François Javaudin

Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial

Importance Bag-mask ventilation (BMV) is a less complex technique than endotracheal intubation (ETI) for airway management during the advanced cardiac life support phase of cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest. It has been reported as superior in terms of survival. Objectives To assess noninferiority of BMV vs ETI for advanced airway management with regard to survival with favorable neurological function at day 28. Design, Settings, and Participants Multicenter randomized clinical trial comparing BMV with ETI in 2043 patients with out-of-hospital cardiorespiratory arrest in France and Belgium. Enrollment occurred from March 9, 2015, to January 2, 2017, and follow-up ended January 26, 2017. Intervention Participants were randomized to initial airway management with BMV (nu2009=u20091020) or ETI (nu2009=u20091023). Main Outcomes and Measures The primary outcome was favorable neurological outcome at 28 days defined as cerebral performance category 1 or 2. A noninferiority margin of 1% was chosen. Secondary end points included rate of survival to hospital admission, rate of survival at day 28, rate of return of spontaneous circulation, and ETI and BMV difficulty or failure. Results Among 2043 patients who were randomized (mean age, 64.7 years; 665 women [32%]), 2040 (99.8%) completed the trial. In the intention-to-treat population, favorable functional survival at day 28 was 44 of 1018 patients (4.3%) in the BMV group and 43 of 1022 patients (4.2%) in the ETI group (difference, 0.11% [1-sided 97.5% CI, −1.64% to infinity]; P for noninferiorityu2009=u2009.11). Survival to hospital admission (294/1018 [28.9%] in the BMV group vs 333/1022 [32.6%] in the ETI group; difference, −3.7% [95% CI, −7.7% to 0.3%]) and global survival at day 28 (55/1018 [5.4%] in the BMV group vs 54/1022 [5.3%] in the ETI group; difference, 0.1% [95% CI, −1.8% to 2.1%]) were not significantly different. Complications included difficult airway management (186/1027 [18.1%] in the BMV group vs 134/996 [13.4%] in the ETI group; difference, 4.7% [95% CI, 1.5% to 7.9%]; Pu2009=u2009.004), failure (69/1028 [6.7%] in the BMV group vs 21/996 [2.1%] in the ETI group; difference, 4.6% [95% CI, 2.8% to 6.4%]; Pu2009<u2009.001), and regurgitation of gastric content (156/1027 [15.2%] in the BMV group vs 75/999 [7.5%] in the ETI group; difference, 7.7% [95% CI, 4.9% to 10.4%]; Pu2009<u2009.001). Conclusions and Relevance Among patients with out-of-hospital cardiorespiratory arrest, the use of BMV compared with ETI failed to demonstrate noninferiority or inferiority for survival with favorable 28-day neurological function, an inconclusive result. A determination of equivalence or superiority between these techniques requires further research. Trial Registration clinicaltrials.gov Identifier: NCT02327026

Systematic review: human gut dysbiosis induced by non‐antibiotic prescription medications

Global prescription drug use has been increasing continuously for decades. The gut microbiome, a key contributor to health status, can be altered by prescription drug use, as antibiotics have been repeatedly described to have both short‐term and long‐standing effects on the intestinal microbiome.

Prognostic performance of early absence of pupillary light reaction after recovery of out of hospital cardiac arrest

INTRODUCTIONnLoss of pupillary light reactivity (PLR) three days after a cardiorespiratory arrest is a prognostic factor. Its predictive value upon hospital admission remains unclear. Our objective was to determine the prognostic value of the absence of PLR upon hospital admission in patients with out-of-hospital cardiac arrest.nnnMETHODSnWe prospectively included all out-of-hospital cardiac arrests occurring between July 2011 and July 2017 treated by a mobile medical team (MMT) based on data from a French cardiac arrest registry database. PLR was evaluated upon hospital admission and the outcome on day 30. The prognosis was classified as good for Cerebral Performance Category (CPC) 1 or 2, and poor for CPC 3-5 or in case of death.nnnRESULTSnData from 10151 patients was analysed. The sensitivity and specificity of the absence of PLR for a poor outcome were 72.2% (71.2-73.2) and 68.8% (66.7-70.1), respectively. We identified several variables modifying the sensitivity values and the false positive fraction of a factor, ranging from 0.49 (0.35-0.69) for the Glasgow Coma Scale to 2.17 (1.09-2.48) for pupillary asymmetry. Among those living with CPC 1 or 2 on day 30 (nu202f=u202f1990; 19.6%), 621 (31.2% (29.2-33.3)) had no PLR upon hospital admission. In the multivariate analysis, loss of PLR was associated with a poor outcome (ORu202f=u202f3.1 (2.7-3.5)).nnnCONCLUSIONSnLoss of pupillary light reactivity upon hospital admission is predictive of a poor outcome after out-of-hospital cardiac arrest. However, it does not have sufficient accuracy to determine prognosis and decision making.

