Jean Mantz

Sepsis-induced brain dysfunction

Systemic infection is often revealed by or associated with brain dysfunction, which is characterized by alteration of consciousness, ranging from delirium to coma, seizure or focal neurological signs. Its pathophysiology involves an ischemic process, secondary to impairment of cerebral perfusion and its determinants and a neuroinflammatory process that includes endothelial activation, alteration of the blood–brain barrier and passage of neurotoxic mediators. Microcirculatory dysfunction is common to these two processes. This brain dysfunction is associated with increased mortality, morbidity and long-term cognitive disability. Its diagnosis relies essentially on neurological examination that can lead to specific investigations, including electrophysiological testing or neuroimaging. In practice, cerebrospinal fluid analysis is indisputably required when meningitis is suspected. Hepatic, uremic or respiratory encephalopathy, metabolic disturbances, drug overdose, sedative or opioid withdrawal, alcohol withdrawal delirium or Wernicke’s encephalopathy are the main differential diagnoses. Currently, treatment consists mainly of controlling sepsis. The effects of insulin therapy and steroids need to be assessed. Various drugs acting on sepsis-induced blood–brain barrier dysfunction, brain oxidative stress and inflammation have been tested in septic animals but not yet in patients.

Physical restraint in mechanically ventilated ICU patients: a survey of French practice

PurposeTo characterize the perceived utilization of physical restraint (PR) in mechanically ventilated intensive care unit (ICU) patients and to identify clinical and structural factors influencing PR use.MethodsA questionnaire was personally handed to one intensivist in 130 ICUs in France then collected on-site 2xa0weeks later.ResultsThe questionnaire was returned by 121 ICUs (response rate, 93xa0%), 66xa0% of which were medical-surgical ICUs. Median patient-to-nurse ratio was 2.8 (2.5–3.0). In 82xa0% of ICUs, PR is used at least once during mechanical ventilation in more than 50xa0% of patients. In 65xa0% of ICUs, PR, when used, is applied for more than 50xa0% of mechanical ventilation duration. Physical restraint is often used during awakening from sedation and when agitation occurs and is less commonly used in patients receiving deep sedation or neuromuscular blockers or having severe tetraparesis. In 29xa0% of ICUs, PR is used in more than 50xa0% of awake, calm and co-operative patients. PR is started without written medical order in more than 50xa0% of patients in 68xa0% of ICUs, and removed without written medical order in more than 50xa0% of patients in 77xa0% of ICUs. Only 21xa0% of ICUs have a written local procedure for PR use.ConclusionsThis survey in a country with a relatively high patient-to-nurse ratio shows that PR is frequently used in patients receiving mechanical ventilation, with wide variations according to patient condition. The common absence of medical orders for starting or removing PR indicates that these decisions are mostly made by the nurses.

Sedation in non-invasive ventilation: do we know what to do (and why)?

This review examines some of the issues encountered in the use of sedation in patients receiving respiratory support from non-invasive ventilation (NIV). This is an area of critical and intensive care medicine where there are limited (if any) robust data to guide the development of best practice and where local custom appears to exert a strong influence on patterns of care.We examine aspects of sedation for NIV where the current lack of structure may be contributing to missed opportunities to improve standards of care and examine the existing sedative armamentarium. No single sedative agent is currently available that fulfils the criteria for an ideal agent but we offer some observations on the relative merits of different agents as they relate to considerations such as effects on respiratory drive and timing, and airways patency. The significance of agitation and delirium and the affective aspect(s) of dyspnoea are also considered.We outline an agenda for placing the use of sedation in NIV on a more systematic footing, including clearly expressed criteria and conditions for terminating NIV and structural and organizational conditions for prospective multicentre trials.

Sedation options for the morbidly obese intensive care unit patient: a concise survey and an agenda for development

BackgroundWe offer some perspectives and commentary on the sedation of obese patients in the intensive care unit (ICU).DiscussionSedation in morbidly obese patients should conform to the same broad principles now current in ICU practice. These include a general presumption against benzodiazepines as first-line agents. Opioids should be avoided in any situation where spontaneous breathing is required. Remifentanil is the preferred agent where continuous stable opioid levels using an infusion are required, because of its lack of context-sensitive accumulation. Volatile anaesthetics may be an option for the same reason but there are no substantial, controlled demonstrations of effectiveness/safety in short-term use in the ICU setting. Propofol is a valuable resource in the morbidly obese patients but the duration of continuous sedation should not exceed 6xa0days, in order to avoid propofol infusion syndrome. Alpha-2 agonists offer a range of theoretically positive features for the sedation of morbidly obese patients, but at present there is a lack of pharmacokinetic data and a critical mass of high-grade clinical data. Dexmedetomidine has the attraction of not causing respiratory depression or obstructive breathing during sedation and its sympatholytic effects should help deliver stable blood pressure and heart rate. Ketamine has a poor tolerability profile in adults so its use in the ICU context is largely confined to paediatrics.ConclusionNone of the agents currently available is ideal for every situation encountered in the management of morbidly obese patients. This article identifies additional research needed to place sedation practice of obese patients on a more systematic footing.

Predictive factors of PACU stay after herniorraphy in infant: a classification and regression tree analysis.

Introduction:u2002 Herniorraphy is a common surgical intervention in infants, particularly in those born prematurely. Prematurity and perioperative sedation have been shown to be risk factors for postoperative apnea. However, their influence upon PACU stay duration has not been evaluated. The goal of this study was to investigate predictive factors for PACU stay in infants undergoing herniorraphy.

Delphi-Consensus Weights for Ischemic and Bleeding Events to Be Included in a Composite Outcome for RCTs in Thrombosis Prevention

Background and Objectives To weight ischemic and bleeding events according to their severity to be used in a composite outcome in RCTs in the field of thrombosis prevention. Method Using a Delphi consensus method, a panel of anaesthesiology and cardiology experts rated the severity of thrombotic and bleeding clinical events. The ratings were expressed on a 10-point scale. The median and quartiles of the ratings of each item were returned to the experts. Then, the panel members evaluated the events a second time with knowledge of the group responses from the first round. Cronbachs a was used as a measure of homogeneity for the ratings. The final rating for each event corresponded to the median rating obtained at the last Delphi round. Results Of 70 experts invited, 32 (46%) accepted to participate. Consensus was reached at the second round as indicated by Cronbachs a value (0.99 (95% CI 0.98-1.00)) so the Delphi was stopped. Severity ranged from under-popliteal venous thrombosis (medianu200a=u200a3, Q1u200a=u200a2; Q3u200a=u200a3) to ischemic stroke or intracerebral hemorrhage with severe disability at 7 days and massive pulmonary embolism (medianu200a=u200a9, Q1u200a=u200a9; Q3u200a=u200a9). Ratings did not differ according to the medical specialty of experts. Conclusions These ratings could be used to weight ischemic and bleeding events of various severity comprising a composite outcome in the field of thrombosis prevention.

Sedation and weaning from mechanical ventilation: time for 'best practice' to catch up with new realities?

Delivery of sedation in anticipation of weaning of adult patients from prolonged mechanical ventilation is an arena of critical care medicine where opinion-based practice is currently hard to avoid because robust evidence is lacking. We offer some views on this subject, hoping to stimulate debate among colleagues.