[Show abstract][Hide abstract] ABSTRACT: In ICU patients with normal serum creatinine (SCr), a state of increased renal drug excretion has been described (creatinine clearance ≥130 ml/min/1.73 m 2 ), and named augmented renal clearance (ARC). In ICU patients, the accuracy of GFR estimates is insufficient. However, in clinical practice, the physician has not at one’s disposal patient measured creatinine clearance (CrCl) when prescribing. The primary objective of this study was to assess the accuracy of 4 formulas to estimate GFR (Cockcroft-Gault (CG), Robert, sMDRD, and CKD-EPI formulas) with other covariates to detect ARC in ICU patients.
We enroled 360 consecutive ICU patients with normal SCr in this prospective observational study conducted in a primary teaching hospital. Comparisons between CrCl values and 4 estimated GFR (eGFR) formulas were estimated.
In these 360 patients, ARC was observed in 33 % of patients most of them trauma. Individual predictive values of equations were poor and the phenomenon increased in ARC subgroup. CG and CKD-EPI were more accurate to detect an ARC. Multivariable analysis showed that the best-fitting model included 3 factors independently correlated to ARC: trauma patients, cut-off values of age ≤58 years, and CKD-EPI more than 108 ml/min/1.73 m 2 .
In ICU patients with normal SCr, eGFR formulas are imprecise in assessing CrCl. If measured CrCl must be ideally used to detect modifications of the renal function, in clinical practice, age, reason for admission, and CKD-EPI could be used as screening tool to identify ARC.
Preview · Article · Dec 2015 · Annals of Intensive Care
[Show abstract][Hide abstract] ABSTRACT: Objective:
We hypothesize that the major consciousness deficit observed in coma is due to the breakdown of long-range neuronal communication supported by precuneus and posterior cingulate cortex (PCC), and that prognosis depends on a specific connectivity pattern in these networks.
We compared 27 prospectively recruited comatose patients who had severe brain injury (Glasgow Coma Scale score <8; 14 traumatic and 13 anoxic cases) with 14 age-matched healthy participants. Standardized clinical assessment and fMRI were performed on average 4 ± 2 days after withdrawal of sedation. Analysis of resting-state fMRI connectivity involved a hypothesis-driven, region of interest-based strategy. We assessed patient outcome after 3 months using the Coma Recovery Scale-Revised (CRS-R).
Patients who were comatose showed a significant disruption of functional connectivity of brain areas spontaneously synchronized with PCC, globally notwithstanding etiology. The functional connectivity strength between PCC and medial prefrontal cortex (mPFC) was significantly different between comatose patients who went on to recover and those who eventually scored an unfavorable outcome 3 months after brain injury (Kruskal-Wallis test, p < 0.001; linear regression between CRS-R and PCC-mPFC activity coupling at rest, Spearman ρ = 0.93, p < 0.003).
In both etiology groups (traumatic and anoxic), changes in the connectivity of PCC-centered, spontaneously synchronized, large-scale networks account for the loss of external and internal self-centered awareness observed during coma. Sparing of functional connectivity between PCC and mPFC may predict patient outcome, and further studies are needed to substantiate this potential prognosis biomarker.
[Show abstract][Hide abstract] ABSTRACT: Background:
Spinal anaesthesia (SA) is a widely used technique of regional anaesthesia but hypotension is an adverse effect commonly observed, especially in elderly patients.
The objective of this study was to assess the cardiovascular effects induced by a single injection of a low-dose SA during elective surgery by using transthoracic echocardiography (TTE) and to compare these effects in patients older and younger than 70 years of age.
Single centre university hospital.
Patients or other participants:
Forty-six patients scheduled for surgery under SA were included in the study (25 patients<70 years and 21 patients ≥ 70 years).
A cardiologist, blinded to all clinical parameters, interpreted the TTE.
Main outcome measures:
Two TTEs were performed for each patient: one at baseline before and the second 20minutes after the placement of the SA.
