[Endocarditis prophylaxis: ten years later].
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Antibiotic Prophylaxis↗
Biomedical subjects
Y Mallédant
Publications and source records attributed to Y Mallédant.
[Hepatorenal syndrome: from physiopathology to treatment].
OBJECTIVES: Data synthesis on physiopathology and treatment of hepatorenal syndrome (HRS). DATA SOURCES: Data were searched in the Medline database from 1975 to 2002 using the following key-words: hepatorenal syndrome, ascite, cirrhosis and portal hypertension. DATA EXTRACTION: Publications from 1986 to 2002 were selected depending on the quality of their methodology and their pertinence. One publication from 1975 was kept. DATA SYNTHESIS: Hepatorenal syndrome is a common and severe complication of patients with advanced liver cirrhosis with ascites. It is a functional renal failure due to intense vasoconstriction of the renal circulation secondary to an intense splanchnic vasodilatation. Two types of HRS are differentiated mainly by the speed and the magnitude of the renal failure. Liver transplantation remains the best treatment but is rarely applicable because of the short survival after diagnosis. In the last few years, new therapy have been developed, vasoconstrictor drugs which mainly elicit their effects on the splanchnic circulation as vasopressin and principally its analogues ornipressine and terlipressine are effective in improving renal function and could act as bridge for liver transplantation. The place of the transjugular intrahepatic portosystemic shunt remain to be evaluated. CONCLUSION: Prognosis of patients with HRS remains poor but the pharmacologic treatment by terlipressine has improved the prognosis particularly in order to wait liver transplantation.
Hepatorenal Syndrome↗
[The measurement of end-tidal carbon dioxide (PETCO2) is not a significant parameter to monitor in patients with severe traumatic brain injury].
PURPOSE: To evaluate the agreement between end-tidal carbon dioxide (PETCO2) and arterial CO2 (PaCO2) in patients with traumatic brain injury and to document the course of the (PaCO2-PETCO2) gradient over time. METHODS: Twenty one traumatic brain injury patients (Coma Glasgow Scale < or = 8) were included in this prospective observational study over a period of six months. Simultaneous determinations of PaCO2 and PETCO2 (by infrared capnometry) were recorded. Agreement between PaCO2 and PETCO2 was determined by the statistical method described by Bland and Altman. Changes in PETCO2 over time were compared with changes in PaCO2. Factors likely to explain a gradient superior to +/- 4 mmHg were explored. RESULTS: One hundred and eleven data pairs were obtained. The bias was 5.5 mmHg with a precision of 5.1 mmHg and limits of agreement ranged from -4.5 mmHg to 15.5 mmHg. The latter exceeded the predefined limits of agreement established to determine interchangeability between methods (+/- 4 mmHg). PETCO2 and PoCO2 changed in opposite directions in 20% of 90 consecutive measurements. Only the duration of ventilation was found to be significantly associated with a gradient superior to +/- 4 mmHg. CONCLUSIONS: In this selected population of patients with severe traumatic brain injury, measurements of PETCO2 and PaCO2 are not interchangeable. Further the PoCO2-PETCO2 gradient is not stable over time and cannot predict variations of PaCO2. The use of PETCO2 instead of PaCO2 could be deleterious in patients in whom strict control of PaCO2 values is required.
Adult↗
[Early systemic antibiotic treatment for severe acute pancreatitis].
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Acute Disease↗
[Digestive hemorrhage originated elsewhere].
We report the case of splenic subcapsular haematoma, that happens to a woman after three months. Breaking and fistulation of the splenic haematoma into the gastric cavity and its subsequent evacuation made it first identify as digestive haemorrhage.
Diagnosis, Differential↗
Evidence for the need of bedside accuracy of pulse oximetry in an intensive care unit.
OBJECTIVE: To compare pulse oximetry saturation (Spo2 with arterial blood gas saturation (SaO2) obtained during clinical routine to determine the optimal lowest reliable value of SpO2 in ventilator-dependent patients before setting up a nurse-directed protocol of FIO2 titration. DESIGN: Prospective clinical study. SETTING: Surgical intensive care unit in a university hospital. PATIENTS: Thirty-three patients with a pulse oximeter probe in whom arterial blood gas was measured with a radial artery line. INTERVENTIONS: SPO2 was recorded by the nurses and compared with SaO2 obtained by blood gas analysis with a co-oximeter. Two sensors currently used in our surgical intensive care unit and connected to a monitor (HP OmniCare M1165/66A; Hewett Packard, Andover, MA) were tested. In group I, the Durensor DS 100A (Nellcor Puritan Bennett, Pleasanton, CA), a reusable sensor, was used. In group II, the Oxisensor D25L (Nellcor Puritan Bennett), a nonreusable sensor, was used. MEASUREMENTS AND MAIN RESULTS: In group 1, 64 data pairs were obtained. In this group, SaO2 ranged from 87 to 98% and SpO2 ranged from 92 to 100%. The bias was -1.90% and the limits of agreement ranged from -5.56 to 1.76%. In group 11, 47 data pairs were obtained. In this group, SaO2 ranged from 87 to 99% and SpO2 ranged from 92 to 100%. The bias was -2.49% and the limits of agreement ranged from -6.62 to 1.64%. CONCLUSIONS: In the range of SaO2 tested, regardless of the sensor used, SpO2 overestimated SaO2. Large limits of agreement were found. Based on this result, the authors concluded that before defining a nurse-directed protocol of FIO2 titration with SpO2, the material used daily must be evaluated. A minimum threshold SpO2 value of 96% in both groups I and II is more reliable to ensure SaO2 > or = 90%.
