Low thoracic skeletal muscle index is associated with negative outcomes in 244 patients with respiratory COVID-19.

BACKGROUND: Sarcopenia is associated with negative outcomes in intensive care unit (ICU) patients and during chronic diseases. We aimed to evaluate if low skeletal muscle index (SMI) measured by computed tomography (CT) at the thoracic level is associated with poor outcomes in hospitalized patients with respiratory COVID-19. METHODS: Patients admitted to the hospital between March 1st and June 9, 2020 with a confirmed diagnosis of respiratory COVID-19 in the Emergency Department were included in this retrospective cohort study. SMI was assessed from a transverse CT image at the T12 level. We analysed the association between thoracic SMI and mortality, ICU admissions, infections, length of stay and gravity scores. RESULTS: We included 244 patients, whose median age was 62 (20-95) years, mean body mass index was 28,6 kg/m2, and 34% were obese patients. 102 patients (41,8%) had low thoracic SMI. On multivariable analysis, low thoracic SMI was associated with more infections (OR = 1,88 [1,06-2,98]) and increased length of stay (OR = 1,87 [1,14-3,49]) but not with mortality (OR = 1.37 [0.54-3.52]), whereas it was inversely associated with ICU admission (OR = 5,56 [1,96-16,67]. CONCLUSION: Low SMI measured by CT at the thoracic level T12 is associated with negative outcomes in patients with respiratory COVID-19.

[Impact of the Lubrizol Rouen plant fire of September 26, 2019 on ophthalmic emergency room visits]. / Impact de l'incendie de l'usine Lubrizol à Rouen le 26 septembre 2019 sur la fréquentation des urgences ophtalmologiques.

INTRODUCTION: A fire at the Lubrizol chemical factory in Rouen on September 26, 2019 generated a huge column of smoke directed northeast toward the city. As the eye might be particularly affected by the smoke and other toxic emissions from the fire, we assessed the impact of this industrial and ecological disaster on irritative eye surface disease in the week following the accident. MATERIALS AND METHODS: We retrospectively collected the medical data of the patients who presented to the Ophthalmology Emergency Department (OED) of Rouen University Hospital (the only OED open during the days following the accident) during the week following the fire (W1). We compared these data with those of patients who presented during the week before the fire (W-1). We also collected data on patients presenting to the ED in general during W-1 and W1, including the number of visits directly related to the fire. RESULTS: 361 patients presented to the OED during W1 following the fire, compared with 384 in W-1. Of these patients, 83 (23%) had ocular surface disease in W1, versus 76 (20%) in W-1. Conjunctivitis was found in 54 patients in W1 (39 viral, 9 allergic, 6 undetermined) versus 44 in W-1 (27 viral, 12 allergic, 5 undetermined). A dry irritative syndrome was present in 29 patients in W1 versus 32 in W-1. Only 4 patients directly attributed their symptoms to the fire: 2 viral conjunctivitis, 1 allergic conjunctivitis and 1 worried patient (at D2, D5, D7 and D7 following the fire respectively). DISCUSSION: The number of emergency eye consultations did not change in the week following the Lubrizol factory fire (except for a decrease the day of the accident, related to the lock-down). There was a higher number of consultations in W1 for conjunctivitis, mostly viral in appearance and probably not directly related to the fire. The number of consultations for dry irritative syndrome was comparable between the two periods. Despite major media coverage of the event at the national level and a very high level of concern among the population, the fire does not seem to have had an effect on OED activity at Rouen University Hospital, nor on general ED visits. The stay-at-home order on the first day may have had a protective effect, avoiding direct exposure to smoke. The long-term consequences of the soot deposits on the ground as the smoke cloud passed over remain undetermined and are under surveillance. A review of the literature on the ocular consequences of industrial accidents is presented. CONCLUSION: The Ophthalmology Emergency Department did not record increased activity in the week following the Lubrizol Rouen fire, and ocular surface disease did not give rise to more consultations than the week before the fire. This suggests that there was no or minimal immediate ocular toxicity of the smoke from the fire.

Nasomaxillary fracture: Retrospective review of 11 consecutive patients and literature review.

