Assessment of dyspnoea in the emergency department by numeric and visual scales : a pilot study

Copyright © 2015 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS All rights reserved.Objective(s): Dyspnoea is a common and often debilitating symptom that affects up to 50% of patients admitted to acute tertiary care hospitals. The primary purpose of this study was to compare the numeric rating scale (NRS) and the visual analogue scale (VAS) for dyspnoea evaluation in the ED setting. Study design and patients: This was a cohort study of patients admitted to the ED in a university hospital, with dyspnoea as the chief complaint. Methods: The agreement of the two dyspnoea scales was assessed using the intraclass correlation coefficient (ICC). Results: One hundred and seventeen patients were included in this analysis. The median age for the whole study population was 67 years and 42% of patients were male. The aetiology of dyspnoea was acute heart failure (AHF) in 35% of patients. There was good agreement between the two scores (ICC = 0.795; 95% CI = 0.717–0.853; P < 0.001). Conclusions: This pilot study demonstrated that numerical rating and visual analogue scales agree well when assessing the severity of dyspnoea in the ED. Further studies with larger cohorts of patients are needed to confirm these preliminary resultsinfo:eu-repo/semantics/publishedVersio

Hematogenous osteomyelitis in childhood can relapse many years later into adulthood: A retrospective multicentric cohort study in France

To describe the epidemiological, clinical, laboratory, and radiological features and the management of adult patients who experienced a relapse between 2003 and 2015 of an acute hematogenous osteomyelitis acquired in childhood.A retrospective multicentric cohort study was conducted in 5 centers in France. Thirty-seven patients were included. The median age was 40 years (28-56), and 26 (70%) were male. The first site of infection was the distal femur (n=23, 62%). The median time between the osteomyelitis in childhood and the relapse in adulthood was 26 years (13-45). Thirty-four (92%) patients reported inflammatory local clinical manifestations, 17 (46%) draining fistula, 10 (27%) fever. Most patients had intramedullary gadolinium deposition (with or without abscess) on magnetic resonance imaging. Most relapses were monomicrobial infections (82%). Staphylococcus aureus was the most commonly found microorganism (82%), expressing a small colony variant phenotype in 3 cases. Most patients (97%) had a surgical treatment, and the median duration of antibiotics for the relapse was 12 weeks. All patients had a favorable outcome, no patient died and no further relapse occurred. We count 2 femoral fractures on osteotomy site.Osteomyelitis in childhood can relapse later in adulthood, especially in patients with lack of care during the initial episode. Osteotomy and prolonged antimicrobial therapy are required for clinical remission

Muscle diffusion of liposomal amphotericin B and posaconazole in critically ill burn patients receiving continuous hemodialysis

International audienceno abstrac

Low cardiac index and stroke volume on admission are associated with poor outcome in critically ill burn patients: a retrospective cohort study.

BackgroundImpact of early systemic hemodynamic alterations and fluid resuscitation on outcome in the modern burn care remains controversial. We investigate the association between acute-phase systemic hemodynamics, timing of fluid resuscitation and outcome in critically ill burn patients.MethodsRetrospective, single-center cohort study was conducted in a university hospital. Forty critically ill burn patients with total body surface area (TBSA) burn-injured &gt;20&nbsp;% with invasive blood pressure and cardiac output monitoring (transpulmonary thermodilution technique) within 8&nbsp;h from trauma were included. We retrospectively examined hemodynamic variables during the first 24&nbsp;h following admission, and their association with 90-day mortality.ResultsThe median (interquartile range 25th-75th percentile) TBSA, Simplified Acute Physiology Score II (SAPS II) and Abbreviated Burn Severity Index of the study population were 41 (29-56), 31 (23-50) and 9 (7-11)&nbsp;%, respectively. 90-Day mortality was 42&nbsp;%. There was no statistical difference between the median pre-hospital and 24-h administered fluid volume in survivors and non-survivors. On admission, stroke volume (SV), cardiac index (CI), oxygen delivery index and mean arterial pressure (MAP) were significantly lower in patients who died despite similar fluid resuscitation volume. ROC curves comparing the ability of initial SV, CI, MAP and lactate to discriminate 90-day mortality gave areas under curves of, respectively, 0.89 (CI 0.77-1), 0.77 (CI 0.58-0.95), 0.73 (CI 0.53-0.93) and 0.78 (CI 0.63-0.92); (p value &lt;0.05 for all). In multivariate analysis, SAPS II and initial SV were independently associated with 90-day mortality (best cutoff value for SV was 27&nbsp;mL, sensitivity 92&nbsp;%, specificity 69&nbsp;%). During 24&nbsp;h, no interaction was found between time and outcome regarding macrocirculatory parameters changes. Hemodynamic parameters improved during the first 24-h resuscitation in all patients but patients who died had lower SV and CI on admission, which remained through the first 24&nbsp;h.ConclusionLow initial SV and CI were associated with poor outcome in critically ill burn patients. Very early hemodynamic monitoring may in help detecting under-resuscitated patients. Future prospective interventional studies should explore the impact of early goal-directed therapy in these specific patients

