Relationship between ANI and qNOX and between MAC and qCON during outpatient laparoscopic cholecystectomy using remifentanil and desflurane without muscle relaxants: a prospective observational preliminary study.

This study was designed to investigate qCON and qNOX variations during outpatient laparoscopic cholecystectomy using remifentanil and desflurane without muscle relaxants and compare these indices with ANI and MAC. Adult patients undergoing outpatient laparoscopic cholecystectomy were included in this prospective observational study. Maintenance of anesthesia was performed using remifentanil targeted to ANI 50-80 and desflurane targeted to MAC 0.8-1.2 without muscle relaxants. The ANI, qCON and qNOX and desflurane MAC values were collected at different time-points and analyzed using repeated measures ANOVA. The relationship between ANI and qNOX and between qCON and MAC were analyzed by linear regression. The ANI was comprised between 50 and 80 during maintenance of anesthesia. Higher values of qNOX and qCON were observed at induction and extubation than during all other time-points where they were comprised between 40 and 60. A poor but significant negative linear relationship (r2 = 0.07, p < 0.001) was observed between ANI and qNOX. There also was a negative linear relationship between qCON and MAC (r2 = 0.48, p < 0.001) and between qNOX and remifentanil infusion rate (r2 = 0.13, p < 0.001). The linear mixed-effect regression correlation (r2) was 0.65 for ANI-qNOX and 0.96 for qCON-MAC. The qCON and qNOX monitoring seems informative during general anesthesia using desflurane and remifentanil without muscle relaxants in patients undergoing ambulatory laparoscopic cholecystectomy. While qCON correlated with MAC, the correlation of overall qCON and ANI was poor but significant. Additionally, the qNOX weakly correlated with the remifentanil infusion rate. This observational study suggests that the proposed ranges of 40-60 for both indexes may correspond to adequate levels of hypnosis and analgesia during general anesthesia, although this should be confirmed by further research.

ANI and BIS variations in supine and prone position during closed-tracheal suction in sedated and myorelaxed ICU patients with severe COVID-19: A retrospective study.

The purpose of this study was to assess Analgesia/Nociception Index (ANI) and bispectral index (BIS) variations in supine and prone position during closed-tracheal suction in intensive care unit (ICU) patients with severe COVID-19 pneumonia requiring myorelaxation and prone positioning. We retrospectively reviewed the data of 15 patients hospitalized in ICU for severe COVID-19 pneumonia requiring sedation, myorelaxation and prone positioning. The BIS, instant ANI (ANIi), mean ANI (ANIm), heart rate (HR), systolic blood pressure (SBP) and SpO2 were retrieved in supine and prone position 1 min before tracheal suction then every minute from the beginning of tracheal suction during 4 min and compared using ANOVA for repeated measures (p < 0.05 considered as statistically significant). Both ANIm and ANIi decreased significantly during tracheal suction with no difference between positions, whereas BIS showed no significant variation within time and between groups. The median [Q1-Q3] ANIm value decreased from 87 [68-98] to 79 [63-09] in supine position and from 79 [63-95] to 78 [66-98] in prone position 2 min after the beginning of tracheal suction. The median [Q1-Q3] ANIi value decreased earlier 1 min after the beginning of tracheal suction from 84 [69-98] to 73 [60-90] in supine position and from 84 [60-99] to 71 [51-88] in prone position. Both HR, SBP and SpO2 varied modestly but significantly during tracheal suction with no difference between positions. Monitoring ANI, but not BIS, may be of interest to detect noxious stimuli such as tracheal suction in ICU myorelaxed patients with severe COVID-19 pneumonia requiring prone positioning.

Reliability of gastric suctioning compared with ultrasound assessment of residual gastric volume: a prospective multicentre cohort study.