Blood Gas Analysis↗
Non steady state and steady state PKS Bayesian forecasting and vancomycin pharmacokinetics in ICU adult patients.
The pharmacokinetics of vancomycin was investigated in adult ICU patients after the first administration and at steady state. Then the predictive performance of a two-compartment Bayesian forecasting program was assessed in these patients by using population-based parameters and three non steady state vancomycin concentrations as feedback information. Finally a prospective investigation was carried out to search potential covariates. At steady state, a significant decrease (around 30%) in clearance (CL) was observed, while creatinine clearance (CLcr) was stable and a significant increase (around 30%) in volume of distribution (V(SS)) was observed. A two-fold increase in elimination half-life was found. CL was weakly correlated with CLcr at onset of therapy and at steady state. The Bayesian program tended to overpredict vancomycin peak and trough concentrations. A larger mean prediction error and a poorer precision were observed when population-based parameter estimates were used (no feedback) compared to feedback prediction, but the differences were not significant. Mechanical ventilation and concurrent opioid therapy may be pertinent covariates of vancomycin pharmacokinetics. The current work has shown that vancomycin pharmacokinetics in ICU patients displayed a significant variability and a significant change in both clearance and distribution during the course of therapy. Further investigation is necessary to clarify these findings. Moreover, the use of the Bayesian forecasting PKS program in our patients led to a prediction with low bias but rather poor precision. This outcome highlights the need to implement a population modeling approach, to determine the vancomycin pharmacokinetic parameters and covariates in our ICU patients, and to apply this information to provide more accurate concentration predictions.
Adolescent↗
[Severe gastrointestinal hemorrhages].
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Endoscopy, Gastrointestinal↗
Evaluation of a new semi-continuous cardiac output system in the intensive care unit.
PURPOSE: A new semi-continuous thermodilution cardiac output (CCO) system has been developed recently (Opti-Q and Q-vue Abbott critical care system). The aim of this study was to compare the accuracy and reproducibility of this new device with conventional ice-bolus thermodilution cardiac output (BCO). METHODS: Fifteen critically ill patients who needed pulmonary artery catheterization were prospectively investigated. Eighty seven paired data using BCO and CCO methods were compared. Reproducibility was assessed from 90 BCO and 87 CCO determinations by calculation of the mean standard error (SEM) and according to Bland and Altman methodology. RESULTS: The BCO and CCO ranged from 2.46 to 11.20 L.min-1 and from 1.75 to 10.05 L.min-1 respectively. Bias (mean difference between BCO and CCO) was null (0.002 L.min-1, P = 0.98), precision (SD of the bias) was 0.74 L.min-1 and the limits of agreement (mean difference +/- 1.96 SD) ranged from -1.45 to 1.45 L.min-1. The threshold to consider two cardiac outputs as different (3 x SEM) was equivalent for BCO and CCO (0.54 and 0.465 L.min-1 respectively). According to the Bland and Altman method, reproducibility of CCO was greater than that of BCO; bias of repeated measurements of BCO and CCO were 0.15 L.min-1 (P < 0.05) and 0.047 L.min-1 (NS), respectively. CONCLUSION: Compared with BCO, this new device was accurate but cannot be considered as interchangeable regarding the limits of agreement. Reproducibility of CCO was superior to BCO.
APACHE↗
[Pressure exerted on tracheal cuffs in intubation in the presence of nitrous oxide].
OBJECTIVE: To compare the time course of endotracheal tube cuff pressures in presence of nitrous oxide (N2O), obtained in a tracheal model with those measured during clinical anaesthesia. STUDY DESIGN: Experimental and clinical prospective study. MATERIAL: Twelve brands of low-pressure tracheal tubes. METHODS: The pressure changes in the cuffs were measured over a three-hour-period in presence of a N2O (50 vol%)/O2 (50 vol%) mixture and mechanical ventilation, the tube being inserted either in a tracheal model or in the trachea of patients during general anaesthesia. RESULTS: The results obtained in vitro were correlated with those measured in the patients. Therefore the tracheal model is a helpful guide for the choice of endotracheal tubes.
