Respiratory changes of the inferior vena cava diameter predict fluid responsiveness in spontaneously breathing patients with cardiac arrhythmias

Background

Whether the respiratory changes of the inferior vena cava diameter during a deep standardized inspiration can reliably predict fluid responsiveness in spontaneously breathing patients with cardiac arrhythmia is unknown.

Methods

This prospective two-center study included nonventilated arrhythmic patients with infection-induced acute circulatory failure. Hemodynamic status was assessed at baseline and after a volume expansion of 500 mL 4% gelatin. The inferior vena cava diameters were measured with transthoracic echocardiography using the bi-dimensional mode on a subcostal long-axis view. Standardized respiratory cycles consisted of a deep inspiration with concomitant control of buccal pressures and passive exhalation. The collapsibility index of the inferior vena cava was calculated as [(expiratory–inspiratory)/expiratory] diameters.

Results

Among the 55 patients included in the study, 29 (53%) were responders to volume expansion. The areas under the ROC curve for the collapsibility index and inspiratory diameter of the inferior vena cava were both of 0.93 [95% CI 0.86; 1]. A collapsibility index ≥ 39% predicted fluid responsiveness with a sensitivity of 93% and a specificity of 88%. An inspiratory diameter < 11 mm predicted fluid responsiveness with a sensitivity of 83% and a specificity of 88%. A correlation between the inspiratory effort and the inferior vena cava collapsibility was found in responders but was absent in nonresponder patients.

Conclusions

In spontaneously breathing patients with cardiac arrhythmias, the collapsibility index and inspiratory diameter of the inferior vena cava assessed during a deep inspiration may be noninvasive bedside tools to predict fluid responsiveness in acute circulatory failure related to infection. These results, obtained in a small and selected population, need to be confirmed in a larger-scale study before considering any clinical application.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0427-1) contains supplementary material, which is available to authorized users.

Endotoxemia Engages the RhoA Kinase Pathway to Impair Cardiac Function By Altering Cytoskeleton, Mitochondrial Fission, and Autophagy

AIMS

The RhoA/ROCK pathway controls crucial biological processes involved in cardiovascular pathophysiology, such as cytoskeleton dynamics, vascular smooth muscle contraction, and inflammation. In this work, we tested whether Rho kinase inhibition would beneficially impact cardiac cytoskeleton organization, bioenergetics, and autophagy in experimental endotoxemia induced by lipopolysaccharides (LPSs) in mice.

RESULTS

Fasudil, a potent ROCK inhibitor, prevented LPS-induced cardiac inflammation, oxidative stress, cytoskeleton disarray, and mitochondrial injury. ROCK inhibition prevented phosphorylation of cofilin and dynamin-related protein-1, which promotes stabilization-polymerization of F-actin and mediates mitochondrial fission, respectively. Pyr1, which exclusively alters actin dynamics, prevented LPS-induced myocardial dysfunction, suggesting that beneficial impact of ROCK inhibition was not mainly related to pleiotropic effects of fasudil on cardiac inflammation and oxidative stress. Fasudil reduced mitochondrial fragmentation, stimulated initiation of autophagy, and elicited cardioprotection in LPS heart. Mdivi-1, a potent mitochondria fission inhibitor, converted cardioprotective autophagy to an inefficient form due to cargo loading failure in which autophagic vacuoles fail to trap cytosolic cargo, despite their formation at enhanced rates and lysosomal elimination.

INNOVATION

In experimental endotoxemia, cardioprotection by RhoA/ROCK inhibition may be related to changes in actin cytoskeleton reorganization and mitochondrial homeostasis. Improvement of LPS-induced mitochondrial dysfunction by fasudil was attributed to inhibition of ROCK-dependent Drp1 phosphorylation and activation of autophagic processes that can limit mitochondrial fragmentation and enhance degradation of damaged mitochondria, respectively.

CONCLUSION

Fasudil prevented LPS-induced heart oxidative stress, abnormal F-actin distribution, and oxidative phosphorylation, which concur to improve cardiac contractile and bioenergetic function. We suggest that fasudil may represent a valuable therapy for patients with sepsis.

Infective endocarditis requiring ICU admission: epidemiology and prognosis

Background

Very few studies focused on patients with severe infective endocarditis (IE) and multiple complications leading to Intensive Care Unit (ICU) admission. Studied primary outcomes depended on the series and multiple prognostic factors have been identified. Our goal was to determinate characteristics of patients, in-hospital mortality and independent prognostic factors in an overall population of patients admitted to ICU for a left-sided, definite, active and severe IE.

Methods

Retrospective study performed in 9 ICUs during an 11-year period.

Results

Data of 248 patients (mean age = 62.4 ± 13.3 years; 63.7 % male) were studied. Native and prosthetic valves were involved in 195 and 53 patients, respectively. Causative pathogens, identified in 225 patients, were mainly streptococci (45.6 %) and staphylococci (43.4 %). On ICU admission, 127 patients exhibited extra-cardiac involvement. Ninety-five patients had one or more neurological complications, as followed: ischemic stroke (n = 66), cerebral hemorrhage (n = 31), meningitis (n = 16), brain abscess (n = 16), and intracranial mycotic aneurysm (n = 10). Criteria prompting to cardiac surgery appeared during ICU stay for 186 patients and between ICU and hospital discharges in 5 patients. Due to contra-indications, surgery required by IE was only performed during hospitalization in 125 patients. Moreover, surgery was considered adequate according to usual guidelines in 76 of 191 patients with indication(s) of valvular surgery: for patients with surgical procedure considered as emergency (n = 69), 17 surgical procedures underwent within the first 24 h following indication; for patients with urgent surgical indication (n = 102), surgery was performed during the first week following indication in 40 patients; finally, elective surgery (n = 20) was performed for 19 patients. During hospitalization, 103 (41.5 %) patients died. Four independent prognostic factors were identified: SAPS II > 35 (AOR = 2.604; 95 % CI: 1.320–5.136; p = 0.0058), SOFA > 8 (AOR = 3.327; 95 % CI: 1.697–6.521; p = 0.0005), IE due to methicillin resistant Staphylococcus aureus (AOR = 4.981; 95 %CI = 1.433–17.306; p = 0.0115) and native IE (AOR = 0.345; 95 % CI: 0.169–0.703; p = 0.0034).

