[Severity factors of aluminium phosphide poisoning (Phostoxin)]. / Facteurs de gravité de l'intoxication aiguë au phosphure d'aluminium (Phostoxin).

OBJECTIVES: To determine characteristics of acute aluminum phosphide poisoning (AAlPP) and to evaluate its severity factors. DESIGN STUDY: Retrospective cohort study. PATIENTS AND METHODS: Consecutive cases of AAlPP admitted in medical ICU (Hospital Avicenne, Rabat, Morocco) between January 1992 and December 2002 were studied. AAlPP was identified by history, symptoms and toxicological results. Almost 50 parameters have been collected and compared between survivors and non-survivors groups. Data were analyzed using Fisher exact test and Mann-Whitney test. RESULTS: Twenty-eight patients were enrolled: 17 female and 11 male, average age = 24+/-11 years, SAPS II = 24.4+/-14.5. The ingested dose was 3.3+/-1.8 g. The self-poisoning was observed in 27 cases and delay before hospital admission was 11+/-13 hours. Mean Glasgow coma scale was 14+/-2. Shock was found in 22 (79%) cases. Average pH was 7.1+/-0.4 and bicarbonate concentration was 16.3+/-8.8 mmol/l. The ECG abnormalities were noted in 20 (72%) cases. The average mortality rate was 61%. The prognostic factors were SAPS II (p = 0.031), Apache II (p = 0.037), shock (p = 0.022), ECG abnormalities (p = 0.05), use of vasoactive drugs (p = 0.05) and use of mechanical ventilation (p = 0.003). CONCLUSION: AAlPP induced a significantly high mortality and haemodynamic disturbances were a risk factor of poor outcome.

[Left ventricular thrombus and myocarditis induced by paraphenylenediamine poisoning]. / Thrombus ventriculaire gauche et myocardite toxique induite par la paraphénylène diamine.

We showed that the paraphenylenediamine (PPD) poisoning caused myocarditis but there is no data on the echocardiographic features. We report a case of myocarditis induced by PPD poisoning with echographic data. After ingestion of 5 g of PPD, a 18-year-old woman was admitted to the hospital with asphyxia and rhabdomyolysis. An electrocardiogram showed ventricular extrasystoles and negative T waves. The serum concentration of CK was 28,020 UI l(-1) (iso-enzyme MB = 840 UI l(-1)). A transthoracic echocardiography showed significant left and right ventricular hypokinesis (shortening fraction = 20% and left ventricular ejection fraction = 35%) and a left ventricular apical thrombus. Anticoagulation treatment with heparin was initiated. A follow-up echocardiogram performed on the 15th day showed normalization of ventricular function and disappearance of the thrombus. No embolic event was noted. Echocardiography is indicated in the myocarditis induced by PPD poisoning to prove the ventricular function as well as the presence of a thrombus.

[Incidence, causes and prognostic factors of hyponatremia in intensive care]. / Incidence, étiologies et facteurs pronostiques de l'hyponatrémie en réanimation.

PURPOSE: The incidence of hyponatremia is unknown, their causes are multiple. The higher mortality, especially in intensive care units, is currently unexplained. The objective of this article is to evaluate the incidence of hyponatremia, to assess their causes and to identify predictors of prognosis in intensive care units. METHODS: We included retrospectively all patients admitted at department of medical intensive care unit between January 1996 and February 2001, who presented at the admission, an hyponatremia (< 130 mmol/l). We excluded all patients who presented a hospital acquired hyponatremia, or hyponatremia associated with hyperglycemia > 13 mmol/l or with mannitol administration. Data were analysed by univariate methods, then by multivariate analysis. RESULTS: During the study period, 300 patients were identified among 2188: the incidence was 13.7% with 95% confidence interval (95% CI) between 9.8 % and 16.7%. Hypovolemic hyponatremia was observed in 25.7%, hypervolemic in 23.7% and normovolemic in 50.6%. In-hospital mortality was 37.7% (95% CI: 31.8% - 42.3%). Nine data were significantly associated with higher mortality in univariate analysis, but only 5 were identified as independant predictors of hospital mortality in multivariate analysis: hyponatremia < 125 mmol/l with a significant relative risk (RR) (RR = 2.10; 95% CI: 1.43-3.08; p < 0.001), Glasgow score < 9 (RR = 2.66; 95% CI: 1.25-5.66; p = 0.01), Glasgow score between 9 and 14 (RR = 1.94; 95% CI: 1.31-2.88; p < 0.001), shock (RR = 1.80; 95% CI: 1.10-3.05; p = 0.02) and blood urea concentration > 10 mmol/l (RR = 1.59; 95% CI : 1.08-2.34; p = 0.02). CONCLUSION: The frequency of hyponatremia is high; the normovolemic type represented 50%. Mortality is linked, in greater part, to organs dysfunction, but the severity of hyponatremia remained a significant predictor of mortality.

