Contrôle échographique de la position de la sonde nasogastrique en préhospitalier

Objective

To assess the feasibility and actual performance of ultrasound control in verification of the correct positioning of a nasogastric tube in pre-hospital settings.

Study type

Prospective, observational, single-centre study.

Patients and methods

Correct positioning of nasogastric tubes in patients intubated in a pre-hospital setting was verified by ultrasound and routinely compared with the results of two pre-hospital tests, namely a test involving insufflation of air through a syringe coupled with epigastric auscultation and a test involving aspiration of gastric fluid with a syringe. Routine x-ray control was carried out and compared with the pre-hospital results.

Results

Ninety-six patients were included. Mean age was 52 years (median: 53.5 years, SD: 23 years). In 83% of the patients (n = 80), the nasogastric tube was located by ultrasound immediately during the insertion procedure. The mean times to ultrasound confirmation of correct positioning of the nasogastric tube were 7 s (median: 2 s; SD: 16 s) and 19 s for the syringe tests (median 19 s, SD: 5 s). Eight ultrasound control tests were negative. Location coupled with insufflation of air through a syringe allowed detection of the nasogastric tube in the stomach but without providing confirmation of the actual gastric position. The pre-hospital ultrasound results were confirmed by subsequent radiological controls at the hospital.

Conclusion

The ultrasound test performed in our study to verify correct positioning of a nasogastric tube is feasible in a pre-hospital setting. This technique is rapid and non-irradiating and is more sensitive and specific than the syringe tests commonly used in pre-hospital settings, and it may be performed in place of the latter tests.     

Altérations de la microcirculation dans les états de choc : physiopathologie,surveillance et traitement

Microcirculation represents a complex system devoted to provide optimal tissue substrates and oxygen. Therefore, pathophysiological and technological knowledge developments tailored for capillary circulation analysis should generate major advances for critically ill patients’ management. In the future, microcirculatory monitoring in several critical care situations will allow recognition of macro-microcirculatory decoupling, and, hopefully, it will promote the use of treatments aimed at preserving tissue oxygenation and substrate delivery.     

L’anesthésie locorégionale sous échographie : de la réalisation au diagnostic des complications

Ultrasound has become a daily practice for anesthesiologists for central venous catheterization and regional anaesthesia, but also for the diagnosis of pleuro-pulmonary, cardiac, and vascular diseases; this is illustrated by our observation. We report a case of a cirrhotic patient who underwent emergency surgery for a Colle's fracture under ultrasound-guided supraclavicular block which was complicated by acute dyspnoea. The use of ultrasound in the operating theater has revealed hepatic hydrothorax which occurred during a diaphragmatic paralysis secondary to the blocking of phrenic nerve due to the regional anaesthesia.     

Prise en charge de la prééclampsie dans un réseau de périnatalité

At community level, the perinatal management can be summarized as follows:     

Évaluation de l’utilisation du sulfate de magnésium dans la prévention secondaire de l’éclampsie : étude rétrospective sur 39 cas

Introduction

The use of magnesium sulfate (MgSO₄) has been advocated since 2000 in France in the management of eclampsia. The aim of this study was to determine the frequency of use of this treatment for eclampsia in a French department.

Patients and methods

All patients obstetrical patients admitted to Critical Care Units of Seine-Maritime for eclampsia over a period of 7 years (2002–2008) were included. Obstetric data, the treatment used for eclampsia and pre-eclampsia and maternofetal complications were collected. The primary outcome parameter was the use of MgSO₄ in the secondary prevention of eclampsia.

Results

Thirty-nine patients were included. Nineteen patients (48%) had eclampsia in prepartum, three (8%) in per-partum and 17 (44%) in post-partum periods. The use of MgSO₄ in the secondary prevention of eclampsia was observed in 92% of cases (36/39). Primary prevention was seen in 8% of cases. The duration of treatment was 2 days (1–7 days). The maternal and perinatal mortality was respectively 2.5 and 11%.

