Covid-19 severe hypoxemic pneumonia: A clinical experience using high-flow nasal oxygen therapy as first-line management.

PURPOSE: To report a French experience in patients admitted to Intensive Care Unit (ICU) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requiring high fractional concentration of inspired oxygen supported by high flow nasal cannula (HFNC) as first-line therapy. METHODS: Retrospective cohort study conducted in two ICUs of a French university hospital. All consecutive patients admitted during 28-days after the first admission for SARS-CoV-2 pneumonia were screened. Demographic, clinical, respiratory support, specific therapeutics, ICU length-of-stay and survival data were collected. RESULTS: Data of 43 patients were analyzed: mainly men (72%), median age 61 (51-69) years, median body mass index of 28 (25-31) kg/m2, median simplified acute physiology score (SAPS II) of 29 (22-37) and median PaO2/fraction of inspired oxygen (FiO2) (P/F) ratio of 146 (100-189) mmHg. HFNC was initiated at ICU admission in 76% of patients. Median flow was 50 (45-50) L/min and median FiO2 was 0.6 (0.5-0.8). 79% of patients presented at least one comorbidity, mainly hypertension (58%). At day (D) 28, 32% of patients required invasive mechanical ventilation, 3 patients died in ICU. Risk factors for intubation were diabetes (10% vs. 43%, P=0.04) and extensive lesions on chest computed tomography (CT) (P=0.023). Patients with more than 25% of lesions on chest CT were more frequently intubated during ICU stay (P=0.012). At ICU admission (D1), patients with higher SAPS II and Sequential Organ Failure Assessment (SOFA) scores (respectively 39 (28-50) vs. 27 (22-31), P=0.0031 and 5 (2-8) vs. 2 (2-2.2), P=0.0019), and a lower P/F ratio (98 (63-109) vs. 178 (126-206), P=0.0005) were more frequently intubated. Among non-intubated patients, the median lowest P/F was 131 (85-180) mmHg. Four caregivers had to stop working following coronavirus 2 contamination, but did not require hospitalization. CONCLUSION: Our clinical experience supports the use of HFNC as first line-therapy in patients with SARS-COV-2 pneumonia for whom face mask oxygen does not provide adequate respiratory support.

Incidence of anaerobic bacteria in patients with suspected pneumonia in surgical Intensive Care Unit.

BACKGROUND: Few studies have investigated the incidence of pulmonary anaerobes in a specific population in surgical Intensive Care Unit (ICU). The objective of this work was to determine the incidence of anaerobes in surgical ICU patients with suspected pneumonia. METHODS: This was a prospective observational, single-center study. Analysis was based on data collected over 30 months from the surgical ICU of a tertiary care hospital (Rouen University Hospital), including data on risk factors for anaerobes in the lungs. Patients with suspected pneumonia (community-acquired or nosocomial) were included. Bacteriological sampling was performed by protected distal bronchial sampling (PDBS) with minilavage under bronchoscopy. Aerobic and anaerobic cultures were performed for each sample. Clinicians were only aware of aerobic results. Univariate and multivariate statistical analysis compared groups with and without anaerobes. RESULTS: A total of 134 samples were obtained from 117 patients. Surgery was performed on 74 patients (63.2%), within 24 hours of admission. Fifty-four patients (46.2%) had a chest trauma and 20 patients (17.1%) were admitted for a digestive pathology. Average age was 53.6±20.9 years and sex ratio was 5.9 (100 men/17 women). Average SAPS II was 41.6±15.1, median length of ICU stay was 23 days (25th percentile=13, 75th percentile=33), and median duration of mechanical ventilation was 21 days (25th percentile=11, 75th percentile=28). Mortality rate in ICU was 14.5%. After sampling, diagnosis of pneumonia was confirmed in 70 cases (52.2%). Anaerobe cultures were positive in 11 samples taken from 11 different patients (overall incidence 8.2%). Aerobic bacteria were also involved in 9 patients (81.8%). In univariate analysis, enteral feeding (P=0.02) and absence of catecholamines at time of sampling (P=0.003) were significantly associated with the presence of anaerobes in PDBS. Enteral nutrition was also found to be a risk factor in multivariate analysis (OR=11.8, 95% CI [1.36 to 102.4] P=0.025). Prior antianaerobic antibiotic treatment was not a protective factor. No difference was observed regarding the notion of aspiration, survival, total length of stay and duration of mechanical ventilation, or evolution of pneumonia between the two groups. CONCLUSION: Our study demonstrates the presence of anaerobic bacteria in the lung samples of patients from surgical ICU with an incidence comparable to that found in populations from medical ICU departments. Anaerobic morbidity in our study is in line with recent literature.

[Impact of Sfar experts' conference entitled "Modalities of sedation and/or analgesia in hospital setting"]. / Impact de la conférence d'experts intitulée "Modalités de la sédation et/ou de l'analgésie en situation extrahospitalière".

