French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury.

OBJECTIVES: To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury. DESIGN: A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset 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 quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS: The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, 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' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in 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 the management of patients with spinal cord injury.

Fluid therapy in neurointensive care patients: ESICM consensus and clinical practice recommendations

Objective To report the ESICM consensus and clinical practice recommendations on fluid therapy in neurointensive care patients. Design A consensus committee comprising 22 international experts met in October 2016 during ESICM LIVES2016. Teleconferences and electronic-based discussions between the members of the committee subsequently served to discuss and develop the consensus process. Methods Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles generated. The consensus focused on three main topics: (1) general fluid resuscitation and maintenance in neurointensive care patients, (2) hyperosmolar fluids for intracranial pressure control, (3) fluid management in delayed cerebral ischemia after subarachnoid haemorrhage. After an extensive literature search, the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were applied to assess the quality of evidence (from high to very low), to formulate treatment recommendations as strong or weak, and to issue best practice statements when applicable. A modified Delphi process based on the integration of evidence provided by the literature and expert opinions­using a sequential approach to avoid biases and misinterpretations­was used to generate the final consensus statement. Results The final consensus comprises a total of 32 statements, including 13 strong recommendations and 17 weak recommendations. No recommendations were provided for two statements. Conclusions We present a consensus statement and clinical practice recommendations on fluid therapy for neurointensive care patients.

[The initial management in intensive care of pelvic ring injury patients]. / Prise en charge initiale en réanimation des traumatisés graves du bassin.

Pelvic trauma care is complex since it is frequently associated with multiple injuries and may lead to dramatic and uncontrollable haemorrhage. After pelvic trauma, the mortality, around 8 to 10%, is mainly related to severe pelvic hemorrhage but also to extrapelvic injuries (thoracic, abdominal or brain injuries). It is therefore crucial to manage pelvic trauma in specialized trauma center. The initial trauma assessment aims to determine the role of the pelvic injury in hemorrhage to define the therapeutic strategy of pelvic trauma care (arterial embolisation/pelvic ring stabilisation). This review was performed with a systematic review of the literature; it describes the pelvic fracture pathophysiology, and the efficacy and safety of haemostatic procedures and with their respective indications. A decision making algorithm is proposed for the treatment of trauma patients with pelvic fracture.

[How can we determine the best cerebral perfusion pressure in pediatric traumatic brain injury?]. / Quelle pression de perfusion cérébrale après traumatisme crânien chez l'enfant?

The management of cerebral perfusion pressure (CPP) is the one of the main preoccupation for the care of paediatric traumatic brain injury (TBI). The physiology of cerebral autoregulation, CO2 vasoreactivity, cerebral metabolism changes with age as well as the brain compliance. Low CPP leads to high morbidity and mortality in pediatric TBI. The recent guidelines for the management of CPP for the paediatric TBI indicate a CPP threshold 40-50 mmHg (infants for the lower and adolescent for the upper). But we must consider the importance of age-related differences in the arterial pressure and CPP. The best CPP is the one that allows to avoid cerebral ischaemia and oedema. In this way, the adaptation of optimal CPP must be individual. To assess this objective, interesting tools are available. Transcranial Doppler can be used to determine the best level of CPP. Other indicators can predict the impairment of autoregulation like pressure reactivity index (PRx) taking into consideration the respective changes in ICP and CPP. Measurement of brain tissue oxygen partial pressure is an other tool that can be used to determine the optimal CPP.

[Aspirin and its danger: Reye syndrome in young adult]. / L'aspirine et ses dangers: syndrome de Reye chez un adulte jeune.

We describe the case of a 19-year-old male diagnosed with Reye syndrome within the context of viral pericarditis and salicylate ingestion. He presented a fatal brain oedema without liver failure. Brain biopsies obtained during a decompressive craniectomy led to the diagnosis.

A prospective video-based observational and analytical approach to evaluate management during brain tumour surgery at a university hospital.

The operating room (OR) is a high-risk complex setting, where patient safety relies on the coordinated efforts of multiple team members. However, little attention has been paid to evaluating the strategies employed by OR practitioners to prevent and correct incidents that inevitably occur during surgery. Therefore, we were prompted to investigate human factor (HF) engineering methods that have been used in an innovative way in order to systematically observe and analyze the management of incidents in the neurosurgical OR of a French university hospital. A technical case report illustrates our approach that associates the following procedures: the recording of OR team member activities and behaviour by video cameras and direct observation of a HF researcher, with the description and the explicit demonstration of safety related procedures in self- and cross-confrontation interviews of OR team members. This technical report emphasizes complementary aspects of clinical performance related to safety skills. Moreover, individual and team performances rely on complementary abilities that associate practical knowledge, skills, and attitudes, which are engaged at various degrees to prevent and manage incidents. This report also enlightens new quality-improvement opportunities as well as further objectives for future studies.

The management of femur shaft fracture associated with severe traumatic brain injury.

The aim of this article is to describe the management of femoral shaft fractures in patients with severe traumatic brain injury (TBI). This is a major problem and two questions remain currently of interest: When and how to perform orthopedic surgery in severe TBI patients? The main point of perioperative management remains the prevention of secondary brain insults and the monitoring of intracranial pressure is essential especially in patients with intracranial lesions on the CT-scan. The "double hit" concept, suggesting that surgery by itself might increase the preexisting systemic inflammatory response, gives argument for very early or delayed surgery. Early definitive femoral osteosynthesis, if requires lengthy surgical procedure, does not seem appropriate in this context and "damage-control orthopedics" with external fixation seems to be a good alternative.

