Philippe Marty

Lactate clearance for death prediction in severe sepsis or septic shock patients during the first 24 hours in Intensive Care Unit: an observational study

BackgroundThis study was design to investigate the prognostic value for death at day-28 of lactate course and lactate clearance during the first 24 hours in Intensive Care Unit (ICU), after initial resuscitation.MethodsProspective, observational study in one surgical ICU in a university hospital. Ninety-four patients hospitalized in the ICU for severe sepsis or septic shock were included. In this septic cohort, we measured blood lactate concentration at ICU admission (H0) and at H6, H12, and H24. Lactate clearance was calculated as followed: [(lactateinitial - lactatedelayed)/ lactateinitial] x 100%].ResultsThe mean time between severe sepsis diagnosis and H0 (ICU admission) was 8.0 ± 4.5 hours. Forty-two (45%) patients died at day 28. Lactate clearance was higher in survivors than in nonsurvivors patients for H0-H6 period (13 ± 38% and −13 ± 7% respectively, p = 0.021) and for the H0-H24 period (42 ± 33% and −17 ± 76% respectively, p < 0.001). The best predictor of death at day 28 was lactate clearance for the H0-H24 period (AUC = 0.791; 95% CI 0.6-0.85). Logistic regression found that H0-H24 lactate clearance was independently correlated to a survival status with a p = 0.047 [odds ratio = 0.35 (95% CI 0.01-0.76)].ConclusionsDuring the first 24 hr in the ICU, lactate clearance was the best parameter associated with 28-day mortality rate in septic patients. Protocol of lactate clearance-directed therapy should be considered in septic patients, even after the golden hours.

Cardiovascular effects of low-dose spinal anaesthesia as a function of age: An observational study using echocardiography

BACKGROUND Spinal anaesthesia (SA) is a widely used technique of regional anaesthesia but hypotension is an adverse effect commonly observed, especially in elderly patients. OBJECTIVE The objective of this study was to assess the cardiovascular effects induced by a single injection of a low-dose SA during elective surgery by using transthoracic echocardiography (TTE) and to compare these effects in patients older and younger than 70 years of age. DESIGN Observational study. SETTING Single centre university hospital. PATIENTS OR OTHER PARTICIPANTS Forty-six patients scheduled for surgery under SA were included in the study (25 patients<70 years and 21 patients ≥ 70 years). INTERVENTION(S) A cardiologist, blinded to all clinical parameters, interpreted the TTE. MAIN OUTCOME MEASURES Two TTEs were performed for each patient: one at baseline before and the second 20 minutes after the placement of the SA. RESULTS Sixty-six percent of patients became hypotensive in the ≥ 70 years group whereas no episode of hypotension occurred in the<70 years group (P<0.0001). At baseline (i.e. prior to SA), when compared to younger patients, elderly patients had both a lower E/A ratio (0.8 [0.5-2.1] vs. 1.4 [0.7-1.6], P=0.001) as well as a lower LVEF (50.4% [37.7-72.3] vs. 60.9% [44.8-69.8], P<0.0001). SA in the elderly induced a larger decrease in the cardiac index (CI) (-0.5 L·min(-1)·m(-2) [-0.8 to -0.3] vs. -0.2 L·min(-1)·m(-2) [-0.8-0.1], P<0.0001), LV stroke volume (-8mL [-13-4] vs. -2mL [-14 to -1], P<0.0001) and systemic vascular resistances (SVR) (-2.2 WU [-6.7-0.3] vs. -0.8 WU [-2.3-0.1], P<0.0001). CONCLUSIONS Hypotension is more frequent among elderly patients, even after low-dose SA. Known age-related changes in cardiovascular performance, such as impaired myocardial relaxation and decreased systolic function could be responsible for the decrease in cardiac output (CO) and SVR seen in these patients.

Patent foramen ovale appearance with association of left ventricular assist device and mechanical ventilation.

We report on a 62-year-old man referred to the cardiac intensive care unit less than 24 hours after anterior ST-segment elevated myocardial infarction. The patient developed cardiogenic shock requiring elective intubation, vasopressor, and inotropic support. Emergency coronary angiography, revascularization, and insertion of an intraaortic balloon pump were performed. Nevertheless, the hemodynamic situation remained unstable, and a left ventricular assist device (LVAD) was inserted. Severe hypoxemia occurred several minutes after initiating the Impella Recover LD/LP 5.0 (Abiomed, Danvers, MA). Transesophageal echocardiography allowed diagnosis of patent foramen ovale. The shunt resulted from abnormal left-to-right pressure gradient due to left ventricular unloading and increased right ventricular afterload induced by mechanical ventilation. Transesophageal echocardiography was used to regulate both LVAD output and positive end-expiratory pressure settings to optimize oxygen transport. Because patent foramen ovale is common in humans, transesophageal echocardiography should be performed systematically after LVAD insertion.

