Management and outcomes of COVID-19 patients admitted in a newly created ICU and an expert ICU, a retrospective observational study.

BACKGROUND: The COVID-19 pandemic abruptly increased the inflow of patients requiring intensive care units (ICU). French health institutions responded by a twofold capacity increase with temporary upgraded beds, supplemental beds in pre-existing ICUs, or newly created units (New-ICU). We aimed to compare outcomes according to admission in expert pre-existing ICUs or in New-ICU. METHODS: This multicenter retrospective observational study was conducted in two 20-bed expert ICUs of a University Hospital (Expert-ICU) and in one 16-bed New-ICU in a private clinic managed respectively by 3 and 2 physicians during daytime and by one physician during the night shift. All consecutive adult patients with COVID-19-related acute hypoxemic respiratory failure admitted after centralized regional management by a dedicated crisis cell were included. The primary outcome was 180-day mortality. Propensity score matching and restricted cubic spline for predicted mortality over time were performed. RESULTS: During the study period, 165 and 176 patients were enrolled in Expert-ICU and New-ICU respectively, 162 (98%) and 157 (89%) patients were analyzed. The unadjusted 180-day mortality was 30.8% in Expert-ICU and 28.7% in New-ICU, (log-rank test, p = 0.7). After propensity score matching, 123 pairs (76 and 78%) of patients were matched, with no significant difference in mortality (32% vs. 32%, OR 1.00 [0.89; 1.12], p = 1). Adjusted predicted mortality decreased over time (p < 0.01) in both Expert-ICU and New-ICU. CONCLUSIONS: In COVID-19 patients with acute hypoxemic respiratory failure, hospitalization in a new ICU was not associated with mortality at day 180.

PCO 2 Gradient Between Inlet and Outlet Blood of Extracorporeal Respiratory Support Is a Reliable Marker of CO 2 Elimination.

Our objective was to assess the relationship between the pre-/post-oxygenator gradient of the partial pressure of carbon dioxide (∆ EC PCO 2 ; dissolved form) and CO 2 elimination under extracorporeal respiratory support. All patients who were treated with veno-venous extracorporeal membrane oxygenation and high-flow extracorporeal CO 2 removal in our intensive care unit over 18 months were included. Pre-/post-oxygenator blood gases were collected every 12 h and CO 2 elimination was calculated for each pair of samples (pre-/post-oxygenator total carbon dioxide content in blood [ ct CO 2 ] × pump flow [extracorporeal pump flow {Q EC }]). The relationship between ∆ EC PCO 2 and CO 2 elimination, as well as the origin of CO 2 removed. Eighteen patients were analyzed (24 oxygenators and 293 datasets). Each additional unit of ∆ EC PCO 2 × Q EC was associated with an increase in CO 2 elimination of 5.2 ml (95% confidence interval [CI], 4.7-5.6 ml; p < 0.001). Each reduction of 1 ml STPD/dl of CO 2 across the oxygenator was associated with a reduction of 0.63 ml STPD/dl (95% CI, 0.60-0.66) of CO 2 combined with water, 0.08 ml STPD/dl (95% CI, 0.07-0.09) of dissolved CO 2 , and 0.29 ml STPD/dl (95% CI, 0.27-0.31) of CO 2 in erythrocytes. The pre-/post-oxygenator PCO 2 gradient under extracorporeal respiratory support is thus linearly associated with CO 2 elimination; however, most of the CO 2 removed comes from combined CO 2 in plasma, generating bicarbonate.

Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial.

