Mismatch negativity to predict subsequent awakening in deeply sedated critically ill patients.

BACKGROUND: Mismatch negativity (MMN) is the neurophysiological correlate of cognitive integration of novel stimuli. Although MMN is a well-established predictor of awakening in non-sedated comatose patients, its prognostic value in deeply sedated critically ill patients remains unknown. The aim of this prospective, observational pilot study was to investigate the prognostic value of MMN for subsequent awakening in deeply sedated critically ill patients. METHODS: MMN was recorded in 43 deeply sedated critically ill patients on Day 3 of ICU admission using a classical 'odd-ball' paradigm that delivers rare deviant sounds in a train of frequent standard sounds. Individual visual analyses and a group level analysis of recordings were performed. MMN amplitudes were then analysed according to the neurological status (awake vs not awake) at Day 28. RESULTS: Median (inter-quartile range) Richmond Assessment Sedation Scale (RASS) at the time of recording was -5 (range, from -5 to -4.5). Visual detection of MMN revealed a poor inter-rater agreement [kappa=0.17, 95% confidence interval (0.07-0.26)]. On Day 28, 30 (70%) patients had regained consciousness while 13 (30%) had not. Quantitative group level analysis revealed a significantly greater MMN amplitude for patients who awakened compared with those who had not [mean (standard deviation) = -0.65 (1.4) vs 0.08 (0.17) µV, respectively; P=0.003). CONCLUSIONS: MMN can be observed in deeply sedated critically ill patients and could help predict subsequent awakening. However, visual analysis alone is unreliable and should be systematically completed with individual level statistics.

[Starvation ketosis in a breastfeeding woman]. / Cétose de jeûne chez une femme allaitante.

INTRODUCTION: Bovine ketosis is a rare cause of metabolic acidosis. It is a starvation ketosis that appears in lactating woman. CASE REPORT: A 29-year-old woman had a previous gastric surgery one month ago while breastfeeding her 6-month child. She presented to emergency with dyspnea, fatigue, weight loss and anorexia. The explorations revealed a serious metabolic acidosis with a high anion gap, for which all other causes have been eliminated. CONCLUSION: A restrictive diet in lactating patients is a major risk of ketosis or bovine ketosis. Medico-surgical treatment of obesity during lactation seems unreasonable. Breastfeeding should be systematically sought before a medical and surgical management of obesity. With the spread of bariatric surgery, starvation ketosis is a cause of metabolic acidosis not to ignore.

An individual scoring system for the prediction of postpartum anaemia.

BACKGROUND: Postpartum anaemia (PPA) is a common postpartum complication. The goal of this study was to prospectively construct a predictive score for individual risk of PPA. PATIENTS ET METHOD: We prospectively analyzed factors associated with PPA (<10gdL(-1) at 48hours postpartum). Parameters analyzed were demographic data, pregnancy characteristics, delivery and postpartum characteristics. Univariate analysis was performed using Anova or X(2); the Cox model was used for multivariate analysis. The scoring system was validated using ROC curve. RESULTS: Analysis was performed in 475 patients and validation was carried using an additional 95 patients. Multivariate analysis found four factors independently associated with PPA: anaemia during the third trimester of the pregnancy, Southeast Asian ethnic origin, episiotomy and severe postpartum haemorrhage (PPH) identified by the use of sulprostone. According to the score derived from the Cox model, patients were classified as low (22%, score=0), medium (55%, score=2 or 3) and high (86%, score>3) probability of PPA. Using the AUC of the ROC curve for both the first and the validation cohorts (performed on 95 further patients), we recorded AUCs of 72% and 70% respectively. CONCLUSIONS: This study allowed the derivation and validation of a predictive score of PPA. This score might be useful in targeting prophylactic strategies for PPA. Such strategies could include a more active treatment of iron deficiency (increasing oral iron treatment observance or intravenous iron therapy) especially in exposed population, improvement in the prevention and treatment of postpartum haemorrhage and decreasing the use of episiotomy. Future studies must focus on the external validation and generalisation of this scoring system.

[Impact of anaesthesia management on post-surgical ventilation in post-anaesthesia care unit]. / Impact de la prise en charge anesthésique sur la ventilation postopératoire en salle de surveillance postinterventionnelle.

INTRODUCTION: Control of residual muscle paralysis and hypothermia reduce postoperative complications rate. Short context sensitive half life anaesthetic agents allow a better adjustment of anaesthesia depth according to surgical requirement and a safe early extubation. Using a large clinical database, impact of these three strategies was assessed on clinical criteria such as use of neostigmine in postanaesthesia care unit (PACU), temperature, sedation score at the arrival into PACU and mechanical ventilation weaning. METHODS: This is a retrospective study on two separated periods. Since 2001, clinical events are entered into the database during and after anaesthesia in the same file. Agreement of anaesthesia staff to these strategies was assessed by the proportion of patients receiving modern anaesthetic agents (desflurane, sevoflurane and remifentanil) and the use of warming devices. Clinical impact was assessed by the number of patients receiving neostigmine in PACU, sedation score and temperature at the arrival in PACU and number of patients with mechanical ventilation in PACU. RESULTS: Between the two periods (12,033 and 11,805 patients, respectively), use of sevoflurane, desflurane and remifentanil markedly increased, as well as the use of warming devices. Number of patients with neuromuscular reversal in PACU decreased from 73 to 11 and sedation score improved dramatically. Incidence of postoperative ventilation in PACU decreased from 1.1% (n=132) to 0.2% (n=30). Incidence of postoperative hypothermia was not changed during the two periods but incidence of hypothermia in the mechanically ventilated patient increased from 34.1 to 46.6%. Length of stay in PACU decreased from 122 to 114 minutes (p<0.05). DISCUSSION: Implementation of new intraoperative protocols induced major effects on postoperative clinical parameters and especially postoperative mechanical ventilation. Failure of our hypothermia prevention associated with a fast return of consciousness lead to wean from mechanical ventilation hypothermic patients. Risks of this strategy were not estimated.

Glucocorticoids and sepsis.

Although systemic inflammation is the hallmark of sepsis, the use of glucocorticoids remained controversial during many years. Gluco-corticoids exert key actions during sepsis, interacting with metabolism, immune and cardiovascular systems. Glucocorticoid insufficiency is common during sepsis and may result from insufficient production of cortisol or peripheral tissues resistance. Thus, recent randomised trials showed that a replacement therapy with long course of low dose corticosteroids reduced mortality from septic shock. Improvement in survival may result from reduced duration of shock, alleviation of the systemic inflammatory response, and reduction in the number and intensity of organs dysfunction. This article summarises why, when and how glucocorticoids should be used in the management of septic shock.