Publications by authors named "Benoît Vivien"

115 Publications

Prehospital hemodynamic optimisation is associated with a 30-day mortality decrease in patients with septic shock.

Am J Emerg Med 2021 Mar 2;45:105-111. Epub 2021 Mar 2.

Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.

Introduction: Septic shock (SS) is characterized by low blood pressure resulting in organ failure and poor prognosis. Among SS treatments, in hospital studies reported a beneficial effect of early hemodynamic resuscitation on mortality rate. This study aims to investigate the relationship between prehospital hemodynamic optimisation and 30-day mortality in patients with SS.

Methods: From April 6th, 2016 to December 31th, 2019, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (mICU) were included. Prehospital hemodynamic optimisation was defined as a arterial blood pressure of >65 mmHg, or >75 mmHg if previous hypertension history, at the end of the prehospital stage.

Results: Three hundred thirty-seven patients were retrospectively analysed. The mean age was 69 ± 15 years, and 226 patients (67%) were male. One hundred and thirty-six patients (40%) had previous hypertension history. Pulmonary, digestive and urinary infections were the suspected cause of the SS in respectively 46%, 23% and 15% of the cases. 30-day overall mortality was 30%. Prehospital hemodynamic optimisation was complete for 204 patients (61%). Cox regression analysis reports a significant association between prehospital hemodynamic optimisation and 30-day mortality (HRa = 0.52 95%CI [0.31-0.86], p = 0.01).

Conclusion: In this study, we report that prehospital hemodynamic optimisation is associated with a decrease in 30-day mortality in patients with SS cared for by a mICU in the prehospital setting. An individualized mean arterial pressure target, based on previous hypertension history, may be considered from the prehospital stage of SS resuscitation.
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http://dx.doi.org/10.1016/j.ajem.2021.02.060DOI Listing
March 2021

Epinephrine's effects on cerebrovascular and systemic hemodynamics during cardiopulmonary resuscitation: metabolic changes may limit the persistence of the effect.

Crit Care 2021 02 16;25(1):67. Epub 2021 Feb 16.

SAMU de Paris, Service d'Anesthésie-Réanimation, Hôpital Universitaire Necker - Enfants Malades, APHP. Centre, Assistance Publique - Hôpitaux de Paris, Paris, France.

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http://dx.doi.org/10.1186/s13054-020-03378-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887812PMC
February 2021

Interchangeability between Respiratory Variations of Subclavian Vein and Pulse Pressure Variation in Ventilated Patients in the Operating Room.

Turk J Anaesthesiol Reanim 2020 Dec 26;48(6):467-472. Epub 2019 Dec 26.

Department of Anesthesia and Intensive Care Unit - Necker-Enfants malades Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.

Objective: For mechanically ventilated patients, the best predictors of fluid responsiveness are dynamic parameters. Many methods that reflect cardiopulmonary interactions have been proposed to evaluate the preload dependency. In this study, we describe the interchangeability between respiratory variations of the subclavian (ΔSCV) vein and pulse pressure variation (PPV) in sedated and mechanically ventilated patients benefiting from kidney transplantation.

Methods: The ΔSCV via infraclavicular transthoracic echocardiography and PPV measurements were recorded simultaneously by a single operator. The Bland-Altman method assessed the interchangeability between ΔSCV and PPV.

Results: A total of 27 patients were prospectively included in the study. The Bland-Altman analysis showed a bias of +1.6 % for ΔSCV measurements vs. PPV. The limit of agreements was, respectively, -4% and 8%. The agreement between PPV >13% and ΔSCV >13% was 100%, and the agreement between PPV<9% and ΔSCV<9% was 58%. No misclassification (PPV<9% [0%] and PPV>13% [0%]) was observed.

Conclusion: ΔSCV and PPV are interchangeable when assessing preload dependency in mechanically ventilated patients benefiting from kidney transplantation. ΔSCV appears to be a suitable tool because it is non-invasive, simple, easy and almost always available.
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http://dx.doi.org/10.5152/TJAR.2019.54289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7720824PMC
December 2020

Open-chest versus closed-chest cardiopulmonary resuscitation in trauma patients: effect size is probably higher for penetrating injury.

Crit Care 2020 11 23;24(1):655. Epub 2020 Nov 23.