Importance: Optimal transfusion strategies in traumatic hemorrhage are unknown. Reports suggest a beneficial effect of 4-factor prothrombin complex concentrate (4F-PCC) on blood product consumption. Objective: To investigate the efficacy and safety of 4F-PCC administration in patients at risk of massive transfusion. Design, Setting, and Participants: Double-blind, randomized, placebo-controlled superiority trial in 12 French designated level I trauma centers from December 29, 2017, to August 31, 2021, involving consecutive patients with trauma at risk of massive transfusion. Follow-up was completed on August 31, 2021. Interventions: Intravenous administration of 1 mL/kg of 4F-PCC (25 IU of factor IX/kg) vs 1 mL/kg of saline solution (placebo). Patients, investigators, and data analysts were blinded to treatment assignment. All patients received early ratio-based transfusion (packed red blood cells:fresh frozen plasma ratio of 1:1 to 2:1) and were treated according to European traumatic hemorrhage guidelines. Main Outcomes and Measures: The primary outcome was 24-hour all blood product consumption (efficacy); arterial or venous thromboembolic events were a secondary outcome (safety). Results: Of 4313 patients with the highest trauma level activation, 350 were eligible for emergency inclusion, 327 were randomized, and 324 were analyzed (164 in the 4F-PCC group and 160 in the placebo group). The median (IQR) age of participants was 39 (27-56) years, Injury Severity Score was 36 (26-50 [major trauma]), and admission blood lactate level was 4.6 (2.8-7.4) mmol/L; prehospital arterial systolic blood pressure was less than 90 mm Hg in 179 of 324 patients (59%), 233 patients (73%) were men, and 226 (69%) required expedient hemorrhage control. There was no statistically or clinically significant between-group difference in median (IQR) total 24-hour blood product consumption (12 [5-19] U in the 4F-PCC group vs 11 [6-19] U in the placebo group; absolute difference, 0.2 U [95% CI, -2.99 to 3.33]; P = .72). In the 4F-PCC group, 56 patients (35%) presented with at least 1 thromboembolic event vs 37 patients (24%) in the placebo group (absolute difference, 11% [95% CI, 1%-21%]; relative risk, 1.48 [95% CI, 1.04-2.10]; P = .03). Conclusions and Relevance: Among patients with trauma at risk of massive transfusion, there was no significant reduction of 24-hour blood product consumption after administration of 4F-PCC, but thromboembolic events were more common. These findings do not support systematic use of 4F-PCC in patients at risk of massive transfusion. Trial Registration: ClinicalTrials.gov Identifier: NCT03218722.

Continuous peripheral nerve blocks for analgesia of ventilated critically ill patients with multiple trauma: a prospective randomized study.

BACKGROUND: Sedation of ventilated critically ill trauma patients requires high doses of opioids and hypnotics. We aimed to compare the consumption of opioids and hypnotics, and patient outcomes using sedation with or without continuous regional analgesia (CRA). METHODS: Multiple trauma-ventilated patients were included. The patients were randomized to receive an intravenous analgesia (control group) or an addition of CRA within 24h of admission. A traumatic brain injury (TBI) patients group was analyzed. The primary endpoint was the cumulative consumption of sufentanil at 2 days of admission. Secondary endpoints were cumulative and daily consumption of sufentanil and midazolam, duration of mechanical ventilation, intensive care unit (ICU) stay, and safety of CRA management. RESULTS: Seventy six patients were analyzed: 40 (67.5% males) in the control group and 36 (72% males) in the CRA group, respectively. The median [IQR] Injury Severity Score was 30.5 [23.5-38.5] and 26.0 [22.0-41.0]. The consumption of sufentanil at 48h was 725 [465-960] µg/48h versus 670 [510-940] µg/48h (p = 0.16). Daily consumption did not differ between the groups except on day 1 when consumption of sufentanil was 360 [270-480] µg vs. 480 [352-535] µg (p = 0.03). Consumptions of midazolam did not differ between the groups. No difference was noted between the groups according to the secondary endpoints. CONCLUSIONS: CRA does not decrease significantly sufentanil and midazolam consumption within the first 5 days after ICU admission in multiple trauma-ventilated patients. The use of peripheral nerve blocks in heavily sedated and ventilated trauma patients in the ICU seems safe.

Performance of the decarboxylation index to predict CO2 removal and minute ventilation reduction under extracorporeal respiratory support.

