[Acute respiratory distress due to tracheostomy tube migration]. / Détresse respiratoire aiguë par migration d'une canule de trachéotomie.

Tracheostomy cannula care is of paramount importance in the daily management of tracheotomized patients. While some complications are commonplace, specific events can occur, often according to type of cannula. We herein report the case of a 71-year-old patient; following a lengthy stay in the intensive care unit, she had received a Safe T-Tube cannula designed to provide support in a stenotic trachea. At home, while suctioning her tracheal secretions, she suddenly experienced respiratory distress requiring a rapid intervention. On arrival, no seeable cannula was found, either in the tracheostomy or in the patient's immediate surroundings. Following her transfer to intensive care, a new cannula was inserted into the tracheostomy opening, enabling mechanical ventilation to begin and achieving rapid relief of dyspnea and improvement of the patient's overall condition. Bronchial fibroscopy was then performed, during which the Safe T-Tube cannula was found folded on itself in a supra-carinal intra-tracheal position. It was extracted and replaced by a cannula of the same model, which was sewn to the skin. Although rare and usually limited to flexible cannulas, this complication is potentially fatal. Generally speaking, when cannula obstruction is suspected, bronchial endoscopy in an intensive care setting is a vital necessity. It is not only the cornerstone of the diagnosis, but also of paramount importance in treatment taking into full account the mechanism of obstruction.

The other great imitator among infectious diseases: Leptospirosis.

INTRODUCTION: Leptospirosis is a worldwide zoonosis responsible for highly diverse clinical presentations with a wide range of severity. Variable environment exposures to infected urines of rodents have been described. OBSERVATION: We report five cases of serologically confirmed leptospirosis leading to hospitalization in an intensive care unit (ICU) of a French center. These patients displayed neurological, respiratory, and abdominal presentation of leptospirosis with variable level of severity. Either professional, leisure related, or daily living exposures have been retrieved. CONCLUSION: These cases underline the diversity of clinical presentation and environmental exposure of this infectious disease. They highlight the interest of an exhaustive anamnesis with collection of professional activity, environmental exposures, and leisure activities.

Invasive aspergillosis and endocarditis.

INTRODUCTION: Aspergillusfumigatus can cause a systemic infection called invasive aspergillosis causing pulmonary and extra-pulmonary damage. Aspergillus endocarditis (AE) is a relatively rare disease but can be life-threatening. CASE REPORTS: We report here on five cases of endocarditis due to invasive aspergillosis: a 58-year-old man receiving immunosuppressive medication following a kidney graft, a 58-year-old man undergoing chemotherapy for chronic lymphocytic leukaemia, a 55-year-old man receiving corticosteroids for IgA vasculitis, a 52-year-old HIV-infected woman under no specific treatment and a 17-year-old boy under immunosuppressive therapy for auto-immune chronic neutropenia. DISCUSSION: Aspergillus accounts for 25-30% of fungal endocarditis and 0.25% to 8.5% of all cases of infectious endocarditis. Aspergillus endocarditis results from invasion of the lung arterioles by hyphae and blood dissemination. It is associated with a very high mortality rate (42-68%). Diagnosing Aspergillus endocarditis is mainly problematic because blood cultures are almost always negative, and fever may be absent. Immunosuppression, haematological malignancies, recent cardiothoracic surgery, negative blood cultures with endocarditis and/or systemic or pulmonary emboli are predictors of AE. In the setting of endocarditis, some clinical characteristics may raise early suspicions of aspergillosis rather than a non-fungal agent: no fever, vegetations affecting the mitral valve, non-valve or aortotomy sites, aortic abscess or pseudo-aneurysm. The identification of invasive aspergillosis is based on a chest CT scan, microscopy/culture or other serological and molecular tests. The treatment of Aspergillus endocarditis requires triazole antifungal drugs, and frequently additional surgical debridement. CONCLUSION: Aspergillus endocarditis is rare but is associated with a very high mortality rate. Knowledge of its predictive factors and key clinical features can help to differentiate aspergillosis from non-fungal endocarditis and may enable improved survival rates.

[Resuscitation management of patients with primary bronchopulmonary cancer]. / Prise en charge en réanimation de patients ayant un cancer broncho-pulmonaire primitif.

OBJECTIVE: There is little data in the literature on the management of patients presenting with a primary broncho-pulmonary cancer in a reanimation unit. The aim of our study was to describe and analyze the prognostic factors of such a population. METHOD: This was a retrospective study of all the patients exhibiting a broncho-pulmonary cancer and admitted to the reanimation unit in the Gustave-Roussy Institute over a period of three years. RESULTS: Out of 67 patients, one out of two was still alive following reanimation. The prognosis was not influenced by the type of broncho-pulmonary cancer or its stage of progression, but essentially depends on the age, severity on admission, presence of acute respiratory failure and the necessity of using mechanical ventilation. The prognosis does not appear poorer when admission to the reanimation unit was related to a tumoral complication rather than an intercurrent affection or therapeutic complication. CONCLUSION: The existence of a broncho-pulmonary cancer, even at an advanced stage, does not appear to stall the management of such patients in reanimation.

Relation between dicrotic notch and mean pulmonary artery pressure studied by using a Swan-Ganz catheter in critically ill patients.

