[Interhospital transport with extracorporeal life support: results and perspectives after 5 years experience]

OBJECTIVE

Describing the experience of a referral center for interhospital patients transport treated with extracorporeal circulatory or respiratory support (ECLS), the difficulties encountered and the results obtained.

STUDY DESIGN

Retrospective and observational study.

PATIENTS AND METHODS

All patients with respiratory or circulatory failure accepted for extracorporeal assistance for which routine medical transport was life threatening.

STATISTICAL ANALYSIS

A descriptive analysis was performed (median and interquartile deviation). Comparison of biological data was performed using a non-parametric Wilcoxon test and 5 years overall survival was determined by a Kaplan-Meier analysis.

RESULTS

Over a 55-month period, 29 patients were selected for transportation under ECMO or ECLS. Indication was respiratory failure in 38 % of cases, hemodynamic instability in 52 % of cases and combined symptoms in 10 % of cases. Average duration of transportation was 40 km (9-64 km). No complication related to transport was observed. Incidence of intrahospital death was 57 %. There was no correlation between death and indication of ECLS. Five-year survival was 55 % and 39 % for venovenous and arteriovenous ECLS, respectively.

CONCLUSION

In our experience, interhospital transport of patients under ECMO is feasible in satisfactory conditions of safety with trained team and standard procedures.

[Refractory infectious ARDS: place of extracorporeal membrane oxygenation]

Acute respiratory distress syndrome (ARDS) is a frequent cause of admission in intensive care unit. The treatment is well codified. Unfortunately some patients die because of hypoxemia despite a well-conducted medical treatment. Extracorporeal oxygenation could be the ultimate treatment for these refractory hypoxemia patients. We report two cases of patients suffering from severe ARDS who beneficiated from extracorporeal oxygenation, pointing out the interest of this technique during severe ARDS as well as the accessibility and the feasibility of the technique even apart from a specialized center.

[From the creation to the appreciation of a personal digital assistant-based clinical decision-support system for the management of artificial nutrition]

OBJECTIVES

The aim of our study was to assess the effect of NutriPDA, a personal digital assistant (PDA)-based clinical decision-support system (CDSS) for the management of artificial nutrition. A CDSS was developed and implemented on a handheld computer for use in the ICU after cardiovascular and thoracic surgery.

STUDY DESIGN

System impact was assessed in a prospective "before/after" cohort trial.

METHODS

After informed consent we studied 61 patients in the postcardiovascular and thoracic surgery ICU (age > 17 years, duration of artificial nutrition > 3 days, length of stay > 8 days). Patients were divided into two groups (before and after the use of NutriPDA: Group A: 32 patients (4-month period in 2005); group B: 29 patients (4-month period in 2006).

RESULTS

There were no significant differences in anthropometric and clinical parameters between the 2 groups. Energetic intakes were < 80% of basal energetic expenditures in 21% and 1% of patients, respectively (P < 0.01). Caloric and nitrogen intakes were below international recommendation in Group A: 20+/-4 kcal/kg/d (mean+/-SD), 104+/-30 mg/kg/d, but not in Group B: 26+/-5 kcal/kg/d, 196+/-41 mg/kg/d (P < 0.01).

CONCLUSION

NutriPDA was found to be able to optimize artificial nutrition by improving caloric intake in ICU. This new software has potential clinical applications.

Comparison of FloTrac™ cardiac output monitoring system in patients undergoing coronary artery bypass grafting with pulmonary artery cardiac output measurements

BACKGROUND

Arterial pulse waveform analysis has been proposed for cardiac output (CO) determination and monitoring without calibration or thermodilution (FloTrac/Vigileo; Edwards Lifesciences, Irvine, CA, USA). The accuracy and clinical applicability of this technology has not been fully evaluated. We designed this prospective study to compare the accuracy of the FloTrac system (CO(FT)) vs. pulmonary artery catheter standard bolus thermodilution (CO(PAC) ) in patients undergoing coronary artery bypass grafting.

METHODS

We studied 11 patients referred for coronary artery bypass grafting. CO(FT) and CO(PAC) were determined at six time points in the operating room including before and 5 min after volume expansion (500 mL 6% hetastarch). Measurements were performed on arrival in the intensive care unit and every 4 h afterwards. Bland-Altman analysis was used to assess the agreement between CO(FT) and CO(PAC).

RESULTS

CO(PAC) ranged from 2.0 to 7.6 L min-1 and CO(FT) ranged from 1.9 to 8.2 L min-1. There was a significant relationship between CO(PAC) and CO(FT) (r = 0.662; P < 0.001). Agreement between CO(PAC) and CO(FT) was -0.26 +/- 0.87 L min-1. Volume expansion induced a significant increase in both CO(PAC) and CO(FT) (from 3.4 +/- 0.8 to 4.4 +/- 1.0 L min-1; P < 0.001 and from 3.9 +/- 1.2 to 5.0 +/- 1.1 L min-1; P < 0.001, respectively) and there was a significant relationship between percent change in CO(PAC) and CO(FT) following volume expansion (r = 0.722; P = 0.01).

CONCLUSION

We found clinically acceptable agreement between CO(FT) and CO(PAC) in this setting. This new device has potential clinical applications.

Emergency cardiac mechanical assistance: place of mucosal gastric tonometry as prognostic indicator

BACKGROUND AND OBJECTIVES

The death of patients treated by ventricular assist device is usually related to multiorgan failure for which a disorder of splanchnic circulation is blamed. Gastric tonometry (measurement of gastric intra-mucosal pressure of CO(2)) has already been studied in many fields and especially in cardiac surgery. The aim of this study was to investigate the prognostic value of gastric tonometry monitoring after implantation of a ventricular assist device.

METHODS

In this prospective study, all consecutive patients scheduled for a ventricular assist device were included. Gastric tonometry was added to standard monitoring. Data were collected (lactate, gastric CO(2) (PgCO(2)) during cardiopulmonary bypass, at admission to ICU, 24 and 48 h later and when norepinephrine was stopped. Preoperative biologic and haemodynamic data were also collected. The primary endpoint was death.

RESULTS

Fifty-six patients (50 men and 6 women) were included. In 91% of the cases, the mechanical assistance was biventricular. The objective of the assistance was a bridge to transplant in 93% (n = 27). Twenty-seven deaths (48%) occurred during the study, 59% (n = 16) of them took place before the cardiac transplantation (mean time = 18 +/- 16 days after assist device insertion). Many factors were found to be associated with death: weight (P = 0.018), red cells administration (P = 0.025), length of surgery (P = 0.016), PgCO(2) on admission to ICU (P = 0.040) and norepinephrine dose at 24 h.

CONCLUSIONS

Gastric tonometry has a prognostic value in the early postoperative hours after the implantation of a ventricular assist device.

Découverte tardive chez un patient de réanimation d'une perforation de la veine cave supérieure par un cathéter veineux sous-clavier

Perforation is a central venous catheterization complication mainly observed in children. Usually, patients develop sudden shock early after catheterization. We report an asymptomatic and delayed superior vena cava perforation after subclavian venous adult catheterization discovered by contrast injection tomography.

Management of an aortic wall ulcer after an aortic dissecting hematoma

We report the case of a 40-year-old woman who presented with an ulcer of the descending aorta 9 months after ascending aortic surgery for intramural aortic hematoma, which was treated surgically with a supra-coronary aortic replacement. Treatment of the second aortic lesion and the choice between endovascular or surgical approaches are discussed.