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C Brun-Buisson

Publications and source records attributed to C Brun-Buisson.

At least 91 records · Page 5Linked to original sources
PubMed1995

Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis.

OBJECTIVE: To examine the incidence, risk factors, and outcome of severe sepsis in intensive care unit (ICU) patients. DESIGN AND SETTING: Inception cohort study from a 2-month prospective survey of 11,828 consecutive admissions to 170 adult ICUs of public hospitals in France. PATIENTS: Patients meeting clinical criteria for severe sepsis were included and classified as having documented infection (ie, documented severe sepsis, n = 742), or a clinical diagnosis of infection without microbiological documentation (ie, culture-negative severe sepsis, n = 310). MAIN OUTCOME MEASURES: Hospital and 28-day mortality after severe sepsis. RESULTS: Clinically suspected sepsis and confirmed severe sepsis occurred in 9.0 (95% confidence interval [CI], 8.5 to 9.5) and 6.3 (95% CI, 5.8 to 6.7) of 100 ICU admissions, respectively. The 28-day mortality was 56% (95% CI, 52% to 60%) in patients with severe sepsis, and 60% (95% CI, 55% to 66%) in those with culture-negative severe sepsis. Major determinants of both early (< 3 days) and secondary deaths in the whole cohort were the Simplified Acute Physiology Score (SAPS) II and the number of acute organ system failures. Other risk factors for early death included a low arterial blood pH (< 7.33) (P < .001) and shock (P = .03), whereas secondary deaths were associated with the admission category (P < .001), a rapidly or ultimately fatal underlying disease (P < .001), a preexisting liver (P = .01) or cardiovascular (P = .002) insufficiency, hypothermia (P = .02), thrombocytopenia (P = .01), and multiple sources of infection (P = .02). In patients with documented sepsis, bacteremia was associated with early mortality (P = .03). CONCLUSIONS: Only three of four patients presenting with clinically suspected severe sepsis have documented infection. However, patients with clinically suspected sepsis but without microbiological documentation and patients with documented infection share common risk factors and are at similarly high risk of death. In addition to the severity of illness score, acute organ failures and the characteristics of underlying diseases should be accounted for in stratification of patients and outcome analyses.

Adult↗
PubMed1995

Frequency of bacteremia associated with transesophageal echocardiography in intensive care unit patients: a prospective study of 139 patients.

OBJECTIVE: To determine the occurrence rate of bacteremia associated with transesophageal echocardiography in intensive care unit (ICU) patients. DESIGN: A prospective study of 139 patients undergoing transesophageal echocardiography. SETTING: The medical ICU of a tertiary referral teaching hospital. PATIENTS: One hundred thirty-nine ICU patients (mean age 58 yrs) who underwent transesophageal echocardiography. INTERVENTIONS: Blood samples were systematically drawn for aerobic and anaerobic culture at the following times: before (blood culture 1), at the end of (blood culture 2), and 30 mins after (blood culture 3) transesophageal echocardiography examinations. MEASUREMENTS AND MAIN RESULTS: The mean duration of transesophageal echocardiography was 35 mins (range 7 to 120). One hundred thirty-four patients received mechanical ventilation; 125 patients had a nasogastric tube. Fifty-one patients had one or more underlying conditions that usually justify antimicrobial prophylaxis of bacterial endocarditis before high-risk procedures. Fifty-six patients did not receive any antibiotic treatment at the time of transesophageal echocardiography. In 114 patients, the three blood cultures were negative. In six patients, transesophageal echocardiography was performed during a preexisting bacteremia. A contamination (only one positive blood culture of the three sampling times) with coagulase-negative staphylococci occurred in four patients at blood culture 1, five patients at blood culture 2, and six patients at blood culture 3. Contamination with Corynebacterium species occurred in two patients at blood culture 2. In one patient receiving cefotaxime and netilmicin, blood culture 1 was sterile and blood cultures 2 and 3 yielded coagulase-negative staphylococci. In one patient receiving no antibiotic treatment, blood culture 1 was sterile and blood cultures 2 and 3 yielded Enterococcus faecalis. None of these two patients received a specific antibiotic treatment or developed any secondary septic focus. CONCLUSIONS: The overall frequency of bacteremia induced by transesophageal echocardiography in ICU patients was 1.4% (two of 139 patients) (95% confidence interval 0.2% to 5.1%). The frequency did not differ whether patients received antibiotics before transesophageal echocardiography (one [1.2%] of 83 patients) or not (one [1.8%] of 56 patients) (p = .96). Therefore, routine antimicrobial prophylaxis does not appear justified before transesophageal echocardiography in ICU patients.

