Independent factors of preventable death in a mature trauma center: a propensity-score analysis.

INTRODUCTION: The rate of potentially preventable deaths (PPD) and preventable deaths (PD) can reach more than 20% of overall trauma mortality. Bleeding is the leading cause of preventable mortality. The aim of our study is to define the independent factors of preventable or potentially preventable mortality in our mature trauma system. MATERIALS AND METHODS: We conducted a single-center retrospective study in the Sainte Anne Military Teaching Hospital, Toulon, France, including all severe trauma patients admitted to our trauma center and discharged alive as well as all severe trauma patients who died with a death considered preventable or potentially preventable from January 2013 to December 2020. We matched the two groups using a propensity score and searched for independent factors using a generalized linear model. RESULTS: 846 patients were included and analyzed. After matching, our cohort consisted of 245 patients in the survivor group and 49 patients in the preventable deaths group. Pre-hospital delays (73 min vs 54 min P = 0.003) as well as delays before incision in the operating room (80 min vs 52 min P < 0.001) were significantly longer in the PD group. These delays were independent factors of preventable mortality OR 10.35 (95% CI [3.44-31.11] P < 0.001) and OR 37.53 (95% CI [8.51-165.46] P < 0.001) as well as pelvic trauma OR 6.20 (95% CI [1.53-25.20] P = 0.011). CONCLUSION: Delays in pre-hospital care, delays in access to the operating room from arrival at the trauma center, and pelvic injuries are independent factors associated with an increased risk of preventable mortality in trauma.

ABO blood type and functional neurological outcome in patients with severe traumatic brain injury.

BACKGROUND: The ABO blood system has been involved in the pathogenesis of several diseases, including coagulopathy and bleeding complications. In trauma patients, blood type A has been associated with acute respiratory distress syndrome, and recently, blood type O has been associated with all-cause mortality. The purpose of this study was to assess the association between ABO blood types and long-term functional outcomes in critically ill patients with severe traumatic brain injury (TBI). METHODS: We conducted a single-center, retrospective, observational study including all patients admitted to the intensive care unit with severe TBI (defined as a Glasgow Coma Scale score of ≤8) between January 2007 and December 2018. Patient characteristics and outcomes were extracted from a prospective registry of all intubated patients admitted to the intensive care unit for TBI. ABO blood types were retrospectively retrieved from patient medical records. The association between ABO blood type (A, B, AB, and O) and unfavorable functional outcome (defined by a Glasgow Outcome Scale score between 1 and 3) 6 months after injury was assessed in univariate and multivariate analysis. RESULTS: A total of 333 patients meeting the inclusion criteria were included. There were 151 type O (46%), 131 type A (39%), 37 type B (11%), and 12 type AB patients (4%). No significant differences in baseline demographic, clinical, or biological characteristics were observed between blood types. The prevalence of unfavorable outcome was significantly different between the four groups. After adjustment for confounders, blood type O was significantly associated with unfavorable outcome at 6 months (odds ratio, 1.97; confidence interval [1.03-3.80]; p = 0.042). The prevalence of coagulopathy or progressive hemorrhagic injury was not statistically different between blood types ( p = 0.575 and p = 0.813, respectively). CONCLUSION: Blood type O appears to be associated with unfavorable long-term functional outcome in critically ill patients with severe TBI. Further studies are needed to detail the mechanism underlying this relationship. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Analysis of mortality over 7 years in a mature trauma center: evolution of preventable mortality in severe trauma patients.

