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An ancillary analysis to the SepsiCoag multicentric prospective observational study on patients entering an intensive care unit with septic shock evaluated the prognostic potential of fibrin generation markers (FGMs) tested at inclusion in the study, on survival at day 30. After centralization of samples, three automated FGMs were compared: D-dimers (DDi), fibrin/fibrinogen degradation products (FDP) and fibrin monomers (FM). FM was the single FGM that was significantly higher in non-surviving patients, area under the receiver-operator characteristic curve (AUCROC ): 0·617, P < 0·0001. Significantly higher International Society on Thrombosis and Haemostasis Disseminated Intravascular Coagulation (ISTH DIC) scores were calculated in non-survivors using each of the three FGMs. A dose-effect relationship was observed between ISTH DIC scores and non-survival, with highest significance obtained using FM as the FGM. An overt DIC diagnosis using the ISTH DIC score calculated using FM was a predictor of non-survival at day 30, independently from overt DIC diagnosis based on scores calculated using FDP or DDi. The AUCROC values testing the ability of the ISTH DIC score to predict non-survival were 0·650, 0·624 and 0·602 using FM, DDi and FDP, respectively, as the FGM. In patients with septic shock, among the commercially-available automated assays, automated FM is the FGM best related with late prognosis.
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Coagulación Intravascular Diseminada , Productos de Degradación de Fibrina-Fibrinógeno/metabolismo , Choque Séptico , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Supervivencia sin Enfermedad , Coagulación Intravascular Diseminada/sangre , Coagulación Intravascular Diseminada/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Choque Séptico/sangre , Choque Séptico/mortalidad , Tasa de SupervivenciaRESUMEN
BACKGROUND: Different modes of death are described in selected populations, but few data report the characteristics of death in a general intensive care unit population. This study analyzed the causes and characteristics of death of critically ill patients and compared anticipated death patients to unexpected death counterparts. METHODS: An observational multicenter cohort study was performed in 96 intensive care units. During 1 yr, each intensive care unit was randomized to participate during a 1-month period. Demographic data, characteristics of organ failures (Sequential Organ Failure Assessment subscore greater than or equal to 3), and organ supports were collected on all patients who died in the intensive care unit. Modes of death were defined as anticipated (after withdrawal or withholding of treatment or brain death) or unexpected (despite engagement of full-level care or sudden refractory cardiac arrest). RESULTS: A total of 698 patients were included during the study period. At the time of death, 84% had one or more organ failures (mainly hemodynamic) and 89% required at least one organ support (mainly mechanical ventilation). Deaths were considered unexpected and anticipated in 225 and 473 cases, respectively. Compared to its anticipated counterpart, unexpected death occurred earlier (1 day vs. 5 days; P< 0.001) and had fewer organ failures (1 [1 to 2] vs. 1 [1 to 3]; P< 0.01) and more organ supports (2 [2 to 3] vs. 1 [1 to 2]; P< 0.01). Withdrawal or withholding of treatments accounted for half of the deaths. CONCLUSIONS: In a general intensive care unit population, the majority of patients present with at least one organ failure at the time of death. Anticipated and unexpected deaths represent two different modes of dying and exhibit profiles reflecting the different pathophysiologic underlying mechanisms.
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Causas de Muerte , Mortalidad Hospitalaria , Unidades de Cuidados Intensivos/estadística & datos numéricos , Insuficiencia Multiorgánica/mortalidad , Anciano , Estudios de Cohortes , Enfermedad Crítica/mortalidad , Femenino , Francia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
INTRODUCTION: Pathophysiology of cardiac arrest corresponds to a whole body ischemia-reperfusion. This phenomenon is usually associated with an oxidative stress in various settings, but few data are available on cardiac arrest in human. The aim of the present study was to evaluate different oxidative stress markers in out-of-hospital cardiac arrest (OHCA) patients treated with therapeutic hypothermia. MATERIALS AND METHODS: We conducted a prospective study assessing oxidative stress markers (thiobarbituric acid reactive species, carbonyls, thiols, glutathione, and glutathione peroxidase) in OHCA patients treated with therapeutic hypothermia. Measurements were performed during the 4 days after admission and compared between good and poor outcome patients according to Cerebral Performance Category. RESULTS: Thirty-four patients were included, 10 good and 24 poor outcomes at 6 months. Thiobarbituric acid reactive species were higher in the poor outcome group on admission and when therapeutic hypothermia was reached. The other markers were not different between groups. No markers seemed modified by the use of therapeutic hypothermia in each group. CONCLUSIONS: After OHCA, good outcome patients exhibit lower oxidative stress markers than poor outcome patients. Thiobarbituric acid reactive species appears to be an early prognostic parameter. Oxidative stress markers seem not mitigated by therapeutic hypothermia.