Adult↗
PubMed1995

Titration of tidal volume and induced hypercapnia in acute respiratory distress syndrome.

Mechanical ventilation may promote overdistension-induced pulmonary lesions in patients with acute respiratory distress syndrome (ARDS). The static pressure-volume (P-V) curve of the respiratory system can be used to determine the lung volume and corresponding static airway pressure at which lung compliance begins to diminish (the upper inflection point, or UIP). This fall in compliance may indicate overdistension of lung units. We prospectively studied 42 patients receiving mechanical ventilation with an FIO2 of 0.5 or more for at least 24 h. According to the Lung Injury Score (LIS), 25 patients were classified as having ARDS (LIS > 2.5), while 17 patients constituted a non-ARDS control group. The P-V curve was obtained every 2 d. Mechanical ventilation initially used standard settings (volume-control mode, a positive end-expiratory pressure [PEEP] adjusted to the lower inflection point on the P-V curve, and a tidal volume [VT] of 10 ml/kg). The end-inspiratory plateau pressure (Pplat) was compared to the UIP, and VT was lowered when the Pplat was above the UIP. In the range of lung volume studied on the P-V curves (up to 1600 ml), a UIP could be shown in only one control patient (at 23 cm H2O). By contrast, a UIP was present on the P-V curve obtained from all patients with ARDS, corresponding to a mean airway pressure of 26 +/- 6 cm H2O, a lung volume of 850 +/- 200 ml above functional residual capacity and 610 +/- 235 ml above PEEP.(ABSTRACT TRUNCATED AT 250 WORDS)

Case-Control Studies↗
PubMed1995

[Cerebral abscess disclosing tetralogy of Fallot with situs inversus in adulthood].

The authors report the case of tetralogy of Fallot (TOF) associated with situs inversus, the first description of this rare association in a previously asymptomatic adult. A 32 years old chauffeur was admitted to hospital with pyrexia and convulsions due to a left temporo-parietal cerebral abscess which had a favourable outcome. The chest X-ray and Doppler echocardiographic study showed a TOF with a high infundibular stenosis and dextrocardia. Abdominal ultrasonography confirmed a complete situs inversus. The good tolerance was attributed to the equilibrated character of the TOF. The orientation of the heart and the cono-truncal septation occur at different times during embryogenesis. However, there are genetic arguments in favour of the non-fortuitous nature of this association.

Adult↗
PubMed1994

Can topical and nonabsorbable antimicrobials prevent cross-transmission of resistant strains in ICUs?

Topical antimicrobials may complement traditional infection control measures and hasten the control of an outbreak. When a suitable nonabsorbable antimicrobial regimen can be found, its use during outbreaks caused by Enterobacteriaceae colonizing the digestive tract appears especially attractive, whether the infection occurs via primary endogenous colonization or exogenous colonization. In the latter circumstance, however, topical antimicrobials are not a substitute for isolation precautions and careful handwashing, which remain insufficiently adhered to in ICUs. Topical antimicrobials should be used as part of a global strategy in which isolation precautions remain of primary importance. It is likely, but unproven by well-designed studies, that nasal decontamination of patient carriers during outbreaks due to methicillin-resistant Staphylococcus aureus can be useful to control the outbreak. In this instance, however, skin and wound disinfection appears as an essential complementary measure, and careful attention should be given to extranasal sites of colonization with MRSA, where resistance to the topical agent can emerge. Whatever the circumstances and setting, prolonged use of topical antimicrobials during protracted outbreaks is less effective and carries a major risk of resistance to the topical agent(s) used against the outbreak strains. In such circumstances, careful microbiologic monitoring of colonization is mandatory.

Administration, Topical↗
PubMed1994

Lack of clinical benefit from subcutaneous tunnel insertion of central venous catheters in immunocompromised patients.

