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PURPOSE: Best clinical management of severe caustic injury is still a subject of debate. Most surgical teams consider severe caustic injury as an indication for emergency surgery. But, under certain circumstances, conservative management is feasible, avoids the need for gastrectomy, and has a low mortality rate. Postponed reconstructive surgery is usually performed several months after caustic ingestion to restore intestinal continuity or to treat stricture sequelae. This study aimed to investigate long-term nutritional and quality of life (QoL) outcomes after reconstructive surgery for high-grade esophageal and gastric caustic injury. METHODS: Twenty-one patients were assessed for biological and nutritional parameters, physical findings, and quality of life surveys at least 25 months after reconstructive surgery among patients who have required emergency surgery (n = 10) and patients who did not undergo emergency surgery (n = 11). RESULTS: After median follow-up of 74 months (after caustic ingestion) and 67 months (after reconstructive surgery), patients who avoided emergency surgery experienced faster oral diet resumption (49 vs. 157 days, p = 0.004), less weight loss (0.3 vs. 20 kg, p = 0.002), greater body fat percentage (22 vs. 18 %, p = 0.046), better nutritional and physical status (SF12 PCS 51 vs. 43, p = 0.036), and less trouble eating (EORTC QLQ-OG 25 31 vs. 56, p = 0.01). CONCLUSIONS: Our study is the first to evaluate long-term nutritional and QoL outcomes, following severe caustic injury. It demonstrates better long-term nutritional outcomes and QoL in patients suitable for initial conservative management. These results support full functional recuperation of spared organs, even severely burned. In the absence of clinical or biological signs necessitating immediate surgery, conservative management should be advocated.
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Quemaduras Químicas/terapia , Cáusticos/toxicidad , Tratamiento Conservador , Sistema Digestivo/lesiones , Estado Nutricional , Calidad de Vida , Adulto , Anciano , Quemaduras Químicas/psicología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: Chronic arsenic toxicity is a global health problem affecting millions of people. Acute arsenic poisoning is less frequent and it is most often lethal. Therefore, its consequences are not well known, more precisely its neurological consequences. OBSERVATION: We report a case of Guillain-Barré-like syndrome and encephalopathy after acute arsenical poisoning in a 50 year-old man. After 4 month follow-up, the improvement was slow and limited with persistent motor and proprioceptive deficits. DISCUSSION: The most frequent neurological complication induced by acute arsenical poisoning is a distal, symmetrical, sensory, axonal polyneuropathy. Yet the clinical course and the electrophysiological findings may also suggest a Guillain-Barré like syndrome. Moreover, the chelating is not very effective on the neurological complications. CONCLUSION: Any discrepancies in the clinical course of a Guillain-Barré syndrome shall lead to reconsider the diagnosis. The association of gastro-intestinal disorders, skin lesions, and encephalopathy and mood disorders leads to discuss intoxication with heavy metal and more precisely with arsenic. Moreover, the chelating is not very effective on the neurological complications.
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Intoxicación por Arsénico/diagnóstico , Síndrome de Guillain-Barré/diagnóstico , Lesión Renal Aguda/inducido químicamente , Intoxicación por Arsénico/tratamiento farmacológico , Intoxicación por Arsénico/fisiopatología , Quelantes/uso terapéutico , Terapia por Quelación , Diagnóstico Diferencial , Dimercaprol/uso terapéutico , Enfermedades Gastrointestinales/inducido químicamente , Humanos , Masculino , Trastornos Mentales/inducido químicamente , Persona de Mediana Edad , Trastornos del Humor/inducido químicamente , Conducción Nerviosa , Trastornos Paranoides/inducido químicamente , Enfermedades de la Piel/inducido químicamente , Intento de SuicidioRESUMEN
The protected specimen brush (PSB) with quantitative cultures is one of the most reliable techniques for assessing pneumonia in mechanically ventilated (MV) patients. The need to select a certain lung segment for bronchoscopic sampling is still debated. We investigated whether the results of PSB specimens collected within an area radiographically involved with pneumonia (inv-PSB) differed from the results of PSB specimens collected within a lung area without radiographic abnormalities (non-inv-PSB) in 39 MV patients with suspected pneumonia. The comparison of bacterial titers of inv-PSB and non-inv-PSB cultures did not disclose significant differences. Agreement regarding the diagnosis of pneumonia according to recommended diagnostic threshold was observed in 34 of 39 patients (87.1 percent). These results which are in accordance with the pathophysiology of ventilator-associated pneumonia and histologic studies do not support the need to select a certain lung segment for bronchoscopic sampling in most MV patients with suspected pneumonia.
