were analyzed with the Mann-Whitney test. Delay to occurrence of CPC 1 to 2 within 28 and 90 days was described by survival curves and compared by log-rank test. The primary end point was also analyzed after adjustment for known risk factors (simpli- fied acute physiological score, age, sex, diabetes mellitus, location of arrest, bystander cardiopulmonary resuscitation, success of percuta- neous coronary intervention) by multivariate logistic regression. All tests were 2 sided with a 5% significance and performed with SAS version 9.2 (SAS Institute Inc, Cary, NC). device compared with basic surface cooling, possibly related to more strictly controlled targeted temperature management in the advanced cooling group. The ICEREA study provides new rationale for considering advanced methods of targeted temperature management after cardiac arrest instead of basic conventional cooling. Despite a higher rate of minor, but not major, side effects with the invasive method, a significant decrease in the workload of intensive care unit nurses was found in the advanced endovascular group. This effect was observed both for the cumulated time spent by nurses on patients’ specific targeted temperature management interventions and for the overall nurses’ workload measured during the entire period of the targeted temperature management. by

We thank Dr Yan Kang and colleagues for their comments assuming that endovascular cooling may theoretically present more advantages than surface cooling. We agree with this assertion as we consider that automated devices control like endovascular cooling allow significant shortening in time-to-target temperature, better controlled maintenance and rewarming phases, and improvement in intensive care unit nurses’ workload as described in our trial.1 However, as reported in several studies, it is not clear whether reaching the targeted temperature more quickly may result in a better prognosis in post–cardiac arrest patients. Although demonstrated by most of animal studies,2 several clinical studies failed to prove any relationship between time-to-target temperature and final outcome.3 In contrast, studies even observed that the lower the time-to-target temperature, the worse the prognosis could be, suggesting that the more the brain is damaged, the more the thermoregulation is impaired leading to lower core temperature on admission.4 This …

Background— Targeted temperature management is recommended after out-of-hospital cardiac arrest. Whether advanced internal cooling is superior to basic external cooling remains unknown. The aim of this multicenter, controlled trial was to evaluate the benefit of endovascular versus basic surface cooling. Methods and Results— Inclusion criteria were the following: age of 18 to 79 years, out-of-hospital cardiac arrest related to a presumed cardiac cause, time to return of spontaneous circulation <60 minutes, delay between return of spontaneous circulation and inclusion <240 minutes, and unconscious patient after return of spontaneous circulation and before the start of cooling. Exclusion criteria were terminal disease, pregnancy, known coagulopathy, uncontrolled bleeding, temperature on admission <30°C, in-hospital cardiac arrest, immediate need for extracorporeal life support or hemodialysis. Patients were randomized between 2 cooling strategies: endovascular femoral devices (Icy catheter, Coolgard, Zoll, formerly Alsius; n=203) or basic external cooling using fans, a homemade tent, and ice packs (n=197). The primary end point, that is, favorable outcome evaluated by survival without major neurological damage (Cerebral Performance Categories 1–2) at day 28, was not significantly different between groups (odds ratio, 1.41; 95% confidence interval, 0.93–2.16; P =0.107). Improvement in favorable outcome at day 90 in favor of the endovascular group did not reach significance (odds ratio, 1.51; 95% confidence interval, 0.96–2.35; P =0.07). Time to target temperature (33°C) was significantly shorter and target hypothermia was more strictly maintained in the endovascular than in the surface group ( P <0.001). Minor side effects directly related to the cooling method were observed more frequently in the endovascular group ( P =0.009). Conclusion— Despite better hypothermia induction and maintenance, endovascular cooling was not significantly superior to basic external cooling in terms of favorable outcome. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00392639.

Sepsis ist die führende Todesursache auf nicht kardiologischen Intensivstationen. Häufig ist auch eine Troponin-Erhöhung zu beobachten, obwohl primär keine kardiale Erkrankung vorliegt. Diese Studie untersucht die prognostische Wertigkeit von erhöhtem Troponin bei septischen Patienten.