[Comparative efficiency of nebulized adrenaline and salbutamol in severe acute asthma. A randomized, controlled prospective study]. / Efficacité comparée de l'adrénaline et du salbutamol en nébulisation dans l'asthme aigu grave. Essai clinique contrôlé prospectif randomisé.

OBJECTIVE: To compare nebulized salbutamol and nebulized adrenaline in acute severe asthma (ASA). STUDY DESIGN: Prospective controlled study. PATIENTS AND METHODS: October 1998 at May 99, 44 patients (31 women and 13 men, 35 +/- 11 yrs) with ASA (defined as peak expiratory flow rate (PEF) < 150 l min-1 and normo- or hypercapnia) were randomized to receive either nebulized salbutamol (n = 22), 10 mg/h-1 during 2 h then 5 mg every 4 h or nebulized adrenaline (n = 22), 6 mg/h-1 during 2 h then 3 mg every 4 h. The efficacy was assessed by PEF, forced expiratory volume in one second (FEV1) and Fischl's score during eight hours and by arterial blood gases during the first hour. Side-effects were evaluated by heart rate, systolic blood pressure, serum potassium and blood glucose. Statistical tests: Wilcoxon, Fischer exact, ANOVA and Scheffe's test. RESULTS: Both groups were similar with respect to age, sex, severity, duration of asthma and length of crisis. With the two treatments, PEF increased significantly but no statistical difference were observed between the two groups during the eight hours: 117.7 +/- 41.6 l min-1 to 203.3 +/- 56.9 l min-1 in the salbutamol group; 116.4 +/- 36.8 l min-1 to 217.3 +/- 188.8 l min-1 in the adrenaline group; p = 0.77. FEV1, Fischl's score and arterial blood gases did not differ significantly between treatments at every time interval. There were no significant difference between the two groups in terms of side-effects. The intravenous way was necessary at 3 cases of the salbutamol group and 4 cases of adrenaline group (NS). CONCLUSION: The results suggest that nebulized adrenaline is as effective as nebulized salbutamol in the ASA without significant side-effects. The nebulization could reduce systemic effects of adrenaline.

Weaning from mechanical ventilation: a model for extubation.

OBJECTIVE: To develop a model able to determine the right time for extubation and to validate its performance. paragraph sign DESIGN: A prospective clinical study. SETTING: 14-bed medical intensive care unit in a university hospital. PATIENTS: 101 patients (37 women/64 men) ventilated over more than 48 h (mean 10.4 +/- 10.3 days) and considered ready to be weaned by the medical team (February 1996-February 1998). METHODS: This study included two series: a development series with 53 patients and a validation series with 48 patients. Before extubation, a weaning test was performed measuring tidal volume (V(T)), respiratory rate (f), f/V(T) ratio, minute ventilation, vital capacity (VC) and maximum inspiratory and expiratory pressures (MIP and MEP). The success of extubation was assessed after 48 h. Receiver operating characteristic (ROC) curves allowed the analysis of the discriminating power of each parameter. Threshold values were determined using the Youden's index. To create the best predictive model, we performed a multiple logistic regression analysis. To assess the calibration and the discrimination of the model, the Hosmer- Lemeshow goodness-of-fit test and area under ROC curves (AUC) were adopted. MEASUREMENTS AND RESULTS: In a development series, 60 tests were carried out with 38 successful extubations and 22 extubation failures. The multivariate analysis found three significant variables: VC (threshold value = 635 ml), f/V(T) ratio (threshold value = 88 breaths/min.l) and MEP (threshold value = 28 cmH(2)O). The validation cohort included 59 tests (38 successes and 21 failures). The validation series shows a good discrimination (AUC = 0.855 +/- 0.059) and calibration (goodness-of-fit test C: p = 0.224) of the model. CONCLUSION: VC together with the f/V(T) ratio and MEP offer accurate prediction of early extubation.

[A rare cause of lower digestive tract bleeding: angiodysplasia of the small bowel]. / Une cause rare d'hémorragie digestive basse: l'angiodysplasie du grêle.

Angiodysplasia of the small bowel is an uncommon condition which causes lower digestive tract bleeding. The aim of this report was to clear up some of the particular problems and to stree the difficulty of diagnosis in low digestive bleeding. We report the case of a 34-year-old patient who had melena for ten years. Explorations performed, mostly endoscopy, had not given the diagnosis. Angiodysplasia was diagnosed on selective angiogram performed during a hemorrhagic episode. The literature emphasizes the difficulty of diagnosis. Selective angiography allows topographic diagnosis and simplifies surgical cure which should be as elective as possible with segmental enterectomy. Different studies on small bowel angiodysplasia have found the disease in both sexes at equivalent frequencies by age. Low digestive hemorrhage is a constant sign. Pathogenesis remains a question of debate: acquired or congenital histology shows an essentially submucosal vessel pastes ectasia. We emphasize the importance of selective angiography for exploring bleeding of the lower digestive tract of unknown cause.