A reappraisal of ICU and long-term outcome of allogeneic hematopoietic stem cell transplantation patients and reassessment of prognosis factors: results of a 5-year cohort study (2009-2013).

Epidemiology and prognosis of complications related to allogeneic hematopoietic stem cell transplant (HSCT) recipients requiring admission to intensive care unit (ICU) have not been reassessed precisely in the past few years. We performed a retrospective single-center study on 318 consecutive HSCT patients (2009-2013), analyzing outcome and factors prognostic of ICU admission. Among these patients, 73 were admitted to the ICU. In all, 32 patients (40.3%) died in ICU, 46 at hospital discharge (63%) and 61 (83.6%) 1 year later. Survivors had a significantly lower sequential organ failure assessment (SOFA) score, serum lactate and bilirubin upon ICU admission. Catecholamine support, mechanical ventilation (MV) and/or renal replacement therapy during ICU stay, a delayed organ support and an active graft versus host disease (GvHD) significantly worsen the outcome. By multivariate analysis, the worsening of SOFA score from days 1 to 3, the need for MV and the occurrence of an active GvHD were predictive of mortality. In conclusion, the incidence of HSCT-related complications requiring an admission to an ICU was at 22%, with an ICU mortality rate of 44%, and 84% 1 year later. A degradation of SOFA score at day 3 of ICU, need of MV and occurrence of an active GvHD are main predictive factors of mortality.

Effect of renal angioembolization on post-traumatic acute kidney injury after high-grade renal trauma: a comparative study of 52 consecutive cases.

BACKGROUND: Acute kidney injury (AKI) is associated with unfavourable outcomes and higher mortality after trauma. Renal angioembolization (RAE) has proved efficiency in the management of high-grade renal trauma (HGRT), but inevitably expose to unavoidable ischaemic areas or contrast medium nephrotoxicity which may impair renal function in the following hours. The aim of this study was to assess the potential acute impact of RAE on renal function in a consecutive series of HGRTs treated nonoperatively. MATERIALS AND METHODS: Of 101 cases of renal trauma admitted to our Regional Trauma Center between January 2005 and January 2010, 52 cases of HGRT were treated nonoperatively; they were retrospectively classified into 2 groups according to whether RAE was used. Incidence and progression of AKI (RIFLE classification), maximum increase in serum creatinine (SCr), level since admission and recovery of renal function at discharge were compared between the groups. Multivariable analysis was performed to determine the role of RAE as an independent risk factor of AKI. RESULTS: RAE was performed in 10 patients within the first 48h. The RAE and no RAE groups were comparable in terms of severity score, renal injury grade, and level of SCr on admission. AKI incidence (RIFLE score Risk or worse) after 48 and 96h was 33% and 10%, respectively and did not differ significantly between groups at 48h (p=1.00) or 96h (p=1.00). The median maximum increase in SCr was significantly higher in no RAE than RAE group (30.4% vs. 6.9%, p=0.04). RAE was not found to be a significant variable in a multiple linear regression analysis predicting maximum SCr rise (p=0.34). SCr at discharge was >120% of baseline in only 5 patients, with no difference according to RAE (p=0.24). CONCLUSION: In a population of nonoperatively treated HGRT, the incidence of AKI decreased from almost 30% to 10% at 48h and 96h. RAE proceeding did not seem to affect significantly the occurrence and course of AKI or renal recovery. The decision to use RAE should probably not be restricted by fear of worsening renal function.

[Occurrence of severe cardiac alterations in Amanita proxima poisoning: two original observations]. / Survenue d'une atteinte cardiaque sévère au cours du syndrome proximien : deux observations originales.

Amanita proxima is one species of white mushroom which can induce poisonings called in France "proximien" syndrome. The clinical feature of "proximien" syndrome is mainly characterized by early digestive troubles, mild hepatic cytolysis and late renal impairment. A cardiac insult has never been reported in such a circumstance. The authors describe herein two cases of white mushroom poisoning occurred in the Mediterranean French coast with a typical clinical feature of "proximien" syndrome plus secondary development of severe cardiac alterations. The outcome was good for the two patients thanks to symptomatic treatment. The cases reported here suggest that A. proxima have a potential severe cardiac toxicity leading to include early and precise cardiac examination in the management of patients poisoned by these mushrooms.

