Les troubles de stress post-traumatique sont une préoccupation importante pour les Armées. Certains symptômes pathognomoniques du traumatisme psychique se traduisent par des conduites d’isolement et d’évitement s’opposant à l’unité groupale et à la cohésion, si fondamentales au métier de militaire. L’hôpital d’Instruction des Armées Robert Picqué se situe au cœur d’une région où sont localisés de nombreux régiments opérationnels. Son service de psychiatrie propose une approche multidisciplinaire et intégrative comprenant notamment des thérapies groupales. La rencontre de deux professionnels de santé, ergothérapeute pour l’une et psychomotricien pour l’autre, a abouti à la création d’un dispositif original. Il s’agit d’un groupe d’expression utilisant les médiations musicales et créatives : diffusion d’une chanson et expression des éprouvés sur des supports multiples. À partir des créations artistiques, nous verrons de quelle manière cette double médiation favorise le liant social pour permettre, le temps d’une chanson, d’accorder un espace de temporisation, de sécurisation et d’élaboration collective des troubles.
Introduction Refractory septic shock (RSS) is characterized by high vasopressor requirements, as a consequence of vasopressor resistance, which may be caused or enhanced by sympathetic hyperactivation. Experimental models and clinical trials show a reduction in vasopressor requirements and improved microcirculation compared to conventional sedation. Dexmedetomidine did not reduce mortality in clinical trials, but few septic shock patients were enrolled. This pilot trial aims to evaluate vasopressor re-sensitization with dexmedetomidine and assess the effect size, in order to design a larger trial. Methods This is an investigator-initiated, multicenter, randomized, double-blind, placebo-controlled trial, comparing dexmedetomidine versus placebo in RSS patients with norepinephrine dose ≥0.5μg/kg/min. The primary outcome is blood pressure response to phenylephrine challenge, 6 hours after completion of a first challenge, after study treatment initiation. Secondary outcomes include feasibility and safety outcomes (bradycardia), mortality, vasopressor requirements, heart rate variability, plasma and urine catecholamines levels. The sample size is estimated at 32 patients to show a 20% improvement in blood pressure response to phenylephrine. Randomization (1:1) will be stratified by center, sedation type and presence of liver cirrhosis. Blood pressure and ECG will be continuously recorded for the first 24 h, enabling high-quality data collection for the primary and secondary endpoints. The study was approved by the ethics committee “Sud-Est VI” (2019-000726-22) and patients will be included after informed consent. Discussion The present study will be the first randomized trial to specifically address the hemodynamic effects of dexmedetomidine in patients with septic shock. We implement a high-quality process for data acquisition and recording in the first 24 h, ensuring maximal quality for the evaluation of both efficacy and safety outcomes, as well as transparency of results. The results of the study will be used to elaborate a full-scale randomized controlled trial with mortality as primary outcome in RSS patients. Trial registration Registered with ClinicalTrials.gov (NCT03953677). Registered 16 May 2019, https://clinicaltrials.gov/ct2/show/NCT03953677.
Petitjeans, Fabrice MD; Leroy, Sandrine MD, PhD; Pichot, Cyrille MD; Ghignone, Marco MD, FRCPC, FCCP; Quintin, Luc MD, PhD; Constantin, Jean-Michel MD, PhD Author Information