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Biomarcadores/sangre , Reanimación Cardiopulmonar/métodos , Paro Cardíaco Extrahospitalario/sangre , Estrés Oxidativo , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/terapia , Pronóstico , Estudios Prospectivos , Adulto JovenAsunto(s)
Arterias Bronquiales/diagnóstico por imagen , COVID-19/diagnóstico por imagen , COVID-19/terapia , Angiografía por Tomografía Computarizada , Embolización Terapéutica/métodos , Neumonía Viral/diagnóstico por imagen , Neumonía Viral/terapia , Anciano , Anciano de 80 o más Años , Prueba de COVID-19 , Medios de Contraste , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Estudios Retrospectivos , SARS-CoV-2RESUMEN
Hyperosmolar lactate-based solutions have been used for fluid resuscitation in ICU patients. The positive effects observed with these fluids have been attributed to both lactate metabolism and the hypertonic nature of the solutions. In a recent issue of Critical Care, Duburcq and colleagues studied three types of fluid infused at the same volume in a porcine model of endotoxic shock. The control group was resuscitated with 0.9% NaCl, and the two other groups received either hypertonic sodium-lactate or hypertonic sodium-bicarbonate. The two hypertonic fluids proved to be more effective than 0.9% NaCl for resuscitation in this model. However, some parameters were more effectively corrected by hypertonic sodium-lactate than by hypertonic sodium-bicarbonate, suggesting that lactate metabolism was beneficial in these cases.
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Fluidoterapia , Hemodinámica/efectos de los fármacos , Microcirculación/efectos de los fármacos , Choque Séptico/tratamiento farmacológico , Lactato de Sodio/uso terapéutico , Equilibrio Hidroelectrolítico/efectos de los fármacos , Animales , FemeninoRESUMEN
In a recent issue of Critical Care, 0.5 M sodium lactate infusion for 24 hours was reported to increase cardiac output in patients with acute heart failure. This effect was associated with a concomitant metabolic alkalosis and a negative water balance. Growing data strongly support the role of lactate as a preferential oxidizable substrate to supply energy metabolism leading to improved organ function (heart and brain especially) in ischemic conditions. Due to its sodium/chloride imbalance, this solution prevents hyperchloremic acidosis and limits fluid overload despite the obligatory high sodium load. Sodium lactate solution therefore shows many advantages and appears a very promising means for resuscitation of critically ill patients. Further studies are needed to establish the most appropriate dose and indications for sodium lactate infusion in order to prevent the occurrence of severe hypernatremia and metabolic alkalosis.
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Desequilibrio Ácido-Base/prevención & control , Fluidoterapia/métodos , Insuficiencia Cardíaca/tratamiento farmacológico , Lactato de Sodio/uso terapéutico , Desequilibrio Hidroelectrolítico/inducido químicamente , Desequilibrio Ácido-Base/etiología , Acidosis/etiología , Acidosis/prevención & control , Alcalosis/prevención & control , Biomarcadores , Gasto Cardíaco/efectos de los fármacos , Humanos , Hiperlactatemia/inducido químicamente , Hiperlactatemia/prevención & control , Hipernatremia/inducido químicamente , Hipernatremia/prevención & control , Hipopotasemia/inducido químicamente , Hipopotasemia/prevención & control , Pronóstico , Lactato de Sodio/administración & dosificación , Lactato de Sodio/efectos adversos , Volumen Sistólico/efectos de los fármacos , Equilibrio Hidroelectrolítico/efectos de los fármacos , Desequilibrio Hidroelectrolítico/prevención & controlRESUMEN
