Facteurs de risque des pneumopathies acquises sous ventilation mécanique précoces chez les patients tétraplégiques

Les patients atteints d'un traumatisme du rachis cervical développent un taux élevé de pneumopathies acquises sous ventilation mécanique (PAVM) précoces. Les facteurs de risque et les complications liés à ces épisodes sont peu étudiés dans la littérature. Nous avons étudiés 57 dossiers. Vingt et un patients (37%) ont développé une PAVM précoce. Après analyse multivariée, l'antibioprophylaxie était un facteur indépendant de protection des PAVM précoces [OR 0,251 ; IC95 (0,07-0,93)] alors que le seul critère associé à une augmentation du risque était le caractère complet du déficit neurologique [OR 7,7 ; IC95 (1,9-31,3)]. Les patients indemnes de PAVM précoces avaient une durée de ventilation mécanique de 13 (8-30) jours versus 20 (12-35) jours (p<0,05). La durée d'hospitalisation en réanimation, la récupération neurologique et la mortalité n étaient pas significativement modifiés par la survenue d une PAVM précoce. Les PAVM précoces sont fréquentes en cas de tétraplégie traumatique. Ces évènements sont associés à une augmentation des durées de ventilation. La réalisation d'une antibioprophylaxie brève en diminue le risque. Un essai multicentrique serait nécessaire pour valider l'intérêt de ce traitement préventif.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF

Risk factors for prolonged duration of mechanical ventilation in acute traumatic tetraplegic patients-a retrospective cohort study.

International audiencePURPOSE: Respiratory complications constitute an important determinant of length of stay in tetraplegic patients. In a population of tetraplegic patients, we investigated the factors involved in the duration of mechanical ventilation (MV) and whether the duration of MV was associated with the long-term neurologic status. MATERIAL AND METHODS: In a retrospective study in 3 intensive care units (ICUs) (January 2001 to December 2009), consecutive patients (≥18 years) hospitalized for acute (≤24 hours) traumatic tetraplegia were included in the study. Patients with severe brain injury or who died in the first 48 hours were excluded. The primary outcome was the duration of MV. The secondary outcomes were the American Spinal Injury Association (ASIA) motor score on ICU discharge and at 1 year. RESULTS: A total of 164 consecutive adult patients with tetraplegia were analyzed. Median (interquartile range) ASIA motor scores were 15 (6-26) on admission, 22 (9-40) on ICU discharge (n = 145 survivors), and 37 (10-80) at 1 year (n = 52 complete follow-up). The median duration of MV was 11 (2-26) days. In multivariate analysis, MV duration increased with pneumonia (P < .0001), atelectasis (P = .0042), and tracheotomy (P < .0001). In exploratory analysis, an increased duration of MV was the only factor associated in multivariate analysis with a low ASIA motor score on ICU discharge (P = .0201) and at 1 year (P = .0003). CONCLUSIONS: Prevention of pneumonia and atelectasis is critical for the reduction of MV in tetraplegic patients. Prolonged MV was independently associated with poor neurologic status

Butyrylcholinesterase Atypical Mutation in a Patient Undergoing Electroconvulsive Therapy

International audienc

Management of Emergency Electroconvulsive Therapy in the Intensive Care Unit for Life-Threatening Psychiatric Conditions: A Case Series

International audienceCatatonia can lead to severe complications and may be lethal but is often underdiagnosed. The clinical presentation can be similar to coma. In these situations, electroconvulsive therapy (ECT) can be used as first-line treatment to enable extubation, recovery of autonomy, and rapid discharge from intensive care. We report 4 cases of patients hospitalized in the intensive care unit with comatose clinical presentation and life-threatening condition caused by catatonia. All patients received ECT sessions, after which the catatonic symptoms partially or fully remitted. We discuss the clinical identification, general considerations, ECT feasibility, and parameters in the intensive care unit, as well as the differential diagnosis, drug precautions, and prevention concerns

Implementation of an Evidence-based Extubation Readiness Bundle in 499 Brain-injured Patients. A Before–After Evaluation of a Quality Improvement Project

