[Refractory oedema: think about systemic capillary leak syndrome]. / Syndrome oedémateux réfractaire: penser au syndrome d'hyperperméabilité capillaire idiopathique.

Systemic Capillary Leak Syndrome (SCLS) is a rare and recently discovered disease. The diagnosis must be evoked in front of an hypovolaemic shock associated with a refractory anasarca. We report an observation of SCLS and then discuss the diagnostic and therapeutic difficulties. SCLS is diagnosed when a patient meet a compatible clinical situation with an hypoalbuminemia in spite of relative hemoconcentration. Evidence of a monoclonal gammapathy constitute an additional clue.

[Trichomonas tenax in pulmonary and pleural diseases]. / Pleuro-pneumopathie à Trichomonas tenax.

INTRODUCTION: Trichomonas is a protozoan rarely incriminated in pulmonary or pleural disorders. CASE: An 84-year-old man, under treatment for chronic lymphoid leukemia with hypogammaglobulinemia, was hospitalized for respiratory distress and fever due to bilateral pulmonary and pleural disorders. Direct examination of the bronchoalveolar lavage fluid revealed a flagella protozoan identified as Trichomonas tenax. DISCUSSION: Although Trichomonas is rare in pulmonary disorders, when it occurs, T. tenax appears to be the most common species. Treatment with metronidazole was effective.

Surgical management of Candida suppurative thrombophlebitis of superior vena cava after central venous catheterization.

Septic deep venous thrombosis is a major complication associated with central venous catheterization in intensive care units. The most common causative organisms are Staphylococcus aureus, gram-negative bacilli and Candida species. The incidence of Candida infections is increasing, especially in intensive care patients receiving total parenteral nutrition and long-term broad-spectrum antibiotics. Although intravascular catheter-induced septic thrombophlebitis is quite common, superior vena cava obstruction is a rare complication. However, few data exist concerning the best strategy for managing septic thrombophlebitis, especially when medical therapy fails. We report successful surgical management of Candida albicans suppurative thrombosis of the superior vena cava in a young patient.

Postpartum cerebral angiopathy associated with the administration of sumatriptan and dihydroergotamine--a case report.

Cerebral angiopathy of the postpartum period is a rare entity, sometimes promoted by vasoconstrictives drug prescription. Its clinical presentation includes headaches, seizures and focal neurological deficits, which develop shortly after a normal pregnancy. The diagnosis is based on clinical findings and angiography, showing multiple narrowing of the intracranial cerebral arteries. This neurological feature is reversible and the clinical outcome is good. We report a case of benign cerebral angiopathy in a 20-year-old woman in the postpartum period, occurring after administration of sumatriptan and ergot derivates.

Economic impact of a rational use of antibiotics in intensive care.

OBJECTIVE: To evaluate the economic impact of a rational policy in antibiotic treatment. DESIGN: Comparative study with a retrospective and a prospective part. SETTING: An 11-bed intensive care unit (ICU) in a general hospital. PATIENTS: All patients admitted to the unit in 1994, 1995 and 1996. INTERVENTIONS: In 1995, a program of cost control was started and a contract of agreed objectives signed with the director of the hospital. This contract included a commitment to refund the eventual savings in order to improve the quality of care. Prescribing protocols were established by consensus as guidelines for a rational policy in antibiotic therapy. MEASUREMENTS AND RESULTS: The cost of antibiotic therapy, the patients' characteristics and the incidence of nosocomial infection were compared prior to and during the program. The expenses for antibiotic drugs decreased by 19% in 1995 and by 22% in 1996. Most of the savings were refunded to the ICU and contributed to the employment of an additional nurse and the purchase of new material. In number of patients, type of disease, mean age, Simplified Acute Physiology Score, occupancy rate, length of stay, omega score, artificial ventilation, readmission within 7 days, mortality and incidence of nosocomial infection, no significant difference was found. CONCLUSIONS: We proved a positive economic impact of a rational policy in antibiotic therapy realized with a contract of agreed objectives. The savings made while applying our program of cost control were used to improve the quality of care.

[Degree of hemodynamic disturbance at the hyperacute phase of stroke: predictive value of 3D-TOF angiography and the T2 fast-FLAIR sequence]. / Volume du trouble hémodynamique à la phase hyperaiguë d'un AVC: valeur prédictive de l'angiographie 3D-Tof et de la séquence T2 fast-FLAIR.

