Biblio du mois : Janvier 2017

L’année se poursuit avec une biblio du mois bien chargée qui reprend d’ailleurs plusieurs éléments de la biblio du mois dernier (https://www.ajar-online.fr/biblio-du-mois-decembre-2016/).

Je vous rappelle qu’il est possible de traduire vos articles en français via

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Intégration à Google Chrome : https://chrome.google.com/webstore/detail/google-translate/aapbdbdomjkkjkaonfhkkikfgjllcleb?hl=fr

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Au total,

• du sepsis (qu’on aime !) dont les nouvelles recommandations de la Surviving Sepsis Campaign, les études de confirmation sur la nouvelle classification du Sepsis
• de l’ACR 
• de la ventilation et surtout sur le sevrage ventilatoire
• de l’insuffisance rénale et du pronostic
• des études pour l’amélioration du pronostic péri-opératoire
• Bonus avec revue sur la drépanocytose et sur l’intérêt du Yoga !

Si la biblio vous plait ou ne vous plait, n’hésitez à nous envoyer un mail pour nous dire pour qu’on puisse l’améliorer : [email protected]

Enfin, si vous aimez l’AJAR, n’oubliez pas de participer à nos études en cours, on va lancer sous peu des études pour mieux vous connaitre, pour mieux vous servir !

Bref, #AnesthDoncRéa

 

 

 

Recommandations pour le Sepsis et le Choc septique

 

Surviving Sepsis Campaign, JAMA, 2017

http://jamanetwork.com/journals/jama/fullarticle/2598892

 

 

Managing infection:

• Antibiotics: Administer broad-spectrum intravenous antimicrobials for all likely pathogens within 1 hour after sepsis recognition (strong recommendation; moderate quality of evidence [QOE]).

• Source control: Obtain anatomic source control as rapidly as is practical (best practice statement [BPS]).

• Antibiotic stewardship: Assess patients daily for deescalation of antimicrobials; narrow therapy based on cultures and/or clinical improvement (BPS).

Managing resuscitation:

• Fluids: For patients with sepsis-induced hypoperfusion, provide 30 mL/kg of intravenous crystalloid within 3 hours (strong recommendation; low QOE) with additional fluid based on frequent reassessment (BPS), preferentially using dynamic variables to assess fluid responsiveness (weak recommendation; low QOE).

• Resuscitation targets: For patients with septic shock requiring vasopressors, target a mean arterial pressure (MAP) of 65 mm Hg (strong recommendation; moderate QOE).

• Vasopressors: Use norepinephrine as a first-choice vasopressor (strong recommendation; moderate QOE).

Mechanical ventilation in patients with sepsis-related ARDS:

• Target a tidal volume of 6 mL/kg of predicted body weight (strong recommendation; high QOE) and a plateau pressure of ≤30 cm H₂O (strong recommendation; moderate QOE).

Formal improvement programs:

• Hospitals and health systems should implement programs to improve sepsis care that include sepsis screening (BPS).

 

 

Etudes confirmant l’utilité de la nouvelle classification du Sepsis-3 (qSOFA) dans le diagnostic et le pronostic

 

En Réanimation

Raith et al., JAMA, 2017

http://jamanetwork.com/journals/jama/fullarticle/2598267

 

Aux Urgences

Freund, et al. JAMA, 2017

http://jamanetwork.com/journals/jama/fullarticle/2598268

 

 

Quoi de mieux qu’une bonne vieille laryngoscopie ?

 

Lascarrou et al, JAMA, 2017

http://jamanetwork.com/journals/jama/fullarticle/2598718

 

Importance

In the intensive care unit (ICU), orotracheal intubation can be associated with increased risk of complications because the patient may be acutely unstable, requiring prompt intervention, often by a practitioner with nonexpert skills. Video laryngoscopy may decrease this risk by improving glottis visualization.

Objective

To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients.

Design, Setting, and Participants

Randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between May 2015 and January 2016; there was 28 days of follow-up.

