[Clinical practices of analgesia for invasive procedures in critically ill sedated patients in Ile-de-France: a phone survey]. / Enquête téléphonique sur les pratiques cliniques d'analgésie pour les actes invasifs chez les patients sédatés en réanimation en Ile-de-France.

To assess the practice of analgesia for invasive procedures in critically ill sedated patient in Ile-de-France (French area including Paris). Observational study: phone survey using a standard questionnaire. Only one senior physician in each of 30 intensive care unit (ICU) was questioned. Baseline sedation included systematic analgesia with narcotics in all ICUs. Only 4 physicians declared using a specific pain scale for sedated patients. Only 3 ICUs used written protocols. Procedures, which were thought to be most invasive (catheterization, pleural drainage, fibroscopy) were in most cases preceded by analgesia, but this was seldom the case for less painful events (venous or arterial puncture, tracheal suctioning). Specific pain scales are still underused. In contrast with current guidelines, analgesia for invasive procedures is not systematic but depends on subjective opinions.

[From asthmatic crisis to severe acute asthma]. / De la crise d'asthme à l'asthme aigu grave.

Life-threatening acute attacks constitute the major complication of asthma. These attacks develop progressively or abruptly, within minutes. They are responsible for a mortality rate which in France has been estimated at 3 in 100,000 inhabitants. Most of the deaths occur before any medical assistance is given. Such deaths in serious attacks are caused by bronchial obstruction and not by possible cardiovascular complications. Since inflammation of the bronchi is now thought to be the primum movens of these near-fatal to fatal attacks, nothing but an early and prolonged anti-inflammatory treatment can prevent them. Because no precise profile of subjects at risk can be drawn, it is necessary to supervise with the utmost attention all patients who suffer from attacks of acute asthma which, unless proven otherwise, should be regarded as potentially serious: signs of severity must be systematically looked for, and strict therapeutic and monitoring measures must be taken.

[Humidification and aspiration of the respiratory tract in patients with mechanical ventilation]. / Humidification et aspiration des voies aériennes du malade sous ventilation mécanique.

Mechanical ventilation through endotracheal prosthesis, suppresses the nose functions and stops elimination of secretions. It is mandatory to heat artificially, humidify insufflated gas and to suction tracheobronchial secretions. Heating humidifiers are very efficient for the first purpose but heat and moisture exchangers, a little less efficient, seem to be a good alternative as they are easiest to use and offer a good bacterial protection. Tracheobronchial suctioning has to be carried out at least each four hours and at the best as soon as adventitious sound are heard in the chest. Suction catheters have to be atraumatic; vacuum has to be between -200 to -400 cm H2O; catheter have not to be pushed further than the carina; suction hypoxemia can be reduced by shortening suction maneuver, by using suction catheter with little diameter, by conducting the suction on mechanical ventilation.

B-type natriuretic peptide (BNP) and N-terminal-proBNP for heart failure diagnosis in shock or acute respiratory distress.

BACKGROUND: Plasma B-type natriuretic peptide (BNP) assay is recommended as a diagnostic tool in emergency-room patients with acute dyspnea. In the intensive care unit (ICU), the utility of this peptide remains a matter of debate. The objectives of this study were to determine whether cut-off values for BNP and N-terminal-proBNP (NT-proBNP) reliably diagnosed right and/or left ventricular failure in patients with shock or acute respiratory distress, and whether non-cardiac factors led to an increase in these markers. METHODS: Plasma BNP and NT-proBNP levels and echocardiographic parameters of cardiac dysfunction were determined in 41 patients within 24 h of the onset of shock or acute respiratory distress. RESULTS: BNP and NT-proBNP levels were higher in the 25 patients with heart failure than in the other 16 patients: 491.7 +/- 418 pg/ml vs. 144.3 +/- 128 pg/ml and 2874.4 +/- 2929 pg/ml vs. 762.7 +/- 1128 pg/ml, respectively (P < 0.05). In the diagnosis of cardiac dysfunction, BNP > 221 pg/ml and NT-proBNP > 443 pg/ml had 68% and 84% sensitivity, respectively, and 88% and 75% specificity, respectively, but there was a substantial overlap of BNP and NT-proBNP values between patients with and without heart failure. BNP and NT-proBNP were elevated, but not significantly, in patients with isolated right ventricular dysfunction. Patients with renal dysfunction and normal heart function had significantly higher levels of BNP (258.6 +/- 144 pg/ml vs. 92.4 +/- 84 pg/ml) and NT-proBNP (2049 +/- 1320 pg/ml vs. 118 +/- 104 pg/ml) than patients without renal dysfunction. CONCLUSION: Both BNP and NT-proBNP can help in the diagnosis of cardiac dysfunction in ICU patients, but cannot replace echocardiography. An elevated BNP or NT-proBNP level merely indicates the presence of a 'cardiorenal distress' and should prompt further investigation.