[Epidemiological features of stress hyperglycemia in elderly at emergency department]

Background: Stress hyperglycemia among patients having an acute pathology is frequently described in recent studies

Aims: The objectives of this work were to describe epidemiologic features of elderly patients hospitalized in the emergency department and having a hyperglycemia due to stress

Methods: A retrospective chart review identified patients older than 65 years with obtained serum glucose levels. Patients with diabetes were excluded. Two levels of serum glucose were considered [>6,9 mmol/l and

Results: We included 165. There were 94 patients with high level of serum glucose level [56,9%]. Multivariate analysis found that only cardio-vascular pathologies were more predictive of having stress hyperglycemia [p=0,014, odds-ratio=2,8, IC=1,2-6,4]. There were no correlation between serum glucose levels and mortality

Conclusion: Stress hyperglycemia is a fairly common disorder but underestimated in emergency department. Its impact on the prognosis of elderly patients remains to be studied

[Pulmonary thromboembolism: incidence, physiopthology, diagnosis and treatment]

The objective of this work was to review current data about the pathophysiology, clinical features, and treatment of pulmonary thromboembolism. Venous thromboembolism [VTE] remains a major challenge in hospitalised especially the care of critically ill patients. Pulmonary embolism [PE] is the major complication of VTE. By occluding the pulmonary arterial bed it may lead to acute life-threatening but potentially reversible right ventricular failure. The outcome of patients with PE is quite variable depending primarily on the cardio-respiratory status and the embolus size. PE is a difficult diagnosis that may be missed because of non-specific clinical presentation. Clinical signs include hypoxia, tachypnea, and tachycardia. Severe cases of untreated PE can lead to circulatory instability, and sudden death. However, in ICU, most of patients require sedation and mechanical ventilation. The clinical manifestations usually observed in this condition [PE] cannot be exhibited by these patients and clinical presentation is usually atypical. For these reasons, the diagnosis of PE is usually suspected when un-explicated hypoxemia and/or shock and arterial hypotension were observed. Positive diagnosis is based on these clinical findings in combination with laboratory tests and imaging studies. D-dimer testing is of clinical use when there is a suspicion of DVT or pulmonary embolism PE. In Emergency department, a negative D-dimer test will virtually rule out thromboembolism with a negative predictive value at 95 to 98%. In massive and submassive PE, dysfunction of the right side of the heart can be seen on echocardiography. While the gold standard for diagnosis is the finding of a clot on pulmonary angiography, CT pulmonary angiography is the most commonly used imaging modality today. When the diagnosis is confirmed, anticoagulant therapy is the mainstay of treatment. Acutely, supportive treatments a pivotal role in the management of patients with PE. Severe cases may require thrombolysis with drugs such as tissue plasminogen activator [tPA] or may require surgical intervention via pulmonary thrombectomy. Prevention is highly warranted

[Prospective study about 45 cases of disseminated intravascular coagulation]

Disseminated intravascular coagulation [DIC] in obstetric disorders is a severe complication. To study the frequency and means of diagnosis of DIC and the therapeutic care and maternal morbidity induced. Monocentric, prospective and descriptive study about 45 cases of intravascular coagulation in an obstetrical service collected at the University Hospital of Obstetrics and Gynecology Hedi Chaker of Sfax over a period ranging from June 2007 to June 2010. All the pregnant patients who have given birth beyond 28 weeks and have presented a DIC were selected for this study. The mean age of patients was 31.4 years. The mean parity was 2.6. The main diseases during pregnancy were: severe preeclampsia [22.2%], diabetes [28.8%], intrauterine fetal death [17.7%], previa placenta [8.8%]. The main causes of DIC were: uterine atony [44.4%], abruptio placenta [22.2%], Hellp syndrome [11.1%] and uterine rupture [6, 6%]. The lowest rate of platelets was 21000/mm3. The fibrinogen level was <0.5 g in 40% of cases. Despite reanimation and transfusion with blood products, surgical treatment was necessary in 77.7% of cases. All the patients were transferred in intensive care unit with an average stay of about three days. No maternal death was reported. DIC is a frequent complication of many obstetrical diseases. The treatment is urgent. It requires first to the cause and the shock by massive transfusions of packed red blood cells, fresh frozen plasma, and platelets, associated with antifibrinolytic drugs, if necessary

[Use of catecholamine and shocks. continuous debate!]

