Outbreak of extended spectrum beta-lactamase-producing Klebsiella pneumoniae in an intensive care unit (Brest).

INTRODUCTION: We had for aim to describe control and investigation of an outbreak caused by a strain of Extended spectrum beta-lactamase producing Klebsiella pneumoniae in intensive care units of the Brest teaching hospital. PATIENTS AND METHOD: The case definition was a patient infected by or carrying the epidemic strain. Control measures and investigations are presented. A case-control study was conducted in the surgical intensive care unit. Each case was matched with two controls based on admission times in the unit. The study focused on diagnostic and therapeutic procedures, and potential contacts with healthcare workers, in this context of cross transmission. RESULTS: Between February and May 2011, nine cases were reported in the surgical ICU and two in the medical ICU. Eighteen controls were matched with the nine surgical ICU cases. Several factors were found to be statistically associated with infection or colonization by the epidemic strain: the surgical block in which patients had been operated and the ward of first hospitalization; the number of trans-esophageal and trans-thoracic echocardiographies, of central venous catheter insertions, and of surgical operations; intubation. The total number of invasive procedures was also found to be statistically higher among cases. CONCLUSION: This study identified factors associated with colonization or infection by the epidemic strain. These factors might have been involved in the transmission tree, and be vulnerable elements for the prevention of nosocomial infections and colonisations, and their epidemic spread.

Prevention of venous thrombosis in patients with acute intracerebral hemorrhage.

OBJECTIVE: To assess intermittent pneumatic compression (IPC) in the prevention of venous thromboembolism (VTE). METHODS: The authors randomly allocated patients with a documented intracerebral hemorrhage (ICH) to elastic stockings (ES) alone or combined with IPC. The primary outcome was a combined criteria assessed at day 10: a symptomatic and well-documented VTE, or a death arising before day 10 and related to pulmonary embolism (PE), or an asymptomatic deep vein thrombosis (DVT) of the lower limbs detected by compression ultrasonography (CUS). Outcome assessment was blinded. RESULTS: One hundred fifty-one patients were randomized; 133 (88%) patients were evaluated at day 10. No clinical suspicion of VTE arose before day 10. Fourteen patients died before having a CUS but no death was definitely related to PE. Fourteen asymptomatic DVT were detected by CUS: three (4.7%) in the ES + IPC group (all distal) and 11 (15.9%) in the ES group (three proximal and eight distal). ES combined with IPC is associated with a reduced risk of asymptomatic DVT compared to ES alone: relative risk, 0.29 (95% CI 0.08 to 1.00). CONCLUSIONS: Asymptomatic deep vein thrombosis (DVT) was detected at day 10 in 15.9% of patients wearing elastic stockings alone. Intermittent pneumatic compression significantly decreased the occurrence of asymptomatic DVT for patients with intracerebral hemorrhage.

[Evaluation of a medical equipment checklist before intensive care room opening]. / Evaluation d'une liste de contrôle du matériel médical avant ouverture de chambre en réanimation.

OBJECTIVE: To describe and to assess the effectiveness of a checklist concerning the intensive care rooms' equipment before patients' admission. STUDY DESIGN: A 4 years prospective study with 3 successive assessments. METHODS: Medical equipment inspection of 20 intensive care unit (ICU) rooms was first checked without using a written checklist (phase I). A written procedure called "room opening checklist" (ROC) was instituted to inspect medical equipment, and then assessment of its use and effectiveness was performed 2 years (phase II) and 4 years later (phase III). RESULTS: Phase I (1998): medical equipment of 20 intensive care rooms was inspected before patients' admission. None of the 20 intensive care rooms was strictly equipped in accordance with the unit's official procedure. Phase II (2000): ROC has been used for all the 20 evaluated ICU rooms, 17 ICU rooms were equipped in accordance with the official procedure. Phase III (2002): ROC has been used for 19 ICU rooms, 18 ICU rooms were correctly equipped. CONCLUSION: The routine use of ROC has improved the adequacy of the ICU room's equipment endowment in our intensive care units.

[Brachiocephalic trunk erosion by a tracheotomy cannula]. / Ulcération du tronc brachio-céphalique par une canule de trachéotomie.

We report the case of a 27-year-old severe head trauma patient who developed an erosion of the brachiocephalic artery, 19 days after the insertion of a tracheal cannula. Emergency treatment included overinflation of the tracheostomy cuff and surgery via sternotomy, with occlusion of the tracheostomy and the tracheo-arterial fistula and reimplantation of the brachiocephalic artery via a vascular prosthesis. This life-threatening complication is due to close anatomic relationships between the trachea and the brachiocephalic artery. In our case, the tip of the cannula eroded the anterior trachea wall resulting in a tracheo-arterial fistula with massive haemorrhage. Warning symptoms such as pulsations of the cannula and aspiration of blood must be recognised without delay and followed by an adequate pre-established management.

[Hip arthroplasty and thromboembolic complications]. / Arthroplastie de hanche et complications thrombo-emboliques.

Orthopedic départment of Centre hospitalo-universitaire de Brest use one upon another two procedures: from 1974 to 1984, for 1287 cases the prevention of thromboembolic complications is done with the help of subcutaneous heparin at standard dose during 12 days; the clinical diagnosis in confirmed by an isotopic phlebography and isotopic lung scan. In 1986 and 1987, for 391 cases this prevention is done with the help of subcutaneous heparin in adapted doses during 21 days; the clinical diagnosis is confirmed by X ray phlebography and isotopic lung scan. The frequency of thromboembolic complications has been 4.6% in the first period and 1.2% in the second period. This results confirm the role of heparin in preventing post operative thromboembolic complications after total hip replacement. The results after knee arthroplasty are not so good.