Outcome of spontaneous and iatrogenic pneumothoraces managed with small-bore chest tubes.

BACKGROUND: Little is known about the efficacy of management of iatrogenic pneumothoraces with small-bore chest tubes. The aim of this study was to assess the outcome of iatrogenic pneumothoraces requiring drainage managed with a small-bore chest tube and to compare the results to spontaneous pneumothoraces treated in the same unit with the same device. The primary outcome was requirement of video-assisted thoracoscopic surgery for drainage failure; secondary outcomes were length of drainage and number of inserted chest tubes. METHODS: Patients with pneumothorax admitted between 1997 and 2007 were retrospectively identified. Traumatic pneumothoraces and those occurring under mechanical ventilation were excluded. All pneumothoraces were drained using the same small-bore chest tube (8 French) according to our local protocol. RESULTS: Five hundred sixty-one pneumothoraces were analysed, 431 (76.8%) were spontaneous pneumothoraces and 130 (23.2%) were iatrogenic. Iatrogenic pneumothoraces were associated with less requirement of video-assisted thoracoscopic surgery for drainage failure [adjusted odds ratio= 0.24 (0.04, 0.86)]. Length of drainage of iatrogenic pneumothoraces was longer than for primary spontaneous pneumothoraces (3.8 ± 3.1 vs. 2.7 ± 1.8 days, P < 0.001) and shorter than for secondary spontaneous pneumothoraces (4.6 ± 2.3 days, P = 0.004). Number of inserted chest tubes per patient was not significantly different according to pneumothoraces' aetiology. CONCLUSION: Small-bore chest tubes are feasible for treatment of iatrogenic pneumothoraces and have a better rate of success and slightly longer drainage duration than when used for spontaneous pneumothoraces.

Haemodilution induced by hydroxyethyl starches 130/0.4 is similar in septic and non-septic patients.

BACKGROUND: Fluid therapy induces haemodilution related to plasma volume expansion. The aim of our study was to compare haemodilution after a single hydroxyethyl starches (HES) 130/0.4 infusion in two groups of patients, one with and one without sepsis. We hypothesized that a single HES challenge would induce similar sustained haemodilution in both groups. METHODS: In this prospective preliminary study, patients predicted to require a single further volume-expander infusion were included immediately before receiving 500 ml of 6% HES 130/0.4 over a 15-min period. No additional fluid was administered over the next 8 h. Haematocrit, and serum albumin and protein were determined immediately before HES infusion then after 1, 2, 3, 4, and 8 h. RESULTS: Twelve patients were included in each group. In both groups, all three haemodilution markers had significantly lower values after 1 h than at baseline. None of the values after 1 and 3 h differed significantly between the two groups. Neither did any of the other study variables show significant differences between the groups with and without sepsis. CONCLUSION: We found that a starch-based compound was as effective in inducing haemodilution in patients with sepsis as in controls without sepsis, suggesting that HES may remain within the intravascular space even in patients with sepsis. Haemodilution parameters such as haematocrit, serum albumin and serum protein are useful for assessing the duration of plasma volume expansion induced by fluid therapy in critically ill patients.

Plasma antiproteinase screen and neutrophil-mediated platelet activation. A major role played by alpha 1 antitrypsin.

Upon activation, human polymorphonuclear neutrophils (PMN) release two serine proteinases, cathepsin G (Cat.G) and elastase (HLE), which in turn synergize to activate nearby platelets. We looked for the inhibitory effect of plasma and the involvement of alpha 1 antichymotrypsin (alpha 1 ACT) and alpha 1 antitrypsin (alpha 1 AT), on this cell-to-cell cooperation. It was observed that inhibition by plasma of PMN-mediated platelet activation was rather correlated with an effect on HLE (r = 0.95) than on Cat.G (r = 0.65) enzymatic activity. Purified alpha 1 AT suppressed in a concentration-dependent manner HLE activity present in the supernatant of activated PMN. When HLE was fully blocked, alpha 1 AT started to inhibit Cat.G activity. By contrast and as expected, purified alpha 1 ACT inhibited only Cat.G activity. Using specific blocking polyclonal antibodies against alpha 1 AT and alpha 1 ACT, it was demonstrated that the inhibitory effect of plasma vs. HLE was entirely mediated by alpha 1 AT. By contrast, blockade of Cat.G activity was only partly due to plasma alpha 1 ACT and around 50% was attributable to alpha 1 AT. When plasma from patients with an acute inflammatory state was used in place of plasma from normal subjects, the inhibitory effect was more pronounced, while plasma depleted in alpha 1 AT and alpha 1 ACT was less effective. These data indicate a predominant role of alpha 1 AT in the inhibition by plasma of the PMN-mediated platelet activation.

