Angiotensin-converting enzyme in human adult respiratory distress syndrome.

Angiotensin-converting enzyme (ACE) levels, complement activation, and intravascular coagulation were studied in 36 patients with adult respiratory distress syndrome (ARDS) (17 aseptic, 19 septic), in order to investigate the possible interrelations among ACE, immunologic data, and hematologic findings. The severity of respiratory impairment was assessed with measurements of mechanical and gas exchange functional qualities of the lung. Serial measurements of ACE could be done in 14 patients during an eight-day period. During the first 24 hours, ACE levels were always normal (38 percent) or decreased (62 percent). No difference could be found between patients with septic and aseptic ARDS. Complement activation occurred in 78 percent (28/36) and used, in most cases, the classic pathway with presence of circulating immune complexes. Criteria for intravascular coagulation were present in 58 percent (21/36). No relation between coagulation, complement, and ACE could be found except for the patients with a greater respiratory impairment, who had complement activation, intravascular coagulation, and significantly lower ACE levels. In all patients together, ACE levels had no diagnostic value for aseptic cause of ARDS and a poor prognostic value. Only intravascular coagulation was linked with a higher significant mortality and a greater functional impairment. Serial measurements showed a diphasic evolution of ACE levels, with a maximum decrease between the 72nd and 96th hours and a further normalization (seventh day). The persistence of low levels seemed to be associated with evolutive sepsis or secondary aggravation and fibrosis.

Autonomic dysfunction in the Guillain-Barré syndrome. Hemodynamic and neurobiochemical studies.

In 12 patients suffering from the Guillain-Barré syndrome, with autonomic dysfunction, a hemodynamic study was performed and biological counts of neurotransmitter metabolites were repeatedly taken in the urine, the plasma and the lumber cerebrospinal fluid. In the course of the Guillain-Barré syndrome with autonomic dysfunction the changes in hemodynamic indices suggest a state of sympathetic hyperactivity. There is an increase in cerebrospinal neurotransmitter metabolite levels with an increase in central cathecholaminergic and serotoninergic activity. The findings point to an interference of central structures in the sympathetic hyperactivity observed.

Intravenous nitroglycerin in acute respiratory failure of patients with chronic obstructive lung disease, secondary pulmonary hypertension and cor pulmonale.

We have studied the hemodynamic effects of an intravenous single dose of nitroglycerin in 13 patients with secondary pulmonary hypertension and Cor Pulmonale, during the acute course of respiratory failure and under assisted ventilation. We observed a significant decrease in systolic, diastolic and mean pulmonary arterial pressures, and in pulmonary resistance and systolic right ventricular work index, without any change in right or left pre-loads. The systolic arterial pressure decreased slightly, without any change in cardiac index or diastolic pressure. The arterial and mixed venous oxygen contents, and the pulmonary shunting ( Qs/Qt) were unchanged. These results suggest that nitroglycerin may be a useful therapy in patients in the acute stages of pulmonary hypertension resulting from chronic lung disease and under assisted ventilation. In addition, the lack of change in cardiac index, intrapulmonary shunting and oxygen content suggests that this decrease in pulmonary resistance is not linked with any deleterious effect in oxygen transfer.

A comparison of three severity score indexes in an evaluation of serious bacterial pneumonia.

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.

Massive arsenic poisoning--effect of hemodialysis and dimercaprol on arsenic kinetics.

In massive arsenic poisoning, the use of hemodialysis and dimercaprol (BAL) therapy is still controversial. Hemodialysis is thought of value only for supportive care. BAL therapy has been criticized because of its delayed action, its own toxicity and its possible influence on arsenic clearance during hemodialysis. We studied arsenic kinetics during an acute suicidal intoxication (10 g of sodium arsenate). Treatment included gastric lavage, oral charcoal and supportive measures. Hemodialysis was performed immediately and repeated the next day. BAL therapy was prescribed only on the second day. Cardiovascular collapse, anuria and hepatic disturbance recovered in a few days and the patient could be discharged on the 15th day. Instantaneous serum arsenic hemodialysis clearance was 85 +/- 75 ml/min without previous BAL injection and 87.5 +/- 75 ml/min with a previous 250 mg BAL injection (difference not significant) indicating that BAL did not impede arsenic dialysis. The calculated total hemodialysis clearance of arsenic was higher than mean serum hemodialysis clearance indicating that erythrocyte bound arsenic is also eliminated during dialysis. We propose to consider early hemodialysis as an elimination measure in massive arsenic poisoning and to choose BAL as a chelator when dialysis is required.

Respiratory and hemodynamic effects of halothane in status asthmaticus.

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.

Inhaled NO preadministration modulates local and remote ischemia-reperfusion organ injury in a rat model.