UNLABELLED: In 1999, the Société française d'anesthésie et de réanimation (Sfar) published guidelines regarding sedation in prehospital setting. The recommendated protocol for emergency intubation was the rapid sequence induction (RSI). The aim of this study was to assess the impact of these guidelines on clinical practices. PATIENTS AND METHODS: A restrospective observational study was conducted in three French mobile emergency and intensive care units. In 1998, 2000 and 2004, during periods of four months, charts from every interventions were analyzed. All the patients over 15 years of age needing to be intubated and not in cardiac arrest were included. The following data were collected: anaesthetic protocol used for intubation, drugs used for maintenance of sedation, circumstances requiring tracheal intubation and side effects related to tracheal intubation or sedation. An anonymous questionnary form was also sent to all physicians from the three units in order to assess sedation protocol used for emergency intubation, knowledge regarding the Sfar conference. RESULTS: Five hundred and thirty-one patients were included, and orotracheal intubation was performed in 84% of cases. RSI was administrated in 23% of cases in 1998, 45% in 2000 and 68% in 2004. Protocol for maintenance sedation complied the guidelines in 45% of cases in 1998, 68% in 2000 and 75% in 2004. Among the 62 physicians who answered the questionnary, 90% indicated they used RSI sequence for orotracheal intubation and 92% achieved sedation maintenance using midazolam fentanyl. CONCLUSION: The Sfar guidelines regarding sedation in prehospital setting seem to meet a good compliance in clinical practice.

[Waterhouse-Friderichsen syndrome associated to a Morganella morganii and Enterococcus faecium peritonitis]. / Syndrome de Waterhouse-Friderichsen au cours d'une péritonite à Morganella morganii et Enterococcus faecium.

About fifty to sixty percent of patients with septic shock acquire acute adrenal insufficiency. This insufficiency is most often relative, but can sometimes be absolute. Bilateral adrenal haemorrhage is a rare aetiology of absolute acute adrenal insufficiency. It is classically described in patients with severe meningococcemia (purpura fulminans), who commonly present many of the risk factors associated with bilateral adrenal haemorrhage (shock, coagulation disorders, sepsis). We report a case of bilateral adrenal haemorrhage during a peritonitis complicated by a septic shock, with no coagulation disorder. This observation shows up that this bilateral adrenal haemorrhage can complicate severe sepsis of various origins, and not only severe meningococcemia. It can be suspected in face of a septic shock with an unfavourable evolution despite adequate treatment.

[An unusual aetiology for septic shock: Capnocytophaga canimorsus. Is always dog man's best friend?]. / Un choc septique d'étiologie inhabituelle: Capnocytophaga canimorsus. Le chien est-il toujours le meilleur ami de l'homme?

The mortality of overwhelming postsplenectomy infections (OPSI) is significant (50 to 80 percent). Capnocytophaga canimorsus belongs to the normal oral flora of dogs and cats. It is seldom responsible for human infections, but its prognosis is bad (about 30 percent of overall mortality), especially in asplenic patients. We report a case of a splenectomized patient who suffered from communal septic shock due to C. canimorsus septicaemia. The course of events was rapidly fatal. Diagnosis and mode of contamination were determined only a few weeks after the patient's death. This late microbiological diagnosis is due to a slow growth of C. canimorsus in vitro.

Periodic limb movement disorder is associated with normal motor conduction latencies when studied by central magnetic stimulation--successful use of a new technique.

This study prospectively tested the hypothesis that patients with periodic limb movement disorder (PLMD) have longer motor conduction latencies than normals. Six healthy adults, 13 patients with PLMD, and 8 patients with long-term multiple sclerosis (MS) had recordings of motor conduction latencies during wake and sleep. MS subjects were included only to show that we could detect prolongation of central conduction; nonMS subjects were used to test the hypothesis. Subjects had no other medical or sleep problems. A novel magnetic stimulator, the Cadwell MES-10, was discharged over the vertex and the C7 cervical spine. It triggered compound muscle action potentials that were recorded in the abductor digiti minimi in the hand. The conduction latencies were the total conduction time (TCT), measured vertex to hand, and the peripheral conduction time (PCT), measured C7 to hand. The difference was the central conduction time (CCT). Only TCT could be obtained during sleep. Supporting the use of TCT as an indirect measure of central conduction was that, in all waking subjects, TCT correlated with CCT (r = 0.91, p = 0.001) but not with PCT. Reliabilities during wake and sleep were 0.95 or higher for TCT and PCT measurements. Waking CCT was greater in MS subjects (13.77 milliseconds) than those without MS (9.21 milliseconds), p = 0.001. Sleeping TCT was much less impressive in distinguishing MS subjects [27.08 milliseconds in nonrapid eye movement (NREM) sleep; 28.64 milliseconds in rapid eye movement (REM) sleep] from nonMS subjects (24.45 milliseconds in NREM; 24.84 milliseconds for REM), p = 0.07 for NREM and p = 0.04 for REM.(ABSTRACT TRUNCATED AT 250 WORDS)

Diabetic ketoacidosis: outcome in a community hospital.

