Reactivation of Epstein-Barr virus among intensive care patients: a prospective observational study.

PURPOSE: Herpesvirus reactivation has been documented among patients in the intensive care unit (ICU) and is associated with increased morbidity and mortality, particularly for cytomegalovirus (CMV). Epstein-Barr virus (EBV) has been poorly studied despite >95% of the population being seropositive. Our preliminary study suggested an association between EBV reactivation and increased morbidity and mortality. This study aimed to investigate this association among patients admitted to the ICU. METHODS: In this multicenter prospective study, polymerase chain reaction was performed to quantify EBV in patients upon ICU admission and then twice a week during their stay. Follow-up was 90 days. RESULTS: The study included 129 patients; 70 (54.3%) had EBV reactivation. On day 90, there was no difference in mortality rates between patients with and without reactivation (25.7% vs 15.3%, p = 0.22). Patients with EBV reactivation at admission had increased mortality compared with those without reactivation and those with later reactivation. EBV reactivation was associated with increased morbidity. Patients with EBV reactivation had fewer ventilator-free days at day 28 than those without reactivation (18 [1-22] vs. 21 days [5-26], p = 0.037) and a higher incidence of acute respiratory distress syndrome (34.3% vs. 17%, p = 0.04), infections (92.9% vs. 78%, p = 0.03), and septic shock (58.6% vs. 32.2%, p = 0.004). More patients with EBV reactivation required renal replacement therapy (30% vs. 11.9%, p = 0.02). EBV reactivation was also associated with a more inflammatory immune profile. CONCLUSION: While EBV reactivation was not associated with increased 90-day mortality, it was associated with significantly increased morbidity.

Keep an Eye on the Intracranial Pressure, Thanks to the Optic Nerve Sheath Diameter.

Neurological examination on sedated patients is challenging and no gold standard monitoring is currently available. We report the case of a patient deeply sedated for the management of acute respiratory distress syndrome secondary to pneumonia. Delay in awakening led to cerebral exploration by transcranial Doppler (TCD) and measurement of optic nerve sheath diameter (ONSD). Abnormal values of ONSD prompted immediate brain computed tomography scan that confirmed high intracranial pressure (ICP) due to multiple deep parenchymal hematomas. Despite raised ICP, values obtained by TCD were normal, thanks to the persistence of cerebral autoregulation. This case highlights the interest of combining noninvasive techniques for neurological examination, especially for sedated patients.

Application of tourniquet in civilian trauma: Systematic review of the literature.

INTRODUCTION: The effectiveness of a tourniquet (TQ) in case of extremity haemorrhages is well recognised to prevent deaths on the battlefield. However, little is known about the usefulness of TQ in civilian trauma settings, including terrorist attack situations. The aim of this systematic review was to analyse the evidence-based medical literature in order to precise the use of TQ in the management of extremity haemorrhages in civilian setting. METHODS: Analysis of all studies published until 12/31/2016 on the Embase, Medline and Opengrey databases. To be included, studies had to contain descriptions, discussions or experiences of TQ application in civilian setting. The quality of the studies was evaluated using the PRISMA and the STROBE criteria. RESULTS: Of the 380 studies identified, 24 were included. The overall level of evidence was low. Three thousand and twenty eight TQ placements were reported. Most of them concerned the Combat Application Tourniquet CAT. Haemorrhages implied in the use of TQ were almost exclusively traumatic, most of the time regarding young men (27-44 years old). Effectiveness rates of TQ varied between 78% and 100%. Complications rates associated with the use of TQ remained low, even when used in elderlies or patients with comorbidities. Finally, caregivers reported a common fear of adverse effects, while reported complications were rare (<2%). CONCLUSION: This systematic review revealed TQ to be an effective tool for the management of extremity haemorrhages in civilian trauma, associated with few complications. Larger studies and dedicated training courses are needed to improve the use of TQ in the civilian standards of care.