[Is it worth delivering Direct-Current Counter shock to critically ill patients with supra-ventricular tachyarrhythmia?] / Vaut-il la peine de délivrer un choc électrique aux patients de réanimation avec tachycardie supra-ventriculaire ?

Supra-ventricular tachyarrhythmia and its treatment have been poorly investigated in ICU patients. AIMS: To evaluate efficacy and safety of cardioversion for supra-ventricular tachyarrhythmia in the intensive care unit (ICU). PATIENTS AND METHODS: Prospective inclusion of all patients who presented supra-ventricular tachyarrhythmias lasting≥30seconds in a single medico-surgical ICU, except cardiac surgery. Anti-arrhythmic drugs and/or direct-current cardioversion were administered on a liberal basis. RESULTS: During the 15-month study period, 108/846 patients (12.8%) experienced supra-ventricular tachyarrhythmias. Anti-arrhythmic drugs were administered in 78 patients (72%); mostly amiodarone (92%), and/or magnesium (23%), resulting in an overall conversion rate of 68%. Direct-current cardioversion was used in 26 patients (24%), (24 patients received drug enhancement by anti-arrhythmic drugs) with an immediate 80.8%-success rate. CONCLUSION: Direct-current cardioversion was associated with sustained conversion to sinus rhythm in 80.8% of ICU patients with supra-ventricular tachyarrhythmias, although most of them had already received drug enhancement.

[Usefulness of B-type natriuretic peptide in emergency medicine]. / Intérêt du dosage des peptides natriurétiques en urgence.

OBJECTIVES: Acute dyspnea is frequent in emergency medicine. The B-type natriuretic peptide is a polypeptide, released by ventricular myocytes directly proportional to wall tension, for lowering renin-angiotensin-aldosterone activation. Conversely, NT-proBNP has no physiological activity. BNP and NT-proBNP concentration closely correlate to various indicators of heart failure. CURRENT KNOWLEDGE AND KEY POINTS: Numerous studies have demonstrated high usefulness of BNP and NT-proBNP to diagnose heart failure, which is the main cause of acute dyspnea in emergency medicine. The diagnostic accuracy of BNP and NT-proBNP seems similar, and is higher than that of the emergency physician. Bedside dosages are now available, with high sensibility and specificity for the diagnosis of heart failure. For BNP, threshold value is ranging from 100 to 300 pg/ml in patients aged over 65 years; for NT-proBNP the threshold value is 1000 to 2000 pg/ml in elderly patients. Briefly, heart failure is unlikely when BNP is below 100 pg/ml (NT-proBNP<500 pg/ml), and very likely when BNP is higher than 400 pg/ml (or NT-proBNP>2000 pg/ml). FUTURE PROJECTS: Early rapid measurement of BNP could improved the evaluation and treatment of patients with acute dyspnea and reduce the total cost of treatment.

[Tracheostomy in intensive care: impact on prognosis and the influence of underlying chronic respiratory insufficiency]. / Trachéotomie en réanimation: pronostic et rôle d'une insuffisance respiratoire chronique.

INTRODUCTION: Numerous uncertainties remain concerning the place of tracheostomy in intensive care. Reluctance to perform tracheostomy is common, particularly in the presence of pre-existing chronic respiratory insufficiency (CRI), but some data suggest there may be benefits. The objective of this study was to evaluate the influence of tracheostomy on mortality in both intensive care and hospital, and to study the role of pre-existing CRI. MATERIAL AND METHODS: In a retrospective study of the records of 2901 patients admitted over a period of 5 years 882 were identified who had been intubated and ventilated. 127 patients who had had tracheostomies (T+) were compared with 755 who had not (T-), and with a sub-group of T- patients (T-app) matched for severity on admission (SAPSII). RESULTS: ICU and hospital mortality were significantly less in the T+ than the T-patients (28 vs 52% and 42 vs 59%) and the duration of stay was longer. This was equally true when matched for severity on admission when T+ were compared with T app (28 vs 49% and 42 vs 59%). Pre-existing CRI did not influence the outcomes of the tracheostomised patients, regardless of whether the CRI was obstructive, restrictive or neuro-muscular. CONCLUSIONS: Tracheostomy can, in certain groups of artificially ventilated patients and in certain care settings, be associated with a reduction in hospital mortality.

Successful weaning from mechanical ventilation after coronary angioplasty.

Weaning failure can be caused by myocardial ischaemia during the switch from mechanical to spontaneous ventilation. We report ischaemic left ventricular failure and ischaemic mitral insufficiency during weaning. Angiography showed that the coronary vessels were stenosed. Transluminal angioplasty made weaning possible. We conclude that acute ischaemic mitral insufficiency may contribute to cardiac failure during weaning and that angioplasty, by reversing it, can allow successful weaning.

Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: A randomized controlled trial.

