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Background Burn inhalation injury (BII) is a major cause of burn-related mortality and morbidity. Despite published practice guidelines, no consensus exists for the best strategies regarding diagnosis and management of BII. A modified DELPHI study using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method (RAM) systematically analysed the opinions of an expert panel. Expert opinion was combined with available evidence to determine what constitutes appropriate and inappropriate judgement in the diagnosis and management of BII. Methods A 15-person multidisciplinary panel comprised anaesthetists, intensivists and plastic surgeons involved in the clinical management of major burn patients adopted a modified Delphi approach using the RAM method. They rated the appropriateness of statements describing diagnostic and management options for BII on a Likert scale. A modified final survey comprising 140 statements was completed, subdivided into history and physical examination (20), investigations (39), airway management (5), systemic toxicity (23), invasive mechanical ventilation (29) and pharmacotherapy (24). Median appropriateness ratings and the disagreement index (DI) were calculated to classify statements as appropriate, uncertain, or inappropriate. Results Of 140 statements, 74 were rated as appropriate, 40 as uncertain and 26 as inappropriate. Initial intubation with ≥ 8.0 mm endotracheal tubes, lung protective ventilatory strategies, initial bronchoscopic lavage, serial bronchoscopic lavage for severe BII, nebulised heparin and salbutamol administration for moderate-severe BII and N-acetylcysteine for moderate BII were rated appropriate. Non-protective ventilatory strategies, high-frequency oscillatory ventilation, high-frequency percussive ventilation, prophylactic systemic antibiotics and corticosteroids were rated inappropriate. Experts disagreed (DI ≥ 1) on six statements, classified uncertain: the use of flexible fiberoptic bronchoscopy to guide fluid requirements (DI = 1.52), intubation with endotracheal tubes of internal diameter < 8.0 mm (DI = 1.19), use of airway pressure release ventilation modality (DI = 1.19) and nebulised 5000IU heparin, N-acetylcysteine and salbutamol for mild BII (DI = 1.52, 1.70, 1.36, respectively). Conclusions Burns experts mostly agreed on appropriate and inappropriate diagnostic and management criteria of BII as in published guidance. Uncertainty exists as to the optimal diagnosis and management of differing grades of severity of BII. Future research should investigate the accuracy of bronchoscopic grading of BII, the value of bronchial lavage in differing severity groups and the effectiveness of nebulised therapies in different severities of BII. Graphical Abstract

Dabigatran is an oral anticoagulant that is mainly renally excreted. Despite its efficacy in preventing thromboembolic events, concerns arise regarding bleeding complications in patients with acute kidney injury. Idarucizumab is its specific antidote and reverses quickly and effectively dabigatran anticoagulation effects in situations of severe bleeding or pending surgical procedures, but its benefit beyond these two indications remains uncertain. We present a case of a woman with atrial fibrillation anticoagulated by dabigatran and admitted with Streptococcus agalactiae meningitis, acute kidney injury and dabigatran accumulation. Idarucizumab was not administered initially as she did not meet its current strict indications. However, subsequently, significant bleeding necessitated its use. A rebound increase in dabigatran concentration was associated with an intracranial hemorrhage, but the combination of additional doses of idarucizumab with hemodialysis lowered the dabigatran concentration and prevented significant rebound increases. Further investigation into the optimal management of dabigatran accumulation and acute kidney injury-associated bleeding is needed to enhance patient outcomes and safety. Early initiation of hemodialysis together with idarucizumab administration may be crucial in preventing life-threatening bleeding events in these patients.

Intravascular large B-cell lymphoma is a rare and aggressive EBV-negative large B-cell lymphoma with a dismal outcome. Here, we describe the case of a 76-year-old HIV-positive patient with an acute presentation of systemic symptoms and rapidly fatal outcome. Autopsy revealed a disseminated large B-cell lymphoma with an intravascular distribution involving the liver, lymph nodes, spleen, and bone marrow and associated to fibrin thrombi in hepatic capillary haemangiomas. The neoplastic B cells (CD79a + / − , CD20 + / − , CD30 + , MUM1 + , PD-L1 +) showed a Hodgkin and Reed-Sternberg-like morphology and were EBV-positive with a latency type II (LMP1 + , EBNA2-). Haemophagocytosis was documented in the bone marrow and lymph nodes. This case illustrates the diagnostic challenges of large B-cell lymphoma with intravascular presentation. We found only five other cases of EBV-positive large B-cell lymphoma with an intravascular presentation in the literature, three of which had an underlying immunodeficiency adding to the broad spectrum of EBV-associated lymphoma in the setting of immunosuppression.

