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Background The properties of semi-elemental enteral nutrition might theoretically improve gastrointestinal tolerance in brain-injured patients, known to suffer gastroparesis. The purpose of this study was to compare the efficacy and tolerance of a semi-elemental versus a polymeric formula for enteral nutrition (EN) in brain-injured critically ill patients. Methods Prospective, randomized study including brain-injured adult patients [Glasgow Coma Scale (GCS) ≤ 8] with an expected duration of mechanical ventilation > 48 h. Intervention: an enteral semi-elemental (SE group) or polymeric (P group) formula. EN was started within 36 h after admission to the intensive care unit and was delivered according to a standardized nurse-driven protocol. The primary endpoint was the percentage of patients who received both 60% of the daily energy goal at 3 days and 100% of the daily energy goal at 5 days after inclusion. Tolerance of EN was assessed by the rate of gastroparesis, vomiting and diarrhea. Results Respectively, 100 and 95 patients were analyzed in the SE and P groups: Age (57[44–65] versus 55[40–65] years) and GCS (6[3–7] versus 5[3–7]) did not differ between groups. The percentage of patients achieving the primary endpoint was similar (46% and 48%, respectively; relative risk (RR) [95% confidence interval (CI)] = 1.05 (0.78–1.42); p  = 0.73). The mean daily energy intake was, respectively, 20.2 ± 6.3 versus 21.0 ± 6.5 kcal/kg/day ( p  = 0.42). Protein intakes were 1.3 ± 0.4 versus 1.1 ± 0.3 g/kg/day ( p  < 0.0001). Respectively, 18% versus 12% patients presented gastroparesis ( p  = 0.21), and 16% versus 8% patients suffered from diarrhea ( p  = 0.11). No patient presented vomiting in either group. Conclusion Semi-elemental compared to polymeric formula did not improve daily energy intake or gastrointestinal tolerance of enteral nutrition. Trial registration EudraCT/ID-RCB 2012-A00078-35 (registered January 17, 2012).

Background Early postoperative glycemic variability is associated with worse outcome after cardiac surgery, but the underlying mechanisms remain unknown. This study aimed to describe the relationship between postoperative glycemic variability and endothelial function, as assessed by serum endocan level in cardiac surgery patients. Methods We performed a post hoc analysis of patients included in the single-center observational ENDOLUNG study. Adult patients who underwent planned isolated coronary artery bypass graft surgery were eligible. Postoperative glycemic variability was assessed by calculating the coefficient of variability (CV) of blood glucose measured within 24 (CV 24 ) and 48 (CV 48 ) hours after surgery. Serum endocan level was measured at 24 (Endocan 24 ) and 48 (Endocan 48 ) hours after surgery. Pearson’s correlation coefficient with 95% confidence interval (95% CI) was calculated between CV 24 and Endocan 24 , and between CV 48 and Endocan 48 . Results Data from 177 patients were analyzed. Median CV 24 and CV 48 were 18% (range 7 to 39%) and 20% (range 7 to 35%) respectively. Neither CV 48 nor CV 24 were significantly correlated to Endocan 48 and Endocan 24 respectively (r (95% CI) = 0.150 (0.001 to 0.290; and r (95% CI) = 0.080 (-0.070 to 0.220), respectively). Conclusions Early postoperative glycemic variability within 48 h after planned cardiac surgery does not appear to be correlated with postoperative serum endocan level. Clinical trial registration number NCT02542423.

•Minimum effective concentration for 90% of ropivacaine in axillary block is unknown.•Using 20 ml ropivacaine, we found a 4.4 mg/ml concentration.•Intravenous adjunct of 8 mg Dexamethasone does not allow to reduce it.•Dexamethasone increases sensory and motor block duration.•Dexamethasone improves post-operative analgesia.

