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1.
Eur Heart J ; 41(21): 1961-1971, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-31670793

RESUMO

AIMS: Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes. METHODS AND RESULTS: We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8-2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5-1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5-10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1-4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5-5.9; P = 0.002). CONCLUSIONS: In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.


Assuntos
Reanimação Cardiopulmonar , Serviços Médicos de Emergência , Parada Cardíaca Extra-Hospitalar , Humanos , Parada Cardíaca Extra-Hospitalar/terapia , Paris/epidemiologia , Sistema de Registros
2.
Notf Rett Med ; 24(4): 406-446, 2021.
Artigo em Alemão | MEDLINE | ID: mdl-34121923

RESUMO

These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

3.
Am J Emerg Med ; 38(7): 1352-1356, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31836349

RESUMO

CONTEXT: In the prehospital setting, early identification of septic shock (SS) with high risk of mortality aims to initiate early treatments and to decide delivery unit (emergency department (ED) or intensive care unit (ICU)). In this context, there is a need for a prognostic measure of severity and death in order to early detect patients with a higher risk of pejorative evolution. In this study, we describe the association between prehospital shock index (SI) and mortality at day 28 of patients with SS initially cared for in the prehospital setting by a mobile intensive care unit (MICU). METHODS: Patients with SS cared for by a MICU between January 2016 and May 2019 were retrospectively analyzed. Using propensity score, the association between SI and mortality was assessed by Odd Ratio (OR) with 95 percent confidence interval [95 CI]. RESULTS: One-hundred and fourteen patients among which 78 males (68%) were analysed. The mean age was 71 ± 14 years old. SS was mainly associated with pulmonary (55%), digestive (20%) or urinary (11%) infection. Overall mortality reached 33% (n = 38) at day 28. Median SI [interquartile range] differed between alive and deceased patients: 0.73 [0.61-1.00] vs 0.80 [0.66-1.10], p < 0.001*). After adjusting for confounding factors, the OR of SI > 0.9 was 1.17 [1.03-1.32]. CONCLUSION: In this study, we report an association between prehospital SI and mortality of patients with prehospital SS. A SI > 0.9 is a readily available tool correlated with increased mortality of patients with SS initially cared for in the prehospital setting.


Assuntos
Pressão Sanguínea , Serviços Médicos de Emergência , Frequência Cardíaca , Unidades de Terapia Intensiva , Choque Séptico/mortalidade , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Doenças do Sistema Digestório , Serviço Hospitalar de Emergência , Feminino , Hidratação , França/epidemiologia , Infecções por HIV/epidemiologia , Humanos , Hospedeiro Imunocomprometido , Masculino , Pessoa de Meia-Idade , Unidades Móveis de Saúde , Neoplasias/epidemiologia , Norepinefrina/uso terapêutico , Razão de Chances , Escores de Disfunção Orgânica , Prognóstico , Pontuação de Propensão , Infecções Respiratórias , Choque Séptico/fisiopatologia , Choque Séptico/terapia , Infecções Urinárias , Vasoconstritores/uso terapêutico
4.
Am J Emerg Med ; 37(1): 56-60, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29709397

RESUMO

OBJECTIVE: Mechanical ventilation can help improve the prognosis of septic shock. While adequate delivery of oxygen to the tissue is crucial, hyperoxemia may be deleterious. Invasive out-of-hospital ventilation is often promptly performed in life-threatening emergencies. We propose to determine whether the arterial oxygen pressure (PaO2) at the intensive care unit (ICU) admission is associated with mortality in patients with septic shock subjected to pre-hospital mechanical ventilation. METHODS: We performed a monocentric retrospective observational study on 77 patients. PaO2 was measured at ICU admission. The primary outcome was mortality at day 28 (D28). RESULTS: Forty-nine (64%) patients were included. The mean PaO2 at ICU admission was 153 ±â€¯77 and 202 ±â€¯82 mm Hg for alive and deceased patients respectively. Mortality concerned 18% of patients for PaO2 < 100, 25% for 100 < PaO2 < 150 and 57% for a PaO2 > 150 mm Hg. PaO2 was significantly associated with mortality at D28 (p = 0.04). Using propensity score analysis including SOFA score, pre-hospital duration, lactate, and prehospital fluid volume expansion, association with mortality at D28 only remained for PaO2 > 150 mm Hg (p = 0.02, OR [CI95] = 1.59 [1.20-2.10]). CONCLUSIONS: In this study, we report a significant association between hyperoxemia at ICU admission and mortality in patients with septic shock subjected to pre-hospital invasive mechanical ventilation. The early adjustment of the PaO2 should be considered for these patients to avoid the toxic effects of hyperoxemia. However, blood gas analysis is hard to get in a prehospital setting. Consequently, alternative and feasible measures are needed, such as pulse oximetry, to improve the management of pre-hospital invasive ventilation.