PURPOSE: The study of preventable trauma deaths is one mechanism used to examine the quality of care and outcomes of a trauma system. The present study aims to define the rate of preventable (PD) and potentially preventable death (PPD) in our mature trauma center, determine its leading causes, and evaluate the evolution of this rate over the years. METHODS: We performed a retrospective observational study in the Sainte Anne Military Teaching Hospital, Toulon (Var), France. From January 2013 to December 2020, all patients with severe trauma admitted to our trauma center and who died were analyzed. An independent group of 4 experts in the management of severe trauma performed the classification of deaths using a DELPHI method. RESULTS: During the study period, 180 deaths occurred among 2642 consecutive severe trauma patients (overall mortality 6.8%). 169 deaths were analyzed, Eleven (6.5%) were considered PD, and thirty-eight (22.1%) were PPD. 69 errors were identified. The most frequent errors were in pre-hospital (excessive pre-hospital times 33.3% and inadequate management 29%). Time before surgery was considered excessive in 15.9% of cases. Over the study period, the rates of PD and PPD deaths remained stable. CONCLUSION: PD and PPD rates are still high and do not decrease over the years in our mature trauma center. It confirms the need for progress in the management of severe trauma patients. Reducing the time to provide care seems to be the main area for improvement. Further studies will be necessary to better target the points to be improved.

Association of Early Norepinephrine Administration With 24-Hour Mortality Among Patients With Blunt Trauma and Hemorrhagic Shock.

Importance: Hemorrhagic shock is a common cause of preventable death after injury. Vasopressor administration for patients with blunt trauma and hemorrhagic shock is often discouraged. Objective: To evaluate the association of early norepinephrine administration with 24-hour mortality among patients with blunt trauma and hemorrhagic shock. Design, Setting, and Participants: This retrospective, multicenter, observational cohort study used data from 3 registries in the US and France on all consecutive patients with blunt trauma from January 1, 2013, to December 31, 2018. Patients were alive on admission with hemorrhagic shock, defined by prehospital or admission systolic blood pressure less than 100 mm Hg and evidence of hemorrhage (ie, prehospital or resuscitation room transfusion of packed red blood cells, receipt of emergency treatment for hemorrhage control, transfusion of >10 units of packed red blood cells in the first 24 hours, or death from hemorrhage). Blunt trauma was defined as any exposure to nonpenetrating kinetic energy, collision, or deceleration. Statistical analysis was performed from January 15, 2021, to February 22, 2022. Exposure: Continuous administration of norepinephrine in the prehospital environment or resuscitation room prior to hemorrhage control, according to European guidelines. Main Outcomes and Measures: The primary outcome was 24-hour mortality, and the secondary outcome was in-hospital mortality. The average treatment effect (ATE) of early norepinephrine administration on 24-hour mortality was estimated according to the Rubin causal model. Inverse propensity score weighting and the doubly robust approach with 5 distinct analytical strategies were used to determine the ATE. Results: A total of 52 568 patients were screened for inclusion, and 2164 patients (1508 men [70%]; mean [SD] age, 46 [19] years; median Injury Severity Score, 29 [IQR, 17-36]) presented with acute hemorrhage and were included. A total of 1497 patients (69.1%) required emergency hemorrhage control, 128 (5.9%) received a prehospital transfusion of packed red blood cells, and 543 (25.0%) received a massive transfusion. Norepinephrine was administered to 1498 patients (69.2%). The 24-hour mortality rate was 17.8% (385 of 2164), and the in-hospital mortality rate was 35.6% (770 of 2164). None of the 5 analytical strategies suggested any statistically significant association between norepinephrine administration and 24-hour mortality, with ATEs ranging from -4.6 (95% CI, -11.9 to 2.7) to 2.1 (95% CI, -2.1 to 6.3), or between norepinephrine administration and in-hospital mortality, with ATEs ranging from -1.3 (95% CI, -9.5 to 6.9) to 5.3 (95% CI, -2.1 to 12.8). Conclusions and Relevance: The findings of this study suggest that early norepinephrine infusion was not associated with 24-hour or in-hospital mortality among patients with blunt trauma and hemorrhagic shock. Randomized clinical trials that study the effect of early norepinephrine administration among patients with trauma and hypotension are warranted to further assess whether norepinephrine is safe for patients with hemorrhagic shock.

Emergency department thoracotomy in a physician-staffed trauma system: the experience of a French Military level-1 trauma center.

