Pierre-Géraud Claret

Predicting peripheral venous access difficulty in the emergency department using body mass index and a clinical evaluation of venous accessibility.

BACKGROUND Peripheral venous (PV) cannulation, one of the most common technical procedures in Emergency Medicine, may prove challenging, even to experienced Emergency Department (ED) staff. Morbid obesity (body mass index [BMI] ≥ 40) has been reported as a risk factor for PV access failure in the operating room. OBJECTIVES We investigated PV access difficulty in the ED, across BMI categories, focusing on patient-related predicting factors. METHODS Prospective, observational study including adult patients requiring PV lines. Operators were skilled nurses and physicians. PV accessibility was clinically evaluated before all cannulation attempts, using vein visibility and palpability. Patient and PV placement characteristics were recorded. Primary outcome was failure at first attempt. Outcome frequency and comparisons between groups were examined. Predictors of difficult cannulation were explored using logistic regression. A p-value <0.05 was considered significant. RESULTS PV lines were placed in 563 consecutive patients (53 ± 23 years, BMI: 26 ± 7 kg/m(2)), with a success rate of 98.6%, and a mean attempt of 1.3 ± 0.7 (range 1-7). Failure at the first attempt was recorded in 21% of patients (95% confidence interval [CI] 17.6-24.4). Independent risk factors were: a BMI ≥ 30 (odds ratio [OR] 1.98, 95% CI 1.09-3.60), a BMI < 18.5 (OR 2.24; 95% CI 1.07-4.66), an unfavorable (OR 1.66, 95% CI 1.02-2.69), and very unfavorable clinical assessment of PV accessibility (OR 2.38, 95% CI 1.15-4.93). CONCLUSION Obesity, underweight, an unfavorable, and a very unfavorable clinical evaluation of PV accessibility are independent risk factors for difficult PV access. Early recognition of patients at risk could help in planning alternative approaches for achieving rapid PV access.

Ultrasound guidance for radial arterial puncture: a randomized controlled trial

UNLABELLED STUDY OBJECTIVE AND BACKGROUND: Arterial puncture for blood gas analysis is a frequent procedure and could be difficult in the emergency setting. The aim of the study was to compare ultrasonographically guided arterial radial puncture vs conventional sampling. MATERIALS AND METHODS This is a prospective, randomized study. The inclusion criteria are all patients needing arterial blood gas at admission in the emergency unit. The exclusion criteria are the following: Hallen test positive, local sepsis, local trauma, known sever local arteriopathy, refusal of consent by the patient, participation in another study, and cardiac arrest. Patients were randomized into 2 groups: radial arterial puncture obtained through an ultrasonographically guided technique (group 1) or radial arterial puncture by conventional method (group 2). The main objective is the number of attempts after enrollment. The secondary objectives are time to success, patient satisfaction and pain, and physician satisfaction. Immediate complications were collected. Groups were compared with nonparametric analysis. RESULTS The data were usable for 72 of 74 patients included. Lung disease (acute exacerbation of chronic obstructive pulmonary disease and pneumonia) at 45% (n = 32) and suspicion of pulmonary embolism in 31% (n = 22) were the most common reasons. Demographics data were comparable in the 2 groups. In group 1, the number of attempts significantly increased (2.35 [1-3] vs 1.66 [1-2] [P = .017]), and the sample was 2.4 times longer (132 seconds [50-200] vs 55 [20-65] [P < .01] by standard method). There was no significant difference in terms of pain (visual analog scale [VAS], 3.6 [2-5] for both groups [P = .743]), patient satisfaction (VAS, 7.2 [5-9] vs 6.8 [5-9] [P = .494]), and physician satisfaction (VAS, 6.0 [3.5-8] vs 6.9 [5-9] [P = .233]). No immediate complications were found in the 2 groups. CONCLUSION Ultrasonographically guided arterial puncture increases the number and duration of implementations. This technique, however, does not alter the patients pain, the number of immediate complications, or patient and physician satisfaction.