CONTEXT: Continuous positive airway pressure (CPAP) is widely used in the belief that it may reduce the need for intubation and mechanical ventilation in patients with acute hypoxemic respiratory insufficiency. OBJECTIVE: To compare the physiologic effects and the clinical efficacy of CPAP vs standard oxygen therapy in patients with acute hypoxemic, nonhypercapnic respiratory insufficiency. DESIGN, SETTING, AND PATIENTS: Randomized, concealed, and unblinded trial of 123 consecutive adult patients who were admitted to 6 intensive care units between September 1997 and January 1999 with a PaO(2)/FIO(2) ratio of 300 mm Hg or less due to bilateral pulmonary edema (n = 102 with acute lung injury and n = 21 with cardiac disease). INTERVENTIONS: Patients were randomly assigned to receive oxygen therapy alone (n = 61) or oxygen therapy plus CPAP (n = 62). MAIN OUTCOME MEASURES: Improvement in PaO(2)/FIO(2) ratio, rate of endotracheal intubation at any time during the study, adverse events, length of hospital stay, mortality, and duration of ventilatory assistance, compared between the CPAP and standard treatment groups. RESULTS: Among the CPAP vs standard therapy groups, respectively, causes of respiratory failure (pneumonia, 54% and 55%), presence of cardiac disease (33% and 35%), severity at admission, and hypoxemia (median [5th-95th percentile] PaO(2)/FIO(2) ratio, 140 [59-288] mm Hg vs 148 [62-283] mm Hg; P =.43) were similarly distributed. After 1 hour of treatment, subjective responses to treatment (P<.001) and median (5th-95th percentile) PaO(2)/FIO(2) ratios were greater with CPAP (203 [45-431] mm Hg vs 151 [73-482] mm Hg; P =.02). No further difference in respiratory indices was observed between the groups. Treatment with CPAP failed to reduce the endotracheal intubation rate (21 [34%] vs 24 [39%] in the standard therapy group; P =.53), hospital mortality (19 [31%] vs 18 [30%]; P =.89), or median (5th-95th percentile) intensive care unit length of stay (6.5 [1-57] days vs 6.0 [1-36] days; P =.43). A higher number of adverse events occurred with CPAP treatment (18 vs 6; P =.01). CONCLUSION: In this study, despite early physiologic improvement, CPAP neither reduced the need for intubation nor improved outcomes in patients with acute hypoxemic, nonhypercapnic respiratory insufficiency primarily due to acute lung injury. JAMA. 2000;284:2352-2360.

Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients.

CONTEXT: Invasive life-support techniques are a major risk factor for nosocomial infection. Noninvasive ventilation (NIV) can be used to avoid endotracheal intubation and may reduce morbidity among patients in intensive care units (ICUs). OBJECTIVE: To determine whether the use of NIV is associated with decreased risk of nosocomial infections and improved survival in everyday clinical practice among patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) or hypercapnic cardiogenic pulmonary edema (CPE). DESIGN AND SETTING: Matched case-control study conducted in the medical ICU of a French university hospital from January 1996 through March 1998. PATIENTS: Fifty patients with acute exacerbation of COPD or severe CPE who were treated with NIV for at least 2 hours and 50 patients treated with mechanical ventilation between 1993 and 1998 (controls), matched on diagnosis, Simplified Acute Physiology Score II, Logistic Organ Dysfunction score, age, and no contraindication to NIV. MAIN OUTCOME MEASURES: Rates of nosocomial infections, antibiotic use, lengths of ventilatory support and of ICU stay, ICU mortality, compared between cases and controls. RESULTS: Rates of nosocomial infections and of nosocomial pneumonia were significantly lower in patients who received NIV than those treated with mechanical ventilation (18% vs 60% and 8% vs 22%; P<.001 and P =.04, respectively). Similarly, the daily risk of acquiring an infection (19 vs 39 episodes per 1000 patient-days; P =.05), proportion of patients receiving antibiotics for nosocomial infection (8% vs 26%; P =.01), mean (SD) duration of ventilation (6 [6] vs 10 [12] days; P =.01), mean (SD) length of ICU stay (9 [7] vs 15 [14] days; P =.02), and crude mortality (4% vs 26%; P =.002) were all lower among patients who received NIV than those treated with mechanical ventilation. CONCLUSIONS: Use of NIV instead of mechanical ventilation is associated with a lower risk of nosocomial infections, less antibiotic use, shorter length of ICU stay, and lower mortality. JAMA. 2000;284:2361-2367.

Multiple organ failure complicating probable scrub typhus.

This report describes a case of life-threatening acute respiratory distress syndrome with multiple organ failure complicating probable scrub typhus. Favorable outcome was associated with fluoroquinolone therapy. Scrub typhus should be suspected in travelers returning from Southeast Asia presenting with unexplained respiratory manifestations.