Evaluation of pulse pressure variation validity criteria in critically ill patients: a prospective observational multicentre point-prevalence study.

BACKGROUND: Respiratory variation in pulse pressure (ΔPP) is commonly used to predict the fluid responsiveness of critically ill patients. However, some researchers have demonstrated that this measurement has several limitations. The present study was designed to evaluate the proportion of patients satisfying criteria for valid application of ΔPP at a given time-point. METHODS: A 1 day, prospective, observational, point-prevalence study was performed in 26 French intensive care units (ICUs). All patients hospitalized in the ICUs on the day of the study were included. The ΔPP validity criteria were recorded prospectively and defined as follows: (i) mechanical ventilation in the absence of spontaneous respiration; (ii) regular cardiac rhythm; (iii) tidal volume ≥8 ml kg(-1) of ideal body weight; (iv) a heart rate/respiratory rate ratio >3.6; (v) total respiratory system compliance ≥30 ml cm H2O(-1); and (vi) tricuspid annular peak systolic velocity ≥0.15 m s(-1). RESULTS: The study included 311 patients with a Simplified Acute Physiology Score II of 41 (39-43). Overall, only six (2%) patients satisfied all validity criteria. Of the 170 patients with an arterial line in place, only five (3%) satisfied the validity criteria. During the 24 h preceding the study time-point, fluid responsiveness was assessed for 79 patients. ΔPP had been used to assess fluid responsiveness in 15 of these cases (19%). CONCLUSIONS: A very low percentage of patients satisfied all criteria for valid use of ΔPP in the evaluation of fluid responsiveness. Physicians must consider limitations to the validity of ΔPP before using this variable.

Multifocal community-acquired necrotizing fasciitis caused by a Panton-Valentine leukocidin-producing methicillin-sensitive Staphylococcus aureus.

We describe a rare case of multifocal necrotizing fasciitis (NF) complicating a single vaccine injection. Injection of hepatitis B vaccine of a 16-year-old immunocompetent woman developed into rapidly spreading multifocal NF of the right arm and the thighs, with septic shock. Treatment with antimicrobial therapy and surgical debridements allowed amputation to be avoided with a favourable outcome. The etiological agent was a methicillin-sensitive Staphylococcus aureus (MSSA) isolate harboring the Panton-Valentine leukocidin (PVL) and five enterotoxins. PVL has recently been reported in large series of methicillin-resistant SA cases and has been associated with necrotizing infections. Some strains of MSSA could harbor PVL and enterotoxins. PCR investigation is not frequent but could improve the understanding of the mechanisms of lesions. This case is in keeping with the increasing incidence of MSSA harboring PVL and enterotoxins with multifocal dissemination NF and emphasizes the necessary precautions for skin decontamination before vaccine injection.

Drug-eluting stent thrombosis in patients undergoing non-cardiac surgery: is it always a problem?

BACKGROUND: Recent publications have reported high incidence of perioperative complications in patients with drug-eluting stent (DES). The recommendations for bare-metal stents (BMS) are not applicable to DES. In fact, large evidence-based studies are lacking on which to base a consensus for the perioperative management of patients with DES. The aim of the present study is to evaluate the postoperative cardiac risk associated with DES. METHODS: Prospectively collected data were examined for the rate of postoperative cardiac complications in 96 consecutive patients with DES who underwent digestive, urologic, orthopaedic, or vascular surgery. The average delay between revascularization and non-cardiac surgery was 14 (11) months (extremes 1 week and 36 months). The occurrence of postoperative troponin release (troponin I > or =0.15 ng ml(-1)) and the rate of in-stent thrombosis were analysed. RESULTS: Twelve patients (12%) presented a postoperative troponin release, without EKG abnormalities in 10 cases (83%). Two patients (2%) developed an in-stent thrombosis. None of the patients had excessive postoperative blood loss. CONCLUSIONS: Patients with DES are at higher risk of postoperative cardiac complications. Nevertheless, the specific thrombotic complications of the DES were uncommon in this series and this is in contrast to previous alarming reports. A balanced perioperative management of anti-platelet agents, considering both risk for bleeding and risk of thrombotic complications, in patients with DES, is associated with a low risk of thrombosis in the postoperative period. The rate of cardiac complications remains high in these patients due to co-morbidities.

Cost analysis of single-use (Ambu® aScope™) and reusable bronchoscopes in the ICU.