Availability and practice of bedside ultrasonography in emergency rooms and prehospital setting: A French survey

INTRODUCTION The utility of bedside ultrasound (US) performed by emergency physicians has been proven for multiple purposes. There are no data about this technique in emergency departments (ED) in France. The primary objective is to determine the availability of ultrasound device (UD) in EDs and in prehospital settings in France. Minor objectives are to determine the number and type of UD, the most current applications of US and the factors correlated with availability of UDs in the setting of emergency medicine. METHODS This is a cross-sectional, descriptive, multicenter survey from December 2010 to June 2011, including all EDs and prehospital units in France. A questionnaire was sent by e-mail. Non-responders were contacted by telephone with one recall. RESULTS The response rate was 74% (327/440) for EDs and 73% (278/379) for prehospital units. A UD is available in 52% (171/327) (CI 95% [46; 58]) of EDs and in 9% (25/278) (CI 95% [5; 13]) of prehospital units. Among departments having no access to UDs, 29% of EDs and 12% of prehospital units have plans to implement emergency physician-performed US. The most common US applications are focused assessment with sonography for trauma and pleural exams. CONCLUSION Availability of UDs in French public hospital EDs is 52% and 9% in prehospital units. Despite the progressive expansion of the technique over the last years, bedside ultrasonography is not yet completely integrated in the physical examination of the patient in an emergency situation in France. A reassessment will be required to confirm the current trend of expansion.

Emergency Department Management of Suspected Carbon Monoxide Poisoning: Role of Pulse CO-Oximetry

BACKGROUND: The RAD-57 pulse CO-oximeter is a lightweight device allowing noninvasive measurement of blood carboxyhemoglobin (SpCO). We assessed the diagnostic value of pulse CO-oximetry, comparing SpCO values from the RAD-57 to standard laboratory blood carboxyhemoglobin (COHb) measurement in emergency department patients with suspected carbon monoxide (CO) poisoning. METHODS: This was a prospective, diagnostic accuracy study according to the Standards for the Reporting of Diagnostic Accuracy Studies criteria in consecutive adult emergency department patients with suspected CO poisoning. SpCO was measured with the RAD-57 simultaneously with blood sampling for laboratory blood gas analysis. We made no changes to our standard management of CO poisoning. Blood COHb > 5% for non-smokers, and > 10% for smokers were applied as the reference standard. RESULTS: We included 93 subjects: 37 smokers and 56 non-smokers. CO poisoning was diagnosed in 26 subjects (28%). The SpCO values ranged from 1% to 30%, with a median of 4% (IQR 2.7–7.3%). The COHb values ranged from 0% to 34%, with a median of 5% (IQR 2–9%). The mean differences between the COHb and SpCO values were −0.2% ± 3.3% (95% limits of agreement of −6.7% and 6.3%) for the whole cohort, −0.7% (limits of agreement −7.7% and 6.2%) for the non-smokers, and 0.6% (limits of agreement −5.0% and 6.2%) for the smokers. The optimal thresholds for detecting CO poisoning were SpCO of 9% and 6% for smokers and non-smokers, respectively. CONCLUSIONS: SpCO measured with the RAD-57 was not a substitute for standard blood COHb measurement. However, noninvasive pulse CO-oximetry could be useful as a first-line screening test, enabling rapid detection and management of CO-poisoned patients in the emergency department.

Breath analyzer screening of emergency department patients suspected of alcohol intoxication.

BACKGROUND Acute alcohol intoxication is a frequent cause of emergency department (ED) visits. Evaluating a patients alcohol intoxication is commonly based on both a physical examination and determination of blood alcohol concentration (BAC). OBJECTIVE To demonstrate the feasibility and usefulness of using a last-generation infrared breath analyzer as a non-invasive and rapid screening tool for alcohol intoxication in the ED. METHODS Adult patients suspected of acute alcohol intoxication were prospectively enrolled over 10 days. Breath alcohol concentrations (BrAC) were measured using a handheld infrared breath analyzer. BAC was determined simultaneously by automated enzymatic analysis of a venous blood sample. The relationship between BAC and BrAC values was examined by both linear regression and Bland-Altman analysis. RESULTS The study included 54 patients (mean age 40±14 years, sex ratio M/F of 3/1). Breath and blood alcohol concentrations ranged from 0 to 1.44 mg/L and from 0 to 4.40 g/L (0-440 mg/dL), respectively. The mean individual BAC/BrAC ratio was 2615±387, 95% confidence interval 2509-2714, which is 30% higher than the legal ratio in France (2000). The correlation between both measurements was excellent: r=0.95 (0.92-0.97). Linear regression revealed BAC=0.026+1.29 (BrAC×2000) and BAC=0.026+0.99 (BrAC×2615). Mean BAC-BrAC differences and limits of agreement were 0.49 g/L [-0.35, 1.34] (or 49 mg/dL [-35, 134] and 0.01 g/L [-0.68, 0.71] (or 1 mg/dL [-68, 71]), for the 2000 and 2615 ratios, respectively. CONCLUSION The calculated conversion coefficient provided a satisfactory determination of blood alcohol concentration. Breath alcohol testing, using appropriate BAC/BrAC conversion, different from the legal BAC/BrAC, could be a reliable alternative for routine screening and management of alcohol intoxication in the ED.

