Frailty and 6-month trajectory of elderly trauma patients over the age of 65 years admitted to intensive care unit for severe trauma: experience of a level 1 trauma center.

BACKGROUND: The aging global population forecasts a significant rise in severe trauma cases among individuals aged 65 and above. Frailty emerges as a paramount predictor of post-traumatic outcomes, surpassing age and trauma severity indices. Despite this, scant attention is given to the trajectory of elderly patients post-intensive care unit (ICU) stay following severe trauma, justifying this study. The objective of this study was to analyze trajectories (frailty, place of residence) following a major trauma requiring an ICU stay. MATERIALS AND METHODS: An observational cohort study was conducted, leveraging data from a level 1 trauma center spanning 2018 to 2023. Inclusion criteria included elderly patients aged 65 and above admitted to the ICU for severe trauma. Data encompassed demographic profiles, trauma severity scores, clinical parameters, and frailty assessments sourced from the Traumabase database. RESULTS: Among 293 patients included 190 were non-frail, frailty was correlated with elevated mortality rates (114 (38.9%) at 6 months), heightened incidence of traumatic brain injuries, and notable declines in post-traumatic autonomy. Only 39.2% of patients had resumed residence at home six months post-injury, with a conspicuous trend towards institutionalization, particularly among frail individuals. CONCLUSION: This study highlights the role of frailty in determining the outcomes of elderly patients following severe trauma. Frailty is associated with higher mortality, increased rates of institutionalization, and a decline in functional status. These results highlight the importance of assessing frailty in the trajectory of severely injured patients over the age of 65 years-old.

Lung concentrations of ceftazidime administered by continuous versus intermittent infusion in patients with ventilator-associated pneumonia.

Ceftazidime is a beta-lactam compound that exerts a time-dependent bactericidal effect. Numerous arguments are in favor of continuous administration of ceftazidime, both for reasons of clinical efficacy and to preserve bacteriological mutation. We report a prospective, single-center, parallel-group, randomized, controlled trial comparing two modes of administration of ceftazidime, namely, continuous administration (loading dose of 20 mg/kg of body weight followed by 60 mg/kg/day) versus intermittent administration (20 mg/kg over 30 min every 8 h) in 34 patients with ventilator-associated pneumonia due to Gram-negative bacilli. The study was performed over 48 h with 13 and 18 assessments of serum ceftazidime in the continuous-infusion group (group A) and the intermittent-fusion group (group B), respectively. Bronchoalveolar lavage (BAL) was performed at steady state in both groups at 44 h to determine ceftazidime levels in the epithelial lining fluid. We chose a predefined threshold of 20 mg/liter for serum concentrations of ceftazidime because of ecological conditions in our center. The median time above 20 mg/liter (T>20 mg) was 100% in group A versus 46% in group B. In group A, 14/17 patients had 100% T>20 mg, versus only 1/17 patients in group B. In the epithelial lining fluid, the median concentration of ceftazidime was 12 mg/liter in group A versus 6 mg/liter in group B. A threshold of 8 mg/liter in the epithelial lining fluid was achieved twice as often in group A as in group B. This study of ceftazidime concentrations in the epithelial lining fluid indicates that continuous infusion presents advantages in terms of pharmacodynamics and predictable efficacy in patients presenting ventilator-associated pneumonia.

French practice of emergency resuscitative thoracotomy. A study based on the Traumabase Registry.

AIM OF THE STUDY: Emergency resuscitative thoracotomy (ERT) has been described as a potentially life-saving procedure for trauma patients who have been admitted in refractory shock or with recent loss of sign of life (SOL). This nationwide registry analysis aimed to describe the French practice of ERT. PATIENTS AND METHODS: From 2015 to 2021, all severe trauma patients who underwent ERT were extracted from the TraumaBase→ registry. Demographic data, prehospital management and in-hospital outcomes were recorded to evaluate predictors of success-to rescue after ERT at 24-hour and 28-day. RESULTS: Only 10/26 Trauma centers have an effective practice of ERT, three of them perform more than 1 ERT/year. Sixty-six patients (74% male, 49/66) with a median age of 37 y/o [26-51], mostly with blunt trauma (52%, 35/66) were managed with ERT. The median pre-hospital time was 64mins [45-89]. At admission, the median injury severity score was 35 [25-48], and 51% (16/30) of patients have lost SOL. ERT was associated with a massive transfusion protocol including 8 RBCs [6-13], 6 FFPs [4-10], and 0 PCs [0-1] in the first 6h. The overall success-to-rescue after ERT at 24-h and 28-d were 27% and 15%, respectively. In case of refractory shock after penetrating trauma, survival was 64% at 24-hours and 47% at 28-days. CONCLUSIONS: ERT integrated into the trauma protocol remains a life-saving procedure that appears to be underutilized in France, despite significant success-to-rescue observed by trained teams for selected patients.

The ROX index as a predictor of standard oxygen therapy outcomes in thoracic trauma.