Sirolimus-associated acute respiratory distress syndrome in a renal transplant recipient.

Sirolimus is a new potent immunosuppressive drug used in organ transplantation; its major advantage is the absence of deterioration in renal function. Documented adverse effects include myelosuppression and hyperlipidemia. Recently several cases of sirolimus-associated interstitial pneumonitis have been reported, usually of mild severity. We report a new case that was complicated by a severe acute respiratory distress syndrome, which required several days of mechanical ventilation. No infectious or cardiogenic etiology was documented. Low sirolimus blood levels and acute CD4 lymphocytic alveolitis suggested an immune-related mechanism rather than a direct toxic effect of the drug. The patient recovered after discontinuation of sirolimus and the administration of corticosteroids.

[Severe imported malaria in adults: a retrospective study of 32 cases admitted to intensive care units]. / Paludisme grave d'importation chez l'adulte: étude rétrospective de 32 cas admis en réanimation.

INTRODUCTION: Few studies have focused on severe imported malaria in patients admitted to intensive care units. We, therefore, undertook a retrospective study in the University Hospital of Montpellier. MATERIAL AND METHODS: All patients, more than 15 years-old with falciparum malaria who were admitted to intensive care units between October 1997 and April 2004 were included. Main epidemiological features, criteria of admission, treatment and outcome were investigated. RESULTS: Thirty-two patients were included, representing 9% of falciparum malaria cases diagnosed in the same period. The mean age was 44 years. All patients acquired falciparum malaria in sub-Sahara Africa and 25 patients were nonimmune. Chemoprophylaxis was absent or inadequate in 94%. The mean time from symptom onset and treatment initiation was 6 days. Mean parasitemia on admission was 15%. Criteria of admission were impaired consciousness in 69%, acute renal failure in 19% and isolated high parasitemia in 19% of the cases. All, but one received quinine therapy and a loading dose was performed in 34%. Seven patients (22%) had community-acquired coinfections and six (19%) had nosocomial infections. Mortality was 16%. Causes of death were refractory shock, cerebral edema, and acute respiratory distress syndrome. CONCLUSION: Severe imported malaria remains associated with a bad outcome. Improving chemoprophylaxis and an earlier diagnosis may reduce significantly this mortality.

Mechanism of in vitro heme-induced LDL oxidation: effects of antioxidants.

BACKGROUND: Heme protein toxicity, owing to generation of reactive oxygen species most likely by direct interaction between heme iron and hydrogen peroxide (H2O2), may be involved in various pathologies, including atherogenesis and pigmentary acute renal failure. The aim of this study was to investigate the mechanism of heme cytotoxicity and the effects of antioxidant therapies in an in vitro model of heme-induced low-density lipoprotein (LDL) oxidation. MATERIALS AND METHODS: Human LDLs were exposed to heme, iron (Fe), protoporphyrin (PPIX) and PPIX-Zinc (Zn) with or without H2O2. Lipid peroxidation was monitored by measurement of conjugated diene formation (at the 234-nm absorbance). The effect of various antioxidants, such as vitamin E and vitamin C, reduced glutathione (GSH), and oxidized glutathione (GSSG), mannitol and desferoxamine (DFO) was further investigated in the established in vitro model of LDL oxidation. RESULTS: Incubation of LDLs in the presence of heme/H2O2 induced lipid peroxidation with the optimal oxidation rate being at 5 microm heme/100 microm H2O2 doses. By contrast, incubation of LDL with H2O2, Fe, Fe/H2O2, PPIX, PPIX/H2O2, heme or PPIX-Zn did not initiate any LDL oxidation. In vitro, the vitamin E load protected native LDLs against heme/H2O2 oxidative modifications. Incubation of LDLs with increasing doses of vitamin C, GSH and DFO conferred a dose-dependent protection, while mannitol and GSSG had no effect. CONCLUSIONS: Initiation and propagation of heme-induced lipid peroxidation is not mediated by a Fenton reaction but depends on specific interactions between heme and H2O2. It may result from the generation of ferryl and perferryl radicals derived from hemic Fe and H2O2 interactions. A protective effect of vitamins E, C, GSH and DFO was demonstrated in this model.