Background Glycemic variability is associated with worse outcomes after cardiac surgery, but the prognosis value of early glycemic variability after transcatheter aortic valve implantation is not known. This study was therefore designed to analyze the prognosis significance of post-procedural glycemic variability within 30 days after transcatheter aortic valve implantation. Methods A post hoc analysis of patients from our center included in the FRANCE and FRANCE-2 registries was conducted. Post-procedural glycemic variability was assessed by calculating the mean daily δ blood glucose during the first 2 days after transcatheter aortic valve implantation. Major complications within 30 days were death, stroke, myocardial infarction, acute heart failure, and life-threatening cardiac arrhythmias. Results We analyzed 160 patients (age (median [interquartile] = 84 [80–88] years; diabetes mellitus (n) = 41 (26%) patients; logistic Euroscore = 20 [12–32]). The median value of mean daily δ blood glucose was 4.3 mmol l −1 . The rate of major complications within 30 days after procedure among patients with the lowest quartile of glycemic variability was 12%, increasing from 12 to 26%, and 39% in the second, third, and fourth quartiles, respectively. In multivariate analysis, glycemic variability was independently associated with an increased risk of major complications within 30 days after the procedure (odds ratio [95% CI] = 1.83 [1.19–2.83]; p = 0.006). Conclusions This study showed that post-procedural glycemic variability was associated with an increased risk of major complications within 30 days after transcatheter aortic valve implantation. Trial registration Clinical trial registration number https://www.clinicaltrials.gov/ ; identifier: NCT02726958; date: April 4th, 2016

Background The aim of the study was to investigate whether intravenous (iv) infusion of exenatide, a synthetic GLP-1 receptor agonist, could provide a protective effect against myocardial ischemia-reperfusion injury after coronary artery bypass graft (CABG) surgery. Methods A sub study analysis of patients > 18 years admitted for elective CABG and included in the ExSTRESS trial was conducted. Patients were randomized to receive either iv exenatide (1-h bolus of 0.05 µg min −1 followed by a constant infusion of 0.025 µg min −1 ) (exenatide group) or iv insulin therapy (control group) for blood glucose control (target range 100–139 mg dl −1 ) during the first 48 h after surgical incision. All serum levels of troponin I measured during routine care in the Cardiac Surgery ICU were recorded. The primary outcome was the highest value of plasma concentration of troponin I measured between 12 and 24 h after ICU admission. The proportion of patients presenting an echocardiographic left ventricular ejection fraction (LVEF) > 50% at the follow-up consultation was compared between the two groups. Results Finally, 43 and 49 patients were analyzed in the control and exenatide groups, respectively {age: 69 [61–76] versus 71 [63–75] years; baseline LVEF < 50%: 6 (14%) versus 16 (32%) patients; on-pump surgery: 29 (67%) versus 33 (67%) patients}. The primary outcome did not significantly differ between the two groups (3.34 [1.06–6.19] µg l −1 versus 2.64 [1.29–3.85] µg l −1 in the control and exenatide groups, respectively; mean difference (MD) [95% confidence interval (95% CI)] 0.16 [− 0.25; 0.57], p = 0.54). The highest troponin value measured during the first 72 h in the ICU was 6.34 [1.36–10.90] versus 5.04 [2.39–7.18] µg l −1 , in the control and exenatide groups respectively (MD [95% CI] 0.20 [− 0.22; 0.61], p = 0.39). At the follow-up consultation, 5 (12%) versus 8 (16%) patients presented a LVEF < 50% in the control and in the exenatide groups respectively (relative risk [95% CI] 0.68 [0.16; 2.59], p = 0.56). Conclusions Postoperative iv exenatide did not provide any additional cardioprotective effect compared to iv insulin in low-risk patients undergoing scheduled CABG surgery. Trial registration ClinicalTrials.gov Identifier NCT01969149, date of registration: January 7th, 2015; EudraCT No. 2009-009254-25 A, date of registration: January 6th, 2009

