Romain Jouffroy

Antimony to Cure Visceral Leishmaniasis Unresponsive to Liposomal Amphotericin B

We report on 4 patients (1 immunocompetent, 3 immunosuppressed) in whom visceral leishmaniasis had become unresponsive to (or had relapsed after) treatment with appropriate doses of liposomal amphotericin B. Under close follow-up, full courses of pentavalent antimony were administered without life-threatening adverse events and resulted in rapid and sustained clinical and parasitological cure.

Extracorporeal Cardiopulmonary Resuscitation (ECPR) in the Prehospital Setting: An Illustrative Case of ECPR Performed in the Louvre Museum

Abstract Introduction: Extracorporeal Cardiopulmonary Resuscitation (ECPR) is now considered for the treatment of refractory cardiac arrest. Case report: In an urban city like Paris, extraction times of in-hospital ECPR can be long for patients presenting with refractory cardiac arrest. Using the medicalized prehospital system, we developed a possible early prehospital ECPR implementation. This case report is an example of ECPR prehospital implementation in the Louvre Museum. Conclusion: Patients eligible for ECPR must be selected according to strict criteria. Further research is necessary to compare prehospital and in-hospital implementation.

A new approach for early onset cardiogenic shock in acute colchicine overdose: place of early extracorporeal life support (ECLS)?

Dear Editor, Colchicine belongs to the family of spindle poisons, which are mainly used to treat and prevent forms of microcrystalline arthritis, such as gout. It has a narrow therapeutic index. Colchicine overdose is associated with a high mortality rate [1]. Early symptoms usually include gastrointestinal pain; multiorgan failure typically occurs next, alongside metabolic derangements and bone marrow suppression. Prognostic factors include a supposed ingested dose of [0.8 mg/kg, cardiogenic shock, and ARDS [1]. Death from acute colchicine poisoning is usually due to hemodynamic collapse and cardiac arrhythmias. A 51-year-old male pharmacist (medical history of depression, high blood pressure, and gout treated with colchicine) was admitted to the ICU for an acute and unexplained circulatory shock. Over the course of his admission he continued to deteriorate and required high doses of norepinephrine (4.2 lg/kg/min), epinephrine (0.4 lg/kg/min), and dobutamine (10 lg/kg/min). After the first 24 h, his wife found a bottle of 1 mg Colchimax (17 tablets missing). The patient then admitted to ingesting those tablets, which was later confirmed by laboratory investigations: 9.7 nmol/L at day 1; 9.25 nmol/L at day 3; 5.75 nmol/L at day 6; and less than 1.25 nmol/L at day 16. Following the confirmation of a colchicine overdose, the patient’s clinical condition worsened. He quickly developed multiorgan failure and was hemodynamically unstable. In the ICU, it was decided to resort to a bedside-to-bench process. For the following 10 days he received extracorporeal life support (ECLS) (CARDIOHELP, Maquet, Rastatt, Germany), which was achieved through femoral venous arterial cannulation surgery with an initial rate of 3 L/min, 3,700 rev/min. He made a good recovery and showed normal organ function by day 6. The ECLS was removed on day 10 and the mechanical ventilator on day 20. He did not present any hematological failure. He suffered from an acute renal failure due to tubular necrosis that required dialysis for 36 days. The patient was discharged on day 52 with a CPC score of 1. Recent studies have proved that human [1] and animal [2] immunotherapy antibodies can be successfully used to treat colchicine overdose. However, there are a few limitations on the use of immunotherapy antibodies:

Early detection of brain death using the Bispectral Index (BIS) in patients treated by extracorporeal cardiopulmonary resuscitation (E-CPR) for refractory cardiac arrest☆

BACKGROUND Despite increasing use of extracorporeal cardiopulmonary resuscitation (E-CPR) for treatment of refractory cardiac arrest patients, prognosis remains dismal, often resulting in brain-death. However, clinical assessment of brain-death occurence is difficult in post-cardiac arrest patients, sedated, paralyzed, under mild therapeutic hypothermia (MTH). Our objective was to assess the usefulness of Bispectral-Index (BIS) monitoring at bedside for an early detection of brain-death occurrence in refractory cardiac arrest patients treated by E-CPR. METHODS This prospective study was performed in an intensive care unit of an university hospital. Forty-six patients suffering from refractory cardiac arrest treated by E-CPR were included. BIS was continuously recorded during ICU hospitalization. Clinical brain-death was confirmed when appropriate by EEG and/or cerebral CT angiography. RESULTS Twenty-nine patients evolved into brain-death and had average BIS values under MTH and after rewarming (temperature ≥35°C) of 4 (0-47) and 0 (0-82), respectively. Among these, 11 (38%) entered into a procedure of organs donation. Among the 17 non-brain-dead patients, the average BIS values at admission and after rewarming were 39 (0-65) and 59 (22-82), respectively. Two patients had on admission a BIS value equal to zero and evolved to a poor prognostic (CPC 4) and died after care limitations. BIS values were significantly different between patients who developed brain death and those who did not. In both groups, no differences were observed between the AUCs of ROC curves for BIS values under MTH and after rewarming (respectively 0.86 vs 0.83, NS). CONCLUSIONS Initial values of BIS could be used as an assessment tool for early detection of brain-death in refractory cardiac arrest patients treated by mild therapeutic hypothermia and E-CPR.