SAMU de Paris, Service d'Anesthésie-Réanimation, Hôpital Universitaire Necker - Enfants Malades, APHP, Centre, Assistance Publique - Hôpitaux de Paris, and Université de Paris, Paris, France.

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http://dx.doi.org/10.1186/s13054-020-03372-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684723PMC
November 2020

Prehospital lactate clearance is associated with reduced mortality in patients with septic shock.

Am J Emerg Med 2020 Oct 17. Epub 2020 Oct 17.

Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.

Background: Assessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, blood lactate measurement is broadly used in combination with the clinical evaluation of patients as the clinical picture alone is not sufficient for assessing disease severity and outcomes.

Methods: From 15th April 2017 to 15th April 2019, patients with SS requiring prehospital mobile Intensive Care Unit intervention (mICU) were prospectively included in this observational study. Prehospital blood lactate clearance was estimated by the difference between prehospital (time of first contact between the patients and the mICU prior to any treatment) and in-hospital (at hospital admission) blood lactate levels divided by prehospital blood lactate.

Results: Among the 185 patients included in this study, lactate measurement was missing for six (3%) in the prehospital setting and for four (2%) at hospital admission, thus 175 (95%) were analysed for prehospital blood lactate clearance (mean age 70 ± 14 years). Pulmonary, digestive and urinary infections were probably the cause of the SS in respectively 56%, 22% and 10% of the cases. The 30-day overall mortality was 32%. Mean prehospital blood lactate clearance was significantly different between patients who died and those who survived (respectively 0.41 ± 2.50 mmol.l vs 1.65 ± 2.88 mmol.l, p = 0.007). Cox regression analysis showed that 30-day mortality was associated with prehospital blood lactate clearance > 10% (HRa [CI95] = 0.49 [0.26-0.92], p = 0.028) and prehospital blood lactate clearance < 10% (HRa [CI95] = 2.04 [1.08-3.84], p = 0.028).

Conclusion: A prehospital blood lactate clearance < 10% is associated with 30-day mortality increase in patients with SS handled by the prehospital mICU. Further studies will be needed to evaluate if prehospital blood lactate clearance alone or combined with clinical scores could affected the triage decision-making process for those patients.
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http://dx.doi.org/10.1016/j.ajem.2020.10.018DOI Listing
October 2020

Pre-Hospital Lactatemia Predicts 30-Day Mortality in Patients with Septic Shock-Preliminary Results from the LAPHSUS Study.

J Clin Med 2020 Oct 14;9(10). Epub 2020 Oct 14.

Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France.

Background: Assessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, the clinical picture alone is not sufficient for assessing disease severity and outcomes. Because blood lactate level is included in the clinical criteria of SS it should be considered to improve the assessment of its severity. This study aims to investigate the relationship between pre-hospital blood lactate level and 30-day mortality in patients with SS.

Methods: From 15 April 2017 to 15 April 2019, patients with SS requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were prospectively included in the LAPHSUS study, an observational, non-randomized controlled study. Pre-hospital blood lactate levels were measured at the time of first contact between the patients and the MICU.

Results: Among the 183 patients with septic shock requiring action by the MICU drawn at random from LAPHSUS study patients, six (3%) were lost to follow-up on the 30th day and thus 177 (97%) were analyzed for blood lactate levels (mean age 70 ± 14 years). Pulmonary, urinary and digestive infections were probably the cause of the SS in respectively 58%, 21% and 11% of the cases. The 30-day overall mortality was 32%. Mean pre-hospital lactatemia was significantly different between patients who died and those who survived (respectively 7.1 ± 4.0 mmol/L vs. 5.9 ± 3.5 mmol/L, < 10). Using Cox regression analysis adjusted for potential confounders we showed that a pre-hospital blood lactate level ≥ 4 mmol/L significantly predicted 30-day mortality in patients with SS (adjusted hazard ratio = 2.37, 95%CI (1.01-5.57), = 0.04).

Conclusion: In this study, we showed that pre-hospital lactatemia predicts 30-day mortality in patients with septic shock handled by the MICU. Further studies will be needed to evaluate if pre-hospital lactatemia alone or combined with clinical scores could affect the triage decision-making process for those patients.
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http://dx.doi.org/10.3390/jcm9103290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7602068PMC
October 2020

[Prehospital management of acute stroke patients].