International audienc

Hydrocortisone plus fludrocortisone for community acquired pneumonia-related septic shock: a subgroup analysis of the APROCCHSS phase 3 randomised trial

International audienceBackground: Glucocorticoids probably improve outcomes in patients hospitalised for community acquired pneumonia (CAP). In this a priori planned exploratory subgroup analysis of the phase 3 randomised controlled Activated Protein C and Corticosteroids for Human Septic Shock (APROCCHSS) trial, we aimed to investigate responses to hydrocortisone plus fludrocortisone between CAP and non-CAP related septic shock.Methods: APROCCHSS was a randomised controlled trial that investigated the effects of hydrocortisone plus fludrocortisone, drotrecogin-alfa (activated), or both on mortality in septic shock in a two-by-two factorial design; after drotrecogin-alfa was withdrawn on October 2011, from the market, the trial continued on two parallel groups. It was conducted in 34 centres in France. In this subgroup study, patients with CAP were a preselected subgroup for an exploratory secondary analysis of the APROCCHSS trial of hydrocortisone plus fludrocortisone in septic shock. Adults with septic shock were randomised 1:1 to receive, in a double-blind manner, a 7-day treatment with daily administration of intravenous hydrocortisone 50 mg bolus every 6h and a tablet of 50 μg of fludrocortisone via the nasogastric tube, or their placebos. The primary outcome was 90-day all-cause mortality. Secondary outcomes included all-cause mortality at intensive care unit (ICU) and hospital discharge, 28-day and 180-day mortality, the number of days alive and free of vasopressors, mechanical ventilation, or organ failure, and ICU and hospital free-days to 90-days. Analysis was done in the intention-to-treat population. The trial was registered at ClinicalTrials.gov (NCT00625209).Findings: Of 1241 patients included in the APROCCHSS trial, CAP could not be ruled in or out in 31 patients, 562 had a diagnosis of CAP (279 in the placebo group and 283 in the corticosteroid group), and 648 patients did not have CAP (329 in the placebo group and 319 in the corticosteroid group). In patients with CAP, there were 109 (39%) deaths of 283 patients at day 90 with hydrocortisone plus fludrocortisone and 143 (51%) of 279 patients receiving placebo (odds ratio [OR] 0·60, 95% CI 0·43-0·83). In patients without CAP, there were 148 (46%) deaths of 319 patients at day 90 in the hydrocortisone and fludrocortisone group and 157 (48%) of 329 patients in the placebo group (OR 0·95, 95% CI 0·70-1·29). There was significant heterogeneity in corticosteroid effects on 90-day mortality across subgroups with CAP and without CAP (p=0·046 for both multiplicative and additive interaction tests; moderate credibility). Of 1241 patients included in the APROCCHSS trial, 648 (52%) had ARDS (328 in the placebo group and 320 in the corticosteroid group). There were 155 (48%) deaths of 320 patients at day 90 in the corticosteroid group and 186 (57%) of 328 patients in the placebo group. The OR for death at day 90 was 0·72 (95% CI 0·53-0·98) in patients with ARDS and 0·85 (0·61-1·20) in patients without ARDS (p=0·45 for multiplicative interaction and p=0·42 for additive interaction). The OR for observing at least one serious adverse event (corticosteroid group vs placebo) within 180 days post randomisation was 0·64 (95% CI 0·46-0·89) in the CAP subgroup and 1·02 (0·75-1·39) in the non-CAP subgroup (p=0·044 for multiplicative interaction and p=0·042 for additive interaction).Interpretation: In a pre-specified subgroup analysis of the APROCCHSS trial of patients with CAP and septic shock, hydrocortisone plus fludrocortisone reduced mortality as compared with placebo. Although a large proportion of patients with CAP also met criteria for ARDS, the subgroup analysis was underpowered to fully discriminate between ARDS and CAP modifying effects on mortality reduction with corticosteroids. There was no evidence of a significant treatment effect of corticosteroids in the non-CAP subgroup.Funding: Programme Hospitalier de Recherche Clinique of the French Ministry of Health, by Programme d'Investissements d'Avenir, France 2030, and IAHU-ANR-0004