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.

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.

[Inhibitors of factor VIIIc and pregnancy. Review of the literature]. / Les inhibiteurs du facteur VIIIc et grossesse. Revue de la littérature.

Circulating anticoagulants directed against factor VIII coagulant activity are very rarely encountered. Eighteen per cent of them have been described in the peripartum period of primiparae aged 28 years on average. The clinical signs are the same as those of constitutional haemophilia, but they differ in frequency. The most common of these signs are haematoma, ecchymoses and haematuria. The diagnosis is confirmed by prolongation of clotting time alone, presence of an anticoagulant in blood and specific assay of the deficient coagulant factor. These inhibitors are usually immunoglobulins of the IgG type. The cause and pathogenesis of the disease are unknown. Treatment consists of administering coagulant factors in haemorrhagic periods and immuno-suppressive therapy. Spontaneous remissions are frequent.

[Acidoketosis in a chronic alcoholic woman]. / Acidocétose chez une alcoolique chronique.

A 37-year-old chronic alcoholic female was admitted with epigastric pain, complete anorexia, vomiting and diarrhoea. She was dehydrated, and had polypnoea. Laboratory investigations revealed severe metabolic acidosis (pH 7.14) with a major anion gap (37.4 mmol.l-1), and ketone bodies in blood and urine. Blood glucose concentration was 6.1 mmol.l-1, there was no glycosuria. Rehydration (2 l.day-1 of 5% glucose) together with sodium bicarbonate (500 ml of 1.4% sodium bicarbonate over the first four hours) normalized the pH (7.37). The ketone bodies disappeared on the following day. During the acute illness, were found high blood levels of glucagon and low levels of insulin. The diagnosis of alcoholic ketoacidosis, the pathogenesis of which remains unknown, is discussed.

[Superior mesenteric artery syndrome]. / Syndrome de l'artère mésentérique supérieure.

The superior mesenteric artery syndrome (SMAS) is a rare complication of spine surgery. A series of four patients who experienced a SMAS after surgery for either post-traumatic quadriplegia, paraplegia or scoliosis is reported. SMAS is a condition in which the third portion of the duodenum is squeezed between the superior mesenteric artery anteriorly, and the aorta and vertebral column posteriorly. Weight loss is the major factor of development of a SMAS. Other causes include either spine surgery or trauma or application of a body cast. Delay in diagnosis may result in death. Diagnosis is obtained with either a CT scan with injection and oral contrast medium or an upper gastro-intestinal X-ray study. The latter allows the insertion of a feeding tube beyond the obstruction. A conservative treatment is started for correction of dehydration and electrolyte imbalance, and followed by nasojejunal feeding. Surgery is indicated in case of failure of conservative treatment.

[Enteral nutrition in patients with chronic obstructive bronchopathy treated by artificial ventilation. Effect of conventional feeding on anthropometric and biochemical parameters]. / Nutrition entérale chez le bronchopathe chronique obstructif soumis à une ventilation artificielle. Influence d'une alimentation conventionnelle sur les paramètres anthropométriques et biochimiques.

The influence of conventional gastric tube feeding on anthropometric and biochemical parameters was studied prospectively during 12 months in 14 patients with chronic obstructive lung disease put on mechanical ventilation for respiratory failure. The anthropometric parameters were: body weight, tricipital skin fold, brachial and brachial muscle circumferences. The biochemical parameters included albumin, transferrin, retinol binding protein, transthyretin, acid alpha-1-glycoprotein, C-reactive protein, fibronectin and amino acids in blood, and 3-methylhistidine in urine. Measurements were performed on inclusion, then every 3 days until D15. After 15 days of a nutrition bringing 28.8 +/- 8.9 calories/kg/day and 13.9 +/- 2.2 grams of nitrogen per day, no improvement in anthropometric parameters was observed. On D0, comparisons with healthy controls showed that visceral serum proteins levels were significantly lower and inflammatory proteins levels significantly higher (P < 0.05); the levels of protein metabolism markers were higher, but not significantly, and those of the principal glucose-forming amino acids were significantly lower (P < 0.01). On D15, comparisons with the initial values showed that the values of retinol binding protein and transthyretin were increased (P < 0.05 and 0.01 respectively), whereas the values of the other visceral proteins were little modified; yet their concentrations remained significantly lower than those found in controls, except for the retinol binding protein. Inflammatory proteins levels were high, with a significant (P = 0.05) difference for the acid alpha-1-glycoprotein, and the patients remained in slight catabolism while their nitrogen balance was positive. These results should encourage to carry out studies on the qualitative composition of artificial nutrition in order to optimize its effectiveness in the treatment of these patients.

