Gaëlle Cheisson

The Limits of Succinylcholine for Critically Ill Patients

BACKGROUND:Urgent tracheal intubations are common in intensive care units (ICU), and succinylcholine is one of the first-line neuromuscular blocking drugs used in these situations. Critically ill patients could be at high risk of hyperkalemia after receiving succinylcholine because one or more etiologic factors of nicotinic receptor upregulation can be present, but there are few data on its real risk. Our objectives in this study were to determine the factors associated with arterial potassium increase (&Dgr;K) and to assess the occurrence of acute hyperkalemia ≥6.5 mmol/L after succinylcholine injection for intubation in the ICU. METHODS:In a prospective, observational study, all critically ill patients intubated with succinylcholine in an ICU were screened. Only intubations with arterial blood gases and potassium measurements before and after (Kafter) a succinylcholine injection were studied. RESULTS:During 18 months, 131 critically ill patients were intubated after receiving succinylcholine with arterial potassium before and after intubation (Kafter) for a total of 153 intubations. After multivariate analysis, the only factor associated with &Dgr;K was the length of ICU stay before intubation (&rgr; = 0.561, P < 0.001). The factors associated with Kafter ≥6.5 mmol/L (n = 11) were the length of ICU stay (P < 0.001) and the presence of acute cerebral pathology (P = 0.047). The threshold of 16 days was found highly predictive of acute hyperkalemia ≥6.5 with 37% (95% confidence interval: 19%–58%) of Kafter ≥6.5 after the 16th day compared with only 1% (95% confidence interval: 0%–4%) of Kafter ≥6.5 when succinylcholine was injected during the first 16 days. CONCLUSIONS:This study shows that the risk of &Dgr;K after succinylcholine injection is strongly associated with the length of ICU stay. The risk of acute hyperkalemia ≥6.5 mmol/L is highly significant after 16 days.

Uncontrolled donation after circulatory death: European practices and recommendations for the development and optimization of an effective programme

The shortage of organs remains one of the biggest challenges in transplantation. To address this, we are increasingly turning to donation after circulatory death (DCD) donors and now in some countries to uncontrolled DCD donors. We consolidate the knowledge on uncontrolled DCD in Europe and provide recommendations and guidance for the development and optimization of effective uncontrolled DCD programmes.

Grief Symptoms in Relatives who Experienced Organ Donation Request in the ICU

Rationale: Studies show that the quality of end‐of‐life communication and care have a significant impact on the living long after the death of a relative and have been implicated in the burden of psychological symptoms after the ICU experience. In the case of organ donation, the patients relatives are centrally involved in the decision‐making process; yet, few studies have examined the impact of the quality of communication on the burden of psychological symptoms after death. Objectives: To assess the experience of the organ donation process and grief symptoms in relatives of brain‐dead patients who discussed organ donation in the ICU. Methods: We conducted a multicenter longitudinal study in 28 ICUs in France. Participants were the relatives of brain‐dead patients who were approached to discuss organ donation. Relatives were followed‐up by phone at three time points: at 1 month, to complete a questionnaire describing their experience of the organ donation process; at 3 months, to complete the Hospital Anxiety and Depression Scale and the Impact of Event Scale‐Revised; and at 9 months, to complete the Impact of Event Scale‐Revised and the Inventory of Complicated Grief. Measurements and Main Results: In total, 202 relatives of 202 patients were included, of whom 158 consented to and 44 refused organ donation. Interviews were conducted at 1, 3, and 9 months with 78%, 68%, and 58% of relatives, respectively. The overall experience of the organ donation process was significantly more burdensome for relatives of nondonors. They were more dissatisfied with communication (27% vs. 10%; P = 0.021), more often shocked by the request (65% vs. 19%; P < 0.0001), and more often found the decision difficult (53% vs. 27%; P = 0.017). However, there were no significant differences in grief symptoms measured at 3 and 9 months between the two groups. Understanding of brain death was associated with grief symptoms; our results show a higher prevalence of complicated grief symptoms among relatives who did not understand the brain death process than among those who did (75% vs. 46.1%; P = 0.026). Conclusions: Experience of the organ donation process varied between relatives of donor versus nondonor patients, with relatives of nondonors experiencing lower‐quality communication, but the decision was not associated with subsequent grief symptoms. Importantly, understanding of brain death is a key element of the organ donation process for relatives.

