End-tidal carbon dioxide and arterial to end-tidal carbon dioxide gradient are associated with mortality in patients with neurological injuries.

Pre-hospital end-tidal carbon dioxide (EtCO2) monitoring and arterial to end-tidal carbon dioxide gradient (Pa-EtCO2) have been associated with mortality in patients with traumatic brain injury. Our study aimed to analyze the association between alveolar EtCO2 or Pa-EtCO2 and mortality in patients admitted in intensive care unit (ICU) with neurological injuries. In our retrospective analysis from using large de-identified ICU databases (MIMIC-III and -IV and eICU databases), we included 2872 ICU patients with neurological injuries, identified according to the International Classification of Diseases (ICD-9 and -10), who underwent EtCO2 monitoring. We performed logistic regression and extended Cox regression to assess the association between mortality and candidate covariates, including EtCO2 and Pa-EtCO2. In-hospital mortality was 26% (n = 747). In univariate analysis, both the Pa-EtCO2 gradient and EtCO2 levels during the first 24 h were significantly associated with mortality (for a 1 mmHg increase: OR = 1.03 [CI95 1.016-1.035] and OR = 0.94 [CI95 0.923-0.953]; p < 0.001). The association remained significant in multivariate analysis. The time-varying evolution of EtCO2 was independently associated with mortality (for a 1 mmHg increase: HR = 0.976 [CI95 0.966-0.985]; p < 0.001). The time-varying Pa-EtCO2 gradient was associated with mortality only in univariate analysis. In neurocritical patients, lower EtCO2 levels at admission and throughout the ICU stay were independently associated with mortality and should be avoided.

Fatal Clostridium septicum gas gangrene complicating ECMO: case report and review of literature.

Clostridium septicum gas gangrene is a severe and deadly infection caused by an anaerobic, spore-forming, Gram-positive bacillus. As previously described, two entities are observed: traumatic and spontaneous (or non-traumatic) forms. In this report, we aim to describe the case of a fulminant and ultimately fatal C. septicum myonecrosis occurring in a patient who was first admitted for refractory cardiac arrest and placed on veino-arterial extracorporeal membrane oxygenation (ECMO). Building upon prior studies that have documented cases of spontaneous gas gangrene caused by C. septicum, we provide an updated compilation, focusing on microbiological characteristics of C. septicum, along with the diagnostic and therapeutic challenges associated with spontaneous gas gangrene. Additionally, the specific clinical situation of our case illustrates the seriousness of this infectious complication that combined both spontaneous and traumatic gas gangrene risk factors. We thus, discuss the antibiotic coverage prior to the initiation of ECMO procedure.

Management of spontaneous septic hypothermia in intensive care. A national survey of French intensive care units.

The benefit of temperature control in sepsis or septic shock is still under debate in the literature. We developed a national survey to assess the current state of knowledge and the practical management of spontaneous septic hypothermia in French intensive care units. Out of more 764 intensivists who were contacted, 436 responded to the survey. The majority of doctors (52.4%) considered spontaneous septic hypothermia to be a frequently encountered situation in intensive care, and 62.1% were interested in this problem. Definition of spontaneous septic hypothermia among French intensivists was not consensual. More than half of the doctors questioned (57.1%) stated that they did not actively rewarm patients suffering from spontaneous septic hypothermia.

Does the participation of a senior plastic surgeon improve conditions of hospitalisation in craniosynostosis repair surgery?

INTRODUCTION: The real impact of the participation of other surgical specialties together with neurosurgeons on perioperative care in craniosynostosis repair surgery has not been determined. The purpose of this study was to determine whether the participation of a second senior surgeon (plastic surgeon) during surgical repair of pediatric monosutural craniosynostosis improved perioperative medical care. MATERIAL AND METHODS: The authors retrospectively reviewed 2 cohorts of patients who had consecutively undergone primary repair surgery for trigonocephaly and unicoronal craniosynostosis. Infants were operated on by a single senior pediatric neurosurgeon before December 2017, and with the collaboration of a senior plastic surgeon after January 2018. RESULTS: Overall, 60 infants were included in the study: 29 in group 1 (single surgeon, 2011-2017), and 31 in group 2 (pair of surgeons, 2018-2021). Median surgery time was significantly shorter in group 2 than group 1: 180 vs. 167minutes; P=0.0045. There was no significant difference between the 2 groups in blood loss or intra/postoperative packed erythrocyte transfusion. Postoperative drain output was significantly lower in group 2. Median length of hospital and intensive care stay were significantly shorter in group 2, by 1 and 2 days, respectively; P<0.0001. Volume of infused solution, diuresis, immediate postoperative hemoglobin level, hematocrit, hemostasis (platelet count, fibrinogen, prothrombin time and activated partial thromboplastin time), and return to oral feeding did not differ from one group to the other. CONCLUSION: Results confirmed our impression of an improvement in perioperative medical care. However, the role of surgical experience and the influence of the medical/nursing staff must not be minimized in these complex surgical procedures.

