Frailty, Outcomes, Recovery and Care Steps of Critically Ill Patients (FORECAST): a prospective, multi-centre, cohort study.

PURPOSE: Frailty is common in critically ill patients but the timing and optimal method of frailty ascertainment, trajectory and relationship with care processes remain uncertain. We sought to elucidate the trajectory and care processes of frailty in critically ill patients as measured by the Clinical Frailty Scale (CFS) and Frailty Index (FI). METHODS: This is a multi-centre prospective cohort study enrolling patients ≥ 50 years old receiving life support > 24 h. Frailty severity was assessed with a CFS, and a FI based on the elements of a comprehensive geriatric assessment (CGA) at intensive care unit (ICU) admission, hospital discharge and 6 months. For the primary outcome of frailty prevalence, it was a priori dichotomously defined as a CFS ≥ 5 or FI ≥ 0.2. Processes of care, adverse events were collected during ICU and ward stays while outcomes were determined for ICU, hospital, and 6 months. RESULTS: In 687 patients, whose age (mean ± standard deviation) was 68.8 ± 9.2 years, frailty prevalence was higher when measured with the FI (CFS, FI %): ICU admission (29.8, 44.8), hospital discharge (54.6, 67.9), 6 months (34.1, 42.6). Compared to ICU admission, aggregate frailty severity increased to hospital discharge but improved by 6 months; individually, CFS and FI were higher in 45.3% and 50.6% patients, respectively at 6 months. Compared to hospital discharge, 18.7% (CFS) and 20% (FI) were higher at 6 months. Mortality was higher in frail patients. Processes of care and adverse events were similar except for worse ICU/ward mobility and more frequent delirium in frail patients. CONCLUSIONS: Frailty severity was dynamic, can be measured during recovery from critical illness using the CFS and FI which were both associated with worse outcomes. Although the CFS is a global measure, a CGA FI based may have advantages of being able to measure frailty levels, identify deficits, and potential targets for intervention.

Interfacility transfer of the critically ill: Transfer status does not influence survival.

PURPOSE: To estimate differences in case-mix adjusted hospital mortality between adult ICU patients who are transferred during their ICU-stay and those who are not. METHODS: 19,260 visits to 12 ICUs in Nova Scotia (NS), Canada April 2018-September 2023 were analyzed. Data were obtained from the NS Provincial ICU database. Generalized additive models (GAMs) were used to estimate differences in case-mix adjusted hospital mortality between patients who underwent transfer and those who did not. RESULTS: 1040/19,260 (5%) ICU visits involved interfacility-transfer. No difference in hospital mortality was identified between transferred and non-transferred patients by GAM (OR, 0.99, 95% CI, 0.82 to 1.19; p = 0.91). No mortality difference was observed between patients undergoing a single transfer versus multiple (OR, 0.87; 95% CI, 0.45 to -1.69; p = 0.68). A GAM including the categories no transfer, one transfer, and multiple transfers identified a difference in hospital mortality for patients that underwent multiple transfers compared to non-transferred patients (OR, 0.68; 95% CI, 0.46 to 1.00, p = 0.05), but no difference was identified in a post-hoc matched cohort sensitivity analysis (OR, 0.68; 95% CI, 0.46 to 1.01, p = 0.05). CONCLUSION: The transfer of critically ill patients between ICUs in Nova Scotia did not impact case-mix adjusted hospital mortality.

Sepsis policy, guidelines and standards in Canada: a jurisdictional scoping review protocol.

INTRODUCTION: To our knowledge, this study is the first to identify and describe current sepsis policies, clinical practice guidelines, and health professional training standards in Canada to inform evidence-based policy recommendations. METHODS AND ANALYSIS: This study will be designed and reported according to the Arksey and O'Malley framework for scoping reviews and the Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews. EMBASE, CINAHL, Medline, Turning Research Into Practice and Policy Commons will be searched for policies, clinical practice guidelines and health professional training standards published or updated in 2010 onwards, and related to the identification, management or reporting of sepsis in Canada. Additional sources of evidence will be identified by searching the websites of Canadian organisations responsible for regulating the training of healthcare professionals and reporting health outcomes. All potentially eligible sources of evidence will be reviewed for inclusion, followed by data extraction, independently and in duplicate. The included policies will be collated and summarised to inform future evidence-based sepsis policy recommendations. ETHICS AND DISSEMINATION: The proposed study does not require ethics approval. The results of the study will be submitted for publication in a peer-reviewed journal and presented at local, national and international forums.