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Infecciones Bacterianas/diagnóstico , Biopsia , Broncoscopía/métodos , Pulmón/microbiología , Neumonía/microbiología , Ventiladores Mecánicos/efectos adversos , Infecciones por Acinetobacter/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Broncoscopios , Cateterismo Periférico/instrumentación , Diseño de Equipo , Femenino , Tecnología de Fibra Óptica , Humanos , Masculino , Persona de Mediana Edad , Infecciones por Pseudomonas/diagnóstico , Pseudomonas aeruginosaRESUMEN
OBJECTIVE: To compare three methods for assessing the excess nurse work load related to recommended procedures for managing nosocomial infections (NI) due to multiresistant bacteria (MRB): two activity scores, the Omega score and the Projet de Recherche en Nursing (PRN) system, and a specific evaluation based on functional analysis of nursing procedures. SETTING: 10 beds in a medical intensive care unit (MICU). PATIENTS: Patients admitted from November 15, 1995, to June 15, 1996, were included and divided in two groups based on presence of MRB colonization or infection (MRB+ and MRB-groups). METHODS: Data were collected regarding length of stay (LOS) in days; Omega score for the entire stay; PRN score for the entire stay and per day; and time required to perform correctly four nursing procedures related to MRB NI, as evaluated specifically by the nursing staff, using a detailed functional analysis document that described all elementary nursing tasks in chronological order and all material needed to carry out those tasks. RESULTS: The LOS and total Omega and PRN scores were higher in the MRB+ group than in the MRB- group: LOS, 23 +/- 20.6 versus 12 +/- 15.3 days, (P<.001); Omega score, 164 +/- 103.4 versus 123 +/- 93.7 points (P<.001); PRN score, 3,606 +/- 3,187 versus 1,854 +/- 2,356 points (P<.001), respectively. The daily PRN score was also higher in MRB+ group (PRN, 160 +/- 25 vs 146 +/- 34 points in the MRB- group; P<.028). Four nursing procedures made necessary by MRB acquisition were identified: isolation precautions, with two levels according to whether the risk of contamination was mild-moderate or high; bathing the patient with antiseptic solution; bedpan management; and microbiological screening. The functional analysis indicated that the time needed to carry out these four procedures correctly was 245 minutes per patient per day, as compared to 85 minutes according to the PRN system. CONCLUSIONS: Our data confirm that MRB NIs are responsible for an increase in nurse work load, as estimated by LOS, Omega, and PRN scores. However, the daily excess nurse work load related directly to recommended procedures for managing MRB NIs in MICUs is underestimated by these activity scores, as compared to a specific functional analysis of nursing tasks. This may be of importance in evaluating potential links between nurse work load and MRB NIs and in determining the number of nurse hours needed to comply with infection control recommendations.
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Infección Hospitalaria/enfermería , Unidades de Cuidados Intensivos , Carga de Trabajo/estadística & datos numéricos , Infección Hospitalaria/microbiología , Infección Hospitalaria/prevención & control , Farmacorresistencia Microbiana , Femenino , Humanos , Control de Infecciones/métodos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estadísticas no Paramétricas , Recursos HumanosRESUMEN
OBJECTIVE: To assess the quality of life of intensive care survivors 6 months after discharge. DESIGN: Multicenter prospective study. SETTING: Medical-surgical intensive care units (ICUs) of four French university hospitals. PATIENTS: Among the 589 patients admitted to the four ICUs between 1 January and 31 March 1989, 329 were investigated. MEASUREMENTS AND RESULTS: A generic scale assessing health-related quality of life, the Nottingham Health Profile (NHP), a satisfaction scale, the Perceived Quality of Life scale (PQOL) and a questionnaire on professional status were sent by mail 6 months after discharge. Data concerning age, severity of acute illness (assessed by the Simplified Acute Physiology Score) and main diagnosis were recorded. A total of 223 questionnaires (67.8 %) were analysable. The professional status remained unchanged in 79.7% of the patients, despite a significant (p < 0.01) increase (15.3 vs 22.1%) in sick leave. Quality of life, assessed with NHP, was fair (50th percentile = 0.73 on a 0 to 1 scale), whereas satisfaction measured by PQOL was lower (50th percentile = 0.61). Both scales correlated well (z = 9.853; p = 0.0001) but with a large dispersion. The NHP scale showed a severe reduction in energy, sleep and emotional reactions, whereas social isolation, pain and physical handicap were infrequent. Family support was rated with the PQOL score as very good, whereas dissatisfaction concerning recreational and professional activities was expressed. Subsequent sick leave was associated with a poor quality of life (p < 0.05). Quality of life was mainly a function of the diagnosis, not of age and severity of illness: patients admitted for suicide attempt or chronic obstructive pulmonary disease fared poorly. CONCLUSIONS: Quality of life measured with a health-related quality of life scale and a satisfaction scale 6 months after an ICU stay depended on the admission diagnosis. Different dimensions of quality of life were variably affected.
