Changes in severity and organ failure scores as prognostic factors in onco-hematological malignancy patients admitted to the ICU.

OBJECTIVE: To determine whether severity and organ failure scores over the first 3 days in an ICU predict in-hospital mortality in onco-hematological malignancy patients. DESIGN AND SETTING: Retrospective study in a 22-bed medical ICU. PATIENTS: 92 consecutive patients with onco-hematological malignancies including 20 hematopoietic stem cell transplantation (HSCT) patients (11 with allogenic HSCT). MEASUREMENTS: Simplified Acute Physiology Score (SAPS) II, Organ Dysfunction and/or Infection (ODIN) score, Logistic Organ Dysfunction System (LODS), and Sequential Organ Failure Assessment (SOFA) score were recorded on admission. The change in each score (Delta score) during the first 3 days in the ICU was calculated as follows: severity or organ failure score on day 3 minus severity or organ failure score on day 1, divided by severity or organ failure score on day 1. RESULTS: In-hospital mortality was 58%. Using multivariate analysis in-hospital mortality was predicted by all scores on day 1 and all Delta scores. Areas under the receiver operating characteristics curves were similar for SAPS II (0.78), ODIN (0.78), LODS (0.83), and SOFA (0.78) scores at day 1. They were also similar for DeltaSAPS II, DeltaODIN, DeltaLODS, and DeltaSOFA. Similar results were observed when excluding patients with allogenic HSCT. CONCLUSION: Severity and three organ failure scores on day 1 and Delta scores perform similarly in predicting in-hospital mortality in ICU onco-hematological malignancy patients but do not predict individual outcome. Decision to admit such patients to the ICU or to forgo life-sustaining therapies should not be based on these scores.

Rapid and beneficial hemodynamic effects of activated protein C in septic shock patients.

OBJECTIVE: Because recombinant human activated protein C (rhAPC) reduces NO production during sepsis, it could improve the vascular tone. We tested whether rhAPC reduces the dose of norepinephrine required to maintain mean arterial pressure (MAP) in septic shock patients. DESIGN AND SETTING: Retrospective study in intensive care unit of two university hospitals. PATIENTS: Twenty-two septic shock patients with at least two organ failures were retrospectively investigated for MAP and the required dose of norepinephrine before and 24 h after rhAPC administration. A control group of 22 septic shock patients with at least two organ failures who did not receive rhAPC was matched on age, SAPS II, MAP, and norepinephrine dose at the time of the theoretical start of rhAPC. MEASUREMENTS AND RESULTS: The MAP remained stable and similar in the two groups (86+/-16 vs. 89+/-9 mmHg at 24 h). The required dose of norepinephrine increased in the control group (+38%, from -41% to +38%) but decreased in the treated group (-33%, from -74% to +11%). CONCLUSIONS: rhAPC rapidly improved the vascular tone in septic shock patients as assessed by a decrease in the norepinephrine dose required to maintain arterial pressure.

[Bickerstaff's brainstem encephalitis]. / La rhombencéphalite postinfectieuse: le syndrome de Bickerstaff.

INTRODUCTION: Bickerstaff's brainstem encephalitis represents a differential diagnostic that must be discuss with meningoencephalitis with ophtalmoplegia, ataxia and confusion. EXEGESE: A 26 year-old woman presented a Bickerstaff syndrome. A severe disturbance of consciousness had lead to admission in intensive care unit with mechanical ventilation. Electrophysiological tests and the brain magnetic resonance were normal. We have not observed systemic anti-G1Qb antibody in our patient. Nevertheless, 66% of patients with Bickerstaff syndrome have anti-GQ1b antibody during the acute phase period. We observed a beneficial effect of IV Ig treatment although no significant improvement was observed with corticosteroids. CONCLUSION: Controlled clinical trials are needed to established the efficacy of IV Ig or plasmapheresis as a specific therapy for this pathology.

[Complications during the intrahospital transport in critically ill patients]. / Complications durant le transport intrahospitalier de malades critiques de réanimation.

