = .40), but the NSAID group required more rescue analgesia (26.3% vs 38.1%; rate ratio, 2.1; 95% CI, 1.3-3.4; P = .003). Pleurodesis failure occurred in 30 patients (20%) in the opiate group and 33 (23%) in the NSAID group, meeting criteria for noninferiority (difference, −3%; 1-sided 95% CI, −10% to ∞; P = .004 for noninferiority). Pain scores were lower among patients in the 12F chest tube group (n = 54) vs the 24F group (n = 56) (mean VAS score, 22.0 mm vs 26.8 mm; adjusted difference, −6.0 mm; 95% CI, −11.7 to −0.2 mm; P = .04) and 12F chest tubes vs 24F chest tubes were associated with higher pleurodesis failure (30% vs 24%), failing to meet noninferiority criteria (difference, −6%; 1-sided 95% CI, −20% to ∞; P = .14 for noninferiority). Complications during chest tube insertion occurred more commonly with 12F tubes (14% vs 24%; odds ratio, 1.91; P = .20).
Conclusions and Relevance
Use of NSAIDs vs opiates resulted in no significant difference in pain scores but was associated with more rescue medication. NSAID use resulted in noninferior rates of pleurodesis efficacy at 3 months. Placement of 12F chest tubes vs 24F chest tubes was associated with a statistically significant but clinically modest reduction in pain but failed to meet noninferiority criteria for pleurodesis efficacy.
Transplantation fécale surgelée : OK
Lee et al., JAMA, 2016; doi:10.1001/jama.2015.18098.
Clostridium difficile infection (CDI) is a major burden in health care and community settings. CDI recurrence is of particular concern because of limited treatment options and associated clinical and infection control issues. Fecal microbiota transplantation (FMT) is a promising, but not readily available, intervention.
To determine whether frozen-and-thawed (frozen, experimental) FMT is noninferior to fresh (standard) FMT in terms of clinical efficacy among patients with recurrent or refractory CDI and to assess the safety of both types of FMT.
Design, Setting, and Participants
Randomized, double-blind, noninferiority trial enrolling 232 adults with recurrent or refractory CDI, conducted between July 2012 and September 2014 at 6 academic medical centers in Canada.
Patients were randomly allocated to receive frozen (n = 114) or fresh (n = 118) FMT via enema.
Main Outcomes and Measures
The primary outcome measures were clinical resolution of diarrhea without relapse at 13 weeks and adverse events. Noninferiority margin was set at 15%.
A total of 219 patients (n = 108 in the frozen FMT group and n = 111 in the fresh FMT group) were included in the modified intention-to-treat (mITT) population and 178 (frozen FMT: n = 91, fresh FMT: n = 87) in the per-protocol population. In the per-protocol population, the proportion of patients with clinical resolution was 83.5% for the frozen FMT group and 85.1% for the fresh FMT group (difference, −1.6% [95% CI, –10.5% to ∞]; P = .01 for noninferiority). In the mITT population the clinical resolution was 75.0% for the frozen FMT group and 70.3% for the fresh FMT group (difference, 4.7% [95% CI, –5.2% to ∞]; P < .001 for noninferiority). There were no differences in the proportion of adverse or serious adverse events between the treatment groups.
Conclusions and Relevance
Among adults with recurrent or refractory CDI, the use of frozen compared with fresh FMT did not result in worse proportion of clinical resolution of diarrhea. Given the potential advantages of providing frozen FMT, its use is a reasonable option in this setting.
La thérapie cognitvo-comportementale en ligne contre le risque suicidaire des Internes en Médecine
Slomski et al., JAMA, 2015
Relation entre consommation non médicale de morphiniques et consommation d’héroïne
Compton et al., NEJM, 2016; DOI: 10.1056/NEJMra1508490
Le taylorisme médical…
Hartzband et Groupman, NEJM, 2016
Sous estimation de la dyspnée durant l’épreuve de VS par l’équipe médicale et para-médicale
Haugdahl et al., AJRCCM, 2016, doi: 10.1164/rccm.201503-0419OC
Breathlessness is a prevalent and distressing symptom in intensive care unit patients. There is little evidence of the ability of healthcare workers to assess the patient’s experiences of breathing. Patient perception of breathing is essential in symptom management, and patient perception during a spontaneous breathing trial (SBT) might be related to extubation success.
