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International audience; Background: Before total body computed tomography scan, an initial rapid imaging assessment should be conducted in the trauma bay. It generally includes a chest x-ray, pelvic x-ray, and an extended focused ultrasonography assessment for trauma. This initial imaging assessment has been poorly described since the increase in the use of ultrasound. Therefore, our study aimed to evaluate the diagnostic accuracy and therapeutic impact of this initial imaging work-up in severe trauma patients. A secondary aim was to assess the therapeutic impact of a chest x-ray according to the lung ultrasonography findings.Methods: Patients with severe trauma who were admitted directly to our level 1 trauma center were consecutively included in this retrospective single center study. The diagnostic accuracy, therapeutic impact, and appropriate decision rate were calculated according to the initial assessment results of the whole body computed tomography scan and surgery reports.Results: Among the 1315 trauma patients admitted, 756 were included in this research. Lung ultrasound showed a higher diagnostic accuracy for haemothorax and pneumothorax cases than the chest x-ray. Sensitivity and specificity of the abdominal ultrasound to detect intraperitoneal effusion were 70% and 96%, respectively. The initial assessment had a therapeutic impact in 76 (10%) of the patients, including 16 (2%) immediate laparotomies and 58 (7%) chest tube insertions. The pelvic x-ray had no therapeutic impact, and when the lung ultrasound was normal, the chest x-ray had a therapeutic impact of only 0.13%. Combining the chest x-ray and lung ultrasound allowed adequate management of all the pneumothorax and haemothorax cases. Only one of the 756 patients had initial management that was judged as inappropriate. This patient had a missed pelvic disjunction with active retroperitoneal bleeding, and Abbreviations: underwent an inappropriate immediate laparotomy.Conclusions: In our cohort, the initial imaging assessment allowed appropriate decisions in 755 of 756 patients, with a global therapeutic impact of 10%. The pelvic x-ray had a minimal therapeutic impact, and in the patients with normal lung ultrasounds, the chest x-ray marginally affected the management of our patients. The potential consequences of abandoning systematic chest and pelvic x-rays should be investigated in future randomized prospective studies. (C) 2018 Elsevier Ltd. All rights reserved.

Background Circadian clock alterations were poorly reported in trauma patients, although they have a critical role in human physiology. Core body temperature is a clinical variable regulated by the circadian clock. Our objective was to identify the circadian temperature disruption in trauma patients and to determine whether these disruptions were associated with the 28-day mortality rate. Methods A retrospective and observational single-center cohort study was conducted. All adult severe trauma patients admitted to the intensive care unit of Aix Marseille University, North Hospital, from November 2013 to February 2018, were evaluated. The variations of core body temperature for each patient were analyzed between days 2 and 3 after intensive care unit admission. Core body temperature variations were defined by three parameters: mesor, amplitude, and period. A logistic regression model was used to determine the variables influencing these three parameters. A survival analysis was performed assessing the association between core body temperature rhythm disruption and 28-day mortality rate. A post hoc subgroup analysis focused on the patients with head trauma. Results Among the 1584 screened patients, 248 were included in this study. The period differed from 24 h in 177 (71%) patients. The mesor value (°C) was associated with body mass index and ketamine use. Amplitude (°C) was associated with ketamine use only. The 28-day mortality rate was 18%. For all trauma patients, age, body mass index, intracranial hypertension, and amplitude were independent risk factors. The patients with a mesor value p 0.6 °C (p p = 0.001 and HR = 4.73, 95% CI [1.38–16.22], p = 0.01). Conclusions Our results highlight an association between core body temperature circadian alteration and 28-day mortality rate. This association was more pronounced in the head trauma patients than in the non-head trauma patients. Further studies are needed to show a causal link and consider possible interventions.