INTRODUCTION: Hyperglycemia is a marker of poor prognosis in severe brain injuries. There is currently little data regarding the effects of intensive insulin therapy (IIT) on neurological recovery. METHODS: A sub-group analysis of the randomized-controlled CGAO-REA study (NCT01002482) in surgical intensive care units (ICU) of two university hospitals. Patients with severe brain injury, with an expected ICU length of stay ≥ 48 hours were included. Patients were randomized between a conventional glucose management group (blood glucose target between 5.5 and 9 mmol.L(-1)) and an IIT group (blood glucose target between 4.4 and 6 mmol.L(-1)). The primary outcome was the day-90 neurological outcome evaluated with the Glasgow outcome scale. RESULTS: A total of 188 patients were included in this analysis. In total 98 (52%) patients were randomized in the control group and 90 (48%) in the IIT group. The mean Glasgow coma score at baseline was 7 (± 4). Patients in the IIT group received more insulin (130 (68 to 251) IU versus 74 (13 to 165) IU in the control group, P = 0.01), had a significantly lower morning blood glucose level (5.9 (5.1 to 6.7) mmol.L(-1) versus 6.5 (5.6 to 7.2) mmol.L(-1), P <0.001) in the first 5 days after ICU admission. The IIT group experienced more episodes of hypoglycemia (P < 0.0001). In the IIT group 24 (26.6%) patients had a favorable neurological outcome (good recovery or moderate disability) compared to 31 (31.6%) in the control group (P = 0.4). There were no differences in day-28 mortality. The occurrence of hypoglycemia did not influence the outcome. CONCLUSIONS: In this sub-group analysis of a large multicenter randomized trial, IIT did not appear to alter the day-90 neurological outcome or ICU morbidity in severe brain injured patients or ICU morbidity.
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Glucemia/metabolismo , Lesiones Encefálicas/sangre , Lesiones Encefálicas/diagnóstico , Enfermedades del Sistema Nervioso/sangre , Enfermedades del Sistema Nervioso/diagnóstico , Índice de Severidad de la Enfermedad , Adulto , Anciano , Lesiones Encefálicas/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/etiología , Prohibitinas , Resultado del TratamientoRESUMEN
A 42-year-old woman presented to our emergency department with headache, nausea, and confusion after completing an Ironman triathlon. She performed the race at a slow pace, in hot and dry weather. The first medical examination reported confusion with a Glasgow Coma Scale score of 13. A few minutes later, she presented with seizures. A cerebral computed tomographic (CT) scan showed major cerebral edema. Blood analysis showed severe acute hyponatremia (123 mEq/L) with hypotonicity (255 mEq/L). Her clinical condition quickly worsened, leading to a Glasgow Coma Scale score of 3 with fixed dilated pupils. After intubation and mechanical ventilation, she was transferred to the intensive care unit. A transcranial Doppler ultrasonography (TCD) showed intracranial hypertension signs motivating emergency osmotherapy by infusion of 20% mannitol over 15 minutes. To guide the therapeutics, an intracranial pressure monitoring was inserted, showing a value of 30 mm Hg. A few minutes later, intracranial pressure (ICP) increased to 68 mm Hg with a low cerebral perfusion pressure. Concomitantly, another TCD reported critical flows with poor cerebral perfusion. A second infusion of mannitol led to an ICP lowering and a decrease in pupil size after 10 minutes. During the next hours, the patient stayed stable without further intervention. Sixteen hours later, natremia was normal, mainly due to hyperdiuresis. On day 2, the tracheal tube was removed. A cerebral CT scan showed disappearance of cerebral edema. One month later, the patient had good recovery apart from some residual memory problems. Six months later, she was able to come back to work.