Air Pressure↗
-Pancreatitis after blunt injuries to the abdomen-.
Three cases of pancreatitis occurring after a trauma to the pancrease are reported. They emphasize the difficulty of diagnosis at the initial phase of the condition. In all cases, computerized tomography (CT) scan was the main diagnostic method. Applying the same therapeutic strategy for pancreatitis as for other aetiologies facilitated a favourable outcome.
Abdominal Injuries↗
-Curative and preventive antibiotic therapy in infective endocarditis-.
Durack's criteria, including echocardiographic manifestations, are the current standard for the diagnosis of infective endocarditis (IE). The most common microorganisms known to cause IE are streptococci and staphylococci, and therapeutic principles are based on an association of parenteral antibiotics, as far as possible bactericidal and prolonged. Treatment also includes the search for the source of infection and its eradication. IE with negative blood cultures requires special techniques to obtain the causal microorganisms. In about half of the cases, a nosocomial bacteriaemia results in IE in patients with a prosthetic valve. Surgery is mandatory in IE with complications and/or caused by particular microorganisms; surgery is essential in most patients with a prosthetic valve. Although the presence of specific links between some procedures and the occurrence of IE has not been clearly proven, a prevention policy is nevertheless justified, considering the morbidity and mortality. Prophylaxis is indicated in patients with the cardiac conditions at risk for IE. IE prophylaxis prevails over prophylactic antibiotics usually administered for surgery.
Anti-Bacterial Agents↗
Value of early blood Th-1 cytokine determination in predicting severity of acute pancreatitis.
BACKGROUND: Early evaluation of the severity of acute pancreatitis (AP) requires measurement of many variables within 48 h after admission. Septic complications (SC) are frequent, and preliminary studies have highlighted the value of prophylactic antibiotherapy; however, single and reliable predictive markers of sepsis are not yet available. The aim of this study was to assess the value of determining early blood Th-1 cytokines and their natural antagonists (interleukin-6 (IL-6), IL-1, IL-1ra, and the soluble form of tumor necrosis factor (sTNF) receptors RI and RII) to predict the severity and SC during AP. METHODS: Thirty-seven patients with AP were prospectively included; 25 of them had severe AP, including 8 with SC. Serum cytokines were measured 48 h and 72 h after the onset of AP with an enzyme-linked immunosorbent assay. The optimal severity or SC diagnostic thresholds was determined using receiver operative curves. RESULTS: Severe AP in accordance with the Atlanta criteria were better predicted by C-reactive protein and IL-6 serum determination, albeit these levels could not predict absolutely the death of two patients. In severe AP cases (n = 25) the IL-1 to IL-1-ra ratio was lower in cases further complicated by sepsis ((6+/-4) 10(-3) versus (34+/-13) 10(-3), P < 0.05); moreover, sTNF RI (2497+/-270 pg/ml versus 2133+/-611 pg/ml, P < 0.05) and RII (3751+/-400 pg/ml versus 3045+/-509 pg/ml, P < 0.05) were higher in AP characterized by further SC. The IL-1 to IL-1-ra ratio and IL-1 concentration were dramatically decreased within the first 48 h ((0.4+/-0.4) 10(-3) versus (30+/-11) 10(-3), P < 0.05, and 0.3+/-0.3 versus 15+/-3 ng/l, P < 0.05) in patients with further infection of the pancreatic necrosis (n = 3). The SC diagnosis was better anticipated by an IL-1 to IL-1-ra ratio lower than 5 x 10(-3) or by an sTNF RI higher than 1750 pg/ml and sTNF RII higher than 2750 pg/ml, and the infection of the pancreatic necrosis by an IL-1 concentration <2 ng/l or an IL-1 to IL-1-ra ratio <2 x 10(-3). CONCLUSION: Besides severity markers, IL-1, IL-1-ra, and sTNF RI and RII should be considered in base-line AP assays and, if confirmed by larger studies, could help to screen patients at risk for SC and candidates for prophylactic antibiotherapy with a good negative predictive value.
Acute Disease↗
[Pneumatic tourniquets in orthopedics].