Conclusions

Mortality in patients admitted to ICU for left-sided IE remains high, especially in cases of endocarditis due to methicillin resistant Staphylococcus aureus, when organ failures occur and ICU scores are high.

The use of static and dynamic haemodynamic parameters before volume expansion: A prospective observational study in six French intensive care units

OBJECTIVE

The aim of the present study was to determine the use of static and dynamic haemodynamic parameters for predicting fluid responsiveness prior to volume expansion (VE) in intensive care unit (ICU) patients with systemic inflammatory response syndrome (SIRS).

METHODS

We conducted a prospective, multicentre, observational study in 6 French ICUs in 2012. ICU physicians were audited concerning their use of static and dynamic haemodynamic parameters before each VE performed in patients with SIRS for 6 consecutive weeks.

RESULTS

The median volume of the 566 VEs administered to patients with SIRS was 1000mL [500-1000mL]. Although at least one static or dynamic haemodynamic parameter was measurable before 99% (95% CI, 99%-100%) of VEs, at least one them was used in only 38% (95% CI, 34%-42%) of cases: static parameters in 11% of cases (95% CI, 10%-12%) and dynamic parameters in 32% (95% CI, 30%-34%). Static parameters were never used when uninterpretable. For 15% of VEs (95% CI, 12%-18%), a dynamic parameter was measured in the presence of contraindications. Among dynamic parameters, respiratory variations in arterial pulse pressure (PPV) and passive leg raising (PLR) were measurable and interpretable before 17% and 90% of VEs, respectively.

CONCLUSIONS

Haemodynamic parameters are underused for predicting fluid responsiveness in current practice. In contrast to static parameters, dynamic parameters are often incorrectly used in the presence of contraindications. PLR is more frequently valid than PPV for predicting fluid responsiveness in ICU patients.

New tools for optimizing fluid resuscitation in acute pancreatitis

Acute pancreatitis (AP) is a frequent disease with degrees of increasing severity responsible for high morbidity. Despite continuous improvement in care, mortality remains significant. Because hypovolemia, together with microcirculatory dysfunction lead to poor outcome, fluid therapy remains a cornerstone of the supportive treatment. However, poor clinical evidence actually support the aggressive fluid therapy recommended in recent guidelines since available data are controversial. Fluid management remains unclear and leads to current heterogeneous practice. Different strategies may help to improve fluid resuscitation in AP. On one hand, integration of fluid therapy in a global hemodynamic resuscitation has been demonstrated to improve outcome in surgical or septic patients. Tailored fluid administration after early identification of patients with high-risk of poor outcome presenting inadequate tissue oxygenation is a major part of this strategy. On the other hand, new decision parameters have been developed recently to improve safety and efficiency of fluid therapy in critically ill patients. In this review, we propose a personalized strategy integrating these new concepts in the early fluid management of AP. This new approach paves the way to a wide range of clinical studies in the field of AP.

[Field 4. Environmental safety practice in the intensive care unit. French-speaking Society of Intensive Care. French Society of Anesthesia and Resuscitation]

Medical devices are known to carry risks from design to scrap. Accident reports in ICU show that medical device account for only 20% of accidents. Formation of users and providing a postmarketing incident reporting are thus essential in health institutions. Clinical and engineering departments should cooperate to produce and secure procedures which should be applied during the lifetime of each clinical device. Several points should be especially fulfilled: close cooperation between clinical departments and biomedical engineering departments with available technicians, computer-based inventory of all devices, evaluation of specifications required before purchasing a new device, education of users on utilisation and maintenance, technical follow-up of devices and keeping maintenance and repair logs, ability to provide users with replacement devices, provision of check-lists before use, forging criteria to decide when device should be discarded. These principles are simple and should be considered as mandatory in order to improve medical device related security.

Can dynamic indicators help the prediction of fluid responsiveness in spontaneously breathing critically ill patients?

OBJECTIVE

To investigate whether the respiratory changes in arterial pulse (DeltaPP) and in systolic pressure (DeltaSP) could predict fluid responsiveness in spontaneously breathing (SB) patients. Because changes in intrathoracic pressure during spontaneous breathing (SB) might be insufficient to modify loading conditions of the ventricles, performances of indicators were also assessed during a forced respiratory maneuver.

DESIGN

Prospective interventional study.

SETTING

A 34-bed university hospital medico-surgical ICU.

PATIENTS AND PARTICIPANTS

Thirty-two SB patients with clinical signs of hemodynamic instability.

INTERVENTION

A 500-ml volume expansion (VE).

MEASUREMENTS AND RESULTS

Cardiac index, assessed using transthoracic echocardiography, increased by at least 15% after VE in 19 patients (responders). At baseline, only dynamic indicators were higher in responders than in nonresponders (13+/-5% vs. 7+/-3%, p=0.003 for DeltaPP and 10+/-4% vs. 6+/-2%, p=0.002 for DeltaSP). Moreover, they significantly decreased after VE (11+/-5% to 6+/-4%, p<0.001 for DeltaPP and 8+/-4% to 6+/-3%, p<0.001 for DeltaSP). DeltaPP and DeltaSP areas under the ROC curve were high (0.81+/-0.08 and 0.82+/-0.08; p=0.888, respectively). A DeltaPP>or=12% predicted fluid responsiveness with high specificity (92%) but poor sensitivity (63%). The forced respiratory maneuver reproducing a dyspneic state decreased the predictive power.

CONCLUSIONS

Due to their lack of sensitivity and their dependence to respiratory status, DeltaPP and DeltaSP are clearly less reliable to predict fluid responsiveness during SB than in mechanically ventilated patients. However, when their baseline value is high without acute right ventricular dysfunction in a participating patient, a positive response to fluid is likely.

Methodological approach for the evaluation of the performances of medical intensive care units

PURPOSE

The purpose of the study was to present a methodological approach enabling the comparison of clinical and economic performances of intensive care units and a graphical visualization based on these 2 dimensions.

PATIENTS AND METHODS

A retrospective analysis of a database of 666 patients admitted in intensive care units over a period of 2 consecutive months.

