Double lung transplantation for adult respiratory distress syndrome after recombinant interleukin 2.

Patients suffering from acute respiratory failure are considered poor candidates for lung transplantation (LT). We report a successful double lung transplantation performed in a patient with adult respiratory distress syndrome (ARDS). The 32-year-old woman received recombinant interleukin 2 (rIL-2) three months after an autologous bone marrow transplant for acute myelogenic leukemia as consolidation treatment. After four days of treatment with rIL-2, she developed ARDS which worsened over a three-week period, despite treatment. Lung transplantation was carried out as ultimate treatment. The postoperative course was uneventful. The patient is alive and in a good condition 11 months after LT. This case demonstrates the feasibility of LT in selected patients with ARDS. However, this case is exceptional since lung grafts should be utilized preferably for evaluated and accepted patients in transplant programs.

Effect of parenteral nutrition on muscle amino acid output and 3-methylhistidine excretion in septic patients.

The effects of adequate total parenteral nutrition (TPN) on nitrogen excretion, urea N percentage, 3-methylhistidine excretion, and leg amino acid output, were studied during the ten-day period following abdominal surgery for generalized peritonitis in nine patients. The first two postoperative days were without nutritional intake, TPN was started on the third postoperative day (57 cal/KgBW--40% as Intralipid--0.30 g of N/KgBW). Leg amino acid outputs were done before TPN (DO), then two days (D2) and eight days (D8) after TPN. Total nitrogen and urea N percentage did not significantly differ before and after TPN. Between DO and D2 there was a significant reduction of urinary 3-methylhistidine (467 +/- 37 to 280 +/- 29 mumol/24 h-P less than 0.001) and leg amino acid release (604 +/- 103 to 254 +/- 87 nmol/mn/100 g of calf muscle--P less than 0.01) reflecting reduction in muscle hypercatabolism despite the persistence of the septic state. Between D2 and D8, 3-methylhistidine remained stable while leg amino acid release continued to decrease (254 +/- 87 to 68 +/- 40 nmol/mn/100 g--P less than 0.05). This association suggests an increased muscle protein synthesis. A closer examination of the clinical evolution of these patients, especially concerning their septic evolution, shows that only improved patients with recovery from sepsis increased their muscle protein synthesis. Thus, in septic hypercatabolic patients TPN seems to be able to reduce muscle catabolism while the increase in protein synthesis is mainly the consequence of recovery from the septic state. In such patients TPN should be used as a preventive therapeutic measure.

Peripheral venous complications of a hyperosmolar (960 mOsm) nutritive mixture: The effect of heparin and hydrocortisone. A multicenter double-blinded random study in 98 patients.

Peripheral intravenous nutrition with hyperosmolar solutions usually results in a high rate of venous complications. The aim of this multicenter double blind randomised study in 98 patients has been to measure: (a) tolerance by the peripheral veins being perfused with a protein-glucose-lipid nutritive mixture of 960 mOsm/l (group A, n = 33), (b) the protective effect of the additive to the nutritive mixture of either heparin: 1000 IU/1 (group B, n = 32) or heparin with hydrocortisone (5 mg/l) group C, n = 33). Tolerance by the veins was evaluated on a single vein site during a 48 h perfusion with 21 per day. The following complications: oedema, erythema, induration, thrombophlebitis led to the interruption of the perfusion. The rate of interruptions of perfusions for total venous complications and for thrombophlebitis has been respectively: at 24 h, in group A: 39 and 15%, in group B: 6 and 3%, in group C: 12 and 0%; at 48 h: in group A: 82 and 42%, in group B: 53 and 18%, in group C: 36 and 6%. Venous complication rates for 24 and 48 h were significantly lower in groups B and C (p<0.05) than in group A and there was no inter group difference between groups B and C. These results suggest that peripheral venous nutrition infusing 14.1 g of nitrogen and 8.5 MJ per day can be performed with a hyperosmolar solution of 960 mOsm/1, if that heparin be added to the nutritive mixture and the perfusion site be changed daily. Under these conditions the observed venous complications rate is equal to or less than 6% of cases.

[Short emergency hospitalization]. / L'hospitalisation de courte durée à l'urgence.

In France, the number of admissions to emergency departments increase by 5 to 10 per cent per year. Traditionally, patients who require services beyond the first hours in the emergency department have been admitted to the acute care hospital. Observation unit are becoming common in hospitals because they allow an additional option to admission or discharge. In France, 60 per cent of emergency departments have observation units. Five to ten per cent of patients seen in an emergency department are transferred to the observation unit. These observation units are staffed with emergency personnel specifically assigned to the function of the unit. The average period of observation is less than 48 h. Of the patients observed, 50 per cent are discharged after extended observation and treatment. These observation units can be a safe, effective and cost-saving way of ensuring that patients who are considered to be in an intermediate category receive appropriate care.