PURPOSE: To investigate survival after emergency department thoracotomy (EDT) in a physician-staffed emergency medicine system. METHODS: This single-center retrospective study included all in extremis trauma patients who underwent EDT between 2013 and 2021 in a military level 1 trauma center. CPR time exceeding 15 minutes for penetrating trauma of 10 minutes for blunt trauma, and identified head injury were the exclusion criteria. RESULTS: Thirty patients (73% male, 22/30) with a median age of 42 y/o [27-64], who presented mostly with polytrauma (60%, 18/30), blunt trauma (60%, 18/30), and severe chest trauma with a median AIS of 4 3-5 underwent EDT. Mean prehospital time was 58 min (4-73). On admission, the mean ISS was 41 29-50, and 53% (16/30) of patients had lost all signs of life (SOL) before EDT. On initial work-up, Hb was 9.6 g/dL [7.0-11.1], INR was 2.5 [1.7-3.2], pH was 7.0 [6.8-7.1], and lactate level was 11.1 [7.0-13.1] mmol/L. Survival rates at 24 h and 90 days after penetrating versus blunt trauma were 58 and 41% versus 16 and 6%, respectively. If SOL were present initially, these values were 100 and 80% versus 22 and 11%. CONCLUSION: Among in extremis patients supported in a physician-staffed emergency medicine system, implementation of a trauma protocol with EDT resulted in overall survival rates of 33% at 24 h and 20% at 90 days. Best survival was observed for penetrating trauma or in the presence of SOL on admission.

Lung-Dependent Areas Collapse, Monitored by Electrical Impedance Tomography, May Predict the Oxygenation Response to Prone Ventilation in COVID-19 Acute Respiratory Distress Syndrome.

OBJECTIVES: ICUs have had to deal with a large number of patients with acute respiratory distress syndrome COVID-19, a significant number of whom received prone ventilation, which is a substantial consumer of care time. The selection of patients that we have to ventilate in prone position seems interesting. We evaluate the correlation between the percentage of collapsed dependent lung areas in the supine position, monitoring by electrical impedance tomography and the oxygenation response (change in Pao2/Fio2 ratio) to prone position. DESIGN: An observational prospective study. SETTING: From October 21, 2020, to 30 March 30, 2021. At the Sainte Anne military teaching Hospital and the Timone University Hospital. PATIENTS: Fifty consecutive patients admitted in our ICUs, with COVID-19 acute respiratory distress syndrome and required mechanical, were included. Twenty-four (48%) received prone ventilation. Fifty-eight prone sessions were investigated. INTERVENTIONS: An electrical impedance tomography recording was made in supine position, daily and repeated just before and just after the prone session. The daily dependent area collapse was calculated in relation to the previous electrical impedance tomography recording. Prone ventilation response was defined as a Pao2/Fio2 ratio improvement greater than 20%. MEASUREMENT AND MAIN RESULTS: The main outcome was the correlation between dependent area collapse and the oxygenation response to prone ventilation. Dependent area collapse was correlated with oxygenation response to prone ventilation (R2 = 0.49) and had a satisfactory prediction accuracy of prone response with an area under the curve of 0.94 (95% CI, 0.87-1.00; p < 0.001). Best Youden index was obtained for a dependent area collapse greater than 13.5 %. Sensitivity of 92% (95% CI, 78-97), a specificity of 91% (95% CI, 72-97), a positive predictive value of 94% (95% CI, 88-100), a negative predictive value of 87% (95% CI, 78-96), and a diagnostic accuracy of 91% (95% CI, 84-98). CONCLUSIONS: Dependent lung areas collapse (> 13.5%), monitored by electrical impedance tomography, has an excellent positive predictive value (94%) of improved oxygenation during prone ventilation.

Severe Aortic Thrombosis and Profound Hypothermia: A Case Report.

