Objective
To describe current use and diagnostic and therapeutic impacts of point-of-care ultrasound (POCUS) in the intensive care unit (ICU).
Background
POCUS is of growing importance in the ICU. ...Several guidelines recommend its use for procedural guidance and diagnostic assessment. Nevertheless, its current use and clinical impact remain unknown.
Methods
Prospective multicentric study in 142 ICUs in France, Belgium, and Switzerland. All the POCUS procedures performed during a 24-h period were prospectively analyzed. Data regarding patient condition and the POCUS procedures were collected. Factors associated with diagnostic and therapeutic impacts were identified.
Results
Among 1954 patients hospitalized during the study period, 1073 (55 %) POCUS/day were performed in 709 (36 %) patients. POCUS served for diagnostic assessment in 932 (87 %) cases and procedural guidance in 141 (13 %) cases. Transthoracic echocardiography, lung ultrasound, and transcranial Doppler accounted for 51, 17, and 16 % of procedures, respectively. Diagnostic and therapeutic impacts of diagnostic POCUS examinations were 84 and 69 %, respectively. Ultrasound guidance was used in 54 and 15 % of cases for central venous line and arterial catheter placement, respectively. Hemodynamic instability, emergency conditions, transthoracic echocardiography, and ultrasounds performed by certified intensivists themselves were independent factors affecting diagnostic or therapeutic impacts.
Conclusions
With regard to guidelines, POCUS utilization for procedural guidance remains insufficient. In contrast, POCUS for diagnostic assessment is of extensive use. Its impact on both diagnosis and treatment of ICU patients seems critical. This study identified factors associated with an improved clinical value of POCUS.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
In France, the pre-hospital field triage of trauma patients is currently based on the Vittel criteria algorithm. This algorithm was originally created in 2002 before the stratification of trauma ...centers and, at the national level, has not been revised since. This could be responsible for the overtriage of trauma patients in Level I Trauma Centers. The principal aim of this study was to evaluate the correlation between each Vittel field triage criterion and trauma patients' Injury Severity Score.
Our Level I Trauma Center receives an average of 300 trauma patients per year. Demographic and physiological data, along with the entire trauma patient management process and Vittel field triage criteria, are recorded in a local trauma registry. The Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) are calculated after a complete assessment of the trauma victim during their in-hospital management. Results were concerned with the presence of an ISS of greater than 15, which defined a major trauma patient; mortality within 30 days; and admission to the intensive care unit. This study is a registry analysis from January 2013 to September 2017.
Of the 1373 patients in the registry, 1151 were included in the analysis with a mean age of 43 years (± 19) and a median ISS of 13 (IQR = 5-22), where 887 (77%) were male. Nine of the 24 Vittel criteria were associated with an ISS > 15. In a multivariate analysis, no criterion related to kinetic elements was significantly correlated with an ISS > 15, mortality within 30 days, or admission to intensive care. Three algorithm categories were predictive of a major trauma patient (ISS > 15): physiological variables, pre-hospital resuscitation, and physical injuries, while kinetic elements were not.
Criteria related to physiological variables, pre-hospital resuscitation, and physical injuries are the most relevant to predicting the severity of a trauma patient's condition. A revision of the VCA could potentially have beneficial effects on the over and undertriage phenomena, which constitute ongoing medical and financial concerns.
OBJECTIVE:The improvement in oxygenation with prone positioning is not persistent when patients with acute respiratory distress syndrome (ARDS) are turned supine. High-frequency oscillatory ...ventilation (HFOV) aims to maintain an open lung volume by the application of a constant mean airway pressure. The aim of this study was to show that HFOV is able to prevent the impairment in oxygenation when ARDS patients are turned back from the prone to the supine position.
DESIGN:Prospective, comparative randomized study.
SETTING:A medical intensive care unit.
PATIENTS:Forty-three ARDS patients with a Pao2/Fio2 ratio <150 at positive end-expiratory pressure ≥5 cm H2O.
