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IntroductionReadiness to be freed from ventilatory support can be evaluated by spontaneous breathing trial (SBT) assessing the patient’s ability to sustain respiratory effort after extubation. Current SBT practices are heterogenous and there are few physiological studies on the topic. The objective of this study is to assess which SBT best reproduces inspiratory effort to breathe after extubation depending on the patient’s illness.Methods and analysisThis will be a multicentre randomised cross-over physiological study, in a large population, in the era of modern intensive care units using last generation modern ventilators. Each included patient will perform three 15-minute SBTs in a random order: pressure support ventilation (PSV) level of 7 cmH2O with positive end expiratory pressure (PEEP) level of 0 cmH2O, PSV 0 cmH2O with PEEP 0 cmH2O and T-piece trial. A rest period of baseline state ventilation will be observed between the SBTs (10 min) and before extubation (30 min). Primary outcome will be the inspiratory muscle effort, reflected by pressure time product per minute (PTPmin). This will be calculated from oesophageal pressure measurements at baseline state, before and after each SBT and 20 min after extubation. Secondary outcomes will be PTPmin at 24 hours and 48 hours after extubation, changes in physiological variables and respiratory parameters at each step, postextubation respiratory management and the rate of successful extubation. One hundred patients with at least 24 hours of invasive mechanical ventilation will be analysed, divided into five categories of critical illness: abdominal surgery, brain injury, chest trauma, chronic obstructive pulmonary disease and miscellaneous (pneumonia, sepsis, heart disease).Ethics and disseminationThe study project was approved by the appropriate ethics committee (2019-A01063-54, Comité de Protection des Personnes TOURS - Région Centre - Ouest 1, France). Informed consent is required, for all patients or surrogate in case of inability to give consent.Trial registration numberNCT04222569.

This paper examines the influence of weaving variables such as yarn count, number of layers, warp and weft ratio, materials of the top layer, weft density and interlocking cell shape, and size on the thermal performance of multilayer interlocked woven fabrics. A split-plot design was used to construct a total of 64 fabric structures, which were assessed for thermal performance in terms of resistance to convective, conductive, and radiative heat. It was found that, for equal weft density and yarn number, protective performance improved with the number of fabric layers and with the presence of air cells between these layers, especially if air was not trapped within and could rather pass freely between the cells. An optimal combination of factors for the thermal response to the three types of heat was established via a Derringer–a much needed desirability function. The results of this paper are useful for identifying the interaction between configuration parameters and thermal performance, and hence for the design of improved heat protective clothing.

Purpose To evaluate efficacy and adverse events related to inhaled sevoflurane for long-term sedation compared with standard intravenous (IV) sedation with propofol or midazolam. Methods Randomized controlled trial. Sixty intensive care unit (ICU) patients expected to require more than 24 h sedation were randomly assigned to one of three groups: group S, inhaled sevoflurane; group P, IV propofol; group M, IV midazolam. All patients also received IV remifentanil for goal-directed sedation (Ramsay scale and pain score) until extubation or for a maximum of 96 h. Primary end points were wake-up times and extubation delay from termination of sedative administration. Proportion of time within Ramsay score 3–4, IV morphine consumption at 24 h post extubation, hallucination episodes after end of sedation, adverse events, inorganic fluoride plasma levels, and ambient sevoflurane concentrations were recorded. Results Forty-seven patients were analyzed. Wake-up time and extubation delay were significantly ( P  < 0.01) shorter in group S (18.6 ± 11.8 and 33.6 ± 13.1 min) than in group P (91.3 ± 35.2 and 326.11 ± 360.2 min) or M (260.2 ± 150.2 and 599.6 ± 586.6 min). Proportion of time within desired interval of sedation score was comparable between groups. Morphine consumption during the 24 h following extubation was lower in group S than in groups P and M. Four hallucination episodes were reported in group P, five in group M, and none in group S ( P  = 0.04). No hepatic or renal adverse events were reported. Mean plasma fluoride value was 82 μmol l −1 (range 12–220 μmol l −1 ), and mean ambient sevoflurane concentration was 0.3 ± 0.1 ppm. Conclusions Long-term inhaled sevoflurane sedation seems to be a safe and effective alternative to IV propofol or midazolam. It decreases wake-up and extubation times, and post extubation morphine consumption, and increases awakening quality.

[...]high levels of PEEP may lead to lung overdistension associated with an increase of alveolar dead space and an alteration of gas exchanges. All consecutive ARDS adult patients with confirmed Covid-19 admitted in our critical care unit are included if they received invasive mechanical. [...]identification of respiratory phenotype seems therefore essential in ventilated SARS-CoV-2 patients to determine optimal mechanical ventilation strategy.

