Changes in the availability of bedside ultrasound practice in emergency rooms and prehospital settings in France.

OBJECTIVE: Ensuring the availability of ultrasound devices is the initial step in implementing clinical ultrasound (CUS) in emergency services. In France in 2011, 52% of emergency departments (EDs) and only 9% of mobile intensive care stations (MICS) were equipped with ultrasound devices. The main goal of this study was to determine the movement of these rates since 2011. METHODS: We conducted a cross-sectional, descriptive, multicentre study in the form of a questionnaire. To estimate the numbers of EDs and MICS equipped with at least one ultrasound system with a confidence level of 95% and margin of error of 5%, 170 responding EDs and 145 MICS were required. Each service was solicited three times by secure online questionnaire and then by phone. RESULTS: Three hundred and twenty-eight (84%) services responded to the questionnaire: 179 (86%) EDs and 149 (82%) MICS. At least one ultrasound machine was available in 127 (71%, 95% CI [64; 78]) EDs vs. 52% in 2011 (P<0.01). 42 (28%, 95% CI [21; 35]) MICS were equipped vs. 9% in 2011 (P<0.01). In 97 (76%) EDs and 24 (55%) MICS, less than a half of physicians were trained. CUS was used at least three times a day in 52 (41%) EDs and in 8 (19%) MICS. CONCLUSION: Our study demonstrates improved access to ultrasound devices in French EDs and MICS. Almost three-quarters of EDs and nearly one-third of MICS are now equipped with at least one ultrasound device. However, the rate of physicians trained per service remains insufficient.

MACVIA-LR (Fighting Chronic Diseases for Active and Healthy Ageing in Languedoc-Roussillon): A Success Story of the European Innovation Partnership on Active and Healthy Ageing.

The Région Languedoc Roussillon is the umbrella organisation for an interconnected and integrated project on active and healthy ageing (AHA). It covers the 3 pillars of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA): (A) Prevention and health promotion, (B) Care and cure, (C) and (D) Active and independent living of elderly people. All sub-activities (poly-pharmacy, falls prevention initiative, prevention of frailty, chronic respiratory diseases, chronic diseases with multimorbidities, chronic infectious diseases, active and independent living and disability) have been included in MACVIA-LR which has a strong political commitment and involves all stakeholders (public, private, patients, policy makers) including CARSAT-LR and the Eurobiomed cluster. It is a Reference Site of the EIP on AHA. The framework of MACVIA-LR has the vision that the prevention and management of chronic diseases is essential for the promotion of AHA and for the reduction of handicap. The main objectives of MACVIA-LR are: (i) to develop innovative solutions for a network of Living labs in order to reduce avoidable hospitalisations and loss of autonomy while improving quality of life, (ii) to disseminate the innovation. The three years of MACVIA-LR activities are reported in this paper.

Preoperative fasting does not affect haemodynamic status: a prospective, non-inferiority, echocardiography study.

BACKGROUND: The link between preoperative fasting and hypovolaemia remains unclear. We tested the hypothesis that preoperative fasting does not significantly increase the proportion of patients with hypovolaemia according to transthoracic echocardiography (TTE) criteria. METHODS: Patients of ASA status I-III and without bowel preparation were included in a non-inferiority, prospective, single-centre trial. Patients underwent passive leg raising (PLR) test and TTE at admission (Day 0) and after 8 h fasting (Day 1). The primary hypothesis was that an 8 h preoperative fasting does not increase the proportion (margin=5%) of patients with a positive PLR test ('functional approach'). The secondary hypothesis was that echocardiographic filling pressures or stroke volume (margin 10%) are not affected by preoperative fasting ('static approach'). RESULTS: One hundred patients were included and 98 analysed. After an 8 h fasting, the change in the proportion of responders to PLR was -6.1% [95% confidence interval (CI)=-16.0 to 3.8] of responders to PLR test on Day 0 when compared with Day 1. Because 95% CI was strictly inferior to 5%, there was no significant increase in the proportion of PLR responders on Day 1 when compared with Day 0. The 95% CI changes of static variables were always fewer than 10%, meaning that preoperative fasting induced significantly no relevant changes in static variables. CONCLUSION: Preoperative fasting did not alter TTE dynamic and static preload indices in ASA I-III adult patients. These results suggest that preoperative fasting does not induce significant hypovolaemia. Clinical trial registration NCT 01258361.