Pneumatic tourniquets, often used to provide a bloodless operating field, carry a risk of adverse effects. Limb exsanguination by gravitation is less aggressive than by mechanical means. Skin, muscles, nerves and vessels suffer maximally under tourniquet because of mechanical pressure, with both a sagittal force, responsible for compression and an axial force responsible for stretchening. All parts of the limb are therefore affected by ischaemia. The restarting of circulation will also increase lesions at the microcirculatory level, responsible for the "no reflow" phenomena. Transient reperfusion intervals are not necessarily beneficial. These effects will significantly contribute to the post tourniquet sensory motor injuries. The tourniquet increases the risk of sepsis. Tourniquet release allows metabolites from the leg to enter into the circulation, and also carries a risk of pulmonary thromboembolism. Carbon dioxide is eliminated by spontaneous hyperventilation under regional anaesthesia. If not eliminated by an increase of mechanical ventilation during general anaesthesia, it may raise intracranial pressure in head trauma patients. Various chemotactic and cytolytic agents may cause lung injury. Mobilization of blood volume at tourniquet placement and release may have detrimental haemodynamic effects in patients with coronary or cardiac insufficiency. The tourniquet increases arterial pressure after 20 to 25 minutes under general anaesthesia. Regional anaesthesia is considered as the technique of choice for the prevention of "tourniquet hypertension", closely linked to pain and relievable by local anaesthetics. Tourniquet modifies also the pharmacokinetics of anaesthetic and other agents. It generates hyperthermia, especially in children. Prospective and comparative studies did not show any advantage as far as duration of surgery and amount of blood loss are concerned. In order to minimize its side effects, the tourniquet must be used within the frame of a strict procedure, with a well adapted and regularly checked equipment. Duration of ischaemia should be as short as possible and not continue for more than two hours, with a reperfusion of 15 minutes every hour. Local hypothermia seems to be a safe means for decreasing side effects.
Blood Loss, Surgical↗
[Transfusion and Jehovah's witnesses. A review of medicosurgical attitudes in a University hospital in 1995].
The aim of this study was to evaluate the attitudes of physicians (anaesthetists + other doctors + surgeons) towards Jehovah's witness patients refusing blood transfusion. Such a situation is not uncommon: 79% of respondents uncountered it. For scheduled surgery in adults, 75% of these physicians (54% of anaesthetists) would accept to lake care of these patients. In case of emergency or unforeseen indication for transfusion, 54% of these physicians (72% of anaesthetists) would administer blood, despite a written transfusion refusal. These figures would be 95 and 97% respectively in children.
Adult↗
[Mesenteric vein infarction associated with congenital antithrombin III (ATIII) deficiency].
A venous mesenteric infarction in a 27-year-old patient is reported. This patient presented a genetic quantitative AT-III deficiency without anticoagulation therapy. Ultrasonography revealed portal vein thrombosis and laparoscopy showed mesenteric vein infarction. Laparotomy was performed mmediately and revealed segmental infarction of 60 cm of the jejunum which was resected; the portal vein was considered to be partially occluded on palpation. No strangulation or mechanical factors were identified. Immediately postoperatively the patient received therapeutic doses of heparin with AT-III concentrates to increase AT-III levels; no recurrent thrombotic episode was observed. A systematic second-look operation 24 hours postoperatively showed good bowel viability. Five days later, long-term anticoagulation with acenocoumarol was decided. Twelve days later, ultrasonography showed complete portal revascularization which was confirmed by a third surgical operation on D60.
Adult↗
[Postoperative autotransfusion and transfusion evaluation in cardiac surgery].
In cardiac surgery, blood retransfusion from the thoracic drainages, though already ancient, still remains controversial either for its quantitative or its qualitative interests. A retrospective study has been conducted, between the 1st january 1992 and the 30th june 1993, over 1.655 consecutive operations. Most of the patients suffered from coronary disease (937) or a valvular disease (605), others had been operated for a combined valvular and coronary revascularization surgery (113). The safety of this technique, guaranteed by strict rules, allowed a "transfusional strategy" which tends to reduce the homologous blood consumption. Twenty-nine percent of all the patients received homologous red cells units and only 23% of the patients operated for a coronary revascularization. This strategy aims to reduce both the risks of blood transfusion and the health cost.
Aged↗
[Resuscitation in severe hepatic injuries].
Hepatic injuries account for about 45% of all abdominal traumas and for 30 to 40% of penetrating abdominal injuries. In 60% of the cases, they are associated with other lesions, especially life-threatening head injuries. Abdominal ultrasonography, a short and safe procedure enabling guided puncture, has developed rapidly relegating to the second rank other diagnostic techniques such as peritoneal lavage and CT scan. First line treatment of severe trauma complicated by haemorragic shock combines fluid resuscitation, prevention of hypothermia and administration of broad spectrum antibiotics. Surgical care, relying mainly on perihepatic packing and vascular exclusion techniques must remain as conservative as possible. Once haemodynamics have been stabilized in patients who do not present any other abdominal lesion requiring laparotomy, the non-interventional attitude is often successful and bears lower morbidity.
Abdominal Injuries↗