Rev Prat 2020 Jun;70(6):617-620

Samu de Paris ; service d'anesthésieréanimation- Samu, hôpital universitaire Necker-Enfants malades, centre Assistance publique-Hôpitaux de Paris ; université de Paris, Paris, France.

Prehospital management of acute stroke patients. In France, prehospital management of patients with suspected acute stroke relies on emergency medical communication centers (Samu), which provides first-line telephone assessment and dispatches the most appropriate emergency vehicle. Such tasks are not straightforward because many clinical symptoms may correspond to stroke and alternative diagnoses - stroke mimics - are common. It is crucial to reduce both prehospital and hospital delays in patients eligible for reperfusion therapies, namely intravenous thrombolysis and/or mechanical thrombectomy. Because mechanical thrombectomy only applies to patients with acute ischemic stroke and large-vessel occlusion, prehospital triage is important. However, clinical prediction of large-vessel occlusion is difficult and whether a specific patient should be sent to the nearest primary stroke center (drip and ship paradigm) or a comprehensive stroke center with thrombectomy capability (mothership paradigm) remains uncertain. Prehospital notification of the hospital-based stroke teams by the emergency medical system crews is crucial in reducing delays to achieve reperfusion.
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June 2020

Whole-Blood Resuscitation of Injured Patients' Plasma.

JAMA Surg 2021 Jan;156(1):101

TraumaBase PréHospitalière, Hôpitaux Universitaires Henri Mondor, Créteil, France.

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http://dx.doi.org/10.1001/jamasurg.2020.4109DOI Listing
January 2021

The interaction between arterial oxygenation and carbon dioxide and hospital mortality following out of hospital cardiac arrest: a cohort study-do not dismiss confounders!

Crit Care 2020 09 3;24(1):544. Epub 2020 Sep 3.

SAMU de Paris, Service d'Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, APHP. Centre and Université de Paris, Paris, France.

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http://dx.doi.org/10.1186/s13054-020-03196-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7650289PMC
September 2020

Pupil Reactivity in Refractory Out-of-Hospital Cardiac Arrest Treated by Extra-Corporeal Cardiopulmonary Resuscitation.

Turk J Anaesthesiol Reanim 2020 Aug 24;48(4):294-299. Epub 2019 Sep 24.

Intensive Care Unit, Anaesthesiology department and SAMU of Paris, Hospital Necker, Assistance Publique Hôpitaux de Paris, Paris Descartes University, Paris, France.

Objective: The objective of this study was to assess the association of early pupil evaluation with death occurrence on Day 28 in patients with refractory out-of-hospital cardiac arrest (ROHCA) admitted to the intensive care unit (ICU) and treated by extra-corporeal cardiopulmonary resuscitation (eCPR).

Methods: The pupil size (miosis, intermediary or mydriasis) and bilateral pupillary light reactivity (present or absent) were monitored in sedated and paralysed patients treated by eCPR. Mortality was assessed on Day 28.

Results: A total of 46 consecutive patients with ROHCA were included in the study. Thirty (65%) patients died on Day 28. Twenty-seven (90%) patients had pupils non-reactive to light, and 18 (60%) had mydriasis at the ICU admission. Using logistic regression, including age, gender, no flow, low-flow, size and pupil reactivity to light, only the pupillary reactivity to light remained associated with death on Day 28 (Odds ratio=0.12, 95%CI=[0.01-0.96]).

Conclusion: Pupils not reacting to light at the ICU admission were associated with mortality on Day 28 in patients with ROHCA. Pupillary light reactivity is a simple and easy tool that can be used to early detect a poor outcome in patients with ROHCA treated by eCPR.
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http://dx.doi.org/10.5152/TJAR.2019.75418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434341PMC
August 2020

Pre-hospital blood transfusion - an ESA survey of European practice.

Scand J Trauma Resusc Emerg Med 2020 Aug 14;28(1):79. Epub 2020 Aug 14.

SAMU de Paris, Anaesthesiology and Critical Care Department, Universitary Hospital Necker - Enfants Malades, APHP Centre - University of Paris, Paris, France.