RESULTS

Calculation of clinical performance is based on the difference between the mortality observed and forecast from the Simplified Acute Physiology Score version 2. The evaluation of resource consumption is carried out from the measure of medical and paramedical care workload. These 2 scores are modeled on the basis of the length of stay and the severity state of the patient. The economic performance is calculated on the basis of the difference between the resource consumption observed and forecast. The graphs are constructed by taking up as coordinates the values of the clinical and economic performances of each center.

CONCLUSION

These graphs enable the identification of the most deviating intensive care units to study, for example, their organizational, technical, or human resource setup accounting for their position.

Multiple-drug-resistant bacteria in patients with severe acute exacerbation of chronic obstructive pulmonary disease: Prevalence, risk factors, and outcome

OBJECTIVE

To determine prevalence, risk factors, and effect on outcome of multiple-drug-resistant (MDR) bacteria in patients with severe acute exacerbation of chronic obstructive pulmonary disease.

DESIGN

Prospective, observational, cohort study.

SETTING

Thirty-bed medical intensive care unit (ICU) in a university hospital.

METHODS

All chronic obstructive pulmonary disease patients with acute exacerbation who required intubation and mechanical ventilation for >48 hrs were eligible during a 4-yr period. Patients with pneumonia or other causes of acute respiratory failure were not eligible. In all patients, quantitative tracheal aspirate was performed at ICU admission (positive at 10 colony-forming units [cfu]/mL). MDR bacteria were defined as methicillin-resistant Staphylococcus aureus, ceftazidime- or imipenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, and extended-spectrum beta-lactamase-producing Gram-negative bacilli. All patients received empirical antibiotic treatment at ICU admission. Univariate and multivariate analyses were used to determine variables associated with MDR bacteria and variables associated with ICU mortality.

RESULTS

A total of 857 patients were included, and 304 bacteria were isolated (>/=10 cfu/mL) in 260 patients (30%), including 75 MDR bacteria (24%) in 69 patients (8%). When patients with MDR bacteria were compared with patients without MDR bacteria, previous antimicrobial treatment (odds ratio [OR], 2.4; 95% confidence interval [95% CI], 1.2-4.7; p = .013) and previous intubation (OR, 31; 95% CI, 12-82; p < .001) were independently associated with MDR bacteria. When patients with bacteria other than MDR or patients with no bacteria were used as a reference group, these risk factors were still independently associated with MDR bacteria. Although ICU mortality rate was higher in patients with MDR bacteria than in patients without MDR bacteria (44% vs. 25%; p = .001; OR, 2.3; 95% CI, 1.4-3.8), MDR bacteria were not independently associated with ICU mortality. Inappropriate initial antibiotic treatment (88% vs. 5%; p = <.001; OR, 6.7; 95% CI, 3.8-12) and ventilator-associated pneumonia (23% vs. 5%; p = <.001; OR, 1.3; 95% CI, 1-1.8) rates were significantly higher in patients with MDR bacteria than in patients with bacteria other than MDR. Inappropriate initial antibiotic treatment was independently associated with increased ICU mortality (OR, 7.1; 95% CI, 1.9-30; p = .003).

CONCLUSION

MDR bacteria are common in patients with acute exacerbation of chronic obstructive pulmonary disease requiring intubation and mechanical ventilation. Previous antimicrobial treatment and previous intubation are independent risk factors for MDR bacteria. Although MDR bacteria are not independently associated with ICU mortality, inappropriate initial antibiotic treatment is an independent risk factor for ICU mortality in these patients. Further studies are needed to determine whether broad-spectrum antibiotic treatment is cost-effective in these patients.

Un cas de neuropathie mimant un syndrome de Guillain-Barré après une intoxication à l’arsenic

INTRODUCTION

Chronic arsenic toxicity is a global health problem affecting millions of people. Acute arsenic poisoning is less frequent and it is most often lethal. Therefore, its consequences are not well known, more precisely its neurological consequences.

OBSERVATION

We report a case of Guillain-Barré-like syndrome and encephalopathy after acute arsenical poisoning in a 50 year-old man. After 4 month follow-up, the improvement was slow and limited with persistent motor and proprioceptive deficits.

DISCUSSION

The most frequent neurological complication induced by acute arsenical poisoning is a distal, symmetrical, sensory, axonal polyneuropathy. Yet the clinical course and the electrophysiological findings may also suggest a Guillain-Barré like syndrome. Moreover, the chelating is not very effective on the neurological complications.

CONCLUSION

Any discrepancies in the clinical course of a Guillain-Barré syndrome shall lead to reconsider the diagnosis. The association of gastro-intestinal disorders, skin lesions, and encephalopathy and mood disorders leads to discuss intoxication with heavy metal and more precisely with arsenic. Moreover, the chelating is not very effective on the neurological complications.

Impact of ventilator-associated pneumonia on outcome in patients with COPD

PURPOSES

The aim of this study was to determine the impact of ventilator-associated pneumonia (VAP) on outcome in patients with COPD.

METHODS

Prospective, observational, case-control study conducted in a 30-bed ICU during a 5-year period. All COPD patients who required intubation and mechanical ventilation (MV) for > 48 h were eligible. VAP diagnosis was based on clinical, radiographic, and quantitative microbiologic criteria. Patients with unconfirmed VAP were excluded, as well as patients with ventilator-associated tracheobronchitis without subsequent VAP. Matching (1:1) criteria included MV duration before VAP occurrence, age +/- 5 years, simplified acute physiology score II on ICU admission +/- 5, and ICU admission category. Variables associated with ICU mortality were determined using univariate and multivariate analyses.

RESULTS

A total of 1,241 patients were eligible; 181 patients (14%) were excluded, including 133 patients for VAT and 48 patients for unconfirmed VAP. VAP developed in 77 patients (6%), and all were successfully matched. Pseudomonas aeruginosa was the most frequently isolated bacteria (31%). ICU mortality rate (64% vs 28%), duration of MV (24 +/- 15 d vs 13 +/- 11 d [+/- SD]), and ICU stay (26 +/- 17 d vs 15 +/- 13 d) were significantly (< 0.001) higher in case patients than in control patients. VAP was the only variable independently associated with ICU mortality (odds ratio [OR], 7.7; 95% confidence interval [CI], 3.2 to 18.6; p < 0.001). In VAP patients who received corticosteroids during their ICU stay compared with those who did not receive corticosteroids, mortality rate (50% vs 82%; OR, 1.8; 95% CI, 1.2 to 2.7; p = 0.002), duration of MV (21 +/- 14 d vs 27 +/- 16 d, p = 0.043), and ICU stay (22 +/- 16 d vs 31 +/- 18 d, p = 0.006) were significantly lower.

CONCLUSION

VAP is associated with increased mortality rates and longer duration of MV and ICU stay in COPD patients.

Effect of ventilator-associated tracheobronchitis on outcome in patients without chronic respiratory failure: a case-control study

Introduction

Our objective was to determine the effect of ventilator-associated tracheobronchitis (VAT) on outcome in patients without chronic respiratory failure.

Methods

This was a retrospective observational matched study, conducted in a 30-bed intensive care unit (ICU). All immunocompetent, nontrauma, ventilated patients without chronic respiratory failure admitted over a 6.5-year period were included. Data were collected prospectively. Patients with nosocomial pneumonia, either before or after VAT, were excluded. Only first episodes of VAT occurring more than 48 hours after initiation of mechanical ventilation were studied. Six criteria were used to match cases with controls, including duration of mechanical ventilation before VAT. Cases were compared with controls using McNemar's test and Wilcoxon signed-rank test for qualitative and quantitative variables, respectively. Variables associated with a duration of mechanical ventilation longer than median were identified using univariate and multivariate analyses.

Results

Using the six criteria, it was possible to match 55 (87%) of the VAT patients (cases) with non-VAT patients (controls). Pseudomonas aeruginosa was the most frequently isolated bacteria (34%). Although mortality rates were similar between cases and controls (29% versus 36%; P = 0.29), the median duration of mechanical ventilation (17 days [range 3–95 days] versus 8 [3–61 days]; P < 0.001) and ICU stay (24 days [range 5–95 days] versus 12 [4–74] days; P < 0.001) were longer in cases than in controls. Renal failure (odds ratio [OR] = 4.9, 95% confidence interval [CI] = 1.6–14.6; P = 0.004), tracheostomy (OR = 4, 95% CI = 1.1–14.5; P = 0.032), and VAT (OR = 3.5, 95% CI = 1.5–8.3; P = 0.004) were independently associated with duration of mechanical ventilation longer than median.

Conclusion

VAT is associated with longer durations of mechanical ventilation and ICU stay in patients not suffering from chronic respiratory failure.

First-generation fluoroquinolone use and subsequent emergence of multiple drug-resistant bacteria in the intensive care unit

OBJECTIVE

The objective of this study was to determine the relationship between fluoroquinolone (FQ) use and subsequent emergence of multiple drug-resistant bacteria (MRB) in the intensive care unit (ICU).

DESIGN

The authors conducted a prospective observational cohort study and a case control study.

SETTING

The study was conducted in a 30-bed ICU.

METHODS

All immunocompetent patients hospitalized for >48 hrs who did not receive antibiotics before ICU admission were eligible during a 15-month period. Routine MRB screening was performed at ICU admission and weekly thereafter. This screening included tracheal aspirate and nasal, anal, and axilla swabs. Univariate and multivariate analyses were used to determine risk factors for MRB emergence in the ICU. In addition, a case control study was performed to determine whether FQ use is associated with subsequent emergence of MRB.

RESULTS

Two hundred thirty-nine patients were included; 108 ICU-acquired MRB were isolated in 77 patients. FQ use and longer duration of antibiotic treatment were identified as independent risk factors for MRB occurrence (odds ratio [95% confidence interval [CI] = 3.3 [1.7-6.5], 1.1 [1.0-1.2]; p < .001; respectively). One hundred thirty-five (56%) patients received FQ; matching was successful for 72 (53%) of them. Number of MRB (40 vs. 15 per 1,000 ICU days; p = .019) and percentage of patients with MRB (40% vs. 22%; OR [95% CI] = 1.5 [1.0-2.4]; p = .028) were significantly higher in cases than in controls. Although methicillin-resistant Staphylococcus aureus (26% vs. 12%; OR [95% CI] = 1.6 [.6-2.9]; p = .028) and extending-spectrum beta-lactamase-producing Gram-negative bacilli (11% vs. 1%; OR [95% CI] = 4.7 [0.7-30.2]; p = .017) rates were higher in cases than in controls, ceftazidime or imipenem-resistant Pseudomonas aeruginosa (15% vs. 8%), Acinetobacter baumannii (1% vs. 5%), and Stenotrophomonas maltophilia (2% vs. 1%) rates were similar (p > .05) in case and control patients.

CONCLUSION

FQ use and longer duration of antibiotic treatment are independently associated with MRB emergence. Reducing antimicrobial treatment duration and restricting FQ use could be suggested to control MRB spread in the ICU.

Outcomes of ventilated COPD patients with nosocomial tracheobronchitis: a case-control study

BACKGROUND

The aim of this study was to determine the impact of nosocomial tracheobronchitis (NTB) related to new bacteria on the outcome in patients with chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

A prospective observational case-control study was conducted in medical COPD patients requiring intubation and mechanical ventilation for more than 48 hours. Patients with nosocomial pneumonia were excluded. Six matching criteria were used, including the duration of mechanical ventilation before NTB occurrence.

RESULTS

81 matched case-control pairs were studied. Although the mortality rate was similar (40% vs 34%; p = 0.48), median duration of mechanical ventilation (20 vs 12 days; p = 0.015) and intensive care unit (ICU) stay (25 vs 18 days; p = 0.022) were higher in cases than in controls. NTB was independently associated with a longer than median period of mechanical ventilation among case and control patients (OR = 4.7 [95%CI = 2-10.9]; p < 0.001). In cases with appropriate antibiotic treatment compared with those who did not receive antibiotics, a shorter median duration of mechanical ventilation (12 vs 23 days; p = 0.006) and ICU stay (16 vs 29 days; p = 0.029) were observed.

CONCLUSION

NTB is associated with an increased duration of mechanical ventilation and ICU stays. Further studies are required to determine whether antibiotics could improve the outcome of patients with NTB.