Prophylactic phenylephrine infusion for the prevention of hypotension after spinal anesthesia in the elderly: a randomized controlled clinical trial ☆ ☆☆ ★

STUDY OBJECTIVE Hypotension frequently occurs during spinal anesthesia (SA), especially in the elderly. Phenylephrine is effective to prevent SA-induced hypotension during cesarean delivery. The objective of this study was to evaluate the efficacy and safety of prophylactic infusion of phenylephrine after SA for orthopedic surgery in the elderly. DESIGN This prospective, randomized, double-blind, and placebo-controlled study included 54 patients older than 60 years undergoing elective lower limb surgery under SA (injection of 10 mg of isobaric bupivacaine with 5 μg of sufentanyl). INTERVENTION Patients were randomized to group P (100-μg/mL solution of phenylephrine solution at 1 mL/min after placement of SA) or the control group C (0.9% isotonic sodium chloride solution). The flow of the infusion was stopped if the mean arterial blood pressure (MAP) was higher than the baseline MAP and maintained or restarted at 1 mL/min if MAP was equal to or lower than the baseline MAP. Heart rate and MAP were collected throughout the case. MEASUREMENTS Hypotension was defined by a 20% decrease and hypertension as a 20% increase from baseline MAP. Bradycardia was defined as a heart rate lower than 50 beats per minute. MAIN RESULTS Twenty-eight patients were randomized to group P and 26 patients to group C. MAP was higher in group P than in group C (92 ± 2 vs 82 ± 2 mm Hg, mean ± SD, P< .001). The number of hypotensive episodes per patient was higher in group C compared with group P (9 [0-39] vs 1 [0-10], median [extremes], P< .01), but the number of hypotensive patients was similar between groups (19 [73%] vs 20 [71%], P= 1). The time to onset of the first hypotension was shorter in group C (3 [1-13] vs 15 [1-95] minutes, P= .004). The proportion of patients without hypotension (cumulative survival) was better in group P (P= .04). The number of hypertensive episodes per patient and the number of bradycardic episodes per patient were similar between groups (P= not significant). CONCLUSION Prophylactic phenylephrine infusion is an effective method of reducing SA-induced hypotension in the elderly. Compared with a control group, it delays the time to onset of hypotension and decreases the number of hypotensive episodes per patient. More data are needed to evaluate clinical outcomes of such a strategy.

Effect of fluid challenge on renal resistive index after major orthopaedic surgery: A prospective observational study using Doppler ultrasonography

BACKGROUND A postoperative renal resistive index (RRI)>0.70 has the best threshold to early predict acute kidney injury (AKI). The response of RRI to a postoperative fluid challenge (FC) is unknown. The aim of our study was to assess the impact of a FC on RRI in suspected hypovolaemia patients after orthopaedic surgery. DESIGN In this single-centre observational study, we prospectively screened 156 patients in the recovery room after having undergone a hip or knee replacement. INTERVENTIONS Forty-six patients with a RRI>0.70 and requiring FC were included. RRI and cardiac output (CO) were measured before and immediately after a fluid challenge with 500mL of isotonic saline. A decrease in RRI>5% was considered significant (renal responders). RESULTS Overall, FC resulted in a consistent decrease in RRI (from 0.74 [0.72-0.79] to 0.70 [0.68-0.73], P<0.01). Thirty-four patients (74%) showed a significant decrease in their RRI (from 0.74 [0.73-0.79] to 0.69 [0.67-0.72], P<0.05, versus non-responders: from 0.73 [0.72-0.75] to 0.72 [0.71-0.79], P=NS). CO increased equally among renal responders and non-responders (P=0.56). No correlation was found between changes in RRI and CO (r2=0.04; P=0.064). AKI was more common in renal non-responders (7/12) than in responders (3/34, P=0.001). CONCLUSIONS After major orthopaedic surgery, a FC can decrease RRI in suspected hypovolaemia patients at risk of postoperative AKI, but the changes are not correlated to changes in CO. Decreases in RRI were associated with better renal outcome.

Regional Anesthesia With Noninvasive Ventilation for Shoulder Surgery in a Patient With Severe Chronic Obstructive Pulmonary Disease: A Case Report

Interscalene block (ISB) impairs ipsilateral lung function and generally is not used for patients with respiratory insufficiency. We present a 49-year-old man with chronic obstructive pulmonary disease scheduled for shoulder surgery. He was given a regional technique with an ISB (short-acting local anesthetic to minimize duration of diaphragmatic dysfunction) and suprascapular and axillary nerves blocks (long-acting local anesthetic). He was supported with noninvasive ventilation during the time of hemidiaphragmatic paralysis as documented by serial ultrasound examination. A discussion about ISB and its alternatives (general anesthesia versus brachial plexus block versus selective peripheral nerve blocks) always should occur for patients at risk for pulmonary complications.

Management of Hand and Finger Injuries

The role of hand therapists in treating sports-related injuries of the upper limb has evolved over the past century. Effective treatment and application of physical modalities depend on accurate diagnosis and appreciation of the cause of injury. Rehabilitation protocols and progression must be based primarily on the physiologic responses of tissue to injury and on an understanding of the wound healing processes of various tissues. Thus, in acute injuries clinical evaluation should focus on the effect of the injury since the degree and nature of tissue disruption have more impact on therapy than the cause of the injury. Conversely, in overuse injuries the intrinsic and extrinsic causes should be considered to eventually achieve effective treatment.