Iatrogenic diseases as a reason for admission to the intensive care unit: incidence, causes, and consequences.

BACKGROUND: Data on iatrogenic diseases (IDs) have been recorded for the past 25 years. We determined whether aging of the general population and medical advances, including more powerful drugs and complex procedures, have altered the incidence, causes, and consequences of severe IDs during this period. METHODS: One-year retrospective study was conducted in an adult medical-surgical intensive care unit (ICU) affiliated with a French general hospital in an area of 200 000 inhabitants. All the patients admitted to the ICU during 1994 were screened for IDs. Patients with community or hospital-acquired IDs on admission were included. Follow-up assessed morbidity, mortality, workload, and costs of care for IDs, and the rate of preventable IDs. were included; the cause of the ID was drugs in 41, medical acts in 12, and surgical acts in 15. These 68 patients were in the ICU for 472 days, with a 13% fatality rate (9 patients) and a financial cost of US $688 470. They were not different from the 555 other ICU patients in terms of severity, mortality, workload, and length of stay in the ICU. Risk factors for ID were old age and the number of prescribed drugs. The rate of preventable ID was 51%. CONCLUSIONS: Iatrogenic diseases are a persistent and important reason for admission to the ICU, and the risk factors, causes, and consequences remain unchanged since 1980. Despite 25 years of experience with high-technology medicine, ID still has a negative impact on the health and resources of society.

Diagnosis of nosocomial bacterial pneumonia in intubated patients undergoing ventilation: comparison of the usefulness of bronchoalveolar lavage and the protected specimen brush.

PURPOSE: To compare the usefulness of specimens recovered using a protected specimen brush and those recovered by bronchoalveolar lavage in the diagnosis of nosocomial pneumonia occurring in intubated patients undergoing ventilation, we performed both procedures in patients suspected of having pneumonia because of the presence of a new pulmonary infiltrate and purulent tracheal secretions. PATIENTS AND METHODS: Twenty-one patients (16 men and five women) with an average age of 57 +/- 12 years were studied. They had been receiving mechanical ventilation for 8 +/- 6 days before inclusion in the trial. The clinical suspicion for nosocomial bacterial pneumonia was high in these patients. Fiberoptic bronchoscopy was performed in each patient. Bronchoscopy specimens were obtained by a protected specimen brush and by bronchoalveolar lavage, and were then processed for quantitative bacterial and fungal culture using standard methods. Total cell counts were performed on an aliquot of resuspended original lavage fluid. Differential cell counts were made on at least 500 cells. In addition, 300 cells were examined at high-power magnification and the percentage of cells containing intracellular microorganisms and the average number of extracellular organisms per oil-immersion field were determined. RESULTS: Quantitative culture of specimens recovered using the protected specimen brush were positive (more than 10(3) colony-forming units [cfu]/ml) in five of five patients with subsequently confirmed pneumonia, and negative (less than 10(3) cfu/ml) in 13 of 13 patients without bacterial pneumonia, but results were not available until 24 to 48 hours after the procedure. Quantification of intracellular organisms in cells recovered by lavage was also useful in distinguishing patients with pneumonia (more than 25 percent of cells with intracellular organisms in five of five patients) from those without pneumonia (less than 15 percent of cells with intracellular organisms in all cases), and results were available immediately. In contrast, quantitative culture of lavage fluid and differential cell counts were of little value in identifying infected patients. CONCLUSION: The protected specimen brush and microscopic identification of intracellular organisms in cells recovered by lavage yield useful and complementary information, and together permit rapid and specific treatment of most patients with nosocomial pneumonia.

Evaluation of clinical judgment in the identification and treatment of nosocomial pneumonia in ventilated patients.

To evaluate the accuracy of clinical judgment in the diagnosis and treatment of nosocomial pneumonia in ventilated patients, we studied 84 patients suspected of having nosocomial pneumonia because of the presence of a new pulmonary infiltrate and purulent tracheal secretions. We prospectively evaluated the accuracy of diagnostic predictions and therapeutic plans independently formulated by a team of physicians aware of all clinical, radiologic and laboratory data, including the results of Gram-stained bronchial aspirates. Definite (n = 51) or probable (n = 33) diagnoses could be established in all patients by strict histopathologic and/or bacteriologic criteria. Only 27/84 patients were diagnosed as having pneumonia. Organisms responsible for pneumonias were identified by quantitative cultures of samples obtained using a protected specimen brush or pleural fluid cultures. Four hundred eight predictions were made for the 84 studied patients. Clinical diagnoses for patients subsequently diagnosed as having pneumonia were accurate in 81/131 cases (62 percent). Furthermore, only 43/131 (33 percent) therapeutic plans proposed for these patients represented effective therapy. Common causes of inappropriate treatment included failure to diagnose pneumonia (50 plans), failure to effectively treat highly resistant organisms (21 plans), and failure to treat all organisms in cases of polymicrobial pneumonia (14 plans). Therapeutic plans formulated for patients without pneumonia included the unnecessary use of antibiotics in 45/277 cases (16 percent). These findings indicate that the use of clinical criteria alone does not permit the accurate diagnosis of nosocomial pneumonia in ventilated patients, and commonly results in inappropriate or inadequate antibiotic therapy for these patients.

