Critical COVID-19 patient evacuation on an amphibious assault ship: feasibility and safety. A case series.

INTRODUCTION: An amphibious assault ship was deployed on 22 March in Corsica to carry out medical evacuation of 12 critical patients infected with COVID-19. The ship has on-board hospital capacity and is the first time that an amphibious assault ship is engaged in this particular condition. The aim is to evaluate the feasibility and safety of prolonged medical evacuation of critical patients with COVID-19. METHODS: We included 12 patients with confirmed COVID-19 infection: six ventilated patients with acute respiratory distress syndrome and six non-ventilated patients with hypoxaemia. Transfer on an amphibious assault ship lasted 20 hours. We collected patients' medical records: age, comorbidities, COVID-19 history and diagnosis, ventilation supply and ventilator settings, and blood gas results. We calculated oxygen consumption (OC). RESULTS: All patients had a medical history. The median delay from onset of symptoms to hospitalisation was 8 (7-10) days. The median Sequential Organ Failure Assessment score on admission was 3 (2-5). There was no significant increase in oxygen during ship transport and no major respiratory complication. There was no significant increase in arterial oxygen pressure to fractional inspired oxygen ratio among ventilated patients during ship transport. Among ventilated patients, the median calculated OC was 255 L (222-281) by hours and 5270 L (4908-5616) during all ship transport. Among non-ventilated patients, the median calculated OC was 120 L (120-480) by hours and 2400 L (2400-9600) during all ship transport. CONCLUSION: The present work contributes to assessing the feasibility and safety condition of critical COVID-19 evacuation on an amphibious assault ship during an extended transport. The ship needs to prepare a plan and a specialised intensive team and conduct patient screening for prolonged interhospital transfers.

Acute retinal arterial ischaemia: silent brain infarcts prevalence and short-term recurrence.

BACKGROUND AND PURPOSE: The purpose was to evaluate, in a consecutive series of patients with isolated acute retinal ischaemia, the proportion of patients with acute silent brain infarcts (SBIs) on diffusion-weighted imaging (DWI) and to assess risk of recurrence within 3 months. METHODS: In all, 103 consecutive patients with isolated acute retinal ischaemia (central retinal artery occlusion, branch retinal artery occlusion or transient monocular vision loss) were included between January 2015 and December 2016. They all had cerebral magnetic resonance imaging including DWI as well as a standardized aetiological workup and 3 months of follow-up. The presence of DWI-positive cerebral lesions was recorded. Main clinical and radiological characteristics between DWI-positive and DWI-negative patients were compared. RESULTS: Of the 103 patients (including 42 transient monocular vision loss), 20 (19.5%) had SBIs on DWI, which were ipsilateral to the acute retinal ischaemia in 30% and involved different and/or multiple vascular territories in 70% of cases. Ipsilateral carotid stenosis and occlusion were respectively identified in 17 and eight patients whereas cardioaortic embolism was found in 19 patients. Overall, patients with and without acute SBIs were comparable. The topography of SBIs was related to the aetiology of the acute retinal ischaemia. At 3 months of follow-up, one patient suffered from ischaemic stroke and five had recurrent retinal ischaemia. CONCLUSIONS: Irrespective of the baseline characteristics of the patients, SBIs are present in about 20% of patients with isolated acute retinal ischaemia and may be of interest in the aetiological workup. Overall risk of recurrence is low, favoured by rapid aetiological workup and appropriate treatment.

Impact of high-dose norepinephrine during intra-hospital damage control resuscitation of traumatic haemorrhagic shock: A propensity-score analysis.