Fatal streptococcal necrotizing fasciitis as a complication of axillary brachial plexus block

A 74-yr-old diabetic woman developed necrotizing fasciitis of the right upper limb after axillary brachial plexus block for carpal tunnel decompression. Clinical signs included oedema, diffuse swelling and bullae; rapidly followed by toxic shock syndrome and multiorgan failure. The patient died 48 h after hospital admission, despite broad-spectrum antibiotics, surgical treatment and supportive measures for the management of shock and multiorgan failure. Cultures yielded group A Streptococcus. Delay in antibiotic and surgical treatment probably affected the outcome. Early diagnosis and treatment are essential to improve the outcome of streptococcal necrotizing fasciitis.

[Early and late nosocomial broncho-pulmonary diseases in intensive care. Comparative study of risk factors and of causing bacteria]

OBJECTIVES

Determine the risk factors and germs responsible for early-onset (E) and late-onset (L) nosocomial broncho-pulmonary infections (NBPI), in order to improve preventive strategies and the choice of initial antibiotherapy.

METHODS

An observational prospective study conducted in an intensive care unit of 30 beds, from March 1993 to September 1999. The patients presenting with an ENBPI and those with an LNBPI were compared with patients without NBPI using univariate and then multivariate analysis.

RESULTS

517 (14%) of early-onset NBPI were diagnosed, but the majority of NBPI were late-onset (87%). Multiresistant bacteria predominated. The similarity in the germs responsible for the early and late onset forms of NBPI was probably related to the large number of patients transferred from other departments (82%) and having already received antibiotics before their admission to the intensive care unit (49%). Multivariate analysis identified anti-ulcer and long term corticosteroid treatments as common risk factors for early and late onset forms of NBPI, digestive failure, tracheotomy and kidney failure as risk factors for ENBPI and the number of antibiotics used in intensive care and the duration of mechanical ventilation as factors of risk for LNBPI.

CONCLUSION

The limited use of antibiotics and anti-ulcer agents could improve the prevention of early and late onset forms of NBPI. The distinction in intensive care between the two forms of NBPI must be emphasized by the notion of prior hospitalization.

[Gastric conservation in severe caustic lesions of the digestive tract: is it legitimate?]

OBJECTIVE

To evaluate advantages and drawbacks of a controlled conservative management of patients with severe gastric caustic injuries.

METHODS

Among 40 patients with severe caustic gastric burns (> IIb), 28 with stade III lesions (mosaic necrosis: n = 10, extensive or circumferential necrosis: n = 18) were managed prospectively from 1990 to 1998. Twenty-two patients had associated stage III oesophageal lesions and 6 had stage III duodenal lesions. All patients were followed up by daily surgical examination. Total gastrectomy with esophageal exclusion or stripping was performed in case of perforation.

RESULTS

Five immediate and 7 secondary total gastrectomies, two associated esophagectomies and two jejunal resections were performed. Mortality rate was 18% (5/28). Sixteen gastric preservations (60%) were achieved, including 7 complete and 9 partial because of gastric stricture. Eighteen esophagoplasties for oesophageal strictures or after gastrectomy were performed without mortality.

CONCLUSION

Stage III caustic injuries of the stomach, when they are not immediately life-threatening, do not systematically require total gastrectomy. A strict conservative attitude can be done with significant morbidity and acceptable mortality and significantly raises the numbers of preserved stomach.

Nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome

The aim of this study was to determine the incidence, the organisms responsible for and the impact on outcome of nosocomial tracheobronchitis (NTB) in the intensive care unit (ICU). This prospective observational cohort study was conducted in a 30-bed medical/surgical ICU over a period of 6.5 yrs. All patients ventilated for >48 h were eligible. Patients with nosocomial pneumonia (NP) without prior NTB were excluded. Patients with first episodes of NTB were compared with those without NTB by univariate analysis. The study diagnosed 201 (10.6%) cases of NTB. Pseudomonas aeruginosa was the most common bacteria. NP rates were similar in patients with NTB compared with patients without NTB. Even in the absence of subsequent NP, NTB was associated with a significantly higher length of ICU stay and duration of mechanical ventilation in both surgical and medical populations. Mortality rates were similar in NTB patients without subsequent NP compared with patients without NTB. Antimicrobial treatment in NTB patients was associated with a trend to a better outcome. Nosocomial tracheobronchitis is common in mechanically ventilated intensive care unit patients. In this population, nosocomial tracheobronchitis was associated with longer durations of intensive care unit stay and mechanical ventilation. Further studies are needed to determine the impact of antibiotics on outcomes of patients with nosocomial tracheobronchitis.

Dewetting of thin-film polymers

In this paper we present a theoretical model for the dewetting of ultrathin polymer films. Assuming that the shear-thinning properties of these films can be described by a Cross-type constitutive equation, we analyze the front morphology of the dewetting film, and characterize the time evolution of the dry region radius, and of the rim height. Different regimes of growth are expected, depending on the initial film thickness, and on the power-law index involved in the constitutive equation. In the thin-films regime, the dry radius and the rim height obey power-law time dependences. We then compare our predictions with the experimental results obtained by Debrégeas et al. [Phys. Rev. Lett. 75, 3886 (1995)] and by Reiter [Phys. Rev. Lett. 87, 186101 (2001)].

Dewetting of thin polymer films near the glass transition

Dewetting of ultrathin polymer films near the glass transition exhibits unexpected front morphologies [G. Reiter, Phys. Rev. Lett. 87, 186101 (2001)]. Here, we present the first theoretical attempt to understand these features, focusing on the shear-thinning behavior of these films. We analyze the profile of the dewetting film, and characterize the time evolution of the dry region radius, R(d)(t), and of the rim height, h(m)(t). After a transient time, depending on the initial thickness, h(m)(t) grows like square root[t] while R(d)(t) increases like exp(square root[t]). Different regimes of growth are expected, depending on the initial film thickness and experimental time range.

Aerosolized iloprost in CREST syndrome related pulmonary hypertension

OBJECTIVE

To assess the outcome of patients with CREST syndrome associated severe pulmonary hypertension treated by aerosolized iloprost in a noncomparative study.

