François Delaunay

Bio: François Delaunay is an academic researcher. The author has contributed to research in topics: Blood transfusion & Whole blood. The author has an hindex of 3, co-authored 6 publications receiving 87 citations.

Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting.

Abstract: Introduction In the emergency setting, focused cardiac ultrasound has become a fundamental tool for diagnostic, initial emergency treatment and triage decisions. A new ultra-miniaturized pocket ultrasound device (PUD) may be suited to this specific setting. Therefore, we aimed to compare the diagnostic ability of an ultra-miniaturized ultrasound device (Vscan™, GE Healthcare, Wauwatosa, WI) and of a conventional high-quality echocardiography system (Vivid S5™, GE Healthcare) for a cardiac focused ultrasonography in patients admitted to the emergency department.

Noninvasive ventilation in blunt chest trauma: beware of missed esophageal injuries!

Abstract: Dear Editor, For several years, there has been an exponential use of noninvasive ventilation (NIV) for the treatment or prevention of acute respiratory failure, while the actual benefit has not been fully documented for all applications [1–4]. In blunt chest trauma patients, early use of NIV has been shown to prevent intubation and decrease overall complications [4]. However, an inappropriate use in nonselected patients can raise the concern of potentially lethal complications due to initially missed aerodigestive injuries. Thus we report the case of a 26-year-old patient admitted in our trauma center after a blunt chest trauma due to high-speed motorvehicle accident. The whole body computed tomography (CT) scan revealed multiple ribs fractures and pulmonary contusions without sepsis or respiratory failure. Moderate mediastinal air was attributed to the fractures and/or lung trauma, as no obvious aerodigestive perforation was identified (Fig. 1a). The initial management consisted of effective pain control by epidural analgesia and early NIV to prevent secondary respiratory failure. After 48 hours of intensive care, the constitution of a pleural effusion and emergence of a septic shock motivated a second CT scan, which revealed an increase of pneumomediastinum due to a large esophageal perforation (Fig. 1b). The patient was then transferred for suture of esophageal perforation and effective pleural and mediastinal drainage. After treatment of the septic shock, a favourable outcome allowed discharge of the patient after 15 days of intensive care. To our knowledge, this is the first published report of esophageal perforation associated with an inappropriate use of NIV in blunt chest trauma patients. Traumatic esophageal perforation is an extremely rare event associated with an important morbidity and mortality [5]. For the diagnosis, the gold standard remains a water-soluble contrast swallow, but this investigation requires a cooperative patient. In ventilated patients, flexible esophagoscopy should be used. Thoracic CT-scan can also be a useful diagnostic modality when allowing direct visualization of esophageal disruption. However, subtle perforations may be missed, especially at the early stage. CT-scan often provides non-specific signs often ascribed to more common blunt thoracic injuries. Indeed, pneumomediastinum is not uncommon in the polytrauma patients, but has been found to have little clinical significance to predict aerodigestive tract injuries. Thus, it can be difficult to justify a systematic endoscopy in front of a pneumomediastinum in the absence of another argument for esophageal perforation in the initial phase of trauma. Consequently, delayed diagnosis of esophageal perforation is very frequent, reaching 50 % in some series [5]. Then, imaging examinations should be controlled in case of persistent diagnostic uncertainty or clinical worsening. Whatever the diagnosis strategy, it is necessary to avoid iatrogenic injury by improper increase in esophageal pressure, as the diagnosis of esophageal injury is not eliminated. In conclusion, this case emphasizes the need for vigilance in the detection of uncommon esophageal injuries when NIV should be indicated in blunt chest trauma patients. Thus, when CT scan cannot rule out traumatic esophageal injury, NIV should be delayed to perform systematic evaluation with more specific esophageal imaging within 12–24 h.

Advantage of using a recombinant activated factor VII in traumatic haemorrhagic shock: The Bordeaux experience

Abstract: Introduction: Several series of patient studies have been published on the use of rFVIIa in traumatic haemorrhagic shock, although to date no international recommendations have been produced. France does not currently recognise traumatic haemorrhagic shock as an appropriate indication for the use of rFVIIa. Materials and methods: In this retrospective study, we present our experience in the use of rFVIIa in traumatic haemorrhagic shock. Results: Twenty-seven patients treated with rFVIIa after a traumatic injury between May 2005 and December 2008 were included. Average age was 46 years old. Eighty per cent of patients were polytransfused. Mortality rate was 33%. Adjusted mortality rate, using the Boffard study criteria, was 8.3%. We observed significant differences between the group of patients who died and the group of survivors in pH, PT, Hb, ionised calcaemia, temperature and platelet count. We observed significant differences between the successful rFVIIa group and the failed rFVIIa group in pH, Hb, platelet count and ionised calcaemia. Ten patients had an rFVIIa injection only and 17 patients had an rFVIIa injection combined with a mechanical procedure to stop the bleeding. Two patients presented with thromboembolic complications. We observed a tendency to recommend an rFVIIa injection before radical treatment is applied. Conclusion: It seems to us legitimate to recommend earlier use of rFVIIa in cases of traumatic haemorrhagic shock in the context of haematological damage control combined with the use of an algorithm to predict the risk involved in polytransfusion and a more aggressive transfusion strategy.

Management of bleeding following major trauma: is a target haemoglobin of 7 to 9 g/dl high enough?