International audience; Ventilator-associated pneumonia (VAP) due to methicillin-resistant Staphylococcus aureus (MRSA) is associated with excess mortality and costs. Molecular biology test allows rapid identification of MRSA in sputum with high negative predictive value. We hypothesized that use of a rapid diagnostic test in patients with suspected VAP was associated with reduced use of antibiotics directed against MRSA. This retrospective, observational study was conducted in a polyvalent intensive care unit (ICU) of a university hospital. We compared two periods: before (2007-2010) and after (2010-2015) the implementation of a rapid diagnostic test, which uses RT-PCR to detect pathogens in 60 minutes. The primary endpoint was the effect on the empirical use of anti-MRSA antibiotics. The second endpoint was the effect of this strategy on the cost regarding antibiotic treatment. The first group included 120 suspected VAP (88 patients) and the second group 121 suspected VAP (89 patients). Empirical use of vancomycin and linezolid decreased by 50 % between the two periods. Twenty-seven VAP (22 %) were treated with an anti-MRSA treatment between 2007 and 2010, and 13 (11 %) between 2010 and 2015 (p = 0.04). The mean cost of anti-MRSA treatment by patients in the first group was 63 +/- 223 a,notsign, and 13 +/- 52 a,notsign in the second group (p < 0.001). This study shows that a rapid diagnostic test was associated with reduced use and cost of anti-MRSA antibiotics in patients with suspected VAP. These results should be confirmed by further multicenter prospective studies.

International audience; Purpose: Reducing discomfort in the intensive care unit (ICU) should have a positive effect on long-term outcomes. This study assessed whether a tailored multicomponent program for discomfort reduction was effective in reducing post-traumatic stress disorder (PTSD) symptoms at 1 year in general ICU survivors.Methods: This study is a prospective observational comparative effectiveness cohort study involving 30 ICUs. It was an extension of the IPREA3 study, a cluster-randomized controlled trial designed to assess the efficacy of a tailored multicomponent program to reduce discomfort in critically ill patients. The program included assessment of ICU-related self-perceived discomforts, immediate and monthly feedback to the healthcare team, and site-specific tailored interventions. The exposure was the implementation of this program. The eligible patients were exposed versus unexposed general adult ICU survivors. The prevalence of substantial PTSD symptoms at 1 year was assessed based on the Impact of Event Scale-Revised (IES-R).Results: Of the 1537 ICU survivors included in the study, 475 unexposed patients and 344 exposed patients had follow-up data at 1 year: 57 (12.0%) and 21 (6.1%) presented with PTSD at 1 year, respectively (p = 0.004). Considering the clustering and after adjusting for age, gender, McCabe classification, and ICU-related self-perceived overall discomfort score, exposed patients were significantly less likely than unexposed patients to have substantial PTSD symptoms at 1 year (p = 0.015).Conclusions: Implementation of a tailored multicomponent program in the ICU that has proved to be effective for reducing self-perceived discomfort in general adult ICU survivors also reduced the prevalence of substantial PTSD symptoms at 1 year.

IF 16.834 (2017); International audience; BACKGROUND Vasopressor agents could have certain specific effects in patients with cardiogenic shock (CS) after myocardial infarction, which may influence outcome. Although norepinephrine and epinephrine are currently the most commonly used agents, no randomized trial has compared their effects, and intervention data are lacking. OBJECTIVES The goal of this paper was to compare in a prospective, double-blind, multicenter, randomized study, the efficacy and safety of epinephrine and norepinephrine in patients with CS after acute myocardial infarction. METHODS The primary efficacy outcome was cardiac index evolution, and the primary safety outcome was the occurrence of refractory CS. Refractory CS was defined as CS with sustained hypotension, end-organ hypoperfusion and hyperlactatemia, and high inotrope and vasopressor doses. RESULTS Fifty-seven patients were randomized into 2 study arms, epinephrine and norepinephrine. For the primary efficacy endpoint, cardiac index evolution was similar between the 2 groups (p = 0.43) from baseline (H0) to H72. For the main safety endpoint, the observed higher incidence of refractory shock in the epinephrine group (10 of 27 [37%] vs. norepinephrine 2 of 30 [7%]; p = 0.008) led to early termination of the study. Heart rate increased significantly with epinephrine from H2 to H24 while remaining unchanged with norepinephrine (p < 0.0001). Several metabolic changes were unfavorable to epinephrine compared with norepinephrine, including an increase in cardiac double product (p = 0.0002) and lactic acidosis from H2 to H24 (p < 0.0001). CONCLUSIONS In patients with CS secondary to acute myocardial infarction, the use of epinephrine compared with norepinephrine was associated with similar effects on arterial pressure and cardiac index and a higher incidence of refractory shock. (Study Comparing the Efficacy and Tolerability of Epinephrine and Norepinephrine in Cardiogenic Shock [OptimaCC]; NCT01367743) (J AmColl Cardiol 2018; 72: 173-82) (C) 2018 by the American College of Cardiology Foundation.

