Factors associated with an unfavourable outcome in elderly intensive care traumatic brain injury patients. a retrospective multicentre study.

BACKGROUND: Changes in the epidemiology of traumatic brain injury (TBI) in older patients have received attention, but limited data are available on the outcome of these patients after admission to intensive care units (ICUs). The aim of this study was to evaluate the outcomes of patients over 65 years of age who were admitted to an ICU for TBI. METHODS: This was a multicentre, retrospective, observational study conducted from January 2013 to February 2019 in the surgical ICUs of 5 level 1 trauma centres in France. Patients aged ≥ 65 years who were hospitalized in the ICU for TBI with or without extracranial injuries were included. The main objective was to determine the risk factors for unfavourable neurological outcome at 3 months defined as an Extended Glasgow Outcome Scale (GOSE) score < 5. RESULTS: Among the 349 intensive care patients analysed, the GOSE score at 3 months was ≤ 4 and ≥ 5 in 233 (67%) and 116 (33%) patients, respectively. The mortality rate at 3 months was 157/233 (67%), and only 7 patients (2%) fully recovered or had minor symptoms. Withdrawal or withholding of life-sustaining therapies in the ICU was identified in 140 patients (40.1%). Multivariate analysis showed that age (OR 1.09, CI 95% 1.04-1.14), male sex (OR 2.94, CI95% 1.70-5.11), baseline Glasgow Coma Scale score (OR 1.20, CI95% 1.13-1.29), injury severity score (ISS; OR 1.04, CI95% 1.02-1.06) and use of osmotherapy (OR 2.42, CI95% 1.26-4.65) were associated with unfavourable outcomes (AUC = 0.79, CI 95% [0.74-0.84]). According to multivariate analysis, the variables providing the best sensitivity and specificity were age ≥ 77 years, Glasgow Coma Scale score ≤ 9 and ISS ≥ 25 (AUC = 0.79, CI 95% [0.74-0.84]). CONCLUSIONS: Among intensive care patients aged ≥ 65 years suffering from TBI, age (≥ 77 years), male sex, baseline Glasgow coma scale score (≤ 9), ISS (≥ 25) and use of osmotherapy were predictors of unfavourable neurological outcome. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04651803. Registered 03/12/2020. Retrospectively registered.

Factors associated with time to defecate and outcomes in critically ill patients: a prospective, multicentre, observational study.

Delayed defecation is common in patients on intensive care. We aimed to determine factors associated with time to defecation after admission to intensive care and in turn its association with length of stay and mortality. We studied 396 adults admitted to one of five intensive care units in whom at least 2 days' invasive ventilation was anticipated during an expected stay of at least 3 days. The median (IQR [range]) time to defecate by the 336 out of 396 (84%) patients who did so before intensive care discharge was 6 (4-8 [1-18]) days. Defecation was independently associated with five factors, hazard ratio (95%CI), higher values indicating more rapid defecation: alcoholism, 1.32 (1.05-1.66), p = 0.02; laxatives before admission, 2.35 (1.79-3.07), p < 0.001; non-invasive ventilation, 0.54 (0.36-0.82), p = 0.004; duration of ventilation, 0.78 (0.74-0.82), p < 0.001; laxatives after admission, 1.67 (1.23-2.26), p < 0.001; and enteral nutrition within 48 h of admission, 1.43 (1.07-1.90), p = 0.01. Delayed defecation was associated with prolonged intensive care stay but not mortality.

[Process, procedure and requested conditions for academic appointment in anesthesia and intensive care]. / Processus, procédures et critères d'évaluation conduisant à la mise sur la liste d'aptitude aux fonctions de Maître de conférences des universités--praticien hospitalier (MCU-PH) et de professeur des universités--praticien hospitalier (PU-PH) en anesthésie-réanimation.

Since several decades, anesthesia care and intensive care, as well, are engaged in the way of excellence in clinical care and research. This requirement is also applied for the selection of professor and academic workers. The goals of this article are twice: first to diffuse this knowledge at the medical community and second to describe in details the long process leading to the final appointment.

