Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

[Risk factors and screening strategy for group B streptococcal colonization in pregnant women: results of a prospective study]

OBJECTIVES

Group B Streptococcus (GBS) continues to be the most important bacterial cause of sepsis, meningitidis in newborns. American consensus guidelines have been published. They recommended the use of either risk-based strategy or screening-based approach for GBS colonization in pregnant women to identify candidates for intrapartum prophylaxis. Screening consists of obtaining vaginal and anorectal specimens for culture at 35 to 37 weeks' gestation. The aim of this prospective study was to assess the usefulness of systematic and concomitant GBS screening by rectal and vaginal swab in pregnant women. A questionnaire designed to determine the risk factors for colonization by GBS was completed.

MATERIALS AND METHODS

We have screened 370 pregnant women with rectal and vaginal swab.

RESULTS

Fifty seven (15.4%) women had positive GBS cultures. Of those women, the rectum and the vagina were the only site of colonization in 16 (4.3%) and 8 (2.2%) women respectively. None of the factors studied was significantly associated with GBS colonization.

CONCLUSION

Detection of GBS is enhanced by 40% by using vaginal and anorectal swabs compared to a vaginal swab alone. No studied factor appeared to predict GBS colonization, which incited us to screen all pregnant women.

Intrathecal morphine and clonidine for coronary artery bypass grafting

BACKGROUND

After cardiac surgery adequate postoperative analgesia is necessary. We assessed analgesia using intrathecal morphine and clonidine.

METHODS

In a double-blind randomized study, 45 patients having coronary artery bypass graft surgery were allocated randomly to receive i.v. patient-controlled analgesia (PCA) morphine (bolus, 1 mg; lock-out interval, 7 min) (control group), either alone or combined with intrathecal morphine 4 microg kg(-1) or with both intrathecal morphine 4 microg kg(-1) and clonidine 1 microg kg(-1). Intrathecal injections were performed before the induction of general anaesthesia. Pain was measured after surgery using a visual analogue scale (VAS). We recorded i.v. PCA morphine consumption during the 24 h after operation.

RESULTS

Morphine dosage [median (25th-75th percentiles)] was less in the first 24 h in the patients who were given intrathecal morphine + clonidine [7 (0-37) mg] than in other patients [40.5 (15-61.5) mg in the intrathecal morphine group and 37 (30.5-51) mg in the i.v. morphine group]. VAS scores were lower after intrathecal morphine + clonidine compared with the control group. Time to extubation was less after intrathecal morphine + clonidine compared with the i.v. morphine group [225 (195-330) vs 330 (300-360) min, P<0.05].

CONCLUSION

Intrathecal morphine and clonidine provide effective analgesia after coronary artery bypass graft surgery and allow earlier extubation.

Traumatic aortic regurgitation: aortic valvuloplasty controlled by aortoscopy

Traumatic aortic insufficiency is a rare occurrence after blunt chest trauma, and requires surgical treatment. Aortic valve replacement has been proposed as the procedure of choice, but primary valve repair is being performed increasingly more often. In a plead for conservative surgery, we report a case of valvuloplasty that was controlled by intraoperative aortic endoscopy. When operative conditions permit aortic valve repair, this should be carried out in order to avoid aortic valve replacement and its potential complications, especially in young patients with healthy valves. Replacement is the safest treatment for complex or multiple injuries of the aortic valve, however.

Mesenteric ischemia after coronary artery bypass grafting: should local continuous intra-arterial perfusion with papaverine be regarded as a treatment?

Mesenteric ischemia after cardiac surgery is rare but dramatic. We present a patient who had acute mesenteric ischemia following low cardiac output after coronary artery bypass grafting. Our patient was successfully treated with continuous intra-arterial perfusion with papaverine. We think that selective angiography must be performed as early as mesenteric ischemia is suspected, to get earlier diagnosis and treatment of an ischemic patient.

[Motor deficit of the lower limbs and urinary incontinence following peridural anesthesia]

Neurological complications of epidural anaesthesia are rare, but can be severe. We report the case of a 49-year-old man, with a history of non equilibrated diabetes, who experienced after an epidural anaesthesia for peripheral vascular surgery a polyneuropathy with muscle weakness of the lower extremities associated with a transient urinary incontinence. A spinal compression was excluded by computed tomography and magnetic resonance imaging. Electromyography showed an impaired nervous motor conduction. An aggravation of a pre-existing diabetic and alcoholic polyneuropathy, associated with possible spinal ischaemia of multifactorial origin could be the cause of these complications. This case emphasizes the importance, during preanesthetic assessment of candidates for epidural or spinal anaesthesia, to search for a possible unrecognized neuropathy at risk of aggravation by regional anaesthesia.

Management and outcome of borderline ovarian tumors incidentally discovered at or after laparoscopy

BACKGROUND

To evaluate in a series of patients with borderline ovarian tumors the clinical findings and the outcome after laparoscopic management.

METHODS

Retrospective study of 25 patients with borderline ovarian tumors first treated by laparoscopic approach.

RESULTS

Thirteen patients had mucinous tumors and 12 had serous tumors. Twenty-one patients had ultrasound examination which detected 24 ovarian cysts including multilocular cysts in 50% of cases and unilocular sonolucent cysts in 25% of cases. The serum CA 125 and CA 199 levels were elevated in 30.7% and 23% respectively. Among the 25 patients first treated by laparoscopic approach, 24 had stage I disease: six of them had cystectomy, seven unilateral salpingo-oophorectomy, two bilateral salpingo-oophorectomy and two laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Seven patients had laparoconversion for presumption of ovarian cancer (5) and failure of laparoscopic procedure (2). One patient with stage III disease had laparoscopic biopsies and subsequent laparotomy. Among the 25 patients, 15 had conservative treatment and 10 had radical treatment. Three recurrences occurred after cystectomy. The mean follow-up was 41 months. Twenty-three patients were alive without evidence of disease, one died of intercurrent disease and one patient was lost to follow-up.

