Predictive Factors of Poor Prognosis After Surgical Management of Traumatic Acute Subdural Hematomas: A Single-Center Series

BACKGROUND: Traumatic acute subdural hematomas (ASDHs) showed the highest mortality of intracranial hematomas. The aim of the current study was to identify predictive factors of poor prognosis among patients who were operated on. METHODS: This is a single-center retrospective cohort study of 82 patients who underwent surgical evacuation of a traumatic ASDH between January 2009 and December 2016. The epidemiologic, clinical, radiologic, and surgical features were recorded. Postoperative outcome were assessed by the Glasgow Outcome Scale (GOS) score at 6 months. Univariate and multivariate analysis and a classification and regression tree (CART) were performed. RESULTS: At 6 months, 76% of patients achieved an unfavorable outcome (GOS score 1-3). The context of polytrauma (P = 0.03) and ASDH thickness ≥20 mm (P = 0.02) were significantly associated with poor outcome in the multivariate analysis. The CART algorithm isolated 3 subgroups of patients with an unfavorable prognosis: polytrauma (91%), isolated head injury (HI) featuring an ASDH thickness ≥20 mm (89%), or isolated HI featuring a thickness <20 mm in a patient older than 54 years (71%). Isolated patients with HI younger than 54 years harboring an ASDH <20 mm thick had the most promising results, with 53% with a GOS score of 4 or 5. CONCLUSIONS: The context of polytrauma, ASDH thickness, and age were major predictive factors of poor prognosis in patients with surgically evacuated traumatic ASDH. The CART algorithm using these features isolated subgroups with decreasingly unfavorable outcome, providing a relevant statistical tool to apply to future studies of traumatic ASDH

Re: Lung and cardiac ultrasound for hemodynamic monitoring of patients with severe pre-eclampsia.

Referee CommentariesInternational audienc

Fluid resuscitation and evidence-based medicine: ``The truth is rarely pure and never simple'' (Oscar Wilde)

International audienc

Diagnostic point-of-care ultrasound: applications in obstetric anaesthetic management

International audienceComplications during pregnancy are not frequent, but may occur abruptly. Point-of-care ultrasound is a non-invasive, non-ionising diagnostic tool that is available at the bed-side when complications occur. This review covers the use of ultrasound in various clinical situations. Gastric ultrasound can identify stomach contents that put the woman at risk for pulmonary aspiration. In the future, this tool will probably be used routinely before induction of anaesthesia to determine the presence of stomach contents above a particular risk threshold. Difficult tracheal intubation, and the potential for can't intubate, can't oxygenate', is more frequent in pregnant women. Point-of-care ultrasound of the airway allows accurate identification of the cricothyroid membrane, permitting rapid and safer establishment of front-of-neck airway access. Combined cardiac and lung ultrasound candetermine the potential risk:benefit of fluid administration in the pregnant patient. Such prediction is of critical importance, given the tendency of pregnant women to develop pulmonary oedema. Combined echocardiography and lung ultrasound can be combined with ultrasound of the leg veins to differentiate between the various causes of acute respiratory failure, and guide treatment in this situation. Finally, as shown in the general population, multi-organ point-of-care ultrasound allows early diagnosis of the main causes of circulatory failure and cardiac arrest at the bed-side. As the importance of point-of-care ultrasound in critical patients is increasingly recognised, it is emerging as an important tool in the therapeutic armoury of obstetric anaesthetists

Reliability of gastric suctioning compared with ultrasound assessment of residual gastric volume: a prospective multicentre cohort study

International audienc

Lung ultrasound for early diagnosis of postoperative need for ventilatory support: a prospective observational study