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Cuidados Críticos , Indicadores de Salud , Evaluación de Resultado en la Atención de Salud , Satisfacción del Paciente , Calidad de Vida , Adolescente , Adulto , Anciano , Análisis de Varianza , Femenino , Francia , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Análisis de Regresión , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Encuestas y CuestionariosRESUMEN
Two non specific severity scoring systems, acute physiological score (APS) and simplified acute physiological score (SAPS) are compared with a specific index (Sc) in an evaluation of 96 ICU patients with "serious" bacterial pneumonia. The three scores were measured during the first 24 h following ICU admission. There is a good correlation between APS, SAPS or Sc. Accuracy and efficiency of the non specific scoring indexes and Sc are similar. There is no statistical difference in sensitivity, specificity, positive and negative predictive values, receiver operating characteristic curves of the three indexes. Simple and reliable non specific index such as SAPS, valid for a variety of pathologies, can be used in an evaluation of mortality and comparative studies of groups of patients with serious bacterial pneumonia.
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Grupos Diagnósticos Relacionados , Neumonía/clasificación , Índice de Severidad de la Enfermedad , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Infecciones Bacterianas/clasificación , Infecciones Bacterianas/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neumonía/mortalidadRESUMEN
The respiratory and hemodynamic effects of halothane in patients with status asthmaticus who required mechanical ventilation was evaluated. Halothane was administered in 12 patients in a concentration of 1% for thirty minutes. Standard drug treatments and ventilator settings were not modified during halothane administration. The following data were collected before and after halothane administration: arterial blood gases, peak inspiratory pressure, VD/VT, pulmonary arterial pressure, right heart pressures and cardiac index (by means of the thermodilution method). After halothane treatment PaCO2 significantly decreased, arterial pH increased, peak inspiratory pressure decreased and VD/VT decreased significantly. Mean pulmonary arterial pressure and right heart pressures decreased and the cardiac index was unchanged. The heart rate significantly decreased and arrhythmias did not occur during halothane administration. The administration of halothane in patients with status asthmaticus requiring mechanical ventilation produces a rapid reduction in bronchospasm and barotraumatic injury and a rapid improvement in arterial blood gases, without any adverse hemodynamic effects.
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Asma/tratamiento farmacológico , Halotano/farmacología , Hemodinámica/efectos de los fármacos , Respiración/efectos de los fármacos , Estado Asmático/tratamiento farmacológico , Administración por Inhalación , Adulto , Femenino , Halotano/administración & dosificación , Halotano/uso terapéutico , Humanos , Masculino , Estudios Prospectivos , Respiración Artificial , Pruebas de Función Respiratoria , Estado Asmático/fisiopatología , Estado Asmático/terapiaRESUMEN
In this paper we present a theoretical model for the dewetting of ultrathin polymer films. Assuming that the shear-thinning properties of these films can be described by a Cross-type constitutive equation, we analyze the front morphology of the dewetting film, and characterize the time evolution of the dry region radius, and of the rim height. Different regimes of growth are expected, depending on the initial film thickness, and on the power-law index involved in the constitutive equation. In the thin-films regime, the dry radius and the rim height obey power-law time dependences. We then compare our predictions with the experimental results obtained by Debrégeas et al. [Phys. Rev. Lett. 75, 3886 (1995)] and by Reiter [Phys. Rev. Lett. 87, 186101 (2001)].