To assess mechanically ventilated patients’ experiences of breathlessness during SBT.
This was a prospective observational multicenter study of 100 mechanically ventilated patients. We assessed the agreement between nurses, physicians, and patients’ 11-point Numerical Rating Scales scores of breathlessness, perception of feeling secure, and improvement of respiratory function at the end of an SBT (most performed with some level of support). We also determined the association between breathlessness and demographic factors or respiratory observations.
Measurements and Main Results
Sixty-two patients (62%) reported moderate or severe breathlessness (Numerical Rating Scales ≥4). The median intensity of breathlessness reported by patients was five compared with two by nurses and physicians (P < 0.001). Patients felt less secure and reported less improvement of respiratory function compared with nurses’ and physicians’ ratings. About half of the nurses and physicians underestimated breathlessness (difference score, ≤−2) compared with the patients’ self-reports. Underestimation of breathlessness was not associated with professional competencies. There were no major differences in objective assessments of respiratory function in patients with moderate or severe breathlessness, and no apparent relationship between breathlessness during the SBT and extubation outcome.
Patients reported higher breathlessness after SBT compared with nurses and physicians.
Des psychologues pour diminuer la détresse des familles dans les situations de fin de vie
Curtis et al., AJRCCM, 2016, doi: 10.1164/rccm.201505-0900OC
Communication with family of critically ill patients is often poor and associated with family distress.
To determine if an intensive care unit (ICU) communication facilitator reduces family distress and intensity of end-of-life care.
We conducted a randomized trial at two hospitals. Eligible patients had a predicted mortality greater than or equal to 30% and a surrogate decision maker. Facilitators supported communication between clinicians and families, adapted communication to family needs, and mediated conflict.
Measurements and Main Results
Outcomes included depression, anxiety, and post-traumatic stress disorder (PTSD) among family 3 and 6 months after ICU and resource use. We identified 488 eligible patients and randomized 168. Of 352 eligible family members, 268 participated (76%). Family follow-up at 3 and 6 months ranged from 42 to 47%. The intervention was associated with decreased depressive symptoms at 6 months (P = 0.017), but there were no significant differences in psychological symptoms at 3 months or anxiety or PTSD at 6 months. The intervention was not associated with ICU mortality (25% control vs. 21% intervention; P = 0.615) but decreased ICU costs among all patients (per patient: $75,850 control, $51,060 intervention; P = 0.042) and particularly among decedents ($98,220 control, $22,690 intervention; P = 0.028). Among decedents, the intervention reduced ICU and hospital length of stay (28.5 vs. 7.7 d and 31.8 vs. 8.0 d, respectively; P < 0.001).
Communication facilitators may be associated with decreased family depressive symptoms at 6 months, but we found no significant difference at 3 months or in anxiety or PTSD. The intervention reduced costs and length of stay, especially among decedents. This is the first study to find a reduction in intensity of end-of-life care with similar or improved family distress.
Oxygénation libérale versus restrictive chez les patients ventilés méchaniquement
Panwar et al., AJRCCM, 2016, doi: 10.1164/rccm.201505-1019OC
There are no randomized controlled trials comparing different oxygenation targets for intensive care unit (ICU) patients.
To determine whether a conservative oxygenation strategy is a feasible alternative to a liberal oxygenation strategy among ICU patients requiring invasive mechanical ventilation (IMV).
At four multidisciplinary ICUs, 103 adult patients deemed likely to require IMV for greater than or equal to 24 hours were randomly allocated to either a conservative oxygenation strategy with target oxygen saturation as measured by pulse oximetry (SpO2) of 88–92% (n = 52) or a liberal oxygenation strategy with target SpO2 of greater than or equal to 96% (n = 51).
