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International audience; Background: Ventilator-associated pneumonia (VAP) is the most frequent health care-associated infection in severely ill patients, and aspiration of contaminated oropharyngeal content around the cuff of the tracheal tube is the main route of contamination.Research question: Is continuous regulation of tracheal cuff pressure using a pneumatic device superior to manual assessment three times daily using a portable manometer (routine care) in preventing VAP in patients with severe trauma?Study design and methods: In this open-label, randomized controlled superiority trial conducted in 13 French ICUs, adults (age ≥ 18 years) with severe trauma (Injury Severity Score > 15) and requiring invasive mechanical ventilation for ≥ 48 h were enrolled. Patients were randomly assigned (1:1) via a secure Web-based random number generator in permuted blocks of variable sizes to one of two groups according to the method of tracheal cuff pressure control. The primary outcome was the proportion of patients developing VAP within 28 days following the tracheal intubation, as determined by two assessors masked to group assignment, in the modified intention-to-treat population. This study is closed to new participants.Results: A total of 434 patients were recruited between July 31, 2015, and February 15, 2018, of whom 216 were assigned to the intervention group and 218 to the control group. Seventy-three patients (33.8%) developed at least one episode of VAP within 28 days following the tracheal intubation in the intervention group compared with 64 patients (29.4%) in the control group (adjusted subdistribution hazard ratio, 0.96; 95% CI, 0.76-1.20; P = .71). No serious adverse events related to the use of the pneumatic device were noted.Interpretation: Continuous regulation of cuff pressure of the tracheal tube using a pneumatic device was not superior to routine care in preventing VAP in patients with severe trauma.Clinical trial registration: ClinicalTrials.gov; No.: NCT02534974; URL: www.clinicaltrials.gov.

Background. The COVID-19 epidemic has resulted in a massive surge in the need for intensive care unit (ICU) care. To avoid being overwhelmed, hospitals had to adapt and support the ICU teams in structured ICU care including involving surgical teams. This work aims at describing the collaborative efforts between the ICU care team and the Surgical Task Force (STF) during a surge of ICU activity in a University Hospital in a French high-density COVID-19 cluster. Study Design. This retrospective single center study analyzed the STF workflow and the ICU population. The study included 55 patients hospitalized in our ICU, ICU-converted step-down units, and post-anesthesia care units. The primary measure was the global daily STF activity. The secondary measure was the daily activity for each of the 5 tasks accomplished by the STF. Results. The STF attempted 415 phone calls for 55 patients’ families, 237 mobilizations of patients requiring prone positions, follow-up of 20 patients requiring medevac, and contribution to ethical discussion for 2 patients. The mean (SD) daily number of successful phones calls, ethical discussions, mobilizations of patients requiring prone positions and medevac follow-up were 18 (7), .1 (.4), 10 (7), and 2 (3), respectively. No actions for discharge summaries writing were required. The maximum number of daily mobilizations for patients requiring prone positions was 25. The maximum number of daily attempted phone calls and successful phone calls were 37 and 26, respectively. Conclusion. Surgeons’ technical and nontechnical skills represented an effective support for ICU teams during the COVID-19 pandemic.

INTRODUCTION During anesthesia, decreases in mean arterial pressure (MAP) are common but the impact on possible cerebral hypoperfusion remains a matter of debate. We evaluated cerebral perfusion in patients with or without cardiovascular comorbidities (Hi-risk vs Lo-risk) during induction of general anesthesia and during hypotensive episodes. METHODS Patients scheduled for neuroradiology procedure using standardized target-controlled Propofol-Remifentanil infusion were prospectively included. Monitoring included Transcranial Doppler (TCD) measuring mean blood velocity of the middle cerebral artery (Vm), Bispectral Index with burst suppression ratio (SR) and cerebral Near-Infrared Spectroscopy (NIRS). Hypotensive episodes were treated with a 10 µg bolus of Norepinephrine. RESULTS Eighty-one patients were included, 37 Hi-risk and 44 Lo-risk. During induction of anesthesia, MAP and Vm decreased in all patients, with greater changes observed in Hi-risk patients compared to Lo-risk patients (-34 [38-29]% vs -17 [25-8]%, P