BACKGROUND: The aim of this study was to assess the interdependence of extracorporeal blood flow (Qec) and gas flow (GF) in predicting CO2 removal and reduction of minute mechanical ventilation under extracorporeal respiratory support. METHODS: All patients who benefited from V-V ECMO and high-flow ECCO2 R in our intensive care unit over a period of 18 months were included. CO2 removal was calculated from inlet/outlet blood port gases during the first 7 days of oxygenator use. The relationship between the Qec × GF product (named decarboxylation index and expressed in L2 /min2 ) and CO2 removal or expired minute mechanical ventilation reduction (EC MV ratio) was studied using linear regression models. RESULTS: Eighteen patients were analyzed, corresponding to 24 oxygenators and 261 datasets. CO2 removal was 393 ml/min (IQR, 310-526) for 1.8 m2 oxygenators and 179 ml/min (IQR, 165-235) for 1.3 m2 oxygenators. The decarboxylation index was associated linearly with CO2 removal (R2  = 0.62 and R2  = 0.77 for the two oxygenators, respectively) and EC MV ratio (R2  = 0.72 and R2  = 0.62, respectively). The 20L2 /min2 value (considering Qec = 2 L/min and GF = 10 L/min) was associated with an EC MV ratio between 61% and 29% for 1.8 m2 oxygenators, and between 62% and 38% for 1.3 m2 oxygenators. CONCLUSION: The decarboxylation index is a simple parameter to predict CO2 removal and EC MV ratio under extracorporeal respiratory support.

Acquisition of extended-spectrum cephalosporin-resistant Gram-negative bacteria: epidemiology and risk factors in a 6-year cohort of 507 severe trauma patients.

OBJECTIVES: Severe trauma patients are at higher risk of infection and often exposed to antibiotics, which could favor acquisition of antimicrobial resistance. In this study, we aimed to assess prevalence, acquisition, and factors associated with acquisition of extended-spectrum cephalosporin-resistant Gram-negative bacteria (ESCR-GNB) in severe trauma patients. METHODS: We conducted a retrospective monocentric cohort study in a French level one Regional Trauma Centre between 01 January 2010and 31 December 2015. Patients admitted for ≥ 7 days, with an Injury Severity Score ≥ 15, and ≥ 1 microbiological sample were included in the analysis. Prevalence and acquisition rate of ESCR-GNB were determined then, factors associated with ESCR-GNB acquisition were assessed using a Cox model. RESULTS: Of 1873 patients admitted during the study period, 507 were included (median Injury Severity Score = 29 [22-34] and median intensive care unit length of stay = 16 days [10-28]). Most of them (450; 89%) had an antimicrobial therapy. Prevalence of ESCR-GNB increased from 13% to 33% during intensive care unit stay, bringing the ESCR-GNB acquisition rate to 29%. Acquisition of ESCR-GNB was mainly related to AmpC beta-lactamase Enterobacterales and was independently associated with mechanical ventilation needs (hazard ratio [HR] = 6.39; 95% confidence interval [CI] [1.51-27.17]; P = 0.01), renal replacement therapy needs (HR = 2.44; 95% CI [1.24-4.79]; P = 0.01), exposure to cephalosporins (HR = 1.06; 95% CI [1.01-1.12]; P = 0.02), and/or combination therapy with non-beta-lactam antibiotics such as vancomycin, linezolid, clindamycin, or metronidazole (HR = 1.03; 95% CI [1.01-1.06]; P = 0.02). CONCLUSIONS: Acquisition of ESCR-GNB was prevalent in severe trauma patients. Our results suggest selecting antibiotics with caution, particularly in the most severely ill.

Acute post-traumatic muscle atrophy on CT scan predicts prolonged mechanical ventilation and a worse outcome in severe trauma patients.

BACKGROUND: The aim of present study was to assess the association between acute post-traumatic atrophy (APTMA) determined on psoas computed tomography [CT] scan and the duration of mechanical ventilation and outcomes in severe trauma patients. METHODS: A retrospective analysis of severe trauma patients (Injury Severity Score [ISS], >15) hospitalized in the intensive care unit (ICU) for more than 7 days between January 2010 and December 2015 was performed. The psoas muscle index (PMI) was measured on admission and at delayed CT scan. ΔPMI was calculated as the percentage PMI loss between these two scans. Three groups were defined and compared a posteriori using the quartiles of the ΔPMI values: low (lower quartile), moderate, and severe (higher quartile) APTMA groups. Linear regression analysis was performed to predict the duration of mechanical ventilation, of catecholamines, length of stay (LOS) in the ICU and hospital, and complications were assessed. RESULTS: A total of 114 trauma patients were included (median age, 40 years; [IQR, 25-54 years]; ISS, 33 [IQR, 25-41]). Based on the ΔPMI determination, 29 patients were allocated in the low APTMA group (range ∆PMI, 0%-6%), 56 in the moderate APTMA group (range ∆PMI, 6%-18%), and 29 in the APTMA group (range ∆PMI, ≥19%). Severity of APTMA was significantly associated with the duration of mechanical ventilation and catecholamines, ICU and hospital LOS (P<0.001). Delayed pneumonia (P=0.006) and other delayed infections (P=0.014), as well as thromboembolic events (P=0.04) were statistically associated with the severity of APTMA, whereas mortality did not differ between the three groups (P=0.20). Using linear regression analysis, each ∆PMI increase of 1% was significantly associated with 0.90 supplementary days of mechanical ventilation (P<0.001), 0.29 supplementary days of catecholamines (P<0.001) and 0.82 supplementary days of hospitalization (P<0.001). All these statistical associations were confirmed in multivariate analysis (P<0.001). CONCLUSION: Acute muscle atrophy diagnosed on CT scan by psoas area measurement (ΔPMI) was strongly associated with poor outcomes in severe trauma patients.