Interventions

Intubation using a video laryngoscope (n = 186) or direct laryngoscopy (n = 185). All patients received general anesthesia.

Main Outcomes and Measures

The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications.

Results

Among 371 randomized patients (mean [SD] age, 62.8 [15.8] years; 136 [36.7%] women), 371 completed the trial. The proportion of patients with successful first-pass intubation did not differ significantly between the video laryngoscopy and direct laryngoscopy groups (67.7% vs 70.3%; absolute difference, −2.5% [95% CI, −11.9% to 6.9%]; P = .60). The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with video laryngoscopy vs 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, −6.3% to 8.6%]; P = .76). The median time to successful intubation was 3 minutes (range, 2 to 4 minutes) for both video laryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; P = .95). Video laryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, −2.7% to 10.4%]; P = .25). In post hoc analysis, video laryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; P = .01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs 14/181 [7.7%]; absolute difference, −2.3% [95% CI, −7.4% to 2.8%]; P = .37).

Conclusions and Relevance

Among patients in the ICU requiring intubation, video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications. Further studies are needed to assess the comparative effectiveness of these 2 strategies in different clinical settings and among operators with diverse skill levels.

 

 

ACR intra-hospitalier : on intube ?

 

Andersen et al., JAMA, 2017

http://jamanetwork.com/journals/jama/fullarticle/2598717

 

Importance

Tracheal intubation is common during adult in-hospital cardiac arrest, but little is known about the association between tracheal intubation and survival in this setting.

Objective

To determine whether tracheal intubation during adult in-hospital cardiac arrest is associated with survival to hospital discharge.

Design, Setting, and Participants

Observational cohort study of adult patients who had an in-hospital cardiac arrest from January 2000 through December 2014 included in the Get With The Guidelines–Resuscitation registry, a US-based multicenter registry of in-hospital cardiac arrest. Patients who had an invasive airway in place at the time of cardiac arrest were excluded. Patients intubated at any given minute (from 0-15 minutes) were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics.

Exposure

Tracheal intubation during cardiac arrest.

Main Outcomes and Measures

The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and a good functional outcome. A cerebral performance category score of 1 (mild or no neurological deficit) or 2 (moderate cerebral disability) was considered a good functional outcome.

Results

The propensity-matched cohort was selected from 108 079 adult patients at 668 hospitals. The median age was 69 years (interquartile range, 58-79 years), 45 073 patients (42%) were female, and 24 256 patients (22.4%) survived to hospital discharge. Of 71 615 patients (66.3%) who were intubated within the first 15 minutes, 43 314 (60.5%) were matched to a patient not intubated in the same minute. Survival was lower among patients who were intubated compared with those not intubated: 7052 of 43 314 (16.3%) vs 8407 of 43 314 (19.4%), respectively (risk ratio [RR] = 0.84; 95% CI, 0.81-0.87; P < .001). The proportion of patients with ROSC was lower among intubated patients than those not intubated: 25 022 of 43 311 (57.8%) vs 25 685 of 43 310 (59.3%), respectively (RR = 0.97; 95% CI, 0.96-0.99; P < .001). Good functional outcome was also lower among intubated patients than those not intubated: 4439 of 41 868 (10.6%) vs 5672 of 41 733 (13.6%), respectively (RR = 0.78; 95% CI, 0.75-0.81; P < .001). Although differences existed in prespecified subgroup analyses, intubation was not associated with improved outcomes in any subgroup.

Conclusions and Relevance

Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding by indication, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.

 

Impact de l’effectif médical dans les réanimations sur la mortalité

 

Gershengorn, et al., JAMA Intern Med, 2017

http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2598511?resultClick=1

 

Importance

The patient-to-intensivist ratio (PIR) across intensive care units (ICUs) is not standardized and the association of PIR with patient outcome is not well established. Understanding the impact of PIR on outcomes is necessary to optimize senior medical staffing and deliver high-quality care.

Objective

To test the hypotheses that: (1) there is significant variation in the PIR across ICUs and (2) higher PIRs are associated with higher hospital mortality for ICU patients.

