Guillaume Marcotte

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.

Effect of Transfusion on Mortality and Other Adverse Events Among Critically Ill Septic Patients: An Observational Study Using a Marginal Structural Cox Model*

Objectives: RBC transfusion is often required in patients with sepsis. However, adverse events have been associated with RBC transfusion, raising safety concerns. A randomized controlled trial validated the 7 g/dL threshold, but previously transfused patients were excluded. Cohort studies led to conflicting results and did not handle time-dependent covariates and history of treatment. Additional data are thus warranted to guide patient’s management. Design: To estimate the effect of one or more RBC within 1 day on three major outcomes (mortality, ICU-acquired infections, and severe hypoxemia) at day 30, we used marginal structural models. A trajectory modeling, based on hematocrit evolution pattern, allowed identification of subgroups. Secondary analyses were performed into each of them. Setting: A prospective French multicenter database. Patients: Patients with sepsis at admission. Patients with hemorrhagic shock at admission were excluded. Interventions: None. Measurements and Main Results: Overall, in our cohort of 6,016 patients, RBC transfusion was not associated with death (hazard ratio, 1.07; 95% CI, 0.88–1.30; p = 0.52). However, RBC transfusion was associated with increased occurrence of ICU-acquired infections (hazard ratio, 2.77; 95% CI, 2.33–3.28; p < 0.01) and of severe hypoxemia (hazard ratio, 1.29; 95% CI, 1.14–1.47; p < 0.01). A protective effect from death by the transfusion was found in the subgroup with the lowest hematocrit level (26 [interquartile range, 24–28]) (hazard ratio, 0.72; 95% CI, 0.55–0.95; p = 0.02). Conclusions: RBC transfusion did not affect overall mortality in critically ill patients with sepsis. Increased occurrence rate of ICU-acquired infection and severe hypoxemia are expected outcomes from RBC transfusion that need to be weighted with its benefits in selected patients.

Management and outcomes of acute respiratory distress syndrome patients with and without comorbid conditions

RationaleThe standard of care for patients with acute respiratory distress syndrome (ARDS) has been developed based on studies that usually excluded patients with major comorbidities.ObjectivesTo describe treatments and outcomes according to comorbidities in patients with ARDS admitted to 19 ICUs (1997–2014).MethodsPatients were grouped based on comorbidities. Determinants of day-28 mortality were identified by multivariable Cox analysis stratified on center.Measurements and main resultsAmong 4953 ARDS patients, 2545 (51.4%) had major comorbidities; the proportion with major comorbidities increased after 2008. Hematological malignancy was associated with severe ARDS and rescue therapies for refractory hypoxemia. COPD, HIV infection, and hematological malignancy were associated with a lower likelihood of invasive mechanical ventilation on the admission day. Admission-day SOFA score was higher in patients with major comorbidities, who more often received vasopressors, dialysis, or treatment-limitation decisions. Day-28 mortality was 33.7% overall, 27.2% in patients without major comorbidities, and 31.1% (COPD) to 56% (hematological malignancy) in patients with major comorbidities. By multivariable analysis, mortality was lower in patients with COPD and higher in those with chronic heart failure, solid tumors, or hematological malignancies. Mortality was independently associated with PaO2/FiO2 and PaCO2 on day 1, ARDS of pulmonary origin, worse SOFA score, and ICU-acquired events.ConclusionsHalf the patients with ARDS had major comorbidities, which were associated with severe ARDS, multiple organ dysfunction, and day-28 mortality. These findings do not support the exclusion of ARDS patients with severe comorbidities from randomized clinical trials. Trials in ARDS patients with whatever comorbidities are warranted.

Respective impact of implementation of prevention strategies, colonization with multiresistant bacteria and antimicrobial use on the risk of early- and late-onset VAP: An analysis of the OUTCOMEREA network