INTERVENTIONS:After an optimization period, the patients were assigned to one of three groupsa) conventional lung-protective mechanical ventilation in the prone position (12 hrs) followed by a 12-hr period of conventional lung-protective mechanical ventilation in the supine position (CVprone-CVsupine); b) conventional lung-protective mechanical ventilation in the supine position (12 hrs) followed by HFOV in the supine position (12 hrs) (CVsupine-HFOVsupine); or c) conventional lung-protective mechanical ventilation in the prone position (12 hrs) followed by HFOV in the supine position (CVprone-HFOVsupine group).
MEASUREMENTS AND MAIN RESULTS:Pao2/Fio2 ratio was higher at the end of the study period in the CVprone-HFOVsupine group than in the CVprone-CVsupine group (p < .02). Venous admixture at the end of the study period was lower in the CVprone-HFOVsupine group than in the two other groups.
CONCLUSIONS:HFOV maintained the improvement in oxygenation related to prone positioning when ARDS patients were returned to the supine position.
Objective
To assess the hysteresis of the pressure–volume curve (PV curve) as to estimate, easily and at the bedside, the recruitability of the lung in ARDS patients.
Design
Prospective study.
...Setting
Twelve medico-surgical ICU beds of a general hospital.
Patients
Twenty-six patients within the first 24 h from meeting ARDS criteria.
Intervention
A Quasi-static inflation and deflation PV curve from 0 to 40 cmH
2
O and a 40 cmH
2
O recruitment maneuver (RM) maintained for 10 s were successively done with an interval of 30 min in between.
Recordings and calculation
Hysteresis of the PV curve (
H
PV
) was calculated as the ratio of the area enclosed by the pressure volume loop divided by the predicted body weight (PBW). The volume increase during the RM (
V
RM
) was measured by integration of the flow required to maintain the pressure at 40 cmH
2
O and divided by PBW, as an estimation of the volume recruited during the RM.
Results
A positive linear correlation was found between
H
PV
and
V
RM
(
r
= 0.81,
P
< 0.0001).
Conclusions
The results suggest using the hysteresis of the PV curve to assess the recruitability of the lung.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background Early optimization of treatment is crucial when admitting patients to the ICU and could depend on the organization of the medical team. The aim of this retrospective observational study ...was to determine whether admissions during morning rounds are independently associated with hospital mortality in a medical ICU. Methods The 3,540 patients admitted from May 2000 to April 2010 to the medical ICU of Sainte Marguerite Hospital in Marseille, France, were divided into two groups based on the time of admission. The non-morning rounds group was admitted between 1:00 pm and 7:59 am , and the morning rounds group was admitted between 8:00 am and 12:59 pm . Hospital mortality (crude and adjusted) was compared between the two groups. Results The 583 patients (16.5%) admitted during morning rounds were older and sicker upon admission compared with those patients admitted during non-morning rounds. The crude hospital mortality was 35.2% (95% CI, 31.4-39.1) in the group of patients admitted during morning rounds and 28.0% (95% CI, 26.4-29.7) in the other group ( P < .001). An admission during morning rounds was not independently associated with hospital death (adjusted hazard ratio, 1.10; 95% CI, 0.94-1.28; P = .24). Conclusions Being admitted to the medical ICU during morning rounds is not associated with a poorer outcome than afternoon and night admissions. The conditions of the patients admitted during morning rounds were more severe, which underlines the importance of the ICU team's availability during this time. Further studies are needed to evaluate if the presence of a specific medical team overnight in the wards would be able to improve patients' outcome by preventing delayed ICU admission.
Managing the distal tibiofibular (DTF) joint remains a challenge despite recent developments. Ankle arthroscopy is emerging as a diagnostic and therapeutic means. Our study aimed to compare ...preoperative imaging data and arthroscopic data, with the hypothesis that imaging alone is insufficient to evaluate acute laxity, and with arthroscopy as the reference examination.
All patients treated in 2023 in our department for an acute isolated DTF lesion were included prospectively. Preoperative radiographic and MRI imaging were compared with arthroscopic data.
Ten patients were treated. For five patients, the instability was doubtful after carrying out an appropriate imaging assessment (X-rays of both ankles, MRI). For four of these five patients, instability was confirmed by arthroscopy. Arthroscopy was useful for suturing the anterior bundle of the DTF joint for two patients and allowed for verifying the reduction in the sagittal and coronal planes for two patients. No complications were detected.