INTRODUCTION: The use of norepinephrine (NE) during uncontrolled haemorrhagic shock (HS) has mostly been investigated in experimental studies. Clinical data including norepinephrine dose and its impact on fluid resuscitation and organ function are scarce. We hypothesized that there is great variability in NE use and that high doses of NE could lead to increased organ dysfunction as measured by the sequential organ failure assessment (SOFA). METHOD: We included patients with HS (systolic blood pressure < 90 mmHg in severely injured patients) who required haemostasis surgery and a transfusion of more than 4 packed red blood cells (PRBC) in the first 6 h of admission and the used of norepinephrine infusion to maintain the blood pressure goal, between admission and the end of haemostasis surgery in a prospective trauma database. A ROC curve determined that, using Youden's criterion, a dose of NE ≥ 0.6 µg/kg/min was the optimal threshold associated with intrahospital mortality. Patients were compared according to this threshold in a propensity score (PS) model. In a generalized linear mixed model, we searched for independent factors associated with a SOFA ≥ 9 at 24 h RESULTS: A total of 89 patients were analysed. Fluid infusion rate ranged from 1.43 to 57.9 mL/kg/h and norepinephrine infusion rate from 0.1 to 2.8 µg/kg/min. The HDNE group received significantly less fluid than the LDNE group. This dose is associated with a higher SOFA score at 24h: 9 (7-10) vs. 7 (6-9) (p = 0.003). Factors independently associated with a SOFA score ≥ 9 at 24 h were maximal norepinephrine rate ≥ 0.6 µg/kg/min (OR 6.69, 95% CI 1.82 - 25.54; p = 0.004), non-blood resuscitation volume < 9 mL/kg/h (OR 3.98, 95% CI 1.14 - 13.95; p = 0.031) and lactate at admission ≥ 5 mmol/L (OR 5.27, 95% CI 1.48 - 18.77; p = 0.010) CONCLUSION: High dose of norepinephrine infusion is associated with deleterious effects as attested by a higher SOFA score at 24 h and likely hypovolemia as measured by reduced non-blood resuscitation volume. We did not find any significant difference in mortality over the long term.

Early transfusion on battlefield before admission to role 2: A preliminary observational study during "Barkhane" operation in Sahel.

INTRODUCTION: Haemorrage is the leading cause of death after combat related injuries and bleeding management is the cornerstone of management of these casualties. French armed forces are deployed in Barkhane operation in the Sahel-Saharan Strip who represents an immense area. Since this constraint implies evacuation times beyond doctrinal timelines, an institutional decision has been made to deploy blood products on the battlefield and transfuse casualties before role 2 admission if indicated. The purpose of this study was to evaluate the transfusion practices on battlefield during the first year following the implementation of this policy. MATERIALS AND METHODS: Prospective collection of data about combat related casualties categorized alpha evacuated to a role 2. Battlefield transfusion was defined as any transfusion of blood product (red blood cells, plasma, whole blood) performed by role 1 or Medevac team before admission at a role 2. Patients' characteristics, battlefield transfusions' characteristics and complications were analysed. RESULTS: During the one year study, a total of 29 alpha casualties were included during the period study. Twenty-eight could be analysed, 7/28 (25%) being transfused on battlefield, representing a total of 22 transfusion episodes. The most frequently blood product transfused was French lyophilized plasma (FLYP). Most of transfusion episodes occurred during medevac. Compared to non-battlefield transfused casualties, battlefield transfused casualties suffered more wounded anatomical regions (median number of 3 versus 2, p = 0.04), had a higher injury severity score (median ISS of 45 versus 25, p = 0,01) and were more often transfused at role 2, received more plasma units and whole blood units. There was no difference in evacuation time to role 2 between patients transfused on battlefield and non-transfused patients. There was no complication related to battlefield transfusions. Blood products transfusion onset on battlefield ranged from 75 min to 192 min after injury. CONCLUSION: Battlefield transfusion for combat-related casualties is a logistical challenge. Our study showed that such a program is feasible even in an extended area as Sahel-Saharan Strip operation theatre and reduces time to first blood product transfusion for alpha casualties. FLYP is the first line blood product on the battlefield.

Feasibility and limits of inguinal hernia repair under local anaesthesia in a limited resource environment: a prospective controlled study.