CONCLUSION

Our data suggest that the laparoscopic approach to borderline ovarian tumors is possible in early stage disease but associated with a high risk of recurrence after cystectomy.

[Borderline ovarian tumors: a series of 43 patients]

Our objective was to evaluate the sonographic features, serum tumor markers in a series of 43 patients with borderline ovarian tumors. At sonographic examination, the majority of borderline tumors were multilocular. Serum CA-125 levels were elevated in 32.1%, CA-19-9 in 17.4%. In contrast, ACE levels were constantly normal. Twenty-four out of 43 patients (55.8%) had serous tumors, 18 (41.9%) had mucinous tumors and 1 (2.3%) had endometrioid tumor. Among, the 43 patients, 9 (20.9%) had first laparotomic approach and 34 had first laparoscopic treatment. Seven out of 34 patients treated by first laparoscopic approach had a laparoconversion (2 for presumption of invasive carcinoma and 5 for failure of laparoscopic procedure). Therefore, 27 had exclusive laparoscopic management. Among the 43 patients, 22 had conservative treatment and 21 radical surgery. The mean follow-up of patients was 41 months. Thirty-seven patients (86.1%) were alive without recurrence, 4 had a recurrence (9.3%), 1 patient (2.3%) was lost to follow-up and the last died of intercurrent disease. The mean delay of recurrence was 22 months (range 6 to 36). Three out of 4 recurrences occurred after cystectomy (2 ipsilateral and 1 controlateral). The fourth recurrence occurred after unilateral salpingo-oophorectomy. All 10 second look procedures were negative. Our results point out about the feasibility of laparoscopic management of borderline tumors. However, cystectomy is associated with a high risk of recurrence.

Epithelial ovarian carcinoma of low malignant potential

OBJECTIVE

The aim of this study was to evaluate the interest of sonographic features, serum marker tumors and conservative treatment especially by laparoscopic approach of epithelial ovarian tumors of low malignant potential (or borderline tumors).

STUDY DESIGN

Thirty-four patients with 40 epithelial ovarian tumors of low malignant potential treated at Bichat Claude Bernard hospital were reviewed. Of these patients, 29 had preoperative sonographic control (85.2%), 19 (55.8%) had pretreatment serum CA 125 determination, 17 (50%) serum CA 199 determination and 19 CEA serum levels. Twenty patients (58.8%) had serous tumor and 14 (41.2%) had mucinous tumor. Six out of the 20 serous lesions were bilateral. Of the patients 31 (91%) had a stage I disease, one had stage II (3%) disease and two had stage III (6%) disease. Nine patients (26.5%) had laparotomic management, 25 (73.5%) had first laparoscopic management with seven laparoconversions (28%).

RESULTS

The majority of borderline tumors (67.7%) exhibited multilocular aspects and seven patients had benign features (unilocular smooth sonolucent). Seven out of the 19 CA 125 serum levels were up to 35 U/ml; 4/17 CA 199 serum levels were above 40 U/ml but the CEA serum levels were always normal. Eighteen patients (52.9%) had radical surgery and 16 patients (47.1%) had conservative surgery including 7 cystectomies. Seven patients (20.6%) had subsequent laparotomic treatment, (five after laparoscopic management, one after laparoconversion management and another one after laparotomic surgery) and no residual disease was found. Fourteen patients (41.1%) had preoperative cyst rupture (13 during laparoscopic management). Four recurrences in stage I disease occurred; one after unilateral salpingo-oophorectomy, three after cystectomy but only one recurrence was in ipsilateral ovary. All four recurrences were diagnosed by sonographic control and one was associated with CA 125 serum level elevation. Ten laparoscopic second look were negative.

CONCLUSION

No specific sonographic aspect exists for borderline tumors but it is the best way to detect recurrence. The preoperative CA 125 serum levels was elevated in 36.8% of patients. The conservative treatment including laparoscopic procedure in borderline ovarian tumors appears to have a high risk of peroperative rupture but the rate of recurrence is similar to laparotomic treatment.

[Cardiac insufficiency caused by arteriovenous fistula. An unusual complication of spinal surgery]

Arteriovenous fistula is one of the main causes of high output cardiac failure. The authors report a case following lumbar disc surgery. There are a number of features which may suggest this complication both during surgery and in the immediate postoperative period which are important because the patient may only become symptomatic a long time after operation with a clinical presentation which leads to a cardiological rather than to a surgical referral.

[Aneurysms of the celiac trunk. Review of the literature. Personal deductions apropos of 2 cases]

Aneurysm of the celiac trunk is the rarest lesion of this type reported in the digestive arterial system. Two cases are reported and the 78 lesions of a similar nature documented in the literature reviewed. The etiology at the present time is mainly atheroma in the over 50' s and dysplasia of the elastic tissue in young subjects. Clinical diagnosis is difficult since symptomatic forms are the cause of errors and latent forms frequent (41 p. 100 of cases). Preoperative angiography must be a complete investigation and allows study of splanchnic vascularization and the presence of collaterals. When there are no contraindications, surgical treatment can prevent progression to rupture. After resection or reduction of the aneurysm revascularization may be envisaged but is not essential: --in the first case reported the failure of revascularization proved its inutility, --whereas failure in the second case led to severe hepatic and gallbladder complications. Successful results have been obtained in 90 p. 100 of 41 cases operated upon since the initial surgical treatment performed by Shumaker in 1958 [47].