[Quetiapine and anticholinergic drugs induced ischaemic colitis: A case study]. / Colite ischémique sous quétiapine associée à d'autres molécules anticholinergiques : à propos d'un cas.

INTRODUCTION: The aim of this paper is to underline the need for systematic monitoring of patients treated with anticholinergic antipsychotic drugs. We present the clinical history of a 34-year-old adult, treated with quetiapine in combination with other drugs with anticholinergic effects. CASE REPORT: A 34-year-old male adult had been suffering from bipolar disorder since 2001. He was treated with risperidone, but he was not compliant due to adverse effects, including decreased libido and erectile dysfunction. On June 5th 2012, it was decided to administrate 600mg per day of quetiapine in combination with tropatepine consequent to an episode of agitation and aggressiveness. On June 14th 2012, while the patient was receiving diazepam and valproic acid, loxapine oral solution was introduced. On June 23th, the patient started mentioning digestive disorders, such as diffuse abdominal pain with constipation but continued to pass gaz. On June 25th, at 6:30 am, he declared abdominal pain, which worsened at 8:15 am despite administration of analgesics, followed by malaise and onset of vomiting. His laboratory tests showed leukocytosis 11.2G/L with neutrophils 7.7G/L. The abdomen's radiograph without preparation showed small bowel and colonic air-fluid levels. The result of the CT scan confirmed an occlusive syndrome affecting the whole small gut and colon. At 1 pm, the patient's condition worsened. He received an intramuscular injection of 100mg of loxapine and an opioid treatment, including tramadol and morphine. At 2:30 pm, the clinical condition further deteriorated with an onset of generalized abdominal contracture, the absence of abdominal breathing, sweating, tachycardia at 104 beats per minute, and hypothermia of 34.5°C. He was transferred to an intensive care unit. Laboratory tests showed metabolic acidosis, elevated liver enzymes and acute renal failure. He received volume expansion and was treated by renal replacement therapy and antibiotics. He was intubated and transferred to the operating room. At laparotomy, both colonic necrosis with perforation and necrosis of the small bowel were seen. The patient underwent total colectomy with small bowel resection, distal ileostomy and closure of the rectal stump. The onset of septic and hemorrhagic state required further surgery on June 26th. The evolution was characterized by multi-organ failure with acute anuric renal failure, multiple cardiac arrests, and systemic bacterial and fungal infection. On July 24th, this unfavorable outcome lead to death. In summary, the patient had an occlusive syndrome due to neuroleptics and complications, including mesenteric ischemia with necrotizing colitis. DISCUSSION/CONCLUSION: Quetiapine, like all antipsychotics, has anticholinergic effects, including cardiac, psychiatric and digestive disorders. The combination of anticholinergic drugs decreases intestinal peristalsis. Without any prompt management, this decrease can result in a colonic ischemia or necrosis. In patients treated with neuroleptics, the onset of constipation must alert medical staff. Systematic monitoring of bowel movements should be performed in any patient receiving anticholinergic drugs.

Impact of imipenem and amikacin pharmacokinetic/pharmacodynamic parameters on microbiological outcome of Gram-negative bacilli ventilator-associated pneumonia.

OBJECTIVES: Despite recent advances, antibiotic therapy of ventilator-associated pneumonia (VAP) in ICU patients is still challenging. We assessed the impact of imipenem and amikacin pharmacokinetic and pharmacodynamic parameters on microbiological outcome in these patients. PATIENTS AND METHODS: Patients with Gram-negative bacilli (GNB) VAP were prospectively included. Blood samples for pharmacokinetic analysis were collected after empirical administration of a combination of imipenem three times daily and one single dose of amikacin. MICs were estimated for each GNB obtained from respiratory samples. Microbiological success was defined as a ≥10(3) cfu/mL decrease in bacterial count in quantitative cultures between baseline and the third day of treatment. RESULTS: Thirty-nine patients [median (min-max) age = 60 years (28-84) and median SAPS2 at inclusion = 40 (19-73)] were included. Median MICs of imipenem and amikacin were 0.25 mg/L (0.094-16) and 2 mg/L (1-32), respectively. Median times over MIC and over 5× MIC for imipenem were 100% (8-100) and 74% (3-100), respectively. The median C1/MIC ratio for amikacin was 23 (1-76); 34 patients (87%) achieved a C1/MIC ≥10. Microbiological success occurred in 29 patients (74%). No imipenem pharmacodynamic parameter was significantly associated with the microbiological success. For amikacin, C1/MIC was significantly higher in the microbiological success group: 26 (1-76) versus 11 (3-26) (P = 0.004). CONCLUSIONS: In ICU patients with VAP, classic imipenem pharmacodynamic targets are easily reached with usual dosing regimens. In this context, for amikacin, a higher C1/MIC ratio than previously described might be necessary.