Importance of tranexamic acid in pediatric monosutural craniosynostosis surgery.

OBJECTIVE: Tranexamic acid (TXA) is an antifibrinolytic drug that has achieved significant reduction in perioperative blood loss and the quantity of blood transfused in many pediatric surgical procedures, without morbidity. Despite the accumulation of evidence regarding its effectiveness in craniosynostosis repair surgery, TXA is not unanimously employed by pediatric neurosurgery teams. The purpose of this study was to evaluate the impact of the routine use of TXA in a homogeneous population of children who underwent open surgery for monosutural craniosynostosis. METHODS: The authors retrospectively reviewed 3 cohorts of patients that were subdivided from 2 cohorts surrounding the initiation of TXA (group 1, TXA- [2008-2011] and group 2, TXA+ [2011-2013]) and a third cohort of more recent patients (group 3, TXA+ [2016-2017]). TXA was administered using the same protocol comprising a loading dose of 10 mg/kg over 15 minutes after induction of general anesthesia followed by a 10 mg/kg per hour infusion until skin closure. Patients in all 3 groups underwent similar standardized procedures for scaphocephaly, trigonocephaly, and unicoronal craniosynostosis by the same pediatric neurosurgeon. RESULTS: Overall, 102 infants were included in the study: 32 infants in group 1, 36 in group 2, and 34 in group 3. Significant reductions in transfusion of packed erythrocytes (PE) and fresh-frozen plasma (FFP) were observed between the TXA- and TXA+ time periods. The median volume of PE transfusion was reduced by > 50% with the use of TXA (42.8 mL/kg in the TXA- group vs 20.0 in the TXA+ groups, p < 0.0001). Reduction in PE transfusion was 100% postoperatively in the TXA+ groups (20.0 mL/kg in the TXA- group vs 0.0 in the TXA+ groups, p < 0.0001). The median volume of FFP transfusion was reduced by 100% with the use of TXA (12.8 mL/kg in the TXA- group vs 0.0 in the TXA+ groups, p < 0.0001). All children in group 1 received a transfusion, whereas 3 children (8%) and 7 children (20%) in groups 2 and 3, respectively, did not. Significant reductions in postoperative drain output were also noted between the TXA- and TXA+ time periods. The total hospital length of stay was significantly lower in the TXA+ groups (p < 0.0001). CONCLUSIONS: Use of TXA reduced blood loss and the need for transfusions but also decreased the hospital length of stay and, thus, minimized overall medical care costs. Intraoperative administration of TXA in craniosynostosis repair surgery should be routinely used in all centers that practice these procedures.

[Hypokalemia with pseudo-hyperaldosteronism: Is it Lidl® syndrome?] / Hypokaliémie avec pseudo-hyperaldostéronisme : est-ce un syndrome de Lidl® ?

INTRODUCTION: Intoxication induced by glycyrrhizin is a common cause of hypokalaemia by pseudo-hyperaldosteronism. OBSERVATION: We hereby present the observation of a 68-year old patient hospitalised following a full hip-prosthesis operation after a deep hypokalaemia at 2.5mM was observed, with ECG signs (flat T waves and appearance of U waves). The kaliuresis was not adapted at 8,4mmol/mmol of creatininuria. We noted a history of axonal and demyelinising polyneuropathy, of psoriasis and chronic ethylism.The evolution after intravenous potassic supplementation and then per os was favourable leading to a normalisation of the blood and urinary potassic concentrations. The blood concentrations of renin and of aldosterone upon admission were lower than the detection threshold and the tests carried out 7 days later were normal with a plasmatic renin of 35.2 pg/mL and a plasmatic aldosterone of 74 pg/mL, therefore indicating a toxic cause. It is the interview of the patient that allowed for the diagnosis, identifying a daily, prolonged and important consumption (around 1L every 2-3 days for several years) of a pastis produced by supermarket brand Lidl®. The composition of the drink mentions 'liquorice infusion' without giving any more information as regards to the real concentration; it was later estimated at 170 mg/L by the distributor. DISCUSSION: The consumption of glycyrrhizin is a well-known aetiology for pseudo-hyperaldosteronism. It is commonly mentioned amongst excessive consumers of liquorice or of non-alcoholic anise drinks. Drinks that are derived from original pastis contain varying levels of glycyrrhizin, which is used as a flavour enhancer and can become toxic in cases of prolonged and important consumption.