Temocillin treatment of serious infections due to gram-negative bacilli in an intensive care unit.

In a group of 27 severely ill patients in an intensive care unit, 40 infections caused by Gram-negative bacilli were treated with temocillin 2g twice daily by the direct intravenous route. The patients (17 men and 10 women) were aged from 35 to 93 years (mean 65.7 years) and 22 had severe underlying diseases. In addition, 10 of the patients were admitted to the intensive care unit following surgery; 6 had acute renal insufficiency, 5 had acute respiratory insufficiency, and 12 were suffering from infectious shock. The infections included septicaemia (19), urinary tract infection (10), respiratory tract infection (4) and biliary tract infection (4). The most frequent bacterial isolate was Escherichia coli (14), followed by Enterobacter cloacae (5), Proteus spp. (5) and Klebsiella pneumoniae (4). The initial pathogens were eliminated in 34/40 infections (85%) and the corresponding clinical cure rate was 60%, with a further 27.5% of patients being improved. In the septicaemic patients, 17/19 pathogens were eradicated from the blood, while clinically, 12 patients were cured and 5 were improved. Eight of the 10 urinary tract pathogens were eliminated, with 6 patients being clinically cured and a further 3 being improved. All of the initial pathogens in both biliary tract and respiratory tract infections were eradicated, accompanied by clinical success in 3 and 2 patients, respectively; the remaining patients were improved. Superinfection with streptococcus group D, Pseudomonas aeruginosa and Staphylococcus aureus was seen in 3 patients. The emergence of resistance to temocillin occurred in an isolate of E. coli, and also possibly in an isolate of K. pneumoniae. No adverse reactions nor abnormal laboratory values related to temocillin administration were observed and, although 7 patients died, none of the deaths were attributable to uncontrolled Gram-negative infection.

Endotoxemia and bacteremia in patients with sepsis syndrome in the intensive care unit.

STUDY OBJECTIVES: To study circulatory endotoxin (ET) in patients with sepsis syndrome (SS) in order to answer three questions: (a) How often and at which concentration is ET present in the plasma of patients with SS and is the presence of ET a prognostic marker in this situation? (b) Is detection of ET helpful in predicting Gram-negative bacterial infections with or without bacteremia? (c) What are the kinetics of clearance of ET concentrations in plasma? DESIGN: Prospective study of consecutive patients fulfilling Bone's criteria for SS. SETTING: Medical ICU in a teaching hospital. PATIENTS: The study included 93 patients. The simplified acute physiologic score was 19 +/- 6, 49 percent were in shock, and 54 percent were mechanically ventilated. The mortality at day 28 was 53 percent. MEASUREMENTS: Endotoxin determinations and blood cultures were performed simultaneously at the onset (day 1) of SS. Samples were collected on several days from 48 patients. Endotoxin concentration was determined using an end point chromogenic Limulus assay. For the first ET determination, the mean circulatory level (mean +/- SEM) was calculated among patients with detectable ET, thus excluding patients with a null value for ET. RESULTS: On day 1, ET was detected in 44 patients (47 percent; 60.2 +/- 16.5 pg/ml) and was statistically more frequent in patients with shock, elevated plasma lactate, and organ failure. There was no statistical difference for age, gender, ratio of PaO2 to fraction of inspired oxygen. Among patients with proven Gram-negative bacterial infection (n = 46), ET was detected in 67 percent as compared with 28 percent without Gram-negative bacterial infection (p = 0.0001). On day 1, among 19 patients who had positive blood cultures with Gram-negative bacteria (GNB), 15 had detectable ET (79 percent, 61 +/- 22 pg/ml). In 14 other patients whose blood cultures were positive for GNB but became negative on day 1, 9 had detectable ET (64 percent; 36 +/- 6.5 pg/ml). Endotoxin declined linearly between days 1 and 4. CONCLUSION: In our study, the plasma ET concentration predicts neither Gram-negative infection, with or without bacteremia, nor the outcome. However, when ET is present in the plasma of patients with SS it remains detectable for a long period of time as compared to its rapid disappearance from plasma of animals or healthy human volunteers receiving ET intravenously. This slow clearance of ET suggests either a continuous release or a defect in its clearance.