BACKGROUND: Flexible optical bronchoscopes are essential for management of airways in ICU, but the conventional reusable flexible scopes have three major drawbacks: high cost of repairs, need for decontamination, and possible transmission of infectious agents. The main objective of this study was to measure the cost of bronchoalveolar lavage (BAL) and percutaneous tracheostomy (PT) using reusable bronchoscopes and single-use bronchoscopes in an ICU of an university hospital. The secondary objective was to compare the satisfaction of healthcare professionals with reusable and single-use bronchoscopes. METHODS: The study was performed between August 2009 and July 2014 in a 16-bed ICU. All BAL and PT procedures were performed by experienced healthcare professionals. Cost analysis was performed considering ICU and hospital organization. Healthcare professional satisfaction with single-use and reusable scopes was determined based on eight factors. Sensitivity analysis was performed by applying discount rates (0, 3, and 5%) and by simulation of six situations based on different assumptions. RESULTS: At a discount rate of 3%, the costs per BAL for the two reusable scopes were 188.86€ (scope 1) and 185.94€ (scope 2), and the costs per PT for the reusable scope 1 and scope 2 and single-use scopes were 1613.84€, 410.24€, and 204.49€, respectively. The cost per procedure for the reusable scopes depended on the number of procedures performed, maintenance costs, and decontamination costs. Healthcare professionals were more satisfied with the third-generation single-use Ambu® aScope™. CONCLUSIONS: The cost per procedure for the single-use scope was not superior to that for reusable scopes. The choice of single-use or reusable bronchoscopes in an ICU should consider the frequency of procedures and the number of bronchoscopes needed.

Neurally adjusted ventilatory assist as an alternative to pressure support ventilation in adults: a French multicentre randomized trial.

PURPOSE: Neurally adjusted ventilatory assist (NAVA) is a ventilatory mode that tailors the level of assistance delivered by the ventilator to the electromyographic activity of the diaphragm. The objective of this study was to compare NAVA and pressure support ventilation (PSV) in the early phase of weaning from mechanical ventilation. METHODS: A multicentre randomized controlled trial of 128 intubated adults recovering from acute respiratory failure was conducted in 11 intensive care units. Patients were randomly assigned to NAVA or PSV. The primary outcome was the probability of remaining in a partial ventilatory mode (either NAVA or PSV) throughout the first 48 h without any return to assist-control ventilation. Secondary outcomes included asynchrony index, ventilator-free days and mortality. RESULTS: In the NAVA and PSV groups respectively, the proportion of patients remaining in partial ventilatory mode throughout the first 48 h was 67.2 vs. 63.3 % (P = 0.66), the asynchrony index was 14.7 vs. 26.7 % (P < 0.001), the ventilator-free days at day 7 were 1.0 day [1.0-4.0] vs. 0.0 days [0.0-1.0] (P < 0.01), the ventilator-free days at day 28 were 21 days [4-25] vs. 17 days [0-23] (P = 0.12), the day-28 mortality rate was 15.0 vs. 22.7 % (P = 0.21) and the rate of use of post-extubation noninvasive mechanical ventilation was 43.5 vs. 66.6 % (P < 0.01). CONCLUSIONS: NAVA is safe and feasible over a prolonged period of time but does not increase the probability of remaining in a partial ventilatory mode. However, NAVA decreases patient-ventilator asynchrony and is associated with less frequent application of post-extubation noninvasive mechanical ventilation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02018666.

[Use of the intraosseous access in adult patients in France in 2012]. / Utilisation de la voie intraosseuse chez l'adulte en France en 2012.

OBJECTIVES: To evaluate theoretical and practical knowledges of intraosseous (IO) access in adults patients in France in 2012. STUDY DESIGN: National observational descriptive transversal study as survey of opinion and practices. MATERIALS AND METHODS: An email, with an URL to online computerized quiz, was sent to residents and medical doctors who were working, in France, in anesthesiologist units, intensive care units or emergency units. Several questions were asked about theoretical and practical knowledges concerning IO access. RESULTS: After 1359 responses, 396 (29%) practitioners have used an IO kit mainly in case of cardiopulmonary arrest in adults (68%). The insurance of operators in this technique and the rate of physicians who has even put an IO catheter increased with the years of experience of physicians. The reasons given for not using an IO access were no trouble placing a peripheral vein (77%) and unfamiliarity with the equipment and technology (32%). Most of practitioners (753 [55%]) have been trained and 90% (n=265) of untrained doctors believe that training was necessary. The powered system was the most used (71%). CONCLUSION: Only 29% of practitioners have ever used an IO kit. With the new IO kits, a theoretical and practical training is needed to ensure IO kit used.

[Tracheostomy in French ICUs and patient outcome: national opinion survey]. / Trachéotomies en réanimation et devenir des patients: enquête déclarative nationale.