A survey of blood transfusion practice in French-speaking pediatric anesthesiologists.

Background:  There are so far no existing consensus guidelines regarding red blood cell transfusion during pediatric surgery, and there is a little information regarding red blood cell transfusion policy among pediatric anesthesiologists.

Coronary lesions in refractory out of hospital cardiac arrest (OHCA) treated by extra corporeal pulmonary resuscitation (ECPR)

PURPOSE Extracorporeal cardiopulmonary resuscitation (ECPR) is a second line treatment for refractory cardiac arrest (R-OHCA). Timing of ECPR before performing coronary angiography (CAG) is still debated. The aim of the study was to describe the clinical and angiographic characteristics of the largest cohort of out-of-hospital cardiac arrest (OHCA) patients undergoing ECPR. METHODS All refractory OHCA patients with ECPR managed by the prehospital mobile intensive care unit (MoICU of the SAMU) in Paris (France) were prospectively included from October 2014 to December 2016. RESULTS Among 74 patients included over the period, 54 patients had coronary artery disease (CAD). There is a trend toward the CAD patients being older but it did not meet statistical significance (55.3 ± 11.8 vs. 50.6 ± 12.8, p = 0,14). Patients were more frequently men and smokers (p = 0.03 for both). The proportion of initial shockable rhythm tended to be higher in patients with CAD (71% vs. 55%). The rate of 1-, 2-, and 3-vessel disease were 43%, 35% and 22% respectively. The Syntax Score was 18 ± 9 and the lesions in each epicardial vessel were mainly proximal. Percutaneous coronary intervention was performed ad hoc in 49 patients (91%). Complete revascularization was performed in 64%. Inhospital death was numerically lower (65% vs. 75%) in patients with CAD, especially in patients with initial shockable rhythm. CONCLUSION In 74 refractory OHCA patients treated with ECPR implanted by a prehospital mobile intensive care unit, the rate of CAD was high (54/74) especially in patients with shockable rhythm. The majority of patients presented with double or triple vessel disease and proximal lesions. The severity and extension of CAD may explain the refractory nature of the cardiac arrest.

Number of Prehospital Defibrillation Shocks and the Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest

Objective It has not been determined yet whether the number of defibrillation shocks delivered over the first 30 min of cardiopulmonary resuscitation (CPR) impacts the rate of successful return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA). Methods We conducted a retrospective observational study in non-traumatic OHCA. Patients who were administered defibrillation shocks using a public automated external defibrillator (AED) were consecutively enrolled in the study. We assessed the relationship between ROSC and the number of prehospital defibrillation shocks and constructed an receiver operating characteristic (ROC) curve to illustrate the ability of repeated defibrillation shocks to predict ROSC over the first 30 min of CPR. Results Increasing the number of defibrillation shocks progressively decreased the probability to achieve ROSC. The highest rate of ROSC (33%) was observed when four shocks were delivered. The ROC curve illustrated that the fourth shock maximised sensitivity and specificity (area under the curve [AUC]=0.72). The positive and negative predictive values for ROSC reached 82% and 48%, respectively, when <4 shocks were delivered. Conclusion The delivery of four defibrillation shocks in OHCA most related to ROSC. The evaluation of the number of delivered shock during the first 30 min of CPR is a simple tool that can be used for an early decision in OHCA patient.