Needs and expectations for artificial intelligence in emergency medicine according to Canadian physicians.

BACKGROUND: Artificial Intelligence (AI) is recognized by emergency physicians (EPs) as an important technology that will affect clinical practice. Several AI-tools have already been developed to aid care delivery in emergency medicine (EM). However, many EM tools appear to have been developed without a cross-disciplinary needs assessment, making it difficult to understand their broader importance to general-practice. Clinician surveys about AI tools have been conducted within other medical specialties to help guide future design. This study aims to understand the needs of Canadian EPs for the apt use of AI-based tools. METHODS: A national cross-sectional, two-stage, mixed-method electronic survey of Canadian EPs was conducted from January-May 2022. The survey includes demographic and physician practice-pattern data, clinicians' current use and perceptions of AI, and individual rankings of which EM work-activities most benefit from AI. RESULTS: The primary outcome is a ranked list of high-priority AI-tools for EM that physicians want translated into general use within the next 10 years. When ranking specific AI examples, 'automated charting/report generation', 'clinical prediction rules' and 'monitoring vitals with early-warning detection' were the top items. When ranking by physician work-activities, 'AI-tools for documentation', 'AI-tools for computer use' and 'AI-tools for triaging patients' were the top items. For secondary outcomes, EPs indicated AI was 'likely' (43.1%) or 'extremely likely' (43.7%) to be able to complete the task of 'documentation' and indicated either 'a-great-deal' (32.8%) or 'quite-a-bit' (39.7%) of potential for AI in EM. Further, EPs were either 'strongly' (48.5%) or 'somewhat' (39.8%) interested in AI for EM. CONCLUSIONS: Physician input on the design of AI is essential to ensure the uptake of this technology. Translation of AI-tools to facilitate documentation is considered a high-priority, and respondents had high confidence that AI could facilitate this task. This study will guide future directions regarding the use of AI for EM and help direct efforts to address prevailing technology-translation barriers such as access to high-quality application-specific data and developing reporting guidelines for specific AI-applications. With a prioritized list of high-need AI applications, decision-makers can develop focused strategies to address these larger obstacles.

Definitions, rates and associated mortality of ICU-acquired pneumonia: A multicenter cohort study.

INTRODUCTION: We aimed to analyze intensive care unit (ICU)-acquired pneumonia according to 7 definitions, estimating associated hospital mortality. METHODS: This cohort study was nested within an international randomized trial, evaluating the effect of probiotics on ICU-acquired pneumonia in 2650 mechanically ventilated adults. Each clinically suspected pneumonia was adjudicated by two physicians blinded to allocation and center. The primary outcome was ventilator-associated pneumonia (VAP) informed by ventilation for ≥2 days, new, progressive or persistent infiltrate plus 2 of: temperature > 38 °C or < 36 °C; leukopenia (<3 × 10(Fernando et al., 20206)/L) or leukocytosis (>10 × 10(Fernando et al., 20206)/L); and purulent sputum. We also used 6 other definitions estimating the risk of hospital mortality. RESULTS: The frequency of ICU-acquired pneumonia varied by definition: the trial primary outcome VAP (21.6%), Clinical Pulmonary Infection Score (CPIS) (24.9%), American College Chest Physicians (ACCP) (25.0%), International Sepsis Forum (ISF) (24.4%), Reducing Oxidative Stress Study (REDOXS) (17.6%), Centers for Disease Control (CDC) (7.8%), and invasively microbiologically confirmed (1.9%). The trial primary outcome VAP (HR 1.31 [1.08, 1.60]), ISF (HR 1.32 [1.09,1.60]), CPIS (HR 1.30 [1.08,1.58]) and ACCP definitions (HR 1.22 [1.00,1.47]) were associated with hospital mortality. CONCLUSIONS: Rates of ICU-acquired pneumonia vary by definition and are associated with differential increased risk of death.