OBJECTIVES: Tracheostomy is a frequent procedure in ICU but patient follow-up and management after ICU has been poorly documented. We conducted a practice survey in French general ICUs and in neurointensive care units concerning tracheostomized ICU patients and their management after ICU. STUDY DESIGN: National observational descriptive transversal study as survey of opinion and practices. MATERIALS AND METHODS: An email, with a link to an automated online questionnaire, was sent to two medical doctors of each French ICU. Demographic data and reported practices concerning indications, technique and post-ICU management were collected. RESULTS: We received 148 intensivists responses from different ICUs, of which 15% from neurointensivists. There was no difference between general intensivists and neurointensivists concerning the reported use of tracheostomy (10±13% vs 20±22%, P=0.05) and concerning the usual timing of the procedure (predominantly between the 10th and the 21th day) (P=0.62). Indications were weaning failure from the ventilator and neurological ventilatory dysfunction. Percutaneous tracheostomy was mainly performed irrespective of the type of unit. Only 48% of doctors declared usually be able to wean patient from the cannula before ICU discharge. Usual difficulties for post-ICU transfer due only to the presence of the cannula were found by 80% of respondants. Eighty-nine per cent of respondents felt that management of tracheostomized patients after the ICU could be improved. CONCLUSION: Tracheostomy is a frequent procedure, mostly percutaneous. Indications and timing for tracheostomy correspond to the recommendations. Reported difficulties in post-ICU management are important and present nationwide.

A pharmacokinetic study of 48-hour sevoflurane inhalation using a disposable delivery system (AnaConDa®) in ICU patients.

BACKGROUND: Little is known regarding sevoflurane kinetics and toxicity during long-term sedation of intensive care unit (ICU) patients using the AnaConDa® system. The objective of the present study was to establish a pharmacokinetic description of 48-h sevoflurane administration, and to estimate plasma concentrations of metabolites. METHODS: Forty-eight hour sedation with sevoflurane vaporized via an AnaConDa® device, with an end-tidal concentration objective of 1.5% (v/v), was initiated in 12 non-obese patients who did not have hepatic or renal failure but who required sedation for more than 48 h in our ICU. Plasma sevoflurane, hexafluoroisopropanol, and fluoride concentrations were determined over this time period and pharmacokinetic analysis was performed. RESULTS: The mean plasma concentration of sevoflurane was 76 mg/L at 24 h and 70 mg/L at 48 h. Wash-out of plasma sevoflurane correlated with a rapid decrease in the mean end-tidal sevoflurane level. The mean free plasma fraction of hexafluoroisopropanol never exceeded 8 mg/mL. The mean fluoride concentration was 0.8 µmol/L on day 0, 51.7 µmol/L on day 1, and 68.1 µmol/L on day 2 (P<0.0001). The distribution volume was 53 L, the elimination constant 2.9 h-1, the transfer constant from compartment 1 to compartment 2 (K1-2) 1.2 h-1, the K2-1 0.26 h-1, the half-life of elimination 3.78 h, and the total clearance 156 L/h. CONCLUSION: Following 48 hours of sedation using sevoflurane inhalation administered using an AnaConDa® delivery device, sevoflurane washout was rapid. Plasma fluoride levels accumulated over the study period without apparent nephrotoxicity.

Ammonia plasma concentration and prolonged infusion of remifentanil in patients with acute kidney injury.

BACKGROUND: Glycine is an excipient of remifentanil and may induce side effects. To investigate glycine and ammonia concentration with the use of remifentanil in Intensive Care Unit patients with acute kidney injury (AKI) defined by a decrease in creatinine clearance above 50%. METHODS: Prospective open-label cohort study in three surgical Intensive Care Units. Thirty-three patients with AKI and requiring sedation for at least 72 hours. Sedation with remifentanil and midazolam or propofol was adapted every six hours according to ATICE. Glycine and ammonia plasma concentrations were measured at H0 (start of infusion) and every 12 hours during a continuous intravenous 72 hours remifentanil infusion, and 24 hours after the end of the infusion. Clinical and biological glycine or ammonia toxicity were evaluated. RESULTS: Fifteen patients required continuous veno-venous hemodiafiltration (CVVHDF). Glycine and ammonia plasma concentrations exceeded the normal value respectively for 11 (33%) and 15 (45%) patients before remifentanil infusion (H0). Accumulation of glycine or ammonia was observed neither for patients with or without CVVHDF. For patients without CVVHDF, the plasma ammonia concentration at the end of remifentanil infusion was significantly correlated with the creatinine clearance at H72 (P=0.03) and with the mean rate of remifentanil infusion (P=0.002). No side effect was reported. CONCLUSION: Remifentanil was not associated with an accumulation of glycine or ammonia in patients with AKI. Plasma ammonia concentration was correlated with the mean rate of remifentanil and creatinine clearance. A 72-hours remifentanil infusion appeared safe for sedation of patients with AKI.