Assuntos
Serviços Médicos de Emergência , Ventilação não Invasiva , Oximetria/métodos , Choque Séptico/terapia , Adulto , Idoso , Gasometria , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pressão Parcial , Prognóstico , Pontuação de Propensão , Estudos Retrospectivos , Choque Séptico/mortalidade , Choque Séptico/fisiopatologia
5.
Am J Emerg Med ; 37(10): 1860-1863, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30638630

RESUMO

BACKGROUND: Mechanical ventilation can cause deleterious effects on the lung and thus alter patient's prognosis. The aim of this study was to describe the characteristics of prehospital mechanical ventilation in patients with septic shock requiring mechanical ventilation in the prehospital setting. METHODS: Patients with septic shock subjected to pre-hospital intubation and mechanical ventilation by a mobile intensive care unit were consecutively included and retrospectively analysed. Septic shock was defined according to the international sepsis-3 consensus conference. Patient's characteristics, interventions, prehospital ventilatory parameters and outcome were retrieved from medical records. The association between the tidal volume indexed on ideal body weight (VTIBW) and mortality at day 28 was evaluated. RESULTS: Fifty-nine patients were included. Septic shock was mainly associated with pulmonary (64%) infection. Mean pre-hospital VTIBW was 7 ±â€¯1 ml.kg-1 in the overall population. Mortality reached 42%. The AUC of VTIBW was 0.83 [0.72-0.94]. Using logistic regression model including: age, prehospital mean blood pressure, volume infused in the prehospital setting, FiO2 and length of stay in the intensive care unit, the association with mortality remained significant for VTIBW (OR adjusted [CI95] = 4.11 [1.89-10.98]), VTIBW >8 ml·kg-1 (OR adjusted [CI95] = 8.29 [2.35-34.98]) and VTIBW <8 ml·kg-1 (OR adjusted [CI95] = 0.12 [0.03-0.43]). CONCLUSION: In this retrospective study, we observed an association between mortality at day 28 and prehospital VTIBW in pre-hospital mechanically ventilated patients with septic shock. A VTIBW <8 ml·kg-1 was associated with a decrease and a VTIBW >8 ml·kg-1 with an increase in mortality.


Assuntos
Cuidados Críticos/métodos , Serviços Médicos de Emergência/métodos , Respiração Artificial , Choque Séptico/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , França/epidemiologia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prognóstico , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Estudos Retrospectivos , Choque Séptico/diagnóstico , Choque Séptico/mortalidade , Choque Séptico/fisiopatologia , Volume de Ventilação Pulmonar
6.
Am J Emerg Med ; 37(4): 664-671, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30001815

RESUMO

OBJECTIVES: The early identification of septic shock patients at high risk of poor outcome is essential to early initiate optimal treatments and to decide on hospital admission. Biomarkers are often used to evaluate the severity. In prehospital settings, the availability of biomarkers, such as lactate, is restricted. In this context, clinical tools such as skin mottling score (SMS) and capillary refill time (CRT) are more suitable. In this study, we describe prehospital SMS and CRT's ability to predict mortality of patients with septic shock initially cared in the prehospital setting by a mobile intensive care unit. METHODS: Patients with septic shock who received prehospital medical care admitted to the intensive care unit were retrospectively analyzed. RESULTS: Sixty-three patients were included. The origin of sepsis was mainly pulmonary (67%). Overall mortality reached 36%. No significant difference was observed in the duration of prehospital medical care between alive and deceased patients. Mean prehospital value of SMS was 3 ±â€¯2 and mean prehospital value of CRT was 5 ±â€¯1 s. A significant association was found between mortality and prehospital SMS (p = 0.02, OR[CI95] = 1.50 [1.08-2.15]) and prehospital CRT (p = 0.04, OR[CI95] = 1.53 [1.04-2.37]). After adjusting for confounding factors using propensity score, the relative risk of death was 6.58 for SMS > 2 and 2.03 for CRT > 4 s. CONCLUSION: In this study, we report an association between prehospital SMS and CRT, and mortality of patients with septic shock. SMS and CRT are simple tools that could be used to optimize the triage and to decide early intensive care admission.