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Edema Encefálico/tratamiento farmacológico , Diuréticos Osmóticos/uso terapéutico , Ejercicio Físico , Hiponatremia/complicaciones , Hipertensión Intracraneal/tratamiento farmacológico , Manitol/uso terapéutico , Adulto , Edema Encefálico/diagnóstico , Edema Encefálico/etiología , Femenino , Humanos , Hipertensión Intracraneal/diagnóstico , Hipertensión Intracraneal/etiología , Tomografía Computarizada por Rayos X , Ultrasonografía Doppler TranscranealRESUMEN
INTRODUCTION: Total knee arthroplasty (TKA) is a procedure associated with risks of electrolyte and kidney function disorders, which are rare but can lead to serious complications if not correctly identified. A routine check-up is very often carried out to assess the seric ionogram and kidney function after TKA, that rarely requires clinical intervention in the event of a disturbance. The aim of this study was to identify perioperative variables that would lead to the creation of a machine learning model predicting the risk of kalaemia disorders and/or acute kidney injury after total knee arthroplasty. HYPOTHESIS: A predictive model could be constructed to estimate the risk of kalaemia disorders and/or acute kidney injury after total knee arthroplasty. MATERIAL AND METHODS: This single-centre retrospective study included 774 total knee arthroplasties (TKA) operated on between January 2020 and March 2023. Twenty-five preoperative variables were incorporated into the machine learning model and filtered by a first algorithm. The most predictive variables selected were used to construct a second algorithm to define the overall risk model for postoperative kalaemia and/or acute kidney injury (K+ A). Two groups were formed of K+ A and non-K+ A patients after TKA. A univariate analysis was performed and the performance of the machine learning model was assessed by the area under the curve representing the sensitivity of the model as a function of 1 - specificity. RESULTS: Of the 774 patients included who had undergone TKA surgery, 46 patients (5.9%) had a postoperative kalaemia disorder requiring correction and 13 patients (1.7%) had acute kidney injury, of whom 5 patients (0.6%) received vascular filling. Eight variables were included in the machine learning predictive model, including body mass index, age, presence of diabetes, operative time, lowest mean arterial pressure, Charlson score, smoking and preoperative glomerular filtration rate. Overall performance was good with an area under the curve of 0.979 [CI95% 0.938-1.02], sensitivity was 90.3% [CI95% 86.2-94.4] and specificity 89.7% [CI95% 85.5-93.8]. The tool developed to assess the risk of impaired kalaemia and/or acute kidney injury after TKA is available on https://arthrorisk.com. CONCLUSION: The risk of kalaemia disturbance and postoperative acute kidney injury after total knee arthroplasty could be predicted by a model that identifies low-risk and high-risk patients based on eight pre- and intraoperative variables. This machine learning tool is available on a web platform accessible for everyone, easy to use and has a high predictive performance. The aim of the model was to better identify and anticipate the complications of dyskalaemia and postoperative acute kidney injury in high-risk patients. Further prospective multicentre series are needed to assess the value of a systematic postoperative biochemical work-up in the absence of risk predicted by the model. LEVEL OF EVIDENCE: IV; retrospective study of case series.
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BACKGROUND: Low-impact laparoscopy (LIL), combining low-pressure insufflation and microlaparoscopy, is a surgical technique that is still not widely used and that has never been evaluated for the management of acute appendicitis. The aim of this study is to assess the feasibility of an LIL protocol, to compare postoperative pain, average length of stay, and in-hospital use of analgesics by patients who underwent appendectomy according to a conventional laparoscopy or an LIL protocol. STUDY DESIGN: Patients presenting with acute uncomplicated appendicitis who were operated on between January 1, 2021, and July 10, 2022, were included in this double-blind, single-center, prospective study. They were preoperatively randomly assigned to a group undergoing conventional laparoscopy, ie with an insufflation pressure of 12 mmHg and conventional instrumentation, and an LIL group, with an insufflation pressure of 7 mmHg and microlaparoscopic instrumentation. RESULTS: Fifty patients were included in this study, 24 in the LIL group and 26 in the conventional group. There were no statistically significant differences between the 2 patient groups, including weight and surgical history. The postoperative complication rate was comparable between the 2 groups (p = 0.81). Pain was reported as significantly lower according to the visual analog scale 2 hours after surgery among the LIL group (p = 0.019). For patients who underwent surgery according to the LIL protocol, the study confirms a statistically significant difference for theoretical and actual length of stay, ie -0.77 days and -0.59 days, respectively (p < 0.001 and p = 0.03). In-hospital use of analgesics was comparable between both groups. CONCLUSIONS: In uncomplicated acute appendicitis, the LIL protocol could reduce postoperative pain and average length of stay compared to conventional laparoscopic appendectomy.
