Rein – foie: une liaison fatale ?

Voici l’excellente présentation de la Dre Belén Ponte sur Rein – foie: une liaison fatale ?

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Il faut se rappeler que la dysfonction rénale est un facteur pronostic majeur dans la cirrhose. Que cette dernière est la 5ème cause d’hospitalisation et que la majorité des patients  (75%) avec maladie hépatique développent une insuffisance rénale.

Cette présentation revient sur quelques définitions, l’épidémiologie, le diagnostic et les nouveautés.

Les conclusions sont (que vous comprendrez mieux en lisant ou écoutant la présentation):

  • IRA = complications fréquente de la cirrhose
  • Etiologie IRA = facteur pronostic important
  • Sévérité IRA détermine aussi le pronostic
  • Nouvelles définition IRA dans la cirrhose
  • Détection précoce nécessaire mais quels moyens ?
  • Nouveaux biomarqueurs en cours d’étude
  • Atteinte multisystémique dans le SHR
  • Cardiomyopathie déterminante
  • Albumine est également altérée

image vedette


Research & Review 137 from Life in The Fast Lane


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Research and Reviews in the Fastlane 037


Welcome to the 37th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.
This edition contains 10 recommended readsThe R&R Editorial Team is Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find out more about the R&R in the FASTLANE project here and check out the team of contributors from all around the world.

This Edition’s R&R Hall of Famer

Critical Care, Trauma, Neurosurgery
R&R Hall of Famer Blue
Traumatic Intracranial Hypertension. Nino Stocchetti, M.D., and Andrew I.R. Maas, M.D., Ph.D.
N Engl J Med 2014; 370:2121-2130May 29, 2014. PMID: 24869722

  • An excellent review on how to monitor and treat intracranial hypertension secondary to trauma. Includes a wonderful graphic demonstrating a staircase approach to the treatment of intracranial hypertension. This tiered approach is accompanied by level’s of evidence and risks of individual treatment. A must read!
  • Recommended by: Nudrat Rashid, Jeremy Fried

The Best of the Rest

Airway
R&R Game Changer? Might change your clinical practice
 Otten D et al. Comparison of Bag-Valve-Mask Hand-Sealing Techniques in a Simulated Model. Ann of EM 2014; 63: 6-12. PubMed ID: 23937957
  • 2-handed BVM delivers a larger portion of the intended tidal volume to the lungs in comparison to 1-handed BVM in simulation mannequins. Although this study is not on actual patients or even on human beings, it makes a strong argument for 2-handed BVM being standard instead of 1-handed BVM.
  • Recommended by: Anand Swaminathan

Emergency Medicine
R&R Game Changer? Might change your clinical practice
R&R WTF
Iserson KV. An hypnotic suggestion: review of hypnosis for clinical emergency care. J Emerg Med. 2014 Apr;46(4):588-96. doi: 10.1016/j.jemermed.2013.09.024.  PMID: 24472351
  • Fascinating review on the history and possible application of clinical hypnosis in the ED setting. Advantages are that it is safe, fast and cost-effective.  Training is required before you add this non-pharmacologic skill to your clinical armamentarium.
  • Recommended by: Jeremy Fried

Emergency Medicine, Critical care, Medicine
R&R Game Changer? Might change your clinical practice
Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Coxib and traditional NSAID Trialists’ (CNT) Collaboration. The Lancet – 31 August 2013 ( Vol. 382, Issue 9894, Pages 769-779 ). PMID: 23726390
  •  Everyone loves NSAIDs! But they do have risks, and this paper was a good reminder of not just the well-known upper GI effects, but the increased risk of vascular events. Even good, old ibuprofen showed a significant increase in major coronary events. Naproxen was the big winner, as it showed no increase in vascular events. All NSAIDs significantly increased risk of upper GI problems. NSAIDs: Use them. Prescribe them. Love them. But remember they are not entirely benign!
  • Recommended by: Zack Repanshek