Inhaled nitric oxide (iNO) has been shown to have a protective effect in lung ischemia-reperfusion (I/R)-induced injuries. We studied the role of iNO (10 parts/million for 4 h) administered before I/R. In an isolated perfused lung preparation, iNO decreased the extravascular albumin accumulation from 2,059 +/- 522 to 615 +/- 105 microl and prevented the increase in lung wet-to-dry weight ratio. To study the mechanisms of this prevention, we evaluated the role of nitric oxide (NO) transport and lung exposure with matched experiments by using either lungs or blood of animals exposed to iNO and blood or lungs of naive animals. iNO-exposed blood with naive lungs did not limit the extravascular albumin accumulation (2,561 +/- 397 microl), but iNO-exposed lungs showed a leak not significantly different from the group in which both lungs and blood were iNO exposed (855 +/- 224 vs. 615 +/- 105 microl). An improvement in heart I/R left ventricular developed pressure in the animals exposed to iNO showed that blood-transported NO was, however, sufficient to trigger remote organ endothelium and reduce the consequences of a delayed injury. In conclusion, preventive iNO reduces the consequences of lung I/R injuries by a mechanism based on tissue or endothelium triggering.

Case report: recovery of Calliphora vicina first-instar larvae from a human traumatic wound associated with a progressive necrotizing bacterial infection.

Human myiasis caused by Calliphora vicina is rare in Europe. Here we report a case of C. vicina infection occurring in the traumatic leg wound of a healthy 21-year-old man. Firstly, a progressive necrotizing infection developed in the wound despite administration of antibiotics. Aeromonas hydrophila was isolated from the wound samples. Secondly, during debridement, C. vicina first-instar larvae were isolated from the wound. To our knowledge, this is the first European case of C. vicina wound myiasis associated with severe A. hydrophila infection.

Enzymes in the cerebrospinal fluid in diagnosis of brain death.

The increase of enzymes in the cerebrospinal fluid is shown to indicate an adverse prognosis, with the implication of irreversibility. The massive increase of glutamate-oxaloacetate transaminase and lactate dehydrogenase and the appearance of alkaline phosphatases in a sample of cerebrospinal fluid in which the cytology is normal constitute an easy and reliable test for brain death. The increase in lactate dehydrogenase fraction V and lysozyme in cerebrospinal fluid supports the macrophagic origin of these enzymes.

Pedicle musculocutaneous flap transplantation: prediction of final outcome by transcutaneous oxygen measurements in hyperbaric oxygen.

In pedicle musculocutaneous flaps, a local circulatory insufficiency with a total or subtotal ischemia may occur and jeopardize the result of the reconstructive surgery. Transcutaneous oxygen pressure (PtcO2) monitoring has been shown to reflect tissue perfusion and has been advocated to predict the final outcome of ischemic flaps. Unfortunately, under normal atmospheric conditions, this test is not sufficiently discriminative. We evaluate the effect of hyperbaric oxygen conditions on the efficiency of this test. Fifteen patients with pedicle musculocutaneous flap were evaluated by clinical examination and transcutaneous oxygen tension measurements. The final outcome was healing in 7 and failure in 8. In order to determine the predictive value of transcutaneous oxygen tension, measurements were done immediately after the surgical procedure. In ambient air, neither the absolute value of transcutaneous oxygen tension (2.6 +/- 3.6 versus 11.7 +/- 12.6 torr; N.S.) nor the difference or the ratio between the transcutaneous oxygen tension of the flap and the subclavicular reference shows any significant difference according to the outcome (failure or success). The same is true in normobaric oxygen. In hyperbaric oxygen, however, there is a significant difference in transcutaneous oxygen tension between the two groups (12 +/- 12 versus 378 +/- 385 torr; p < 0.01). A transcutaneous oxygen tension higher than 50 torr in hyperbaric oxygen (2.5 atm abs) is the best cutoff value to discriminate success from failure.

Hyperbaric oxygen therapy in chronic vascular wound management.

Many nonhealing tissues are hypoxic, with oxygen tensions frequently ranging from 5 to 15 mmHg. In such an environment, the normal wound healing sequence is disrupted or halted and phagocytic killing activity depressed. So the adjunctive use of hyperbaric oxygen (HBO), based on physiologic data and clinical observations, can provide the substrate necessary to initiate and sustain the healing process. During a twelve-month period, 20 patients with a nonhealing wound were referred to the hyperbaric center: chronic arterial insufficiency ulcers in 9 cases, diabetic wounds (foot lesions) in 11 cases. Adjunctive HBO therapy, initiated twice a day, consisted of pure oxygen, 2.5 ATA, 90 min. The average length of sessions was 46 (15-108). Complete healing was observed in 15 of 20 cases. The wound management can be helped with the transcutaneous oxygen measurements under hyperbaric oxygen. The distal TCPO2 at 2.5 ATA pure oxygen is a reliable test to predict final outcome (healing or no change), when these values were not different in normal air and in normobaric oxygen: (table; see text) In hyperbaric oxygen therapy, when the distal TCPO2 value was inferior to 100 mmHg, all patients showed either no improvement or aggravation, and when the value was higher than 100 mmHg, wound healing was achieved with all patients.