Generalized air cysts complicated by fatal bilateral pneumothoraces in a patient with AIDS-related Pneumocystis carinii pneumonia.

We describe a case of air cyst lesions in an AIDS patient suffering from Pneumocystis carinii pneumonia. This case is unique because these lesions were generalized to both lungs and initially well tolerated. Pathologic examination revealed extensive tissue invasion by P carinii. The prognosis was complicated by bilateral pneumothoraces. Surgical right pleurodesis allowed lung re-expansion but did not prevent recurrence of fatal contralateral pneumothorax.

Bedside detection of retained tracheobronchial secretions in patients receiving mechanical ventilation: is it time for tracheal suctioning?

OBJECTIVE: To identify parameters that indicate retained secretions and the need for tracheal suctioning (TS) in patients receiving mechanical ventilation (MV). DESIGN: Prospective observational study. SETTING: A 14-bed medical ICU in a 946-bed university hospital. PATIENTS: Sixty-six consecutive patients receiving MV. INTERVENTIONS: Two successive tracheal suctions, TS1 and TS2, performed at a 2-h interval as usual patient care. Retained secretions were considered significant if the volume of secretions removed by TS2 was > 0.5 mL. MEASUREMENTS AND RESULTS: Variations between TS1 and TS2 of pulse oximetric saturation (SpO(2)), peak inspiratory pressure (Ppeak), tidal volume (VT), and Ramsay score were compared between patients with TS2 < or = 0.5 mL (group 1; n = 27) and patients with TS2 > 0.5 mL (group 2; n = 39). The presence of a sawtooth pattern on flow-volume loop displayed on the monitor screen of the ventilator and of respiratory sounds heard over the trachea before TS2 were compared between the two groups. Variations of Ppeak, VT, SpO(2), and Ramsay score between TS1 and TS2 did not differ between the two groups. However, group 2 had a sawtooth pattern (82% vs 29.6%; p = 0.0001) and respiratory sounds (66.6% vs. 25.9%; p = 0. 001) more frequently than group 1 before TS2. For the sawtooth pattern, the likelihood ratio (LR) of a positive test was 2.70 and the LR of a negative test was 0.25, while for respiratory sounds it was 2.50 and 0.45, respectively. When the presence of a sawtooth pattern and of respiratory sounds was combined, the LR of a positive test rose to 14.7 and the LR of a negative test was 0.42. CONCLUSIONS: A sawtooth pattern and/or respiratory sounds over the trachea are good indicators of retained secretions in patients receiving MV and may indicate the need for TS. Conversely, the absence of a sawtooth pattern may rule out retained secretions.

A paradoxical effect of bronchodilators.

Lactic acidosis previously has been reported during treatment of asthma with beta-2 agonists. However, this metabolic disturbance never had any clinical consequence. We report a case of a patient with asthma in whom beta-2 agonist administration increased dyspnea by metabolic acidosis due to a sharp increase in lactate levels (hyperlactatemia) and led to inappropriate intensification of bronchodilator therapy.

Polycythemia in chronic obstructive pulmonary disease. A study of serum and urine erythropoietin and medullary erythroid progenitors.