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Quality of care assessment is based on three main prerequisites: to describe precisely patients or case-mix, to measure the level of care, to evaluate the outcomes and finally to consider the relationships between these parameters. Indicators to measure the level of nurses' workload have been developed from different concepts and methodologies: The range of nurses' activities is very wide, such as cares achieved in the presence of patient, cares achieved after medical prescription or specific nurse cares, administrative tasks, research activities, etc. Indicators may take into account a more or less important part of this field, but most of them are usually focused on patient's care. The value of each parameter may be a calculated coefficient or a time unit. If one considers the time as the best unit to measure the intensity of work, it is also an underlying concept to differentiate the actual time, obtained by timing, from the required time, necessary to achieve correctly the action. In the same way, required cares are also the best to consider. Indeed measuring required time for required cares is necessary to reach quality aim. The nurses' workload may be directly calculated with a specific indicator or indirectly estimated from a severity or disability scoring system. The selection of the indicator depends of the purpose of the evaluation process. If the question is to improve and develop quality of care and professional practices, the indicator has to take into account the required cares. The PRN system (Project de Recherche en Nursing) developed in Canada is probably the reference indicator. However this score is complex and cannot be daily used.(ABSTRACT TRUNCATED AT 250 WORDS)
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Atención de Enfermería , Investigación en Evaluación de Enfermería , Carga de Trabajo , Francia , Métodos , Proyectos Piloto , Calidad de la Atención de SaludRESUMEN
Hemodynamic effects and gas exchange were studied in twenty COPD patients undergoing mechanical ventilation before and 30 and 60 minutes after an intravenous administration of 1 mg/kg enoximone. Enoximone decreased significantly pulmonary arterial pressure and pulmonary vascular resistances without significantly decrease of systemic vascular resistances 60 minutes after a slight dose of 1 mg/kg. Right ventricular ejection fraction increased; O2 arterial pressure, CO2 arterial pressure, intrapulmonary shunt remained unchanged. We concluded that enoximone induced pulmonary vasodilation in patients with decompensated COPD and increased right ventricular function without deleterious effects in gas exchange.
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Cardiotónicos/farmacología , Hemodinámica/efectos de los fármacos , Imidazoles/farmacología , Enfermedades Pulmonares Obstructivas/complicaciones , Respiración/efectos de los fármacos , Insuficiencia Respiratoria/tratamiento farmacológico , Enfermedad Aguda , Enoximona , Humanos , Insuficiencia Respiratoria/fisiopatologíaRESUMEN
OBJECTIVE: To evaluate advantages and drawbacks of a controlled conservative management of patients with severe gastric caustic injuries. METHODS: Among 40 patients with severe caustic gastric burns (> IIb), 28 with stade III lesions (mosaic necrosis: n = 10, extensive or circumferential necrosis: n = 18) were managed prospectively from 1990 to 1998. Twenty-two patients had associated stage III oesophageal lesions and 6 had stage III duodenal lesions. All patients were followed up by daily surgical examination. Total gastrectomy with esophageal exclusion or stripping was performed in case of perforation. RESULTS: Five immediate and 7 secondary total gastrectomies, two associated esophagectomies and two jejunal resections were performed. Mortality rate was 18% (5/28). Sixteen gastric preservations (60%) were achieved, including 7 complete and 9 partial because of gastric stricture. Eighteen esophagoplasties for oesophageal strictures or after gastrectomy were performed without mortality. CONCLUSION: Stage III caustic injuries of the stomach, when they are not immediately life-threatening, do not systematically require total gastrectomy. A strict conservative attitude can be done with significant morbidity and acceptable mortality and significantly raises the numbers of preserved stomach.