Hypotension and shocks are frequently observed in patients requiring admission in ICU. However, the optimal adrenergic support in shock is controversial. To perform a descriptive approach of the current use of catecholamine in a medico-surgical ICU in patients with schoks. Our study is prospective over 3 month period. Were included all patients admitted in our ICU during the study period's. We compared the populations with and without catecholamine, we analysed the catecholamine selected in various clinical settings and we studied the impact of the use of catecholamine on the patient outcomes. During the study's period, 226 patients were hospitalized in our service and were the subject of this study. The median age [ +/- SD] was of 47 +/- 24 years. During their hospitalization in the ICU, 132 patients [58.4%] presented a shock. The cardiogenic shock and the hypovolemic shock were the most observed [37.8% and 35.6% respectively]. Hundred thirty patients [57.5%] received catecholamines during their stay in ICU. Eighty four patients [64.6% of the patients having received catecholamines] had received dopamine. Sixty two patients [47.7% of the patients having received catecholamines] had received dobutamine, 63 patients [48.5%] had received epinephrine and 22 patients [16.9%] had received norepinephrine. The mean's period of catecholamines use was 5 +/- 4 days. Among drugs proposed in order to manage patients with cardiogenic shock, dobutamine was chosen as the first choice agent in 62% of the cases. Among drugs proposed in order to manage patients with septic shock, Dopamine was chosen as the first choice agent in 85.7% of the cases. In our study the patients of the class C or D in the Knauss classification are significantly predisposed to receive catecholamines during their ICU stay [OR: 5.3 ; IC 95%: 1.7 - 5.7].Moreover, the needing of catecholamine use is strongly associated with high mortality [OR: 16,8; IC 95%: 16.4 - 49.2]. The choice of catecholamines is a matter of debate for critically ill patients. The use of catecholamines is a clinical marker of severity and provider of mortality

Pulmonary embolism in intensive care unit: predictive factors, clinical manifestations and outcome

To determine predictive factors, clinical and demographic characteristics of patients with pulmonary embolism [PE] in ICU, and to identify factors associated with poor outcome in the hospital and in the ICU. During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study periods, all patients admitted to our ICU were classified into four groups. The first group includes all patients with confirmed PE; the second group includes some patients without clinical manifestations of PE; the third group includes patients with suspected and not confirmed PE and the fourth group includes all patients with only deep vein thromboses [DVTs] without suspicion of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion [V/Q] scan or by a spiral computed tomography [CT] scan showing one or more filling defects in the pulmonary artery or in tits branches. The diagnosis was also confirmed by echocardiography when a thrombus in the pulmonary artery was observed. During the study periods, 4408 patients were admitted in our ICU. The diagnosis of PE was confirmed in 87 patients [1.9%]. The man delay of development of PE was 7.8 +/- 9.5 days. On the day of PE diagnosis, clinical examination showed that 50 patients [57.5%] were hypotensive, 63 [72.4%] have SIRS, 15 [17.2%] have clinical manifestations of DVT and 71 [81.6%] have respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 81 cases [93.1%] and low molecular weight heparins were used in 4 cases [4.6%]. The mean ICU stay was 20.2 +/- 25.3 days and the mean hospital stay was 25.5 +/- 25 days. The mortality rate in ICU was 47.1% and the in-hospital mortality rate was 52.9%. Multivariate analysis showed that factors associated with a poor prognosis in ICU are the use of norepinephrine and epinephrine. Furthermore, factors associated with in-hospital poor outcome in multivariate analysis were a number of organ failure associated with PE >/= 3. Moreover, comparison between patients with and without pe showed that predictive factors of pe are: acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO[2]/FiO[2] ration < 300 and the absence of pharmacological prevention of venous thromboembolis, Despite the high frequency of DVT in critically ill patients, symptomatic PE remains not frequently observed, because systematic screening is not performed. Pulmonary embolism is associated with a high ICU and in-hospital mortality rate. Predictive factors of PE are acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO[2]/FiO[2] < 300 and absence of pharmacological prevention of venous thromboembolism