Driving pressure is not predictive of ARDS outcome in chest trauma patients under mechanical ventilation.

BACKGROUND: The relationship between the driving pressure of the respiratory system (ΔPrs) under mechanical ventilation and worse outcome has never been studied specifically in chest trauma patients. The objective of the present study was to assess in cases of chest trauma the relationship between ΔPrs and severity of acute respiratory distress syndrome (ARDS) or death and length of stay. METHODS: A retrospective analysis of severe trauma patients (ISS > 15) with chest injuries admitted to the Trauma Centre from January 2010 to December 2018 was performed. Patients who received mechanical ventilation were included in our analysis. Mechanical ventilation parameters and ΔPrs were recorded during the stay in the intensive care unit. Association of ΔPrs with mortality and outcomes was specifically studied at the onset of ARDS (ΔPrs-ARDS) by receiver operator characteristic curve analysis, Kaplan-Meier curves, and multivariate analysis. RESULTS: Among the 266 chest trauma patients studied, 194 (73%) developed ARDS. ΔPrs was significantly higher in the ARDS group versus in the no ARDS group (11.6 ± 2.4 cm H2O vs. 10.9 ± 1.9 cm H2O, p = 0.04). Among the patients with ARDS, no difference according to the duration of mechanical ventilation was found between the high ΔPrs group (ΔPrs-ARDS > 14 cm H2O) and the low ΔPrs group (ΔPrs-ARDS ≤ 14 cm H2O), (p = 0.75). ΔPrs-ARDS was not independently associated with the duration of mechanical ventilation (hazard ratio [HR], 1.006; 95% CI, 0.95-1.07; p = 0.8) or mortality (HR, 1.07; 95% CI, 0.9-1.28; p = 0.45). High mechanical power (≥ 12 J/min) was associated with a lower time for weaning of mechanical ventilation in Kaplan-Meier curves but not in multivariate analysis (HR, 0.98; 95% CI, 0.94-1.02; p = 0.22). CONCLUSION: A high ΔPrs-ARDS was not significantly associated with an increase in mechanical ventilation duration or mortality risk in ARDS patients with chest trauma in contrast with medical patients.

Mathematical modelling of oxygenation under veno-venous ECMO configuration using either a femoral or a bicaval drainage.

BACKGROUND: The bicaval drainage under veno-venous extracorporeal membrane oxygenation (VV ECMO) was compared in present experimental study to the inferior caval drainage in terms of systemic oxygenation. METHOD: Two mathematical models were built to simulate the inferior vena cava-to-right atrium (IVC → RA) route and the bicaval drainage-to-right atrium return (IVC + SVC → RA) route using the following parameters: cardiac output (QC), IVC flow/QC ratio, venous oxygen saturation, extracorporeal pump flow (QEC), and pulmonary shunt (PULM-Shunt) to obtain pulmonary artery oxygen saturation (SPAO2) and systemic blood oxygen saturation (SaO2). RESULTS: With the IVC → RA route, SPAO2 and SaO2 increased linearly with QEC/QC until the threshold of the IVC flow/QC ratio, beyond which the increase in SPAO2 reached a plateau. With the IVC + SVC → RA route, SPAO2 and SaO2 increased linearly with QEC/QC until 100% with QEC/QC = 1. The difference in required QEC/QC between the two routes was all the higher as SaO2 target or PULM-Shunt were high, and occurred all the earlier as PULM-Shunt were high. The required QEC between the two routes could differ from 1.0 L/min (QC = 5 L/min) to 1.5 L/min (QC = 8 L/min) for SaO2 target = 90%. Corresponding differences of QEC for SaO2 target = 94% were 4.7 L/min and 7.9 L/min, respectively. CONCLUSION: Bicaval drainage under ECMO via the IVC + SVC → RA route gave a superior systemic oxygenation performance when both QEC/QC and pulmonary shunt were high. The VV-V ECMO configuration (IVC + SVC → RA route) might be an attractive rescue strategy in case of refractory hypoxaemia under VV ECMO.

