[Show abstract][Hide abstract] ABSTRACT: Microdialysis enables the chemistry of the extracellular interstitial space to be monitored. Use of this technique in patients with acute brain injury has increased our understanding of the pathophysiology of several acute neurological disorders. In 2004, a consensus document on the clinical application of cerebral microdialysis was published. Since then, there have been significant advances in the clinical use of microdialysis in neurocritical care. The objective of this review is to report on the International Microdialysis Forum held in Cambridge, UK, in April 2014 and to produce a revised and updated consensus statement about its clinical use including technique, data interpretation, relationship with outcome, role in guiding therapy in neurocritical care and research applications.
Intensive Care Medicine 07/2015; 41(9). DOI:10.1007/s00134-015-3930-y · 7.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Because of restricted information given by monitoring solely intracranial pressure and cerebral perfusion pressure, assessment of the cerebral oxygenation in neurocritical care patients would be of interest. The aim of this study was to determinate the correlation between the non--invasive measure regional saturation in oxygen (rSO2) with a third generation NIRS monitor and an invasive measure of brain tissue oxygenation tension (PbtO2).
We conducted a prospective, observational, unblinded study including neurocritical care patients requiring a PbtO2 monitoring. Concomitant measurements of rSO2 were performed with a four wavelengths forehead sensor (EQUANOX Advance™) of the EQUANOX™ 7600 System. We determined the correlation between rSO2 and PbtO2 and the ability of the rSO2 to detect ischemic episodes defined by a PbtO2 less than 15 mmHg. The rSO2 ischemic threshold was 60%.
During 2 months, 8 consecutives patients, including 275 measurements, were studied. There was no correlation between rSO2 and PbtO2 (r = 0.016 [--0.103 - 0,134], r2 = 0.0003, p = 0.8). On the 86 ischemic episodes detected by PbtO2, only 13 were also detected by rSO2. ROC curve showed the inability for rSO2 to detect cerebral hypoxia episodes (AUC = 0.54).
rSO2 cannot be used as a substitute for PbtO2 to monitor cerebral oxygenation in neurocritical care patients.
[Show abstract][Hide abstract] ABSTRACT: Traumatic brain injury (TBI) is an important cause of death and disability. Safety and pharmacodynamics of 4-amino-tetrahydrobiopterin (VAS203), a nitric oxide (NO)-synthase inhibitor, were assessed in TBI in an exploratory Phase IIa study (NOSynthase Inhibition in TRAumatic brain injury=NOSTRA). The study included 32 patients with TBI in six European centers. In a first open Cohort, eight patients received three 12-h intravenous infusions of VAS203 followed by a 12-h infusion-free interval over 3 days (total dose 15 mg/kg). Patients in Cohorts 2 and 3 (24) were randomized 2:1 to receive either VAS203 or placebo as an infusion for 48 or 72 h, respectively (total dose 20 and 30 mg/kg). Effects of VAS203 on intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain metabolism using microdialysis, and the therapy intensity level (TIL) were end points. In addition, exploratory analysis of the extended Glasgow Outcome Score (eGOS) after 6 months was performed. Metabolites of VAS203 were detected in cerebral microdialysates. No significant differences between treatment and placebo groups were observed for ICP, CPP, and brain metabolism. TIL on day 6 was significantly decreased (p<0.04) in the VAS203 treated patients. The eGOS after 6 months was significantly higher in treated patients compared with placebo (p<0.01). VAS203 was not associated with hepatic, hematologic, or cardiac toxic effects. At the highest dose administered, four of eight patients receiving VAS203 showed transitory acute kidney injury (stage 2-3). In conclusion, the significant improvement in clinical outcome indicates VAS203-mediated neuroprotection after TBI. At the highest dose, VAS203 is associated with a risk of acute kidney injury.