GOAL: To define during the hyperacute phase of stroke the value of 3D-TOF MR angiography (MRA) and T2 fast-FLAIR sequence for predicting the volume of tissue presenting a hemodynamic disturbance. MATERIAL: and method: Thirty-five cases of hyperacute stroke located in following territories: middle cerebral artery (MCA) (n=29), anterior choroidal artery (AChoA) (n=5) and watershed (n=1) were retrospectively reviewed. The vascular abnormalities defined on MRA (vessel stenosis or occlusion) or FLAIR sequence (vessel hyperintensity) were classified into 3 groups: normal (I), distal abnormalities (II), abnormalities of the entire arterial territory (III). These results were compared with the volume of tissue showing a prolonged mean transit time (MTT) determined on relative MTT maps calculated from bolus tracking MR perfusion images. RESULTS: The abnormal volume measured on the MTT map was significantly correlated to the results of the MRA and FLAIR sequence. In the 12 cases of group III defined on the MRA (abnormality from M1), the volume of hemodynamic disturbance was always higher than 100 ml. For the MCA territory, it was not possible to predict the presence of a hemodynamic disturbance in any of the 3 groups defined on the FLAIR sequence and in the groups I and II defined on the MRA. For the AChoA territory, a hemodynamic disturbance was never observed in groups I and II defined either on MRA or FLAIR sequence. CONCLUSION: When there was no flow within the M1 segment on the MRA, there was always a hemodynamic disturbance larger than 100 ml on the MTT map. In the case of AChoA ischemic lesion, when no vascular abnormality was observed on the MRA or FLAIR images, the MTT map was always normal.

[Nasogastric tube: intratracheal malposition and entrapment in a bronchial suture]. / Sonde nasogastrique: fausse route intratrachéale et inclusion dans une suture bronchique.

We report the unrecognized accidental intratracheal insertion of a nasogastric tube, following endotracheal intubation in a patient scheduled to undergo right lower lobectomy for carcinoma. After surgery, which had an unremarkable course, the trachea was extubated. However, the gastric tube was entrapped and attempts to withdraw it elicited fits of coughing. A chest X-ray showed the tube malpositioned in the right bronchus. A fibreoptic bronchoscopy did not permit removal of the tube extremity which was embedded in the bronchial suture. Finally an additional thoracotomy was required to withdraw the tube securely. The manifestations of the intratracheal position of a nasogastric tube as well as the preventive and diagnostic measures of such a complication are considered.

[Economic impact of a prescription protocol in an intensive care unit]. / Impact économique d'un protocole de prescription en réanimation.

OBJECTIVE: To assess the economic impact of a prescribing protocol for i.v. fluid therapy and artificial nutrition. STUDY DESIGN: Comparative study, before and during use of the protocol. PATIENTS: The study included 555 ICU patients allocated into two groups, before and after starting with the protocol. The groups were comparable for number, pathologies, age, severity score, duration of ICU stay, incidence of nosocomial infections, mortality rate. METHOD: In February 1995, a written literature-based prescribing protocol for fluid therapy (hydroxyethylstarch and albumin), and artificial nutrition (enteral nutrition as first-line therapy) was devised. A cost analysis was made for two 6-month periods: before (August 1994 to January 1995) and after start of protocol (February to July 1995). RESULTS: The prescription of albumin and hydroxyethylstarch decreased (by 33 and 58% respectively), whereas administration of Ringer lactate and gelatine solutes increased simultaneously. This induced a cost saving of 15,000 FF (a 20% decrease in cost). The reduction of parenteral nutrition in favour of early enteral nutrition induced a cost saving of 56,000 FF (31% decrease in cost). CONCLUSION: Our prescribing protocol generated a cost saving of 9% of the pharmaceutical budget and decreased the cost-benefit ratio of our ICU.

[Efficacy, safety and cost of sedation with sevoflurane in intensive care unit]. / Efficacité, tolérance et coût d'une sédation par sévoflurane en réanimation.

OBJECTIVES: To study efficacy, systemic and cerebral haemodynamic, and cost of sedation with sevoflurane after midazolam failure. STUDY DESIGN: Prospective observational study in a mixed intensive care unit. PATIENTS AND METHODS: Mechanically ventiled patients in whom deep sedation failed (Ramsay score<5 despite midazolam 10mg/h and fentanyl 400µg/h) were enrolled. Sedation with sevoflurane and fentanyl (200µg/h) was performed during 48 hours. Sevoflurane was administered with a dedicated filter (AnaConDa™) and sevoflurane infusion rate was adjusted in order to achieve a Ramsay score ≥5. Ramsay score, mean arterial blood pressure, norepinephrine dose/24h, intracranial pressure and cerebral perfusion pressure in patients with brain injury were measured. Directs costs for sedation were calculated. An analysis of variance for repeated measures compared values between D0 (intravenous sedation), D1 and D2 (inhaled sedation). RESULTS: Twenty-five patients (age=51 [38-63], SAPS II=43 [33-49]) were enrolled. Ramsay score was 4 [4,5] at D0 and 6 [6] at D1 and D2 (P<0.05 vs D0). Mean arterial pressure was significantly lower at D1 (80 [73-86] mmHg) as compared to D0 (84 [77-92] mmHg) and D2 (84 [78-91] mmHg) (P<0,05). Norepinephrine consumption was lower at D2 as compared to D1 (P<0,05). Intracranial pressure was lower at D1 (9 [5-13] mmHg) and D2 (11 [7-15] mmHg) as compared to D0 (12 [7-17] mmHg) (P<0.05). PPC was stable at D1 and increased at D2. Directs costs were significantly increased with sevoflurane. CONCLUSION: Sevoflurane is an effective and safe alternative to midazolam in ICU patients associated with a moderate increase in costs.