PURPOSE: Nasomaxillary fractures can be mistaken for fractures confined to the nasal bones, resulting in inappropriate treatments that jeopardize patient outcomes. Our purpose here was to provide information on nasomaxillary fractures via a retrospective study and literature review. MATERIAL AND METHODS: We retrospectively collected clinical, computed tomography (CT), therapeutic, and outcome data in consecutive patients managed for unilateral impacted nasomaxillary fractures at our centre over a 5-year period (2013-2017). Long-term outcomes were further assessed by administering scoring tools for subjectively assessed cosmesis, nasal obstruction, and pain during a telephone interview. RESULTS: The 11 included patients had a mean age of 33.4 years. The clinical manifestations included nasal asymmetry in all 11 patients and infra-orbital rim step-off deformity in 9 patients. Consistent CT findings were involvement of the nasal bone, canine pillar, and anterior maxillary bone; and presence of blood within the maxillary sinus. The treatment in 8 patients consisted in open reduction and internal fixation via the intraoral approach, with or without an added infra-orbital approach; 1 patient was managed by endonasal reduction and 2 patients declined reduction. Almost 1 year after surgery, the cosmetic outcome was good (mean score, 22/25) and few patients reported nasal obstruction (mean score, 3.6/20) or pain (mean score, 1.6/10). CONCLUSION: Nasomaxillary fracture is a specific entity that must be differentiated from nasal bone fracture. Open reduction and internal fixation via the intraoral approach, with an added infra-orbital approach if needed, provides good outcomes.

[Pre-hospitalization unit: A simple organization and a place for internists to improve the non-scheduled hospitalization stream from emergencies]. / Unité d'attente d'hospitalisation : une organisation simple et une place pour les internistes pour améliorer la filière d'hospitalisation non programmée à partir des urgences.

INTRODUCTION: The adult emergency department at Rouen University hospital (CHU) welcomes over 100.000 patients per year. In order to streamline unscheduled hospital admissions from the emergency room (ER), a 20-bed pre-hospitalization unit and a centralized bed management system (bed manager, bed manager software, dedicated beds) have been put into place. PATIENTS AND METHODS: Emergency admissions have increased by (+3.5% between 2017 and 2018) with 20% direct hospitalization from the ER to other conventional units (2/3 in medicine, 1/3 in surgery). In 2018, 3450 patients, of which 54% aged over 75 years have been admitted in the pre-hospitalization unit with an average length of stay of 1.3±1.4 days: 35.4% stayed less than 24hours and 34.8% more than 48hours of which 5.2% stated more than 4 days, 132 patients (3.8%) died, 805 patients (23.3%) were discharged at home, 220 (6.4%) transferred to another facility, and 2287 (66.3%) were secondarily hospitalized in another hospital unit: more than 9 times out of 10 in a medicine unit (internal medicine 30%, geriatrics 27.9%, respiratory medicine 12.2%). This unscheduled emergency hospitalization allowed a daily hospitalization of 50 short stay inpatients beds. It has to be noted that the number of available inpatient beds clearly decreases during the week-ends. The main pathologies were respiratory infections (14.2%), heart diseases (9.7%), metabolic disorders (3.9%), and urinary tract infections (13.6%). CONCLUSION: This pre-hospitalization unit associated with a centralized bed management system has clearly improved the unscheduled hospital admissions, in particular concerning the emergency medical sector. The lack of inpatient beds at the week-end and the management of epidemic periods still remain a challenge that has to be taken up.

[Monitoring of cerebral oxygenation with SvjO(2) or PtiO(2)]. / Intérêt du monitorage de l'oxygénation cérébrale par SvjO(2) ou PtiO(2).

Jugular venous oxygen saturation (SvjO(2)) monitoring has been developed in order to detect cerebral ischaemia. The interpretation of SvjO(2) values remains nevertheless complex, and should be associated with cerebral haemodynamic multimonitoring with ICP and transcranial Doppler. With the hypothesis of a constant cerebral oxygen consummation, and also with a constant haematocrit, SvjO(2) variations correlates with cerebral blood flow variations. After a brain trauma, an SvjO(2)<50% or>75% is associated with a bad prognosis. To maintain SvjO(2)>50% constitutes a reasonable therapeutic objective, but the benefice associated with such a strategy has not been validated. Oxygen partial pressure (PtiO(2)) in the brain parenchyma may be monitored in the non-lesioned area (usually frontal) in order to detect a global cerebral ischaemia, or in the penumbra of a cerebral lesion in order to detect a local ischaemia. The values associated with an ischemic risk are not fully defined and may be under 10-15 mmHg. A concomitant metabolic monitoring by cerebral microdialysis is of importance to fully address the real cerebral local ischaemic burden. Scientific studies are mainly focused on patients with a brain traumatism. Nor SvjO(2), nor PtiO(2) monitoring have at present been demonstrated to be associated with a clinical benefit, and their use should be restricted to scientific research.

