Maxime Maignan

Pulmonary Pressure and Cardiac Function in Chronic Mountain Sickness Patients

BACKGROUND Chronic mountain sickness (CMS) is characterized by a loss of adaptation to hypoxia in high-altitude (HA) dwellers. Chronic hypoxemia, excessive erythrocytosis and frequently pulmonary hypertension (PH), which may lead to cardiac failure, develop in patients. We sought to assess the determinants of cardiac function in CMS patients with hypoxia-induced PH. METHODS Fifteen healthy men living at sea level (SL) were compared to 15 healthy men living at HA and 55 patients with CMS from Cerro de Pasco, Peru (altitude, 4,300 m). Pulmonary pressures and cardiac function were estimated by echocardiography. RESULTS None of the subjects had overt cardiac failure symptoms. CMS patients exhibited elevated mean pulmonary pressures as assessed by high-tricuspid pressure gradients (CMS patients, 34 +/- 10 mm Hg; HA subjects, 25 +/- 4 mm Hg [p = 0.002]; and SL subjects, 19 +/- 3 mm Hg [p < 0.001]). They also showed right ventricular (RV) dilation (mean end-diastolic RV area: CMS patients, 17 +/- 2 cm(2); HA subjects, 13 +/- 2 cm(2); SL subjects, 12 +/- 2 cm(2); p < 0.001) but did not display impaired systolic ventricular function. However, the RV Tei index was increased in CMS and HA subjects (CMS patients, 0.56 +/- 0.15; HA subjects, 0.52 +/- 0.12; SL subjects, 0.21 +/- 0.12; p < 0.001). CONCLUSION Despite obvious pulmonary arterial hypertension and right heart dilation, CMS patients did not show any symptom or echocardiographic parameter of heart failure. TRIAL REGISTRATION ClinicalTrials.gov. Identifier: NCT00424970.

Acetazolamide for Monge's Disease Efficiency and Tolerance of 6-Month Treatment

RATIONALE Monges disease is characterized by an excessive erythrocytosis, frequently associated with pulmonary hypertension, in high-altitude dwellers. It has a considerable impact on public health in high-altitude regions. A preliminary study demonstrated the efficiency of acetazolamide (Acz) (250 mg/d for 3 wk) in reducing serum erythropoietin and hematocrit. OBJECTIVES Evaluate the efficacy and tolerance of a 6-month treatment with 250 mg Acz that could be chronically implemented and its effects on pulmonary artery pressure and cardiac function. METHODS A two-phase study was performed in patients (hematocrit > or = 63%) from Cerro de Pasco, Peru (4,300 m). First phase: a double-blind, placebo-controlled study in 55 patients who received a single dose of either 250 mg Acz (n = 40) or placebo (n = 15) by daily oral administration for 12 weeks. Second phase (open label): after a 4-week washout period, all patients received 250 mg Acz for 12 weeks. Hematocrit, blood gases, clinical outcome, and pulmonary artery circulation were evaluated. MEASUREMENTS AND MAIN RESULTS First phase: Acz decreased by 44% the number of polycythemic subjects (P = 0.02), decreased hematocrit from 69 to 64% (P < 0.001), and increased arterial O(2) pressure from 42 to 45 mm Hg (P < 0.001). No severe adverse effect or hypokalemia was recorded. The second phase reproduced the effects observed during the first phase, without cumulative effects on hematocrit. A 4-week washout restored basal hematocrit. Only patients who received Acz for 6 months showed a clear reduction in pulmonary vascular resistance. CONCLUSIONS Acz reduces erythrocytosis and improves pulmonary circulation in Monges disease without adverse effects. Its implementation as a chronic treatment for this disease appears efficient and safe.

Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis

PURPOSE Association estimates between baseline characteristics and outcomes are imprecise and inconsistent among extracorporeal cardiopulmonary resuscitation (ECPR) recipients following refractory out-of-hospital cardiac arrest (OHCA). This systematic review and meta-analysis aimed to investigate the prognostic significance of pre-specified characteristics for OHCA treated with ECPR. METHODS The Medline electronic database was searched via PubMed for articles published from January 2000 to September 2016. The electronic search was supplemented by scanning the reference lists of retrieved articles and contacting field experts. Eligible studies were historical and prospective cohort studies of adult patients undergoing ECPR following OHCA. RESULTS Fifteen primary studies were included, totaling 841 participants. The median prevalence of the primary outcome (i.e., short- or long-term survival for five studies and cerebral performance for ten studies) was 15% (range, 0-50%). The primary outcome was associated with an increased odds ratio of initial shockable cardiac rhythm (2.20; 95% confidence interval [CI], 1.30-3.72; P=0.003), shorter low-flow duration (geometric mean ratio, 0.90; 95% CI, 0.81-0.99; P=0.04), higher arterial pH value (difference, 0.12; 95% CI, 0.03-0.22; P=0.01) and lower serum lactate concentration (difference, -3.52mmol/L; 95% CI, -5.05 to -1.99; P<0.001). No significant association was found between the primary outcome and patient age (the odds of female gender and bystander CPR attempt. CONCLUSION Observational evidence from published primary studies indicates that shorter low-flow duration, shockable cardiac rhythm, higher arterial pH value and lower serum lactate concentration on hospital admission are associated with better outcomes for ECPR recipients after OHCA.

