Alexandre Faure

Early coagulopathy in trauma patients: An on-scene and hospital admission study

PURPOSE Amongst trauma patients, early coagulopathy is common on hospital admission. No studies have evaluated the initial coagulation status in the pre-hospital setting. We hypothesise that the coagulopathic process begins at the time of trauma. We studied the on-scene and on hospital arrival coagulation profile of trauma patients. METHODS Prospective, observational study investigating the on-scene coagulation profile and its time course. We studied 45 patients at the scene of the accident, before fluid administration, and on hospital admission and classified their coagulopathy using the International Society on Thrombosis and Haemostasis score during a 2-month period. Prothrombin time, activated partial thromboplastin time, fibrinogen concentration, factors II, V and VII activity, fibrin degradation products, antithrombin and protein C activities, platelet counts and base deficit were measured. RESULTS The median injury severity score was 25 (13-35). On-scene, coagulation status was abnormal in 56% of patients. Protein C activities were decreased in the trauma-associated coagulopathy group (p=.02). Drops in protein C activities were associated with changes in activated partial thromboplastin time, prothrombin time, fibrinogen concentration, factor V and antithrombin activities. Only factor V levels decreased significantly with the severity of the trauma. On hospital admission, coagulation status was abnormal in 60% of patients. The on-scene coagulopathy was spontaneously normalised only in 2 patients whereas others had the same or a poorer coagulopathy status. All parameters of coagulation were significantly abnormal comparing to the on-scene phase. Decreases in protein C activities were related to the coagulation status (p<.0001) and changes in other coagulation parameters. Patients with base deficit ≤-6 mmol/L had changes in antithrombin, factor V and protein C activities but no significant coagulopathy. CONCLUSION Coagulopathy occurs very early after injury, before fluid administration, at the site of accident. Coagulation and fibrinolytic systems are activated early. The incidence of coagulopathy is high and its severity is related to the injury and not to hypoperfusion.

Lack of recovery in monocyte human leukocyte antigen-DR expression is independently associated with the development of sepsis after major trauma

IntroductionMajor trauma is characterized by an overwhelming pro-inflammatory response and an accompanying anti-inflammatory response that lead to a state of immunosuppression, as observed after septic shock. Diminished monocyte Human Leukocyte Antigen DR (mHLA-DR) is a reliable marker of monocyte dysfunction and immunosuppression. The main objective of this study was to determine the relation between mHLA-DR expression in severe trauma patients and the development of sepsis.MethodsWe conducted a prospective observational study over 23 months in a trauma intensive care unit at a university hospital. Patients with an Injury Severity Score (ISS) over 25 and age over 18 were included. mHLA-DR was assessed by flow cytometry protocol according to standardized protocol. Mann-Whitney U-test for continuous non-parametric variables, independent paired t test for continuous parametric variables and chi-square test for categorical data were used.ResultsmHLA-DR was measured three times a week during the first 14 days. One hundred five consecutive severely injured patients were monitored (ISS 38 ± 17, SAPS II 37 ± 16). Thirty-seven patients (35%) developed sepsis over the 14 days post-trauma. At days 1-2, mHLA-DR was diminished in the whole patient population, with no difference with the development of sepsis. At days 3-4, a highly significant difference appeared between septic and non-septic patients. Non- septic patients showed an increase in mHLA-DR levels, whereas septic patients did not (13,723 ± 7,766 versus 9,271 ± 6,029 antibodies per cell, p = .004). Most importantly, multivariate logistic regression analysis, after adjustment for usual clinical confounders (adjusted OR 5.41, 95% CI 1.42-20.52), revealed that a slope of mHLA-DR expression between days1-2 and days 3-4 below 1.2 remained associated with the development of sepsis.ConclusionsMajor trauma induced an immunosuppression, characterized by a decrease in mHLA-DR expression. Importantly, after multivariate regression logistic analysis, persistent decreased expression was assessed to be in relation with the development of sepsis. This is the first study in trauma patients showing a link between the lack of immune recovery and the development of sepsis on the basis of the standardized protocol. Monitoring immune function by mHLA-DR measurement could be useful to identify trauma patients at a high risk of infection.

Use of a hand-held digital cognitive aid in simulated crises: the MAX randomized controlled trial

Background Cognitive aids improve the technical performance of individuals and teams dealing with high-stakes crises. Hand-held electronic cognitive aids have rarely been investigated. A randomized controlled trial was conducted to investigate the effects of a smartphone application, named MAX (for Medical Assistance eXpert), on the technical and non-technical performance of anaesthesia residents dealing with simulated crises. Methods This single-centre randomized, controlled, unblinded trial was conducted in the simulation centre at Lyon, France. Participants were anaesthesia residents with >1 yr of clinical experience. Each participant had to deal with two different simulated crises with and without the help of a digital cognitive aid. The primary outcome was technical performance, evaluated as adherence to guidelines. Two independent observers remotely assessed performance on video recordings. Results Fifty-two residents were included between July 2015 and February 2016. Six participants were excluded for technical issues; 46 participants were confronted with a total of 92 high-fidelity simulation scenarios (46 with MAX and 46 without). Mean (sd) age was 27 (1.8) yr and clinical experience 3.2 (1.0) yr. Inter-rater agreement was 0.89 (95% confidence interval 0.85-0.92). Mean technical scores were higher when residents used MAX [82 (11.9) vs 59 (10.8)%; P<0.001]. Conclusion The use of a hand-held cognitive aid was associated with better technical performance of residents dealing with simulated crises. These findings could help digital cognitive aids to find their way into daily medical practice and improve the quality of health care when dealing with high-stakes crises. Clinical trial registration NCT02678819.

