Publications by authors named "Pierre Carli"

132 Publications

European Resuscitation Council Guidelines 2021: Adult advanced life support.

Resuscitation 2021 Apr 24;161:115-151. Epub 2021 Mar 24.

University of Warwick, Warwick Medical School, Coventry, CV4 7AL; Royal United Hospital, Bath, UK.

These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
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http://dx.doi.org/10.1016/j.resuscitation.2021.02.010DOI Listing
April 2021

A new hybrid technique for extracorporeal cardiopulmonary resuscitation for use by nonsurgeons.

Emergencias 2021 Abr;33(2):156-157

SAMU de Paris-ICU, Necker University Hospital, París Francia. René Descartes University, París, Francia.

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March 2021

Assessment of the mass casualty triage during the November 2015 Paris area terrorist attacks: towards a simple triage rule.

Eur J Emerg Med 2021 Apr;28(2):136-143

Sorbonne Université.

Backround: Triage is key in the management of mass casualty incidents.

Objective: The objective of this study was to assess the prehospital triage performed during the 2015 Paris area terrorist attack.

Design Setting And Participant: This was a retrospective cohort study that included all casualties of the attacks on 13 November 2015 in Paris area, France, that were admitted alive at the hospital within the first 24 h after the events. Patients were triaged as absolute emergency or relative emergency by a prehospital physician or nurse. This triage was then compared to the one of an expert panel that had retrospectively access to all prehospital and hospital files.

Outcomes Measures And Analysis: The primary endpoints were the rate of overtriage and undertriage, defined as number of patients misclassified in one triage category, divided by the total number of patients in this triage category.

Main Result: Among 337 casualties admitted to the hospital, 262 (78%) were triaged during prehospital care, with, respectively, 74 (28%) and 188 (72%) as absolute and relative emergencies. Among these casualties, the expert panel classified 96 (37%) patients as absolute emergencies and 166 (63%) as relative emergency. The rate of undertriage and overtriage was 36% [95% confidence interval (CI), 27-47%] and 8% (95% CI, 4-13%), respectively. Among undertriaged casualties, 8 (23%) were considered as being severely undertriaged. Among overtriaged casualties, 10 (77%) were considered as being severely overtriaged.

Conclusion: A simple prehospital triage for trauma casualties during the 13 November terrorist attack in Paris could have been performed triaged in 78% of casualties that were admitted to the hospital, with a 36% rate of undertriage and 8% of overtriage. Qualitative analysis of undertriage and overtriage indicate some possibilities for further improvement.
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http://dx.doi.org/10.1097/MEJ.0000000000000771DOI Listing
April 2021

Elimination of fluconazole during continuous renal replacement therapy. An in vitro assessment.

Int J Artif Organs 2020 Nov 21:391398820976144. Epub 2020 Nov 21.

Department of Anesthesiology and Intensive Care Medicine, SAMU de Paris, Adult Intensive Care Unit, Necker Hospital, Paris, France.

Introduction: Continuous renal replacement therapy (CRRT) efficiently eliminates fluconazole. However, the routes of elimination were not clarified. Adsorption of fluconazole by filters is a pending question. We studied the elimination of fluconazole in a model mimicking a session of CRRT in humans using the NeckEpur model. Two filters were studied.

Methods: The AV1000-polysulfone filter with the Multifiltrate Pro. Fresenius and the ST150-polyacrylonitrile filter with the Prismaflex. Baxter-Gambro were studied. Continuous filtration used a flowrate of 2.5 L/h in post-dilution only. Session were made in duplicate. Routes of elimination were assessed using the NeckEpur model.

Results: The mean measured initial fluconazole concentration (mean ± SD) for the four sessions in the central compartment (CC) was 14.9 ± 0.2 mg/L. The amount eliminated from the CC at the end of 6 h-session at a 2.5 L/h filtration flowrate for the AV1000-polysulfone and the ST150-polyacrylonitrile filters were 90%-93% and 96%-94%, respectively; the clearances from the central compartment (CC) were 2.5-2.6 and 2.4-2.3 L/h, respectively. The means of the instantaneous sieving coefficient were 0.94%-0.91% and 0.99%-0.91%, respectively. The percentages of the amount eliminated from the CC by filtration/adsorption were 100/0%-95/5% and 100/0%-100/0%, respectively.

Conclusion: Neither the ST150-polyacrylonitrile nor the AV1000-polysulfone filters result in any significant adsorption of fluconazole.
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http://dx.doi.org/10.1177/0391398820976144DOI Listing
November 2020

Alteration of the pharmacokinetics of aminoglycosides by adsorption in a filter during continuous renal replacement therapy. An in vitro assessment.

Therapie 2020 Oct 29. Epub 2020 Oct 29.

Department anesthesia and reanimation, adult intensive care unit, Necker hospital, 75015 Paris, France; University of Paris, 75006 Paris, France.

Objectives: Filters used in continuous renal replacement therapy (CRRT) induce elimination by filtration, dialysis, and adsorption. The worldwide used ST150® filter adsorbs cytokines. However, adsorption is a non-specific process which might alter the pharmacokinetics of drugs. Pharmacodynamic/pharmacokinetic relationship of aminoglycosides evidences the importance of the peak concentration at the first dose. We hypothesize an in vitro study may clarify the routes of elimination of aminoglycosides using the ST150® filter.