Sixty-six percent of patients became hypotensive in the ≥ 70 years group whereas no episode of hypotension occurred in the<70 years group (P<0.0001). At baseline (i.e. prior to SA), when compared to younger patients, elderly patients had both a lower E/A ratio (0.8 [0.5-2.1] vs. 1.4 [0.7-1.6], P=0.001) as well as a lower LVEF (50.4% [37.7-72.3] vs. 60.9% [44.8-69.8], P<0.0001). SA in the elderly induced a larger decrease in the cardiac index (CI) (-0.5 L·min(-1)·m(-2) [-0.8 to -0.3] vs. -0.2 L·min(-1)·m(-2) [-0.8-0.1], P<0.0001), LV stroke volume (-8mL [-13-4] vs. -2mL [-14 to -1], P<0.0001) and systemic vascular resistances (SVR) (-2.2 WU [-6.7-0.3] vs. -0.8 WU [-2.3-0.1], P<0.0001).
Hypotension is more frequent among elderly patients, even after low-dose SA. Known age-related changes in cardiovascular performance, such as impaired myocardial relaxation and decreased systolic function could be responsible for the decrease in cardiac output (CO) and SVR seen in these patients.
[Show abstract][Hide abstract] ABSTRACT: Cette étude observationnelle et prospective a inclus les patients de réanimation bénéficiant d’une évaluation hémodynamique non invasive. Une échographie transthoracique a été réalisée et les valeurs mesurées du dVAo et du débit cardiaque ont été comparées aux valeurs estimées à partir de la formule : dVAoestimé = 5,7 × BSA + 12,1. La concordance était évaluée par un test de Bland et Altman.
[Show abstract][Hide abstract] ABSTRACT: Background:
Weaning from mechanical ventilation is associated with the presence of asynchronies between the patient and the ventilator. The main objective of the present study was to demonstrate a decrease in the total number of patient-ventilator asynchronies in invasively ventilated patients for whom difficulty in weaning is expected by comparing neurally adjusted ventilatory assist (NAVA) and pressure support ventilation (PSV) ventilatory modes.
We performed a prospective, non-randomized, non-interventional, single-center study. Thirty patients were included in the study. Each patient included in the study benefited in an unpredictable way from both modes of ventilation, NAVA or PSV. Patients were successively ventilated for 23 h in NAVA or in PSV, and then they were ventilated for another 23 h in the other mode. Demographic, biological and ventilatory data were collected during this period. The two modes of ventilatory support were compared using the non-parametric Wilcoxon test after checking for normal distribution by the Kolmogorov-Smirnov test. The groups were compared using the chi-square test.
The median level of support was 12.5 cmH2O (4-20 cmH2O) in PSV and 0.8 cmH2O/μvolts (0.2-3 cmH2O/μvolts) in NAVA. The total number of asynchronies per minute in NAVA was lower than that in PSV (0.46 vs 1, p < 0.001). The asynchrony index was also reduced in NAVA compared with PSV (1.73 vs 3.36, p < 0.001). In NAVA, the percentage of ineffective efforts (0.77 vs 0.94, p = 0.036) and the percentage of auto-triggering were lower compared with PSV (0.19 vs 0.71, p = 0.038). However, there was a higher percentage of double triggering in NAVA compared with PSV (0.76 vs 0.71, p = 0.046).
The total number of asynchronies in NAVA is lower than that in PSV. This finding reflects improved patient-ventilator interaction in NAVA compared with the PSV mode, which is consistent with previous studies. Our study is the first to analyze patient-ventilator asynchronies in NAVA and PSV on such an important duration. The decrease in the number of asynchronies in NAVA is due to reduced ineffective efforts and auto-triggering.
[Show abstract][Hide abstract] ABSTRACT: Diabetic neuropathy is one of the most common complications of diabetes and causes various problems in daily life. The aim of this study was to assess the effect of regional anaesthesia on post surgery opioid induced hyperalgesia in diabetic and non-diabetic mice.