International audience; Objective: To assess the impact of an electronic checklist during the morning rounds on ventilatorassociated pneumonia (VAP) in the intensive care unit (ICU). Patients and methods: We conducted a retrospective, before/after study in a single ICU of a university hospital. A systematic electronic checklist focusing on guidelines adherence was introduced in January 2012. From January 2008 to June 2014, we screened patients with ICU stay durations of at least 48 hours. Propensity score-matched analysis with conditional logistic regression was used to compare the rate of VAP and number of days free of invasive devices before and after implementation of the electronic checklist. Results: We analysed 1711 patients (before group, n = 761; after group, n = 950). The rates of VAP were 21% and 11% in the before and after groups, respectively (p < 0.001). In propensity-score matched analysis (n = 742 in each group), VAP occurred in 151 patients (21%) during the before period compared with 72 patients (10%) during the after period (odds ratio [OR] = 0.38; 95% confidence interval [CI] = 0.27-0.53). The after group showed increases in ICU-free days (OR = 1.05; 95% CI = 1.04-1.07) and mechanical ventilation-free days (OR = 1.03; 95% CI = 1.01-1.04). Conclusion: In this matched before/after study, implementation of an electronic checklist was associated with positive effects on patient outcomes, especially on VAP. Further prospective studies are needed to confirm these observations. (C) 2017 Societefrancaise d'anesthesie et de reanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

International audience; The aim of this study was to compare septic shock directly associated-mortality between severe trauma patients and nontrauma patients to assess the role of comorbidities and age. We conducted a retrospective study in an intensive care unit (ICU) (15 beds) of a university hospital (928 beds). From January 2009 to May 2015, we reviewed 2 anonymized databases including severe trauma patients and nontrauma patients. We selected the patients with a septic shock episode. Among 385 patients (318 nontrauma patients and 67 severe trauma patients), the ICU death rate was 43%. Septic shock was directly responsible for death among 35% of our cohort, representing 123 (39%) nontrauma patients and 10 (15%) trauma patients (P

Critically ill patients are exposed to stressful conditions and experience several discomforts. The primary objective was to assess whether a tailored multicomponent program is effective for reducing self-perceived discomfort. In a cluster-randomized two-arm parallel trial, 34 French adult intensive care units (ICUs) without planned interventions to reduce discomfort were randomized, 17 to the arm including a 6-month period of program implementation followed by a 6-month period without the program (experimental group), and 17 to the arm with an inversed sequence (control group). The tailored multicomponent program consisted of assessment of ICU-related self-perceived discomforts, immediate and monthly feedback to healthcare teams, and site-specific tailored interventions. The primary outcome was the overall discomfort score derived from the 16-item IPREA questionnaire (0, minimal, 100, maximal overall discomfort) and the secondary outcomes were the discomfort scores of each IPREA item. IPREA was administered on the day of ICU discharge with a considered timeframe from the ICU admission until ICU discharge. During a 1-month assessment period, 398 and 360 patients were included in the experimental group and the control group, respectively. The difference (experimental minus control) of the overall discomfort score between groups was − 7.00 (95% CI − 9.89 to − 4.11, p

International audience; beta-lactams therapeutic drug monitoring (TDM) appears as an essential tool to ensure the achievement of pharmacokinetic-pharmacodynamic targets and prevent induced toxicity in intensive care unit patients. Indeed, those patients exhibit important pharmacokinetic variabilities that could lead to unpredictable plasma concentrations, potentially associated with poor clinical outcome, development of antibiotic resistance or increased side effects. Here, we report the case of a 48-year-old-patient admitted to intensive care unit and treated by cefepime using TDM. Due to inconsistency between observed cefepime plasma concentrations and patient clinical examination, investigations were started. After analytical tests, we highlighted an underlying analytical interference that overestimated cefepime plasma concentration with our in-house high performance liquid chromatography with ultraviolet detection (HPLC-UV) method. Only the inadequacy between plasmatic concentration and patient situation alerted pharmacologists and clinicians. As we found no previous case in literature, we believe this report must serve as an example of analytical limits that required pharmacologist awareness and expertise in TDM realization. Copyright (C) 2017 Societe francaise de pharmacologie et de therapeutique. Published by Elsevier Masson SAS. All rights reserved.