Measurements and Main Results
The mean area under the curve and 95% confidence interval (CI) for SpO2 (93.4% [92.9–93.9%] vs. 97% [96.5–97.5%]), SaO2 (93.5% [93.1–94%] vs. 96.8% [96.3–97.3%]), PaO2 (70 [68–73] mm Hg vs. 92 [89–96] mm Hg), and FiO2 (0.26 [0.25–0.28] vs. 0.36 [0.34–0.39) in the conservative versus liberal oxygenation arm were significantly different (P < 0.0001 for all). There were no significant between-group differences in any measures of new organ dysfunction, or ICU or 90-day mortality. The percentage time spent with SpO2 less than 88% in conservative versus liberal arm was 1% versus 0.3% (P = 0.03), and percentage time spent with SpO2 greater than 98% in conservative versus liberal arm was 4% versus 22% (P < 0.001). The adjusted hazard ratio for 90-day mortality in the conservative arm was 0.77 (95% CI, 0.40–1.50; P = 0.44) overall and 0.49 (95% CI, 0.20–1.17; P = 0.10) in the prespecified subgroup of patients with a baseline PaO2/FiO2 less than 300.
Our study supports the feasibility of a conservative oxygenation strategy in patients receiving IMV. Larger randomized controlled trials of this intervention appear justified.
Attention à la généralisation mondiale des critères de Berlin du SDRA
Riviello et al., AJRCCM, 2016; doi: 10.1164/rccm.201503-0584OC
Estimates of the incidence of the acute respiratory distress syndrome (ARDS) in high- and middle-income countries vary from 10.1 to 86.2 per 100,000 person-years in the general population. The epidemiology of ARDS has not been reported for a low-income country at the level of the population, hospital, or intensive care unit (ICU). The Berlin definition may not allow identification of ARDS in resource-constrained settings.
To estimate the incidence and outcomes of ARDS at a Rwandan referral hospital using the Kigali modification of the Berlin definition: without requirement for positive end-expiratory pressure, hypoxia cutoff of SpO2/FiO2 less than or equal to 315, and bilateral opacities on lung ultrasound or chest radiograph.
We screened every adult patient for hypoxia at a public referral hospital in Rwanda for 6 weeks. For every patient with hypoxia, we collected data on demographics and ARDS risk factors, performed lung ultrasonography, and evaluated chest radiography when available.
Measurements and Main Results
Forty-two (4.0%) of 1,046 hospital admissions met criteria for ARDS. Using various prespecified cutoffs for the SpO2/FiO2 ratio resulted in almost identical hospital incidence values. Median age for patients with ARDS was 37 years, and infection was the most common risk factor (44.1%). Only 30.9% of patients with ARDS were admitted to an ICU, and hospital mortality was 50.0%. Using traditional Berlin criteria, no patients would have met criteria for ARDS.
ARDS seems to be a common and fatal syndrome in a hospital in Rwanda, with few patients admitted to an ICU. The Berlin definition is likely to underestimate the impact of ARDS in low-income countries, where resources to meet the definition requirements are lacking. Although the Kigali modification requires validation before widespread use, we hope this study stimulates further work in refining an ARDS definition that can be consistently used in all settings.
Les dysnatrémies pré-opératoires, facteur de risque de mortalité
Cecconi et al., BJA, 2016; doi: 10.1093/bja/aev373
Abnormal serum sodium concentrations are common in patients presenting for surgery. It remains unclear whether these abnormalities are independent risk factors for postoperative mortality.
This is a secondary analysis of the European Surgical Outcome Study (EuSOS) that provided data describing 46 539 patients undergoing inpatient non-cardiac surgery. Patients were included in this study if they had a recorded value of preoperative serum sodium within the 28 days immediately before surgery. Data describing preoperative risk factors and serum sodium concentrations were analysed to investigate the relationship with in-hospital mortality using univariate and multivariate logistic regression techniques.
Of 35 816 (77.0%) patients from the EuSOS database, 21 943 (61.3%) had normal values of serum sodium (138–142 mmol litre−1) before surgery, 8538 (23.8%) had hyponatraemia (serum sodium ≤137 mmol litre−1) and 5335 (14.9%) had hypernatraemia (serum sodium ≥143 mmol litre−1). After adjustment for potential confounding factors, moderate to severe hypernatraemia (serum sodium concentration ≥150 mmol litre−1) was independently associated with mortality [odds ratio 3.4 (95% confidence interval 2.0–6.0), P<0.0001]. Hyponatraemia was not associated with mortality.
Preoperative abnormalities in serum sodium concentrations are common, and hypernatraemia is associated with increased mortality after surgery. Abnormalities of serum sodium concentration may be an important biomarker of perioperative risk resulting from co-morbid disease.