Lactic acidosis as a complication of β-adrenergic aerosols

Lactic acidosis is a marker of tissue hypoperfusion and impairs oxygen delivery. High lactate levels are associated with altered systemic hemodynamics, tissue hypoperfusion, and altered cellular metabolism. Increased lactate levels have also been reported as a complication of β-adrenergic agents administered during asthma therapy. A 49-year-old woman with a prior diagnosis of asthma presented to the emergency department in respiratory distress. She immediately received, in 2 hours, 4 bronchodilator aerosols (ipratropium bromide 0.5 mg/2 mL and terbutaline 5 mg/2 mL) and methylprednisolone intravenous (120 mg). After these 4 aerosols, she was still dyspneic. First, arterial blood gases (pH 7.38; PCO2, 3.92 kPa; HCO3, 19.2 mmol/L) and arterial lactate (lactate, 7.96 mmol/L) were performed with a second series of 4 aerosols. Second, arterial blood gases (pH 7.29; PCO2, 4.01 kPa; HCO3, 15.4 mmol/L) and arterial lactate (lactate, 10.47 mmol/L) were performed at the end of the second series of aerosols. There was no hypoxemia, no inadequate cardiac output state, no anemia, no sepsis, and no use of biguanides. Previous studies have suggested that administration of β agonists can lead to lactic acidemia in the absence of hypoxia or shock, but it is the highest level of lactate that we found in the literature. In sepsis and shock, lactic acidosis is used as a marker of disease severity. In this case, it is not necessarily the sign of an immediate gravity.

Indices de réponse au remplissage vasculaire lors de la prise en charge d’un choc septique : utilisation par les médecins urgentistes

INTRODUCTION Fluid therapy is one of the major elements of severe sepsis and septic shock management. A systematic initial fluid bolus is recommended before evaluation of left ventricular filling pressure by the use of indicators of fluid responsiveness, preferentially dynamic ones. A massive fluid therapy could be damaging for the patient. Dynamic indicators of fluid responsiveness are not often relevant in the emergency department. This study was aimed to evaluate the use of indicators of fluid responsiveness by emergency practitioners during septic shock management. STUDY DESIGN Cross sectional survey using anonymous self-questionnaire. METHODS We included all practitioners working in public emergency department of Languedoc-Roussillon (France). Primary-end point was the use of one indicator of fluid responsiveness at least. Uni- and multivariate analysis was conducted to find associated factors. RESULTS Of 232 practitioners included, we collected 149 questionnaires (response rate=64%). Hundred and eight practitioners (72% [64-79%]) used at least one indicator of fluid responsiveness. Fifty-six practitioners (38% [30-46%]) used echocardiography, 54 practitioners (36% [29-44%]) used blood lactate concentration, 45 practitioners (30% [23-38%]) used passive leg raising. The use of indicators of fluid responsiveness is associated with easy access to echography device (odd ratio=2.94 [1.16-7.62], P=0.03). CONCLUSION Emergency practitioners use preferentially less invasive and less time-consuming indicators of fluid responsiveness.

Comparison of Miller and Airtraq laryngoscopes for orotracheal intubation by physicians wearing CBRN protective equipment during infant resuscitation: a randomized crossover simulation study