Resume Le traumatisme severe reste greve d’une mortalite et d’une morbidite particulierement elevees, au point de constituer la premiere cause d’annees de vie perdues ponderees par la qualite (QALYs). Si le choc hemorragique et les lesions severes du systeme nerveux central restent les deux premieres causes de mortalite precoce apres un traumatisme grave, 25 a 30 % des deces post-traumatiques surviennent plus tard en reanimation des suites de defaillances d’organes (secondary organ failures ou SOF). Ces SOF font intervenir principalement deux mecanismes physiopathologiques : 1) une reaction exacerbee de l’immunite innee, dont l’intensite est proportionnelle a l’etendue des lesions traumatiques et aux concentrations d’alarmines circulantes (aussi nommees Damage-Associated Molecular Patterns ou DAMPs). Ces alarmines de natures diverses (complement, polynucleaires neutrophiles et leur arsenal proteolytique) vont directement leser les cellules endotheliales et epitheliales des organes vitaux (poumon, foie, rein) aboutissant a des syndromes qui menacent le pronostic vital (ALI, ARDS, AKI, vasoplegie et coagulopathie post-traumatiques…) A cote des lesions tissulaires traumatiques directement liees au stress mecanique et a la destruction des barrieres macro- et microscopiques, le choc hemorragique constitue un facteur aggravant et decuple la liberation de DAMPs par un mecanisme d’hypoperfusion tissulaire et cellulaire. Il en va de meme pour les interventions chirurgicales extensives lorsqu’elles sont realisees en phase inflammatoire a un moment ou elles amplifient la reponse immunitaire innee ; 2) une immunosuppression post-traumatique, qui s’initie dans les suites immediates du traumatisme mais dont les consequences (anergie immunitaire, desactivation monocytaire, reponse de type Th2, reactivations virales, susceptibilite accrue aux infections bacteriennes et fongiques) n’apparaissent qu’apres quelques jours et confinent le patient dans un etat persistant d’inflammation, d’immunosuppression et de catabolisme (PICS syndrome). En plus de conforter le bien-fonde de doctrines deja adoptees (parfois de facon empirique) sur des bases cliniques (damage-control surgery, reanimation hemostatique, administration precoce d’acide tranexamique), ces decouvertes recentes laissent entrevoir des voies therapeutiques nouvelles, ciblant les DAMPs eux-memes (dornase alfa), leurs recepteurs (cyclosporine H) et l’arsenal des polynucleaires ou modulant l’activite de l’immunite innee (glucocorticoides, IFNγ, GM-CSF).

Resume La prise en compte du point de vue du patient pour evaluer son etat de sante est un developpement important pour la medecine perioperatoire. En complement des monitorages cliniques et paracliniques habituels des patients operes, elle permet de completer la semeiologie et ainsi la finesse analytique de l’etat de sante des patients recemment operes. De nombreux outils ont ete developpes pour recueillir directement le point de vue du patient de maniere standardisee et etudies du point de vue psychometrique. Ces outils permettant l’autoevaluation directe par le patient de son etat de sante sont parfois decrits par le terme anglais « Patient-Reported Outcomes Mesures » (PROMs). Ils sont de constructions et caracteristiques tres variees. Leurs utilisations principales en medecine perioperatoire peuvent se regrouper sous deux axes : 1) en pratique courante pour l’evaluation in situ de la performance des protocoles de soins standardises, du parcours patient et la personnalisation de la prise en charge ; 2) en recherche clinique en tant que critere de jugement de la qualite des soins. Dans l’ensemble de ces domaines, bien que prometteurs, les PROMs doivent encore faire l’objet d’etudes visant notamment a caracteriser leurs limites methodologiques et analytiques.