Assuntos
Cuidados Críticos/métodos , Microcirculação , Choque Séptico/diagnóstico , Choque Séptico/fisiopatologia , Pele/patologia , Idoso , Idoso de 80 Anos ou mais , Serviços Médicos de Emergência , Feminino , França , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Índice de Gravidade de Doença , Choque Séptico/mortalidade , Triagem
7.
Crit Care Med ; 46(6): e523-e529, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29543597

RESUMO

OBJECTIVES: To investigate the magnitude of lactic acidosis in response to cyanide poisoning compared with the secondary response caused by cardiovascular shock. DESIGN: Retrospective case-control observational study. SETTING: University Hospital of Assistance Publique - Hôpitaux de Paris. SUBJECTS: Patients admitted for suspicion of cyanide poisoning or drug overdose. Medical charts provided by Assistance Publique - Hôpitaux de Paris of patients between January 1988 and December 2015. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Twelve cyanide poisoned patients were matched to 48 controls by age, sex, systolic blood pressure, catecholamine administration, and outcome at discharge from ICU. Extracted data included age, sex, vital signs, symptoms, biochemical parameters, toxicological analysis, treatment, and outcome. Non-parametric tests were used. Multivariable analysis was used to adjust for confounders causing hyperlactacidemia. The median blood lactate concentration was significantly greater in the cyanide group (15.6 mmol/L) compared to the control group (4.1 mmol/L; p = 0.0003). Similarly, blood lactate concentration greater than or equal to 8 mmol/l was observed in 83% of the cyanide cases versus 27% of the matched controls. Multivariate analysis conferred hyperlactacidemia as the lone factor which significantly predicted cyanide poisoning at an odds of 73.0 (5.7-936.1). Moreover, blood cyanide level significantly correlated with the increase of blood lactate (p = 0.0033). CONCLUSIONS: This study supports the hypothesis lactic acidosis primarily results from the direct toxicity of cyanide.


Assuntos
Acidose Láctica/induzido quimicamente , Cianetos/intoxicação , Acidose Láctica/etiologia , Adolescente , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Choque Cardiogênico/complicações , Adulto Jovem
9.
Prehosp Emerg Care ; 21(3): 386-389, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28103127

RESUMO

INTRODUCTION: Extracorporeal Cardiopulmonary Resuscitation (ECPR) is now considered for the treatment of refractory cardiac arrest. CASE REPORT: In an urban city like Paris, extraction times of in-hospital ECPR can be long for patients presenting with refractory cardiac arrest. Using the medicalized prehospital system, we developed a possible early prehospital ECPR implementation. This case report is an example of ECPR prehospital implementation in the Louvre Museum. CONCLUSION: Patients eligible for ECPR must be selected according to strict criteria. Further research is necessary to compare prehospital and in-hospital implementation.


Assuntos
Reanimação Cardiopulmonar/métodos , Serviços Médicos de Emergência/métodos , Oxigenação por Membrana Extracorpórea/métodos , Parada Cardíaca Extra-Hospitalar/terapia , Idoso , Evolução Fatal , Humanos , Masculino , Museus , Fatores de Tempo , Transporte de Pacientes
10.
Ann Intern Med ; 165(11): 770-778, 2016 Dec 06.
Artigo em Inglês | MEDLINE | ID: mdl-27618681