METHODS

Five patients with CREST syndrome associated severe pulmonary hypertension were treated with 100 microg/day of aerosolized iloprost. New York Heart Association functional class and exercise tolerance (6 min walk test) were assessed at baseline, after one month, and then every 6 months. A right heart catheterization was performed at baseline in all but one patient. Systolic pulmonary artery pressure (PAP) was measured with Doppler echocardiography after one month and every 6 months.

RESULTS

The mean followup was 13.2 +/- 8.8 months (median 6, range 6-24). Subjective quality of life improved in all patients. NYHA functional class decreased from Class III to II in 3 patients, from Class III to I in one patient, and from Class IV to III in one patient. At 6 months, the distance walked in 6 min had increased from 352 +/- 48 to 437 +/- 56 m (p = 0.06). At one month the mean systolic PAP was 58 +/- 13 vs 81 +/- 9 mm Hg at baseline (p = 0.04). At 6 months the mean systolic PAP was 57 +/- 13 mm Hg (p = 0.06). The improvement of both clinical and hemodynamic status was maintained in the 2 patients treated for 2 years. Neither adverse effects nor need to increase the daily dose of iloprost were observed. One patient died of right heart failure and one patient did not experience any improvement of exercise tolerance and hemodynamics.

CONCLUSION

Aerosolized iloprost might be potentially useful as treatment for CREST syndrome associated pulmonary hypertension. However, patients who could benefit from this treatment will probably have to undergo careful criteria selection.

Camel (camelus dromedarius) milk PP3: evidence for an insertion in the amino-terminal sequence of the camel milk whey protein

The camel (camelus dromedarius) milk proteose peptone 3 (PP3) was purified successively by size exclusion fast protein liquid chromatography and reversed phase high performance liquid chromatography and then characterized by amino acid residue composition determination and chemical microsequencing after CNBr or trypsin cleavages. In comparison with the previously reported structure of camel milk whey protein, the camel PP3 contains an insertion in the N-terminal region which has approximately 24 residues, whereas the remaining C-terminal regions of these two homologous proteins are essentially identical. The camel PP3 seems to contain a potential O-glycosylation site localized in this insertion and 2 or 3 phosphorylated serine residues. PP3 belongs to the glycosylation-dependent cell adhesion molecule 1 (GlyCAM-1) family and could therefore play an immunological role in the camel or its suckling young.

Balance between proinflammatory cytokines and their inhibitors in bronchial lavage from patients with status asthmaticus

Status asthmaticus (SA) is an acute respiratory failure combining an acute bronchospastic reaction with a severe airway inflammation. We previously reported an important influx of neutrophils and an increased secretion of interleukin-8 (IL-8) in patients with SA. The aim of this prospective study was to evaluate in bronchial lavage (BL) of patients with SA (n = 9) under mechanical ventilation (MV) the concentrations of cytokines and related mediators which have the ability to modulate inflammation, either proinflammatory (interleukin-1beta [IL-1beta], IL-6, tumor necrosis factor-alpha [TNF-alpha]), or anti-inflammatory mediators (IL-10, transforming growth factor-beta1 [TGF-beta1]), interleukin-1 receptor antagonist [IL-1Ra], soluble TNF receptor I and II [sTNFRI and II]). To determine the relative importance of both pro- and anti-inflammatory mediators, the net inflammatory activity was analyzed by the capacity of BL fluids (BLF) to increase intercellular adhesion molecule-1 (ICAM-1) expression in the human lung A549 epithelial cell line. These data were compared with those obtained from patients who required MV without respiratory disease (V, n = 4), controlled asthma (A, n = 11), and nonsmoking healthy volunteers (C, n = 8). Levels of IL-1, IL-6, TNF-alpha, and of the active form of TGF-beta1 were significantly higher in SA compared with the other groups. The concentrations of IL-1Ra, IL-10, the latent form of TGF-beta1, and of the sTNFRI and II were not significantly different between SA and V, albeit higher in SA than in A and C. The ratio between IL-1Ra and IL-1beta was significantly higher in patients with SA compared with the other groups, whereas there was no difference for the ratio between both types of sTNFR and TNF-alpha. Despite a marked increase of anti-inflammatory mediators in BL from patients with SA, the net inflammatory activity was found to be proinflammatory and mainly due to the presence of bioactive IL-1beta (79% inhibition of ICAM-1 expression with anti-IL-1beta antibodies) and to a lesser extent TNF-alpha (32% inhibition with anti-TNF-alpha antibodies).

Bronchial neutrophilia in patients with noninfectious status asthmaticus

Cellular events that occur in status asthmaticus (SA) remain poorly investigated. Autopsy studies frequently emphasized about the presence of eosinophils in bronchial airway wall, whereas recent studies reported increased number of neutrophils in patients dying of sudden-onset fatal asthma. Mucus plugs occluding the bronchial lumen are almost constant features during SA. Bronchial lavage (BL) may be useful to remove mucus plugs in cases of atelectasis and/or refractory SA. We investigated the contribution of different cell types and cellular mediators (neutrophil elastase, eosinophil cationic protein [ECP], histamine, interleukin-8 [IL-8]) to the pathogenesis of SA. We studied 16 BL from eight patients undergoing mechanical ventilation (MV) for SA (time interval from onset of MV = Day 0 to Day 11), four BL from patients undergoing MV without preexisting respiratory disease (V), 11 BL from patients with stable asthma (A) and eight BL from healthy controls (C). SA exhibited higher number and percentage of neutrophils (81.5 +/- 4.5%) than V (44.3 +/- 12.2) (p < 0.05), A (6.9 +/- 2.7) and C (9.5 +/- 3.8) (p < 0.0001), and higher number of eosinophils than V, A, and C (p < 0.01). Neutrophil elastase, ECP, and IL-8 levels were dramatically increased in SA. Histamine was higher in SA than in C and V (p < 0.05). Bronchial neutrophilia was not related to concomitant bacterial infection as bacteriological cultures were positive in only three BL. Eosinophils, mast cells and histamine were higher in BL performed within the first 48 h of MV (p < 0.05) than in BL performed later on. Our results indicate that bronchial inflammation in SA differs from bronchial inflammation in mild asthma. Persistent bronchial neutrophilia is associated with increased eosinophils and mast cells in the early phase of SA. Neutrophils may result in tissue damage and participate to the shedding of the epithelium in SA.