Rationale The impact of prevention strategies and risk factors for early-onset (EOP) versus late-onset (LOP) ventilator-associated pneumonia (VAP) are still debated. Objectives To evaluate, in a multicenter cohort, the risk factors for EOP and LOP, as the evolution of prevention strategies. Methods 7,784 patients with mechanical ventilation (MV) for at least 48 hours were selected into the multicenter prospective OUTCOMEREA database (1997–2016). VAP occurring between the 3rd and 6th day of MV defined EOP, while those occurring after defined LOPs. We used a Fine and Gray subdistribution model to take the successful extubation into account as a competing event. Measurements and main results Overall, 1,234 included patients developed VAP (EOP: 445 (36%); LOP: 789 (64%)). Male gender was a risk factor for both EOP and LOP. Factors specifically associated with EOP were admission for respiratory distress, previous colonization with multidrug-resistant Pseudomonas aeruginosa, chest tube and enteral feeding within the first 2 days of MV. Antimicrobials administrated within the first 2 days of MV were all protective of EOP. ICU admission for COPD exacerbation or pneumonia were early risk factors for LOP, while imidazole and vancomycin use within the first 2 days of MV were protective factors. Late risk factors (between the 3rd and the 6th day of MV) were the intra-hospital transport, PAO2-FIO2<200 mmHg, vasopressor use, and known colonization with methicillin-resistant Staphylococcus aureus. Among the antimicrobials administered between the 3rd and the 6th day, fluoroquinolones were the solely protective one.Contrarily to LOP, the risk of EOP decreased across the study time periods, concomitantly with an increase in the compliance with bundle of prevention measures. Conclusion VAP risk factors are mostly different according to the pneumonia time of onset, which should lead to differentiated prevention strategies.

Transthoracic echography assessment of the superior vena cava flow: a pilot study

Dear Editor, Acute circulatory failure is frequent, affecting up to onethird of patients admitted to intensive care units (ICU) [1, 2]. Monitoring hemodynamics and cardiac function is therefore a major concern [3]. Analysis of respiratory diameter variations of the superior vena cava (SVC) is easily obtained with transesophageal echocardiography (TEE) and is helpful to assess fluid responsiveness [4]. Transthoracic echocardiography (TTE) exploration of the SVC is not used in routine. Recently, microconvex ultrasound transducers have been marketed and these may be of use for non-invasive SVC flow examination. However, analysis of diameter variations of the SVC with TTE does not seem to be possible since the approach from the supraclavicular fossa does not allow for a good visualization of the SVC walls. We therefore designed a prospective cohort pilot study to evaluate the feasibility and reproducibility of TTE examination of the SVC flow. After approval by an ethics committee, we included all intubated patients requiring controlled invasive mechanical ventilation in our ICU between November 2015 and April 2016. Exclusion criteria were aged less than 18 years, spontaneous breathing, cardiac arrhythmia, right ventricular failure, or severe acute respiratory distress syndrome. Ten ICU physicians received brief theoretical training about TTE measurement of the SVC, including setting the parameters of the device, positioning of the transducer, sonoanatomy, and SVC flow. Then, they received practical bedside training on healthy volunteers and ventilated patients. For each patient, echo-Doppler measurement of the SVC was performed by two different physicians within a 5-min interval, without any hemodynamic or respiratory intervention. Measurements were performed at the end of expiration with a Vivid S6 Ultrasound System (GE Healthcare) equipped with a micro-convex GE 8C-RS transducer. Measurements were performed in the upper part of the SVC, approximately 1–2 cm below the brachiocephalic vein. From this view, pulse Doppler was performed (Fig. 1). Pulse Doppler waves obtained in the SVC were used to measure velocity time integrals (VTI) of the systolic (VTIS) and diastolic (VTID) waves. The systolic fraction of the SVC flow (SFSVC) was calculated as the ratio VTIS/VTIS+D. The reproducibility of the technique was calculated from the SFSVC using intraclass correlation coefficient (ICC). Fifty-three patients were included. The mean number of patients evaluated per physician was 10.6. Among the 45 patients in whom the measurements were performed, ICC for the SFSVC was 0.90 (95% confidence interval [0.86–0.93]). There was no significant interoperator variability for the VTIS, VTID, or for the SFSVC. Measurements were not possible in eight patients; thus feasibility was 84.9%. Failure was explained by major hemodynamic instability (four patients), extended cervico-facial cellulitis (two patients), venous thrombosis (one patient), and ongoing hemodialysis on an internal jugular vein catheter (one patient). The present study describes a new non-invasive echographic approach of the SVC. This tool seems both easy to learn and to use, and is reproducible in most ventilated ICU patients. The analysis of respiratory variations of the

Continuous renal replacement therapy versus intermittent hemodialysis in intensive care patients: impact on mortality and renal recovery (vol 42, pg 1408, 2016)

