Pharmacokinetics and pharmacodynamics of sequential intravenous and subcutaneous teicoplanin in critically ill patients without vasopressors.

OBJECTIVE: To compare the pharmacokinetic parameters of sequential intravenous and subcutaneous teicoplanin in the plasma of surgical intensive care unit patients. DESIGN AND SETTING: Prospective, randomized, crossover study in the surgical ICU of a university hospital. PATIENTS: Twelve patients with a suspected nosocomial infection, a serum albumin level higher than 10 g/l, body mass index less than 28 kg/m(2), and estimated creatinine clearance higher than 70 ml/min. INTERVENTIONS: Teicoplanin was first administered intravenously as a loading dose of 6 mg/kg per 12 h for 48 h and then continued at a daily dose of 6 mg/kg. On the fourth day patients were randomized in two groups according to the order of the pharmacokinetic studies. MEASUREMENTS AND RESULTS: Serial plasma samples were obtained to measure teicoplanin levels. Compared with a 30-min intravenous infusion the peak concentration of teicoplanin after a 30-min subcutaneous administration occurred later (median 7 h, range 5-18) and was lower (16 micro g/ml, 9-31; vs. 73, 53-106). Despite large and unpredictable interindividual differences no significant differences between subcutaneous and intravenous administration were observed in: trough antibiotic concentrations (10 micro g/ml, 6-24; vs. 9, 5-30), the area under the teicoplanin plasma concentration vs. time curves from 0 to 24 h (AUC(0-24h); 309 micro g/ml per minute, 180-640; vs. 369, 171-955), the proportion of the dosing interval during which the plasma teicoplanin concentration exceeded 10 micro g/ml (96%, 0-100%; vs. 79%, 13-100%), and the ratio of AUC(0-24h) to 10 (77, 45-160; vs. 92, 43-239). CONCLUSIONS: In critically ill patients without vasopressors a switch to the subcutaneous teicoplanin after an initial intravenous therapy seems to give comparable pharmacodynamic indexes of therapeutic success.

Rupture of a primary aortic aneurysm infected with Shewanella alga.

Bacteria of the genus Shewanella are rarely implicated in bacteremia. We report a case of rupture of a primary aneurysm infected with Shewanella alga.

[Catheter-related infection in intensive care. Physiopathology, diagnosis, treatment and prevention]. / Infections liées aux cathéters veineux en réanimation. Physiopathologie, diagnostic, traitement et prévention.

PURPOSE: To review the mechanisms, diagnosis, treatment and prophylaxis of catheter-related sepsis in intensive care unit patients. DATA SOURCES: A Medline research of the English- or French-language reports published between 1966 and 2000 and a manual research of references of relevant papers. STUDY SELECTION: Experimental, clinical and basic research studies related to catheter-related sepsis. DATA EXTRACTION: Data in selected articles were reviewed, and relevant clinical information was extracted. DATA SYNTHESIS: Infection remains the major complication related to catheter insertion. No bacteriological exam or systematic catheter change is required in the absence of infection suspicion. In the intensive care unit, and without septic shock, the surveillance of skin cultures at the catheter insertion site or the time to positivity of hub-blood versus peripheral-blood culture determination may reduce the number of unnecessary removed catheters. Catheter change over a guidewire is not recommended because of the risk of dissemination of infection. When the catheter is removed, a quantitative culture is warranted. The treatment of catheter-related sepsis is based on catheter removal. The use of antibiotics is limited to some organisms or when the infection is complicated. The persistence of fever and positive blood cultures 72 h after catheter removal require to look for dissemination of infection or septic thrombophlebitis, especially if S. aureus or Candida are incriminated. The treatment of infection without catheter removal is not recommended in the intensive care unit because of a high risk of treatment failure. Compliance with catheter care guidelines and continuing quality improvement programs are the two major procedures in reducing catheter infection. CONCLUSIONS: Improved understanding of the pathophysiology of catheter-related sepsis has led to improved prevention. Compliance with catheter care guidelines and continuing quality improvement programs are majors procedures to reduce the risk of catheter infection.

Complication profiles of adult asthmatics requiring paralysis during mechanical ventilation.

OBJECTIVE: To assess the characteristics and the incidence of morbidity of intubated asthmatic patients who received long-term paralysis. DESIGN: Retrospective cohort study. SETTING: Five intensive care units (ICUs) in Paris and the surrounding suburbs. PATIENTS AND PARTICIPANTS: The NMB group consisted of patients who received neuromuscular blocking agents for more than 12 h (NMB group) versus sedation alone (SED). INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The incidence of post-extubation muscle weakness and/or myopathy was 18% in the NMB group compared to 2% in the SED group ( p=0.01). The occurrence of ventilator-associated pneumonia was higher in the NMB group (42% versus 4%; p<0.0001). The duration of ICU stay and of mechanical ventilation were significantly greater in the NMB group. Multiple logistic regression analysis showed that inclusion in the NMB group was the only independent predictor of the presence of the overall morbidity [odds ratio 6.4 (2.09; 19.64)]. CONCLUSION: While greater initial severity of respiratory compromise in the NMB group may explain part of the difference, use of NMB agents appears to be strongly related to the presence of significant complications among mechanically-ventilated asthmatic patients.

Survey of out-of-hospital emergency intubations in the French prehospital medical system: a multicenter study.

STUDY OBJECTIVE: To determine the clinical characteristics of endotracheal intubation in the French emergency prehospital medical system and compare these data with those of other systems. METHODS: This study was performed in lle de France (Paris Region) in mobile ICUs staffed by physicians. This prospective, descriptive study involved completion of a questionnaire by the operator just after endotracheal intubation was performed. RESULTS: Six hundred eighty-five (99.1%) of 691 consecutive prehospital intubations were performed successfully in the field. The orotracheal route was used in 96.0%, and no surgical approaches such as cricothyroidotomy were used. Mechanical complications occurred in 84 patients, at a rate of 15.9% for nonarrest patients and 8.1% for arrest patients. A wide variety of sedation protocols were used. Difficult intubations (10.8%) were comparable in incidence to the number seen in US emergency departments, not US prehospital systems. By the same token, intubation success rates (99.1%) were comparable to US EDs and much higher than US prehospital results. CONCLUSION: The characteristics of French prehospital airway management differ significantly from those of other countries. These differences may be explained by differences in approach to prehospital management rather than differences of skill.