Low-dose hydrocortisone reduces norepinephrine duration in severe burn patients: a randomized clinical trial

Introduction

The aim of this study was to assess the effect of low-dose corticosteroid therapy in reducing shock duration after severe burn.

Methods

A placebo-controlled, double-blind, randomized clinical trial (RCT) was performed on two parallel groups in the burn intensive care unit (ICU). Patients were randomized to receive either low-dose corticosteroid therapy or placebo for seven days. A corticotropin test was performed at the time of randomization, before the administration of the treatment dose. Thirty-two severely burned patients with refractory shock (>0.5 μg/kg/min of norepinephrine) were prospectively included in the study.

Results

We included 12 patients in the hydrocortisone-treated group and 15 patients in the placebo group in the final analysis. Among these patients, 21 were nonresponders to the corticotropin test. Median norepinephrine treatment duration (primary objective) was significantly lower in the corticosteroid-treated versus the placebo group (57 hours versus 120 hours, P = 0.035). The number of patients without norepinephrine 72 hours after inclusion was significantly lower in the treated group (P = 0.003, log-rank test analysis). The total quantities of norepinephrine administered to patients were lower in the hydrocortisone-treated versus the placebo group (1,205 μg/kg (1,079 to 2,167) versus 1,971 μg/kg (1,535 to 3,893), P = 0.067). There was no difference in terms of ICU or hospital length of stay, sepsis incidence, cicatrization or mortality.

Conclusions

In this placebo-controlled, randomized, double-blind clinical trial, we show for the first time that the administration of low-dose hydrocortisone in burn patients with severe shock reduces vasopressor administration.

Trial registration

Clinicaltrial.gov NCT00149123. Registered 6 September 2005.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0740-0) contains supplementary material, which is available to authorized users.

Prospective observational study of the non-invasive assessment of immediate postoperative pain using the analgesia/nociception index (ANI)

BACKGROUND

The analgesia/nociception index (ANI), a 0-100 non-invasive index calculated from heart rate variability, reflects the analgesia/nociception balance during general anaesthesia. The aim of this study was to evaluate the ANI in the assessment of immediate postoperative pain in adult patients undergoing general anaesthesia.

METHODS

Two-hundred patients undergoing scheduled surgery or endoscopy with general anaesthesia were included in this prospective observational study. Pain intensity was assessed using a 0-10 numerical rating scale (NRS) after arousal from general anaesthesia. Receiver-operating characteristic (ROC) curves were built to assess the performance of ANI to detect patients with NRS>3 and NRS ≥ 7 on arrival in the postoperative care unit.

RESULTS

A negative linear relationship was observed between ANI and NRS (ANI=-5.2 × NRS+77.9, r(2)=0.41, P<0.05). At the threshold of 57, the sensitivity and specificity of ANI to detect patients with NRS>3 were 78 and 80%, respectively, with a negative predictive value of 88%, corresponding to an area under the ROC curve (AUC) of 0.86. At the threshold of 48, the sensitivity and specificity of ANI to detect NRS ≥ 7 were 92 and 82%, respectively, with a negative predictive value of 99%, corresponding to a ROC curve AUC of 0.91.

CONCLUSIONS

A measurement of ANI during the immediate postoperative period is significantly correlated with pain intensity. The measurement of ANI appears to be a simple and non-invasive method to assess immediate postoperative analgesia.

Methemoglobinemia by cerium nitrate poisoning

Cerium nitrate is a topical antiseptic used with silver sulfadiazine (Flammacerium) for the treatment of serious burns. This topical agent can induce methemoglobinemia, but no cases have been reported in the recent literature. In this article, we present the case of a 16-year old girl, with third-degree burns over 95% of her body. After daily dressings of Flammacerium, on the sixth day she developed a bluish skin coloring. When tested for methemoglobinemia, levels of 31.8% were found. These returned to normal after classic treatment with Methylene blue.

[Prevention of arterial hypotension during spinal anesthesia using intramuscular ephedrine in older people]

OBJECTIVE

To assess the efficacy of intramuscular ephedrine for prevention of hypotension following subarachnoid block (SB) in the elderly.

STUDY DESIGN

Prospective, randomized double blind study vs placebo.

PATIENTS

Twenty patients, aged 60 years or more, of physical class ASA 2 or 3, scheduled for surgical fixation of fractured neck of femur under SB, allocated into two groups of ten each.