[Fibroscopic bronchoscopy in intensive care]

The field of application for fibreoptic bronchoscopy (FB) in the intensive care unit has been extended since the generalised introduction of fibroscopes of 4.9 mm in diameter (previously called paediatric fibroscopes). Paediatric and neonatal intensive care units have benefited from the availability in the market of these small endoscopes for 3.5 and 2.2 mm. The protected brush and alveolar lavage (LBA) enables a specific diagnosis to be made in bacterial pneumonia acquired during ventilation. The sensitivity of these techniques however is insufficient to be able to recommend their use as routine. Inversely, the FB with LBA remains a fundamental feature in the diagnosis of opportunistic infections in pneumonia. For the treatment of atelectasis, FB is overall not superior to physiotherapy. Aspiration with a fibroscope can however be recommended straight away in cases of alteration in blood gasses if cough is ineffective or if the atelectasis complicates endobronchial bleeding. The FB enables problems with difficult intubation to be resolved or for the positioning of probes. The conditions under which this is performed are more delicate than in routine anaesthesia (in cases of urgency, hypoxia). In the case of respiratory burns, tracheobronchial fracture and post intubation stenosis, FB enables both the diagnosis to be established and the level at which the lesion occurs. In paediatric intensive care, a fibroscope of 3.5 mm is used for performing LBA (opportunistic pneumonias), difficult intubation (facial dysmorphia), endoscopic diagnoses, in particular where there is a suspicion of an endobronchial foreign body, the assessment of unexplained dyspnoea (tracheal stenosis by vascular ring) and obstructive lesions. In neonatal intensive care, a fibroscope of 2.2 mm is used for difficult intubation and the localisation of lesions induced by ventilation.

Quality of life 6 months after intensive care: results of a prospective multicenter study using a generic health status scale and a satisfaction scale

OBJECTIVE

To assess the quality of life of intensive care survivors 6 months after discharge.

DESIGN

Multicenter prospective study.

SETTING

Medical-surgical intensive care units (ICUs) of four French university hospitals.

PATIENTS

Among the 589 patients admitted to the four ICUs between 1 January and 31 March 1989, 329 were investigated.

MEASUREMENTS AND RESULTS

A generic scale assessing health-related quality of life, the Nottingham Health Profile (NHP), a satisfaction scale, the Perceived Quality of Life scale (PQOL) and a questionnaire on professional status were sent by mail 6 months after discharge. Data concerning age, severity of acute illness (assessed by the Simplified Acute Physiology Score) and main diagnosis were recorded. A total of 223 questionnaires (67.8 %) were analysable. The professional status remained unchanged in 79.7% of the patients, despite a significant (p < 0.01) increase (15.3 vs 22.1%) in sick leave. Quality of life, assessed with NHP, was fair (50th percentile = 0.73 on a 0 to 1 scale), whereas satisfaction measured by PQOL was lower (50th percentile = 0.61). Both scales correlated well (z = 9.853; p = 0.0001) but with a large dispersion. The NHP scale showed a severe reduction in energy, sleep and emotional reactions, whereas social isolation, pain and physical handicap were infrequent. Family support was rated with the PQOL score as very good, whereas dissatisfaction concerning recreational and professional activities was expressed. Subsequent sick leave was associated with a poor quality of life (p < 0.05). Quality of life was mainly a function of the diagnosis, not of age and severity of illness: patients admitted for suicide attempt or chronic obstructive pulmonary disease fared poorly.

CONCLUSIONS

Quality of life measured with a health-related quality of life scale and a satisfaction scale 6 months after an ICU stay depended on the admission diagnosis. Different dimensions of quality of life were variably affected.

[Pulmonary artery hypertension caused by carcinomatous lymphangitis ]

A 58 year old man without significant past medical history developed a cough and effort dyspnoea of a few weeks. A computed tomographic scan showed bilateral interstitial disease with linear thickening of the septa and also a ground glass effect in the lung parenchyma. Echocardiography and right heart catheterisation confirmed the existence of pulmonary arterial hypertension (mean pulmonary artery pressure 45 mmHg) with a normal pulmonary artery wedge pressure (12 mmHg). There was a rapidly progressive worsening with an unfavourable outcome. A necropsy examination showed the development of bilateral pulmonary lymphangitis carcinomatosis secondary to an adenocarcinoma of the head of the pancreas. There was no metastatic emboli of the vessels but there was lymphatic infiltration and the physiopathological hypothesis suggested a compression of the pulmonary arterial vessels secondary to lymphatic obstruction.

The Logistic Organ Dysfunction system. A new way to assess organ dysfunction in the intensive care unit. ICU Scoring Group

OBJECTIVE

To develop an objective method for assessing organ dysfunction among intensive care unit (ICU) patients on the first day of the ICU stay.

DESIGN AND SETTING

Physiological variables defined dysfunction in 6 organ systems. Logistic regression techniques were used to determine severity levels and relative weights for the Logistic Organ Dysfunction (LOD) score and for conversion of the LOD score to a probability of mortality.

PATIENTS

A total of 13 152 consecutive admission to 137 adult medical/surgical ICUs in 12 countries from the European/North American Study of Severity Systems.

OUTCOME MEASURES

Patient vital status at hospital discharge.

RESULTS

The LOD System identified from 1 to 3 levels of organ dysfunction for 6 organ systems: neurologic, cardiovascular, renal, pulmonary, hematologic, and hepatic. From 1 to 5 LOD points were assigned to the levels of severity, and the resulting LOD scores ranged from 0 to 22 points. Model calibration was very good in the developmental and validation samples (P=.21 and P=.50, respectively), as was model discrimination (area under the receiver operating characteristic curves of 0.843 and 0.850, respectively).

CONCLUSION

The LOD System provides an objective tool for assessing severity levels for organ dysfunction in the ICU, a critical component in the conduct of clinical trials. Neurologic, cardiovascular, and renal dysfunction were the most severe organ dysfunctions, followed by pulmonary and hematologic dysfunction, with hepatic dysfunction the least severe. The LOD System takes into account both the relative severity among organ systems and the degree of severity within an organ system.

The Logistic Organ Dysfunction system. A new way to assess organ dysfunction in the intensive care unit. ICU Scoring Group

OBJECTIVE

To develop an objective method for assessing organ dysfunction among intensive care unit (ICU) patients on the first day of the ICU stay.

