Gary Duclos

Risk factors for death in septic shock A retrospective cohort study comparing trauma and non-trauma patients

Abstract The aim of this study was to compare septic shock directly associated-mortality between severe trauma patients and nontrauma patients to assess the role of comorbidities and age. We conducted a retrospective study in an intensive care unit (ICU) (15 beds) of a university hospital (928 beds). From January 2009 to May 2015, we reviewed 2 anonymized databases including severe trauma patients and nontrauma patients. We selected the patients with a septic shock episode. Among 385 patients (318 nontrauma patients and 67 severe trauma patients), the ICU death rate was 43%. Septic shock was directly responsible for death among 35% of our cohort, representing 123 (39%) nontrauma patients and 10 (15%) trauma patients (P < 0.0). A sequential organ failure assessment score above 12 (odds ratio [OR]: 6.8; 95% confident interval (CI) [1.3–37], P = 0.025) was independently associated with septic shock associated-mortality, whereas severe trauma was a protective factor (OR: 0.26; 95% CI [0.08–0.78], P = 0.01). From these independent risk factors, we determined the probability of septic shock associated-mortality. The receiver-operating characteristics curve has an area under the curve at 0.76 with sensitivity of 55% and specificity of 86%. Trauma appears as a protective factor, whereas the severity of organ failure has a major role in the mortality of septic shock. However, because of the studys design, unmeasured confounding factors should be taken into account in our findings.

Antimicrobial therapy in patients with septic shock

Providing antibiotics is a life-saving intervention in patients with septic shock. Cultures as clinically appropriate before antimicrobial therapy are required. Guidelines recommend providing broad-spectrum antibiotics within the first hour after recognition of shock. The site of infection, the patients history and clinical status, and the local ecology all affect the choice of empirical treatment. The appropriateness of this choice is an important determinant of patient outcome. At 48-96h, the antimicrobial treatment should be systematically reassessed based on the clinical course and culture results. Cessation, de-escalation, continuation, or escalation are discussed according to these variables. Unnecessary treatment should be avoided to reduce the emergence of multidrug resistant pathogens.

The Patient with Septic Shock

Septic shock may occur during surgery or may be a cause for emergent surgery. The patients with septic shock in the operating room should be managed according to international guidelines. This implies the use of monitoring to assess the need for fluid, vasopressor, and positive inotrope. The choice of hypnotics remains challenging in those patients with an impaired sympathetic tone. Ketamine seems a reasonable choice for induction, whereas sevoflurane or desflurane can be used for maintenance. Surgery should not be a reason for delaying the administration of antibiotics. Each hour of delay is associated with worsening of outcomes. Sampling blood and secretion are mandatory before the initiation of the antimicrobial treatment.

Complemental analysis about postoperative opioid consumption between video-assisted thoracic surgery (VATS) and roboticassisted thoracic surgery (RATS) for early-stage lung cancer

We would like to thank Dr. Bayman and Dr. Brennan for their interesting comments about our study.

Postoperative morphine consumption and anaesthetic management of patients undergoing video-assisted or robotic-assisted lung resection: a prospective, propensity score-matched study

Background Robotic assistance is increasingly being used for treatment of early stage of non-small cell lung cancer. Our objectives were to compare the morphine consumption during the postoperative 48 hours after robotic-assisted thoracic surgery and that after video-assisted thoracic surgery as well as compare the patients haemodynamic and respiratory function during the procedures. Methods This observational, prospective study was conducted in a single referral centre for thoracic surgery from January 2016 to March 2017. Patients who were scheduled to undergo surgical lung resection were included. A propensity score based on age, sex, American society of Anesthesiology score was used between groups. Linear regression analyses were used to determine the mean difference in the postoperative morphine consumption. We also compared the haemodynamic and respiratory function during the two procedures. Results Among the 194 patients included, 105 (54%) and 89 (46%) underwent video and robotic surgery, respectively. Total 75 of each group were matched using the propensity score. The consumption of morphine was 23.0 (16.5-39.0) mg and 33.0 (19.3-46.5) mg (P=0.05) in the video and robotic groups, respectively. Linear regression revealed an average difference β (95% CI) of 6.76 mg (0.32-13.26) (P=0.04) in the morphine consumption after adjusting for the body mass index and local anaesthetic use. Robotic surgery was associated with worse haemodynamic and respiratory function than video surgery. Conclusions As compared with video, robotic surgery was associated with increased use of morphine and greater alteration in the haemodynamic and respiratory functions.

Clearsight™ use for haemodynamic monitoring during the third trimester of pregnancy – a validation study

BACKGROUND We assessed the validity of Clearsight™ as a non-invasive cardiac output and stroke volume monitoring device, comparing it with transthoracic echocardiography measurements during the third trimester of pregnancy. METHODS Measurements obtained from Clearsight™ were compared with those from echocardiography as the gold standard. The precision and accuracy of the Clearsight™ was measured using the Bland and Altman method. Clinical agreement with echocardiography was assessed using the agreement tolerability index. RESULTS Measurements were recorded from 44 pregnant women with a median [IQR range] gestational age of 33 [30-37] weeks. We found that Clearsight™ measurements presented a systematic overestimation of cardiac output, with mean bias [CI 95%] of 2.7 [2.3-3.0] L/min, with limits of agreement of  -0.1 to 5.4 L/min. It overestimated stroke volume, with a bias of 29.5 [25.0-33.4] mL and a limit of agreement of -1.6 to 60.1 mL. In addition, the analysis of cardiac output showed a percentage of error of 41% and intra-class correlation [CI 95%] of 0.37 [0.17 to 0.53, P <0.001]. For stroke volume, the percentage of error was 40% and intra-class correlation 0.16 [-0.1 to 0.34; P=0.27]. We found that agreement tolerability index scores were unacceptable. We evaluated the ability of the device to track changes in cardiac output by inducing a left lateral decubitus position, but the analysis was inconclusive. CONCLUSION The agreement between Clearsight™ and the echocardiography measurements of cardiac output and stroke volume were not within an acceptable range in the third trimester of pregnancy.

