Prescriptions analysis by clinical pharmacists in the post-operative period: a 4-year prospective study.

BACKGROUND: Clinical pharmacists can help prevent medication errors. However, data are scarce on their role in preventing medication prescription errors in the post-operative period, a high-risk period, as at least two prescribers can intervene, the surgeon and the anesthetist. We aimed to describe and quantify clinical pharmacist' intervention (PIs) during validation of drug prescriptions on a computerized physician order entry system in a post-surgical and post-transplantation ward. We illustrate these interventions, focusing on one clearly identified recurrent problem. METHODS: In a prospective study lasting 4 years, we recorded drug-related problems (DRPs) detected by pharmacists and whether the physician accepted the PI when prescription modification was suggested. RESULTS: Among 7005 orders, 1975 DRPs were detected. The frequency of PIs remained constant throughout the study period, with 921 PIs (47%) accepted, 383 (19%) refused and 671 (34%) not assessable. The most frequent DRP concerned improper administration mode (26%), drug interactions (21%) and overdosage (20%). These resulted in a change in the method of administration (25%), dose adjustment (24%) and drug discontinuation (23%) with 307 drugs being concerned by at least one PI. Paracetamol was involved in 26% of overdosage PIs. Erythromycin as prokinetic agent, presented a recurrent risk of potentially severe drug-drug interactions especially with other QT interval-prolonging drugs. Following an educational seminar targeting this problem, the rate of acceptation of PI concerning this DRP increased. CONCLUSION: Pharmacists detected many prescription errors that may have clinical implications and could be the basis for educational measures.

Time course of liver nitric oxide concentration in early septic shock by cecal ligation and puncture in rats.

An overwhelming nitric oxide (NO) production is a crucial step in the circulatory events as well as in the cellular alterations taking place in septic shock. However, evidences of this role arise from studies assessing the NO production on an intermittent basis precluding any clear evaluation of temporal relationship between NO production and circulatory alterations. We evaluated this relationship by using a NO specific electrode allowing a continuous measurement of NO production. Septic shock was induced by a cecal ligation and puncture (CLP) in a first group of anesthetized rats. After the same CLP, a second group received a selective iNOS inhibitor (L-NIL). Control rats were sham operated or sham operated with L-NIL administration. While NO concentration was measured every 2 min by a NO-sensitive electrode over 7h following CLP, the liver microcirculation was recorded by a laser-Doppler flowmeter. CLP induced a severe septic shock with hypotension occurring at a mean time of 240 min after CLP. At the same time, an increase in liver NO concentration was observed, whereas a decrease in microvascular liver perfusion was noted. In the septic shock group, L-NIL administration induced an increase in arterial pressure whereas the liver NO concentration returned to baseline values. In addition, shock groups experienced an increase in iNOS mRNA. These data showed a close temporal relationship between the increase in liver NO concentration and the microvascular alteration taking place in the early period of septic shock induced by CLP. The iNOS isoform is involved in this NO increase.

Post-operative pressure lability and cardiac baroreflex in normotensive patients as a function of age.

BACKGROUND: Pressure lability may be linked to the loss of the cardiac baroreflex. The reduction of the sensitivity of the cardiac baroreflex has not been delineated in the post-operative period according to age in normotensive patients. This study addresses pressure lability and slope of the cardiac baroreflex as a function of age. METHODS: Patients were allocated to the following three groups: young (20-39 years, n=7), middle aged (40-59 years, n=7) and elderly (60-79 years, n=6), and studied before minor intra-abdominal surgery under CO(2) peritoneal insufflation and nitrous oxide-isoflurane-sufentanil anesthesia, up to 24 h after extubation. An electrocardiogram and non-invasive beat-by-beat pressure monitoring (Finapres) allowed offline calculation of the sensitivity of the cardiac baroreflex ('sequence' technique) and standard deviation (SD) of heart rate (HR; HR variability) and systolic blood pressure (SBP; pressure lability). RESULTS: Before anesthesia, (a) an inverse relationship was observed between the slope of the cardiac baroreflex and age and (b) a trend (P<0.09) existed between the slope of the cardiac baroreflex and pressure lability, irrespective of age. During the early post-operative period, young patients returned to their baseline slope of the cardiac baroreflex; no inverse relationship between increased SD of SBP and decreased SD of RR interval was observed. Middle-aged and elderly patients displayed a depressed slope of the cardiac baroreflex both before and after anesthesia. CONCLUSION: At variance with the pre-operative period, no simple inverse relationship was observed between increased pressure lability and depressed HR variability in young patients during the early post-operative period.