Design, Setting, and Participants

Retrospective cohort analysis of patients (≥16 years) admitted to ICUs staffed by a single intensivist during daytime hours in the United Kingdom from 2010 to 2013.

Exposures

Patient-to-intensivist ratios, which we defined for each patient as the number of patients cared for by the intensivist each day averaged over the patient’s stay.

Main Outcomes and Measures

Using standard summary statistics, we evaluated PIR variation across ICUs. We used multivariable, mixed-effect, logistic regression analysis to evaluate the association between PIR and hospital mortality at ultimate discharge from acute hospital (primary outcome) and at ICU discharge.

Finding

Among 49 686 adults in 94 ICUs, median age was 66 (interquartile range [IQR], 52-76) years, and 45.1% were women. The ultimate hospital mortality was 25.7%. The median PIR for patients was 8.5 (IQR, 6.9-10.8; full range, 1.0-23.5), and varied substantially among individual ICUs. The association between PIR and ultimate hospital mortality was U-shaped; there was a reduction in the odds of mortality associated with an increasing PIR up to 7.5 after which the odds of mortality increased again significantly (average patient mortality for lowest PIR, 22%; PIR of 7.5, 15%; highest PIR, 19%; P = .003). A similar U-shaped association was seen for PIR and mortality in the ICU (nadir of mortality at a PIR of 7.8, P < .001).

Conclusions and Relevance

PIR varied across UK ICUs. The optimal PIR in this cohort of UK ICU patients was 7.5, with significantly increased ICU and hospital mortality above and below this ratio. The number of patients cared for by 1 intensivist may impact patient outcomes.

 

 

 

Hypothermie thérapeutique dans l’ACR pédiatrique intra-hospitalier

 

THAPCA trial investigators, NEJM, 2017

http://www.nejm.org/doi/full/10.1056/NEJMoa1610493

 

 

Epidémiologie de l’IRA en Réanimation pédiatrique

 

Kaddourah, et al., NEJM, 2017

http://www.nejm.org/doi/full/10.1056/NEJMoa1611391

 

 

 

Utilisation d’Exacyl en Chirurgie cardiaque de pontage coronarien

 

Myles et al., NEJM, 2017

http://www.nejm.org/doi/full/10.1056/NEJMoa1606424

 

 

 

Revue sur l’Obésité

 

Heymsfiel et al., NEJM, 2017

http://www.nejm.org/doi/full/10.1056/NEJMra1514009

 

 

 

Thrombolyse intra-ventriculaire dans les Hémorragies intra-cérébrales avec inondation intra-ventriculaire ?

 

Hanley et al., Lancet, 2017

http://www.sciencedirect.com/science/article/pii/S0140673616324102

 

Background

Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome.

Methods

In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators.

Findings

Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88–1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90–1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41–0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22–3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31–0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64–0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37–3·91], p=0·771) was similar.

Interpretation

In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status.

 

Intérêt de l’Optiflow dans la bronchiolite modérée ?

 

Kepreotes et al., Lancet, 2017

http://ac.els-cdn.com/S0140673617300612/1-s2.0-S0140673617300612-main.pdf?_tid=56f021d4-e923-11e6-9a1d-00000aab0f6c&acdnat=1486025047_3f0c61bcb9abc4de64f398ddcf255ba9

 

Revue sur la drépanocytose

 

Ware et al? Lancet, 2017

http://ac.els-cdn.com/S0140673617301939/1-s2.0-S0140673617301939-main.pdf?_tid=5b0d92c4-e923-11e6-9b6b-00000aab0f01&acdnat=1486025054_317ee274a8523af0c5f73b6b700cc42d

 

 

 

 

Seuil d’hypotension artérielle per-opératoire à 65mmHg : suffisant ?

 

Salmasi et al., Anesthesiology, 2017

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2579833

 

Background

How best to characterize intraoperative hypotension remains unclear. Thus, the authors assessed the relationship between myocardial and kidney injury and intraoperative absolute (mean arterial pressure [MAP]) and relative (reduction from preoperative pressure) MAP thresholds.

