Anaesthesia Critical Care & Pain Medicine最新文献

Survival rates for trauma cardiac arrest (TCA) routinely range from 2-5% and have not improved in high-income countries over the past two decades, unlike those for medically induced cardiac arrests. This persisting low TCA survival rates have led to debates, about the value of resuscitating TCA patients, considering the significant risks and costs involved compared to the low chances of favorable outcomes. As well, TCA patients are frequently excluded from large randomized controlled trials on cardiac arrest management, with most research consisting of retrospective studies and clinical case series. The causes of cardiac arrest following injury are diverse, and hypovolemia, particularly from hemorrhagic shock, is a significant cause of early death. Direct cardiac or large vessel injuries, such as myocardial contusions or tamponade, can also lead to TCA. While TCA from severe brain or spinal injuries are less frequent, survival rates in these cases can be slightly better if return of spontaneous circulation (ROSC) is achieved. The presence of bystander CPR, shockable initial rhythms, and rapid identification and treatment of reversible causes are associated with favorable outcomes. A few strategies should be applied systematically, such as early bleeding source control, oxygen supplementation, hypovolemia correction, and diagnosing and treating compressive pleural or pericardial effusions. Emerging techniques are suggested for the management of refractory hemorrhagic shock and cardiac arrest, such as the REBOA (Resuscitative Balloon Occlusion of the Aorta), but further research is needed to determine the most effective approaches to prehospital and in-hospital TCA management.

Background: Weaning from external ventricular drainage (EVD) following subarachnoid hemorrhage (SAH) typically requires an EVD closure trial, performed either straightforwardly (rapid weaning) or after gradual elevation of EVD (gradual weaning). We wanted to compare these two methods and build a sore to predict closure trial failure.

Methods: Among adult SAH patients, this multicenter (n = 5) retrospective study, compared rapid and gradual EVD weaning methods, and identified factors associated with EVD closure trial failure through logistic regressions. We developed a score to predict closure trial failure by splitting the dataset into training (2/3) and testing (1/3) sets.

Results: Among 1141 patients with an EVD between 01/01/2018 and 12/31/2022, 407 were hospitalized for SAH and had at least one EVD weaning attempt, 249 (61%) underwent gradual and 158 (39%) rapid weaning. Rapid weaning was associated with more failure (72 (46%)vs. 86 (35%), p = 0.044), but shorter length of stay (LOS) in both ICU and hospital. EVD closure trial failure was independently associated with prolonged EVD maintenance (p < 0.001), prolonged ICU (p = 0.001) and hospital LOS (p = 0.05). We developed a failure closure score using the difference in intracranial pressures (from H0 to H3 after closure), time since EVD insertion, and EVD level. The model's area under the receiver operating curve was 0.63 [0.53 - 0.74], indicating fair discrimination ability.

Conclusions: EVD weaning strategies vary across centres. Rapid weaning was associated with a high risk of closure trial failure, but shorter LOS. EVD closure trial failure was associated with worse outcomes. A simple 3-criteria score could help.

Stevens-Johnson Syndrome is a rare disorder of the skin and mucous membranes accompanied by systemic symptoms that are life threatening and require immediate intervention. We sought to determine if different hospital types, specifically urban nonteaching hospitals versus urban teaching hospitals, have different outcomes among patients presenting with Stevens-Johnson Syndrome during hospitalization. Patients presenting to urban teaching and urban nonteaching hospitals were compared. Compared to patients at urban nonteaching hospitals, patients at urban teaching hospitals had significantly increased risk of mortality, and urban nonteaching hospitals had higher rates of transferring patients to another hospital. Future research is needed to explore patient outcomes beyond the hospitalization period and in different hospital settings.

Introduction: Intraoperative hypotension (IOH) is a common complication in the operating room. Vasopressors are crucial in managing IOH but data on their use in children, particularly norepinephrine (NE), are limited. This study aimed to explore NE use in IOH management among French pediatric anesthesiologists.

Materials and methods: A survey was conducted using an online Google Forms® questionnaire, validated by experienced pediatric anesthesiologists and the ADARPEF board. Distributed via the ADARPEF Research Network, the survey covered demographics, IOH definitions, treatment approaches, and NE use.

Results: We received 205 responses (44.1%). IOH was defined as a percent of fall of preoperative arterial pressure for 63.9% of respondents and normogram or age-based formulae value for 33.6%. Cerebral NIRS and invasive arterial blood pressure were the most common tools for monitoring patients with high risk of IOH. For vasoplegia-induced IOH, the first-line treatment was fluid bolus (49.2%) or ephedrine (35.3%). NE was used as second line treatment by 26.2 % of respondents. For IOH due to blood loss, fluid bolus was the primary treatment followed by NE. NE was used monthly by 79.3% of respondents and weekly by 45.3%. Variations in dilution and dosage practices were noted, with 70.5% reporting the use of highly diluted NE. Side effects were reported by 86.1% of NE users.

Conclusion: The survey highlights significant variability to determine the threshold of IOH requiring treatment and vasopressors use. NE is widely used by pediatric anesthesiologists, but practices vary, indicating the need for standardised guidelines and further safety studies.

Introduction: Bedside tools have been developed to assess inspiratory muscle function and inspiratory drive for patients under invasive mechanical ventilation. Occlusion maneuvers are currently considered but their pitfalls remain underexplored. We aimed to assess the impact of respiratory system compliance and resistance on P0.1 (addressing respiratory drive and inspiratory muscle function) and maximal inspiratory pressure (MIP, assessing global inspiratory muscle function) monitoring for fixed inspiratory muscle pressure (P_MUS) through an in-silico model.

Methods: The Active Servo Lung 5000 (ASL-5000) was used to reproduce respiratory conditions under fixed P_MUS of 5, 10 and 20 cmH₂O. From baseline, resistance and compliance challenges were performed. P0.1 and MIP were monitored on a ventilator (Dräger Evita Infinity V500).

Results: Resistance challenge impacted the monitoring of both P0.1 and MIP while compliance challenge barely modified P0.1 and MIP under all P_MUS settings. Statistical analysis confirmed significant correlations for increased Resistance and under-estimation of P0.1 and MIP (Spearman coefficient - 0.80, p-value < 0.01), while reduced compliance had inconsistent effect on occlusion maneuver values. We found expiratory (rather than inspiratory) resistances impacted pressure monitoring.

Discussion: Lung Resistance - but not Compliance - impairs P0.1 and Maximal Inspiratory Pressure Measurements. Further clinical studies are mandatory to define pitfalls and limits of occlusion maneuver monitoring.

Introduction: The present study aimed at assessing gender balance in the Editorial roles of Critical Care Medicine (CCM) journals.

Methods: A cross-sectional survey was performed for assessing the gender distribution in Editorial Board (EB) roles of journals indexed under Clarivate Journal Citation Reports and Scimago Journal & Country Rank. The influences of editorial roles and of journal rank (separated in quartiles) on gender balance were also assessed.

Results: Among 99 screened CCM journals, 92 journals were included. There were 937 women among 4002 EB members (23.4%). We found a greater imbalance among Editors-in-Chief (females: n = 12/104, 11.5%) as compared to editorial roles with lower responsibilities (Senior Editors, n = 22/104, 21.2%, p = 0.04; Associate Editors, n = 208/739, 28.1%, p = 0.0002; EB members, n = 695/3055, 22.7%, p = 0.0038). In a post-hoc analysis conducted separating the journals according to their ranking quartiles (1-2 vs 3-4), we found no influence of ranking on gender balance. When exploring the gender balance according to the journals' impact factor, there was a majority of men as editors in all 4 quartiles across all EB roles.

Conclusions: We found a large gap in gender distribution across EB members' roles in CCM journals, especially in the role of Editor-in-Chief, regardless of the journal ranking.

Background: We explored the risk factors of post-induction hypotension during rapid sequence intubation.

Methods: We performed an ancillary analysis of a multicenter randomized clinical trial comparing remifentanil versus neuromuscular blockers associated with hypnotic in patients at risk for aspiration who underwent tracheal intubation in the operating room. The primary outcome was post-induction hypotension, defined as an episode of hypotension (MBP ≤ 55 mmHg and/or SBP ≤ 80 mmHg) within 10 minutes after anesthetic induction.

Results: From 15 hospitals, 1137 adult patients were included, and 291 (26%) had post-induction hypotension. Propofol was used in 1117 (98%) patients and was associated with low doses of ketamine in 209 (18 %) patients. The independent risk factors associated with post-induction hypotension were age (OR 1.03, 95% CI [1.02; 1.04] p < 0.0001), baseline heart rate (p = 0.0068), bowel occlusion requiring nasogastric tube placement before intubation (OR 1.96, 95% CI [1.33; 2.87] p = 0.0006) and use of remifentanil (OR 3.54, 95%CI (2.61; 4.81) p < 0.0001). Use of low doses of ketamine (OR 0.61, 95% CI [0.41; 0.92] p = 0.0175) and basal SBP (OR 0.98, 95% CI [0.97; 0.99] p < 0.0001) were protective factors. The precision of the final model including the above-mentioned variables gave an AUC of 0.74 [95% CI 0.71; 0.77] for post-induction hypotension prediction.

Conclusions: Post-induction hypotension was frequent during rapid sequence intubation. Sedation associating propofol with low doses of ketamine was associated with a low risk of post-induction hypotension. Further studies are required to demonstrate a causal effect.

Registration: ClinicalTrials.gov NCT03960801.