Conclusion

In this study, the use of MgSO₄ in the secondary prevention is frequent. This result emphasizes the importance of the recommendations of learned societies in the homogenization of the management of rare but serious conditions such as eclampsia.     

Apport de l’échographie pleuropulmonaire en pédiatrie

An increasingly amount of evidence suggests that lung ultrasonography constitutes a relevant complementary diagnostic tool for adults patient in acute respiratory failure. A comprehensive and standardized ultrasonographic semiology has been described, relying on accurate and reproducible data directly obtained at patient's bedside. Therefore, pleural effusion, pneumothorax, pulmonary consolidation and interstitial lung disease can be diagnosed in a critical care environment with a similar level of performance than when reference diagnosis methods such as thoracic CT-scan are employed. Furthermore, lung ultrasonography seems to be able to contribute to an early therapeutic decision based on such online physiopathological data. Pioneers works in this field have suggested an attractive similarity between the ultrasonographic patterns described in adults and children. Nevertheless, the clinical usefulness of lung ultrasonographic approach in the pediatric critical care medicine still needs to be confirmed by specifically designed studies.     

Aspects médicolégaux de la prise en charge de la prééclampsie

When analyzing various recommendations formulated by the colleges of specialty, as well as precedents, the following guidelines can be formulated with respect to communication as part to the management of PE.     

Impact clinique et économique d’une politique de contrôle de la sédation par protocole dans un service de réanimation médicochirurgicale

Objective

Since the last consensus conducted by Sfar/SRLF, the use of protocol for sedation became the reference in our ICUs. Decrease in length of stay and length of mechanical ventilation with used of these protocols have been already described. We would like to investigate the economic impact associated.

Study design

Using the PMSI data, we studied retrospectively, the economic effect, one year before and one year after protocol implementation in our ICU.

Method

The economic evaluation compared the cost of sedation but also the cost of mechanical ventilation and length of stay in ICU.

Results

Characteristic and number of patients were equivalent during the two years. We described a significant decrease in length of mechanical ventilation (8.8 vs. 8.4; p < 0.05) but not in length of stay (11.4 vs. 11.7; NS) between the two periods. We described a decrease of sedation cost of 11 412 euros and a decrease of mechanical ventilation cost of 27 360 Euros between the two years.

Conclusion

We confirm in this study that use of sedation protocol in ICU is associated with a clinical impact but also with an economic effect.     

Conditions de prise de décision d’admission ou de non admission en réanimation chirurgicale

Objectives

To describe the condition of the decision-making of admission and non-admission in intensive care unit.

Study design

Non-interventional observational cohort.

Patients and methods

Retrospective analysis of declarative terms of decision-making of patients admitted or denied in a surgical intensive care unit. The decision-making in the two admitted or not admitted troops was compared.

Results

That it is during a non-admission (149 decisions) or of an admission (149 decisions), the decision-making process was not very different. The instruction of the files was regarded as collegial in nearly 80% of the cases by the intensivist in load. The dialogue precedent the decision utilized generally several speakers but who could be residents. The participation of the patient and/or his close relations, as that of the ancillary medical personnel was rare. No person of confidence or anticipated directive was quoted. More than 50% of the decisions were taken within a time lower than 30 minutes. The decisions of non-admission were considered to be more difficult than the decisions of admission. Traceability was not automatically given.

Conclusion

Thus, this study shows that in its current form the intensivists of the service estimate that in the majority of the cases the instruction of the files was collegial. However, the conditions of seniorisation of the decision, the collection of opinion of the patient and/or his close relations and the traceability are tracks of improvement to be implemented in certain circumstances of admission or non-admission.     

Principes généraux de la prise en charge hospitalière de la prééclampsie

The management of the PE patient requires admission in order to perform a meticulous assessment of the mothers’ and fetal state, distinguishing between the severe and the mild forms.