Impact of the humidification device on intubation rate during noninvasive ventilation with ICU ventilators: results of a multicenter randomized controlled trial.

PURPOSE: The use of heat and moisture exchangers (HME) during noninvasive ventilation (NIV) can increase the work of breathing, decrease alveolar ventilation, and deliver less humidity in comparison with heated humidifiers (HH). We tested the hypothesis that the use of HH during NIV with ICU ventilators for patients with acute respiratory failure would decrease the rate of intubation (primary endpoint) as compared with HME. METHODS: We conducted a multicenter randomized controlled study in 15 centers. After stratification by center and type of respiratory failure (hypoxemic or hypercapnic), eligible patients were randomized to receive NIV with HH or HME. RESULTS: Of the 247 patients included, 128 patients were allocated to the HME group and 119 to the HH group. Patients were comparable at baseline. The intubation rate was not significantly different: 29.7% in the HME group and 36.9% in the HH group (p = 0.28). PaCO2 did not significantly differ between the two arms, even in the subgroup of hypercapnic patients. No significant difference was observed for NIV duration, ICU and hospital LOS, or ICU mortality (HME 14.1 vs. HH 21.5%, p = 0.18). CONCLUSIONS: In this study, the short-term physiological benefits of HH in comparison with HME during NIV with ICU ventilators were not observed, and no difference in intubation rate was found. The physiologic effects may have been obscured by leaks or other important factors in the clinical settings. This study does not support the recent recommendation favoring the use of HH during NIV with ICU ventilators.

[Severe overdose in vitamin K antagonist secondary to grapefruit juice absorption]. / Surdosage grave en antivitamine K secondaire à l'absorption de jus de pamplemousse.

Vitamin K antagonists (VKA) are very currently used. Nevertheless, they are known to interact with numerous drugs and foods. Grapefruit juice is known to interact with some drugs metabolized by the enterocytary cytochrome P450 3A4 but its interaction with drugs as VKA that have a good biodisponibility is not clearly demonstrated. We report here the case of a woman treated with VKA in whom massive absorption of grapefruit juice entailed an excessive VKA dosage and a severe haemorrhage.

Abdominal compartment syndrome and intraabdominal sepsis: two of the same kind?

BACKGROUND: Abdominal compartment syndrome and intra-abdominal hypertension are frequently associated with peritonitis. The aim of this study is to establish the relationship between intra-abdominal hypertension and intra-abdominal sepsis especially in critically ill patients. METHODS: Relevant information was identified through a Medline search (1966-October 2006). The terms used were "intra-abdominal sepsis", "peritonitis", "abdominal compartment syndrome", "intra-abdominal hypertension" and "relaparotomy for sepsis". The search was limited to English- and French-language publications. RESULTS: Only a few clinical trials exist on this specific topic. Further investigations are required to define the incidence of intra-abdominal hypertension in intra-abdominal sepsis, and the prognostic impact of this setting and finally the potential specific treatment. Abdominal compartment syndrome is more likely linked to the abdominal surgery than to peritonitis itself. CONCLUSION: Intra-abdominal pressure monitoring can be valuable in critically ill patients with suspicion of persisting intra-abdominal sepsis after surgical peritonitis treatment.

Abdominal compartment syndrome and intraabdominal sepsis: two of the same kind?