Methods

The authors characterized hypotension by the lowest MAP below various absolute and relative thresholds for cumulative 1, 3, 5, or 10 min and also time-weighted average below various absolute or relative MAP thresholds. The authors modeled each relationship using logistic regression. The authors further evaluated whether the relationships between intraoperative hypotension and either myocardial or kidney injury depended on baseline MAP. Finally, the authors compared the strength of associations between absolute and relative thresholds on myocardial and kidney injury using C statistics.

Results

MAP below absolute thresholds of 65 mmHg or relative thresholds of 20% were progressively related to both myocardial and kidney injury. At any given threshold, prolonged exposure was associated with increased odds. There were no clinically important interactions between preoperative blood pressures and the relationship between hypotension and myocardial or kidney injury at intraoperative mean arterial blood pressures less than 65 mmHg. Absolute and relative thresholds had comparable ability to discriminate patients with myocardial or kidney injury from those without.

Conclusions

The associations based on relative thresholds were no stronger than those based on absolute thresholds. Furthermore, there was no clinically important interaction with preoperative pressure. Anesthetic management can thus be based on intraoperative pressures without regard to preoperative pressure.

 

 

Score de prédiction d’échec d’extubation chez les cérébro-lésés

 

Godet, et al., Anesthesiology, 2017

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2566210

 

 

Background

The decision to extubate brain-injured patients with residual impaired consciousness holds a high degree of uncertainty of success. The authors developed a pragmatic clinical score predictive of extubation failure in brain-injured patients.

Methods

One hundred and forty brain-injured patients were prospectively included after the first spontaneous breathing trial success. Assessment of multiparametric hemodynamic, respiratory, and neurologic functions was performed just before extubation. Extubation failure was defined as the need for ventilatory support during intensive care unit stay. Extubation failure within 48 h was also analyzed. Neurologic outcomes were recorded at 6 months.

Results

Extubation failure occurred in 43 (31%) patients with 31 (24%) within 48 h. Predictors of extubation failure consisted of upper-airway functions (cough, gag reflex, and deglutition) and neurologic status (Coma Recovery Scale-Revised visual subscale). From the odds ratios, a four-item predictive score was developed (area under the curve, 0.85; 95% CI, 0.77 to 0.92) and internally validated by bootstrap. Cutoff was determined with sensitivity of 92%, specificity of 50%, positive predictive value of 82%, and negative predictive value of 70% for extubation failure. Failure before and beyond 48 h shared similar risk factors. Low consciousness level patients were extubated with 85% probability of success providing the presence of at least two operating airway functions.

Conclusions

A simplified clinical pragmatic score assessing cough, deglutition, gag reflex, and neurologic status was developed in a preliminary prospective cohort of brain-injured patients and was internally validated (bootstrapping). Extubation appears possible, providing functioning upper airways and irrespective of neurologic status. Clinical practice generalizability urgently needs external validation.

 

 

Pas d’effet « week-end » sur le pronostic des patients en Réanimation ?

 

Arulkumaran et al., BJA, 2017

https://academic.oup.com/bja/article-lookup/doi/10.1093/bja/aew398

 

 

Background.

We aimed to identify any association between day and time of admission to critical care and acute hospital outcome.

Methods.

We conducted a cohort study using prospectively collected data from the national clinical audit of adult critical care. We included 195 428 unplanned admissions from 212 adult general critical care units in England, Wales and Northern Ireland, between April 1, 2013 and March 31, 2015 in the analysis.

Results.

Hourly admission rates for unplanned admissions varied more than three-fold during the 24 h cycle. Overall acute hospital mortality was 26.8%. Before adjustment, acute hospital mortality was similar between weekends and weekdays but was significantly lower for admissions at night compared with the daytime (−3.4%, −3.8 to −3.0%; P<0.001). After adjustment for casemix, there remained no difference between weekends and weekdays (−0.0%, −0.4 to +0.3%; P=0.87) or between nighttime and daytime (−0.2%, −0.5 to +0.1%; P=0.21). Delays in admission were reported for 4.3% of admissions and were slightly more common during weekdays than weekends and in the daytime than at night. Delayed admission was associated with a small increase in acute hospital mortality, but adjusting for this did not affect the estimates of the effect of day and time of admission.