Microbiological characteristics of catheter-related bacteremia in a Tunisian intensive care unit

Prevalence of catheter-related bacteremia in intensive care units is increasing as central venous catheters [CVC] are used more frequently. In the most of the published literature, Gram positive cocci are the leading cause of catheter-related bacteremia and the systemic empiric treatment recommended include the administration of glycopeptides. To search for the microbiological characteristics of catheterrelated bacteremia in a Tunisian ICU. Prospective observational cohort survey conducted in the ICU of the Habib Bourguiba university hospital, Tunisia [a 22 bed medical-surgical intensive care unit]. We had included all patients admitted to the unit over the study period [from August 1[st], 2001 to March 31[st], 2002], and who submitted to a central venous catheter for more than 24 hours. Catheter-tip specimens were cultured using a semiquantitative method. During the study period 218 central venous catheters [CVC] were assessed. The mean length of time the catheter was kept in place was 8 +/- 6.7 days [range; 2 and 46 days]. The CVC insertion site was the subclavian vein in 156 cases [71.6%], the jugular vein in 35 cases [16%], and the femoral vein in 27 cases [12.4%]. Seventy four catheters [33.9%] were removed because of suspicion of catheterrelated sepsis. The catheter-related bacteremia rate was 6.1 infections/1000 days-CVC. Unlike Gram-positive cocci which caused only one case of catheter-related bacteremia, Gram-negative rods, namely Klebsiella pneumoniae and Serratia marcescens were responsible for 91.7% of cases of catheter-related bacteremia. Our findings translate a specific microbiological flora in our Tunisian intensive care unit and highlight the importance of a treatment strategy based on local epidemiology in patients with catheter related bacteremia

[lnvestigaton of three nosocomial outbreaks of serratia marcescens in an intensive care unit in Sfax Tunisia]

Of the study was to type Serraria marcescens responsible for nosocnmial outbreaks in an intensive care unit in Stax-Tunisia. The relatedness between S. marcescens isolates was studied by Pulsed field get electrophoresis [PFGE]. We included 56 strains of Serratia marcescens isolated from patients hospitatized in the intensive care unit during 2003 and 2004. Seven epidemiological unrelated strains of Serratia marcescens were also tested. Samples from environment and hands of the nursing and medical staff were collected and cultured to identify the source of contanirnation. All strains showed a wild type of antimicrobial susceptibility. PEGE typing revealed that three different clones were present. None of the cultures taken from hands of unit staff and from environmental samples yielded positive results for S. snarcescens. We have confirmed the presence of three consecutive outbreaks caused by rhree genetically unrelated bacterial clones of Serraria marcescens in the intensive care unit ward. These outbreaks are closely related to the frequent use of colistin and the lack of measures of hygiene in this ward

[Traumatic head injury in children in south Tunisia epidemiology, clinical manifestations and evolution. a propos 454 cases]

To determine epidemiological, causes, clinical and Para clinical manifestations and outcome in children with traumatic head injury in south Tunisia. A retrospective study over a 8 year period [1997 - 2004] of 454 children's with head injury admitted to the Intensive Care Unit [ICU] of a university hospital [Sfax-Tunisia]. Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay. Mean age [SD] was of 7, 2 - 3, 8 years. The main cause of trauma was traffic accidents [69, 4%]. There were a predominance of male patient's with a sex-ratio of 2, 21. The Score of coma of Glasgow adapted to the child, was on average from8-3 points. Extra-cranial pathology was present were observed in 38, 9%. The cerebral CT-Scan performed on admission for all patients was pathological in 86, 3% of the cases. The most observed lesions were meningeal Haemorrhage [35, 2%] and the cerebral contusion [34, 5%]. According to the " Traumatic Coma Dated Bank classification " we noted a high proportion of type 2 group[46%]. Secondary systemic insults were observed in 377 children [83%]. Evolution was marked by the death of 82 children [18%]. Among survivors, a good recovery was observed in 229 children [50%]. In Tunisia, head injury is a frequent cause of hospitalization. It is essentially involved in traffic accidents. The short term prognosis is poor with a high [18%] mortality. Prevention is highly advised