Availability and practice of bedside ultrasonography in emergency rooms and prehospital setting: a French survey.

INTRODUCTION: The utility of bedside ultrasound (US) performed by emergency physicians has been proven for multiple purposes. There are no data about this technique in emergency departments (ED) in France. The primary objective is to determine the availability of ultrasound device (UD) in EDs and in prehospital settings in France. Minor objectives are to determine the number and type of UD, the most current applications of US and the factors correlated with availability of UDs in the setting of emergency medicine. METHODS: This is a cross-sectional, descriptive, multicenter survey from December 2010 to June 2011, including all EDs and prehospital units in France. A questionnaire was sent by e-mail. Non-responders were contacted by telephone with one recall. RESULTS: The response rate was 74% (327/440) for EDs and 73% (278/379) for prehospital units. A UD is available in 52% (171/327) (CI 95% [46; 58]) of EDs and in 9% (25/278) (CI 95% [5; 13]) of prehospital units. Among departments having no access to UDs, 29% of EDs and 12% of prehospital units have plans to implement emergency physician-performed US. The most common US applications are focused assessment with sonography for trauma and pleural exams. CONCLUSION: Availability of UDs in French public hospital EDs is 52% and 9% in prehospital units. Despite the progressive expansion of the technique over the last years, bedside ultrasonography is not yet completely integrated in the physical examination of the patient in an emergency situation in France. A reassessment will be required to confirm the current trend of expansion.

Does the type of fluid affect rapidity of shock reversal in an anaesthetized-piglet model of near-fatal controlled haemorrhage? A randomized study.

BACKGROUND: The optimal resuscitation fluid for the early treatment of severe bleeding patients remains highly debated. The objective of this experimental study was to compare the rapidity of shock reversal with lactated Ringer (LR) or hydroxyethyl starch (HES) 130/0.4 at the early phase of controlled haemorrhagic shock. To assess the influence of vascular permeability in this model, we measured plasma vascular endothelial growth factor (VEGF) levels during the experiment. METHODS: Thirty-six anaesthetized and mechanically ventilated piglets were bled (<30 ml kg(-1)) to hold mean arterial pressure (MAP) at 40 mm Hg for more than 30 min and were resuscitated in two randomized groups: LR (n=14) or HES (n=14) at 1 ml kg(-1) min(-1) until MAP reached its baseline value of ±10%. MAP was maintained at its baseline value for 1 h. The time and fluid volume necessary to restore the baseline MAP value were measured. RESULTS: The time to restore the baseline MAP value of ±10% was significantly lower in the HES group (P<0.001). During the initial resuscitation phase, the infused volume was 279 (119) ml in the HES group and 1011 (561) ml in the LR group (P<0.0001). During the stabilization phase, the infused volume was 119 (124) ml in the HES group and 541 (506) ml in the LR group. Biological data and plasma VEGF levels were similar between the groups. CONCLUSIONS: Restoration of MAP was four times faster with HES than with LR in the early phase of controlled haemorrhagic shock. However, there was no evidence of increased vascular permeability.

Stroke volume optimization after anaesthetic induction: An open randomized controlled trial comparing 0.9% NaCl versus 6% hydroxyethyl starch 130/0.4.

OBJECTIVE: Postinduction hypotension during general anaesthesia could be corrected by a rapid cardiac preload optimization by fluid infusion. The type of fluid to be used in this context remains debated. The aim of our study was to compare the amount of fluid challenges required to optimize stroke volume after induction of anaesthesia with colloid (HES) or crystalloid (0.9% NaCl). DESIGN: Open randomized prospective parallel-group study. PATIENTS AND METHODS: Fifty-six adult patients scheduled to undergo orthopaedic surgery under general anaesthesia were randomly assigned to receive, either 0.9% NaCl (n=28), or HES (n=28). Cardiac preload optimization directed by oesophageal Doppler was performed after induction with fluid challenges of 250ml of solution until stroke volume (SV) no longer increased by 10%. Primary endpoint was: number of fluid challenges required to achieve SV optimization. Secondary endpoints were: number of patients responding to the first fluid challenge, proportion of patients requiring ephedrine and the ephedrine dose required to restore arterial pressure. RESULTS: Percentages of responders were 61% and 63% in the 0.9% NaCl and HES groups, respectively. Number of fluid challenges necessary for SV optimization was not significantly different between 0.9% NaCl group and HES group (2 [1-2] versus 2 [1-2], P=0.33). Number of patients needing ephedrine, and well as the associated ephedrine dose, did not differ significantly. CONCLUSIONS: Our study suggests that after induction, crystalloid and colloid expand the intravascular volume with equivalent efficacy immediately after administration and correct in a similar way the postinduction hypotension.