[Massive haemorrhage after dorsal decompressive laminectomy]. / Hémorragie massive après laminectomie dorsale décompressive.

We describe a case of a massive haemorrhage after dorsal decompressive laminectomy. The biological syndrome was at first a disseminated intravascular coagulation (DIC), rapidly complicated by a secondary fibrinolysis. The usual treatment of DIC with plasma and platelet transfusion failed to control bleeding and the patient underwent four repeat operations for relapsing rapidly evolving paraplegia. Aprotinine treatment stopped the haemorrhage. The vertebral metastasis causing spinal compression proved to be of prostatic origin.

[Prevalence of dysphosphoremia in patients admitted in intensive care unit with an impaired renal function]. / Prévalence des dysphosphorémies chez les patients admis en réanimation avec une altération de la fonction rénale.

OBJECTIVE: To assess the frequency of dysphosphoremia in patients admitted in intensive care unit with an impaired renal function and to determine the associated risks factors. Study design. - Epidemiological prospective study. PATIENTS AND METHODS: The creatinine clearance and the phosphoremia were measured in 134 consecutive patients admitted in intensive care unit over a six-month period. Patients with chronic renal failure were excluded. Known risk factors for hypophosphoremia in intensive care unit were recorded. RESULTS: Seventy-nine out of one hundred thirty-four patients (59%) had an impaired renal function (arbitrarily defined by a creatinine clearance < 60 ml/min). The proportion of patients with impaired renal function that where hypo-, normo- (0.8 to 1.2 mmol/l) or hyperphosphoremic was 16, 34 and 50% respectively. Hypophosphoremia was severe (< 0.5 mmol/l) in 5 patients, all with impaired renal function. No risk factors usually associated with hypophosphoremia could be identified. CONCLUSION: As opposed to chronic renal failure patients who are mainly hyperphosphoremic, patients admitted in intensive care unit with an impaired renal function may present with a normo-, or hypophosphoremia. These dysphosphoremias are sometimes severe. Phosphate status should be promptly determined at admission.

Clinical evaluation of the Abbott Qvue-OptiQ continuous cardiac output system in critically ill medical patients.

PURPOSE: The aim of this study was to evaluate the reliability of a new continuous cardiac output (CCO) monitoring device (Qvue/OptiQ system; Abbott Critical Care Systems, Mountain View, CA) based on the pulsed warm thermodilution technique in critically ill medical patients. METHODS: Nineteen patients with cardiogenic or septic shock were included in the study. Pairs of CCO and intermittent bolus cardiac output (ICO) were noted at least every 6 hours for determination of bias, precision, and limits of agreement. Simultaneously, blood samples were collected, and arterial-venous oxygen content difference (C[a-v]O2) was determined. A multiple stepwise logistic regression was used to identify situations associated with a CCO-ICO difference exceeded 20%. A multiple linear regression was performed to analyze the respective accuracy of CCO and ICO to predict the variations of C[a-v]O2. RESULTS: A total of 203 pairs of cardiac output measurements was obtained. The bias was 0.12 L/min (1.2% of pairs mean) and the precision 1.0 L/min (13%). The 95% limits of agreement were between -1.7 L/min (-25%) and 1.9 L/min (+26%). Low blood temperatures and heart rates above 120 beats/min were significantly associated with a ICO-CCO difference higher than 20%. In a multiple linear regression, CCO was significantly correlated with C[a-v]O2, an independent reflection of the patient's cardiac output; by contrast, ICO did not. CONCLUSION: These results suggest that ICO and CCO measurement by the Qvue/OptiQ system are interchangeable, except for temperature or heart rate extreme values.

[The endonasal approach to pituitary adenomas: experience in 105 procedures]. / Intérêt de la voie d'abord endonasale pour l'exérèse des adénomes hypophysaires.

