Stratégie de la prise en charge de l’arrêt cardiaque

Almost 50,000 people are victims of cardiac arrest every year. Their average outcome is below 4%. The success of CardioPulmonary Resuscitation (CPR) includes immediate diagnosis of cardiac arrest, early defibrillation and chain of survival. External cardiac massage only slightly increases cardiac output. The latter can be improved by different techniques such as active compression-decompression or the impedance threshold valve if performed by well-trained teams. The principal drugs for resuscitation are epinephrine and amiodarone. Monitoring means such as capnography and invasive arterial pressure allow evaluating the efficiency of CPR. The assessment and the treatment of specific etiologies are also keys of success both during CPR and after return of spontaneous circulation.     

Devenir des enfants quittant la réanimation après une décision de limitation ou d’arrêt des traitements. État des connaissances en France

Children survival after a decision of treatment limitation (DTL) in the paediatric intensive care unit (PICU) is a recent concern. Our objectives were to present data on the outcome of children who survived despite DTL, and review how information about DTL is transmitted between PICUs and the teams in charge of the children after PICU discharge. Interestingly, more than 20% of the children survive despite DTL; however, all these children remain dependent on their parents for all activities of daily life. Half of them would be referred to PICU if presenting any severe illness. Additionally, despite significant progress in the transmission of information regarding DLT by PICUs, improvement is still expected to better involve the teams in charge after PICU discharge.     

Optimisation de la ventilation mécanique dans l’arrêt cardiaque

Mechanical ventilation is one of the significant components of specialized cardiopulmonary resuscitation. Its role is that of oxygenation and release of carbon dioxide (CO₂). However, it has a major impact on haemodynamics. The interaction between the heart and lungs increases in patients during cardiac arrest, as intermittent positive ventilation is closely linked to thoracic compressions and decompressions during external cardiac massage. In order to limit this potentially negative impact, international recommendations stipulate a low tidal volume (6–7 ml / kg) as well as a low ventilation rate (10 / min). Oxgenation is far more dependent on the cardiac flow output, and minimal ventilation is sufficient for alveolar lavage. Conversely, it is recognised that increasing the ventilation rate has a negative impact on the coronary perfusion pressure. So as to reduce the negative haemodynamic effect of positive intermittent ventilation, some authors are interested in a new continuous ventilation technique, allowing a permanent positive pressure to be maintained in the airways; the oxygenation and release of CO₂ occur through simple external cardiac massage actions. Nevertheless, very few studies have concentrated on optimizing the inspired oxygen fraction during resuscitation. Post-resuscitation hyperoxygenation is now recognized as an issue due to oxidative stress and evidence of secondary neuronal lesions. Thus, mechanical ventilation must be optimized, more for the haemodynamic impact and the resulting effects, than for its role as an oxygenator.     

L’arrêt cardiaque de l’enfant

Paediatric cardiac arrests are rare and represent only 2% of out-of-hospital cardiac arrests. The majority (i.e. 70%) are due to poor oxygenation or infections. Survival at discharge after out-of-hospital cardiac arrest is 2.6?C4% and 45% after in-hospital cardiac arrest. European guidelines are written according to evidence-based sciences, aiming to improve survival rate without sequelae. The last modifications of the European guidelines are summarised in this article: healthcare providers should search for signs of life to diagnose circulatory arrest; ventilation is required in cardiopulmonary resuscitation in children; and interruption of chest compressions should be reduced at the minimum to limit no-flow time. Automated external defibrillator (AED) may be used in children aged more than 1 year (preferably with an attenuator before the age of 8 years). In infants, a manual defibrillator is preferred. But if arrhythmia is likely, in the absence of manual defibrillator, AED could be used. Advanced life support follows the same rules in adult. Cuffed tracheal tubes can be used in children if the size is chosen according to an appropriate formula and the pressure cuff monitored. Post-cardiac arrest management aims at brain protection and prevention of secondary organ damage and includes therapeutic hypothermia.     

Prélèvements d’organes sur donneurs décédés après arrêt circulatoire de la catégorie III de Maastricht en France en 2015

Organ retrieval from deceased donors following Maastricht category III circulatory arrest has been authorised in France in certain establishments for a little more than a year. It involves patients presenting with circulatory arrest subsequent to a decision to withhold or withdraw treatment. The initiation of this pilot phase comes following several years of discussions, led by learned societies within the fields of intensive care, anaesthesia and resuscitation, emergency and transplantation and the Agency for Biomedicine (ABM). A single and national protocol, drafted jointly by the representatives of the various parties involved and the ABM, describes the ethical and technical aspects that need to be closely followed. The functions and responsibilities of those involved are set out in order to avoid any conflict of interest. Its implementation is complex and requires compliance from the healthcare professionals and support from institutions. It requires a period of subsequent preparation, focused on work to inform and train the teams. The initial results are satisfactory, in terms of the perceptions from the families, the care teams and the quality of the transplant organs retrieved. An overall assessment is expected in 2016, which will provide direction for the future of this new activity.     

Collégialité dans les décisions de limitation ou d’arrêt de traitement en réanimation

A French law about patient’s rights at end of life was published in 2005 and ratified that physicians could withdraw or withhold inappropriate life sustaining treatments and that the decision-making process (DMP) had to be collegial when the patient was not competent. A decree in 2006 stated that nurses, because of their proximity to the patients, should be involved in DMP. The term “pluridisciplinarity” is used rather than “collegiality” because of the different status and skills of the participants in DMP. In critical care medicine, interdisciplinarity includes physicians and nurses. Interdisciplinary communication in DMP is essential to guarantee that ethical aspects are not considered solely from the perspective of a single professional practice that remains medical but from a more holistic approach of the patient by nurses. Validity of each professional’s opinion should be recognized. Nurse involvement in DMP remains poor. Poor collaboration between physicians and nurses in end-of-life situation is associated with moral distress, burnout, and conflicts. Improvement in collaboration between nurses and physicians is required to promote an accomplished interdisciplinary communication in DMP at the end of life.     

Pseudomélanose duodénale : un aspect rare. Régression après arrêt du sulfate de fer

A 65 year old woman underwent upper gastrointestinal endoscopy for reflux and dysphagia. She had been taking ferrous sulfate 200 mg for 10 years. Endoscopy revealed oesophagitis and also diffuse brownish spotting in the upper portion of the second part of the duodenum. Perls staining was partially positive. Fourteen months after cessation of ferrous sulfate the pseudomelanosis had almost completely disappeared. Macro- and microscopic features were typical of duodenal pseudomelanosis. The granules consisted of ferrous sulfide, which explains the weak affinity for Perls stain