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Circulation 03/2013; 127(11):e504. · 14.74 Impact Factor
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ABSTRACT: The accuracy of combined clinical examination (CE) and chest radiography (CXR) (CE + CXR) vs thoracic ultrasonography in the acute assessment of pneumothorax, hemothorax, and lung contusion in chest trauma patients is unknown.
We conducted a prospective, observational cohort study involving 119 adult patients admitted to the ED with thoracic trauma. Each patient, secured onto a vacuum mattress, underwent a subsequent thoracic CT scan after first receiving CE, CXR, and thoracic ultrasonography. The diagnostic performance of each method was also evaluated in a subgroup of 35 patients with hemodynamic and/or respiratory instability.
Of the 237 lung fields included in the study, we observed 53 pneumothoraces, 35 hemothoraces, and 147 lung contusions, according to either thoracic CT scan or thoracic decompression if placed before the CT scan. The diagnostic performance of ultrasonography was higher than that of CE + CXR, as shown by their respective areas under the receiver operating characteristic curves (AUC-ROC): mean 0.75 (95% CI, 0.67-0.83) vs 0.62 (0.54-0.70) in pneumothorax cases and 0.73 (0.67-0.80) vs 0.66 (0.61-0.72) for lung contusions, respectively (all P < .05). In addition, the diagnostic performance of ultrasonography to detect pneumothorax was enhanced in the most severely injured patients: 0.86 (0.73-0.98) vs 0.70 (0.61-0.80) with CE + CXR. No difference between modalities was found for hemothorax.
Thoracic ultrasonography as a bedside diagnostic modality is a better diagnostic test than CE and CXR in comparison with CT scanning when evaluating supine chest trauma patients in the emergency setting, particularly for diagnosing pneumothoraces and lung contusions.
Chest 10/2011; 141(5):1177-83. · 5.25 Impact Factor
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ABSTRACT: Variability of American Society of Anesthesiologists' (ASA) physical status scores attributed to the same patient by multiple physicians has been reported in several studies. In these studies, the population was limited and diseases that induced disagreement were not analysed.
To evaluate the reproducibility of ASA physical status assessment on a large population, as used in current practice before scheduled surgery.
Multicentre, randomised, blinded cross-over observational study.
During a 2-week period in nine institutions, ASA physical status and details of assessment performed routinely by anaesthesiologists for patients who underwent elective surgery were recorded. Records were blinded (including ASA physical status) by an independent statistical division and returned randomly to one of the nine centres for reassessment by accredited specialist anaesthesiologists.
The level of agreement between the two measurements of the ASA physical status was calculated by using the weighted Kappa coefficient.
During the study period, 1554 anaesthesia records were collected and 197 were excluded from analysis because of missing data. After the initial evaluation, the distribution of ASA physical status grades was as follows: ASA 1, 571; ASA 2, 591; ASA 3, 177; and ASA 4, 18. After the final evaluation, the distribution of ASA grades was as follows: ASA 1, 583; ASA 2, 520; ASA 3, 223; and ASA 4, 31. Two per cent of the patients had an underestimation of their physical status. The degree of agreement between the two measures evaluated by the weighted Kappa coefficient was 0.53 (0.49-0.56). No difference was observed between public and private institutions. Patients with co-existing diseases, obesity, allergy, sleep apnoea, obstructive lung disease, renal insufficiency and hypertension were least likely to have been graded correctly.
The degree of agreement between two measures of the ASA physical status grade is moderate and influenced by staff characteristics and the complexity of diseases.
European Journal of Anaesthesiology 10/2011; 28(10):742-7. · 2.23 Impact Factor
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Pierre Albaladejo,
Emmanuel Marret,
Charles-Marc Samama,
Jean-Philippe Collet,
Kou Abhay,
Olivier Loutrel,
Hélène Charbonneau,
Samir Jaber,
Sophie Thoret,
Jean-Luc Bosson,
Vincent Piriou
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ABSTRACT: Interruption or maintenance of oral antiplatelet therapy (OAT) during an invasive procedure may result in ischaemic and/or haemorrhagic complications. There is currently a lack of clear guidance regarding the issue of treatment interruption during surgical procedures.
To evaluate the rate of major adverse cardiac and cerebrovascular events (MACCEs) and major or minor bleeding complications and their associated independent correlates in coronary stented patients undergoing urgent or planned non-cardiac surgery.
Prospective, multicentre, observational cohort study of 1134 consecutive patients with coronary stents.
The co-primary endpoints consisted of the incidence of MACCE and major bleeding within the first 30 days of an invasive procedure.