Opioid and Sedative Coprescription: Prescribing Patterns after an ICU Admission.

Background: Opioid misuse constitutes a health care crisis in Canada, and coprescription of opioids with sedatives has been associated with adverse events. Opioids and sedatives are frequently administered in the intensive care unit (ICU). The rate of continuation of opioid-sedative combinations after an ICU admission at the study institution was unknown. Objectives: To determine the rates of opioid and sedative coprescriptions following an ICU admission and to identify factors associated with continuation of hospital-initiated opioid-sedative coprescriptions at ICU transfer and hospital discharge. Methods: This retrospective chart review involved patients admitted to ICUs at a tertiary care centre between April 1, 2018, and March 31, 2019. Baseline characteristics were obtained from a clinical database and medication information from medication reconciliation forms. An opioid coprescription was defined as prescription of an opioid in combination with a sedative (benzodiazepine, z-drug, gabapentinoid, tricyclic antidepressant, or antipsychotic), and hospital-initiated coprescriptions encompassed various predefined scenarios of therapy started or modified before ICU transfer. Factors associated with hospital-initiated opioid coprescription were analyzed by multivariable logistic regression. Results: A total of 735 patients met the inclusion criteria. At ICU transfer, 23.0% (169/735) of the patients had an opioid coprescription, and 87.0% (147/169) of these coprescriptions were hospital-initiated. At hospital discharge, 8.6% (44/514) of the patients had an opioid coprescription, and 56.8% (25/44) of these coprescriptions were hospital-initiated. Male sex, home opioid coprescription, surgical patient, prolonged hospital stay, and in-hospital death were significantly associated with hospital-initiated opioid coprescription at the time of ICU transfer. Home opioid coprescription was significantly associated with opioid coprescription at the time of hospital discharge. Conclusions: Hospital-initiated opioid coprescriptions accounted for the majority of opioid coprescriptions at ICU transfer and hospital discharge. Pharmacists should assess all opioid coprescriptions to determine whether discontinuation and/or dose reduction is appropriate.

Contexte: L'abus d'opioïdes est une crise sanitaire au Canada, et les opioïdes coprescrits avec des sédatifs ont été associés à des événements indésirables. Les opioïdes et les sédatifs sont fréquemment utilisés en unité de soins intensifs (USI). Sur le lieu de l'étude, on ne connaissait pas le taux de maintien de l'utilisation de la combinaison opioïdes-sédatifs après une admission en USI. Objectifs: Déterminer les taux de coprescription d'opioïdes et de sédatifs suite à une admission en USI et identifier les facteurs associés au maintien de l'utilisation des coprescriptions d'opioïdes et de sédatifs amorcées par l'hôpital au moment du transfert hors de l'USI et du congé hospitalier. Méthodes: Cet examen rétrospectif des dossiers portait sur des patients admis en USI d'un centre de soins tertiaires entre le 1er avril 2018 et le 31 mars 2019. Les caractéristiques de base ont été obtenues à partir d'une base de données clinique et des informations sur les médicaments à partir des formulaires de bilan comparatif des médicaments. Une coprescription d'opioïdes a été définie comme « La prescription d'un opioïde associée à un sédatif (benzodiazépine, médicament z, gabapentinoïde, antidépresseur tricyclique ou antipsychotique) ¼. Les « coprescriptions amorcées par l'hôpital ¼ correspondaient à des coprescriptions initiées ou modifiées avant le transfert hors de l'USI, selon des scénarios préalablement définis. Les facteurs associés à la coprescription d'opioïdes amorcée par l'hôpital ont été analysés par régression logistique multivariée. Résultats: Au total, 735 patients répondaient aux critères d'inclusion. Lors du transfert hors de l'USI, des opioïdes étaient coprescrits à 23,0 % (169/735) d'entre eux; de ces coprescriptions, 87,0 % (147/169) étaient amorcées par l'hôpital. Au moment du congé hospitalier, des opioïdes étaient coprescrits à 8,6 % (44/514) d'entre eux; de ces coprescriptions, 56,8 % (25/44) étaient amorcées par l'hôpital. Le sexe masculin, la coprescription d'opioïdes à domicile, l'admission en chirurgie, le séjour prolongé à l'hôpital et le décès à l'hôpital étaient fortement associés à la coprescription d'opioïdes amorcée par l'hôpital au moment du transfert hors de l'USI. La coprescription d'opioïdes à domicile était fortement associée à la coprescription d'opioïdes au moment du congé de l'hôpital. Conclusions: Les coprescriptions d'opioïdes amorcées par l'hôpital représentaient la majorité des coprescriptions au moment du transfert hors de l'USI et au moment du congé de l'hôpital. Les pharmaciens doivent évaluer toutes les coprescriptions d'opioïdes pour déterminer si l'arrêt et/ou la réduction de la dose est appropriée.