[Epidemiology and prognosis of hyperosmolar state in the elderly]. / Epidémiologie et facteurs pronostiques des états hyperosmolaires chez le sujet âgé.

OBJECTIVE: We studied elderly patients admitted for hyperosmolar state (HS) to evaluate current outcome of HS and identify prognosis factors associated with mortality. STUDY DESIGN: A clinical retrospective study in an eight bed ICU. PATIENTS AND METHODS: Eighteen over 65-year-old patients admitted with a serum osmolality greater than 325 mOsm/kg were reviewed. Age, sex, diabetes mellitus, underlying medical condition, presence of an acute precipitating factor, Apache II and Glasgow scores, systolic arterial pressure, state of hydration, core temperature, heart rate, serum osmolality, creatininemia, lactatemia, plasma urea and bicarbonate, and protidemia were collected at the admission. Amount of fluid, time course of osmolality correction, length of hospitalization and mortality were recorded. All data were analyzed to identify possible correlations with patient outcome. RESULTS: Mean age: 75 +/- 11 years; sex ratio 1/2; hyperosmolar hyperglycemic states: 13 patients; hyperosmolar hypernatremic states: five patients; mean Apache II score: 18 +/- 7; Glasgow coma score: 11 +/- 3; mean osmolality: 370 +/- 25 mOsm/kg. In nine patients, infection was the precipitating factor. Five patients died (28%). At the admission, low blood pressure and high heart rate were related to mortality. During hospitalization, the occurrence of an acute cardiocirculatory failure and/or the need of mechanical ventilation significantly worsens the outcome. CONCLUSION: Our results showed that ICU mortality of HS in the elderly was at 28%. Haemodynamic state was the only factor of prognosis at the admission. Deaths were mostly related to acute respiratory and circulatory failure.

[Diagnosis by blood smear of a fulminant pneumococcemia complicating a myeloma]. / Diagnostic sur le frottis sanguin d'une pneumococcémie fulminante compliquant un myélome.

INTRODUCTION: During a pneumococcal septicemia, the direct revelation of bacteria on a blood smear is rare and has been mainly described in splenectomised patients. OBSERVATION: A 62 year-old non-splenectomised man suffering from myeloma died, a few hours after his admission to emergency department, from a fulminant pneumococcemia, the diagnosis of which had been rapidly evoked on the examination of a blood smear showing numerous Gram positive diplococci. COMMENTS: This observation highlights the potential severity of pneumococcal infections in patients suffering from altered humoral immunity and the diagnostic interest, in this case, of a systematic routine blood smear permitting rapid initiation of appropriate treatment.

[Thyreotoxic periodic paralysis. A cause of pseudo-paralysing hypokalemia that should not be ignored in Caucasians]. / Paralysie périodique thyréotoxique. Une cause d'hypokaliémie pseudoparalysante à ne pas méconnaître chez le Caucasien.

INTRODUCTION: Despite its rare occurrence in Caucasians, thyreotoxic periodic paralysis should be evoked in young male Caucasians presenting with episodes of pseudo-paralytic hypokalemia. OBSERVATION: A 37 year-old Caucasian was admitted in intensive care for an acute episode of hypotonic tetraplegia and hypokalemia during which laboratory tests revealed hyperthyroidism due to Basedow's disease. The clinical course was rapidly favourable after a small dose of intravenous potassium. Antithyroid treatment avoided any new occurrence of similar episodes. DISCUSSION: In Caucasians, sporadic acute paralysis with hypokalemia requires testing for hyperthyroidism. Though it is well know that hypokalemia results from potassium intracellular shift, the underlying mechanism remains poorly elucidated. Treatment includes potassium administration with caution and/or beta blockers but the specific treatment is that of hyperthyroidism.

alpha-Methylnorepinephrine, a selective alpha2-adrenergic agonist for cardiac resuscitation.