We aimed to compare the reliability of aspiration via a nasogastric tube with ultrasound for assessment of residual gastric volume. Sixty-one adult patients who were mechanically ventilated and received continuous enteral feeding through a nasogastric tube for > 48 h were included. A first qualitative and quantitative ultrasound examination of the gastric antrum was followed by gastric suctioning, performed by an operator blinded to the result of the ultrasound examination. A second ultrasound examination was performed thereafter, followed by re-injection of the aspirated gastric contents (≤ 250 ml) into the stomach. A third ultrasound assessment was then immediately performed. If the suctioned volume was ≥ 250 ml, 250 mg erythromycin was infused over 30 min. A fourth ultrasound was performed 90 min after the third. Sixty (98%) patients had a qualitatively assessed full stomach at first ultrasound examination vs. 52 (85%) after gastric suctioning (p = 0.016). The calculated gastric volume significantly decreased after gastric suctioning, without a significant decrease in the number of patients with volume ≥ 250 ml. Four of the nine patients with calculated gastric volume ≥ 250 ml had vomiting within the last 24 h (p = 0.013). The antral cross-sectional area significantly decreased between the third and the fourth ultrasound examination (p = 0.015). Erythromycin infusion did not make a significant difference to gastric volume (n = 10). Our results demonstrate that gastric suctioning is not a reliable tool for monitoring residual gastric volume. Gastric ultrasound is a feasible and promising tool for gastric volume monitoring in clinical practice.

Prevalence and factors predictive of full stomach in elective and emergency surgical patients: a prospective cohort study.

Background: This prospective observational study sought to assess the rate of full and empty stomach in elective and emergency patients and to determine the factors associated with full stomach. Methods: Non-premedicated patients were consecutively included between May 2014 and October 2014. Ultrasound examination of the gastric antrum was performed by an operator blinded to the history of the patient. It included measurement of the antral cross-sectional area, performed in the supine position with the head of the bed elevated to 45°, and qualitative assessment of the gastric antrum, performed in both semirecumbent and right lateral decubitus positions. Full stomach was defined by the appearance of any gastric content in both positions (Grade 2). Empty stomach was defined either by empty antrum in both positions (Grade 0) or by empty antrum in the semirecumbent position only (Grade 1) with measured antral area <340 mm2. The combination of Grade 1 and antral area >340 mm2 defined intermediate stomach. Logistic regression analyses were performed for the identification of factors associated with full stomach. Results: Four hundred and forty patients were analysed. The prevalence of full stomach was 5% (95% confidence interval: 2­9) in elective patients and 56% (95% confidence interval: 50­62) in emergency patients (P<0.0001). Obesity, diabetes mellitus, emergency surgery, and preoperative consumption of opiates were independent factors predictive of full stomach. Conclusions: The results suggest that preoperative ultrasound assessment of gastric content should be performed in all emergency patients, and in elective patients with identified predictive factors for full stomach.

Prediction of hemodynamic reactivity using dynamic variations of Analgesia/Nociception Index (∆ANI).

The Analgesia/Nociception Index (ANI), a 0-100 non-invasive index calculated from heart rate variability, reflects the analgesia/nociception balance during general anesthesia. We hypothesized that dynamic variations of ANI (∆ANI) would provide better performance than static values to predict hemodynamic reactivity during desflurane/remifentanil general anesthesia. One hundred and twenty-eight patients undergoing ear-nose-throat or lower limb orthopedic surgery were analyzed in this prospective observational study. The ANI, heart rate and systolic blood pressure were recorded before induction, at skin incision, during procedure and at emergence from general anesthesia. Changes in these variables were recorded after 1 min for ANI (ANI1min) and 5 min for heart rate and systolic blood pressure. The dynamic variation of ANI at the different time points was defined as: ∆ANI = (ANI1min - ANI)/([ANI + ANI1min]/2). Receiver-operating characteristic (ROC) curves were built to evaluate the performance of ANI, ANI1 min and ∆ANI to predict hemodynamic reactivity (increase by more than 20 % in heart rate and/or systolic blood pressure within 5 min). For the prediction of hemodynamic reactivity, better performance was observed with ∆ANI (area under ROC curve (AUC ROC) = 0.90) in comparison to ANI (ROC AUC = 0.50) and ANI1min (ROC AUC = 0.77). A ∆ANI threshold of -19 % predicts hemodynamic reactivity with 85 % [95 % CI 77-91] sensitivity and 85 % [95 % CI 81-89] specificity. Dynamic variations of ANI provide better performance than static values to predict hemodynamic reactivity during desflurane/remifentanil general anesthesia. These findings may be of interest for the individual adaptation of remifentanil doses guided by ∆ANI during general anesthesia, although this remains to be demonstrated.