Concordance of longitudinal strain and MRI in a case of myocardial contusion in a patient with normal conventional 2D echocardiography

A 42-year-old man was admitted with a blunt traumatic thorax injury after a high-velocity road traffic accident. Initial extended focused assessment with sonography for trauma echography found no abnormality. A whole-body computed tomography scan was performed and found a sternal fracture with fracture of the 12th thoracic vertebra. The patient had a sinus bradycardia (around 35 beats per min) and an increased troponin level up to 1.25 μg/L (normal value < 0.05 μg/L). A 12-lead electrocardiography showed a normal tracing. A transthoracic echocardiography was performed: B-mode exam showed a normal left ventricle ejection fraction of 65% with no segmental abnormality and no pericardial effusion.

A picture’s worth a thousand words: speckle tracking for quantification and assessment of lung sliding

A 19-year-old female was admitted to our intensive care unit for a blunt chest trauma due to a road traffic accident. The whole-body computed tomography scan revealed left-side costal fractures and a left pneumothorax. Two days after pleural drainage, a chest tube was set in gravity causing a decrease in oxygen saturation. We performed a lung ultrasound examination with a linear probe (4 MHz) from Vivid IQ (General Electric, Chicago, IL, USA). Due to the poor echogenicity, we used a speckle-tracking evaluation to quantify lung sliding in spontaneous breathing (Fig. 1). Hence, the quantification of lung sliding is feasible with an important ratio (10×) between normal and abolished lung sliding during spontaneous breathing. To our knowledge, this case is the first assessment of lung sliding using speckle-tracking technology. Lung sliding assessment can be challenging in B-mode ultrasonography. Its quantification with speckletracking technology could help make the diagnosis of pneumothorax, opening new perspectives in the field of lung ultrasound.

Integrating extended focused assessment with sonography for trauma (eFAST) in the initial assessment of severe trauma: Impact on the management of 756 patients

BACKGROUND Before total body computed tomography scan, an initial rapid imaging assessment should be conducted in the trauma bay. It generally includes a chest x-ray, pelvic x-ray, and an extended focused ultrasonography assessment for trauma. This initial imaging assessment has been poorly described since the increase in the use of ultrasound. Therefore, our study aimed to evaluate the diagnostic accuracy and therapeutic impact of this initial imaging work-up in severe trauma patients. A secondary aim was to assess the therapeutic impact of a chest x-ray according to the lung ultrasonography findings. METHODS Patients with severe trauma who were admitted directly to our level 1 trauma center were consecutively included in this retrospective single center study. The diagnostic accuracy, therapeutic impact, and appropriate decision rate were calculated according to the initial assessment results of the whole body computed tomography scan and surgery reports. RESULTS Among the 1315 trauma patients admitted, 756 were included in this research. Lung ultrasound showed a higher diagnostic accuracy for haemothorax and pneumothorax cases than the chest x-ray. Sensitivity and specificity of the abdominal ultrasound to detect intraperitoneal effusion were 70% and 96%, respectively. The initial assessment had a therapeutic impact in 76 (10%) of the patients, including 16 (2%) immediate laparotomies and 58 (7%) chest tube insertions. The pelvic x-ray had no therapeutic impact, and when the lung ultrasound was normal, the chest x-ray had a therapeutic impact of only 0.13%. Combining the chest x-ray and lung ultrasound allowed adequate management of all the pneumothorax and haemothorax cases. Only one of the 756 patients had initial management that was judged as inappropriate. This patient had a missed pelvic disjunction with active retroperitoneal bleeding, and underwent an inappropriate immediate laparotomy. CONCLUSIONS In our cohort, the initial imaging assessment allowed appropriate decisions in 755 of 756 patients, with a global therapeutic impact of 10%. The pelvic x-ray had a minimal therapeutic impact, and in the patients with normal lung ultrasounds, the chest x-ray marginally affected the management of our patients. The potential consequences of abandoning systematic chest and pelvic x-rays should be investigated in future randomized prospective studies.

Implementation of an electronic checklist in the ICU: Association with improved outcomes

OBJECTIVE To assess the impact of an electronic checklist during the morning rounds on ventilator-associated pneumonia (VAP) in the intensive care unit (ICU). PATIENTS AND METHODS We conducted a retrospective, before/after study in a single ICU of a university hospital. A systematic electronic checklist focusing on guidelines adherence was introduced in January 2012. From January 2008 to June 2014, we screened patients with ICU stay durations of at least 48hours. Propensity score-matched analysis with conditional logistic regression was used to compare the rate of VAP and number of days free of invasive devices before and after implementation of the electronic checklist. RESULTS We analysed 1711 patients (before group, n=761; after group, n=950). The rates of VAP were 21% and 11% in the before and after groups, respectively (p<0.001). In propensity-score matched analysis (n=742 in each group), VAP occurred in 151 patients (21%) during the before period compared with 72 patients (10%) during the after period (odds ratio [OR]=0.38; 95% confidence interval [CI]=0.27-0.53). The after group showed increases in ICU-free days (OR=1.05; 95% CI=1.04-1.07) and mechanical ventilation-free days (OR=1.03; 95% CI=1.01-1.04). CONCLUSION In this matched before/after study, implementation of an electronic checklist was associated with positive effects on patient outcomes, especially on VAP. Further prospective studies are needed to confirm these observations.