IF 12.015; International audience; Prone position (PP) improves oxygenation and outcome of acute respiratory distress syndrome (ARDS) patients with a PaO2/FiO(2) ratio < 150 mmHg. Regional changes in lung aeration can be assessed by lung ultrasound (LUS). Our aim was to predict the magnitude of oxygenation response after PP using bedside LUS. We conducted a prospective multicenter study that included adult patients with severe and moderate ARDS. LUS data were collected at four time points: 1 h before (baseline) and 1 h after turning the patient to PP, 1 h before and 1 h after turning the patient back to the supine position. Regional lung aeration changes and ultrasound reaeration scores were assessed at each time. Overdistension was not assessed. Fifty-one patients were included. Oxygenation response after PP was not correlated with a specific LUS pattern. The patients with focal and non-focal ARDS showed no difference in global reaeration score. With regard to the entire PP session, the patients with non-focal ARDS had an improved aeration gain in the anterior areas. Oxygenation response was not associated with aeration changes. No difference in PaCO2 change was found according to oxygenation response or lung morphology. In ARDS patients with a PaO2/FiO(2) ratio aecurrency sign150 mmHg, bedside LUS cannot predict oxygenation response after the first PP session. At the bedside, LUS enables monitoring of aeration changes during PP.

To describe current use and diagnostic and therapeutic impacts of point-of-care ultrasound (POCUS) in the intensive care unit (ICU). POCUS is of growing importance in the ICU. Several guidelines recommend its use for procedural guidance and diagnostic assessment. Nevertheless, its current use and clinical impact remain unknown. Prospective multicentric study in 142 ICUs in France, Belgium, and Switzerland. All the POCUS procedures performed during a 24-h period were prospectively analyzed. Data regarding patient condition and the POCUS procedures were collected. Factors associated with diagnostic and therapeutic impacts were identified. Among 1954 patients hospitalized during the study period, 1073 (55 %) POCUS/day were performed in 709 (36 %) patients. POCUS served for diagnostic assessment in 932 (87 %) cases and procedural guidance in 141 (13 %) cases. Transthoracic echocardiography, lung ultrasound, and transcranial Doppler accounted for 51, 17, and 16 % of procedures, respectively. Diagnostic and therapeutic impacts of diagnostic POCUS examinations were 84 and 69 %, respectively. Ultrasound guidance was used in 54 and 15 % of cases for central venous line and arterial catheter placement, respectively. Hemodynamic instability, emergency conditions, transthoracic echocardiography, and ultrasounds performed by certified intensivists themselves were independent factors affecting diagnostic or therapeutic impacts. With regard to guidelines, POCUS utilization for procedural guidance remains insufficient. In contrast, POCUS for diagnostic assessment is of extensive use. Its impact on both diagnosis and treatment of ICU patients seems critical. This study identified factors associated with an improved clinical value of POCUS.

The study was designed to assess whether high dosages of norepinephrine are associated with increased death rate and to determine the dosage of norepinephrine associated with an intensive care unit (ICU) death rate greater than 90%. We conducted a retrospective, noninterventional, observational study in a single ICU (15 beds) of an academic hospital. From January 2009 to May 2013, data of all patients with a diagnosis of septic shock were extracted from our database. Data were collected at the time of the admission in ICU, at the onset of septic shock, and when the maximal posology of norepinephrine was reached. Mortality was assessed in ICU, in hospital, and at day 90. Among the 324 patients with septic shock, the death rate was 48%. The death rate reached 90% for the quantile of patients receiving more than 1 μg/kg per minute of norepinephrine. In our cohort, four independent factors associated with mortality were identified: age (odds ratio, 1.02 [95% confidence interval, 1.00-1.04]; P = 0.02), thrombocytopenia (odds ratio, 3.8 [95% confidence interval, 1.8-8.5]; P < 0.001), urine output less than 500 mL (odds ratio, 8.7 [95% confidence interval, 3.6-25]; P < 0.001), and dosage of norepinephrine greater than 1 μg/kg per minute (odds ratio, 9.7 [95% confidence interval, 4.5-23]; P < 0.001). However, because of the study's design, unmeasured confounding factors should be taken into account in our findings.