Effect of acute cigarette smoking on gastric contents in regular smoker volunteers. A prospective randomized cross-over study.

BACKGROUND: The authors sought to assess the effect of acute smoking on gastric contents in regular smoker volunteers. The primary endpoint was the variation in antral area during the 120-min study period after cigarette smoking. METHODS: Regular smoker volunteers were included in this prospective randomized single blind cross-over study. Volunteers attended two separate study sessions: Control and Smoking sessions. The study started with an initial ultrasound measurement of the antral area, immediately followed by a 30-min periods of waiting (Control session) or of two-cigarettes smoking (Smoking session). Ultrasound measurements of the antral area were then performed 30, 60, 90 and 120 min after the initial ultrasonography, allowing for the calculations of the variation rates in antral area during the periods 0-30, 0-60, 0-90 and 0-120 min in both sessions. RESULTS: The variation in antral area during the period 0-120 min was equivalent in both sessions, as the difference in the variation rates between both sessions was -1.2%, with 90% confidence interval of the difference including 0 and lying entirely within the range of equivalence of -10% to 10%. No equivalence was found for the periods 0-30, 0-60 and 0-90 min, because of a non-significant decrease in antral area in the Smoking sessions during these periods. CONCLUSIONS: Preoperative acute smoking did not affect the variation in the gastric volume in regular smoker volunteers during the study period. These results allow for the suggestion that acute preoperative smoking does not probably change the risk of pulmonary aspiration of gastric contents in healthy regular smokers. CLINICAL TRIAL REGISTRATION: NCT 02080598.

Renal haemodynamic response to amino acids infusion in an experimental porcine model of septic shock.

BACKGROUND: Acute kidney injury (AKI) is common in sepsis. Treatments allowing maintenance of renal blood flow (RBF) could help to prevent AKI associated with renal hypoperfusion. Amino acids (AA) have been associated with an increase of RBF and glomerular filtration rate (GFR) in several species. The aim of this study was to evaluate the effects of an AA infusion on RBF and GFR in a porcine model of septic shock. METHODS: A total of 17 piglets were randomly assigned into three groups: Sham (Sham, n = 5), sepsis without AA (S-NAA, n = 6), sepsis treated with AA (S-AA, n = 6). Piglets preparation included the placement of ultrasonic transit time flow probes around left renal artery for continuous RBF measurement; ureteral catheters for GFR and urine output evaluation; pulmonary artery catheter for cardiac output (CO) and pulmonary arterial pressure measurements. Mean arterial pressure (MAP) and renal vascular resistance (RVR) were also determined. Septic shock was induced with a live Pseudomonas aeruginosa infusion. Crystalloids, colloids and epinephrine infusion were used to maintain and restore MAP > 60 mmHg and CO > 80% from baseline. RESULTS: Renal haemodynamic did not change significantly in the Sham group, whereas RBF increased slightly in the S-NAA group. Conversely, a significant increase in RVR and a decrease in RBF and GFR were observed in the S-AA group. AA infusion was associated with a higher requirement of epinephrine [340.0 (141.2; 542.5) mg vs. 32.5 (3.8; 65.0) mg in the S-NAA group P = 0.044]. CONCLUSION: An infusion of amino acids impaired renal haemodynamics in this experimental model of septic shock.

Ultrasound-guided intermediate cervical plexus block for carotid endarterectomy using a new anterior approach: a two-centre prospective observational study.