Outcome after severe accidental hypothermia in the French Alps: A 10-year review

OBJECTIVE To describe the factors associated with outcome after accidental deep hypothermia. METHODS We conducted a retrospective cohort study on patients with accidental hypothermia (core temperature <28 °C) admitted to a Level I emergency room over a 10-year period. RESULTS Forty-eight patients were included with a median temperature of 26 °C (range, 16.3-28 °C) on admission. The etiology of hypothermia was exposure to a cold environment (n = 27), avalanche (n = 13) or immersion in cold water (n = 8). Mean age was 47 ± 22 years, and 58% were males. Thirty-two patients had a cardiac arrest (CA): 15 patients presented unwitnessed cardiac arrest (UCA) and 17 patients presented rescue collapse (RC). Extracorporeal life support (ECLS) was implemented in 21 patients with refractory cardiac arrest and in two patients with hemodynamic instability. Overall mortality was 50%. For cardiac arrest patients, only three out of 15 patients with UCA survived at day 28, whereas eight out of 17 patients with RC survived. The cerebral performance category score was 4 for all the survivors of UCA and 1 [range, 1-2] for survivors of RC. Patients with poor outcome presented more UCA, a lower pH, a higher serum potassium, creatinine, serum sodium or lactate level as well as more severe coagulation disorders. CONCLUSION Cardiac arrest related to rescue collapse was associated with favorable outcome. On-scene rescue collapse should prompt prolonged resuscitation and ECLS rewarming in all CA patients with deep hypothermia. Conversely, unwitnessed cardiac arrest was associated with unfavorable outcome and will likely not benefit from ECLS.

Acetazolamide and chronic hypoxia: effects on haemorheology and pulmonary haemodynamics

We tested the effect of acetazolamide on blood mechanical properties and pulmonary vascular resistance (PVR) during chronic hypoxia. Six groups of rats were either treated or not treated with acetazolamide (curative: treated after 10 days of hypoxic exposure; preventive: treated before hypoxic exposure with 40 mg·kg−1·day−1) and either exposed or not exposed to 3 weeks of hypoxia (at altitude >5,500 m). They were then used to assess the role of acetazolamide on pulmonary artery pressure, cardiac output, blood volume, haematological and haemorheological parameters. Chronic hypoxia increased haematocrit, blood viscosity and PVR, and decreased cardiac output. Acetazolamide treatment in hypoxic rats decreased haematocrit (curative by -10% and preventive by -11%), PVR (curative by -36% and preventive by -49%) and right ventricular hypertrophy (preventive -20%), and increased cardiac output (curative by +60% and preventive by +115%). Blood viscosity was significantly decreased after curative acetazolamide treatment (-16%) and was correlated with PVR (r=0.87, p<0.05), suggesting that blood viscosity could influence pulmonary haemodynamics. The fall in pulmonary vascular hindrance (curative by -27% and preventive by -45%) after treatment suggests that acetazolamide could decrease pulmonary vessels remodelling under chronic hypoxia. The effect of acetazolamide is multifactorial by acting on erythropoiesis, pulmonary circulation, haemorheological properties and cardiac output, and could represent a pertinent treatment of chronic mountain sickness.

Deliberate drug poisoning with slight symptoms on admission: Are there predictive factors for intensive care unit referral? A three-year retrospective study

Deliberate drug poisoning leads to 1% of emergency department (ED) admissions. Even if most patients do not exhibit any significant complication, 5% need to be referred to an intensive care unit (ICU). Emergency physicians should distinguish between low‐ and high‐acuity poisoned patients at an early stage to avoid excess morbidity. Our aim was to identify ICU transfer factors in deliberately self‐poisoned patients without life‐threatening symptoms on admission. We performed a 3‐year retrospective observational study in a university hospital. Patients over 18 years of age with a diagnosis of deliberate drug poisoning were included. Clinical and toxicological data were analysed with univariate tests between groups (ED stay versus ICU transfer). Factors associated with ICU admission were then included in a logistic regression analysis. Two thousand five hundred and sixty‐five patients were included. 63.2% were women, and median age was 40 (28–49). 142 patients (5.5%) were transferred to ICU. Cardiac drugs [adjusted OR (aOR) = 19.81; 95% confidence interval (95% CI): 7.93–49.50], neuroleptics (aOR = 2.78; 95% CI: 1.55–4.97) and meprobamate (aOR = 2.71; 95% CI: 1.27–5.81) ingestions were significantly linked to ICU admission. A presumed toxic dose ingestion (aOR = 2.27; 95% CI: 1.28–4.02), number of ingested tablets (aOR = 1.01; 95% CI: 1.01–1.02 for each tablet) and delay between ingestion and ED arrival <2 hr (aOR = 2.85; 95%CI: 1.62–5.03) were also factors for ICU referral. The Glasgow Coma Scale was the only clinical feature associated with ICU admission (aOR = 1.57; 95% CI: 1.44–1.70 for each point loss). These results suggest that emergency physicians should pay particular attention to toxicological data on ED admission to distinguish between low‐ and high‐acuity self‐poisoned patients.