BACKGROUND: Abdominal compartment syndrome and intra-abdominal hypertension are frequently associated with peritonitis. The aim of this study is to establish the relationship between intra-abdominal hypertension and intra-abdominal sepsis especially in critically ill patients. METHODS: Relevant information was identified through a Medline search (1966-October 2006). The terms used were "intra-abdominal sepsis", "peritonitis", "abdominal compartment syndrome", "intra-abdominal hypertension" and "relaparotomy for sepsis". The search was limited to English- and French-language publications. RESULTS: Only a few clinical trials exist on this specific topic. Further investigations are required to define the incidence of intra-abdominal hypertension in intra-abdominal sepsis, and the prognostic impact of this setting and finally the potential specific treatment. Abdominal compartment syndrome is more likely linked to the abdominal surgery than to peritonitis itself. CONCLUSION: Intra-abdominal pressure monitoring can be valuable in critically ill patients with suspicion of persisting intra-abdominal sepsis after surgical peritonitis treatment.

Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications.

OBJECTIVE: To study the frequency of and risk factors for increased gastric aspirate volume (GAV) and upper digestive intolerance and their complications during enteral nutrition (EN) in critically ill patients. DESIGN: Prospective observational study. SETTING: Intensive care unit (ICU) in a general hospital. PATIENTS: A total of 153 patients with nasogastric tube feeding. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Upper digestive intolerance was considered when GAV was between 150 and 500 mL at two consecutive measurements, when it was >500 mL, or when vomiting occurred. Forty-nine patients (32%; 95% confidence interval [CI], 25%-42%) presented increased GAV after a median EN duration of 2 days (range, 1-16 days), and 70 patients (46%; 95% CI, 38%-54%) presented upper digestive intolerance. Independent risk factors for high GAV were GAV >20 mL before the start of EN (odds ratio [OR], 2.16; 95% CI, 1.11-4.18; p =.02), GAV >100 mL during EN (OR, 1.49; 95% CI, 1.01-2.19; p <.05), sedation during EN (OR, 1.78; 95% CI, 1.17-2.71; p =.007), use of catecholamines during EN (OR, 1.81; 95% CI, 1.21-2.70; p =.004). Complications related to high GAV were a lower feed intake (15 +/- 7 vs. 19 +/- 8 kcal/kg/day; p =.0004) and vomiting (53% vs. 23%; p =.0002). Complications related to upper digestive intolerance were the development of pneumonia (43% vs. 24%; p =.01), a longer ICU stay (23 +/- 21 vs. 15 +/- 16 days; p =.007), and a higher ICU mortality (41% vs. 25%; p =.03), even after adjustment for Simplified Acute Physiology Score II (OR, 1.48; 95% CI, 1.04-2.10; p =.028). CONCLUSION: In ICU patients receiving nasogastric tube feeding, high gastric aspirate volume was frequent, occurred early, and was more frequent in patients with sedation or catecholamines. High gastric aspirate volume was an early marker of upper digestive intolerance, which was associated with a higher incidence of nosocomial pneumonia, a longer ICU stay, and a higher ICU mortality.

Continuous versus intermittent infusion of vancomycin in severe Staphylococcal infections: prospective multicenter randomized study.

A continuous infusion of vancomycin (CIV) may provide an alternative mode of infusion in severe hospital-acquired methicillin-resistant staphylococcal (MRS) infections. A multicenter, prospective, randomized study was designed to compare CIV (targeted plateau drug serum concentrations of 20 to 25 mg/liter) and intermittent infusions of vancomycin (IIV; targeted trough drug serum concentrations of 10 to 15 mg/liter) in 119 critically ill patients with MRS infections (bacteremic infections, 35%; pneumonia, 45%). Microbiological and clinical outcomes, safety, pharmacokinetics, ease of treatment adjustment, and cost were compared. Microbiological and clinical outcomes and safety were similar. CIV patients reached the targeted concentrations faster (36 +/- 31 versus 51 +/- 39 h, P = 0.029) and fewer samples were required for treatment monitoring than with IIV patients (7.7 +/- 2.2 versus 11.8 +/- 3.9 per treatment, P < 0.0001). The variability between patients in both the area under the serum concentration-time curve (AUC(24h)) and the daily dose given over 10 days of treatment was lower with CIV than with IIV (variances, 14,621 versus 53,975 mg(2)/liter(2)/h(2) [P = 0.026] and 414 versus 818 g(2) [P = 0.057], respectively). The 10-day treatment cost per patient was $454 +/- 137 in the IIV group and was 23% lower in the CIV group ($321 +/- 81: P < 0.0001). In summary, for comparable efficacy and tolerance, CIV may be a cost-effective alternative to IIV.

Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator-associated pneumonia.

OBJECTIVES: To evaluate the impact of appropriate initial antibiotic therapy (AB) on the outcome of ventilator-associated pneumonia (VAP). DESIGN: Retrospective study (1992-97). PATIENTS AND METHODS: Episodes of VAP diagnosed on both clinical and microbiological criteria after > or = 48 h of mechanical ventilation (MV). Initial AB was considered appropriate when all significant organisms were susceptible to at least one of the antibiotics started after distal bronchial sampling. Antibiotic treatment was modified within 48 h when susceptibility testing was available. Outcome was recorded at the ICU and hospital discharge. RESULTS: One hundred and eleven patients were included (SAPS II = 48 +/- 18, age = 62 +/- 14 years, mean duration of MV before VAP = 12 +/- 9 days). Initial AB was appropriate in 55 patients (49.5%). No difference between appropriate initial AB and inappropriate initial AB was found concerning severity indices at the time of VAP diagnosis. ICU length of stay was shorter with appropriate initial AB than with inappropriate initial AB for survivors (12 +/- 11 days vs 20 +/- 24 days, P = 0.01). Crude hospital mortality tended to be lower with appropriate initial AB than with inappropriate initial AB (47.3% vs 60.7%, odds ratio = 1.72, 95% CI = 0.81-3.7). Relative crude mortality reduction with appropriate initial AB was 22%, 95% CI = -10% to 45%. CONCLUSION: Inappropriate initial AB of VAP during the first 48 h increased ICU length of stay after VAP diagnosis and tended to increase crude hospital mortality despite equal severity of illness at the time of VAP diagnosis, when compared to appropriate initial AB in a population of 111 ICU patients.

Short-term effect of inhaled nitric oxide and prone positioning on gas exchange in patients with severe acute respiratory distress syndrome.

OBJECTIVE: To compare the short-term effects of inhaled nitric oxide (NO) and prone positioning in improving oxygenation in acute respiratory distress syndrome (ARDS). METHODS: Charts of consecutive ARDS patients (lung injury score >2) during a 2-yr period, tested for both inhaled NO and prone positioning efficacy were retrospectively reviewed. Variations in the Pao2/Fio2 ratio induced by inhaled NO and prone positioning were evaluated. MEASUREMENTS AND MAIN RESULTS: Twenty-seven patients (age, 42+/-17 yrs) were included. Simplified Acute Physiology Score II was 45+/-14. Mortality rate in the intensive care unit was 63%. The causes of ARDS were pneumonia (n = 14), extra-lung infection (n = 5), and noninfectious systemic inflammatory response syndrome (n = 8). Lung injury score was 2.7+/-0.3. At baseline, before the initiation of inhaled NO, the Pao2/Fio2 ratio was 97+/-46 torr and before prone positioning, 92+/-26 torr. Variations in the Pao2/Fio2 ratio were lower at start of NO therapy (11+/-4 ppm) than that observed at prone positioning initiation (23+/-31 vs. 62+/-78 torr, p<.05). An increase in variations in the Pao2/Fio2 ratio of >15 torr was associated with prone positioning in 16 patients (59%) and with NO inhalation in 13 patients (48%) (not significant). An increase in variations in the Pao2/Fio2 ratio of >15 torr was associated with both techniques in only six patients (22%). There was no correlation between the response to prone positioning and the response to inhaled NO (r2 = .005; p = .73). CONCLUSIONS: Prone positioning improves hypoxemia significantly better than does inhaled NO. The response to one technique is not predictive of the response to the other technique.

Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients. SRLF Collaborative Group on Mechanical Ventilation. Société de Réanimation de Langue Française.

OBJECTIVE: To evaluate the prevalence and outcome of the acute respiratory distress syndrome (ARDS) among patients requiring mechanical ventilation. DESIGN: A prospective, multi-institutional, initial cohort study including 28-day follow-up. SETTINGS: Thirty-six French intensive care units (ICUs) from a working group of the French Intensive Care Society (SRLF). PATIENTS: All the patients entering the ICUs during a 14-day period were screened prospectively. Hypoxemic patients, defined as having a PaO(2)/FIO(2) ratio (P/F) of 300 mmHg or less and receiving mechanical ventilation, were classified into three groups, according to the Consensus Conference on ARDS: group 1 refers to ARDS (P/F: 200 mmHg or less and bilateral infiltrates on the chest X-ray); group 2 to acute lung injury (ALI) without having criteria for ARDS (200 < P/F

Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. The Multicenter Trail Group on Tidal Volume reduction in ARDS.

Because animal studies have demonstrated that mechanical ventilation at high volume and pressure can be deleterious to the lungs, limitation of airway pressure, allowing hypercapnia if necessary, is already used for ventilation of acute respiratory distress syndrome (ARDS). Whether a systematic and more drastic reduction is necessary is debatable. A multicenter randomized study was undertaken to compare a strategy aimed at limiting the end-inspiratory plateau pressure to 25 cm H2O, using tidal volume (VT) below 10 ml/kg of body weight, versus a more conventional ventilatory approach (with regard to current practice) using VT at 10 ml/kg or above and close to normal PaCO2. Both arms used a similar level of positive end-expiratory pressure. A total of 116 patients with ARDS and no organ failure other than the lung were enrolled over 32 mo in 25 centers. The two groups were similar at inclusion. Patients in the two arms were ventilated with different VT (7.1 +/- 1.3 versus 10.3 +/- 1.7 ml/kg at Day 1, p < 0.001) and plateau pressures (25.7 +/- 5. 0 versus 31.7 +/- 6.6 cm H2O at Day 1, p < 0.001), resulting in different PaCO2 (59.5 +/- 15.0 versus 41.3 +/- 7.6 mm Hg, p < 0.001) and pH (7.28 +/- 0.09 versus 7.4 +/- 0.09, p < 0.001), but a similar level of oxygenation. The new approach did not reduce mortality at Day 60 (46.6% versus 37.9% in control subjects, p = 0.38), the duration of mechanical ventilation (23.1 +/- 20.2 versus 21.4 +/- 16. 3 d, p = 0.85), the incidence of pneumothorax (14% versus 12%, p = 0. 78), or the secondary occurrence of multiple organ failure (41% versus 41%, p = 1). We conclude that no benefit could be observed with reduced VT titrated to reach plateau pressures around 25 cm H2O compared with a more conventional approach in which normocapnia was achieved with plateau pressures already below 35 cm H2O.

Saccharomyces boulardii prevents diarrhea in critically ill tube-fed patients. A multicenter, randomized, double-blind placebo-controlled trial.

