Médecine tactique CITERA 69 - Baron Desgenettes : Archives

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04/12/2010

Perfusion intraosseuse: Le BIG c'est bien par voie humérale

Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study

Bernd A. Leidel^a^,^c^,^,, Chlodwig Kirchhoff^b, Volker Braunstein^b, Viktoria Bogner^b, Peter Biberthaler^band Karl-Georg Kanz^b

Resuscitation
Volume 81, Issue 8, August 2010, Pages 994-999

PREMIER POINT: Le BIG est aussi efficace que l'EZ-IO

Table 2. Success rates on first attempt and procedure times of the two different intraosseous devices BIG and EZ-IO for vascular access in adult emergency patients under resuscitation were not significantly different.

	Overall (n = 40)	BIG (n = 20)	EZ-IO (n = 20)	p (BIG versus EZ-IO)
Success rate on first attempt (%)	34/40 (85)	16/20 (80)	18/20 (90)	0.66
95% CI	73.9–96.1%	62.5–97.5%	76.9–100%

Mean procedure time ± SD (min)	2.0 ± 0.9	2.2 ± 1.0	1.8 ± 0.9	0.27
95% CI	1.7–2.3 min	1.7–2.6 min	1.4–2.2 min

Procedure time, min–max (min)	1.0–4.0	1.0–4.0	1.0–3.0

SECOND POINT: Le BIG une fois sur 2 en HUMERAL

Table 1. Patient characteristics: distribution of gender, age, obesity, trauma and insertion site in adult emergency patients under resuscitation were not significantly different between the two applied different intraosseous devices BIG and EZ-IO for vascular access.

	Overall (n = 40)	BIG (n = 20)	EZ-IO (n = 20)
Gender male (%)	27/40 (68)	13/20 (65)	14/20 (70)
Age ± SD (years) min–max (years)	48 ± 21 18–87	53 ± 22 18–87	43 ± 18 18–79
Obesity BMI > 30 kg/m² (%)	7/40 (18)	3/20 (15)	4/20 (20)
Trauma (%)	29/40 (73)	15/20 (75)	14/20 (70)
Insertion site humeral (%)	22/40 (55)	11/20 (55)	11/20 (55)

TROISIEME POINT: Le BIG : Des échecs en tibial, des diifcultés pour sortir le mandrin à la main

In all four unsuccessful attempts with the BIG, the cannula did not penetrate the bone cortex, probably due to incorrect insertion site in three patients and excessive overlying soft tissue in one patient. All four unsuccessful attempts were tibial. In five patients the stylet was stuck within the cannula and could only be removed with a clamp. After removal of the stylet the administration of drugs and fluids through the cannula was possible without further complications and the IO insertion deemed successful.

Two unsuccessful attempts with the EZ-IO failed because of extravasation at the humeral head insertion site, probably due to incorrect insertion site and excessive overlying soft tissue.

Other technical problems like bending and breaking of the cannula or further relevant complications, likeinfection, extravasation, compartment syndrome, and cannula dislodgment or bleeding were not observed.

Remplissage vasculaire: Un document à méditer !

ICI

Mettez cela en perspective avec les conditions de combat

NICE has issued preliminary recommendations on the pre-hospital initiation of fluid replacement therapy in trauma for consultation. The guidance covers the management of adults with trauma injury in whom there is evidence of obvious or probable blood loss. It does not cover the management of isolated closed head injury.

In summary:

1. It is recommended that in the pre-hospital management of adults with trauma injuries, intravenous fluid (IV fluid) should not be administered if a radial pulse can be felt (or, for penetrating torso injuries, if a central pulse can be felt).

2. In the absence of a radial pulse (or a central pulse for penetrating torso injuries), it is recommended that IV fluid in boluses of no more than 250 ml should be administered, followed by reassessment until a radial (or central) pulse is palpable.

3. The administration of IV fluid should not delay transportation to hospital, but when given in accordance with 2 above, administration may take place en route to hospital.

4. It is recommended that crystalloid solutions should normally be administered in the pre-hospital setting.

5. There is inadequate evidence, and a lack of professional consensus, on which to base recommendations on the pre-hospital use of IV fluid in children with trauma injury. However, it is recommended that the general principles for IV fluid administration in children should be based on those recommended for adults. Thus, in children considered to be at risk of hypovolaemia, IV fluids should be administered in aliquots with frequent re-assessment of the child's physiological state and transfer to hospital should not be delayed.

6. It is recommended that only paramedics or other healthcare professionals who have been appropriately trained in advanced life-support techniques and pre-hospital care should administer IV fluid therapy to trauma patients in the pre-hospital setting and that training should incorporate the above recommendations.

Remplissage: Cristalloïdes vs Colloïdes

Une publication récente met à nouveau en garde contre le recours immodéré aux solutés colloïdes pour le remplissage vasculaire. Bien qu'employé en routine les colloïdes ne sont pas dénués d'effets secondaires et leur intérêt est remis en question. On rappelle que le soluté chois pour équiper la trousse individuelle du combattant est un flacon de 250 ml de sérum salé à 7.5%, choix dicté par l'excellent compromis efficacité en terme de remplissage, anti-oedémateux cérébral et poids.

L'article est le suivant:

The Efficacy and Safety of Colloid Resuscitation in the Critically Ill

Christiane S. Hartog, MD, Michael Bauer, MD, and Konrad Reinhart, MD

(Anesth Analg 2011;112:156 –64)

Despite evidence from clinical studies and meta-analyses that resuscitation with colloids or crystalloids is equally effective in critically ill patients, and despite reports from high-quality clinical trials and meta-analyses regarding nephrotoxic effects, increased risk of bleeding, and a trend toward higher mortality in these patients after the use of hydroxyethyl starch (HES) solutions, colloids remain popular and the use of HES solutions is increasing worldwide. We investigated the major rationales for colloid use, namely that colloids are more effective plasma expanders than crystalloids, that synthetic colloids are as safe as albumin, that HES solutions have the best risk/benefit profile among the synthetic colloids, and that the third-generation HES 130/0.4 has fewer adverse effects than older starches. Evidence from clinical studies shows that comparable resuscitation is achieved with considerably less crystalloid volumes than frequently suggested, namely, 2-fold the volume of colloids.

Albumin is safe in intensive care unit patients except in patients with closed head injury. All synthetic colloids, namely, dextran, gelatin, and HES have dose-related side effects, which are coagulopathy, renal failure, and tissue storage. In patients with severe sepsis, higher doses of HES may be associated with excess mortality. The assumption that third-generation HES 130/0.4 has fewer adverse effects is yet unproven. Clinical trials on HES 130/0.4 have notable shortcomings.

Mostly, they were not performed in intensive care unit or emergency department patients, had short observation periods of 24 to 48 hours, used cumulative doses below 1 daily dose limit (50 mL/kg), and used unsuitable control fluids such as other HES solutions or gelatins.

In conclusion, the preferred use of colloidal solutions for resuscitation of patients with acute hypovolemia is based on rationales that are not supported by clinical evidence. Synthetic colloids are not superior in critically ill adults and children but must be considered harmful depending on the cumulative dose administered. Safe threshold doses need to be determined in studies in high-risk patients and observation periods of 90 days. Such studies on HES 130/0.4 are still lacking despite its widespread and increasing use. Because there are safer and equally effective alternatives in the form of crystalloids, use of synthetic colloids should be avoided except in the context of clinical studies.