Effects of cyclosporine a in ex vivo reperfused pig lungs.

Several works highlight the role of CsA in the prevention of IRI, but none focus on isolated lungs. Our objective was to evaluate the effects of CsA on IRI on ex vivo reperfused pig lungs.

Experience feedback committee in emergency medicine: a tool for security management

Objective Emergency departments are high-risk structures. The objective was to analyse the functioning of an experience feedback committee (EFC), a security management tool for the analysis of incidents in a medical department. Methods We conducted a descriptive study based on the analysis of the written documents produced by the EFC between November 2009 and May 2012. We performed a double analysis of all incident reports, meeting minutes and analysis reports. Results During the study period, there were 22 meetings attended by 15 professionals. 471 reported incidents were transmitted to the EFC. Most of them (95%) had no consequence for the patients. Only one reported incident led to the patients death. 12 incidents were analysed thoroughly and the committee decided to set up 14 corrective actions, including eight guideline writing actions, two staff trainings, two resource materials provisions and two organisational changes. Conclusions The staff took part actively in the EFC. Following the analysis of incidents, the EFC was able to set up actions at the departmental level. Thus, an EFC seems to be an appropriate security management tool for an emergency department.

Impact of laryngeal tube use on chest compression fraction during out-of-hospital cardiac arrest. A prospective alternate month study

AIM Supraglottic devices are thought to allow efficient ventilation and continuous chest compressions during cardiac arrest. Therefore, the use of supraglottic devices could increase the chest compression fraction (CCF), a critical determinant of patient survival. The aim of this study was to assess the CCF in out-of-hospital cardiac arrest (OHCA) patients ventilated with a supraglottic device. METHODS We conducted an open prospective multicenter study with temporal clusters. OHCA patients treated by emergency nurses received either intermittent chest compressions with bag-valve mask ventilations (30:2 rhythm; BVM group); or continuous chest compressions with asynchronous ventilations by laryngeal tube (LT group). The primary endpoint was the CCF assessed using an accelerometer connected to the defibrillator. We also investigated the ease of use of the laryngeal tube. RESULTS Eighty-two patients were included (41 in each group); 68% were male and the median age was 68 (54-80) years. Patients and cardiac arrest characteristics did not differ between groups. The CCF was 75% (68-79%) in the LT group and 59% (51-68%) in the BVM group (p<0.01). LT insertion failed in nine out of 40 cases (23%). The median time of LT insertion was 26s (11-56 s). CCF was significantly lower when LT insertion failed (58% (48-74%) vs. 76% (72-80%) when LT insertion succeeded; p=0.01). CONCLUSION The use of the LT during OHCA increases the CCF when compared to standard BVM ventilation. However, the impact of LT use on mortality remains unclear.

Association between serum YKL-40 level and dysglycemia in cystic fibrosis.

BACKGROUND YKL-40, a chitinase-like protein, is a biomarker for type 1 and type 2 diabetes prognosis. We hypothesized that YKL-40 protein levels are elevated in CF patients with dysglycemia. METHODS Seventeen healthy control subjects and 66 CF patients were prospectively recruited and subjected to an oral glucose tolerance test. In all participants, fasting serum YKL-40 was compared between control and CF patients and between normal glucose-tolerant patients (NG-CF) and CF patients with dysglycemia (DG-CF). A Botnia clamp procedure was performed on a subset of patients for each group to determine the impact of acute increases of either glucose or insulin on YKL-40 concentration. RESULTS CF patients had higher serum YKL-40 values than the controls (113 [49;288] vs. 38 [30;50] ng/ml, p<0.001). YKL-40 concentrations in CF patients were mainly increased in the DG-CF group, who had significantly higher values: 213 [93;383] vs. 67 [27;97] ng/ml in the NG-CF group, p<0.001). No significant modulation of YKL-40 concentration was observed in serum of CF (NG or DG-CF) or non-CF patients, after acute exposure to glucose or insulin. CONCLUSIONS Higher serum YKL-40 levels in CF patients are significantly associated with dysglycemia. The increase in YKL-40 is potentially associated with an inflammatory response resulting from chronic glucose intolerance or CF disease evolution.