OBJECTIVE: To assess the preventive effect of Saccharomyces boulardii on diarrhea in critically ill tube-fed patients and to evaluate risk factors for diarrhea. DESIGN: Prospective, multicenter, randomized, double-blind placebo-controlled study. SETTING: Eleven intensive care units in teaching and general hospitals. PATIENTS: Critically ill patients whose need for enteral nutrition was expected to exceed 6 days. INTERVENTION: S. boulardii 500 mg four times a day versus placebo. MEASUREMENTS AND RESULTS: Diarrhea was defined by a semiquantitative score based on the volume and consistency of stools. A total of 128 patients were studied, 64 in each group. Treatment with S. boulardii reduced the mean percentage of days with diarrhea per feeding days from 18.9 to 14.2% [odds ratio (OR) = 0.67, 95% confidence interval (CI) = 0.50-0.90, P = 0.0069]. In the control group, nine risk factors were significantly associated with diarrhea: nonsterile administration of nutrients in open containers, previous suspension of oral feeding, malnutrition, hypoalbuminemia, sepsis syndrome, multiple organ failure, presence of an infection site, fever or hypothermia, and use of antibiotics. Five independent factors were associated with diarrhea in a multivariate analysis: fever or hypothermia, malnutrition, hypoalbuminemia, previous suspension of oral feeding, and presence of an infection site. After adjustment for these factors, the preventive effect of S. boulardii on diarrhea was even more significant (OR = 0.61, 95% CI = 0.44-0.84, P < 0.0023). CONCLUSIONS: S. boulardii prevents diarrhea in critically ill tube-fed patients, especially in patients with risk factors for diarrhea.

Testicular choriocarcinoma revealed by a localized pulmonary edema: a case report.

We report the case of a young man hospitalized because of an acute pulmonary embolism presenting as a focal pulmonary edema, without evidence of left ventricular failure. This pulmonary embolism was caused by a testicular choriocarcinoma that entailed both a neoplastic venous involvement with pulmonary neoplastic embolism, and a compression of inferior vena cava with thrombosis and subsequent pulmonary thromboembolism. This case combines two unusual associations: (i) Pulmonary embolism causing a localized pulmonary edema, (ii) Neoplastic pulmonary embolism of a testicular choriocarcinoma.

Frequency of bacteremia associated with transesophageal echocardiography in intensive care unit patients: a prospective study of 139 patients.

OBJECTIVE: To determine the occurrence rate of bacteremia associated with transesophageal echocardiography in intensive care unit (ICU) patients. DESIGN: A prospective study of 139 patients undergoing transesophageal echocardiography. SETTING: The medical ICU of a tertiary referral teaching hospital. PATIENTS: One hundred thirty-nine ICU patients (mean age 58 yrs) who underwent transesophageal echocardiography. INTERVENTIONS: Blood samples were systematically drawn for aerobic and anaerobic culture at the following times: before (blood culture 1), at the end of (blood culture 2), and 30 mins after (blood culture 3) transesophageal echocardiography examinations. MEASUREMENTS AND MAIN RESULTS: The mean duration of transesophageal echocardiography was 35 mins (range 7 to 120). One hundred thirty-four patients received mechanical ventilation; 125 patients had a nasogastric tube. Fifty-one patients had one or more underlying conditions that usually justify antimicrobial prophylaxis of bacterial endocarditis before high-risk procedures. Fifty-six patients did not receive any antibiotic treatment at the time of transesophageal echocardiography. In 114 patients, the three blood cultures were negative. In six patients, transesophageal echocardiography was performed during a preexisting bacteremia. A contamination (only one positive blood culture of the three sampling times) with coagulase-negative staphylococci occurred in four patients at blood culture 1, five patients at blood culture 2, and six patients at blood culture 3. Contamination with Corynebacterium species occurred in two patients at blood culture 2. In one patient receiving cefotaxime and netilmicin, blood culture 1 was sterile and blood cultures 2 and 3 yielded coagulase-negative staphylococci. In one patient receiving no antibiotic treatment, blood culture 1 was sterile and blood cultures 2 and 3 yielded Enterococcus faecalis. None of these two patients received a specific antibiotic treatment or developed any secondary septic focus. CONCLUSIONS: The overall frequency of bacteremia induced by transesophageal echocardiography in ICU patients was 1.4% (two of 139 patients) (95% confidence interval 0.2% to 5.1%). The frequency did not differ whether patients received antibiotics before transesophageal echocardiography (one [1.2%] of 83 patients) or not (one [1.8%] of 56 patients) (p = .96). Therefore, routine antimicrobial prophylaxis does not appear justified before transesophageal echocardiography in ICU patients.

Titration of tidal volume and induced hypercapnia in acute respiratory distress syndrome.