OBJECTIVE: The endonasal approach to the sella turcica is supposed to simplify surgical techniques and reduce the risk and sequelae linked to removal of pituitary adenomas. We report our experience with 105 procedures using this approach. METHOD: The series included 45 men and 60 women, aged 17 to 83 years. Their intrasellar lesions were: 43 non-functional adnomas, 37 prolactinomas, 7 GH- adenomas, 9 corticotrop adenomas, 9 miscellaneous lesions (abscess, Rathke cleft cysts, empty sella). Mean duration of the procedures was 50 minutes. Mean hospital stay was 4 days. RESULTS: There were no deaths. Morbidity included: 1 (0.95%) rhinorrhea associated with meningitis which cured without sequelae, 11 (10.5%) transient diabetes insipidus lasting no longer than 48 hours, 2 cases of permanent diabetes insipidus (1 non-functional macroadenoma, 1 pituitary abscess), 1 transient hyposmia (3 months), 2 transient nasal obstructions. There were no cases of septal perforation, nasal deformation, partial or complete mucosal anesthesia, nasal pain, dental pain, or epistaxis. CONCLUSION: This surgical approach is easier to perform and causes less rhinological sequelae than the sublabial transsphenoidal approach. It allows an as effective tumor removal than the latter. Hospitalization stay is significantly shortened.

[When and how to start sedation in a neuro-intensive care patient?]. / Quand et comment débuter une sédation en neuroréanimation ?

Sedatives drugs are part of the everyday care in the neuro-ICU. Reasons to sedate patients in neuro-ICU are as usual to ensure the comfort and to secure the patients, to permit nursing as well as to permit adaptation to the ventilator. But some objectives are specific in neuro-ICU as optimisation of cerebral haemodynamics and oxygenation, and to avoid a convulsive state or a dysautonomic syndrome. Starting the sedation usually necessitate a tracheal intubation and mechanical ventilation. Patients presenting with intracranial hypertension are at risk of developing cerebral ischaemia in case of cerebral haemodynamics alteration associated with anaesthetic drugs injection. Morphinomimetics increase intracranial pressure (ICP), but cerebral perfusion pressure and oxygenation (CPP) remain usually unaltered. Injection of an intravenous bolus of thiopental or propofol lowers ICP and CPP, but also the cerebral tissular oxygen consumption: the cerebral oxygenation seems therefore protected. The succinylcholine used for emergency tracheal intubation has no effect on the cerebral haemodynamic. Some more studies are needed to better understand the cerebral oxygenation at the local level when sedative drugs are injected or perfused in patients with intracranial hypertension.

[Artificial ventilation in acute respiratory distress syndrome in adults. Towards an individual optimization]. / Prise en charge ventilatoire du syndrome de détresse respiratoire aiguë de l'adulte. Vers une optimisation individuelle.

Artificial ventilation plays a key role in the treatment of acute respiratory distress syndrome (ARDS). Initially, the goal is to normalize gas exchange compromised by the lung disease. Positive pressure ventilation can however aggravate prior lesions of the pulmonary parenchyma, at least in areas of the lung accessible to ventilation. Computed tomography of the lung has given us a better understanding of the pathogenesis of these ventilation-induced lesions, leading to new ventilatory strategies aimed at assuring adequate oxygenation without damaging the parenchyma. These ventilatory modes may tolerate a certain degree of hypercapnia to avoid lung injury. Improved oxygenation relies on optimizing the ventilation/perfusion ratio, either with inhaled nitric oxide or a supine position to improve alveolar recruitment. In the most severe cases, extra-corporal gas exchange systems have shown their efficacy for patients whose lungs cannot be ventilated. Thus ventilation should be carefully adapted to each patient based on the severity of the ARDS and its clinical course. We present a practical protocol based on a hierarchy rationale for each ventilation mode and indicate the explorations required to adapt each mode to a specific patient.

[Newer inhalation anaesthetics and neuro-anaesthesia: what is the place for sevoflurane or desflurane?]. / Les nouveaux agents volatils halogénés en neuro-anesthésie: quelle place pour le sévoflurane ou le desflurane?

