[ICU performance: results of a French study involving 80,000 ICU stays]. / Performance en réanimation: résultats du PHRC Sfar-SRLF.

OBJECTIVE: The Standard Mortality Ratio (SMR), comparing the observed in-hospital mortality to the predicted, may measure the intensive care units (ICU) performance. STUDY DESIGN: Multicentric retrospective national study. METHODS: A probability model using a severity score such SAPS II calculated the predicted mortality rate. A national French study has been undertaken to compare the SMR of ICUs and looked for explanation. RESULTS: One hundred six units, 34 were medical (32%), 18 surgical (17%) and 57 medical/surgical (51%) participated to the study. Forty-six ICUs (43%) were located in teaching hospitals. The SMR of the 87,099 stays was 0.84 (0.82-0.85). The SMR of ICUs varied from 0.41 to 1.55. Ten units had a SMR>0.85, which suggested a low performance. They had more stays for cardiovascular failures, as compared with others. The best units (SMR<0.82) had more stays for drug overdose. The SMR increased with the number of organ failures, from 0.47 with zero failure to 1.11 with 4 or more organ failures. The stays with cardiovascular failure, either unique or associated, had a higher SMR. The 7935 stays with a drug overdose had a SMR of 0.12 (0.10-0.14), which suggested a bad calibration of the model in theses cases. CONCLUSION: The case mix must be taken in account when comparing the ICUs performance by the mean of SMR, particularly when the units admitted a lot of drug overdoses.

[Completeness of ICU activity reports sent to French healthcare authorities]. / Exhaustivité des résumés d'unité médicale adressés aux départements d'information médicale.

INTRODUCTION: Hospital units report on their inpatient care activity by writing yearly activity reports, which are used by their Medical Information Department (MID) to develop standardized summaries for communication to healthcare authorities. The data are categorized by uniform patient groups and used to describe inpatient care activity and to guide resource allocation. The objective of this study was to evaluate the completeness of activity reports from intensive care units (ICUs) in France. METHODS: Activity reports sent in 1998 and 1999 by French ICUs participating in the study were collected using dedicated abstracting software supplied to the relevant MIDs. Completeness of data in the activity reports was evaluated, with special attention to the SAPSII score, Omega rating of ICU procedures according to the Classification of Medical Procedures, and primary and secondary diagnoses. RESULTS: The 106 ICUs that volunteered for the study reported data on 107,652-hospital stays. Mean age and SAPSII were 55 +/- 21 years and 35 +/- 21 years, respectively. Mean ICU and hospital lengths of stay were 6.2 +/- 12.4 and 16.1 +/- 21.6 days, respectively. Mean ICU and hospital mortality rates were 15% and 19%. The SAPSII and Omega procedures were reported for 81% and 80% of stays, respectively. The SAPSII and Omega procedures were calculated or coded in 94% (100/106) and 96% (102/106) of ICUs, respectively. Mean number of Omega procedures was 4.3+/-3.9. However, only 5% (5/106) of ICUs entered the SAPSII for every stay, and 21% (22/106) of ICUs failed to enter the SAPSII for over 20% of stays. Similarly, 53% (56/106) of ICUs rated no more than five Omega procedures on average per stay. The primary diagnosis was reported for all stays, and the mean number of secondary diagnoses was 3.5 +/- 3.8. In 80% (86/106) of ICUs, no more than five secondary diagnoses were coded on average per stay. CONCLUSION: The analysis of this national database shows that data communicated to the MIDs and therefore to the healthcare authorities, are incomplete regarding SAPSII, ICU procedures, treatment intensity, and diagnoses. This may lead to the underestimation of ICU activity and resource needs, particularly if the SAPSII and selected procedures identified as markers for high-intensity critical care are used in the future.

Single- versus triple-lumen central catheter-related sepsis: a prospective randomized study in a critically ill population.

PURPOSE: A prospective randomized study was conducted over a 23-month period in an adult medical-surgical intensive care unit to determine whether triple-lumen catheters reduce the need for peripheral vascular access and whether they are associated with a higher rate of infection than single-lumen catheters. PATIENTS AND METHODS: After the insertion route, internal jugular or subclavian, was selected by the physician, patients were randomized either to single-lumen or triple-lumen catheter groups. Complementary peripheral vascular access was allowed in both groups. Catheters were removed according to preestablished defined reasons: suspicion of catheter-related sepsis, uselessness of central venous access, duration of catheterization of more than 21 days, discharge from the intensive care unit, or death. RESULTS: Data on 129 central venous catheters were collected from 91 consecutive patients. Twenty-five of 68 patients from the single-lumen group and 1 of 61 patients from the triple-lumen group needed peripheral vascular access (p less than 0.001). Catheter-related sepsis rates, defined either by clinical signs and positive qualitative tip cultures (8.9% versus 11.5%) or by quantitative tip cultures (16.2% versus 11.5%), were identical in the single-lumen and triple-lumen groups (type II error: 8%). CONCLUSION: In intensive care units, the use of triple-lumen catheters is associated with a dramatic decrease in the need for peripheral vascular access. The incidence of central venous catheter-related sepsis appears identical for single- and triple-lumen catheters.

