[D-Dimer determination combined with clinical probability for the diagnosis of leg venous thrombosis]. / Association en pratique clinique du dosage des D-Dimères et d'une probabilité clinique pour le diagnostic de thrombose veineuse des membres inférieurs.

OBJECTIVE: To evaluate the results of combination of D-Dimer test and simple clinical model for the diagnosis of deep vein thrombosis (DVT). MATERIALS AND METHODS: Inclusion: clinical suspicion of DVT. Non inclusion criteria were Clinical model performed by the referring physician included probability varying from high to low. D-Dimer test was performed by five different rapid techniques. Standard of reference was Doppler ultrasonography (DU) performed by a senior radiologist. RESULTS: Eight hundred and fifty-four DU were performed on a 14 months time period, including 206 suspicion of pulmonary embolism, 109 postoperative time period, 120 non-included or excluded patients, 278 incomplete observations, 141 complete observations. DVT was present in 33 cases and absent in the other 108 cases (prevalence 23%). Sensitivity and negative predictive value of the five tests were between 82 and 97% and 90 et 97%. The most sensitive test had a specificity of 36% and a positive predictive value of 32%. Combination of clinical model and D-Dimer test did not improve the diagnostic accuracy. CONCLUSION: None of the test evaluated in the present study, even when combined with the clinical model results, did allow the exclusion of DVT.

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.

Circulating endotoxin during initial antibiotic treatment of severe gram-negative bacteremic infections.

The impact of antibiotics on total endotoxemia and circulating tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and IL-8 in 18 patients with severe bacteremic sepsis or septic shock due to gram-negative species was investigated. Endotoxemia, TNF-alpha, IL-6, and IL-8 were assayed before (H0) and 1 h (H1) and 4 h (H4) after the first antibiotic infusion. Endotoxemia decreased from H0 (median, 0.4 EU/mL; interquartile interval, 0.09-1.23) to H1 (median, 0.19 EU/mL; interquartile interval, 0.07-0.75; P = .03) and remained stable between H1 and H4 (median, 0.12 EU/mL; interquartile interval, 0.09-0.30; P = .4). IL-6 levels fell between H0 and H4 (P = .01) and between H1 and H4 (P = .03). IL-8 was higher at H0 than at H1 (P = .04) and at H4 (P = .01). These results suggest that endotoxemia is not increased by antibiotherapy of severe gram-negative bacteremia.

Influence of acute renal failure on FPIA rapid serum assay of midazolam and its main metabolite.

We recently developed a simple and fast assay technique, providing the possibility of monitoring of midazolam (M) during sedation. We compared HPLC vs FPIA for the measurement of the sum M plus alpha 1-hydroxymidazolam (OM), its main and pharmacologically active metabolite, in the serum of sedated ICU patients; this activity referred to as M-like. We identified certain patients in whom M-like activity appeared abnormally high in comparison with HPLC assays. Their common denominators were: long-term sedation with M, and seriously impaired renal function. Further, the conjugates of OM (OMG) accumulated in patients with acute renal failure could contribute to the sedation. We compared the metabolic and analytic behavior of M, OM, and OMG in 2 groups of sedated patients either presenting with normal renal functions (group 1) or with a picture of acute renal failure (group 2). Blood samples were assayed by HPLC and by FPIA and analysis was performed before and after hydrolysis of OMG. Before hydrolysis there was a dramatic accumulation of OMG in the patients of group 2, HPLC vs FPIA results were not different within group 1, while in group 2 the FPIA response exceeded that of HPLC. After hydrolysis, measurement by HPLC was greatly increased in group 2, in each group (vs HPLC) and from one group to another, the FPIA signal (the M-like activity) showed a significant increase. It would be important to take OMG into account as a coprotagonist in sedation whenever circumstances predispose to its accumulation.

[Analysis of patients' perception of their stay in a medical intensive care unit. Les trois equipes d'infirmières]. / Analyse de la perception par les malades de leur séjour en réanimation médicale. Les trois equipes d'infirmières.

OBJECTIVES: Evaluate patients' appraisal of their stay in a medical intensive care unit and analyze their anxiety. PATIENTS AND METHODS: Two 5-month prospective studies with specific questionnaires were filled out by patients with the help of a psychologist. The first study (61 patients) evaluated global appraisal of the stay and the second study (53 patients) focused on anxiety using questionnaires also filled out by nurses. RESULTS: The study population was not different from the global population admitted to intensive care during the same period. The patients felt secure in 97% of the cases but suffered pain (53%), insomnia (62%), discomfort due to noise (49%) or light (37%), and expressed anxiety (55%). The second study confirmed the anxiety in 61% of the patients. Using surrogate markers of anxiety, the psychologist judged that anxiety was underestimated in 20% of the cases. In 17%, anxiety was expressed by patients but not felt to be present by nurses. DISCUSSION: In order to decrease the anxiety of patients admitted to a medical intensive care unit, every effort should be made to lessen pain and unnecessary discomfort. All personnel working in the unit should be able to recognize the patients' anxiety.

Comparison of high-performance liquid chromatography and polyclonal fluorescence polarization immunoassay for the monitoring of midazolam in the plasma of intensive care unit patients.