In order to investigate the mechanism of polycythemia in chronic obstructive pulmonary disease (COPD), serum and urinary levels of erythropoietin and medullary erythroid progenitors were studied in 21 patients; nine were nonpolycythemic (hematocrit, 39 +/- 4 percent; red blood cell [RBC] mass, 28 +/- 5 ml/kg; forced expiratory volume in one second [FEV1], 0.6 +/- 0.1 L), and 12 patients were polycythemic (hematocrit, 52 +/- 7 percent; RBC mass, 46 +/- 7 ml/kg; FEV1, 0.9 +/- 0.3 L). Hypoxia was severe in both groups, with mean arterial oxygen pressure of 47 mm Hg. The following parameters of tissue oxygenation were not significantly different between the two groups: arterial and mixed-venous oxygen saturations; cardiac output; oxygen utilization coefficient; 2, 3-diphosphoglycerate, and carboxyhemoglobin level. The level of erythropoietin was measured by bioassay in vitro. The level was increased in the serum of 85 percent (18) and in the urine of 38 percent (8) of the patients. There was no significant difference between the nonpolycythemic and polycythemic groups. Without exogenous erythropoietin, none of the subjects showed spontaneous colonies of erythroid progenitors. The addition of one unit of erythropoietin induced a similar normal proliferation of erythroid progenitors in both groups. The absence of adaptative polycythemia in the nonpolycythemic group with severe hypoxia was seemingly related neither to a quantitative deficit of erythropoietin nor to a lack of sensitivity of erythroid progenitors to its action.

Mechanical ventilation for Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome. Is the prognosis really improved?

The mortality rate among patients with human immunodeficiency virus (HIV) requiring mechanical ventilation (MV) for acute respiratory failure (ARF) secondary to Pneumocystis carinii pneumonia (PCP) is still a matter of discussion. For some authors, it is in the 50 percent range, while for others the prognosis is grim, with virtually no survivors. The aim of this retrospective study conducted between January 1987 and January 1992 was to analyze the outcome of such patients. We studied 33 patients, 29 men and 4 women (38.6 +/- 9.9 years, 21 homosexuals, 8 intravenous drug users, 3 transfusion related, 1 heterosexual) infected by HIV for at least 19.7 +/- 21.6 months. It was the first PCP episode in all but 2 patients and the diagnosis was made by bronchoalveolar lavage (n = 32) or lung biopsy specimen (n = 1). Only three patients were receiving primary prophylaxis for PCP (trimethoprim-sulfamethoxazole [TMP-SMZ], n = 2; pentamidine, n = 1). Pneumocystis carinii pneumonia was the first manifestation of AIDS in nine patients. The duration of symptoms prior to treatment was 19.6 +/- 11.3 days. At the time of hospital admission, laboratory findings were as follows: PaO2 = 40.7 +/- 7.8 mm Hg on room air; serum LDH = 1,172 +/- 792 IU/L; T4 cell count = 60.2 +/- 67/mm3. Mechanical ventilation was always required for ARF, which was never induced by bronchoscopy. The interval between treatment and MV was 8.1 +/- 6.5 days and the duration of MV was 11.4 +/- 9.9 days. The patients were classified into 3 groups on the basis of the duration and type of treatment before MV, as follows: group 1, n = 10: TMP-SMZ (20-100 mg/kg) IV and methylprednisolone (MP) < 5 days before MV; group 2, n = 4: TMP-SMZ > or = 5 days and MP < 5 days; group 3, n = 19: TMP-SMZ and MP > or = 5 days before MV. (The MP dose was as follows: 240 mg/d once a day from day 1 to day 3; 120 mg/d from day 4 to day 6; and 60 mg/d from day 7 to day 9.) Despite MV, TMP-SMZ, and MP, death secondary to PCP-related ARF occurred in 81.9 percent of patients, 20 +/- 4.8 days after the beginning of treatment and 11.4 +/- 9.9 days after the beginning of MV. Six patients survived, five in group 1 and one in group 3.(ABSTRACT TRUNCATED AT 400 WORDS)

Severe accidental hypothermia treated in an ICU: prognosis and outcome.