Purpose To characterize the perceived utilization of physical restraint (PR) in mechanically ventilated intensive care unit (ICU) patients and to identify clinical and structural factors influencing PR use. Methods A questionnaire was personally handed to one intensivist in 130 ICUs in France then collected on-site 2 weeks later. Results The questionnaire was returned by 121 ICUs (response rate, 93 %), 66 % of which were medical-surgical ICUs. Median patient-to-nurse ratio was 2.8 (2.5–3.0). In 82 % of ICUs, PR is used at least once during mechanical ventilation in more than 50 % of patients. In 65 % of ICUs, PR, when used, is applied for more than 50 % of mechanical ventilation duration. Physical restraint is often used during awakening from sedation and when agitation occurs and is less commonly used in patients receiving deep sedation or neuromuscular blockers or having severe tetraparesis. In 29 % of ICUs, PR is used in more than 50 % of awake, calm and co-operative patients. PR is started without written medical order in more than 50 % of patients in 68 % of ICUs, and removed without written medical order in more than 50 % of patients in 77 % of ICUs. Only 21 % of ICUs have a written local procedure for PR use. Conclusions This survey in a country with a relatively high patient-to-nurse ratio shows that PR is frequently used in patients receiving mechanical ventilation, with wide variations according to patient condition. The common absence of medical orders for starting or removing PR indicates that these decisions are mostly made by the nurses.

Prediction of massive transfusion (MT) is challenging in management of trauma patients. However, MT and its prediction were poorly studied in obese patients. The main objective was to assess the relationship between obesity and MT needs in trauma patients. The secondary objectives were to validate the Trauma Associated Severe Hemorrhage (TASH) score in predicting MT in obese patients and to use a grey zone approach to optimize its ability to predict MT. An observational retrospective study was conducted in a Level I Regional Trauma Center Trauma in obese and non-obese patients. MT was defined as ≥10 U of packed red blood cells in the first 24h and obesity as a BMI≥30 kg/m². Between January 2008 and December 2012, 119 obese and 791 non-obese trauma patients were included. The rate of MT was 10% (94/910) in the whole population. The MT rate tended to be higher in obese patients than in non-obese patients: 15% (18/119, 95%CI 9‒23%) versus 10% (76/791, 95%CI 8‒12%), OR, 1.68 [95%CI 0.97‒2.92], p = 0.07. After adjusting for Injury Severity Score (ISS), obesity was significantly associated with MT rate (OR, 1.79[95%CI 1.00‒3.21], p = 0.049). The TASH score was higher in the obese group than in the non-obese group: 7(4-11) versus 5(2-10) (p<0.001). The area under the ROC curves of the TASH score in predicting MT was very high and comparable between the obese and non-obese groups: 0.93 (95%CI, 0.89‒0.98) and 0.94 (95%CI, 0.92‒0.96), respectively (p = 0.80). The grey zone ranged respectively from 10 to 13 and from 9 to 12 in obese and non obese patients, and allowed separating patients at low, intermediate or high risk of MT using the TASH score. Obesity was associated with a higher rate of MT in trauma patients. The predictive performance of the TASH score and the grey zones were robust and comparable between obese and non-obese patients.