Infection Control, Hand Hygiene
R&R Eureka
Ghareeb PA, Bourlai T, Dutton W, McClellan WT. Reducing pathogen transmission in a hospital setting. Handshake verses fist bump: a pilot study. J Hosp Infect. 2013 Dec;85(4):321-3. PMID: 24144553
  • Fist bump instead of handshake in the clinical setting to reduce the risk of bacterial transmission between healthcare providers. Works by reducing the overall contact time and total surface area exposed compared to the standard handshake. Don’t be surprised if this takes off in your institution. 
  • Recommended by: Anand Swaminathan

Emergency Medicine, Critical Care, Respiratory medicine
R&R Game Changer? Might change your clinical practice
Assessment of the safety and efficiency of using an age-adjusted d-dimer threshold to exclude suspected pulmonary embolism. Chest. 2014 May 15. doi: 10.1378/chest.13-2386. PMID : 24831769
  • Authors Conclusion: Use of an age-adjusted d-dimer threshold reduces imaging among patients age <50 years with a Revised Geneva Score ≤ 10. While the adoption of an age-adjusted d-dimer threshold is probably safe, the confidence intervals surrounding the additional 1.5% of PE that was missed using an age-adjusted threshold necessitate a prospective study before this practice can be adopted into routine clinical care.
  • Recommended by: Salim R. Rezaie,  Jeremy Fried
  • Read More: The Adventure of the Golden Standard (Rory Spiegel)

Resuscitation
R&R Hot Stuff
Wik L et al. Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation 2014. PMID: 24642406
  • Mechanical CPR offers no benefit over manual CPR in patients with OHCA in terms of survival to discharge. Although a number of physicians have argued the merits of these devices in terms of freeing up hands, ensuring adequate compression’s etc, this is an expensive device ($15,000/unit) to adopt without proof of benefit.
  • Recommended by: Anand Swaminathan

 Critical Care
R&R Hot Stuff
ICU-Acquired Weakness and Recovery from Critical Illness.  John P. Kress, M.D., and Jesse B. Hall, M.D.
N Engl J Med 2014; 370:1626-1635April 24, 2014. PMID: 24758618

  • ICU acquired weakness contributes significantly to the considerable functional impairment survivors of critical illness face. This excellent review provides a nice summary and emphasizes the importance of aggressive and early treatment of sepsis and of BSL control with insulin therapy. In addition to this, early mobilization and minimizing sedation may contribute to the reduction in deconditioning and debility faced by this group.
  • Recommended by: Nudrat Rashid

Emergency, Critical Care, Ultrasonography
R&R Hot Stuff
High versus low blood-pressure target in patients with septic shock. Asfar P et al.N Engl J Med. 2014 Apr 24;370(17):1583-93. doi: 10.1056/NEJMoa1312173. Epub 2014 Mar 18, PMID: 24635770
  • This study suggests that amongst patients with septic shock, there is no significant difference in 28-day or 90-day mortality between those treated to reach a target mean arterial pressure of 80-85 mm Hg and those who were treated to reach a target of 65-70 mm Hg. The results support the guidelines of the Surviving Sepsis Campaign, which recommend targeting a mean arterial pressure of at least 65 mmHg.
  • Recommended by: Nudrat Rashid

Anaesthetics, Critical Care
R&R Game Changer? Might change your clinical practice
Futier E1, Constantin JM, Jaber S .Protective lung ventilation in operating room: a systematic review. Minerva Anestesiol. 2014 Jun;80(6):726-35. PMID: 24226493
  • Well written review on lung protective ventilation during general anesthesia offering some recommendations for mechanical ventilation in the surgical context. Time to change! – at least during abdominal surgery
  • Recommended by: Søren Steemann Rudolph
The R&R iconoclastic sneak peek icon key
R&R in the FASTLANE 009 RR Authors 64 The list of contributorsR&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
RR ICON Hall of famerR&R Hall of fame You simply MUST READ this!R&R Hot StuffR&R Hot stuff! Everyone ‘s going to be talking about this
RR ICON LandmarkR&R Landmark paper A paper that made a differenceR&R Game Changer 64R&R Game Changer? Might change your clinical practice
RR ICON EurekaR&R Eureka! Revolutionary idea or conceptRR ICON WTFR&R WTF! Weird, transcendent or funtabulous!
R&R in the FASTLANE 009 RR Boffin 64 R&R Boffintastic High quality researchRR ICON TrashR&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR Mona Lisa 64 R&R Mona Lisa Brilliant writing or explanation
 That should keep you busy for a week at least… 
Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading. Thanks to our wonderful group of contributors!