Injury characteristics, initial clinical status, and severe injuries associated with spinal fractures in a retrospective cohort of 506 trauma patients.

BACKGROUND: Our aim was to describe the characteristics of vertebral fractures, the presence of associated injuries, and clinical status within the first days in a severe trauma population. METHODS: All patients with severe trauma admitted to our level 1 trauma center between January 2015 and December 2018 with a vertebral fracture were analyzed retrospectively. The fractures were determined by the AO Spine classification as stable (A0, A1, and A2 types) or unstable (A3, A4, B, and C types). Clinical status was defined as stable, intermediate, or unstable based on clinicobiological parameters and anatomic injuries. Severe extraspinal injuries and emergent procedures were studied. Three groups were compared: stable fracture, unstable fracture, and spinal cord injury (SCI) group. RESULTS: A total of 425 patients were included (mean ± SD age, 43.8 ± 19.6 years; median Injury Severity Score, 22 [interquartile range, 17-34]; 72% male); 72 (17%) in the SCI group, 116 (27%) in the unstable fracture group, and 237 (56%) in the stable fracture group; 62% (95% confidence interval [CI], 57-67%) had not a stable clinical status on admission (unstable, 30%; intermediate, 32%), regardless of the group (p = 0.38). This decreased to 31% (95% CI, 27-35%) on day 3 and 23% (95% CI, 19-27%) on day 5, regardless of the group (p = 0.27 and p = 0.25). Progression toward stable clinical status between D1 and D5 was 63% (95% CI, 58-68%) overall but was statistically lower in the SCI group. Severe extraspinal injuries (85% [95% CI, 82-89%]) and extraspinal emergent procedures (56% [95% CI, 52-61%]) were comparable between the three groups. Only abdominal injuries and hemostatic procedures significantly differed significantly (p = 0.003 and p = 0.009). CONCLUSION: More than the half of the patients with severe trauma had altered initial clinical status or severe extraspinal injuries that were not compatible with safe early surgical management for the vertebral fracture. These observations were independent of the stability of the fracture or the presence of an SCI. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Effect of a temporary lying position on cerebral hemodynamic and cerebral oxygenation parameters in patients with severe brain trauma.

BACKGROUND: Temporary transition from the half-seated position (HSP) to the lying position (LyP) is often associated with an increase in intracranial pressure (ICP) during management of patients with severe traumatic brain injury (TBI). This study was designed to assess the impact of the temporary LyP on cerebral perfusion and oxygenation in cases of severe TBI. METHOD: Patients with a severe blunt TBI with indication of ICP monitoring were prospectively included. Patients underwent standardized management according to the international guidelines to minimize secondary insults. For each patient, a maneuver to a LyP for 30 min was performed daily during the first 7 days of hospitalization. ICP, cerebral perfusion pressure (CPP), mean velocity (Vm), pulsatility index (PI), regional cerebral oxygen saturation (rScO2), jugular venous oxygen saturation (SvjO2)) were compared in the HSP and the LyP. RESULTS: Twenty-four 24 patients were included. The median Glasgow coma scale score was 6 (interquartile range (IQR), 3-8), the median injury severity score was 32 (IQR, 25-48), and the mean age was 39 ± 16 years. On day 1, ICP (+ 6 mmHg (IQR, 4-7 mmHg)) and CPP (+ 10 mmHg (IQR, 5-14 mmHg) were significantly increased in the LyP compared with the HSP. Vm increased significantly in the LyP on the mainly injured side (+ 6 cm/s (IQR, + 0-11 cm/s); P = 0.01) and on the less injured side (+ 4 cm/s (IQR, + 1-8 cm/s); P < 0.01). rScO2 behaved similarly (+ 2 points (IQR, + 2-4 points) and + 3 points (IQR, + 2-5 points), respectively; P < 0.001). Mixed models highlighted the significant association between the position and CPP, Vm, rScO2, with more favorable conditions in the lying position. CONCLUSIONS: Within the first week of management, the temporary LyP in cases of severe TBI was associated with a moderate increase in CPP, Vm, and rScO2despite a moderate increase in ICP.