Incidence and morbidity of cytomegaloviral infection in patients with mediastinitis following cardiac surgery.

To determine the incidence and morbidity of infections with CMV associated with mediastinitis after conventional cardiac surgery, 115 consecutive adult patients with mediastinitis were evaluated with viral cultures of blood and urine. Shedding of CMV was seen in 29 patients (25 percent) within a mean period of 37 +/- 22 days after cardiopulmonary bypass. Viremia was documented in 79 percent (23) of these 29 patients. Acute renal failure and enzymatic abnormalities (AST and LDH) were significantly more common in patients with virologically proven infection with CMV (p less than 0.05). In patients who survived the initial period of bacterial infection, major differences in their clinical course were observed according to their virologic status. After the 15th day of hospitalization following the débridement, the persistence of local infection was more frequent (p less than 0.05) and the mortality was higher (p less than 0.01) in CMV-infected patients. Moreover, the mean duration of hospitalization in the ICU for survivors was 69 +/- 36 days in viral shedders, compared with 48 +/- 27 days in nonshedders (p less than 0.05). Infection with CMV in mediastinitis occurs frequently and is associated with persistence of local infection, prolonged hospitalization, and increased late mortality.

Delayed admission for ethylene glycol poisoning: lack of elevated serum osmol gap.

In the absence of an immediately available serum ethylene glycol (EG) assay, the diagnosis of EG poisoning is usually based on anamnesis, clinical findings and presence of metabolic acidosis with elevated serum anion gap, elevated serum osmol gap, hypocalcemia and crystalluria. We report two cases of EG poisoning, both presenting without an elevated serum osmol gap and we discuss conditions which facilitate such a presentation, especially delayed hospital admission. Finally, we confirm the fact that determination of the osmol gap can fail as a screen for EG poisoning.

Teicoplanin: a well-tolerated and easily administered alternative to vancomycin for gram-positive infections in intensive care patients.

A prospective, randomized multicentre study was conducted in order to evaluate the potentially superior tolerability profile of teicoplanin plus netilmicin compared with vancomycin plus netilmicin in patients in ICUs. We considered that these glycopeptides have been shown to have comparable efficacy and that comparative tolerability is of paramount importance, particularly in severely ill patients. A total of 56 patients were enrolled into the study (36 males and 20 females). Twenty-four patients were included in the teicoplanin plus netilmicin group (15 males, 9 females: mean age 56.8 years). The mean simplified acute physiological score (SAPS) was 9.4 (range 4-20). Thirty-two patients were randomized to receive vancomycin plus netilmicin (21 males, 11 females; mean age 56.4 years). The mean SAPS was 9.3 (range 2-16). Septicaemia was the most common infection (14 cases in each group). Most infections were caused by Staphylococcus aureus or coagulase-negative staphylococci. The mean daily doses were: for teicoplanin, 457 mg (6.7 mg/kg); for vancomycin, 1678 mg (24.4 mg/kg); and for netilmicin 263.3 mg (3.9 mg/kg) in the teicoplanin group and 248 mg (3.8 mg/kg) in the vancomycin group. The trough levels of teicoplanin in the serum remained mostly between 7 and 10 mg/l, while more fluctuation was seen in patients receiving vancomycin. The mean trough levels of netilmicin in the serum were 1.2 (SD 0.9) mg/l in the teicoplanin group, compared with 1.7 (SD 1.4) mg/l in the vancomycin group (NS: p > 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Patients admitted to the intensive care unit for iatrogenic disease. Risk factors and consequences]. / Patients admis en réanimation pour pathologie iatrogène: facteurs de risque et conséquences.

