Search

Metabolic phenotyping consists in the identification of subtle and coordinated metabolic variations associated with various pathophysiological stimuli. Different analytical methods, such as nuclear magnetic resonance, allow the simultaneous quantification of a large number of metabolites. Statistical analyses of these spectra thus lead to the discrimination between samples and the identification of a metabolic phenotype corresponding to the effect under study. This approach allows the extraction of candidate biomarkers and the recovery of perturbed metabolic networks, driving to the generation of biochemical hypotheses (pathophysiological mechanisms, diagnostic tests, therapeutic targets…). Metabolic phenotyping could be useful in anaesthesiology and intensive care medicine for the evaluation, monitoring or diagnosis of life-threatening situations, to optimise patient managements. This review introduces the physical and statistical fundamentals of NMR-based metabolic phenotyping, describes the work already achieved by this approach in anaesthesiology and intensive care medicine. Finally, potential areas of interest are discussed for the perioperative and intensive management of patients, from newborns to adults.

The case of 3-year-old girl severely injured, as restrained car passenger in a road crash, is reported. She presented with isolated circulatory failure, without specific clinical signs except skin contusions corresponding to seat belt. Because of mediastinum enlargement on systematic chest X-ray, a pericardial effusion was suspected, which was confirmed by echography, rapidly complicated by an acute tamponade without visible cause on CT-scan. The radiological assessment showed a moderate peritoneal haemorrhage related to a splenic injury. A persistent haemodynamic instability required a pericardial puncture, after rapid sequence tracheal intubation of the child, but without clinical improvement, despite fluid bolus, red-blood cell transfusion and epinephrine infusion. The child was rapidly transferred to the cardiac operating room for sternotomy, which showed a right atrial laceration. The injury was repaired, allowing the child to survive without disability. Tamponade due to traumatic cardiac injury is extremely rare in children. The clinical diagnosis is particularly difficult to establish in the context of polytrauma. The classical symptoms of cardiac tamponade are rarely complete. The association of chest injury, isolated circulatory failure and enlargement of mediastinum at chest X-ray should alert the physician. As the severity of these injuries is high, a rapid and multidisciplinary management is required, as well as specific anaesthetics precautions.

Bacterial meningitis is still a serious disease with a high risk of mortality and sequels. The progress in antibiotic treatment has not improved the prognosis. Thus, optimizing the initial care and the treatment of the most severe cases should improve the outcome. No study has compared the outcome according to the level of care at the admission site. There is evidence that the most severe cases should be managed by critical care units. It seems reasonable to recommend initial admission of common cases to units able to provide intensive care. Most people now agree that fluid restriction has not demonstrated its efficiency, furthermore it might have deleterious effects. However, a fluid overload should be avoided. Maintaining cerebral perfusion is a key issue in the treatment of bacterial meningitis and requires monitoring both arterial blood pressure and intracranial pressure. Intracranial pressure monitoring is probably useful to optimize the treatment of the most severe cases. The aggressive treatments of cerebral edema have not been evaluated but seem, in some limited series, able to improve some life threatening situations. The benefit of systematic glycerol administration needs confirmation. Seizures should be treated with the usual medications. However, drugs with potentially deleterious effects on hemodynamics should be avoided. There is no sufficient evidence to support the administration of a systematic prophylactic treatment. Fever should be treated when above 39.5 degrees C/40 degrees C and in the case of intracranial hypertension. There is no clinical study to explore the modifications of fever on bacterial growth or on inflammation as observed in some experimental studies.

La dialyse peritoneale (DP) est une des trois modes d’epuration extrarenale (EER) utilisee en pediatrie pour traiter une insuffisance renale aigue (IRA). Elle fait appel a deux mecanismes de dialyse : la diffusion et la convection. Les proprietes anatomiques du peritoine permettent des echanges d’eau et de solutes. Ces proprietes peuvent etre alterees dans certaines situations cliniques. Les indications de la DP ont beaucoup evolue ces 20 dernieres annees du fait du developpement de machines d’hemofiltration automatisees et securisees permettant de realiser de l’hemofiltration ou de l’hemodialyse continue chez des enfants de poids inferieur a 10 kg [1,2]. Il reste neanmoins une place pour la DP dans certaines indications que nous detaillerons, car meme si les techniques continues ont fait des progres, les complications sont frequentes, la mise en place n’est pas toujours facile chez des malades fragiles et la DP a de nombreux avantages et un moindre cout [2]. Actuellement, aucune technique d’EER n’a montre sa superiorite par rapport a une autre en termes de survie. Celle-ci est faible dans les situations d’IRA en reanimation puisque les etudes rapportent des taux de survie au mieux de 60–70 %. L’apprentissage de la technique est assez simple mais exige un protocole strict et une surveillance etroite. La DP est source d’une charge en soin non negligeable. Nous exposons ici les principes de cette technique d’EER, ses indications et ses modalites pratiques.

US11 protein, one of herpes simplex virus type 1 (HSV-1) true late gene products, plays a role in the virally induced post-transcriptional control of gene expression. In addition, US11 expression also interferes with the cellular response to HSV-1 infection that can lead to apoptosis. We have previously shown that US11 expression enhanced the recovery of cellular protein synthesis and increased cell survival in response to thermal stress. Since heat shock can activate apoptosis, we tested for a possible anti-apoptotic behavior of US11. Here, we show that, in HeLa cells, US11 expression strongly reduced heat induced apoptosis, a phenomenon independent of Hsp expression and characterized by a delayed cytochrome c efflux from mitochondria and reduced caspase 3 activation. Moreover, US11 expression also protected against staurosporine induced apoptosis. Hence, our results favor an anti-apoptotic activity of US11 polypeptide that appears to be located at the level of mitochondria or upstream signaling pathways.

Background and aims Many sources of conflict exist in intensive care units between family’s members, team–family, or within the ICU team. These conflicts are frequents (48%) in adults ICU, and most are in relation to end-of-life decisions especially with decisions to forgo LST. In PICU, no study has previously reported the prevalence, characteristics and effects of these conflicts. Methods We conducted a retrospective observational study of children admitted to PICU of Lyon, France, for whom a meeting to forgo LST had been held between October 1st 2010 and February 28th 2014. We search in medical record if conflict or disagreement were noticed and we interviewed the referent physician about conflict. We distinguished simple disagreement (quickly resolved), continuing disagreement (parents refuse recommendations with communication still possible), and conflict (communication impossible). Results For 72 children (31 girls, 41 boys), 91 decision-making meetings were organised. We identified 27.7% (20/72) disagreements or conflicts: 4 simple disagreements, 12 continuing disagreements and 4 conflicts. Five children had acute disease and 15 children had chronic disease. Source of disagreements was continuing LST in 19 cases (families wanted to continue aggressive treatment). In 1 case, the family wanted to stop treatments despite medical opinion (refusal of tracheotomy). Consequences of theses disagreements were continuation of treatments despite LST decisions in 12 cases. For 3 cases a compromise solution was found. Conclusion Disagreements are frequent in decisions to forgo LST (27,7%) and most of the child undergo treatments that are medically futile.