[Use of ECMO (extracorporeal membrane oxygenation) in a traumatic brain injured patient with severe hypoxemia]. / Utilisation d'un ECMO (extracorporeal membrane oxygenation) dans un cas d'hypoxémie réfractaire associée à un traumatisme crânien grave.

Traumatic brain injuries are fairly sensitive to hypoxia. For patient with associated lung and brain traumas, different means used to improve oxygen blood level are poorly described. We report the use of ECMO in a refractory hypoxemia occurred to a multitrauma young patient with neurological lesions.

[Non-invasive evaluation of intracranial pressure: how and for whom?]. / Mesure de la pression intracrânienne sans capteur : comment et pour qui ?

The invasive monitoring of intracranial pressure is useful in circumstances associated with high-risk of raised intracranial pressure. However the placement of intracranial probe is not always possible and non-invasive assessment of intracranial pressure may be useful, particularly in case of emergencies. Transcranial Doppler measurements allow the estimation of perfusion pressure with the pulsatility index. Recently, new ultrasonographic methods of cerebral monitoring have been developed: the diameter of the optic nerve sheath diameter, a surrogate marker of raised intracranial pressure and the estimation of median shift line deviation.

[Experts' recommendations for stroke management in intensive care: intracranial hypertension]. / Recommandations formalisées d'experts pour la prise en charge de l'AVC en réanimation: hypertension intracrânienne (HTIC).

This article aims to describe the arguments underlying the experts' recommendations for management of stroke patients in the intensive unit, focusing on intracranial hypertension. This article describes the pathophysiology, diagnostic methods and therapeutic options for intracranial hypertension after stroke, including medical and surgical management.

Relative accuracy of arterial and capillary glucose meter measurements in critically ill patients.

AIM: As optimizing glucose control in critically ill patients remains a challenge for intensive-care physicians, this study aimed to determine the accuracy of glucose measurements. METHODS: The accuracy of capillary and arterial blood glucose meter measurements was compared with central laboratory arterial glucose measurements; the factors associated with inaccurate measures were also determined. RESULTS: Altogether, 302 samples from 75 patients were assessed. Mean glucose levels were 126±52 mg/dL for capillary measurements, 133±50 mg/dL for arterial measurements and 143±54 mg/dL for serum glucose laboratory measurements. Compliance with the ISO 15197 guidelines was observed in 74.8% of the capillary samples and 88.7% of the arterial samples. However, all measurements by glucose meter (with either capillary or arterial samples) led to underestimations of serum glucose. CONCLUSION: In critically ill patients, glucose measurements from capillary and arterial blood by glucose meter are inaccurate, and can potentially lead to inappropriate use of insulin-infusion protocols and failure to achieve glycaemic targets.

[Medical handovers in ICU: a snapshot of practice in the South West of France]. / État des lieux des transmissions médicales en réanimation en Midi-Pyrénées.

INTRODUCTION: Medical handover is critical for quality of care in ICU. Time assigned to medical handovers can vary across different units, with significant impact on the organization of medical work. We aimed to study the time spent for medical handover in ICU and its variation across academic, general and private hospitals in the area of the South West of France, the Midi-Pyrénées region. METHODS: Between August and October 2010, we questioned by phone, 86 physicians issued from 19 different ICUs. This prospective observational study mainly focused on four items: unit's characteristics, health diaries organization, medical handovers procedures, and self-assessment of satisfaction for medical handover (numeric scale from 0 to 10). RESULTS: Eleven general hospital centers, three private hospitals, five university hospitals were concerned by the survey. The mean time spent for medical handover was 59±35 min on monday morning, significantly longer than other days, evening, and to weekend handovers (P<0.001 for all comparisons). When reporting it to the number of ICU bed, the time spent for handover per patient was significantly shorter in private hospital compared to general and academic hospital (P<0.05 for all comparison). CONCLUSION: Time spent for medical handover is important, with an approximate total time of 1h 30 min on monday, and 1h the other days. Physician in private hospitals spend less time for medical handovers. This fact should be considered for medical timework organization, especially in academic hospital and in hospital with large ICU.

Early encephalic toxicity after inadvertent intrathecal injection of low osmolar contrast medium.

Only nonionic contrast media are allowed for intrathecal use because of their lower neurotoxicity. In case of inadvertent intrathecal administration of an ionic contrast medium, the typical following syndrome is called ascending tonic clonic seizure syndrome. We describe the case of a 61-year-old woman with low back pain who underwent myelography. Ioxaglate, a water-soluble ionic low osmolar contrast medium was accidentally injected intrathecally. She first presented encephalic signs of neurotoxicity, followed by opisthotonic spasms and respiratory distress. In our case, ioxaglate is a low osmolar agent, leading to early encephalic toxicity (preceding medullary signs), because of its cephalic migration. The patient was successfully treated by sedation, anticonvulsant therapy and fluid hydration. Intrathecal administration of an ionic contrast medium is clearly contraindicated. In case of inadvertent injection of a low osmolar product, encephalic signs are seen first.