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Apendicitis , Laparoscopía , Humanos , Apendicectomía/efectos adversos , Estudios Prospectivos , Apendicitis/cirugía , Apendicitis/etiología , Tiempo de Internación , Laparoscopía/métodos , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Analgésicos/uso terapéutico , Enfermedad AgudaRESUMEN
RATIONALE: We previously reported outcome-associated decreases in muscle energetic status and mitochondrial dysfunction in septic patients with multiorgan failure. We postulate that survivors have a greater ability to maintain or recover normal mitochondrial functionality. OBJECTIVES: To determine whether mitochondrial biogenesis, the process promoting mitochondrial capacity, is affected in critically ill patients. METHODS: Muscle biopsies were taken from 16 critically ill patients recently admitted to intensive care (average 1-2 d) and from 10 healthy, age-matched patients undergoing elective hip surgery. MEASUREMENTS AND MAIN RESULTS: Survival, mitochondrial morphology, mitochondrial protein content and enzyme activity, mitochondrial biogenesis factor mRNA, microarray analysis, and phosphorylated (energy) metabolites were determined. Ten of 16 critically ill patients survived intensive care. Mitochondrial size increased with worsening outcome, suggestive of swelling. Respiratory protein subunits and transcripts were depleted in critically ill patients and to a greater extent in nonsurvivors. The mRNA content of peroxisome proliferator-activated receptor γ coactivator 1-α (transcriptional coactivator of mitochondrial biogenesis) was only elevated in survivors, as was the mitochondrial oxidative stress protein manganese superoxide dismutase. Eventual survivors demonstrated elevated muscle ATP and a decreased phosphocreatine/ATP ratio. CONCLUSIONS: Eventual survivors responded early to critical illness with mitochondrial biogenesis and antioxidant defense responses. These responses may partially counteract mitochondrial protein depletion, helping to maintain functionality and energetic status. Impaired responses, as suggested in nonsurvivors, could increase susceptibility to mitochondrial damage and cellular energetic failure or impede the ability to recover normal function. Clinical trial registered with clinical trials.gov (NCT00187824).
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Enfermedad Crítica/mortalidad , Mitocondrias Musculares/metabolismo , Insuficiencia Multiorgánica/mortalidad , Músculo Esquelético/metabolismo , Factores de Transcripción/metabolismo , Anciano , Estudios de Casos y Controles , Metabolismo Energético , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mitocondrias Musculares/patología , Enfermedades Mitocondriales/fisiopatología , Proteínas Mitocondriales/metabolismo , Insuficiencia Multiorgánica/metabolismo , Músculo Esquelético/patología , Tasa de Supervivencia , Factores de TiempoRESUMEN
Perioperative ventilation is an important challenge of anaesthesia, especially in obese patients: body mass index is correlated with reduction of the pulmonary volume and they develop significantly more perioperative atelectasis and pulmonary complications. The alveolar recruitment manoeuvre is the most effective technique to reverse atelectasis. However, the clinical benefit on lung function in the perioperative period is not clear. The aim of the present study is to assess the perioperative clinical results of systematic alveolar recruitment manoeuvre associated with protective ventilation in patients undergoing laparoscopic bariatric surgery. It was a single-centre, randomised, double blind, superiority trial: control group with standard protective ventilation and recruitment group with protective ventilation and systematic recruitment manoeuvre. The primary outcome was a composite clinical criterion of pulmonary dysfunction including oxygen saturation, oxygen needs and dyspnoea in recovery room and at day 1. Secondary outcomes were recruitment manoeuvre tolerance, pulmonary and non-pulmonary complications, length of hospital stay and proportion of Intensive Care Unit admission. Two hundred and thirty patients were included: 115 in the recruitment manoeuvre group and 115 in the control group, 2 patients were excluded from the analysis in the control group. Patients in the recruitment manoeuvre group had significantly lower rate of pulmonary dysfunction in the recovery room (73% versus 84% (p = 0.043) and 77% versus 88% at postoperative day 1 (p = 0.043)). No significant differences were found for secondary outcomes. No patient was excluded from the recruitment manoeuvre group for intolerance to the manoeuvre. Recruitment manoeuvre is safe and effective in reducing early pulmonary dysfunction in obese patients undergoing bariatric surgery.
