[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.

The hemodynamic effects of hypoxemia in anesthetized pigs: a comparison between right heart catheter and echocardiography.

UNLABELLED: During hypoxemia, hypoxic pulmonary vasoconstriction and tachycardia are often observed in association with increases in pulmonary artery pressure and cardiac output. Nevertheless, the hemodynamic consequences of hypoxemia have never been evaluated by echocardiography and simultaneously compared with invasive hemodynamic variables. Fourteen open-chest, anesthetized piglets (weight 29-36 kg) were submitted to progressive hypoxemia and reoxygenation. Usual invasive hemodynamic variables were obtained from peripheral and central heart catheters. Direct epicardial echocardiography was used to measure right and left ventricular areas on a short-axis view at mid-papillary level. The mean pulmonary artery pressure (MPAP) increased with pulmonary vascular resistance in a dose-related manner as the fraction of inspired oxygen (FIO2) declined from 0.5 to 0.12. The MPAP correlated with right ventricular end-diastolic area (RVEDA) only at FIO2 0.08. There was a 49% reduction in left ventricular end systolic wall stress (LVESWS) between FIO2 0.5 and 0.08. Left ventricular ejection fraction area (LVEFA) increased by 33% above baseline and correlated with the decrease in LVESWS. No correlation was observed between left ventricular end-diastolic area and pulmonary artery occlusion pressure or left atrial pressure and between cardiac output and LVEFA. Systemic vascular resistance underestimates the magnitude of changes in LVESWS but overestimates the afterload compared with LVESWS. This study demonstrates that, for the lowest FIO2 (0.08), changes in MPAP correlated with changes in RVEDA but not in pulmonary vascular resistance. Moreover, LVESWS decreases significantly in a dose-related manner under progressive hypoxemia and normalizes immediately after reoxygenation. This study also shows that, under hypoxemic conditions, echocardiography enhances understanding of hemodynamic changes compared with right heart catheterization alone. IMPLICATIONS: Acute hypoxemia in pigs is responsible for pulmonary vasoconstriction-induced pulmonary hypertension (which is restricted by the right ventricular failure), as well as a PaO2-dependent decrease in left ventricular afterload. These changes are better displayed by echocardiography than by right heart catheter.

Confirmatory platelet-activating factor receptor antagonist trial in patients with severe gram-negative bacterial sepsis: a phase III, randomized, double-blind, placebo-controlled, multicenter trial. BN 52021 Sepsis Investigator Group.

OBJECTIVE: To determine the efficacy and safety of using natural platelet-activating factor receptor antagonist (PAFra), BN 52021, to treat patients with severe Gram-negative bacterial sepsis. DESIGN: A prospective, randomized, double-blind, placebo-controlled, multicenter clinical trial. SETTING: Fifty-nine academic medical center intensive care units in Europe. PATIENTS: Six hundred nine patients with severe sepsis, suspected to be related to Gram-negative bacterial infection, who received PAFra or placebo. INTERVENTIONS: Patients were randomized to receive either a dose of PAFra (120 mg iv) every 12 hrs over a 4-day period or placebo over a 4-day period. MEASUREMENTS AND MAIN RESULTS: The patients were well matched at study entry for severity of illness and for risk factors known to influence the outcome of sepsis. Among all randomized patients, the 28-day, all-cause mortality rate was 49% (152/308) in the placebo group, and 47% (140/300) in the PAFra group (p=.50). When analyzed on the basis of the previously defined target population, the 28-day, all-cause mortality rate was 50% (115/232) in the placebo group and 44% (94/212) in the PAFra group, yielding a 12% reduction in mortality rate (p=.29). In patients with documented infection involving other organisms, there was no difference between treated and placebo groups. When the outcomes of organ dysfunctions were examined in the overall population and in the documented Gram-negative bacterial infection population, the number of patients who resolved hepatic dysfunction tended to be higher in the treated group than in the placebo group (p=.06). The number of adverse events reported were not different between the two groups. CONCLUSIONS: A 4-day administration of the studied PAFra (BN 52021) failed to demonstrate a statistically significant reduction in the mortality rate of patients with severe sepsis suspected to be related to Gram-negative bacterial infection. If PAFra treatment has any therapeutic activity in severe Gram-negative bacterial sepsis, the incremental benefits are small and will be difficult to demonstrate in a patient population as defined by this clinical trial.