Objectives To describe the coinfections in invasive aspergillosis (IA), to identify factors associated with coinfections, and to evaluate the impact of coinfection on mortality. Patients and methods We conducted a monocentric retrospective study of consecutive putative, probable, or proven IA that occurred between 1997 and 2017. All coinfections, with an onset within 7 days before or after the first sign of aspergillosis, were identified. Factors associated with coinfections and mortality were analysed by multivariable analysis. Results Among the 690 patients with IA included in the study, the median age was 57 years (range 7 days to 90 years). A coinfection was diagnosed in 272/690 patients (39.4%, 95%CI 35.8–43.2). The location of this coinfection was pulmonary only in 131/272 patients (48%), bloodstream only in 66/272 patients (24%) and other/multiple sites in 75/272 patients (28%). Coinfections were bacterial (110/272 patients, 40%), viral (58/272, 21%), fungal (57/272, 21%), parasitic (5/272, 2%) or due to multiple types of pathogens (42/272, 15%). Factors associated with a coinfection in adjusted analysis were: allogeneic haematopoietic stem-cell transplantation (OR 2.3 (1.2–4.4)), other haematological malignancies (OR 2.1 (1.2–3.8)), other underlying diseases (OR 4.3 (1.4–13.6)), lymphopenia (OR 1.7 (1.1-2.5)), C-reactive protein >180 mg/L (OR 1.9 (1.2–3.0)), fever (OR 2.4 (1.5–4.1)), tracheal intubation (OR 2.6 (1.5–4.7)), isolation of two or more different Aspergillus species (OR 2.7 (1.1–6.3)), and the presence of non-nodular lesions on chest computed tomography (OR 2.2 (1.3–3.7) and OR 2.2 (1.2–4.0)). Coinfections were independently associated with a higher mortality at week 12 (adjusted HR 1.5 (1.1–1.9), p Conclusions Coinfections are frequent in IA patients and are associated with higher mortality.

SARS-CoV-2 is the cause of worldwide COVID-19, which severity has been linked to the immune and inflammatory response. Here, we investigate Torquetenovirus (TTV) DNA load - a marker reflecting the intensity of the overall immune response - as well as SARS-CoV-2 RNAemia and IgM/IgG antibodies in COVID-19-positive patients.Two hundred and fifteen COVID-19-positive patients were enrolled, including 87 severe cases and 128 mild-moderate cases. SARS-CoV-2 RNAemia and IgM/IgG antibodies, as well as TTV DNA loads, were measured on longitudinal plasma samples.The rate of severe cases was higher in patients with low TTV DNA load in plasma considering a threshold of 700 copies/mL. In severe patients, SARS-CoV-2 RNAemia positivity rates were higher than those in mild-moderate cases at any timepoint. When combined, TTV DNA load and SARS-CoV-2 RNAemia allowed to predict the outcome of COVID-19 infection, with a higher risk (HR=12.4) of ICU admission in patients with low TTV DNA load and positive SARS-CoV-2 RNAemia.TTV DNA load and SARS-CoV-2 RNAemia may be effective, non-invasive markers reflecting disease severity and poor outcome that could be conveniently measured in a clinical laboratory setting, as soon as COVID-19 diagnosis is made.

Objective: Ground-glass opacities are the most frequent radiologic features of COVID-19 patients. We aimed to determine the feasibility of automated lung volume measurements, including ground-glass volumes, on the CT of suspected COVID-19 patients. Our goal was to create an automated and quantitative measure of ground-glass opacities from lung CT images that could be used clinically for diagnosis, triage and research. Design: Single centre, retrospective, observational study. Measurements: Demographic data, respiratory support treatment (synthetised in the maximal respiratory severity score) and CT-images were collected. Volume of abnormal lung parenchyma was measured with conventional semi-automatic software and with a novel automated algorithm based on voxels X-Ray attenuation. We looked for the relationship between the automated and semi-automated evaluations. The association between the ground-glass opacities volume and the maximal respiratory severity score was assessed. Main results: Thirty-seven patients were included in the main outcome analysis. The mean duration of automated and semi-automated volume measurement process were 15 (2) and 93 (41) min, respectively (p=8.05*10-8). The intraclass correlation coefficient between the semi-automated and automated measurement of ground-glass opacities and restricted normally aerated lung were both superior to 0.99. The association between the automated measured lung volume and the maximal clinical severity score was statistically significant for the restricted normally aerated (p=0.0097, effect-size: -385mL) volumes and for the ratio of ground-glass opacities/restricted normally aerated volumes (p=0.027, effect-size: 3.3). Conclusion: The feasibility and preliminary validity of automated impaired lung volume measurements in a high-density COVID-19 cluster was confirmed by our results. Keywords: ARDS; COVID-19; CT-scan; Infectious disease; Severity assessment; Triage.

