Intérêt du dosage couplé de la troponine I hypersensible et de la copeptine pour le diagnostic d exclusion de SCA non ST+ chez les patients se présentant pour une douleur thoracique aux urgences

Objectif : Le but de cette étude est d étudier les performances diagnostiques du dosage couplé de la troponine I hypersensible (TnI hs) et de la copeptine, pour le diagnostic d exclusion des syndrome coronarien aigu sans élévation du segment ST (SCA non ST+) chez les patients arrivant aux urgences pour douleur thoracique. Méthodes : C est une étude en soins courants, prospective. Le dosage couplé de la Tni hs et de la copeptine a été réalisé chez 58 patients se présentant aux urgences pour douleur thoracique ayant débuté il y a moins de 6 heures, avec absence d élévation du segment ST sur l électrocardiogramme (ECG). Le diagnostic final était posé soit par un cardiologue, soit par deux urgentistes, toujours en aveugle des résultats de la copeptine. Résultats : Le diagnostic de SCA non ST+ a été posé pour 6 patients. La sensibilité et la valeur prédictive négative ( VPN) de la TnI hs seule et du dosage couplé de la TnI hs et de la copeptine était respectivement de 16,7% (intervalle de confiance (IC)à 95% = 0,4-64,1) et 91,1% (IC95% = 80,4-97) versus 50% (IC95%=11,8-88,2) et 92,3%(IC95% = 71,1-98,4). Conclusion : Les résultats de cette étude bien que n étant pas statistiquement significatifs, tendent à aller dans le sens des études faites sur le sujet. Une méta-analyse permettrait de confirmer ces résultats et d utiliser la copeptine en pratique courante.Objectives : The aim of this study was to analyze of the performance of high sensivity cardiac troponin I(TnI hs) and Copeptin coupled assay as a mean to rule out a diagnosis of non-ST elevation myocardial infarction (NSTEMI) for patients admitted in emergency department (ED) because of chest pain. Methods : The study is prospective and carried out during emergency care. Coupled assay of Tni hs and Copeptin was carried out for 58 patients admitted in ED because of chest pain that had started less than 6 hours before and without ST-segment elevation on the electrocardiogram. In each case, the final diagnosis was given either by a cardiologist or two emergency physicians, blinded to the copeptin results. Results : NSTEMI was diagnosed in 6 patients. The sensitivity and the negative predictive value (NPV) of TnI hs alone and the coupled assay of TnI hs with copeptin were respectively 16,7% (95% Confidence Interval of 0,4-64,1) and 91,1% (CI95%=80,4-97) versus 50% (CI95%=11,8-88,2) and 92,3% (CI95%=71,1-98,4). Conclusion : The results of the study, however not statistically significant, tend to support the other studies carried out on the same topic. To run a meta analysis would enable to confirm the results and to put into common practice the use of Copeptin.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Cannabis et complications cardiovasculaires chez le sujet jeune

REIMS-BU Santé (514542104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Ultrasonography helps emergency physician identify the best lumbar puncture site under the conus medullaris

Abstract Background Ultrasonography – assisted lumbar puncture helps physicians identify traditional anatomical landmarks. However, it could help to overcome the anatomical dogmas and thus identify the best interspinous space under the medullary cone. Methods Traditional anatomical landmarks were reported on a tracing paper in patients with an indication for lumbar puncture. Then, ultrasonography was used to locate the optimal interspinous level defined as the widest subarachnoid space located below the conus medullaris. Primary endpoint was the distance between traditional and ultrasound landmarks. Results Fifty-seven patients were included. Seven emergency physicians practiced the procedure. The median absolute distance between traditional anatomical landmarks and ultrasound marking was 32 [interquartile (IQR) 27 – 37] mm. The inter-spinous space identified in the two procedures was different in 68% of the cases. Conclusions Ultrasound not only allows us to better identify anatomical structures before lumbar puncture, but it also allows us to choose a site of puncture different from recommendations

Effect of non-invasive ventilation after extubation in critically ill patients with obesity in France: a multicentre, unblinded, pragmatic randomised clinical trial

International audienc

Restrictive use of Restraints and Delirium Duration in the Intensive Care Unit (R2D2-ICU): protocol for a French multicentre parallel-group open-label randomised controlled trial