Effects of breathing air at 4 atm abs: evidence for a change in strategy.

The effect of breathing air at 4 atm abs on two tasks was investigated. For the recognition memory task, subjects learned a list of symbols in anticipation of a recognition test. The second task was a speed test in which subjects were instructed to detect all occurrences of a given target. A signal detection analysis of performance to the recognition test showed that sensitivity index was invariant, but the criterion (beta) became stricter under hyperbaric pressure. For the speed test, the results showed that under pressure the error rate increased progressively with time while the working speed remained constant. It is argued that strategic variables may be particularly sensitive to the hyperbaric environment.

[Hemodynamic and respiratory effects of enoximone in acute respiratory insufficiency of chronic obstructive bronchopneumopathy]. / Retentissement hémodynamique et respiratoire de l'enoximone au cours de l'insuffisance respiratoire aiguë des bronchopneumopathies chroniques obstructives.

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.

[Anaerobic infections of the soft tissues]. / Les infections anaérobies des tissus mous.

Anaerobic soft tissue infections are still life threatening infections. Although their frequency is actually moderate; they remain severe because physicians are often insufficiently aware of them. Although the classification between myonecrosis and necrotizing fasciitis is still valid, these infections share so many points in common that they can be considered together. Their origin is often traumatic or surgical but may also be secondary to an ulcer or a small wound in a high-risk patient: arteriosclerotic, diabetic. Hypoxia, traumatic muscle crush, heavy bacterial contamination as well as incorrect antibiotic prophylaxis are the major reasons for their occurrence. Management consists of antibiotics adapted to both anaerobic and associated aerobic bacteria, large and early surgical debridement, but with conservative excision, and intensive hyperbaric oxygen therapy. Strict prevention measures must be applied to avoid their occurrence.

[Meadows syndrome. A case history (author's transl)]. / Le syndrome de Meadows. A propos d'une observation.

The authors, having studied a case of Meadows syndrome, confirm that this cardiomyopathy is a specific entity in pregnancy and the puerperium. They point out the difficulties in diagnosis, as Meadows syndrome seems to be diagnosis of elimination. They point out that a paraclinical balance has to be drawn up very fully on the biological and haemodynamic planes to confirm this condition. Finally, after a short discussion about the therapy, they tackle the problem of the prognosis for life and for future childbearing in these patients, which is determined by the persistence or absence of cardiac enlargement.

[Pseudosurgical acute abdomen syndrome in primary pulmonary hypertension]. / Syndrome douloureux abdominal pseudochirurgical lors d'une hypertension artérielle pulmonaire primitive.

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".

[Carbon monoxide poisoning]. / L'intoxication au monoxyde de carbone.

Carbon monoxide (CO) poisoning still represents a frequent and severe casualty in France. Aside from the well-known effect of CO on hemoglobin, the role of CO binding to other hemoproteins like myoglobin and cytochrome a3 has been more recently recognized. Moreover, in addition to these hypoxic injuries, the reoxygenation phase may itself induce toxic effects by a mechanism close to the ischemia-reperfusion phenomenon. Clinical manifestations include neurologic disturbances, cardiac arrhythmia, respiratory and circulatory failures which usually disappear with removal from toxic atmosphere and administration of oxygen. However, long term neurologic manifestations may occur and lead to important functional impairment and disability. Hyperbaric oxygen is actually the treatment of choice to avoid the occurrence of delayed sequelae. HBO is advocated in every patient who remains comatose on hospital admission, who has lost consciousness during toxic exposure or with persisting neurologic abnormalities. CO poisoned pregnant women should also undergo HBO.

[Inhaled nitric oxide test for patients with stable chronic obstructive pulmonary disease: value and feasibility]. / Test au monoxyde d'azote chez l'insuffisant respiratoire chronique à l'état stable: intérêt et faisabilité.

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.

[New method of weaning from respiratory assistance. Ventilation based on carbon dioxide]. / Nouvelle technique de sevrage de l'assistance ventilatoire. Ventilation asservie au gaz carbonique.

The authors describe a new device for weaning from mechanical ventilation, based on continuous measurement of end-expiratory concentration of CO 2 (FCO 2 ET). The spontaneous or controlled mode of ventilation is automatically determined by the level of FCO 2 ET in relation to preselected maximum and minimum thresholds. The authors call this device "CO 2MV".

[Use of a severity index in 8 multidisciplinary resuscitation centers]. / Utilisation d'un indice de gravité dans huit services de réanimation multidisciplinaire.

A universal severity index for acutely ill patients was applied to 794 acute patients treated in eight medical and surgical French intensive care units located in teaching or community hospitals either in Paris or in provincial towns. Measured on the first day in hospital from objective numerical data, the index proved reliable and correlated well with hospital mortality and the sustained therapeutic efforts of the first 24 hours. It could be used in multicentre studies to compare outcomes and evaluate new treatments.