Alvo hemodinâmico: uma ferramenta visual de terapia "goal-directed" para pacientes sépticos

OBJECTIVE: To improve understanding of the hemodynamic status of patients with sepsis by nursing teams through the attainment of hemodynamic parameters using a pentaxial "target" diagram as a clinical tool. Parameters include cardiac index (CI), arterial oxygen saturation (SaO2), mean arterial pressure (MAP), arterial blood lactate, and central venous oxygen saturation (ScvO2). METHODS: Design: Prospective descriptive study. Setting: The intensive care unit of a university hospital. Patients: During a 6-month period, 38 intubated septic shock patients were included in the study. Survivors and nonsurvivors were compared. Interventions: MAP, CI, SaO2, ScvO2 and lactate were measured at 0, 6, 12, 24, 36, and 48 h. Measurements were recorded on the target diagram along with the norepinephrine infusion rate and the hemoglobin (Hb) level. The number of lactate and ScvO2 measurements achieved during the target period were compared to a 6-month retrospective control period just before starting the protocol. We assessed the nurse knowledge status prior to the introduction of target diagram. We then performed a post-test after implementing the new recording technique. MEASUREMENTS AND RESULTS: The nursing team expressed a positive attitude toward the target concept. The mean number of lactate and ScvO2 measurements performed for each patient during the control period was significantly lower than during the target period, and those values were rarely used as goal values before the introduction of the target diagram. At 24 hours, 46% of the survivors had achieved all the goal parameter values of the target diagram, compared to only 10% of nonsurvivors (P = .01). CONCLUSION: The target diagram is a visual multiparametric tool involving all the medical and nursing team that helps achieve goal-directed therapy for septic patients. The number of goal values reached at each time point during the first 48 hours was closely linked to mortality.OBJETIVO: Melhorar a compreensão do "status" hemodinâmico de pacientes em sepse pelas equipes de enfermagem através da obtenção de parâmetros hemodinâmicos usando um diagrama-alvo pentaxial como ferramenta clínica. Os parâmetros usados foram índice cardíaco, saturação arterial de oxigênio, pressão arterial media, lactato sangüíneo arterial e saturação venosa central de oxigênio. MÉTODOS: Estudo descritivo prospectivo, realizado na Unidade de Terapia Intensiva de um Hospital Universitário. Pacientes: Durante um período de 6 meses, 38 pacientes intubados em choque séptico foram incluídos no estudo. Foram comparados sobreviventes vs. não sobreviventes. Intervenções: Os cinco parâmetros referidos foram medidos nas horas 0, 6, 12, 24, 36 e 48. As medidas foram registradas no diagrama alvo, juntamente com a velocidade de infusão de norepinefrina e nível de hemoglobina. O número de medidas de lactato e saturação venosa central de oxigênio realizado durante o período de estudo foi comparado com um período retrospectivo de 6 meses imediatamente precedendo a introdução do protocolo. Avaliamos o nível de conhecimento das equipes de enfermagem antes da introdução do diagrama-alvo. Após a realização do protocolo realizamos uma nova avaliação. MEDIDAS E RESULTADOS: A equipe de enfermagem exprimiu uma atitude positiva em relação ao conceito de diagrama alvo. O número de medidas de lactato e saturação venosa central de oxigênio foi significativamente menor durante o período controle anterior ao protocolo. E os valores medidos raramente foram empregados como valores meta antes da introdução do diagrama-alvo. Na medida de 24 horas, 46% dos sobreviventes haviam atingido todas as metas do diagrama-alvo, contra apenas 10% dos não sobreviventes (P = 0,01). CONCLUSÃO. O diagrama-alvo é uma ferramenta visual multiparamétrica envolvendo, as equipes médicas e de enfermagem, que auxilia a obtenção de uma estratégia terapêutica para pacientes sépticos. O número de valores meta atingidos a cada momento durante as primeiras 48 horas relaciona-se à mortalidade

Increased creatinine clearance in polytrauma patients with normal serum creatinine: a retrospective observational study

International audienceINTRODUCTION: The aim of this study, performed in an intensive care unit (ICU) population with a normal serum creatinine, was to estimate urinary creatinine clearance (CLCR) in a population of polytrauma patients (PT) through a comparison with a population of non trauma patients (NPT). METHODS: This was a retrospective, observational study in a medical and surgical ICU in a university hospital. A total of 284 patients were consecutively included. Two different groups were studied: PT (n = 144) and NPT (n = 140). Within the second week after admission to the ICU, renal function was assessed using serum creatinine, 24 h urinary CLCR . RESULTS: Among the 106 patients with a CLCR above 120 mL minute(-1) 1.73 m(-2), 79 were PT and 27 NPT (P < 0.0001). Only 63 patients had a CLCR below 60 mL minute(-1) 1.73 m(-2) with 15 PT and 48 NPT (P < 0.0001). Patients with CLCR greater than 120 mL minute(-1). 1.73 m(-2) were younger, had a lower SAPS II score and a higher male ratio as compared to those having CLCR lower than 120 mL minute(-1). 1.73 m(-2). Through a logistic regression analysis, age and trauma were the only factors independently correlated to CLCR. CONCLUSIONS: In ICU patients with normal serum creatinine, CLCR, is higher in PT than in NPT. The measure of CLCR should be proposed as routine for PT patients in order to adjust dose regimen, especially for drugs with renal elimination

Anesthésie ambulatoire pour curetages gynécologiques (comparaison de trois protocoles anesthésiques et recherche du délai optimum d'aptitude à la rue)

TOULOUSE3-BU Santé-Centrale (315552105) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

HEMODYNAMIQUE CEREBRALE EN NEUROTRAUMATOLOGIE (DOCTORAT (ANESTHESIE-REANIMATION))

LE KREMLIN-B.- PARIS 11-BU Méd (940432101) / SudocPARIS-BIUM (751062103) / SudocPARIS-BIUP (751062107) / SudocSudocFranceF

Bloc supra-claviculaire (abord périvasculaire)

TOULOUSE3-BU Santé-Centrale (315552105) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Recommandations aux voyageurs aériens (enquête auprès de 71 médecins généralistes de Haute-Garonne)

L augmentation du trafic aérien et le vieillissement de la population confrontent les médecins généralistes à des demandes croissantes de conseils avant de prendre l avion. Le but de ce travail est d évaluer la pratique en matière de recommandations aux voyageurs aériens à l aide d un questionnaire adressé à 100 médecins généralistes de Haute-Garonne sélectionnés de façon aléatoire. Le taux élevé de répondants (71%) signe l intérêt porté au sujet. 97% d entre eux ont donné des conseils (surtout sur l insuffisance veineuse et la prévention de la thrombophlébite) et 56% contre-indiqué un voyage aérien. Pourtant, seuls 8% ont cité leur source d information, la pratique n est pas souvent cohérente avec les recommandations internationales disponibles. Une évaluation clinique soigneuse est la clé de la prévention pour sélectionner les voyageurs à risque pour l avion. Une fiche de conseils pourrait être remise aux passagers à la réservation et une formation spécifique dispensée aux médecins.TOULOUSE3-BU Santé-Centrale (315552105) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

L'hyperthermie maligne anesthésique (une famille représentative)

TOULOUSE3-BU Santé-Centrale (315552105) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Evaluation de la prise en charge de la douleur aiguë dans le Service d'accueil des urgences du CHU de Cahors

TOULOUSE3-BU Santé-Centrale (315552105) / SudocTOULOUSE3-BU Santé-Allées (315552109) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF