[Danger of mechanical ventilation : Macklin effect during induced barotrauma]. / Danger de la ventilation mécanique : l'effet Macklin sur un barotraumatisme induit.

Intubation followed by mechanical ventilation is a classic technic for managing severe respiratory failure in hospital practice. Far from being exempted of risks, this technic can lead to serious complications. We hereby present illustrating images of a complication directly linked to the non-physiological respiratory mode on which mechanical ventilation is based, namely barotrauma linked to positive ventilatory pressures.

L'intubation suivie de ventilation mécanique est une technique classique de gestion de l'insuffisance respiratoire grave en pratique hospitalière. Loin d'être dénuée de risques, cette technique de support vital peut elle-même être source de complications graves. Nous vous présentons en images une complication directement liée au mode respiratoire non physiologique sur lequel repose la ventilation mécanique, à savoir le barotraumatisme lié aux pressions ventilatoires positives.

[Chronic paracetamol intoxication : under-diagnosed iatrogenic cause of metabolic acidosis with increased anion gap]. / L'intoxication chronique au paracétamol : cause iatrogène sous-diagnostiquée d'acidose métabolique à trou anionique augmenté.

The occurrence of metabolic acidosis with increased anion gap in the context of chronic paracetamol intoxication is an easily treatable clinical situation. Its rapid recognition is essential given its complete reversibility in the event of adequate management by eviction of the toxic agent, in this case paracetamol. It has an unknown cause and therefore potentially under-diagnosed, to be considered in the same way as the other more frequent etiologies. Because of this lack of knowledge, its frequency is probably underestimated considering the widespread consumption of paracetamol in the population.

La survenue d'une acidose métabolique à trou anionique augmenté dans le cadre d'une intoxication chronique au paracétamol est une situation clinique facile à traiter. Sa reconnaissance rapide est essentielle compte tenu de son entière réversibilité en cas de prise en charge adéquate par éviction de l'agent toxique, en l'occurrence le paracétamol. C'est une cause méconnue et de ce fait potentiellement sous-diagnostiquée, à envisager au même titre que les autres étiologies plus fréquentes. Du fait de cette méconnaissance, sa fréquence est probablement sous-estimée au vu de la consommation répandue de paracétamol au sein de la population.

[The first wave of COVID-19 in Intensive care]. / La première vague de la COVID-19 aux Soins intensifs, mars-mai 2020.

In December 2019, in Wuhan, a new human infectious pathology was born, COVID-19, consisting above all in pneumoniae, induced by the coronavirus named SARS-CoV-2 because of the respiratory distress it caused (SARS for severe acute respiratory syndrome, and CoV for Coronavirus). A real health and planetary crisis has appeared, much more substantial than that linked to SARS-CoV-1 in 2002-2004 and to MERS-CoV (Middle East Respiratory Syndrome Coronavirus) in 2012. In addition to respiratory damage that can be dramatic, this pathology is complicated by the frequency of cardiovascular, renal and coagulation diseases. Health care systems have had to adapt urgently, in the absence of hindsight from the pathology, and without effective therapeutic weapons. Through this review of the literature, we detail our local practices for the overall management of patients hospitalized in Intensive care.

En décembre 2019, à Wuhan, une nouvelle pathologie infectieuse humaine est née, le COVID-19, consistant avant tout en une pneumonie, induite par le coronavirus nommé SARS-CoV-2 en lien avec l'intensité de la détresse respiratoire qu'il entraîne (SARS pour syndrome respiratoire aigu sévère, et CoV pour coronavirus). Une véritable crise sanitaire et planétaire est apparue, bien plus conséquente que celle liée au SARS-CoV-1 en 2002-2004 et au MERS-CoV (Middle East Respiratory Syndrome Coronavirus) en 2012. Outre une atteinte respiratoire pouvant être dramatique, cette pathologie est complexifiée par la fréquence des atteintes cardiovasculaires, rénales et de la coagulation. Les systèmes de soins de santé ont dû s'adapter urgemment, en l'absence de recul face à la pathologie, et sans armes thérapeutiques efficaces. Au travers de cette revue de la littérature, nous détaillons nos pratiques locales pour la prise en charge globale des patients hospitalisés aux Soins intensifs.

[Acute respiratory distress syndrome]. / Le syndrome de détresse respiratoire aiguë.

Since its first description in 1967, a lot of progress has been made in understanding the pathophysiology, diagnosis and management of acute respiratory distress syndrome (ARDS). This nosological entity is based on the appearance of a diffuse alveolar damage associating pulmonary epithelial barrier disruption with an alveolar filling, both responsible of profound hypoxemia and important morbi-mortality. Nowadays, ARDS remains a frequent syndrome, associated with various etiologies. Diagnosis is based on the occurrence of acute hypoxic respiratory failure not explained by cardiac insufficiency or volume overload, within 7 days after a recognized risk factor, and in the presence of bilateral pulmonary opacities not fully explained by effusions, atelectasis or nodules on the chest radiography. Survivors present an increased risk of developing cognitive decline, depression, post-traumatic stress, and typical ICU related side-effects such as polyneuropathy and sarcopenia. In this context and not withstanding significant recent progress in the field of mechanical ventilation and extra-corporeal respiratory assistance, early diagnosis remains essential to identify patients with ARDS in order to offer them the most appropriate therapy.

Depuis sa première description en 1967, des progrès majeurs ont été réalisés dans la compréhension de la physiopathologie, le diagnostic et la prise en charge du syndrome de détresse respiratoire aiguë (SDRA). Cette entité nosologique repose sur l'apparition d'un dommage alvéolaire diffus associant une rupture de la barrière épithéliale pulmonaire avec un comblement alvéolaire à l'origine d'une hypoxémie profonde. De nos jours, le SDRA reste un syndrome fréquent, grevé d'une mortalité élevée, et prenant source dans de multiples situations pathologiques. Le diagnostic du SDRA repose sur l'apparition d'une insuffisance respiratoire aiguë hypoxique non expliquée par une insuffisance cardiaque ou une surcharge volémique, dans un délai de 7 jours suivant l'apparition d'un facteur de risque reconnu, en présence d'opacités pulmonaires bilatérales non complètement expliquées par des épanchements, des atélectasies ou des nodules. Les survivants sont à haut risque de développer un déclin cognitif, une dépression, ou un stress post-traumatique en plus des effets secondaires classiques d'une longue hospitalisation en unité de soins intensifs que sont la polyneuropathie ou la sarcopénie. Dans ce contexte, et en dépit de progrès importants dans le domaine de la ventilation mécanique et de l'assistance respiratoire par circulation extra-corporelle, il reste primordial d'identifier précocement les patients souffrant de SDRA afin de leur proposer la thérapeutique la plus appropriée dès les premiers signes cliniques.

[High anion gap metabolic acidosis (pyroglutamic acidosis) induced by chronic acetaminophen use]. / Acidose métabolique à trou anionique élevé (acidose pyroglutamique) induite par une prise chronique de paracétamol.

Acetaminophen is the most consumable analgesic in the world in the form of medical prescription or self-medication. It is one of the active ingredients most often involved in voluntary poisoning. Lethal dose of acetaminophen classically induces acute hepatic failure on hepatic necrosis. Chronic intake of sub-lethal doses (i.e. near recommended therapeutic doses) of acetaminophen in the presence of certain risk factors may be responsible for another much less recognized pathological manifestation: severe metabolic acidosis with an increased anion gap due to the accumulation of 5-oxoproline or pyroglutamic acid.

Le paracétamol est l'analgésique le plus consommé au monde sous forme de prescription médicale ou en automédication. Il compte parmi les principes actifs les plus souvent impliqués dans les intoxications volontaires, induisant en cas de prise d'une dose létale une insuffisance hépatique aiguë sur nécrose hépatique. La prise chronique de doses proches des doses thérapeutiques recommandées de paracétamol en présence de facteurs de risque peut être responsable d'une autre manifestation pathologique beaucoup moins reconnue : une acidose métabolique sévère à trou anionique augmenté, due à l'accumulation de 5-oxoproline ou acide pyroglutamique.

Lipomatous hypertrophy of the interatrial septum: the typical echographic aspect is worth being known.

A 65-year-old man was scheduled for an on-pump coronary artery bypass graft procedure because of a three-vessels coronary artery disease. A right atrial mass appended to the interatrial septum was discovered during intraoperative transoesophageal echocardiography. Therefore, the right atrium was opened. Gross examination revealed a fatty lesion of the interatrial septum. A biopsy was performed before the atrium was closed. A histological diagnosis of lipomatous hypertrophy of the interatrial septum was made. Lipomatous hypertrophy of the interatrial septum is a mass of adipocytes infiltrating the interatrial septum. The aspect of "dumbbell" produced by the sparing of the Fossa Ovalis is typical. The lesion is benign and remains asymptomatic most of the time although it can be responsible for cardiac arrhythmias or circulatory obstruction. The typical echographic aspect should be known to avoid unnecessary surgical resection.

[Extracorporeal membrane oxygenation (ECMO) in ICU patients suffering from cardiogenic shock, refractory hypoxemia or cardiac arrest]. / L'ECMO (extracorporeal membrane oxygenation) aux soins intensifs: intérêt chez le patient en choc cardiogénique réfractaire, en hypoxémie réfractaire ou en arrêt cardiaque.

ExtraCorporeal Membrane Oxygenation (ECMO) is a cardiopulmonary assistance device able to support patients in cardiac arrest, refractory cardiogenic shock or refractory hypoxemia otherwise sentenced to death. Recent technical progresses, early indication decision, bedside multidisciplinary implant, specific complications screening and echocardiographic weaning testing are crucial points to allow success of this exceptional technique.

Pulmonary veno-occlusive disease in myeloproliferative disorder.

The present study reports a case of biopsy-proven pulmonary veno-occlusive disease as a cause of severe pulmonary hypertension in a patient suffering from a chronic myeloproliferative disorder. The pulmonary disease evolved favourably under treatment with defibrotide, a pro-fibrinolytic medication used in hepatic veno-occlusive disease.

[Clinical case of the month. Spontaneous pneumopericardium after sternal dehiscence]. / Pneumopéricarde dans les suites d'une déhiscence de sternum.

We report a case of pneumopericardium occuring after cardiac surgery. Pneumopericardium is a rare condition; trauma is the most frequent etiology. Nontraumatic causes include fistulae in relationship with the bronchial tree or oesophagus and intrapericardial gazeous production due to bacterial pericarditis. Pericardiocentesis is indicated in case of air tamponade and local infection.

[Invasive pulmonary mucormycosis with invasion of the thoracic spine in a patient with myelodysplastic syndrome]. / Mucormycose invasive du poumon et du rachis dorsal.

We report the case of a 67-year-old patient who presented with a myelodysplastic syndrome and who developed a pulmonary mucormycosis with a rare extension to the dorsal spine. A decompressive laminectomy was attempted after failure of broad-spectrum antifungal treatment (Cancidas, V-Fend). The diagnosis was obtained after surgical biopsy. The scheduled lobectomy could not be performed because of altered clinical condition. The patient eventually died despite adapted antifungal treatment (Abelcet, Posaconazole). Pulmonary mucormycosis is a rare cause of mycotic infection that reaches most of the time immunocompromised patients. The pathogenic agent is part of zygomyces that have angio-invasive ability. Perineural propagation was recently described. Immunodepression, late diagnosis and lack of response to new generation antifungal drugs (V-Fend, Cancidas) are responsible for therapeutic failure in this disease. This case emphasizes the risk inherent to empirical antifungal treatment and the need of early biopsy in cases that do not respond to treatment.

[What's new in intensive care medicine?]. / Actualités thérapeutiques en médecine intensive.

Over the last ten years, much progress has been achieved in intensive care medicine. Large randomized studies, most often their multicentric, were performed and their results were translated into rules to be followed for the most appropriate treatment of life-threatening organ failures. The place of non-invasive ventilation in the management of hypercapnic or hypoxic respiratory insufficiencies was thus defined, and the methods for less traumatic mechanical ventilation were specified. The techniques of renal replacement therapy were compared and the optimal doses of dialysis or hemofiltration were established. The metabolic support of the patients was also altered following landmark studies, such as the management of blood glucose, which deeply influenced the approach to critically ill patients.

[Surgical left ventricular remodelling via endoventriculoplasty: clinical observation]. / Remodelage chirurgical du ventricule gauche par endoventriculoplastie: observation clinique.

A case of dilated ischemic cardiomyopathy, with severely impaired left ventricular systolic function, treated by endoventriculoplasty and CABG, is reported. The authors discuss the modern concepts regarding the surgical treatment of large anterior asynergic scars following occlusion of the LAD. Since there are more similarities between akinesia and dyskinesia than previously thought, the endoventriculoplasty of DOR may constitute a new way to surgically remodel the left ventricle in dilated cardiomyopathies with large anterior akinesia. This surgery significantly improves the ventricular function and the overall patients' prognosis at short and mid term follow up.

[Aspergillus pericarditis with cardiac tamponade and haemophagocytic syndrome: a non-classical case of immunodeficiency]. / Péricardite aspergillaire avec tamponnade cardiaque et syndrome hémophagocytaire: un cas non classique d'immunodéficience.

We report the case of a 31-year-old woman who died in a context of haemophagocytic syndrome with multiple opportunist infections:viral, mycobacterial and fungal. To our knowledge, this is the tenth case of invasive aspergillosis manifested by an aspergillus pericarditis with cardiac tamponade. Search for HIV infection, neoplasia, haematological malignancies was negative. In addition, the patient carried on a nonviral, non-ethylic cirrhosis, the etiology of which remained unknow. We will particularly develop the aspergillus pericarditis with cardiac tamponade and the haemophagocytic syndrome.

Origin of highly active metal-organic framework catalysts: defects? Defects!

This article provides a comprehensive review of the nature of catalytic sites in MOFs. In the last decade, a number of striking studies have reported outstanding catalytic activities of MOFs. In all cases, the authors were intrigued as it was unexpected from the ideal structure. We demonstrate here that (surface) defects are at the origin of the catalytic activities for the reported examples. The vacancy of ligands or linkers systematically generates (surface) terminations which can possibly show Lewis and/or Brønsted acido-basic features. The engineering of catalytic sites at the nodes by the creation of defects (on purpose) appears today as a rational approach for the design of active MOFs. Similarly to zeolite post-treatments, post-modifications of MOFs by linker or metal cation exchange appear to be methods of choice. Despite the mild acidity of defective MOFs, we can account for very active MOFs in a number of catalytic applications which show higher performances than zeolites or benchmark catalysts.

Retinopathy and plasma growth hormone levels in idiopathic hemochromatosis with diabetes.

In patients with idiopathic hemochromatosis, retinopathy was investigated by ophthalmoscopy and fluorescein angiography and was present in eight out of 23; this prevalence is similar to that reported in patients with diabetes aged between 30 and 60 years at onset of diabetes and with the same duration of the disease; in these eight patients retinopathy was of mild degree, with no impairment of visual acuity, fewer than 10 microaneurysms in each fundus, and no other retinal abnormatic islets directly. These studies confirm that anticholinergic drugs may be useful adjuvants in treating these patients.

Hemodynamic changes induced by laparoscopy and their endocrine correlates: effects of clonidine.

OBJECTIVES: We investigated endocrine correlates of the hemodynamic changes induced by carbon dioxide pneumoperitoneum (PNO). We then studied whether clonidine might modulate the hemodynamic changes induced by PNO by reducing release of catecholamines and vasopressin. BACKGROUND: Both mechanical and neurohumoral factors contribute to the hemodynamic changes induced by carbon dioxide PNO. Several mediators have been proposed, but no study has correlated hemodynamic changes with changes in levels of these potential mediators. METHODS: We conducted two studies, each including 20 healthy patients scheduled for elective laparoscopic cholecystectomy. In the first study serial measurements of hemodynamics (thermodilution technique) were done during laparoscopy and after exsufflation. Plasma concentrations of cortisol, catecholamines, vasopressin, renin, endothelin and prostaglandins were measured at the same time points. In the second study patients were randomly allocated to receive 8 microg/kg clonidine infused over 1 h or placebo before PNO. Hemodynamics and plasma levels of cortisol, catecholamines and vasopressin were measured during PNO and after exsufflation. RESULTS: Peritoneal insufflation resulted in a significant reduction of cardiac output (18+/-4%) and increases in mean arterial pressure (39+/-8%) and systemic (70+/-12%) and pulmonary (98+/-18%) vascular resistances. Laparoscopy resulted in progressive and significant increases in plasma concentrations of cortisol, epinephrine, norepinephrine and renin. Vasopressin plasma concentrations markedly increased immediately after the beginning of PNO (before PNO 6+/-4 pg/ml; during PNO 129+/-42 pg/ml; p < 0.05). The profile of vasopressin release paralleled the time course of changes in systemic vascular resistance. Prostaglandins and endothelin did not change significantly. Clonidine significantly reduced mean arterial pressure, heart rate and the increase in systemic vascular resistance. Clonidine also significantly reduced catecholamine concentrations but did not alter vasopressin and cortisol plasma concentrations. CONCLUSIONS: Vasopressin and catecholamines probably mediate the increase in systemic vascular resistance observed during PNO. Clonidine before PNO reduces catecholamine release and attenuates hemodynamic changes during laparoscopy.

Effect of hydroxyethylstarch on renal function in cardiac surgery: a large scale retrospective study.

BACKGROUND: Recent reports indicated negative effects of hydroxyethylstarch (HES) on renal function. The goal of this large scale retrospective study was to detect whether there was an association between postoperative deterioration of renal function and the use of HES 200 kD, 0.5 DS in the cardiac surgery setting. METHODS: Retrospective analysis of daily collected data in 3124 patients who underwent coronary artery bypass and/or valvular surgery. Three groups were compared according to differences in fluid therapy: --GEL: gelatin was used as priming fluid of extracorporeal circulation (ECC) and for postoperative filling (n = 1276). --MIX: HES was used as priming fluid of ECC an gelatin was used for postoperative filling (n = 1008). --HES: HES was used as priming fluid of ECC and for postoperative filling (n = 840). MAIN RESULTS: There were no significant differences in postoperative serum creatinine concentrations between the 3 groups: GEL: 12,2 +/- 0,5 mg/l; MIX: 12,3 +/- 0.5 mg/l; HES: 12,3 +/- 0.6 mg/l. The need for postoperative extrarenal epuration was not significantly different between the 3 periods: GEL: 2,9%; MIX: 3,1%; HES: 3,8%. CONCLUSION: The use of HES 200 kD, 0.5 DS in cardiac surgery does not seem to be associated with a clinically significant deterioration of postoperative renal function.

The usual causes of left ventricular outflow tract obstruction below the aortic valve in normal ventriculoarterial connection: review of the physiopathology and surgical implications.

Subaortic narrowing leading to left ventricular outflow tract obstruction (LVOTO) is a significant pathology that may be encountered pre- or postoperatively in both acquired or congenital cardiac disease. Through a review of the morphological features and mechanisms in the different clinical situations, the anatomic, dynamic and mixed forms of subaortic obstruction are emphasized. Knowledge of the substrate of LVOTO, its physiopathology and natural history allows to plan accordingly the surgical repair and the postoperative management.

["Fulminant" endocarditis due to Staphyloccocus aureus]. / Le cas clinique du mois. Endocardite "fulminante" a Staphylocoque doré.

We report two cases of "fulminant" endocarditis due to Staphyloccoccus aureus. In both cases, the echocardiographic and bacteriologic diagnosis was esthablished in a clinical picture of severe sepsis and thrombocytopenia evolving after a fever of less than 3 days duration.