[Eligibility to a Maastricht III - type organ donation according to the protocol proposed by the French organ procurement organization (Agence de la biomedicine) among patients in a medico surgical intensive care unit]. / Potentiel de patients éligibles à un prélèvement d'organes de type Maastricht III dans le cadre du protocole de l'Agence de la biomédecine dans un service de réanimation polyvalente.

OBJECTIVE: Because of graft shortages, an experimental programme of organ donation after Maastricht 3-type circulatory death (M3) has been proposed by the French organ procurement organization (Agence de la biomedicine: ABM). The aim of the study was to estimate how many potential patients were eligible for an M3-type organ donation, amongst deceased patients who have had life-support withdrawn. PATIENTS AND METHODS: We conducted a retrospective study looking at the notes of deceased patients in a French general intensive care unit (ICU), where organ donation is arranged in DBD donors. RESULTS: Over the year 2013, 1475 patients were admitted in ICU and 215 died. One hundred and one patients were brain-injured and 26 of them died following a decision to withdrawn life-support and without contraindication to organ donation. Among them, 2 patients (8%) met the criteria for the French M3-type organ donation protocol. A 12.5% increase in organ donation activity of our team and five organ transplantations could have been considered. CONCLUSION: If M3 organ donation is considered, a significant increase in transplantation would be expected.

Echocardiographic features, mortality, and adrenal function in patients with cirrhosis and septic shock.

OBJECTIVES: Cirrhosis of the liver is associated with an increased susceptibility to bacterial infections capable of causing septic shock and with a basal hyperdynamic circulatory state. The primary objective of this study was to delineate the echocardiographic characteristics and outcomes of septic shock in patients with liver cirrhosis. The secondary objective was to determine whether adrenal insufficiency, which may contribute to hyperdynamic syndrome, was more marked in patients with cirrhosis than in other patients with septic shock. DESIGN: Prospective single-center cohort study. PATIENTS AND METHODS: Thirty-four patients admitted to the intensive care unit (ICU) for septic shocks were included, 14 with and 20 without liver cirrhosis. Echocardiography was performed within the first 24 h to measure the cardiac index (CI), systolic index (SI), and left ventricular ejection fraction (LVEF). A Synacthen test was performed. RESULTS: Patients with cirrhosis had higher values for the CI (3.69+/-1.0 vs. 2.86+/-0.8 l/min/m(2); P=0.02), SI (37.5+/-8 vs. 32.4+/-7 ml/m(2); P=0.04), and LVEF (67+/-7 vs. 55.9+/-12%; P=0.005). ICU mortality was 53% overall, 64% in patients with cirrhosis, and 45% in patients without cirrhosis (P=0.27). Serum cortisol levels under basal conditions (H0) and after stimulation (H1) showed no significant differences between patients with and without cirrhosis. The proportion of patients with no response to Synacthen was 77% among patients with cirrhosis and 50% among patients without cirrhosis (P=0.18). CONCLUSION: In a population with septic shock, left ventricular function was more hyperdynamic in the subset with cirrhosis. Relative adrenal insufficiency occurred in similar proportions of patients with and without cirrhosis.

[Interest of the brain natriuretic peptide as a marker of acute cor pulmonale in acute respiratory distress syndrome]. / Analyse du peptide natriurétique de type B comme marqueur du coeur pulmonaire aigu dans le syndrome de détresse respiratoire aiguë.

OBJECTIVE: The aim of this study was to evaluate the accuracy of the BNP as a marker of acute cor pulmonale in patients with ARDS. STUDY DESIGN: Prospective clinical trial. PATIENTS AND METHODS: At day 2 or 3 after the onset of the ARDS, an echocardiography was performed. Patients with left ventricular dysfunction were excluded. Right ventricular area (RVA) and RVA/LVA ratio were measured. ACP was defined as RVA/LVA > 0.6 associated with septal dyskinesia. Simultaneously, 5 ml of blood was collected for BNP measurement. RESULTS: 26 patients were studied. BNP levels were higher in 10 patients with ACP: 585.5 [189-4830] vs 145.5 [36.5-346] pg/ml (P=0.01) but in those with creatinine clearance < 90 ml/min: 602 [331-3530] vs 125 [39-189] pg/ml (P=0.007). BNP was correlated with RVA (r=0.5; p=0.01), RVA/LVA ratio (r=0.61; p=0.001), sPAP (r=0.58; p=0.002) and with age, cardiac index and creatinine clearance (r=0.61; p=0.001). In multivariate analysis, BNP was only correlated with creatinine clearance (p=0.03), and RVA (p=0.06). CONCLUSION: In ARDS patients without left ventricular dysfunction, BNP level is more elevated in patients with acute cor pulmonale than patients without cor pulmonale.

B-type natriuretic peptide (BNP) and N-terminal-proBNP for heart failure diagnosis in shock or acute respiratory distress.