To determine the effect of implementing a daily lung ultrasound round on the number of chest radiographs and chest computed tomography (CT) scans in a polyvalent intensive care unit (ICU).Retrospective study comparing two consecutive periods.All patients hospitalized for longer than 48 hours in a polyvalent ICU.Implementation of a daily lung ultrasound round after a short educational program. The number of chest radiographs and chest CT scans and the patient outcome were measured before (group PRE) and after (group POST) the implementation of a daily lung ultrasound round.No demographic difference was found between the two groups, with the exception of a higher severity score in the group POST. For each ICU stay, the number of chest radiographs was 10.3 ± 12.4 in the group PRE and 7.7 ± 10.3 in the group POST, respectively (P0.005) The number of chest CT scans was not reduced in the group POST, as compared with the group PRE (0.5 ± 0.7 CT scan/patient/ICU stay versus 0.4 ± 0.6 CT scan/patient/ICU stay, P=0.01). The ICU mortality was similar in both groups (21% versus 22%, P=0.75) CONCLUSION: The implementation of a daily lung ultrasound round was associated with a reduction in radiation exposure and medical cost without altering patient outcome.

Introduction Les pneumonies postoperatoires et les infections de site operatoire sont des complications frequentes et graves en chirurgie thoracique. Actuellement le choix de l’antibiotherapie repose sur les donnees publiees dans le cadre du traitement des pneumonies communautaires, nosocomiales et acquises sous ventilation mecanique. L’objectif de notre etude est d’apporter au clinicien des elements pour argumenter le choix d’une antibiotherapie probabiliste a large spectre dans cette situation clinique. Premierement nous avons recherche des facteurs de risque d’infection a bacteries multi-resistantes (BMR) dans cette population. Dans un second temps, nous avons etudie l’impact d’une antibiotherapie adaptee sur le pronostic. Patients et methodes Il s’agit d’une etude retrospective conduite dans une reanimation polyvalente de 15 lits. Notre etude a recu l’autorisation du Correspondant Informatique et Libertes (CIL) local. Tous les patients operes en chirurgie thoracique pris en charge en reanimation en postoperatoire ont ete eligibles. L’epidemiologie analytique a porte sur l’ensemble des patients ayant presente une pneumonie postoperatoire ou une infection de site operatoire documentees. Resultats Entre juin 2010 et decembre 2013, 272 patients ont ete admis en reanimation dans les suites d’une intervention de chirurgie thoracique. Parmi les 111 patients ayant developpe un sepsis postoperatoire, 74 ont ete documentes dont 31 pneumonies postoperatoires (42 %), 39 infections de site operatoire (53 %) et 4 sepsis d’autre origine (5 %). Les facteurs de risque de BMR retrouves en analyse multivariee etaient : un antecedent de broncho-pneumopathie chronique obstructive (BPCO), OR = 5,4, IC [1,4 ; 25,0], p = 0,02 et la presence d’au moins un des facteurs de risque de pneumonie liee aux soins a germes multi-resistants selon l’American Thoracic Society [1] (hospitalisation d’au moins deux jours au cours des 90 derniers jours, antibiotherapie dans les 90 jours, immunodepression, vie en institution medicalisee), OR = 6,8, IC[1,9–30,0], p = 0,05. L’antibiotherapie probabiliste initiale etait adaptee chez 60 (81 %) patients. La mortalite en reanimation etait de 64 % dans le groupe des patients ayant recu une antibiotherapie inadaptee contre 34 % chez ceux ayant recu une antibiotherapie adaptee, p = 0,04. Discussion Ces resultats suggerent qu’un antecedent de BPCO est un facteur de risque d’infection a BMR dans les sepsis postoperatoires en chirurgie thoracique. Les facteurs de risque d’infection a BMR decrits dans le cadre des pneumonies nosocomiales et acquises sous ventilation mecanique semblent applicables aux pneumonies postoperatoires et infection de site operatoire. Une antibiotherapie inadaptee est associee a une augmentation de 30 % de mortalite en reanimation.