Health economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (E-PROSPECT): a cost-effectiveness analysis.

PURPOSE: We sought to compare the cost-effectiveness of probiotics and usual care with usual care without probiotics in mechanically ventilated, intensive care unit patients alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT). METHODS: We conducted a health economic evaluation alongside the PROSPECT randomized control trial (October 2013-March 2019). We adopted a public healthcare payer's perspective. Forty-four intensive care units in three countries (Canada/USA/Saudi Arabia) with adult critically ill, mechanically ventilated patients (N = 2,650) were included. Interventions were probiotics (Lactobacillus rhamnosus GG) vs placebo administered enterally twice daily. We collected healthcare resource use and estimated unit costs in 2019 United States dollars (USD) over a time horizon from randomization to hospital discharge/death. We calculated incremental cost-effectiveness ratios (ICERs) comparing probiotics vs usual care. The primary outcome was incremental cost per ventilator-associated pneumonia (VAP) event averted; secondary outcomes were costs per Clostridioides difficile-associated diarrhea (CDAD), antibiotic-associated diarrhea (AAD), and mortality averted. Uncertainty was investigated using nonparametric bootstrapping and sensitivity analyses. RESULTS: Mean (standard deviation [SD]) cost per patient was USD 66,914 (91,098) for patients randomized to probiotics, with a median [interquartile range (IQR)] of USD 42,947 [22,239 to 76,205]. By comparison, for those not receiving probiotics, mean (SD) cost per patient was USD 62,701 (78,676) (median [IQR], USD 41,102 [23,170 to 75,140]; incremental cost, USD 4,213; 95% confidence interval [CI], -2,269 to 10,708). Incremental cost-effectiveness ratios for VAP or AAD events averted, probiotics were dominated by usual care (more expensive, with similar effectiveness). The ICERs were USD 1,473,400 per CDAD event averted (95% CI, undefined) and USD 396,764 per death averted (95% CI, undefined). Cost-effectiveness acceptability curves reveal that probiotics were not cost-effective across wide ranges of plausible willingness-to-pay thresholds. Sensitivity analyses did not change the conclusions. CONCLUSIONS: Probiotics for VAP prevention among critically ill patients were not cost-effective. Study registration data www. CLINICALTRIALS: gov (NCT01782755); registered 4 February 2013.