OBJECTIVE: It has been recently shown that there is a match between dicrotic notch and mean pulmonary artery (PA) pressures in spontaneously breathing patients studied by means of high-fidelity pressure catheters. The aim of the study was to analyze the relation between mean PA pressure and PA pressure at the incisura by using a Swan-Ganz catheter in critically ill, mechanically ventilated patients. MEASUREMENTS AND RESULTS: Fluid-filled PA pressures were obtained over four ventilatory cycles in 32 consecutive, mechanically ventilated patients in the intensive care unit. We measured mean PA pressure and dicrotic notch pressure. We also calculated the widely used approximation of mean PA pressure (mean PAPapprox = diastolic + 1/3 pulse pressure). Cardiac output was measured in triplicate by using the thermodilution technique. Dicrotic notch was clearly identified in 30 of 32 patients. Mean PA pressure (32.1 +/- 10.2 mm Hg) and PA dicrotic notch pressure (31.8 +/- 10.4 mm Hg) were linearly related (r = 0.989, p < 0.001). Agreement between dicrotic notch and mean PA pressures was suggested (mean difference +/- SD = -0.3 +/- 1.5 mm Hg). Similar agreement was found between mean PAPapprox and mean PA pressure (mean difference +/- SD = -0.7 +/- 0.8 mm Hg; p = 0.20). CONCLUSION: By using a Swan-Ganz catheter we found that dicrotic notch pressure equalled mean PA pressure in the critically ill, mechanically ventilated patients studied. This indicated that right-sided ejection was completed at a PA pressure equal to mean PA pressure in these patients.

Septic shock in patients with the acquired immunodeficiency syndrome.

OBJECTIVE: To evaluate the prognosis of patients with septic shock admitted to an intensive care unit (ICU), according to their HIV serostatus. DESIGN: Retrospective study. SETTING: Medical ICU of a university hospital. PATIENTS: 76 patients with septic shock admitted to the same ICU, of whom 28 were HIV positive and 48 were HIV negative. MEASUREMENTS AND RESULTS: Severity scores, number and type of organ failures, and survival rates were assessed in the two groups of patients. Glasgow Coma Scale and general severity scores [Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score (SAPS)] were significantly worse in HIV-infected patients. The total number of organ failures was also higher in the HIV-positive group: 3.7 +/- 0.2 vs 3.1 +/- 0.2 in the HIV-negative group (p < 0.001). On day 28, 21 (46%) HIV-negative patients were dead compared to 26 (93%) patients in the HIV-positive group (p < 0.001). In the multivariate analysis, HIV infection was an independent risk factor for mortality, as were the SAPS score, use of mechanical ventilation, and the McCabe score. CONCLUSIONS: This study reports a considerable excess mortality in HIV-infected patients with septic shock. Although severity of illness was clearly much more pronounced in HIV-positive patients, retroviral infection was independently associated with death. Improving survival in HIV-positive patients with septic shock may require earlier diagnosis and treatment of the causative infection.

Blood flow acceleration in the carotid and brachial arteries of healthy volunteers: respective contributions of cardiac performance and local resistance.

The influence of local resistance and cardiac performance on peripheral blood acceleration was investigated in 14 healthy male volunteers. Steady and pulsatile flow was studied in the brachial and in the common carotid arteries, ie, two territories that exhibit marked differences in resistive characteristics. Instantaneous blood velocity (V), mean blood velocity (Vm) and artery diameter (D) were evaluated at rest by an ultrasonic range-gated pulsed Doppler flowmeter using a double transducer probe, thus allowing the calculation of mean blood flow (Q). Mean local resistance (R) was obtained by dividing the mean arterial pressure by Q. The peak value of the local acceleration of the blood was obtained by computer-assisted calculation of the first derivative of instantaneous blood velocity (Gmax = +dV/dtmax). Peak aortic blood acceleration (GAo) was simultaneously measured from the suprasternal notch using a pulsed Doppler velocity meter. In the branchial and the common carotid arteries, Gmax was of a similar magnitude (551 +/- 30 and 555 +/- 44 cm/s2, respectively) despite major differences in the respective D, Vm, Q and R values. In neither artery was there a relationship between Gmax and either resting Q or R. At the brachial artery level, Gmax was positively related to GAo (r = 0.79, P = 0.0008). At the common carotid artery level, there was a weak, although non significant relationship between Gmax and GAo (P = 0.08). Our results indicate that the local acceleration of peripheral blood flow in the brachial artery is related rather to upstream central impulse than to downstream hemodynamics, and suggest some regional differences in the hemodynamic determinants of the local acceleration of peripheral blood flow.

[Physiopathology of myocardial dysfunction in septic shock]. / Physiopathologie de la dysfonction myocardique au cours du choc septique.

Left ventricular dysfunction is rarely a prominent feature of septic shock. Initially, it is masked by circulatory changes and adaptive phenomena which increase the cardiac output. Evaluation of intrinsic myocardial function is therefore difficult in this pathology. The different experimental models used (cell culture, isolated muscle, isolated perfused heart and whole animal) and recent clinical studies using angiographic, catheter and echocardiographic data, have confirmed that this condition exists. Its physiopathology is not yet fully understood and involves several mediators. The direct effect of bacterial endotoxins has not been formally established. However, therapy with anti-endotoxin antibodies does give encouraging results. The cytokines, such as interleukin-1, tumour necrosis factor, and platelet activating factor play a key role between the infectious factors and cellular mediators. Their effects on the myocardium are subject of much on-going research. Current date, in particular with respect to the tumour necrosis factor, suggest that they may have a direct cardiodepressor factor. The presence of a circulating negative inotropic substance has been suspected for many years. Recent studies tend to confirm this hypothesis though the substance itself has not yet been isolated. The theory of reduced coronary flow causing myocardial dysfunction in septic shock has fallen out of favour. Some experimental evidence supports the clinical impression of reduced vascular and cardiac reactivity to catecholaminergic stimulation. The actions of different membrane structures involved have not been determined. At cellular level, changes in calcium metabolism, which regulates muscle contraction and relaxation, probably play an important role in septic shock. In addition to the symptomatic therapeutic advances that have been made in septic shock, specific myocardial treatment could be beneficial.