Jean-Christophe Orban

The Practice of Therapeutic Hypothermia after Cardiac Arrest in France: A National Survey

Aims Cardiac arrest is a major health concern worldwide accounting for 375,000 cases per year in Europe with a survival rate of <10%. Therapeutic hypothermia has been shown to improve patients’ neurological outcome and is recommended by scientific societies. Despite these guidelines, different surveys report a heterogeneous application of this treatment. The aim of the present study was to evaluate the clinical practice of therapeutic hypothermia in cardiac arrest patients. Methods This self-declarative web based survey was proposed to all registered French adult intensive care units (ICUs) (n = 357). Paediatrics and neurosurgery ICUs were excluded. The different questions addressed the structure, the practical modalities of therapeutic hypothermia and the use of prognostic factors in patients admitted after cardiac arrest. Results One hundred and thirty-two out of 357 ICUs (37%) answered the questionnaire. Adherence to recommendations regarding the targeted temperature and hypothermia duration were 98% and 94% respectively. Both guidelines were followed in 92% ICUs. During therapeutic hypothermia, sedative drugs were given in 99% ICUs, mostly midazolam (77%) and sufentanil (59%). Neuromuscular blocking agents (NMBA) were used in 97% ICUs, mainly cisatracurium (77%). Numerous prognostic factors were used after cardiac arrest such as clinical factors (95%), biomarkers (53%), electroencephalography (78%) and evoked potentials (35%). Conclusions In France, adherence to recommendations for therapeutic hypothermia after cardiac arrest is higher than those previously reported in other countries. Numerous prognostic factors are widely used even if their reliability remains controversial.

Effects of acetylcysteine and ischaemic preconditioning on muscular function and postoperative pain after orthopaedic surgery using a pneumatic tourniquet.

Background and objective: The use of a pneumatic tourniquet can induce muscular and neurological complications in the operated limb. The genesis of these injuries could involve an ischaemia/reperfusion phenomenon and a compression under the cuff. We evaluated effects of an antioxidant, acetylcysteine and ischaemic preconditioning on the rhabdomyolysis and postoperative pain following a knee ligamentoplasty using a pneumatic tourniquet. Methods: We included 31 patients scheduled for a knee ligamentoplasty randomly assigned in three groups (control, acetylcysteine 1200 mg the day before and 600 mg at the operative day, ischaemic preconditioning). Results: There was a moderate rise in myoglobin and creatinine phosphokinase with no significant difference between the three groups. The muscular functional parameters were similar in all the groups. However, the morphine consumption within the first 48 h was smaller in the treatment groups (0.22 ± 0.31 mg kg−1 and 0.22 ± 0.23 mg kg−1 in the preconditioning and antioxidant groups, respectively) than in the control group (0.47 ± 0.33 mg kg−1, P <0.05). Conclusions: Acetylcysteine and ischaemic preconditioning do not decrease the extent of rhabdomyolysis related to the use of a pneumatic tourniquet and do not improve the postoperative muscle recovery. On the other hand, they allow a significant reduction in the postoperative morphine consumption.

L’acidose lactique reste une complication grave du traitement par metformine

We report 4 cases of lactic acidosis in diabetic patients usually treated with metformin. For the first 3 patients, the clinical history was similar because lactic acidosis was precipitated by gastro-intestinal disorders whereas all of them were simultaneously treated with several nephrotoxic drugs. These 3 patients presented with acute renal failure on arrival at hospital. Their issue was fatal whereas any obvious cause of overproduction of lactate was found. The fourth case, which was due to a voluntary intoxication, was the only one presenting with a favourable evolution. The metformin plasma and red blood cell levels were performed for 2 of 4 patients and confirmed the overdose. These observations remind that metformin-associated lactic acidosis remains a serious complication, and that medical doctors must respect strictly contra-indications and guidelines for withdrawing metformin.

Incidence and characteristics of acute kidney injury in severe diabetic ketoacidosis.

Aims Acute kidney injury is a classical complication of diabetic ketoacidosis. However, to the best of our knowledge, no study has reported the incidence and characteristics of acute kidney injury since the consensus definition was issued. Methods Retrospective study of all cases of severe diabetic ketoacidosis hospitalised consecutively in a medical surgical tertiary ICU during 10 years. Patients were dichotomised in with AKI and without AKI on admission according to the RIFLE classification. Clinical and biological parameters were compared in these populations. Risk factors of presenting AKI on admission were searched for. Results Ninety-four patients were included in the study. According to the RIFLE criteria, 47 patients (50%) presented acute kidney injury on admission; most of them were in the risk class (51%). At 12 and 24 hours, the percentage of AKI patients decreased to 26% and 27% respectively. During the first 24 hours, 3 patients needed renal replacement therapy. Acute renal failure on admission was associated with a more advanced age, SAPS 2 and more severe biological impairments. Treatments were not different between groups except for insulin infusion. Logistic regression found 3 risk factors of presenting AKI on admission: age (odds ratio 1.060 [1.020–1.100], p<0.01), blood glucose (odds ratio 1.101 [1.039–1.166], p<0.01) and serum protein (odds ratio 0.928 [0.865–0.997], p = 0.04). Conclusions Acute kidney injury is frequently associated with severe diabetic ketoacidosis on admission in ICU. Most of the time, this AKI is transient and characterised by a volume-responsiveness to fluid infusion used in DKA treatment. Age, blood glucose and serum protein are associated to the occurrence of AKI on ICU admission.