Introduction En reanimation, la ventilation mecanique peut etre prolongee avec une morbi-mortalite elevee notamment en cas de pneumonies acquises sous ventilation mecanique. La tracheotomie peut alors etre proposee bien que ces avantages sur la morbi-mortalite ne soient pas demontres [1] . Or la litterature actuelle ne permet pas de predire la duree de ventilation et le moment ideal de la tracheotomie [2] . L’objectif de cette etude etait de rechercher des criteres predictifs de ventilation mecanique prolongee chez les patients en postoperatoire de chirurgie thoracique. Patients et methodes Nous avons realise une etude retrospective sur 3 ans dans une reanimation polyvalente : 221 patients analyses repartis en 2 populations. Population A patients ventiles plus et moins de 48 h et population B : patients ventiles plus et moins de 14 jours. L’objectif etait de determiner si des criteres cliniques, biologiques ou des scores de gravite, a l’admission et pendant le sejour pouvaient predire une ventilation superieure a 48 heures et a 14 jours. Resultats L’analyse statistique unie variee a montre pour la population A, que l’index de masse corporelle (IMC), l’albuminemie preoperatoire, les scores SOFA et IGS2 sont correles de facon significative avec une duree de ventilation longue. Ces resultats sont confirmes dans la population B pour le SOFA et l’IGS2. Pour les populations A et B, les patients ventiles plus longtemps ont presente significativement plus de complications a type de pneumonies, syndrome de detresse respiratoire (SDRA), fistules, pleuresie, fibrillation auriculaire (FA), et echec d’extubation. Les analyses multivariees ont montre pour la population A que les facteurs predictifs de ventilation superieure a 48 h sont le score SOFA et la survenue d’une FA avec des odds ratio respectifs de 1,6 [1,3–2] et 7 [2,7–19], p p Tableau 1 . Discussion L’impact de l’ALR sur la prise en charge postoperatoire permet une rehabilitation precoce et est retrouve dans notre etude comme un facteur protecteur de ventilation prolongee. A l’inverse : le score IGS2, la survenue d’une complication a type de FA, de pneumonie ou de SDRA sont des facteurs de risque. Isolement ces facteurs ne peuvent predire une duree de ventilation superieure a 14 jours mais ensemble ils peuvent aider a definir un groupe a risque chez qui la tracheotomie peut etre discutee precocement.

Introduction La prise en charge des patients apres un traumatisme grave represente un enjeu sanitaire et economique. Le temps est un element important du pronostic et l’imagerie est indispensable pour decider de l’orientation de ces patients [1] . L’objectif de cette etude etait l’analyse du parcours intrahospitalier et des delais de prise en charge de ces patients au cours des 24 heures suivant le traumatisme. Materiel et methodes Etude observationnelle retrospective monocentrique conduite dans un service de reanimation traumatologique et polyvalente au CHU Nord de Marseille entre juillet 2011 et juillet 2013. Nous avons analyses les dossiers des 343 patients traumatises graves admis directement en reanimation (Les 191 patients admis via le service des urgences ou un autre centre hospitalier ont ete exclus). L’analyse a porte sur : profil demographique, mecanisme et bilan lesionnel, lieu d’admission, transfert au scanner et/ou bloc operatoire ou arterioembolisation), et sur les delais de prise en charge : obtention du bilan radiologique initial (radiographie thorax + bassin + FAST echographie), du scanner corps entier et delai avant chirurgie urgente. Resultats L’âge moyen des patients etait de 39 ans (± 18 ans), l’IGS median etait a 33 [24–36]. Le mecanisme lesionnel etait dans 61 % des cas un accident de la voie publique, 14 % des patients presentaient un traumatisme penetrant, parmi eux 5 patients (1,5 %) ont ete admis directement au bloc operatoire devant une instabilite hemodynamique majeure. Apres une admission en reanimation et la realisation du bilan radiologique initial (delai median : 14 min [10–22]), 300 patients (87 %) ont ete conduits au scanner (IGS median 35 [6–102], mortalite 16 %) pour un bilan lesionnel exhaustif (delai median : 41 min [24–59]). Seuls 20 patients (6 %) etaient transferes directement au bloc operatoire (IGS median 54 [28–80], mortalite 30 %, p Fig. 1 ). Discussion L’analyse du parcours de soins, dans le cadre de l’evaluation des pratiques professionnelles, met en evidence la place cruciale de l’imagerie dans la strategie diagnostique et decisionnelle des l’admission du patient traumatise. La chirurgie urgente des l’admission concerne tres peu de patients et est associee a une mortalite elevee. La tres grande majorite des patients (87 %) est concernee par la realisation en premiere intention d’une tomodensitometrie pour bilan lesionnel exhaustif. L’optimisation de la prise en charge doit permettre l’obtention de ce bilan dans le delai le plus court possible.