Conclusions

The day of week and time of admission have no influence on patient mortality for unplanned admissions to adult general critical care units within the UK. Ways to improve critical care and hospital systems to minimize delays in admission and potentially improve outcomes need to be ascertained in future research.

 

 

 

 

Facteur pronostique des MICI dans le sepsis sévère

 

Colbert et al, Shock, 2017

https://www.ncbi.nlm.nih.gov/pubmed/27617672

 

 

 

 

Mise à jour des recommandations pour le sevrage ventilatoire

 

Ouelette et al., Chest, 2017

http://www.sciencedirect.com/science/article/pii/S0012369216623243

 

 

Oxygénothérapie post-opératoire chez les patients avec un SAOS

 

Liao et al., Chest, 2017

http://www.sciencedirect.com/science/article/pii/S0012369216625941

 

 

Background

Surgical patients with obstructive sleep apnea (OSA) are at increased risk for perioperative complications. Postoperative supplemental oxygen is commonly used but it may contribute to respiratory depression in OSA patients receiving opioids. The objective of the study is to investigate the effect of postoperative supplemental oxygen on SaO₂, sleep respiratory events, and CO₂ level in patients with untreated OSA.

Methods

Consented patients with an apnea hypopnea index (AHI) >5 events/h on a preoperative polysomnography were randomized (1:1) to oxygen (O₂) or no oxygen (Control). Oxygen group received O₂ at 3 l/min via nasal prongs for 3 postoperative nights. The primary outcomes were polysomnographic parameters measuring SaO₂, sleep respiratory events, and PCO₂ measured by transcutaneous CO₂ monitor (P_tcCO₂) on night 1-3. The intention-to-treat and per protocol analysis were done.

Results

123 patients were randomized; O₂-group:62, and Control-group:61. On night-3, the O₂ vs. Control-group had a higher average SaO₂: 95.2±3% vs. 91.4±4% (p<0.001) and lower oxygen desaturation index: 2.3(0.2, 13.8) vs. 18.5(8.2, 45.9) events/h [median (25^th,75^th percentile), p<0.0001]. The O₂ group had a decreased AHI, 8.0(2.1, 19.9) vs, 15.6(9.5, 45.8) (p=0.016) ; hypopnea index (p<0.001), central apnea index (p=0.026) and a shortened longest apnea-hypopnea duration (p=0.002). Although P_tcCO2-CT55 ≥ 10% on postoperative night 1, 2 or 3 was found in 11.4% patients, there was no difference in P_tcCO₂ between the groups.

Conclusions

Postoperative supplemental O₂ was found to improve oxygenation and decrease AHI without increasing the duration of apnea-hypopnea event or P_tcCO₂ level. A small number of patients had significant CO₂ retention while receiving supplemental O_2.

 

 

 

2 sous-phénotypes de SDRA pour des stratégies thérapeutiques différentes ?

 

 

ARDS Network, AJRCCM, 2017

http://www.atsjournals.org/doi/full/10.1164/rccm.201603-0645OC

 

 

Epidémiologie des passages en FA chez les patients septiques en Réanimation

 

 

Klein Klouwenberg et al., AJRCCM, 2017

http://www.atsjournals.org/doi/full/10.1164/rccm.201603-0618OC#readcube-epdf

 

 

Rationale

Patients admitted to intensive care units with sepsis are prone to developing cardiac dysrhythmias, most commonly atrial fibrillation.

Objectives

To determine the incidence, risk factors, and outcomes of atrial fibrillation in a cohort of critically ill patients with sepsis.