Background: Blood products are a lifesaving commodity in the treatment of major trauma. Although there is little evidence for use of pre-hospital blood products (PHBP) in seriously injured patients, an increasing number of emergency medical services have started using PHBP for treatment of major haemorrhage. The primary aim of this survey was to establish the degree of prehospital blood product use throughout Europe and discover main indications. The secondary aim was to evaluate opinions about PHBP and also the experience and the personal views of its users.

Methods: The subcommittee for Critical Emergency Medicine of the European Society of Anaesthesiology (ESA) held an online survey of European Helicopter Emergency Services (HEMS) and all French Services d'Aide Médicale Urgente (SAMU) regions. It contained 13 questions both open and multiple-choice about the frequency transfusions are carried out, the PHBP used and the perceived benefit. The survey was distributed to the corresponding HEMS leads in 14 European countries.

Results: In total there were 172 valid responses; overall 48% of all respondents have prehospital access to packed red cells, 22% to fresh plasma and 14% use lyophilised plasma. Besides blood product administration, 94% of all services use tranexamic acid. Sixty five percent of all replies came from French and from German services (37 and 28% respectively). PHBP were mainly used for trauma related emergencies. France has the highest uptake of use of blood products at 89%, whereas the rate in Germany was far lower at 6%. Fifty five percent of the service leads felt that PHBP are beneficial, and even lifesaving in individual cases despite being needed infrequently.

Conclusions: We found remarkable dissimilarities in practice between the different European countries. Even if there is not an absolute consensus amongst providers on the benefit of PHBP, the majority feel they are beneficial. The difference in practice is possibly related to the perceived lack of evidence on prehospital blood transfusion. We suggest to include the use of PHBP in trauma registries in order to consolidate the existing evidence.
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http://dx.doi.org/10.1186/s13049-020-00774-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7427720PMC
August 2020

Re-assessment of re-warming for out-of-hospital births.

Scand J Trauma Resusc Emerg Med 2020 08 5;28(1):76. Epub 2020 Aug 5.

SAMU de Paris, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, AP-HP, 149 rue de Sèvres, 75015, Paris, France.

Therapeutic controlled cooling is routinely practiced on neonates with core temperatures of 33-34 °C attained during cooling for birth related hypoxic-ischaemia encephalopathy (HIE). Rewarming after therapeutic cooling in clinical trials for HIE takes place at 0.25-0.5 °C/h over 6-12 h. Javaudin et al. looked at four methods for re-warming infants born out-of-hospital. The incubator group had a 0.8 °C median increase in body temperature for a median transfer time of 38 min (IQR-31-49 min); equating to 1.3 °C/h. In contrast, the group plastic bag+skin-to-skin+cap had a median temperature rise of 0.2 °C (median transport time 43 min [IQR-33-61 min]); equating to 0.28 °C/h, which is closer to therapeutic controlled methods. Javaudin et al. proposed incubator re-warming for out-of-hopital births whereas we consider that an alternative interpretation of the article's results leads to the different conclusion that plastic bag+skin-to-skin+cap, rather than an incubator, is the preferable method due to the more progressive re-warming and lower frequency of hyperthermia.
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http://dx.doi.org/10.1186/s13049-020-00770-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409397PMC
August 2020

Antimicrobials administration time in patients with suspected sepsis: faster is better for severe patients.

J Intensive Care 2020 22;8:52. Epub 2020 Jul 22.

SAMU de Paris, Service d'Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, AP-HP.Centre and Université de Paris, Paris, France.

In a recent report, Ascuntar et al. describes the impossibility to demonstrate a significant association between early antibiotic therapy administration and mortality in sepsis patients. Nevertheless, we believe that some methodological issues deserve their conclusions. First, the objective of the authors of an early antibiotic therapy may be ambitious considering practical daily emergency department limitation. Second, most of patients included in the study appear to suffer from sepsis and not from septic shock, which limits the impact of an early and aggressive management. At last, more than a single intervention such as antibiotic therapy, sepsis treatment is now considered as based on a "bundle of care."
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http://dx.doi.org/10.1186/s40560-020-00471-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7374954PMC
July 2020

Effects of early high-dose erythropoietin on acute kidney injury following cardiac arrest: exploratory analyses from an open-label randomized trial.

Clin Kidney J 2020 Jun 17;13(3):413-420. Epub 2019 Jun 17.