BACKGROUND: Blood clot formation is a multifactorial process and has been related many times in intensive care units. Here is presented a multiple thrombosis formation in a rewarming patient. CASE DESCRIPTION: A 68-year-old patient was admitted to our intensive care unit after lying on the floor for an unknown time. She presented a severe hypothermia at 26° and a severe cardiogenic shock. Because she was confused and was hypoxemic, she had been intubated at her admission. After intravascular warming, we could stop sedative medications. She presented a right hemiparesis and acute left leg ischemia. Computed tomography (CT) scan revealed a constituted left Sylvian stroke and a massive clot along the aorta. She required a surgical embolectomy and fasciotomy. She died after she presented a severe bowel ischemia on the third day after her admission. CONCLUSION: Relevant hypothesis for blood clot formation in this patient may include prolonged lying position or blood temperature variation. Hypothermia and rewarming responsibilities may explain multiple thrombosis development. HOW TO CITE THIS ARTICLE: Schmitt J, Esnault P, Sartre M, Cungi PJ, Meaudre E. Severe Aortic Thrombosis and Profound Hypothermia: A Case Report. Indian J Crit Care Med 2021;25(5):588-589.

The French Pre-Deployment Advanced Course in Anesthesia and Resuscitation: Development and Future Prospects.

INTRODUCTION: Military anesthesiologists from the French Military Medical Service (FMMS) are part of the Forward Surgical Teams deployed in overseas military operations. The practice of anesthesia in combat zones requires specific skills that are not taught during the initial curriculum for French civilian anesthesiologist. The Pre-Deployment Advanced Course in Anesthesia and Resuscitation (DACAR) program was developed to prepare military anesthesiologist from the FMMS before their deployment in overseas military operations. METHODS: Created in 2013 by the French Military Medical Academy, the DACAR program is divided into two modules and carried out once a year. The DACAR program trains all military anesthesiologist residents at the end of their curricula. Since 2019, a number of Certified Registered Nurse Anesthetists have completed the DACAR program. The DACAR program is organized around the main axes of experience feedback from previous deployments in combat zones as well as didactic learning and practical training using high-fidelity simulation. RESULTS: Since 2013, a total of 99 trainees completed the DACAR program during six complete cycles of two modules. The DACAR program has gradually been enriched from 14 courses in 2013 to 28 in 2019. Participants' reported satisfaction rates have increased steadily since 2016, when 88% of courses were rated as "interesting" or "very interesting," and only 4% as "not very interesting." By 2019, those figures had improved to 96% and 2%, respectively. CONCLUSION: The DACAR program is a structured and adapted military medical course aimed at completing the curriculum of military anesthesiologists from the FMMS before deployment in overseas military operations. Regular audits and updates ensure that the DACAR training program maintains the highest standards of quality and rigor.

A national healthcare response to intensive care bed requirements during the COVID-19 outbreak in France.

BACKGROUND: Whereas 5415 Intensive Care Unit (ICU) beds were initially available, 7148 COVID-19 patients were hospitalised in the ICU at the peak of the outbreak. The present study reports how the French Health Care system created temporary ICU beds to avoid being overwhelmed. METHODS: All French ICUs were contacted for answering a questionnaire focusing on the available beds and health care providers before and during the outbreak. RESULTS: Among 336 institutions with ICUs before the outbreak, 315 (94%) participated, covering 5054/5531 (91%) ICU beds. During the outbreak, 4806 new ICU beds (+95% increase) were created from Acute Care Unit (ACU, 2283), Post Anaesthetic Care Unit and Operating Theatre (PACU & OT, 1522), other units (374) or real build-up of new ICU beds (627), respectively. At the peak of the outbreak, 9860, 1982 and 3089 ICU, ACU and PACU beds were made available. Before the outbreak, 3548 physicians (2224 critical care anaesthesiologists, 898 intensivists and 275 from other specialties, 151 paediatrics), 1785 residents, 11,023 nurses and 6763 nursing auxiliaries worked in established ICUs. During the outbreak, 2524 physicians, 715 residents, 7722 nurses and 3043 nursing auxiliaries supplemented the usual staff in all ICUs. A total number of 3212 new ventilators were added to the 5997 initially available in ICU. CONCLUSION: During the COVID-19 outbreak, the French Health Care system created 4806 ICU beds (+95% increase from baseline), essentially by transforming beds from ACUs and PACUs. Collaboration between intensivists, critical care anaesthesiologists, emergency physicians as well as the mobilisation of nursing staff were primordial in this context.