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Cirugía Bariátrica , Atelectasia Pulmonar , Humanos , Pulmón , Obesidad/complicaciones , Obesidad/terapia , Respiración con Presión Positiva , Atelectasia Pulmonar/etiología , Atelectasia Pulmonar/prevención & controlRESUMEN
INTRODUCTION: The present study assessed the opinion of general practitioners (GPs) concerning their relationships with intensivists. METHODS: An anonymous questionnaire was mailed to 7,239 GPs. GPs were asked about their professional activities, postgraduate intensive care unit (ICU) training, the rate of patient admittance to ICUs, and their relationships with intensivists. Relationship assessment was performed by using a graduated visual analogue scale (VAS) ranging from 0 (dissatisfaction) to 100 (satisfaction). A multivariate analysis with stepwise logistic regression was performed to isolate factors explaining dissatisfaction (VAS score, < 25th percentile). RESULTS: Twenty-two percent of the GPs (1,561) responded. The median satisfaction score was 57 of 100 (interquartile (IQ), 35 to 77]. Five independent factors of dissatisfaction were identified: no information provided to GPs at patient admission (odds ratio (OR) = 2.55 (1.71 to 3.80)); poor quality of family reception in the ICU (OR = 2.06 (1.40 to 3.02)); the ICU's family contact person's identity or function or both is unclear (OR = 1.48 (1.03 to 2.12)), lack of family information (OR = 2.02 (2.48 to 2.75)), and lack of discharge report (OR = 3.39 (1.70 to 6.76)). Three independent factors prevent dissatisfaction: age of GPs Asunto(s)
Médicos Generales/psicología
, Unidades de Cuidados Intensivos
, Relaciones Interprofesionales
, Adulto
, Actitud del Personal de Salud
, Femenino
, Francia
, Humanos
, Masculino
, Persona de Mediana Edad
, Análisis Multivariante
, Dimensión del Dolor
, Grupo de Atención al Paciente
, Encuestas y Cuestionarios
, Recursos Humanos
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BACKGROUND AND OBJECTIVE: Evaluation of volaemia is a crucial question for the management of patients during anaesthesia and in the ICU. Numerous methods have been described, but there is as yet no single ideal parameter. Another way to approach this problem is to predict the extent of hypovolaemia. The initial distribution volume of glucose (IDVG) has been shown to predict the development of hypovolaemic hypotension following oesophageal surgery. In this study, we evaluated the use of the IDVG in predicting hypovolemic hypotension after abdominal aortic surgery. METHODS: All patients undergoing elective abdominal aortic surgery had IDVG measured following admission to the ICU. Other haemodynamic parameters, such as heart rate, blood pressure, urine output and central venous pressure, were also collected during the first postoperative day. Patients were divided into two groups depending on the occurrence of hypovolaemic hypotension, indicated by a SBP lower than 90 mmHg rapidly corrected by administration of intravenous fluid boluses. RESULTS: Out of the 27 patients who underwent aortic surgery, 13 developed hypovolaemic hypotension. IDVG was significantly lower in this group when compared with the haemodynamically stable group, that is, 78 (59-122) vs. 120 (63-151) ml kg(-1). This was despite similar haemodynamic parameters between the two groups. The best area under the receiver-operating characteristic curve was obtained for an IDVG value of 91.1 ml kg(-1). CONCLUSION: In this study, IDVG predicts the occurrence of hypovolaemic hypotension after elective abdominal aortic surgery.
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Aneurisma de la Aorta Abdominal/cirugía , Glucemia/análisis , Hipotensión/diagnóstico , Hipovolemia/diagnóstico , Complicaciones Posoperatorias/diagnóstico , Anciano , Humanos , Hipotensión/etiología , Hipovolemia/complicaciones , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Método Simple CiegoRESUMEN
Background Recent literature reports a strong thrombotic tendency in patients hospitalized for a coronavirus disease 2019 (COVID-19) infection. This characteristic is unusual and seems specific to COVID-19 infections, especially in their severe form. Viral infections can trigger acquired thrombophilia, which can then lead to thrombotic complications. We investigate for the presence of acquired thrombophilia, which could participate in this phenomenon, and report its prevalence. We also wonder if these thrombophilias participate in the bad prognosis of severe COVID-19 infections. Methods and Results In 89 consecutive patients hospitalized for COVID-19 infection, we found a 20% prevalence of PS (protein S) deficiency and a high (ie, 72%) prevalence of antiphospholipid antibodies: mainly lupus anticoagulant. The presence of PS deficiency or antiphospholipid antibodies was not linked with a prolonged activated partial thromboplastin time nor with D-dimer, fibrinogen, or CRP (C-reactive protein) concentrations. These coagulation abnormalities are also not linked with thrombotic clinical events occurring during hospitalization nor with mortality. Conclusions We assess a high prevalence of positive tests detecting thrombophilia in COVID-19 infections. However, in our series, these acquired thrombophilias are not correlated with the severity of the disease nor with the occurrence of thrombotic events. Albeit the strong thrombotic tendency in COVID-19 infections, the presence of frequent acquired thrombophilia may be part of the inflammation storm of COVID-19 and should not systematically modify our strategy on prophylactic anticoagulant treatment, which is already revised upwards in this pathological condition. Registration URL: https://www.cliniâcaltrâials.gov; Unique identifier: NCT04335162.