Mechanical ventilation may promote overdistension-induced pulmonary lesions in patients with acute respiratory distress syndrome (ARDS). The static pressure-volume (P-V) curve of the respiratory system can be used to determine the lung volume and corresponding static airway pressure at which lung compliance begins to diminish (the upper inflection point, or UIP). This fall in compliance may indicate overdistension of lung units. We prospectively studied 42 patients receiving mechanical ventilation with an FIO2 of 0.5 or more for at least 24 h. According to the Lung Injury Score (LIS), 25 patients were classified as having ARDS (LIS > 2.5), while 17 patients constituted a non-ARDS control group. The P-V curve was obtained every 2 d. Mechanical ventilation initially used standard settings (volume-control mode, a positive end-expiratory pressure [PEEP] adjusted to the lower inflection point on the P-V curve, and a tidal volume [VT] of 10 ml/kg). The end-inspiratory plateau pressure (Pplat) was compared to the UIP, and VT was lowered when the Pplat was above the UIP. In the range of lung volume studied on the P-V curves (up to 1600 ml), a UIP could be shown in only one control patient (at 23 cm H2O). By contrast, a UIP was present on the P-V curve obtained from all patients with ARDS, corresponding to a mean airway pressure of 26 +/- 6 cm H2O, a lung volume of 850 +/- 200 ml above functional residual capacity and 610 +/- 235 ml above PEEP.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic accuracy and therapeutic impact of transthoracic and transesophageal echocardiography in mechanically ventilated patients in the ICU.

STUDY OBJECTIVES: To assess the respective diagnostic accuracy of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) and their therapeutic implications in mechanically ventilated patients, in the intensive care unit (ICU). DESIGN: A prospective study. SETTINGS: Intensive care units of two tertiary referral teaching hospitals. PATIENTS: One hundred eleven ICU patients (81 men and 30 women; mean age 57 +/- 16 years). Fifty-seven percent were hospitalized for medical illnesses, 16.5 percent after thoracic surgery, 10.5 percent after other surgery, and 16.0 percent for multiple trauma. Their Simplified Acute Physiologic Score was 16 +/- 5. INTERVENTIONS: The echocardiograms were performed in order to solve well-defined clinical problems. TTE was the first step of the procedure and TEE was performed only when (1) TTE did not solve the clinical problems, and (2) TTE yielded unsuspected findings requiring TEE. During each echocardiographic study, the following were noted: ventilatory mode, clinical problems, imaging quality, results, consequence on acute care, duration of the procedure, and potential complications of TEE. Diagnostic accuracy was defined as the proportion of solved problems, and therapeutic impact was defined as changes on acute care that resulted directly from the procedure. MEASUREMENTS AND RESULTS: One hundred twenty-eight consecutive TTE and 96 TEE were performed. TTE solved 60 of 158 clinical problems (38 percent), whether positive end-expiratory pressure (> 4 cm H2O) was present or not (28 of 74 vs 32 of 84: p > 0.50). TTE allowed evaluation of left ventricular function in 77 percent of cases and pericardial effusion in every case, but it did not solve most of the other clinical problems. Indeed, the diagnostic accuracy of TEE was markedly superior (95/98 vs 60/158: p < 0.001), but TEE required a physician's presence longer (43 +/- 17 min vs 27 +/- 12 min: p < 0.001). When TTE and TEE were scheduled (n = 96), TEE yielded an additional diagnosis or excluded with more certitude a suspected diagnosis, except in two cases. TEE had a therapeutic impact more frequently than TTE (35/96 vs 20/128: p < 0.001). Cardiovascular surgery was prompted by echocardiographic findings in ten patients. TEE was well tolerated in all patients; there were no complications. CONCLUSIONS: TEE is a valuable well-tolerated imaging technique in mechanically ventilated patients. For the assessment of left ventricular systolic function and pericardial effusion; however, TTE continues to be an excellent diagnostic tool, even when positive end-expiratory pressure is present. Both TTE and TEE have a therapeutic impact in approximately 25 percent of cases.