[Management of infection risk in asplenic patients]. / Gestion du risque infectieux chez le splénectomisé

Each year in France 6000 to 9000 patients are splenectomised or spleen embolized. As spleen has immunological functions, it contributes to protect against infections. Thus, hypo or asplenia increase the risk of infection, especially the risk of Overwhelming Post-Splenectomy Infection (OPSI). OPSI is a medical emergency, characterized by aspecific symptoms, which may rapidly progress to fulminant infection and death in 50% of cases within 48 h. Encapsulated bacteria as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis are most of the time responsible of these infections in asplenic patients. To prevent OPSI, several measures are essential and must begin before a scheduled surgery or just after an urgent splenectomy. Patients must carry a card. The first proposed prevention measure is to enhance partial surgery when it's possible. Then, the two other measures, antibiotic prophylaxis and vaccination, shall be implemented whatever is the indication of surgery. Postoperative antibiotic prophylaxis by phenoxymethyl-penicillin is prescribed for two years minimum and lifelong prophylaxis should be offered to high risk of pneumococcal infection patients. Pneumococcal, H. influenzae type b and meningococcal vaccination should be administered 2 to 6 weeks before scheduled splenectomy and 2 weeks after urgent surgery. Yearly, patients must receive Influenza vaccination. As an interindividual variation exists in vaccinal response, measurement of serotype-specific antibodies can be used, if available, to individualized risk patients and to organize revaccination. Finally, to prevent OPSI, patient and next-of-kin must be educated about prevention measures and infectious risk to optimize patient's compliance.

[Inhaled agents in neuroanaesthesia for intracranial surgery: pro or con]. / Pour ou contre les halogénés en neuroanesthésie pour chirurgie intracrânienne.

Isoflurane, desflurane and sevoflurane all preserve cerebrovascular carbone dioxide (CO(2)) reactivity. They are all concentration-dependant cerebral vasodilatators and decrease cerebral metabolism. Sevoflurane induces the smallest cerebral vasodilatation and preserve cerebral autoregulation up to 1.5CAM, compared to isoflurane and desflurane which impair it upon 1CAM. Propofol has been compared to inhaled agents. Propofol preserve cerebrovascular CO(2) reactivity, blood flow-metabolism coupling, cerebral autoregulation and has no vasodilatation effect. None of the three inhaled agents induce any clinical relevant increase of intracranial pressure (ICP), but studies were conducted in patients without any intracranial hypertension (ICHT). However, compared to propofol, ICP and brain swelling were higher with inhaled agents, more with isoflurane compared to sevoflurane. Finally, neuroprotective properties have been described in experimental model for all the inhaled agents but clinical proofs are still lacking. In conclusion, for intracranial surgery without any ICHT inhaled agents can be used as a maintenance anesthetic with a preference for sevoflurane. In case of ICHT or a risk of ICHT during the surgery, propofol is preferred for it slightest effect on ICP and cerebral hemodynamic.

In vivo microdialysis in pharmacological studies of antibacterial agents in the brain.

Cerebral microdialysis (MD) has proven to be a valuable clinical and research tool in neuroscience. It allows sampling of endogenous and exogenous molecules of interest from the extracellular fluid (ECF) of the brain. MD has also been successfully used to assess drug delivery to the target tissues in pharmacokinetic (PK) studies. There is a concern that due to the blood-brain barrier (BBB), current regimens of commonly used antibiotics might be inadequate. Although PK/pharmacodynamic (PK/PD) studies play an important role in drug evaluation, PK MD studies of antibacterial agents in cerebral tissue are few in number. These studies demonstrate a significant variation in drug penetration in the presence of intracranial pathology. Antibacterial agents from the same chemical group have significantly different PK profiles due to different affinity to the transport proteins of the BBB. Some studies suggest that commonly used antibiotics do not reach a therapeutic concentration range in brain ECF. Studies reviewed in this article are small and performed in different patient populations (brain tumour, head injury, epilepsy) using different methodological approaches to the drug recovery estimation. Nevertheless, they provide interesting and important data on the variability of antibiotic penetration that could be utilized for PK/PD studies and which may have clinical relevance.

Reliability of the HemoCue® hemoglobinometer in critically ill patients: a prospective observational study.

BACKGROUND: The aim of the study was to assess the reliability of hemoglobin measurements made with HemoCue®, compared with those made with the reference method in critically ill patients. METHODS: A prospective observational study was conducted in three adult surgical intensive care units of a university hospital. One hundred and ninety-eight consecutive patients were included, and a total of 1166 hemoglobin concentrations were measured using arterial blood samples in the laboratory (HbLAB) and at bedside (HbHC.art) with a portable hemoglobinometer (HemoCue® Hb201+). Simultaneously, a capillary measurement (HbHC.cap) was performed at bedside using the same device. RESULTS: The mean difference (bias) between HbHC.cap and HbLAB was 0.2 g/dL (95%CI, 0.1;0.3), and limits of agreement were -1.3 g/dL (95%CI, -1.4;-1.2) to 1.7 g/dL (95%CI, 1.6;1.9). The discrepancies between HbHC.cap and HbLAB were greater than 1 g/dL in 30.8% of cases. The bias between HbHC.art and HbLAB was -0.1 g/dL (95% CI, -0.2;0.2), and limits of agreement were slightly better at -1.1 g/dL (95% CI, -1.2;-1.0) and 1.0 g/dL (95% CI, 0.9;1.1). The HemoCue®'s accuracy was not affected by the hospital unit, the puncture site (finger or ear), norepinephrine administration or by hemoglobin levels below 10 g/dL or 8 g/dL. CONCLUSION: Capillary HemoCue® is not sufficiently accurate to make a therapeutic decision such as whether a blood transfusion should be performed. The method's performance was moderately improved by the use of arterial blood.