STUDY OBJECTIVES: To assess the characteristics and outcomes of patients admitted to an ICU for severe accidental hypothermia, and to identify risk factors for mortality. METHODS: All consecutive patients admitted to an ICU between January 1, 1979, and July 31, 1998, with a temperature of < or = 32 degrees C were retrospectively analyzed. Rewarming was always conducted passively with survival blankets and conventional covers. Prognostic factors were studied by means of univariate analysis (Mann-Whitney U and chi(2) tests) and multivariate analysis (logistic regression). RESULTS: Forty-seven patients were enrolled (mean +/- SD age, 61.7 +/- 16 years). Five patients had a cardiac arrest before ICU admission. Patient characteristics at ICU admission were as follows: temperature, 28.8 +/- 2.5 degrees C; systolic BP, 85 +/- 23 mm Hg; heart rate, 60 +/- 24 beats/min; Glasgow Coma Scale, 10.4 +/- 3.7; and simplified acute physiology score (SAPS) II, 50.9 +/- 27. Mechanical ventilation was necessary in 23 cases, and 22 patients in shock received vasoactive drugs. The mean length of stay in the ICU was 6.7 +/- 9 days. Eighteen patients (38%) died, but ventricular arrhythmia was never the cause. Univariate analysis identified several prognostic factors (p < 0.05): age (57 +/- 16 years vs 69 +/- 14 years), systolic arterial BP (93 +/- 20 mm Hg vs 71 +/- 21 mm Hg), blood bicarbonate level (23.5 +/- 5.2 mmol/L vs 16.6 +/- 6.2 mmol/L), SAPS II score (35.3 +/- 19.5 vs 72 +/- 21), mechanical ventilation (34% vs 81%), vasopressor agents (42% vs 82%), rewarming time (11.5 +/- 7.2 h vs 17.2 +/- 7 h), and discovery of the patient at home (2.3% vs 54.5%). The initial temperature did not influence vital outcome (28.9 +/- 2.6 degrees C vs 28.6 +/- 2.2 degrees C). Only the use of vasoactive drugs (odds ratio, 9; 95% confidence interval, 1.6 to 50.1) was identified as a prognostic factor in the multivariate analysis. CONCLUSION: Severe accidental hypothermia is a rare cause of ICU admission in an urban area. Its mortality remains high, but there is no overmortality according to the SAPS II-derived prediction of death. Shock, requiring treatment with vasoactive drugs, is an independent risk factor for mortality, while initial core temperature is not. It remains to be determined whether aggressive rather than passive rewarming procedures are better.

Capillary leakage complicated by compartment syndrome necessitating surgery.

A single episode of systemic capillary leak syndrome is reported in a HIV-positive patient. The shock had necessitated the infusion of large amounts of fluid with concomitant diffuse swelling and weight gain leading to compartment syndrome of both legs. This required surgical relief. The initial high hematocrit (62%) and low serum protein concentration (48 g/l) with normal factor V (molecular weight above 300,000) concentrations are the hallmark of capillary leak when they are associated with hypovolemic shock. It must be emphasized that fluid resuscitation may worsen the muscle damage with ultimate compartment syndrome. Therefore, it appears reasonable to monitor muscular pressure during volume expansion in patients with capillary leak syndrome, severe shock and muscular swelling.

Prospective evaluation of self-extubations in a medical intensive care unit.

OBJECTIVE: To evaluate the incidence, associated factors and gravity of self-extubations. DESIGN: Prospective study about all patients intubated over an 8 month period. SETTING: A medical intensive care unit of a University Hospital. PATIENTS: Patients were divided into two groups: self-extubated and those that did not. The self-extubations were separated into deliberate acts by the patients and accidental. RESULTS: 24 of the 197 patients included presented a total of 27 extubations (12%). There were 21 deliberate incidents and 6 accidental. The only differences between the cases and the rest of the population were a higher mean age (67 vs 59 years) and a larger proportion of chronic respiratory failure (66% versus 35%). Reintubation was necessary in 20 cases (74%) within 30 min in 16 cases. The main indication for reintubation was acute respiratory distress (90%). Reintubation was associated with one death. CONCLUSION: Self-extubation is a frequent and serious complication of mechanical ventilation. Deliberate self-extubation, the most frequent type of incident could possibly be reduced by better sedation of agitated patients and accidental self-extubation by better training of the nursing staff.