RéSUMé: OBJECTIF: Nous avons cherché à comparer le rapport coût-efficacité d'un traitement avec probiotiques ajoutés aux soins habituels avec des soins habituels prodigués sans probiotiques chez les patients des soins intensifs sous ventilation mécanique dans le cadre de l'étude PROSPECT (Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial). MéTHODE: Nous avons réalisé une évaluation de l'économie de la santé parallèlement à l'étude randomisée contrôlée PROSPECT (octobre 2013-mars 2019). Nous avons adopté le point de vue d'un payeur public de services de santé. Quarante-quatre unités de soins intensifs dans trois pays (Canada/États-Unis/Arabie saoudite) prenant soin de patients adultes gravement malades sous ventilation mécanique (n = 2650) ont été inclus. Les interventions ont été les suivantes : probiotiques (Lactobacillus rhamnosus GG) vs placebo administrés par voie entérale deux fois par jour. Nous avons recueilli les données concernant l'utilisation des ressources en soins de santé et estimé les coûts unitaires en dollars américains (USD) de 2019 sur un horizon temporel allant de la randomisation au congé de l'hôpital / décès. Nous avons calculé des rapports coût-efficacité différentiels (RCED) en comparant les probiotiques vs les soins habituels. Le critère d'évaluation principal était le coût différentiel par événement évité de pneumonie associée au ventilateur (PAV); les critères d'évaluation secondaires étaient les coûts par diarrhée associée au Clostridioides difficile (DACD), diarrhée associée aux antibiotiques (DAA) et mortalité évitées. L'incertitude a été étudiée à l'aide d'analyses d'amorçage et de sensibilité non paramétriques. RéSULTATS: Le coût moyen (écart type [ÉT]) par patient était de 66 914 (91 098) USD pour les patients randomisés au groupe probiotiques, avec une médiane [écart interquartile (ÉIQ)] de 42 947 USD [22 239 à 76 205]. En comparaison, pour ceux ne recevant pas de probiotiques, le coût moyen (ÉT) par patient était de 62 701 USD (78 676) (médiane [ÉIQ], 41 102 USD [23 170 à 75 140]; coût différentiel, 4213 USD; intervalle de confiance [IC] à 95%, -2269 à 10 708). En matière de rapports coût-efficacité différentiels pour les événements de PAV ou DAA évités, les probiotiques étaient dominés par les soins habituels (plus coûteux, avec une efficacité similaire). Les RCED étaient de 1 473 400 USD par événement de DACD évitée (IC 95 %, non défini) et de 396 764 USD par décès évité (IC 95 %, non défini). Les courbes d'acceptabilité coût-efficacité révèlent que les probiotiques n'étaient pas rentables dans de larges gammes de seuils plausibles de volonté de payer. Les analyses de sensibilité n'ont pas modifié les conclusions. CONCLUSION: Les probiotiques utilisés pour prévenir la PAV chez les patients gravement malades n'étaient pas rentables. Enregistrement de l'étude : www.clinicaltrials.gov (NCT01782755); enregistrée le 4 février 2013.

Protocol for a scoping review of sepsis epidemiology.

INTRODUCTION: Sepsis is a common, life-threatening syndrome of physiologic, pathologic, and biochemical abnormalities that are caused by infection and propagated by a dysregulated immune response. In 2017, the estimated annual incidence of sepsis around the world was 508 cases per 100,000 (95% confidence interval [CI], 422-612 cases per 100,000), however, reported incidence rates vary significantly by country. A scoping review will identify knowledge gaps by systematically investigating the incidence of sepsis. METHODS AND ANALYSIS: This scoping review will be guided by the updated JBI (formerly Joanna Briggs Institute) methodology. We will search the following electronic databases: MEDLINE, EMBASE, CINAHL, and Cochrane Database of Systematic Reviews/Central Register of Controlled Trials. In addition, we will search websites of trial and study registries. We will review titles and abstracts of potentially eligible studies and then full-texts by two independent reviewers. We will include any study that is focused on the incidence of sepsis or septic shock in any population. Data will be abstracted independently using pre-piloted data extraction forms, and we will present results according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Extension for Scoping Reviews. ETHICS AND DISSEMINATION: The results of this review will be used to create a publicly available indexed and searchable electronic registry of existing sepsis research relating to incidence in neonates, children, and adults. With input from stakeholders, we will identify the implications of study findings for policy, practice, and research. Ethics approval was not required given this study reports on existing literature.

N-Acetylcysteine treatment of neonatal acetaminophen toxicity caused by transplacental transfer - a case report.

We describe a case of maternal acetaminophen toxicity leading to Caesarean section delivery of a pre-term neonate with acetaminophen-induced hepatic injury and encephalopathy at 33 weeks gestational age. Delayed treatment with N-acetylcysteine (NAC) was initiated in the baby 11 h after delivery, with eventual discharge of a healthy baby at 12 days of age. The baby was treated with a standard but extended duration NAC protocol. Post-operatively, liver biopsy of the mother demonstrated acetaminophen-induced hepatic injury overlying mild hepatic steatosis. This was also managed with NAC therapy leading to complete clinical resolution of acetaminophen induced hepatic injury and discharge on post-operative day 10. This case of delayed NAC therapy for the treatment of pre-term neonatal acetaminophen toxicity is one of very few reported in the literature and can be used as a guide in the management of subsequent cases.

Successful Use of Extracorporeal Membrane Oxygenation Therapy in Patients With 80% Full Thickness Burns.