BackgroundThe purpose of this study was to evaluate the performance of orotracheal intubation with the Miller laryngoscope compared with the Airtraq laryngoscope by emergency and pediatric physicians wearing CBRN-PPE type III on infant manikins with conventional airway. We hypothesized that in this situation, the orotracheal intubation with the Airtraq laryngoscope would be faster and more effective than with the Miller laryngoscope.MethodsThis was a prospective, randomized, crossover, single-center study who recruited emergency department physicians on a voluntary basis. Each physician performed a total of 20 intubation trials while in CBRN-PPE with the two intubation techniques, Miller and Airtraq. Intubations by each airway device were tested over ten consecutive runs. The order of use of one or the other devices was randomized with a ratio of 1:1. The primary endpoint was overall orotracheal intubation success.ResultsFifty-five emergency and pediatric physicians were assessed for eligibility. Forty-one physicians were included in this study and 820 orotracheal intubation attempts were performed. The orotracheal intubation success rate with the Airtraq laryngoscope was higher than with the Miller (99 % vs. 92 %; p-adjusted <.001). The orotracheal intubation and glottis visualization times decreased with the number of attempts (p <.001). The median orotracheal intubation time with the Airtraq laryngoscope was lower than with the Miller laryngoscope (15 s vs. 20 s; p-adjusted <.001). The median glottis visualization time with the Airtraq laryngoscope and with the Miller laryngoscope were not different (6.0 s vs. 7.5 s; p-adjusted =.237). Thirty-four (83 %) physicians preferred the Airtraq laryngoscope versus 6 (15 %) for the Miller (p-adjusted <.001).DiscussionFor tracheal intubation by physicians wearing CBRN-PPE during infant resuscitation simulation, we showed that the orotracheal intubation success rate with the Airtraq laryngoscope was higher than with the Miller laryngoscope and that orotracheal intubation time with the Airtraq laryngoscope was lower than with the Miller laryngoscope.ConclusionsIt seems useful to train the physicians in emergency departments in the use of pediatric Airtraq and for the management of CBRN risks.

Collinearity and multivariable analysis

We read with interest the article by Martin‐Loeches et al. entitled “Determinants of time to death in hospital in critically ill patients around the world” [1]. In this article, the authors aimed to investigate which factors influence time to death in hospital in critically ill patients worldwide. They found that time to death in hospital is longer in older patients, surgical patients, and patients with infection. We congratulate the authors for this valuable study. To obtain these results, the authors performed a multivariable analysis using a multilevel multinomial logistic model. Among the explanatory variables considered in the model, we found SAPS II and age. However, SAPS II uses a point score based upon initial values of 17 variables included age or type of admission [2]. Unfortunately, collinearity occurs when there are high correlations among variables. In this situation, the coefficient estimates of the regression can change capriciously in response to small changes in the model or the data. Thus, the coefficient estimates are unstable and very difficult to interpret. I wonder if the authors can reassure us concerning a possible collinearity bias between SAPS II and age, type of admission, or the other explanatory variables used in the model?

Integrated chronic disease management to avoid emergency departments: the MACVIA-LR® approach

Chronic diseases are diseases of long duration and generally slow progression. They include the four major NonCommunicable Diseases (NCDs) listed by WHO [1]: cardiovascular disease, cancer, chronic respiratory diseases and diabetes, and other NCDs such as mental disorders and skeletomuscular diseases [2]. As survival rates and duration of life have improved, chronic diseases also include communicable diseases (HIV/AIDS) and genetic disorders (cystic fibrosis). Aging increases the likelihood of NCDs and comorbidities, thereby confounding their effects on health and well-being [3]. The novel trend for NCDs management evolves toward integrative approaches in which emergency medicine should be considered as an integral part of the disease management. European innovation partnerships (EIP) attempt to enhance EU competitiveness, and tackle societal challenges by fostering innovation. Active and healthy aging (AHA) is a major societal challenge common to all countries and to all populations [4]. The EIP on AHA is deployed in three areas and six action plans including scaling up and replication of successful innovative integrated care models for chronic diseases amongst older patients [5]. The Région Languedoc-Roussillon is the umbrella organization for an interconnected and integrated project on AHA covering the three pillars of the EIP on AHA [6]. All sub-activities (A1: electronic pharmaceutical file, A2: falls prevention initiative, A3: frailty, B3: chronic respiratory diseases, chronic diseases with comorbidities, oral health and hepatitis virus C chronic infection, C2 and D4 active and independent living and handicap) are included in MACVIA-LR (MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon) that has a strong political commitment and includes all stakeholders (public, private, patients, policy makers). It is a Reference Site of the EIP on AHA built around chronic diseases, aging and handicap. MACVIA-LR framework has the vision that NCDs prevention and management is essential for AHA promotion and reduction of handicap. MACVIA-LR main objective is to develop innovative solutions to improve the care of patients affected by NCDs, reduce avoidable hospitalization, and scale up the innovation to regions of Europe. The MACVIA-LR project also aims to reduce the overuse of emergency department (ED) by NCDs patients. P.-G. Claret (&) X. Bobbia J.-E. de La Coussaye Pôle Anesthésie Réanimation Douleur Urgences, University Hospital Nı̂mes, CHU de Nı̂mes, Avenue du Professeur Debré, 30000 Nimes, France e-mail: pierre.geraud.claret@gmail.com