[Not Available]. / L'infection bactérienne chez le patient brûlé.

Mortality in burn patients is most often caused by infections, which are frequently bacterial. These patients are subject to loss of the cutaneous barrier, invasive devices and immunosuppression which are all contributing factors to the onset of infections. Unfortunately, it is not easy to distinguish general signs of infection from other symptoms associated with burn injuries, making diagnosis difficult. Since infection is a great threat in burns patients, its prevention is a fundamental part of the treatment process. Moreover, due to the anomalous pharmacokinetic characteristics of burns patients, it is also mandatory to adapt any antimicrobial regimen to the outcomes of regular patient blood tests and sampling. At a time when bacterial resistance is becoming an increasing concern, research on alternative treatment (e.g. inhibitors of virulence factors, antimicrobial peptides, polyphenols, immunotherap, and so on) is crucial. One of the more promising possibilities in this area seems to be phagotherapy.

Pharmacokinetics of ertapenem in burns patients.

The aims of this study were to evaluate pharmacokinetic (PK) parameters of total and unbound ertapenem (ERT) in burns patients and to identify which covariates influence these PK parameters. ERT plasma concentrations were measured in burns patients (n = 8) who received a 0.5-h infusion of ERT (1000 mg) every 24 h. PK parameters were estimated by a non-compartmental approach and the influence of covariates was estimated by multivariate analysis using a population approach. Clearance (CL) and the volume of distribution (V) of total ERT were lower than the results for unbound ERT [CL, 22.2 ± 5.6 mL/min vs. 279.4 ± 208.2 mL/min; V, 9.7 ± 1.4L vs. 120.6 ± 130.6L (mean ± standard deviation)]. Creatinine clearance (CL(Cr)) and the burned surface area (BSA) were the covariates identified that significantly (P<0.01) affected the pharmacokinetics of total ERT [CL (L/h)=0.373 +{0.00666 x CL(Cr) (mL/min)}] and unbound ERT [peripheral volume of distribution (L) = 3.05 + {0.959 x BSA (% of the total body surface)}], respectively. The influences of albuminaemia, glomerular filtration and burn wound on ERT pharmacokinetics are proposed to explain these results. These first results support that the ERT plasma concentration should be closely monitored particularly for patients with high values of BSA and/or CL(Cr) to avoid suboptimal exposure.

[Opinion of different professional categories about the intensity of procedural pain in adult intensive care units]. / Estimation de la douleur induite par les soins de réanimation par les différentes catégories de soignants.

OBJECTIVES: to assess the procedures considered as the most painful by health personnel of two adult critical care units. METHODS: individual written survey with a questionnaire about 46 potentially painful procedures. Each individual has to estimate the pain intensity as well as the frequency of performance for each painful procedures. RESULTS: one hundred questionnaires were provided (15 physicians, 71 nurses and 14 auxiliaries). The rate of answer was 53 % and 2110 scores were recorded and analyzed. The insertion of a pleural drain was associated with the higher pain score (7.5 [6.5-9]). Discrepancies were observed between the professional categories in ranking painful procedures. However, the mobilization of a severe trauma patient, the removal of an otorhinolaryngological or a pleural drain were classified in the 10 most painful procedures by physicians, nurses as well as auxiliaries. Whatever the procedure was, the median global scores estimated by the auxiliaries (n=385; 6 [4-7]) were higher than those corresponding to the nurses (n=1267; 5 [3-7]) (p<0.01). Nurses attributed a higher score than the physicians for 39 of 46 procedures. No relation was found between the estimated pain intensity and the estimated frequency of the procedures. CONCLUSION: as in paediatrics, adult intensivist physicians underestimate pain during procedure comparing with nurses and auxiliaries. Consequently, health care professionals should elaborate protocols to accurately assess, prevent, or treat painful procedures in intensive care units.

[Antimicrobial blood concentrations in burns. A five years' retrospective survey]. / Concentrations sanguines d'antibiotiques chez les patients brûlés. Etude rétrospective sur cinq ans.