Guidelines for the acute care of severe limb trauma patients.

GOAL: To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre. DESIGN: A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded. METHODS: The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS: The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS: There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.

Guidelines for the acute care of severe limb trauma patients

To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre. A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded. The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.

Interstitial Lung Disease Worsens Short- and Long-Term Outcomes of Systemic Rheumatic Disease Patients Admitted to the ICU: A Multicenter Study.

Critically ill patients with systemic rheumatic diseases (SRDs) have a fair prognosis, while those with interstitial lung disease (ILD) have a poorer outcome. However, the prognosis of SRD patients with ILD admitted to the intensive care unit (ICU) remains unclear. We conducted a case-control study to investigate the outcomes of critically ill SRD-ILD patients. Consecutive SRD-ILD patients admitted to five ICUs from January 2007 to December 2017 were compared to SRD patients without ILD. Mortality rates were compared between groups, and prognostic factors were then identified. One hundred and forty critically ill SRD patients were included in the study. Among the 70 patients with SRD-ILD, the SRDs were connective tissue diseases (56%), vasculitis (29%), sarcoidosis (13%), and spondylarthritis (3%). Patients were mainly admitted for acute exacerbation of SRD-ILD (36%) or infection (34%). ICU, in-hospital, and one-year mortality rates in SRD-ILD patients were higher than in SRD patients without ILD (n = 70): 40% vs. 16% (p < 0.01), 49% vs. 19% (p < 0.01), and 66% vs. 40% (p < 0.01), respectively. Hypoxemia, high sequential organ failure assessment (SOFA) score, and admission for ILD acute exacerbation were associated with ICU mortality. In conclusion, ILD worsened the outcomes of SRD patients admitted to the ICU. Admissions related to SRD-ILD acute exacerbation and the severity of the acute respiratory failure were associated with ICU mortality.

Structural recirculation and refractory hypoxemia under femoro-jugular veno-venous extracorporeal membrane oxygenation.

The performance of each veno-venous extracorporeal membrane oxygenation (vv-ECMO) configuration is determined by the anatomic context and cannula position. A mathematical model was built considering bicaval specificities to simulate femoro-jugular configuration. The main parameters to define were cardiac output (QC ), blood flow in the superior vena cava (QSVC ), extracorporeal pump flow (QEC ), and pulmonary shunt (kS-PULM ). The obtained variables were extracorporeal flow ratio in the superior vena cava (EFRSVC  = QEC /[QEC  + QSVC ]), recirculation coefficient (R), effective extracorporeal pump flow (Qeff-EC  = [1 - R] × QEC ), Qeff-EC /QC ratio, and arterial blood oxygen saturation (SaO2 ). EFRSVC increased logarithmically when QEC increased. High QC or high QSVC /QC decreased EFRSVC (range, 68%-85% for QEC of 5 L/min). R also increased following a logarithmic shape when QEC increased. The R rise was earlier and higher for low QC and high QSVC /QC (range, 12%-49% for QEC of 5 L/min). The Qeff-EC /QC ratio (between 0 and 1) was equal to EFRSVC for moderate and high QEC . The Qeff-EC /QC ratio presented the same logarithmic profile when QEC increased, reaching a plateau (range, 0.67-0.91 for QEC /QC  = 1; range, 0.75-0.94 for QEC /QC  = 1.5). The Qeff-EC /QC ratio was linearly associated with SaO2 for a given pulmonary shunt. SaO2  < 90% was observed when the pulmonary shunt was high (Qeff-EC /QC  ≤ 0.7 with kS-PULM  = 0.7 or Qeff-EC /QC  ≤ 0.8 with kS-PULM  = 0.8). Femoro-jugular vv-ECMO generates a systematic structural recirculation that gradually increases with QEC . EFRSVC determines the Qeff-EC /QC ratio, and thereby oxygen delivery and the superior cava shunt. EFRSVC cannot exceed a limit value, explaining refractory hypoxemia in extreme situations.