International audiencePulmonary complications have a significant impact on morbidity and mortality in patients after major surgery. Lung ultrasound can be used at the bed-side, and has gained widespread acceptance in the intensive care unit. We conducted a prospective study to evaluate whether lung ultrasound could be used as a predictive marker for postoperative ventilatory support in high-risk surgical patients. We included 109 patients admitted to the intensive care unit while having mechanical ventilation of the lungs following major surgery. The PaO2/FIO2 ratio was calculated on admission and an ultrasound examination performed, including: lung ('lung ultrasound score', number of consolidated lung areas); cardiac (mitral flow); and inferior vena cava imaging (diameter and respiratory variation). Respiratory outcomes included: the need for ventilation support (mechanical ventilation, non-invasive ventilation or high-flow nasal cannula oxygen therapy); acute respiratory distress syndrome; cardiogenic pulmonary oedema; and early or late pulmonary infection. Patients with a lung ultrasound score >= 10 had a lower PaO2/FIO2 ratio, and needed more postoperative ventilatory support, than patients with lung ultrasound score = 2 areas of consolidated lung was associated with a lower PaO2/FIO2 ratio, postoperative ventilatory support, longer intensive care stay and episodes of ventilator-associated pneumonia requiring antibiotics. Our results suggest that at intensive care unit admission, lung ultrasound scoring and detection of atelectasis can predict postoperative pulmonary outcomes after major visceral surgery, and could enhance bed-side decision making

Use of speckle-tracking strain in preload-dependent patients, need for cautious interpretation!

International audienceBackground: In critical patients, left ventricular ejection fraction and fractional shortening are used to reflect left ventricular systolic function. An emerging technique, two-dimensional-strain echocardiography, allows assessment of the left ventricle systolic longitudinal deformation (global longitudinal strain) and the speed at which this deformation occurs (systolic strain rate). This technique is of increasing use in critical patients in intensive care units and in the peri-operative period where preload constantly varies. Our objective, in this prospective single-center observational study, was to evaluate the effect of fluid resuscitation on two-dimensional-strain echocardiography measurements in preload-dependent critically ill patients. We included 49 patients with preload dependence attested by an increase of at least 10% in the left ventricular outflow track velocity-time integral measured by echocardiography during a passive leg raising maneuver. Echocardiography was performed before fluid resuscitation (echocardiography 1) and after preload independency achievement (echocardiography 2).Results: Two-dimensional-strain echocardiography was feasible in 40 (82%) among the 49 patients. With preload dependence correction, the absolute value of global longitudinal strain and systolic strain rate was significantly increased from, respectively, -13.3 +/- 3.5 to -18.4% +/- 4.5 (p < 0.01) and -1.11 s(-1) +/- 0.29 to -1.55 s(-1) +/- 0.55 (p < 0.001). The fluid resuscitation affects GLS and SSR in preload-dependent patients, with a shift, for GLS, from pathological to normal values.Conclusion: In critically ill patients, the assessment of the systolic function by two-dimensional-strain echocardiography needs prior evaluation of preload dependency, in order to adequately interpret this variable. Future studies should assess the ability of global longitudinal strain to guide fluid management in the critically ill patients

Clearsight (TM) use for haemodynamic monitoring during the third trimester of pregnancy - a validation study

International audienceBackground: We assessed the validity of Clearsight (TM) as a non-invasive cardiac output and stroke volume monitoring device, comparing it with transthoracic echocardiography measurements during the third trimester of pregnancy. Methods: Measurements obtained from Clearsight (TM) were compared with those from echocardiography as the gold standard. The precision and accuracy of the Clearsight (TM) was measured using the Bland and Altman method. Clinical agreement with echocardiography was assessed using the agreement tolerability index. Results: Measurements were recorded from 44 pregnant women with a median [IQR range] gestational age of 33 [30-37] weeks. We found that Clearsight (TM) measurements presented a systematic overestimation of cardiac output, with mean bias [CI 95%] of 2.7 [2.3-3.0] L/min, with limits of agreement of -0.1 to 5.4 L/min. It overestimated stroke volume, with a bias of 29.5 [25.0-33.4] mL and a limit of agreement of -1.6 to 60.1 mL. In addition, the analysis of cardiac output showed a percentage of error of 41% and intra-class correlation [CI 95%] of 0.37 [0.17 to 0.53, P <0.001]. For stroke volume, the percentage of error was 40% and intra-class correlation 0.16 [-0.1 to 0.34; P=0.27]. We found that agreement tolerability index scores were unacceptable. We evaluated the ability of the device to track changes in cardiac output by inducing a left lateral decubitus position, but the analysis was inconclusive. Conclusion: The agreement between Clearsight (TM) and the echocardiography measurements of cardiac output and stroke volume were not within an acceptable range in the third trimester of pregnancy. (C) 2018 Elsevier Ltd. All rights reserved