[Feasibility study for ambulatory surgery in emergency]. / Étude de faisabilité pour la mise en place d'une filière de chirurgie ambulatoire en urgence.

INTRODUCTION: Development of outpatient care is one of the major goals of public health policy in our country. For the purpose of this study, we set up an emergency outpatient surgery unit 24hours a day in our hospital. We assessed the feasibility of such a unit with a length of stay less than 12hours and no patient readmission. PATIENTS AND METHODS: A prospective observational and monocentric study was conducted in our hospital by systematically including patients eligible for emergency surgery outpatient care. We built a database compiling patient characteristics, lengths of stay, surgical and anesthesic procedures, complications and readmission rate. Satisfaction was then assessed by the « EVAN-G ¼ questionnaire. RESULTS: From May 2011 to October 2012, 147 patients were included in our research. They were 31years old [25-43]. Hundred and twenty-six of them (86%) remained in the outpatient procedure without any readmission. Twenty-one (14%) were excluded, essentially for surgical contraindications or due to the absence of an accompanying person. Length of stay was of 10.5hours [8.5-13]. The satisfaction survey showed an average score of 83/100. CONCLUSION: The setting up of an ambulatory emergency surgery unit is possible after proper training of emergency care specialists, anesthesiologists, and surgeons. This activity is compatible with safe care and a high level of patient satisfaction. It must be considered as part of the emergency procedures available and should not be systematically ruled out.

Differential diagnosis of acute dyspnea: the value of B natriuretic peptides in the emergency department.

Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presenting to an emergency department (ED) and is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes in direct proportion to wall tension, which lowers renin-angiotensin-aldosterone activation. For the diagnosis of CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in an elderly population, and in patients with renal dysfunction. They might also have a prognostic value. Studies have demonstrated that the use of BNP or NT-proBNP in dyspneic patients early following admission to the ED, reduced the time to discharge and total treatment cost. BNP and NT-proBNP should be available in every ED 24 h a day, because the literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients. The purpose of this review is to indicate recent developments in biomarkers of heart failure and to evaluate their impact on clinical use in the emergency setting.

Useulness of B Natriuretic Peptides and Procalcitonin in Emergency Medicine.

Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presented to an emergency department (ED), and it is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes directly proportional to wall tension, for lowering renin-angiotensin-aldosterone activation. For diagnosing CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in elderly population, and in patients with renal dysfunction. They might have also a prognostic value. Studies demonstrated that the use of BNP or NT-proBNP in dyspneic patients early in the ED reduced the time to discharge, total treatment cost. BNP and NT-proBNP should be available in every ED 24 hours a day, because literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients.Etiologic diagnosis of febrile patients who present to an ED is complex and sometimes difficult. However, new evidence showed that there are interventions (including early appropriate antibiotics), which could reduce mortality rate in patients with sepsis. For diagnosing sepsis, procalcitonin (PCT) is more accurate than C-reactive protein. Thus, because of its excellent specificity and positive predictive value, an elevated PCT concentration (higher than 0.5 ng/mL) indicates ongoing and potentially severe systemic infection, which needs early antibiotics (e.g. meningitis). In lower respiratory tract infections, CAP or COPD exacerbation, PCT guidance reduced total antibiotic exposure and/or antibiotic treatment duration.

[Descriptive study of the patients admitted to an intensive care unit during the heat wave of August 2003 in France]. / Etude descriptive des patients admis en réanimation pour coup de chaleur au cours de la canicule d'août 2003.

INTRODUCTION: Several thousands of deaths were attributed to heat stroke during August 2003 in France. To date, only a very few studies have analyzed the prognosis in the intensive care unit (ICU) of the most severely hyperthermic patients. METHOD: Descriptive observational study of the patients admitted to the intensive care unit at the Lariboisière hospital in Paris, for heat stroke defined by an elevated core body temperature above 40 degrees C with central nervous system dysfunction, in the absence of other etiologies explaining the hyperthermia. RESULTS: In the Lariboisière hospital, an elevation in the ICU (+143%) and hospital mortality rate (+191%) were registered during August 2003, in comparison with August 2002. Fifteen patients (10 men, 5 women, median age: 57 years) were admitted to the ICU for heat stroke between the 4th and 14th of August 2003. Seven of them (47%) died. On admission, the occurrence of a pre-hospital cardiac arrest, the presence of coagulation abnormalities (reduction in prothrombin time and in platelet count) or of an elevation in plasma lactate concentration were significantly associated with the risk of death in the ICU. Conversely, age, body temperature, coma depth on admission and convulsions were not predictive of death. Neurological after effects (cerebellar syndrome, polyneuropathy and residual brain damage) were noted in 50% of the survivors. DISCUSSION: Although it is possible that heat alone precipitated the death of very sick people, our study clearly showed that young and valid patients died of heat stroke and suggests the possible increase in the 2003 death rate secondary to the heat wave. Moreover, it is still difficult at the moment to really appreciate the long-term consequences for survivors who presented serious neurological after effects. CONCLUSION: The August 2003 heat wave resulted in an elevation of the hospital and ICU death rates in the Lariboisière hospital in Paris. Despite adequate cooling and supportive therapies, the mortality of patients admitted to the ICU for heat stroke remained elevated and the neurological after effects severe. These preliminary results should be confirmed by larger cohort studies.

Post-operative course after conventional or laparoscopic gastroplasty in morbidly obese patients.

The post-operative period is particularly dangerous for obese patients. The aim of this study was to compare the immediate post-operative course after either laparoscopic or open gastroplasty. We studied retrospectively 20 and 14 consecutive patients who underwent laparoscopic or open adjustable silicone gastric banding, respectively. After the laparoscopic procedure, patients had a significantly shorter stay in the post-anaesthesia care unit (0.3 +/- 0.4 and 1.1 +/- 1 days), reduced analgesic requirements, a shorter period of intravenous catheter use (2.3 +/- 1.9 and 4.8 +/- 1.4 days), were able to walk sooner (1 +/- 0.4 and 2.1 +/- 1.6 days) and had a significantly shorter duration of in-hospital stay (5.4 +/- 2.3 and 15.8 +/- 4.5 days) than after an open procedure. This report suggests that the use of laparoscopy for gastroplasty in morbidity obese patients may significantly improve the immediate post-operative course.