Valéry Blasco

Oxygen tissue saturation is lower in nonsurvivors than in survivors after early resuscitation of septic shock.

Background:Growing evidence suggests that the microvascular dysfunction is the key element of the pathogenesis of septic shock. This studys purpose was to explore whether the outcome of septic shock patients after early resuscitation using early goal-directed therapy is related to their muscle tissue oxygenation. Methods:Tissue oxygen saturation (Sto2) was monitored in septic shock patients using a tissue spectrometer (InSpectra Model 325; Hutchinson Technology, Hutchinson, MN). For the purpose of this retrospective study, the Sto2 values were collected at the first measurement done after the macrohemodynamic variables (mean arterial pressure, urine output, central venous saturation in oxygen) were optimized. Results:After the hemodynamic variables were corrected, no difference was observed between the nonsurvivors and survivors, with the exception of pulse oximetry saturation (94% [92–97%] vs. 97% [94–99%], P = 0.04). The Sto2 values were significantly lower in the nonsurvivors than in the survivors (73% [68–82%] vs. 84% [81–90%], P = 0.02). No correlations were found between the Sto2 and Spo2 (P = 0.7). Conclusions:In septic shock patients, tissue oxygen saturation below 78% is associated with increased mortality at day 28. Further investigations are required to determine whether the correction of an impaired level of tissue oxygen saturation may improve the outcome of these patients.

Impact of intensive care on renal function before graft harvest: results of a monocentric study

BackgroundThe aim of life-support measures in brain-dead donors is to preserve the functional value of their organs. In renal transplantation, serum creatinine level is one of the criteria for graft harvest. The aim of this study was to assess the impact of intensive care on donor renal function through two criteria: preharvesting serum creatinine level above 120 μmol/L and the elevation of serum creatinine level above 20% between intensive care unit (ICU) admission and graft harvest.MethodsBetween 1 January 1999 and 31 December 2005, we performed an observational study on 143 brain-dead donors. ICU chronology, hemodynamic, hematosis, and treatment data were collected for each patient from ICU admission to kidney removal.ResultsTwenty-two percent of the 143 patients had a serum creatinine level above 120 μmol/L before graft harvest. The independent factors revealed by multivariate analysis were the administration of epinephrine (odds ratio [OR]: 4.36, 95% confidence interval [CI]: 1.33 to 14.32; p = 0.015), oliguria (OR: 3.73, 95% CI: 1.22 to 11.36; p = 0.021), acidosis (OR: 3.26, 95% CI: 1.07 to 9.95; p = 0.038), the occurrence of disseminated intravascular coagulation (OR: 3.97, 95% CI: 1.05 to 15.02; p = 0.042), female gender (OR: 0.13, 95% CI: 0.03 to 0.50; p = 0.003), and the administration of desmopressin (OR: 0.12, 95% CI: 0.03 to 0.44; p = 0.002). The incidence of elevated serum creatinine level above 20% between admission and graft harvest was 41%. The independent risk factors were the duration of brain death greater than 24 hours (OR: 2.64, 95% CI: 1.25 to 5.59; p = 0.011) and the volume of mannitol (OR: 2.08, 95% CI: 1.03 to 4.21; p = 0.041).ConclusionThis study shows that the resuscitation of brain-dead donors impacts on their renal function. The uses of epinephrine and mannitol are associated with impairment of kidney function. It seems that graft harvest should be performed less than 24 hours after brain death diagnosis.

Impact of a goal-directed therapy protocol on postoperative fluid balance in patients undergoing liver transplantation: a retrospective study.

OBJECTIVE Liver transplantation carries major risks during the perioperative period. Few studies focused on the hemodynamics of patients undergoing liver transplantation. The present study was aimed to evaluate the impact of the implementation of a protocol including goal-directed therapy in patients undergoing liver transplantation. Our first goal was to determine its impact on the fluid balance. Secondarily, we evaluated possible improvements in the patient outcomes. STUDY DESIGN A before and after study. PATIENTS AND METHODS Fifty patients undergoing liver transplantation were included during two successive six-month periods. During the first period, the management of the patients was left at the discretion of the senior physicians (control group, n=25). During the second period, the patients were treated according to a predetermined protocol including a specific hemodynamic monitoring (protocol group, n=25). RESULTS The fluid balance was negative in the protocol group and positive in the control group at 24h (-606mL vs. +3445mL, P<0.01) and 48h (-2315mL vs. +1170mL, P<0.01) after liver transplantation. The volume of the crystalloid administration was lower in the protocol group than in the control group (5000mL vs. 8000mL, P<0.01, and 1500mL vs. 6000mL, P<0.01, during surgery and 48h after liver transplantation, respectively). The duration of mechanical ventilation and postoperative ileus were significantly reduced in the protocol group, as compared with the control group, 20h vs. 94h (P<0.01) and 4days vs. 6days (P<0.01), respectively. CONCLUSION For patients undergoing liver transplantation, the implementation of a protocol aiming to optimize hemodynamics was associated with reduced fluid balance and decreased requirement for mechanical ventilation and postoperative ileus duration.