METHODS

After oral premedication with hydroxyzine 50 mg, 90 min before surgery, and preloading with cristalloid solution 10 mL.kg-1, the subarachnoid space was punctured with the patient in lateral position using a 22 Gauge spinal needle at the L3-L4 or L4-L5 interspace. Patients were given 0.5% hyperbaric bupivacaine intrathecally, according to body weight. Patients in ephedrine group received intramuscular ephedrine 30 mg immediately after SB. Patients in placebo group received 1 mL of intramuscular saline immediately after SB. When blood pressure decreased below 100 mmHg repeated bolus of ephedrine 6 mg were given intravenously.

RESULTS

Patients in both groups experienced a significant decrease in systolic pressure after SB, the decrease being significantly greater in the placebo group.

CONCLUSION

Prophylactic intramuscular ephedrine is effective to prevent hypotension associated with SB in the elderly.

Comparison of transesophageal and transthoracic contrast echocardiography for detection of an intrapulmonary shunt in liver disease

STUDY OBJECTIVES

Contrast transthoracic echocardiography (TTE) is currently used to identify intrapulmonary shunt (IPS) in patients with end-stage liver disease. The aim of this study was to compare the use of contrast TTE and transesophageal echocardiography (TEE) in detecting IPS.

DESIGN

Thirty-seven consecutive outpatients with severe liver disease awaiting liver transplantation underwent contrast TEE and TTE. The IPS was assessed semiquantitatively in four grades with TEE and as positive or negative with TTE.

SETTING

ICU.

INTERVENTIONS

Patients underwent contrast TEE after pharyngeal anesthesia alone followed by contrast TTE. Contrast echocardiography was performed with a modified fluid gelatin solution.

RESULTS

Overall detection rate of an IPS was 51% with TEE and 32% with TTE (p < 0.001). Four patients had an IPS detected with TEE but not with TTE. Quality of imaging was poor in 22% with TTE and 0% with TEE (p < 0.001). A PaO2 < 80 mm Hg or a dyspnea was associated with an IPS in 56% and 50% of patients with TEE and in 33% and 25% with TTE, respectively.

CONCLUSION

Contrast-enhanced TEE is superior to TTE for detecting an IPS in patients with severe liver disease awaiting liver transplantation. The use of gelatin contrast solution allows an early detection of IPS. Because of the high sensitivity of TEE, all patients suspected of hepatopulmonary syndrome should undergo TEE in search of an IPS if TTE is normal.

Ultrastructural changes in superior vestibular commissural neurons following vestibular neurectomy in the cat

The ultrastructural changes of the feline superior vestibular commissural neurons (CNs) were quantitatively assessed 8 weeks following ipsilateral vestibular neurectomy. Results indicated a slight degeneration of synaptic profiles (SPs; 25%) representing the primary vestibular afferent input onto CN soma. The synaptic vesicles of the remaining SPs, which likely originate from the cerebellum and the contralateral CNs, were smaller and rounder, suggesting a transition from an inhibitory to an excitatory mode of response. The SP loss had little impact on the CNs' capacity for protein synthesis and structural maintenance, since there was no change in the volume fraction of intracellular organelles. These data suggest that CNs do not degenerate and are likely functional after vestibular compensation. These findings support the role of the commissural pathway in vestibular compensation as proposed by Galiana et al, which is based on the assumption that the intervestibular commissural connections remain intact following vestibular neurectomy.

[Tooth injuries during general anesthesia, oral endoscopy and vibro-massage]

It is generally recognized that dental injury during and after tracheal intubation is a significant problem. Damage may occur during oro-tracheal intubation, oral endoscopy or seismotherapy. The incidence was reported in a study conducted in the contentious department of Lyon hospitals, in France, from 1978 to 1988. Results confirm that damage is relatively common and that the majority of damaged teeth (67%) were known to have been previously restored, or weakened through periodontal disease prior to the damage occurring. Maxillary incisors were the most frequently injured teeth. Fracture of crowns and roots of natural teeth (44,8%), followed by partial luxation (20,8%) and avulsion (20,8%) were the most common injury. Several cases are presented which reveal the clinical value of dental damages that occur during orotracheal intubation, oral endoscopy or seismotherapy. Besides dental or gingival complications can appear immediately but also after a few days or weeks. Some of the most recent development in dental therapy such as the butterfly bridge, titanium implants and porcelain laminate veneers are described. Tooth protective guards must be put into widespread use. Legal implications of dental lesions occurring during oro-tracheal intubation, oral endoscopy or seismotherapy are presented.