KEYWORDS: NO-synthase inhibition; clinical trial; microdialysis; traumatic brain injury
[Show abstract][Hide abstract] ABSTRACT: Introduction:
Face and/or neck burn (FNB) exposes patients to the double respiratory risk of obstruction and hypoxia, and these risks may require a tracheal intubation. This study aims to describe the incidence and the characteristics of difficult intubation in FNB patients.
We conducted a 5-year retrospective, single-center study including all patients meeting the following criteria: 18 years of age or older, an FNB at least 1% of burned surface area with a severity equal to or greater than the superficial second degree, and intubation and a burn center admission within the first 24 hours after the burn. Patients were compared according to the difficulty of their intubation.
Between January 2007 and December 2011, we included 134 patients. The incidence of difficult intubation was 11.2% but was greater in the burn center than in the pre-burn center: 16.9% vs 3.5% (P = .02). The most important difference between patients with or without difficult intubation was the time between the burn injury and the intubation: 210 (105-290) vs 120 (60-180) minutes (P = .047). After multivariate analysis, an intubation performed at a burn center was independently associated with difficult intubation: odds ratio = 3.2; 95% confidence interval, 1.1-528.
This study underlines the high incidence of difficult intubation in FNB patients, greater than 11.2%, and demonstrates that intubation is more difficult when realized at a burn center, probably because it is performed later, allowing for development of cervical and laryngeal edema.
American Journal of Emergency Medicine 07/2014; 32(10). DOI:10.1016/j.ajem.2014.07.014 · 1.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Management of critically ill patients in austere environments is a logistic challenge. Availability of oxygen cylinders for the mechanically ventilated patient may be difficult in such a context. A solution is to use a ventilator able to function with an oxygen concentrator. Objectives: We tested the SeQual Integra (TM) (SeQual, San Diego, CA) 10-OM oxygen concentrator paired with the Pulmonetic System (R) LTV 1000 ventilator (Pulmonetic Systems, Minneapolis, MN) and evaluated the delivered fraction of inspired oxygen (FiO(2)) across a range of minute volumes and combinations of ventilator settings. Methods: Two LTV 1000 ventilators were tested. The ventilators were attached to a test lung and FiO(2) was measured by a gas analyzer. Continuous-flow oxygen was generated by the OC from 0.5 L/min to 10 L/min and injected into the oxygen inlet port of the LTV 1000. Several combinations of ventilator settings were evaluated to determine the factors affecting the delivered FiO(2). Results: The LTV 1000 ventilator is a turbine ventilator that is able to deliver high FiO(2) when functioning with an oxygen concentrator. However, modifications of the ventilator settings such as increase in minute ventilation affect delivered FiO(2) even if oxygen flow is constant on the oxygen concentrator. Conclusions: The ability of an oxygen concentrator to deliver high FiO(2) when used with a turbine ventilator makes this method of oxygen delivery a viable alternative to cylinders in austere environments when used with a turbine ventilator. However, FiO(2) has to be monitored continuously because delivered FiO(2) decreases when minute ventilation is increased. (C) 2014 Elsevier Inc.
Journal of Emergency Medicine 06/2014; 47(3). DOI:10.1016/j.jemermed.2014.04.033 · 0.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction
Acute cytomegalovirus (CMV) infection increases the risk of vascular thrombosis but reports of cerebral venous thrombosis are rare.
We report a 36-year-old woman who presented with a cerebral venous thrombosis and acute CMV infection heralded by a cytolytic hepatitis. Heterozygous factor V Leiden mutation was also identified. The patient was treated with anticoagulation for 1 year with favourable outcome.
Serologic tests for CMV infection should be performed in case of cerebral venous thrombosis with liver cytolysis or flu-like symptoms. CMV infection often triggers thrombosis in combination with other inherited or genetic predisposing risk factors that should always be searched.