INTRODUCTION: Intrahospital transport (IHT) of mechanically ventilated critically ill patients is associated with an important risk of complications. OBJECTIVES: The purpose of this study was to assess the incidence of complications occurring during the IHT and to analyse the causes and the consequences of such complications. PATIENTS AND METHODS: All the IHT performed in mechanically ventilated patients, hospitalised in medical and surgical intensive care units of a university hospital were prospectively included during a three-month period. Complications were defined as follows: patient related problems (desaturation, restlessness, haemodynamic instability, extubation) and ventilator related problems (breakdown or defect of the material). RESULTS: 123 IHT concerning 64 patients were analysed, with 64 IHT were realised for diagnostic procedure (computed tomography) and 59 for therapeutic procedure (surgical procedure or interventional radiology). At least one patient related problem occurred during 41 IHT (33%) (desaturation n = 11, agitation n = 21, haemodynamic alterations n = 19, extubation n = 0). In two patients, these complications led to cardiac arrest. Patient related problems were observed more frequently in sedated patient (66 %, p = 0.0001) as well as during IHT for diagnostic procedure (p = 0.03). A ventilator problem occurred in 26 transports (21 %) and was more frequently reported when a turbine ventilator was used (p = 0.0056). CONCLUSION: This study supports the fact that IHT of mechanically ventilated critically ill patients, is a high-risk procedure associated with potentially severe complications. This finding emphasises the need of standardised procedures and medical surveillance during IHT.

Metronidazole kinetics in patients with acute renal failure on dialysis: a cumulative study.

Nine patients with acute renal failure who were undergoing dialysis at intervals depending on clinical state were injected with metronidazole, 7.5 mg . kg-1 iv every 8 hr. Plasma samples were drawn during the 8 hr after the first infusion, during the first dialysis session, and during the course of the fourth infusion after the first three dialysis sessions. Metronidazole and its two main metabolites (alcohol [M1] and acid [M2]) were assayed by HPLC. The plasma t 1/2 of metronidazole (6.8 hr) is of the same order as that in healthy subjects. M1 and M2 plasma levels increased continuously until the next infusion. Dialysis clearances of metronidazole and its metabolites were about 60 ml . min-1; 25% of metronidazole in the body at the beginning of hemodialysis was eliminated. The corresponding apparent t 1/2 s are 3.3 hr (metronidazole), 8.0 hr (M1), and 7.9 hr (M2). In patients with acute renal disease under hemodialysis, there was no cumulation of metronidazole and its metabolites; hence there is no need for change in dosage regimen.

Comparative physiologic effects of noninvasive assist-control and pressure support ventilation in acute hypercapnic respiratory failure.

STUDY OBJECTIVE: To compare the effects of noninvasive assist-control ventilation (ACV) and pressure support ventilation (PSV) by nasal mask on respiratory physiologic parameters and comfort in acute hypercapnic respiratory failure (AHRF). DESIGN: A prospective randomized study. SETTING: A medical ICU. PATIENTS AND INTERVENTIONS: Fifteen patients with COPD and AHRF were consecutively and randomly assigned to two noninvasive ventilation (NIV) sequences with ACV and PSV mode, spontaneous breathing (SB) via nasal mask being used as control. ACV and PSV settings were always subsequently adjusted according to patient's tolerance and air leaks. Fraction of inspired oxygen did not change between the sequences. MEASUREMENTS AND RESULTS: ACV and PSV mode strongly decreased the inspiratory effort in comparison with SB. The total inspiratory work of breathing (WOBinsp) expressed as WOBinsp/tidal volume (VT) and WOBinsp/respiratory rate (RR), the pressure time product (PTP), and esophageal pressure variations (deltaPes) were the most discriminant parameters (p<0.001). ACV most reduced WOBinsp/VT (p<0.05), deltaPes (p<0.05), and PTP (0.01) compared with PSV mode. The surface diaphragmatic electromyogram activity was also decreased >32% as compared with control values (p<0.01), with no difference between the two modes. Simultaneously, NIV significantly improved breathing pattern (p<0.01) with no difference between ACV and PSV for VT, RR, minute ventilation, and total cycle duration. As compared to SB, respiratory acidosis was similarly improved by both modes. The respiratory comfort assessed by visual analog scale was less with ACV (57.23+/-30.12 mm) than with SB (75.15+/-18.25 mm) (p<0.05) and PSV mode (81.62+/-25.2 mm) (p<0.01) in our patients. CONCLUSIONS: During NIV for AHRF using settings adapted to patient's clinical tolerance and mask air leaks, both ACV and PSV mode provide respiratory muscle rest and similarly improve breathing pattern and gas exchange. However, these physiologic effects are achieved with a lower inspiratory workload but at the expense of a higher respiratory discomfort with ACV than with PSV mode.

Intrapulmonary haematoma complicating mechanical ventilation in patients with chronic obstructive pulmonary disease.

Intrapulmonary haematomas occurred during mechanical ventilation of two patients with advanced chronic obstructive pulmonary disease and bullous dystrophy. In both cases, the haematomas were revealed by blood-stained aspirates, a fall in haemoglobin level, and the appearance of radiological opacities. Haematoma occurrence in the area of a bulla which recently has rapidly increased in size, suggests that the haematoma is due to the rupture of stretched vessels embedded in the wall of the bulla.