Acute colorectal ischemia after aortic surgery: pathophysiology and prognostic criteria.

Acute colorectal ischemia is a rare though potentially lethal complication of aortic surgery. We reviewed our recent experience with 16 cases in order to analyze its causative and prognostic factors. The incidence was 2.8%, and the inferior mesenteric artery was occluded in all cases. All patients also had severe occlusive disease of at least two of the hypogastric or deep femoral arteries. Hypoperfusion due to arterial ligation, prosthetic occlusion or embolism was responsible in half the cases. Ischemia and perfusion due to aortic cross-clamping or perioperative hemorrhage were involved in the rest of the cases. Postoperative mortality was 31%. The mortality was lower for partial, nontransmural necrosis, and for elective operations. Recurrent intestinal ischemia, transmural necrosis, surgery for ruptured aneurysm, intestinal hemorrhage and pulmonary edema were associated with a higher mortality rate. All patients with anuria or extrarenal epuration and hepatic cytolysis died. Although reconstruction of the inferior mesenteric artery might lessen the incidence of postoperative colonic ischemia due to hypoperfusion, the role of oxygen free radicals should be investigated in humans, in order to afford colonic protection against the consequences of ischemia-reperfusion.

Dysregulation of in vitro cytokine production by monocytes during sepsis.

The production by monocytes of interleukin-1 alpha (IL-1 alpha), interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF alpha) in intensive care unit (ICU) patients with sepsis syndrome (n = 23) or noninfectious shock (n = 6) is reported. Plasma cytokines, cell-associated cytokines within freshly isolated monocytes and LPS-induced in vitro cytokine production were assessed at admission and at regular intervals during ICU stay. TNF alpha and IL-6 were the most frequently detected circulating cytokines. Despite the fact that IL-1 alpha is the main cytokine found within monocytes upon in vitro activation of cells from healthy individuals, it was very rarely detected within freshly isolated monocytes from septic patients, and levels of cell-associated IL-1 beta were lower than those of TNF alpha. Cell-associated IL-1 beta and TNF alpha were not correlated with corresponding levels in plasma. Upon LPS stimulation, we observed a profound decrease of in vitro IL-1 alpha production by monocytes in all patients, and of IL-1 beta, IL-6, and TNF alpha in septic patients. This reduced LPS-induced production of cytokines was most pronounced in patients with gram-negative infections. Finally, monocytes from survival patients, but not from nonsurvival ones recovered their capacity to produce normal amounts of cytokines upon LPS stimulation. In conclusion, our data indicate an in vivo activation of circulating monocytes during sepsis as well as in noninfectious shock and suggest that complex regulatory mechanisms can downregulate the production of cytokines by monocytes during severe infections.

Dissociation between plasma and monocyte-associated cytokines during sepsis.

We report our investigations of circulating interleukin (IL) 1 beta, IL 6 and tumor necrosis factor (TNF)-alpha, as well as cell-associated IL 1 alpha, IL 1 beta and TNF-alpha in plasma and monocytes of 21 patients with sepsis syndrome and 6 patients with non-septic shock. Longitudinal studies reveal that (a) the most frequent detectable plasma cytokines were TNF-alpha and IL 6, (b) the presence and the kinetics of circulating cytokines were independent of one other, (c) detectable levels of cytokines could be found for a long period of time, and (d) significantly higher levels of IL 6 were found for non-surviving patients. Because of the in vivo half-life of cytokines and of the existence of numerous specific high-affinity receptors, it is quite probable that detectable plasma cytokines represent the excess of produced mediators which have not been trapped by the target cells. TNF-alpha (410 +/- 65 pg/10(6) monocytes) and IL 1 beta (153 +/- 60 pg/10(6) monocytes) were frequently found associated to monocyte lysates (88% and 50%, respectively). Despite the fact that IL 1 alpha is the most abundant cytokine found associated to monocytes following in vitro activation, IL 1 alpha was rarely found in monocytes of intensive care unit patients (29%). No correlation was found to exist between the levels of plasma cytokines and cell-associated cytokines. Some patients had plasma TNF-alpha or IL 1 beta in the absence of the corresponding monocyte-associated cytokine. This observation suggests that cells other than monocytes can participate in the production of circulating cytokines. At the end of the longitudinal study (day 14 +/- 2), only 2/12 surviving patients still had plasma TNF-alpha, whereas 8/12 had monocyte-associated TNF-alpha. These results indicate that activation of monocytes still occurs in patients for whom no plasma cytokines can be detected. Thus, in addition to the measurement of plasma cytokine, measurement of cell-associated cytokine appears useful to assess cytokine production and monocyte activation in vivo.

