Self-processing in coma, unresponsive wakefulness syndrome and minimally conscious state

IntroductionBehavioral and cerebral dissociation has been now clearly established in some patients with acquired disorders of consciousness (DoC). Altogether, these studies mainly focused on the preservation of high-level cognitive markers in prolonged DoC, but did not specifically investigate lower but key-cognitive functions to consciousness emergence, such as the ability to take a first-person perspective, notably at the acute stage of coma. We made the hypothesis that the preservation of self-recognition (i) is independent of the behavioral impairment of consciousness, and (ii) can reflect the ability to recover consciousness.MethodsHence, using bedside Electroencephalography (EEG) recordings, we acquired, in a large cohort of 129 severely brain damaged patients, the brain response to the passive listening of the subject’s own name (SON) and unfamiliar other first names (OFN). One hundred and twelve of them (mean age ± SD = 46 ± 18.3 years, sex ratio M/F: 71/41) could be analyzed for the detection of an individual and significant discriminative P3 event-related brain response to the SON as compared to OFN (‘SON effect’, primary endpoint assessed by temporal clustering permutation tests).ResultsPatients were either coma (n = 38), unresponsive wakefulness syndrome (UWS, n = 30) or minimally conscious state (MCS, n = 44), according to the revised version of the Coma Recovery Scale (CRS-R). Overall, 33 DoC patients (29%) evoked a ‘SON effect’. This electrophysiological index was similar between coma (29%), MCS (23%) and UWS (34%) patients (p = 0.61). MCS patients at the time of enrolment were more likely to emerged from MCS (EMCS) at 6 months than coma and UWS patients (p = 0.013 for comparison between groups). Among the 72 survivors’ patients with event-related responses recorded within 3 months after brain injury, 75% of the 16 patients with a SON effect were EMCS at 6 months, while 59% of the 56 patients without a SON effect evolved to this favorable behavioral outcome.DiscussionAbout 30% of severely brain-damaged patients suffering from DoC are capable to process salient self-referential auditory stimuli, even in case of absence of behavioral detection of self-conscious processing. We suggest that self-recognition covert brain ability could be an index of consciousness recovery, and thus could help to predict good outcome

Gestion préopératoire des agents antiplaquettaires par les médecins anesthésistes de la région Midi-Pyrénées

[Résumé en français]TOULOUSE3-BU Santé-Centrale (315552105) / SudocTOULOUSE3-BU Santé-Allées (315552109) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Etude comparative de l'aprotinine et de l'acide tranexamique dans la réduction du saignement et des besoins transfusionnels en chirurgie de remplacement valvulaire isolé

Objectif : comparer l'effet de l'acide tranexamique et de l'aprotinine dans la chirurgie de remplacement valvulaire isolée, en terme de pertes sanguines et de besoins transfusionnels. Matériel et méthode : étude rétrospective, observationnelle, monocentrique, portant sur 262 patients opérés de remplacement valvulaire aortique ou mitral isolé. Les patients ont été répartis en deux groupes. Le groupe APR (n=171) a reçu de fortes doses d'aprotinine (protocole Royston), et le groupe AT (n=91) a reçu de l'acide tranexamique. Résultats : pas de différence significative de saignement entre les deux groupes (633 +- 421 ml dans le groupe APR et 601 +- 639 ml dans le groupe AT). Nous avons observé une quantité de culots globulaires transfusés plus importante dans le groupe APR que dans le groupe AT (3 +- 3 culots dans le groupe APR versus 1 +- 2 dans le groupe AT, P<0,003*). Conclusion : cette étude a mis en évidence une équivalence des deux molécules comme moyens de réduction pharmacologique du saignement en cas de chirurgie de remplacement valvulaire isolé.TOULOUSE3-BU Santé-Centrale (315552105) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

An unusual cause of severe lactic acidosis: cyanide poisoning after bitter almond ingestion

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A Clustered Case Series of Mucorales Detection in Respiratory Samples from COVID-19 Patients in Intensive Care, France, August to September 2021

International audienceWhile COVID-19-associated pulmonary aspergillosis is now well described in developed countries, COVID-19-associated mucormycosis (CAM) has seemed to remain quite rare in Europe. A retrospective study was performed between March 2020 to September 2021 among COVID-19 adult patients in the intensive care unit (ICU) at Toulouse Hospital (Southern France). PCR screening on respiratory samples, which target Aspergillus or Mucorales DNA, were performed, and the number of fungal detections was evaluated monthly during the study period. During the 19 months of the study, 44 (20.3%) COVID-19 ICU patients had a positive PCR for Aspergillus, an overall rate in keeping with the incidence of ICU COVID-19 patients. Ten patients (7.1%) had a positive Mucorales PCR over the same period. Surprisingly, 9/10 had a positive Mucor/Rhizopus PCR in August-September 2021, during the fourth Delta SARS-CoV-2 variant wave. Epidemic investigations have identified a probable environmental cause linked to construction works in the vicinity of the ICU (high levels of airborne spores due to the mistaken interruption of preventive humidification and summer temperature). Even if CAM are apparently rare in Europe, a cluster can also develop in industrialised countries when environmental conditions (especially during construction work) are associated with a high number of COVID-19 patients in the ICU

Predicting preload responsiveness using simultaneous recordings of inferior and superior vena cavae diameters

