Bronchoalveolar lavage in trauma patients for diagnosis of fat embolism syndrome.

Fat embolism syndrome (FES) is a rare but serious complication occurring after long bone fractures. Presence of fat droplets in cells obtained by bronchoalveolar lavage has been proposed as a specific tool for FES diagnosis in trauma patients. We evaluated this technique over a 15-month period in 85 patients. Twenty-eight patients were excluded. The remaining 57 patients were divided into three groups: group 1, 26 patients without trauma as control; group 2, 22 patients with trauma but without evidence of FES; and group 3, nine patients with trauma and evidence of FES. Six of 26 patients in group 1 and nine of 22 patients in group 2 exhibited fat droplets in alveolar macrophages, whereas three of nine patients of group 3 had not. This study suggests that (1) presence of fat droplets in alveolar macrophages is not a reliable method for diagnosis of FES after long bone trauma, and (2) many conditions are associated with fat droplets in alveolar macrophages.

Comparison of transesophageal and transthoracic contrast echocardiography for detection of an intrapulmonary shunt in liver disease.

STUDY OBJECTIVES: Contrast transthoracic echocardiography (TTE) is currently used to identify intrapulmonary shunt (IPS) in patients with end-stage liver disease. The aim of this study was to compare the use of contrast TTE and transesophageal echocardiography (TEE) in detecting IPS. DESIGN: Thirty-seven consecutive outpatients with severe liver disease awaiting liver transplantation underwent contrast TEE and TTE. The IPS was assessed semiquantitatively in four grades with TEE and as positive or negative with TTE. SETTING: ICU. INTERVENTIONS: Patients underwent contrast TEE after pharyngeal anesthesia alone followed by contrast TTE. Contrast echocardiography was performed with a modified fluid gelatin solution. RESULTS: Overall detection rate of an IPS was 51% with TEE and 32% with TTE (p < 0.001). Four patients had an IPS detected with TEE but not with TTE. Quality of imaging was poor in 22% with TTE and 0% with TEE (p < 0.001). A PaO2 < 80 mm Hg or a dyspnea was associated with an IPS in 56% and 50% of patients with TEE and in 33% and 25% with TTE, respectively. CONCLUSION: Contrast-enhanced TEE is superior to TTE for detecting an IPS in patients with severe liver disease awaiting liver transplantation. The use of gelatin contrast solution allows an early detection of IPS. Because of the high sensitivity of TEE, all patients suspected of hepatopulmonary syndrome should undergo TEE in search of an IPS if TTE is normal.

Plasma fibronectin and complement following infusion of colloidal solutions after spinal anaesthesia.

A randomized study of 30 patients undergoing uncomplicated surgery under spinal anesthesia was conducted to assess the influence of colloids on the kinetics of plasma fibronectin and complement. Both are opsonins of the reticuloendothelial system; moreover fibronectin is concerned with host resistance against septic complications following trauma and surgery. The patients were assigned to receive either Ringer's lactate (Group 1), gelatin (Group 2) or dextran 40 (Group 3). Blood samples were withdrawn before colloids or Ringer's infusion and during the 4 postoperative days. There was a reduction in plasma fibronectin throughout the study in groups 1 and 3, but an increase in group 2 by 24 h. The adhesion of plasma fibronectin to gelatin was maximal 1 h after infusion (44%) and remained significant up to day 2 in group 2. There was no relationship in groups 1 and 3. C3 and C4 components of complement exhibited a low value in the early post-operative period, due to hemodilution. This study shows an in vivo fibronectin-gelatin interaction, and suggests that gelatin infusion inhibits the increased shift of plasma fibronectin at the site of tissue injury after surgery.

Increased lactate/pyruvate ratio with normal beta-hydroxybutyrate/acetoacetate ratio and lack of oxygen supply dependency in a patient with fatal septic shock.

