Clinical Usefulness of Transcranial Doppler as a Screening Tool for Early Cerebral Hypoxic Episodes in Patients with Moderate and Severe Traumatic Brain Injury.

BACKGROUND: Brain tissue oxygenation (PbtO2) in traumatic brain injury (TBI) is known to be dependent on cerebral blood flow (CBF) which remains difficult to assess during the very early phase of TBI management. This study evaluates if blood flow velocity measurement with 2D color-coded transcranial Doppler (TCD) can predict cerebral hypoxic episodes in moderate-to-severe TBI measured with a PbtO2 probe. METHODS: This is a prospective observational study of serial TCD measurements to assess blood flow velocity and its association with PbtO2. Measurements were done bilaterally on the middle cerebral artery (MCA) early after the insertion of PbtO2 monitoring, daily for 5 days and during dynamic challenge tests. Physiological parameters affecting PbtO2 and Doppler velocities were collected simultaneously (PaO2, PaCO2, hemoglobin [Hb] level, intracranial pressure, and cerebral perfusion pressure [CPP]). RESULTS: We enrolled 17 consecutive patients with a total of 85 TCD studies. Using 2D color-coded TCD, signal acquisition was successful in 96% of the cases. Twenty-nine (34%) TCD measures were performed during an episode of cerebral hypoxia (PbtO2 ≤ 20 mmHg). For early episodes of cerebral hypoxia (occurring ≤ 24 h from trauma), all Vmean < 40 cm/s were associated with an ipsilateral PbtO2 ≤ 20 mmHg (positive predictive value 100%). However, when considering all readings over the course of the study, however, we found no correlation between PbtO2 and MCA's mean blood flow velocity (Vmean). Vmean is also positively correlated with PaCO2, whereas PbtO2 is also correlated with PaO2, CPP, and Hb level. CONCLUSIONS: Early TCD measurements compatible with low CBF (mean velocity < 40 cm/s) detect brain tissue hypoxia early after TBI (≤ 24 h) and could potentially be used as a screening tool before invasive monitoring insertion to help minimize time-sensitive secondary injury. Various factors influence the relationship between Vmean and PbtO2, affecting interpretation of their interaction after 24 h.

The First 2 Years of Activity of a Specialized Organ Procurement Center: Report of an Innovative Approach to Improve Organ Donation.

The number of patients requiring organ transplants continues to outgrow the number of organs donated each year. In an attempt to improve the organ donation process and increase the number of organs available, we created a specialized multidisciplinary team within a specialized organ procurement center (OPC) with dedicated intensive care unit (ICU) beds and operating rooms. The OPC was staffed with ICU nurses, operating room nurses, organ donor management ICU physicians, and multidisciplinary staff. All organ donors within a designated geographic area were transferred to and managed within the OPC. During the first 2 years of operation, 126 patients were referred to the OPC. The OPC was in use for a total of 3527 h and involved 253 health workers. We retrieved 173 kidneys, 95 lungs, 68 livers, 37 hearts, and 13 pancreases for a total of 386 organs offered for transplantation. This translates to a total of 124.6 persons transplanted per million population, which compares most favorably to recently published numbers in developed countries. The OPC clearly demonstrates potential to increase the number of deceased donor organs available for transplant. Further studies are warranted to better understand the exact influence of the different components of the OPC on organ procurement.

Performances and limits of Bag-Valve-Device for pre-oxygenation and manual ventilation: A comparative bench and cadaver study.

