Delayed awakening after cardiac arrest: prevalence and risk factors in the Parisian registry

PURPOSE: Although prolonged unconsciousness after cardiac arrest (CA) is a sign of poor neurological outcome, limited evidence shows that a late recovery may occur in a minority of patients. We investigated the prevalence and the predictive factors of delayed awakening in comatose CA survivors treated with targeted temperature management (TTM). METHODS: Retrospective analysis of the Parisian Region Out-of-Hospital CA Registry (2008-2013). In adult comatose CA survivors treated with TTM, sedated with midazolam and fentanyl, time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h. RESULTS: A total of 326 patients (71 % male, mean age 59 ± 16 years) were included, among whom 194 awoke. Delayed awakening occurred in 56/194 (29 %) patients, at a median time of 93 h (IQR 70-117) from discontinuation of sedation. In 5/56 (9 %) late awakeners, pupillary reflex and motor response were both absent 48 h after sedation discontinuation. In multivariate analysis, age over 59 years (OR 2.1, 95 % CI 1.0-4.3), post-resuscitation shock (OR 2.6 [1.3-5.2]), and renal insufficiency at admission (OR 3.1 [1.4-6.8]) were associated with significantly higher rates of delayed awakening. CONCLUSIONS: Delayed awakening is common among patients recovering from coma after CA. Renal insufficiency, older age, and post-resuscitation shock were independent predictors of delayed awakening. Presence of unfavorable neurological signs at 48 h after rewarming from TTM and discontinuation of sedation did not rule out recovery of consciousness in late awakeners

Diagnostic accuracy of procalcitonin in critically ill immunocompromised patients

<p>Abstract</p> <p>Background</p> <p>Recognizing infection is crucial in immunocompromised patients with organ dysfunction. Our objective was to assess the diagnostic accuracy of procalcitonin (PCT) in critically ill immunocompromised patients.</p> <p>Methods</p> <p>This prospective, observational study included patients with suspected sepsis. Patients were classified into one of three diagnostic groups: no infection, bacterial sepsis, and nonbacterial sepsis.</p> <p>Results</p> <p>We included 119 patients with a median age of 54 years (interquartile range [IQR], 42-68 years). The general severity (SAPSII) and organ dysfunction (LOD) scores on day 1 were 45 (35-62.7) and 4 (2-6), respectively, and overall hospital mortality was 32.8%. Causes of immunodepression were hematological disorders (64 patients, 53.8%), HIV infection (31 patients, 26%), and solid cancers (26 patients, 21.8%). Bacterial sepsis was diagnosed in 58 patients and nonbacterial infections in nine patients (7.6%); 52 patients (43.7%) had no infection. PCT concentrations on the first ICU day were higher in the group with bacterial sepsis (4.42 [1.60-22.14] vs. 0.26 [0.09-1.26] ng/ml in patients without bacterial infection, <it>P </it>< 0.0001). PCT concentrations on day 1 that were > 0.5 ng/ml had 100% sensitivity but only 63% specificity for diagnosing bacterial sepsis. The area under the receiver operating characteristic (ROC) curve was 0.851 (0.78-0.92). In multivariate analyses, PCT concentrations > 0.5 ng/ml on day 1 independently predicted bacterial sepsis (odds ratio, 8.6; 95% confidence interval, 2.53-29.3; <it>P </it>= 0.0006). PCT concentrations were not significantly correlated with hospital mortality.</p> <p>Conclusion</p> <p>Despite limited specificity in critically ill immunocompromised patients, PCT concentrations may help to rule out bacterial infection.</p

Hypothermia as an adjuvant treatment in paediatric refractory or super-refractory status epilepticus

International audienceTherapeutic hypothermia is among the adjuvant therapies suggested for refractory or super-refractory status epilepticus (R/SR-SE) in paediatric patients. Experimental evidence of neuroprotective and antiseizure effects provides a strong rationale for using therapeutic hypothermia in patients with status epilepticus. Thus, hypothermia between 20°C and 33°C in animals with status epilepticus is associated not only with significantly less neuronal damage, predominantly in the hippocampal CA1, CA2, and CA3 areas, but also with increased seizure latency and decreased seizure frequency and duration. Therapeutic hypothermia has rarely been used in paediatric R/SR-SE. In the few reported cases, seizure control was markedly improved but nearly half the patients experienced recurrences after rewarming. Studies are needed to clarify the modalities and indications of therapeutic hypothermia in paediatric patients with R/SR-SE. What this paper adds: Hypothermia at 20°C to 33°C is neuroprotective and has antiseizure effects in experimental status epilepticus. In children, antiseizure effects are marked but recurrences after rewarming are common

Évaluation de facteurs prédictifs de la survenue d un état de mal épileptique post anoxique