Background Bayesian methods, with the predictive probability (PredP), allow multiple interim analyses with interim posterior probability (PostP) computation, without the need to correct for multiple looks at the data. The objective of this paper was to illustrate the use of PredP by simulating a sequential analysis of a clinical trial. Methods We used data from the Laryngobloc trial that planned to include 480 patients to demonstrate the equivalence of success between a laryngoscopy performed with the Laryngobloc® device and a control device. A crossover Bayesian design was used. The success rates of the two laryngoscopy devices were compared. Interim analyses, computed from random numbers of subjects, were simulated. Results The PostP of equivalence rapidly reached the predefined bound of 0.95. The PredP computed with an equivalence margin of 10% reached the efficacy bound between 352 and 409 of the 480 included patients. If a frequentist analysis had been made on the basis of 217 out of 480 subjects, the study would have been prematurely stopped for equivalence. The PredP indicated that this result was nonetheless unstable and that the equivalence was, thus far, not guaranteed. Conclusions Based on these interim analyses, we can conclude with a sufficiently high probability that the equivalence would have been met on the primary outcome before the predetermined end of this particular trial. If a Bayesian approach using PredP had been used, it would have allowed an early termination of the trial by reducing the calculated sample size by 15–20%.

Quality of recovery is an important component of perioperative health status. The 15-item Quality of Recovery (QoR-15) scale is a validated multidimensional questionnaire that measures postoperative quality of recovery. The aim of this study was to translate and assess the psychometric properties of a French version of the QoR-15 scale (QoR-15F) to measure postoperative recovery in French-speaking patients.After translation into French of the original English version of the QoR-15 scale, psychometric validation of the QoR-15F scale to measure postoperative quality of recovery was performed. This psychometric validation included validity, reliability, responsiveness, and feasibility. The QoR-15F scale was administered before operation and on Postoperative day 1 in French-speaking patients. Patient-perceived global recovery assessment was measured at Postoperative day 1 using a VAS.We enrolled 150 patients, and 144 completed the study protocol. The completion rate of administered questionnaires was 100%. Pearson (r) correlation between postoperative QoR-15F and the global recovery assessment by the patient was 0.60 (P0.0001). As expected, there was a significant negative correlation between QoR-15F score and duration of surgery (r=-0.29; P0.01), duration of PACU stay (r=-0.21; P=0.01), and duration of hospital stay (r=-0.34; P0.01). Cronbach's alpha was 0.81, split-half alpha was 0.83, and the global test-retest intra-class coefficient was 0.98 (0.95-0.99).The QoR-15F is a valid and reliable tool to measure postoperative quality of recovery in French-speaking patients. The psychometric properties to measure postoperative quality of recovery were similar to the seminal English version.NCT03578068.

Supplemental Material, Supplemental_Material for Surgical Support for Severe COVID-19 Patients: A Retrospective Cohort Study in a French High-Density COVID-19 Cluster by Eric Noll, Christophe Muccioli, Pierre-Olivier Ludes, Julien Pottecher, Pierre Diemunsch, Sophie Diemunsch, Anaëlle Tchentcheli, Philippe Clavert, Girish P. Joshi and Philippe A. Liverneaux in Surgical Innovation

Whether a specific way of infusing albumin affects outcome in patients with major oxidative stress remains uncertain. To determine whether outcome measurements (survival, organ failure and care-related infections) are different according to different regimens of albumin infusion, we conducted a phase IV, randomized, open-label trial to compare the effects of continuous infusion of 4 percent albumin versus intermittent 20 percent albumin on outcome measurements in three third level-hospital intensive care unit (ICU) patients with septic shock. We randomly assigned 125 consecutive patients with septic shock when serum albumin became