Meningoencephalitis due to penicillin-resistant Streptococcus pneumoniae.

The case of a 68-year-old man suffering from pneumococcal meningoencephalitis is reported. Antibacterial susceptibility tests revealed a multiply resistant pneumococcal strain. High doses of cefotaxime were necessary to sterilize the cerebrospinal fluid despite the achievement of a satisfactory level of antibiotic in the cerebrospinal fluid with moderate dosage. In France, as well as in many countries, high doses of third-generation cephalosporins such as cefotaxime or ceftriaxone should be administered for the initial therapy of suspected pneumococcal meningitis.

Prolonged sedation requiring mechanical ventilation and continuous flumazenil infusion after routine doses of clorazepam for alcohol withdrawal syndrome.

We report the cases of two patients who developed prolonged sedation after routine doses of clorazepam for alcohol withdrawal syndrome. They required prolonged mechanical ventilation (10 days for both patients) followed by continuous flumazenil infusion (16 days for one patient and 3 days for the other) to avoid reintubation. In the two patients, nordazepam accumulation (main active metabolite of clorazepam) was demonstrated as the cause of the coma. This accumulation could be attributed, in one case, to impaired hepatic cytochrome P 450 3A4 activity. Caution is required when prescribing benzodiazepines to alcoholic patients and the use of benzodiazepine which do not undergo hepatic oxidation by cytochrome P 450 such as oxazepam or lorazepam is suggested.

Fatal herpetic hepatitis in adult following short corticotherapy: a case report.

Herpes simplex virus hepatitis (HSV hepatitis) is an uncommon and severe complication of HSV type 1 and HSV type 2 infection. HSV hepatitis affects mostly immunocompromised patients. We report the case of a young man without any previous known immunodeficiency who developed fatal HSV hepatitis in the first 8 days of oral corticotherapy given for ulcerative colitis. A prompt diagnosis was possible because HSV was recovered from peripheral blood leukocytes.

Phospholipase and prophospholipase activities in bronchoalveolar lavage fluid in severe acute pulmonary disease with or without ARDS.

Bronchoalveolar lavages were performed in 21 patients undergoing mechanical ventilation: Group I: coma due to sedative overdose (11 cases), without pulmonary impairment, serving as control group; Group II: severe acute pulmonary disease without ARDS (5 cases); Group III: patients with ARDS (5 cases). In the recovered fluid we measured: total proteins (P) and phospholipids (PL), phospholipasic (PLase) and prophospholipasic (PPLase) activities. In ARDS group, considerable increase of P, (p less than 0.001), and a doubling of PL (p less than 0.02) was found. Total PLase activity was present in all three groups, with a higher mean level in Group III (p less than 0.01). PPLase activities were low or undetectable in four patients of this group. PLase/PL ratio was increased in acute respiratory insufficiency, with or without ARDS, suggesting an increase of surfactant catabolism. The decrease of this ratio when pulmonary function improved, or its increase after deterioration suggest that it is related to changes of surfactant.

A monthly systematic bacteriological report improves accuracy of identification of hospital-acquired infections in an ICU.