[Digestive complications of oral contraceptives: a case of extensive digestive necrosis in a young woman]. / Les accidents digestifs des contraceptifs oraux: un cas de nécrose digestive étendue chez une femme jeune.

PIP: A case of acute intestinal vascular necrosis in a 19-year-old user of oral contraceptives (OCs) is described, and hypotheses explaining the digestive complications of synthetic estrogens are reviewed. The patient had originally presented with a violent gastric pain that subsequently spread to the entire abdomen. An abrupt worsening of her condition involved cardiovascular collapse associated with a peritoneal syndrome, vomiting and dehydration, and hyperleukocytosis. Emergency opening of the peritoneum was followed by evacuation of a large quantity of fetid gas and alimentary debris, and observation of a completely necrosed stomach. A careful lavage of the entire intestinal cavity led to temporary improvement, but it became clear during an attempt at gastrectomy that further treatment would be unavailing and the patient died shortly thereafter. Estrogens were believed to be responsible for the digestive necrosis because it occurred in a young woman who had used an estrogen-rich OC for 3 years and who smoked; a hapatic biopsy confirmed the diagnosis. No traces of other risk factors such as hypertension, hyperlipidemia, diabetes, neoplasia, or obesity were observed. Recent publications indicate that OCs are responsible for a certain number of digestive problems, which may include acceleration of intestinal transit, severe diarrhea, rectorrhagia, ischemic or ulcerative colitis, intestinal infarct which is usually localized, and hepatocellular problems ranging from moderate hepatic insufficiency to malignant tumor and Budd-Chiari syndrome. OCs do not modify hemodynamic regimes, but they may cause elevation of fibrinogen and thrombin, diminution of antithrombin III acitivty, increased platelet adhesivity, and decreased fibrinolysis leading to hypercoagulability. These modifications in hemostasis occur in all OC users and are not statistically correlated with occurence of thrombotic accidents. OCs are probably responsible for parietal vascular lesions; experimental injection of synthetic estrogens is associated with both arterial and venous lesions. The most characteristic anomaly is at the level of the intima, with proliferation of smooth muscle cells and increased conjunctive tissue fibers associated with proliferation of the media or the endothelium. The absence of lipid deposits, the simultaneous appearance of arterial and venous lesions, and other evidence argues against and atheromatous origin of parietal lesions. A significant correlation has been found between high levels of anti-synthetic ethinyl estradiol antibodies and the presence of vascular lesions. It is hypothesized that these circulating immune complexes penetrate the vascular walls of OC users and produce lesions, which may depend on factors such as smoking.^ieng

[Should metabolic acidosis be alkalinized?]. / Faut-il alcaliniser les acidoses métaboliques?

At present, the administration of bicarbonate for metabolic acidosis has become controversial with regard to the indications and the modalities of treatment. Scientific evidence of the therapeutic value of bicarbonate is still lacking. In the opposite, there is a strong evidence of its adverse effects, such a paradoxical acidosis, sodium load and over all a worsening of haemodynamic status. Other therapeutic measures are limited. They include the administration of Carbicarb which does not increase the CO2 content, haemodialysis with bicarbonate and/or hyperventilation. As for every therapeutic action, the treatment must rely on an interpretation of the pathophysiological mechanism, resulting in the definition of therapeutic goals. The amendment of acidosis is not always a therapeutic priority. In ketoacidosis for instance, the depth of acidosis is mainly related to the degree of dehydration, the treatment of which results in a normalization of pH.

[Neuromeningeal listeriosis in adults. Clinical aspects and contribution of cotrimoxazole in monotherapy]. / Listériose neuroméningée de l'adulte. Aspects cliniques et apport du cotrimoxazole en monothérapie.

A series of 28 patients suffering from neuromeningeal listeriosis is reported. This disease is consecutive to infection by Listeria monocytogenes--an ubiquitous and opportunistic Gram-positive bacillus--and has become a public health problem: its incidence is increasing and its prognosis is very severe despite the development of new bacteriological identification methods. Human beings are contaminated by food, which explains the frequent outbreaks of epidemics which are widely publicized, the infection being one of the consequences of the unprecedented development of the food industry and the cold food chain. The predominant clinical picture is one of non-specific meningoencephalitis. In about 50 percent of the cases the subjects infected are "immunodepressed" and/or more than 60 years' old. The diagnosis is difficult since the bacteriological identification is delayed (direct examination of the cerebrospinal fluid is rarely positive) and this fluid may be sterile (hence the value of blood cultures). A probability treatment therefore must be initiated before the diagnosis is confirmed if an unfavourable outcome is to be avoided. In Listeria monocytogenes infection cotrimoxazole administered alone seems to be a better antibacterial therapy than the reference ampicillin-aminoside combination.