[Misplacement of a central femoral catheter in the urinary conduit of a renal transplant]. / Migration extravasculaire d'un cathéter veineux fémoral dans les cavités excrétrices d'un rein transplanté.

Femoral vein catheterization is often carried out during resuscitation and in critical care units. Thrombosis and infections are the most current reported complications. Catheter malpositions have been reported. We described the inadvertent cannulation of the urinary tractus in a patient with a right iliac renal transplant.

[Amniotic fluid embolism: a review]. / Embolie de liquide amniotique: mise au point.

Amniotic fluid embolism occurs rarely but is a leading cause of maternal mortality. It is a difficult and somewhat intangible diagnosis that warrants a high index of suspicion by physicians. AFE is an unpredictable, unpreventable, and, for the most part, an untreatable obstetric emergency. Management of this condition includes prompt recognition of the signs and symptoms, aggressive resuscitation efforts, and supportive therapy. Any delays in diagnosis and treatment can result in increased maternal and/or foetal impairment or death. Whereas once the invariable outcome of AFE was death of the mother, today the prognosis is somewhat brighter thanks to increased awareness of the syndrome and advances in intensive care medicine. No laboratory test is specific to attest the diagnosis and autopsy must to be realised in case of maternal death. Although non-specific, the diagnosis of AFE could be supported by the observation of amniotic fluid in the central venous blood as well as in the bronchoalveolar fluid. This easy and quick test will be helpful in decision-making. Prompt and aggressive supportive treatment is required to lessen an otherwise dismal outcome, which may include death and permanent disability. This article provides an account of the protean clinical features, pathogenesis, and principles involved in treatment.

[Amniotic fluid embolism: successful evolution course of isolated disseminated intravascular coagulation and early biological diagnosis]. / Embolie de liquide amniotique : évolution favorable d'une CIVD isolée et diagnostic biologique précoce.

Amniotic embolism is a sudden, unexpected and devastating complication of pregnancy. The diagnosis is usually made on the basis of clinical presentation after excluding differential diagnosis or at autopsy in the event of death of the parturient. We need to develop simple, non-invasive, sensitive tests for a reliable and early diagnosis. We report the case of a 34-year-old woman, who presented soon after delivery, an isolated disseminated intravascular coagulation with severe haemorrhage, an haemostatic hysterectomy was required. A 3370 g child was delivered by caesarean section. The patient survived without sequelae. The diagnosis of amniotic embolism was established by the presence of amniotic cells in the maternal central venous blood as well as in the bronchoalveolar fluid.

Spontaneous cardiac baroreflex in humans. Comparison with drug-induced responses.

We compared two methods of assessment of baroreflex sensitivity in eight supine healthy volunteers during repeated baseline measurements and various conditions of cardiac autonomic blockade. The spontaneous baroreflex method involved computer scanning of recordings of continuous finger arterial pressure and electrocardiogram to locate sequences of three or more beats in which pressure spontaneously increased or decreased, with parallel changes in pulse intervals. The mean regression slope of all these sequences during each study condition was considered to represent the mean spontaneous baroreflex slope. In the drug-induced method, sigmoidal curves were constructed from data obtained by bolus injections of phenylephrine and nitroprusside; the tangents taken at the resting pressure of each of these curves were compared with the mean spontaneous baroreflex slopes. The two methods yielded slopes that were highly correlated (r = .96, P < .001), with significant but similar intraindividual baseline variability. Atropine virtually eliminated the baroreflex slope; subsequent addition of propranolol did not alter it further. Propranolol or clonidine alone increased average baroreflex slope to the extent that they increased resting pulse interval (r = .69 to .83). The spontaneous baroreflex method provides a reliable, noninvasive assessment of human vagal cardiac baroreflex sensitivity within its physiological operating range.

Recovery of [13C]bicarbonate as respiratory 13CO2 in mechanically ventilated patients.

Measurement of the nutrient oxidation rate with 13C as a tracer requires knowledge of the value of its coefficient of fractional recovery in the expired gas (FR). We measured FR in nine intensive care patients who were mechanically ventilated and received total parenteral nutrition. NaH13CO3 was administered at a priming dose (3.75 mumol.kg-1.min-1) followed by a continuous infusion (0.05 mumol.kg-1.min-1). Metabolic rate and pulmonary carbon dioxide elimination (VCO2) were measured by using a mass-spectrometer system. The 13C-12C ratio was measured in the expired gas with an isotopic-ratio mass spectrometer and FR was calculated by using standard equations. The average value of FR was 0.899 +/- 0.026 (means +/- SE) and remained stable for each patient on 2 consecutive days. Between patients, the coefficient of variation of FR was 8.6%. Metabolic rate was the only physiological factor found to affect the FR value.

Reversal of early acute rejection with increased doses of tacrolimus in liver transplantation: a pilot study.

BACKGROUND: In this pilot study, we present the results of treatment of early (3 months after liver transplantation) acute rejection episodes by increasing only the tacrolimus doses. METHODS: Ten patients who received tacrolimus as primary treatment experienced acute mild (one case), moderate (four cases), or severe (five cases) rejection episodes. Tacrolimus dosing was increased 1-2 mg every 1 or 2 days until hepatic enzymes started to improve. Steroid basic daily doses were kept unchanged. RESULTS: With the daily dose of tacrolimus increased by a median 1.89-fold (range: 1.2-5), alanine aminotransferase, bilirubin, and gamma-glutamyltranspeptidase levels rapidly reached normal values within the first month. During a median follow-up time of 19.5 months (range: 14-24), none of the 10 patients died or lost their graft. Control liver biopsies were done 13.5 months (range: 7-19) after rejection episode in all patients, and none demonstrated evidence of rejection or sequela. CONCLUSION: This pilot study suggests that increasing tacrolimus dosage could be considered as treatment against early acute rejection episodes including the severe grade.

Oxygen cost of breathing in postoperative patients. Pressure support ventilation vs continuous positive airway pressure.

In seven postoperative patients with normal preoperative pulmonary function tests, we evaluated the oxygen cost of breathing (VO2resp) during continuous positive pressure ventilation (CPAP) and during a 15 cm H2O inspiratory pressure support ventilation (IPSV). For both periods, VO2 resp was estimated as the difference between total oxygen uptake of the period (VO2tot), measured by a mass-spectrometer system, and that during controlled ventilation. During CPAP ventilation, VO2resp was found to be 11.2 +/- 1.4 percent of VO2tot. During IPSV, VO2resp was found insignificant. It is concluded that a 15 cm H2O IPSV takes over the major part of the work of breathing in postoperative patients without preexisting pulmonary disease.

Oxygen cost of breathing and diaphragmatic pressure-time index. Measurement in patients with COPD during weaning with pressure support ventilation.

The oxygen cost of breathing and the time integral of the transdiaphragmatic pressure were measured at the onset of the weaning period in eight patients with chronic obstructive pulmonary disease requiring mechanical ventilation. Measurements were achieved during continuous positive airway pressure ventilation and during 15 cmH2O pressure support ventilation. For both periods, the O2COB was estimated as the difference between oxygen uptake of the period and that during controlled ventilation. During CPAP ventilation, the O2COB was 16.9 +/- 1.5 percent. During PSV, it was only 6.3 +/- 1.3 percent, and PTdi decreased by 73 percent compared to the CPAP period. Both effects illustrate the ability of PSV to facilitate spontaneous breathing during weaning from mechanical ventilation. However, we found these measurements to be of no help in predicting the duration of the weaning process.

Added inspiratory work of breathing during CPAP ventilation: comparison of two demand-valve devices with a continuous flow-system.

Measurements of added inspiratory work (AIW) of breathing imposed by three different CPAP systems were performed in 10 patients. One system was a continuous flow system while the two others were demand flow systems separated from respirators (Ohmeda VD 101 and Draeger CPAP 800 devices). AIW was calculated from pressure and flow signals recorded at the mouthpiece level. The AIW calculated with the two demand-flow systems was found to be the same as the AIW calculated with the continuous flow system although the results obtained by the Draeger device were less constant. The results obtained with the Ohmeda device in our patients conflicted with data previously published using a lung model.

Clinical validation of the Deltatrac monitoring system in mechanically ventilated patients.

OBJECTIVE: To evaluate a monitor of pulmonary gas exchange (Deltatrac, Datex) in a clinical setting. DESIGN: After in vitro evaluation, comparison over 2 min between VO2 and VCO2 values measured by the Deltatrac and the Douglas bag technique. Comparisons were also achieved over 8 h periods between the Deltatrac and a system using a mass-spectrometer. SETTING: Polyvalent intensive care unit (ICU 15 beds) in a 1200 bed general hospital. PATIENTS: Comparison with the Douglas bag technique in 10 patients undergoing controlled ventilation. Comparison with the mass-spectrometer system in 25 other patients undergoing controlled or pressure support ventilation. MEASUREMENTS AND RESULTS: Compared to the results obtained by the Douglas bag technique, the bias (+/- 2 SD) for VO2 and VCO2 was -3.5 +/- 26.6 and 6.1 +/- 12.7 ml.min-1, respectively. By comparison with the mass-spectrometer system, the bias for VO2 and RQ was -5.8 +/- 16.0 ml.min-1 and 0.018 +/- 0.048, respectively. No drift between the two systems was observed over time. CONCLUSIONS: The Deltatrac appears suitable for VO2 and VCO2 measurements in ventilated patients and equivalent to a mass-spectrometer system for long term measurements.