Abstract Introduction Echocardiographic indices based on respiratory variations of superior and inferior vena cavae diameters (ΔSVC and ΔIVC, respectively) have been proposed as predictors of fluid responsiveness in mechanically ventilated patients, but they have never been compared simultaneously in the same patient sample. The aim of this study was to compare the predictive value of these echocardiographic indices when concomitantly recorded in mechanically ventilated septic patients. Methods Septic shock patients requiring hemodynamic monitoring were prospectively enrolled over a 1-year period in a mixed medical surgical ICU of a university teaching hospital (Toulouse, France). All patients were mechanically ventilated. Predictive indices were obtained by transesophageal and transthoracic echocardiography and were calculated as follows: (Dmax - Dmin)/Dmax for ΔSVC and (Dmax - Dmin)/Dmin for ΔIVC, where Dmax and Dmin are the maximal and minimal diameters of SVC and IVC. Measurements were performed at baseline and after a 7-ml/kg volume expansion using a plasma expander. Patients were separated into responders (increase in cardiac index ≥15%) and nonresponders (increase in cardiac index <15%). Results Among 44 included patients, 26 (59%) patients were responders (R). ΔSVC was significantly more accurate than ΔIVC in predicting fluid responsiveness. The areas under the receiver operating characteristic curves for ΔSVC and ΔIVC regarding assessment of fluid responsiveness were significantly different (0.74 (95% confidence interval (CI): 0.59 to 0.88) and 0.43 (95% CI: 0.25 to 0.61), respectively (P = 0.012)). No significant correlation between ΔSVC and ΔIVC was found (r = 0.005, P = 0.98). The best threshold values for discriminating R from NR was 29% for ΔSVC, with 54% sensitivity and 89% specificity, and 21% for ΔIVC, with 38% sensitivity and 61% specificity. Conclusions ΔSVC was better than ΔIVC in predicting fluid responsiveness in our cohort. It is worth noting that the sensitivity and specificity values of ΔSVC and ΔIVC for predicting fluid responsiveness were lower than those reported in the literature, highlighting the limits of using these indices in a heterogeneous sample of medical and surgical septic patients

Co-Infection and Ventilator-Associated Pneumonia in Critically Ill COVID-19 Patients Requiring Mechanical Ventilation: A Retrospective Cohort Study

International audienceConsidering virus-related and drug-induced immunocompromised status of critically ill COVID-19 patients, we hypothesize that these patients would more frequently develop ventilator-associated pneumonia (VAP) than patients with ARDS from other viral causes. We conducted a retrospective observational study in two intensive care units (ICUs) from France, between 2017 and 2020. We compared bacterial co-infection at ICU admission and throughout the disease course of two retrospective longitudinally sampled groups of critically ill patients, who were admitted to ICU for either H1N1 or SARS-CoV-2 respiratory infection and depicted moderate-to-severe ARDS criteria upon admission. Sixty patients in the H1N1 group and 65 in the COVID-19 group were included in the study. Bacterial co-infection at the endotracheal intubation time was diagnosed in 33% of H1N1 and 16% COVID-19 patients (p = 0.08). The VAP incidence per 100 days of mechanical ventilation was 3.4 (2.2–5.2) in the H1N1 group and 7.2 (5.3–9.6) in the COVID-19 group (p < 0.004). The HR to develop VAP was of 2.33 (1.34–4.04) higher in the COVID-19 group (p = 0.002). Ten percent of H1N1 patients and 30% of the COVID-19 patients had a second episode of VAP (p = 0.013). COVID-19 patients have fewer bacterial co-infections upon admission, but the incidence of secondary infections increased faster in this group compared to H1N1 patients

Facteurs pronostiques issus du contrôle glycémique en réanimation : de nouveaux objectifs grâce à l’étude CGAO-REA ?

International audienceIntroductionLes objectifs du contrôle glycémique en réanimation se sont complexifiés depuis la première étude de Louvain [1] mettant en évidence une réduction de mortalité associée au seul respect d’une cible glycémique stricte (4,4–6,1 mmol/L). Au-delà de la controverse concernant la cible glycémique qui s’en est suivie, hypoglycémie et variabilité glycémique élevée seraient associées à un pronostic défavorable [2]. Le but de l’étude est de vérifier si ces associations existent dans le collectif de patients inclus dans l’étude multicentrique CGAO-REA visant à comparer l’impact sur la mortalité à J90 d’un contrôle glycémique informatisé strict (4,4–6,1 mmol/L) à un contrôle glycémique conventionnel (< 10 mmol/L) [3].Matériel et méthodesPour chacun des 2556 patients (parmi les 2648 randomisés analysables de l’étude CGAO-REA) pour lesquels les données de monitorage glycémique étaient disponibles, nous avons déterminé, pour l’ensemble du séjour en réanimation, la glycémie minimale Gmin, la glycémie maximale Gmax, la différence Gmax–Gmin, et la glycémie moyenne. La division en quintiles de la distribution de ces paramètres descriptifs du contrôle glycémique a permis de construire 5 groupes de patients pour chaque paramètre. La mortalité à J90 a été déterminée dans chacun des groupes et comparée à l’aide d’un test Chi2 à la mortalité attendue.RésultatsParmi les 2556 patients, 835 sont décédés à J90 (mortalité attendue 32,7 %). Les 4 graphiques suivants indiquent la mortalité dans chacun des quintiles pour chaque paramètre (Fig. 1)DiscussionL’analyse des patients inclus dans l’étude CGAO-REA semble confirmer l’association entre hypoglycémie et variabilité glycémique et pronostic défavorable

Contrôle glycémique strict informatisé en réanimation : étude multicentrique prospective contrôlée randomisée (étude CGAO-REA)

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