The effects on cerebral circulation and metabolism of sevoflurane and desflurane are largely comparable to isoflurane. Both induce a direct vasodilation of the cerebral vessels, resulting in a less pronounced decrease in cerebral blood flow compared to the decrease in cerebral metabolism. This direct vasodilation seems to be dose-dependent and more pronounced for desflurane > isoflurane > sevoflurane. Many reports suggest luxury perfusion at high concentrations of desflurane. Sevoflurane maintains intact cerebral autoregulation up to 1.5 MAC. Desflurane induces a significant impairment in autoregulation, with a completely abolished autoregulation at 1.5 MAC. Both sevoflurane and desflurane (up to 1.5 MAC) maintain normal CO(2) regulation. As to their effect on final intracranial pressure (ICP), both sevoflurane and desflurane revealed no increases in ICP. However, compared to intravenous hypnotics, subdural ICP is higher with volatiles because of their tendency to increase cerebral swelling after dura opening (isoflurane > sevoflurane). Several case reports have noted seizure-like movements, as well as EEG recorded seizures during induction of sevoflurane anesthesia. Especially, in children during inhalational induction with hyperventilation at a high sevoflurane concentration, severe epileptiform EEG with a hyperdynamic response were observed, which urges for caution using inhalational sevoflurane induction in children for neurosurgical procedures. Neuroprotective properties (reduced neuronal death either by necrosis or apoptosis) have been attributed to all volatile agents. However, these neuroprotective effects have been described in experimental or animal models, so their possible effect on humans remains to be proven.

[Is measurement of body temperature by infrared tympanic thermometry reproducible?]. / La mesure de la température corporelle par thermomètre tympanique infrarouge est-elle reproductible?

OBJECTIVE: To assess the reliability of body temperature estimated by infrared tympanic thermometry. STUDY DESIGN: Prospective study. PATIENTS AND METHODS: 71 patients in a neurosurgical intensive care unit. 393 triplets of measurements were performed: right ear, left ear and right ear again. RESULTS: Limits of agreements are [-1, +1 degree C] between both ears, and [-0.6, +0.7 degree C] for two consecutive measurements in the right ear. The Bland and Altman diagram show that most of the points responsible for the lack of accuracy are between 36 and 37 degrees C. CONCLUSION: These values give an estimation of the technique's accuracy. In our point of view, such a reproducibility is adequate for daily clinical practice. The accuracy of infrared tympanic thermometry with the First Temp Genius seems reasonable for the clinical practice when the temperature is over 37 degrees C.

[Severe pulmonary embolism with two indications for inferior vena cava filter placement]. / Une embolie pulmonaire grave avec deux indications à la mise en place d'un filtre dans la veine cave inférieure.

A case of severe pulmonary embolism, treated with thrombolysis, and complicated by a haemorrhagic shock (peritoneal bleeding after a spleen trauma) is reported. A paradoxical renal artery embolism occurred, due to a patent foramen ovale. The benefit of a inferior vena cava filter insertion in case of paradoxical embolism is discussed.

[Functional neurosurgery for epilepsy]. / La chirurgie fonctionnelle de l'épilepsie.

Introduced at the end of the last century, epilepsy surgery is indicated in patients with intractable partial seizures and based on the resection of the epileptogenic cerebral tissue from which ictal discharges originate. Palliative procedures include seizure spread pathways interruption (callosotomy, multiple subpial transections) and chronic stimulation of the vagus nerve. Complete preoperative investigations including seizure observation, clinical tests, video-EEG, MRI and functional MRI, and PET-scan are performed in order to identify the epileptogenic zone. In difficult cases, invasive seizure monitoring through depth electrode implantation (SEEG) is performed. Resections for temporal lobe seizures are associated with favorable outcome: 60 to 90% of patients will be seizure-free after surgery. A less favorable outcome is observed after extra-temporal resections: 40 to 60% seizure-free patients. A better outcome is observed after surgery for epilepsy associated with an image-defined lesion, most often a tumor, rather than for cryptogenic epilepsy. Tumors associated with chronic partial epilepsy are indolent, most of them are dysembryoplastic neuroepithelial tumors (DNET). Outcome after palliative procedures are more variable, depending on the etiology of epilepsy.

Unique blood culture for diagnosis of bloodstream infections in emergency departments: a prospective multicentre study.

