[Severe stroke: prognosis, intensive care admission and withhold and withdrawal treatment decisions]. / AVC graves : pronostic, critères d'admission en réanimation et décisions de limitations et arrêt de traitements.

INTRODUCTION: Stroke can produce irreversible brain damage of massive proportion leading to severe disability and poor quality of life. Resuscitation and mechanical ventilation of these patients remain controversial because of the high mortality and severe disability involved. STATE OF ART: When prognosis is very poor, do-not-resuscitate orders (DNR orders) and withhold or withdrawal of treatment may be discussed. Studies have shown that DNR orders are relatively frequent in acute stroke: up to 30% of all patients, and 50% of which are given upon admission. DNR orders are closely associated with severity of the neurological deficit and age. Precise estimates of withhold and withdrawal of treatment are not available, but terminal extubations in severe stroke could contribute to 40,000 to 60,000 acute stage deaths per year. Little is known about the decision making process and palliative care in these situations. The neurological prognosis is the main explicit criterion. However, evaluation of neurological outcome is highly uncertain and difficult, and does not always reflect quality of life. Several studies have raised the issue of this disability paradox. Thus, physician estimation of prognosis has a profound impact on decisions for life sustaining therapies, and may lead to self-fulfilling prophecies in case of false appreciation of published evidence. Other criteria could influence the withhold and withdrawal of treatment decision, such as social conditions and patient values. PERSPECTIVES AND CONCLUSION: Decisions for life-sustaining therapies in severe stroke are always difficult and often based on subjective and uncertain criteria. We have to improve prognosis estimation and our understanding of patient preferences to promote patient-centered care. An ethical approach may guide these complex decisions.

[Neuromuscular abnormalities in critical illness]. / Neuvièmes Journées des Maladies du Système Nerveux Périphérique.

Critical illness neuromuscular abnormalities (CINMA) are found in 25 percent of ITU patients who recover consciousness and are characterized by a bilateral and symmetric weakness that involves the four limbs but spares the facial muscles. Electrophysiological testing shows an axonal sensory motor polyneuropathy and/or myopathy. The main risk factors of CINMA are prolonged durations of multiple organ failure and mechanical ventilation, use of corticosteroids and hyperglycaemia. CINMA contribute also to increase the duration of mechanical ventilation, this effect being mediated by diaphragm weakness. The median duration of limb weakness is 21 days, although it can exceed several months in some patients. Few preventive measures have been assessed. Whether the benefit of strict blood glucose control in ITU patients recovering from heart surgery on CINMA incidence can be extended to medical ICU patients needs to be determined.

"Colonization pressure" and risk of acquisition of methicillin-resistant Staphylococcus aureus in a medical intensive care unit.

OBJECTIVE: To determine the roles of "colonization pressure," work load or patient severity in patient acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care units (ICUs). DESIGN: Prospectively collected data from October 1996 through December 1998. SETTING: A 12-bed medical ICU in a university-affiliated general hospital. PATIENTS: Patients with risk factors for MRSA admitted to the ICU were screened within 72 hours of admission and weekly thereafter. MRSA was considered imported if detected during the first 72 hours of admission and nosocomial if detected only thereafter. Three screening strategies were used on admission during three consecutive periods. INTERVENTIONS: The unit of time chosen for measurements was the week. Weekly colonization pressure (WCP) was defined as the number of MRSA-carrier patient-days/total number of patient-days. Patient severity (number of deaths, Simplified Acute Physiologic Score [SAPS] II), work load (number of admis sions, Omega score), and colonization pressure (number of MRSA carriers at the time of admission, WCP) were compared with the number of MRSA-nosocomial cases during the following week. RESULTS: Of the 1,016 patients admitted over 116 weeks, 691 (68%) were screened. MRSA was imported in 91 (8.9%) admitted patients (13.1% of screened patients) and nosocomial in 46 (4.5%). The number of MRSA-nosocomial cases was correlated to the SAPS II (P=.007), the Omega 3 score (P=.007), the number of MRSA-imported cases (P=.01), WCP (P<.0001), and the screening period (P<.0001). In multivariate analysis, WCP was the only independent predictive factor for MRSA acquisition (P=.0002). Above 30% of WCP, the risk of acquisition of MRSA was approximately fivefold times higher (relative risk, 4.9; 95% confidence interval, 1.2-19.9; P<.0001). CONCLUSION: Acquisition of MRSA in ICU patients is strongly and independently influenced by colonization pressure.

Using and understanding sedation scoring systems: a systematic review.