Midazolam (M) is used as an induction agent for anesthesia. The main metabolite is alpha-hydroxymidazolam (OM), which is pharmacologically active. Use of M for sedation is a recent application, rapidly gaining favor. Monitoring of the level of sedation is fundamental in that an excessive and prolonged effect is associated with the risk of complications. Thus, it was felt both necessary and useful to measure circulating M levels. We compared a high-performance liquid chromatography (HPLC) assay with fluorescence polarization immunoassay (FPIA) for the measurement of M in the serum of 138 sedated patients in the intensive care unit (i.e., 179 samples). Response of the OM was also assessed. The degree of crossover of the metabolite was between 76.8 and 32.7%. The equation of the regression line for sigma HPLC (i.e., the sum M + OM) versus FPIA was TDx = 1.1585 sigma HPLC + 143.42 (R = 0.966). The 95% confidence interval for the slope was 1.1551, 1.1619. The regression slope differed significantly from 1 (p < 0.001) and shows that FPIA measurements overestimated concentrations obtained by HPLC on the order of 19%. The discrepancy between the two techniques was all the more notable when concentrations were > 1,000 ng/ml. The relative selectivity of Abbott industrial reagent in terms of benzodiazepines leads to the identification of what might be called a midazolam-like (M-like) activity covering both M and OM. The development of a global FPIA method for measurement of this M-like activity in sedated patients provides a satisfactory solution to the question raised.

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.

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.

[Efficacy and tolerance of Elohes in plasma exchanges]. / Efficacité et tolérance de l'Elohes dans les échanges plasmatiques.

This study aimed to compare two plasma substitution regimens used during plasma exchanges (PE). It was a prospective cross-over randomized trial. Each patient (n = 12) had two PE at a 48 h interval. During one PE, only albumin was administered (PEA), and during the other one, equal volumes of albumin and low molecular weight hydroxyethylstarch (HES) (Elohes) were given (PEA+E). The order in which these different protocols were used was random. Plasma was separated by filtration, and the total volume extracted was one and a half the plasma volume. The parameters recorded every 15 min until 1 h after the end of PE, were heart rate, blood pressure and central venous pressure (CVP). Plasma volume, calculated from the mean body haematocrit and blood volume, was measured before and after PE. The clinical and biological tolerance of the rapid infusion of a large volume of HES was also assessed. PE characteristics were similar in both groups. For PEA and PEA+E, PE lasted 152 +/- 21 min and 154 +/- 25 min; the plasma volume extracted was 3,907 +/- 772 ml and 3,933 +/- 717 ml; the volume of plasma substitute infused was 4,097 +/- 617 ml and 3,933 +/- 717 ml, respectively. As haemodynamic and biochemical values were not significantly different in both groups, they were pooled together irrespective of the order of PE.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fortuitous discovery of the association of true and false aneurysm of the left ventricle after cardiogenic shock]. / Découverte fortuite de l'association d'un vrai et d'un faux anévrysme du ventricule gauche au décours d'un choc cardiogénique.

The authors report the fortuitous diagnosis of a true and a false left ventricular aneurysm in a 77 year old man with severe ischaemic heart disease and calcific aortic stenosis, admitted for cardiogenic shock. The association of these two forms of aneurysm is very rare. Clinical and paraclinical diagnosis is difficult. Conventional left ventriculography is the investigation of reference but the diagnosis has been facilitated by Technetium 99 cardiac scintigraphy and color Doppler echocardiography. Surgery may be considered in cases of true aneurysm especially in patients with left ventricular failure, but the indication is formal in cases of false aneurysm.

[Severe immunoallergic hemolytic anemia caused by a glafenine metabolite]. / Anémie hémolytique immuno-allergique grave provoquée par un métabolite de la glafénine.

Three weeks after a surgical operation, a 74-year old woman was admitted to hospital for severe haemolytic anaemia. A strongly positive IgG type direct Coombs test pointed to a iatrogenic origin, but a search for anti-molecule antibodies directed against all medicines taken by the patient after surgery was negative. We extended our immunological investigations and were able to demonstrate the presence of IgG type antibodies directed against an ex vivo metabolite of glafenine.

[Pneumococcal pneumonia resistant to penicillin]. / Pneumopathie à pneumocoque résistant à la pénicilline.

The authors report a case of community-acquired pneumonia in a patient with chronic obstructive lung disease. The initial antibiotic therapy consisted of an amoxicillin-clavulanic acid combination and intravenous macrolides. Twenty-four hours after admission, blood cultures were positive for pneumococcus. Pending the results of disc sensitivity tests, the antibiotic therapy was modified and amoxicillin alone was prescribed. Clinical deterioration then developed rapidly, as the pathogen was amoxicillin-resistant. Subsequently, the patient recovered under erythromycin therapy. As illustrated by this case, the emergence of pneumococci resistant, or showing low sensitivity to penicillins raises the problem of the antibiotic therapy to be used against community-acquired lung diseases.

[Access of torsades de pointes in Legionnaires' disease: an uncommon adverse effect of erythromycin]. / Accès de torsades de pointes au cours d'une maladie des légionnaires:un accident exceptionnel de l'érythromycine.

We report the case of a 77-year-old man with legionnaires's disease who, immediately after an intravenous infusion of one gram of erythromycin presented with wave burst arrhythmia with widening of the QT space. The blood level of erythromycin at the time of this adverse reaction was the same as the peak observed in young subjects after intravenous administration of this drug. Fourteen similar cases were found in the literature. In vitro and in vivo studies have shown that erythromycin may exert on the cardiac muscle fibres an electrophysiological effect similar to that of class I antiarrhythmic agents.