A prospective international observational prevalence study on prone positioning of ARDS patients: the APRONET (ARDS Prone Position Network) study.

INTRODUCTION: While prone positioning (PP) has been shown to improve patient survival in moderate to severe acute respiratory distress syndrome (ARDS) patients, the rate of application of PP in clinical practice still appears low. AIM: This study aimed to determine the prevalence of use of PP in ARDS patients (primary endpoint), the physiological effects of PP, and the reasons for not using it (secondary endpoints). METHODS: The APRONET study was a prospective international 1-day prevalence study performed four times in April, July, and October 2016 and January 2017. On each study day, investigators in each ICU had to screen every patient. For patients with ARDS, use of PP, gas exchange, ventilator settings and plateau pressure (Pplat) were recorded before and at the end of the PP session. Complications of PP and reasons for not using PP were also documented. Values are presented as median (1st-3rd quartiles). RESULTS: Over the study period, 6723 patients were screened in 141 ICUs from 20 countries (77% of the ICUs were European), of whom 735 had ARDS and were analyzed. Overall 101 ARDS patients had at least one session of PP (13.7%), with no differences among the 4 study days. The rate of PP use was 5.9% (11/187), 10.3% (41/399) and 32.9% (49/149) in mild, moderate and severe ARDS, respectively (P = 0.0001). The duration of the first PP session was 18 (16-23) hours. Measured with the patient in the supine position before and at the end of the first PP session, PaO2/FIO2 increased from 101 (76-136) to 171 (118-220) mmHg (P = 0.0001) driving pressure decreased from 14 [11-17] to 13 [10-16] cmH2O (P = 0.001), and Pplat decreased from 26 [23-29] to 25 [23-28] cmH2O (P = 0.04). The most prevalent reason for not using PP (64.3%) was that hypoxemia was not considered sufficiently severe. Complications were reported in 12 patients (11.9%) in whom PP was used (pressure sores in five, hypoxemia in two, endotracheal tube-related in two ocular in two, and a transient increase in intracranial pressure in one). CONCLUSIONS: In conclusion, this prospective international prevalence study found that PP was used in 32.9% of patients with severe ARDS, and was associated with low complication rates, significant increase in oxygenation and a significant decrease in driving pressure.

Hemoperitoneum in peripartum: A case-series.

Hemorrhages are the first cause of perinatal deaths in French women. Thirteen percent of these deaths are not linked to obstetrical problems but rather to hemoperitoneum. These incidents are under-diagnosed and as a result, treatment is delayed and fetal and maternal mortality increases. We report three cases of patients, all White female in their last trimester of a non-problematic pregnancy presenting with hemoperitoneum and resulting in different outcomes. The analysis of published materials and of our cases leads us to infer that a diagnosis of hemoperitoneum must be considered in pregnant women when abdominal pain, symptoms of shock and a decrease in hemoglobin are associated. An immediate response and intensive care followed by hemostatic surgery give these patients the best chance to survive.

Cost analysis of single-use (Ambu® aScope™) and reusable bronchoscopes in the ICU.

BACKGROUND: Flexible optical bronchoscopes are essential for management of airways in ICU, but the conventional reusable flexible scopes have three major drawbacks: high cost of repairs, need for decontamination, and possible transmission of infectious agents. The main objective of this study was to measure the cost of bronchoalveolar lavage (BAL) and percutaneous tracheostomy (PT) using reusable bronchoscopes and single-use bronchoscopes in an ICU of an university hospital. The secondary objective was to compare the satisfaction of healthcare professionals with reusable and single-use bronchoscopes. METHODS: The study was performed between August 2009 and July 2014 in a 16-bed ICU. All BAL and PT procedures were performed by experienced healthcare professionals. Cost analysis was performed considering ICU and hospital organization. Healthcare professional satisfaction with single-use and reusable scopes was determined based on eight factors. Sensitivity analysis was performed by applying discount rates (0, 3, and 5%) and by simulation of six situations based on different assumptions. RESULTS: At a discount rate of 3%, the costs per BAL for the two reusable scopes were 188.86€ (scope 1) and 185.94€ (scope 2), and the costs per PT for the reusable scope 1 and scope 2 and single-use scopes were 1613.84€, 410.24€, and 204.49€, respectively. The cost per procedure for the reusable scopes depended on the number of procedures performed, maintenance costs, and decontamination costs. Healthcare professionals were more satisfied with the third-generation single-use Ambu® aScope™. CONCLUSIONS: The cost per procedure for the single-use scope was not superior to that for reusable scopes. The choice of single-use or reusable bronchoscopes in an ICU should consider the frequency of procedures and the number of bronchoscopes needed.