To assess the efficacy of subcutaneous tunneling, we randomly designated 212 central venous catheters for tunneling (107 catheters) or for standard insertion (105 catheters) in 169 immunocompromised patients. The patients who received tunneled catheters (TCs) and the patients who received nontunneled catheters (NTCs) were similar with respect to age, gender, underlying disease, incidence of leukopenic episodes, receipt of blood product transfusions or parenteral nutrition, and medical care and attendants. The life span of catheters was 112.5 +/- 9.5 days in the TC group and 119 +/- 9 days in the NTC group (P = .5). Clinically relevant bacteremia occurred in 26 cases in the TC group (0.22 episode per 100 catheter-days), a rate not significantly different from that in the NTC group (25 episodes; 0.20 episode per 100 catheter-days). Catheter-related bacteremia was documented in seven cases and non-catheter-related bacteremia in five cases. In most instances, the precise origin of the septic episode could not be determined. Cutaneous infection and bacteremia were associated with the same microorganism in two cases in each group. Since the present study failed to demonstrate any clinical benefit of subcutaneous tunneling, such a procedure is no longer performed in our hospital.

Adolescent↗
PubMed1994

Pulmonary artery catheterization in critically ill patients: a prospective analysis of outcome changes associated with catheter-prompted changes in therapy.

OBJECTIVE: To evaluate physician accuracy in predicting patients' hemodynamic profiles, associated morbidities, rates of change in therapy resulting from catheterization, and the outcome variations associated with such change before the insertion of a pulmonary artery catheter. DESIGN: Prospective, descriptive, cohort study with no interventions. SETTING: Medical intensive care unit (ICU) of a university hospital. PATIENTS: One hundred twelve catheterizations performed in 112 patients without acute myocardial infarction. In 43 cases, catheterizations were indicated because of circulatory shock that was unresponsive to two standard therapeutic measures. MEASUREMENTS AND MAIN RESULTS: Before catheterization, physicians were asked to predict the hemodynamic profile of the patients who were to be catheterized, and to provide a plan for therapy. After catheterization, each patient's chart was reviewed and compared with precatheterization predictions. Hemodynamic profiles were correctly predicted in only 56% of the cases. Information obtained from pulmonary artery catheters prompted changes in therapy in 58% of all cases and in 63% of patients in shock who were unresponsive to standard therapy. Modifications varied among hemodynamic profiles, from 33% (fluid overloaded) to 87% (hypovolemia). Complications occurred in 11 catheterizations, but only two complications required therapy (pneumothorax [n = 1] and one episode of arrhythmia). No systemic infection occurred, and all blood cultures sampled through catheters before the catheters were withdrawn were sterile. In the entire group of patients, those patients in whom catheterization induced a change in therapy and those patients in whom no change in therapy occurred had similar precatheterization characteristics and mortality rates. However, in the subgroup of patients in shock that was unresponsive to standard therapy, the mortality rate was significantly lower when the assessment of hemodynamic data led to a change in therapy (59% vs. 100%, p = .009), despite identical precatheterization characteristics. CONCLUSIONS: Prompted by assessment of pulmonary artery catheter measurements in patients with circulatory shock who were unresponsive to standard therapeutic measures, a change in therapy for these patients was associated with an improved prognosis, independent of other variables influencing outcome.

Adult↗
PubMed1994

Characterization of a hospital outbreak of imipenem-resistant Acinetobacter baumannii by phenotypic and genotypic typing methods.

During a 13-month period, 31 patients hospitalized primarily in two intensive care units (ICUs) were either colonized or infected by imipenem-resistant Acinetobacter baumannii. Typing of the isolates by three methods (antibiotyping, biotyping, and pulsed-field gel electrophoresis) revealed that two distinct strains were involved in the first 9 cases of the outbreak and that one of these strains, which had acquired a higher level of imipenem resistance as well as resistance to all aminoglycosides, accounted for 21 of 22 cases in the second part of the outbreak. ICU environmental contamination was recognized as an important reservoir of this epidemic strain. The outbreak ceased only after the ICUs were closed for complete cleaning and disinfection.

Acinetobacter↗
PubMed1994

Intravenously administered atrial natriuretic factor in patients with COPD. Effects on ventilation-perfusion relationships and pulmonary hemodynamics.