Effet de l’IMC dans le SDRA
Chiumelli et al., BJA, 2016; doi: 10.1093/bja/aev378
Obesity is associated in healthy subjects with a great reduction in functional residual capacity and with a stiffening of lung and chest wall elastance, which promote alveolar collapse and hypoxaemia. Likewise, obese patients with acute respiratory distress syndrome (ARDS) could present greater derangements of respiratory mechanics than patients of normal weight.
One hundred and one ARDS patients were enrolled. Partitioned respiratory mechanics and gas exchange were measured at 5 and 15 cm H2O of PEEP with a tidal volume of 6–8 ml kg−1 of predicted body weight. At 5 and 45 cm H2O of PEEP, two lung computed tomography scans were performed.
Patients were divided as follows according to BMI: normal weight (BMI≤25 kg m−2), overweight (BMI between 25 and 30 kg m−2), and obese (BMI>30 kg m−2). Obese, overweight, and normal-weight groups presented a similar lung elastance (median [interquartile range], respectively: 17.7 [14.2–24.8], 20.9 [16.1–30.2], and 20.5 [15.2–23.6] cm H2O litre−1 at 5 cm H2O of PEEP and 19.3 [15.5–26.3], 21.1 [17.4–29.2], and 17.1 [13.4–20.4] cm H2O litre−1 at 15 cm H2O of PEEP) and chest elastance (respectively: 4.9 [3.1–8.8], 5.9 [3.8–8.7], and 7.8 [3.9–9.8] cm H2O litre−1 at 5 cm H2O of PEEP and 6.5 [4.5–9.6], 6.6 [4.2–9.2], and 4.9 [2.4–7.6] cm H2O litre−1 at 15 cm H2O of PEEP). Lung recruitability was not affected by the body weight (15.6 [6.3–23.4], 15.7 [9.8–22.2], and 11.3 [6.2–15.6]% for normal-weight, overweight, and obese groups, respectively). Lung gas volume was significantly lower whereas total superimposed pressure was significantly higher in the obese compared with the normal-weight group (1148 [680–1815] vs 827 [686–1213] ml and 17.4 [15.8–19.3] vs 19.3 [18.6–21.7] cm H2O, respectively).
Obese ARDS patients do not present higher chest wall elastance and lung recruitability.
Dexmedetomidine associée aux morphiniques dans la prévention des NVPO
Young et al., EJA, 2016; doi: 10.1097/EJA.0000000000000327
Dexmedetomidine, an α2 adrenergic receptor agonist, has analgesic, sedative and sympatholytic properties, with a lack of respiratory depression. It is licensed only for intensive care sedation.
The objective of this study is to investigate whether intravenous (i.v.) patient-controlled analgesia (PCA) with dexmedetomidine added to a fentanyl-based drug mixture could reduce postoperative nausea and vomiting (PONV) in highly susceptible patients undergoing lumbar spinal surgery.
A randomised, double-blinded study.
At a tertiary university hospital between September 2012 and September 2013.
One hundred and eight patients undergoing level 1 or 2 posterior lumbar spinal fusion who had at least three risk factors for PONV (female, nonsmoker, use of postoperative opioids) were randomised into two groups. Three patients were excluded from analysis and 105 patients completed the study.
Patients received either dexmedetomidine 0.5 μg kg−1 i.v. (dexmedetomidine group) or 0.9% normal saline (control group) 30 min before the completion of surgery followed by fentanyl 0.5 μg kg−1 and 4 mg ondansetron. Postoperatively, the PCA (fentanyl 10 μg kg−1with 120 mg ketorolac, with or without dexmedetomidine 10 μg kg−1 made up to a total volume of 100 ml) was programmed to deliver 1 ml bolus (lockout 15 min) with a continuous background infusion of 2 ml h−1. The PCA was used for the first 48 h postoperatively.
MAIN OUTCOME MEASURES
The incidence and severity of PONV, cumulative dose of PCA fentanyl consumed and pain scores were assessed for 48 h.