Despite its known harmful effects, normal saline is still commonly used in the treatment of hypovolemia in polytrauma patients. Given the lack of pre-hospital research on this topic, the current study aims to assess the current practice of fluid administration during the pre-hospital phase of care and its effects on initial metabolic acid-base status in trauma patients. We extracted and completed data from patients recorded in the Lausanne University Hospital (CHUV) trauma registry between 2008 and 2019. Patients were selected according to their age, the availability of a blood gas analysis after arrival at the emergency room, data availability in the trauma registry, and the modality of arrival in the ED. The dominantly administered pre-hospital fluid was normal saline. No association between the type of fluid administered during the pre-hospital phase and the presence of hyperchloremic acidosis in the ED was observed.

Background Emergency medical services regularly encounter severe burns. As standards of care are relatively well-established regarding their hospital management, prehospital care is comparatively poorly defined. The aim of this study was to describe burned patients taken care of by our physician-staffed emergency medical service (PEMS). Methods All patients directly transported by our PEMS to our burn centre between January 2008 and December 2017 were retrospectively enrolled. We specifically addressed three “burn-related” variables: prehospital and hospital burn size estimations, type and volume of infusion and pain assessment and management. We divided patients into two groups for comparison: TBSA < 20% and ≥ 20%. We a priori defined clinically acceptable limits of agreement in the small and large burn group to be ±5% and ± 10%, respectively. Results We included 86 patients whose median age was 26 years (IQR 12–51). The median prehospital TBSA was 10% (IQR 6–25). The difference between the prehospital and hospital TBSA estimations was outside the limits of agreement at 6.2%. The limits of agreement found in the small and large burn groups were − 5.3, 4.4 and − 10.1, 11, respectively. Crystalloid infusion was reported at a median volume of 0.8 ml/kg/TBSA (IQR 0.3–1.4) during the prehospital phase, which extrapolated over the first 8 h would equal to a median volume of 10.5 ml/kg/TBSA. The median verbal numeric rating scale on scene was 6 (IQR 3–8) and 3 (IQR 2–5) at the hospital ( p  < 0.001). Systemic analgesia was provided to 61 (71%) patients, predominantly with fentanyl ( n  = 59; 69%), followed by ketamine ( n  = 7; 8.1%). The median doses of fentanyl and ketamine were 1.7 mcg/kg (IQR 1–2.6) and 2.1 mg/kg (IQR 0.3–3.2), respectively. Conclusions We found good agreement in burn size estimations. The quantity of crystalloid infused was higher than the recommended amount, suggesting a potential risk for fluid overload. Most patients benefited from a correct systemic analgesia. These results emphasized the need for dedicated guidelines and decision support aids for the prehospital management of burned patients.

ObjectivesEarly identification of SARS-CoV-2 infection is important to guide quarantine and reduce transmission. This study evaluates the diagnostic performance of lung ultrasound (LUS), an affordable, consumable-free point-of-care tool, for COVID-19 screening.Design, setting and participantsThis prospective observational cohort included adults presenting with cough and/or dyspnoea at a SARS-CoV-2 screening centre of Lausanne University Hospital between 31 March and 8 May 2020.InterventionsInvestigators recorded standardised LUS images and videos in 10 lung zones per patient. Two blinded independent experts reviewed LUS recording and classified abnormal findings according to prespecified criteria to investigate their predictive value to diagnose SARS-CoV-2 infection according to PCR on nasopharyngeal swabs (COVID-19 positive vs COVID-19 negative).Primary and secondary outcome measuresWe finally combined LUS and clinical findings to derive a multivariate logistic regression diagnostic score.ResultsOf 134 included patients, 23% (n=30/134) were COVID-19 positive and 77% (n=103/134) were COVID-19 negative; 85%, (n=114/134) cases were previously healthy healthcare workers presenting within 2–5 days of symptom onset (IQR). Abnormal LUS findings were significantly more frequent in COVID-19 positive compared with COVID-19 negative (45% vs 26%, p=0.045) and mostly consisted of focal pathologic B lines. Combining clinical findings in a multivariate logistic regression score had an area under the receiver operating curve of 80.3% to detect COVID-19, and slightly improved to 84.5% with the addition of LUS features.ConclusionsCOVID-19-positive patients are significantly more likely to have lung pathology by LUS. However, LUS has an insufficient sensitivity and is not an appropriate screening tool in outpatients. LUS only adds little value to clinical features alone.