We report a case of fatal septic shock, with hyperlactatemia and blood cultures positive for Streptococcus pneumoniae, in a 70-year-old patient. On two occasions (5 days, and 2 days before the patient's death), the relationship between oxygen delivery (DO2) and consumption (VO2) was examined in conjunction with two presumed markers of tissue oxygenation: the lactate/pyruvate ratio (L/P), and the beta-hydroxybutyrate acetoacetate ratio (beta OHB/AcAc). Increasing DO2 by about 30% ("oxygen flux test") failed to increase VO2. The beta OHB/AcAc ratio remained within normal limits, thus suggesting uncompromised tissue oxygenation at the hepatic level. The L/P ratio remained persistently above normal limits, thus suggesting actual organ or regional hypoxia. This case shows that during an overwhelming septic shock, the "oxygen flux test" can be negative, despite the presence of hyperlactatemia and of an increased L/P ratio suggestive of impaired tissue oxygenation.

Major cellulitis following percutaneous tracheostomy.

Percutaneous tracheostomy, a technique that can be performed at the bedside in the intensive care unit (ICU), is increasingly used for critically ill ventilator-dependent patients. Based on many clinical studies, this procedure appears to be simple, rapid and safer than conventional surgical tracheostomy. This technique produces a stoma tissue tract that fits snugly around the cannula, and this could explain the low incidence of infective complications. However, we report two cases of life-threatening cellulitis, a serious complication that has rarely been reported previously.

Bacteremia following cardiac arrest and cardiopulmonary resuscitation.

After out of hospital CPR thirty three resuscitated patients were studied for bacteremic complications. Thirteen patients (39%) had two or more positive blood cultures during the twelve hours following CPR. Source of superinfection was a central venous catheter in one case (staphylococcus). The twelve other bacteremic patients had fetid diarrhea a few hours after admission. The same organism were found in blood and faeces (streptococcus D, Escherichia coli, Pseudomonas aeruginosa, acinetobacter, enterobacter). Mesenteric ischemia caused by a low cardiac output may explain the diarrhea and the intestinal origin of the septicemia. All patients (12 cases) with diarrhoea and bacteremia died. Patients who recovered without neurologic sequelae (4 cases) had never been septic and never had diarrhea.

[Selective embolization of ruptured mycotic aneurysm of the duodeno-pancreatic arcade disclosing infectious endocarditis]. / Embolisation sélective d'un anévrysme mycotique rompu de l'arcade duodéno-pancréatique révélant une endocardite infectieuse.

The authors report a case of rupture of a mycotic aneurysm of the duodenal pancreatic arcade in a 68 year old man presenting with shock, abdominal pain and rigidity, complicating a case of infectious endocarditis. Emergency treatment consisted of selective embolisation with a coil. This treatment, proposed in view of the clinical condition of the patient and the anatomical particularity of the regional arterial vascularisation, may be a valuable alternative to classical surgery in this type of pathology.

[Effects of mechanical ventilation with PEEP on right to left intra-cardiac shunt caused by patent foramen ovale]. / Effets de la ventilation mécanique avec PEP sur le shunt intracardiaque droit-gauche par un foramen ovale perméable.

OBJECTIVE: To assess the presence of a patent foramen ovale (PFO) using colloid contrast transoesophageal echocardiography in mechanically ventilated patient with and without PEEP and it repercussion on PaO2. STUDY DESIGN: Prospective open before-after trial. PATIENTS: Forty-nine mechanically ventilated patients with respiratory failure (PaO2/FiO2 < 250). METHODS: PEEP assessment before and after adding a PEEP = 10 cmH2O. At each level of PEEP, semi-quantification of PFO was performed and arterial blood gases were withdrawn at FiO2 = 1, with 15 min at each level. Semi-quantification of the right-to-left intra cardiac shunt through a patent foramen ovale was obtained using the quantity of microbubbles in the left atrium on a basal short axis view. RESULTS: A PFO was detected in 11 out of 49 patients (22%). A right-to-left shunt developed in one and worsen in three patients when PEEP was added. In patients without a PFO, PaO2 increased significantly (from 119 +/- 10 mmHg to 145 +/- 10 mmHg, P < 0.001). In patients with a PFO, non significant changes occurred (118 +/- 15 mmHg to 120 +/- 17 mmHg). After adding PEEP, the difference between the two groups was significant (ANOVA, P < 0.05). Moreover, a PFO was present during the whole respiratory cycle in two out of 11 patients. These 2 patients exhibited a PaO2 < 100 mmHg with or without PEEP. CONCLUSION: This study suggests that mechanical ventilation with PEEP enhances an intracardiac right-to-left shunt through a PFO. This condition is responsible for the lack of improvement in blood oxygenation when PEEP is added. When a PFO is present all over the respiratory cycle, or when the oxygenation is worsened with PEEP, this positive pressure ventilation should be avoided. The deleterious consequences of mechanical ventilation on venous return may be minimized by partial ventilation and weaning from ventilator.