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.

Haemodynamic changes induced by two I:E ratios: a transoesophageal echocardiographic study.

PURPOSE: To assess the effects of controlled ventilation with two I:E ratios on haemodynamic and left ventricular function in mechanically ventilated patients with moderate to severe respiratory disease, using fluctuation of the arterial pressure waveform and the changes in left ventricular areas obtained by transoesophageal echocardiography. METHODS: Nine patients had their lungs ventilated using volume controlled ventilation with two I:E ratios 1:3 and 1:1). Respiratory rate was adjusted so that six cardiac beats occurred during a respiratory cycle. Systolic blood pressure variation (SBPV), left ventricular area variations measured by TEE and haemodynamic variables measured by PA catheter were compared. RESULTS: When compared with I:E (1:3), I:E (1:1) decreased end diastolic area (EDA) throughout the respiratory cycle from 3% to 8% (P < 0.01) and increased SBPV from 6 +/- 1 to 11 +/- 1 mmHg (P < 0.01). In four patients, SBPV was > 12 mmHg with I:E 1:1. Conversely, SBPV was < 10 mmHg in all patients with I:E 1:3. With I:E (1:1), EDA decreased up to 7% during expiration (P < 0.01). The ejection fraction area remained stable for both ventilatory patterns and throughout the ventilatory cycle for a given I:E. The usual invasive haemodynamic variables were unchanged throughout the study, as was PaO2/FIO2. CONCLUSION: In this setting, EDA and SBPV allow beat-to-beat evaluation of left ventricular preload during change of I:E ratio. Switch from I:E 1:3 to 1:1 may be used as a rapid, safe and reversible test to estimate intravascular volume status assessed by changes in SBPV or EDA.

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.

[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.

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.

[Cervical necrotizing fasciitis disclosing HIV infection]. / Fasciite nécrosante cervicale révélant une maladie à VIH.

Necrotizing fasciitis is a rapidly progressing necrotizing process which affects subcutaneous tissue and fascia. The leading cause of these infections in neck is odontogenic infection. Its occurrence is reported to be rare, but often fatal. The therapeutic regimen includes three essential principles: appropriate antimicrobial therapy, prompt surgical treatment, and supportive measures. Two cases of cervical necrotizing fasciitis revealing human immunodeficiency virus (HIV) infection are reported. Clinicians should be aware of this underlying condition, and every patient with cervical necrotizing fasciitis should be tested for HIV.

[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.

Transesophageal echocardiographic assessment of left ventricular function in brain-dead patients: are marginally acceptable hearts suitable for transplantation?

BACKGROUND: The brain-dead donor supply has become one of the criteria limiting the performance of heart transplantation. Conventional screening criteria are too limiting and exclude suitable heart donors. Echocardiography is now widely available and is a reliable tool to assess left ventricular dysfunction in brain-dead donors. Yet few data are available on the degree of left ventricular dysfunction where a transplantation is possible. METHODS: Fifty-five potential brain-dead heart donors (age 38 +/- 11 years) were prospectively evaluated by transesophageal echocardiography (TEE) before harvesting. Fractional area change (FAC) was used to assess left ventricular function in potential brain-dead donors. Transplanted hearts were evaluated on the fifth postoperative day. The transplantation was considered a success if the recipient was alive, not retransplanted, without an assistance device or an epinephrine infusion of more than 1 mg/h and showed an ejection fraction above 40%. RESULTS: Of the 55 potential heart donors, 20 exhibited an FAC of less than 50%. Forty hearts were harvested, 36 of which were successfully transplanted. Nine patients had an FAC below 50% (group H2) and 27 had an FAC over 50% (group H1). Four patients died: 2 from hemorrhage (FAC > 50% in donors); 1 from right and one from left ventricular dysfunction (FAC < 50% in donors). The FAC increased significantly from 51 +/- 15% to 57 +/- 11% in 18 hearts that underwent TEE in donors and afterwards in recipients. Overall actuarial survival was 86.2% versus 64.6% at 1 and 2 years in group H1 and group H2, respectively (p = NS). CONCLUSIONS: TEE is useful to assess left ventricular function in potential brain-dead donors. An FAC less than 50% is present in 36% of potential heart donors. Because left ventricular dysfunction is often reversible shortly after transplantation, an FAC below 50% may not necessarily preclude the use of hearts for transplantation.