Diabetic and non-diabetic mice underwent plantar surgery. Levobupivacaine and sufentanil were used before surgery, for sciatic nerve block (regional anaesthesia) and analgesia, respectively. Diabetic and non-diabetic groups were each randomly assigned to three subgroups: control, no sufentanil and no levobupivacaine; sufentanil and no levobupivacaine; sufentanil and levobupivacaine. Three tests were used to assess pain behaviour: mechanical nociception; thermal nociception and guarding behaviours using a pain scale.
Sufentanil, alone or in combination with levobupivacaine, produced antinociceptive effects shortly after administration. Subsequently, sufentanil induced hyperalgesia in diabetic and non-diabetic mice. Opioid-induced hyperalgesia was enhanced in diabetic mice. Levobupivacaine associated to sufentanil completely prevented hyperalgesia in both groups of mice.
The results suggest that regional anaesthesia can decrease opioid-induced hyperalgesia in diabetic as well as in non-diabetic mice. These observations may be clinically relevant for the management of diabetic patients.
Full-text · Article · Jul 2015 · Journal of Translational Medicine
[Show abstract][Hide abstract] ABSTRACT: L’hypothermie fait partie, avec l’acidose et la coagulopathie, de la triade létale aggravant le pronostic des traumatisés graves. Si l’hypothermie accidentelle est facile à reconnaître par une simple mesure, elle n’en reste pas moins délétère si elle n’est pas prévenue ou traitée dès la phase initiale de la prise en charge du patient. Elle est multifactorielle et est un facteur de risque de mortalité chez le traumatisé grave. Les conséquences de l’hypothermie sont multiples : elle modifie la contractilité myocardique et favorise les arythmies. Elle participe à la coagulopathie traumatique. Du point de vue immunologique, elle diminue la réponse inflammatoire et augmente le taux de pneumopathies chez le traumatisé. Elle diminue l’élimination des médicaments utilisés pour l’anesthésie et la sédation et perturbe l’interprétation des dosages biologiques en particulier, elle entraîne une surestimation de l’activité des facteurs de la coagulation. Cette mise au point se propose de détailler les conséquences physiopathologiques de l’hypothermie, ainsi que les principales recommandations récemment formulées sur ce thème.
[Show abstract][Hide abstract] ABSTRACT: IntroductionBrain midline shift (MLS) is a life-threatening condition that requires urgent diagnosis and treatment. We aimed to validate bedside assessment of MLS with Transcranial Sonography (TCS) in neurosurgical ICU patients by comparing it to CT.Methods
In this prospective single centre study, patients who underwent a head CT were included and a concomitant TCS performed. TCS MLS was determined by measuring the difference between the distance from skull to the third ventricle on both sides, using a 2 to 4 MHz probe through the temporal window. CT MLS was measured as the difference between the ideal midline and the septum pellucidum. A significant MLS was defined on head CT as >0.5 cm.ResultsA total of 52 neurosurgical ICU patients were included. The MLS (mean¿±¿SD) was 0.32¿±¿0.36 cm using TCS and 0.47¿±¿0.67 cm using CT. The Pearson¿s correlation coefficient (r2) between TCS and CT scan was 0.65 (P <0.001). The bias was 0.09 cm and the limits of agreements were 1.10 and -0.92 cm. The area under the ROC curve for detecting a significant MLS with TCS was 0.86 (95% CI =0.74 to 0.94), and, using 0.35 cm as a cut-off, the sensitivity was 84.2%, the specificity 84.8% and the positive likelihood ratio =5.56.Conclusions
This study suggests that TCS could detect MLS with reasonable accuracy in neurosurgical ICU patients and that it could serve as a bedside tool to facilitate early diagnosis and treatment for patients with a significant intracranial mass effect.