Impact of Prehospital Mobile Intensive Care Unit Intervention on Mortality of Septic Patients

Background: The outcome of sepsis relies on the early diagnosis and implementation of appropriate treatments. For the management of out-of-hospital sepsis patients, prehospital emergency services, named SAMU in France dispatch to the scene an emergency mobile team (EMT) or a prehospital mobile intensive care unit (MICU) based on the patient’s severity. Patients are therefore admitted to the emergency department (ED) or to the intensive care unit (ICU). The impact of prehospital MICU intervention on patient’s prognosis remains unclear. The aim of this study was to describe the impact of prehospital MICU intervention on mortality at day 28 (D28) of sepsis patients. Methods: We performed a retrospective study on sepsis patients managed by prehospital teams, MICU or EMT, before admission to the ED or ICU. The primary outcome was mortality at D28. Results: During the study period, 30,642 calls were received by the SAMU, 140 concerned patients with suspected sepsis. The suspected origin of sepsis was mainly pulmonary for 78 (55%) patients. Forty-five (32%) patients had a qSOFA ≥ 2. Thirteen (9%) patients deceased at D28, 12 in ED and 1 in the ICU. Of these, 2 patients were admitted to the hospital by a MICU. After adjusting for confounding factors, the relative risk of mortality at D28 for sepsis patients admitted to the hospital by a MICU was 0.40. Conclusion: We describe an association between prehospital MICU intervention and mortality at D28 of patients with sepsis. Prehospital MICU intervention for out-of-hospital sepsis patients is associated with 60% reduced mortality at D28. Larger studies are needed to confirm the impact of the intervention of prehospital MICU on mortality of septic patients. *Correspondence to: Romain Jouffroy, Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades 149 rue de Sèvres 75015 Paris, University Paris Descartes, France, E-mail: romain.jouffroy@gmail.com

Lactate POCT in mobile intensive care units for septic patients? A comparison of capillary blood method versus venous blood and plasma-based reference methods

AIM OF THE STUDY We evaluated if the StatStrip Xpress Meter, a Lactate point of care testing (POCT) handled device, could be a valuable tool in the mobile intensive care units (MICU) to assess the severity of septic patients. METHODS We first investigated POCT analytical performance, then, using samples collected from 50 identified septic patients admitted to the intensive care unit (ICU), we compared lactate values obtained with the device to those obtained with four central laboratory analysers: one whole blood and three plasma-based methods. RESULTS Results were compared by least squares regression, Bland-Altman plot and by comparing concordance within clinically relevant lactate ranges. We observed a reliable analytical performance of the POCT (CVs < 3.8% for repeatability and <5.0% for reproducibility) an excellent correlation between POCT and central laboratory analysers (R2: 0.96-0.98, slopes:0.83-0.90, intercepts: 0.02-0.03) and an excellent concordance of the POCT results to the central laboratory analyser results (98-100%). CONCLUSION Whatever the methodology used, lactate values obtained are comparable and transferable between POCT and central laboratory analysers meaning that POCT could be a valuable tool in the MICU to evaluate the severity of septic patients and to better manage their hospital triage.

Prognosis value of partial arterial oxygen pressure in patients with septic shock subjected to pre-hospital invasive ventilation

Objective: Mechanical ventilation can help improve the prognosis of septic shock. While adequate delivery of oxygen to the tissue is crucial, hyperoxemia may be deleterious. Invasive out‐of‐hospital ventilation is often promptly performed in life‐threatening emergencies. We propose to determine whether the arterial oxygen pressure (PaO2) at the intensive care unit (ICU) admission is associated with mortality in patients with septic shock subjected to pre‐hospital mechanical ventilation. Methods: We performed a monocentric retrospective observational study on 77 patients. PaO2 was measured at ICU admission. The primary outcome was mortality at day 28 (D28). Results: Forty‐nine (64%) patients were included. The mean PaO2 at ICU admission was 153 ± 77 and 202 ± 82 mm Hg for alive and deceased patients respectively. Mortality concerned 18% of patients for PaO2 < 100, 25% for 100 < PaO2 < 150 and 57% for a PaO2 > 150 mm Hg. PaO2 was significantly associated with mortality at D28 (p = 0.04). Using propensity score analysis including SOFA score, pre‐hospital duration, lactate, and prehospital fluid volume expansion, association with mortality at D28 only remained for PaO2 > 150 mm Hg (p = 0.02, OR [CI95] = 1.59 [1.20–2.10]). Conclusions: In this study, we report a significant association between hyperoxemia at ICU admission and mortality in patients with septic shock subjected to pre‐hospital invasive mechanical ventilation. The early adjustment of the PaO2 should be considered for these patients to avoid the toxic effects of hyperoxemia. However, blood gas analysis is hard to get in a prehospital setting. Consequently, alternative and feasible measures are needed, such as pulse oximetry, to improve the management of pre‐hospital invasive ventilation.