[Liver abscess caused by Streptococcus intermedius, following hemorrhoidectomy]. / Abcès hépatique à Streptococcus intermedius compliquant une hémorroïdectomie.

The pyogenic liver abscess is an uncommon but potentially lethal complication of colo-anal surgery. The authors report a case due to Streptococcus intermedius, a pathogen with a known ability to produce visceral abscesses, after haemorrhoidectomy. According to the French consensus conference, the patient had received a prophylactic preoperative antibiotic regimen consisting of metronidazole, active against S intermedius. Despite surgical therapy and adequate antibiotics, the patient died of hepatic failure.

[Superiority of fiberoptic inflation compared to fiberoptic bronchoscopy in the early treatment of atelectasis under mechanical ventilation]. / Supériorité de la fibroinsufflation par rapport à la fibroscopie bronchique dans le traitement précoce des atélectasies sous ventilation mécanique.

The purpose of this study was to compare the effectiveness of a simple technique of active lung reexpansion through a fiberoptic bronchoscope, using a large volume syringe, with that of the conventional fiberoptic bronchoscope suction. Thirty consecutive patients with atelectasis were divided at random into two groups: with and without active inflation. The two groups were similar as regards age, sex-ratio, side and area involved in atelectasis. The group without inflation was less hypoxaemic than the other group (PaO2 202 and 140 mmHg respectively). Early and lasting improvement in chest X-ray and arterial blood gases occurred in both groups, but patients were significantly more improved during fiberoptic inflation. No pneumothorax or haemoptysis was observed during the procedure. These data prompt us to recommend active inflation instead of fiberoptic bronchoscopy suction alone for the emergency treatment of patients with severe hypoxaemic atelectasis.

[Intra-macrophage lipid particles collected by bronchoalveolar lavage: incidence and diagnostic value]. / Particules lipidiques intramacrophagiques recueillies par lavage bronchoalvéolaire: fréquence et intérêt diagnostique.

This study aimed to determine the incidence and diagnostic value of fat-laden alveolar macrophages obtained by bronchoalveolar lavage (BAL). In 128 patients, including 66 patients admitted for multiple trauma, 158 BAL were carried out. However, 41 BAL from 32 patients were excluded because of poor quality of samples (not enough macrophages, too many ciliated cells, or haemorrhage). All the patients were intubated and mechanically ventilated, having pulmonary infiltrates on the chest film. BAL samples were examined after staining with oil-red-O. They were considered to be positive when more than 5% of alveolar macrophages contained fat droplets. Among them 14 out of 47 patients (30%) without multiple trauma were positive; 7/14 had never been given any intravenous lipid infusion, and 5/14 had aspiration pneumonia (as opposed to 3/32 patients with negative BAL). Further 27 patients out of the 49 (55%) with multiple trauma were positive. Among them 10/49 had clinical evidence of fat embolism, however, only 7/10 had positive samples. All these last ten patients had been given intravenous lipid infusions. The rate of positive alveolar macrophages was correlated neither with the plasma triglyceride concentration, nor the Fracture Index Score, nor the delay between the end of the lipid infusion and the BAL. There was no significant difference in PaO2/FIO2 ratio between the patients with positive and negative BAL. Positive BAL was significantly associated with lipid infusions. The data therefore suggest that the presence of fat-laden alveolar macrophages are associated with various pathological pulmonary conditions, particularly aspiration pneumonia and lipid infusions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Post-traumatic dissection of the aortic isthmus with favorable outcome without surgical treatment. Value of transesophageal echocardiography]. / Dissection post-traumatique de l'isthme de l'aorte d'évolution favorable sans traitement chirurgical. Intérêt de l'échocardiographie transoesophagienne.