Introduction L’echographie pleuro-pulmonaire (EP) et la radiographie pulmonaire (RP) sont recommandees dans la prise en charge du traumatise grave. La puissance diagnostique de l’echographie est superieure a celle de la radiographie pour les epanchements pleuraux. L’impact therapeutique des deux techniques en association est peu etudie. L’objectif principal etait de comparer la puissance diagnostique de l’EP et de la RP pour le diagnostic du pneumothorax (PNO) et de l’hemothorax. L’objectif secondaire etait d’evaluer l’impact therapeutique respectif de ces procedures. Materiel et methodes Etude retrospective monocentrique (CHU Nord, Marseille) avec collecte prospective des donnees. Pour chaque patient traumatise primaire, une RP, une EP et une TDM corps entier etaient realisees. Selon les protocoles de service, une fiche de recueil des resultats des imageries et des traitements etait remplie avec une analyse retrospective. Les dossiers des patients etaient ensuite relus (un seul relecteur) pour determiner si les decisions etaient appropriees. La puissance diagnostique de la RP et de l’EP etaient definies par rapport a la TDM. L’impact therapeutique etait defini par le nombre de modifications induites par les examens d’imagerie (RP, EP ou RP + EP) avant TDM rapportes au nombre d’examens realises. Resultats En 30 mois, 146 patients traumatises primaires ont ete inclus dans l’etude. Les puissances diagnostiques et impacts therapeutiques des deux examens sont resumes dans le Tableau 1 . En cas d’EP anormale, l’impact therapeutique de la RP etait de 28 %. En cas d’EP normale, il etait nul. Les PNO n’etaient draines que sur une positivite des deux examens (EP + RP). Trois hemothorax non detectes a la RP ont ete draines sur les donnees de l’EP. Aucun drainage inapproprie n’etait detecte a la relecture des dossiers. Trois abstentions de drainage ont ete analyses comme inappropriees (PNO draines secondairement non detectes a l’EP et a la RP). Discussion L’EP a une puissance diagnostique et un impact therapeutique superieurs a la RP sans toutefois etre parfaite dans le contexte de l’urgence. L’association des deux techniques evite de drainer a tort des PNO minimes detectes par l’EP. Cependant, si l’EP est normale, la RP n’apportait aucune modification therapeutique. Les consequences d’une prescription de RP basee sur les resultats de l’EP en termes de qualite de prise en charge initiale restent a evaluer par de futures etudes.