The dexmedetomidine group experienced less nausea during the time interval 1 to 3 h postoperatively compared with the control group [odds ratio (OR) 0.32; 95% confidence interval (CI) 0.13 to 0.77; P = 0.019]. The intensity of nausea between the groups during the first 48 h was comparable, but the dexmedetomidine group had a lower incidence of moderate to severe nausea (OR 0.28; 95% CI 0.12 to 0.67; P < 0.003). Pain scores were not significantly different between the groups, but patients in the dexmedetomidine group required less fentanyl and less rescue analgesia in the first 12 h. Compared with the control group, patients in the dexmedetomidine group experienced almost twice as many episodes of hypotension and bradycardia, but this failed to reach statistical significance.
Adding dexmedetomidine to a fentanyl-based PCA drug mixture reduces the frequency and severity of acute postoperative nausea in highly susceptible patients.
Emend et Zophren dans la prévention/traitement des NVPO
Sung Yeon et al., EJA, 2016; doi: 10.1097/EJA.0000000000000242
Ondansetron, a 5-HT3 receptor antagonist, and aprepitant, a neurokinin-1 receptor antagonist, block the emetic effect of serotonin and neurokinin, respectively. Aprepitant combined with ondansetron can be more effective for preventing emesis in patients at high risk of postoperative nausea and vomiting (PONV).
To investigate the prophylactic effect of combining aprepitant with ondansetron compared with ondansetron alone on PONV in patients with fentanyl-based patient-controlled analgesia (PCA) after laparoscopic gynaecological surgery.
Single-centre, double-blinded randomised controlled trial.
A major university hospital in Seoul, Korea, between July 2012 and April 2013.
One hundred and twenty-five female patients (American Society of Anesthesiologists’ physical status 1 or 2) with fentanyl-based intravenous PCA after gynaecological laparoscopy were recruited to the study, and 110 completed the protocol.
Oral aprepitant 80 mg or placebo was given 1 h before anaesthesia. In all patients, ondansetron 4 mg was administered intravenously at the end of surgery and 12 mg was added to the PCA solution.
MAIN OUTCOME MEASURES
The primary outcome measure was complete response (no PONV and no rescue antiemetics) up to 48 h postoperatively.
There was no difference in the proportion of complete responses to 48 h between the groups (P = 0.05), but in the post-anaesthesia care unit and up to 24 h postoperatively, the proportion was significantly higher in the aprepitant and ondansetron group than in the ondansetron only group (76 vs. 50%, P = 0.004 and 38 vs. 16%, P = 0.011, respectively). In the aprepitant and ondansetron group, the time to first PONV was delayed (P = 0.014) and the incidence of nausea up to 24 h postoperatively was lower (P = 0.014). However, there were no differences in the incidences of retching or vomiting, the severity of nausea, use of rescue antiemetics or the incidence of side-effects.
Aprepitant 80 mg orally with ondansetron is effective in suppressing early PONV up to 24 h postoperatively and delays the time to first PONV in patients with fentanyl-based intravenous PCA after gynaecological laparoscopy. However, the combination prophylaxis with aprepitant and ondansetron failed to reach the predefined primary study outcome when compared with ondansetron alone.
Echec de l’ANI : non spécifique des stimulations douloureuses ?
Gunnar et al., EJA, 2016; doi: 10.1097/EJA.0000000000000304
Pain assessment using a numerical rating scale (NRS) is considered good clinical practice, but objective assessment in noncommunicating patients is still a challenge. A potential solution is to monitor changes in heart rate variability transformed into the analgesia nociception index (ANI), that offers a noninvasive means of pain quantification.
The aim was to measure magnitudes, descending slopes and time courses of ANI following expected and unexpected painful, nonpainful and sham experimental stimuli and compare these with pain intensity as assessed by NRS in conscious human volunteers. We expected a negative correlation between ANI and NRS after painful stimuli.
Randomised stimuli and placebo-controlled, single-blinded study.
Experimental pain simulation laboratory, Bochum, Germany.
Twenty healthy male students, (mean ± standard deviation; 24.2 ± 1.9 years) recruited via local advertising, were consecutively included.
ANI values were continuously recorded. After resting, four stimuli were applied in a random order on the right forearm (unexpected and expected electrical pain, expected nonpainful and sham stimuli). Blinded volunteers were asked to rate all four stimuli on NRS.
MAIN OUTCOME MEASURES
ANI means (0–100), amplitudes, maxima, minima and slopes with NRS pain intensity scores (0–10).