Effect of N-acetylcysteine pretreatment of deceased organ donors on renal allograft function: a randomized controlled trial.

Background Antioxidant donor pretreatment is one of the pharmacologic strategy proposed to prevent renal ischemia-reperfusion injuries and delayed graft function (DGF). The aim of the study was to investigate whether a donor pretreatment with N-acetylcysteine (NAC) reduces the incidence of DGF in adult human kidney transplant recipients. Methods In this randomized, open-label, monocenter trial, 160 deceased heart-beating donors were allowed to perform 236 renal transplantations from September 2005 to December 2010. Donors were randomized to receive, in a single-blind controlled fashion, 600 mg of intravenous NAC 1 hr before and 2 hr after cerebral angiography performed to confirm brain death. Primary endpoint was DGF defined by the need for at least one dialysis session within the first week or a serum creatinine level greater than 200 &mgr;mol/L at day 7 after kidney transplantation. Results The incidence of DGF was similar between donors pretreated with or without NAC (39/118; 33% vs. 30/118; 25.4%; P = 0.19). Requirement for at least one dialysis session was not different between the NAC and No NAC groups (17/118; 14.4% vs. 14/118; 11.8%, P = 0.56). The two groups had comparable serum creatinine levels, estimated glomerular filtration rates, and daily urine output at days 1, 7, 15, and 30 after kidney transplantation as well as at hospital discharge. No difference in recipient mortality nor in 1-year kidney graft survival was observed. Conclusion Donor pretreatment with NAC does not improve delayed graft function after kidney transplantation.

Effects of tight computerized glucose control on neurological outcome in severely brain injured patients: a multicenter sub-group analysis of the randomized-controlled open-label CGAO-REA study

IntroductionHyperglycemia is a marker of poor prognosis in severe brain injuries. There is currently little data regarding the effects of intensive insulin therapy (IIT) on neurological recovery.MethodsA sub-group analysis of the randomized-controlled CGAO-REA study (NCT01002482) in surgical intensive care units (ICU) of two university hospitals. Patients with severe brain injury, with an expected ICU length of stay ≥48 hours were included. Patients were randomized between a conventional glucose management group (blood glucose target between 5.5 and 9 mmol.L−1) and an IIT group (blood glucose target between 4.4 and 6 mmol.L−1). The primary outcome was the day-90 neurological outcome evaluated with the Glasgow outcome scale.ResultsA total of 188 patients were included in this analysis. In total 98 (52%) patients were randomized in the control group and 90 (48%) in the IIT group. The mean Glasgow coma score at baseline was 7 (±4). Patients in the IIT group received more insulin (130 (68 to 251) IU versus 74 (13 to 165) IU in the control group, P = 0.01), had a significantly lower morning blood glucose level (5.9 (5.1 to 6.7) mmol.L−1 versus 6.5 (5.6 to 7.2) mmol.L−1, P <0.001) in the first 5 days after ICU admission. The IIT group experienced more episodes of hypoglycemia (P <0.0001). In the IIT group 24 (26.6%) patients had a favorable neurological outcome (good recovery or moderate disability) compared to 31 (31.6%) in the control group (P = 0.4). There were no differences in day-28 mortality. The occurrence of hypoglycemia did not influence the outcome.ConclusionsIn this sub-group analysis of a large multicenter randomized trial, IIT did not appear to alter the day-90 neurological outcome or ICU morbidity in severe brain injured patients or ICU morbidity.

Efficacy of Low-Dose Intrathecal Morphine for Postoperative Analgesia After Abdominal Aortic Surgery: A Double-Blind Randomized Study

Background and Objectives: Several studies suggest that intrathecal morphine (ITM) improves analgesia after aortic surgery. We tested the hypothesis that in combination with multimodal postoperative pain management, low-dose ITM associated with general anesthesia would decrease postoperative analgesic requirements in patients undergoing abdominal aortic surgery. Methods: Thirty patients were randomized to receive either general anesthesia alone or preceded by low-dose ITM (0.2 mg) administration. Patients and providers were blinded to treatment. Postsurgical multimodal pain management was similar in both groups, including parenteral paracetamol, followed by intravenous nefopam and then morphine if not sufficient. Intravenous analgesic requirements, visual analog scale (VAS) scores, and the incidence and severity of side effects were recorded for 48 hours after surgery. Results: Intraoperative data were comparable between the 2 groups, except sufentanil consumption, which was significantly lower in the ITM group when compared with the control group (P = .023). ITM decreased postoperative total-morphine requirements with respect to both the number of patients who received morphine (4 v 12 patients, P = .003) and the cumulative dose of morphine administered (0 [0-12.4] v 23 [13.9-45.6] mg, P = .006). VAS scores at rest were higher in the control group than in the ITM group at awakening (P < .01), at 4 hours (P < .01) after surgery, and at 8 hours (P < .05) after surgery but did not differ between groups after this period. Whereas VAS scores on coughing were higher in the control group at awakening (P < .01) and 4 hours after surgery (P < .05), no differences were found between groups from 8 hours after surgery. Conclusion: In patients undergoing abdominal aortic surgery, intrathecal morphine (0.2 mg) improves postoperative analgesia and decreases the need in intraoperative and postoperative analgesics. Further studies are indicated to evaluate the role of ITM in postoperative recovery.

