An Analgesic Technique for Orogastric Tube Insertion in Newborns: DOLATSONG, a Randomized Multicentric Controlled Trial.

BACKGROUND: Gastric tube insertion is necessary to support early enteral feeding of newborns during their neonatal intensive care stay. This frequent and invasive procedure is known to be painful. Very few analgesic techniques (sweet solutions, sucking, swaddling, and skin-to-skin contact) are available to reduce the pain caused by orogastric tube insertion procedure. OBJECTIVE: To determine whether a new orogastric tube insertion technique modifies the pain response in newborns, we hypothesize that inserting an orogastric tube through the nipple of a bottle reduces pain caused by this procedure. DESIGN: Prospective, controlled, randomized, multicentered and open label study. SETTINGS: Three neonatal intensive care units in France (2 level 3 units and 1 level 2B). PARTICIPANTS: Full-term or premature newborns at 32 weeks of gestation or more, postnatal age between 48 hours and 21 days, not ventilated and requiring enteral feeding, were randomized into 2 groups: usual technique (n = 36) and experimental technique (n = 35). METHODS: Our experimental technique was to insert the orogastric tube through a modified nipple of a bottle. This method was compared with the usual technique of inserting the tube directly into the newborn's mouth without a support to guide it accompanied by a nipple encouraging sucking with a nonnutritive solution. An association of nonnutritive sucking and orally administered 30% glucose was given to all children for analgesic purposes. Pain during the orogastric tube insertion was assessed on video recordings by 2 independent experts, using a heteroassessment behavioral scale for pain (DAN-Douleur Aiguë du Nouveau-né; APN-Acute Pain in Newborns). The primary outcome was an Acute Pain in Newborns score of less than 3 at the time of the procedure. Comparisons were made using Fisher exact test or Mann-Whitney U test. Factors associated with an Acute Pain in Newborns score of 3 and greater were explored using univariable and multivariable regression models. RESULTS: All but 1 video recording in each group were analyzed. Among the 34 neonates in the experimental group, 71.4% (95% CI: [53.7-85.4]) had an Acute Pain in Newborns score of less than 3 during orogastric tube insertion versus 41% (95% CI: [27.9-61.9]) in the control group (P = .031). Gagging was frequent and nonsignificantly different between the 2 groups (69% in the control group, 51% in the experimental group, P = .13). In multivariable analysis, the experimental technique was an independent factor of pain prevention compared with the usual technique (odds ratio = 0.21 [0.06-0.71], P = .015). CONCLUSIONS: This study suggests that a simple, inexpensive, and feasible technique of orogastric tube insertion through the nipple of a bottle limits pain associated with this procedure in newborns.

Prevention of hypothermia in trauma victims - the HYPOTRAUM 2 study.

INTRODUCTION: Hypothermia is common in trauma patients. It contributes to increasing mortality rate. Hypothermia is multifactorial, favoured by exposure to cold, severity of the patient's state and interventions such as infusion of fluids at room temperature. AIM: To demonstrate that specific management of hypothermia (or of the risk of hypothermia) increases the number of trauma patients arriving at the hospital with a temperature >35°C. DESIGN: This is a prospective, multicentre, open-label, pragmatic, cluster randomized clinical trial of an expected 1,200 trauma patients included by 12 out-of-hospital mobile intensive care units (MICU). Trauma patients are included in a prehospital setting if they present at least one of the following criteria known to be associated with an increased incidence of hypothermia: ambient temperature <18°C, Glasgow coma scale <15, systolic arterial blood pressure <100 mm Hg or body temperature <35°C. Patients are randomized, by cluster, to receive a conventional management or 'interventional' nursing management associating: continuous epitympanic temperature monitoring, early installation in the heated ambulance (temperature target >30°C controlled by infrared thermometer), protection by a survival blanket, and use of heated solutes (temperature objective >35°C controlled by infrared thermometer). The primary end point is the prevalence of hypothermia on arrival at the hospital. The hypothesis tested is a reduction from 20% to 13% in the prevalence of hypothermia. Secondary end points are to evaluate the interaction between the effectiveness of the measures taken and: (1) the severity of the patients assessed by the Revised Trauma Score; (2) the meteorological conditions when they are managed; (3) the time of care; and (4) therapeutic interventions. DISCUSSION: This trial will assess the effectiveness of an invasive, out-of-hospital, temperature management on the onset of hypothermia in moderate to severe trauma patients. IMPACT: Specific management of hypothermia is expected to decrease hypothermia in trauma patients.

[Refractory cardiac arrest patients in prehospital care, potential organ donors]. / Le patient en arrêt cardiaque réfractaire en pré-hospitalier, un donneur d'organes potentiel.

Under the authority of the French Biomedicine Agency, a new care pathway integrates refractory cardiac arrest patients into a process of organ donation. It is a medical, logistical and ethical challenge for the staff of the mobile emergency services.

Preparing Drugs for Infusion Via Syringe Pump: A Key Step to Ensure Homogeneous Concentration.