Erratum to: Intensive Care Med DOI 10.1007/s00134‐016‐4404‐6 This article was first published without inclusion of the OUTCOMEREA Study Group in the authorship and without the electronic supplementary material file that lists the members of this group. These omissions have now been rectified. The wording of the take-home message was erroneous; the correct text is provided here. Take-home message: Optimal renal replacement therapy (RRT) technique in the ICU remains controversial, in patients with shock or fluid overload. Cohort studies suggested increased risk of persistent acute kidney injury or dialysis dependency with intermittent hemodialysis. In a MSM Cox model in a cohort of 1360 patients adjusted on daily patients’ characteristics, we found that RRT modality did not influenced neither 30-day mortality nor renal outcome. In subgroups continuous RRT benefits patients with positive fluid balance and is deleterious in patients without hemodynamic instability. Author details 1 UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018 Paris, France. 2 Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France. 3 Nephrology, Grenoble Uni‐ versity Hospital, La Tronche, France. 4 Medical Intensive Care Unit, Saint Etienne University Hospital, Saint‐Etienne, France. 5 Jacques Lisfranc Medicine University, Jean Monnet University, Saint‐Etienne, France. 6 Grenoble Alpes University, U823, Rond‐point de La Chantourne, 38700 La Tronche, France. 7 Intensive Care Unit, AP‐HP, Avicenne Hospital, Paris, France. 8 Medicine University, Paris 13 University, Bobigny, France. 9 AP‐HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018 Paris, France. 10 Intensive Care Unit, Saint Joseph Hospital Network, Paris, France. 11 Sorbonne Cite, Medicine University, Paris Descartes University, Paris, France. 12 Medical Intensive Care Unit, AP‐HP, Saint Louis Hospital, Paris, France. 13 Medicine University, Paris 5 University, Paris, France. 14 Medical Surgical ICU, Centre Hospitalier de Cayenne, Guyane, France. 15 Physiology Department, Cochin University Hospital, Assistance Publique Des Hôpitaux de Paris (AP‐HP), Paris Descartes University, Sorbonne Cite, Paris, France. 16 AP‐HP, Antoine Béclère University Hospital, Medical‐surgical Intensive Care Unit, Clamart, France. 17 Medical Intensive Care Unit, Lyon Univer‐ sity Hospital, Lyon, France. 18 Surgical ICU, Edouard Herriot University Hospital, Lyon, France. 19 Critical Care Medicine Unit Dourdan Hospital, Dourdan, France. 20 Medical Intensive Care Unit, André Mignot Hospital, Versailles, France. 21 Inten‐ sive Care Unit, Gonesse Hospital, Gonesse, France. 22 Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont‐Ferrand, France. 23 Université Paris Diderot/Hôpital Bichat, Réanimation Medicale et des maladies infectieuses, 46 rue Henri Huchard, Paris 75018, France.

Surgical fixation of rib fractures in chest wall trauma.

J.-S. David Trauma and Emergency Surgery Unit, Department of Anesthesia and Critical Care, Lyon Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Benite Cedex, France A 42-year-old male pedestrian was admitted to our trauma center after being hit by a car. His medical history reported chronic alcohol intoxication and a 30-pack-year tobacco use with COPD II and emphysema. Clinical findings were a Glasgow Coma Scale (GCS) score of 15, sinus tachycardia with 85 % oxygen saturation on air and bilateral disappearance of breath sound. A body CT scan with 3D reconstruction revealed facial fracture, right pneumothorax with multiples rib fractures [from 2 to 8 on the right side with flail chest (Fig. 1a) and chest wall deformation (Fig. 1b)]. An intraoperative view showed the chest wall deformation (Fig. 1c). Right chest wall stabilization was performed using plates from MatrixRIB (DePuy Synthes) from rib 2 to 8 without chest wall opening (Fig. 2a), in association; video thoracoscopy was performed to allow pleural toilet and clot removal. The postoperative chest

Néphrectomie élargie gauche chez deux patients atteints d’hypertension portale porteurs d’un shunt veineux spléno-rénal

Resume Nous rapportons les cas de deux patients atteints d’une cirrhose hepatique compliquee d’hypertension portale avec shunt veineux porto-sytemique spleno-renal et porteurs d’une tumeur renale gauche pour laquelle nous avons realise une nephrectomie elargie gauche avec conservation du shunt.