IMPORTANCE Despite advances in care, mortality and morbidity remain high in adults with acute bacterial meningitis, particularly when due to Streptococcus pneumoniae. Induced hypothermia is beneficial in other conditions with global cerebral hypoxia.OBJECTIVE To test the hypothesis that induced hypothermia improves outcome in patients with severe bacterial meningitis.DESIGN, SETTING, AND PATIENTS An open-label, multicenter, randomized clinical trial in 49 intensive care units in France, February 2009-November 2011. In total, 130 patients were assessed for eligibility and 98 comatose adults (Glasgow Coma Scale [GCS] score of <= 8 for <12 hours) with community-acquired bacterial meningitis were randomized.INTERVENTIONS Hypothermia group received a loading dose of 4 degrees C cold saline and were cooled to 32 degrees C to 34 degrees C for 48 hours. The rewarming phase was passive. Controls received standard care.MAIN OUTCOMES AND MEASURES Primary outcome measure was the Glasgow Outcome Scale score at 3 months (a score of 5 [favorable outcome] vs a score of 1-4 [unfavorable outcome]). All patients received appropriate antimicrobial therapy and vital support. Analyses were performed on an intention-to-treat basis. The data and safety monitoring board (DSMB) reviewed severe adverse events and mortality rate every 50 enrolled patients.RESULTS After inclusion of 98 comatose patients, the trial was stopped early at the request of the DSMB because of concerns over excess mortality in the hypothermia group (25 of 49 patients [51%]) vs the control group (15 of 49 patients [31%]; relative risk [RR], 1.99; 95% CI, 1.05-3.77; P = .04). Pneumococcal meningitis was diagnosed in 77% of patients. Mean (SD) temperatures achieved 24 hours after randomization were 33.3 degrees C (0.9 degrees C) and 37.0 degrees C (0.9 degrees C) in the hypothermia and control group, respectively. At 3 months, 86% in the hypothermia group compared with 74% of controls had an unfavorable outcome (RR, 2.17; 95% CI, 0.78-6.01; P = .13). After adjustment for age, score on GCS at inclusion, and the presence of septic shock at inclusion, mortality remained higher, although not significantly, in the hypothermia group (hazard ratio, 1.76; 95% CI, 0.89-3.45; P = .10). Subgroup analysis on patients with pneumococcal meningitis showed similar results. Post hoc analysis showed a low probability to reach statistically significant difference in favor of hypothermia at the end of the 3 planned sequential analyses (probability to conclude in favor of futility, 0.977).CONCLUSIONS AND RELEVANCE Moderate hypothermia did not improve outcome in patients with severe bacterial meningitis and may even be harmful. Careful evaluation of safety issues in future trials on hypothermia are needed and may have important implications in patients presenting with septic shock or stroke.

523 Joint Annual Meeting of the Swiss Society for Allergology and Immunology and the Swiss Respiratory Society Bern, April 17–19, 2013 624 Congress Calendar

Purpose: Delirium has severe consequences on hospital mortality, length of stay, costs, and long-term cognitive function. No study has ever investigated French intensivists’ attitude, a basis for management improvement. We conducted a national survey to describe the attitudes of French intensivists toward delirium screening and management. Methods: A questionnaire was sent by e-mail to the intensivists of the French intensive care society. Up to three e-mails have been sent to nonrespondents during a 75-day period. Results: The response rate was 25.7% (n = 283). Twentyeight respondents (10%) reported screening for delirium with a validated screening tool. Among respondents, 60% estimated that delirium occurs in less than 25% of intubated patients. Antipsychotics, benzodiazepines, and hydroxizine were prescribed as first-line therapy in 77%, 53%, and 36% of the cases, respectively. Mobilization of intubated patients occurred less frequently than estimated as possible. Physicians who screened for delirium had a higher estimation of its severity and occurrence than physicians who did not. Conclusions: Respondents among French intensivists rarely screen for delirium with a dedicated tool. Treatments reported as used in that setting are often different from the guidelines.

In their recent paper, Michelle Chew and colleagues [1] evaluated the performance accuracy of three extra vascular lung water (EVLW) ratios in patients with shock at risk for or with acute lung injury (ALI).Th ey indexed EVLW to actual body weight (ABW), predicted body weight (PBW) and pulmonary blood volume (PBV), and confi rmed that all EVLW ratios were higher in patients with ALI and in non-survivors and correlated with respiratory parameters.Although these fi ndings are interesting, they deserve some comments.First, whereas indexing EVLW to PBW may reduce the number of patients with acute respiratory distress syndrome (ARDS) with normal EVLW, in this population, the EVLW/ABW index performed best [2].Furthermore, the absence of a link between EVLW and PaO 2 /FiO 2 (calculated r2 of 0.14 to 0.23) could explain that these indices identifi ed only 33% of ALI and 38% of ARDS cases.Second, the EVLW/PBV terminology appears very unusual.Th e transpulmonary thermodilution technique determines cardiac output, intrathoracic thermal volume (ITTV), pulmonary thermal volume (PTV) and global end-diastolic volume (Global end-diastolic volume (GEDV) = ITTV -PTV).Th e estimated blood volume of the chest (Intra thoracic blood volume (ITBV) = GEDV + PBV) permits the calculation of PBV (ITBV = 1.25 × GEDV -28.4 ml) [3].Importantly, the PiCCO monitor automatically provides, at each calibration, an estimation of the pulmonary vascular permeability index (PVPI), based on the ratio of EVLW to PBV, which refl ects alveolar-capillary barrier permeability and is of importance for the mechanisms of pulmonary edema [4,5].Th us, I believe that it would be more pertinent to use the PVPI instead of the EVLW/PBV ratio and that it is time to promote an international consensus on this.