Fibrin monomers and association with significant hemorrhage or mortality in severely injured trauma patients.

BACKGROUND: Post-traumatic hemorrhage is still the leading cause of potentially preventable death in patients with severe trauma. Traumatic-induced coagulopathy has been described as a risk factor for significant hemorrhage and mortality in this population. Fibrin monomers (FMs) are a direct marker of thrombin action, and thus reflect coagulation activation. This study sought to determine the association of FMs levels at admission with significant hemorrhage and 28-day mortality after a severe trauma. METHODS: We conducted a retrospective, observational study including all severe trauma patients admitted in a level-1 trauma center between January 2012 and December 2017. Patients with severe traumatic brain injury or previous anticoagulant / antiaggregant therapies were excluded. FMs measurements and standard coagulation test were taken at admission. Significant hemorrhage was defined as a hemorrhage requiring the transfusion of ≥ 4 Red Blood Cells units during the first 6 h. Multivariable analysis was applied to identify predictors of significant hemorrhage and a simple logistic regression analysis was applied to identify an association between FMs and 28-day mortality. RESULTS: Overall, 299 patients were included. A total of 47 (16%) experienced a significant hemorrhage. The ROC curve demonstrated that FMs had a poor accuracy to predict the occurrence of significant hemorrhage with an AUC of 0.65 (0.57-0.74). The best threshold at 92.45 µg/ml had excellent sensitivity (87%) and negative predictive value (95%), but was not independently associated with significant hemorrhage (OR = 1.5; 95%CI (0.5-4.2)). The 28-day mortality rate was 5%. In simple logistic regression analysis, FMs values ≥109.5 µg/ml were significantly associated with 28-day mortality (unadjusted OR = 13.2; 95%CI (1.7-102)). CONCLUSIONS: FMs levels at admission are not associated with the occurrence of a significant hemorrhage in patients with severe trauma. However, the excellent sensitivity and NPV of FMs could help to identify patients with a low risk of severe bleeding during hospital care. In addition, FMs levels ≥109.5 µg/ml might be predictive of 28-day mortality.

In COPD, Nocturnal Noninvasive Ventilation Reduces the FIO2 Delivered Compared With Long-Term Oxygen Therapy at the Same Flow.

BACKGROUND: Nocturnal noninvasive ventilation is recommended for patients with hypercapnic COPD. Long-term oxygen therapy improves survival in patients with hypoxemic disease. However, leaks during noninvasive ventilation are likely to reduce the fraction of inspired oxygen. OBJECTIVES: To compare nocturnal inspired O2 fractions during noninvasive ventilation with daytime pharyngeal inspired O2 fractions during nasal cannula oxygen therapy (with the same O2 flow) in patients with COPD at home (ie, real-life conditions). METHODS: This single-center prospective observational study included 14 subjects with COPD who received long-term O2 therapy. We analyzed pharyngeal inspired O2 fractions in the evening, with a nasopharyngeal probe (sidestream gas analyzer). The O2 flow was measured with a precision flow meter, at the usual flow. Then, the same O2 flow was implemented for noninvasive ventilation with a study's home ventilator. The all-night noninvasive ventilation parameters were delivered in pressure mode with a single-limb leaking circuit. Daytime and nighttime inspired O2 fractions were compared. RESULTS: The mean ± SD daytime pharyngeal inspired O2 fraction, measured with normobaric basal O2 flow, 0.308 ± 0.026%, was significantly higher than the mean ± SD nighttime inspired O2 fraction, measured during noninvasive ventilation (0.251 ± 0.011; P < .001). CONCLUSIONS: The nighttime inspired O2 fraction decreased with a modern noninvasive ventilation pattern, pressure target, and intentional leaks. This partial lack of O2 therapy is likely to be harmful. It might explain the poor results in all but 2 randomized controlled trials on long-term noninvasive ventilation in COPD. (ClinicalTrials.gov registration NCT02599246.).

Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources.