RESUMO

BACKGROUND: In patients with out-of-hospital cardiac arrest (OHCA), care requirements can conflict with the need to promptly focus efforts on organ donation in patients who are pronounced dead. OBJECTIVE: To evaluate objective criteria for identifying patients with OHCA with no chance of survival during the first minutes of cardiopulmonary resuscitation to enable prompt orientation toward organ donation. DESIGN: Retrospective assessment using OHCA data from 2 registries and 1 trial. SETTING: France (Paris Sudden Death Expertise Center [SDEC] prospective cohort [2011 to 2014] and PRESENCE multicenter cluster randomized trial [ClinicalTrials.gov: NCT01009606] [2009 to 2011]) and the United States (King County, Washington, prospective cohort [2006 to 2011]). PATIENTS: 1771 patients from the Paris SDEC 1-year cohort (2011 to 2012) and 5192 from the validation cohorts. MEASUREMENTS: Evaluation of 3 objective criteria (OHCA not witnessed by emergency medical services personnel, nonshockable initial cardiac rhythm, and no return of spontaneous circulation before receipt of a third 1-mg dose of epinephrine), survival rate at hospital discharge among patients meeting these criteria, performance of the criteria, and number of patients eligible for organ donation. RESULTS: In the Paris SDEC 1-year cohort, the survival rate among the 772 patients with OHCA who met the objective criteria was 0% (95% CI, 0.0% to 0.5%), with a specificity of 100% (CI, 97% to 100%) and a positive predictive value of 100% (CI, 99% to 100%). These results were verified in the validation cohorts. Ninety-five (12%) patients in the Paris SDEC 1-year cohort may have been eligible for organ donation. LIMITATION: Several patients had unknown outcomes. CONCLUSION: Three objective criteria enable the early identification of patients with OHCA with essentially no chance of survival and may help in decision making about the organ donation process. PRIMARY FUNDING SOURCE: French Ministry of Health.


Assuntos
Parada Cardíaca Extra-Hospitalar/diagnóstico , Parada Cardíaca Extra-Hospitalar/mortalidade , Obtenção de Tecidos e Órgãos , Idoso , Tomada de Decisão Clínica , Diagnóstico Precoce , Feminino , França/epidemiologia , Humanos , Masculino , Estudos Retrospectivos , Estados Unidos/epidemiologia
11.
Circulation ; 132(3): 182-93, 2015 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-26092673

RESUMO

BACKGROUND: Targeted temperature management is recommended after out-of-hospital cardiac arrest. Whether advanced internal cooling is superior to basic external cooling remains unknown. The aim of this multicenter, controlled trial was to evaluate the benefit of endovascular versus basic surface cooling. METHODS AND RESULTS: Inclusion criteria were the following: age of 18 to 79 years, out-of-hospital cardiac arrest related to a presumed cardiac cause, time to return of spontaneous circulation <60 minutes, delay between return of spontaneous circulation and inclusion <240 minutes, and unconscious patient after return of spontaneous circulation and before the start of cooling. Exclusion criteria were terminal disease, pregnancy, known coagulopathy, uncontrolled bleeding, temperature on admission <30°C, in-hospital cardiac arrest, immediate need for extracorporeal life support or hemodialysis. Patients were randomized between 2 cooling strategies: endovascular femoral devices (Icy catheter, Coolgard, Zoll, formerly Alsius; n=203) or basic external cooling using fans, a homemade tent, and ice packs (n=197). The primary end point, that is, favorable outcome evaluated by survival without major neurological damage (Cerebral Performance Categories 1-2) at day 28, was not significantly different between groups (odds ratio, 1.41; 95% confidence interval, 0.93-2.16; P=0.107). Improvement in favorable outcome at day 90 in favor of the endovascular group did not reach significance (odds ratio, 1.51; 95% confidence interval, 0.96-2.35; P=0.07). Time to target temperature (33°C) was significantly shorter and target hypothermia was more strictly maintained in the endovascular than in the surface group (P<0.001). Minor side effects directly related to the cooling method were observed more frequently in the endovascular group (P=0.009). CONCLUSION: Despite better hypothermia induction and maintenance, endovascular cooling was not significantly superior to basic external cooling in terms of favorable outcome. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00392639.


Assuntos
Temperatura Corporal , Gerenciamento Clínico , Procedimentos Endovasculares/métodos , Hipotermia Induzida/métodos , Parada Cardíaca Extra-Hospitalar/terapia , Idoso , Procedimentos Endovasculares/mortalidade , Feminino , Seguimentos , Humanos , Hipotermia Induzida/mortalidade , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/diagnóstico , Parada Cardíaca Extra-Hospitalar/mortalidade , Estudos Prospectivos , Método Simples-Cego , Taxa de Sobrevida/tendências
12.
Crit Care ; 20: 85, 2016 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-27039082

RESUMO

On Friday November 13th at 9:20 pm, three kamikaze bombs went off around the Stade de France a stadium in Saint-Denis just outside Paris, 4 different shootings took place and bombings in Paris and hundreds of people were held hostage in a theater.This multi-site terrorist attack was the first of this magnitude in France. Drawing the lessons of these attacks and those which occurred in other countries from a health perspective is essential to continuously adapt and improve the French response to possible future attacks. Several issues would need to be further explored: Management of uncertainties: When to trigger the plans: after the 1st attack, the 2nd? When do attacks end and when to release mobilized resources? Management of victims: How to ensure that all victims are secured or taken care of? How to provide assistance when attacks are ongoing? Management of teams: Proper follow-up of persons involved in the response: health professionals, police and firemen, emergency call centers but also civil servants within administration that contributed to the response. Communication: Reactivity of all is a key element to secure appropriate resource is mobilized for the response. All actors have to be able to communicate quickly in a secured way.