PURPOSE: Data pertaining to iatrogenic diseases have been recorded over the last 25 years. Regarding the evolution of medical practice (general ageing, more and more powerful drugs and complex procedures), it is not known whether the incidence and the consequences of iatrogenic diseases have changed since their first evaluation. METHODS: To determine the admission rate to intensive care units for iatrogenic diseases, with the purpose of analyzing risk factors and consequences, and to compare our results with previous data recorded in 1979 (admission rate: 12.6%, mortality: 20%, preventable events: 47%), a 1-year retrospective study was conducted in an intensive care unit (ICU). RESULTS: During 1994, 68 (10.9%) out of 623 patients were admitted to the ICU for iatrogenic diseases (drugs: 41, medical acts: 12, surgical acts: 15). They were not different--in terms of severity, mortality, workload and length of stay in the ICU--from the other 555 patients hospitalized for other reasons. They were hospitalized on average for 472 days in the ICU, with a 13% fatality rate and a financial cost of US $688,470. Risk factors for iatrogenic diseases were the age and the number of prescribed drugs. The rate of preventable events was 51%. CONCLUSIONS: In this study, the occurrence of life-threatening iatrogenic diseases was a persistent and important purpose for admission to the ICU. Risk factors and consequences are still identical to those reported in 1979. Our results emphasize the persistence of the noxious impact of iatrogenic diseases on the quality and cost of medical care.

[Therapeutic principles of staphylococcal infections--Role and limitations of standard compounds]. / Principes thérapeutiques des infections à staphylocoques. Place et limites des molécules classiques.

Antibiotic therapy plays an important (but not exclusive) role in the treatment of staphylococcal infections. Measures aimed at reducing the bacterial inoculum through local procedures must be envisaged as often as possible. The removal of any foreign, infected materials is essential to success. In this article, we review the different, active antibiotics available, their advantages and disadvantages and their indications. In the light of these data, we propose a therapeutic approach to severe bacterial infection caused by a cluster of Gram-positive cocci. Staphylococcal infections pose daily therapeutic problems, whether in open-care practice or intensive care units. The specificity of staphylococcal infections encountered in an intensive care setting require a therapeutic approach which takes account of the context, and particularly of the incidence of resistant staphylococcal infections.

[Coronary gas embolism after laparoscopic surgery]. / Embolie gazeuse coronaire lors de la chirurgie coelioscopique.

Gas embolism is a severe complication of laparoscopic surgery. We report two cases: one with lethal peroperative cardiac arrest from massive coronary artery gas embolism recognized during open-chest cardiac massage; the second case, also associated with coronary artery gas embolism, resulted in severe but transient abnormal left ventricular anterior wall motion, subepicardial ischaemia and injury in ECG leads V1 to V5, but unremarkable coronary arteriography and full recovery. The pathophysiology of gas embolism occurring during a laparoscopic procedure, the mechanisms of gas entry into the systemic vascular bed, the clinical, ECG, pulse oximetry, end-tidal CO2 concentration changes and alarm signs are discussed. The diagnostic value of Doppler transoesophageal echocardiography when possible is underlined, and emergency management of gas embolism is considered.

[Urinary tract obstruction by Candida bezoars, or fungus balls]. / Obstruction des voies urinaires par des bézoars candidosiques, ou "fungus balls".

Two patients admitted to an intensive care unit for severe bacterial infection develops Candida albicans superinfection with obstruction of the urinary canals by "fungus balls". The development of medico-surgical techniques using antibiotics and immunosuppressive drugs accounts for the increasing incidence of disseminated candidiasis. The kidneys are particularly sensitive to Candida infections. Fungus balls are conglomerates of mycelium which may result in obstruction of the urinary tract. Their clinical, radiological and ultrasonic features, as well as the microbiological and serological diagnostic problems they raise are described. Ultrasonically guided percutaneous nephrostomy is a very interesting technique for the diagnosis of the condition and its local treatment by drainage and lavage with amphotericin B. This antifungal, combined with flucytosine is still used for the systemic treatment of candidiasis.

[Necrotic skin lesions caused by pet rats in two teenagers]. / Lésions cutanées nécrotiques liées au Cowpox virus inoculé par des rats de compagnie.

We report 2 observations in young girls who, after exposure to domestic rats from the same pet shop, presented with inflammatory and necrotic skin wounds in the neck and face. Since lesions did not improve with antibiotic therapy, surgical excision of necrosis healed the wounds, with a 2nd intervention necessary in 1 patient. All bacteriological investigations appeared to be negative; finally, electron microscopy of excised subepidermal tissue and PCR characterization provided the diagnosis of cowpox virus (CPXV) infection. CPXV is part of the Orthopox virus genus, like variola virus, and is generally transmitted to humans by infected cats or rodents. CPXV infection should be kept in mind when macular, vesicular, or necrotic cutaneous wounds do not improve with antibiotics.