The potent pulmonary vasodilating property of atrial natriuretic factor (ANF) may alter gas exchange in patients with COPD. We examined the hemodynamic and gas exchange responses to intravenous infusion of ANF (0.01 and 0.03 ng/min/kg body weight) in eight stable patients with COPD studied during spontaneous breathing, using the inert gas elimination technique. When compared with baseline, ANF infusion was associated with a dose-dependent decrease in pulmonary artery pressure (from 27.3 +/- 2.5 to 23.9 +/- 1.8 and 20.2 +/- 1.7 mm Hg, respectively) and a dose-dependent increase in blood flow perfusing poorly ventilated and unventilated units (VA/Q < 0.1: from 5.80 +/- 2.05 to 7.25 +/- 2.5 and 12.0 +/- 5.4 percent of total blood flow, respectively; p = 0.02). However, PaO2 remained unchanged (70.2 +/- 3.6, 68.1 +/- 3.8 65.4 +/- 3.5 mm Hg, respectively) because of a significant increase in minute ventilation (VE) from 8.6 +/- 0.8 to 9.6 +/- 0.8 and 10.3 +/- 0.7 L/min (p < 0.002). Six additional COPD patients receiving intravenously administered ANF at the same dosages were studied during controlled mechanical ventilation using right heart catheterization. In these patients, pulmonary vasodilation was associated with a significant increase in venous admixture (from 12.7 +/- 2.4 to 14.4 +/- 2.9 and 17.5 +/- 3.5 percent of total blood flow, respectively; p < 0.02), and a dose-dependent reduction in arterial PO2 (from 117 +/- 17 to 110 +/- 15 and 96.4 +/- 8.8 mm Hg, respectively; p < 0.05). The present results show that ANF infusion is associated with alterations in the VA/Q relationship in patients with COPD. However, a decrease in arterial oxygenation may be prevented by an increase in VE.

Aged↗
PubMed1994

Evaluation of new diagnostic technologies: bronchoalveolar lavage and the diagnosis of ventilator-associated pneumonia.

OBJECTIVE: To present criteria to aid intensive care workers in the assessment of diagnostic technologies, using the example of bronchoalveolar lavage for the evaluation of ventilator-associated pneumonia. DATA SOURCES: MEDLINE was used to search for articles published from 1969 to the present that concerned diagnostic tests, diagnostic technology, pneumonia, and critically ill patients. STUDY SELECTION: Clinical investigations, case control studies, case series, and experimental data on the use of bronchoalveolar lavage. Studies of diagnostic technology were also included. DATA EXTRACTION: We extracted relevant data in duplicate, independently. DATA SYNTHESIS: Diagnostic technology assessment should begin by establishing the capability of the technology under ideal or laboratory conditions, followed by an exploration of the range of possible uses as well as the accuracy of the test. Bronchoalveolar lavage is a well-established technology for the diagnosis of pneumonia in immunocompromised patients. Studies of the accuracy of bronchoalveolar lavage in ventilator-dependent but nonimmunocompromised patients have shown promising diagnostic accuracy. Accuracy, however, is insufficient for dissemination of a test; an evaluation of the impact of a test on management decisions and, most importantly, on patient outcome, is required. Investigators have not addressed the full impact of bronchoalveolar lavage, and, even if the test is accurate, there are reasons to doubt whether patients will be better off if the test becomes part of routine clinical practice. CONCLUSIONS: We present guidelines for the assessment of diagnostic technology, and apply them to bronchoalveolar lavage for the evaluation of ventilator-associated pneumonia. Bronchoalveolar lavage has been studied in both the laboratory and clinical setting, and the diagnostic sensitivity and specificity of this technique are high. Further randomized trials evaluating management decisions and patient benefit would facilitate decisions regarding the appropriate dissemination of bronchoalveolar lavage.

Bronchoalveolar Lavage Fluid↗
PubMed1993

[Antibiotic treatment of septic states].

The antibiotic therapy in septic syndrome is most often empiric. Decisions and antibiotic choices should result from a careful analysis of past history and setting (hospital-acquired infections vs community acquired infections), risk factors specific to the host, and characteristics of the suspected infections focus: direct examination of body fluid specimens should be obtained rapidly to guide the empiric choice. The choice of antibiotics should conform to usual guidelines, with the aim of a rapid bactericidal effect in blood, while attempting to avoid risks of toxicity. Changes in pharmacokinetics of drugs are usual in this context, and frequent dosing is necessary. While effective antibiotic therapy is a recognized prognostic parameter, antibiotics are only one part of therapy, besides supportive therapy of failing organs, and effective drainage or surgery of the infected focus, when feasible.

Anti-Bacterial Agents↗