Methods: Prismaflex® and the STX150® filter, Baxter-Gambro were used. The diafiltration mode combined flowrates of dialysis and filtration at 2.5/1.5L/h, respectively, over 6h. One ionic solute was used in the different compartments. Pharmacokinetic analyses were performed using the NeckEpur® software.

Results: Percentages of gentamicin, tobramycin, and amikacin eliminated from the central compartment were 97±1, 95±3, and 94±6, %, respectively. The clearances were 8.4±2.3, 5.4±5, and 4.2±0.4L/h, respectively. The contributions of dialysis, filtration, and adsorption for gentamicin, tobramycin, and amikacin were 34.3±2.1, 0±0, and 67.7±2.1; 51.1±1.6, 6.3±3.1, and 46.3±2.0, and 37.8±6.3, 46.3±2.0, and 16.0±5.7%, respectively. Among physico-chemical properties, the rate of adsorption linearly and inversely correlated with the polar surface area of aminoglycosides (Y=-0.44X+161.7; R=0.9993).

Discussion: Using the ST150® filter, dialysis, filtration, and adsorption play a role depending on the chemical structure of aminoglycosides. In the diafiltration mode, elimination of gentamicin and tobramycin by filtration is not detected or weak, respectively. Adsorption should be considered as a potential adverse effect of CRRT. Polar surface area of drugs is a physico-chemical parameter which should be considered regarding adsorption of drugs in filters. The risk needs to be systematically assessed.
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http://dx.doi.org/10.1016/j.therap.2020.10.005DOI Listing
October 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

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

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

Diafiltration flowrate is a determinant of the extent of adsorption of amikacin in renal replacement therapy using the ST150-AN69 filter: An in vitro study.

Int J Artif Organs 2020 Dec 1;43(12):758-766. Epub 2020 May 1.

Department of Anesthesiology an Intensive Care Medicine, Adult Intensive Care Unit, SAMU de Paris, Necker Hospital, Paris, France.

Introduction: In continuous renal replacement therapy, conduction and convection are controlled allowing prescribing dosage regimen improving survival. In contrast, adsorption is an uncontrolled property altering drug disposition. Whether adsorption depends on flowrates is unknown. We hypothesized an in vitro model may provide information in conditions mimicking continuous renal replacement therapy in humans.

Methods: ST150-AN69 filter and Prismaflex dialyzer, Baxter-Gambro were used. Simulated blood flowrate was set at 200 mL/min. The flowrates in the filtration (continuous filtration), dialysis (continuous dialysis), and diafiltration (continuous diafiltration) were 1500, 2500, and 4000 mL/h, respectively. Routes of elimination were assessed using NeckEpur analysis.

Results: The percentages of the total amount eliminated by continuous filtration, continuous dialysis, and continuous diafiltration were 82%, 86%, and 94%, respectively. Elimination by effluents and adsorption accounted for 42% ± 7% and 58% ± 5%, 57% ± 7% and 43% ± 6%, and 84% ± 6% and 16% ± 6% of amikacin elimination, respectively. There was a linear regression between flowrates and amikacin clearance: Y = 0.6 X ± 1.7 (R = 0.9782). Conversely, there was a linear inverse correlation between the magnitude of amikacin adsorption and flowrate: Y = -16.9 X ± 84.1 (R = 0.9976).

Conclusion: Low flowrates resulted in predominant elimination by adsorption, accounting for 58% of the elimination of amikacin from the central compartment in the continuous filtration mode at 1500 mL/h of flowrate. Thereafter, the greater the flowrate, the lower the adsorption of amikacin in a linear manner. Flowrate is a major determinant of adsorption of amikacin. There was an about 17% decrease in the rate of adsorption per increase in the flowrate of 1 L/min.
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http://dx.doi.org/10.1177/0391398820911928DOI Listing
December 2020

Blood product needs and transfusion timelines for the multisite massive Paris 2015 terrorist attack: A retrospective analysis.

