Administration automatisée des agents anesthésiques (évaluation de l' hyperalgésie post-opératoire (résultats préliminaires))

Le rémifentanil de par ses propriétés est un opiacé de choix en anesthésie. Toutefois, il entrainerait des phénomènes d hyperalgésie et de tolérance aiguë, semblant être dose-dépendants, et se traduisant par une augmentation de la consommation de morphine post-opératoire. Le système automatisé d anesthésie intraveineuse de propofol et de remifentanil en boucle fermée asservie à l index bispectral a démontré sa faisabilité, mais avec des doses totales de rémifentanil plus importantes qu en administration manuelle. Nous avons réalisé une étude prospective randomisée en chirurgie digestive afin d évaluer l hyperalgésie post-opératoire après une anesthésie par cette technique comparée à une analgésie conventionnelle par du sufentanil . 38 patients ont été étudiés, 20 dans le groupe rémifentanil et 18 dans le groupe sufentanil. La consommation de morphine, les aires d hyperalgésie secondaire, et les scores de douleur au premier et au deuxième jours post-opératoires étaient similaires dans les deux groupes. L administration automatisée de rémifentanil en boucle fermée asservie au BIS n entraîne pas plus d hyperalgésie post-opératoire en chirurgie digestive, par rapport à une analgésie conventionnelle par sufentanil. Ceci peut être expliqué par le fait que les doses totales de rémifentanil utilisées sont moindres que celles décrites dans la littérature pour le même type de chirurgie. Or les phénomènes de tolérance et d hyperalgésie sont dose dépendants. Toutefois, tous nos patients recevaient, comme dans la pratique, une analgésie multimodale, par paracétamol et néfopam, qui a peut être permis de limiter l hyperalgésie.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF

Impact d’un protocole d’examens pronostiques dans la prise en charge des arrêts cardio-respiratoires en réanimation

International audienc

Analytical interference during cefepime therapeutic drug monitoring in intensive care patient: About a case report

International audiencebeta-lactams therapeutic drug monitoring (TDM) appears as an essential tool to ensure the achievement of pharmacokinetic-pharmacodynamic targets and prevent induced toxicity in intensive care unit patients. Indeed, those patients exhibit important pharmacokinetic variabilities that could lead to unpredictable plasma concentrations, potentially associated with poor clinical outcome, development of antibiotic resistance or increased side effects. Here, we report the case of a 48-year-old-patient admitted to intensive care unit and treated by cefepime using TDM. Due to inconsistency between observed cefepime plasma concentrations and patient clinical examination, investigations were started. After analytical tests, we highlighted an underlying analytical interference that overestimated cefepime plasma concentration with our in-house high performance liquid chromatography with ultraviolet detection (HPLC-UV) method. Only the inadequacy between plasmatic concentration and patient situation alerted pharmacologists and clinicians. As we found no previous case in literature, we believe this report must serve as an example of analytical limits that required pharmacologist awareness and expertise in TDM realization. Copyright (C) 2017 Societe francaise de pharmacologie et de therapeutique. Published by Elsevier Masson SAS. All rights reserved

Risk factors for death in septic shock A retrospective cohort study comparing trauma and non-trauma patients

International audienceThe aim of this study was to compare septic shock directly associated-mortality between severe trauma patients and nontrauma patients to assess the role of comorbidities and age. We conducted a retrospective study in an intensive care unit (ICU) (15 beds) of a university hospital (928 beds). From January 2009 to May 2015, we reviewed 2 anonymized databases including severe trauma patients and nontrauma patients. We selected the patients with a septic shock episode. Among 385 patients (318 nontrauma patients and 67 severe trauma patients), the ICU death rate was 43%. Septic shock was directly responsible for death among 35% of our cohort, representing 123 (39%) nontrauma patients and 10 (15%) trauma patients (P<0.0). A sequential organ failure assessment score above 12 (odds ratio [OR]: 6.8; 95% confident interval (CI) [1.3-37], P=0.025) was independently associated with septic shock associated-mortality, whereas severe trauma was a protective factor (OR: 0.26; 95% CI [0.08-0.78], P=0.01). From these independent risk factors, we determined the probability of septic shock associated-mortality. The receiver-operating characteristics curve has an area under the curve at 0.76 with sensitivity of 55% and specificity of 86%. Trauma appears as a protective factor, whereas the severity of organ failure has a major role in the mortality of septic shock. However, because of the study's design, unmeasured confounding factors should be taken into account in our findings

Circadian disruption of core body temperature in trauma patients: a single-center retrospective observational study

International audienc

Implementation of an electronic checklist in the ICU: Association with improved outcomes

International audienceObjective: To assess the impact of an electronic checklist during the morning rounds on ventilatorassociated pneumonia (VAP) in the intensive care unit (ICU). Patients and methods: We conducted a retrospective, before/after study in a single ICU of a university hospital. A systematic electronic checklist focusing on guidelines adherence was introduced in January 2012. From January 2008 to June 2014, we screened patients with ICU stay durations of at least 48 hours. Propensity score-matched analysis with conditional logistic regression was used to compare the rate of VAP and number of days free of invasive devices before and after implementation of the electronic checklist. Results: We analysed 1711 patients (before group, n = 761; after group, n = 950). The rates of VAP were 21% and 11% in the before and after groups, respectively (p < 0.001). In propensity-score matched analysis (n = 742 in each group), VAP occurred in 151 patients (21%) during the before period compared with 72 patients (10%) during the after period (odds ratio [OR] = 0.38; 95% confidence interval [CI] = 0.27-0.53). The after group showed increases in ICU-free days (OR = 1.05; 95% CI = 1.04-1.07) and mechanical ventilation-free days (OR = 1.03; 95% CI = 1.01-1.04). Conclusion: In this matched before/after study, implementation of an electronic checklist was associated with positive effects on patient outcomes, especially on VAP. Further prospective studies are needed to confirm these observations. (C) 2017 Societefrancaise d'anesthesie et de reanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved

Circadian Rhythm Disruption and Sepsis in Severe Trauma Patients

International audienc

Integrating extended focused assessment with sonography for trauma (eFAST) in the initial assessment of severe trauma: Impact on the management of 756 patients

International audienceBackground: Before total body computed tomography scan, an initial rapid imaging assessment should be conducted in the trauma bay. It generally includes a chest x-ray, pelvic x-ray, and an extended focused ultrasonography assessment for trauma. This initial imaging assessment has been poorly described since the increase in the use of ultrasound. Therefore, our study aimed to evaluate the diagnostic accuracy and therapeutic impact of this initial imaging work-up in severe trauma patients. A secondary aim was to assess the therapeutic impact of a chest x-ray according to the lung ultrasonography findings.Methods: Patients with severe trauma who were admitted directly to our level 1 trauma center were consecutively included in this retrospective single center study. The diagnostic accuracy, therapeutic impact, and appropriate decision rate were calculated according to the initial assessment results of the whole body computed tomography scan and surgery reports.Results: Among the 1315 trauma patients admitted, 756 were included in this research. Lung ultrasound showed a higher diagnostic accuracy for haemothorax and pneumothorax cases than the chest x-ray. Sensitivity and specificity of the abdominal ultrasound to detect intraperitoneal effusion were 70% and 96%, respectively. The initial assessment had a therapeutic impact in 76 (10%) of the patients, including 16 (2%) immediate laparotomies and 58 (7%) chest tube insertions. The pelvic x-ray had no therapeutic impact, and when the lung ultrasound was normal, the chest x-ray had a therapeutic impact of only 0.13%. Combining the chest x-ray and lung ultrasound allowed adequate management of all the pneumothorax and haemothorax cases. Only one of the 756 patients had initial management that was judged as inappropriate. This patient had a missed pelvic disjunction with active retroperitoneal bleeding, and Abbreviations: underwent an inappropriate immediate laparotomy.Conclusions: In our cohort, the initial imaging assessment allowed appropriate decisions in 755 of 756 patients, with a global therapeutic impact of 10%. The pelvic x-ray had a minimal therapeutic impact, and in the patients with normal lung ultrasounds, the chest x-ray marginally affected the management of our patients. The potential consequences of abandoning systematic chest and pelvic x-rays should be investigated in future randomized prospective studies. (C) 2018 Elsevier Ltd. All rights reserved

Lung ultrasonography for assessment of oxygenation response to prone position ventilation in ARDS

IF 12.015International audienceProne position (PP) improves oxygenation and outcome of acute respiratory distress syndrome (ARDS) patients with a PaO2/FiO(2) ratio < 150 mmHg. Regional changes in lung aeration can be assessed by lung ultrasound (LUS). Our aim was to predict the magnitude of oxygenation response after PP using bedside LUS. We conducted a prospective multicenter study that included adult patients with severe and moderate ARDS. LUS data were collected at four time points: 1 h before (baseline) and 1 h after turning the patient to PP, 1 h before and 1 h after turning the patient back to the supine position. Regional lung aeration changes and ultrasound reaeration scores were assessed at each time. Overdistension was not assessed. Fifty-one patients were included. Oxygenation response after PP was not correlated with a specific LUS pattern. The patients with focal and non-focal ARDS showed no difference in global reaeration score. With regard to the entire PP session, the patients with non-focal ARDS had an improved aeration gain in the anterior areas. Oxygenation response was not associated with aeration changes. No difference in PaCO2 change was found according to oxygenation response or lung morphology. In ARDS patients with a PaO2/FiO(2) ratio aecurrency sign150 mmHg, bedside LUS cannot predict oxygenation response after the first PP session. At the bedside, LUS enables monitoring of aeration changes during PP

Effect of early hyperoxemia on the outcome in servere blunt chest trauma: A propensity score-based analysis of a single-center retrospective cohort

International audiencePurpose Our study aimed to explore the association between early hyperoxemia of the first 24 h on outcomes in patients with severe blunt chest trauma.Materials and methods In a level I trauma center, we conducted a retrospective study of 426 consecutive patients. Hyperoxemic groups were classified in severe (average PaO2 ≥ 200 mmHg), moderate (≥150 and < 200 mmHg) or mild (≥ 100 and < 200 mmHg) and compared to control group (≥60 and < 100 mmHg) using a propensity score based analysis. The first endpoint was the incidence of a composite outcome including death and hospital-acquired pneumonia occurring from admission to day 28. The secondary endpoints were the incidence of death, the number of hospital-acquired pneumonia, mechanical ventilation-free days and intensive care unit-free day at day 28.Results The incidence of the composite endpoint was lower in the severe hyperoxemia group(OR, 0.25; 95%CI, 0.09–0.73; P < 0.001) compared with control. The 28-day mortality incidence was lower in severe (OR, 0.23; 95%CI, 0.08–0.68; P < 0.001) hyperoxemia group (OR, 0.41; 95%CI, 0.17–0.97; P = 0.04). Significant association was found between hyperoxemia and secondary outcomes.Conclusion In our cohort early hyperoxemia during the first 24 h of admission after severe blunt chest trauma was not associated with worse outcome