[Use of indicators of fluid responsiveness in septic shock: a survey in public emergency departments]. / Indices de réponse au remplissage vasculaire lors de la prise en charge d'un choc septique : utilisation par les médecins urgentistes.

INTRODUCTION: Fluid therapy is one of the major elements of severe sepsis and septic shock management. A systematic initial fluid bolus is recommended before evaluation of left ventricular filling pressure by the use of indicators of fluid responsiveness, preferentially dynamic ones. A massive fluid therapy could be damaging for the patient. Dynamic indicators of fluid responsiveness are not often relevant in the emergency department. This study was aimed to evaluate the use of indicators of fluid responsiveness by emergency practitioners during septic shock management. STUDY DESIGN: Cross sectional survey using anonymous self-questionnaire. METHODS: We included all practitioners working in public emergency department of Languedoc-Roussillon (France). Primary-end point was the use of one indicator of fluid responsiveness at least. Uni- and multivariate analysis was conducted to find associated factors. RESULTS: Of 232 practitioners included, we collected 149 questionnaires (response rate=64%). Hundred and eight practitioners (72% [64-79%]) used at least one indicator of fluid responsiveness. Fifty-six practitioners (38% [30-46%]) used echocardiography, 54 practitioners (36% [29-44%]) used blood lactate concentration, 45 practitioners (30% [23-38%]) used passive leg raising. The use of indicators of fluid responsiveness is associated with easy access to echography device (odd ratio=2.94 [1.16-7.62], P=0.03). CONCLUSION: Emergency practitioners use preferentially less invasive and less time-consuming indicators of fluid responsiveness.

Pre-hospital treatment of STEMI patients. A scientific statement of the Working Group Acute Cardiac Care of the European Society of Cardiology.

In ST-elevation myocardial infarction (STEMI) the pre-hospital phase is the most critical, as the administration of the most appropriate treatment in a timely manner is instrumental for mortality reduction. STEMI systems of care based on networks of medical institutions connected by an efficient emergency medical service are pivotal. The first steps are devoted to minimize the patient's delay in seeking care, rapidly dispatch a properly staffed and equipped ambulance to make the diagnosis on scene, deliver initial drug therapy and transport the patient to the most appropriate (not necessarily the closest) cardiac facility. Primary PCI is the treatment of choice, but thrombolysis followed by coronary angiography and possibly PCI is a valid alternative, according to patient's baseline risk, time from symptoms onset and primary PCI-related delay. Paramedics and nurses have an important role in pre-hospital STEMI care and their empowerment is essential to increase the effectiveness of the system. Strong cooperation between cardiologists and emergency medicine doctors is mandatory for optimal pre-hospital STEMI care. Scientific societies have an important role in guideline implementation as well as in developing quality indicators and performance measures; health care professionals must overcome existing barriers to optimal care together with political and administrative decision makers.

[Triple nerve block for ambulatory knee arthroscopy]. / Tribloc (fémoral, sciatique, obturateur) pour la chirurgie ambulatoire arthroscopique de genou: étude prospective de faisabilité et d'efficacité.