Myocardial protection during coronary artery bypass graft surgery: a randomized, double-blind, placebo-controlled study with trimetazidine.

We conducted a randomized, double-blind, placebo-controlled study to assess the cardioprotective effects of trimetazidine (TMZ), an antiischemic drug, on left ventricular function using transesophageal echocardiography (TEE) after coronary artery bypass grafting (CABG). Forty patients undergoing elective CABG received either TMZ or a placebo (PCB). The primary measures of efficacy were serial measurements of fractional area change (FAC), percent of systolic wall thickening (SWT), and malonedialdehyde (MDA) production. The two groups were similar for the following variables: number of vessels revascularized (2.5 +/- 0.2 in the TMZ group and 2.8 +/- 0.1 in the PCB group), duration of aortic clamping (46 +/- 4 min in the TMZ group and 48 +/- 3 min in the PCB group), and bypass time (63 +/- 4 min in the TMZ group and 70 +/- 4 min in the PCB group). FAC increased by 12% in both groups 20 min after aortic unclamping (P < 0.05) and remained above the initial value at the sixth postoperative hour. SWT was 23.8% +/- 1.6%, 25.4% +/- 1.9%, then 21.6% +/- 1.5% in the TMZ group and 22.8% +/- 1.6%, 23.8% +/- 1.4%, then 22.3% +/- 1.6 % in the PCB group, after induction of anesthesia and 1 and 6 h after aortic unclamping (not significant). MDA increased by 24% in the PCB group and 25% in the TMZ group 20 min after aortic unclamping (P < 0.01). Lactate levels were lower in the TMZ group (P < 0.05) and patients from the TMZ group received less intravenous calcium before aortic clamping (P < 0.02) and less calcium channel entry blocking drugs in the early phase after aortic unclamping (P < 0.01) compared to the PCB group. We conclude that in patients with good preoperative ejection fraction undergoing CABG, TMZ as administered did not demonstrate clinically significant cardioprotective effects on left ventricular performance and lipid peroxidation compared to PCB.

[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.

[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.

Role of transesophageal echocardiography in the diagnosis and management of traumatic aortic disruption.

BACKGROUND: Traumatic disruption of the aorta (TDA) is a life-threatening injury that requires rapid diagnosis and treatment. Emergency aortography, which is the current standard diagnostic imaging modality, is invasive, time-consuming, and difficult to perform in hemodynamically unstable patients with multiple trauma. We performed transesophageal echocardiography (TEE) in patients with suspected TDA to determine the diagnostic accuracy and impact on patient management of this alternative, portable imaging modality. METHODS AND RESULTS: Thirty-two consecutive trauma patients (mean age, 40 +/- 16 years) with suspected TDA (violent deceleration accident and mediastinum > 8 cm on admission chest x-ray) prospectively underwent a TEE examination in the emergency room. Findings during TEE were compared with those encountered during aortography, surgery, or necropsy. Two subsets of traumatic aortic injuries with distinct echocardiographic signs were observed: (1) subadventitial TDA (n = 10) and (2) traumatic intimal tears (n = 3). Eighteen patients had normal TEE confirmed by aortography. One 2-mm medial tear was missed by TEE (necropsy). The sensitivity and specificity of TEE for the diagnosis of subadventitial TDA were 91% and 100%, respectively. Patients with subadventitial TDA were taken to surgery immediately, whereas patients with intimal aortic tears were treated conservatively. Eighteen patients (mean age, 57 +/- 15 years) with confirmed acute aortic dissection involving the aortic isthmus were also included to establish the echocardiographic differential diagnostic criteria between this entity and TDA. CONCLUSIONS: TEE should be considered the first-line imaging modality for the evaluation of trauma patients with suspected injuries of the thoracic aorta because of its portability, safety, diagnostic accuracy, and potential impact on patient management.