Antifungal therapy for patients with proven or suspected Candida peritonitis: Amarcand2, a prospective cohort study in French intensive care units.

OBJECTIVE: The clinical characteristics and prognosis of patients treated for Candida peritonitis (CP) were compared according to the type of systemic antifungal therapy (SAT), empiric (EAF) or targeted (TAF) therapies, and the final diagnosis of infection. METHODS: Patients in intensive care units (ICU) treated for CP were selected among the AmarCAND2 cohort, to compare patients receiving EAF for unconfirmed suspicion of CP (EAF/nonCP), to those with suspected secondarily confirmed CP (EAF/CP), or with primarily proven CP receiving TAF. RESULTS: In all, 279 patients were evaluated (43.4% EAF/nonCP, 29.7% EAF/CP and 25.8% TAF patients). At SAT initiation, the severity of illness was similar among EAF/nonCP and EAF/CP patients, lower among TAF patients (median Simplified Acute Physiology Score II (SAPS II) 49 and 51 versus 35, respectively; p 0.001). Candida albicans was involved in 67%, Candida glabrata in 15.6%. All strains were susceptible to echinocandin; 84% to fluconazole. Echinocandin was administered to 51.2% EAF/nonCP, 49% EAF/CP and 40% TAF patients. At day 28, 72%, 76% and 75% of EAF/nonCP, EAF/CP and TAF patients, respectively, were alive. An increased mortality was observed in patients with a Sequential Organ Failure Assessment (SOFA) score <7 if SAT was delayed by ≥6 days (p 0.04). Healthcare-associated CP (OR 3.82, 95% CI 1.52-9.64, p 0.004), SOFA ≥8 at ICU admission (OR 2.61, 95% CI 1.08-6.34; p 0.03), and SAPS II ≥45 at SAT initiation (OR 5.08, 95% CI 1.04-12.67; p 0.001) impacted the 28-day mortality. CONCLUSIONS: In summary, only 56.6% of ICU patients receiving SAT had CP. Most strains were susceptible to SAT. A similar 28-day mortality rate was observed among groups; the late administration of SAT significantly worsened the prognosis of patients with less severe CP.

Guidelines for management of intra-abdominal infections

Intra-abdominal infections are one of the most common gastrointestinal emergencies and a leading cause of septic shock. A consensus conference on the management of community-acquired peritonitis was published in 2000. A new consensus as well as new guidelines for less common situations such as peritonitis in paediatrics and healthcare-associated infections had become necessary. The objectives of these Clinical Practice Guidelines (CPGs) were therefore to define the medical and surgical management of community-acquired intra-abdominal infections, define the specificities of intra-abdominal infections in children and describe the management of healthcare-associated infections. The literature review was divided into six main themes: diagnostic approach, infection source control, microbiological data, paediatric specificities, medical treatment of peritonitis, and management of complications. The GRADE(®) methodology was applied to determine the level of evidence and the strength of recommendations. After summarising the work of the experts and application of the GRADE(®) method, 62 recommendations were formally defined by the organisation committee. Recommendations were then submitted to and amended by a review committee. After 2 rounds of Delphi scoring and various amendments, a strong agreement was obtained for 44 (100%) recommendations. The CPGs for peritonitis are therefore based on a consensus between the various disciplines involved in the management of these patients concerning a number of themes such as: diagnostic strategy and the place of imaging; time to management; the place of microbiological specimens; targets of empirical anti-infective therapy; duration of anti-infective therapy. The CPGs also specified the value and the place of certain practices such as: the place of laparoscopy; the indications for image-guided percutaneous drainage; indications for the treatment of enterococci and fungi. The CPGs also confirmed the futility of certain practices such as: the use of diagnostic biomarkers; systematic relaparotomies; prolonged anti-infective therapy, especially in children.(AU)

Mechanical ventilation in abdominal surgery.

One of the key challenges in perioperative care is to reduce postoperative morbidity and mortality. Patients who develop postoperative morbidity but survive to leave hospital have often reduced functional independence and long-term survival. Mechanical ventilation provides a specific example that may help us to shift thinking from treatment to prevention of postoperative complications. Mechanical ventilation in patients undergoing surgery has long been considered only as a modality to ensure gas exchange while allowing maintenance of anesthesia with delivery of inhaled anesthetics. Evidence is accumulating, however, suggesting an association between intraoperative mechanical ventilation strategy and postoperative pulmonary function and clinical outcome in patients undergoing abdominal surgery. Non-protective ventilator settings, especially high tidal volume (VT) (>10-12mL/kg) and the use of very low level of positive end-expiratory pressure (PEEP) (PEEP<5cmH2O) or no PEEP, may cause alveolar overdistension and repetitive tidal recruitment leading to ventilator-associated lung injury in patients with healthy lungs. Stimulated by previous findings in patients with acute respiratory distress syndrome, the use of lower tidal volume ventilation is becoming increasingly more common in the operating room. However, lowering tidal volume, though important, is only part of the overall multifaceted approach of lung protective mechanical ventilation. In this review, we aimed at providing the most recent and relevant clinical evidence regarding the use of mechanical ventilation in patients undergoing abdominal surgery.