[...]a posterior position of the HB compared to the thyroid cartilage as assessed by US is not associated with a higher risk of DTI, and parasagittal US measurements of SHB and ST distances did not provide any additional information compared to conventional criteria for the prediction of DTI.Disclosure of funding The work was not funded by National Institutes of Health (NIH), Howard Hughes Medical Institutes (HHMI), Medical Research Council (MRC), or Wellcome Trust. The financial cost of the study was supported by the Department of Anesthesiology and Intensive Care Medicine, 3 Bvd Alexander Fleming, University Hospital of Besancon, F-25000 Besancon, France.Declaration of Competing Interest None. CONTROL group n = 369 patients DTI group n = 85 patients P valueb Sensitivity [95% CI] Specificity [95% CI] Area under the ROC curve [95% CI] Baseline characteristics Age (years) 57 (17) 60 (15) 0.051 Malea 180 (49) 47 (55) 0.28 ASA physical status >2a 92 (25) 33 (39) 0.01 Obesea 87 (24) 24 (28) 0.37 Diabetes mellitusa 48 (13) 13 (15) 0.60 Emergency surgerya 36 (10) 9 (11) 0.82 Previous difficult tracheal intubationa 4 (1) 16 (19) <0.0001 Type of surgerya <0.0001 Orthopedic 55 (15) 20 (24) Abdominal 139 (38) 12 (14) Cardiovascular 46 (12) 28 (33) Urology 20 (5) 5 (6) Neurosurgery 81 (22) 12 (14) Other 28 (8) 8 (9) Anesthetic management BURP maneuvera 28 (8) 45 (53) <0.0001 Neuromuscular blocking agenta 262 (71) 63 (74) 0.56 Cormack and Lehane class 1 or 2aa 363 (98) 8 (9) <0.0001 First individual who intubates <0.0001 Anesthesia nurse 262 (71) 5 (6) Resident 101 (27) 11 (13) Physician 6 (2) 69 (81) Conventional clinical criteria Mouth opening <35 mma 15 (4) 14 (16) <0.0001 Thyromental distance <65 mma 23 (6) 27 (32) <0.0001 0.32 [0.22–0.42] 0.94 [0.91–0.96] 0.657 [0.586–0.727] Modified Mallampati class >2a 44 (12) 46 (54) <0.0001 0.54 [0.44–0.65] 0.88 [0.85–0.91] 0.768 [0.654–0.885] Neck ultrasound measures Skin-hyoid bone distance (SHB) (cm) 1.62 (0.46) 1.75 (0.45) 0.02 0.64 [0.53–0.74]c 0.54 [0.49–0.59]c 0.584 [0.538–0.630] Skin-thyroid distance (ST) (cm) 1.56 (0.45) 1.69 (0.49) 0.02 0.45 [0.34–0.56]c 0.67 [0.62–0.72]c 0.577 [0.530–0.622] ST/SHB ratio < 1a 225 (61) 53 (62) 0.81 0.38 [0.28–0.48] 0.61 [0.56–0.66] 0.515 [0.468–0.562] Table 1 Baseline characteristics and neck ultrasound measurements of patients with (DTI group) and without (CONTROL group) difficult tracheal intubation.