OBJECTIVES: The purpose of this study was to investigate the effects of a selective alpha2-adrenergic agonist, alpha-methylnorepinephrine (alphaMNE) as an alternative vasopressor agent during cardiopulmonary resuscitation (CPR). BACKGROUND: For more than 40 years, epinephrine has been the vasopressor agent of choice for CPR. Its beta- and alpha1-adrenergic effects increase myocardial oxygen consumption, magnify global myocardial ischemia and increase the severity of postresuscitation myocardial dysfunction. METHODS: Ventricular fibrillation (VF) was induced in 20 Sprague-Dawley rats. After 8 min of untreated VF, mechanical ventilation and precordial compression began. AlphaMNE, epinephrine or saline placebo was injected into the right atrium 2 min after the start of precordial compression. As an additional control, one group of animals was pretreated with alpha2-receptor blocker, yohimbine, before injection of alphaMNE. Defibrillation was attempted 4 min later. Left ventricular pressure, dP/dt40, negative dP/dt and cardiac index were measured for an interval of 240 min after resuscitation. RESULTS: Except for saline placebo and yohimbine-treated animals, comparable increases in coronary perfusion pressure were observed after each drug intervention. All animals were successfully resuscitated. Left ventricular diastolic pressure, cardiac index, dP/dt40 and negative dP/dt were more optimal after alphaMNE; this was associated with significantly better postresuscitation survival. Pretreatment with vohimbine abolished the beneficial effects of alphaMNE. CONCLUSIONS: The selective alpha2-adrenergic agonist, alphaMNE, was as effective as epinephrine for initial cardiac resuscitation but provided strikingly better postresuscitation myocardial function and survival.

A comparison of myocardial function after primary cardiac and primary asphyxial cardiac arrest.

Although myocardial dysfunction after resuscitation from ventricular fibrillation (VF) has been extensively investigated, less is known of the function of the myocardium after asphyxial cardiac arrest. The present experimental study was designed to compare postresuscitation left ventricular (LV) function after cardiac arrest caused by asphyxia with that of cardiac arrest induced by dysrhythmia. Four groups of Sprague-Dawley rats, which included eight animals in each group, were investigated. In the first two groups, cardiac arrest followed asphyxia produced by neuromuscular blockade with and without airway obstruction. In a third group, cardiac arrest was induced by electrical fibrillation of the ventricle. The fourth group represented animals in which the duration of asphyxial cardiac arrest was maintained for a time interval corresponding to that of the VF group. The fourth group received approximately the same number of electrical shocks as the third (VF) group. All animals were successfully resuscitated with precordial compression and mechanical ventilation. Postresuscitation measurements, including cardiac output, LV end-diastolic pressure (LVEDP), rate of pressure rise at LV pressure of 40 mm Hg (LV dP/dt40), and negative LV dP/dt, demonstrated decreased myocardial function in each group. No differences in cardiac function were observed between the animals with primary respiratory arrest whether or not the airway was obstructed. However, disproportionate and consistently greater impairment in myocardial function followed primary cardiac arrest due to VF when compared with equal duration of asphyxial cardiac arrest. We conclude that in this healthy animal model, asphyxial cardiac arrest resulted in significantly lesser impairment of postresuscitation myocardial function when compared with cardiac arrest caused by VF.

A comparison of biphasic and monophasic waveform defibrillation after prolonged ventricular fibrillation.

STUDY OBJECTIVE: To compare the effects of biphasic defibrillation waveforms and conventional monophasic defibrillation waveforms on the success of initial defibrillation, postresuscitation myocardial function, and duration of survival after prolonged duration of untreated ventricular fibrillation (VF), including the effects of epinephrine. DESIGN: Prospective, randomized, animal study. SETTING: Animal laboratory and university-affiliated research and educational institute. PARTICIPANTS: Domestic pigs. INTERVENTIONS: VF was induced in 20 anesthetized domestic pigs receiving mechanical ventilation. After 10 min of untreated VF, the animals were randomized. Defibrillation was attempted with up to three 150-J biphasic waveform shocks or a conventional sequence of 200-J, 300-J, and 360-J monophasic waveform shocks. When reversal of VF was unsuccessful, precordial compression was performed for 1 min, with or without administration of epinephrine. The protocol was repeated until spontaneous circulation was restored or for a maximum of 15 min. MEASUREMENTS AND RESULTS: No significant differences in the success of initial resuscitation or in the duration of survival were observed. However, significantly less impairment of myocardial function followed biphasic shocks. Administration of epinephrine reduced the total electrical energy required for successful resuscitation with both biphasic and monophasic waveform shocks. CONCLUSIONS: Lower-energy biphasic waveform shocks were as effective as conventional higher-energy monophasic waveform shocks for restoration of spontaneous circulation after 10 min of untreated VF. Significantly better postresuscitation myocardial function was observed after biphasic waveform defibrillation. Administration of epinephrine after prolonged cardiac arrest decreased the total energy required for successful resuscitation.