BACKGROUND: The purpose of this study was to evaluate intra- and postoperative conditions of the triple nerve block technique (femoral, obturator, sciatic block) for outpatient knee arthroscopic procedures. METHODS: After written informed consent, ASA I-III patients received a combined triple nerve block with 30-40 ml lidocaine or mepivacaine (1,5%). Blocks were performed using a nerve stimulation technique. Onset time, block failure, supplemental general anesthesia (GA) or analgesia and pain score were recorded intraoperatively. After surgery, side effects (at days 0, 1, 3, 7 and after 4 weeks), patient and surgeon satisfactions were noted. RESULTS: Three hundred and twelve patients were screened and 115 triple blocks were performed (157 chose GA, 19 spinal anaesthesia, 21 exclusion for regional anaesthesia). Failed blocks occurred for 12 (10%) patients. These 12 patients received GA before surgery incision. Time to complete block was 40 (10-60) min. Supplemental GA was required for 12 patients (12%) due to surgical (n=7, 7%) or tourniquet (n=5, 5%) pain. Intraoperative surgeon satisfaction was 90 (60-100). After surgery, time to discharge the postoperative care unit was 15 (5-60) min. Pain score at rest (Visual Analog Scale) until six hours was less than 30 /100, without any additional morphine. Two patients (< 2%) failed for ambulatory discharge criteria (no relation with triple block). At day 0, 3, 5% patients suffered PONV (8% at D1), paresthesia was noted in 1.7% at D0 (0,8% D3). No other secondary effects were observed after seven days and 91% patients "would like same anaesthesia" for next surgery. CONCLUSION: We conclude that triple nerve block provided reliable intraoperative patient and surgical conditions for outpatient knee arthroscopy. Failed block (10%) was the major reason of supplemental anaesthesia. To increase surgical turn over under triple nerve block, a preoperative room may be required (block onset time).

[Impact of Express study on clinical practice in ARDS patients: a single French ICU experience]. / Evolution des pratiques ventilatoires chez les patients en SDRA lors de la participation à un essai clinique randomisé: l'expérience d'une unité de réanimation française.

INTRODUCTION: The French Express study compared two alveolar recruitment managements (maximal versus standard) in Acute Respiratory Distress Syndrome (ARDS) patients ventilated with 6 ml/kg of ideal body weight (IBW). The objective of the present study was to assess in a single intensive care unit, the impact of Express study on the mechanical ventilation settings in non-included ARDS patients. PATIENTS AND METHODS: From 16 October 2002 to 14 January 2005 all consecutive eligible but non-included patients in Express study were studied. The maximal and minimal tidal volumes, and the minimal and maximal respiratory rates were retrospectively recorded. These parameters were compared according to the date of patient's admission and then the patients were separated in four quartiles (14, 15, 15, 15 patients). RESULTS: From the first to the last study period separated by 26 months, the mean maximal tidal volume decreased from 9.0+/-1.3 to 7.4+/-1.0 ml/kg of IBW (p=0.03), the proportion of patients ventilated with a maximal tidal volume greater than 8 ml/kg decreased from 93% to 20% (p<0.01), the median minimal respiratory rate increased from 14 to 18 b/min (p=0.03) and the proportion of patients with a respiratory rate less than 20 b/min decreased from 100% to 73% (p<0.01). There were correlations between the time of patient's admission and the maximal tidal volume (r=-0.43, p<0.01), the minimal tidal volume (r=-0.28, p<0.04) and the minimal respiratory rate (r=0.33, p<0.02). CONCLUSION: The participation in Express study led physicians to modify their mechanical ventilation settings. The maximal tidal volume decreased and the minimal respiratory rate increased in the ARDS eligible but non-included patients.

[Lipid emulsions for the treatment of systemic local anesthetic toxicity: Efficacy and limits]. / Les émulsions lipidiques dans le traitement de la toxicité systémique des anesthésiques locaux : efficacité et limites.

Local anaesthetic toxicity always results from rapid and important increase in their plasma concentrations. Clinically, neurologic and cardiovascular symptoms may occur, especially life-threatening cardiac arrhythmias and cardiac depression. Resuscitating patients from cardiac toxicity was known as difficult, until the introduction of lipid emulsion therapy. From experimental data, at least two mechanisms of action can be proposed, a sink-effect and an improvement of cardiomyocyte metabolism. The present article is a mini-review of the current use of lipid emulsions for the treatment of local anaesthetic cardiac toxicity. The mechanisms of cardiac toxicity and those of lipid emulsion therapy are summarized, and the clinical experience of this therapy and its limits are presented.

Could B-type Natriuretic Peptide (BNP) plasma concentration be useful to predict fluid responsiveness [corrected] in critically ill patients with acute circulatory failure?