Influence of opioid choice on mechanical ventilation duration and ICU length of stay.

BACKGROUND: The aim of this study was to assess the impact on mechanical ventilation and ICU outcomes of substituting remifentanil for sufentanil, in an analgesia-based sedation protocol. A database of data prospectively collected was retrospectively analyzed. The study was carried out in a 16-bed tertiary-care ICU. METHODS: The study included 1544 mechanically ventilated patients admitted from January 2001 to December 2006. Patients were compared between two consecutive phases. Analgesia-based sedation guidelines were the same, except for the opiate used. The patient-to-nurse ratio (2.5) and ventilator weaning practices remained unchanged. 794 patients were included during the sufentanil phase, and 750 during the remifentanil phase. Remifentanil was associated with significantly less time spent on mechanical ventilation (10 days[3-21] vs. 14 days[3-27], P<0.01) and in the ICU (16 days[3-22] vs. 19 days[4-26], P<0.01). The difference was significant for patients ventilated no longer than four days (P=0.0035) but not for patients ventilated more than four days (P=0.058). Sedation target on the Ramsay scale was reached more often with remifentanil. The use and amount of hypnotic agents in addition to the opiate were significantly lower with remifentanil. The cost of analgesia-based sedation was similar in the sufentanil and the remifentanil group. CONCLUSION: Our study suggests that using a short-acting opiate with short context-sensitive half-life in an analgesia-based sedation protocol may significantly decrease the duration of mechanical ventilation and the ICU length of stay even though not significantly in long term sedation, while improving the achievement of sedation goals despite a lower requirement for adjunctive hypnotic agents, with no additional costs.

Management of HSV-1 encephalitis due to reactivation of HSV-1 during late pregnancy.

A previously healthy 31-year-old G4P2 woman at 33 weeks of gestation was admitted as an emergency with a pyrexia of 39°C, vomiting, headache and neck stiffness associated with photophobia, phonophobia and visual and auditory symptoms. There were no heraldic signs of eclampsia. Polymerase chain reaction and testing for herpes simplex virus in the cerebrospinal fluid diagnosed herpes simplex-1 meningoencephalitis. Following acyclovir, the clinical course improved. Spontaneous vaginal delivery occurred at 39 weeks of gestation with epidural analgesia using ropivacaine. Mother and child were neurologically normal and healthy 15 months later. Early administration of acyclovir is essential to reduce the risk of neurological complications. After treatment and a negative polymerase chain reaction for herpes simplex virus in the cerebrospinal fluid, epidural analgesia with local anesthetic and sufentanil is possible.

[Use of neuromuscular blocking agents in prehospital medicine: practice survey in Emergency Mobile Services of the South-East of France]. / Utilisation des curares en médecine préhospitalière : enquête de pratique dans les Smur de la région Sud-Est.

OBJECTIVE: To evaluate the use of neuromuscular blocking agents (NMBA) in the French adult Prehospital Emergency Medical Services (PEMS). STUDY DESIGN: Telephone survey of practices. MATERIALS AND METHODS: A survey was conducted from April to July 2009 in every PEMS of the South-East of France. A PEMS physician by center was interviewed using a standardized quiz including demographic data, methods of anesthetic induction, use of NMBA and succinylcholine. RESULTS: All 86 EMS were interviewed. Succinylcholine was used in 98% of cases for rapid sequence induction. Nondepolarizing NMBA were never used by 38%. They were not available in 21% of PEMS. Among the practitioners using them, 79% prescribed them rarely (less than 25% of intubated patients). Nondepolarizing NMBA were prescribed in more than half of cases of patient ventilator asynchrony by 27% of physicians, of ventilator high pressure (23%), of acute status asthmaticus (23%), of suspicion of intracranial hypertension (22%), of refractory hypoxemia (16%), therapeutic hypothermia (10%). Limitations of prescription were essentially little guidance and lack of training. Atracurium and cisatracurium were the most used. The exact dosages were known by only 18% of practitioners. None of the practitioners were performing a monitoring of NMBA. CONCLUSION: This survey highlights the very frequent use of succinylcholine for rapid sequence induction and low use of nondepolarizing NMBA for selected indications. A training endeavor could be undertaken to improve the use of these anesthetic drugs by prehospital physicians.

