Claude Jacquot

Assessing pain in critically ill sedated patients by using a behavioral pain scale

Objective To establish the validity and reliability of a new behavioral pain scale (BPS) for critically ill sedated adult patients. Design Prospective evaluation. Setting Ten-bed trauma and surgical intensive care unit in a university teaching hospital. Patients Thirty mechanically ventilated patients who were receiving analgesia and sedation. Intervention Assessments with the BPS were completed consecutively at standardized times (morning, afternoon, night) by pairs of evaluators (nurse and nurse’s aide). They collected physiologic parameters and BPS results before and during care procedures: nonnociceptive (group 1, compression stockings application and central venous catheter dressing change), nociceptive (group 2, endotracheal suctioning and mobilization), and retested nociceptive (group 3). The BPS score was the sum of three items that had a range score of 1–4: facial expression, movements of upper limbs, and compliance with mechanical ventilation. Measurements and Main Results Two hundred and sixty nine assessments were completed, including 104, 134, and 31 measurements in groups 1, 2 and 3, respectively. There was no difference in Ramsay scale scores between the three groups (Ramsay 4–6). Nociceptive stimulations (group 2) resulted in significantly higher BPS values than nonnociceptive ones (group 1, 4.9 vs. 3.5, p < .01), whereas the two groups had comparable BPS values before stimulation (3.1 vs. 3.0). A trend was found in group 2 between the dosage of sedation/analgesia and BPS: the higher the dosage, the lower BPS values and BPS changes to nociceptive stimulation. Group 3 had BPS values similar to group 2 at rest (3.2 vs. 3.2) and during the procedure (4.4 vs. 4.5), with good interrater correlations (r2 = .71 and .50, respectively). Conclusions These results indicate that the expression of pain can be scored validly and reliably by using the BPS in sedated, mechanically ventilated patients. Further studies are warranted regarding the utility of the BPS in making clinical decisions about the use of analgesic drugs in the intensive care unit.

Equimolar doses of mannitol and hypertonic saline in the treatment of increased intracranial pressure.

Objective:To compare the effects of equimolar doses of 20% mannitol solution and of 7.45% hypertonic saline solution (HSS) in the treatment of patients with sustained elevated intracranial pressure (ICP). Design:Parallel, randomized, controlled trial. Setting:Two intensive care units in a university hospital. Patients:A total of 20 stable patients with a sustained ICP of >20 mm Hg secondary to traumatic brain injury (n = 17) or stroke (n = 3). Interventions:A single equimolar infusion (255 mOsm dose) of either 231 mL of 20% mannitol (mannitol group; n = 10 patients) or 100 mL of 7.45% hypertonic saline (HSS group; n = 10 patients) during 20 mins of administration. Measurements:ICP, arterial blood pressure, cerebral perfusion pressure, blood flow velocities of middle cerebral artery using continuous transcranial Doppler, brain tissue oxygen tension, serum sodium and osmolality, and urine output during a study period of 120 mins. Main Results:The two treatments equally and durably reduced ICP during the experiment. At 60 mins after the start of the infusion, ICP was reduced by 45% ± 19% of baseline values (mean ± sd) in the mannitol group vs. 35% ± 14% of baseline values in the HSS group. Cerebral perfusion pressure and diastolic and mean blood flow velocities were durably increased in the mannitol group, resulting in lower values of pulsatility index at the different times of the experiment (p < .01 vs. HSS). No major changes in brain tissue oxygen tension were found after each treatment. Mannitol caused a significantly greater increase in urine output (p < .05) than HSS, although there was no difference in the vascular filling requirement between the two treatments. HSS caused a significant elevation of serum sodium and chloride at 120 mins after the start of the infusion (p < .01). Conclusions:A single equimolar infusion of 20% mannitol is as effective as 7.45% HSS in decreasing ICP in patients with brain injury. Mannitol exerts additional effects on brain circulation through a possible improvement in blood rheology. Pretreatment factors, such as serum sodium, systemic hemodynamics, and brain hemodynamics, thus should be considered when choosing between mannitol and HSS for patients with increased ICP.

Transcranial Doppler to screen on admission patients with mild to moderate traumatic brain injury.