Resting alert volunteers showed ANI values of 82.05 ± 10.71. ANI decreased after a random stimulus (maximal decrease of 25.0 ± 7.3%), but different kinds of stimuli evoked similar results. NRS scores (median; interquartiles) were significantly (P = 0.008) higher after expected (5.25; 3.5–6.75) compared with unexpected (4.50; 3.0–5.0) pain stimuli. No correlation was found between ANI and NRS.
ANI did not allow a differentiation of painful, nonpainful or sham stimuli in alert volunteers. Therefore, ANI does not exclusively detect nociception, but may be modified by stress and emotion. Thus, we conclude that ANI is not a specific, robust measure for assessment of pain intensity.
Revue sur l’intérêt de la prémédication par Mélatonine en Pédiatrie
Mihara et al., EJA, 2016; doi: 10.1097/EJA.0000000000000323
Sédation par Isoflurane en Réanimation : Diminution de la mortalité ?
Bellgardt et al., EJA, 2016;doi: 10.1097/EJA.0000000000000252
Isoflurane has shown better control of intensive care sedation than propofol or midazolam and seems to be a useful alternative. However, its effect on survival remains unclear.
The objective of this study is to compare mortality after sedation with either isoflurane or propofol/midazolam.
A retrospective analysis of data in a hospital database for a cohort of consecutive patients.
Sixteen-bed interdisciplinary surgical ICU of a German university hospital.
Consecutive cohort of 369 critically ill surgical patients defined within the database of the hospital information system. All patients were continuously ventilated and sedated for more than 96 h between 1 January 2005 and 31 December 2010. After excluding 169 patients (93 >79 years old, 10 <40 years old, 46 mixed sedation, 20 lost to follow-up), 200 patients were studied, 72 after isoflurane and 128 after propofol/midazolam.
Sedation with isoflurane using the AnaConDa system compared with intravenous sedation with propofol or midazolam.
MAIN OUTCOME MEASURES
Hospital mortality (primary) and 365-day mortality (secondary) were compared with the Kaplan–Meier analysis and a log-rank test. Adjusted odds ratios (ORs) [with 95% confidence interval (95% CI)] were calculated by logistic regression analyses to determine the risk of death after isoflurane sedation.
After sedation with isoflurane, the in-hospital mortality and 365-day mortality were significantly lower than after propofol/midazolam sedation: 40 versus 63% (P = 0.005) and 50 versus 70% (P = 0.013), respectively. After adjustment for potential confounders (coronary heart disease, chronic obstructive pulmonary disease, acute renal failure, creatinine, age and Simplified Acute Physiology Score II), patients after isoflurane were at a lower risk of death during their hospital stay (OR 0.35; 95% CI 0.18 to 0.68, P = 0.002) and within the first 365 days (OR 0.41; 95% CI 0.21 to 0.81, P = 0.010).
Compared with propofol/midazolam sedation, long-term sedation with isoflurane seems to be well tolerated in this group of critically ill patients after surgery.
Cathéter d’analgésie in situ chez les nouveaux-nés : non toxique et efficace ?
Krylborn et al., EJA, 2016; doi: 10.1097/EJA.0000000000000317
Epidurals may be challenging in neonatal patients due to technical difficulties relating to insertion and the risk of local anaesthesia toxicity. The use of wound catheters with an infusion of local anaesthetic has been shown to be well tolerated in adults and older children. There are few data concerning wound catheter techniques in neonatal patients.
The primary aim of this study was to analyse plasma levels of levobupivacaine associated with continuous wound infiltration via a catheter following neonatal surgical procedures. Secondary parameters, including the quality of postoperative analgesia and wound healing, were also noted.
A prospective, observational study.
Paediatric ICU at the Karolinska University Hospital, Stockholm, Sweden, from March 2008 to December 2010.
Twenty newborn infants (median weight 3.48 kg) scheduled for major abdominal or thoracic surgery were included. Exclusion criteria were known or suspected hepatic dysfunction. Before skin closure, a subcutaneous catheter was inserted into the wound followed by a 0.5 mg kg−1 bolus of levobupivacaine (0.125%, 0.4 ml kg−1) through the catheter. A continuous infusion was started 20 to 30 min later at a rate of 0.2 mg kg−1 h−1(0.16 ml kg−1 h−1).
