Percutaneous tracheostomy simulation training for ENT physicians in the treatment of COVID-19-positive patients.

Tracheostomy in COVID-19-related severe acute respiratory syndrome is at high risk of viral dissemination. The percutaneous dilatation technique could reduce this risk, being performed at the bedside and minimising airway opening. In the COVID-19 context, however, with precarious respiratory status, it requires specific preparation. We designed a 3-hour training module, and here provide a step-by-step schedule, including video analysis, a demonstration of the kit, the recommended precautions related to COVID-19, and several simulation scenarios of increasing difficulty, using a high-tech mannequin. A low-tech procedural simulator was also developed for practicing the steps of the procedure. Our experience (3 sessions with 14 participants) highlighted the difficult points of the procedure in the COVID-19 context, and defined a checklist for clinical practice and an assessment grid. This type of simulation helps to prepare teams for a potentially delicate technical act.

[Hypercalcemia revealing iatrogenic hypervitaminosis A in a child with autistic troubles]. / Hypercalcémie révélant une hypervitaminose A iatrogène chez un enfant atteint de troubles autistiques.

UNLABELLED: Hypervitaminosis A is an unusual cause of infant hypercalcemia. The way it occurs can be very surprising, as one can notice from the following case report. CASE REPORTS: A three-year-old boy, presenting important behavioral disorders, was hospitalized because of a deterioration of his general state of health associated with vomiting, cephalgias, fever and cutaneous abnormalities. A 168 mg/L hypercalcemia was found. The only etiology is a deviant consumption of vitamin A within the framework of an "autistic diet": 100000 UI/d during three months, and then 150000 UI/d the three following months. Intoxication was confirmed by the increased vitamin A plasmatic level, and vitamin A/RBP molar ratio and by the presence of plasmatic retinyl palmitate. An emergency treatment by rehydration, biphosphonates and furosemide led to effective calcemia normalization. CONCLUSION: In the case of nonobvious causes of hypercalcemia, a thorough cross-examination must look for vitamin A intoxication. Our observation illustrates the danger of certain diets suggested for autistic children.

The ANTIBIOPERF study: a nationwide cross-sectional survey about practices for ß-lactam administration and therapeutic drug monitoring among critically ill patients in France.

Our objective was to assess current practices about the administration (intermittent, extended, or continuous infusions) and therapeutic drug monitoring (TDM) of ß-lactam antibiotics and vancomycin in France. We conducted a nationwide cross-sectional survey in May-August 2015, using an online questionnaire, sent as an e-mail link to infectious disease specialists and intensive care specialists through national mailing lists. We used clinical vignettes of critically ill patients to assess physicians' practices about administration and TDM practices for amoxicillin, cloxacillin, piperacillin/tazobactam, cefotaxime, ceftazidime, cefepime, meropenem and vancomycin. In all, 507 physicians participated (507/1200, response rate 42%). TDM was rarely available for ß-lactams (from 16.5% (81/490) for cloxacillin to 30% (145/490) for ceftazidime), whereas vancomycin TDM was available in 97% (477/490) of the cases. In the clinical vignettes, ceftazidime and piperacillin/tazobactam were the ß-lactams administered most frequently by extended or continuous infusions (76% (336/440) and 57% (252/444), respectively). Gaps in knowledge about the duration of stability of intravenous ß-lactams were common (correct answers ranged from 8% (35/432) for cloxacillin to 33% (146/438) for ceftazidime). Most physicians (77%, 339/442) were convinced of the value of extended or continuous infusions for ß-lactams in critically ill patients, but 48% (211/442) did not have access to practical guidelines. Our survey found that most infectious disease and intensive care specialists are favourable to optimized administration of ß-lactams in critically ill patients. But the lack of guidelines and limited TDM availability for ß-lactams in hospitals are potential barriers to its implementation.

LACTATE or ScvO2 as an endpoint in resuscitation of shock states?

In the current management of critically ill patients, variables such as blood pressure, urine output or central venous pressure guide resuscitative efforts. Unfortunately, global tissue hypoxia may persist leading to multiple organ failure and death. To address tissue well-being, indices such as central venous oxygen saturation (ScvO2) and lactataemia are widely used and are strongly linked to outcome. Implementing these indices in haemodynamic optimization protocols have been shown to reduce morbidity and mortality in numerous studies especially in septic shock. Nevertheless, choosing one index over the other remains controversial. Herein, we review the physiology and rationale for ScvO2 and lactate monitoring. Clinical uses, evidence-based outcome implications and limitations are also examined to aid the clinician in daily practice. Key words: lactate, central venous oxygen saturation, shock, goal-directed therapy.

Lactate or ScvO2 as an endpoint in resuscitation of shock states?

In the current management of critically ill patients, variables such as blood pressure, urine output or central venous pressure guide resuscitative efforts. Unfortunately, global tissue hypoxia may persist leading to multiple organ failure and death. To address tissue well-being, indices such as central venous oxygen saturation (ScvO2) and Lactatemia are widely used and are strongly linked to outcome. Implementing these indices in haemodynamic optimization protocols have been shown to reduce morbidity and mortality in numerous studies especially in septic shock. Nevertheless, choosing one index over the other remains controversial. Herein, we review the physiology and rationale for ScvO2 and lactate monitoring. Clinical uses, evidence-based outcome implications and limitations are also examined to aid the clinician in daily practice.

Vascular hyporesponsiveness to vasopressors in septic shock: from bench to bedside.

PURPOSE: To delineate some of the characteristics of septic vascular hypotension, to assess the most commonly cited and reported underlying mechanisms of vascular hyporesponsiveness to vasoconstrictors in sepsis, and to briefly outline current therapeutic strategies and possible future approaches. METHODS: Source data were obtained from a PubMed search of the medical literature with the following MeSH terms: Muscle, smooth, vascular/physiopathology; hypotension/etiology; shock/physiopathology; vasodilation/physiology; shock/therapy; vasoconstrictor agents. RESULTS: Nitric oxide (NO) and peroxynitrite are crucial components implicated in vasoplegia and vascular hyporeactivity. Vascular ATP-sensitive and calcium-activated potassium channels are activated during shock and participate in hypotension. In addition, shock state is characterized by inappropriately low plasma glucocorticoid and vasopressin concentrations, a dysfunction and desensitization of alpha-receptors, and an inactivation of catecholamines by oxidation. Numerous other mechanisms have been individualized in animal models, the great majority of which involve NO: MEK1/2-ERK1/2 pathway, H(2)S, hyperglycemia, and cytoskeleton dysregulation associated with decreased actin expression. CONCLUSIONS: Many therapeutic approaches have proven their efficiency in animal models, especially therapies directed against one particular compound, but have otherwise failed when used in human shock. Nevertheless, high doses of catecholamines, vasopressin and terlipressin, hydrocortisone, activated protein C, and non-specific shock treatment have demonstrated a partial efficiency in reversing sepsis-induced hypotension.