Relaxation before Debriefing during High-fidelity Simulation Improves Memory Retention of Residents at Three MonthsA Prospective Randomized Controlled Study

Background: High-fidelity simulation is known to improve participant learning and behavioral performance. Simulation scenarios generate stress that affects memory retention and may impact future performance. The authors hypothesized that more participants would recall three or more critical key messages at three months when a relaxation break was performed before debriefing of critical event scenarios. Methods: Each resident actively participated in one scenario and observed another. Residents were randomized in two parallel-arms. The intervention was a 5-min standardized relaxation break immediately before debriefing; controls had no break before debriefing. Five scenario-specific messages were read aloud by instructors during debriefings. Residents were asked by telephone three months later to recall the five messages from their two scenarios, and were scored for each scenario by blinded investigators. The primary endpoint was the number of residents participating actively who recalled three or more messages. Secondary endpoints included: number of residents observing who recalled three or more messages, anxiety level, and debriefing quality. Results: In total, 149 residents were randomized and included. There were 52 of 73 (71%) residents participating actively who recalled three or more messages at three months in the intervention group versus 35 of 76 (46%) among controls (difference: 25% [95% CI, 10 to 40%], P = 0.004). No significant difference was found between groups for observers, anxiety or debriefing quality. Conclusions: There was an additional 25% of active participants who recalled the critical messages at three months when a relaxation break was performed before debriefing of scenarios. Benefits of relaxation to enhance learning should be considered for medical education.

Hypothermic pulsatile preservation of kidneys from uncontrolled deceased donors after cardiac arrest - a retrospective study.

Kidneys from uncontrolled donors after cardiac arrest (uDCD) suffer from a period of warm ischemia between cardiac arrest and cold flushing. Aim of the study was to evaluate renal outcomes of uDCD kidneys selected on the basis of renal Resistance Index (RI) and its influence on graft function and survival. The study included 44 kidneys procured from 26 uDCD starting 1.1.2006 until 12.31.2013. The donors (Maastricht category II) underwent cardiopulmonary resuscitation by assisted ventilation and chest compression; the organs were preserved with in situ cold perfusion or a normothermic regional perfusion. All kidneys were perfused on hypothermic (1–4 °C) pulsatile perfusion machine (RM3; Waters Medical System) and discarded when RI ≥0.5 mmHg/ml/min after 6 h of perfusion. There was one (2.2%) primary non function, while 37 recipients (84.1%) experienced delayed graft function. Graft survival was 97.6% at 1 and 3 post‐transplantation years. Linear regression models showed that lower values of RI at the end of perfusion were associated with higher values of Modification of Diet in Renal Disease at 3 (P = 0.049) and 6 months after transplantation (P = 0.010) and with higher values of inulin clearance at 1 year (P = 0.030). RI showed to be a useful tool to select uDCD kidneys allowing to achieve good clinical results.

Where is the pacemaker lead

Dear Editor, In May, 2009, a 64-year-old man was brought to our trauma resuscitation room following a car crash with high speed deceleration. He had undergone an aortic valve replacement in 2001 and pacemaker implantation (VVI mode, with right ventricular lead) for intermittent atrioventricular block in 2008. Medications included an oral antivitamin K. On examination, his blood pressure was 100 mmHg and he was conscious, with chest pain. Electrocardiogram revealed an electrostimulated rhythm and his heart rate was accelerated by a magnet on the pacemaker. The initial international normalized ratio (INR) was 2.4 and troponin I level was 9 lg/L. An echocardiography showed a pericardial effusion of 2 cm without right ventricular collapse and a hypokinetic left ventricle. A CT scan revealed contrast extravasation in the heart apex pericardium due to the migration of the pacemaker lead from the right ventricle into the pericardium (Fig. 1). During the subsequent days, the patient was haemodynamically stabilized and troponin I level decreased. Repeated echocardiographies showed stable pericardial effusion. A CT scan revealed the persistence of contrast extravasation in the pericardium with a stable haemopericardium. The patient developed a systemic inflammatory response syndrome without sepsis, due to the haemopericardium. Two weeks after admission, the patient was transferred to the cardiology department. No sign of cardiac tamponade occurred. A CT scan showed intra-pericardial haematoma localised in the right ventricle apex, without contrast extravasation (Fig. 1). The pacemaker was checked, without changes in pacing and sensing thresholds. Three weeks after the crash, the patient was discharged to a rehabilitation centre. Lead perforation in either the right atrium or the right ventricle is an uncommon complication of pacemakers, with an incidence of less than 1%. This is a severe complication that requires prompt treatment; the displaced lead is usually repositioned or extracted. The majority of lead perforations have been described within 1 month after implantation. Recently, some delayed perforations have been described [1, 2]. Patients presented chronic pericarditis or cardiac tamponade and were haemodynamically stable [1]. However, in this study 80% of the patients had significant changes in pacing or sensing thresholds. After blunt trauma, only pacing lead fracture or pulse generator failures have been published [3–5]. This is the first case report of lead perforation after blunt trauma. The striking feature in this report is the haemodynamically well-tolerated perforation with haemopericardium without cardiac tamponade. It was decided to not extract the displaced lead as a priority, because pericardial symphysis due to previous surgery limited the blood extravasation. Moreover there were no changes in pacing or sensing thresholds. Therefore it was useless and dangerous to try an extraction and a new implantation. This case highlights the importance of a global review of all data by an experienced physician before clinical decisions are made. In addition, this case report emphasizes that a high degree of suspicion must be maintained by physicians caring for trauma patients utilizing permanent pacing systems. Its recognition is imperative in the overall management of the trauma patient.