J Trauma Acute Care Surg 2020 09;89(3):496-504

From the Department of Anaesthesiology and Critical Care (T.M., S.A.), Percy Military Hospital, Clamart; French Blood Institute (A.F.), Paris, France; French Military Blood Institute (T.P.), Clamart, France; SAMU 75 (P.C.), Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France; SAMU 93 (F.L.), Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, Bobigny, France; Department of Anaesthesiology and Critical Care (T.G.), Hôpital Beaujon, Hôpitaux Universitaires Paris Nord-Val-De-Seine, Assistance Publique-Hôpitaux de Paris, Clichy, France; Université Paris Sud, Department of Anesthesiology and Critical Care (S.R.H.), Assistance Publique-Hôpitaux de Paris, Bicêtre Hôpitaux Universitaires Paris Sud, Le Kremlin Bicêtre, France; CESP, INSERM, Université Paris-Sud (S.R.H.), UVSQ, Université Paris-Saclay, France; CESP, INSERM, Maison de Solenn (S.R.H.), France; Service Médical du RAID (M.L.), Bièvres, France; Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Department of Anaesthesiology and Critical Care (M.L., E.D., M.R.), Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Department of Emergency Medicine and Surgery (B.R.), Hôpital Saint-Antoine, Department of Emergency (Y.Y., D.P.), France, Hôpital Européen Georges Pompidou, Emergency Department (A.-L.F.-P.), Assistance Publique-Hôpitaux de Paris, Paris, France; Begin Military Hospital, Department of Emergency (A.W.), Saint Mandé, France; Hôpital Saint Louis, Department of Emergency (C.O.), Hôpital Lariboisière, Department of Anesthesiology and Critical Care (E.G.), Assistance Publique-Hôpitaux de Paris, Paris, France; Hôpital Henri Mondor, Department of Anaesthesiology and Critical Care (A.A.), Assistance Publique-Hôpitaux de Paris, Créteil, France; Hôpital Bichat, Division of Vascular Surgery (Y.C.), Assistance Publique-Hôpitaux de Paris, Paris, France; Institut Médico-légal de Paris (B.L.), Paris, France; Paris Fire Brigade, Emergency Medical Department (J.-P.T.), Paris, France; French Military Health Service Schools (S.A.), Lyon, France; Université Paris Diderot (E.G., Y.C.), Paris, France; Université Paris Descartes (P.C., B.L.), Paris, France; Université Paris 13 (F.L.), Bobigny, France; Sorbonne Université (M.R.), UMRS Inserm 1158, France; Sorbonne Université (D.P., B.R.), UMRS Inserm 1166, IHU ICAN, Paris, France; and Sorbonne Université (Y.Y.), UMRS Inserm 1136, Paris, France.

Objective: Hemorrhage is the leading cause of death after terrorist attack, and the immediacy of labile blood product (LBP) administration has a decisive impact on patients' outcome. The main objective of this study was to evaluate the transfusion patterns of the Paris terrorist attack victims, November 13, 2015.

Methods: We performed a retrospective analysis including all casualties admitted to hospital, aiming to describe the transfusion patterns from admission to the first week after the attack.

Results: Sixty-eight of 337 admitted patients were transfused. More than three quarters of blood products were consumed in the initial phase (until November 14, 11:59 PM), where 282 packed red blood cell (pRBC) units were transfused along with 201 plasma and 25 platelet units, to 55 patients (16% of casualties). Almost 40% of these LBPs (134 pRBC, 73 plasma, 8 platelet units) were transfused within the first 6 hours after the attack. These early transfusions were massive transfusion (MT) for 20 (6%) of 337 patients, and the average plasma/red blood cell ratio was 0.8 for MT patients who received 366 (72%) of 508 LBPs.The median time from admission to pRBC transfusion was 57 (25-108) minutes and 208 (52-430) minutes for MT and non-MT patients, respectively. These same time intervals were 119 (66-202) minutes and 222 (87-381) minutes for plasma and 225 (131-289) minutes and 198 (167-230) minutes for platelets.

Conclusion: Our data suggest that improving transfusion procedures in mass casualty setting should rely more on shortening the time to bring LBP to the bedside than in increasing the stockpile.

Level Of Evidence: Epidemiological study, Therapeutic IV.
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http://dx.doi.org/10.1097/TA.0000000000002729DOI Listing
September 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

Prehospital shock index to assess 28-day mortality for septic shock.

Am J Emerg Med 2020 07 4;38(7):1352-1356. Epub 2019 Dec 4.

Department of Anesthesia & Intensive Care Unit, SAMU, University Paris Descartes, Hôpital Necker - Enfants, Malades, 149 Rue de Sèvres, 75015 Paris, France.

Context: In the prehospital setting, early identification of septic shock (SS) with high risk of mortality aims to initiate early treatments and to decide delivery unit (emergency department (ED) or intensive care unit (ICU)). In this context, there is a need for a prognostic measure of severity and death in order to early detect patients with a higher risk of pejorative evolution. In this study, we describe the association between prehospital shock index (SI) and mortality at day 28 of patients with SS initially cared for in the prehospital setting by a mobile intensive care unit (MICU).

Methods: Patients with SS cared for by a MICU between January 2016 and May 2019 were retrospectively analyzed. Using propensity score, the association between SI and mortality was assessed by Odd Ratio (OR) with 95 percent confidence interval [95 CI].

Results: One-hundred and fourteen patients among which 78 males (68%) were analysed. The mean age was 71 ± 14 years old. SS was mainly associated with pulmonary (55%), digestive (20%) or urinary (11%) infection. Overall mortality reached 33% (n = 38) at day 28. Median SI [interquartile range] differed between alive and deceased patients: 0.73 [0.61-1.00] vs 0.80 [0.66-1.10], p < 0.001*). After adjusting for confounding factors, the OR of SI > 0.9 was 1.17 [1.03-1.32].

Conclusion: In this study, we report an association between prehospital SI and mortality of patients with prehospital SS. A SI > 0.9 is a readily available tool correlated with increased mortality of patients with SS initially cared for in the prehospital setting.
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http://dx.doi.org/10.1016/j.ajem.2019.11.004DOI Listing
July 2020

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study.