[Quality of blood salvaged in orthopedic surgery by washing swabs]. / Qualité du sang récupéré en chirurgie orthopédique par le lavage des compresses.

OBJECTIVE: To establish the feasibility and safety of recuperating blood absorbed by swabs used during orthopaedic surgery. STUDY DESIGN: Open, prospective study. PATIENTS: Included were children undergoing potentially haemorrhagic orthopaedic surgery for whom intraoperative blood salvage seemed possible. Excluded were those with contraindications for this procedure such as septic surgery and cancer surgery. METHOD: Intraoperative swabs used within the surgical field were collected by a surgical assistant, also in charge of weighing and washing them. The liquid was collected by the aspiration system of a recuperation-washing machine (RWM). The salvaged red blood cells were collected and retransfused at the end of surgery. Several samples of the washing liquid of the swabs and salvaged blood were taken during the procedure. The correlation between the quantity of blood shed and salvaged was calculated. The biological and clinical tolerance of the transfusion was assessed. RESULTS: Twelve patients undergoing surgery for scoliosis have been included. An average of 278 mL of blood were salvaged. In the washed cell concentrates the haematocrit was 54% and the free haemoglobin concentration was 3.84 g.L-1. All the bacteriological tests were negative over the first 24 hours. CONCLUSION: Provided that a strict operatory protocol is followed, this study demonstrates the possibility of recuperating blood from swabs used during major orthopaedic surgery.

[Lung diseases complicating acute poisoning with psychotropic drugs]. / Pneumopathies compliquant les intoxications aiguës par les drogues psychotropes.

474 patients admitted in ICU between 1976 and 1981 were retrospectively analysed. Pneumonia (P) was assessed by condensation on chest X ray. P developed in 14,3%. 24 hours after admission 77,6% of P had appeared. Initial location was unilateral in 79,4% with predilection to the inferior half of the right lung. Fever was almost constant (89,5%). Promoting factors were observed: delay between ingestion and admission, vomiting and tracheobronchial embarrassment, coma depth. Recovery was simple in 83,3%. Among the 14 deads, 6 died because only of p, in 4 other P was aggravating. Duration in ICU was much longer when P was present (9 +/- 8,1 days) than when P was absent (2,5 +/- 2,1) p less than 0,001.

Skin versus hub cultures to predict colonization and infection of central venous catheter in intensive care patients.

Central venous catheters (CVC) are an important source of nosocomial infection in intensive care units. The unnecessary removal of CVC suspected to be infected can probably be minimized. In order to test the accuracy of non-invasive methods for predicting catheter colonization, we prospectively compared the results of 50 consecutive CVC tip cultures, with cultures of the CVC hub and the skin at the insertion site. The CVC were separated into two groups based upon the underlying reason for CVC removal: group I (n = 20), suspicion of infection; group II (n = 30), no suspicion of infection. The skin culture (with a threshold of 15 CFU) was useful in both groups for assessing catheter colonization since it was always positive in cases of catheter colonization and always negative in the absence of catheter colonization. The contribution of the CVC hub cultures alone was minimal since there was no case of catheter colonization with negative skin cultures and positive hub cultures suggesting that the main route of catheter colonization was via the skin. Catheter-related bacteremia was identified in seven patients (six in group I and one in group II). In these patients, the ratio of bacterial colony counts (central/peripheral) was greater than 10:1 in only two cases.