We report a case of intimal rupture of aortic isthmus in a severe polytrauma patient diagnosed with transoesophageal echocardiography (TEE). TEE findings were as follows: localized intimal tear without increased aortic diameter or pseudoaneurysm, absence of mediastinal haematoma or false lumen. CT scan and MRI confirmed the diagnosis. Because of the associated injuries, surgery was delayed. Conservative management was successful and the patient was discharged without aortic surgery. A follow up TEE, 3 and 6 months later showed a thrombosis of the intimal tear without false aneurysm. This case underlines the value of TEE in patients with thoracic trauma, for surgical or nonsurgical management of aortic rupture and for the follow up of the patients.

[Clostridium perfringens septicemia associated with foodborne toxic infection and abortion]. / Septicémie à Clostridium perfringens associée à une toxi-infection alimentaire et un avortement.

A 32-year-old pregnant woman with poor life and hygiene conditions presented with premature labour, fever and diarrhoea. After admission she gave birth to a stillborn child. The examination revealed a septicaemia with massive haemolysis and renal failure. Six blood cultures obtained on admission yielded Clostridium perfringens. The outcome was favourable after an adapted antibiomicrobial therapy. This case illustrates the potential severity of Clostridium perfringens foodborne toxi-infection which can lead to abortion and septicaemia with massive haemolysis.

[Arterial embolism caused by an intra-aortic thrombus or a patent foramen ovale? Diagnosis by transesophageal echocardiography]. / Embolie artérielle par thrombus aortique ou foramen ovale perméable? Diagnostic par échocardiographie transoesophagienne.

This case report demonstrates the value of transoesophageal echocardiography (TOE) in comparison with transthoracic echocardiography as it allows a better view of the thoracic aorta, the auricles, the interauricular septum and the cardiac valves, especially in the intubated and ventilated patients. A 84-year-old woman was admitted to the ICU for hypoxia after carotid-subclavian bypass surgery for acute ischaemia of the left upper limb. The TOE showed a dilated right heart and a patent foramen ovale, compatible with pulmonary embolism as well as two thrombi in the aortic arch. The patient died on the 8th postoperative day from refractory hypoxia. the autopsy confirmed the pulmonary embolism and the intraaortic thrombi. It is concluded that TOE, readily feasible is indicated in case of hypoxia, shock and systemic embolism without cause immediately recognizable, especially in ventilated patients.

[The good use of antibiotics in intensive care: results of a program for rationalization of prescriptions]. / Du bon usage des antibiotiques en réanimation: résultats d'un programme de rationalisation de la prescription.

OBJECTIVE: To assess the impact of an antibiotic prescribing programme in a intensive therapy unit. TYPE OF STUDY: Prospective comparative study. METHODS: We compared antibiotic prescriptions and bacterial susceptibility to antimicrobial agents before and after introduction of a programme focusing on injection control and therapeutic indications. RESULTS: The introduction of the programme resulted in a major decrease in antibiotic administration. Moreover, the susceptibility of Pseudomonas aeruginosa to ticarcillin increased from 40 to 68%, and susceptibility of Staphylococcus aureus to methicillin increased from 55 to 73%. CONCLUSIONS: Antibiotic control policies must be considered integral to any effort to decrease resistance and cost of therapy with antibiotics.

[Colloid substitutes and hematocrit measurement by micromethods]. / Substituts colloïdaux et mesure de l'hématocrite par microméthodes.

A study was carried out to determine whether centrifugation and resistivity were reliable methods for measuring haematocrit of blood diluted with dextran or gelatin. The values obtained with the minicentrifuge Compur M 1100 (Bayer) (group 2) and with the Stat-Crit (Fumouze) (group 3) were compared with those obtained with the reference method (Coulter counter Model S + 2, Coultronics) (group 1). The study included 10 healthy subjects, aged 21 to 43 years. In each, sodium, potassium, chloride and protein concentrations were determined. Two further 10 ml blood samples were taken to be diluted with increasing amounts of either a fluid modified gelatin (Plasmion) or a dextran 40 (Piasmacair). The dilutions carried out were 0, 10, 20, 30, 40 and 50%. For each one, the haematocrit was measured using all three methods. The values obtained with undiluted blood were similar with the three methods. However, when blood was diluted with a dextran, haematocrit values were underestimated, whatever method was used, but by no more than 5% (difference not statistically significant). The result was the same with the centrifugation method for blood diluted with gelatin. On the other hand, values obtained with the resistivity technique for these samples were underestimated up to 15.5% (50% dilution; p less than 0.05). This was due to the negative electric charge of the gelatin, which lowered the haematocrit value in proportion to the concentration of gelatin. Although the technique is easier than centrifugation, measuring haematocrit with a resistivity method should be avoided in patients receiving a fluid modified gelatin.

