Penetration of ertapenem into muscle measured by in vivo microdialysis in mechanically ventilated patients.

Ertapenem at 1 g once daily has been suggested to be underdosed in intensive care unit (ICU) patients to attain optimal concentrations in target tissues. Therefore, our study aimed to assess the kinetics of ertapenem in plasma and skeletal muscle in ICU patients using microdialysis. Average muscle free-ertapenem concentrations were above the MIC values of targeted pathogens. In a few patients, the concentrations were below the MIC values. The clinical efficiency of ertapenem at 1 g once daily should be evaluated in a large population of ICU patients.

[Sedation an acute respiratory distress syndrome]. / Sédation du patient présentant un syndrome de détresse respiratoire aiguë.

AIM: To assess the role of sedation and myorelaxant agents in acute respiratory distress syndrome (ARDS) and to propose an updated management according to recent literature. EXTRACTION OF DATA: From Medline and Cochrane database of English and French language articles. Keywords were: acute respiratory distress syndrome, acute lung injury, general anaesthetics, inhalation, intravenous anaesthetics and intensive care. Selection of original articles, reviews and expert reports. Case reports have been included. TOPIC: ARDS is a clinical picture in which respiratory constraints are major because of hypoxemia. To insure correct haematosis, mechanical ventilation has to be considered. It constitutes, then, the most frequent indication of sedation in the intensive care unit. The objectives are to help the ventilation of lungs and to improve gas exchange, by controlling agitation, fight against ventilation and to reduce mechanical ventilation associated injuries. In this situation, use of myorelaxant agents is aimed at facilitating synchronization of the patient with his/her ventilator and serves to improve oxygenation during the early inflammatory phase of ARDS. Several mechanisms may enflame this improvement of oxygenation. One of the most probable effect on optimization is the possibility of optimize protective ventilation at the cares phase of ARDS and to reduce mechanical ventilation-associated injuries. CONCLUSION: With regard to benefits and inconvenient, sedation is considered as a treatment of ARDS. Its goals are the well being of patient and his/her adaptation to ventilator, but also the prevention on mechanical ventilation associated injuries. Hence, most authors suggest using a deep sedation at the early phase of ARDS. In this contact, use of myorelaxant agent is an intersecting adjuvant if sedation is not enough. The benefit is terms of survival and outcome remains to show.

[Management of ventilator acquired pneumonia]. / Prise en charge des pneumonies acquises sous ventilation mécanique.

Ventilator-associated pneumonia occurs in the evolution of 8 to 70% of patients in the Intensive Care Unit. It is the main site of nosocomial infection for mechanically ventilated patients. Nosocomial pneumonia represents an important cause of morbidity and mortality, despite progresses in antibiotic prescription, use of intensive care and prevention. This review is based on the ATS guidelines, and reviews epidemiology, diagnosis and treatment of ventilator-acquired pneumonia, in non-immunocompromised adults.

[How about blood pressure in brain injury?]. / Comment moduler la pression artérielle en cas de lésion cérébrale ?

One of the goals of the medical management of head injured patients is to get a cerebral perfusion pressure between 60 and 70 mmHg. To reach such a goal, catecholamines are used after fluid challenge. Systemic effects of catecholamines depend on their affinity for the receptors alpha and beta. The topical application of norepinephrine (alpha predominant) induced a vasoconstriction on large cerebral arteries only. Cerebral blood flow increased in the pericontusionnal area, suggesting a loss of autoregulation. The topical application of dopamine at low concentration relaxed large cerebral arteries. Dopamine increased cerebral blood flow in the pericontusional area but data suggest a possible raise in the volume of contusion. Four human comparative studies have been published. The first study, which was not randomized, showed an intracranial pressure increase associated with dopamine. Two randomized clinical trials, published by the same group, demonstrated a better predictability with norepinephrine. The fourth study did not find any difference regarding cerebral haemodynamics. In conclusion, the quality of data on the effects of catecholamines on cerebral haemodynamics of head injured patients do not make it possible to conclude about their use.

[A case of type A botulism]. / Un cas de botulisme de type A.

The neurotoxin produced by Clostridium botulinum, is responsible for botulism. The clinical signs are digestive disorders, pupillar alterations, and peripheral muscular weakness. The failure of thoracic muscles is responsible for the severity of botulism. We describe a case of a 74 year old woman who presented a severe form of botulism, requiring a prolonged intensive care unit stay.

The combination of a heat and moisture exchanger and a Booster: a clinical and bacteriological evaluation over 96 h.

OBJECTIVE: To determine whether the combination with a new device (Booster ) for active humidification improves the efficacy of a hydrophobic heat and moisture exchanger (HME). DESIGN AND SETTING: Prospective, interventional study in the ICU of a university hospital. PATIENTS: Consecutive patients requiring controlled mechanical ventilation INTERVENTIONS: Patients were ventilated with a HME, and a Booster was added for 96 h to the ventilatory circuit. MEASUREMENTS AND RESULTS: During the inspiration phase the following factors were measured: peak and mean airway pressures, maximal (beginning of inspiration), minimal (end of inspiration), and mean values of temperature of inspired gases, and relative and absolute humidity of inspired gases. Microbiological samples were obtained from the Booster, the ventilator side of the HME, and the tracheal secretions on days 1 and 4. Minimal and mean temperatures were increased as soon as the Booster was used and this increase was maintained for 96 h until the Booster was withdrawn. Then the temperature returned to baseline values. Absolute humidity values followed the same course. There was also some indirect evidence of very little, if any, changes in the HME resistance. The ventilatory side of the HMEs remained sterile in each patient, and the Booster was colonized by the same bacteria as those in the tracheal secretions. CONCLUSIONS: Adding the Booster to a hydrophobic HME improved the heat and water preservation of ventilatory gas.