A propos des QRS fragmentés… fQRS

jim.fr logo


S’il y a des complexes QRS fragmentés dans les dérivations latérales de l’ECG…

A l’ECG, la présence de complexes QRS fragmentés c’est-à-dire ayant différents aspects RSR’ dans les 12 dérivations enregistrées, témoigne d’une activation inhomogène des ventricules au niveau d’un infarctus du myocarde. Chez les patients qui ont une maladie coronaire, ces QRS fragmentés constituent généralement un facteur de risque indépendant d’événements cardiaques et de moindre survie indemne de tout événement.

Cependant, aucune étude n’avait jusqu’alors été consacrée à l’évaluation de la prévalence et de la signification de la fragmentation des QRS dans la population générale. C’est ce qui a conduit Terho et coll. à se pencher sur la question auprès d’une cohorte de 10 904 finlandais (hommes : 52 % ; âge moyen : 44 ± 8,5 ans) issus de la population générale et qui avaient (n = 2 543) ou non une affection cardiaque connue (n = 8 361).

La fragmentation des complexes QRS a été définie par la présence de différents aspects RSR’ dans au moins 2 dérivations consécutives du même territoire (inferieur : II, III, aVF ; latéral : I, aVL, V4 à V6 ; antérieur : V1 à V3).
Critère principal : décès de toute cause, décès d’origine cardiaque et décès d’origine rythmique.
Dans l’ensemble de la population, une fragmentation des complexes QRS était présente chez 19,7 % (n = 2 147) des sujets ; elle prédominait largement dans les dérivations inférieures (15,7 % ; n = 1714), vs 0,8 % (n = 84) dans les dérivations latérales et 2,9 % (n = 314) dans les dérivations antérieures.

Sur un suivi de 30 ± 11 ans, la fragmentation des QRS n’est pas apparue être associée à une augmentation de la mortalité chez les sujets indemnes d’affection cardiovasculaire connue.
Il en était de même pour les patients ayant une maladie cardiovasculaire connue et qui présentaient une fragmentation des complexes QRS dans les dérivations inférieures et antérieures. En revanche, dans le groupe de patients avec maladie cardiovasculaire connue, la présence d’une fragmentation des complexes QRS dans les dérivations latérales était associée à un risque accru de décès de toute cause (p = 0,001), de décès d’origine cardiaque (p = 0,001) et de décès d’origine rythmique (p = 0,004).
En conclusion, contrairement aux études antérieures qui avaient évalué globalement les conséquences pronostique de la fragmentation des complexes QRS, cette étude individualise le pronostic en fonction des différentes localisations ECG de la fragmentation et du terrain sur lequel elle est mise en évidence. Il apparaît ainsi que la fragmentation des complexes QRS reflète un trouble mineur de la conduction intraventriculaire qui est assez fréquent, surtout dans les dérivations inférieures. La présence d’une fragmentation des complexes QRS a un bon pronostic chez les sujets indemnes d’affection cardiovasculaire connue et chez les cardiaques quand elle est antérieure ou inférieure. En contraste, la fragmentation des complexes QRS dans les dérivations latérales, qui est beaucoup plus rare, se trouve être associée à un plus mauvais pronostic chez les seuls patients qui ont une maladie cardiovasculaire connue.

Dr Robert Haïat
Références
Terho HK et coll. : Prevalence and Prognostic Significance of Fragmented QRS Complex in Middle-Aged Subjects With and Without Clinical or Electrocardiographic Evidence of Cardiac Disease. Am J Cardiol., 2014; 114: 141-147. 