Sleep apnea (SA) was reported as possibly exacerbating symptoms of COVID-19, a disease induced by SARS-CoV-2 virus. The same comorbidities are common with both pathologies. This study aimed to estimate the prevalence, characteristics of SA and variation in AHI three months after severe COVID-19 requiring intensive care unit (ICU) admission. A prospective cohort of patients admitted to ICU for severe COVID-19 underwent an overnight home polygraphy 3 months after onset of symptoms, as part of a comprehensive follow-up program (pulmonary function tests, 6-minute walk tests and chest CT-scan). Patients with an apnea hypopnea index (AHI) ≥5 were considered as having SA. We performed a comparative descriptive analysis of 2 subgroups according to the existence, severity of SA and indication for effective SA treatment: patients with absent or mild SA (AHI <15) vs patients with moderate to severe SA (AHI ≥15). Among 68 patients included, 62 (91%) had known comorbidities (34 hypertension, 21 obesity, 20 dyslipidemia, 16 type 2 diabetes). It has been observed a preexisting SA for 13 patients (19.1%). At 3 months, 62 patients (91%) had SA with 85.5% of obstructive events. Twenty-four patients had no or a mild SA (AHI <15) and 44 had moderate to severe SA (AHI ≥15). Ischemic heart disease exclusively affected the moderate to severe SA group. Except for thoracic CT-scan which revealed less honeycomb lesions, COVID-19 symptoms were more severe in the group with moderate to severe SA, requiring a longer curarization, more prone position sessions and more frequent tracheotomy. SA involved 91% of patients in our population at 3 months of severe COVID-19 and was mainly obstructive type. Although SA might be a risk factor as well as consequences of ICU care in severe COVID-19 infection, our results underline the importance of sleep explorations after an ICU stay for this disease.

Purpose Severe postpartum haemorrhage (SPPH) is the leading cause of peripartum hysterectomy and maternal death. There are no easily measurable parameters that indicate the failure of medical therapy and the need for an advanced interventional procedure (AIP) to stop genital tract bleeding. The aim of the study was to define factors predictive of the need for an AIP in the management of emergent PPH. Methods The study included two phases: (1) an initial retrospective study of 257 consecutive patients with SPPH, allowing the determination of independent predictors of AIP, which were subsequently grouped in a predictive score, followed by (2) a multicentre study of 239 patients admitted during 2007, designed to validate the score. The main outcome measure was the need for an AIP, defined as uterine artery embolization, intraabdominal packing, arterial ligation or hysterectomy. Results Abnormalities of placental implantation, prothrombin time <50% (or an International Normalized Ratio >1.64), fibrinogen <2 g/l, troponin detectable, and heart rate >115 bpm were independently predictive of the need for an AIP. The SPPH score included each of the five predictive factors with a value of 0 or 1. The greater the SPPH score, the greater the percentage of patients needing an AIP (11% for SPPH 0, to 75% for SPPH ≥2). The AUC of the ROC curve of the SPPH score was 0.80. Conclusions We identified five independent predictors of the need for an AIP in patients with SPPH and persistent bleeding. Using these predictors in a single score could be a reliable screening tool in patients at risk of persistent genital tract bleeding and needing an AIP.

Background and objectivesThe effect of intravenous dexamethasone on the duration of axillary plexus block performed using ropivacaine is not described. The aim of this study is to assess the effect of intravenous dexamethasone on the duration of axillary plexus block analgesia after distal upper arm surgery.MethodsIn this prospective, randomized, placebo-controlled, double-blinded trial, consenting patients scheduled for hand or forearm surgery under ultrasound-guided axillary plexus block performed using 0.5 mL/kg of 0.475% ropivacaine, were randomized to receive an intravenous injection of either 8 mg/2 mL of dexamethasone (Dexa group) or 2 mL of saline (Control). The primary outcome was the time of first analgesic intake after axillary block. Secondary outcomes included motor or sensory block duration, total use of postoperative analgesics, and block-related complications.ResultsAmong the 98 patients included, 6 and 2 patients did not require postoperative analgesic intake in Dexa and Control groups, respectively (p=0.06). The time of first analgesic intake was significantly longer in the Dexa (20.9±9.3 hours) than in the Control group (14.7±6.6 hours, p<0.0004). Motor and sensory recovery occurred significantly later, and total analgesic consumption was lower in the Dexa than in the Control group. No nerve complication related to intravenous dexamethasone injection was recorded.ConclusionsThis study showed that intravenous dexamethasone delayed for 6 hours the time to first analgesic intake after upper arm surgery under axillary plexus block performed with the long-lasting local anesthetic ropivacaine. This suggests that intravenous dexamethasone could be an interesting adjuvant to axillary plexus block.Trial registration numberNCT02862327