Detection of microorganisms by blood cultures (BCs) is essential in managing patients with bacteraemia. Rather than the number of punctures, the volume of blood drawn is considered paramount in efficient and reliable detection of microorganisms. We performed a 1-year prospective multicentre study in adult emergency departments of three French university hospitals comparing two methods for BCs: a unique blood culture (UBC) collecting a large volume of blood (40 mL) and the standard method of multiple blood cultures (MBC). The performances of both methods for bacterial contamination and efficient microbial detection were compared, each patient serving as his own control. Amongst the 2314 patients included, three hundred were positive for pathogens (n=245) or contaminants (n=55). Out of the 245 patients, 11 were positive for pathogens by UBC but negative by MBC and seven negative by UBC but positive by MBC (p 0.480). In the subgroup of 137 patients with only two BCs, UBC was superior to MBC (p 0.044). Seven and 17 patients had contaminated BCs by UBC and MBC only, respectively (p 0.062). Considering the sums of pathogens missed and contaminants, UBC significantly outperformed MBC (p 0.045). Considering the complete picture of cost savings, efficient detection of microorganisms and decrease in contaminations, UBC offers an interesting alternative to MBC.

[Reliability of pulsatile saturometry in patients with shock. Digital standard sensors are not reliable for facial measurement!]. / Fiabilité de la saturométrie pulsée chez les patients en état de choc. Les capteurs digitaux standard ne sont pas fiables sur les sites faciaux !

INTRODUCTION: Non-invasive monitoring of oxygen saturation by pulse oxymetry (SpO(2)) is sometimes perturbed on fingers during shock states. Other sites are possible (toes, forehead, nose, ear). Self-adhesive standard digital sensors are commonly used off-label in these sites. We have assessed their reliability for all of these sites. METHODS: We have studied patients presenting a stabilized shock state and receiving vasoconstrictive catecholamines. When an arterial blood gas was ordered, six SpO(2) were measured quasi-simultaneously (self-adhesive standard sensors): right and left index, toe, forehead, nose and ear. SpO(2) at "finger", "toe", "forehead", "nose" and "ear" were compared to the arterial oxygen saturation (SaO(2)) by using the Bland and Altman method. The plethysmographic curve was assessed as "correct" or "unsatisfactory". RESULTS: Hundred and ten patients were included (63 ± 15 years, SAPSII 46 ± 16, catecholamines: 0.6 ± 0.5 µg/kg/min). Plethysmographic curves are more often of "correct" quality for fingers (90%) than for the other locations (50 to 70%). Bias are low for all the locations (-0.1 to +1.5%). Limits of agreement are around ±5% for fingers and toes, but as high as ±15% for the face locations. When the analysis is restricted to plethysmographic curves of "good" quality, the limits of agreement are unchanged for fingers and toes, but improved (between ±5 to ±10%) for face locations. CONCLUSION: In patients with a shock receiving vasoconstrictive catecholamines, the reliability of SpO(2) measurements with standard sensors appears better for fingers than for toes and face locations. These standard sensors should be discouraged for facial measurement because of their low reliability, even when the plethysmographic curve seems correct. Sensors specifically designed for each facial site exist, and their reliability should be estimated in patients receiving vasoconstrictive catecholamines.

Ventilation during total intravenous anaesthesia with ketamine.

Total intravenous anaesthesia with ketamine (TIVAK) is widely used throughout the world especially in precarious conditions. Although ketamine is usually considered to provide good respiratory function and may be used with spontaneous ventilation, recent studies have shown that desaturations may occur. Seventy-six adults and 64 children scheduled for peripheral surgery were randomly allocated to breathe spontaneously room air or 40% oxygen during TIVAK. Pulse oximetry was continuously assessed during anaesthesia and recovery. Desaturation (SpO2 < 92%) occurred immediately after induction in 20 adults breathing air and in only three adults breathing oxygen (P < 0.05). Respiratory abnormalities were sufficiently severe to warrant tracheal intubation in two patients. Desaturations were not observed during the recovery period. Very similar results were observed in children although desaturations observed after induction in paediatric patients breathing room air were less frequent than in adults occurring in only nine patients. These desaturations were also less severe and never required tracheal intubation. The high incidence of arterial desaturation observed immediately after induction of anaesthesia with intravenous ketamine should prompt anaesthetists to provide oxygen in every adult patient at least for the first 15 min. The large decrease in SpO2 sometimes observed requires that trained personnel be present and that equipment for tracheal intubation be available.