DESIGN AND SETTING

Physiological variables defined dysfunction in 6 organ systems. Logistic regression techniques were used to determine severity levels and relative weights for the Logistic Organ Dysfunction (LOD) score and for conversion of the LOD score to a probability of mortality.

PATIENTS

A total of 13 152 consecutive admission to 137 adult medical/surgical ICUs in 12 countries from the European/North American Study of Severity Systems.

OUTCOME MEASURES

Patient vital status at hospital discharge.

RESULTS

The LOD System identified from 1 to 3 levels of organ dysfunction for 6 organ systems: neurologic, cardiovascular, renal, pulmonary, hematologic, and hepatic. From 1 to 5 LOD points were assigned to the levels of severity, and the resulting LOD scores ranged from 0 to 22 points. Model calibration was very good in the developmental and validation samples (P=.21 and P=.50, respectively), as was model discrimination (area under the receiver operating characteristic curves of 0.843 and 0.850, respectively).

CONCLUSION

The LOD System provides an objective tool for assessing severity levels for organ dysfunction in the ICU, a critical component in the conduct of clinical trials. Neurologic, cardiovascular, and renal dysfunction were the most severe organ dysfunctions, followed by pulmonary and hematologic dysfunction, with hepatic dysfunction the least severe. The LOD System takes into account both the relative severity among organ systems and the degree of severity within an organ system.

Pulmonary hypertension associated with POEMS syndrome

Pulmonary hypertension (PH) is an uncommon but lethal complication of some connective tissue diseases. We describe two cases of PH associated with plasma cell dyscrasia, with polyneuropathy (P), organomegaly (O), endocrinopathy (E), M protein (P) and skin changes (S) described as POEMS syndrome. Two patients, one female and one male, were hospitalized for dyspnoea. Both had a history of POEMS syndrome a few years previously. PH was diagnosed from cardiac catherization, and complete investigations did not reveal other underlying disease. In Case No. 1, mean pulmonary artery pressure was 40 mmHg and pulmonary vascular resistance was 775 dyne x s x cm-5 x m2, with a significant reversibility to vasodilators. Nifedipine and fluindrone treatment was initiated. The patient was still alive 18 months later. In Case No. 2, mean pulmonary artery pressure was 28 mmHg and pulmonary vascular resistance was 243 dyne x s x cm-5x m2, with a slight reversibility to vasodilators. The patient died 6 months later. Our observations suggest that pulmonary hypertension (PH) may be associated with the POEMS syndrome, and that patients suffering from the POEMS syndrome and dyspnoea should be tested for PH.

Effect of dialysis on exogenous dopamine in haemodialysed critically ill patients

A sensitive and specific high performance liquid chromatographic method (HPLC) was developed for measuring dopamine (DA) in human plasma samples. Dihydroxybenzylamine (DHBA) was employed as an internal standard. Following solvent extraction and separation on a C18 ion-pairing reversed phase column, the drug was detected by a fluorescence detector with excitation and emission wavelengths of 233 nm and 345 nm, respectively. This method was employed to evaluate dopamine dialysability in seven haemodialysed patients under continuous infusion of a positive inotropic agent. Results showed a high dialyser extraction ratio averaging 38.3%, but a low dialysis clearance of 67 ml/min. The fraction removed by dialysis is 2.5%. We concluded that haemodialysis has little effect on dopamine blood levels, and consequently on drug pharmacokinetics, when the drug is delivered to haemodialysed patients under intravenous infusion.

Diagnostic tests for pneumonia in ventilated patients: prospective evaluation of diagnostic accuracy using histology as a diagnostic gold standard

The diagnostic accuracy of protected-specimen brush (PSB), bronchoalveolar lavage (BAL), and endotracheal aspirates (EA) was prospectively evaluated in a series of 28 mechanically ventilated patients (MV patients) who died within 3 d of the bronchoscopic procedure, using postmortem lung examination as the gold standard for establishing the diagnosis of pneumonia. The entire fixed lungs were carefully dissected along the bronchovascular axes and each segment was cut into 5- to 10-mm thick sections, enabling gross examination of the lung parenchyma. Two tissue blocks were taken from each segment, including grossly abnormal areas whenever present. In several cases, two peripheral (subpleural) lung-tissue blocks were also taken from each lobe prior to systematic dissection of the lungs. Quantitative cultures (QC) and direct cytologic and microbiologic examination (DE) was performed on respiratory samples obtained within 72 h before death. Values of 10(3) cfu/ml of Ringer's solution, 10(4) cfu/ml of retrieved fluid, and 10(6) cfu/ml of respiratory secretions were used as cutoff points for quantitative PSB, BAL, and EA cultures, respectively. The main findings in this study were that: (1) Pneumonia was present in 67% of the patients. (2) Histologic lesions of pneumonia were mainly bilateral and predominated in the dependent lung segments. (3) Coexistence of a variety of noninfectious processes was a common finding in patients with pneumonia. (4) In several cases pneumonia was absent from peripheral lung samples while more central areas of the same segment displayed typical foci of pneumonia. (5) The sensitivity of quantitative cultures was 55%, 57%, and 47% for EA, PSB, and BAL, respectively, and the specificity was 85%, 88%, and 100%, respectively. Reducing the diagnostic threshold of EA to 10(5) cfu/ml of respiratory secretions instead of 10(6) cfu/ml resulted in a sensitivity of 63.1% and a specificity of 75% for EA. The sensitivity of direct examination (DE) was 50%, 47%, and 47%, respectively, and the specificity was 75%, 88%, and 87%. (6) The presence of intracellular organisms (ICO) in BAL had a 36.8% sensitivity and 100% specificity in establishing the diagnosis of pneumonia regardless of their percentage. (7) Although 15 patients (53%) were not on antibiotics or were off antibiotics for more than 48 h before testing, no relationship could be established between the patients' antibiotic status and the result of any diagnostic test. By using a recommended methodology for respiratory sampling techniques together with complete postmortem lung examination as a diagnostic "gold standard," this study provides a realistic insight into the diagnostic values of EA, PSB, and BAL in MV patients with suspected pneumonia.