Assuntos
Atenção à Saúde/organização & administração , Serviços Médicos de Emergência/métodos , Terrorismo/tendências , Atenção à Saúde/métodos , Planejamento em Desastres/organização & administração , Planejamento em Desastres/normas , Serviços Médicos de Emergência/organização & administração , Serviços Médicos de Emergência/estatística & dados numéricos , Explosões/estatística & dados numéricos , Humanos , Paris , Terrorismo/psicologia , Terrorismo/estatística & dados numéricos
13.
Rev Infirm ; 65(225): 18-21, 2016 Nov.
Artigo em Francês | MEDLINE | ID: mdl-27968964

RESUMO

In France, there are 40 000 sudden deaths each year and the cardiac arrest survival rate is less than 10%. The arrival of extracorporeal cardio pulmonary resuscitation (ECPR) offers hope in the event of refractory cardiac arrest in prehospital care. Extending ECPR programmes requires more scientific evidence, training and an evolution of the role of paramedics.


Assuntos
Reanimação Cardiopulmonar/enfermagem , Parada Cardíaca/enfermagem , Papel do Profissional de Enfermagem , Humanos
14.
Crit Care Med ; 43(10): e420-30, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26110489

RESUMO

OBJECTIVES: Total liquid ventilation provides ultrafast and potently neuro- and cardioprotective cooling after shockable cardiac arrest and myocardial infarction in animals. Our goal was to decipher the effect of hypothermic total liquid ventilation on the systemic and cerebral response to asphyxial cardiac arrest using an original pressure- and volume-controlled ventilation strategy in rabbits. DESIGN: Randomized animal study. SETTING: Academic research laboratory. SUBJECTS: New Zealand Rabbits. INTERVENTIONS: Thirty-six rabbits were submitted to 13 minutes of asphyxia, leading to cardiac arrest. After resumption of spontaneous circulation, they underwent either normothermic life support (control group, n = 12) or hypothermia induced by either 30 minutes of total liquid ventilation (total liquid ventilation group, n = 12) or IV cold saline (conventional cooling group, n = 12). MEASUREMENTS AND MAIN RESULTS: Ultrafast cooling with total liquid ventilation (32 °C within 5 min in the esophagus) dramatically attenuated the post-cardiac arrest syndrome regarding survival, neurologic dysfunction, and histologic lesions (brain, heart, kidneys, liver, and lungs). Final survival rate achieved 58% versus 0% and 8% in total liquid ventilation, control, and conventional cooling groups (p < 0.05), respectively. This was accompanied by an early preservation of the blood-brain barrier integrity and cerebral hemodynamics as well as reduction in the immediate reactive oxygen species production in the brain, heart, and kidneys after cardiac arrest. Later on, total liquid ventilation also mitigated the systemic inflammatory response through alteration of monocyte chemoattractant protein-1, interleukin-1ß, and interleukin-8 transcripts levels compared with control. In the conventional cooling group, cooling was achieved more slowly (32 °C within 90-120 min in the esophagus), providing none of the above-mentioned systemic or organ protection. CONCLUSIONS: Ultrafast cooling by total liquid ventilation limits the post-cardiac arrest syndrome after asphyxial cardiac arrest in rabbits. This protection involves an early limitation in reactive oxidative species production, blood-brain barrier disruption, and delayed preservation against the systemic inflammatory response.