The aim of this prospective, double-centre, observational study performed in 116 patients was to describe a new anterior approach of ultrasound-guided intermediate cervical plexus block for carotid endarterectomy. The median (IQR [range]) volume of ropivacaine 0.5% administered was 30 (25-30 [20-45]) ml. Supplemental local anaesthesia (infiltration and topical) was needed in 66 (57%) patients. Overall, 41 (35%) patients needed additional sedation (18 midazolam; 23 remifentanil). There was no intra-operative complication or systemic toxicity of ropivacaine. One regional anaesthesia procedure was converted to general anaesthesia because of patient agitation. Adverse effects were of short duration and did not affect surgery. Satisfaction scores were high for 92 (79%) patients (63 satisfied; 29 very satisfied) and 104 (90%) surgeons (51 satisfied; 53 very satisfied). This study shows that the ultrasound-guided intermediate cervical plexus block using an anterior approach is feasible and provides similar results to other regional techniques during carotid endarterectomy.

Neurotoxicity of intrathecal 6% hydroxyethyl starch 130/0.4 injection in a rat model.

Epidural blood patch is the gold standard treatment for post-dural puncture headache, although hydroxyethyl starch may be a useful alternative to blood if the latter is contraindicated. The aim of this experimental study was to assess whether hydroxyethyl starch given via an indwelling intrathecal catheter resulted in clinical or histopathological changes suggestive of neurotoxicity. The study was conducted in rats that were randomly allocated to receive three 10-µl injections on consecutive days of either saline or hydroxyethyl starch administered via the intrathecal catheter. Eight rats were given injections of saline 0.9% and 11 were given 6% hydroxyethyl starch 130/0.4 derived from thin boiling waxy corn starch in 0.9% sodium chloride (Voluven). Daily clinical evaluation, activity measured by actimetry and neuropathological analysis of the spinal cord were subsequently performed to assess for signs of neurotoxicity. No clinical or actimetric changes were observed in either group following intrathecal saline or hydroxyethyl starch administration. Histopathological examination showed non-specific changes with no differences between the two groups. This experimental study in the rat suggests that repeated intrathecal injection of hydroxyethyl starch is not associated with neurotoxicity.

Prediction of immediate postoperative pain using the analgesia/nociception index: a prospective observational study.

BACKGROUND: The analgesia/nociception index (ANI) is derived from heart rate variability, ranging from 0 (maximal nociception) to 100 (maximal analgesia), to reflect the analgesia/nociception balance during general anaesthesia. This should be correlated with immediate postoperative pain in the post-anaesthesia care unit (PACU). The aim of this study was to evaluate the performance of ANI measured at arousal from general anaesthesia to predict immediate postoperative pain on arrival in PACU. METHODS: Two hundred patients undergoing ear, nose, and throat or lower limb orthopaedic surgery with general anaesthesia using an inhalational agent and remifentanil were included in this prospective observational study. The ANI was measured immediately before tracheal extubation and pain intensity was assessed within 10 min of arrival in PACU using a 0-10 numerical rating scale (NRS). The relationship between ANI and NRS was assessed using linear regression. A receiver-operating characteristic (ROC) curve was used to evaluate the performance of ANI to predict NRS>3. RESULTS: A negative linear relationship was observed between ANI immediately before extubation and NRS on arrival in PACU. Using a threshold of <50, the sensitivity and specificity of ANI to discriminate between patients with NRS≤3 and NRS>3 were both 86% with 92% negative predictive value, corresponding to an area under the ROC curve of 0.89. CONCLUSIONS: The measurement of ANI immediately before extubation after inhalation-remifentanil anaesthesia was significantly associated with pain intensity on arrival in PACU. The performance of ANI for the prediction of immediate postoperative pain is good and may assist physicians in optimizing acute pain management. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT01796249.

Resuscitation with lipid, epinephrine, or both in levobupivacaine-induced cardiac toxicity in newborn piglets.