Are third-generation cephalosporins associated with a better prognosis than amoxicillin–clavulanate in patients hospitalized in the medical ward for community-onset pneumonia?

OBJECTIVESnWe aimed to assess whether treatment with ceftriaxone/cefotaxime is associated with lower in-hospital mortality than amoxicillin-clavulanate in pati0ents hospitalized in medical wards for community-onset pneumonia.nnnMETHODSnWe conducted a retrospective and multicentre study of patients hospitalized in French medical wards for community-onset pneumonia between 2002 and 2015. Treatments with ceftriaxone/cefotaxime or amoxicillin-clavulanate were defined by their start in the emergency department for a duration of 5 days or more with no other β-lactam. A logistic regression analysis was performed on the overall population, and a propensity score analysis was restricted to patients treated with either ceftriaxone/cefotaxime or amoxicillin-clavulanate.nnnRESULTSn1698 patients (median age, 80 y) were included, of which 716 and 198 were treated withxa0amoxicillin-clavulanate and ceftriaxone/cefotaxime, respectively. In-hospital mortality was 10% (9-12%). In multivariate analysis, factors associated with in-hospital mortality were treatment with ceftriaxone/cefotaxime (aOR 2.9; (1.4-5.7)), pneumonia severity index class 4 or 5 (aOR 7.8 (4.3-15.7)), do-not-resuscitate order (aOR 8.7 (5.2-14.6)) and fluid therapy (aOR 6.3 (2.5-15.1)). The propensity score analysis was performed on 178 patients treated with ceftriaxone/cefotaxime matched with 178 patients treated with amoxicillin-clavulanate; no significant association between treatment with ceftriaxone/cefotaxime and in-hospital mortality was found (OR 1.5 (0.7-3.0)).nnnCONCLUSIONnIn the largest study aiming to compare amoxicillin-clavulanate and ceftriaxone/cefotaxime in community-onset pneumonia, ceftriaxone/cefotaxime was not associated with lower in-hospital mortality than amoxicillin-clavulanate. Our results suggest that ceftriaxone/cefotaxime should not be preferred over amoxicillin-clavulanate for patients hospitalized in medical wards with community-onset pneumonia.

Evaluation of a short formation on the performance of point-of-care renal ultrasound performed by physicians without previous ultrasound skills: prospective observational study

BackgroundPoint-of-Care Ultrasound (PoCUS) is recommended by emergency medicine societies for the detection of hydronephrosis. Training of certified Emergency Physicians (EP) without prior ultrasound experience remains debated. We investigate performance of a brief training session for the detection of hydronephrosis with PoCUS performed by EP without previous ultrasound experience.Patients and methodsThis was a prospective observational study of a convenience sample of patients older than 18xa0years with presumed renal colic, acute pyelonephritis or documented acute renal failure. Exclusion criteria were pregnancy and documented end of life.After inclusion and informed consent, a PoCUS was performed. A radiologist’s renal ultrasound (RRUS) was then conducted, the radiologist being blind to PoCUS result.The objective was to determine the diagnostic performance of PoCUS performed by EP for the detection of hydronephrosis using RRUS as gold standard.ResultsSix EP participated in this study. 55 patients were included, five secondary excluded for lack of RRUS. Age was 47xa0±xa022xa0years, sex ratio 1. Hydronephrosis prevalence was 38% (CI 95% [26–52%]). Sensitivity of PoCUS was 100% (CI 95% [82–100%]) while its specificity was 71% (CI 95% [52–86%]) with a NPV of 100% (CI 95% [85–100%]) and a 68% (CI 95% [48–84%]) PPV. Kappa coefficient was 0.65 (CI 95% [0.45–0.85]).DiscussionWe demonstrated that a short training program enables EP without previous ultrasound skills to rule out hydronephrosis with satisfactory performances. The main limitation was the absence of collection of the number of PoCUS by EP. After this didactic course, an experiential phase must be carried out.

Is intravenously administered, subdissociative-dose KETAmine non-inferior to MORPHine for prehospital analgesia (the KETAMORPH study): study protocol for a randomized controlled trial