[Physicochemical stability study of injectable solutions of cisatracurium besilate in clinical conditions]. / Stabilité physico-chimique des solutions injectables de bésilate de cisatracurium dans les conditions cliniques d'utilisation.

OBJECTIVES: To assess the stability of cisatracurium besilate solution stored at 5°C and 25°C. MATERIALS AND METHODS: Cisatracurium solutions at 2, 5 and 0.1mg/mL in 0.9 % sodium chloride or 5 % glucose were exposed to 5°C and 25°C under 60 % relative humidity for seven days. The physicochemical stability was assessed at 24, 48hours and seven days with dosage of the active substance, detection of degradation products and a possible racemization, measuring pH, osmolality and turbidity, assessment of coloration, visible particles and invisible particles count. RESULTS: Cisatracurium besilate present good stability for 24hours at 5°C and 25°C for concentrations between 0.1 and 5mg/mL. Beyond 24hours, the solutions at 2 and 5mg/mL remained stable for seven days at 5°C. At 25°C, potentially toxic degradation products appear in solutions of 0.1mg/mL between 24 and 48hours. No racemization was detected, the drug remains in its active form cis. CONCLUSION: Cisatracurium solutions at 2 and 5mg/mL may be stored at 5°C or 25°C for seven days. It's advisable to keep the solutions in a dilution of 0.1mg/mL in 0.9 % sodium chloride or 5 % glucose in the refrigerator. No diluted solution should be stored at room temperature beyond 24hours.

[Use of the intraosseous access in adult patients in France in 2012]. / Utilisation de la voie intraosseuse chez l'adulte en France en 2012.

OBJECTIVES: To evaluate theoretical and practical knowledges of intraosseous (IO) access in adults patients in France in 2012. STUDY DESIGN: National observational descriptive transversal study as survey of opinion and practices. MATERIALS AND METHODS: An email, with an URL to online computerized quiz, was sent to residents and medical doctors who were working, in France, in anesthesiologist units, intensive care units or emergency units. Several questions were asked about theoretical and practical knowledges concerning IO access. RESULTS: After 1359 responses, 396 (29%) practitioners have used an IO kit mainly in case of cardiopulmonary arrest in adults (68%). The insurance of operators in this technique and the rate of physicians who has even put an IO catheter increased with the years of experience of physicians. The reasons given for not using an IO access were no trouble placing a peripheral vein (77%) and unfamiliarity with the equipment and technology (32%). Most of practitioners (753 [55%]) have been trained and 90% (n=265) of untrained doctors believe that training was necessary. The powered system was the most used (71%). CONCLUSION: Only 29% of practitioners have ever used an IO kit. With the new IO kits, a theoretical and practical training is needed to ensure IO kit used.

A pharmacokinetic study of 48-hour sevoflurane inhalation using a disposable delivery system (AnaConDa®) in ICU patients.

BACKGROUND: Little is known regarding sevoflurane kinetics and toxicity during long-term sedation of intensive care unit (ICU) patients using the AnaConDa® system. The objective of the present study was to establish a pharmacokinetic description of 48-h sevoflurane administration, and to estimate plasma concentrations of metabolites. METHODS: Forty-eight hour sedation with sevoflurane vaporized via an AnaConDa® device, with an end-tidal concentration objective of 1.5% (v/v), was initiated in 12 non-obese patients who did not have hepatic or renal failure but who required sedation for more than 48 h in our ICU. Plasma sevoflurane, hexafluoroisopropanol, and fluoride concentrations were determined over this time period and pharmacokinetic analysis was performed. RESULTS: The mean plasma concentration of sevoflurane was 76 mg/L at 24 h and 70 mg/L at 48 h. Wash-out of plasma sevoflurane correlated with a rapid decrease in the mean end-tidal sevoflurane level. The mean free plasma fraction of hexafluoroisopropanol never exceeded 8 mg/mL. The mean fluoride concentration was 0.8 µmol/L on day 0, 51.7 µmol/L on day 1, and 68.1 µmol/L on day 2 (P<0.0001). The distribution volume was 53 L, the elimination constant 2.9 h-1, the transfer constant from compartment 1 to compartment 2 (K1-2) 1.2 h-1, the K2-1 0.26 h-1, the half-life of elimination 3.78 h, and the total clearance 156 L/h. CONCLUSION: Following 48 hours of sedation using sevoflurane inhalation administered using an AnaConDa® delivery device, sevoflurane washout was rapid. Plasma fluoride levels accumulated over the study period without apparent nephrotoxicity.