Low frequency hearing threshold determination in newborns, infants and mentally retarded children by middle latency responses

Middle latency (10-50 ms) responses (MLR) evoked by tone-pips (1,000 Hz 500 Hz) and early (0-10 ms) auditory evoked potentials (EAEP) evoked by chicks were recorded on 68 newborn babies (premature or at term), infants and children, some with central nervous system or psychiatric disorders, who had normal or impaired hearing. MLR were obtained either during sleep, chloral-hydrate sedation or ketamine anesthesia. Thresholds estimated from MLR and EAEP were compared to those from subsequent psychoacoustic pure tone testing. We confirm that MLR provide good threshold estimates for hearing in the low frequency range, whereas click evoked EAEP are good threshold indicators only for high frequencies.

[Tooth injuries during intubation: a new preventive device]

This study analyses 126 cases of dental injuries occurring during endotracheal intubation, reported to the service of litigations of the hospitals in Lyon over a ten-year period, and giving rise to a complaint. The overall rate was 1 out of 4,000 cases of intubation. The true incidence may be greater. As expected, the upper jaw teeth are most often involved, especially the left incisors. Among them 24.3% of the involved teeth were normal. Dental fractures were the most common lesion, together with total or partial dislocations. A questionnaire was sent to 534 anaesthetists to assess the main difficulties which they encounter when carrying out endotracheal intubation. The results of this enquiry demonstrated that anaesthetists were very aware of dental risks when carrying out intubation, and that there was a lack of efficient protective measures. Among them 81.2% claimed they would use a protective device from time to time, and 17.4% routinely, if one were available. Therefore we designed such a device. It is gutter-shaped, made with two different plastics, the more rigid one being on the outside. It fits over the upper jaw teeth. There is an indentation in the front, to check whether the device is placed correctly. The inner surface is made of foam which dulls the pressure which may be exerted on the device during intubation. This device was tested in 108 patients. Intubation was easy with the device in place in 73.2% of patients; mouth opening was reduced by a mean of 4.2 +/- 0.5 mm. The device made intubation more difficult, and even impossible, in patients whose mouth opened no more than 3.5 cm.(ABSTRACT TRUNCATED AT 250 WORDS)

[High frequency jet-ventilation in esophagotracheal fistula]

High-frequency jet-ventilation (HFJV) is not widely used, mainly because of technical problems and difficulty to assess its efficiency. However, there is general agreement on following major indication: artificial ventilation in patients with oesotracheal fistula. In the case reported here, HFJV allowed efficient ventilatory support through an endotracheal tube with deflated cuff. Weaning was progressively obtained. Surgery and postoperative course were uneventful.

[Per- and postoperative buprenorphine analgesia: cardiocirculatory and respiratory effects]

In 25 non-premedicated patients, buprénorphine (5 micrograms/kg - 1) has been injected i.v. 30 mn before coelioscopic sterilization under general anaesthesia. Following the i.v. injection there no significant modification of the arterial systolic and diastolic blood pressure was observed but post-operative bradycardia. Tidal volume and minute/ventilation decreased whereas the respiratory rate remained stable. Arterial blood gaz analysis showed slightly hypoxaemia and a significant rise of PaCO2 with post-operative acidosis similar to that in the control group. Good postoperative analgesia was achieved but with profound sedation and a high incidence of nausea and vomiting.

[Ultrastructural study of anomalies of the acrosome in spermatozoa with irregular heads]

The study of the ultrastructure of spermatozoa having an irregular head, encountered in large number in semen of men supposed to be sterile, shows that the acrosome is often modified in its shape or its texture. In several samples the spermatozoa have either no acrosome or a small one, at a certain distance from the nucleus. In other cases the ratio between the segments of the acrosome is modified and the parallelism between the edges is not conserved. These acrosomes are often covered with a cytoplasmic velum the post acrosomal cape is missing. Finally the acrosome can be deformed by local expansions of the subacrosomal space, or by large gaps. Other anomalies which are less common have been observed. The elimination of possible artefacts and the comparison between these human anomalies and similar acrosomal anomalies of mammalian semen, are discussed in this paper.