BACKGROUND:Detecting patients at risk for secondary neurological deterioration (SND) after mild to moderate traumatic brain injury is challenging. OBJECTIVE:To assess the diagnostic accuracy of transcranial Doppler (TCD) on admission in screening these patients. METHODS:This prospective, observational cohort study enrolled 98 traumatic brain injury patients with an initial Glasgow Coma Scale score of 9 to 15 whose initial computed tomography (CT) scan showed either absent or mild lesions according to the Trauma Coma Data Bank (TCDB) classification, ie, TCDB I and TCDB II, respectively. TCD measurements of the 2 middle cerebral arteries were obtained on admission under stable conditions in all patients. Neurological outcome was reassessed on day 7. RESULTS:Of the 98 patients, 21 showed SND, ie, a decrease of ≥ 2 points from the initial Glasgow Coma Scale or requiring any treatment for neurological deterioration. Diastolic cerebral blood flow velocities and pulsatility index measurements were different between patients with SND and patients with no SND. Using receiver-operating characteristic analysis, we found the best threshold limits to be 25 cm/s (sensitivity, 92%; specificity, 76%; area under curve, 0.93) for diastolic cerebral blood flow velocity and 1.25 (sensitivity, 90%; specificity, 91%; area under curve, 0.95) for pulsatility index. According to a recursive-partitioning analysis, TCDB classification and TCD measurements were the most discriminative among variables to detect patients at risk for SND. CONCLUSION:In patients with no severe brain lesions on CT after mild to moderate traumatic brain injury, TCD on admission, in complement with brain CT scan, could accurately screen patients at risk for SND.

Impact of emergency medical helicopter transport directly to a university hospital trauma center on mortality of severe blunt trauma patients until discharge

IntroductionThe benefits of transporting severely injured patients by helicopter remain controversial. This study aimed to analyze the impact on mortality of helicopter compared to ground transport directly from the scene to a University hospital trauma center.MethodsThe French Intensive Care Research for Severe Trauma cohort study enrolled 2,703 patients with severe blunt trauma requiring admission to University hospital intensive care units within 72 hours. Pre-hospital and hospital clinical data, including the mode of transport, (helicopter (HMICU) versus ground (GMICU), both with medical teams), were recorded. The analysis was restricted to patients admitted directly from the scene to a University hospital trauma center. The main endpoint was mortality until ICU discharge.ResultsOf the 1,958 patients analyzed, 74% were transported by GMICU, 26% by HMICU. Median injury severity score (ISS) was 26 (interquartile range (IQR) 19 to 34) for HMICU patients and 25 (IQR 18 to 34) for GMICU patients. Compared to GMICU, HMICU patients had a higher median time frame before hospital admission and were more intensively treated in the pre-hospital phase. Crude mortality until hospital discharge was the same regardless of pre-hospital mode of transport. After adjustment for initial status, the risk of death was significantly lower (odds ratio (OR): 0.68, 95% confidence interval (CI) 0.47 to 0.98, P = 0.035) for HMICU compared with GMICU. This result did not change after further adjustment for ISS and overall surgical procedures.ConclusionsThis study suggests a beneficial impact of helicopter transport on mortality in severe blunt trauma. Whether this association could be due to better management in the pre-hospital phase needs to be more thoroughly assessed.

Le MEOPA (Kalinox®) : Mélange Equimolaire Oxygène et Protoxyde d'Azote dans le traitement de la douleur

Resume Le MEOPA est un melange gazeux associant 50 % de protoxyde d’azote et 50 % d’oxygene. Il est largement utilise pour la prise en charge de l’analgesie en particulier lors des gestes douloureux de courte duree. La faible solubilite dans le sang et les tissus du protoxyde d’azote lui confere des proprietes pharmacocinetiques originales avec une apparition et une reversibilite rapide de ses effets cliniques. Son conditionnement sous forme equimolaire avec de l’oxygene permet son utilisation en toute securite en dehors du bloc operatoire, par des medecins non anesthesistes et chez le sujet non a jeun. Les effets indesirables du gaz sont rares et toujours mineurs. Les mecanismes a l’origine de ces effets antalgiques restent imparfaitement connus mais le systeme opioide endogene et l’activation des voies descendantes noradrenergiques semblent jouer un role important. Cet article developpe les principaux aspects theoriques et pratiques du MEOPA dans le traitement de la douleur a partir d’une revue de la litterature.