FOAMed to read during the week…

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Research and Reviews in the Fastlane 036


Welcome to the 36th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.
This edition contains 11 recommended readsThe R&R Editorial Team is Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find out more about the R&R in the FASTLANE project here and check out the team of contributors from all around the world.

This Edition’s R&R Hall of Famer

Emergency Medicine, Critical Care

R&R Hall of Famer Blue
Chatterjee S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564
  • This meta-analysis suggests potential mortality benefit in patients with haemodynamically stable pulmonary embolism with right ventricular dysfunction (intermediate-risk PE). However, this advantage must be tempered against the increased risk of major bleeding and intracranial haemorrhage associated with thrombolytic therapy, particularly for patients greater than 65yrs. Thrombolysis was also associated with a lower risk of recurrence of pulmonary embolism.
  • Recommended by: Nudrat Rashid, Anand Swaminathan, Salim R. Rezaie, Chris Nickson


The Best of the Rest

Emergency Medicine, Infectious diseases

R&R Game Changer? Might change your clinical practice
Stevens DL, Bisno a. L, Chambers HF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2014. PubMed ID: 24947530
  • For a common emergency department complaint, management of skin and soft tissue infections (SSTIs) is rife with dogma and marginal quality evidence. The IDSA released updated guidelines once again urging physicians to target streptococcus (i.e. no MRSA coverage) in most non-severe cases of non-purulent cellulitis, use an initial 5 day course of antibiotics in cellulitis, and only give antibiotics after incision and drainage to moderate/severe purulent infections (defined by systemic symptoms). Take a gander at the article for some excellent theoretical algorithms, recommendations on less common SSTIs (bubonic plague), and read these updates yourself, since even the recommendations persisting from the 2005 iteration still haven’t made it into practice.
  • Recommended by: Lauren Westafer

Emergency Medicine, ENT

R&R Eureka
2. Noble S, Chitnis J. Case report: use of topical tranexamic acid to stop localised bleeding. Emerg Med J. 2013 Jun;30(6):509-10. PubMed ID: 22833592.
  • Tranexamic acid has become a popular drug for dealing with difficult to control areas of bleeding including epistaxis and oral mucosa bleeding. Here, the authors discuss a case of bleeding from a nipple after piercing in a patient with hemophilia.
  • Recommended by: Sean Fox

Emergency Medicine

R&R Game Changer? Might change your clinical practice
3. Stiell IG et al. Clinical characteristics associated with adverse events in patients with exacerbation of chronic obstructive pulmonary disease: a prospective cohort study. CMAJ 2014. PubMed ID: 24549125
  • This study found that a high percentage (49%) of patients with serious adverse outcomes after an ED visit for COPD were not initially admitted to the hospital. The authors used logistic regression to derive a decision instrument to aid in determining which patients with COPD exacerbation should be admitted based on risk stratification. The study does not show that admission improves outcomes but the instrument may prove useful for risk stratification if it is prospectively validated.
  • Recommended by: Anand Swaminathan

Emergency Medicine, Critical care, Anaesthetics

R&R WTF
Barends CRM ,Absalom AR. Tied up in science: unknotting an old anaesthetic problem. BMJ 2013;347:f6735. PubMed ID: 24335667
  • Anyone who has transferred a patient – whether from ED to CT, between theatre & ICU or between institutions will be familiar with one of the universal laws of transfer medicine – cables and lines will inevitably become tangled.

    But why?

    Clever physicists and topological mathematicians have the answer, with knot formation a function of the length of lines and their movement. It’s not exactly string theory in the sense of cosmology and quantum physics – but it’s highly relevant to anyone caring for a critical patient with multiple lines…

    A deeper dive for the maths geeks can be found here

    “Based on the observation that long, stiff strings tend to form a coiled structure when confined, we propose a simple model to describe the knot formation based on random “braid moves” of the string end. Our model can qualitatively account for the observed distribution of knots and dependence on agitation time and string length.”
  • Recommended by: Tim Leeuwenburg