[Improvement in the prognosis of severe mediastinitis by the use of muscle flaps]. / Amélioration du pronostic des médiastinites graves par les musculoplasties pédiculées.

Between 1984 and 1988, 12 mediastinitis were observed in a series of 1.724 cases of cardiac surgical procedures by sternotomy (0.7%). These 12 patients were retrospectively separated in 2 groups in terms of surgical management. In group I (5 patients in 1984 and 1985) the treatment was mediastinal irrigation and in case of failure, an omental transposition. In group II (7 patients in 1986, 86 and 88) the treatment was mediastinal irrigation and in case of failure, a mobilization of muscle flaps. Four patients died in group I of poly-visceral failure with a persistent severe sepsis. In group II, there was no death and the cicatrization was quickly obtained with an average length of stay in intensive care unit of 62 days. The mediastinal irrigation is the treatment of choice for benign mediastinitis, but the prognosis of severe mediastinitis was in our series greatly improved by muscle flap procedures realized with plastic and reconstructive surgical techniques.

[Importance of antibiotic combinations with ceftazidime and usefulness in the prevention of resistance]. / Intérêt des associations d'antibiotiques avec la ceftazidime et utilité dans la prévention de la résistance.

Different antibiotics can be used in combinations to extend the antibacterial spectrum, to obtain a synergistic bactericidal effect or to prevent bacterial resistance. Ceftazidime may be combined with other antibiotic to extend its spectrum to Staphylococci and Enterococci, or even anaerobes. A synergistic effect is mainly obtained with aminoglycosides. To prevent the emergence of resistant strains, ceftazidime may be combined with aminoglycosides and the new quinolones.

Strategies in aminoglycoside use and impact upon resistance.

Assessment of amikacin resistance over a 10-year period at our institution revealed that the number of resistant strains remained stable. Qualitatively, amikacin-resistant Enterobacteriaceae and Pseudomonas were fairly stable. There was a slight increase in amikacin-resistant Acinetobacter and staphylococci. Different factors influencing the emergence and spread of resistant hospital bacteria have been studied at different periods and compared with similar data on gentamicin-resistant strains. Transmissible plasmids, multiple mechanisms of resistance, and high levels of resistance were more frequent in gentamicin-resistant strains. In the amikacin-resistant strains, the level of resistance was 16 to 32 mg/liter with few autotransferable plasmids. A synergistic or additive effect with cephalosporins, which may be a factor in decreasing the risk of selection of the resistant strains since there is no plasmid-mediated resistance to cephalosporins, was demonstrated in Enterobacteriaceae. To control the development of aminoglycoside resistance in hospitals, it may be necessary to restrict the use of more than the one drug to which resistance is developing; to use the antibiotic at the right dosage and, when necessary, in a combination that may prevent the emergence of resistant organisms and plasmids; and to develop measures to control bacterial and R factor transmission.

Timentin in the antimicrobial treatment of nosocomial and polymicrobial infections.

The combination of ticarcillin and clavulanic acid (Timentin) was used in a nonrandomized open study in 28 patients with severe nosocomial infections. The infections were polymicrobial in 19 cases. Ten patients were bacteraemic and all were severely ill, receiving mechanical ventilation and with at least one organ system failure. Seventeen patients were treated with Timentin alone, 11 with a combination of Timentin and aminoglycosides. Timentin was used empirically, before identification of the bacteria in 14 patients (group I) and after identification of all the micro-organisms in 14 patients (group II). In group I, the empirical choice of Timentin was wrong in four cases, because at least one micro-organism was resistant to this drug. In the remaining 24 evaluable patients 12 patients were definitively cured. A relapse of the infection occurred in two cases. Five patients were initially improved but a secondary failure occurred due to a residual abscess in one case and to the underlying disease in four cases. Five initial failures due to the underlying disease in three cases were noted. The antimicrobial spectrum of Timentin is valuable in the management of nosocomial and polymicrobial infection, especially intra-abdominal infections and this study confirms a good clinical efficacy. However, combination with aminoglycosides seems mandatory, at least until the identification of all the micro-organisms involved in the infection.

[Acute anuric hemolysis caused by antiajmaline antibodies]. / Hémolyse aiguë anurique par anticorps anti-ajmaline.

In a 32-year old woman under ajmaline therapy for cardiac arrhythmia, a sudden episode of acute haemolytic anaemia and renal failure led to the identification of a potent agglutinating, haemolysing and lymphocytotoxic antibody specific to ajmaline and cross-reacting with quinine and quinidine. The immunological features of the antibody and the pathophysiological mechanism of blood cell destruction are presented, together with a brief synopsis of drugs incriminated so far in the induction of specific antibody formation and immune haemolytic anaemia.