Urine sodium concentration to predict fluid responsiveness in oliguric ICU patients: a prospective multicenter observational study

International audienceBackground: Oliguria is one of the leading triggers of fluid loading in patients in the intensive care unit (ICU). The purpose of this study was to assess the predictive value of urine Na+ (uNa(+)) and other routine urine biomarkers for cardiac fluid responsiveness in oliguric ICU patients. Methods: We conducted a prospective multicenter observational study in five university ICUs. Patients with urine output (UO) 65 mmHg received a fluid challenge. Cardiac fluid responsiveness was defined by an increase in stroke volume >15 % after fluid challenge. Urine and plasma biochemistry samples were examined before fluid challenge. We examined renal fluid responsiveness (defined as UO >0.5 ml/kg/h for 3 consecutive hours) after fluid challenge as a secondary endpoint. Results: Fifty-four patients (age 51 +/- 37 years, Simplified Acute Physiology Score II score 40 +/- 20) were included. Most patients (72 %) were not cardiac responders (CRs), and 50 % were renal responders (RRs) to fluid challenge. Patient characteristics were similar between CRs and cardiac nonresponders. uNa(+) (37 +/- 38 mmol/L vs 25 +/- 75 mmol/L, p = 0.44) and fractional excretion of sodium (FENa+) (2.27 +/- 2.5 % vs 2.15 +/- 5.0 %, p = 0.94) were not statistically different between those who did and those who did not respond to the fluid challenge. Areas under the receiver operating characteristic (AUROC) curves were 0.51 (95 % CI 0.35-0.68) and 0.56 (95 % CI 0.39-0.73) for uNa(+) and FENa+, respectively. Fractional excretion of urea had an AUROC curve of 0.70 (95 % CI 0.54-0.86, p = 0.03) for CRs. Baseline UO was higher in RRs than in renal nonresponders (1.07 +/- 0.78 ml/kg/3 h vs 0.65 +/- 0.53 ml/kg/3 h, p = 0.01). The AUROC curve for RRs was 0.65 (95 % CI 0.53-0.78) for uNa(+). Conclusions: In the present study, most oliguric patients were not CRs and half were not renal responders to fluid challenge. Routine urinary biomarkers were not predictive of fluid responsiveness in oliguric normotensive ICU patients

MOESM3 of Low cardiac index and stroke volume on admission are associated with poor outcome in critically ill burn patients: a retrospective cohort study

Additional file 3: Table S1. Characteristics of the main clinical studies assessing the association between hemodynamics on admission and outcome in critically ill burn patients

Impact of an Acinetobacter baumannii outbreak on kidney events in a burn unit: A targeted machine learning analysis

International audienceBackground: Multidrug-resistant (MDR) bacteria outbreaks represent a major threat in intensive care units. Patients may then be exposed to drug-related direct toxicity during such outbreaks. The objective of this study was to explore the impact of an outbreak of imipenem-resistant Acinetobacter baumannii (IR-AB) on renal outcomes.Methods: We performed a before-and-after observational study in a French burn intensive care unit during an IR-AB outbreak: a 13-month period before (period A, October 2013-October 2014) and a 13-month period after outbreak control (period B, December 2014-December 2015). A total of 409 patients were included, 195 during period A and 214 during period B. The main endpoint was major adverse kidney events at day 90 (MAKE 90). Secondary endpoints were acute kidney injury (AKI) and persistent renal dysfunction.Results: Incidence of MAKE 90 was 15.9% during period A versus 11.2% during period B (P = .166) and AKI 28.2% versus 18.7% (P = .023). The use of colistin was associated with renal outcomes in univariate analysis. After adjustment of potential confounding factors using a targeted Machine Learning Analysis (ie, IR-AB-related infection, septic shock, severity scores, other nephrotoxics, chronic kidney disease, serum creatinine at admission, Staphylococcus aureus), colistin remained associated with the risk of MAKE and AKI (relative risk = 2.909, 95% confidence interval [CI] [1.364, 6.204], P = .006 for MAKE 90, and relative risk = 2.14, 95% CI [1.52, 3.02], P<.0001 for AKI).Conclusions: The episode of IR-AB outbreak was associated with an increased risk of kidney events, which appears to be driven by the use of colistin

Urine sodium concentration to predict fluid responsiveness in oliguric ICU patients: a prospective multicenter observational study.