PURPOSE: Local anaesthesia (LA) has proven effective for inguinal hernia repair in developed countries. Hernias in low to middle income countries represent a different issue. The aim of this study was to analyse the feasibility of LA for African hernia repairs in a limited resource environment. METHODS: Data from patients who underwent herniorrhaphy under LA or spinal anaesthesia (SA) by the 6th and 7th Forward Surgical Team were prospectively collected. All of the patients benefited from a transversus abdominis plane (TAP) block for postoperative analgesia. Primary endpoints concerned the pain response and conversion to general anaesthesia. Secondary endpoints concerned the complication and recurrence rates. Predictors of LA failure were then identified. RESULTS: In all, 189 inguinal hernias were operated during the study period, and 119 patients fulfilled the inclusion criteria: 57 LA and 62 SA. Forty-eight percent of patients presented with inguinoscrotal hernias. Local anaesthesia led to more pain during surgery and necessitated more administration of analgesics but resulted in fewer micturition difficulties and better postoperative pain control. Conversion rates were not different. Inguinoscrotal hernia and a time interval <50 min between the TAP block and skin incision were predictors of LA failure. Forty-four patients were followed-up at one month. No recurrence was noted. CONCLUSIONS: Local anaesthesia is a safe alternative to SA. Small or medium hernias can easily be performed under LA in rural centres, but inguinoscrotal hernias required an ultrasound-guided TAP block performed 50 min before surgery to achieve optimal analgesia, and should be managed only in centres equipped with ultrasonography.

Coagulopathy and transfusion requirements in war related penetrating traumatic brain injury. A single centre study in a French role 3 medical treatment facility in Afghanistan.

INTRODUCTION: Traumatic brain injury associated coagulopathy is frequent, either in isolated traumatic brain injury in civilian practice and in combat traumatic brain injury. In war zone, it is a matter of concern because head and neck are the second most frequent site of wartime casualty burden. Data focusing on transfusion requirements in patients with war related TBI coagulopathy are limited. MATERIALS AND METHODS: A descriptive analysis was conducted of 77 penetrating traumatic brain injuries referred to a French role 3 medical treatment facility in Kabul, Afghanistan, deployed on the Kabul International Airport (KaIA), over a 30 months period. RESULTS: On 77 patients, 23 died during the prehospital phase and were not included in the study. Severe traumatic brain injury represented 50% of patients. Explosions were the most common injury mechanism. Extracranial injuries were present in 72% of patients. Traumatic brain injury coagulopathy was diagnosed in 67% of patients at role 3 admission. Red blood cell units (RBCu) were transfused in 39 (72%) patients, French lyophilized plasma (FLYP) in 41 (76%), and fresh whole blood (FWB) in 17 (31%). CONCLUSION: The results of this study support previous observations of coagulopathy as a frequent complication of traumatic brain injury. The majority of patients with war related penetrating traumatic brain injury presented with extracranial lesions. Most of them required a high level of transfusion capacity.

Assessment of cerebral oxygenation in neurocritical care patients: comparison of a new four wavelengths forehead regional saturation in oxygen sensor (EQUANOX®) with brain tissue oxygenation. A prospective observational study.

BACKGROUND: Because of restricted information given by monitoring solely intracranial pressure and cerebral perfusion pressure, assessment of the cerebral oxygenation in neurocritical care patients would be of interest. The aim of this study was to determinate the correlation between the non-invasive measure regional saturation in oxygen (rSO2) with a third generation NIRS monitor and an invasive measure of brain tissue oxygenation tension (PbtO2). METHODS: We conducted a prospective, observational, unblinded study including neurocritical care patients requiring a PbtO2 monitoring. Concomitant measurements of rSO2 were performed with a four wavelengths forehead sensor (EQUANOX Advance®) of the EQUANOX® 7600 System. We determined the correlation between rSO2 and PbtO2 and the ability of the rSO2 to detect ischemic episodes defined by a PbtO2 less than 15 mmHg. The rSO2 ischemic threshold was 60%. RESULTS: During 2 months, 8 consecutives patients, including 275 measurements, were studied. There was no correlation between rSO2 and PbtO2 (r=0.016 [-0.103-0.134], r2=0.0003, P=0.8). On the 86 ischemic episodes detected by PbtO2, only 13 were also detected by rSO2. ROC curve showed the inability for rSO2 to detect cerebral hypoxia episodes (AUC=0.54). CONCLUSION: rSO2 cannot be used as a substitute for PbtO2 to monitor cerebral oxygenation in neurocritical care patients.

[Cerebral venous thrombosis: an unusual complication of acute cytomegalovirus infection]. / Thrombophlébite cérébrale: une complication rare de l'infection aiguë à cytomégalovirus.