Eur Heart J 2020 06;41(21):1961-1971

Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75787 Paris, France.

Aims: Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods And Results: We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8-2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5-1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5-10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1-4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5-5.9; P = 0.002).

Conclusions: In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.
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http://dx.doi.org/10.1093/eurheartj/ehz753DOI Listing
June 2020

Prognostic Value of Blood Lactate and Base Deficit in Refractory Cardiac Arrest Cases Undergoing Extracorporeal Life Support.

Turk J Anaesthesiol Reanim 2019 Oct 24;47(5):407-413. Epub 2019 Apr 24.

Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France.

Objective: Cardiac arrest (CA) resuscitation is associated with an 'ischaemia-reperfusion' syndrome characterised by lactic acidosis as assessed by lactate and base deficit (BD). Both biomarkers are usually measured in patients suffering from refractory CA (RCA) subjected to extracorporeal life support (ECLS) to evaluate tissue reperfusion. However, their prognostic value has never been compared. The aim of the present study was to compare the prognostic value of both biomarkers measured at 0 and 3 h after the initiation of ECLS in patients with RCA on mortality.

Methods: Patients who were admitted to the intensive care unit with RCA were consecutively included in the study.

Results: Sixty-six patients were included. Lactate correlated with BD (R2=0.44, p<0.001). An area under the curve of 0.72 (95% confidence interval (CI) 0.59-0.84) was found for lactate and of 0.60 (95% CI 0.46-0.73) for BD. Using multivariable logistic regression, lactate (odds ratio (OR) 1.22, 95% CI 1.03-1.48) remained associated with mortality on day 28, but not BD (OR 0.99, 95% CI 0.86-1.14).

Conclusion: We report a difference in the prognostic value of lactate and BD on mortality. Three hours from the initiation of ECLS in patients with RCA, lactate should be preferred to BD to predict the efficiency of ECLS.
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http://dx.doi.org/10.5152/TJAR.2019.65391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6756315PMC
October 2019

Continuous renal replacement therapy in the treatment of severe hyperkalemia: An in vitro study.

Int J Artif Organs 2020 Feb 11;43(2):87-93. Epub 2019 Sep 11.

Département d'Anesthésie et de Réanimation, Adult Intensive Care Unit, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.

Introduction: Continuous renal replacement therapy is not presently recommended in the treatment of life-threatening hyperkalemia. There are no specific recommendations in hemodialysis to treat hyperkalemia. We hypothesized an in vitro model may provide valuable information on the usefulness of continuous renal replacement therapy to treat severe hyperkalemia.

Methods: A potassium-free solute was used instead of diluted blood for continuous renal replacement therapy with a simulated blood flowrate set at 200 mL/min. The mode of elimination included continuous filtration, continuous dialysis, and continuous diafiltration using a flowrate of 4000 mL/min for continuous filtration and continuous dialysis modes, and a ratio of 2500/1500 in the continuous diafiltration mode.

Results: The mean initial potassium in the central compartment was 10.1 ± 0.4 mmol/L. The clearances in the continuous diafiltration, continuous filtration, and continuous dialysis were 3.4 ± 0.5, 3.6 ± 0.1, and 3.7 ± 0.1 L/h, respectively, not significantly different. Continuous dialysis resulted in the lowest workload for staff. Increasing the continuous dialysis flowrates from 2000 to 8000 mL/h increased clearance from 2.3 ± 0.3 to 6.2 ± 0.8 L/h. The delays in decreasing the potassium concentration to 5.5 mmol/L dropped from 120 to 45 min, respectively. Potassium eliminated in the first hour increased from 18 to 38 mmol that compared favorably with hemodialysis. Decrease in simulated blood flowrate from 200 to 50 mL/min moderately but significantly decreased the clearance from 3.7 to 3.0 L/h.

Conclusion: Hyperkalemia is efficiently treated by continuous renal replacement therapy using the dialysis mode. Caution is needed to prevent the onset of severe hypokalemia within 40 min after initiation of the session.
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http://dx.doi.org/10.1177/0391398819865748DOI Listing
February 2020

Analysis of the medical response to November 2015 Paris terrorist attacks: resource utilization according to the cause of injury.

Intensive Care Med 2019 09 15;45(9):1231-1240. Epub 2019 Aug 15.

Sorbonne Université, INSERM, UMRS1166, IHU ICAN, Paris, France.

Purpose: The majority of terrorist acts are carried out by explosion or shooting. The objective of this study was first, to describe the management implemented to treat a large number of casualties and their flow together with the injuries observed, and second, to compare these resources according to the mechanism of trauma.

Methods: This retrospective cohort study collected medical data from all casualties of the attacks on November 13th 2015 in Paris, France, with physical injuries, who arrived alive at any hospital within the first 24 h after the events. Casualties were divided into two groups: explosion injuries and gunshot wounds.