Energy expenditure in the acute renal failure patient mechanically ventilated.

Twenty mechanically ventilated patients with acute renal failure were studied on 31 occasions to determine their energy expenditure (EE) during a 2 h period before a hemodialysis. Oxygen consumption and CO2 elimination were measured continuously with a mass spectrometer system. EE (1660 +/- 48 kcal day-1) was close to the total caloric intake (1682 +/- 83 kcal day-1) and represented 1.19 +/- 0.03 times the predicted resting energy expenditure (PREE) with large inter-individual variations (0.7-1.7 PREE). EE/PREE was higher when sepsis was present (1.31 +/- 0.03 versus 1.14 +/- 0.02; p less than 0.05). Glucose oxidation rate (4.35 mg kg-1 min-1) exceeded glucose intake (2.6 mg kg-1 min-1). Respiratory quotient was 1.02 +/- 0.01. Nitrogen loss was 17.3 +/- 1.7 g day-1 and nitrogen balance -11.9 +/- 1.9 g day-1. In conclusion, EE values were scattered but never exceeded 1.7 times the PREE. Sepsis increased EE. With a nutritional support covering EE, nitrogen balance remained markedly negative and a preferential utilisation of glucose and lipogenesis occurred.

Increased lactate/pyruvate ratio with normal beta-hydroxybutyrate/acetoacetate ratio and lack of oxygen supply dependency in a patient with fatal septic shock.

We report a case of fatal septic shock, with hyperlactatemia and blood cultures positive for Streptococcus pneumoniae, in a 70-year-old patient. On two occasions (5 days, and 2 days before the patient's death), the relationship between oxygen delivery (DO2) and consumption (VO2) was examined in conjunction with two presumed markers of tissue oxygenation: the lactate/pyruvate ratio (L/P), and the beta-hydroxybutyrate acetoacetate ratio (beta OHB/AcAc). Increasing DO2 by about 30% ("oxygen flux test") failed to increase VO2. The beta OHB/AcAc ratio remained within normal limits, thus suggesting uncompromised tissue oxygenation at the hepatic level. The L/P ratio remained persistently above normal limits, thus suggesting actual organ or regional hypoxia. This case shows that during an overwhelming septic shock, the "oxygen flux test" can be negative, despite the presence of hyperlactatemia and of an increased L/P ratio suggestive of impaired tissue oxygenation.

The effects of norepinephrine infusion on oxygen consumption in a patient with septic shock.

A 65-year-old man developed postsurgical septic shock, unresponsive to plasma volume expansion and administration of dopamine and dobutamine. A continuous norepinephrine infusion was then started and the dose increased to 0.62 micrograms.kg-1.min-1 until the mean arterial pressure was 70 mmHg. Prior to and during the norepinephrine infusion, oxygen consumption was continuously measured with a mass spectrometer system. There was a parallel increase in mean arterial pressure and oxygen consumption (+ 35%). There was also an increase in cardiac index and oxygen delivery. Systemic vascular resistance was only transiently increased. In this case with septic shock, norepinephrine infusion improved hemodynamic variables with an associated increase in oxygen consumption.

Energy expenditure during severe acute pancreatitis.

Energy expenditure (EE) was measured, during 3 consecutive days, in six patients suffering from acute pancreatitis. Measurements were achieved postoperatively, under mechanical ventilation, using a mass spectrometer system. EE represented 1.49 times (range: 1.08-1.78) the predicted resting energy expenditure (PREE) according to the reevaluated Harris-Benedict equation. There was a weak positive correlation between EE and core temperature and a negative correlation between EE and nitrogen balance. EE/PREE was not different between septic and nonseptic patients (1.58 +/- 0.06 vs. 1.39 +/- 0.07). The calculations of nutrient oxidation rate indicated a high protein catabolic rate, a neoglucogenesis, and a lipolysis.

Amniotic fluid embolism during caesarean section.

Amniotic fluid embolism occurs rarely but is a leading cause of maternal mortality. A high index of clinical suspicion is necessary to make an early diagnosis to reduce morbidity and mortality. We report a non-fatal case of amniotic fluid embolism occurring during a caesarean section, with special emphasis on the mode of development and diagnosis. The initial presentation of this syndrome was a coagulopathy, followed by the usual complications of massive bleeding. Although non-specific, the diagnosis of amniotic fluid embolism was supported by the observation of amniotic fluid in the central venous blood as well as in the broncho-alveolar fluid.