Background The interaction between chronic medications on admission and the association between serum potassium level and outcome in patients with acute heart failure (AHF) are unknown. Methods Observational intercontinental study of patients admitted with AHF. 15954 patients were included from 12 cohorts in 4 continents. Main outcome was 90-day mortality. Clinical presentation (medication use, hemodynamics, comorbidities), demographic, echocardiographic, and biochemical data on admission were recorded prospectively in each cohort, with prospective adjudication of outcomes. Results Positive and negative linear relationships between 90-day mortality and sK+ above 4.5 mmol/L (hyperkalemia) and below 3.5 mmol/L (hypo-kalemia) were observed. Hazard ratio for death was 1.46 [1.34-1.58] for hyperkalemia and 1.22 [1.06-1.40] for hypokalemia. In a fully adjusted model, only hyperkalemia remained associated with mortality (HR 1.03 [1.02-1.04] for each 0.1 mmol/l change of sK+ above 4.5 mmol/L). Interaction tests revealed that the association between hyperkalemia and outcome was significantly affected by chronic medications. The association between hyperkalemia and mortality was absent for patients treated with beta blockers and in those with preserved renal function. Conclusions In patients with AHF, sK+ > 4.5 mmol/L appears to be associated with 90-day mortality. B-blockers have potentially a protective effect in the setting of hyperkalemia.

Resume La mise en place des catheters veineux centraux s’accompagne parfois d’echecs lors des ponctions, voire de complications qui entrainent une morbidite qui peut etre reduite par l’emploi de l’echographie. En effet, le developpement et la plus large diffusion des appareils d’echographie permettent de securiser le geste et d’ameliorer le confort des patients. On a pu noter une diminution des complications mecaniques a type de d’hemo-pneumothorax ou d’hematome, ainsi qu’une reduction des echecs de ponction et des infections liees aux catheters centraux. La duree de mise en œuvre de la technique d’echoguidage ne semble pas superieure a celle n’utilisant que les reperes anatomiques. La technique repose sur des regles strictes d’asepsie, l’emploi d’une sonde lineaire a frequence elevee, sur une ponction en grand axe avec une visualisation constante de l’extremite de l’aiguille et enfin sur un controle radiographique final. La mise en place echoguidee des catheters veineux centraux doit s’imposer a tous les anesthesistes-reanimateurs tant elle apporte efficacite et securite.

Aims Heart failure (HF) is accompanied by major neuroendocrine changes including the activation of the natriuretic peptide (NP) pathway. Using the unique model of patients undergoing implantation of the CARMAT total artificial heart and investigating regional differences in soluble neprilysin (sNEP) in patients with reduced or preserved systolic function, we studied the regulation of the NP pathway in HF. Methods and results Venous blood samples from two patients undergoing replacement of the failing ventricles with a total artificial heart were collected before implantation and weekly thereafter until post-operative week 6. The ventricular removal was associated with an immediate drop in circulating NPs, a nearly total disappearance of circulating glycosylated proBNP and furin activity and a marked decrease in sNEP. From post-operative week 1 onwards, NP concentrations remained overall unchanged. In contrast, partial recoveries in glycosylated proBNP, furin activity, and sNEP were observed. Furthermore, while in patients with preserved systolic function (n = 6), sNEP concentrations in the coronary sinus and systemic vessels were similar (all P > 0.05), in patients with reduced left-ventricular systolic function, sNEP concentration, and activity were ∼three-fold higher in coronary sinus compared to systemic vessels (n = 21, all P Conclusion The heart plays a pivotal role as a regulator of the endocrine response in systolic dysfunction, not only by directly releasing NPs but also by contributing to circulating sNEP, which in turn determines the bioavailability of other numerous vasoactive peptides.

Fundamental events driving the pathological processes of septic shock-induced multiorgan failure (MOF) at the cellular and subcellular levels remain debated. Emerging data implicate mitochondrial dysfunction as a critical factor in the pathogenesis of sepsis-associated MOF. If macrocirculatory and microcirculatory dysfunctions undoubtedly participate in organ dysfunction at the early stage of septic shock, an intrinsic bioenergetic failure, sometimes called “cytopathic hypoxia,” perpetuates cellular dysfunction. Short-term failure of vital organs immediately threatens patient survival but long-term recovery is also severely hindered by persistent dysfunction of organs traditionally described as nonvital, such as skeletal muscle and peripheral blood mononuclear cells (PBMCs). In this review, we will stress how and why a persistent mitochondrial dysfunction in skeletal muscles and PBMC could impair survival in patients who overcome the first acute phase of their septic episode. First, muscle wasting protracts weaning from mechanical ventilation, increases the risk of mechanical ventilator-associated pneumonia, and creates a state of ICU-acquired muscle weakness, compelling the patient to bed. Second, failure of the immune system (“immunoparalysis”) translates into its inability to clear infectious foci and predisposes the patient to recurrent nosocomial infections. We will finally emphasize how mitochondrial-targeted therapies could represent a realistic strategy to promote long-term recovery after sepsis.