MAIN OUTCOME MEASURES
Plasma concentrations of levobupivacaine (total and unbound) at 12, 24, 48 and 72 h postoperatively. Morphine consumption, pain scores and wound healing were also analysed.
Median concentrations of unbound and total levobupivacaine at 72 h were 0.018 and 1.305 μg ml−1, respectively. In 18 out of 20 infants [90%; 95% confidence interval (CI) 68.3 to 98.8], the unbound plasma concentration of levobupivacaine remained relatively stable and below 0.05 μg ml−1 throughout the 72 h observation period. Pain scores and morphine consumption levels were low. All wounds except one healed within 10 days.
The studied infusion regimen was associated with plasma levels of levobupivacaine well below those associated with toxicity. Adequate wound healing, low pain scores and a reduced need for opioids were also noted.
Prédiction de l’échec de la VNI par le VTe
Carteaux et al., CCM, 2016; doi: 10.1097/CCM.0000000000001379
A low or moderate expired tidal volume can be difficult to achieve during noninvasive ventilation for de novo acute hypoxemic respiratory failure (i.e., not due to exacerbation of chronic lung disease or cardiac failure). We assessed expired tidal volume and its association with noninvasive ventilation outcome.
Prospective observational study.
Twenty-four bed university medical ICU.
Consecutive patients receiving noninvasive ventilation for acute hypoxemic respiratory failure between August 2010 and February 2013.
Noninvasive ventilation was uniformly delivered using a simple algorithm targeting the expired tidal volume between 6 and 8 mL/kg of predicted body weight.
Expired tidal volume was averaged and respiratory and hemodynamic variables were systematically recorded at each noninvasive ventilation session.
Sixty-two patients were enrolled, including 47 meeting criteria for acute respiratory distress syndrome, and 32 failed noninvasive ventilation (51%). Pneumonia (n = 51, 82%) was the main etiology of acute hypoxemic respiratory failure. The median (interquartile range) expired tidal volume averaged over all noninvasive ventilation sessions (mean expired tidal volume) was 9.8 mL/kg predicted body weight (8.1–11.1 mL/kg predicted body weight). The mean expired tidal volume was significantly higher in patients who failed noninvasive ventilation as compared with those who succeeded (10.6 mL/kg predicted body weight [9.6–12.0] vs 8.5 mL/kg predicted body weight [7.6–10.2]; p = 0.001), and expired tidal volume was independently associated with noninvasive ventilation failure in multivariate analysis. This effect was mainly driven by patients with PaO2/FIO2 up to 200 mm Hg. In these patients, the expired tidal volume above 9.5 mL/kg predicted body weight predicted noninvasive ventilation failure with a sensitivity of 82% and a specificity of 87%.
A low expired tidal volume is almost impossible to achieve in the majority of patients receiving noninvasive ventilation for de novo acute hypoxemic respiratory failure, and a high expired tidal volume is independently associated with noninvasive ventilation failure. In patients with moderate-to-severe hypoxemia, the expired tidal volume above 9.5 mL/kg predicted body weight accurately predicts noninvasive ventilation failure.
L’approche « Open Lung » dans la gestion du SDRA
Kacmarek et al., CCM, 2015; doi: 10.1097/CCM.0000000000001383
The open lung approach is a mechanical ventilation strategy involving lung recruitment and a decremental positive end-expiratory pressure trial. We compared the Acute Respiratory Distress Syndrome network protocol using low levels of positive end-expiratory pressure with open lung approach resulting in moderate to high levels of positive end-expiratory pressure for the management of established moderate/severe acute respiratory distress syndrome.
A prospective, multicenter, pilot, randomized controlled trial.
A network of 20 multidisciplinary ICUs.
Patients meeting the American-European Consensus Conference definition for acute respiratory distress syndrome were considered for the study.
At 12-36 hours after acute respiratory distress syndrome onset, patients were assessed under standardized ventilator settings (FIO2≥0.5, positive end-expiratory pressure ≥10 cm H2O). If Pao2/FIO2 ratio remained less than or equal to 200 mm Hg, patients were randomized to open lung approach or Acute Respiratory Distress Syndrome network protocol. All patients were ventilated with a tidal volume of 4 to 8 ml/kg predicted body weight.