Methods

We assessed the association between atrial fibrillation and mortality using time-dependent competing risks survival analysis. Subsequently, for development of a risk score estimating the probability of a first occurrence of atrial fibrillation within the following 24 hours, we performed logistic regression analysis.

Measurements and Main Results

Among 1,782 patients with sepsis admitted to two tertiary intensive care units in the Netherlands between January 2011 and June 2013, a total of 1,087 episodes of atrial fibrillation occurred in 418 (23%) individuals. The cumulative risk of new-onset atrial fibrillation was 10% (95% confidence interval [CI], 8–12), 22% (95% CI, 18–25), and 40% (95% CI, 36–44) in patients with sepsis, severe sepsis, and septic shock, respectively. New-onset atrial fibrillation was associated with a longer stay (hazard ratio [HR], 0.55; 95% CI, 0.48–0.64), an increased death rate (HR, 1.52; 95% CI, 1.16–2.00), and an overall increased mortality risk (subdistribution HR, 2.10; 95% CI, 1.61–2.73) when considering discharge as a competing event. A simple risk score for daily prediction of atrial fibrillation occurrence yielded good discrimination (C statistic, 0.81; 95% CI, 0.79–0.84) and calibration (chi-square, 9.38; P = 0.31), with similar performance in an independent validation cohort (C statistic, 0.80; 95% CI, 0.76–0.85).

Conclusions

Atrial fibrillation is a common complication of sepsis and independently associated with excess mortality. A simple risk score may identify patients at high risk of this complication.

Epidémiologie des LATAs après ACR

 

Grossesteuer et al., Resuscitation, 2017

http://www.sciencedirect.com/science/article/pii/S0300957216305330

 

Introduction

Most successfully resuscitated cardiac arrest patients do not survive to hospital discharge. Many have withdrawal of life sustaining therapy (WLST) as a result of the perception of poor neurologic prognosis. The characteristics of these patients and differences in their post-arrest care are largely unknown.

Methods

Utilizing the Penn Alliance for Therapeutic Hypothermia Registry, we identified a cohort of 1311 post-arrest patients from 26 hospitals from 2010 to 2014 who remained comatose after return of spontaneous circulation. We stratified patients by whether they had WLST post-arrest and analyzed demographic, arrest, and post-arrest variables.

Results

In our cohort, 565 (43%) patients had WLST. In multivariate regression, patients who had WLST were less likely to go to the cardiac catheterization lab (OR 0.40; 95% CI: 0.26–0.62) and had shorter hospital stays (OR 0.93; 95% CI: 0.91–0.95). When multivariate regression was limited to patient demographics and arrest characteristics, patients with WLST were older (OR 1.18; 95% CI: 1.07–1.31 by decade), had a longer arrest duration (OR 1.14; 95% CI: 1.05–1.25 per 10 min), more likely to be female (OR: 1.41; 95% CI: 1.01–1.96), and less likely to have a witnessed arrest (OR 0.65; 95% CI: 0.42–0.98).

Conclusion

Patients with WLST differ in terms of demographic, arrest, and post-arrest characteristics and treatments from those who did not have WLST. Failure to account for this variability could affect both clinical practice and the interpretation of research.

 

 

Dysrégulation du microbiote fécal en Réanimation

 

Lankelma et al., ICM, 2017

http://link.springer.com/article/10.1007%2Fs00134-016-4613-z

 

10 points clés de la prise en charge palliative en Réanimation

 

Edwards et al., ICM, 2017

http://link.springer.com/article/10.1007%2Fs00134-016-4481-6

 

 

 

 

Performance du test d’extubation chez les enfants

 

Faustino et al., CCM, 2017

http://journals.lww.com/ccmjournal/Abstract/2017/01000/Accuracy_of_an_Extubation_Readiness_Test_in.11.aspx

 

Objective

Identifying children ready for extubation is desirable to minimize morbidity and mortality associated with prolonged mechanical ventilation and extubation failure. We determined the accuracy of an extubation readiness test (Randomized Evaluation of Sedation Titration for Respiratory Failure extubation readiness test) in predicting successful extubation in children with acute respiratory failure from lower respiratory tract disease.