Cathétérisme veineux périphérique: influence de la composition du cathéter dans l'apparition de thrombophlébites

Infusion thrombophlebitis is a common troublesome complication of intravenous therapy. This study compared peripheral intravenous Teflon ® and Vialon ® catheters. The incidence of phlebitis, bacterial adherence and mechanical resistance (distortion) were assessed on 170 catheters, 85 of each type. The Vialon ® catheter resulted in less phlebitis than the Teflon ® one (18 vs. 35; p<0.01). During the period 49 to 72 h after the insertion of the catheter, the risk of phlebitis in the Teflon ® group was twice that in the Vialon ® group. The study of bacterial adherence using a semi-quantitative culture method demonstrated that 9.0% of the catheters were infected with Staphylococcus epidermidis. There was no statistically significant difference between the two groups (5.7% Vialon ® group vs. 12.5% Teflon ® group). The Teflon ® catheters were much more distorted than Vialon ® catheters: 1.7% vs. 55.7% in the macroscopic study; 1.75% vs. 8.2% in the microscopic study. As Vialon ® softens at body temperature, it would seem likely that it generates a lesser degree of endothelial injury, explaining the lower rate of phlebitis with Vialon ® catheters.

Évaluation de la tenue du dossier d'anesthésie

OBJECTIVE: To assess the quality of the anaesthetic record for surgical and non surgical procedures and for elective and emergency surgery. STUDY DESIGN: Retrospective study in a university hospital. MATERIAL AND METHODS: Anaesthetic records collected over one month were analysed. The record included a referential with 38 items: nine for the identification of the patient and those who completed the record, 16 for the preoperative period and 13 for the operative period. Each item was qualified either as present (or correct), or absent, or unreadable or not applicable. RESULTS: Overall, 2,422 anaesthesia records were analysed, including 88,732 items. The mean level of correct items was 72%, and 1% of them were unreadable. Items for identification were significantly more correctly recorded (86%) than those concerning the preoperative (63%) and the operative (73%) periods (P < 0.01). Anaesthetic data for surgical procedures were significantly more correctly recorded (73%) than those for non-surgical procedures (63%) and surgery under local anaesthesia (52%; P < 0.01). Emergency surgical procedures were significantly less correctly recorded than elective ones (70 vs. 72%; P < 0.01). CONCLUSIONS: These results suggest that the quality of the anaesthetic records should be improved, mainly for the preoperative period and for non-surgical procedures.

An Experience Feedback Committee for Improving Patient Safety: An Observational Study in Anaesthesiology

Background & Aims: An experience feedback committee (EFC) is a management method for patientsafety designed for a medical team. The aim of this study was to analyse the functioning of an EFC in an anaesthesia department and to explore its contribution to patient safety.

TO30 Traitement multimodal de l’algoneurodystrophie rebelle

Le retard de la prise en charge therapeutique de l’algoneurodystrophie expose au risque de douleurs chroniques et de sequelles. Dans ce but, l’equipe du centre de la douleur en collaboration avec les services d’orthopedie et de traumatologie, a elabore un protocole de prise en charge en fonction du stade de l’algoneurodystrophie et de son retentissement fonctionnel et psycho-comportemental. Methodologie Nous avons etudie les benefices du protocole dans la prise en charge de l’algoneurodystrophie. Il comporte 3 volets : (i) Criteres cliniques et pratiques de diagnostic ; (ii) Traitement initial (antalgique selon EVA, Kinesitherapie et physiotherapie, calcitonine). En cas de non-amelioration dans un delai de 30 jours, le patient doit etre adresse au centre de la douleur ; (iii) Traitement au centre de la douleur. Si composante neuro-pathique : Antiepileptique et/ou antidepresseur. Si composante anxieuse : bilan psychologique, relaxation, sophrologie, anxiolytiques. Si echec des traitements ci-dessus : calcium-bloquant, TENS, perfusions de bispho-phonates. Si forme rebelle : blocs sympathiques locaux par fonzylane, perfusions de ketamine ; ALR continue ; neurostimulation medullaire. Resultat 41 Nouveaux cas d’algoneurodystrophie ont ete pris en charge au Centre de la Douleur du janvier 2006 a mai 2007. Il s’agit de 22 femmes et 19 hommes. Âge moyen : 49 ans. Les traitements instaures, principalement au Centre de la Douleur, sont : calcitonine : 73 % des cas, neurostimulation transcutanee : 36 %, consultation avec le psychiatre ou le psychologue : 20 %, antalgique palier II : 65 % antalgique palier III : 29 %, antiepileptique et/ou antidepresseur : 73 %, anxiolytique : 26 %, calcium bloquant : 22 %, perfusion de biphosphonate : 34 %, perfusion de ketamine : 14 %, blocs sympathiques locaux par fonzylane : 10 %, ALR continue : 2,4 %. Groupe I (46 % des patients) Anciennete de l’algoneurodystrophie > 8 mois. Amelioration nette : 79 % des cas ; Amelioration partielle : 16 % ; Pas d’amelioration : 5 %. Groupe II (54 % des patients) Anciennete de l’algoneurodystrophie > 8 mois. Amelioration partielle : 68 % des cas ; Amelioration minime ou pas d’amelioration : 32 % des cas. Discussion La grande variabilite du syndrome, explique les difficultes a proposer un schema therapeutique classique. On constate que les patients qui ont beneficie d’un traitement initial precoce, repondent mieux au traitement multimodal au Centre : p Conclusion Le traitement precoce de l’algoneurodystrophie est un element essentiel determinant son evolution. La prise en charge des formes rebelles doit etre globale et multidisciplinaire. La recherche des facteurs d’entretiens et la prise en compte du contexte psychosocial font partie integrale de la strategie therapeutique. L’analgesie multimodale, visant les composantes nociceptive, neuropathique et psychogene des douleurs, diminue le risque de chronicisation.