Preview · Article · Dec 2014 · Critical care (London, England)
[Show abstract][Hide abstract] ABSTRACT: IntroductionEchocardiographic indices based on respiratory variations of superior and inferior vena cava diameters (¿SVC and ¿IVC, respectively) have been proposed as predictors of fluid responsiveness in mechanically ventilated patients but they have never been compared simultaneously in the same patient sample. The aim of this study was to compare the predictive value of these echocardiographic indices when concomitantly recorded in mechanically ventilated, septic patients.Methods
Septic shock patients requiring hemodynamic monitoring were prospectively enrolled over a 1-year period in a mixed medical surgical ICU of a University Teaching Hospital (Toulouse, France). All patients were mechanically ventilated. Predictive indices were obtained by transesophageal and transthoracic echocardiography and were calculated as follows: (Dmax-Dmin) / Dmax for ¿SVC and (Dmax-Dmin) / Dmin for ¿IVC where Dmax and Dmin are the maximal or minimal diameter of SVC and IVC. Measurements were performed at baseline and after a 7 ml/kg volume expansion using a plasma expander. Patients were separated into responders (increase in cardiac index¿¿¿15%) and non-responders (increase in cardiac index¿<¿15%).ResultsAmong 44 included patients, 26 (59%) patients were responders (R). ¿SVC was significantly more accurate than ¿IVC to predict fluid responsiveness (the area under the ROC curve for ¿SVC and ¿IVC regarding assessment of fluid responsiveness were significantly different (0.74 (95% confidence interval (CI): 0.59 to 0.88) and 0.43 (95% CI: 0.25 to 0.61) respectively with P¿=¿0.012)). No significant correlation between ¿SVC and ¿IVC was found (r¿=¿0.005, P¿=¿0.98). The best threshold value to discriminate R from NR was 29% for ¿SVC with a 54% sensitivity and 89% specificity, and 21% for ¿IVC with a 38% sensitivity and 61% specificity.Conclusions¿SVC was better in predicting fluid responsiveness than ¿IVC in our cohort. It is worth noting that the sensitivity and specificity of ¿SVC and ¿IVC to predict fluid responsiveness were lower than those reported in the literature, highlighting the limits of using these indices in a heterogeneous sample of medical and surgical septic patients.
[Show abstract][Hide abstract] ABSTRACT: Introduction
Certaine études suggèrent que lors d’une encéphalopathie hépatique, une hypertension intracrânienne (HTIC) peut dans certains cas être observée . Toutefois, l’incidence de l’HTIC lors d’une encéphalopathie hépatique reste inconnue. Évaluation de l’incidence de l’hypertension intracrânienne (HTIC) par méthodes non invasives chez les patients présentant une encéphalopathie hépatique et son évolution avec le traitement de la maladie hépatique.
Matériel et méthodes
Étude prospective, observationnelle au sein d’un CHU. Des patients présentant une encéphalopathie hépatique (critères de West Haven) ont été inclus. Les patients ont bénéficié d’une estimation non invasive de la pression intracrânienne par mesure échographique du diamètre des enveloppes du nerf optique (DENO) (HTIC si > 0,58 cm) et mesures des vélocités cérébrales dans les artères cérébrales moyennes (ACM) au Doppler transcrânien (DTC) de l’inclusion et jusqu’à 4 jours après le début de l’étude (j4). Les tests de Mann-Whithney ou Kruskal-Wallis ont été appliqués quand ils étaient appropriés (p significatif < 0,05).
Vingt-neuf patients ont été inclus. Le DENO médian à j0 était de 0,54 cm (extrêmes de 0,42 à 0,60 cm). Il n’y avait pas de différences ou pour les vélocités au DTC entre les différents stades d’encéphalopathie pour les DENO à j0 (p = 0,13) et à j1 (p = 0,41), ni pour les index de pulsatilité (p = 0,38 pour les IP droits et p = 0,39 pour les IP gauches), entre les différents groupes d’encéphalopathie clinique à j0 et à j1 ( Fig. 1). De même, l’analyse de l’évolution lors du traitement de l’encéphalopathie ne retrouvait pas de différences significatives entre les valeurs des DENO (p = 0,7) et les index de pulsatilité (IP) des ACM entre j0 et j4 (IP droit p = 0,4 et IP gauche p = 0,5).
La mesure par des techniques non invasives ne confirment pas la présence d’HTIC chez les patients en encéphalopathie hépatique.
No preview · Article · Sep 2014 · Annales francaises d'anesthesie et de reanimation