BACKGROUND: Thoracic trauma is commonplace and accounts for 50-70% of the injuries found in severe trauma. Little information is available in the literature as to timing of endotracheal intubation. The main objective of this study was to assess the accuracy of the ROX index in predicting successful standard oxygen (SO) therapy outcomes, and in pre-empting intubation. METHODS: Patient selection included all thoracic trauma patients treated with standard oxygen who were admitted to a Level I trauma center between January 1, 2013 and April 30, 2020. Successful standard SO outcomes were defined as non-requirement of invasive mechanical ventilation within the 7 first days after thoracic trauma. RESULTS: One hundred seventy one patients were studied, 49 of whom required endotracheal intubation for acute respiratory distress (28.6%). A ROX index score ≤ 12.85 yielded an area under the ROC curve of 0.88 with a 95% CI [0.80-0.94], 81.63sensitivity, 95%CI [0.69-0.91] and 88.52 specificity, 95%CI [0.82-0.94] involving a Youden index of 0.70. Patients with a median ROX index greater than 12.85 within the initial 24 h were less likely to require mechanical ventilation within the initial 7 days of thoracic trauma. CONCLUSION: We have shown that a ROX index greater than 12.85 at 24 h was linked to successful standard oxygen therapy outcomes in critical thoracic trauma patients. It is our belief that an early low ROX index in the initial phase of trauma should heighten vigilance on the part of the attending intensivist, who has a duty to optimize management.

Use of BRASS in sedated critically-ill patients as a predictable mortality factor: BRASS-ICU.

Objectives: To demonstrate that a BRASS score≥ 3 at admission of intubated, ventilated and sedated patients is predictive of mortalityMethods: we have realized an Observational prospective multicenter study.All Major patients without neurological history, admitted to ICU for a non-neurological cause, sedated and admitted under mechanical ventilation were included.Results: One hundred and ten patients were included, the BRASS score as well as the FOUR and RASS scores were collected.At day 28, patients with a BRASS score ≥ 3 had an excess mortality (OR 3.29 - CI 95% [1.42-7.63], p = 0.005) as well as day 90 (OR 2.65 - CI 95% [1.19-5.88], p = 0.02), without impact on the delirium measured by CAM-ICU (OR 1.8 - CI 95% [0.68-4.77], p = 0.023). After adjustment with SAPS II, FOUR and RASS, difference in mortality was not any more different.It is also noted that patients with BRASS ≥ 3 are more sedated (RASS: -5 [-5 - -5] vs -4 [-5 - -3], p < 0.0001) and more comatose (FOUR: 2 [1-4] vs 6 [4-9], p < 0.0001), and have higher doses of midazolam (10 mg/h [5-15] vs 7.5 mg/h [5-10], p = 0.02) and sufentanil (20 µg/h [15-22.5] vs 10 [10-12.5], p = 0.01).Conclusions: The early alteration of brainstem reflexes measured by the BRASS score was not independently predictable in terms of mortality in the non-neurological ICU patients, admitted under sedation and mechanical ventilation.Trial registration: ClinicalTrials.gov Identifier: NCT03835091,Registered 8 February 2019 - prospectively registered, https://clinicaltrials.gov/ct2/show/NCT03835091.

Severe post-artesunate delayed onset anaemia responding to corticotherapy: a case report.

Delayed onset haemolysis occurring post-artesunate and post-artemisinin combination therapy is secondary to delayed clearance of infected erythrocytes spared by pitting during treatment. We report a case of severe post-treatment delayed haemolytic anaemia with a positive direct antiglobulin test and a positive response to corticosteroid therapy, suggesting an associated immune mechanism.

Evaluation of the depth of sedation in an intensive care unit based on the photo motor reflex variations measured by video pupillometry.

BACKGROUND: Evaluating depth of sedation in the intensive care unit (ICU) is crucial for the management of mechanically ventilated patients but can be challenging in some situations. Because the depth of hypnosis is correlated with the decrease in photomotor reflex (PMR), we suggest using pupillometric video as an automated, noninvasive, simple, and reproducible technique to evaluate the depth of sedation in ICU patients. We compare the effectiveness of this procedure to the bispectral index (BIS). METHODS: Thirty-one patients requiring sedation and ventilation were included in this monocentric, observational study. The posology of hypnotics and morphinics were based on the Richmond Agitation and Sedation Scale (RASS). PMR was measured by the Neurolight® (IDMED) system and BIS value by BIS Vista® (Anandic Medical Systems). RASS, PMR, and BIS were measured three times daily in all patients. Data acquired by pupillometric video included variation in pupillary diameter (ΔPD), latency time (LT), and maximal speed of pupillary constriction (Vmax). These parameters were analyzed after having classified BIS values in three groups (<40 heavy sedation; 40 ≤ BIS ≤ 60 acceptable sedation; >60 light sedation). Exclusion criteria were neurological or ophthalmologic pathologies that could interfere with PMR. RESULTS: There was a significant difference in Vmax and ΔPD between the BIS < 40 group and 40 ≤ BIS ≤ 60 groups (p < 0.0001 for each) and between the BIS < 40 and BIS > 60 groups (p < 0.0001 for each). There were no significant differences in Vmax and ΔPD between the 40 ≤ BIS ≤ 60 and BIS > 60 groups. There was no correlation between any of the BIS groups and LT. CONCLUSIONS: Vmax and ΔPD seem to be relevant criteria compared with the BIS and the RASS. Pupillometric video monitoring of depth of sedation could be beneficial in ICU patients, especially for those under myorelaxant drugs, where no clinical evaluation of sedation is possible.