BACKGROUND: Plasma B-type natriuretic peptide (BNP) assay is recommended as a diagnostic tool in emergency-room patients with acute dyspnea. In the intensive care unit (ICU), the utility of this peptide remains a matter of debate. The objectives of this study were to determine whether cut-off values for BNP and N-terminal-proBNP (NT-proBNP) reliably diagnosed right and/or left ventricular failure in patients with shock or acute respiratory distress, and whether non-cardiac factors led to an increase in these markers. METHODS: Plasma BNP and NT-proBNP levels and echocardiographic parameters of cardiac dysfunction were determined in 41 patients within 24 h of the onset of shock or acute respiratory distress. RESULTS: BNP and NT-proBNP levels were higher in the 25 patients with heart failure than in the other 16 patients: 491.7 +/- 418 pg/ml vs. 144.3 +/- 128 pg/ml and 2874.4 +/- 2929 pg/ml vs. 762.7 +/- 1128 pg/ml, respectively (P < 0.05). In the diagnosis of cardiac dysfunction, BNP > 221 pg/ml and NT-proBNP > 443 pg/ml had 68% and 84% sensitivity, respectively, and 88% and 75% specificity, respectively, but there was a substantial overlap of BNP and NT-proBNP values between patients with and without heart failure. BNP and NT-proBNP were elevated, but not significantly, in patients with isolated right ventricular dysfunction. Patients with renal dysfunction and normal heart function had significantly higher levels of BNP (258.6 +/- 144 pg/ml vs. 92.4 +/- 84 pg/ml) and NT-proBNP (2049 +/- 1320 pg/ml vs. 118 +/- 104 pg/ml) than patients without renal dysfunction. CONCLUSION: Both BNP and NT-proBNP can help in the diagnosis of cardiac dysfunction in ICU patients, but cannot replace echocardiography. An elevated BNP or NT-proBNP level merely indicates the presence of a 'cardiorenal distress' and should prompt further investigation.

[Clinical practices of analgesia for invasive procedures in critically ill sedated patients in Ile-de-France: a phone survey]. / Enquête téléphonique sur les pratiques cliniques d'analgésie pour les actes invasifs chez les patients sédatés en réanimation en Ile-de-France.

To assess the practice of analgesia for invasive procedures in critically ill sedated patient in Ile-de-France (French area including Paris). Observational study: phone survey using a standard questionnaire. Only one senior physician in each of 30 intensive care unit (ICU) was questioned. Baseline sedation included systematic analgesia with narcotics in all ICUs. Only 4 physicians declared using a specific pain scale for sedated patients. Only 3 ICUs used written protocols. Procedures, which were thought to be most invasive (catheterization, pleural drainage, fibroscopy) were in most cases preceded by analgesia, but this was seldom the case for less painful events (venous or arterial puncture, tracheal suctioning). Specific pain scales are still underused. In contrast with current guidelines, analgesia for invasive procedures is not systematic but depends on subjective opinions.

[Color M-mode Doppler for postoperative estimation of pulmonary capillary wedge pressure]. / Estimation postopératoire de la pression artérielle pulmonaire d'occlusion par étude Doppler, en mode M couleur, du flux transmitral.

OBJECTIVE: The aim of this study was to evaluate the accuracy of the combined index E/Vp (peak E velocity combined with color M-mode color Doppler flow propagation) for estimating pulmonary capillary wedge pressure, in post cardiac surgery patients. STUDY DESIGN: Prospective clinical trial. PATIENTS AND METHODS: In post cardiac surgery patients (D1), we have measured with transthoracic echocardiography peak early E transmitral pulsed Doppler velocities and color M-mode Doppler flow propagation velocity (Vp). The E/Vp ratio was compared with pulmonary capillary wedge pressure (PAPO) obtained simultaneously. RESULTS: Thirty eight patients were studied. The coefficient of correlation between PAPO and E/Vp was r = 0.71 (p < 0.0001). The sensitivity and the specificity of E/Vp > 1.5 for prediction of PAPO > 15 mmHg were 79% and 79% respectively. CONCLUSION: In post cardiac surgery patients, PAPO can be reasonably estimated by measuring the ratio E/Vp obtained with Doppler echocardiography.

[Spontaneous splenic rupture in the second quarter of pregnancy]. / Rupture spontanée de la rate au second trimestre de grossesse

We report the case of a 33 year-old woman at the second quarter of pregnancy, with known brain aneurysm admitted in intensive care unit for sudden coma. The coma was not related to a rupture of the brain aneurysm but to a serious haemorrhagic shock caused by a spontaneous splenic rupture. This case report illustrates the difficulty of this unrecognized diagnosis and reminds us to suspect a spontaneous splenic rupture in front of any pregnant woman with atypic abdominal pain and haemorrhagic shock.

Recurarization in the recovery room.

A case of recurarization in the recovery room is reported. Accumulation of atracurium in the intravenous line led to recurarization after flushing the line in the recovery room. A respiratory arrest with severe desaturation and bradycardia occurred. Circumstances leading to this event and the mechanisms enabling a neuromuscular blockade to occur, following the administration of a small dose of relaxant, are discussed.