A combined management with vv-ECMO and independent lung ventilation for asymmetric chest trauma.

Association of independent lung ventilation (ILV) and veno-venous extracorporeal membrane oxygenation (vv-ECMO) may be life-saving therapy in cases of refractory hypoxemia. We report the case of a trauma patient affected by asymmetric hypoxemic lung contusions and massive air leak managed by association of ILV and vv-ECMO. This combined strategy allowed us first to restore physiologic conditions and later to achieve safe thoracic surgery with reduced resection of pulmonary parenchyma. This case highlights the success of a new damage control strategy in extreme cases of persistent air leak with refractory hypoxemia allowing initial vital rescue and a more conservative treatment.

Influence of a temporary stabilization device on respiratory status in patients with severe trauma with a femoral shaft fracture treated by damage control strategy.

BACKGROUND: There are few studies on the safety and respiratory consequences of the use of a skeletal traction (ST) device in the management of femoral shaft fractures with damage control orthopaedics (DCO) strategy, particularly in cases of prolonged use. The aim of this study was to assess the influence of ST compared with an external fixator (EF) on respiratory complications and mechanical ventilation requirements in patients with severe trauma with a femoral shaft fracture managed by DCO strategy. METHODS: We retrospectively reviewed all patients with severe trauma patients with a unilateral femoral shaft fracture admitted to our institution from 2010 to 2015. Patients who did not undergo definitive osteosynthesis during the first 24 h were included and divided into two groups: DCO-ST group and DCO-EF group. In addition to trauma severity, global management of respiratory complications, the incidence of acute respiratory distress syndrome (ARDS) and mechanical ventilation requirements and outcome were compared. RESULTS: Fifty-five patients were managed with DCO strategy (mean Injury Severity Score, 28.4); there were 31 in the DCO-ST group and 24 in the DCO-EF group. No significant difference in terms of the main characteristics, initial severity and associated injuries was observed between the two groups. In contrast, ARDS was found more frequently in the DCO-ST group (81% versus 54%; P = 0.035). Number of ventilation days also tended to be higher in the DCO-ST group (9 days [IQR 3-15 days] versus 7 [IQR 2-16 days]; P = 0.24). No difference was found for mortality and hospitalization duration between the DCO-ST and DCO-EF groups. CONCLUSION: The prolonged use of an ST device in the present cohort was associated with a higher incidence of impaired respiratory function. Therefore, our findings suggest that EF is preferable to ST in the DCO setting for femoral shaft fracture, especially in trauma patients at high risk of developing delayed respiratory failure.

One-Year Outcome of Critically Ill Patients With Systemic Rheumatic Disease: A Multicenter Cohort Study.

BACKGROUND: Critically ill patients with systemic rheumatic disease (SRD) have benefited from better provision of rheumatic and critical care in recent years. Recent comprehensive data regarding in-hospital mortality rates and, most importantly, long-term outcomes are scarce. RESEARCH QUESTION: The aim of this study was to assess short and long-term outcome of patients with SRD who were admitted to the ICU. STUDY DESIGN AND METHODS: All records of patients with SRD who were admitted to ICU between 2006 and 2016 were reviewed. In-hospital and one-year mortality rates were assessed, and predictive factors of death were identified. RESULTS: A total of 525 patients with SRD were included. Causes of admission were most frequently shock (40.8%) and acute respiratory failure (31.8%). Main diagnoses were infection (39%) and SRD flare-up (35%). In-hospital and one-year mortality rates were 30.5% and 37.7%, respectively. Predictive factors that were associated with in-hospital and one-year mortalities were, respectively, age, prior corticosteroid therapy, simplified acute physiology score II ≥50, need for invasive mechanical ventilation, or need for renal replacement therapy. Knaus scale C or D and prior conventional disease modifying antirheumatic drug therapy was associated independently with death one-year after ICU admission. INTERPRETATION: Critically ill patients with SRD had a fair outcome after an ICU stay. Increased age, prior corticosteroid therapy, and severity of critical illness were associated significantly with short- and long-term mortality rates. The one-year mortality rate was also associated with prior health status and conventional disease modifying antirheumatic drug therapy.