Abstract: In the latest recommendations for the management of bleeding following major trauma, Spahn and colleagues recommend a target haemoglobin of 7 to 9 g/dl to initiate blood transfusion [1]. In their rationale the authors use a subgroup of trauma patients from the Transfusion Requirements in Critical Care study; however, patients with active blood loss were excluded from this trial. Expressing a current opinion about transfusion and trauma patients, in 2006 McIntyre and Hebert wrote: 'It is important to put RBC [red blood cell] transfusions into the context of three main time frames, i.e. prehospital care, initial 24-48 h after admission to hospital and thereafter, because each frame has its own set of circumstances which may dictate the need for different timing, volume and rapidity of transfusions' [2]. To our knowledge, the only trial to evaluate a target haemoglobin in shock involved early goal-directed therapy in septic shock [3]. The early goal-directed therapy protocol included maintaining a haematocrit of 30% (haemoglobin at 10 g/dl). In the results, the early goal-directed therapy group had a significantly higher haematocrit than the control group and also received more transfusions. Raising the target haemoglobin to 10 g/dl has two interesting effects: haemodilution is reduced, harmful in the present case; and the transfusion delay is decreased. Riskin and colleagues showed that reducing the transfusion delay may decrease the mortality rate [4]. For the first time, three studies suggest that transfusion may be associated with a reduced mortality rate [5]. The real beneficial effect of blood transfusion is probably that it gives time to stop the bleeding.

International Evidence-Based Recommendations for Focused Cardiac Ultrasound

Abstract: Background Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. Methods The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. Results During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. Conclusions This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Ultrasound for "lung monitoring" of ventilated patients.

Abstract: LUS is normally performed in supine patients. Operator should firstly locate the diaphragm and the lungs. Lung consolidation or pleural effusion is found predominantly in dependent and dorsal lung regions and can be easily distinguished from liver or spleen once the diaphragm has been identified. By using the anterior and posterior axillary lines as anatomical landmarks, three areas per hemithorax (anterior, lateral, and posterior) can be iden-tified. Each area is divided in two, superior and inferior. In a given region of interest, lung surface of all adjacent inter-costal spaces must be explored by moving the probe trans-versally.

Less invasive hemodynamic monitoring in critically ill patients

Abstract: Over the last decade, the way to monitor hemodynamics at the bedside has evolved considerably in the intensive care unit as well as in the operating room. The most important evolution has been the declining use of the pulmonary artery catheter along with the growing use of echocardiography and of continuous, real-time, minimally or totally non-invasive hemodynamic monitoring techniques. This article, which is the result of an agreement between authors belonging to the Cardiovascular Dynamics Section of the European Society of Intensive Care Medicine, discusses the advantages and limits of using such techniques with an emphasis on their respective place in the hemodynamic management of critically ill patients with hemodynamic instability.

Microparticles: a critical component in the nexus between inflammation, immunity, and thrombosis

Abstract: Plasma membrane remodeling characterized by phosphatidylserine exposure and consecutive microparticle (MP) shedding is an ubiquitous process enabling the clearance of senescent cells and the maintenance of tissue homeostasis. MPs are released as fragments from the budding plasma membrane of virtually all eukaryotic cell types undergoing stimulation or apoptosis and may be considered a broad primitive response to stress. MP release is dependent on cytoskeleton degradation pathways involving caspases, requires a sustained increase in intracellular calcium triggering K+ and Cl- efflux and is possibly tuned by mitochondria permeability changes. Because they convey a broad spectrum of bioactive molecules, circulating MPs may serve as shuttles promoting cellular cross talk in various pathological settings such as inflammation or immunity-induced thrombotic disorders. If the drastic shedding of procoagulant MPs appears clearly noxious in thrombotic disorders or in some models of inflammation-induced coagulopathy, this does not necessarily endorse their invariably harmful nature. In the vessel, endothelial cytoprotection reported in the early regulation of inflammation-induced coagulopathy is emblematic of the beneficial effects provided by MPs. In addition, MPs would prove beneficial in the prevention of blood leakage. Because of their multiple properties that are characteristic of a private response of the parental cell, MPs could act as cytoprotective and anti-inflammatory agents through the delivery of activated protein C or annexin 1 and could contribute to the limitation of vascular hyporeactivity. Owing to their ability to cargo bioactive signals, MPs could be viewed as an integrated communication network enabling the coordination of complex cellular responses in biological fluids and the maintenance of the homeostasis equation. A better understanding of the molecular mechanisms involved in MP shedding would pave the way of a new pharmacological approach aiming at the control of MP-driven cellular responses.

American Society of Echocardiography: Remote Echocardiography with Web-Based Assessments for Referrals at a Distance (ASE-REWARD) Study.

Abstract: Background Developing countries face the dual burden of high rates of cardiovascular disease and barriers in accessing diagnostic and referral programs. The aim of this study was to test the feasibility of performing focused echocardiographic studies with long-distance Web-based assessments of recorded images for facilitating care of patients with cardiovascular disease. Methods Subjects were recruited using newspaper advertisements and were prescreened by paramedical workers during a community event in rural north India. Focused echocardiographic studies were performed by nine sonographers using pocket-sized or handheld devices; the scans were uploaded on a Web-based viewing system for remote worldwide interpretation by 75 physicians. Results A total of 1,023 studies were interpreted at a median time of 11:44 hours. Of the 1,021 interpretable scans, 207 (20.3%) had minor and 170 (16.7%) had major abnormalities. Left ventricular systolic dysfunction was the most frequent major abnormality (45.9%), followed by valvular (32.9%) and congenital (13.5%) defects. There was excellent agreement in assessing valvular lesions (κ = 0.85), whereas the on-site readings were frequently modified by expert reviewers for left ventricular function and hypertrophy (κ = 0.40 and 0.29, respectively). Six-month telephone follow-up in 71 subjects (41%) with major abnormalities revealed that 57 (80.3%) had improvement in symptoms, 11 (15.5%) experienced worsening symptoms, and three died. Conclusions This study demonstrates the feasibility of performing sonographer-driven focused echocardiographic studies for identifying the burden of structural heart disease in a community. Remote assessment of echocardiograms using a cloud-computing environment may be helpful in expediting care in remote areas.