After surgery, patients reported the delay in receiving help as the primary factor for poorly controlled pain. This study aimed to compare the effectiveness of patient management through two communication modalities: remote transmission (RT) versus bedside control (BC). We hypothesized that using remote technology for pump programming may provide the best postoperative infusion regimen for the patient's self-assessment of pain and adverse events. A multicenter, randomized, parallel-group, controlled trial. Anesthesiology department and orthopedic surgery ward at three university hospitals. Eighty patients undergoing orthopedic surgery with postoperative perineural patient-controlled analgesia were included. Two groups (n = 40 for each group) were formed by randomization. In the postoperative period, perineural analgesia was followed up via an RT system or BC for 72 h. A nurse assessed daily pain, sensory and motor blocks and adverse events. Patients completed a questionnaire three times a day and alerted for any problem according to the group (RT system or nurses' follow-up). On the third postoperative day, the nurse removed the catheter, completed the final assessment, and collected the historical data from the pump. A physician's shorter response time to change the patient control analgesia (PCA) program was the primary endpoint. Of the 80 patients, 71 were analyzed (34 were randomized to the RT group and 37 to the BC group). Fifty-eight pump setting changes were noted. Analysis of repeated evaluations shows that mean time (SD) to change the PCA pump settings was significantly lower in the RT group (20 min (22.3 min)) than in the BC group (55.9 min (71.1 min)); mean difference [95% CI], −35.9 min [−74.3 to 2.4]); β estimation [95% CI], −34 [−63 to −6], p = 0.011). Pain relief, sensory and motor blocks did not differ between the groups: β estimation [95% CI], 0.1 [−0.4 to 0.6], p = 0.753; 0.5 [−0.4 to 1.4], p = 0.255; 0.9 [−0.04 to 1.8], p = 0.687, respectively. β = −34 [−63 to −6], p = 0.011). The consumption of ropivacaine, nurse workload and the cost of the analgesia regimen decreased in the RT group. No differences were noted in satisfaction scores or complication rates. The response time for the physician to change the PCA program when necessary was shorter for patients using RT and alerts to the physician were more frequent compared with spot checks by nurses. RT helps to decrease nurses' workload, ropivacaine consumption, and costs but did not affect postoperative pain relief, complication rate, or patient-reported satisfaction score. Comité de Protection des Personnes, Sud Méditerranée III, Montpellier-Nîmes, France, registration number EudraCT A01698-35. ClinicalTrials.gov ID:NCT02018068 The full trial protocol can be accessed at Department of Anesthesiology and Critical Care Medicine, Medical Research and Statistics Unit, Lapeyronie University Hospital, Avenue Doten G Giraud, Montpellier, France. s-bringuierbranchereau@chu-montpellier.fr •Forty percent of patients experienced moderate to severe pain after orthopedic surgery.•Patients reported the delay in receiving help for pain relief improvement as the primary factor for poorly controlled pain.•RT for perineural analgesia may provide the best infusion regimen for patient self-assessment of pain.•RT decreased the time to change pump programs.•RT allowed the patients to self-report adverse events more easily compared to bedside care.•RT helped to decrease nurse workload , ropivacaine consumption and costs.

Association of independent lung ventilation (ILV) and veno-venous extracorporeal membrane oxygenation (vv-ECMO) may be life-saving therapy in cases of refractory hypoxemia. We report the case of a trauma patient affected by asymmetric hypoxemic lung contusions and massive air leak managed by association of ILV and vv-ECMO. This combined strategy allowed us first to restore physiologic conditions and later to achieve safe thoracic surgery with reduced resection of pulmonary parenchyma. This case highlights the success of a new damage control strategy in extreme cases of persistent air leak with refractory hypoxemia allowing initial vital rescue and a more conservative treatment.

Ultrasound guidance does not eliminate the risk of intraneural injection, which must be avoided during PNB. Combining ultrasound guidance (USG), nerve stimulation (NS), and injection pressure monitoring is advocated to prevent nerve injury during PNB. We hypothesized that combining patient-tailored dynamic NS and real-time pressure sensing (RTPS) could reduce the incidence of intraneural injection and nerve puncture during USG PNB compared with a traditional fixed thresholds (Control) procedure. Randomized, prospective study. Operating room. One hundred ASA physical status I to III patients undergoing orthopedic surgery. Patient anesthetized using axillary, sciatic or femoral USG PNB were randomized to the PresStim group (Dynamic RTPS and NS set at 1.5 mA then decreased; n = 50) or Control group (fixed thresholds for in-line pressure mechanical manometer and NS at 0.2 mA; n = 50). Procedural ultrasound images and videos were recorded, stored and reviewed in random order by two experts in ultrasound-guided PNB blinded to the group. They noted the needle-to-nerve relationship and intraneural injection for all blocked nerves. One hundred and twenty-three USG PNBs were performed (56 axillary brachial plexus blocks, 40 femoral nerve blocks and 27 sciatic popliteal nerve blocks); 235 blocked nerves and videos were recorded and analyzed (PresStim, 118; Control, 117). Less paresthesia was noted in the PresStim group (12.7%) compared with the Control group (18.8%). The risk of intraneural injection was significantly higher in the Control group (odds ratio [OR], 17.1; 95% confidence interval [CI], 2.2–135, P = 0.007). The risk of nerve puncture (OR, 22.7; 95% CI, 2.9–175, p = 0.003) and needle-nerve contact (OR, 4.7; 95% CI, 2.4–9.5, p < 0.001) was significantly higher in the Control group than the PresStim group. Under the conditions of the study, dynamic triple monitoring combining RTPS, NS and USG decreases intraneural injection and unintentional needle-nerve contact and puncture during a PNB procedure. •Ultrasound guidance (USG) does not eliminate the risk of intraneural injection.•USG, Nerve Stimulation and pressure sensing could reduce the incidence of intraneural injection.•A triple dynamic monitoring decreases nerve injury suurogates and paresthesia compared to an USG control group.