Acute fatty liver of pregnancy [Incidence, pathogenesis, diagnosis, treatment and prognosis]

Acute fatty liver of pregnancy [AFLP] is a rare, potentially fatal complication that occurs in the third trimester or early postpartum period. It generally appears between weeks 30 and 38. Usually the APLF symptoms start one to two weeks before hospitalization with nausea, emesis, general uneasiness, jaundice, epigastric pain and other symptoms. A careful history and physical examination, in conjunction with compatible laboratory and imaging results, are often sufficient to make the diagnosis, and liver biopsy is rarely indicated. The maternal outcome has improved enormously during the last decade. Early diagnosis, pregnancy interuption and handling in special care or treating complications has lead to good materno-fetal results

Contribution of the liver biopsy in intensive care unit

Our aim was to evaluate the indications and contribution of liver biopsy [LB] in intensive care [ICU] and to compare them to those of LB in gastroenterology. We included retrospectively 37 successive LB achieved in ICU and 38 successive LB achieved in gastroenterology. All data were reviewed by three intensivists and three gastroenterologists to determine the contribution of the LB. The indications of LB were different in the two units. The most frequent indications were cirrhosis [36.8%], isolated biological hepatic disruptions [26.3%] and histological classification of viral hepatitis [18.4%] in gastroenterology and isolated biological hepatic disruptions [48.6%], hepatopathy during pregnancy [27%] and fever of unknown origin [10.8%] in intensive care unit. According to the six reviewers, LB was enough contributive in the two units, [78.4% in ICU and 71.1% in gastroenterology -p=0.46-]. It allowed to eliminate, to confirm, or to change a diagnosis in more than 70% of cases and allowed to modify the course of therapy in 21.6% of cases in ICU and in 26.3% of cases in gastroenterology [p=0.6]. The LB is a feasible technique in ICU and can be as contributive as it is in gastroenterology

traumatismes doudeno-pancreatiques, a propos de 14 cas

Through a series of 14 cases brought over a period of 12 years, we realized a retrospective, analytical and descriptive study of these traumata. We aimed to release recommendations to improve their management. It was 2 women and 12 men, whose mean age was 24.4 years [extremes: 50 and 60 years], divided into 10 pancreatic injuries, 2 duodenal injuries and 2 duodeno-pancreatic injuries. Etiology was dominated by traffic accidents 7 cases [50%]. Trauma was closed in 13 cases [92%]. -Associated lesions were present among 13 patients [92%]. The traumatism appeared by an urgent surgical abdomen among 9 patients, secondarily in 3 cases, tardily in 2 cases: a case of deep suppuration 3 months after a traumata treated into ambulatory and a case of persistent ascites after a past unperceived traumata. Abdominal ultrasonography was made among 4 patients. It allowed diagnosing only a case. Scanner was made among 4 patients. It allowed diagnosing all the cases. Only a patient was treated medically, it was a post-traumatic acute pancreatitis. Surgical treatment was made in 13 cases: conservative in 7 cases and radical in 6 cases. Follow-up was complicated in 11 cases [78%] and non-complicated in 3 cases. Mortality rate was 7.1%

[Mechanical ventilation in intensive care units: indications, modalities and complications. A prospective multicentric survey in Tunisia]

The survey was perfomed during the month of march 1998 and concerned 9 ICUs located in teraching hospitals. Tp be included each ICU had to MV for more than 12 hours were included in the study and had a 28 day follow-up in the ICU or until hospital discharge. Collected parameters were indications of MV, modalities of MV and of weaning, complication and outcome at ospoital discharge. Assist-control ventilation was the most used ventilation modality [69,8%]. Weaning of MV was performed in 63% of the study patients and was based on a once-a-day attempt of spontaneous breathing through a T-piece [59,5%] and a combination of intermittent mandatory ventilation with pressure support [IMV-PS: 27%] or pressure support alone [11,2%]. Mean lenght of hospital stay was 19,7 +/- 15,9 days of which 11,6 days were spent in the ICU. Fifty nine pateints [54%] were alive at discharge form the ICU of whom 4 ultimately died during their hospital stay. MV pratice as well as ICU facilities are not homogenous in Tunisia. Recommendations and guidelines should be buil in order to standardize MV practice in Tunisia