Resume La denutrition est un facteur important de complications postoperatoires. Elle doit donc etre diagnostiquee et prise en charge avant la chirurgie, afin d’ameliorer la cicatrisation, les fonctions immunitaires, musculaires et cognitives ainsi que le confort perioperatoire et la duree d’hospitalisation du patient. La nutrition artificielle n’etant pas denuee de risque, l’anesthesiste doit participer aux decisions concernant les modalites nutritionnelles pre- et postoperatoires.

Il n’est pas rare que le chirurgien-dentiste soit confronte a une tumefaction cervico-faciale (TCF) per ou post-operatoire immediate. Bien qu’il s’agisse generalement d’un phenomene benin, il est souvent source d’inquietude pour le praticien et le patient. Une revue de litterature se propose de presenter les differentes etiologies de tumefactions cervico-faciales per et post-operatoires, et d’apporter les elements pratiques pour leur diagnostic. Parmi ces tumefactions, l’emphyseme sous-cutane est un evenement banal, benin et facile a diagnostiquer mais souvent meconnu, ce dont temoigne le nombre de cas rapportes. Plus rares, mais potentiellement graves, il convient egalement de citer l’hematome du plancher buccal et l’angiœdeme qui peuvent etre la consequence du geste bucco-dentaire ou des medicaments. Dans ce cadre, il est en effet necessaire de savoir reconnaitre les prodromes d’une detresse respiratoire. Enfin, la fasciite necrosante cervico-faciale se doit d’etre reconnue tot du fait de son extreme gravite, d’autant que son incidence parait croissante. Un tableau recapitulatif presente les principales causes de TCF per et post-operatoires apres chirurgie dentaire, leur chronologie, leurs principaux symptomes et les mesures therapeutiques a mettre en œuvre.

Introduction Les patients en insuffisance cardiaque aigue (ICA) sont a risque de dyskaliemie. Ces dyskaliemies sont liees aux comorbidites ou aux traitements recus, et mettent en jeu leur pronostic vital. L’objectif de ce travail etait d’etudier la survie des malades admis a l’hopital pour insuffisance cardiaque aigue en fonction de leur kaliemie d’admission. L’objectif secondaire etait d’etudier l’interaction du traitement par antialdosterone et de la dyskaliemie sur la survie. Materiel et methodes Etude observationnelle retrospective sur les patients de la cohorte internationale Global Research on Acute conditions Team (GREAT) admis pour insuffisance cardiaque aigue et pour lesquels la kaliemie a l’admission et le statut a 30 et 90 jours etaient connus. Une analyse de survie en fonction de la kaliemie a l’admission et du traitement par antialdosterone ainsi qu’une analyse en sous-groupes ont ete realisees. Resultats Ont ete inclus 15 578 patients. Dans cette etude la mortalite globale des malades etait la plus basse pour une kaliemie comprise entre 3,8 et 4,2 mmol/L. Apres ajustement, il existait une surmortalite des patients dyskaliemiques a 30 et 90 jours. Cette surmortalite a 30 jours n’etait pas retrouvee pour les malades hypokaliemiques traites par antialdosterone ou a FEVG preservee ; ni pour les malades hyperkaliemiques traites par antialdosterone ou a FEVG alteree. La surmortalite a 90 jours n’etait pas retrouvee pour les malades hypokaliemiques avec une FEVG conservee ( Tableau 1 et Fig. 1 ). Discussion Dans cette etude la normokaliemie est comprise entre 3,8 et 4,2 mmol/L. Les malades dyskaliemiques presentent un surrisque de mortalite, mais un antialdosterone semble les proteger a 30 jours. Un resultat surprenant est l’absence de surmortalite a 30 jours des malades hyperkaliemiques ayant une FEVG basse. L’hyperkaliemie pourrait etre un marqueur de la bonne observance au traitement par antialdosterone et ceci pourrait expliquer l’absence de surmortalite.