Transfusions de plasma en réanimation pédiatrique

Whereas red blood cell transfusions have been used since the nineteenth century, plasma has only been available since 1941. It was originally mainly used as volume replacement, mostly during World War II and the Korean War. Over the years, its indication has shifted to correcting coagulation factors deficiencies or to preventing bleeding. Currently, it remains a frequent treatment in the intensive care unit, both for critically ill adults and children. However, observational studies have shown that plasma transfusion fail to correct mildly abnormal coagulation tests. Furthermore, recent epidemiological studies have shown that plasma transfusions are associated with an increased morbidity and mortality in critically ill patients. Therefore, plasma as any other treatment has to be used when the benefits outweigh the risks. Based on observational data, most experts suggest limiting its use either to massively bleeding patients, or bleeding patients who have documented abnormal coagulation tests, and refraining for transfusing plasma to non-bleeding patients whatever their coagulation tests. In this paper, we will review current evidence on plasma transfusions and discuss its indications.     

Prévention des hémorragies digestives hautes de stress en réanimation Révision de la conférence de consensus de 1988

Experts designated by the Société de réanimation de langue française had to audit the 1988 French consensus about upper gastrointestinal bleeding in critically ill patients. In the last decades the incidence of this nosocomial complication has dramatically decreased. A high-risk population has to be defined. H2 antagonists and sucralfate seemed to be more effective than antacids and prostaglandins. Proton pump inhibitors and enteral nutrition could be alternative prophylaxis. The cost-effectiveness ratio wasn't completely defined but implantation of clinical guidelines may reduce costs and limit such treatment for high-risk patients.     

Désescalade de l’antibiothérapie en réanimation

Successful treatment of severe infections in the intensive care unit (ICU) often requires broad-spectrum empiric therapy, while attempting to control the source of infection. However, this liberal antibiotic strategy may be associated with adverse effects on the patients as well as on the overall microbial ecology of the unit. This “antibiotic dilemma” may be solved by early de-escalation of antibiotic therapy, which allows reducing the overall antibiotic exposure of ICU patients by shortening the duration of therapy (including early stop when infection is not confirmed), switching from combined to single therapy, and/or substituting broad-spectrum agent with narrower-spectrum regimen. The opportunity for de-escalation varies across series from 20% to 50%, depending on the empiric antibiotic policy and the epidemiological context. Adapting the antibiotic regimen, possible as early as 24 h after obtaining the first results from adequate samples, is mandatory at 48–72 h, once full microbiological results are obtained. Subsequently, the intensivist must reassess daily the continued need for antibiotics, just like sedation is reassessed daily in mechanically ventilated patients. Several studies have confirmed that early deescalation is safe, and recent evidence suggests that it may even be associated with improved outcome of patients.     

La performance en réanimation. Le point de vue du réanimateur

To evaluate the performance of intensive care units (ICU) the severity scores are measured on the first day or organ system dysfunctions are measured several times during the stay. The severity scores are developed from large database of thousands of patients. They include the patients’ age, previous health status, severity and sometimes the main diagnosis. Prediction models are published to evaluate the risk of death for each patient. By adding the risk of death of each patient and dividing by the number of patients, the expected mortality rate is calculated. By comparing the observed and expected mortality rates the standard mortality ratio (SMR) may be measured. The data collection must be rigorous, the studied population must be similar to the population of the large database. Other elements of performance may be evaluated, such as the cost-efficiency or the quality of life of surviving patients.