The monitoring of antimicrobial agents is a routine in our unit. We reviewed the results either of peak-and-through concentrations (peak and through is one sample) or concentrations at steady state (Css) of all antimicrobials given over five years (2001 to 2005) and studied the antimicrobials with at least 20 samples. We found 706 samples in 122 patients, the antimicrobials being amikacin, amoxicillin, ceftazidime, ciprofloxacin, cloxacillin, gentamicin, imipenem, ofloxacin, tobramycin and vancomycin. When comparing samples in witch the concentrations were above a value thought to be predictive of efficacy to those were not, we could notice: that no parameter about patients or burn surface was predictable for achieving targeted blood concentration; that usual regimen could not achieve targeted concentrations, excepted with ceftazidime, provided it was used in continuous infusion; that, with the other beta-lactams, continuous infusion was more likely to achieve targeted blood concentrations; that, with fluoroquinolones, both higher and more frequent injections were needed; that, with aminoglycosides used once a day, the dosage had to be higher than usually recommended. We conclude that antimicrobial regimen should be altered in burns and that a monitoring of blood concentrations should be performed in these patients.

[Unusual haemostasis disorder in a seriously burned patient]. / Trouble inhabituel de l'hémostase au cours d'une brûlure grave.

We report the case of a woman severely burned during a gas explosion with an unusual disorder of haemostasis. The prothrombin time was very elevated, essentially by a drop in factor II. This abnormality persisted for a long time after the correction of the dilutional and consumption coagulopathy which followed immediately the burn. Blood analysis found fluindione and benzodiazepine derivatives. Such a disorder during a potentially suicidal burn must evoke a toxic aetiology.

Use of remifentanil for analgesia during dressing change in spontaneously breathing non-intubated burn patients.

We report our experience in using remifentanil as sole agent for the analgesia of spontaneously breathing non-intubated burn patients during dressing changes. Sixty procedures were collected and analysed. Remifentanil was used during monitoring of vital functions, with oxygen inhalation throughout the procedure, at the bedside in the intensive care unit ward. Infusion speed was varied by the nurse in charge, depending on pain, analgesia, and adverse effects. The dosage of continuous infusion ranged from 0.125 to 1 mg.kg-1.mn-1 (average, 0.42). All patients received intravenously morphine 30 min before the end of the procedure (average, 10 mg). The main side effects were hypoxia and drowsiness, always quickly reversed when the doses were reduced. All patients had low levels of pain during and after the procedure, and were satisfied with the analgesia protocol. We conclude that remifentanil is another possible manner of analgesia in the dressing of burn patients, but that it must be used in an "anaesthesiological" environment.

[Parasigmoid abscess revealed by anaerobic osteomyelitis]. / Abcès périsigmoïdien révélé par une ostéomyélite à germes anaérobies.

We report the case of a 66 year-old-patient, who profited by a laminectomy T4 to T7 for spinal cord compression due to an osteomyelitis. Bacteriological samples showed positives gram cocci and Bacteroides fragilis by the culture. The systematic research of a primitive source permitted to find a parasigmoidis abscess, which was treated by a sigmoidectomy with a colorectal anastomosis.

[Sciatic nerve block: an new lateral mediofemoral approach. The value of its combination with a "3 in 1" block for invasive surgery of the knee]. / Bloc du nerf sciatique: une nouvelle voie d'abord latérale médiofémoral. Intérêt de son association à un bloc "3 en 1" pour la chirurgie invasive du genou.

OBJECTIVE: To describe a new midfemoral lateral approach for the sciatic nerve block. Its combination with the "3 in 1" block was tested for postoperative analgesia following major surgery of the knee. STUDY DESIGN: Descriptive, anatomical and clinical study prospective. PATIENTS: After testing in four unembalmed corpses the new approach was applied to 42 ASA 1-2 patients, in combination with a continuous "3 in 1" block. METHODS: The new approach was analysed for reliability of the surface landmarks (a line drawn from the posterior margin of the greater trochanter towards the knee and parallel to the femur) and block extent assessed on the foot. Its combination with the "3 in 1" block was evaluated with a visual analogue scale (VAS) scoring, for postoperative analgesia after total knee arthroplasty. RESULTS: The sciatic nerve was located in less than 10 min. A block of the sciatic nerve was fully achieved in all patients. Its median duration was 16 h. The median VAS score at rest was 0 mm (sciatic bloc + continuous block "3 in 1"), but increased to 40 mm (block "3 in 1" alone). CONCLUSION: The new lateral midfemoral sciatic block is easy to master. Combined with a continuous "3 in 1" block, it provides excellent analgesia during the early postoperative period after major surgery of the knee.