Introduction Dans le choc septique, l’utilisation de la noradrenaline est recommandee en premiere intention. L’impact des hautes doses de noradrenaline sur la survie des patients reste meconnu. L’objectif de cette etude etait de determiner la dose de noradrenaline pour laquelle le pourcentage de deces excede 90 % et de determiner si la dose maximale de noradrenaline administree est un facteur de risque independant de mortalite. Materiel et methodes Nous avons conduit une etude retrospective, observationnelle et monocentrique de janvier 2009 a mai 2013. Tous les patients ayant presente un choc septique ont ete inclus. Nous avons recueilli les donnees demographiques, le score SOFA et SAPS 2, le site infectieux, la presence d’une defaillance d’organe, la dose maximale en μg/kg/min de noradrenaline et sa duree d’administration. Nous avons recueilli au premier jour du choc septique et le jour ou la dose maximale de noradrenaline a ete atteinte les parametres hemodynamiques. A la sortie de reanimation nous avons egalement releve la duree de ventilation mecanique, la duree totale du sejour en reanimation, ainsi que le recours a l’adrenaline, la dobutamine, l’isoprenaline, la terlipressine et l’hemisuccinate d’hydrocortisone. Nous avons recherche la survenue du deces, en reanimation, en hospitalisation ou dans les 28 premiers jours. Resultats Sur les 324 patients inclus le taux de mortalite etait de 48 %. Le taux de mortalite atteint 90 % pour les patients qui depassent la dose de 1 μg/kg/min de noradrenaline. Nous avons identifie quatre facteurs de risque independants de mortalite : l’âge (1,02 [1,0–1,04], p = 0,019), la thrombopenie (3,8 [1,7–8,5], p Discussion Au cours du choc septique, une dose de noradrenaline superieure a 1 μg/kg/min constitue un facteur de risque independant de mortalite. Une dose maximale de noradrenaline superieure a 1ug/kg/min est associee a un risque de mortalite superieur a 90 %. Ce resultat peut aider a definir une dose dite « refractaire » dans de futures etudes.

Introduction L’acces a une imagerie pulmonaire performante est necessaire en reanimation, exposant aux radiations ionisantes et aux transferts dangereux [1] . L’echographie pulmonaire (EP) est une technique non irradiante et disponible aux performances diagnostiques superieures a la radiographie thoracique (RT) [2] . Elle represente une alternative aux examens ionisants [3] . L’objectif de notre etude etait de determiner l’impact de l’echographie pleuro-pulmonaire en reanimation sur le nombre de RT et de scanners thoraciques (ST) prescrits. Une analyse en sous-groupe excluant les patients ayant eu une chirurgie thoracique (prescription de radios et de scanner par les chirurgiens) etait realisee. Materiel et methodes Etude retrospective comparant deux periodes consecutives dans une reanimation de 15 lits d’un hopital universitaire. Inclusion des patients hospitalises plus de 48 h. Mise en place d’un examen d’EP a la demande quotidien apres courte periode de formation du personnel medical a la technique. Le nombre de RT, de ST ainsi que les caracteristiques des patients etaient mesures avant (groupe PRE) et apres (groupe POST) l’introduction de l’echographie, le personnel medical n’etait pas informe de la realisation d’une etude. Resultats Les donnees epidemiologiques des deux groupes etaient comparables, seul le score de gravite IGS II etait plus eleve dans le groupe POST 35 ± 16 vs. 39 ± 17 ( p = 0,005). Pour chaque sejour en reanimation, le nombre de RT et de ST etait significativement reduit dans le groupe POST (10,3 ± 12 RT dans le groupe PRE vs. 7,7 ± 10 dans le groupe POST ( p vs. 0,4 ± 1 dans le groupe POST ( p = 0,01)). Apres exclusion des patients ayant eu une chirurgie thoracique, la reduction de prescription etait plus importante (9,4 ± 11 vs. 6,4 ± 8 ( p = 0,0001)). La mortalite en reanimation etait similaire dans les deux groupes (21 % vs. 22 %, ( p = 0,75)) ( Tableau 1 ). Discussion L’introduction de l’echographie pleuro-pulmonaire etait associee a une reduction significative du nombre de RT et de ST reduisant l’exposition des patients aux radiations ionisantes et les depenses de sante sans consequence pronostique. L’economie realisee sur un an dans notre structure est evaluee a 1000 mGy et 30 000 euros. Ce resultat a ete obtenu sans protocole dictant les indications respectives des examens d’imagerie thoracique de reanimation. L’impact d’un tel protocole pourrait accentuer la tendance constatee et reste a evaluer dans de futurs travaux prospectifs.