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Quemaduras Químicas/etiología , Quemaduras Químicas/terapia , Cáusticos/efectos adversos , Esofagectomía , Esófago/lesiones , Esófago/cirugía , Gastrectomía , Yeyuno/lesiones , Yeyuno/cirugía , Selección de Paciente , Estómago/lesiones , Estómago/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Quemaduras Químicas/diagnóstico , Quemaduras Químicas/mortalidad , Urgencias Médicas , Esofagectomía/efectos adversos , Esofagectomía/mortalidad , Gastrectomía/efectos adversos , Gastrectomía/mortalidad , Gastroscopía , Humanos , Persona de Mediana Edad , Morbilidad , Necrosis , Peritonitis/etiología , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Absceso Subfrénico/etiología , Resultado del TratamientoRESUMEN
The natural history of conduction disorders in infarction and their prognostic significance are now well known and determine the choice of treatment. In the acute phase of inferior infarction without bundle branch block, temporary pacing is only indicated in cases with poor clinical tolerance or with a bradycardia of less than 50. Prophylactic pacing, on the other hand, appears to be necessary in cases of anterior infarction with branch block, at least in the high risk group in which the block is recent and bifascicular. In this case, the pacemaker is only permanent in cases of high degree atrio-ventricular block in the acute phase. The subsequent prognosis of anterior infarction with branch block and without high degree atrio-ventricular block in the acute phase carries a high incidence of sudden death. Primary delayed ventricular fibrillation during the first eight weeks seems to be the cause for this sudden death. Prolonged hospital surveillance of these patients would appear to be indicated.
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Arritmias Cardíacas/etiología , Infarto del Miocardio/complicaciones , Arritmias Cardíacas/terapia , Humanos , PronósticoRESUMEN
The case is reported of a 49-year-old chronic alcoholic woman, who presented with severe pulmonary arterial hypertension (PAH) mimicking as an acute abdomen. She was admitted with right-sided hypochondrial abdominal pain and hepatomegaly, with a moderate jaundice. On admission to intensive care unit, she had an arterial blood pressure of 110/70 mmHg, a heart rate of 100 b.min-1, and a respiratory rate of 36 c.min-1. An electrocardiogram showed sinus rhythm and right-sided heart failure. Whilst breathing 6 l.min-1 oxygen, her arterial blood gases were: PaO2 47 mmHg PaCO2 29 mmHg. Severe PAH was confirmed by measuring her mean pulmonary arterial pressure, which was 46 mmHg, whilst her pulmonary wedge pressure was 7 mmHg. Hepatic function was also altered: total bilirubin 41 mumol.l-1, alkaline phosphatase 145 UI.l-1 and gamma glutamyl transferase 1 340 UI.l-1. She developed arterial hypotension, which did not respond to increasing doses of isoproterenol. She died on the third day. Necropsy confirmed the diagnosis of primary PAH, with acute "cardiac liver".
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Abdomen Agudo/etiología , Hipertensión Pulmonar/complicaciones , Alcoholismo/complicaciones , Cateterismo Cardíaco , Femenino , Hemodinámica , Hepatomegalia/etiología , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/fisiopatología , Ictericia/etiología , Persona de Mediana Edad , Función Ventricular DerechaRESUMEN
The field of application for fibreoptic bronchoscopy (FB) in the intensive care unit has been extended since the generalised introduction of fibroscopes of 4.9 mm in diameter (previously called paediatric fibroscopes). Paediatric and neonatal intensive care units have benefited from the availability in the market of these small endoscopes for 3.5 and 2.2 mm. The protected brush and alveolar lavage (LBA) enables a specific diagnosis to be made in bacterial pneumonia acquired during ventilation. The sensitivity of these techniques however is insufficient to be able to recommend their use as routine. Inversely, the FB with LBA remains a fundamental feature in the diagnosis of opportunistic infections in pneumonia. For the treatment of atelectasis, FB is overall not superior to physiotherapy. Aspiration with a fibroscope can however be recommended straight away in cases of alteration in blood gasses if cough is ineffective or if the atelectasis complicates endobronchial bleeding. The FB enables problems with difficult intubation to be resolved or for the positioning of probes. The conditions under which this is performed are more delicate than in routine anaesthesia (in cases of urgency, hypoxia). In the case of respiratory burns, tracheobronchial fracture and post intubation stenosis, FB enables both the diagnosis to be established and the level at which the lesion occurs. In paediatric intensive care, a fibroscope of 3.5 mm is used for performing LBA (opportunistic pneumonias), difficult intubation (facial dysmorphia), endoscopic diagnoses, in particular where there is a suspicion of an endobronchial foreign body, the assessment of unexplained dyspnoea (tracheal stenosis by vascular ring) and obstructive lesions. In neonatal intensive care, a fibroscope of 2.2 mm is used for difficult intubation and the localisation of lesions induced by ventilation.