MACCE and haemorrhagic complications were observed in 124 (10.9%) and 108 (9.5%) patients, respectively, within an average time delay from invasive procedure to event of 3.3±3.9 and 5.3±5.3 days. Independent preoperative correlates for MACCE were complete OAT interruption for more than 5 days prior to surgery, preoperative haemoglobin <10 g/dl, creatinine clearance of <30 ml/min and emergency or high-risk surgery. Independent factors for haemorrhagic complications were preoperative haemoglobin <10 g/dl, creatinine clearance between 30 and 60 ml/min, a delay from stent implantation to surgery <3 months and high-risk surgery according to the Lee classification.
Patients with coronary stents undergoing an invasive procedure are at high risk of perioperative myocardial infarction including stent thrombosis irrespective of the stent type and major bleeding. Interruption of OAT more than 5 days prior to an invasive procedure is a key player for MACCE.
NCT01045850.
Heart (British Cardiac Society) 07/2011; 97(19):1566-72. · 4.22 Impact Factor
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ABSTRACT: To weight ischemic and bleeding events according to their severity to be used in a composite outcome in RCTs in the field of thrombosis prevention.
Using a Delphi consensus method, a panel of anaesthesiology and cardiology experts rated the severity of thrombotic and bleeding clinical events. The ratings were expressed on a 10-point scale. The median and quartiles of the ratings of each item were returned to the experts. Then, the panel members evaluated the events a second time with knowledge of the group responses from the first round. Cronbach's a was used as a measure of homogeneity for the ratings. The final rating for each event corresponded to the median rating obtained at the last Delphi round.
Of 70 experts invited, 32 (46%) accepted to participate. Consensus was reached at the second round as indicated by Cronbach's a value (0.99 (95% CI 0.98-1.00)) so the Delphi was stopped. Severity ranged from under-popliteal venous thrombosis (median = 3, Q1 = 2; Q3 = 3) to ischemic stroke or intracerebral hemorrhage with severe disability at 7 days and massive pulmonary embolism (median = 9, Q1 = 9; Q3 = 9). Ratings did not differ according to the medical specialty of experts.
These ratings could be used to weight ischemic and bleeding events of various severity comprising a composite outcome in the field of thrombosis prevention.
PLoS ONE 01/2011; 6(4):e18461. · 4.09 Impact Factor
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ABSTRACT: The early diagnosis of traumatic internal carotid artery dissection (TICAD) is essential for initiating appropriate treatment and improving outcome. We searched for criteria from transcranial Doppler (TCD) measurements on admission that could be associated with subsequent TICAD diagnosis in patients with traumatic brain injury (TBI).
We conducted a retrospective 1:4 matched (age, mean arterial blood pressure) cohort study of 11 TBI patients with TICAD and absent or mild brain lesions on initial CT scan, 22 TBI controls with comparable brain CT scan lesions (controls 1), and 22 TBI controls with more severe brain CT scan lesions (controls 2) on admission. TCD measurements were obtained on admission from both middle cerebral arteries (MCA). All patients had subsequent CT angiography to diagnose TICAD.
A >25% asymmetry in the systolic blood flow velocity between the two MCA was found in 9/11 patients with TICAD versus 0/22 in controls 1 and 5/22 in controls 2 (p < 0.01). The combination of this asymmetry with an ipsilateral pulsatility index < or =0.80 was found in 9/11 patients with TICAD versus none in the two groups of controls (p < 0.01).
Our results suggest that significant asymmetry in the systolic blood flow velocity between the MCAs and a reduced ipsilateral pulsatility index could be criteria from TCD measurements associated with the occurrence of TICAD in head-injured patients. If prospectively validated, these findings could be incorporated in screening protocols for TICAD in patients with TBI.
European Journal of Intensive Care Medicine 09/2010; 36(9):1514-20. · 5.17 Impact Factor
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ABSTRACT: Interruption or maintenance of anti-platelet agents (APAs) during surgical or invasive procedures is associated with an increase in cardiovascular or haemorrhagic complications, respectively. The pharmacology and indications of aspirin, clopidogrel and prasugrel are summarised. The utility and risks of interruption, the optimal delay between stent implantation and surgery, the appropriate window of preoperative interruption, the potential usefulness of bridging, the safest delay between the end of surgery and resumption of APA are detailed in this review. Some non-evidence-based suggestions are given to help the physicians in their daily clinical practice.
Baillière' s Best Practice and Research in Clinical Anaesthesiology 03/2010; 24(1):41-50.
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JAMA The Journal of the American Medical Association 02/2006; 295(1):36; author reply 36. · 30.03 Impact Factor
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Archives of Internal Medicine 03/2005; 165(3):348; author reply 349. · 11.46 Impact Factor