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Síndrome Antifosfolípido/epidemiología , Infecciones por Coronavirus/epidemiología , Neumonía Viral/epidemiología , Deficiencia de Proteína S/epidemiología , Trombosis/epidemiología , Anciano , Anticuerpos Antifosfolípidos/sangre , Síndrome Antifosfolípido/sangre , Síndrome Antifosfolípido/diagnóstico , Biomarcadores/sangre , COVID-19 , Infecciones por Coronavirus/sangre , Infecciones por Coronavirus/diagnóstico , Femenino , Francia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/sangre , Neumonía Viral/diagnóstico , Prevalencia , Pronóstico , Proteína S/análisis , Deficiencia de Proteína S/sangre , Deficiencia de Proteína S/diagnóstico , Factores de Riesgo , Índice de Severidad de la Enfermedad , Trombosis/sangre , Trombosis/diagnósticoRESUMEN
OBJECTIVES: The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic. METHODS: The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions. RESULTS: The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms. CONCLUSION: We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.
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Analgesia/normas , Anestesia/normas , Betacoronavirus , Infecciones por Coronavirus , Control de Infecciones/normas , Pandemias , Neumonía Viral , Adulto , Manejo de la Vía Aérea , Analgesia/efectos adversos , Analgesia/métodos , Anestesia/efectos adversos , Anestesia/métodos , COVID-19 , Prueba de COVID-19 , Niño , Técnicas de Laboratorio Clínico , Comorbilidad , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/prevención & control , Infecciones por Coronavirus/transmisión , Vías Clínicas , Infección Hospitalaria/prevención & control , Infección Hospitalaria/transmisión , Desinfección , Procedimientos Quirúrgicos Electivos , Contaminación de Equipos/prevención & control , Accesibilidad a los Servicios de Salud , Humanos , Control de Infecciones/métodos , Consentimiento Informado , Enfermedades Profesionales/prevención & control , Quirófanos/normas , Pandemias/prevención & control , Aislamiento de Pacientes , Equipo de Protección Personal/provisión & distribución , Neumonía Viral/prevención & control , Neumonía Viral/transmisión , Cuidados Preoperatorios , Comité de Profesionales , Riesgo , SARS-CoV-2 , Evaluación de Síntomas , Precauciones UniversalesRESUMEN
BACKGROUND: Renal transplantation represents the treatment of choice of end-stage kidney disease. Delayed graft function (DGF) remains the most frequent complication after this procedure, reaching more than 30%. Its prevention is essential as it impedes early- and long-term prognosis of transplantation. Numerous pharmacological interventions aiming to prevent ischemia-reperfusion injuries failed to reduce the rate of DGF. We hypothesize that cyclosporine as an early preconditioning procedure in donors would be associated with decreased DGF. METHODS: The Cis-A-rein study is an investigator-initiated, prospective, multicenter, double-blind, randomized, controlled study performed to assess the effects of a donor preconditioning with cyclosporine A on kidney grafts function in transplanted patients. After randomization, a brain dead donor will receive 2.5 mg kg-1 of cyclosporine A or the same volume of 5% glucose solution. The primary objective is to compare the rate of DGF, defined as the need for at least one dialysis session within the 7 days following transplantation, between both groups. The secondary objectives include rate of slow graft function, mild and severe DGF, urine output and serum creatinine during the first week after transplantation, rate of primary graft dysfunction, renal function and mortality at 1 year. The sample size (n = 648) was determined to obtain 80% power to detect a 10% difference for rate of DGF at day 7 between the two groups (30% of the patients in the placebo group and 20% of the patients in the intervention group). DISCUSSION: Delayed graft function is a major issue after renal transplantation, impeding long-term prognosis. Cyclosporine A pretreatment in deceased donors could improve the outcome of patients after renal transplantation. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02907554 Registered on 20 September 2016.