Complete atrio-ventricular block after furosemide.

We report a case of nonfatal complete atrio-ventricular (A-V) block after injection of 125 mg of furosemide by a central vena cava catheter. Accidents with this diuretic are very rare but this observation shows that it could induce A-V conduction disturbances. When large quantities of this diuretic must be used, we would recommend a slow injection rate to avoid such accidents.

Acute pancreatitis after carbamate insecticide intoxication.

A 29-year-old woman was admitted to the Rouen University Hospital for attempted suicide by ingestion of a carbamate insecticide (Temik G, containing 10% aldicarb). Cardio-respiratory arrest occurred at the second hour and acute necrotic hemorrhagic pancreatitis on the second day. Further evolution was uneventful, and the patient was discharged after 43 days. Carbamate intoxication was confirmed by high urinary aldicarb metabolite concentrations. Pseudocholinesterase levels took 77 days to return to normal. Carbamate pesticides share the same pancreatic risk as organophosphorus pesticides, and should be monitored similarly.

Increased initial flow rate reduces inspiratory work of breathing during pressure support ventilation in patients with exacerbation of chronic obstructive pulmonary disease.

OBJECTIVE: To investigate whether the level of initial flow rate alters the work of breathing in chronic obstructive pulmonary disease (COPD) patients ventilated in pressure support ventilation (PSV). DESIGN: Prospective study. SETTINGS: Medical ICU in University hospital. PATIENTS: Eleven intubated COPD patients. METHODS: We modulated the initial flow rate in order to achieve seven different sequences. In each sequence, the plateau pressure was reached within a predetermined time: 0.1, 0.25, 0.50, 0.75, 1, 1.25 or 1.50 s. The more rapidly the pressure plateau was achieved, the higher was the initial flow rate. In each patient, the pressure support level was an invariable parameter. The order of the seven sequences for each patient was determined randomly. MEASUREMENTS AND RESULTS: Ten minutes after application of each initial flow rate, we measured the following parameters: inspiratory work of breathing, electromyogram (EMG) of the diaphragm (EMGdi), breathing pattern, and intrinsic positive end-expiratory pressure (PEEPi). Comparison between the means for each sequence and each variable measured was performed by two-way analysis of variance with internal comparisons between sequences by Duncan's test. The reduction of the initial flow rate induced a progressive increase in the values of the work of breathing, EMGdi, and mouth occlusion pressure (P 0.1). In contrast, the reduction of the initial flow rate did not induce any significant change in tidal volume, respiratory frequency or PEEPi. CONCLUSIONS: As the objective of PSV is to reduce the work of breathing, it seems logical to use the highest initial flow rate to induce the lowest possible work of breathing in COPD ventilated patients.

[Diffusion of 5-fluorocytosine in bronchial secretions in patients with respiratory insufficiency]. / Diffusion de la 5-fluorocytosine dans les sécrétions bronchiques chez l'insuffisant respiratoire.

The 5-Fluorocytosine bronchial secretion levels of 14 patients with a chronic respiratory disease were determined using a microbiological method. The mean maximal concentrations (7.76 +/- 7 micrograms/ml) were obtained at the end of a single 25 mg/kg i v perfusion over 30 minutes. The level increased when five i v perfusions were performed every 6 hours and bronchial diffusion was higher and faster by concomitant administration of (bromhexin hydrochloride). Therefore, 5-Fluorocytosine was not found in bronchial secretions of four patients in spite of a normal serum levels (21.5 +/- 5 micrograms/ml).

[VENISE: Non-invasive ventilation during mechanical ventilation weaning in chronic respiratory failure patients. A prospective randomised controlled and multicenter trial]. / VENISE: VEntilation Non Invasive au cours du SEvrage de la ventilation mécanique des patients insuffisants respiratoires chroniques. Une étude prospective contrôlée randomisée multicentrique.