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Broncoscopios , Broncoscopía/métodos , Cuidados Críticos , Adulto , Líquido del Lavado Bronquioalveolar , Niño , Tecnología de Fibra Óptica , Humanos , Recién Nacido , Intubación Intratraqueal , Enfermedades Pulmonares/diagnóstico , Enfermedades Pulmonares/terapia , Selección de Paciente , Sensibilidad y EspecificidadRESUMEN
We report the case of a 73 year old man presenting with severe hypoxaemia due to an anatomical right to left shunt from a persistent left superior vena cava (VCSG) anastomosing with the left auricle. This was fortuitously discovered while placing a left sub clavicular catheter; the diagnosis of the VCSG draining into the left auricle was confirmed by superior phlebography and CT scanning. The discovery of this shunt after a pulmonary embolus suggested to us that the rise in venous pressure secondary to the embolus led to both clinical symptoms and hypoxaemia from the shunt, which had until then been clinically silent. No surgical treatment was performed.
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Vena Cava Superior/anomalías , Anciano , Atrios Cardíacos/anomalías , Humanos , Masculino , Radiografía , Vena Cava Superior/diagnóstico por imagenRESUMEN
A 58 year old man without significant past medical history developed a cough and effort dyspnoea of a few weeks. A computed tomographic scan showed bilateral interstitial disease with linear thickening of the septa and also a ground glass effect in the lung parenchyma. Echocardiography and right heart catheterisation confirmed the existence of pulmonary arterial hypertension (mean pulmonary artery pressure 45 mmHg) with a normal pulmonary artery wedge pressure (12 mmHg). There was a rapidly progressive worsening with an unfavourable outcome. A necropsy examination showed the development of bilateral pulmonary lymphangitis carcinomatosis secondary to an adenocarcinoma of the head of the pancreas. There was no metastatic emboli of the vessels but there was lymphatic infiltration and the physiopathological hypothesis suggested a compression of the pulmonary arterial vessels secondary to lymphatic obstruction.
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Adenocarcinoma/complicaciones , Hipertensión Pulmonar/etiología , Linfangitis/complicaciones , Neoplasias Pancreáticas/complicaciones , Adenocarcinoma/patología , Cateterismo Cardíaco , Ecocardiografía , Resultado Fatal , Humanos , Hipertensión Pulmonar/diagnóstico , Masculino , Persona de Mediana Edad , Neoplasias Pancreáticas/patología , Tomografía Computarizada por Rayos XRESUMEN
The aim of this study was to verify whether a relationship exists between neuroleptic malignant syndrome (NMS) and anaesthetic-induced malignant hyperthermia (MH) or not. The in vitro halothane-caffeine tests were performed on muscle tissue obtained from 32 patients with documented NMS episodes. The diagnosis of NMS relied on Levenson's criteria. The results, expressed in accordance with the criteria of the European MH Group, defined 29 subjects as MH non-susceptible. Three patients were classified as MH equivocal. These findings demonstrate the lack of any link between NMS and MH. Therefore, patients with a history of NMS are not likely to be at risk of developing MH and special measures against MH are not required for anaesthesia in these patients.
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Anestesia General , Hipertermia Maligna , Síndrome Neuroléptico Maligno/complicaciones , Adolescente , Adulto , Anciano , Cafeína , Contractura/inducido químicamente , Creatina Quinasa/sangre , Dantroleno/uso terapéutico , Susceptibilidad a Enfermedades , Femenino , Halotano , Humanos , Masculino , Persona de Mediana Edad , Síndrome Neuroléptico Maligno/tratamiento farmacológicoRESUMEN
OBJECTIVES: Determine the risk factors and germs responsible for early-onset (E) and late-onset (L) nosocomial broncho-pulmonary infections (NBPI), in order to improve preventive strategies and the choice of initial antibiotherapy. METHODS: An observational prospective study conducted in an intensive care unit of 30 beds, from March 1993 to September 1999. The patients presenting with an ENBPI and those with an LNBPI were compared with patients without NBPI using univariate and then multivariate analysis. RESULTS: 517 (14%) of early-onset NBPI were diagnosed, but the majority of NBPI were late-onset (87%). Multiresistant bacteria predominated. The similarity in the germs responsible for the early and late onset forms of NBPI was probably related to the large number of patients transferred from other departments (82%) and having already received antibiotics before their admission to the intensive care unit (49%). Multivariate analysis identified anti-ulcer and long term corticosteroid treatments as common risk factors for early and late onset forms of NBPI, digestive failure, tracheotomy and kidney failure as risk factors for ENBPI and the number of antibiotics used in intensive care and the duration of mechanical ventilation as factors of risk for LNBPI. CONCLUSION: The limited use of antibiotics and anti-ulcer agents could improve the prevention of early and late onset forms of NBPI. The distinction in intensive care between the two forms of NBPI must be emphasized by the notion of prior hospitalization.