[Practice assessment of central venous lines care in surgical ICU of French university hospitals]. / Evaluation des pratiques de gestion des cathéters veineux centraux dans les réanimations chirurgicales universitaires françaises.

INTRODUCTION: Recommendations on insertion and maintenance of central venous catheters (CVC) in intensive care unit (ICU) patients were updated in 2002. The aim of this study was to estimate their knowledge and/or application by physicians in French university hospital ICUs. METHODS: Two forms were sent to 124 professors of anaesthesia and intensive care encouraging them to participate to the survey. The first one was completed by the physician in charge of each unit and concerned the structure and activity of the unit in 2006. The second one was filled by each junior or senior physician working in the units and asked for experience, CVC insertion modalities and knowledge of CVC care protocols. RESULTS: Forty-one (75 %) university hospitals with at least one adult surgical ICU took part to the study. A questionnaire was filled by 124 senior (75 % of the staff) and 53 junior (43 % of the staff) physicians inserting an average of 10 CVC per month (range, 1-35). A written protocol for CVC insertion was known by 127 (72 %) of them. CVC insertion was done while wearing sterile gown (97 %), cap (100 %) and surgical mask (100 %) and using large sterile drapes (96 %). The antiseptic solution used for cutaneous antisepsis was povidone iodine in aqueous (36 %) or alcoholic solution (40 %), or an alcoholic solution of chlorhexidine (24 %) applied one (9 %), two (64 %) or three (27 %) times before insertion. A 4-times disinfection sequence (washing, rinsing, drying and disinfection) was performed by 161 (91 %) physicians. Ultrasound-guided insertion was realized by only eight (5 %) operators. CVCs were made of polyurethane (84 %), usually multi-lumens (>96 %) and rarely tunnelised (14 %). Only two physicians (1 %) sometimes use catheters coated with antibiotics or antiseptics. The site for catheter insertion was mostly the sub-clavian (47 %) or internal jugular vein (34 %), and rarely the femoral vein (20 %). CVCs were secured with a thread (99 %) and covered with a semi-permeable dressing (76 %). Concerning CVCs maintenance, 91 % of physicians acknowledged the existence of a written protocol in the unit. Dressings were changed every day (10 %), every two days (49 %), every three days (29 %) or every four days or more (12 %) by using the same antiseptic solution and semi-permeable transparent dressing in 78 % of cases. Venous lines changes were done during dressing maintenance (48 %), every day in case of administration of lipids (32 %) or just after administration of blood products via the catheter (32 %). Routine change of CVC was rarely recommended (11 %). CONCLUSION: The high number of answers allows setting of a precise state of CVCs insertion practices in adult surgical ICUs. Recommendations for central venous catheter insertion and maintenance are not still known and\or applied.

Ventriculostomy for control of raised ICP in acute traumatic brain injury.

UNLABELLED: The aim of this study was to evaluate the effect of ventriculostomy on intracranial pressure (ICP), and related parameters, including cerebrospinal compensation, cerebral oxygenation (PbtO2) and metabolism (microdialysis) in patients with traumatic brain injury (TBI). MATERIALS AND METHODS: Twenty-four patients with parenchymal ICP sensors were prospectively included in the study. Ventriculostomy was performed after failure to control ICP with initial measures. Monitoring parameters were digitally recorded before and after ventriculostomy and compared using appropriate tests. RESULTS: In all patients ventriculostomy led to rapid reduction in ICP. Pooled mean daily values of ICP remained < 20mmHg for 72h after ventriculostomy and were lower than before (p < 0.001). In 11 out of 24 patients during the initial 24-h period following ventriculostomy an increase in ICP to values exceeding 20mmHg was observed. In the remaining 13 patients ICP remained stable, allowing reduction in the intensity of treatment. In this group ventriculostomy led to significant improvement in craniospinal compensation (RAP index), cerebral perfusion pressure and PbtO2. Improvement in lactate/pyruvate ratio, a marker of energy metabolism, was correlated with the increase in PbtO2. CONCLUSION: Ventriculostomy is a useful ICP-lowering manoeuvre, with sustained ICP reduction and related physiological improvements achieved in > 50% of patients.