Background: Renal replacement therapy has been suggested as a therapeutic option in the setting of acute right ventricular failure in patients with severe precapillary pulmonary hypertension. However, there are few data supporting this strategy. Objectives: To describe the clinical course and the prognosis of pulmonary hypertensive patients undergoing renal replacement therapy in the setting of acute right heart failure. Methods: This was a single-center retrospective study over an 11-year period. Data were collected from all patients with chronic precapillary pulmonary hypertension requiring catecholamine infusions for clinical worsening and acute kidney injury that necessitated renal replacement therapy. Results: Fourteen patients were included. At admission, patients had a blood urea of 28.2 mmol/l (22.3-41.2), a creatinine level of 496 µmol/l (304-590), and a mean urine output in the 24 h preceding hospitalization of 200 ml (0-650). Sixty-eight renal replacement therapy sessions were performed, 36 of which were continuous and 32 of which were intermittent. Systemic hypotension occurred in 16/32 intermittent and 16/36 continuous sessions (p = 0.9). Two patients died during a continuous session. The intensive care unit-related, 1-, and 3-month mortality was 46.7, 66.7, and 73.3%, respectively. Conclusion: Renal replacement therapy is feasible in the setting of acute right ventricular failure in patients with severe precapillary pulmonary hypertension but is associated with a poor prognosis. The best modality and timing in this population remain to be defined.

SUMMARY: Toxoplasmosis is a disease caused by an obligate intracellular protozoal parasite, Toxoplasma gondii. It is the most common cause of focal brain lesions in patients with AIDS. The imaging features and endocrine disorders of CNS toxoplasmosis in patients with AIDS are reviewed.

In adults, type B lactic acidosis is rare and generally associated with a toxin, particularly metformin or antiretroviral nucleosides analogues. We report a case of lactic acidosis caused by carboplatin in a 50-year-old woman suffering from primary peritoneal carcinoma. She was admitted for severe lactic acidosis (pH 6.77, lactate 19 mmol/L) associated with multiple organ failure (PaO₂/FiO₂ 96, creatinine 231 μmol/L, aspartate aminotransferase > 25,000 UI, factor V 13%) occurring during the sixth carboplatin cycle. In the absence of sepsis, internal bleeding, alcohol poisoning, or other causes of lactic acidosis, the hypothesis of mitochondrial DNA (mtDNA) damage secondary to carboplatin and subsequent mitochondrial dysfunction leading to increase in glycolysis and lactic acidosis was suspected. L-Carnitine therapy associated with aggressive intensive care support led to a progressive improvement (pH 7.29, bicarbonate 24 mmol/L, lactate 7.8 mmol/L), but life support was withdrawn on day 7 because of peritoneal relapse. A respiratory chain dysfunction of enzyme activities encoded by mtDNA and multiple mtDNA deletions were found in muscle and liver tissue. It is generally accepted that carboplatin toxicity results in bone marrow suppression, renal dysfunction, or neurotoxicity and that platinating agents have no direct mitochondrial effect. However, although very unusual, emergency physicians must be aware that carboplatin can cause mitochondrial toxicity and trigger lactic acidosis.

Backgroud. Hereditary angioedema (HAE) is characterized by recurrent swelling of the skin, the abdomen (causing severe acute pain), and the airways. A recently discovered type caused by mutations in the factor XII gene (designated as HAE type III) occurs mainly in women. Estrogens may play an important role, but few obstetrical complications have been reported. Case. We report the symptoms and obstetrical complications of women in two families with HAE attributable to the p. Thr328Lys mutation in the F12 gene. Clinical manifestations included acute and severe maternal abdominal pain, with transient ascites, laryngeal edema, and fetal and neonatal deaths. Patients had normal C4 levels and a normal C1 inhibitor gene. Administration of C1-inhibitor concentration twice monthly decreased the attack rate in one mother, and its predelivery administration (1000 U) led to the delivery of healthy girls. Conclusions. Obstetricians and anesthesiologists should be aware of this rare cause of unexplained maternal ascites and in utero or fetal death associated with edema.

Le delirium en réanimation est un problème fréquent dont les implications pronostiques sont majeures. Son diagnostic doit reposer sur des outils de mesure validés dans le cadre d’une approche systématique, permettant de le distinguer d’autres entités telles que l’agitation ou le syndrome de sevrage. La reconnaissance de certains facteurs de risque modifiables permet d’envisager des mesures prophylactiques parmi lesquelles l’administration des substances sédatives selon des objectifs de sédation prédéfinis est primordiale. La qualité du sommeil, la mobilisation précoce pourraient également avoir une influence favorable sur l’incidence de survenue du delirium. Le traitement pharmacologique repose principalement sur les neuroleptiques. L’halopéridol reste le produit le plus employé, mais d’autres semblent entraîner moins d’effets indésirables. De nouvelles molécules comme la dexmétedomidine présentent également des résultats intéressants, mais l’expérience issue de leur utilisation reste encore limitée.