Medical Intensive Care Unit, Cochin Hospital (AP-HP), Paris, France.

Background: Acute kidney injury (AKI) is frequent in patients resuscitated from cardiac arrest (CA) and may worsen outcome. Experimental data suggest a renoprotective effect by treating these patients with a high dose of erythropoietin (Epo) analogues. We aimed to evaluate the efficacy of epoetin alpha treatment on renal outcome after CA.

Methods: We did a analysis of the Epo-ACR-02 trial, which randomized patients with a persistent coma after a witnessed out-of-hospital CA. Only patients admitted in one intensive care unit were analysed. In the intervention group, patients received five intravenous injections of Epo spaced 12 h apart during the first 48 h, started as soon as possible after resuscitation. In the control group, patients received standard care without Epo. The main endpoint was the proportion of patients with persistent AKI defined by Kidney Disease: Improving Global Outcomes criteria at Day 2. Secondary endpoints included the occurrence of AKI through Day 7, estimated glomerular filtration rate (eGFR) at Day 28, haematological indices and adverse events.

Results: A total of 162 patients were included in the primary analysis (74 in the Epo group, 88 in the control group). Baseline characteristics were similar in the two groups. At Day 2, 52.8% of the patients (38/72) in the intervention group had an AKI, as compared with 54.4% of the patients (46/83) in the control group (P = 0.74). There was no significant difference between the two groups regarding the proportion of patients with AKI through Day 7. Among patients with persistent AKI at Day 2, 33% (4/12) in the intervention group had an eGFR <75 mL/min/1.73 m compared with 25% (3/12) in the control group at Day 28 (P = 0.99). We found no significant differences in haematological indices or adverse events.

Conclusion: After CA, early administration of Epo did not confer any renal protective effect as compared with standard therapy.
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http://dx.doi.org/10.1093/ckj/sfz068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7367106PMC
June 2020

Bolus potassium in frustrated ventricular fibrillation storm: Evidence are growing!

J Card Surg 2020 Aug 11;35(8):2116. Epub 2020 Jul 11.

SAMU de Paris, Service d'Anesthésie Réanimation, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France.

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http://dx.doi.org/10.1111/jocs.14735DOI Listing
August 2020

Sepsis alerts called in the field vs the ED: impact of severity and in-hospital confounders.

Am J Emerg Med 2020 09 10;38(9):1940. Epub 2020 Jun 10.

Departments of Anaesthesia & Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris, France 149 rue de Sevres, 75015 Paris, France.

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http://dx.doi.org/10.1016/j.ajem.2020.06.016DOI Listing
September 2020

Prehospital Shock Precautions on Triage (PSPoT) score to assess in-hospital mortality for septic shock.

Am J Emerg Med 2020 Mar 25. Epub 2020 Mar 25.

Intensive Care Unit, Anesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.

Context: In the prehospital setting, early identification of septic shock (SS) with high risk of poor outcome is a daily issue. There is a need for a simple tool aiming to early assess outcome in order to decide delivery unit (emergency department (ED) or intensive care unit (ICU)). In France, prehospital emergencies are managed by the Service d'Aide Médicale d'Urgence (SAMU). The SAMU physician decides the destination ward either to the ICU or to the ED after on scene severity assessment. We report the association between The Prehospital Shock Precautions on Triage (PSPoT) score, and in-hospital mortality of SS patients initially cared for in the prehospital setting by a mobile ICU (MICU).

Methods: SS patients cared for by MICU were prospectively included between February 2017 and July 2019. The PSPoT score was established by adding shock index>1 and criterion based on past medical history: age >65 years and at least 1 previous comorbidity (chronic cardiac failure, chronic renal failure, chronic obstructive pulmonary disease, previous or actual history of cancer, institutionalization, hospitalisation within previous 3 months. A threshold of ≥2, was arbitrarily chosen for clinical relevance and usefulness in clinical practice.

Results: One-hundred and sixty-nine with a median age of 72 [20-93] years were analysed. SS origin was mainly pulmonary (54%), abdominal (19%) and urinary (15%). The median PSPoT score was 2 [1-2]. PSPoT score and PSPoT score ≥ 2 were associated with in-hospital mortality: OR = 1.24 [0.77-2.05] and OR = 2.19 [1.09-4.59] respectively.