Design

Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure clinical trial, a pediatric multicenter cluster randomized trial of sedation.

Setting

Seventeen PICUs in the intervention arm.

Patients

Children 2 weeks to 17 years receiving invasive mechanical ventilation for lower respiratory tract disease.

Intervention

Extubation readiness test in which spontaneously breathing children with oxygenation index less than or equal to 6 were placed on FIO₂ of 0.50, positive end-expiratory pressure of 5 cm H₂O, and pressure support.

Measurements and Main Results

Of 1,042 children, 444 (43%) passed their first extubation readiness test. Of these, 295 (66%) were extubated within 10 hours of starting the extubation readiness test, including 272 who were successfully extubated, for a positive predictive value of 92%. Among 861 children who were extubated for the first time within 10 hours of performing an extubation readiness test, 788 passed their extubation readiness test and 736 were successfully extubated for a positive predictive value of 93%. The median time of day for extubation with an extubation readiness test was 12:15 hours compared with 14:54 hours for extubation without an extubation readiness test within 10 hours (p < 0.001).

Conclusions

In children with acute respiratory failure from lower respiratory tract disease, an extubation readiness test, as described, should be considered at least daily if the oxygenation index is less than or equal to 6. If the child passes the extubation readiness test, there is a high likelihood of successful extubation.

 

Pronostic rénal à 3 mois et à 1 an après EER pour IRA

 

Jung Nam, et al., CCM, 2017

http://journals.lww.com/ccmjournal/Abstract/2017/01000/Chronic_Kidney_Disease_After_Acute_Kidney_Injury.6.aspx

 

Objectives

Severe acute kidney injury requiring continuous renal replacement therapy is associated with a high risk of early mortality. Our objectives were to identify a cohort of early survivors and to follow their renal progress and long-term mortality.

Design

Multicenter, observational, retrospective cohort study.

Setting

ICUs in tertiary academic hospitals in Korea.

Patients

From 2009 to 2013, we identified 1,764 severe acute kidney injury patients who were started on continuous renal replacement therapy at four hospitals. Of these, we identified 331 survivors for whom we could identify renal function at baseline and at 3 months.

Interventions: None.

Measurements and Main Results

The 331 patients were separated into two groups based on their renal function at 3 months after the start of continuous renal replacement therapy. Those who displayed significant deterioration in renal function compared to baseline, defined as greater than or equal to 50% increase in serum creatinine or greater than or equal to 35% decrease in the estimated glomerular filtration rate, or those who continued to receive renal replacement therapy were designated as a “3-month chronic kidney disease progression” group. Those with a return to baseline, less than 50% increase in serum creatinine or less than 35% decrease in the estimated glomerular filtration rate, were designated as a “3-month chronic kidney disease nonprogression” group. The acute kidney injury patients requiring continuous renal replacement therapy showed a higher risk of progression to end-stage renal disease compared to that of stage 3 chronic kidney disease patients who did not undergo an acute kidney injury episode, even if the acute kidney injury was recovered at 3 months after continuous renal replacement therapy initiation. Furthermore, “3-month chronic kidney disease progression” was associated with a high risk of progression to end-stage renal disease and long-term mortality over a median follow-up period of 12.7 (3.8–33.2) and 20.4 (7.5–39.7) months, respectively. Older age, higher baseline serum creatinine levels, and higher blood urea nitrogen concentrations at continuous renal replacement therapy initiation, and lower 24-hour urine output after continuous renal replacement therapy initiation are associated with an increased risk of “3-month chronic kidney disease progression.”

Conclusions

Renal functional assessment at 3 months after continuous renal replacement therapy initiation can be useful in predicting progression to end-stage renal disease and long-term mortality. Furthermore, continuous close monitoring and management of acute kidney injury patients requiring continuous renal replacement therapy are required, even in those with recovered renal function.