OBJECTIVE: To systematically review instruments for measuring the level and effectiveness of sedation in adult and pediatric ICU patients. STUDY IDENTIFICATION: We searched MEDLINE, EMBASE, the Cochrane Library and reference lists of the relevant articles. We selected studies if the sedation instrument reported items related to consciousness and one or more additional items related to the effectiveness or side effects of sedation. DATA ABSTRACTION: We extracted data on the description of the instrument and on their measurement properties (internal consistency, reliability, validity and responsiveness). RESULTS: We identified 25 studies describing relevant sedation instruments. In addition to the level of consciousness, agitation and synchrony with the ventilator were the most frequently assessed aspects of sedation. Among the 25 instruments, one developed in pediatric ICU patients (the Comfort Scale), and 3 developed in adult ICU patients (the Ramsay scale, the Sedation-Agitation-Scale and the Motor Activity Assessment Scale), were tested for both reliability and validity. None of these instruments were tested for their ability to detect change in sedation status over time (responsiveness). CONCLUSION: Many instruments have been used to measure sedation effectiveness in ICU patients. However, few of them exhibit satisfactory clinimetric properties. To help clinicians assess sedation at the bedside, to aid readers critically appraise the growing number of sedation studies in the ICU literature, and to inform the design of future investigations, additional information about the measurement properties of sedation effectiveness instruments is needed.

Acquired neuromuscular disorders in critically ill patients: a systematic review. Groupe de Reflexion et d'Etude sur les Neuromyopathies En Reanimation.

OBJECTIVE: To summarize the prospective clinical studies of neuromuscular abnormalities in intensive care unit (ICU) patients. STUDY IDENTIFICATION AND SELECTION: Studies were identified through MEDLINE, EMBASE, references in primary and review articles, personal files, and contact with authors. Through duplicate independent review, we selected prospective cohort studies evaluating ICU-acquired neuromuscular disorders. DATA ABSTRACTION: In duplicate, independently, we abstracted key data regarding design features, the population, clinical and laboratory diagnostic tests, and clinical outcomes. RESULTS: We identified eight studies that enrolled 242 patients. Inception cohorts varied; some were mechanically ventilated patients for > or = 5 days, others were based on a diagnosis of sepsis, organ failure, or severe asthma while others were selected on the basis of exposure to muscle relaxants, or because of participation in muscle biochemistry studies. Weakness was systematically assessed in two of the eight studies, concerning patients with severe asthma, with a reported frequency of 36 and 70%, respectively. Electrophysiologic and histologic abnormalities consisted of both peripheral nerve and muscle involvement and were frequently reported, even in non-selected ICU patients. In a population of patients mechanically ventilated for more than 5 days, electrophysiologic abnormalities were reported in 76 % of cases. Two studies showed a clinically important increase (5 and 9 days, respectively) in duration of mechanical ventilation and a mortality twice as high in patients with critical illness neuromuscular abnormalities, compared to those without. CONCLUSIONS: Prospective studies of ICU-acquired neuromuscular abnormalities include a small number of patients with various electrophysiologic findings but insufficiently reported clinical correlations. Evaluation of risk factors for these disorders and studies examining their contribution to weaning difficulties and long-term disability are needed.

Mechanical ventilation in patients with acute ischemic stroke: survival and outcome at one year.

OBJECTIVE: To assess the prognosis of patients with acute ischemic stroke who require mechanical ventilation and to determine early factors influencing mortality. DESIGN: Prospective observational study. SETTING: Medical intensive care unit with a cerebrovascular emergency unit in a university-affiliated hospital. PATIENTS: Fifty-eight consecutive patients (mean age 65+/-13 years) requiring mechanical ventilation in the early course of an acute ischemic stroke. MEASUREMENTS AND RESULTS: Clinical data were recorded before intubation according to a standardized procedure. Mortality and functional outcome were assessed after a 1-year follow-up. Mechanical ventilation was started within 48 h after admission in 53 patients (91.4%). The mean duration of ventilation was similar in survivors (9.7+/-9.0 days) and non-survivors (8.6+/-8.7 days). Mortality was 72.4% at 1 year. Among the 16 survivors, none were in a persistent vegetative state and 11 had a Barthel index of 60, reflecting good functional status. Bilateral absence of corneal reflex and bilateral absence of pupillary light reflex had a positive predictive value of death of 1 (95% CI 0.78-1.00 and 0.74-1.00, respectively). After Cox regression analysis, presence of stupor or coma (OR 2.6, 95% CI 1.5-5.0), bilateral absence of corneal reflex before intubation (OR 3.4, 95% CI 1.4-8.7) and presence of ischemic cardiopathy (OR 2.8, 95% CI 1.4-5.5) were independent predictors of mortality. CONCLUSIONS: Systematic withholding of endotracheal intubation in patients with AIS is not recommended. Careful and rigorous neurologic examination, including assessment of brain stem reflexes, might help to identify patients with a very high probability of death despite mechanical ventilation.

Candida albicans prosthetic arthritis treated with fluconazole alone.

Conventional treatment of Candida prosthetic joint infection usually includes surgery followed by a long period of antifungal medication. We report a case of Candida albicans prosthetic arthritis successfully treated with fluconazole alone.

[Management of adult refractory convulsive status epilepticus in the intensive care unit]. / Prise en charge des états de mal épileptiques convulsifs réfractaires en réanimation.

Patients with convulsive status epilepticus in whom first line treatment is not rapidly effective, or with a persistent delay in recovering consciousness must be admitted in an ICU even if assisted, mechanical ventilation is not performed. Continuous EEG monitoring performed in close collaboration with a neurophysiologist/epileptologist is mandatory to detect and treat subtle status epilepticus and to exclude post-anoxic encephalopathy. A number of drugs and anaesthetic agents have been proposed to control refractory status epilepticus. Midazolam and/or propofol have been recently recommended before performing general barbiturate anaesthesia. However, this approach is not rigorously assessed, because patients and series are heterogeneous, and controlled studies are difficult to design. Prognosis is closely related to the quality of initial management, to the development of subtle status epilepticus and, above all, to aetiology.

[Hemiplegia during carbon monoxide poisoning revealing multiple cerebral artery abnormalities including the hypoglossal artery]. / Hémiplégie au cours d'une intoxication oxycarbonée révélant des anomalies artérielles cérébrales multiples dont une artère hypoglosse.

Hemiplegia after carbon monoxide (CO) poisoning is rare since only 9 such lesions have been reported from among 1480 cases of poisoning. The patient reported was a 43 year-old man with a left hemiplegia with coma following CO poisoning. Right carotid angiography demonstrated a hypoglossal artery supplying both posterior cerebral arteries. Left carotid angiography showed a dolichocarotid artery supplying the territories of the anterior and middle cerebral arteries on both sides. Complete regression of the hemiplegia occurred after 2 months following rapid administration of hyperbaric oxygen. Normal CT scan images and cerebral blood flow rates on follow-up examination suggest that the left hemiplegia was due to the combined effects of arterial anomalies and CO poisoning.

[Solitary listerial abscess of the brain stem. Cure with antibiotic treatment]. / Abcès listerien solitaire du tronc cérébral. Guérison sous traitement antibiotique.

A healthy 26-year-old man, without initially presenting fever, rapidly developed a focal right pontomedullary deficit associated with an aseptic lymphocytic meningitis. The diagnosis of Listeria infection was confirmed by blood cultures. CT and MRI demonstrated an abscess extending from the superior cerebellar peduncle to the lateral portion of the medulla. Immunological controls gave no indication of deficiency. With ampicillin therapy, started on the 5th day, clinical recovery was almost complete, but a soft palate right paresis persisted as the unique sequel. Antibiotic therapy was maintained for 5 months up to normal CSF and CT. One year after the onset, MRI was also normal. The rare nature of listerial abscess in the brainstem is discussed with regard to rhombencephalitides.

[Diabetic hyperlipemia with or without acute pancreatitis in patients with chronic alcoholism. A study of 4 cases]. / Lipémie diabétique avec ou sans pancréatite aiguë chez l'alcoolique chronique. Etude de 4 observations.

Diabetic lipemia with and without acute pancreatitis in chronic alcoholism. A report of 4 cases. Diabetic lipemia was observed in 4 chronic alcoholic men after ingestion of high doses of alcohol and/or sugar-rich beverages, including one patient who was treated for insulin-dependent diabetes. None had a previous history of serum lipid disturbances. All had marked hyperglycemia, hyperosmolality and hypertriglyceridemia (mean: 60.8 mmol/l), 2 of undetermined type and 2 of type IV with eruptive xanthomas. Factitious hyponatremia was present in 3 cases, but true serum sodium was normal (138 mmol/l) or elevated (154, 156, 182 mmol/l) after correction. Three patients developed acute pancreatitis ascribed to high serum triglyceride levels and/or to alcohol ingestion. Serum and urine amylase activity was inhibited by hypertriglyceridemia. The diagnosis of pancreatitis was assessed twice by echography and computed tomographic scan, and once by tomographic scan and an elevation of the amylase on creatinine clearance ratio. It is likely that hypertriglyceridemia predisposed these patients to develop pancreatitis, alcoholism being a precipitating factor. We suggest that the diagnosis of acute pancreatitis should be systematically considered in any case of diabetic lipemia without true hyponatremia.