Emergency Medicine


Partyka C, Taylor B. Review article: ventricular assist devices in the emergency department. EMA 2014; 26(2):104-12 PubMed ID: 24707998
  • Great FOAM review article on trouble shooting and management of patients who present with left ventricular assist devices (LVADs).
  • Recommended by: Anand Swaminathan, Chris Nickson
  • Learn more: Part man, part machine… – thebluntdissection

Critical Care, Respiratory

R&R Hot Stuff
6. Lee JM, Bae W, Lee YJ, Cho YJ. The efficacy and safety of prone positional ventilation in acute respiratory distress syndrome: updated study-level meta-analysis of 11 randomized controlled trials.Crit Care Med. 2014 May;42(5):1252-62. PubMed ID: 24368348
  • This meta-analysis elucidated the effect of prone positioning on overall mortality and associated complications.Ventilation in the prone position and duration of proning significantly reduced overall mortality in patients with severe ARDS. The major complications were pressure ulceration and airway problems.
  • Recommended by: Nudrat Rashid

Emergency Medicine, Critical Care

R&R Landmark
Straus SE, Thorpe KE, Holroyd-Leduc J. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis? JAMA. 2006 Oct 25;296(16):2012-22. Review. PubMed PMID: 17062865
  • Techniques that reduce Post LP Headaches: (a) Use small gauge, atraumatic needles (b) Re-insertion of stylet before removal of needle (c) Patients DO NOT need bed rest after LP
  • Recommended by: Salim R. Rezaie

Airway

R&R Hot Stuff
R&R Game Changer? Might change your clinical practice
Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014; ePub. PubMed ID: 24859931
  • In this meta-analysis, ketamine was not shown to increase intracranial pressure in comparison to opiates in patients with ICP monitors. Although there were only 5 studies included and there was significant heterogeneity, the evidence showing that ketamine does not significantly raise ICP is far more robust than the evidence behind the old dogma.
  • Recommended by: Anand Swaminathan

Emergency, Critical Care, Ultrasonography

R&R Hot Stuff
Nazerian P et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest 2014; 145(5):950-7PubMed ID: 24092475
  • Point of care multi-organ ultrasound in the hands of experienced Emergency Medicine sonographers is a promising modality for the diagnosis or exclusion of pulmonary embolism in place of CT scan. In this study a negative multi-organ ultrasound (lungs looking for subpleural consolidation, the heart looking for RV dilation and the lower extremities looking for DVT) along with ultrasound revealing an alternative diagnosis had a sensitivity of 100% when compared to CT scan as the gold standard. The study shows that CT scanning could be reduced by 50% with application of this modality.
  • Recommended by: Anand Swaminathan
  • Learn more: Multi-Organ US for PE (Ultrasound Podcast)

Infection Control

R&R Eureka
Rock C, Harris AD, Reich NG, Johnson JK, Thom KA. Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time?–a randomized controlled trial. Am J Infect Control. 2013 Nov;41(11):994-6. doi: 10.1016/j.ajic.2013.04.007. Epub 2013 Jul 24. PubMed ID: 17618418
  • This thought must cross every health care worker’s mind. Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of our time? This randomized controlled trial showed that hand hygiene before donning nonsterile gloves does not decrease already low bacterial counts on gloves. The utility of hand hygiene before donning non-sterile gloves may therefore be unnecessary.
  • Recommended by: Nudrat Rashid

The R&R iconoclastic sneak peek icon key

R&R in the FASTLANE 009 RR Authors 64 The list of contributorsR&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
RR ICON Hall of famerR&R Hall of fame You simply MUST READ this!R&R Hot StuffR&R Hot stuff! Everyone ‘s going to be talking about this
RR ICON LandmarkR&R Landmark paper A paper that made a differenceR&R Game Changer 64R&R Game Changer? Might change your clinical practice
RR ICON EurekaR&R Eureka! Revolutionary idea or conceptRR ICON WTFR&R WTF! Weird, transcendent or funtabulous!
R&R in the FASTLANE 009 RR Boffin 64 R&R Boffintastic High quality researchRR ICON TrashR&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR Mona Lisa 64 R&R Mona Lisa Brilliant writing or explanation

That should keep you busy for a week at least…


Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading. Thanks to our wonderful group of contributors!