What place for virtual reality in the intensive care unit during medical procedures?

In the intensive care unit, patients are subject to discomforts and pain. Their management is essentially based on pharmacologic approaches. Immersive virtual reality could represent an adjunctive non-invasive and non-pharmacological pain control technique. It is based on real-time interaction with an artificial 360° immersive world using interfaces that enable physical and emotional perceptions to make the user feel better trying to reduce pain perception and to limit anxiety. Evaluation of virtual reality in intensive care unit is lacking and further studies are necessary before to introduce this alternative method for critical patients.

Assessment of Electrical Impedance Tomography to Set Optimal Positive End-Expiratory Pressure for Venoarterial Extracorporeal Membrane Oxygenation-Treated Patients.

OBJECTIVES: Patients on venoarterial extracorporeal membrane oxygenation have many risk factors for pulmonary complications in addition to their heart failure. Optimal positive end-expiratory pressure is unknown in these patients. The aim was to evaluate the ability of electrical impedance tomography to help the physician to select the optimal positive end-expiratory pressure in venoarterial extracorporeal membrane oxygenation treated and mechanically ventilated patients during a positive end-expiratory pressure trial. DESIGN: Observational prospective monocentric. SETTING: University hospital. PATIENTS: Patients (n = 23) older than 18 years old, on mechanical ventilation and venoarterial extracorporeal membrane oxygenation. INTERVENTIONS: A decreasing positive end-expiratory pressure trial (20-5 cm H2O) in increments of 5 cm H2O was performed and monitored by a collection of clinical parameters, ventilatory and ultrasonographic (cardiac and pulmonary) to define an optimal positive end-expiratory pressure according to respiratory criteria (optimal positive end-expiratory pressure selected by physician with respiratory parameters), and then adjusted according to hemodynamic and cardiac tolerances (optimal positive end-expiratory pressure selected by physician with respiratory, hemodynamic, and echocardiographic parameters). At the same time, electrical impedance tomography data (regional distribution of ventilation, compliance, and overdistension collapse) were recorded and analyzed retrospectively to define the optimal positive end-expiratory pressure. MEASUREMENTS AND MAIN RESULTS: The median of this optimal positive end-expiratory pressure was 10 cm H2O in our population. Electrical impedance tomography showed that increasing positive end-expiratory pressure promoted overdistention of ventral lung, maximum at positive end-expiratory pressure 20 cm H20 (34% [interquartile range, 24.5-40]). Decreasing positive end-expiratory pressure resulted in collapse of dorsal lung (29% [interquartile range, 21-45.8]). The optimal positive end-expiratory pressure selected by physician with respiratory parameters was not different from the positive end-expiratory pressure chosen by the electrical impedance tomography. However, there is a negative impact of a high level of intrathoracic pressure on hemodynamic and cardiac tolerances. CONCLUSIONS: Our results support that electrical impedance tomography appears predictive to define optimal positive end-expiratory pressure on venoarterial extracorporeal membrane oxygenation, aided by echocardiography to optimize hemodynamic assessment and management.

Assessment of electrical impedance tomography to set optimal positive end-expiratory pressure for veno-venous ECMO-treated severe ARDS patients.

PURPOSE: Ultra-protective ventilation with low tidal volume is used in severe acute respiratory distress syndrome (ARDS) patients under extracorporeal membrane oxygenation (ECMO). However, the optimal positive end-expiratory pressure (PEEP) is unknown. The aim of our study was to assess electrical impedance tomography's (EIT) ability to choose the best PEEP for these patients. MATERIALS AND METHODS: A recruitment maneuver and after a decremental PEEP trial from 20 to 5 cmH20 were monitored by EIT, with lung images divided into four ventral-to-dorsal horizontal regions of interest. For each patient, three EIT-based PEEP were defined: PEEP ODCLmin (lowest pressure with the least EIT-based collapse lung [CL] and overdistension [OD]), PEEP ODCL15 (lowest pressure able to limit EIT-based collapse to less than or equal to 15% with the least overdistension) and PEEP Comp (PEEP with the highest EIT-based compliance). RESULTS: High PEEP levels were significantly associated with more overdistension while decreasing PEEP led to more collapsed zones. PEEP ODCL15 and PEEP Comp were in complete agreement with the reference Pulmonary PEEP (chosen according to usual respiratory clinical and ultrasound criteria), PEEP ODCLmin was in average agreement with the Pulmonary PEEP. CONCLUSION: EIT may be a useful real-time monitoring technique to optimize the PEEP level in severe ARDS patients under ECMO. TAKE-HOME MESSAGE: Ultra-protective ventilation with low tidal volume is used in severe acute respiratory distress syndrome patients under extracorporeal membrane oxygenation (ECMO), but the optimal positive end-expiratory pressure is unknown. This trial shows that electrical impedance tomography may be an interesting non-invasive bedside tool to provide real-time monitoring of PEEP impact in severe ARDS patients under ECMO. The Pulmovista® electrical impedance tomography was provided by Dräger (Lübeck, Germany) during the study period. Dräger had no role in the study design, collection, analysis and interpretation of the data, writing the article, or the decision to submit the article for publication.

Prospective cohort study assessing chronic pain in patients following minor surgery for breast cancer.

PURPOSE: Pain after tumorectomy and sentinel lymph node dissection is poorly reported in the literature. We carried out a prospective survey aimed at assessing pain three months after such minor surgery for breast cancer. METHODS: The study was approved by the local ethics committee. Most surgeries followed a standard protocol involving general anesthesia with no regional analgesia technique, laryngeal mask, sufentanil and propofol for induction, and multimodal analgesia during the postoperative period. Three months after the surgery, a questionnaire was sent to the patients with a pre-stamped envelope for return. The questions probed responses required to calculate a Brief Pain Inventory score and modified neuropathic pain score (DN3). RESULTS: Over a 5-month period, 150 patients (aged 60 (11) years, body mass index of 25 (6) kg/m2) were included in the final analysis. In the recovery room, 43% of patients required morphine at a mean dose of 5.2 (1.8) mg. Three months post surgery, 60 patients (40%) reported persistent pain for which 62% took analgesic drugs. We found no risk factor associated with this persistent pain among our studied population. Neuropathic pain was noted in 61% of patients who reported persistent pain primarily associated with periareolar incision. CONCLUSIONS: Pain persisted up to three months after minor surgery for breast cancer in 40% of patients with mostly a neuropathic component (61%).