INTRODUCTION: Acute cytomegalovirus (CMV) infection increases the risk of vascular thrombosis but reports of cerebral venous thrombosis are rare. CASE REPORT: We report a 36-year-old woman who presented with a cerebral venous thrombosis and acute CMV infection heralded by a cytolytic hepatitis. Heterozygous factor V Leiden mutation was also identified. The patient was treated with anticoagulation for 1 year with favourable outcome. CONCLUSION: Serologic tests for CMV infection should be performed in case of cerebral venous thrombosis with liver cytolysis or flu-like symptoms. CMV infection often triggers thrombosis in combination with other inherited or genetic predisposing risk factors that should always be searched.

[Upper airway management during anesthesia for reconstructive surgery in patients with noma]. / Gestion des voies aériennes supérieures pour l'anesthésie du noma.

Noma causes tissue degeneration of the face resulting in impaired mouth opening with secondary malnutrition and metabolic disorders. Reconstructive plastic surgery for noma can be lifesaving but requires special airway and ventilation techniques because of limited mouth opening. In addition, the African context imposes logistic and budgetary constraints. The purpose of this article is to describe an upper airway management strategy that takes into account disease factors and available resources.

Bedside percutaneous tracheostomy: a prospective randomised comparison of PercuTwist versus Griggs' forceps dilational tracheostomy.

Tracheostomy is considered the airway management of choice for patients who require prolonged mechanical ventilation. The development of percutaneous techniques offers many advantages including the ability to perform the procedure in the intensive care unit. The aim of this study was to compare the controlled rotating dilation method (PercuTwist) and the Griggs' forceps dilational tracheostomy. Patients over 18 years of age undergoing tracheostomy in the intensive care unit were included in the study. They were divided in two random samples--either PercuTwist or forceps dilational tracheostomy. Data collected prospectively included demographic characteristics, procedure duration, blood gas analysis, intracranial pressure, arterial blood pressure and heart rate before and after the procedure. Any complications during or after the procedure due to the tracheostomy were also recorded. Contrary to the main hypothesis, PercuTwist technique took significantly longer to perform than forceps dilational tracheostomy technique (five minutes [2 to 25] vs three minutes [1 to 17][P=0.006]). A significant increase in P(a)CO2 and decrease in arterial pH were observed in both groups between the pre-tracheostomy and post-tracheostomy blood gas analysis. Haemodynamic tolerance was good. Our results show that intracranial pressure is affected by the procedure whatever the technique used. However we did not observe a decrease in cerebral perfusion pressure. The incidence of complications was 23% (20/87). These complications were minor in 18/20 and were not significantly different between the two groups. In conclusion, we consider that the PercuTwist technique is safe despite the longer duration of the procedure. Nevertheless the forceps dilational technique remains our routine procedure.

[Carotid dissection during angioplasty for vasospasm induced by subarachnoid haemorrhage. The use of multimodal cerebral monitoring]. / Dissection carotidienne au cours d'une angioplastie pour vasospasme après hémorragie sous-arachnoïdienne. Apport du monitorage cérébral "multimodal".

We report the case of a 54-year-old woman presenting subarachnoid haemorrhage. She experienced multiple vasospasms and treatment included triple-H (hypervolaemia, hypertension, and haemodilution) and endovascular therapies. Right internal carotid dissection complicated angioplasty of the right middle cerebral artery. Combined brain tissue partial pressure of oxygen monitoring and transcranial echo-Doppler could have facilitated early diagnosis. Despite successful revascularization of right internal carotid by stenting, this complication caused acute stroke with refractory intracranial hypertension.

[Post traumatic air tamponade under assisted ventilation. Case report from Dakar, Senegal]. / Une ventilation mortelle.

Compressive pnemopericardium is an uncommon cause of shock after blunt trauma. The purpose of this report is to describe a case of air tamponnade observed during management of a patient with thoraco-abominal injuries in Dakar, Senegal. Diagnosis was suspected based on chest x-rays and subsequently confirmed by CT-scan. Clinical features included shock syndrome, small heart sign, and constant deterioration under assisted ventilation. Despite initial improvement after needle aspiration, the patient died due to probable recurrence of air tamponnade. Based on their review of the literature, the authors discuss the physiopathology of air tamponande and emergency treatment by needle aspiration that must be followed by surgery for creation of a pericardial window.