BACKGROUND: The optimal dosing regimens of lipid emulsion, epinephrine, or both are not yet determined in neonates in cases of local anaesthetic systemic toxicity (LAST). METHODS: Newborn piglets received levobupivacaine until cardiovascular collapse occurred. Standard cardiopulmonary resuscitation was started and electrocardiogram (ECG) was monitored for ventricular tachycardia, fibrillation, or QRS prolongation. Piglets were then randomly allocated to four groups: control (saline), Intralipid(®) alone, epinephrine alone, or a combination of Intralipd plus epinephrine. Resuscitation continued for 30 min or until there was a return of spontaneous circulation (ROSC) accompanied by a mean arterial pressure at or superior to the baseline pressure and normal sinus rhythm for a period of 30 min. RESULTS: ROSC was achieved in only one of the control piglets compared with most of the treated piglets. Mortality was not significantly different between the three treatment groups, but was significantly lower in all the treatment groups compared with control. The number of ECG abnormalities was zero in the Intralipid only group, but 14 and 17, respectively, in the epinephrine and epinephrine plus lipid groups (P<0.05). CONCLUSIONS: Lipid emulsion with or without epinephrine, or epinephrine alone were equally effective in achieving a return to spontaneous circulation in this model of LAST. Epinephrine alone or in combination with lipid was associated with an increased number of ECG abnormalities compared with lipid emulsion alone.

Prospective observational study of the non-invasive assessment of immediate postoperative pain using the analgesia/nociception index (ANI).

BACKGROUND: The analgesia/nociception index (ANI), a 0-100 non-invasive index calculated from heart rate variability, reflects the analgesia/nociception balance during general anaesthesia. The aim of this study was to evaluate the ANI in the assessment of immediate postoperative pain in adult patients undergoing general anaesthesia. METHODS: Two-hundred patients undergoing scheduled surgery or endoscopy with general anaesthesia were included in this prospective observational study. Pain intensity was assessed using a 0-10 numerical rating scale (NRS) after arousal from general anaesthesia. Receiver-operating characteristic (ROC) curves were built to assess the performance of ANI to detect patients with NRS>3 and NRS ≥ 7 on arrival in the postoperative care unit. RESULTS: A negative linear relationship was observed between ANI and NRS (ANI=-5.2 × NRS+77.9, r(2)=0.41, P<0.05). At the threshold of 57, the sensitivity and specificity of ANI to detect patients with NRS>3 were 78 and 80%, respectively, with a negative predictive value of 88%, corresponding to an area under the ROC curve (AUC) of 0.86. At the threshold of 48, the sensitivity and specificity of ANI to detect NRS ≥ 7 were 92 and 82%, respectively, with a negative predictive value of 99%, corresponding to a ROC curve AUC of 0.91. CONCLUSIONS: A measurement of ANI during the immediate postoperative period is significantly correlated with pain intensity. The measurement of ANI appears to be a simple and non-invasive method to assess immediate postoperative analgesia.

Immediate allergic cross-reactivity to levobupivacaine and ropivacaine.

Allergic reactions to amide local anaesthetic agents are rare. We report the case of a 74-year-old man who suffered anaphylaxis, presenting with cardiovascular collapse, immediately after receiving regional anaesthesia on two separate occasions, the first involving the use of levobupivacaine and the second using ropivacaine. Skin testing revealed positive reactions to both levobupivacaine and ropivacaine, and negative reactions to articaine and lidocaine. Severe allergic reactions can be caused by the amide local anaesthetic drugs, levobupivacaine and ropivacaine.

Residents and ICU nurses get reliable static and dynamic haemodynamic assessments with aortic oesophageal Doppler.

