Comparative Population Plasma and Tissue Pharmacokinetics of Micafungin in Critically Ill Patients with Severe Burn Injuries and Patients with Complicated Intra-Abdominal Infection.

Severely burned patients have altered drug pharmacokinetics (PKs), but it is unclear how different they are from those in other critically ill patient groups. The aim of the present study was to compare the population pharmacokinetics of micafungin in the plasma and burn eschar of severely burned patients with those of micafungin in the plasma and peritoneal fluid of postsurgical critically ill patients with intra-abdominal infection. Fifteen burn patients were compared with 10 patients with intra-abdominal infection; all patients were treated with 100 to 150 mg/day of micafungin. Micafungin concentrations in serial blood, peritoneal fluid, and burn tissue samples were determined and were subjected to a population pharmacokinetic analysis. The probability of target attainment was calculated using area under the concentration-time curve from 0 to 24 h/MIC cutoffs of 285 for Candida parapsilosis and 3,000 for non-parapsilosis Candida spp. by Monte Carlo simulations. Twenty-five patients (18 males; median age, 50 years; age range, 38 to 67 years; median total body surface area burned, 50%; range of total body surface area burned, 35 to 65%) were included. A three-compartment model described the data, and only the rate constant for the drug distribution from the tissue fluid to the central compartment was statistically significantly different between the burn and intra-abdominal infection patients (0.47 ± 0.47 versus 0.15 ± 0.06 h(-1), respectively; P < 0.05). Most patients would achieve plasma PK/pharmacodynamic (PD) targets of 90% for non-parapsilosis Candida spp. and C. parapsilosis with MICs of 0.008 and 0.064 mg/liter, respectively, for doses of 100 mg daily and 150 mg daily. The PKs of micafungin were not significantly different between burn patients and intra-abdominal infection patients. After the first dose, micafungin at 100 mg/day achieved the PK/PD targets in plasma for MIC values of ≤0.008 mg/liter and ≤0.064 mg/liter for non-parapsilosis Candida spp. and Candida parapsilosis species, respectively.

Acute kidney injury in critically burned patients resuscitated with a protocol that includes low doses of Hydroxyethyl Starch.

Acute kidney injury (AKI) is an important complication in burn patients. Recently, it has been recommended that hydroxyethyl starch (HES) be avoided in burn patients because it increases the incidence of AKI. Our purpose was to study incidence of AKI in critically ill burn patients resuscitated with Ringer's solution and supplements of HES. We conducted an observational study of 165 patients admitted to the critical care burn unit (with 30 ± 15% TBSA burned). The main outcome measures were incidence of AKI, contributions of colloids and crystalloids, various severity scores, comorbidities, complications and mortality. According to the RIFLE criteria, 10 (6.1%) patients presented with Risk, 11 (6.7%) presented with Injury and 11 (6.7%) presented with Failure. According to the AKIN criteria, 9.7% presented stage I, 3% stage II and 10.3% stage III. Replacement therapy (RRT) was performed in 15 patients (9.1%), but in 6 of them RRT was employed in the final stages of multi-organ failure. The incidence of AKI in severe burn patients is high according to the RIFLE or AKIN criteria and these patients experience more complications and higher mortality. Our study suggests that the use of HES in low doses in the burn resuscitation phase does not cause more AKI than resuscitation without HES, but further evaluation is required. Further studies should be conducted.

La souffrance rénale aiguë (SRA) est une complication sévère des patients brûlés. Il a récemment été recommandé d'éviter les HydroxyEthylAmidons (HEA) chez les patients brûlés en raison de l'augmentation de l'incidence des SRA. Le but de ce travail est d'évaluer l'incidence de la SRA chez des patients réanimés avec du Ringer Lactate et des HEA. Il s'agit d'une étude observationnelle conduite auprès de 165 patients admis en réanimation pour brûlés (surface 30 +/-15%). Les principaux paramètre recueillis étaient la SRA, les cristalloïdes et colloïdes utilisés, les scores de gravité, les comorbidités, les complications et la mortalité. Selon la classification de Rifle, 10 (6,1%) patients étaient dans le groupe à risque, 11 (6,7%) avaient une souffrance rénale et 11 (6,7%) une insuffisance rénale. Selon les critères AKIN, 9,7% des patients étaient au stade 1, 3% au stade 2 et 10,3% au stade 3. Une épuration extra-rénale a été nécessaire à 15 (9,1%) patients, 6 d'entre eux étant à un stade avancé de défaillance multiviscérale. Basée sur les scores Rifle comme AKIN, l'incidence de souffrance rénale est élevée chez les brûlés et ceux qui en souffrent ont une morbidité et une mortalité plus élevées. Toutefois, notre étude laisse à penser que les patients ayant reçu des HEA n'ont pas plus de souffrance rénale que ceux n'en ayant pas reçu, des études plus poussées restant nécessaires.

Endoscopic treatment of posterior epistaxis.

Posterior epistaxis management remains a challenge. Besides their traumatic character, the usual treatments may cause as much morbidity and even mortality as the underlying pathology. A technique of endoscopically guided monopolar selective cauterisation was introduced in Lausanne at the end of 1987. Since then, 163 patients with a posterior epistaxis have been treated in our department. For 139 of these, endoscopic monopolar cauterization was the first treatment applied. Haemostasis was achieved at the first attempt in 82% of cases. The total success rate, including early recurrences controlled by a new cauterization, was 92%. Endoscopic monopolar cauterization requires the ability to perform nasal endoscopy, but presents few disadvantages. This technique represents a selective, relatively atraumatic, rapid and effective treatment. Moreover, costs are much lower than those of other methods. In our opinion, endoscopic monopolar cauterization should be the treatment of choice for posterior epistaxis.