Conclusion: We report an association between PSPoT score, and in-hospital mortality of SS patients cared for by a MICU. A PSPoT score ≥ 2 early identifies poorer outcome.
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http://dx.doi.org/10.1016/j.ajem.2020.03.048DOI Listing
March 2020

Association between low pH and unfavorable neurological outcome among out-of-hospital cardiac arrest patients treated by extracorporeal CPR: do not dismiss confounders!

J Intensive Care 2020 22;8:42. Epub 2020 Jun 22.

SAMU de Paris, Service d'Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, AP-HP, Centre and Université de Paris, Paris, France.

Recently, Okada et al. reported an association between low pH value before the implementation of extracorporeal cardiopulmonary resuscitation (ECPR) and 1-month unfavorable neurological outcome among out-of-hospital cardiac arrest (OHCA) patients treated with ECPR. Nevertheless, we believe that some methodological flaws deserve their conclusions. The time duration between OHCA occurrence and blood gas analysis (BGA), a major confounder for misinterpretation, was not taken into account. It is not reported whether the result of BGA analysis was considered and/or treated, and if ECPR implementation decision had been influenced by the results analysis. Furthermore, the no-flow duration and the in-hospital phase confounders for neurological outcome are not included as covariates in the logistic regression. Therefore, we believe that causes and consequences should not be confused: the longer is the no-flow duration, the greater are the metabolic consequences.
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http://dx.doi.org/10.1186/s40560-020-00461-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7310087PMC
June 2020

Association between Blood Pressure after Haemodynamic Resuscitation in the Prehospital Setting and 28-Day Mortality in Septic Shock.

Turk J Anaesthesiol Reanim 2020 Jun 22;48(3):229-234. Epub 2019 Oct 22.

Department of Anaesthesia and Intensive Care Unit, SAMU, Paris, France.

Objective: Septic shock results in a decreased blood pressure (BP) leading to organ failure. The haemodynamic resuscitation aims at restoring the BP to allow efficient tissue perfusion. The aim of the present study was to evaluate the association between the mean BP (MBP) reached after haemodynamic resuscitation in patients with septic shock cared for in the prehospital setting by a mobile intensive care unit (MICU) and mortality at 28 days after intensive care unit (ICU) admission.

Methods: Patients with septic shock managed by a mobile intensive care unit (MICU) and admitted in the ICU were retrospectively analysed. The association between mortality and MBP after prehospital resuscitation was studied.

Results: A total of 85 patients with septic shock were included in the study. The origin of sepsis was mainly pulmonary (64%). Mortality reached 35%. Haemodynamic resuscitation was performed using crystalloids (98%) with a mean infused volume indexed on a body weight of 16±11 mL kg in the prehospital setting. No patient received catecholamine or antibiotic prior to hospital admission. Final prehospital MBP was 64±8 mm Hg in the overall population and 66±8 mm Hg versus 62±8 mm Hg in alive and deceased patients, respectively (p=0.02). After adjustment, final prehospital MBP [odds ratio adjusted (ORa) (95% confidence interval (CI)]=0.89 (0.80-0.99), MBP <65 mmHg [ORa (95% CI)=14.3 (3.35-77.7)] and MBP >65 mmHg [ORa (95% CI)=0.06 (0.01-0.25)] were associated with mortality.

Conclusion: Persistent low MBP after prehospital initial resuscitation measures in patients with septic shock managed in the prehospital setting is associated with increased mortality. Further studies are needed to evaluate the impact of prehospital haemodynamic management in septic shock to further optimise prehospital care and improve outcome.
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http://dx.doi.org/10.5152/TJAR.2019.45577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7279876PMC
June 2020

Success and complications by team composition for prehospital pediatric intubation: children also need physicians!

Crit Care 2020 06 15;24(1):344. Epub 2020 Jun 15.

SAMU de Paris, SMUR Pédiatrique Necker, Service d'Anesthésie-Réanimation, Centre Hospitalier Universitaire Necker - Enfants Malades, AP-HP.Centre, and Université de Paris, Paris, France.

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http://dx.doi.org/10.1186/s13054-020-03029-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296626PMC
June 2020

Admission decisions to intensive care units in the context of the major COVID-19 outbreak: local guidance from the COVID-19 Paris-region area.