BACKGROUND: Aortic oesophageal Doppler (ODM) allows continuous non-invasive haemodynamic monitoring. We tested to confirm if residents and nurses were able to reposition oesophageal probe (OP), obtain aortic blood flow of good quality and so perform reliable static and dynamic haemodynamic assessments. METHODS: Prospective observational study assessing ODM measurements were obtained by six residents and three nurses after they have participated in training. Measured (aortic diameter) and calculated haemodynamic data [indexed stroke volume (SVI), cardiac index] were directly obtained from ODM, after residents and nurses repositioned the OP. In a second group of patients, we tested the ability of residents and nurses to detect rapid haemodynamic changes after a passive leg raising. SVI comparison was the primary end point. Statistical analysis was performed using the method of Bland and Altman. RESULTS: Sixty-six haemodynamic measurements were performed on 42 patients. Mean bias for SVI between the skilled physician and residents, and between the skilled physician and nurses were -0.9 ± 5.2 ml/m(2) (P = 0.15), with a percentage error of 31%, and 0.9 ± 5.1 ml/m(2) (P = 0.14), with a percentage error of 33%, respectively. There was an excellent correlation for SVI between the physician and residents (r = 0.9; P < 0.0001) and between the physician and nurses (r = 0.9; P < 0.0001). Induced changes in SVI measured by residents and nurses strongly followed those of our skilled physician. CONCLUSION: Residents and nurses get reliable static and dynamic haemodynamic assessments with ODM compared to our skilled physician.

A multicentre observational study of intra-operative ventilatory management during general anaesthesia: tidal volumes and relation to body weight.

We conducted an observational prospective multicenter study to describe the practices of mechanical ventilation, to determine the incidence of use of large intra-operative tidal volumes (≥10 ml.kg(-1) of ideal body weight) and to identify patient factors associated with this practice. Of the 2960 patients studied in 97 anaesthesia units from 49 hospitals, volume controlled mode was the most commonly used (85%). The mean (SD) tidal volume was 533 (82) ml; 7.7 (1.3) ml.kg(-1) (actual weight) and 8.8 (1.4) ml.kg(-1) (ideal body weight)). The lungs of 381 (18%) patients were ventilated with a tidal volume>10 ml.kg(-1) ideal body weight. Being female (OR 5.58 (95% CI 4.20-7.43)) and by logistic regression, underweight (OR 0.06 (95% CI 0.01-0.45)), overweight (OR 1.98 (95% CI 1.49-2.65)), obese (OR 5.02 (95% CI 3.51-7.16)), severely obese (OR 10.12 (95% CI 5.79-17.68)) and morbidly obese (OR 14.49 (95% CI 6.99-30.03)) were the significant (p ≤ 0.005) independent factors for the use of large tidal volumes during anaesthesia.

ED50 and ED95 of intrathecal levobupivacaine with opioids for Caesarean delivery.

BACKGROUND: This prospective randomized double-blind dose-response study aimed to determine the ED50 and ED95 of intrathecal levobupivacaine combined with morphine and sufentanil for elective Caesarean delivery. METHODS: Parturients undergoing elective Caesarean delivery were included and allocated to five levobupivacaine dose groups (6, 8, 10, 12, or 14 mg). Combined spinal-epidural (CSE) anaesthesia was performed, allowing intrathecal administration of the allocated dose of levobupivacaine with intrathecal morphine 100 µg and intrathecal sufentanil 2.5 µg, and insertion of epidural catheter for completing anaesthesia in the case of failure. The dose was considered as successful if a bilateral T6 sensory block to pinprick occurred in 15 min and if no epidural supplement was required during surgery. A probit regression analysis was performed to calculate the ED50 and ED95 of intrathecal levobupivacaine for Caesarean delivery. RESULTS: Eighty-five parturients were included. A block to T6 sensory level was reached in 15 min for most of the patients. The ED50 and ED95 of levobupivacaine were 6.2 mg (95% CI: 2.6-7.6) and 12.9 mg (11.1-17.9), respectively. Haemodynamic stability and the rate of nausea and vomiting were similar among groups. Greater doses of levobupivacaine were associated with increased motor block duration. CONCLUSIONS: When combined with intrathecal sufentanil 2.5 µg and intrathecal morphine 100 µg, the ED95 of intrathecal levobupivacaine is 12.9 mg for Caesarean delivery. If doses of levobupivacaine less than the ED95, particularly near the ED50, are used, these doses should be administered under a CSE technique.

Impact of flow and temperature on non-dyspnoeic dogs' tolerance undergoing high-flow oxygen therapy.