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Enfermedades Bronquiales/microbiología , Infección Hospitalaria/microbiología , Infecciones por Bacterias Gramnegativas/microbiología , Infecciones por Bacterias Grampositivas/microbiología , Unidades de Cuidados Intensivos , Enfermedades Pulmonares/microbiología , Antibacterianos/uso terapéutico , Enfermedades Bronquiales/tratamiento farmacológico , Enfermedades Bronquiales/epidemiología , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/epidemiología , Resistencia a Múltiples Medicamentos , Femenino , Infecciones por Bacterias Gramnegativas/tratamiento farmacológico , Infecciones por Bacterias Gramnegativas/epidemiología , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Infecciones por Bacterias Grampositivas/epidemiología , Humanos , Incidencia , Enfermedades Pulmonares/tratamiento farmacológico , Enfermedades Pulmonares/epidemiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
Patients suffering from chronic lung disease (CLDP) often develop secondary pulmonary hypertension (HP), which contributes to right ventricular dysfunction and worsens their prognosis. In order to evaluate the severity of this HP, pharmacodynamics tests are periodically proposed to these patients. Therefore, the administration of vasodilators is limited by systemic and pulmonary side-effects. Inhaling nitric oxide gas (NO) has been reported to induce a selective pulmonary vasodilation. The purpose of this study was to evaluate the safety and efficacy of an inhaled NO test perfected in our service. Sixteen CLDP were investigated in the absence of acute pulmonary failure. All had severe pre-capillary HP, confirmed after placement of a thermodilution pulmonary-artery catheter (mean pulmonary artery pressure >20 mmHg, pulmonary capillary wedge pressure >12 mmHg). Each subject breathed spontaneously NO in a concentration of 10 ppm for 15 minutes. They were connected through a facial mask and a one-way valve put on the inspiratory connection of a ventilator (Drager-Evita), to a tank of nitrogen with a NO concentration of 900 ppm. Hemodynamic variables and gas exchange were measured before, during and after gas inhalation. The inspired fractions of NO and NO2 were determined using a Polytron analyser (Drager). The methemoglobin levels were measured with spectrophotometry (OSM3). Inhaled NO acts as a selective pulmonary arterial vasodilator, without systemic effect. The action on the shunt is variable. Methemoglobin levels are remained <0.01%. All the patients were satisfied with the way of NO administration. In view of the lack of systemic effects, its seems that the NO inhaled test proposed in this study may be used accurately to evaluate the HP of chronic lung disease patients.
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Hipertensión Pulmonar/diagnóstico , Enfermedades Pulmonares Obstructivas/complicaciones , Óxido Nítrico , Pruebas de Función Respiratoria/métodos , Adulto , Análisis de los Gases de la Sangre , Estudios de Factibilidad , Hemodinámica , Humanos , Hipertensión Pulmonar/etiología , Persona de Mediana Edad , Intercambio Gaseoso Pulmonar , Presión Esfenoidal Pulmonar , Reproducibilidad de los Resultados , TermodiluciónRESUMEN
Nosocomial bronchopulmonary infections are common and severe complications, particularly in intensive care units. The high incidence of pneumonia is related to multiple factors such as underlying disease, acute respiratory failure, nutritional disorders, depressed mental status and the frequent need tracheal intubation. The most frequent cause of respiratory tract infection is aspiration of oropharyngeal secretions. In hospitalized patients, there is usually an oropharyngeal colonization with Gram-negative bacteria. Prevention of nosocomial bronchopulmonary infections requires close attention to the patient's environment, proper techniques, handwashing and decontamination of respiratory equipment.