La Revue de Médecine Interne 04/2014; 35(4):268–270. DOI:10.1016/j.revmed.2013.04.001 · 1.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Ischemia and metabolic crisis are frequent post-traumatic secondary brain insults that negatively influence outcome. Clinicians commonly mix up these two types of insults, mainly because high lactate/pyruvate ratio (LPR) is the common marker for both ischemia and metabolic crisis. However, LPR elevations during ischemia and metabolic crisis reflect two different energetic imbalances: ischemia (Type 1 LPR elevations with low oxygenation) is characterized by a drastic deprivation of energetic substrates, whereas metabolic crisis (Type 2 LPR elevations with normal or high oxygenation) is associated with profound mitochondrial dysfunction but normal supply of energetic substrates. The discrimination between ischemia and metabolic crisis is crucial because conventional recommendations against ischemia may be detrimental for patients with metabolic crisis. Multimodal monitoring, including microdialysis and brain tissue oxygen monitoring, allows such discrimination, but these techniques are not easily accessible to all head-injured patients. Thus, a new "gold standard" and adapted medical education are required to optimize the management of patients with metabolic crisis.
Frontiers in Neurology 10/2013; 4:146. DOI:10.3389/fneur.2013.00146
[Show abstract][Hide abstract] ABSTRACT: La tracheotomia è definita come l’apertura della trachea cervicale seguita dal posizionamento di una cannula; contrariamente ai paesi anglosassoni, il termine di tracheostomia è in Francia riservato alla patologia otorinolaringoloiatrica e toracica e corrisponde all’abboccamento definitivo della trachea alla cute cervicale. La tracheotomia, procedura invasiva, riguarda circa il 10% dei pazienti sotto ventilazione meccanica in rianimazione. Essa è utile quando lo svezzamento dalla ventilazione meccanica è difficile o prolungato. Tuttavia, non rappresenta l’unica strategia, in quanto il ruolo della ventilazione non invasiva nello svezzamento dalla ventilazione meccanica è molto progredito in questi ultimi anni. Non potendo basarsi su delle prove scientifiche solide, le indicazioni e le raccomandazioni professionali sono assai poco direttive, lasciando uno spazio importante alla decisione individuale al letto del paziente. In effetti, i risultati degli studi forniscono poche informazioni. Questa è la ragione per cui il momento e la tecnica della tracheotomia restano discussi e, a volte, legati alle opinioni. Malgrado ciò, nel corso dello svezzamento dalla ventilazione, è probabile che la tracheotomia migliori il comfort dei pazienti e riduca i fabbisogni di sedazione. La mortalità, l’incidenza delle pneumopatie acquisite sotto ventilazione meccanica e la durata di ospedalizzazione non sono ridotte da una tracheotomia precoce (< 7 giorni di ventilazione). A differenza della tracheotomia chirurgica, le tecniche percutanee iniziano con l’introduzione, tra due anelli tracheali, di una guida metallica sulla quale un dispositivo di dilatazione realizza l’orifizio di tracheotomia. Le differenze di complicanze tra le due tecniche sono complessivamente modeste. I postumi della tracheotomia percutanea sono più semplici, con meno infezioni peritracheali e una migliore cicatrizzazione. La tracheotomia è una procedura invasiva che impone delle precauzioni prima della sua realizzazione, durante e dopo. Le cannule di tracheotomia sono varie, richiedono delle cure ed espongono a delle complicanze.