Introduction : L état de mal épileptique post-anoxique (EMPA) est un facteur indépendant de mauvais pronostic. Depuis l avènement de l hypothermie thérapeutique, des survivants avec peu de séquelles ont été décrits. L'objectif de cette étude était d'évaluer les facteurs prédictifs de survenue d'EMPA, afin d identifier une population à risque chez qui la surveillance par EEG serait à optimiser pour éviter tout retard diagnostique et thérapeutique. Patients et méthodes : Etaient prospectivement inclus tous les patients hospitalisés dans le service de réanimation du CH Versailles entre 2005 et 2012 pour un coma post-anoxique, et ayant bénéficié de la réalisation d'au moins un EEG. Résultats : Un EMPA était retrouvé chez 55 des 193 patients inclus (28,5%), dans un délai AC/EMPA de 35(19-47) heures et était réfractaire dans 37 cas (67,3%). Un EEG était réalisé lors de la procédure d'hypothermie thérapeutique chez 160 patients (92,5%). Vingt-cinq patients présentant un EMPA (45,4%), bénéficiaient d un EEG continu. L'analyse univariée a révélé que la survenue d'un EMPA était significativement associée à l aréactivité à l'EEG durant la procédure d'hypothermie thérapeutique [OR, 0,11; 95% IC 0,02-0,48; p 0,003], et durant le séjour en réanimation [OR, 0,30; 95% IC 0,14-0,66; p 0,002]. Conclusion : L'aréactivité à l EEG notamment lors de la procédure d'hypothermie thérapeutique est un déterminant lié à la survenue d'un EMPA après AC récupérés. L'intérêt en terme pronostique d'une stratégie associant une surveillance EEG intensive (continue ou séquentielle) et une thérapeutique précoce et agressive reste à déterminerObjectives : The postanoxic status epilepticus (PSE) is a independent factor from poor prognosis. Since the advent of the therapeutic hypothermia, survivors with few sequelae were described. The objective of this study was to estimate the predictive factors of arisen PSE, to identify a population "with risk" to whom the surveillance by EEG would be in optimized to avoid any diagnostic and therapeutic delay. Methods : All the patients hospitalized in the intensive care unit of CH Versailles, in France, between 2005 and 2012 for a post-anoxic coma, and having benefited of at least an EEG, were prospectively included. Results : An PSE was found to 55 of 193 inclusive patients (28.5%), for a lapse of time of 35 (19-47) hours and was refractory in 37 cases (67.3%). An EEG was realized during the procedure of therapeutic hypothermia at 160 patients (92.5%). Twenty five patients presenting an PSE (45.4%), benefited from a continuous EEG. The univariate analysis revealed that the arisen of an PSE was significantly associated with the areactivity in the EEG during the procedure of therapeutic hypothermia [OR, 0.11; 95% IC 0.02-0.48; p 0.003], and during the stay in intensive care unit [OR, 0.30; 95% IC 0.14-0.66; p 0.002]. Conclusion : The areactivity in the EEG in particular during the procedure of therapeutic hypothermia is one connected to the arisen of an PSE after cardiac arrest. The interest in term prognosis of a strategy associating an intensive surveillance EEG (continuous or sequential) and one early and aggressive therapeutics remains to determineST QUENTIN EN YVELINES-BU (782972101) / SudocSudocFranceF

Etat de mal épileptique (Expérience d'un service de réanimation et place de EEG dans la prise en charge )

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

Syndrome d'encéphalopathie postériere réversible en réanimation (épidémiologie et facteurs pronostics)

Le syndrome d encéphalopathie postérieure réversible (PRES) peut induire des séquelles définitives, mais ses critères pronostics en réanimation n ont jamais été étudiés. Une enquête rétrospective a été menée dans 23 réanimations adultes entre 2001 et 2010 pour rechercher les déterminants du pronostic fonctionnel à 3 mois (Glasgow Outcome Scale < 5) et décrire les caractéristiques des 70 patients identifiés.Il s agissait de 45 femmes et 25 hommes âgés de 36 (25-52) ans. Les signes cliniques étaient : crises convulsives (81%), troubles de la conscience (94%), troubles visuels (36%), céphalées (51%), hypertension artérielle (83%). Les anomalies radiologiques d œdème vasogénique, toujours réversibles, impliquaient outre les régions postérieures, les lobes frontaux (9%), les noyaux gris centraux (36%), le cervelet (33%), le tronc cérébral (17%). Une aggravation hémorragique et/ou ischémique était notée chez 12 (17%) patients. Les étiologies, parfois associées, étaient : prise d agents toxiques (44%), encéphalopathie hypertensive (41%), éclampsie (23%), maladies auto-immunes (11%). Onze (16%) patients sont décédés.Un GOS < 5 à 3 mois était noté chez 37 (53%) patients. En analyse multivariée, 3 facteurs étaient indépendamment associés à cette évolution: l éclampsie (facteur protecteur), l hyperglycémie et la soustraction à la cause du PRES après H29 (facteurs aggravants).Une prise en charge précoce, intensive, diagnostique et thérapeutique permet une récupération fonctionnelle favorable à 3 mois chez près de la moitié des patients, et ce quelque soit la gravité des co-morbidités et de la présentation clinique initiale. Un contrôle prudent de l hyperglycémie est préconisé.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF