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During the first Covid-19 wave, our paediatric intensive care unit (PICU), like many others across the globe, was transformed into an adult ICU for patients with severe Covid-19, due to a shortage of adult ICU beds. Here, we provide a comprehensive description of all the conditions that must be fulfilled to successfully accomplish this transformation. Strong support from all hospital departments was crucial, as their activity was modified by the change. Healthcare workers from various units, notably the paediatric anaesthesiology department, worked in the adult ICU to ensure sufficient staffing. The number of physiotherapists and psychologists was increased. A support system for both healthcare workers and patients' relatives was set up with the help of the mobile paediatric palliative care and support team. Supplies suitable for adults were ordered. Protocols for numerous procedures were written within a few days. Video tutorials, checklists, and simulation sessions were circulated to the entire staff. The head nurses guided and supported the new staff and usual PICU staff. The transformation was achieved within a week. The main difficulties were healthcare worker stress, changes in recommendations over time, absence of visits from relatives, and specific adult issues that paediatricians are unfamiliar with.Conclusion: For the staff, caring for adult patients was made easier by working in their familiar unit instead of being moved to an adult hospital with unfamiliar staff members and equipment. Strong support from the hospital and the assistance of consultants from adult hospital departments were crucial. What is Known: • The dramatic spread across the world of coronavirus disease 2019 generated critical care needs that drastically exceeded resources in many countries worldwide. • Paediatric ICU activity during this period decreased due to lockdown measures and the fact that children rarely required ICU for coronavirus disease 2019. What is New: • We describe how an 18-bed adult Covid-19 ICU was successfully set up in a paediatric hospital during the first wave of the Covid-19 pandemic. • Specific requirements regarding supply, human resources, and procedures, as well as difficulties encountered, are described.

International audience; War is back in Europe. With all its horrific pictures and live videos.In its report issued on the 24th of March 2022, the World Health Organization (WHO) [1] states that the Ukrainian conflict has involved 18 million persons so far, with 3.4 million refugees in bordering countries and 6.4 million persons internally displaced (Fig. 1). In this report, 1,035 deaths and 1,650 civilian injuries were reported in Ukraine without any reported data from Russia.

A correction to this paper has been published: https://doi.org/ https://doi.org/10.1007/s00431-021-04026-x

Resume L’acharnement therapeutique, defini par la mise en route ou la poursuite d’un traitement deraisonnable, est assimile a un acte malveillant moralement condamnable. La loi no 2005-370 du 22 avril 2005 relative aux droits des malades et a la fin de vie l’a rendu illegal. Lorsque le patient informe n’est plus competent pour d’exprimer ses preferences, notre problematique consiste a decider ce qui definit, au cas par cas, l’obstination deraisonnable. La decision se doit de retenir une des deux options suivantes : (1) mettre en route ou poursuivre un traitement ; (2) ne pas mettre en route ou limiter ou arreter un traitement. Comment prendre la bonne decision, ou au minimum la moins mauvaise ? Apres avoir brievement rappele le cadre legislatif dans lequel cette decision doit necessairement s’inscrire, nous detaillerons le processus decisionnel usuel, tel qu’il a ete modelise. Il apparait clairement que nos decisions ne sont pas seulement rationnelles. La connaissance du role de nos emotions peut permettre d’eviter certains biais, notamment dans les situations d’urgence. La collegialite, lorsqu’elle est envisageable, est une contre-mesure supplementaire qui permet au medecin-decideur d’echapper a ces biais, en mobilisant le systeme collectif de pensee lente, plus raisonnable. La decision peut alors se prevaloir d’une procedure rationnelle effective, qui la legitime, y compris dans le cas ou elle implique l’abstention de la mise en route d’un traitement juge deraisonnable.

In the perioperative period, several potential conflicts between anaesthetists/intensive care specialists and surgeons may exist. They are detrimental to the quality of patient care and to the well-being of the teams. They are a source of medical errors and contribute to burn-out. Patients can become the victims of such conflicts, which deserve ethical reflection. Their resolution through analysis and shared solutions is necessary. This article seeks to analyse these conflicts, taking into account their specificities and constraints. In order to understand this context, it is important to consider the specificities of each group involved and the records of such situations. Several factors can prevent these conflicts, first and foremost the patients themselves and the quality of the care that is provided. Medical deontology aims mainly at preventing and resolving these conflicts. Generally speaking, the quality approach which is increasingly applied in health care institutions (involving declarations of adverse events, morbidity/mortality reviews, benchmarking, analysis and improvement of practices, etc.) also contributes to the prevention and resolution of disagreements. The teaching of communication techniques that begins with the initial training, the evaluation of team behaviours (through simulation training for example), the respect of others' constraints, particularly when it comes to learning, as well as transparency regarding conflicts of interests, are all additional elements of conflict prevention. Lastly, conflicts may at times be caused by deviant behaviours, which must be met with a clear and uncompromising collective and institutional approach. This article concludes by offering a standardised approach for conflict resolution.

Contexte : La prise en charge de la fin de vie constitue un enjeu societal crucial auquel le legislateur a repondu par la loi du 22 avril 2005. Neanmoins, un debat emerge de la societe civile sur l'opportunite de depenaliser/legaliser l'euthanasie et/ou le suicide assiste (E/SA). Cette question interroge directement les medecins, en particulier les anesthesistesreanimateurs (AR). Objectif : Mettre en perspective les concepts a partir d'une analyse de la litterature medicale et de l'experience des pays qui ont legifere sur E/SA. Resultats : La loi du 22 avril 2005 constitue une reponse adaptee a l'essentiel des situations de fin de vie auxquelles est confronte l'AR. Sa force tient a l'obligation de dispenser des soins palliatifs quand les therapeutiques devenues vaines sont interrompues. Neanmoins, les demarches d'accompagnement et de soins palliatifs sont introduites trop tard durant le cours des maladies fatales. Leur enseignement et des mesures incitatives fortes s'imposent. Les rares cas ou E/SA sont demandes par les patients ou leurs proches resultent souvent de decisions non-prises en amont et/ou de traitements qui ne considerent pas le patient dans sa globalite. La mise en oeuvre d'E/SA ne se resume pas a la simple affirmation d'un principe d'autonomie. Les procedures d'E/SA laissent entrevoir de reelles difficultes et des risques de derives. Conclusion : Nous formulons un message de prudence et de mesure. Peut-on repondre aux questions douloureuses de la fin de vie, de la souffrance morale, en supprimant le sujet lorsqu'une reelle demarche de soins palliatifs n'a pas ete pleinement mise en oeuvre ? ER - End of Reference

Resume Le comite d’ethique de la Societe francaise d’anesthesie et de reanimation (Sfar) a ete sollicite par l’agence de la biomedecine sur la question des prelevements d’organes apres arret des therapeutiques actives (ATA). Ce type de prelevement est autorise et pratique aux Etats-Unis, au Canada, au Royaume-Uni, aux Pays-Bas et en Belgique. Les trois premiers pays ont redige des recommandations concernant ce type de prelevement. Ces recommandations fixent pour l’essentiel une procedure ou une conduite a tenir operationnelle, une fois l’ATA valide. Le comite a deliberement cadre sa reflexion selon un champ plus large et global que celui qui prevaut dans l’approche anglo-saxonne. Cette analyse qui envisage toutes les etapes d’un tel prelevement, nous a conduits a emettre des reserves quant a l’applicabilite de ce type de prelevement a tout patient chez qui une decision d’ATA aurait ete validee. Dans un souci de coherence par rapport aux pratiques du prelevement d’organes chez des patients en mort encephalique qui prevalent en France, nous avons souligne la necessite de n’envisager l’ATA-M3, pour le moment, que chez les patients cerebro-leses chez qui un tres mauvais pronostic neurologique pouvait etre predit avec un niveau de certitude eleve, au moyen d’examens paracliniques. Dans notre esprit, les elements de preuve doivent etre fixes et assumes par la collectivite, representee par l’agence de biomedecine, et pas par le medecin en charge du malade. Ils doivent etre opposables au cas ou l’on s’interrogerait sur la qualite de la pronostication neurologique. Ce texte a ete endosse par le conseil d’administration de la Sfar.

Severe postpartum haemorrhage (SPPH) is the leading cause of peripartum hysterectomy and maternal death. There are no easily measurable parameters that indicate the failure of medical therapy and the need for an advanced interventional procedure (AIP) to stop genital tract bleeding. The aim of the study was to define factors predictive of the need for an AIP in the management of emergent PPH.The study included two phases: (1) an initial retrospective study of 257 consecutive patients with SPPH, allowing the determination of independent predictors of AIP, which were subsequently grouped in a predictive score, followed by (2) a multicentre study of 239 patients admitted during 2007, designed to validate the score. The main outcome measure was the need for an AIP, defined as uterine artery embolization, intraabdominal packing, arterial ligation or hysterectomy.Abnormalities of placental implantation, prothrombin time50% (or an International Normalized Ratio1.64), fibrinogen2 g/l, troponin detectable, and heart rate115 bpm were independently predictive of the need for an AIP. The SPPH score included each of the five predictive factors with a value of 0 or 1. The greater the SPPH score, the greater the percentage of patients needing an AIP (11% for SPPH 0, to 75% for SPPH ≥2). The AUC of the ROC curve of the SPPH score was 0.80.We identified five independent predictors of the need for an AIP in patients with SPPH and persistent bleeding. Using these predictors in a single score could be a reliable screening tool in patients at risk of persistent genital tract bleeding and needing an AIP.

Background Single-use metal laryngoscope blades are cheaper and carry a lower risk of infection than reusable metal blades. The authors compared single-use and reusable metal blades during rapid sequence induction of anesthesia in a multicenter cluster randomized trial. Methods One thousand seventy-two adult patients undergoing general anesthesia under emergency conditions and requiring rapid sequence induction were randomly assigned on a weekly basis to either single-use or reusable metal blades (cluster randomization). After induction, a 60-s period was allowed to complete intubation. In the case of failed intubation, a second attempt was performed using the opposite type of blade. The primary endpoint was the rate of failed intubation, and the secondary endpoints were the incidence of complications (oxygen desaturation, lung aspiration, and/or oropharynx trauma) and the Cormack and Lehane score. Results Both groups were similar in their main characteristics, including the risk factors for difficult intubation. The rate of failed intubation was significantly decreased with single-use metal blades at the first attempt compared with reusable blades (2.8 vs. 5.4%, P < 0.05). In addition, the proportion of grades III and IV in Cormack and Lehane score were also significantly decreased with single-use metal blades (6 vs. 10%, P < 0.05). The global complication rate did not reach statistical significance, although the same trend was noted (6.8% vs. 11.5%, P = not significant). An investigator survey and a measure of illumination pointed that illumination might have been responsible for this result. Conclusions The single-use metal blade was more efficient than a reusable metal blade in rapid sequence induction of anesthesia.

Whether cardiac ventricles can acutely dilate during septic myocardial dysfunction.A prospective echocardiographic study was performed to assess changes of left ventricular dimensions over time in patients with septic shock.A 20-bed surgical intensive care unit of Pitié-Salpêtrière university hospital in Paris.Forty-five patients were studied over the first 10 days of septic shock.None.Left ventricular end-diastolic area (LVEDA), fractional area change (FAC), velocity time integral of the aortic flow, echocardiographic indices of left ventricular relaxation, and cardiac troponin I (cTnI) were measured at day 1, 2, 3, 4, 7, and 10. Three groups were defined: 29 patients without increased cTnI and cardiac impairment (group 1), eight patients with increased cTnI and left systolic ventricular dysfunction (group 2), and eight patients with increased cTnI and isolated impairment of left ventricular relaxation (group 3). At day 1, LVEDA was significantly higher in group 2 (13 +/- 3 cm/m, p0.05) compared with groups 1 (10 +/- 2 cm/m) and 3 (11 +/- 2 cm/m). LVEDA did not change in groups 1 and 3. In group 2, LVEDA and FAC returned within 10 days to values observed in groups 1 and 2. A significant correlation was found between aortic velocity time integral and LVDEA (r =.78, p = 0.022) and FAC (r =.89, p = 0.003) only in group 2.Acute and reversible left ventricular dilation accompanies septic shock-induced systolic left ventricular dysfunction. When septic myocardial abnormalities are limited to reversible impairment of left ventricular relaxation, left ventricular dimensions remain unchanged.

Many patients with septic shock and increased cardiac troponin I (cTnI) do not exhibit significant left ventricular systolic dysfunction. We hypothesized that an isolated and reversible impairment of ventricular relaxation may be associated with the increase in cTnI.Prospective, observational study.Surgical intensive care unit in a university hospital.Total of 54 patients with septic shock.Fractional area change, early diastolic velocity of mitral annulus, flow propagation velocity of early diastolic mitral inflow, cTnI, tumor necrosis factor-alpha, interleukin (IL)-6, -1beta, -8, and -10 were measured at days 1, 2, 3, 4, 7, and 10 after onset of septic shock. Patients were classified into three groups: normal cTnI (group 1), increased cTnI and fractional area change50% (group 2), and increased cTnI and fractional area change50% (group 3).A total of 22 patients had an increase in cTnI, 11 with both systolic and diastolic dysfunctions and 11 with isolated impairment of left ventricular relaxation. At day 1, early diastolic velocity of mitral annulus and flow propagation velocity of early diastolic mitral inflow were significantly lower and tumor necrosis factor-alpha, IL-8, and IL-10 significantly higher in groups 2 and 3 compared with group 1. With resolution of septic shock, early diastolic velocity of mitral annulus and flow propagation velocity of early diastolic mitral inflow measured in patients of groups 2 and 3 returned progressively to values observed in group 1, with a parallel normalization of tumor necrosis factor-alpha, IL-8, and IL-10.Isolated and reversible impairment of left ventricular relaxation, associated with transient increases in cTnI, tumor necrosis factor-alpha, IL-8, and IL-10, was observed in 20% of patients with septic shock.

BACKGROUND AND OBJECTIVE: Diagnosis of brain death usually requires the absence of spontaneous respiratory movements during the apnoea test and an arterial carbon dioxide partial pressure above 60 mmHg. On the other hand, although capnography (end-tidal CO(2)) is currently monitored in intensive care unit patients, it has not been evaluated during the apnoea test in brain-dead patients. Therefore, the aim of this prospective study was first to investigate the usefulness of capnography monitoring, and secondly to evaluate the variation of the carbon dioxide partial pressure-end-tidal CO(2) gradient during the apnoea test in clinically brain-dead patients. METHODS: After local Ethics Committee approval, 60 clinically brain-dead patients were investigated. End-tidal CO(2) was continuously recorded before, during and after the apnoea test. Arterial blood gases were sampled immediately before and after the apnoea test for calculation of the carbon dioxide partial pressure-end-tidal CO(2) gradient. RESULTS: The apnoea test was clinically positive in 58 patients, whereas end-tidal CO(2) was equal to 0 during the apnoea. During the 20-min apnoea test, carbon dioxide partial pressure increased from 40 +/- 7 to 97 +/- 19 mmHg (P < 0.001) with a rate of 2.8 +/- 0.9 mmHg min(-1), end-tidal CO(2) increased from 31 +/- 6 to 68 +/- 17 mmHg (P < 0.001) and carbon dioxide partial pressure-end-tidal CO(2) gradient increased from 9 +/- 4 to 29 +/- 10 mmHg (P < 0.001). In two patients, the apnoea test was clinically negative because of the occurrence of spontaneous respiratory movements, whereas capnography showed contemporaneously significant increases in end-tidal CO(2). CONCLUSIONS: End-tidal CO(2) should be systematically monitored and recorded, at least for medico-legal considerations, during the apnoea test in brain-dead patients. The high variability in the carbon dioxide partial pressure-end-tidal CO(2) gradient increase precludes any extrapolation of the carbon dioxide partial pressure from the end-tidal CO(2) at the end of the apnoea test.

Delayed graft function is a major determinant of long-term renal allograft survival. Despite considerable efforts to improve donor selection and matching, incidence of delayed graft function remains close to 25%. As neutrophil gelatinase-associated lipocalin (NGAL) has been shown to predict acute renal failure, the authors tested the hypothesis that NGAL measurement in brain-dead donors predicts delayed graft function in kidney recipients.In a prospective, multicenter, observational study, serum NGAL was measured in donors at the time of transfer to operating room. The primary endpoint was the delayed graft function, defined as the need for renal replacement therapy during the first week posttransplantation.Among 159 included brain-dead donors, 146 were analyzable leading to 243 renal transplantations. Of these, 56 (23%) needed renal replacement therapy. Donors' NGAL values were similar in case of both delayed and normal graft function in recipients. The area under the receiver-operating curve for NGAL to predict the need for renal replacement therapy before day 8 was 0.50 (95% CI, 0.42 to 0.59). The area under curve for NGAL to predict failure to return to a normal graft function at day 8 was 0.51 (95% CI, 0.44 to 0.59). Using multivariate analysis, NGAL was not associated to the need for renal replacement therapy (odds ratio, 0.99; 95% CI, 0.98 to1.00) or failure to return to a normal graft function at day 8 (odds ratio, 1.00; 95% CI, 0.99 to 1.00).NGAL measurement in brain-dead donors at the time of recovery failed to predict delayed or normal graft function in kidney recipients.

Background Plastic single-use laryngoscope blades are inexpensive and carry a lower risk of infection compared with metal reusable blades, but their efficiency during rapid sequence induction remains a matter of debate. The authors therefore compared plastic and metal blades during rapid sequence induction in a prospective randomized trial. Methods Two hundred eighty-four adult patients undergoing general anesthesia requiring rapid sequence induction were randomly assigned on a weekly basis to either plastic single-use or reusable metal blades (cluster randomization). After induction, a 60-s period was allowed to complete intubation. In the case of failed intubation, a second attempt was performed using metal blade. The primary endpoint of the study was the rate of failed intubations, and the secondary endpoint was the incidence of complications (oxygen desaturation, lung aspiration, and oropharynx trauma). Results Both groups were similar in their main characteristics, including risk factors for difficult intubation. On the first attempt, the rate of failed intubation was significantly increased in plastic blade group (17 vs. 3%; P < 0.01). In metal blade group, 50% of failed intubations were still difficult after the second attempt. In plastic blade group, all initial failed intubations were successfully intubated using metal blade, with an improvement in Cormack and Lehane grade. There was a significant increase in the complication rate in plastic group (15 vs. 6%; P < 0.05). Conclusions In rapid sequence induction of anesthesia, the plastic laryngoscope blade is less efficient than a metal blade and thus should not be recommended for use in this clinical setting.

Background In cardiac patients, pulmonary capillary wedge pressure (PCWP) is estimated using color M-mode Doppler study of left ventricular filling and Doppler tissue imaging. The goal of this study was to assess whether echocardiography accurately estimates PCWP in critically ill patients. Methods Sixty ventilated patients admitted for septic shock and acute lung injury were prospectively studied using simultaneously transesophageal echocardiography and pulmonary artery catheterization. Initial PCWP values and their changes measured invasively were compared to initial values and corresponding changes of early diastolic velocity of mitral annulus displacement measured by Doppler tissue imaging (Ea), flow propagation velocity of early diastolic mitral inflow measured by color M-mode Doppler (Vp), and their respective ratio to early mitral inflow velocity (E) measured by conventional Doppler: E/Ea and E/Vp. Relations between E/Ea, E/Vp, and PCWP were prospectively tested in 20 additional patients. Results E/Ea and E/Vp gave a rough estimate of initial PCWP values with mean biases of 0.4 +/- 2.2 and 0.1 +/- 2.9 mmHg, respectively. Receiving operating characteristic curves demonstrated that an E/Ea of 6 or greater is an accurate predictor of a PCWP of 13 mmHg or greater and that an E/Ea of 5.4 is a good predictor of a PCWP of 8 mmHg or less. Changes in PCWP were significantly correlated to changes in E/Ea (Rho = 0.84, P < 0.0001). Conclusions In patients with postoperative circulatory shock and acute lung injury, transesophageal echocardiography estimates noninvasively PCWP. However, echocardiographic estimation of PCWP may not be accurate enough for adjusting therapy.

Lung tissue deposition and antibacterial efficiency of nebulized and intravenous amikacin (AMK) were compared in anesthetized and ventilated piglets suffering from a bronchopneumonia produced by the intrabronchial inoculation of Escherichia coli. AMK was administered 24 hours after the inoculation either through an ultrasonic nebulizer (45 mg x kg-1, n = 10) or by intravenous infusion (15 mg x kg-1, n = 8). Piglets were killed 1 hour after a second AMK administration performed 24 hours after the first one, and lung tissue concentrations of AMK and lung bacterial burden were assessed on multiple lung specimens. The amount of nebulized AMK reaching the tracheobronchial tree represented 38 +/- 6% of the initial nebulizer AMK charge. After nebulization, AMK lung tissue concentrations were 3- to 30-fold higher than after intravenous administration and were influenced by the severity of lung lesions: 188 +/- 175 microg x g-1 in lung segments with mild bronchopneumonia versus 40 +/- 65 microg x g-1 in lung segments with severe bronchopneumonia (p0.01). Lung bacterial burden was significantly lower in the aerosol group than in the intravenous group (median = 0 colony forming units. g-1 versus median = 5 x 10(2) colony forming units x g-1, p0.001). In conclusion, the deposition of AMK in infected lung parenchyma and the efficiency of bacterial killing were greater after nebulization than after intravenous administration.

Post-anaesthesia care units (PACUs) with 24/7 activity and consequently artificial light and noise may disturb the sleep of patients who require prolonged medical supervision. After one postoperative night, we compared sleep quality in patients with and without noise (earplug) and light (eye mask) protection.After ethical board approval, 46 patients without any neurological or respiratory failure undergoing major non-cardiac surgery were prospectively included. They were randomized to sleep with or without protective devices during the first postoperative night in the PACU. Sleep quality was simultaneously measured by sleep-quality scales (Spiegel score and Medical Outcomes Study Sleep), nurses' assessment, and through a wrist actigraph (Actiwatch). Secondary outcomes such as pain control and nocturnal activity were recorded. Comparisons between groups were made by Student's t-test or non-parametric test for repeated measures as appropriate (SPSS 10.0). A P-value0.05 was considered significant.Data from 41 patients were analysed. Protective devices during the first postoperative night prevented a decrease in sleep quality compared with standard care, as evaluated by the Spiegel scale: 20 (4) vs 15 (5), P=0.006. These devices significantly decreased the need for a nap [50% 95% confidence interval (CI) (20-80) vs 95% 95% CI (85-100), P0.001], but had no effect on sleep length evaluated by Actiwatch. The total consumption of morphine was significantly reduced in the first 24 h [respectively, 15(12) mg and 27(17) mg, P=0.02].Earplugs and eye masks applied in the PACU during the first postoperative night significantly preserve sleep quality. Such non-invasive and cheap devices may be generalized in the PACU or in intensive care units.

Purpose of review The purpose of the present review is to describe the methods using an extracorporeal membranous oxygenation (ECMO) circuit in donors after cardiac death and to evaluate their impact on the outcome of renal transplantation. Recent findings ECMO can be used either in hypothermic conditions for total body cooling or in normothermic conditions and limited to the abdomen in a first phase, before subsequent in-situ cooling. In both cases, oxygen is added to the perfusion, as compared with the usual and simple cold in-situ perfusion. There is a strong experimental rationale to use ECMO in normothermic conditions. The clinical studies in renal transplantation are still few, retrospective with small cohorts (level 3 or 4, according to the Oxford Centre for Evidence-Based Medicine). However, they all reach consistent conclusions with better kidney transplant outcome, both in uncontrolled (type I and II) and controlled (type III) donors, according to the Maastricht classification. Summary The use of ECMO in donors after cardio-circulatory death should be encouraged and further developed. Experimental work is in progress to better define the optimal conditions of the technique, which will help to limit or even repair the injuries, induced by warm ischaemia.

Background After brain death, adrenal insufficiency (AI) is very common and may be one of the mechanisms that contributes to hemodynamic instability and loss of potential organ donors. However, when diagnosed by total cortisol measurement, critically ill patients may be overdiagnosed as having AI. The aims of this study were to assess the prevalence of AI when diagnosed using free cortisol measurement and the accuracy of total cortisol measurement to diagnose AI in brain-dead patients. Methods All consecutive brain-dead patients were included in this single-center noninterventional clinical observation study. Assessment of adrenocorticotropin, corticosteroid-binding globulin, baseline and tetracosactin-stimulated serum free and total cortisol concentrations were performed. AI was defined as a baseline free cortisol concentration ≤ 55 nM(-1) and/or Δ free cortisol ≤ 55 nM(-1). Patients were considered to have a low albumin concentration if less than 25 g · L(-1) and a low corticosteroid-binding globulin concentration if less than 27 mg · L(-1) in men or 31 mg · L(-1) in women. Results Among the 42 included patients, the incidence of AI was 83% (95% CI, 69-93%). Baseline total cortisol was correlated with baseline free cortisol, whatever the albumin or corticosteroid-binding globulin concentration. The area under the receiver operating characteristic curve of baseline total cortisol measurement to diagnose AI was 0.94 (95% CI, 0.81-0.98). The optimal cutoff was 485 nM(-1), providing a sensitivity and a specificity of 89% and 100%, respectively. Conclusion Total baseline cortisol measurement is accurate and sufficient to diagnose AI in brain-dead patients, even if albumin or corticosteroid-binding globulin concentrations are low.

Introduction: Extracorporeal life support (ECLS) has recently shown encouraging results in the resuscitation of inhospital (IH) refractory cardiac arrest. We assessed the use of ECLS following out-of-hospital (OH) refractory cardiac arrest. Methods: We evaluated 51 consecutive patients who experienced witnessed OH refractory cardiac arrest and received automated chest compression and ECLS upon arrival in the hospital. Patients with preexisting severe hypothermia who experienced IH cardiac arrest were excluded. A femorofemoral ECLS was set up on admission to the hospital by a mobile cardiothoracic surgical team. Results: Fifty-one patients were included (mean age, 42 ± 15 years). The median delays from cardiac arrest to cardiopulmonary resuscitation and ECLS were, respectively, 3 minutes (25th to 75th interquartile range, 1 to 7) and 120 minutes (25th to 75th interquartile range, 102-149). Initial rhythm was ventricular fibrillation in 32 patients (63%), asystole in 15 patients (29%) patients and pulseless rhythm in 4 patients (8%). ECLS failed in 9 patients (18%). Only two patients (4%) (95% confidence interval, 1% to 13%) were alive at day 28 with a favourable neurological outcome. There was a significant correlation (r = 0.36, P = 0.01) between blood lactate and delay between cardiac arrest and onset of ECLS, but not with arterial pH or blood potassium level. Deaths were the consequence of multiorgan failure (n = 43; 47%), brain death (n = 10; 20%) and refractory hemorrhagic shock (n = 7; 14%), and most patients (n = 46; 90%) died within 48 hours. Conclusions: This poor outcome suggests that the use of ECLS should be more restricted following OH refractory cardiac arrest.

Background Hemodynamic instability is frequent in brain-dead patients and may result, in part, from absolute or relative adrenal insufficiency. Corticosteroid supplementation is widely used to restore hemodynamic stability in septic shock and to reduce the time of shock resolution. The authors verified that supplementation with hydrocortisone may enhance hemodynamic stability in brain-dead patients. Methods All consecutive brain-dead patients with hypotension requiring vasopressor agents were included in this single-center noninterventional clinical observation study. Assessment of baseline and adrenocorticotropic hormone (ACTH)-stimulated plasma cortisol concentrations was performed. Immediately after, patients were systematically treated with a single intravenous injection of hydrocortisone (50 mg), and norepinephrine administration was adjusted every 15 min to maintain mean arterial pressure between 65 and 90 mmHg. Adrenal insufficiency was defined as baseline plasma cortisol concentration less than 15 microg/dl and/or delta plasma cortisol concentration less than 9 microg/dl. Patients were considered as ACTH responders when delta cortisol concentration was more than 9 microg/dl 30 min after ACTH injection. Results Among the 31 patients included, the incidence of adrenal insufficiency was 87% [95% CI, 70-96%]. A significant (> or =30%) decrease in norepinephrine dose was obtained 180 min after hydrocortisone injection in 18 (59%) patients, from 0.31 [0.16-0.44] microg . kg(-1) . min(-1) to 0.18 [0.10-0.24] microg . kg(-1) . min(-1) (P < 0.01). The incidence of hemodynamic response was greater in ACTH nonresponders than in ACTH responders: 86% versus 50%, respectively, P < 0.05. Conclusions Adrenal insufficiency with hemodynamic instability is frequent in brain-dead patients. After ACTH stimulation testing and hydrocortisone infusion, hemodynamic stability is enhanced especially in patients with true adrenal nonfunction.

Single-use metal laryngoscope blades are cheaper and carry a lower risk of infection than reusable metal blades. The authors compared single-use and reusable metal blades during rapid sequence induction of anesthesia in a multicenter cluster randomized trial.One thousand seventy-two adult patients undergoing general anesthesia under emergency conditions and requiring rapid sequence induction were randomly assigned on a weekly basis to either single-use or reusable metal blades (cluster randomization). After induction, a 60-s period was allowed to complete intubation. In the case of failed intubation, a second attempt was performed using the opposite type of blade. The primary endpoint was the rate of failed intubation, and the secondary endpoints were the incidence of complications (oxygen desaturation, lung aspiration, and/or oropharynx trauma) and the Cormack and Lehane score.Both groups were similar in their main characteristics, including the risk factors for difficult intubation. The rate of failed intubation was significantly decreased with single-use metal blades at the first attempt compared with reusable blades (2.8 vs. 5.4%, P0.05). In addition, the proportion of grades III and IV in Cormack and Lehane score were also significantly decreased with single-use metal blades (6 vs. 10%, P0.05). The global complication rate did not reach statistical significance, although the same trend was noted (6.8% vs. 11.5%, P = not significant). An investigator survey and a measure of illumination pointed that illumination might have been responsible for this result.The single-use metal blade was more efficient than a reusable metal blade in rapid sequence induction of anesthesia.

BACKGROUND As a result of donor heart shortage, resorting to marginal heart donors is being promoted. Dobutamine is usually used to support these potential donors and has been proposed to identify the reversible part of the brain death-induced myocardial dysfunction before potential organ donation. But dobutamine impairs the oxygen supply-demand balance and may increase myocardial ischemia. The aim of this study was to compare the effects of dobutamine and glucose-insulin-potassium on the left ventricular systolic dysfunction in brain dead patients. METHODS AND RESULTS One hundred thirty-five consecutive brain dead patients were prospectively screened. Twelve of them with severe acute heart failure defined by an echocardiographic ejection fraction area

The use of human recombinant CuZn superoxide dismutase (rhSOD) in addition to exogenous surfactant has been studied as a therapeutic strategy to prevent acute and chronic lung injury in premature infants with blood monocytes (MO). However, scavenging of superoxide by rhSOD may compromise bacterial killing by phagocytes. In the present study, we investigated the interaction of exogenous surfactant and rhSOD with the antibacterial activity of human blood MO. MO were preincubated in the presence or absence of: (1) modified natural surfactant (Curosurf®; 1 mg/ml); (2) rhSOD (2,500 U/ml) and (3) bovine catalase (25,000 U/ml). Bacteria (Legionella pneumophila or Escherichia coli) were then added and incubated for 6 h. Viable bacteria were determined by counting colony-forming units. The ability of the MO to generate superoxide anions (O–2) in response to bacterial infection was also investigated. The antibacterial capacity of MO was not impaired by the presence of rhSOD either alone or combined with Curosurf®. In some instances, bactericidal activity was even potentiated by the addition of rhSOD. Exposure of MO to catalase interfered with the increased bacterial killing of MO and rhSOD, suggesting that hydrogen peroxide (H2O2) production was critically important in the process of bacterial killing. Both bacterial species were also found to induce the generation of intra- and extracellular O–2 by MO. Data indicate that rhSOD potentiates the killing of bacteria by human MO. The mechanism of action appears to be related to the ability of bacteria to induce the generation of O–2, which in turn is converted to H2O2 in the presence of rhSOD. This has important implications in the development of therapeutic intervention strategies using antioxidant therapy in premature infants with respiratory distress syndrome.

Introduction Many potential lung transplants are lost because of hypoxemia during donor management. We hypothesized that the apnea test, necessary to confirm the diagnosis of brain death in potential lung donors, was involved in the decrease in the ratio of partial pressure of arterial O2 to fraction of inspired O2 (PaO2/FiO2) and that a single recruitment maneuver performed just after the apnea test can reverse this alteration. Methods In this case-control study, we examined the effectiveness of the recruitment maneuver with a comparison cohort of brain dead patients who did not receive the maneuver. Patients were matched one-to-one on the basis of initial PaO2/FiO2 and on the duration of mechanical ventilation before the apnea test. PaO2/FiO2 was measured before (T1), at the end (T2) and two hours after apnea test (T3). Results Twenty-seven patients were included in each group. The apnea test was associated with a significant decrease in PaO2/FiO2 from 284 ± 98 to 224 ± 104 mmHg (P < 0.001). The decrease in PaO2/FiO2 between T1 and T3 was significantly lower in the recruitment maneuver group than in the control group (-4 (-68-57) vs -61 (-110--18) mmHg, P = 0.02). The number of potential donors with PaO2/FiO2 > 300 mmHg decreased by 58% (95% CI: 28-85%) in the control group vs 0% (95% CI: 0-34%) in the recruitment maneuver group (P < 0.001). Conclusions The apnea test induced a decrease in PaO2/FiO2 in potential lung donors. A single recruitment maneuver performed immediately after the apnea test can reverse this alteration and may prevent the loss of potential lung donors.