CC03 Utilisation de la stimulation magnétique transcranienne répétitive (SMTR) dans le traitement de la douleur neuropathique chronique résistante aux thérapeutiques conventionnelles

Introduction Dans le cadre de la prise en charge non medicamenteuse de la douleur chronique, notre equipe a developpe cette annee l’utilisation de la technique de SMTr. Nous rapportons le cas d’une patiente souffrant d’une nevralgie trigeminale rebelle et resistante aux traitements medicamenteux. Cas clinique Il s’agit d’une patiente âgee de 72 ans qui presente une nevralgie trigeminale gauche tres invalidante depuis 2 ans, associant des dysesthesies, des decharges electriques, des picotements et des sensations de brulures. L’EVA initiale est evaluee a 8/10. Les differents traitements entrepris (anti-epileptiques, antidepresseurs, antalgiques, bloc du trijumeau) se sont averes totalement inefficaces. La patiente n’est pas favorable a l’implantation d’un stimulateur cortical. Debut des seances de SMTr en fevrier 2007 : Les parametres de stimulation : frequence 10 HZ, 40 trains de 5 secondes, intervalle inter train de 25 secondes ; au total 2 000 impulsions pendant 20 minutes L’intensite de stimulation est delivree a 80 % du seuil moteur. La zone stimulee : l’aire de la main controlaterale a la zone algique (SMTr est plus efficace lorsque la stimulation s’applique sur une aire adjacente) [1]. Le rythme des seances : J1-J15 : 4 fois/semaine, J15-J30 : 2 fois/sem, j 30-j45 : 1 fois/sem, J45-J75 : 2 fois/mois et ensuite 1 fois/mois. Evolution A partir de la 2e semaine, on constate une amelioration significative des douleurs puis au terme des 19 seances, une disparition complete des sensations desagreables, avec une EVA a 2/10. Impression clinique globale : tres fortement amelioree. L’index therapeutique (degres d’efficacite therapeutique et d’effets secondaires) evalue a 01. Pas de traitement antalgique ou co-antalgique en cours. Bonne tolerance de la SMTr. Amelioration constante, malgre l’espacement des seances. Discussion L’utilisation de la technique de SMTr permet d’obtenir une antalgie avec un effet cumulatif par la repetition des seances et un effet dans le temps probablement par remanence. Les avantages : Pas d’effets secondaires ; technique non invasive ; evite la polymedication et ses effets secondaires. Les inconvenients : temps medical non negligeable ; appareil de SMTr tres couteux ; les parametres et les indications ne sont pas valides et des travaux multicentriques sont en cours. Conclusion La SMTr est une technique pertinente pour selectionner les patients repondeurs a une eventuelle implantation corticale et pour soulager leurs douleurs en attente de ce geste. Des seances repetees bimensuelles ou mensuelles, peuvent etre une alternative de traitement, particulierement chez les patients repondeurs, dont une implantation chirurgicale est contre-indiquee ou refusee (protocole court en curatif puis le relais en SMTr d’entretien avec un maintien dans le temps de l’efficacite). Le cout de cette technique reste a evaluer, mais il parait moindre qu’une polymedication.