Hospitalized patients with COVID‐19 suffered initially from high rates of venous thromboembolism (VTE), with possible associations between therapeutic anticoagulation and better clinical outcomes in observational studies. To test whether therapeutic anticoagulation improves clinical outcomes in severe COVID‐19. In this multicenter, open‐label, randomized controlled trial, we recruited acutely ill medical COVID‐19 patients with D‐dimer >1000 ng/ml or critically ill COVID‐19 patients in four Swiss hospitals, from April 2020 until June 2021, with a 30‐day follow‐up. Participants were randomized to in‐hospital therapeutic anticoagulation versus low‐dose anticoagulation in acutely ill participants/intermediate‐dose anticoagulation in critically ill participants, with enoxaparin or unfractionated heparins. The primary outcome was a centrally adjudicated composite of 30‐day all‐cause mortality, VTE, arterial thrombosis, and disseminated intravascular coagulopathy (DIC), with screening for proximal deep vein thrombosis. Among 159 participants, 55.3% were critically ill and 94.3% received corticosteroids. Before study inclusion, pulmonary embolism had been excluded in 71.7%. The primary outcome occurred in 4/79 participants randomized to therapeutic anticoagulation and 4/80 to low/intermediate anticoagulation (5.4% vs. 5.0%; risk difference +0.4%; adjusted hazard ratio 0.76, 95% confidence interval 0.18–3.21), including three deaths in each group. All primary outcomes and major bleeding (n = 3) occurred in critically ill participants. There was no asymptomatic proximal deep vein thrombosis and no difference in major bleeding. Among patients with severe COVID‐19 treated with corticosteroids and with exclusion of pulmonary embolism at hospital admission for most, risks of mortality, thrombotic outcomes, and DIC were low at 30 days. The lack of benefit of therapeutic anticoagulation was too imprecise for definite conclusions.

ARDS acute respiratory distress syndrome, MAP mean arterial pressure, PPV pulse pressure variation, SVV stroke volume variation, TBSA total body surface burn area, UO urine output The results of this international survey highlight the use of albumin (> 60%) and vasopressors (80%) during the early resuscitation phase. Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. (PDF 155 kb) Authors’ Affiliations (1) Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France (2) Service of Adult Intensive Care Medicine and Burns, University Hospital, 1011 Lausanne, Switzerland (3) Department of Intensive Care and Burns, Ghent University Hospital, Ghent, Belgium (4) Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria (5) Department of Anaesthesiology and Intensive Care, Haukeland University Hospital and University of Bergen, Bergen, Norway (6) Department of Intensive Care Medicine, Academic Medical Center, Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam, The Netherlands (7) Department of Anesthesiology, Red Cross Hospital, Beverwijk, The Netherlands (8) Department of Anesthesiology and Reanimation, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey (9) Burn Unit, Papanikolaou Hospital, Thessaloniki, Greece (10) Burn Centre, Percy Military Hospital, Clamart, France (11) Critical Care and Burn Unit, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Universidad Europea de Madrid, Madrid, Spain (12) Department of Clinical Medicine, Trinity College, Welcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin, Ireland (13) Department of General Anaesthesiology, Emergency and Intensive Care Medicine, LKH - University Hospital of Graz, Medical University of Graz, Graz, Austria (14) Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy (15) Burn Centre and Intensive Care Department, University Hospital of Liège, Liège, Belgium (16) Departments of Hand, Plastic and Burns and Intensive Care, Linköping University Hospital, Linköping University, 581 85 Linkoping, Sweden (17) Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Hôpital Lariboisière, UMR Institut National de la Santé et de la Recherche Médicale (INSERM) 942, Université Paris Diderot, F-75475 Paris, France Soussi S, Deniau B, Ferry A, Levé C, Benyamina M, Maurel V, et al.

Adult patients with uncorrected congenital heart diseases and chronic intracardiac shunt may develop Eisenmenger syndrome (ES) due to progressive increase of pulmonary vascular resistance, with significant morbidity and mortality. Acute decompensation of ES in conditions promoting a further increase of pulmonary vascular resistance, such as pulmonary embolism or pneumonia, can precipitate major arterial hypoxia and death. In such conditions, increasing systemic oxygenation with veno‐venous extracorporeal membrane oxygenation (VV‐ECMO) could be life‐saving, serving as a bridge to treat a potential reversible cause for the decompensation, or to urgent lung transplantation. Anticipating the effects of VV‐ECMO in this setting could ease the clinical decision to initiate such therapeutic strategy. Here, we present a series of equations to accurately predict the effects of VV‐ECMO on arterial oxygenation in ES and illustrate this point by a case of ES decompensation with refractory hypoxaemia consecutive to an acute respiratory failure due to viral pneumonia.