The mortality among patients with diabetic ketoacidosis (DKA) has been reported to be as high as 5% to 15%. To determine the outcome of DKA, we reviewed the charts of all patients admitted to one of our community affiliated hospitals for the period of January 1979 to December 1981. We identified 66 episodes of DKA in 42 patients. All patients received intravenous fluids. Insulin was given by continuous infusion in six (9%), by bolus only in 14 (20%), and by a combination of the two in 46 (71%). The mean time for recovery from DKA was similar in all three subgroups. All patients recovered from DKA and were discharged from the hospital; no deaths occurred. We conclude that it is possible to treat DKA effectively in a community hospital, with mortality approaching zero.

[Infections in surgery under extracorporeal circulation. Results of 3 years of antibioprophylaxis]. / Infections en chirurgie sous circulation extra-corporelle. Bilan de 3 ans d'antibioprophylaxie.

The present study was designed to evaluate perioperative antibio-therapy with cefamandol for the prevention of post-operative infections after surgery under cardiopulmonary bypass. 1 300 patients were studied. The incidence for wound infections was 1.3%, 0.9% for systemic, 1.3% for other infections. These results show a decrease in the frequency of infections in comparison with data from the literature.

Secretion of hormones influencing water and electrolyte balance (antidiuretic hormone, aldosterone, prolactin) during sleep in normal adult men.

Renal conservation of electrolytes and water occurs normally during sleep. Antidiuretic hormone (ADH), aldosterone (ALDO), and prolactin (PRL) are hormones that may have interactive effects on kidney function. The availability of a radioimmunoassay for ADH as well as for ALDO and PRL permitted the study of the simultaneous secretion patterns of these three hormones during all-night sleep in eight normal young adult men, by blood sampling every 20 min from 2300 to 0700 on two consecutive night. ADH, ALDO, and PRL all appeared to be secreted episodically. The pulsatile release of ADH was random, and average plasma ADH levels were unchanged during the night. ALDO and PRL, on the other hand, had an approximately 90-min secretion rhythm, and average plasma concentrations of both hormones consistently increased during the hours of sleep. Average plasma sodium concentration was constant throughout the night. The nocturnal increase in plasma ALDO may be responsible for the normal reduction of urine sodium excretion during the night. The concomitant increase in plasma PRL might synergize with ALDO in influencing the renal retention of sodium, but PRL alone has little apparent effect on human kidney function. REM sleep-related decreases in urine flow have been noted both in humans and in monkeys, but ADH secretion was not REM related in out subjects. Autonomic activation during REM is one possible explanation for decreased urine flow during this stage of sleep.

Selective neuroendocrine effects of low-dose haloperidol in normal adult men.

The neuroendocrine effects of haloperidol, usually reported as side effects of this drug when given in antipsychotic doses, have not been systematically investigated. In the present study five normal adult men were administered saline and two doses of of haloperidol (0.25 mg, 0.5 mg) intramuscularly in a double-blind randomized block design. The anterior pituitary hormones GH, LH, FSH, and PRL were measured in blood samples taken every 20 min for several hours thereafter. The low doses of haloperidol used have been shown by others to alter the human EEG; in our subjects these doses produced no objective or subjective clinical effects. There were no drug related changes in GH, LH, or FSH. PRL, however, showed a prompt, statistically significant, dose-related increase in plasma levels, with a return to baseline with 5 h. Haloperidol has strong dopamine-blocking effects, and the hypothalamic inhibitory mechanism for PRL release is believed to be dopamine-mediated. The results of this study suggest that haloperidol may have utility in low doses primarily for its hypothalamic neuroendocrine effects, and that dose-related PRL release may be a useful paradigm for comparing dopamine-blocking antipsychotic agents in humans.

Nocturnal increase of plasma testosterone in men: relation to gonadotropins and prolactin.

The nocturnal increase of plasma testosterone (T) in adult men has been well established. Luteinizing hormone (LH) does not show a similar increase throughout the night, whereas prolactin (PRL) does, suggesting the possibility of other hormone influence on T secretion. To investigate this possibility, 8 young adult men were studied for 4 consecutive nights in the sleep laboratory (2 nights adaptation, 2 nights blood sampling), by blood samples taken every 30 min during the 8-h sleep period, for measurement of LH, follicle stimulating hormone (FSH), PRL, and T. LH and FSH were secreted episodically, with little or no change in baseline levels during the night. PRL and T also were secreted episodically, but their baseline levels increased as the night progressed. Both LH and PRL had maximum within-subject correlations (averages equal +0.35 and +0.48 respectively) with T when they led T by 60 min. Within-subject correlations done on first differences (to remove the effect of slow trends) were near zero. LH and PRL had larger correlations with T than did FSH, for both calculations. These data suggest that both LH and PRL levels precede T levels by about 60 min. PRL thus may participate in the regulation of nocturnal T secretion in adult men.