Evaluation of the bone resistance of the sphenoid and ethmoid sinuses.

Functional endoscopic sinus surgery can be associated with iatrogenic complications. Some anatomical structures have been identified this clinically as specific danger sites. The aim of this study was to confirm and to compare these clinical data with measurements of the bone resistance of the sphenoid and ethmoid walls and to point out regions that have increased bony fragility. Critical dynamometric evaluation of the resistance to breakage of these bony structures was made on 21 anatomic specimens. This study allowed the authors to localization of surgical complications, to demonstrate that other regions renowned for their fragility can be relatively robust, and to point out that robust sites can be dangerously fragile as a result of individual morphological variations. Results from this study provide a supplement to the guidelines for novice surgeons to use in identifying dangerous areas.

[Influence of naso-sinusal anatomic variants on recurrent, persistent or chronic sinusitis. X-ray computed tomographic evaluation in 112 patients]. / Influence des variantes anatomiques nasosinusales sur les sinusites récidivantes, persistantes ou chroniques. Evaluation TDM chez 112 patients.

Using CT scan, we studied the influence of the most important sinonasal anatomic variants on 112 patients, aged more than 16 years, suffering from recurrent, persistent or chronic sinusitis. The series was characterized by the absence of: multifocal sinusitis, polyposis, dental or mycotic sinusitis, traumatic, tumour, actinic or prior surgery. We compared our results with those of the literature. Our findings confirmed the association between recurrent, persistent or chronic sinusitis, and ipsilateral septal ridges or spurs (33%), unusual ipsilateral deflexions of uncinate process (31%), and contralateral septal watch glass like deviation (42%). We found no correlation for the other studied variants (concha bullosa, paradoxical curve of middle turbinate, pneumatised uncinate process, hypertrophic ethmoid bulla, Haller cell and accessory maxillary ostium).

[Surgical anatomy of the middle meatus and ethmoid]. / Anatomie chirurgicale du méat moyen et de l'ethmoïde.

The evolution of rhino-sinusal endoscopy and the progress in endonasal surgery under endoscopic guidance, justifies a review of the ethmoid anatomy. A simple and logical scheme of the ethmoid bone is presented. The observer has to develop an "endoscopic eye" since the panoramic view offered by the optics modifies the image. Special attention is drawn upon the endoscopic anatomical fine points in the crucial area of the "bullar circus". These are necessary guides in surgical practice.

[Anatomic and endoscopic studies of the anterior ethmoid]. / Etude anatomique et endoscopique de l'ethmoïde antérieur.

Introduction of present-day sinonasal endoscopy and progress in endonasal surgery under endoscopic guidance of endoscopy provide for anatomical exploration of the anterior part of the ethmoid bone, which is the crosspoint of the facial sinus draining paths. We propose to present here a simple and logical scheme of the topographical anatomy of the ethmoid bone. Classification of the ethmoidal cells allows to define the structures, whereby appropriate nomenclature may be adopted and certain confusions avoided. Thus, each cell within particular cell groups acquires a specific designation based on its draining paths and location in relation to basal lamellae. Endoscopic analysis also deserves being described in some length, since the panoramic view afforded by currently used optics modifies the image ans requires that the observer develop an "endoscopic eye". We draw attention to the endoscopic anatomical fine points in the crucial area of the bullar "circus". These landmarks come in as necessary guides in surgical practice.

[Topographic anatomy of the ethmoid labyrinth in x-ray computed tomography]. / Anatomie topographique du labyrinthe ethmoïdal en tomodensitométrie.

These last years the surgical treatment of inflammatory ethmoid disease has been completely modified, with new endoscopic conservative procedures. In a preoperative phase it is mandatory to provide optimal CT imaging of the ethmoid labyrinth, and for this purpose sections perpendicular and parallel to the nasofrontal duct axis are better than axial and coronal slices. The anatomy of the ethmoid is fairly complex; however certain constant anatomic landmarks allow a systematic analysis of the ethmoid labyrinth: the unciform process, the bulla, the middle turbinate, the superior turbinate and their respective basal lamellae.

Prevalence of ethmoid sinus abnormalities on brain CT of asymptomatic adults.

To evaluate the prevalence of ethmoid sinus abnormalities in adults without clinical history of sinusitis or allergic rhinitis, the brain CT scans of 156 patients were analyzed prospectively. In 17 cases (10.9%) the ethmoid labyrinth showed abnormalities. In most of these cases (88%) the ethmoid disease was localized to four or fewer cells. Men were more often affected than women (ratio, 2.5:1), and the prevalence of abnormalities was fairly similar across age groups.

[X-ray computed tomographic evaluation of the anterior ethmoid by parallel and perpendicular sections to the axis of nasofrontal duct. Preliminary study]. / Evaluation tomodensitométrique (TDM) de l'ethmoïde antérieur par des sections parallèles et perpendiculaires à l'axe du canal fronto-nasal. Etude préliminaire.

The anterior ethmoid is revisited with CT sections parallel and perpendicular to the axis of the naso-frontal duct. The sections obtained in these 2 planes allow a more precise topographic study of the anterior ethmoid than the routinely used axial and coronal CT slices. For the surgeon these sections provide an optimal preoperative study of the anterior ethmoid allowing the most conservative endoscopic surgical treatment.