A prospective cohort study with retrospective validation was initiated in order to assess whether a monthly bacteriological report improves the accuracy in detecting hospital-acquired infections (HAI). The setting was a 14-bed medical intensive care unit (ICU) in a 821 bed French university affiliated hospital. One thousand, six hundred and two patients were admitted during the two-year study period, the mean age was 58+/-19 years, the mean Simplified Acute Physiology Score 2 (SAPS 2) was 34+/-21, and ICU mortality was 14%. The microbiology laboratory sent monthly bacteriological reports of urine samples and central venous catheter (CVC) tips back to the intensive-care unit physician in charge of the HAI surveillance programme. This enabled a comparison to be made between prospectively and retrospectively diagnosed hospital-acquired urinary tract infections (HAUTI) and CVC-related infections (HACVCI), HAUTI were prospectively identified in 51 cases (incidence density=10.03/1,000 days) and 23 more cases were found after receiving the monthly bacteriological report (final HAUTI incidence density=14.6/1,000 days, P<0.05). HACVCI were prospectively recognized in 13 cases (incidence density=4/1,000 days) and eight more cases were discovered (final HACVCI incidence density=6.52/1,000 days,P >0.1). All retrospectively diagnosed HAI occurred during the last 48 h of the patients' ICU stay. We conclude that the routine HAI surveillance programme is reliable, except for the last 48 h in the ICU. The monthly bacteriological report improved the accuracy of the HAI reporting rate.

Biochemical assessment of nutritional status in patients with chronic obstructive pulmonary disease and acute respiratory failure on admission to an intensive care unit.

Although chronic obstructive pulmonary disease (COPD) is associated with weight loss and malnutrition, there is a paucity of relevant data on COPD patients with acute respiratory failure (ARF). We studied 30 consecutive patients on the day of admission to our intensive care unit for ARF. In addition to a clinical work-up, the following biochemical parameters were determined: markers of nutritional status (albumin - ALB, transferrin - TRF, transthyretin - TTR, retinol binding protein - RBP, fibronectin), inflammation (C-reactive protein - CRP, alpha(1) glycoprotein acid - alpha(1)GPA) and catabolism (plasma phenylalanine - PHE, urinary 3-methylhistidine - 3-MH). Values were expressed as mean +/- SD and compared to those of 10 healthy subjects matched for age. COPD-ARF patients had a poor protein status (ALB = 30 +/- 5 vs 42 +/- 3 g.l(-1); TTR = 118 +/- 75 vs 251 +/- 43 mg.l(-1); RBP = 23 +/- 12 vs 46 +/- 8 mg.l(-1); p < 0.001), were hypercatabolic (3-MH Cr = 31 +/- 12 vs 22 +/- 7 mumol.mmol Cr (-1); PHE = 62 +/- 27 vs 46 +/- 10 mumol.l(-1); p < 0.001) and inflamed (CRP = 68 +/- 50 vs 12 +/- 5 mg.l(-1); alpha(1)GPA = 1.2 +/- 0.4 vs 0.5 +/- 0.1 g.l(-1); p < 0.001). Severity of the disease correlated with short half-life proteins and protein catabolism markers but not with inflammation markers. Considering ALB, TTR, RBP, the 3- MH Cr ratio and PHE values, the 30 COPD patients fell into 3 groups: chronic malnutrition (n = 7), acute malnutrition (n = 2), and acute + chronic malnutrition (n = 18). 3 patients had normal nutritional status. We conclude that an assessment of nutritional status at admission to intensive care units could contribute towards a rapid formulation of specific nutritional therapy.

Hemodynamic tolerance and plasma volume variations during plasma exchange. Replacement fluid: albumin alone or albumin plus gelatin?

Little is known about mechanisms of systemic hypotension frequently reported during plasma exchange (PE). Type of substitution fluids may interfere with hemodynamic tolerance. In a prospective study, right heart catheterization was performed during 18 PE by filtration with isovolumic substitution. Blood volume was measured with 51Cr tagged erythrocytes and plasma volume (PV) calculated from hematocrit. Substitution fluids were either albumin (A; n = 9) or A + gelatin (A + G; n = 9). In both groups, PE induces significant (p less than 0.01) decreases of mean arterial pressure: group A: - 21 +/- 14%; group A + G: - 23 +/- 15%; of pulmonary wedge pressure: group A: - 41 +/- 33%; group A + G: - 36 +/- 22%; of cardiac index: group A: - 38 +/- 18%; group A + G: - 25 +/- 15%. Plasma volume also decreases after PE: group A: - 13.5 +/- 4%; group A + G: - 18.5 +/- 4%. None of the variations are significantly different between the two groups. So we think that substitution with albumin alone has no advantage for hemodynamic tolerance.