Introduction Physical restraint (PR) is prescribed in patients receiving invasive mechanical ventilation in the intensive care unit (ICU) to avoid unplanned removal of medical devices. However, it is associated with an increased risk of delirium. We hypothesise that a restrictive use of PR, as compared with a systematic use, could reduce the duration of delirium in ICU patients receiving invasive mechanical ventilation.Methods and analysis The Restrictive use of Restraints and Delirium Duration in ICU (R2D2-ICU) study is a national multicentric, parallel-group, randomised (1:1) open-label, controlled, superiority trial, which will be conducted in 10 ICUs. A total of 422 adult patients requiring invasive mechanical ventilation for an expected duration of at least 48 hours and eligible for prescription of PR will be randomly allocated within 6 hours from intubation to either the restrictive PR use group or the systematic PR use group, until day 14, ICU discharge or death, whichever comes first. In both groups, PR will consist of the use of wrist straps. The primary endpoint will be delirium or coma-free days, defined as the number of days spent alive in the ICU without coma or delirium within the first 14 days after randomisation. Delirium will be assessed using the Confusion Assessment Method-ICU twice daily. Key secondary endpoints will encompass agitation episodes, opioid, propofol, benzodiazepine and antipsychotic drug exposure during the 14-day intervention period, along with a core outcome set of measures evaluated 90 days postrandomisation.Ethics and dissemination The R2D2-ICU study has been approved by the Comité de Protection des Personnes (CPP) ILE DE FRANCE III—PARIS (CPP19.09.06.37521) on June 10th, 2019). Participant recruitment started on 25 January 2021. Results will be published in international peer-reviewed medical journals and presented at conferences.Trial registration number NCT04273360

Prone Positioning During Extracorporeal Membrane Oxygenation in Patients With Severe ARDS

International audienceImportance Prone positioning may improve outcomes in patients with severe acute respiratory distress syndrome (ARDS), but it is unknown whether prone positioning improves clinical outcomes among patients with ARDS who are undergoing venovenous extracorporeal membrane oxygenation (VV-ECMO) compared with supine positioning. Objective To test whether prone positioning vs supine positioning decreases the time to successful ECMO weaning in patients with severe ARDS supported by VV-ECMO. Design, Setting, and Participants Randomized clinical trial of patients with severe ARDS undergoing VV-ECMO for less than 48 hours at 14 intensive care units (ICUs) in France between March 3, 2021, and December 7, 2021. Interventions Patients were randomized 1:1 to prone positioning (at least 4 sessions of 16 hours) (n = 86) or to supine positioning (n = 84). Main Outcomes and Measures The primary outcome was time to successful ECMO weaning within 60 days following randomization. Secondary outcomes included ECMO and mechanical ventilation–free days, ICU and hospital length of stay, skin pressure injury, serious adverse events, and all-cause mortality at 90-day follow-up. Results Among 170 randomized patients (median age, 51 [IQR, 43-59] years; n = 60 women [35%]), median respiratory system compliance was 15.0 (IQR, 10.7-20.6) mL/cm H 2 O; 159 patients (94%) had COVID-19–related ARDS; and 164 (96%) were in prone position before ECMO initiation. Within 60 days of enrollment, 38 of 86 patients (44%) had successful ECMO weaning in the prone ECMO group compared with 37 of 84 (44%) in the supine ECMO group (risk difference, 0.1% [95% CI, −14.9% to 15.2%]; subdistribution hazard ratio, 1.11 [95% CI, 0.71-1.75]; P = .64). Within 90 days, no significant difference was observed in ECMO duration (28 vs 32 days; difference, −4.9 [95% CI, −11.2 to 1.5] days; P = .13), ICU length of stay, or 90-day mortality (51% vs 48%; risk difference, 2.4% [95% CI, −13.9% to 18.6%]; P = .62). No serious adverse events were reported during the prone position procedure. Conclusions and Relevance Among patients with severe ARDS supported by VV-ECMO, prone positioning compared with supine positioning did not significantly reduce time to successful weaning of ECMO. Trial Registration ClinicalTrials.gov Identifier: NCT0460755

Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial

International audienc

High-Dose Dexamethasone and Oxygen Support Strategies in Intensive Care Unit Patients With Severe COVID-19 Acute Hypoxemic Respiratory Failure

International audienc