BACKGROUND: Relying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources. RATIONALE: Prioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients. PRIORITISATION STRATEGY: Prioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1-high priority, P2-intermediate priority, P3-not needed, P4-not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount. PERSPECTIVE: Prioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation.

Maintaining a high inspired oxygen fraction with the Elisée 350 turbine transport ventilator connected to two portable oxygen concentrators in an austere environment.

BACKGROUND: Management of critically ill patients requiring mechanical ventilation in austere environments or during disaster response is a logistic challenge. Availability of oxygen cylinders for mechanically ventilated patient may be difficult in such a context. A solution to ventilate patients requiring high fraction of inspired oxygen (FiO2) is to use a ventilator able to be supplied by a low-pressure oxygen source connected with two oxygen concentrators (OCs). We tested the Elisée 350 (ResMedBella Vista, Australia) ventilator paired with two Newlife Intensity 10 (Airsep, Ball Ground, Georgia) OCs and evaluated the delivered FiO2 across a range of minute volumes and combinations of ventilator settings. METHODS: The ventilators were attached to a test lung, OC flow was adjusted with a Certifier FA ventilator test systems from 2 to 10 L/min and injected into the oxygen inlet port of the Elisée 350. The FiO2 was measured by the analyzer integrated in the ventilator, controlled by the ventilator test system. Several combinations of ventilator settings were evaluated to determine the factors affecting the delivered FiO2. RESULTS: The Elisée 350 ventilator is a turbine ventilator able to deliver high FiO2 when functioning with two OCs. However, modifications of the ventilator settings such as an increase in minute ventilation affect delivered FiO2 even if oxygen flow is constant on the OC. CONCLUSION: The ability of two OCs to deliver high FiO2 when used with a turbine ventilator makes this method of oxygen delivery a viable alternative to cylinders to ventilate patients requiring an FiO2 of ≥80% in austere place or during disaster response. LEVEL OF EVIDENCE: Feasibility study on test bench, level V.

Acute respiratory distress syndrome in the forward environment. Retrospective analysis of acute respiratory distress syndrome cases among French Army war casualties.

BACKGROUND: According to the Joint Theater Trauma Registry, 26% to 33% of war casualties develop acute respiratory distress syndrome (ARDS), with high mortality. Here, we aimed to describe ARDS incidence and severity among patients evacuated from war zones and admitted to French intensive care units (ICUs). METHODS: We performed an observational retrospective multicentric review of all patients evacuated from war zones and admitted to French ICUs between 2003 and 2018. Our analysis included all medical and trauma patients developing ARDS according to the Berlin definition. We evaluated ARDS incidence, and determined ARDS severity from arterial blood gas analysis. Analyzed parameters included invasive ventilation duration, ARDS treatments, ICU stay length, and 30-day and 90-day mortalities. RESULTS: Among 141 included patients (84% military; median age, 30 years), 57 (42%) developed ARDS. Acute respiratory distress syndrome was mild in 13 (22%) patients, moderate in 24 (42%) patients, and severe in 20 (36%) patients. Evacuation occurred in less than 26 hours for 32 war casualties, 17 non-war-related trauma patients, and 8 medical patients. Among severe trauma patients, median Injury Severity Score was 34, and Abbreviated Injury Scale thorax was 3. Upon French ICU admission, median partial pressure of oxygen in arterial blood/inspirated fraction of oxygen ratio was 241 [144-296]. Administered ARDS treatments included intubation (98%, n = 56), protective ventilation (87%, n = 49), neuromuscular blockade (76%, n = 43), prone position (16%, n = 9), inhaled nitric oxide (10%, n = 6), almitrine (7%, n = 7), and extracorporeal life support (4%, n = 2). Median duration of invasive ventilation was 13 days, ICU stay was 18 days, 30-day mortality was 14%, and 90-day mortality was 21%. CONCLUSION: Acute respiratory distress syndrome was frequent and severe among French patients evacuated from war theaters. Improved treatment capacities are needed in the forward environment-for example, a specialized US team can provide extracorporeal life support for highly hypoxemic war casualties. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.