[Lung volume reduction in patients with emphysema after prolonged ventilatory assistance]. / Réduction de volume pulmonaire chez un patient avec emphysème après ventilation assistée prolongée.

A 42-year-old patient with emphysema was hospitalized in the intensive care unit for an episode of acute respiratory failure. The patient became dependent on invasive mechanical ventilation and surgical lung volume reduction was performed. The indication of lung volume reduction in this pathological situation but was followed by rapid weaning 48 hours postoperatively. The patient was discharged without ventilatory assistance and has not required further ventilatory assistance after more than 2 years follow-up.

[Mesenteric clamp syndrome complicating pancreatic trauma (author's transl)]. / Syndrome de la pince mésentérique compliquant un traumatisme du pancréas.

Duodenal obstruction by the mesenteric artery has mostly been reported in profoundly denutrated patients. We here report one case after left spleno-pancreatectomy following pancreatic isthmus rhexis concerning a seventeen years old injured young boy, who was kept in supination position because of a backbone fracture. Vertebral osteo-synthesis allowed a quickly efficient postural treatment.

[Interest and limits of arteriography in one case of abdomino-pelvic trauma (author's transl)]. / Intérêt et limites de l'artériographie dans un cas de traumatisme abdomino-pelvien

Hepatic and pelvic arteriography were carried out in one case of trauma of the liver and pelvis. Initial hepatic arteriography did not give more information than per-operative cholangiography. Secondary hepatic arteriography suggests the presence of lesions which, in fact, do not exist. Pelvic arteriography permitted us to localise on one obturator artery, the origin of a voluminous retroperitoneal hematoma. We were able to stop the hemorrhage by embolisation and this facilitated surgical removal of the hematoma.

[Assessment of 81 traumatic vascular lesions of the limbs (author's transl)]. / Bilan de 81 lésions vasculaires traumatiques des membres.

A review of 81 cases of vascular trauma of the limbs in 75 patients treated at the Grenoble University Hospital from 1967 to 1975 confirms the classical etiological, pathological and clinical findings. Analysis of the results led us to emphasise the necessity of bone and vascular repair which should be complete from the start, verified by peroperative radiological control. The application of now well-established rules to the treatment of vascular trauma should lead to a better prognosis in the case of popliteal lesions (76 p. cent of good results out of 17 revascularisations).

[Severe neurologic complications secondary to poisoning by slow-release theophylline]. / Complications neurologiques graves secondaires à une intoxication par les théophyllines-retard.

Three cases of severe slow-release theophylline toxicity (plasma theophylline levels above 30 mg/l) in patients with severe chronic pulmonary disease are reported. Seizures were noted in all patients, and one had tachyarrhythmia. Two of the patients died. Several factors were present which may have impaired theophylline clearance, leading to toxic plasma levels. The mortality rate of theophylline intoxication being high, the initial doses should be sufficiently low to minimize the risk of adverse affects, and the best way to prevent theophylline toxicity is to monitor plasma concentrations. A management of patients with theophylline overdosage is suggested: oral administration of activated charcoal is the primary therapeutic measure; haemoperfusion or haemodialysis should be considered only in patients in whom conservative measures have failed.

[Use of helium and oxygen mixtures in status asthmaticus]. / Utilisation de mélanges hélium-oxygène au cours de l'état de mal asthmatique.

Four patients in status asthmaticus and with alveolar hypoventilation were given a helium-oxygen (He-O2) mixture to breathe during 4 hours. Clinical improvement and return to normal of arterial blood gas levels were rapid and dramatic in all patients. The He-O2 mixture, which is a low density gas, causes a reduction in pulmonary resistance and an improvement in overall alveolar ventilation.

[Peritoneal irrigation and lavage using iodinated polyvinyl-pyrrolidone in acute generalized peritonitis (70 cases treated in an intensive care unit)]. / L'irrigation-lavage du péritoine a la polyvinyl-pyrrolidone iodée dans les péritonites aiguës généralisées (70 cas traités dans un service de réanimation).

The authors report 70 cases of severe acute generalise peritonitis treated during the immediate postoperative periode by peritoneal irrigation-lavage using iodinated polyvinyl-pyrrolidone for 16 days. All of the patients were hospitalised in an intensive care unit because of septicaemia, respiratory distress, acute renal failure, etc. After an aetiological study of these cases of peritonitis, the technique of installation and surveillance and the complications of peritoneal irrigation-lavage are analysed. The results in this series confirm the efficacy of the technique as long as it is used from the outset, immediately following the onset of peritonitis.