BackgroundAcute pain is a common condition among prehospital patients and prompt management is pivotal. Opioids are the most frequently analgesics used in the prehospital setting. However, opioids are highly addictive, and some patients may develop opioid dependence, even when they are exposed to brief opioid treatments. Therefore, alternative non-opioid analgesia should be developed to manage pain in the prehospital setting. Used at subdissociative doses, ketamine, a noncompetitive N-methyl-D-aspartate and glutamate receptor antagonist, provides analgesic effects accompanied by preservation of protective airway reflexes. In this context, we will carry out a randomized controlled, open-label, multicenter trial to compare a subdissociative dose of ketamine to morphine to provide pain relief in the prehospital setting, in patients with traumatic and non-traumatic pain.Methods/designThis will be a multicenter, single-blind, randomized controlled trial. Consecutive adults will be enrolled in the prehospital setting if they experience moderate to severe, acute, non-traumatic and traumatic pain, defined as a numeric rating scale score greater or equal to 5. Patients will be randomized to receive ketamine or morphine by intravenous push. The primary outcome will be the between-group difference in mean change in numeric rating scale pain scores measured from the time before administration of the study medication to 30xa0min later.DiscussionThis upcoming randomized clinical trial was design to assess the efficacy and safety of ketamine, an alternative non-opiate analgesia, to manage non-traumatic and traumatic pain in the prehospital setting. We aim to provide evidence to change prescribing practices to reduce exposition to opioids and the subsequent risk of addiction.Trial registrationClinicalTrials.gov, ID: NCT03236805. Registered on 2 August 2017.

Impact of pre-hospital vital parameters on the neurological outcome of out-of-hospital cardiac arrest: Results from the French National Cardiac Arrest Registry

INTRODUCTIONnThe targets for vital parameters following return of spontaneous circulation (ROSC) from an out-of-hospital cardiac arrest (OHCA) are based on studies carried out predominantly in intensive care units. Therefore, we studied the pre-hospital phase.nnnMETHODnWe included all adult OHCA from the French OHCA Registry. Vital parameters [peripheral oxygen saturation level (SpO2), end-tidal carbon dioxide (ETCO2) and systolic blood pressure (SBP)] documented during the pre-hospital phase by mobile medical team, were evaluated with regard to the neurological outcome on day 30 (classified as good for Cerebral Performance Category (CPC) 1u2009-u20092, and poor for CPC 3u2009-u20095 or death).nnnRESULTSnWhen compared with a reference range of 94-98%, SpO2 values less than 94% were associated with a worse outcome on univariate analysis [relative risk (RR)u2009=u20091.108(1.069u2009-u20091.147)]. An SpO2 of 99u2009-u2009100% did not appear to be harmful [RRu2009=u20090.9851(0.956-1.015)]. ETCO2 values that deviated from the reference of 30u2009-u200940u2009mmHg were associated with a worse outcome on univariate analysis [<20, RRu2009=u20091.191(1.143u2009-u20091.229); 20u2009-u200929, RRu2009=u20091.092(1.061u2009-u20091.123); 41u2009-u200950, RRu2009=u20091.075(1.039u2009-u20091.110); >50, RRu2009=u20091.136(1.085u2009-u20091.179)]. When compared with a reference range of 100u2009-u2009130, higher or lower values of SBP were associated with a worse outcome on univariate analysis [<80, RRu2009=u20091.203(1.158u2009-u20091.243); 80u2009-u200999, RRu2009=u20091.069(1.033u2009-u20091.105); 131u2009-u2009160, RRu2009=u20091.076(1.043u2009-u20091.110); >160, RRu2009=u20091.168(1.126u2009-u20091.208)]. The multivariate analysis yielded similar results.nnnCONCLUSIONnIn comatose patients who have achieved ROSC after OHCA, vital parameters in the pre-hospital phase appear to have a real impact on the 30-day neurological outcome. We found that an SpO2 ≥ 94%, an ETCO2 of 30u2009-u200940u2009mmHg, and an SBP of 100u2009-u2009130u2009mmHg were associated with a better prognosis.

Traumatic cardiac arrest is associated with lower survival rate vs. medical cardiac arrest – Results from the French national registry

INTRODUCTIONnThe survival from traumatic vs. medical out-of-hospital cardiac arrest (OHCA) are not yet well described. The objective of this study was to compare survival to hospital discharge and 30-day survival of non-matched and matched traumatic and medical OHCA cohorts.nnnMATERIAL & METHODSnNational case-control, multicentre study based on the French national cardiac arrest registry. Following descriptive analysis, we compared survival rates of traumatic and medical cardiac arrest patients after propensity score matching.nnnRESULTSnCompared with medical OHCA (nu2009=u200940,878) trauma victims (nu2009=u20093209) were younger, more likely to be male and away from home at the time and less likely to be resuscitated. At hospital admission and at 30 days their survival odds were lower (OR: respectively 0.456 [0.353;0.558] and 0.240 [0.186;0.329]). After adjustment the survival odds for traumatic OHCA were 2.4 times lower at admission (OR: 0.416 [0.359;0.482]) and 6 times lower at day 30 (OR: 0.168 [0.117;0.241]).nnnCONCLUSIONSnThe survival rates for traumatic OHCA were lower than for medical OHCA, with wider difference in matched vs. non-matched cohorts. Although the probability of survival is lower for trauma victims, the efforts are not futile and pre-hospital resuscitation efforts seem worthwhile.