Crit Care 2020 06 5;24(1):293. Epub 2020 Jun 5.

Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris University, 1 Avenue Claude Vellefaux, 75010, Paris, France.

SARS-CoV-2 has caused a global pandemic unprecedented in size, spread, severity, and mortality. The influx of patients with severe or life-threatening disease means that in some cases, the available medical resources are not sufficient to meet the needs of all patients. Hence, healthcare providers may be forced to make difficult choices about which patients should be referred to the ICU. This document is intended to provide conceptual support to all healthcare teams currently engaged in the frontline management of the COVID-19 pandemic. It aims to assist physicians in the decision-making process for ICU admission and to help them provide uninterrupted and high-quality care.
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http://dx.doi.org/10.1186/s13054-020-03021-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274070PMC
June 2020

Prehospital Plasma Transfusion and Survival in Trauma Patients With Hemorrhagic Shock.

JAMA Surg 2020 Aug;155(8):784

SAMU de Paris, Service d'Anesthésie Réanimation, Centre Hospitalier Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, and Université Paris Descartes, Paris, France.

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http://dx.doi.org/10.1001/jamasurg.2020.1131DOI Listing
August 2020

Prognostic value of venous blood analysis at the start of CPR in non-traumatic out-of-hospital cardiac arrest: association with ROSC and the neurological outcome: do not forget the no-flow influence!

Crit Care 2020 05 18;24(1):232. Epub 2020 May 18.

SAMU de Paris, Service d'Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, AP-HP. Centre, and Université de Paris, Paris, France.

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http://dx.doi.org/10.1186/s13054-020-02898-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236184PMC
May 2020

Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality.

Prehosp Emerg Care 2021 May-Jun;25(3):317-324. Epub 2020 May 15.

Background: Septic shock (SS) is associated with high morbidity and mortality rate. Early antibiotic therapy administration in septic patients was shown to reduce mortality but its impact on mortality in a prehospital setting is still under debate. To clarify this point, we performed a retrospective analysis on patients with septic shock who received antibiotics in a prehospital setting. From April 15, 2017 to March 1, 2020, patients with septic shock requiring Mobile Intensive Care Unit (MICU) intervention were retrospectively analyzed to assess the impact of prehospital antibiotic therapy administration on a 30-day mortality. Three-hundred-eight patients with septic shock requiring MICU intervention in the prehospital setting were analyzed. The mean age of the study population was 70 ± 15 years. Presumed origin of SS was mainly pulmonary (44%), digestive (21%) or urinary (19%) infection. Overall 30-day mortality was 29%. Ninety-eight (32%) patients received antibiotic therapy. Using Cox regression analysis, we showed that prehospital antibiotic therapy significantly reduces 30-day mortality for patients with septic shock (hazard ratio = 0.56, 95%CI [0.35-0.89], p = 0.016). In this retrospective study, prehospital antibiotic therapy reduces 30-day mortality of septic shock patients cared for by MICU. Further studies will be needed to confirm the beneficial effect of prehospital antibiotic therapy in association or not with prehospital hemodynamic optimization to improve the survival of septic shock patients.
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http://dx.doi.org/10.1080/10903127.2020.1763532DOI Listing
May 2020

The authors Reply: Mortality Benefit Shock Index in Prehospital Level Care.

Am J Emerg Med 2020 10 25;38(10):2236-2237. Epub 2020 Mar 25.

Intensive Care Unit, Anesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.

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http://dx.doi.org/10.1016/j.ajem.2020.03.040DOI Listing
October 2020

Prehospital Severe Trauma Management in Tactical Medicine.

JAMA Surg 2020 05;155(5):451

SAMU de Paris, Service d'Anesthésie Réanimation, Centre Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, France.

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http://dx.doi.org/10.1001/jamasurg.2019.6037DOI Listing
May 2020

Contribution of the Pre-Hospital Blood Lactate Level in the Pre-Hospital Orientation of Septic Shock: The LAPHSUS Study.

Turk J Anaesthesiol Reanim 2020 Feb 24;48(1):58-61. Epub 2019 Sep 24.

Intensive Care Unit, Anesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.