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Ciclosporina/administración & dosificación , Funcionamiento Retardado del Injerto/prevención & control , Inmunosupresores/administración & dosificación , Trasplante de Riñón/métodos , Riñón/efectos de los fármacos , Riñón/cirugía , Donantes de Tejidos , Adolescente , Adulto , Anciano , Ciclosporina/efectos adversos , Funcionamiento Retardado del Injerto/diagnóstico , Funcionamiento Retardado del Injerto/etiología , Funcionamiento Retardado del Injerto/fisiopatología , Método Doble Ciego , Esquema de Medicación , Femenino , Francia , Supervivencia de Injerto/efectos de los fármacos , Humanos , Inmunosupresores/efectos adversos , Riñón/fisiopatología , Trasplante de Riñón/efectos adversos , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
AIMS OF THE STUDY: Most interventional and observational studies include cardiac arrest from cardiac origin. However, an increasing proportion of cardiac arrest results from an extra-cardiac origin, mainly respiratory. The aim of our study was to compare the characteristics and outcome of cardiac arrest patients according to the presumed cardiac or respiratory causes. METHODS: This retrospective multicenter observational study included out-of-hospital cardiac arrest patients from presumed cardiac and respiratory origin treated with therapeutic hypothermia. Demographic data (age, sex, initial rhythm as shockable or non-shockable, durations of no-flow and low-flow), clinical evolution in ICU, lactate and outcome (CPC scale at ICU discharge) were compared between patients according to the presumed cardiac or respiratory origin of the cardiac arrest. RESULTS: Two hundred and fifty-one cardiac arrest patients were included, 156 from presumed cardiac origin (62%) and 95 from presumed respiratory origin (38%). Patients with presumed cardiac cause presented more frequently a shockable rhythm (68% vs. 5%, pâ¯<â¯0.001), received more defibrillations attempts (2 [1-5] vs. 0 [0-0], <0.001) and needed less adrenaline (3â¯mg [0-5] vs. 4â¯mg [2-7], pâ¯=â¯0.01). The arterial lactate concentration on admission was higher in patients with presumed respiratory causes (6.3â¯mmol/L [4.2-9.8] vs. 3.2â¯mmol/L [1.6-5.0], pâ¯<â¯0.001). The proportion of patients presenting a favorable outcome was higher in the population with presumed cardiac causes, compared to its respiratory counterpart (42% vs. 19%, pâ¯<â¯0.001). CONCLUSIONS: Compared to presumed cardiac origin, a worse outcome and a different mode of death are associated with the presumed respiratory origin, resulting from a greater insult preceding cardiac arrest. The presumed cause of cardiac arrest could be integrated in the multimodal prognostication process.
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Reanimación Cardiopulmonar/métodos , Cardiopatías/complicaciones , Paro Cardíaco Extrahospitalario/etiología , Sistema de Registros , Insuficiencia Respiratoria/complicaciones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Francia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
Anaesthesia, Critical Care and Pain Medicine is the journal of the French Society of Anaesthesia and Intensive Care Medicine (Société Francaise d'Anesthésie et de Réanimation), aimed at promoting the French approach to anaesthesiology, critical care and perioperative medicine. Here, the Intensive Care Committee of the French Society of Anaesthesia and Intensive Care Medicine provides an overview of the organisation of the 400 French Intensive Care Units (ICU), which are polyvalent (50%), surgical (20%), or medical (12%). Around 150,000 patients are admitted to these units each year. Law Decrees govern the frame of practices, including architecture, nurse staffing - two nurses for five patients and one nurse-assistant for four patients - and 24/7 medical coverage. The daily cost of ICU hospitalisation is around 1425 , entirely ensured by the National Health System. The clinical practices are variable but guidelines produced by intensivists are invited to adhere to guidelines available and freely accessible. End-of-life practices are framed by a Law Decree (Claeys Léonetti) aiming at protecting patients against stubbornly and unreasonable cares. The biomedical research plays a critical role in the French ICU, and practices are performed under the supervision of the Jardé Law. An Institutional Research Board approval is required for prospective studies. In conclusion, the French ICU practice is surrounded by a legal frame.
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Unidades de Cuidados Intensivos/organización & administración , Cuidados Críticos , Francia , Humanos , Unidades de Cuidados Intensivos/economía , Unidades de Cuidados Intensivos/legislación & jurisprudencia , Unidades de Cuidados Intensivos/estadística & datos numéricos , Admisión del Paciente , Cuidado TerminalRESUMEN
Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term "targeted temperature management" (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de réanimation de langue française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie réanimation [SFAR]) with the participation of the French Emergency Medicine Association (Société française de médecine d'urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe francophone de réanimation et urgences pédiatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association nationale de neuro-anesthésie réanimation française [ANARLF]), and the French Neurovascular Society (Société française neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts' opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.