Despite advances in burn care, mortality in adult patients with extensive burn injuries remains a concern, particularly in those who develop concurrent acute respiratory distress syndrome (ARDS). In cases of ARDS refractory to conventional treatments, venovenous extracorporeal membrane oxygenation (ECMO) may represent a viable salvage therapy, even in the major burn population. We present the case of a 38-year-old man with full thickness burns to over 80% of his body, who developed severe ARDS 4 days postburn. After failing to respond to deep sedation, paralysis, and proning, ECMO therapy was initiated to maintain oxygenation and ventilation. Over the next 14 days, while the patient was treated with ECMO, he successfully underwent three major operations to debride and allograft approximately 65% of his body surface area, including one in the prone position. ECMO therapy was discontinued on postburn day 18, and the patient had his wounds reconstructed and survived his injuries. To the best of our knowledge, this is the first report of a burn patient with such severe burns requiring surgical intervention that has been treated with ECMO and survived, and the first case of a burn patient on ECMO having surgery in the prone position. They conclude this case serves as a "proof of concept" that ECMO is a potential treatment for appropriately selected major burn patients with ARDS who fail to respond to other therapies.

Bowel Puncture During Insertion of a Femoral Central Line in the Emergency Department.

BACKGROUND Central venous catheter (CVC) insertion is commonly performed in the emergency department. The femoral vein is often chosen for insertion of CVCs due to its lower risk for complication. We present a rare complication of bowel puncture during insertion of a femoral CVC in the emergency department in a 46-year-old female. CASE REPORT A 46-year-old female with a history of partial gastrectomy and colostomy was transported to the emergency department after being found unconscious. Despite multiple attempts, intravenous access could not be obtained. The emergency physician proceeded to insert a left femoral CVC to obtain venous access. Ultrasound was not used due to perceived urgency, as well as a bedside assessment that the patient's anatomy was straight forward. Stool-like material was aspirated upon inserting the introducer needle, which was quickly removed. An upright x-ray showed no free air, but due to the patient history, an exploratory laparotomy was performed. A single-side perforation in the mid-sigmoid with a small hematoma along the antimesenteric wall was found. The puncture was over sewn, and the patient recovered well; the patient's initial presentation was ultimately considered to be due to medication misuse. CONCLUSIONS This case highlights the importance of using caution in blind attempts at femoral CVC in patients with prior abdominal surgery. It is also important to note the need to avoid insertion of CVCs without the use of ultrasound or when in a rush. If venous access is needed quickly, peripheral or intraosseous venous access can be obtained much more quickly and safely.

Does apneic oxygenation prevent desaturation during emergency airway management? A systematic review and meta-analysis.

RéSUMé: OBJECTIF: L'oxygénation apnéique (OA) par lunettes nasales est une méthode de prévention de la désaturation en oxygène au cours des intubations en urgence. L'objectif de cette revue systématique était de déterminer l'efficacité de l'OA sur la prévention de la désaturation en oxygène au cours des intubations en urgence. SOURCE: Des recherches systématiques ont été effectuées dans trois bases de données électroniques (MEDLINE, EMBASE et CINAHL) pour identifier les études portant sur la prévention de la désaturation en oxygène au moyen de l'OA par lunettes nasales. Notre critère d'évaluation principal était l'incidence des désaturations telle que définie dans chaque étude; nous avons ensuite évalué l'incidence de la désaturation sévère en oxygène (SpO2 < 80%). Une méta-analyse a été effectuée sur les études présentant des données sur la désaturation en oxygène telle que définie par chaque étude et chez des patients ayant une désaturation sévère pour générer une estimation groupée de l'effet. CONSTATATIONS PRINCIPALES: Au total, 544 études ont été examinées, parmi lesquelles dix (2 322 patients) satisfaisaient tous les critères d'éligibilité. Comparativement à l'absence d'OA, l'utilisation de cette méthode a été associée à une réduction de la désaturation en oxygène (risque relatif [RR] : 0,76; intervalle de confiance à 95% [IC] : 0,61 à 0,95; P = 0,02), mais n'a pas été associée à une réduction de la désaturation sévère (RR, 0,65; IC à 95% : 0,38 à 1,11; P = 0,12). Néanmoins, il y avait une hétérogénéité significative des facteurs liés aux patients, des interventions et des définitions de la désaturation en oxygène entre les études. CONCLUSION: Nos constatations suggèrent que l'OA par lunettes nasales est associée à un moindre risque de désaturation en oxygène au cours des intubations en urgence. Cependant, compte de tenu de l'hétérogénéité des études, d'autres essais de grande qualité sont nécessaires pour déterminer quels patients pourraient bénéficier de l'OA au cours des intubations d'urgence.