Protective lung ventilation in operating room: a systematic review.

Postoperative pulmonary and extrapulmonary complications adversely affect clinical outcomes and healthcare utilization, so that prevention has become a measure of the quality of perioperative care. Mechanical ventilation is an essential support therapy to maintain adequate gas exchange during general anesthesia for surgery. Mechanical ventilation using high tidal volume (VT) (between 10 and 15 mL/kg) has been historically encouraged to prevent hypoxemia and atelectasis formation in anesthetized patients undergoing abdominal and thoracic surgery. However, there is accumulating evidence from both experimental and clinical studies that mechanical ventilation, especially the use of high VT and plateau pressure, may potentially aggravate or even initiate lung injury. Ventilator-associated lung injury can result from cyclic alveolar overdistension of non-dependent lung tissue, and repetitive opening and closing of dependent lung tissue resulting in ultrastructural damage at the junction of closed and open alveoli. Lung-protective ventilation, which refers to the use of lower VT and limited plateau pressure to minimize overdistension, and positive end-expiratory pressure to prevent alveolar collapse at end-expiration, was shown to improve outcome in critically ill patients with acute respiratory distress syndrome (ARDS). It has been recently suggested that this approach might also be beneficial in a broader population, especially in critically ill patients without ARDS at the onset of mechanical ventilation. There is, however, little evidence regarding a potential beneficial effect of lung protective ventilation during surgery, especially in patients with healthy lungs. Although surgical patients are frequently exposed to much shorter periods of mechanical ventilation, this is an important gap in knowledge given the number of patients receiving mechanical ventilation in the operating room. This review developed the benefits of lung protective ventilation during surgery and general anesthesia and offers some recommendations for mechanical ventilation in the surgical context.

Comparison of three high flow oxygen therapy delivery devices: a clinical physiological cross-over study.

AIM: High-flow-oxygen-therapy is provided by various techniques and patient interfaces, resulting in various inspired-fraction of oxygen (FiO2) and airway-pressure levels. However, tracheal measurements have never been performed. METHODS: Three oxygen-delivery-devices were evaluated: 1) standard-high-flow-oxygen-facemask with reservoir-bag, 2) Optiflow(TM)-high-flow-nasal-cannulae and 3) Boussignac(TM)-oxygen-therapy-system. Main judgment criteria were airway-pressure and FiO2 measured in the trachea. The three devices were randomly evaluated in cross-over in 10 Intensive-Care-Unit patients using three oxygen flow-rates (15, 30 and 45 L/min) and two airway-tightness conditions (open and closed mouth). Airway-pressures and FiO2 were measured by a tracheal-catheter inserted through the hole of a tracheotomy tube. Comfort was evaluated by self-reporting. Data are presented as median [25-75th]. RESULTS: 1) Regarding oxygen-delivery devices, BoussignacTM provided the highest mean tracheal pressure (13.9 [10.4-14.5] cmH20) compared to Optiflow(TM) (2 [1-2.3] cmH2O, P<0.001). BoussignacTM provided both positive inspiratory and expiratory airway-pressures, whereas Optiflow(TM) provided only positive expiratory airway-pressure. Reservoir-bag-facemask provided airway pressure close to zero. For FiO2, highest value was obtained for both Optiflow(TM) and facemask (90%) compared to Boussignac(TM) (80%), P<0.01. 2) Regarding oxygen-flow, airway-pressure and FiO2 systematically increased with oxygen-flow with the three devices except airway-pressure for the facemask. 3) Regarding the open-mouth position, mean airway-pressure decreased with Optiflow(TM) only (2 [1.2-3.3] vs. 0.6 [0.3-1] cmH2O, P<0.001). Opening the mouth had little impact on FiO2. 4) finally, discomfort-intensities were low for both Optiflow(TM) and reservoir-bag-facemask compared to Boussignac(TM), P<0.01. CONCLUSION: On one hand, Boussignac(TM) is the only device that generates a relevant positive-airway-pressure during both inspiration-and-expiration, independently of mouth-position. Optiflow(TM) provides a low positive-airway-pressure (<4 cmH2O), highly dependent of mouth-closing. The reservoir-bag-facemask provides no positive-airway-pressure. On the other hand, FiO2 are slightly but significantly higher for Optiflow(TM) and reservoir-bag-facemask than for Boussignac(TM). Discomfort was lesser for Optiflow(TM) and reservoir-bag-facemask.