[Survey on anaesthetic practices for electroconvulsivotherapy in French university hospitals]. / Anesthésie pour électroconvulsivothérapie: résultats d'une enquête dans les CHU.

OBJECTIVES: To evaluate the anaesthetic management of electroconvulsive therapy (ECT) in French university hospitals. STUDY DESIGN: National survey in university hospitals by mail. MATERIALS AND METHODS: An email was sent to heads of department of anaesthesiology in French university hospitals to identify a referent practitioner, which we then sent a computerized quiz. The questions were about the volume and organization of the activity, pre-, per- and post-anaesthetic management of patients undergoing ECT. RESULTS: Of the 33 sites performing ECT, 28 (85%) responded. The anaesthesia consultation was systematic at least 48 hours before the start of treatment but the preanaesthetic visit was performed in 32% of the centers. A routine electrocardiogram was performed in 89% of patients. In four centers (25%), neuromuscular blockade was not systematic. Propofol was the agent most widely used (82%) and etomidate and thiopental in 11% and 7% respectively. In two centers, practitioners did not report using oral protection. The psychiatrist was present in 71% of cases. The electroencephalogram was continuously recorded in 45% of the centers. CONCLUSION: The recommendations remain valid while old and may be updated. They are not always followed by the teams. Continuing medical education should be promoted to a better understanding of the factors interfering between anesthesia and ECT.

[French national survey on evaluation by residents in anesthesiology and critical care of choice's motivations of the specialty and their practical and theoretical training]. / Evaluation des motivations de choix et de leur cursus d'apprentissage par les internes d'anesthésie-réanimation: enquête nationale.

INTRODUCTION: The duration of Anesthesiology and Intensive Care (AIC) residency increased from four to five years in 2002 in France. AIC is a specialty increasingly chosen in relation to medical and surgical specialties. We conducted a national survey by questionnaire on the evaluation of their theoretical and practical training by the French residents. MATERIAL AND METHODS: A questionnaire (demographics, motivations for the choice, training) was sent to 1422 residents, enrolled since 2002, in each province. RESULTS: In total, 562 questionnaires (40 %) were returned. The mean age of residents is 28+/-2 years, 46 % are women, on average in 6th semester [1-10th]. The obtained specialty was their first choice for 90 % and of the obtained city home for 73 %. Residents declare that the place of their definitive installation will be chosen depending on the quality of life mainly. So, 97 % referred the same choice of specialty. Training in locoregional anaesthesia (LRA) was evaluated correct or good by 53 % of residents and in the management of difficult intubation correct or good by 62 %. Theoretical training was assessed correct by 31 % of responders and good by 53 % and practical training correct by 25 % and good by 61 %. DISCUSSION: The AIC is now a specialty of positive choice by students. This choice is reinforced by teaching and practice during the residency. The global training is as good as a whole. Residents wish to deepen in some areas (ultrasound, LRA, critical reading, medical redaction) and an evaluation of their practical training with simulations. CONCLUSION: French AIC residents seem satisfied with almost all their training and referred the same choice of specialty.

[Impact of sophrology on non-invasive ventilation tolerance in patients with acute respiratory failure]. / Impact de la sophrologie sur la tolérance des séances de ventilation non invasive chez des patients en insuffisance respiratoire aiguë.

OBJECTIVES: Non-invasive ventilation (NIV) in patients with acute respiratory failure (ARF) is subject to a large number of failures due to discomfort of the art, the feeling of difficulty breathing and pain. The purpose of this study was to evaluate the efficiency of sophrology to improve conditions for the realization of NIV in patients with ARF. PATIENTS AND METHODS: In this prospective randomized and controlled study, consecutive patients with ARF were included. From the very first NIV session, they received either sophrology during the first 30 min of NIV (S group), or standard care by the same nurse during 30 min (T group). The hemodynamic and ventilatory data were recorded continuously; pain, respiratory difficulty and discomfort were measured with a numeric scale at the end of the session. RESULTS: Thirty patients were included in the study, 27 have been analysed. Each patient received an average of four sessions NIV during the protocol. There was no significant difference between the two groups in terms of improvement in gas exchange. In contrast, there was a significant difference in terms of reduction of difficulty in breathing (-76%), discomfort (-60%) and decrease the pain (-40%) in the sophrology group (p<0.001). Respiratory rate, heart rate and systolic arterial blood pressure were decrease during NIV. CONCLUSION: Sophrology constitutes aid for the achievement of the meetings of NIV in patients' IRA.