A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters.

PURPOSE: The aim of this study was to collect and describe all published reports of local tissue injury or extravasation from vasopressor administration via either peripheral intravenous (IV) or central venous catheter. METHODS: A systematic search of Medline, Embase, and Cochrane databases was performed from inception through January 2014 for reports of adults who received vasopressor intravenously via peripheral IV or central venous catheter for a therapeutic purpose. We included primary studies or case reports of vasopressor administration that resulted in local tissue injury or extravasation of vasopressor solution. RESULTS: Eighty-five articles with 270 patients met all inclusion criteria. A total of 325 separate local tissue injury and extravasation events were identified, with 318 events resulting from peripheral vasopressor administration and 7 events resulting from central administration. There were 204 local tissue injury events from peripheral administration of vasopressors, with an average duration of infusion of 55.9 hours (±68.1), median time of 24 hours, and range of 0.08 to 528 hours. In most of these events (174/204, 85.3%), the infusion site was located distal to the antecubital or popliteal fossae. CONCLUSIONS: Published data on tissue injury or extravasation from vasopressor administration via peripheral IVs are derived mainly from case reports. Further study is warranted to clarify the safety of vasopressor administration via peripheral IVs.

My patient has got abdominal pain: identifying biliary problems.

Right upper quadrant and epigastric abdominal pain are common presenting complaints in the emergency department. With increasing access to point-of-care ultrasound, emergency physicians now have an added tool to help identify biliary problems as a cause of a patient's right upper quadrant pain. Point-of-care ultrasound has a sensitivity of 89.8% (95% CI 86.4-92.5%) and specificity of 88.0% (83.7-91.4%) for cholelithiasis, very similar to radiology-performed ultrasonography. In addition to assessment for cholelithiasis and cholecystitis, point-of-care ultrasound can help emergency physicians to determine whether the biliary system is the source of infection in patients with suspected sepsis. Use of point-of-care ultrasound for the assessment of the biliary system has resulted in more rapid diagnosis, decreasing costs, and shorter emergency department length of stay.

Circuits for grasping: spinal dI3 interneurons mediate cutaneous control of motor behavior.

Accurate motor performance depends on the integration in spinal microcircuits of sensory feedback information. Hand grasp is a skilled motor behavior known to require cutaneous sensory feedback, but spinal microcircuits that process and relay this feedback to the motor system have not been defined. We sought to define classes of spinal interneurons involved in the cutaneous control of hand grasp in mice and to show that dI3 interneurons, a class of dorsal spinal interneurons marked by the expression of Isl1, convey input from low threshold cutaneous afferents to motoneurons. Mice in which the output of dI3 interneurons has been inactivated exhibit deficits in motor tasks that rely on cutaneous afferent input. Most strikingly, the ability to maintain grip strength in response to increasing load is lost following genetic silencing of dI3 interneuron output. Thus, spinal microcircuits that integrate cutaneous feedback crucial for paw grip rely on the intermediary role of dI3 interneurons.

The V-line: a sonographic aid for the confirmation of pleural fluid.

BACKGROUND: Ultrasound is being used increasingly to diagnose pathological free fluid accumulation at the bedside. In addition to the detection of peritoneal and pericardial fluid, point-of-care ultrasound allows rapid bedside diagnosis of pleural fluid. FINDINGS: In this short report, we describe the sonographic observation of the vertebral or 'V-line' to help confirm the presence of pleural fluid in the supine patient. The V-line sign is a result of the fluid acting as an acoustic window to enable visualization of vertebral bodies and posterior thoracic wall, thus confirming the presence of pleural fluid. CONCLUSIONS: The V-line is a useful sonographic sign to aid the diagnosis of pleural free fluid.