How the relationships between general practitioners and intensivists can be improved: the general practitioners' point of view

IntroductionThe present study assessed the opinion of general practitioners (GPs) concerning their relationships with intensivists.MethodsAn anonymous questionnaire was mailed to 7,239 GPs. GPs were asked about their professional activities, postgraduate intensive care unit (ICU) training, the rate of patient admittance to ICUs, and their relationships with intensivists. Relationship assessment was performed by using a graduated visual analogue scale (VAS) ranging from 0 (dissatisfaction) to 100 (satisfaction). A multivariate analysis with stepwise logistic regression was performed to isolate factors explaining dissatisfaction (VAS score, < 25th percentile).ResultsTwenty-two percent of the GPs (1,561) responded. The median satisfaction score was 57 of 100 (interquartile (IQ), 35 to 77]. Five independent factors of dissatisfaction were identified: no information provided to GPs at patient admission (odds ratio (OR) = 2.55 (1.71 to 3.80)); poor quality of family reception in the ICU (OR = 2.06 (1.40 to 3.02)); the ICUs family contact persons identity or function or both is unclear (OR = 1.48 (1.03 to 2.12)), lack of family information (OR = 2.02 (2.48 to 2.75)), and lack of discharge report (OR = 3.39 (1.70 to 6.76)). Three independent factors prevent dissatisfaction: age of GPs ≤45 years (OR = 0.69 (0.51 to 0.94)); the GP is called at patient ICU admission (OR = 0.44 (0.31 to 0.63)); and GP involvement in treatment decisions (OR = 0.17 (0.07 to 0.40)).ConclusionsConsiderable improvement in GP/intensivist relationships can be achieved through increased communication measures.

A near-fatal case of exercise-associated hyponatremia

A 42-year-old woman presented to our emergency department with headache, nausea, and confusion after completing an Ironman triathlon. She performed the race at a slow pace, in hot and dry weather. The first medical examination reported confusion with a Glasgow Coma Scale score of 13. A few minutes later, she presented with seizures. A cerebral computed tomographic (CT) scan showed major cerebral edema. Blood analysis showed severe acute hyponatremia (123 mEq/L) with hypotonicity (255 mEq/L). Her clinical condition quickly worsened, leading to a Glasgow Coma Scale score of 3 with fixed dilated pupils. After intubation and mechanical ventilation, she was transferred to the intensive care unit. A transcranial Doppler ultrasonography (TCD) showed intracranial hypertension signs motivating emergency osmotherapy by infusion of 20% mannitol over 15 minutes. To guide the therapeutics, an intracranial pressure monitoring was inserted, showing a value of 30 mm Hg. A few minutes later, intracranial pressure (ICP) increased to 68 mm Hg with a low cerebral perfusion pressure. Concomitantly, another TCD reported critical flows with poor cerebral perfusion. A second infusion of mannitol led to an ICP lowering and a decrease in pupil size after 10 minutes. During the next hours, the patient stayed stable without further intervention. Sixteen hours later, natremia was normal, mainly due to hyperdiuresis. On day 2, the tracheal tube was removed. A cerebral CT scan showed disappearance of cerebral edema. One month later, the patient had good recovery apart from some residual memory problems. Six months later, she was able to come back to work.

Transcranial Doppler shortens the time between clinical brain death and angiographic confirmation: a randomized trial.

Background Brain death diagnosis relies on clinical signs, but confirmatory tests are legally mandatory in some countries. In France, transcranial Doppler (TCD) is not recognized as a legal test to confirm brain death. Nevertheless, experts recommend its use to determine the need for a legal confirmatory test. The aim of this study was to test the hypothesis that TCD shortens the time between clinical brain death and computed tomography angiography (CTA) confirmation. Methods We conducted a prospective randomized controlled study to evaluate the benefit of a TCD-directed strategy before performing the CTA to confirm brain death. Once the clinical diagnosis of brain death was established, subjects were randomized in a conventional group (CTA 6 hr later as recommended in France) or a TCD group (TCD examination every 2 hr until intracranial brain death flow patterns were found). Forty-four subjects were needed to show a difference of 2 hr between the two strategies. Results TCD strategy resulted in a shorter time between clinical diagnosis of brain death and CTA confirmation compared with conventional strategy (2.0 [1.3–2.6] vs. 7.2 [6.3–9.5] hr, P<0.0001). The number of brain CTA performed to confirm the diagnosis of brain death was not different between groups. Conclusions Our results suggest that TCD-directed strategy allows reducing the time between clinical diagnosis of brain death and CTA confirmation.