Objective: In the pre-hospital setting, the assessment of septic shock severity is essential when determining the optimal initial in-hospital level of care. As clinical signs can be faulted, there is a need for an additional component to enhance the severity assessment and to decide on in-hospital admission in the intensive care unit (ICU) or in the emergency department (ED). Point-of-care medical devices by yielding blood lactate value since the pre-hospital setting may give an easy and valuable component for the severity assessment and decision-making. The aim of this study is to provide clinical evidence that the pre-hospital blood lactate level predicts the 30-day mortality in patients with septic shock.

Methods: This trial is a prospective, observational, non-randomised controlled study. A total of 1,000 patients requiring a mobile ICU intervention for septic shock in the pre-hospital setting will be included. Pre-hospital blood lactate levels will not be taken into account to decide patients' treatments and/or ED or ICU admission. In the pre-hospital setting, each patient will benefit from two measurements of the blood lactate level: initial measurement at the first contact, and final measurement at the hospital admission with a specific point-of-care medical device.

Conclusion: This study could provide clinical evidence that the pre-hospital blood lactate level predicts the 30-day mortality of patients with septic shock. The results from this study could also prove the utility of the pre-hospital blood lactate level for the triage and early orientation of patients with septic shock.
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http://dx.doi.org/10.5152/TJAR.2019.42027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7001804PMC
February 2020

Epinephrine, inodilator, or no inotrope in venoarterial extracorporeal membrane oxygenation implantation: a single-center experience-an RCT would be desirable.

Crit Care 2020 01 22;24(1):21. Epub 2020 Jan 22.

SAMU de Paris, Service d'Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, and Université Paris Descartes - Paris 5, Paris, France.

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http://dx.doi.org/10.1186/s13054-019-2712-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6977294PMC
January 2020

Implementation of earlier antibiotic administration in patients with severe sepsis and septic shock in Japan: antibiotic action needs time and tissue perfusion to reach target.

Crit Care 2020 01 14;24(1):17. Epub 2020 Jan 14.

SAMU de Paris, Service d'Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, and Université Paris Descartes - Paris 5, Paris, France.

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http://dx.doi.org/10.1186/s13054-020-2727-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6958718PMC
January 2020

Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial.

JAMA 2019 12;322(23):2303-2312

Department of Emergency, CHU de la Réunion, Université de la Réunion, Réunion, France.

Importance: Rocuronium and succinylcholine are often used for rapid sequence intubation, although the comparative efficacy of these paralytic agents for achieving successful intubation in an emergency setting has not been evaluated in clinical trials. Succinylcholine use has been associated with several adverse events not reported with rocuronium.

Objective: To assess the noninferiority of rocuronium vs succinylcholine for tracheal intubation in out-of-hospital emergency situations.

Design, Setting And Participants: Multicenter, single-blind, noninferiority randomized clinical trial comparing rocuronium (1.2 mg/kg) with succinylcholine (1 mg/kg) for rapid sequence intubation in 1248 adult patients needing out-of-hospital tracheal intubation. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. The date of final follow-up was August 31, 2016.

Interventions: Patients were randomly assigned to undergo tracheal intubation facilitated by rocuronium (n = 624) or succinylcholine (n = 624).

Main Outcomes And Measures: The primary outcome was the intubation success rate on first attempt. A noninferiority margin of 7% was chosen. A per-protocol analysis was prespecified as the primary analysis.

Results: Among 1248 patients who were randomized (mean age, 56 years; 501 [40.1%] women), 1230 (98.6%) completed the trial and 1226 (98.2%) were included in the per-protocol analysis. The number of patients with successful first-attempt intubation was 455 of 610 (74.6%) in the rocuronium group vs 489 of 616 (79.4%) in the succinylcholine group, with a between-group difference of -4.8% (1-sided 97.5% CI, -9% to ∞), which did not meet criteria for noninferiority. The most common intubation-related adverse events were hypoxemia (55 of 610 patients [9.0%]) and hypotension (39 of 610 patients [6.4%]) in the rocuronium group and hypoxemia (61 of 616 [9.9%]) and hypotension (62 of 616 patients [10.1%]) in the succinylcholine group.

Conclusions And Relevance: Among patients undergoing endotracheal intubation in an out-of-hospital emergency setting, rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate.

Trial Registration: ClinicalTrials.gov Identifier: NCT02000674.
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http://dx.doi.org/10.1001/jama.2019.18254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990819PMC
December 2019