[Show abstract][Hide abstract] ABSTRACT: La traqueotomía se define como la abertura de la tráquea cervical y la colocación subsiguiente de una cánula. La traqueotomía es un procedimiento invasivo que se realiza en alrededor del 10% de los pacientes que reciben ventilación mecánica en reanimación. Es útil cuando el retiro de la ventilación mecánica resulta difícil o prolongada. Sin embargo, no es la única estrategia, ya que la ventilación no invasiva como sustitución de la ventilación mecánica ha progresado mucho en los últimos años. Al no contar con pruebas científicas sólidas, las indicaciones y recomendaciones profesionales son bastante poco específicas, lo que deja un lugar considerable a la decisión individual. Los resultados de los estudios no ofrecen suficientes datos. Por esta razón, el momento y la técnica de la traqueotomía son motivo de controversias y a veces de opiniones contrarias. Sin embargo, ante el retiro de la ventilación, es probable que la traqueotomía mejore la comodidad de los pacientes y disminuya las necesidades de sedación. La mortalidad, la incidencia de las neumopatías adquiridas bajo ventilación mecánica y la duración de la hospitalización no disminuyen a causa de una traqueotomía precoz (<7 días de ventilación). A diferencia de la traqueotomía quirúrgica, las técnicas percutáneas comienzan por la introducción, entre dos anillos traqueales, de una guía metálica sobre la que un dispositivo de dilatación crea el orificio de traqueotomía. Las diferencias entre las dos técnicas en cuanto a las complicaciones suelen ser moderadas. Los cuidados posteriores de la traqueotomía percutánea son más simples, con menos infección peritraqueal y mejor cicatrización. La traqueotomía es un procedimiento invasivo que exige tomar precauciones antes, durante y después de su realización. Las cánulas de traqueotomía son variadas, necesitan cuidados y exponen a complicaciones.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study is to prospectively compare the accuracies of transcranial color-coded sonography (TCCS) and transcranial Doppler (TCD) in the diagnosis of elevated intracranial pressure.
A prospective, blinded, head-to-head comparison of TCD and TCCS methods using intracranial pressure (ICP) measured continuously via an intraparenchymal catheter as the reference standard in 2 groups of 20 neurocritical care patients each: high ICP (group 1) and normal ICP (group 2). Middle cerebral artery (MCA) pulsatility index (PI) recordings from all patients' sonographic reports were selected based on the highest left or right recorded MCA PI. Transcranial Doppler was performed using a dedicated TCD device, and TCCS was performed using a portable ultrasound system.
The PI values obtained did not differ significantly between the 2 methods (group 1, P = .46; group 2, P = .11). Linear regression analysis identified a significant relationship between PI obtained with both methods (r = 0.897; P < .0001). The duration of PI measurement was statistically longer with TCCS than TCD (group 1, P < .01; group 2, P < .01). Diagnostic accuracies were good and similar for both methods (TCD area under curve, 0.901; TCCS area under curve 0.870; P = .69).
This work is a pilot study comparing TCCS and TCD in the detection of elevated ICP. This study suggests that a bedside portable ultrasound system may be useful to determine MCA PI with accuracy similar to that of a dedicated TCD device.
The American journal of emergency medicine 06/2011; 30(6):936-41. DOI:10.1016/j.ajem.2011.05.005 · 1.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Tracheostomy is considered the airway management of choice for patients who require prolonged mechanical ventilation. The development of percutaneous techniques offers many advantages including the ability to perform the procedure in the intensive care unit. The aim of this study was to compare the controlled rotating dilation method (PercuTwist) and the Griggs' forceps dilational tracheostomy. Patients over 18 years of age undergoing tracheostomy in the intensive care unit were included in the study. They were divided in two random samples--either PercuTwist or forceps dilational tracheostomy. Data collected prospectively included demographic characteristics, procedure duration, blood gas analysis, intracranial pressure, arterial blood pressure and heart rate before and after the procedure. Any complications during or after the procedure due to the tracheostomy were also recorded. Contrary to the main hypothesis, PercuTwist technique took significantly longer to perform than forceps dilational tracheostomy technique (five minutes [2 to 25] vs three minutes [1 to 17][P=0.006]). A significant increase in P(a)CO2 and decrease in arterial pH were observed in both groups between the pre-tracheostomy and post-tracheostomy blood gas analysis. Haemodynamic tolerance was good. Our results show that intracranial pressure is affected by the procedure whatever the technique used. However we did not observe a decrease in cerebral perfusion pressure. The incidence of complications was 23% (20/87). These complications were minor in 18/20 and were not significantly different between the two groups. In conclusion, we consider that the PercuTwist technique is safe despite the longer duration of the procedure. Nevertheless the forceps dilational technique remains our routine procedure.
Anaesthesia and intensive care 03/2011; 39(2):209-16. · 1.30 Impact Factor