Arthroscopy in isolated acute DTF lesions seems to provide a diagnostic and therapeutic advantage. Its use may allow for exhaustive assessment and complete repair of lesions. It must be offered as soon as possible; a delay in specialized imaging may delay therapeutic care.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background and objectives
Haemorrhagic shock is a leading cause of avoidable mortality in prehospital care. For several years, our centre has followed a procedure of transfusing two units of packed ...red blood cells outside the hospital. Our study’s aim was twofold: describe the patient characteristics of those receiving prehospital blood transfusions and analyse risk factors for the 7‐day mortality rate.
Materials and methods
We performed a monocentric retrospective observational study. Demographic and physiological data were recovered from medical records. The primary outcome was mortality at seven days for all causes. All patients receiving prehospital blood transfusions between 2013 and 2018 were included.
Results
Out of 116 eligible patients, 56 patients received transfusions. Trauma patients (n = 18) were younger than medical patients (n = 38) (P = 0·012), had lower systolic blood pressure (P = 0·001) and had higher haemoglobin levels (P = 0·016). Mortality was higher in the trauma group than the medical group (P = 0·015). In‐hospital trauma patients received more fresh‐frozen plasma and platelet concentrate than medical patients (P < 0·05). Predictive factors of 7‐day mortality included transfusion for trauma‐related reasons, low Glasgow Coma Scale, low peripheral oxygen saturation, prehospital intensive resuscitation, existing coagulation disorders, acidosis and hyperlactataemia (P < 0·05).
Conclusion
Current guidelines recommend early transfusion in patients with haemorrhagic shock. Prehospital blood transfusions are safe. Coagulation disorders and acidosis remain a cause of premature death in patients with prehospital transfusions.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
OBJECTIVE:To evaluate the effects of neuromuscular blocking agents (NMBAs) on pulmonary and systemic inflammation in patients with acute respiratory distress syndrome ventilated with a ...lung-protective strategy.
DESIGN:Multiple-center, prospective, controlled, and randomized trial.
SETTING:One medical and two medical–surgical intensive care units.
PATIENTS:A total of 36 patients with acute respiratory distress syndrome (Pao2/Fio2 ratio of ≤200 at a positive end-expiratory pressure of ≥5 cm H2O) were included within 48 hrs of acute respiratory distress syndrome onset.
INTERVENTIONS:Patients were randomized to receive conventional therapy plus placebo (n = 18) or conventional therapy plus NMBAs (n = 18) for 48 hrs. Both groups were ventilated with a lung-protective strategy (tidal volume between 4 and 8 mL/kg ideal body weight, plateau pressure of ≤30 cm H2O).
MEASUREMENTS AND MAIN RESULTS:Bronchoalveolar lavages and blood samples were performed, before randomization and at 48 hrs, to determine the concentrations of tumor necrosis factor-α, interleukin (IL)-1β, IL-6, and IL-8. Pao2/Fio2 ratio was evaluated before randomization and at 24, 48, 72, 96, and 120 hrs. A decrease over time in IL-8 concentrations (p = .034) was observed in the pulmonary compartment of the NMBA group. At 48 hrs after randomization, pulmonary concentrations of IL-1β (p = .005), IL-6 (p = .038), and IL-8 (p = .017) were lower in the NMBA group as compared with the control group. A decrease over time in IL-6 (p = .05) and IL-8 (p = .003) serum concentrations was observed in the NMBA group. At 48 hrs after randomization, serum concentrations of IL-1β (p = .037) and IL-6 (p = .041) were lower in the NMBA group as compared with the control group. A sustained improvement in Pao2/Fio2 ratio was observed and was reinforced in the NMBA group (p < .001).
CONCLUSION:Early use of NMBAs decrease the proinflammatory response associated with acute respiratory distress syndrome and mechanical ventilation.
Background
In the intensive care unit (ICU), the outcomes of patients with acute mesenteric ischemia (AMI) are poorly documented. This study aimed to determine the risk factors for death in ICU ...patients with AMI.
Methods
A retrospective, observational, non-interventional, multicenter study was conducted in 43 ICUs of 38 public institutions in France. From January 2008 to December 2013, all adult patients with a diagnosis of AMI during their hospitalization in ICU were included in a database. The diagnosis was confirmed by at least one of three procedures (computed tomography scan, gastrointestinal endoscopy, or upon surgery). To determine factors associated with ICU death, we established a logistic regression model. Recursive partitioning analysis was applied to construct a decision tree regarding risk factors and their interactions most critical to determining outcomes.
Results
The death rate of the 780 included patients was 58 %. Being older, having a higher sequential organ failure assessment (SOFA) severity score at diagnosis, and a plasma lactate concentration over 2.7 mmol/l at diagnosis were independent risk factors of ICU mortality. In contrast, having a prior history of peripheral vascular disease or an initial surgical treatment were independent protective factors against ICU mortality. Using age and SOFA severity score, we established an ICU mortality score at diagnosis based on the cutoffs provided by recursive partitioning analysis. Probability of survival was statistically different (
p
< 0.001) between patients with a score from 0 to 2 and those with a score of 3 and 4.
Conclusion
Acute mesenteric ischemia in ICU patients was associated with a 58 % ICU death rate. Age and SOFA severity score at diagnosis were risk factors for mortality. Plasma lactate concentration over 2.7 mmol/l was also an independent risk factor, but values in the normal range did not exclude the diagnosis of AMI.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
OBJECTIVE:To evaluate the effect of mean airway pressure under high-frequency oscillatory ventilation on right ventricular function.
DESIGN:Prospective randomized study.
SETTING:Intensive care unit ...of a tertiary care hospital.
PATIENTS:Sixteen consecutive patients within the first 48 hrs of mainly pulmonary acute respiratory distress syndrome.
INTERVENTIONS:After a 6-hr-period of protective conventional mechanical ventilation, patients were submitted to three 1-hr periods of high-frequency oscillatory ventilation (+ 5, + 10, + 15) in a randomized order, with a mean airway pressure level determined by adding 5, 10, or 15 cm H2O to the mean airway pressure recorded during conventional mechanical ventilation.
MEASUREMENTS AND MAIN RESULTS:Mean airway pressure was 18 ± 3 cm H2O during conventional mechanical ventilation and was increased until 33 ± 3 cm H2O at high-frequency oscillatory ventilation + 15. Right ventricular function was assessed using transesophageal echocardiography. During conventional mechanical ventilation, nine patients presented a right ventricular dysfunction (right ventricular end-diastolic area/left ventricular end-diastolic area ratio >0.6) of whom four patients had a right ventricular failure (right ventricular end-diastolic area/left ventricular end-diastolic area ratio >0.9). High-frequency oscillatory ventilation + 10 and + 15 further worsened right ventricular function, resulting in about a 40% increase in right ventricular end-diastolic area/left ventricular end-diastolic area ratio and a 30% increase in end-diastolic eccentricity index when compared with conventional mechanical ventilation or high-frequency oscillatory ventilation + 5 periods. At high-frequency oscillatory ventilation + 15, 15 patients had right ventricular dysfunction and nine had right ventricular failure. High-frequency oscillatory ventilation did not improve oxygenation whatever the mean airway pressure level. A significant redistribution of tidal variation to the posterior parts of the lung was observed on electrical impedance tomography measurements when increasing mean airway pressure. However, this redistribution was not observed in patients who presented a worsening of right ventricular function (right ventricular end-diastolic area/left ventricular end-diastolic area increase >40%) at high-frequency oscillatory ventilation + 15.
CONCLUSIONS:In patients with mainly pulmonary acute respiratory distress syndrome, using high mean airway pressure under high-frequency oscillatory ventilation can worsen right ventricular function when compared with protective conventional mechanical ventilation, notably in patients in whom high-frequency oscillatory ventilation produced less alveolar recruitment of the posterior parts of the lungs. This study highlights the interest of monitoring right ventricular function during high-frequency oscillatory ventilation. (Crit Care Med 2012; 40:–6)
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