Factors associated with unfavorable outcome in a multicenter audit of 100 infective endocarditis.

We aimed to identify factors associated with unfavorable outcome in patients treated for infective endocarditis (IE), with a focus on departure from European guidelines. We conducted a retrospective audit of all adult patients treated for endocarditis during a 1-year period across a regional network of nine care centers in the south-east of France. Medical records were reviewed regarding patient and infection characteristics, antibiotic therapy, outcome, and compliance to the European Society of Cardiology guidelines. Antibiotic treatment appropriateness was evaluated regarding molecule, dosage, and duration, according to guidelines. Primary endpoint was the assessment of factors associated with unfavorable outcome, defined as in-hospital mortality or IE relapse at 1-year follow-up. Secondary endpoints were intensive care admission, iatrogenic events, and nosocomial infections that occurred during hospital stay. One hundred patients were included. Median age was 71 years old. Twenty-two patients died and IE relapse occurred in two patients, representing 24 patients with unfavorable outcome. Overall, antibiotic treatment was deemed appropriate in 28 cases. Thirty-three patients required intensive care, 34 iatrogenic events were found, including 19 acute kidney injuries, and 13 nosocomial infections occurred during care. Using a logistic regression, factors associated with unfavorable outcome were admission in the intensive care unit (adjusted odd ratio 7.26 [1.8-29.28]; p = 0.005), new-onset nosocomial infection (adjusted odd ratio 8.83 [1.42-54.6]; p = 0.019), and age > 71 years old (adjusted odd ratio 11.2 [2.76-46.17]; p < 0.001). Departure from guidelines was frequent but not related to unfavorable outcome in our study. Only intensive care, age, and nosocomial infections were associated with mortality and relapse. Iatrogenic events were numerous, with no impact on outcome.

Fast-track anesthesia with remifentanil and spinal analgesia for cardiac surgery: the effect on pain control and quality of recovery.

OBJECTIVES: To assess pain intensity and quality of postoperative recovery in patients given fast-track anesthesia and spinal analgesia versus patients treated with standard anesthesia. DESIGN: A prospective, randomized, controlled study. SETTING: A private institution. PARTICIPANTS: Eighty-three patients who underwent cardiac surgery with cardiopulmonary bypass were analyzed. INTERVENTIONS: General anesthesia consisted of remifentanil and spinal analgesia (low-dose morphine and clonidine) for the fast-track group (FTG) and sufentanil without spinal analgesia for the control group (CG). During the postoperative period, paracetamol and patient-controlled intravenous analgesia (PCA) with morphine were given. MEASUREMENTS AND MAIN RESULTS: Postoperative pain intensity was evaluated during 48 hours with visual analog scale scores and intravenous morphine consumption. Pain impact on quality of life was assessed with the brief pain inventory (BPI) score (days 1-8), and recovery was evaluated with the quality of recovery score (QoR-40, day 4). Compared with the CG, FTG pain intensity was significantly lower 0 to 4 (p < 0.01) and 6 to 12 hours (p < 0.05) after surgery, as was their cumulative intravenous PCA morphine consumption (p = 0.01). BPI scores supported that FTG patients had significantly (p < 0.01) less "pain at its worst" on days 1 and 2, their BPI-assessed pain interfered significantly less with daily life on day 1 (p < 0.001), and their global QoR-40 score (day 4) was significantly higher (p < 0.05). CONCLUSIONS: Fast-track anesthesia combined with morphine-clonidine spinal analgesia controlled postoperative pain better and obtained a better QoR than conventional analgesia.

Minor increase of endtidal CO2 during sevoflurane-induced malignant hyperthermia.

Malignant hyperthermia (MH) in a pediatric patient during sevoflurane anesthesia with only a minor rise of endtidal CO(2) is described. MH was considered because of increased rectal temperature. The outcome was favorable after the initiation of a few simple measures (increased minute ventilation, cessation of sevoflurane). As recommended by the regional MH Reference Center, dantrolene was not used. In vitro contracture tests were performed on muscle biopsies from both parents. A strong contracture in response to halothane confirmed the father's MH susceptibility, thereby according a high probability of an MH episode in his son.

The treatment of severe pulmonary edema induced by beta adrenergic agonist tocolytic therapy with continuous positive airway pressure delivered by face mask.

IMPLICATIONS: We report the case of a pregnant patient who developed severe pulmonary edema secondary to beta-adrenergic agonist tocolytic therapy (salbutamol) and was successfully treated with mask-delivered continuous positive airway pressure ventilation.