 

Survie à long terme après ECMO pour Insuffisance respiratoire et sepsis

 

Von Bahr,  et al., CCM, 2017

http://journals.lww.com/ccmjournal/Fulltext/2017/02000/Long_Term_Survival_in_Adults_Treated_With.3.aspx

 

Objective

The use of extracorporeal membrane oxygenation in adults with respiratory failure and sepsis is steadily increasing, but the knowledge on long-term survival in this group is scarce. The aim of the present study was to investigate the 5-year survival rates and causes of late death in this group of patients.

Design

Single-center retrospective cohort study.

Setting

Karolinska University Hospital, Stockholm, Sweden.

Patients

Adult patients treated with extracorporeal membrane oxygenation for respiratory failure and sepsis between the service being established for adults in 1995 and December 2013.

Interventions: None.

Measurements and Main Results

Survival status was attained from a national Causes of Death registry. Minimal patient background data, along with data on survival and causes of death were collected. Survival rates were calculated using the Kaplan-Meier method. Of 255 subjects, 64% survived to discharge. The median follow-up time in survivors was 4.4 years. There was a high mortality rate within the first months after discharge. In the group of patients who survived the first 90 days after treatment, the 5-year survival rate was 87% and was particularly beneficial in patients treated for infectious diseases (88–100%). Late deaths were seen in most diagnostic groups, but the Kaplan-Meier curves flattened out over time.

Conclusions

Extracorporeal membrane oxygenation treatment in adult patients with respiratory failure and sepsis can be lifesaving in appropriately selected patients. For patients who survive the first months after extracorporeal membrane oxygenation treatment, long-term survival seems good, especially in patients treated for infections.

 

 

Recommandations sur une stratégie centrée sur la famille en Réanimation pédiatrique/néonatale et adulte

 

Davidson et al., CCM, 2017

http://journals.lww.com/ccmjournal/Fulltext/2017/01000/Guidelines_for_Family_Centered_Care_in_the.12.aspx

 

 

 

Colonisation par SARM/BLSE plus importante chez les Migrants

 

Rein Jan Piso, et al., Plos One, 2017

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0170251

 

 

 

 

+ d’Insuffisance rénale avec Tazo+Vanco versus Axépim+Vanco ?

 

Navalkele et al., CID, 2017

https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciw709

 

Background.

Recent evidence suggests that among patients receiving vancomycin, receipt of concomitant piperacillin–tazobactam increases the risk of nephrotoxicity. Well-controlled, adequately powered studies comparing rates of acute kidney injury (AKI) among patients receiving vancomycin + piperacillin–tazobactam (VPT) compared to similar patients receiving vancomycin + cefepime (VC) are lacking. In this study we compared the incidence of AKI among patients receiving combination therapy with VPT to a matched group receiving VC.

Methods.

A retrospective, matched, cohort study was performed. Patients were eligible if they received combination therapy for ≥48 hours. Patients were excluded if their baseline serum creatinine was >1.2mg/dL or they were receiving renal replacement therapy. Patients receiving VC were matched to patients receiving VPT based on severity of illness, intensive care unit status, duration of combination therapy, vancomycin dose, and number of concomitant nephrotoxins. The primary outcome was the incidence of AKI. Multivariate modeling was performed using Cox proportional hazards.

Results.

A total of 558 patients were included. AKI rates were significantly higher in the VPT group than the VC group (81/279 [29%] vs 31/279 [11%]). In multivariate analysis, therapy with VPT was an independent predictor for AKI (hazard ratio = 4.27; 95% confidence interval, 2.73–6.68). Among patients who developed AKI, the median onset was more rapid in the VPT group compared to the VC group (3 vs 5 days P =< .0001).

Conclusion.

The VPT combination was associated with both an increased AKI risk and a more rapid onset of AKI compared to the VC combination.

 

 

 

Transfusion de plaquettes associée à un surrisque infectieux ?

 

Aubron et al., Crit Care, 2017

https://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1593-x

 

 

 

 

Traitement par Yoga des douleurs lombaires chroniques

 

Susan Wieland, et al., Cochrane, 2017

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010671.pub2/full