INTRODUCTION: Bag-Valve-Device (BVD) is the most frequently used device for pre-oxygenation and ventilation during cardiopulmonary resuscitation (CPR). A minimal expired fraction of oxygen (FeO2) above 0.85 is recommended during pre-oxygenation while insufflated volume (VTi) should be reduced during manual ventilation. The objective was to compare the performances of different BVD in simulated conditions. METHODS: Nine BVD were evaluated during pre-oxygenation: spontaneous breathing patients were simulated on a test lung (mild and severe conditions). FeO2 was measured with and without positive end-expiratory pressure (PEEP). CO2 rebreathing was evaluated. Then, manual ventilation was performed by 36 caregivers (n = 36) from three hospitals on a specific manikin; same procedure was repeated by 3 caregivers (n = 3) on two human cadavers with three of the nine BVD: In non-CPR scenario and during mechanical CPR with Interrupted Chest Compressions strategy (30:2). RESULTS: Pre-oxygenation: FeO2 was lower than 0.85 for three BVD in severe condition and for two BVD in mild condition. FeO2 was higher than 0.85 in eight of nine BVD with an additional PEEP valve (PEEP 5 cmH2O). One BVD induced CO2 rebreathing. Manual ventilation: For non-CPR manual ventilation, mean VTi was within the predefined lung protective range (4-8 mL/kg PBW) for all BVD on the bench. For CPR manual ventilation, mean VTi was above the range for three BVD on the bench. Similar results were observed on cadavers. CONCLUSIONS: Several BVD did not reach the FeO2 required during pre-oxygenation. Manual ventilation was significantly less protective in three BVD. These observations are related to the different BVD working principles.

Anti-apolipoprotein A-1 IgG in patients with myocardial infarction promotes inflammation through TLR2/CD14 complex.

OBJECTIVES: Toll-like receptor (TLR)-mediated vascular inflammation, inducible by - amongst other factors - auto-antibodies, is increasingly recognized as a potential mediator of cardiovascular disease. We investigated whether anti-apolipoprotein (Apo)A-1 IgG was associated with a pro-inflammatory cytokine profile in myocardial infarction (MI) patients and whether anti-ApoA-1 IgG elicited a pro-inflammatory response by activating TLRs. METHODS: As surrogate markers of atherosclerotic plaque vulnerability, interleukin (IL)-6, tumour necrosis factor (TNF)-α, matrix metalloproteinase (MMP)-9 and MMP-3 levels were assessed in 221 consecutive MI patients. Using human monocyte-derived macrophages (HMDMs) we investigated (i) the anti-ApoA-1 IgG interaction with TLRs using proximity ligation assay and (ii) anti-ApoA-1 IgG-dependent IL-6/TNF-α production. TLR involvement was further confirmed using HEK293-Blue TLR-2/-4 cells and by computational docking simulations. RESULTS: In MI patients, anti-ApoA-1 IgG positivity was associated with higher levels of IL-6, TNF-α and MMP-9, but lower MMP-3 levels. In in vitro experiments, anti-ApoA-1 antibodies bound to HDMDs in a TLR2-dependent manner, resulting in nuclear translocation of NFκB and a significant increase in TNF-α and IL-6 production. Subsequent functional studies highlighted the importance of CD14 as co-receptor in the anti-ApoA-1 IgG-TLR2-induced cytokine production. Additional bioinformatic studies identified structural homologies between TLR2 and ApoA-1, which may explain the observed cross-reactivity between antibodies against these two molecules. CONCLUSIONS: Anti-ApoA-1 IgG positivity in MI is associated with a high-risk cytokine profile. These auto-antibodies promote inflammation by stimulating the TLR2/CD14 receptor complex, probably because of molecular mimicry, which may contribute to atherosclerosis-related complications in patients.

[Acute chest syndrome in sickle cell disease and acute respiratory distress syndrome--from pathophysiology to therapy]. / Drépanocytose: syndromes thoracique aigu et de détresse respiratoire. De la pathophysiologie au traitement.

Acute chest syndrome is frequent in the homozygous sickle cell disease population. It can evolve to an acute respiratory distress syndrome. Pulmonary artery hypertension or chronic lung sequellae are common. The vasoocclusive phenomenon is due to capillary blockade, followed by an activation of inflammation, and adhesion phenomena further increasing the damage. Decreased blood oxygenation leads to an aggravation of the sickle crisis. Nitric oxide disregulation has been recently highlighted. Diagnosis must be suspected in patients presenting with sickle crisis, fever, low blood oxygenation and lung infiltrates. Early antibiotherapy, adequate oxygenation, blood transfusion and erythrocytapheresis are key points for management. Preventive measures such as iterative transfusion-chelation, hydroxyurea or repetitive erythrocytapheresis are all useful.