Craniocerebral penetrating injury caused by a spear gun through the mouth: case report.

The authors report a case of a craniocerebral penetrating injury caused by the shaft of a spear gun. The entry point of the spear was located in the mouth without an obvious exit point. The authors first note the presentation of the patient, whose airway was obstructed by the shaft, and then discuss the surgical procedure, which was focused on removing the shaft in an anterograde direction because of an articulated wishbone located at the tip of the shaft.

Hypoxia-inducible factor (HIF1α) gene expression in human shock states

IntroductionHypoxia-inducible factor-1 (HIF1) controls the expression of genes involved in the cellular response to hypoxia. No information is available on its expression in critically ill patients. Thus, we designed the first clinical study in order to evaluate the role of HIF1α as a prognosis marker in patients suffering from shock.MethodsFifty consecutive adult patients with shock and 11 healthy volunteers were prospectively enrolled in the study. RNA was extracted from whole blood samples and expression of HIF1α was assessed over the first four hours of shock. The primary objective was to assess HIF1α as a prognostic marker in shock. Secondary objectives were to evaluate the role of HIF1α as a diagnostic and follow-up marker. Patient survival was evaluated at day 28.ResultsThe causes of shock were sepsis (78%), hemorrhage (18%), and cardiac dysfunction (4%). HIF1α expression was significantly higher in the shock patients than in the healthy volunteers (121 (range: 72-168) versus 48 (range: 38-54) normalized copies, P <0.01), whatever the measured isoforms. It was similar in non-survivors and survivors (108 (range 84-183) versus 121(range 72-185) normalized copies, P = 0.92), and did not significantly change within the study period.ConclusionsThe present study is the first to demonstrate an increased expression of HIF1α in patients with shock. Further studies are needed to clarify the potential association with outcome. Our findings reinforce the value of monitoring plasma lactate levels to guide the treatment of shock.

Monitoring of plasma creatinine and urinary γ-glutamyl transpeptidase improves detection of acute kidney injury by more than 20%*

Objectives:We sought to determine how early we can detect acute kidney injury inpatients at intensive care unit admission by combining the use of plasma creatinine and urinary &ggr;-glutamyl transpeptidase. Design:Prospective study including development (n = 100) and validation (n = 56) cohorts. Settings:Intensive care unit of a university hospital. Interventions:None. Measurements and Main Results:To determine acute kidney injury, we subtracted measured creatinine clearance from theoretical creatinine clearance with a 25% reduction signifying acute kidney injury. Its incidence in 100 consecutive patients was 36%. An indexed urinary &ggr;-glutamyl transpeptidase–to–urinary creatinine ratio was significantly increased in the patients with acute kidney injury and did not correlate with plasma creatinine (p = .3). Using a predefined threshold of indexed urinary &ggr;-glutamyl transpeptidase–to–urinary creatinine ratio (>12.4 units/mmol) and plasma creatinine (>89 &mgr;mol/L), acute kidney injury detection was significantly improved, making it possible to detect 22 (22%) additional patients with acute kidney injury. This finding was confirmed in the validation group. The rates of false-positive results were 30% and 19% in the data development and internal validation cohorts, respectively. Conclusions:The use of low-cost, widely available markers (creatinine and urinary &ggr;-glutamyl transpeptidase) increases the detection of acute kidney injury. Further studies are needed to determine the impact on outcome with the use of these biomarkers.

A novel intravascular rewarming method to treat severe hypothermia.

We report here a patient with severe hypothermia (27 degrees C), who was successfully rewarmed by using a novel intravascular rewarming method (in combination with an airways rewarming method) through endotracheal tube.

About baclofen withdrawal syndrome

La Presse Medicale - In Press.Proof corrected by the author Available online since jeudi 24 mars 2016

Coma éthylique secondaire à une sclérothérapie alcoolique

INTRODUCTION Simple serous renal cysts are an often asymptomatic benign disease, sometimes treated with ethanol sclerotherapy. We report a case of iatrogenic acute alcohol intoxication following percutaneous injection of alcohol into a renal cyst under local anesthesia. CASE The percutaneous injection was guided by computed tomography. At the end of the procedure, the patient went into a coma due to alcohol intoxication: the cyst ruptured and ethanol was resorbed into the systemic circulation. DISCUSSION Alcohol injection for sclerotherapy is used for several indications. This rare event has not previous been described, but should be known so that physicians can be prepared to manage it correctly.

Two-dimensional-strain echocardiography in intensive care unit patients: A prospective, observational study

Two‐dimensional‐strain echocardiography (2D‐strain) is a promising technique for the early detection of myocardial dysfunction. Our study was aimed to assess its feasibility in the intensive care unit (ICU). Our secondary goal was to determine if 2D‐strain could predict the patients outcome.