Assuntos
Encefalopatias/etiologia , Encefalopatias/prevenção & controle , Parada Cardíaca/complicações , Hipotermia Induzida , Ventilação Líquida , Animais , Asfixia/complicações , Barreira Hematoencefálica , Parada Cardíaca/etiologia , Parada Cardíaca/fisiopatologia , Hemodinâmica , Hipotermia Induzida/métodos , Ventilação Líquida/métodos , Masculino , Coelhos , Distribuição Aleatória , Sepse/fisiopatologia
15.
Paediatr Anaesth ; 25(2): 160-6, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24814690

RESUMO

BACKGROUND: Thoracic bioreactance is a noninvasive and continuous method of cardiac output (CO) measurement that is being developed in adult patients. Very little information is available on thoracic bioreactance use in children. OBJECTIVE: The aim of the study was to evaluate the ability of a bioreactance device (NICOM(®) ; Cheetah Medical, Tel Aviv, Israel) to estimate CO and to track changes in CO induced by volume expansion (VE) in children. METHODS: Cardiac output values obtained using the NICOM(®) device (CONICOM ) and measured by trans-thoracic echocardiography (COTTE ) were compared in pediatric neurosurgical patients during the postoperative period. RESULTS: Seventy-three pairs of measurements of CO obtained in 30 children were available for analysis. The bias (lower and upper limits of agreement) between CONICOM and COTTE was -0.11 (-1.4 to 1.2) l·min(-1). The percentage error (PE) was 55%. The precision of the NICOM(®) device was 45%. A significant correlation was observed between the CO values obtained using the two methods (r = 0.89, <0.001). The concordance percentage between changes in COTTE and CON icom induced by VE was 84% following exclusion of patients with changes in CO <15% (n = 5). CONCLUSIONS: The PE observed is too large, and the limits of agreement too wide, to enable us to comment on the equivalence of the two techniques of CO measurements. However, the NICOM(®) device performs well in tracking changes in CO following VE.


Assuntos
Débito Cardíaco/fisiologia , Cardiopatias Congênitas/cirurgia , Monitorização Fisiológica/instrumentação , Monitorização Fisiológica/métodos , Cuidados Pós-Operatórios/métodos , Pré-Escolar , Feminino , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias Congênitas/fisiopatologia , Humanos , Lactente , Masculino , Período Pós-Operatório , Estudos Prospectivos , Reprodutibilidade dos Testes , Termodiluição/instrumentação , Termodiluição/métodos , Ultrassonografia
16.
Rev Prat ; 65(1): 59-61, 63-4, 2015 Jan.
Artigo em Francês | MEDLINE | ID: mdl-25842432

RESUMO

For over 30 years, the French hospital and pre-hospital medical teams are trained in disaster medicine. In fact, they are regularly confronted with the management of multiple casualties in accidents or even terrorist attacks, and more rarely to large-scale disasters. The intervention of physicians of the EMS system (SAMU-SMUR) in the field allows an original healthcare organization: in an advanced medical post, the victims are triaged according to their severity and benefit if needed of initial resuscitation. SAMU medical regulating center then organize their transport and repartition in several hospitals put on alert. To cope with a mass casualty situation, the hospital also has a specific organization, the White Plan. This plan, initiated by the director, assisted by a medico-administrative cell crisis can mobilize all the resources of the institution. Personnel are recalled and the ability of emergency units is increased. Care, less urgent, other patients are postponed. There are many plans for responding to disasters. ORSEC plans of the ministry of Interior articulate with the ORSAN plans of the ministry of Health. This complementarity allows a global mobilization of public services in disasters or exceptional medical situations.


Assuntos
Medicina de Desastres , Acidentes , Medicina de Desastres/organização & administração , Desastres , Emergências , Serviços Médicos de Emergência/organização & administração , França , Implementação de Plano de Saúde/métodos , Humanos , Triagem/métodos , Triagem/organização & administração
17.
Crit Care Med ; 42(8): 1849-61, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24717455