BackgroundOliguria is one of the leading triggers of fluid loading in patients in the intensive care unit (ICU). The purpose of this study was to assess the predictive value of urine Na(+) (uNa(+)) and other routine urine biomarkers for cardiac fluid responsiveness in oliguric ICU patients.MethodsWe conducted a prospective multicenter observational study in five university ICUs. Patients with urine output (UO) &lt;0.5 ml/kg/h for 3 consecutive hours with a mean arterial pressure &gt;65 mmHg received a fluid challenge. Cardiac fluid responsiveness was defined by an increase in stroke volume &gt;15 % after fluid challenge. Urine and plasma biochemistry samples were examined before fluid challenge. We examined renal fluid responsiveness (defined as UO &gt; 0.5 ml/kg/h for 3 consecutive hours) after fluid challenge as a secondary endpoint.ResultsFifty-four patients (age 51 ± 37 years, Simplified Acute Physiology Score II score 40 ± 20) were included. Most patients (72 %) were not cardiac responders (CRs), and 50 % were renal responders (RRs) to fluid challenge. Patient characteristics were similar between CRs and cardiac nonresponders. uNa(+) (37 ± 38 mmol/L vs 25 ± 75 mmol/L, p = 0.44) and fractional excretion of sodium (FENa(+)) (2.27 ± 2.5 % vs 2.15 ± 5.0 %, p = 0.94) were not statistically different between those who did and those who did not respond to the fluid challenge. Areas under the receiver operating characteristic (AUROC) curves were 0.51 (95 % CI 0.35-0.68) and 0.56 (95 % CI 0.39-0.73) for uNa(+) and FENa(+), respectively. Fractional excretion of urea had an AUROC curve of 0.70 (95 % CI 0.54-0.86, p = 0.03) for CRs. Baseline UO was higher in RRs than in renal nonresponders (1.07 ± 0.78 ml/kg/3 h vs 0.65 ± 0.53 ml/kg/3 h, p = 0.01). The AUROC curve for RRs was 0.65 (95 % CI 0.53-0.78) for uNa(+).ConclusionsIn the present study, most oliguric patients were not CRs and half were not renal responders to fluid challenge. Routine urinary biomarkers were not predictive of fluid responsiveness in oliguric normotensive ICU patients

Undetectable haptoglobin is associated with major adverse kidney events in critically ill burn patients.

BackgroundIntravascular haemolysis has been associated with acute kidney injury (AKI) in different clinical settings (cardiac surgery, sickle cell disease). Haemolysis occurs frequently in critically ill burn patients. The aim of this study was to assess the predictive value of haptoglobin at admission to predict major adverse kidney events (MAKE) and AKI in critically ill burn patients.MethodsWe conducted a retrospective, single-centre cohort study in a burn critical care unit in a tertiary centre, including all consecutive severely burned patients (total burned body surface &gt; 20% and/or shock and/or mechanical ventilation at admission) from January 2012 to April 2017 with a plasmatic haptoglobin dosage at admission.ResultsA total of 130 patients were included in the analysis. Their mean age was 49 (34-62) years, their median total body surface area burned was 29% (15-51%) and the intensive care unit (ICU) mortality was 25%. Early haemolysis was defined as an undetectable plasmatic haptoglobin at admission. We used logistic regression to identify MAKE and AKI risk factors. In multivariate analysis, undetectable haptoglobin was associated with MAKE and AKI (respectively, OR 6.33, 95% CI 2.34-16.45, p &lt; 0.001; OR 8.32, 95% CI 2.86-26.40, p &lt; 0.001).ConclusionsUndetectable plasmatic haptoglobin at ICU admission is an independent risk factor for MAKE and AKI in critically ill burn patients. This study provides a rationale for biomarker-guided therapy using haptoglobin in critically ill burn patients