[Maxillary cyst of dental origin with uncommon ocular complication]. / A propos d'un kyste maxillaire d'origine dentaire avec complication oculaire inhabituelle.

A 23-year-old woman was referred for decreased vision and central scotoma. Fundus examination disclosed unilateral acute oedematous optic neuritis. A nasolabial cyst was diagnosed, probably of dental origin, because numerous apical granuloma were noticed. The abscess did not produce any fistula which explained the absence of clinical and radiological dental sinusitis. Treatment included excision of the nasolabial cyst and systemic antibiotics. The prognosis was excellent with recovery of a normal visual acuity and normal fundus appearance. There was no evidence of any recurrent episode. The nasolabial cyst was the cause likely of the neuritis. Nevertheless, multiple sclerosis must be considered. Only long-term absence of neurological signs could prove that the maxillary lesion was directly responsible for the optic disorder.

[Enterococcal meningitis revealing endocarditis]. / Méningite à entérocoque révélant une endocardite.

INTRODUCTION: Enterococci are frequently responsible for endocarditis, but a rare cause of meningitis. OBSERVATION: A 55 years-old man presented with Enterococcus faecium meningitis. Systematic transoesophageal echocardiography (TOE), despite the absence of organic murmur and the negativity of the hemocultures, revealed a concomitant aortic endocarditis. CONCLUSION: Review of the literature suggests that the association of endocarditis with enterococcal meningitis is far from accidental. We suggest that a TOS be conducted systematically when faced with this disease. The therapeutic implications are important, notably regarding the duration of antibiotherapy.

[Severe forms of rubella encephalitis: arguments for a better vaccination policy]. / Formes sévères d'encéphalites au décours d'une infection rubéolique: arguments pour une meilleure couverture vaccinale.

BACKGROUND: Two cases of rubella encephalitis in young adults are reported. CASES REPORTS: 2 patients, 19 and 16-year-old, presented with severe encephalitis. One required mechanical ventilation. Neither were vaccinated against rubella. MRI scan of the brain was normal. The diagnosis was confirmed by serology. Good recovery was noted in both patients. DISCUSSION: Both cases of rubella encephalitis occurring in young adults illustrate the severity of this rare disease. As already shown in Finland, improvement with the French vaccination policy should lead to the prevention of rubella encephalitis.

[Enterobacter cloacae and E. aerogenes septicemia: emergence of resistant variants (derepressed cephalosporinase) during treatment with third-generation cephalosporins]. / Septicémies à Enterobacter cloacae et E. aerogenes: émergence de variants résistants (céphalosporinase déréprimée) en cours de traitement par des céphalosporines de troisième génération.

From three patients hospitalised in intensive care units with Enterobacter septicaemia (two cases with E. cloacae, and one with E. aerogenes), cefotaxime therapy, alone or in combination with an aminoglycoside, selected variants (R) with increased resistance to beta-lactam antibiotics. The cross-resistance extended to all the beta-lactam antibiotics tested, penicillins and cephalosporins, including third-generation cephalosporins. The crude extracts of uninduced cultures of R variants showed high beta-lactamase activity and of the cephalosporinase type. These variants were selected in vitro with a frequency of 10(-6) to 10(-7) and may result from a mutation involving the regulation of Enterobacter cephalosporinases, usually inducible. Data from the literature indicated that this new type of resistance is actually emerging and observed not only in Enterobacter sp. The problem of emergence of R variants exhibiting cross-resistance to beta-lactam antibiotics should be considered when third-generation cephalosporins are used.

[Prognosis of post-anoxic coma]. / Pronostic des comas post-anoxiques.

The outcome of anoxic coma following cardiac arrest depends on the aetiological circumstances, on pre-existing visceral deficiencies and on the duration of inefficient circulation. Outside the extreme cases of prompt return to consciousness or early death, in many patients this course is marked by neurological sequelae of varying severity which may result in a persistent vegetative state. Initially, there is nothing that can predict the quality of survival, but within 72 hours the neurological examination usually makes it possible to foresee irreversible situations with permanent loss of consciousness. The decisional problems that ensue are discussed.