[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

[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

[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