Pupil diameter and light reaction during cardiac arrest and resuscitation.

OBJECTIVE: Traditionally, both pupil diameter and reaction to light have been examined to confirm the diagnosis of death. In the present study, we investigated quantitative changes in pupil diameter and light reaction for assessing the efficacy of cardiopulmonary resuscitation (CPR) and as a predictor of outcome. DESIGN: Controlled experimental study. SETTING: Animal research laboratory at a university-affiliated research institute. SUBJECTS: Fifteen domestic male pigs weighing between 33 and 40 kg. INTERVENTIONS: Ventricular fibrillation was induced with an alternating current delivered to the right ventricular endocardium. After 7 mins of untreated ventricular fibrillation, chest compression and mechanical ventilation were initiated and maintained for 6 mins. Restoration of spontaneous circulation then was attempted by electrical defibrillation. MEASUREMENTS AND MAIN RESULTS: Spontaneous circulation was reestablished in 9 of 15 animals. Pupils were fully dilated, and pupillary reaction to light was absent in 7 of the 9 resuscitated animals during untreated cardiac arrest. Progressive decreases in pupil diameter were observed together with restoration of light reaction during CPR, in each animal that was successfully resuscitated. When the pupils remained dilated and unreactive after 6 mins of CPR, resuscitation efforts were uniformly unsuccessful. A highly significant linear correlation between coronary perfusion pressure generated during precordial compression and pupil diameter was documented. Both were predictive of outcome. CONCLUSIONS: Dynamic changes of pupil diameter and reactions to light during cardiac arrest and resuscitation were correlated with coronary perfusion pressure, and both predicted the likelihood that spontaneous circulation and cerebral function would be restored.

Fatal systemic reaction after multiple doses of intravesical bacillus Calmette-Guérin for polyposis.

OBJECTIVE: To report a case of fatal systemic reaction after intravesical administrations of bacillus Calmette-Guérin (BCG) for polyposis. CASE SUMMARY: A 72-year-old white man was treated by monthly injections of intravesical BCG immunotherapy for polyposis of the urinary bladder. He received a total of eight injections; four hours after the seventh injection, he presented with pyrexia associated with chills, sweating, headache, and vomiting, which quickly resolved. Four hours after the eighth injection, the patient presented with the same symptoms plus a left-hemisphere deficiency. Results of a cerebral scan performed at this time were normal. The clinical status of the patient quickly worsened, with the appearance of disseminated intravascular coagulation, acute anuric renal insufficiency, rhabdomyolysis, hemolysis, and cytolytic and cholestatic hepatitis. The patient required hemodialysis and symptomatic treatment. Lactic acidosis with hemolytic-uremic syndrome appeared, and he died as the result of a multivisceral (respiratory, renal, hepatic) deficiency. DISCUSSION: The patient presented with symptoms compatible with a severe systemic reaction to BCG therapy, a rare but possible adverse effect. CONCLUSIONS: BCG instillation is a valuable tool in the therapy of bladder carcinoma, but increasing reports of severe adverse reactions should continue to remind practicing urologists to be alert to the possibility of common and uncommon reactions after its use.

Echo-Doppler observations during cardiac arrest and cardiopulmonary resuscitation.

We describe a series of investigations that used transesophageal echo-Doppler observations during cardiac arrest and cardiopulmonary resuscitation. Regular contractions of the left atrium persisted during the initial 7 mins of untreated ventricular fibrillation. Ventricular chamber deformation and mitral valve closing and opening followed precordial compression and relaxation. Stroke volumes computed from differences between diastolic and systolic areas of the left ventricle were predictive of the success of the resuscitation. Progressive decreases in left ventricular compliance were associated with decreases in left ventricular diastolic and stroke volumes and progressed to a stone heart.