OBJECTIVE: Preparation of drug solutions used with electronic syringe infusion pumps plays a crucial role in the delivery of an accurate drug concentration. Is there a correlation between drug concentrations during syringe pump infusion and preparation protocols? METHOD: Norepinephrine, insulin, and sufentanil were prepared in 3 different ways: (1) the drug was taken from the vial, then the solvent was added followed by an air bubble, and mixing was performed by turning the syringe top-to-bottom in a 180° shaking movement 5 consecutive times; (2) the drug was taken from the vial, then the solvent was added and not mixed; and (3) the solvent was taken from a stock solution, then the drug was added and not mixed. Concentrations of drugs were determined at different times during administration by reverse-phase high-performance liquid chromatography with ultraviolet detection. All analyses were performed in triplicate and were based on measurement of peak areas. RESULTS: With no shaking of the syringe, the concentration of the injected drugs varies widely. In any case, mixing of the syringe contents by turning the syringe in a top-to-bottom 180° shaking movement 5 times with an air bubble would ensure administration of the drug at a constant concentration. CONCLUSIONS: Without mixing, the concentrations of all drug solutions varied widely when administered via an electronic syringe infusion pump. Mixing syringe contents should be made part of the compulsory curriculum for administering medications at all levels of medical education. (Critical Care Nurse. 2016;36[4]:36-45).

Prospective evaluation of peripheral venous access difficulty in emergency care.

OBJECTIVE: Although frequently used and crucial in emergency care, peripheral intravenous access has been poorly documented. We examined whether criteria related to patient characteristics, underlying disease, devices, or environment were associated with difficult peripheral intravenous access. DESIGN AND SETTING: Prehospital prospective observational study. PARTICIPANTS AND MEASUREMENTS: For each peripheral intravenous access attempt a questionnaire was filled in until final success or procedure abandonment. This questionnaire included data on the patient, operator, disease, degree of emergency, cannulation, nature of fluid infused and the use of gloves, environment, and particular medical observations such as recent peripheral intravenous access and chemotherapy. Criteria associated with peripheral intravenous access difficulty were identified comparing successful and unsuccessful attempts. A total of 671 attempts at peripheral intravenous access in 495 patients were studied. RESULTS: The first attempt was successful in 368 cases (74%) and unsuccessful in 127 (26%). Final success was reported in all cases, including the use of central venous access in three cases. No abandonment was reported. Significantly correlated with a successful attempt were: the caliber of the catheter (OR 0.793), cannulation performed by a nurse specialized in emergency care (OR 3.959), lack of particular observations (OR 0.120), and a clean patient (OR 0.505). CONCLUSIONS: Peripheral intravenous access was achieved in 99% of the patients in out-of-hospital settings. Improved success rate was reported when attempts were performed by a nurse specialized in emergency care using a 16- or 18-G catheter in clean patients without a particular medical history.

Intracuff pressures of endotracheal tubes in the management of airway emergencies: the need for pressure monitoring.

STUDY OBJECTIVE: Excessive pressure exerted on the tracheal mucosa is an avoidable factor implicated as a cause of damage after intubation of the trachea with cuffed tubes. Many patients are intubated in the out-of-hospital setting by emergency medical teams. The time spent in the out-of-hospital setting could very well be long enough for tracheal mucosal damage to occur if cuff pressure is not controlled. The objective of this study is to assess the incidence of intracuff excessive pressure in the out-of-hospital setting. METHODS: We performed an observational prospective study. Every patient who required tracheal intubation was included in the study, regardless of indication. When the patient was stabilized, the cuff was connected to a manometer, and pressure was systematically recorded. Corrections to inflation were performed if necessary to achieve a cuff pressure of 14 to 27 cm H2O. RESULTS: One hundred seven patients were included. Eighty-five were out-of-hospital patients and 22 were transfers between 2 hospitals who had been previously intubated when the mobile intensive care unit team arrived. The first recorded cuff pressures were greater than 27 cm H2O among 79% of patients (85/107), with a mean pressure of 56 cm H2O (SD+/-34 cm H2O) in out-of-hospital patients and 69 cm H2O (SD+/-37 cm H2O) for transferred patients. Pressure correction was made in 72% of patients (77/107). There were corrections in 69% (59/85) of out-of-hospital patients and 82% (18/22) of transferred patients. CONCLUSION: This study revealed that the majority of cuff pressures exceeded safe pressure and required correction. Frequent measurement and adjustment of cuff pressure has been recommended, but this method requires a specific manometer.

Intravenous fluid temperature management by infrared thermometer.

BACKGROUND: The management of intravenous (IV) fluid temperature is a daily challenge in critical care, anesthesiology, and emergency medicine. Infusion of IV fluids at the right temperature partly influences clinical outcomes of critically ill patients. Nowadays, intravenous fluid temperature is poorly managed, as no suitable device is routinely available. Infrared (IR) thermometers have been recently developed for industrial, personal, or medical purposes. The aim of this study was to evaluate the accuracy of an IR thermometer in measuring temperature of warmed and cooled infusion fluids in fluid bags. METHODS: This study compared temperatures simultaneously recorded by an infrared thermometer and a temperature sensor. Temperatures of warmed (41 degrees C) and cooled (4 degrees C) infusion fluids in fluid bags were recorded by 2 independent operators every minute until IV bags' temperature reached ambient temperature. RESULTS: The relation curve was established with 576 measures. Temperature measures performed with an IR thermometer were perfectly linear and perfectly correlated with the reference method (R(2) = 0.995, P < 10(-5)). CONCLUSION: Infrared thermometers are efficient to measure IV fluid bag temperature in the range of temperatures used in clinical practice. As these devices are easy to use and inexpensive, they could be largely used in critical care, anesthesiology, or emergency medicine.