[Thrombolytic therapy with rt-PA of recurrent thrombosis in tricuspid valve prosthesis during pregnancy]. / Traitement thrombolytique par rt-PA d'une thrombose récidivante de prothèse valvulaire tricuspidienne durant la grossesse.

The authors report a case of a woman who had two episodes of a tricuspid Saint-Jude prosthesis thrombosis treated with fibrinolysis using rt-PA, during the fourth month of pregnancy. A first course of thrombolytic therapy was successful with normal valve function despite threatening abortion and uterine bleeding. An early rethrombosis of the prosthetic valve and a failure of a second course of thrombolysis required the interruption of pregnancy with a replacement of the tricuspid valve prosthesis.

[An unusual cause of oxygen desaturation: isorhythmic atrioventricular dissociation]. / Une cause inhabituelle de désaturation en oxygène: la dissociation auriculoventriculaire isorythmique.

A 69-year-old man, with a history of angina pectoris treated with verapamil, was admitted in the intensive care unit after a right liver resection. On admission, the chest X ray and the arterial blood gases (PaO2/FlO2 = 320) were normal. There after, the patient exhibited brief decreases of SpO2 (at 82%) which were spontaneously reversible. The ECG showed an isorhythmic atrioventricular dissociation associated with SpO2 falls. The SpO2 returned to normal values when cardiac rhythm became sinusal again. This case shows that in case of an important and brief decrease in SpO2, unexplained by a respiratory cause, a decrease of arterial pressure due to rhythmic disease should be considered.

[Acute parathion poisoning. Value of repeated determination of plasma pseudocholinesterases]. / Intoxication aiguë au parathion. Intérêt du dosage répété des pseudocholinestérases plasmatiques.

A case is reported of acute massive overdose with parathion in a 48 year old male farmer. Despite an adapted and early treatment, the clinical course was unusually prolonged. The need for repeat titration of plasma pseudocholinesterases, as the best indicator of overdose, is stressed. Recovery without after-effects coincided with the return to normal plasma levels of pseudocholinesterases.

[Prevention of arterial hypotension during spinal anesthesia using intramuscular ephedrine in older people]. / Prévention de l'hypotension artérielle au cours de la rachianesthésie par l'éphédrine intramusculaire chez la personne âgée.

OBJECTIVE: To assess the efficacy of intramuscular ephedrine for prevention of hypotension following subarachnoid block (SB) in the elderly. STUDY DESIGN: Prospective, randomized double blind study vs placebo. PATIENTS: Twenty patients, aged 60 years or more, of physical class ASA 2 or 3, scheduled for surgical fixation of fractured neck of femur under SB, allocated into two groups of ten each. METHODS: After oral premedication with hydroxyzine 50 mg, 90 min before surgery, and preloading with cristalloid solution 10 mL.kg-1, the subarachnoid space was punctured with the patient in lateral position using a 22 Gauge spinal needle at the L3-L4 or L4-L5 interspace. Patients were given 0.5% hyperbaric bupivacaine intrathecally, according to body weight. Patients in ephedrine group received intramuscular ephedrine 30 mg immediately after SB. Patients in placebo group received 1 mL of intramuscular saline immediately after SB. When blood pressure decreased below 100 mmHg repeated bolus of ephedrine 6 mg were given intravenously. RESULTS: Patients in both groups experienced a significant decrease in systolic pressure after SB, the decrease being significantly greater in the placebo group. CONCLUSION: Prophylactic intramuscular ephedrine is effective to prevent hypotension associated with SB in the elderly.