INTRODUCTION: The clinical efficacy of non-invasive ventilation (NIV) has now been demonstrated in the management of acute-on-chronic respiratory failure (ACRF) in various etiologies. Endotracheal mechanical ventilation (ETMV) can lead to numerous complications and weaning difficulties increasing the risk of prolonged ETMV, morbidity and mortality as well as excess cost of intensive care. Therefore, it could be useful to consider NIV for delivering effective ventilatory support to reduce the length of ETMV in ACRF patients who are still not capable of maintaining spontaneous breathing. From the interesting but discordant results of two recent randomised controlled trials, a working group from the Société de Réanimation de Langue Française (SRLF) decided to perform a new prospective randomised controlled multicenter trial. The aim of the study will be to assess the usefulness of NIV as an extubation and weaning technique in ventilated ACRF patients. METHODS: The methodology used will compare three parallel weaning strategies in ACRF patients considered difficult to wean: invasive conventional weaning (group A), extubation relayed by nasal oxygentherapy (group B), and extubation relayed by NIV (group C). Based on the main end-point defined as the weaning success rate, 208 patients from 17 investigator centers are planned to be included. Results of the study will also allow to assess the respective impact of the three weaning strategies on the length of ETMV and weaning, the mechanical ventilation-related morbidity, the patients lengths of stay and mortality. EXPECTED RESULTS: Results of the VENISE trial should permit to improve the management of the difficult to wean ACRF patients and thus contribute to more precisely define the place of NIV in the weaning and prevention of re-intubation strategies in these patients.

[Drugs used in a medical intensive care unit]. / Les médicaments utilisés dans un service de réanimation médicale.

The treatments of 400 consecutive patients admitted in a 22-bed adult medical intensive care unit (ICU) were analysed prospectively. One hundred and thirty-one different drugs were prescribed with a mean of 5 +/- 4 drugs per patient (means +/- SD), during 8 +/- 11 days. The most commonly prescribed drugs were 1) preventive drugs, 2) antibiotics, 3) psychoactive drugs and analgesics. Two-thirds of the drugs were administered by a parenteral route. Mean daily cost was low: 57 FF per patient (6.3 US dollars, 1984), most of this being due to the prescription of antibiotics (59.8%). The wide range of drugs prescribed in different ICU precludes the compilation of a restricted list of drugs to be used in ICU. Nevertheless, prescription guidelines are suggested consisting of the discussion, for each patient, of the prescription of any of four types of drugs: those of the organ failure(s), of the underlying disease(s), preventive drugs, and finally comfort drugs.

[Massive digestive hemorrhage in typhoid fever. A case report]. / Hémorragie digestive massive de la fièvre typhoïde. Une observation.

In a case of massive intestinal haemorrhage during typhoid fever the bleeding area was located by angiography to the superior mesenteric artery, and excision of the ileo-colonic junction was performed. Pathological study of the lesions showed necrosis of Peyer's plaques resulting in section of small submucosal arterioles. The necrosis itself was caused by initially endothelial lesions, later completed by thrombosis. The complication is exceptional. This case is reported in order to draw attention to the usefulness of mesenteric arteriography and the effectiveness of surgery in massive intestinal haemorrhages.

[Splenectomy and pneumococcal septicemia]. / Splénectomie et septicémie à pneumocoque.

A literature review, following the observation of 4 cases of pneumococcal septicemia in splenectomized patients, demonstrated that infection was frequent in subjects with functional or anatomical asplenia, usually in the form of a pneumococcal septicemia. Infection occurs one hundred times more frequently in splenectomized patients than in the general population. The risk of developing an infection varies from one patient to another, and is related to the motive for splenectomy, the period since operation, and the age of the patient at the time of surgery. Pneumococcal septicemia in such cases is distinguished by its insidious nature and its very poor prognosis, the outcome being fatal in 50 to 70 p. cent of cases. This justifies intensive prophylactic measures: partial splenectomy, heterotopic transplantation, anti-pneumococcal vaccination, and long-term antibiotic therapy. None of these methods offers absolute protection, and indications for splenectomy should therefore be limited to the strict minimum.

[Acute respiratory failure in patients with chronic respiratory insufficiency]. / Défaillance aiguë des insuffisances respiratoires chroniques.

In the absence of severe clinical signs requiring endotracheal intubation, non-invasive mechanical ventilation is the first-line treatment in patients with chronic respiratory insufficiency. For a patient with non-invasive support, the probability to avoid intubation is 2 or 3 times higher than for a patient initially treated by oxygen therapy alone. Oxygen therapy will remain the recommended approach for staff unfamiliar with non-invasive support. In chronic obstructive pulmonary disease (COPD) ventilated patients, keeping the intrinsic positive end-expiratory pressure to a minimum level decreases the risk of barotrauma. During exacerbation, in these patients, the 3 most often prescribed medications are inhaled bonchodilators, corticosteroids, and antibiotics. In addition to long term home oxygen therapy, the preventive measures include education of patients, pulmonary rehabilitation programs, and eventually routine use of ventilatory support in a home ventilatory setting.