RESUMO

OBJECTIVES: In patients treated with therapeutic hypothermia after out-of-hospital cardiac arrest, two blood gas management strategies are used regarding the PaCO2 target: α-stat or pH-stat. We aimed to compare the effects of these strategies on cerebral blood flow and oxygenation. DESIGN: Prospective observational single-center crossover study. SETTING: ICU of University hospital. PATIENTS: Twenty-one therapeutic hypothermia-treated patients after out-of-hospital cardiac arrest more than 18 years old without history of cerebrovascular disease were included. INTERVENTIONS: Cerebral perfusion and oxygenation variables were compared in α-stat (PaCO2 measured at 37 °C) versus pH-stat (PaCO2 measured at 32-34 °C), both strategies maintaining physiological PaCO2 values: 4.8-5.6 kPa (36-42 torr). MEASUREMENTS AND MAIN RESULTS: Bilateral transcranial middle cerebral artery flow velocities using Doppler and jugular vein oxygen saturation were measured in both strategies 18 hours (14-23 hr) after the return of spontaneous circulation. Pulsatility and resistance indexes and cerebral oxygen extraction were calculated. Data are expressed as median (interquartile range 25-75) in α-stat versus pH-stat. No differences were found in temperature, arterial blood pressure, and oxygenation between α-stat and pH-stat. Significant differences were found in minute ventilation (p = 0.006), temperature-corrected PaCO2 (4.4 kPa [4.1-4.6 kPa] vs. 5.1 kPa [5.0-5.3 kPa], p = 0.0001), and temperature-uncorrected PaCO2 (p = 0.0001). No differences were found in cerebral blood velocities and pulsatility and resistance indexes in the overall population. Significant differences were found in jugular vein oxygen saturation (83.2% [79.2-87.6%] vs. 86.7% [83.2-88.2%], p = 0.009) and cerebral oxygen extraction (15% [11-20%] vs. 12% [10-16%], p = 0.01), respectively. In survivors, diastolic blood velocities were 25 cm/s (19-30 cm/s) versus 29 cm/s (23-35 cm/s) (p = 0.004), pulsatility index was 1.10 (0.97-1.18) versus 0.94 (0.89-1.05) (p = 0.027), jugular vein oxygen saturation was 79.2 (71.1-81.8) versus 83.3% (76.6-87.8) (p = 0.033), respectively. However, similar results were not found in nonsurvivors. CONCLUSIONS: In therapeutic hypothermia-treated patients after out-of-hospital cardiac arrest at physiological PaCO2, α-stat strategy increases jugular vein blood desaturation and cerebral oxygen extraction compared with pH-stat strategy and decreases cerebral blood flow velocities in survivors.


Assuntos
Gasometria/métodos , Encéfalo/irrigação sanguínea , Circulação Cerebrovascular , Hipotermia Induzida , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Parada Cardíaca Extra-Hospitalar/terapia , Velocidade do Fluxo Sanguíneo , Estudos Cross-Over , Feminino , Humanos , Concentração de Íons de Hidrogênio , Unidades de Terapia Intensiva , Veias Jugulares , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio , Estudos Prospectivos
20.
Paediatr Anaesth ; 24(3): 303-8, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24205822

RESUMO

BACKGROUND: Little information is available on the titration of morphine postoperatively in children. This observational study describes the technique in terms of the bolus dose, the number of boluses required, the time to establish analgesia, and side effects noted. METHODS: Morphine was administered if pain score (VAS or FLACC) was >30. Patients weighing less than 45 kg received a 50 µg·kg(-1) bolus of morphine with subsequent boluses of 25 µg kg(-1) as required. Patients weighing over 45 kg received boluses of 2 mg. Pain and Ramsay scores were recorded up to 90 min after the end of the titration and any side effect or complication was noted. Data are presented as the median [interquartile Q1-Q3 range]. RESULTS: Overall, 103 children were studied. The median age was 4.2 years [0.8-12.2 years]. The median weight was 15.5 kg [8.2-35.0 kg]. The protocol was effective for pain control with a significant decrease in pain scores over time. The median pain score (VAS or FLACC) was 70 [50-80] prior to the initial bolus and 0 [0-10] 90 min after the last bolus. Median Ramsay score was 1 [1-2] before the initial bolus administration and 4 [2-4] at 90 min. The median total dose of morphine was 100 [70-140] µg·kg(-1) , and the median number of boluses was 3 [2-5]. Side effects were observed in 17% of cases. No serious complications were observed. CONCLUSIONS: Our study of morphine titration for children shows that our protocol was effective for pain control with a significant decrease in pain scores over time. No serious complications were encountered. More studies on larger cohorts of patients are needed to confirm the efficacy and safety of this protocol.


Assuntos
Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Morfina/administração & dosagem , Morfina/uso terapêutico , Adolescente , Analgésicos Opioides/efeitos adversos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Injeções Intravenosas , Masculino , Morfina/efeitos adversos , Medição da Dor/efeitos dos fármacos , Dor Pós-Operatória/tratamento farmacológico , Náusea e Vômito Pós-Operatórios/prevenção & controle , Sala de Recuperação
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