OBJECTIVES: To prospectively describe the impact of gas flow rate and temperature on dog's tolerance of high-flow nasal oxygen therapy during recovery from anaesthesia, hypothesizing that higher flow rates and temperatures will decrease tolerance. MATERIALS AND METHODS: Twelve non-dyspnoeic client-owned dogs recovering from general anaesthesia were included in this study. After extubation, a nasal cannula was positioned and high-flow nasal oxygen therapy was initiated. Two flow rates (two or four time the theoretical minute ventilation: HF2 and HF4), each of them combined with two temperatures (31 and 37°C: T31 and T37), were randomly applied (four conditions per dog). For each condition, cardiovascular and respiratory parameters (heart rate, respiratory rate, systolic arterial blood pressure and pulse oximeter oxygen saturation), sedation score and tolerance score were recorded at initiation (T0 ) and after 10 minutes of accommodation (T10 ). RESULTS: Sedation scores were not significantly different between the four conditions. Cardiovascular and respiratory parameters were not significantly different between any condition at both T0 and T10 . Tolerance scores were good and not significantly different between any flow rate or temperature (HF2-T31: 4 (2-4), HF4-T31: 4 (2-4), HF2-T37: 4 (2-4), HF4-T37: 4 (1-4)). CLINICAL SIGNIFICANCE: The gas flow rates and temperatures studied have no impact on tolerance during the recovery period of non-dyspnoeic dogs, and high-flow nasal cannula is well tolerated. Further studies are required to confirm these results in dyspnoeic dogs.

Study of prone positioning to reduce ventilator-associated pneumonia in hypoxaemic patients.

The aim of the present study was to examine whether prone positioning (PP) affects ventilator associated-pneumonia (VAP) and mortality in patients with acute lung injury/adult respiratory distress syndrome. 2,409 prospectively included patients were admitted over 9 yrs (2000-2008) to 12 French intensive care units (ICUs) (OUTCOMEREA). The patients required invasive mechanical ventilation (MV) and had arterial oxygen tension/inspiratory oxygen fraction ratios <300 during the first 48 h. Controls were matched to PP patients on the PP propensity score (+/-10%), MV duration longer than that in PP patients before the first turn prone, and centre. VAP incidence was similar in the PP and control groups (24 versus 13 episodes.1,000 patient-days MV(-1) respectively, p = 0.14). After adjustment, PP did not decrease VAP occurrence (HR 1.64 (95% CI 0.70-3.84); p = 0.25) but significantly delayed hospital mortality (HR 0.56 (95% CI 0.39-0.79); p = 0.001), without decreasing 28-day mortality (37% in both groups). Post hoc analyses indicated that PP did not protect against VAP but, when used for >1 day, might decrease mortality and benefit the sickest patients (Simplified Acute Physiology Score >50). In ICU patients with hypoxaemic acute respiratory failure, PP had no effect on the risk of VAP. PP delayed mortality without decreasing 28-day mortality. PP >1 day might decrease mortality, particularly in the sickest patients.

Diagnosis and treatment of spontaneous group A streptococcal peritonitis.

BACKGROUND: Primary group A streptococcal peritonitis (PSAP) is a rare, fulminant and often fatal infection. The clinical manifestations include diffuse peritoneal signs with toxic shock syndrome and sometimes fasciitis. METHODS: Patients with PSAP diagnosed between December 2002 and December 2006 were studied retrospectively, focusing on the initial presentation, diagnosis, treatment and outcome. RESULTS: Six patients were identified (five women and one man). The clinical presentation was heterogeneous. All six patients had diffuse peritonitis, four had toxic shock syndrome on hospital admission and two patients also had fasciitis. All patients were treated surgically, and the final diagnosis was confirmed after operation. There were no deaths, but two patients had aesthetic sequelae owing to necrotizing fasciitis. CONCLUSION: PSAP is a rare condition, often requiring aggressive surgical treatment. Group A streptococcal peritonitis should be suspected in patients with no radiological evidence of a peritoneal portal of entry and no history of ascites.