Measurements and Main Results
From 1,874 screened patients with acute respiratory distress syndrome, 200 were randomized: 99 to open lung approach and 101 to Acute Respiratory Distress Syndrome network protocol. Main outcome measures were 60-day and ICU mortalities, and ventilator-free days. Mortality at day-60 (29% open lung approach vs. 33% Acute Respiratory Distress Syndrome Network protocol, p = 0.18, log rank test), ICU mortality (25% open lung approach vs. 30% Acute Respiratory Distress Syndrome network protocol, p = 0.53 Fisher’s exact test), and ventilator-free days (8 [0-20] open lung approach vs. 7 [0-20] d Acute Respiratory Distress Syndrome network protocol, p = 0.53 Wilcoxon rank test) were not significantly different. Airway driving pressure (plateau pressure – positive end-expiratory pressure) and PaO2/FIO2 improved significantly at 24, 48 and 72 hours in patients in open lung approach compared with patients in Acute Respiratory Distress Syndrome network protocol. Barotrauma rate was similar in both groups.
In patients with established acute respiratory distress syndrome, open lung approach improved oxygenation and driving pressure, without detrimental effects on mortality, ventilator-free days, or barotrauma. This pilot study supports the need for a large, multicenter trial using recruitment maneuvers and a decremental positive end-expiratory pressure trial in persistent acute respiratory distress syndrome.
Le volume lors de recrutement alvéolaire prédictif d’une surmortalité dans le SDRA ?
Beitler, et al., CCM, 2016; doi: 10.1097/CCM.0000000000001355
Global lung stress varies considerably with low tidal volume ventilation for acute respiratory distress syndrome. High stress despite low tidal volumes may worsen lung injury and increase risk of death. No widely available parameter exists to assess global lung stress. We aimed to determine whether the volume delivered during a recruitment maneuver (VRM) is inversely associated with lung stress and mortality in acute respiratory distress syndrome.
Substudy of an acute respiratory distress syndrome clinical trial on esophageal pressure-guided positive end-expiratory pressure titration.
U.S. academic medical center.
Forty-two patients with acute respiratory distress syndrome in whom airflow, airway pressure, and esophageal pressure were recorded during the recruitment maneuver.
A single recruitment maneuver was performed before initiating protocol-directed ventilator management. Recruitment maneuvers consisted of a 30-second breath hold at 40 cm H2O airway pressure under heavy sedation or paralysis. VRM was calculated by integrating the flow-time waveform during the maneuver. End-inspiratory stress was defined as the transpulmonary (airway minus esophageal) pressure during end-inspiratory pause of a tidal breath and tidal stress as the transpulmonary pressure difference between end-inspiratory and end-expiratory pauses.
Measurements and Main Results
VRM ranged between 7.4 and 34.7 mL/kg predicted body weight. Lower VRM predicted high end-inspiratory and tidal lung stress (end-inspiratory: β = –0.449; 95% CI, –0.664 to –0.234; p < 0.001; tidal: β = –0.267; 95% CI, –0.423 to –0.111; p = 0.001). After adjusting for PaO2/FIO2 and either driving pressure, tidal volume, or plateau pressure and positive end-expiratory pressure, VRM remained independently associated with both end-inspiratory and tidal stress. In unadjusted analysis, low VRM predicted increased risk of death (odds ratio, 0.85; 95% CI, 0.72–1.00; p = 0.026). VRM remained significantly associated with mortality after adjusting for study arm (odds ratio, 0.84; 95% CI, 0.71–1.00;p = 0.022).
Low VRM independently predicts high lung stress and may predict risk of death in patients with acute respiratory distress syndrome.
Une créatininémie < 30µmol/L à l’admission associée à une surmortalité
Udy et al., CCM, 2016; doi: 10.1097/CCM.0000000000001348
L’hypoalbuminémie pré-opératoire de transplantation hépatique, facteur de risque d’IRA
Sang et al., CCM, 2016; doi: 10.1097/CCM.0000000000001279
Pharmacocinétique du Fentanyl chez les patients en réanimation
Choi et al., CCM, 2016; doi: 10.1097/CCM.0000000000001347
Recommandations 2016 américaines sur le support nutritionnel en réanimation
Trop de bruit en Réanimation !
Tainter et al., CCM, 2016; doi: 10.1097/CCM.0000000000001378