Bispectral Index Measurements Are Not Degraded During Aeromedical Evacuations.

For a decade, depth of anesthesia monitoring has become a reality in the operating room. It provides valuable help for managing anesthesia, especially for unstable patients. This might be particularly relevant during aeromedical evacuation. In this study, we aimed to assess the validity of the bispectral index (BIS) during long-range patient transportation aboard fixed-wing aircraft. BIS was recorded in 30 patients, 25 under anesthesia and 5 awake, during aeromedical evacuations performed by the French Air Force. BIS index was available and analyzable (signal quality index above 50%) more than 90% of time. Despite potential pitfalls related to mechanical or electrical interference, BIS monitor can be reliably used to monitor depth of anesthesia during individual strategic aeromedical evacuations.

Validation of a pre-established triage protocol for critically ill patients in a COVID-19 outbreak under resource scarcity: A retrospective multicenter cohort study.

INTRODUCTION: In case of COVID-19 related scarcity of critical care resources, an early French triage algorithm categorized critically ill patients by probability of survival based on medical history and severity, with four priority levels for initiation or continuation of critical care: P1 -high priority, P2 -intermediate priority, P3 -not needed, P4 -not appropriate. This retrospective multi-center study aimed to assess its classification performance and its ability to help saving lives under capacity saturation. METHODS: ICU patients admitted for severe COVID-19 without triage in spring 2020 were retrospectively included from three hospitals. Demographic data, medical history and severity items were collected. Priority levels were retrospectively allocated at ICU admission and on ICU day 7-10. Mortality rate, cumulative incidence of death and of alive ICU discharge, length of ICU stay and of mechanical ventilation were compared between priority levels. Calculated mortality and survival were compared between full simulated triage and no triage. RESULTS: 225 patients were included, aged 63.1±11.9 years. Median SAPS2 was 40 (IQR 29-49). At the end of follow-up, 61 (27%) had died, 26 were still in ICU, and 138 had been discharged. Following retrospective initial priority allocation, mortality rate was 53% among P4 patients (95CI 34-72%) versus 23% among all P1 to P3 patients (95CI 17-30%, chi-squared p = 5.2e-4). The cumulative incidence of death consistently increased in the order P3, P1, P2 and P4 both at admission (Gray's test p = 3.1e-5) and at reassessment (p = 8e-5), and conversely for that of alive ICU discharge. Reassessment strengthened consistency. Simulation under saturation showed that this two-step triage protocol could have saved 28 to 40 more lives than no triage. CONCLUSION: Although it cannot eliminate potentially avoidable deaths, this triage protocol proved able to adequately prioritize critical care for patients with highest probability of survival, hence to save more lives if applied.

Quality of postoperative care after major orthopedic surgery is correlated with both long-term cardiovascular outcome and troponin Ic elevation.

BACKGROUND: The aim of this study performed in patients undergoing major orthopedic surgery was to assess the impact of changes in practice on both the incidence of postoperative myocardial ischemia (PMI) detected by serial measurements of troponin Ic and long-term cardiac outcome. METHODS: During a 3-yr period, troponin Ic was measured on the first 3 days after major orthopedic surgery in a multidisciplinary hospital. After 16 months of study, postoperative care was improved. Cardiac death, myocardial infarction, and cardiac failure were considered major adverse cardiac events and were recorded during the hospital stay and the first postoperative year. The incidences of PMI and major adverse cardiac events were used as result indicators for quality of care and compared before (P1) and after (P2) quality enhancement. RESULTS: Three hundred seventy-eight surgical procedures were included (P1, 123; P2, 255). Incidences of PMI and major adverse cardiac events were 8.9 versus 3.9% (P=0.04) and 8.1 versus 1.9% (P=0.004) for P1 and P2, respectively. Using a multivariate Cox regression analysis adjusted for baseline data, independent factors associated with the occurrence of a major adverse cardiac event were phase P1 (hazard ratio=4.5; 97.8% confidence interval [CI], 1.1-17.4) and PMI (Hazard ratio=6.4; 97.8% CI, 1.6-26.4). CONCLUSIONS: Our postoperative care policy after major orthopedic surgery strongly correlated with both short-term cardiac outcome (i.e., PMI with troponin Ic release) and long-term cardiac outcome. Thus, in a given surgical population, variation of incidence of troponin Ic elevations could be used as a result indicator for postoperative care policy.

Acute respiratory distress syndrome: performance of ventilator at simulated altitude.

BACKGROUND: Ventilation of Acute Respiratory Distress Syndrome (ARDS) is a challenge, and there is definitely a need for lack of variations between delivered and set tidal volume (Vt). We have assessed the ability of the ventilator T-birdVS02 and LTV-1000 to deliver to a lung model with ARDS a set Vt at different simulated altitudes. METHODS: We used a decompression chamber to mimic the hypobaric environment at a range of simulated cabin altitudes of 1,500, 2,500, and 3,000 m (4,000, 6,670, and 8,000 feet, respectively). Ventilators were tested with realistic parameters. Vt was set at 400 mL and 250 mL in an ARDS lung model. Comparisons of preset to actual measured values were accomplished using a t test for each altitude. RESULTS: The T-birdVS02 showed a decrease in the volume delivered. Comparisons of actual delivered Vt and set Vt demonstrated a significant difference starting at 1,500 m for a Vt set of 400 mL and at 2,500 m for Vt set of 250 mL. At these altitudes, the variations between Vt set and delivered were more than 10%. With decreasing barometric pressure, the LTV-1000 showed mostly an increase in volume delivered. Comparisons of actual delivered Vt and set Vt demonstrated a significant difference at 2,500 m for a Vt set of 400 mL and at 3,000 m for Vt set of 250 mL. The delivered Vt remained within 10% of the set Vt. CONCLUSION: Clinicians involved in aerial evacuations must keep in mind the performance and limitations of their ventilator system.

Cultured epithelial autografts in massive burns: a single-center retrospective study with 63 patients.

UNLABELLED: Cultured epithelial autografts (CEAs) have long been used to tackle limited donor site availability and difficulty of permanent skin coverage in massive burns, but this approach still has limited documentation. METHODS: In this retrospective, single-center study, medical records of patients treated with CEAs in our burn center from 1991 until 2008 were analyzed in search of factors associated with outcome. RESULTS: Out of 68 patients, 63 records were analyzable. Patients were aged 29 [17-41.5] years (seven children). Total body surface area (TBSA) burned was 81±10%, of which 69±14% TBSA full thickness. CEAs were first applied after 45±34 days, on a surface of 32±14% TBSA. Success rate at take down was 65±19%, correlating only with young age (r(2)=0.18; p=0.0006). At discharge, CEAs covered 26±15% TBSA. Infections (4.3±2 per patient), most frequently of skin, often complicated the clinical course. Mortality was 16% (10 patients). In multivariate analysis, the number of infections was the only factor associated with mortality (OR=2.05 per single infection, 95%CI 1.03-4.07, p=0.04). CONCLUSION: Although complex and costly, CEAs can be used with reasonable success and satisfying survival results for the treatment of massive burns. In this study, favorable outcome was principally associated with young age and low number of infectious complications.