Traumi del bacino

I traumi del bacino, spesso legati a un incidente stradale o a una caduta da un’altezza elevata, sono associati a una mortalita elevata a causa del politraumatismo spesso presente e della comparsa potenziale di sindromi emorragiche. Il rischio vitale immediato e legato alla comparsa di uno shock emorragico refrattario con insufficienza multiorgano. La gestione iniziale deve essere integrata negli algoritmi di gestione dei politraumatizzati, il cui obiettivo e quello di collegare precocemente il sanguinamento a una lesione retroperitoneale accessibile a un atto di emostasi, senza sottovalutare gli altri fattori di emorragia intratoracica, intraperitoneale o degli arti. La TC toraco-addomino-pelvica con iniezione di mezzo di contrasto, quando lo stato emodinamico del paziente lo consente, permette lo screening delle lesioni arteriose. Le tecniche a scopo emostatico, come l’embolizzazione arteriosa pelvica o la clamp pelvica, possono essere applicate rapidamente e non sono antagoniste, ma, piuttosto, complementari. La gestione multidisciplinare concertata (anestesista/rianimatore, chirurgo e radiologo) e, quindi, indispensabile per l’ottimizzazione terapeutica. Anche le complicanze ritardate come le infezioni, legate alle lesioni rettali o cutanee e alle tromboflebiti, sono responsabili di una morbi/mortalita non trascurabile.

Working party approved by the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French Society for the study of Diabetes (SFD)

Follow on from continuous intravenous administration of insulin with an electronic syringe (IVES) is an important element in the postoperative management of a diabetic patient. The basal-bolus scheme is the most suitable taking into account the nutritional supply and variable needs for insulin, reproducing the physiology of a normal pancreas: (i) slow (long-acting) insulin (=basal) which should immediately take over from IVES insulin simulating basal secretion; (ii) ultra-rapid insulin to simulate prandial secretion (=bolus for the meal); and (iii) correction of possible hyperglycaemia with an additional ultra-rapid insulin bolus dose. A number of schemes are proposed to help calculate the dosages for the change from IV insulin to subcutaneous insulin and for the basal-bolus scheme. Postoperative resumption of an insulin pump requires the patient to be autonomous. If this is not the case, then it is mandatory to establish a basal-bolus scheme immediately after stopping IV insulin. Monitoring of blood sugar levels should be continued postoperatively. Hypoglycaemia and severe hyperglycaemia should be investigated. Faced with hypoglycaemia <3.3mmol/L (0.6g/L), glucose should be administered immediately. Faced with hyperglycaemia >16.5mmol/L (3g/L) in a T1D or T2D patient treated with insulin, investigations for ketosis should be undertaken systematically. In T2D patients, unequivocal hyperglycaemia should also call to mind the possibility of diabetic hyperosmolarity (hyperosmolar coma). Finally, the modalities of recommencing previous treatments are described according to the type of hyperglycaemia, renal function and diabetic control preoperatively and during hospitalisation.

Perioperative management of adult diabetic patients. The role of the diabetologist

A patient should be referred to a diabetologist perioperatively in several circumstances: preoperative recognition of a previously unknown diabetes or detection of glycaemic imbalance (HbA1c <5% or >8%); during hospitalisation, recognition of a previously unknown diabetes, persisting glycaemic imbalance despite treatment or difficulty resuming previously used chronic treatment; postoperatively and after discharge from hospital, for all diabetic patients in whom HbA1c is >8%.