Valeur pronostique de la dénutrition en chirurgie cardiaque

La dénutrition est un déséquilibre entre les apports et les besoins protéino-énergétiques. Nombreux sujets souffrent de dénutrition, malheureusement elle est sous-estimée, car peu recherchée en pratique courante. Des recommandations claires sont parues en 2003 et permettent un diagnostic de dénutrition à partir de moyens simples. L'obésité est considérée comme le facteur de risque nutritionnel de morbi-mortalité chez les malades de chirurgie cardiaque. Des travaux récents remettent en cause cette notion, et insistent sur le fait que la dénutrition serait plutôt un facteur de mauvais pronostic en chirurgie cardiaque. Notre étude montre que la dénutrition est un facteur de risque indépendant d'allongement de la durée de ventilation et de la durée de séjour en réanimation, associé à un état hémodynamique plus précaire.GRENOBLE1-BU Médecine pharm. (385162101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

L index de résistance vasculaire rénal et le dosage du Neutrophil Gelatinase Associated Lipocalin sont ils des marqueurs d insuffisance rénale aiguë après chirurgie cardiaque ?

L insuffisance rénale aiguë (IRA) est une complication sévère de la chirurgie cardiaque sous circulation extra corporelle (CEC). La créatininémie (Cr) est un marqueur tardif de l IRA. Le but de cette étude était de comparer les valeurs de 2 marqueurs précoces d IRA : l index de résistance vasculaire rénal (IR) et le NGAL plasmatique. Après accord du CPP, 44 patients adultes, devant bénéficier d une chirurgie cardiaque sous CEC et à haut risque d IRA (score de Cleveland >3) ont été étudiés prospectivement. L IR était mesuré la veille de la chirurgie et en post opératoire (op) immédiat (H0) ; le NGAL, mesuré pour 32 patients/44, était dosé à H0 et H6. Un IR > 0,7 et un taux de NGAL > 150ng/ml étaient considérés comme pathologiques. L IRA était définie par un score de RIFLE I ou F au cours des 5 premiers jours après la CEC. 9 Patients sur 44 ont présentés une IRA post-op. Les patients ayant une IRA post opératoire avaient un IR préop plus élevé que ceux dont la fonction rénale était stable (0,73 [0,08] vs 0,79 [0,07], p=0,03). Les patients ayant une IRA avaient un NGAL non différent à H0 (227 [98] vs 299 [149] ng/ml, p=0,13) mais significativement augmenté à H6 (194 [91] vs 329 [150] ng/ml, p0,7), la Cr pré opératoire et à H0 ne différait pas mais s élevait significativement à J3. De même, la Cr s élevait significativement si le NGAL à H6 était >150 ng/ml. Aucun patient n ayant un taux de NGAL normal (12/32) n a présenté d IRA. La mesure de l IR en préop est corrélée à la survenue d une insuffisance rénale post op. En post op, des valeurs pathologiques de NGAL et d IR sont liées à la survenue de l IRA.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Functional outcome after convulsive status epilepticus

International audienc

Additional file 1 of Prevention of post-operative delirium using an overnight infusion of dexmedetomidine in patients undergoing cardiac surgery: a pragmatic, randomized, double-blind, placebo-controlled trial

Additional file 1. Table S1. Minimum and maximum dose of dexmedetomidine and its corresponding placebo administered every night (from 8 pm to 8 am) from Day 0 to Day 7. Table S2. All concomitant treatments administered from inclusion to Day 7 in both groups. Table S3. Main reason why CAM-ICU assessment and sleep quality evaluation were not performed or missing from Day 1 to Day 7. Table S4. Comparison of dexmedetomidine versus placebo on secondary outcomes: daily evaluation of sleep quality. Data are expressed as median and IQR. Table S5. Comparison of dexmedetomidine versus placebo on secondary outcomes: detailed sections of LSEQ during the 7 days of observation. Data are expressed as median and IQR. Table S6. Baseline creatinine level and daily renal component of the SOFA (Sequential Organ Failure Assessment) score. Table S7. Preplanned sub-group analysis for the primary outcome. Occurrence of PoD within the 7 days after surgery are expressed as number (%). Appendix 1. The cognitive failures questionnaire. Appendix 2. The PCL-5 standard form checklist. Appendix 3. The Leeds Sleep Evaluation Questionnaire (LSEQ). Each item is rated from -5 to +5. Negative score corresponded to negative effects on sleep quality

Prevention of post-operative delirium using an overnight infusion of dexmedetomidine in patients undergoing cardiac surgery: a pragmatic, randomized, double-blind, placebo-controlled trial

International audienceBackground: After cardiac surgery, post-operative delirium (PoD) is acknowledged to have a significant negative impact on patient outcome. To date, there is no valuable and specific treatment for PoD. Critically ill patients often suffer from poor sleep condition. There is an association between delirium and sleep quality after cardiac surgery. This study aimed to establish whether promoting sleep using an overnight infusion of dexmedetomidine reduces the incidence of delirium after cardiac surgery.Methods: Randomized, pragmatic, multicentre, double-blind, placebo controlled trial from January 2019 to July 2021. All adult patients aged 65 years or older requiring elective cardiac surgery were randomly assigned 1:1 either to the dexmedetomidine group or the placebo group on the day of surgery. Dexmedetomidine or matched placebo infusion was started the night after surgery from 8 pm to 8 am and administered every night while the patient remained in ICU, or for a maximum of 7 days. Primary outcome was the occurrence of postoperative delirium (PoD) within the 7 days after surgery.Results: A total of 348 patients provided informed consent, of whom 333 were randomized: 331 patients underwent surgery and were analysed (165 assigned to dexmedetomidine and 166 assigned to placebo). The incidence of PoD was not significantly different between the two groups (12.6% vs. 12.4%, p = 0.97). Patients treated with dexmedetomidine had significantly more hypotensive events (7.3% vs 0.6%; p < 0.01). At 3 months, functional outcomes (Short-form 36, Cognitive failure questionnaire, PCL-5) were comparable between the two groups.Conclusion: In patients recovering from an elective cardiac surgery, an overnight infusion of dexmedetomidine did not decrease postoperative delirium. Trial registration This trial was registered on ClinicalTrials.gov (number: NCT03477344; date: 26th March 2018)

Evolution over Time of Ventilatory Management and Outcome of Patients with Neurologic Disease∗

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease