Background In the perioperative setting, the most accurate way to continuously measure arterial blood pressure (ABP) is using an arterial catheter. Surrogate methods such as finger cuff have been ...developed to allow non-invasive measurements and are increasingly used, but need further evaluation. The aim of this study is to evaluate the accuracy and clinical concordance between two devices for the measurement of ABP during neuroradiological procedure. Methods This is a prospective, monocentric, observational study. All consecutive patients undergoing a neuroradiological procedure were eligible. Patients who needed arterial catheter for blood pressure measurement were included. During neuroradiological procedure, ABP (systolic, mean and diatolic blood pressure) was measured with two different technologies: radial artery catheter and Nexfin. Bland-Altman and error grid analyses were performed to evaluate the accuracy and clinical concordance between devices. Results From March 2022 to November 2022, we included 50 patients, mostly ASA 3 (60%) and required a cerebral embolization (94%) under general anaesthesia (96%). Error grid analysis showed that 99% of non-invasive ABP measures obtained with the Nexfin were located in the risk zone A or B. However, 65.7% of hypertension events and 41% of hypotensive events were respectively not detected by Nexfin. Compared to the artery catheter, a significant relationship was found for SAP (r.sup.2 = 0.78) and MAP (r.sup.2 = 0.80) with the Nexfin (p < 0.001). Bias and limits of agreement (LOA) were respectively 9.6 mmHg (- 15.6 to 34.8 mmHg) and - 0.8 mmHg (- 17.2 to 15.6 mmHg), for SAP and MAP. Conclusions Nexfin is not strictly interchangeable with artery catheter for ABP measuring. Further studies are needed to define its clinical use during neuroradiological procedure. Trial registration Clinicaltrials.gov, registration number: NCT05283824. Keywords: Blood pressure, Hemodynamic monitoring, Intraoperative, Neuroradiology
IntroductionIncidence of delirium after cardiac surgery remains high and delirium has a significant burden on short-term and long-term outcomes. Multiple causes can trigger delirium occurence, and it ...has been hypothesised that sleep disturbances can be one of them. Preserving the circadian rhythm with overnight infusion of low-dose dexmedetomidine has been shown to lower the occurrence of delirium in older patients after non-cardiac surgery. However, these results remain controversial. The aim of this study was to demonstrate the usefulness of sleep induction by overnight infusion of dexmedetomidine to prevent delirium after cardiac surgery.Methods and analysisDexmedetomidine after Cardiac Surgery for Prevention of Delirium is an investigator-initiated, randomised, placebo-controlled, parallel, multicentre, double-blinded trial. Nine centres in France will participate in the study. Patients aged 65 years or older and undergoing cardiac surgery will be enrolled in the study. The intervention starts on day 0 (the day of surgery) until intensive care unit (ICU) discharge; the treatment is administered from 20:00 to 08:00 on the next day. Infusion rate is modified by the treating nurse or the clinician with an objective of Richmond Agitation and Sedation Scale score from −1 to +1. The primary outcome is delirium occurrence evaluated with confusion assessment method for the ICU two times per day during 7 days following surgery. Secondary outcomes include incidence of agitation related events, self-evaluated quality of sleep, cognitive evaluation 3 months after surgery and quality of life 3 months after surgery. The sample size is 348.Ethics and disseminationThe study was approved for all participating centers by the French Central Ethics Committee (Comité de Protection des Personnes Ile de France VI, registration number 2018-000850-22). The results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT03477344.
Anaemia is common prior to cardiac surgery and contributes to perioperative morbidity. Iron deficiency is the main cause of anaemia but its impact remains controversial in the surgical setting. We ...aimed to estimate the impact of iron deficiency on in-hospital perioperative red blood cell transfusion for patients undergoing elective and urgent cardiac surgery. Secondary objectives were to identify risk factors associated with in-hospital red blood cell transfusion.
We conducted a prospective multicentre observational study in three university hospitals performing cardiac surgery. We determined iron status prior to surgery and collected all transfusion data to compare iron-deficient and iron-replete patients during hospital stay. We performed a multivariable logistic regression to compare transfusion among groups.
Five hundred and two patients were included. A trend of low haemoglobin levels associated with iron deficiency persisted until discharge. Red blood cell transfusion was significantly higher in the group of iron deficient patients during surgery (22% vs 13%, p = 0.017), however the incidence during the whole hospital stay was 31% in the iron-deficient group, not significantly different with the non-deficient group (26%, p = 0.28). Iron deficiency was not independently associated with in-hospital red blood cell transfusion (adjusted OR = 0.85 0.53-1.36, p = 0.49).
In-hospital red blood cell transfusion was not significantly higher in iron-deficient patients and iron deficiency was not associated with in-hospital red blood cell transfusion in patients undergoing elective and urgent cardiac surgery. Iron deficiency was the main cause of anaemia and anaemia was a strong driver of red blood cell transfusion. Further studies should identify sub-population of iron-deficient patients which may benefit from preoperative iron deficiency management and explore the long-term impact of lower haemoglobin levels at discharge in the iron deficient population.
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Rapid-onset paralytic agents are recommended to achieve muscle relaxation and facilitate tracheal intubation during rapid sequence induction in patients at risk of pulmonary aspiration of gastric ...contents. However, opioids are frequently used in this setting. The study's objective is to demonstrate the non-inferiority of remifentanil compared to rapid-onset paralytic agents, in association with an hypnotic drug, for tracheal intubation in patients undergoing procedure under general anesthesia and at risk of pulmonary aspiration of gastric contents.
The REMICRUSH (Remifentanil for Rapid Sequence Induction of Anaesthesia) study is a multicenter, single-blinded, non-inferiority randomized controlled trial comparing remifentanil (3 to 4 μg/kg) with rapid-onset paralytic agents (succinylcholine or rocuronium 1 mg/kg) for rapid sequence induction in 1150 adult surgical patients requiring tracheal intubation during general anesthesia. Enrolment started in October 2019 in 15 French anesthesia units. The expected date of the final follow-up is October 2021. The primary outcome is the proportion of successful tracheal intubation without major complications. A non-inferiority margin of 7% was chosen. Analyses of the intent-to-treat and per-protocol populations are planned.
The REMICRUSH trial protocol has been approved by the ethics committee of The Comité de Protection des Personnes Sud-Ouest et Outre-Mer II and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentations at scientific conferences and publications in peer-reviewed journals. The REMICRUSH trial is the first randomized controlled trial powered to investigate whether remifentanil with hypnotics is non-inferior to rapid-onset paralytic agents with hypnotic in rapid sequence induction of anesthesia for full stomach patients considering successful tracheal intubation without major complication.
ClinicalTrials.gov NCT03960801. Registered on May 23, 2019.
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Summary Introduction Most survivors of out-of-hospital cardiac arrest (OHCA) will die subsequently from post-anoxic encephalopathy. In animals, the severity of brain damage is mainly influenced by ...the duration of cardiac arrest and also by the cerebral blood flow (CBF) and oxygen extraction (CEO2 ) abnormalities observed during the post-resuscitation period. The aim of our study was to describe CBF and CEO2 modifications during the first 72 h in OHCA patients treated by induced mild hypothermia. Methods Consecutive OHCA patients were studied every 12 h over 72 h. Diastolic flow velocities (dFV), mean flow velocities (mFV) and pulsatility index (PI) were assessed by transcranial doppler (TCD) as an estimate of CBF changes. Simultaneous measurements of CEO2 were obtained using retrograde jugular catheterisation. Results Eighteen patients (61 47–74 years) were studied (12 non-survivors and 6 survivors). At admission, mFV values were low (27.3 21.5–33.6 cm/s) but reached normal values after 72 h (50.5 36.7–58.1 cm/s). Initial PI values were high (1.6 1.3–1.9) but reached normal values after 72 h (1.04 0.82–1.2). No differences were found between survivors and non-survivors regarding these CBF estimates. CEO2 values were quite normal at admission (20.4 11–27%) but decreased over time in non-survivors until H72 (25.8% 19.3–31.1 versus 5.7% 5.1–11.5, p = 0.02). Conclusion Cerebral haemodynamic and oxygenation values are altered considerably but evolve during the first 72 h following resuscitation after cardiac arrest. In particular, these changes may lead to a mismatch between CBF and CEO2 leading to a “luxurous perfusion” in non-survivors.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Uropathogenic strains of Escherichia coli cause symptomatic infections whereas asymptomatic bacteriuria (ABU) strains are well adapted for growth in the human urinary tract, where they establish ...long-term bacteriuria. Human urine is a very complex growth medium that could be perceived by certain bacteria as a stressful environment. To investigate a possible imbalance between endogenous oxidative response and antioxidant mechanisms, lipid oxidative damage estimated as thiobarbituric acid reactive substances (TBARS) content was evaluated in twenty-one E. coli belonging to various pathovars and phylogenetic groups. Antioxidant defense mechanisms were also analysed.
During exponential growth in urine, TBARS level differs between strains, without correlation with the ability to grow in urine which was similarly limited for commensal, ABU and uropathogenic strains. In addition, no correlation between TBARS level and the phylogroup or pathogenic group is apparent. The growth of ABU strain 83972 was associated with a high level of TBARS and more active antioxidant defenses that reduce the imbalance.
Our results indicate that growth capacity in urine is not a property of ABU strains. However, E. coli isolates respond very differently to this stressful environment. In strain ABU 83972, on one hand, the increased level of endogenous reactive oxygen species may be responsible for adaptive mutations. On the other hand, a more active antioxidant defense system could increase the capacity to colonize the bladder.
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The Prophylactic hypOthermia to Lessen trAumatic bRain injury-Randomised Controlled Trial (POLAR-RCT) will evaluate whether early and sustained prophylactic hypothermia delivered to patients with ...severe traumatic brain injury improves patient-centred outcomes.
The POLAR-RCT is a multicentre, randomised, parallel group, phase III trial of early, prophylactic cooling in critically ill patients with severe traumatic brain injury, conducted in Australia, New Zealand, France, Switzerland, Saudi Arabia and Qatar. A total of 511 patients aged 18-60 years have been enrolled with severe acute traumatic brain injury. The trial intervention of early and sustained prophylactic hypothermia to 33 °C for 72 h will be compared to standard normothermia maintained at a core temperature of 37 °C. The primary outcome is the proportion of favourable neurological outcomes, comprising good recovery or moderate disability, observed at six months following randomisation utilising a midpoint dichotomisation of the Extended Glasgow Outcome Scale (GOSE). Secondary outcomes, also assessed at six months following randomisation, include the probability of an equal or greater GOSE level, mortality, the proportions of patients with haemorrhage or infection, as well as assessment of quality of life and health economic outcomes. The planned sample size will allow 80% power to detect a 30% relative risk increase from 50% to 65% (equivalent to a 15% absolute risk increase) in favourable neurological outcome at a two-sided alpha of 0.05.
Consistent with international guidelines, a detailed and prospective analysis plan has been developed for the POLAR-RCT. This plan specifies the statistical models for evaluation of primary and secondary outcomes, as well as defining covariates for adjusted analyses and methods for exploratory analyses. Application of this statistical analysis plan to the forthcoming POLAR-RCT trial will facilitate unbiased analyses of these important clinical data.
ClinicalTrials.gov, NCT00987688 (first posted 1 October 2009); Australian New Zealand Clinical Trials Registry, ACTRN12609000764235 . Registered on 3 September 2009.
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Identifying patients at risk of secondary neurologic deterioration (SND) after moderate traumatic brain injury (moTBI) is a challenge, as such patients will need specific care. No simple scoring ...system has been evaluated to date. This study aimed to determine clinical and radiological factors associated with SND after moTBI and to propose a triage score.
All adults admitted in our academic trauma center between January 2016 and January 2019 for moTBI (Glasgow Coma Scale GCS score, 9-13) were eligible. SND during the first week was defined either by a decrease in GCS score of >2 points from the admission GCS in the absence of pharmacologic sedation or by a deterioration in neurologic status associated with an intervention, such as mechanical ventilation, sedation, osmotherapy, transfer to the intensive care unit (ICU), or neurosurgical intervention (for intracranial mass lesions or depressed skull fracture). Clinical, biological, and radiological independent predictors of SND were identified by logistic regression (LR). An internal validation was performed using a bootstrap technique. A weighted score was defined based on beta (β) coefficients of the LR.
A total of 142 patients were included. Forty-six patients (32%) showed SND, and 14-day mortality rate was 18.4%. Independent variables associated with SND were age above 60 years (odds ratio OR, 3.45 95% confidence interval {CI}, 1.45-8.48; P = .005), brain frontal contusion (OR, 3.22 95% CI, 1.31-8.49; P = .01), prehospital or admission arterial hypotension (OR, 4.86 95% CI, 2.03-12.60; P = .006), and a Marshall computed tomography (CT) score of 6 (OR, 3.25 95% CI, 1.31-8.20; P = .01). The SND score was defined with a range from 0 to 10. The score included the following variables: age >60 years (3 points), prehospital or admission arterial hypotension (3 points), frontal contusion (2 points), and Marshall CT score of 6 (2 points). The score was able to detect patients at risk of SND, with an area under the receiver operating characteristic curve (AUC) of 0.73 (95% CI, 0.65-0.82). A score of 3 had a sensitivity of 85%, a specificity of 50%, a VPN of 87%, and a VPP of 44 % to predict SND.
In this study, we demonstrate that moTBI patients have a significant risk of SND. A simple weighted score at hospital admission could be able to detect patients at risk of SND. The use of the score may enable optimization of care resources for these patients.
Critically ill patients including trauma patients are at high risk of urinary tract infection (UTI). The composition of urine in trauma patients may be modified due to inflammation, systemic stress, ...rhabdomyolysis, life support treatment and/or urinary catheter insertion.
Prospective, single-centre, observational study conducted in patients with severe trauma and without a history of UTIs or recent antibiotic treatment. The 24-hour urine samples were collected on the first and the fifth days and the growth of Escherichia coli in urine from patients and healthy volunteers was compared. Biochemical and hormonal modifications in urine that could potentially influence bacterial growth were explored.
Growth of E. coli in urine from trauma patients was significantly higher on days 1 and 5 than in urine of healthy volunteers. Several significant modifications of urine composition could explain these findings. On days 1 and 5, trauma patients had an increase in glycosuria, in urine iron concentration, and in the concentrations of several amino acids compared to healthy volunteers. On day 1, the urinary osmotic pressure was significantly lower than for healthy volunteers.
We showed that urine of trauma patients facilitated growth of E. coli when compared to urine from healthy volunteers. This effect was present in the first 24 hours and until at least the fifth day after trauma. This phenomenon may be involved in the pathophysiology of UTIs in trauma patients. Further studies are required to define the exact causes of such modifications.
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