Results: 337 casualties were admitted to hospital, 286 (85%) from gunshot wounds and 51 (15%) from explosions. Gunshot casualties had more severe injuries and required more in-hospital resources than explosion casualties. Emergency surgery was required in 181 (54%) casualties and was more frequent for gunshot wounds than explosion injuries (57% vs. 35%, p < 0·01). The types of main surgery needed and their delay following hospital admission were as follows: orthopedic [n = 107 (57%); median 744 min]; general [n = 27 (15%); 90 min]; vascular [n = 19 (10%); median 53 min]; thoracic [n = 19 (10%); 646 min]; and neurosurgery [n = 4 (2%); 198 min].

Conclusion: The resources required to deal with a terrorist attack vary according to the mechanism of trauma. Our study provides a template to estimate the proportion of various types of surgical resources needed overall, as well as their time frame in a terrorist multisite and multitype attack.

Funding: Assistance Publique-Hôpitaux de Paris.
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http://dx.doi.org/10.1007/s00134-019-05724-9DOI Listing
September 2019

Impact of Prehospital Mobile Intensive Care Unit Intervention on Mortality of Patients with Sepsis.

Turk J Anaesthesiol Reanim 2019 Aug 21;47(4):334-341. Epub 2019 Feb 21.

Department of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Necker, University Paris Descartes, Paris, France.

Objective: The outcome of sepsis relies on the early diagnosis and implementation of appropriate treatments. For management of out-of-hospital patients with sepsis, prehospital emergency services, named Service d'Aide Médicale d'Urgence (SAMU) in France, dispatch to the scene an emergency mobile team (EMT) or a mobile intensive care unit (MICU) based on the patient's severity. Therefore, patients are admitted to the emergency department (ED) or to the intensive care unit (ICU). The impact of MICU intervention on patient's prognosis remains unclear. The aim of the present study was to describe the impact of MICU intervention on mortality on day 28 (D28) of patients with sepsis.

Methods: We performed a retrospective study on patients with sepsis managed by prehospital teams, MICU or EMT, before admission to the ED or ICU. The primary outcome was mortality on D28.

Results: The SAMU received 30,642 calls during the study period with 140 patients with suspected sepsis. The suspected origin of sepsis was mainly pulmonary for 78 (55%) patients. Thirteen (9%) patients died on D28, 12 in the ED and 1 in the ICU. Two patients were admitted to the hospital by a MICU. After adjusting for confounding factors, the relative risk of mortality on D28 for patients admitted to the hospital by a MICU was 0.40.

Conclusion: We describe an association between MICU intervention and mortality on D28. MICU intervention for out-of-hospital patients with sepsis is associated with 60% reduced mortality on D28. Larger studies are needed to confirm the impact of the intervention of MICU on mortality of patients with sepsis.
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http://dx.doi.org/10.5152/TJAR.2019.26576DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6645836PMC
August 2019

Prognostic Value of Blood Lactate and Lactate Clearance in Refractory Cardiac Arrest Treated by Extracorporeal Life Support.

Turk J Anaesthesiol Reanim 2019 Feb 1;47(1):48-54. Epub 2019 Feb 1.

Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France.

Objective: During cardiac arrest (CA) resuscitation, an 'ischaemia-reperfusion' syndrome occurs leading to multiorgan failure reflected by an increase in blood lactate. Blood lactate is a diagnosis and prognosis biomarker in extracorporeal life support (ECLS), but its kinetic appears more informative to assess a patient's outcome. The aim of the present study was to describe the prognostic value of blood lactate and lactate clearance (LC) 3 (H3) and 6 h (H6) after the initiation of ECLS in the treatment of refractory CA.

Methods: Patients admitted to the intensive care unit for refractory CA were included. Lactate measurements were performed at the initiation of ECLS (H0) and at H3 and H6 upon the initiation of ECLS. LC was measured from 0 to 3 h (LC03), 0 to 6 h (LC06) and 3 to 6 h (LC36). The primary endpoint was in-hospital mortality within 28 days.

Results: Sixty-six patients were enrolled in the study. Lactate levels were higher in deceased patients. Increased mortality was observed with increasing levels of lactate at H3 and H6 and with decreasing LC03. Using logistic regression, an association was observed between mortality and lactate at H3 with an odds ratio (OR) of 1.21 (95% confidence interval (CI) 1.05-1.42); LC03, OR of 0.93 (95% CI 0.87-0.99) and LC06, OR of 0.96 (95% CI 0.92-0.99).

Conclusion: Blood lactate and LC within the first 3 h of ECLS in refractory CA are associated with mortality. LC is a more relevant parameter than blood lactate, taking into account both the production and elimination of lactate. We suggest to preferentially use LC to assess the patient's outcome.
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http://dx.doi.org/10.5152/TJAR.2018.96992DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6598657PMC
February 2019

Effect of Mean Blood Pressure During Extracorporeal Life Support on Outcome After Out-of-Hospital Cardiac Arrest.

Turk J Anaesthesiol Reanim 2019 Apr 14;47(2):134-141. Epub 2019 Feb 14.

Intensive Care Unit, Anaesthesiology Department and SAMU of Paris, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université Paris Descartes, Paris, France.

Objective: Extracorporeal Life Support (ECLS) can help to improve the outcome of refractory cardiac arrest (CA). ECLS allows to maintain blood pressure and tissue perfusion until the cause of CA is treated. The aim of the present study was to describe the mean blood pressure (MBP) during the first 24 h of ECLS for out-of-hospital CA (OHCA).

Methods: We performed a retrospective analysis of consecutive refractory OHCA requiring ECLS admitted to the intensive care unit. MBP was examined after starting ECLS (H0) and every 6 h during the first 24 h (H6, H12, H18 and H24).

Results: Forty patients were analysed. MBP significantly differs between survivors and non-survivors since 6 h: 77 vs 44 mm Hg (p=0.002), 51 vs 87 mm Hg at H12 (p=0.008), 57 vs 75 mm Hg at H18 (p=0.015) and 79 vs 53 mm Hg at H24 (p=0.004), whereas no difference was observed at H0: 69 vs 55 mm Hg (p=0.06). An MBP lower than 65 mm Hg since 6 h is associated with a poor outcome (sensitivity and specificity of death of 87% and 66% at H6, 80% and 75% at H12, 100% and 75% at H18 and 70% and 80% at H24, respectively).

Conclusion: Despite high levels of catecholamine, the inability to maintain MBP higher than 60 mm Hg after starting ECLS for OHCA is associated with a poor outcome.
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http://dx.doi.org/10.5152/TJAR.2019.73558DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6499042PMC
April 2019

Early blood transcriptomic signature predicts patients' outcome after out-of-hospital cardiac arrest.

Resuscitation 2019 05 15;138:222-232. Epub 2019 Mar 15.

Service de Réanimation Médicale, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Paris, France.

Background: Early prognostication is a major challenge after out-of-hospital cardiac arrest (OHCA).

Aims: We hypothesized that a genome-wide analysis of blood gene expression could offer new prognostic tools and lines of research.

Methods: Sixty-nine patients were enrolled from an ancillary study of the clinical trial NCT00999583 that tested the effect of erythropoietin (EPO) after OHCA. Blood samples were collected in comatose survivors of OHCA at hospital admission and 1 and 3 days after resuscitation. Gene expression profiles were analyzed (Illumina HumanHT-12 V4 BeadChip; >34,000 genes). Patients were classified into two categories representing neurological favorable outcome (cerebral performance category [CPC] = 1-2) vs unfavorable outcome (CPC > 2) at Day 60 after OHCA. Differential and functional enrichment analyses were performed to compare transcriptomic profiles between these two categories.

Results: Among the 69 enrolled patients, 33 and 36 patients were treated or not by EPO, respectively. Among them, 42% had a favorable neurological outcome in both groups. EPO did not affect the transcriptomic response at Day-0 and 1 after OHCA. In contrast, 76 transcripts differed at Day-0 between patients with unfavorable vs favorable neurological outcome. This signature persisted at Day-1 after OHCA. Functional enrichment analysis revealed a down-regulation of adaptive immunity with concomitant up-regulation of innate immunity and inflammation in patients with unfavorable vs favorable neurological outcome. The transcription of many genes of the HLA family was decreased in patients with unfavorable vs favorable neurological outcome. Concomitantly, neutrophil activation and inflammation were observed. Up-stream regulators analysis showed the implication of numerous factors involved in cell cycle and damages. A logistic regression including a set of genes allowed a reliable prediction of the clinical outcomes (specificity = 88%; Hit Rate = 83%).

Conclusions: A transcriptomic signature involving a counterbalance between adaptive and innate immune responses is able to predict neurological outcome very early after hospital admission after OHCA. This deserves confirmation in a larger population.
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http://dx.doi.org/10.1016/j.resuscitation.2019.03.006DOI Listing
May 2019

Pre-hospital mechanical ventilation in septic shock patients.

Am J Emerg Med 2019 10 7;37(10):1860-1863. Epub 2019 Jan 7.

Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker - Enfants Malades, 149 rue de Sèvres, University Paris Descartes, 75015 Paris, France.

Background: Mechanical ventilation can cause deleterious effects on the lung and thus alter patient's prognosis. The aim of this study was to describe the characteristics of prehospital mechanical ventilation in patients with septic shock requiring mechanical ventilation in the prehospital setting.

Methods: Patients with septic shock subjected to pre-hospital intubation and mechanical ventilation by a mobile intensive care unit were consecutively included and retrospectively analysed. Septic shock was defined according to the international sepsis-3 consensus conference. Patient's characteristics, interventions, prehospital ventilatory parameters and outcome were retrieved from medical records. The association between the tidal volume indexed on ideal body weight (VTIBW) and mortality at day 28 was evaluated.

Results: Fifty-nine patients were included. Septic shock was mainly associated with pulmonary (64%) infection. Mean pre-hospital VTIBW was 7 ± 1 ml.kg in the overall population. Mortality reached 42%. The AUC of VTIBW was 0.83 [0.72-0.94]. Using logistic regression model including: age, prehospital mean blood pressure, volume infused in the prehospital setting, FiO and length of stay in the intensive care unit, the association with mortality remained significant for VTIBW (OR adjusted [CI95] = 4.11 [1.89-10.98]), VTIBW >8 ml·kg (OR adjusted [CI95] = 8.29 [2.35-34.98]) and VTIBW <8 ml·kg (OR adjusted [CI95] = 0.12 [0.03-0.43]).

Conclusion: In this retrospective study, we observed an association between mortality at day 28 and prehospital VTIBW in pre-hospital mechanically ventilated patients with septic shock. A VTIBW <8 ml·kg was associated with a decrease and a VTIBW >8 ml·kg with an increase in mortality.
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http://dx.doi.org/10.1016/j.ajem.2018.12.047DOI Listing
October 2019

First description of successful use of zone 1 resuscitative endovascular balloon occlusion of the aorta in the prehospital setting.

Resuscitation 2018 12 26;133:e1-e2. Epub 2018 Jul 26.

SAMU de Paris-DAR Necker University Hospital-Assistance Public Hopitaux de Paris, Paris, France; Paris Descartes University, Paris, France.

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http://dx.doi.org/10.1016/j.resuscitation.2018.07.027DOI Listing
December 2018

Reply to Karim et al.: "Pre-hospital invasive ventilation in patients with septic shock: Is hyperoxemia an unwanted company?"

Am J Emerg Med 2019 03 6;37(3):532-533. Epub 2018 Jul 6.

Intensive Care Unit, Anesthesiology Department and SAMU of Paris, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Paris Descartes University, Paris, France.

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http://dx.doi.org/10.1016/j.ajem.2018.07.011DOI Listing
March 2019

Skin mottling score and capillary refill time to assess mortality of septic shock since pre-hospital setting.

Am J Emerg Med 2019 04 6;37(4):664-671. Epub 2018 Jul 6.

Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker - Enfants Malades, 149 rue de Sèvres, 75015 Paris, University Paris Descartes, France.

Objectives: The early identification of septic shock patients at high risk of poor outcome is essential to early initiate optimal treatments and to decide on hospital admission. Biomarkers are often used to evaluate the severity. In prehospital settings, the availability of biomarkers, such as lactate, is restricted. In this context, clinical tools such as skin mottling score (SMS) and capillary refill time (CRT) are more suitable. In this study, we describe prehospital SMS and CRT's ability to predict mortality of patients with septic shock initially cared in the prehospital setting by a mobile intensive care unit.

Methods: Patients with septic shock who received prehospital medical care admitted to the intensive care unit were retrospectively analyzed.

Results: Sixty-three patients were included. The origin of sepsis was mainly pulmonary (67%). Overall mortality reached 36%. No significant difference was observed in the duration of prehospital medical care between alive and deceased patients. Mean prehospital value of SMS was 3 ± 2 and mean prehospital value of CRT was 5 ± 1 s. A significant association was found between mortality and prehospital SMS (p = 0.02, OR[CI95] = 1.50 [1.08-2.15]) and prehospital CRT (p = 0.04, OR[CI95] = 1.53 [1.04-2.37]). After adjusting for confounding factors using propensity score, the relative risk of death was 6.58 for SMS > 2 and 2.03 for CRT > 4 s.

Conclusion: In this study, we report an association between prehospital SMS and CRT, and mortality of patients with septic shock. SMS and CRT are simple tools that could be used to optimize the triage and to decide early intensive care admission.
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http://dx.doi.org/10.1016/j.ajem.2018.07.010DOI Listing
April 2019

Reply to Zhou et al.: "fluid resuscitation in pre-hospital patients with septic shock: one size does not fit all".

Am J Emerg Med 2019 01 26;37(1):169-171. Epub 2018 May 26.

Intensive Care Unit, Anesthesiology Department and SAMU of Paris, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Paris Descartes University, Paris, France.

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http://dx.doi.org/10.1016/j.ajem.2018.05.057DOI Listing
January 2019

Early ECPR for out-of-hospital cardiac arrest: Best practice in 2018.

Resuscitation 2018 09 5;130:44-48. Epub 2018 May 5.

SAMU de Paris-DAR Necker University Hospital-Assistance Public Hopitaux de Paris, Paris. France; Paris Descartes University, Paris, France; INSERM U970 Team 4 "Sudden Death Expertise Center", Paris, France. Electronic address:

Extracorporeal CPR is a second line treatment for refractory cardiac arrest, as written in the latest International Guidelines. Optimal timing, patient selection, location and method of implementation vary across the world. The objective here is to present an international consensus on the pillars of an ECPR program. The major aspect the group agrees on in that ECPR should be implemented within 60 minutes of collapse. With this in mind, the program should be built according to local resources knowing that the optimal team will require pre-established specific roles with personnel dedicated to resuscitation and others to ECPR.
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http://dx.doi.org/10.1016/j.resuscitation.2018.05.004DOI Listing
September 2018

Prognosis value of partial arterial oxygen pressure in patients with septic shock subjected to pre-hospital invasive ventilation.

Am J Emerg Med 2019 01 24;37(1):56-60. Epub 2018 Apr 24.

Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France.

Objective: Mechanical ventilation can help improve the prognosis of septic shock. While adequate delivery of oxygen to the tissue is crucial, hyperoxemia may be deleterious. Invasive out-of-hospital ventilation is often promptly performed in life-threatening emergencies. We propose to determine whether the arterial oxygen pressure (PaO) at the intensive care unit (ICU) admission is associated with mortality in patients with septic shock subjected to pre-hospital mechanical ventilation.

Methods: We performed a monocentric retrospective observational study on 77 patients. PaO was measured at ICU admission. The primary outcome was mortality at day 28 (D28).

Results: Forty-nine (64%) patients were included. The mean PaO at ICU admission was 153 ± 77 and 202 ± 82 mm Hg for alive and deceased patients respectively. Mortality concerned 18% of patients for PaO < 100, 25% for 100 < PaO < 150 and 57% for a PaO > 150 mm Hg. PaO was significantly associated with mortality at D28 (p = 0.04). Using propensity score analysis including SOFA score, pre-hospital duration, lactate, and prehospital fluid volume expansion, association with mortality at D28 only remained for PaO > 150 mm Hg (p = 0.02, OR [CI95] = 1.59 [1.20-2.10]).

Conclusions: In this study, we report a significant association between hyperoxemia at ICU admission and mortality in patients with septic shock subjected to pre-hospital invasive mechanical ventilation. The early adjustment of the PaO should be considered for these patients to avoid the toxic effects of hyperoxemia. However, blood gas analysis is hard to get in a prehospital setting. Consequently, alternative and feasible measures are needed, such as pulse oximetry, to improve the management of pre-hospital invasive ventilation.
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http://dx.doi.org/10.1016/j.ajem.2018.04.050DOI Listing
January 2019

Determinants of Lactic Acidosis in Acute Cyanide Poisonings.

Crit Care Med 2018 06;46(6):e523-e529

Adult Intensive Care Unit, Department of anesthesiology and intensive care and SAMU 75, CHU Necker-Enfants Malades.

Objectives: To investigate the magnitude of lactic acidosis in response to cyanide poisoning compared with the secondary response caused by cardiovascular shock.

Design: Retrospective case-control observational study.

Setting: University Hospital of Assistance Publique - Hôpitaux de Paris.

Subjects: Patients admitted for suspicion of cyanide poisoning or drug overdose. Medical charts provided by Assistance Publique - Hôpitaux de Paris of patients between January 1988 and December 2015.

Intervention: None.

Measurements And Main Results: Twelve cyanide poisoned patients were matched to 48 controls by age, sex, systolic blood pressure, catecholamine administration, and outcome at discharge from ICU. Extracted data included age, sex, vital signs, symptoms, biochemical parameters, toxicological analysis, treatment, and outcome. Non-parametric tests were used. Multivariable analysis was used to adjust for confounders causing hyperlactacidemia. The median blood lactate concentration was significantly greater in the cyanide group (15.6 mmol/L) compared to the control group (4.1 mmol/L; p = 0.0003). Similarly, blood lactate concentration greater than or equal to 8 mmol/l was observed in 83% of the cyanide cases versus 27% of the matched controls. Multivariate analysis conferred hyperlactacidemia as the lone factor which significantly predicted cyanide poisoning at an odds of 73.0 (5.7-936.1). Moreover, blood cyanide level significantly correlated with the increase of blood lactate (p = 0.0033).

Conclusions: This study supports the hypothesis lactic acidosis primarily results from the direct toxicity of cyanide.
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http://dx.doi.org/10.1097/CCM.0000000000003075DOI Listing
June 2018

Fluid resuscitation in pre-hospital management of septic shock.

Am J Emerg Med 2018 10 1;36(10):1754-1758. Epub 2018 Feb 1.

Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France.

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http://dx.doi.org/10.1016/j.ajem.2018.01.078DOI Listing
October 2018

Number of Prehospital Defibrillation Shocks and the Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest.

Turk J Anaesthesiol Reanim 2017 Dec 1;45(6):340-345. Epub 2017 Dec 1.

Service d'anesthésie Réanimation - SAMU - Hôpital Necker-Enfants maladies, Paris, France.

Objective: It has not been determined yet whether the number of defibrillation shocks delivered over the first 30 min of cardiopulmonary resuscitation (CPR) impacts the rate of successful return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA).

Methods: We conducted a retrospective observational study in non-traumatic OHCA. Patients who were administered defibrillation shocks using a public automated external defibrillator (AED) were consecutively enrolled in the study. We assessed the relationship between ROSC and the number of prehospital defibrillation shocks and constructed an receiver operating characteristic (ROC) curve to illustrate the ability of repeated defibrillation shocks to predict ROSC over the first 30 min of CPR.

Results: Increasing the number of defibrillation shocks progressively decreased the probability to achieve ROSC. The highest rate of ROSC (33%) was observed when four shocks were delivered. The ROC curve illustrated that the fourth shock maximised sensitivity and specificity (area under the curve [AUC]=0.72). The positive and negative predictive values for ROSC reached 82% and 48%, respectively, when <4 shocks were delivered.

Conclusion: The delivery of four defibrillation shocks in OHCA most related to ROSC. The evaluation of the number of delivered shock during the first 30 min of CPR is a simple tool that can be used for an early decision in OHCA patient.
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http://dx.doi.org/10.5152/TJAR.2017.58067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772413PMC
December 2017