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An increase of pyroglutamic acid, or 5-oxoproline plasmatic concentration was reported in metabolic acidosis observed after chronic intake of some drugs, as acetaminophen. We developed a simple, fast and reproducible method by capillary zone electrophoresis using a commercial Anion Analysis Kit ® to quantify pyroglutamic acid, in plasma after acetonitrile precipitation, and after simple dilution in urines. Fumaric acid was used as internal standard in both. In less than 7 min, the method separates pyroglutamic acid from other organic and inorganic anions. The method is linear between 0.25 and 10 mmol/L in plasma, and 0.15 and 10 mmol/L in urines. The quantification limits are 0.25 mmol/L and 0.15 mmol/L for plasma and urines, respectively. For repeatability and intermediate precision, the variation coefficients are less than 15% and the bias values are between ± 10%. For the 2 matrices, the recoveries are between 88% and 101%. The method does not interfere with physiological organic and inorganic anions. Pyroglutamic acid concentrations measured in 9 children were between 0.45 and 3.96 mmol/L in the plasma and between 0.15 and 3.2 mmol/L in the urine. No correlation between pyroglutamic acid and acetaminophen concentrations were found, regardless of the biological media. In conclusion, our method measures pathophysiological concentrations of pyroglutamic acid and highlights the increase in other organic acids that may explain metabolic acidosis due to chronic acetaminophen intake.

Objectives: To elaborate guidelines for inter-hospital transfer for severe postpartum hemorrhage., Materials and Methods: Bibliographic search in Medline and Cochrane Database by PubMed., Results: Severe postpartum hemorrhage sometimes needs inter-hospital transfer for arterial embolization or admission in intensive care unit. Validation of this transfer needs multidisciplinary decision, including obstetricians, anesthesiologist-intensivists of primary and tertiary center and prehospital medical team. If bleeding is too important or in case of uncontrolled hemorrhagic shock, inter-hospital transfer may be dangerous and local surgical hemostasis should be preferred. In such situation, prehospital medical team should stay on scene for help especially in small institutions where medical and paramedical resources are sometimes insufficient. In case of inter-hospital transportation, organ failure should be controlled and blood transfusion, if needed, should be initiated before. The patient should be transferred to a multidisciplinary center (surgery, anesthesiology and ICU, interventional radiologist, blood bank)., Conclusion: Inter-hospital transfer for severe postpartum hemorrhage is possible under certain conditions including continuation of blood transfusion and organ failure correction., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Tako-tsubo syndrome is a rare cardiomyopathy secondary to catecholamine toxicity responsible of myocardial stunning. Severe complications such as cardiogenic shock or ventricular arrhythmia can occur. We presented the case of a 32-year-old woman victim of a tako-tsubo syndrome with severe cardiogenic shock during surgical procedure for urgent caesarean section. After refractory haemodynamic failure, the patient benefits from extracorporeal membrane oxygenation support device with success., (Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Objective: Propofol is commonly used for sedation of children or adult patients in intensive care unit as an alternative to benzodiazepines for the long-term sedation of mechanically ventiled patient. However, the life-threatening complication of propofol-infusion syndrome (PRIS) may in some case occur. The objective of this article is to review the clinical features, physiopathology and management of PRIS., Data Sources: A PubMed database research in English and French languages published until December 2008. Keywords were propofol, propofol infusion syndrome (PRIS), rhabdomyolysis, heart failure, arrhythmias, metabolic acidosis, brain injury, sedation, intensive care., Data Synthesis: PRIS is a rare and potentially lethal complication, especially if there's no early identification of the syndrome. The physiopathology of PRIS mechanism remains unclear, however a dysfunction of mitochondrial respiratory chain could be involved and potential genetic factor may account. Clinical features consist of arrhythmias, metabolic acidosis, lipemia, rhabdomyolisis, myoglobinuria. PRIS has been described classically in children and adults undergoing a long term infusion with propofol (more than 48 hours) at doses higher than 4 mg/kg per hour. However, it can be observed with lower doses and after shorter duration of sedation. Steroids, vasopressors and low carbohydrate intake act as triggering factors. Early recognition of the syndrome improve patient's outcome. Propofol infusion must be avoided in susceptible patients and another sedative agent should be considered. When using prolonged sedation with propofol, arrhythmia and serum triglyceridemia level should be monitored., (Copyright 2010 Elsevier Masson SAS. All rights reserved.)

Objectives: Decision-making bringing to an admission or not in intensive care is complex. The aim of this study is to analyze with an ethical point of view the making decision process leading to the refusal and its consequences. It is proposed a setting in prospect through the principles of beneficence, non-maleficience, respect for autonomy, justice, and the Leonetti law., Patients and Methods: Prospective study in surgical reanimation at the University Hospital of Rouen over 9 months (November 2007-September 2008). Systematic collection for each non-admitted patient of the general characters, the methods of decision making, immediate becoming and within 48 h Constitution of two groups: patients for whom an admission in intensive care could be an unreasonable situation of obstinacy, and patients for whom an admission in reanimation would not be about unreasonable if it occurred., Results: One hundred and fifty situations were analyzed. The potentially unreasonable character of an admission does not involve necessarily a refusal of care in intensive care. The question of the lack of place and equity in the access to the care is real but relative according to the typology of the patients. The research of the respect of the autonomy of the patient is difficult but could be facilitated. The Leonetti law does not appear to be able to be a framework with the situation of refusal of care in intensive care., Conclusion: It is not a question of going towards a systematic admission in intensive care of any patient proposed, but to make sure that so if there is a refusal, it is carried out according to a step ethically acceptable.

Objectives: The life expectancy of the population increasing, contrary to the resources of beds in reanimation, the question of the admission of the old subject in reanimation is increasingly frequent. We will be interested in the role of the age in the medical decision-making., Patients and Methods: A questionnaire was sent to the intensivists of the same department, then the troop of the subjects refused within an intensive care of the University Hospital of this same department was studied., Results: The age arrives in third place among the factors of refusal of admission quoted. It does not seem to be an appalling criterion for access to intensive care, but rather to lead to a thorough evaluation of the patient. This idea is translated in the open questions as in the clinical settings in situation. The age modulates the recourse to the entry in intensive care. It tends to be integrated in a total process of evaluation of a patient, even if the consensus is not total... The analysis of the troop of the refused subjects showed a first reason for refusal which is the lack of place. The age is not quoted., Conclusion: The age does not seem a determining element. It cannot solve the question which is to know if the admission in reanimation is relevant or not for the patient proposed. More than the admission or not of a possibly old subject in reanimation, the problem lies in the resolution with accuracy of the acute dilemma which is the decision-making to admit or refuse a patient whatever it is for the benefit of the person.

Smokers have an elevated risk of perioperative respiratory distress and of transfer to intensive care. Tobacco smoke substantially alters the healing process and constitutes a documented risk factor for postoperative complications (anastomotic leakage, delayed healing etc.). Risk of postoperative infection is also higher in smokers. When patients stop smoking 6 to 8 weeks before surgery, the incidence of complications related to tobacco smoke drops nearly to zero. Even stopping for a short period reduces the risk of complications, although the benefits of stopping increase with length of time. Preoperative smoking cessation should take place as early as possible. The general practitioner and the surgeon both have essential roles to play. Identification of smokers must be accompanied by measures to help the patient stop smoking, including advice, and if necessary, nicotine substitutes. Anxiety levels are higher in smokers than nonsmokers. Nonetheless smoking cessation for hospitalization does not increase these levels, even without nicotine substitutes. There is no interaction between anesthetic agents and nicotine substitutes: the latter may be continued through the morning of surgery and reinitiated in the immediate postoperative period. Patients who stop smoking for surgery should be encouraged to continue to stop, permanently. The general practitioner's support is essential for this.

Introduction: Intrahospital transport (IHT) of mechanically ventilated critically ill patients is associated with an important risk of complications., Objectives: The purpose of this study was to assess the incidence of complications occurring during the IHT and to analyse the causes and the consequences of such complications., Patients and Methods: All the IHT performed in mechanically ventilated patients, hospitalised in medical and surgical intensive care units of a university hospital were prospectively included during a three-month period. Complications were defined as follows: patient related problems (desaturation, restlessness, haemodynamic instability, extubation) and ventilator related problems (breakdown or defect of the material)., Results: 123 IHT concerning 64 patients were analysed, with 64 IHT were realised for diagnostic procedure (computed tomography) and 59 for therapeutic procedure (surgical procedure or interventional radiology). At least one patient related problem occurred during 41 IHT (33%) (desaturation n = 11, agitation n = 21, haemodynamic alterations n = 19, extubation n = 0). In two patients, these complications led to cardiac arrest. Patient related problems were observed more frequently in sedated patient (66 %, p = 0.0001) as well as during IHT for diagnostic procedure (p = 0.03). A ventilator problem occurred in 26 transports (21 %) and was more frequently reported when a turbine ventilator was used (p = 0.0056)., Conclusion: This study supports the fact that IHT of mechanically ventilated critically ill patients, is a high-risk procedure associated with potentially severe complications. This finding emphasises the need of standardised procedures and medical surveillance during IHT.

Objective: To evaluate computed tomography quantification of injured pulmonary volume after thoracic trauma and its relevance for severity grade of patients with lung contusion., Study Design: Retrospective study in a major French Level I university trauma center., Patients and Methods: Clinical and biological data including oxygenation index (PaO2/FIO2) and therapeutics modalities during the first 5 days: positive end expiratory pressure (Peep) and nitric oxide (NO), were collected on 49 patients with lung contusion resulting from thoracic trauma. Injured pulmonary volume was evaluated on initial thoracic tomodensitometry by 2 senior radiologists. The correlation between oxygenation index, therapeutics modalities and initial injured pulmonary volume was assessed for signification., Results: Injured pulmonary volume larger than 37.75% of total lung volume is associated with both hypoxemia at the twenty-fourth hour (PaO2/FIO2 <300), and need for Peep >6 cm H2O and /or ongoing NO administration on day 5., Conclusion: Injured parenchymal pulmonary volume evaluation on initial tomodensitometry seems to be an important indicator of lung contusion severity. Thoracic computed tomography provides additional prognostic information in the initial evaluation of thoracic trauma with parenchymal injury.

THE SURVIVAL CHAIN: The delay to restoration of spontaneous circulation is the key to prognosis of cardiac arrest occurring outside the hospital. Among the many etiologies of cardiac arrest, sudden onset ventricular fibrillation is the number one cause of sudden death in adults. Better prognosis depends on effective organisation founded on the concept of a "survival chain". ALERT AND RESUSCITATION: By alerting the emergency units and performing the basic gestures of cardiopulmonary resuscitation (freeing the airways, mouth-to-mouth ventilation and closed chest cardiac massage) those witnessing the event take the first steps in the survival chain while waiting for the paramedical and medical teams to arrive. DEFIBRILLATION: In case of ventricular fibrillation, prognosis is directly related to the delay to defibrillation. Defibrillators used by specially trained paramedics before a physician arrives on the scene have considerably improved prognosis. SPECIALIZED RESUSCITATION: Precise algorithms help guide treatment in accordance with the observed cardiac rhythm. Tracheal intubation and artificial ventilation are fundamental. Among the useful drugs, epinephrine is by far the most important for improving myocardial and cerebral perfusion, improving the chances of recovering spontaneous circulation. The only anti-arrhythmic drug currently used is lidocaine. Infusion of alkaline fluid is only useful in specific cases of prolonged resuscitation. Expired CO2 monitoring may be a useful guide, but discontinuing resuscitation is strictly a medical decision. AFTER RESUSCITATION: When spontaneous circulation has been achieved, the patient must be transported to a cardiac hospital for specialized care and etiological treatment.

Blunt thoracic trauma are frequent and often severe. Their management is improved in the prehospital settings by the involvement of a medical team, and the admission in a specialized trauma center. Diagnostic and therapeutic steps are closely linked. They are based on the stabilization of life threatening problems and the appropriate use of recent advances in medical imaging. Endotracheal intubation and mechanical ventilation are indicated for respiratory distress. Immediate surgical management is mandatory for an hypovolemic shock related to massive hemothorax. On the contrary, multiple ribs fractures and flail chest without major pulmonary contusion are managed with regional analgesia allowing effective physiotherapy and avoiding the infectious complications related to prolonged mechanical ventilation.

The use of albumin in prehospital care is very limited. Generally, in France, volume loading in acute hypovolaemia is obtained mainly with artificial colloids. However, albumin may be useful in the prehospital care of hypovolaemic pregnant women; but this indication remains theoretical. In many emergency medical services, albumin is available if needed, but the very rare indications and the technical requirements limit its use.

In the past few years, many studies have been devoted to cardiac arrest (CA) resuscitation. The "Chain of Survival" concept is considered as the best comprehensive approach of CA prognostic improvement. It includes 4 links: early access (recognition of early signs of CA and activation of the emergency medical system), early cardiopulmonary resuscitation, early defibrillation of ventricular fibrillations and early advanced cardiac life support (intubation, intravenous medication). Non withstanding all the recent progress en physiology or therapeutics, the early management is still the basis of the prognosis. That is why prehospital care organization is the main determinant of CA survival.

A new apparatus for anaesthesia has been developed for disaster situations. A turbine pushes room air through a halothane vaporizer to a modified D. Mapleson system. A battery provides an autonomy of two hours with an air flow of 5 liters per minute. Electrical current used is 220 volts external or 12 volts. Oxygen can be added during inductions and when there is imbalance in the hemodynamic or respiratory function. One series of 20 patients successfully underwent this procedure. Oxygen monitoring was performed with percutaneous PO2, SaO2, FiO2. Only one patient with cardiac disease needed oxygen adjonction (2 l.min-1) to raise his SaO2 level above 95%. Thus it is possible to have the optimum FiO2 with the lowest amount of halothane and oxygen.

An original metabolic calculator is realized with common and fiable transducers: a "microgaz Roche Kontron 7640" gives the PiO2-PeO2 and PeCO2 (Clark and Stow Severinghaus electrods), a pneumotachograph Gould 17212 (or the reliable integrated flow meter of the respirator) gives the expiratory minute volume. These values are inserted in an micro computer (Sharp PC 1261). The soft is wrote so that results are not altered when high FiO2 are used. Consumption of lipids and glucids is displayed in percentage when diuresis and urea values are entered. This device is compared with a well known expenditure monitor: Deltatrac (Datex): simultaneous measures are carried out in patients with miscellaneous diseases (15 series of 10 measures). Regression curves appear to be very reliable, as well for VO2(r = 0.98), VCO2 (r = 0.94) energy expenditure (0.97) as for R.Q (r = 0.77).