BACKGROUND AND OBJECTIVES: As B-type Natriuretic Peptide (BNP) is a marker of ventricular wall stress, the present study was aimed at determining whether plasma BNP concentration could predict fluid responsiveness in critically ill patients with acute circulatory failure. METHODS: This prospective and non randomized interventional study included 33 sedated, mechanically ventilated patients, with acute circulatory failure requiring cardiac output measurement and fluid challenge. Plasma BNP concentration was measured before and after fluid challenge (250 to 500 ml with infusion rate=999 ml/h). An increase in stroke index (SI) greater than or equal to 15% allowed separation of responders from nonresponders. Receiver operating characteristic (ROC) curves were generated for BNP and compared to that of central venous pressure (CVP) that is routinely considered as a marker of cardiac preload. RESULTS: Among 33 patients, there were 24 responders. At baseline, BNP plasma values were less in responders (328 [35-1190] pg/ml versus 535 [223-5000] pg/ml, p<0.03). The area under the ROC curves was 0.74+/-0.11, that was similar to the area under the ROC curve for CVP (0.77+/-0.10). The best cut-off value of plasma BNP level for predicting fluid responsiveness was 193 pg/ml (sensitivity: 38%, specificity: 100%, positive predictive value: 100%, negative predictive value: 38%, accuracy: 55%). Fluid challenge did not increase plasma BNP concentrations in responders and nonresponders. CONCLUSION: In critically ill patients with acute circulatory failure, BNP does not accurately predict fluid responsiveness.

Impact of the use of propofol remifentanil goal-directed sedation adapted by nurses on the time to extubation in mechanically ventilated ICU patients: the experience of a French ICU.

AIM: Inappropriate sedation could prolong the duration of mechanical ventilation. The present "before-after" study assessed the impact of a goal-directed sedation using an algorithm with a combination of propofol and remifentanil on the time to extubation. METHODS: During 16 months, ICU-patients requiring sedation greater than 24 h were prospectively studied. In the first eight months, sedation was achieved using continuous infusions of a benzodiazepine (flunitrazepam or midazolam) and an opioid (fentanyl or sufentanil). In the following eight months, sedation using a propofol-remifentanil combination was given and adapted by the nurses according to the Ramsay score and a pain scale. The main endpoint was the time to extubation (from the cessation of sedation to extubation). The secondary endpoints were the duration of mechanical ventilation, the length of ICU stay, the ICU mortality rate, the need of vasopressive support, the occurrence of self-extubations and Ventilator-Associated Pneumonia (VAP). RESULTS: Forty-six and 39 patients were included in the first and second periods, respectively. The durations of sedation were similar. The time to extubation was shorter in the second period (10 versus 92h, p<0.0001). The duration of mechanical ventilation, the length of stay in ICU, the mortality rate, the need for vasopressor support and the occurrence of VAP were similar. Five self-extubations occurred in the second period versus one in the first one (p=0.02). CONCLUSION: Sedation with adapted infusions of propofol and remifentanil according to the Ramsay score and a pain scale decreases the time to extubation in ICU patients requiring sedation longer than 24h but increases the rate of self-extubations.

[General practitioners' and intensivists' relationships: intensivists' point of view from eight French southern regional areas]. / Relations entre médecin traitant et médecin réanimateur: l'opinion des réanimateurs de huit départements du sud de la France.

OBJECTIVES: Assessment of relationship between general practitioners and intensivists. STUDY DESIGN: Intensivists were questioned by phone from June 14th to September 28th 2004. METHODS: 245 out of 264 intensivists from 8 French Southern regional areas were questioned concerning their relationship with critically ill patients' general practitioner. RESULTS: Patients were mainly admitted into Intensive care Unit (ICU) from the Emergency Department (55%). An information letter from the general practitioner was reported for 20% of admitted patients but 50% of these letters was assumed as not informative. The informations concerning the patient's medical history, therapies, and disease leading to admission and the patient's status were assessed with 6.5, 7.0, 6.0 and 2.0, respectively (maximal note=10). The intensivists contacted the general practitioner for 30% of admitted patients. During the stay in ICU, 33% general practitioners were reported to request informations by phone or visit in ICU. When the stay in ICU was>10 days, the general practitioner was nearly never regularly informed about patient's status. When the patient was discharged from the ICU, 80% of intensivists used an exhaustive typed report to inform the general practitioner. The overall relationship between the general practitioner and the intensivist was assessed as 5.5/10. Insufficient information in the general practitioner's letter at admission, the lack of request for information during the stay in ICU, the lack of contact with the general practitioner by the intensivist and an intensivist's age between 46 and 55 were associated with a relationship assessment<4/10).