Usefulness of nefopam in treating pain of severe uncomplicated renal colics in adults admitted to emergency units: a randomised double-blind controlled trial. The 'INCoNU' study.

BACKGROUND: Renal colic pain is a frequent cause of emergency department admissions (1-2% of admissions). It is extremely painful, often requiring intravenous morphine titration. The aim of this study was to estimate the effect of adding nefopam to ketoprofen upon subsequent morphine consumption and the time needed to achieve adequate analgesia in renal colic. METHODS: The authors undertook a prospective, monocentric, randomised, double-blind, placebo-controlled, parallel-group study, using an intent-to-treat analysis. Patients admitted to the emergency department for suspected hyperalgesic (evaluated with a visual analogue scale (VAS)) renal colic were enrolled in the study. They were administered an initial treatment of ketoprofen before being randomly assigned to either the placebo or nefopam group. RESULTS: Thirty patients admitted to the emergency department were enrolled in the study. Morphine analgesia was necessary for 10 patients (66.6%) (95% CI 40% to 90%) in the nefopam group and 8 (53.3%) (95% CI 30% to 80%) in the placebo group, with no statistically significant difference found (difference 13.3%, 95% CI -51% to 24%). The time needed to achieve adequate analgesia in the case of morphine titration was 8.3 min (95% CI 4.2 to 12.5) in the nefopam group and 9 min (95% CI 2.7 to 15.3) in the placebo group, with no statistically significant difference (difference 0.7, 95% CI 7.25 to 8.58). CONCLUSION: This study did not reveal any significant difference between nefopam and placebo. This may be due to lack of statistical power or lack of effectiveness. CLINICAL TRIAL REGISTRATION NUMBER: http://ClinicalTrials.gov ID number NCT00639574.

Accuracy of C-reactive protein, procalcitonin, and mid-regional pro-atrial natriuretic peptide to guide site of care of community-acquired pneumonia.

BACKGROUND: The use at bedside of C-reactive protein (CRP), procalcitonin (PCT) or mid-regional pro-atrial natriuretic peptide (ANP) has been advocated to help management of patients with community-acquired pneumonia (CAP) in emergency medicine. OBJECTIVE: To assess the effectiveness of CRP, PCT, and ANP measures in assisting emergency physicians deciding hospital admission for CAP with low risk of complication. DESIGN: Multicenter, prospective, observational study with blind evaluation. SETTING: Emergency departments of 12 French hospitals. PATIENTS: Five hundred forty-nine consecutive, immunocompetent adult patients with mild CAP. MEASUREMENTS: Centralized and blind measure of baseline CRP, PCT, and ANP; sensitivity, specificity, and positive and negative likelihood ratios for determining hospital admission. Gold standard for admission was defined by experts' advice combined with admission requirement or death at 28 days. Optimal threshold values were determined by receiver operating characteristic (ROC) curves, and area under curve (AUC) of the three biomarkers was compared. RESULTS: According to gold standard, 310 (56%) patients required admission and 239 (44%) needed to be discharged. PCT and ANP levels increased with Pneumonia Severity Index risk categories. ANP (AUC 0.76 [95% CI 0.72-0.80]) more accurately predicted admission requirement than did PCT (AUC 0.65 [95% CI 0.61-0.70]) or CRP (AUC 0.59 [95% CI 0.54-0.64]) (both p values <0.01). We determined that 135 pmol/L was a threshold for ANP level to discriminate admission requirement (positive likelihood ratio 7.45 [95% CI 4.22-8.16]). CONCLUSIONS: In a selected population of CAP with low risk of complication, a single ANP measurement was more accurate than CRP and PCT to predict appropriate admission. These results should be confirmed by additional studies.

ICU-acquired nosocomial infection: impact of delay of adequate antibiotic treatment.

In order to measure the impact on survival of the early introduction of adequate antibiotic treatment for nosocomial bacteremia and pneumonia, a retrospective, cohort study was carried out over a period of 17 months in a 6-bed respiratory ICU. All patients presenting with a first episode of ICU-acquired nosocomial bacteremic infection (Centers for Disease Control criteria) or pneumonia [BAL culture > or = 10(4) colony-forming units (CFU)/ml or protected specimen brush culture > or = 10(3) CFU/ml] were included. The organ failure score (Fagon criteria) was recorded on the day of diagnosis. Adequate antibiotic treatment was defined by the sensitivity of each etiologic organism to at least 1 prescribed antibiotic. A total of 25 patients (Simplified Acute Physiology Score II = 44) were included in the study with pneumonia (n = 17) or bacteremia (n = 8), on average 6.5 +/- 4.6 d after admission. At the time of diagnosis, 23 patients were receiving mechanical ventilation. The overall mortality rate was 48% and was significantly associated with the length of time without adequate antibiotic treatment (p = 0.011) and the number of organ failures on the day of diagnosis (p = 0.017). Adequate antibiotic treatment only had an impact on survival if it was started within the first 24 h after sampling (p < 0.02 on Day 0 and < 0.04 on Day 1). On the day of diagnosis, a failure score > 2 was associated with increased mortality (p = 0.009). After adjusting for the number of organ failures, the length of time without adequate antibiotic treatment remained associated with mortality (< or = 2 organ failures, p < 0.02; > 2 organ failures, p = 0.05). This study suggests that, during the course of nosocomial pneumonia and bacteremia, the time at which adequate antibiotic treatment is started is a key factor influencing survival.