Iatrogenic diseases as a reason for admission to the intensive care unit: incidence, causes, and consequences.

BACKGROUND: Data on iatrogenic diseases (IDs) have been recorded for the past 25 years. We determined whether aging of the general population and medical advances, including more powerful drugs and complex procedures, have altered the incidence, causes, and consequences of severe IDs during this period. METHODS: One-year retrospective study was conducted in an adult medical-surgical intensive care unit (ICU) affiliated with a French general hospital in an area of 200 000 inhabitants. All the patients admitted to the ICU during 1994 were screened for IDs. Patients with community or hospital-acquired IDs on admission were included. Follow-up assessed morbidity, mortality, workload, and costs of care for IDs, and the rate of preventable IDs. were included; the cause of the ID was drugs in 41, medical acts in 12, and surgical acts in 15. These 68 patients were in the ICU for 472 days, with a 13% fatality rate (9 patients) and a financial cost of US $688 470. They were not different from the 555 other ICU patients in terms of severity, mortality, workload, and length of stay in the ICU. Risk factors for ID were old age and the number of prescribed drugs. The rate of preventable ID was 51%. CONCLUSIONS: Iatrogenic diseases are a persistent and important reason for admission to the ICU, and the risk factors, causes, and consequences remain unchanged since 1980. Despite 25 years of experience with high-technology medicine, ID still has a negative impact on the health and resources of society.

[Patients admitted to the intensive care unit for iatrogenic disease. Risk factors and consequences]. / Patients admis en réanimation pour pathologie iatrogène: facteurs de risque et conséquences.

PURPOSE: Data pertaining to iatrogenic diseases have been recorded over the last 25 years. Regarding the evolution of medical practice (general ageing, more and more powerful drugs and complex procedures), it is not known whether the incidence and the consequences of iatrogenic diseases have changed since their first evaluation. METHODS: To determine the admission rate to intensive care units for iatrogenic diseases, with the purpose of analyzing risk factors and consequences, and to compare our results with previous data recorded in 1979 (admission rate: 12.6%, mortality: 20%, preventable events: 47%), a 1-year retrospective study was conducted in an intensive care unit (ICU). RESULTS: During 1994, 68 (10.9%) out of 623 patients were admitted to the ICU for iatrogenic diseases (drugs: 41, medical acts: 12, surgical acts: 15). They were not different--in terms of severity, mortality, workload and length of stay in the ICU--from the other 555 patients hospitalized for other reasons. They were hospitalized on average for 472 days in the ICU, with a 13% fatality rate and a financial cost of US $688,470. Risk factors for iatrogenic diseases were the age and the number of prescribed drugs. The rate of preventable events was 51%. CONCLUSIONS: In this study, the occurrence of life-threatening iatrogenic diseases was a persistent and important purpose for admission to the ICU. Risk factors and consequences are still identical to those reported in 1979. Our results emphasize the persistence of the noxious impact of iatrogenic diseases on the quality and cost of medical care.

Clinical and bacteriologic survey of epidural analgesia in patients in the intensive care unit.

BACKGROUND: The risk of bacterial contamination related to epidural analgesia in patients cared for in the intensive care unit has not been assessed. Thus the authors studied patients who received care in the intensive care unit who were given epidural analgesia for more than 48 h to determine the rates of local, epidural catheter, and spinal space infection and to identify risk factors. METHODS: Each patient receiving epidural analgesia for longer than 48 h was examined daily for local and general signs of infection. A swab sample for culture was taken if there was local discharge; all epidural catheters were cultured on withdrawal. All patients underwent weekly neurologic monitoring for 1 month; those with positive epidural catheter cultures had one spinal magnetic resonance image scan. RESULTS: The 75 patients cared for in the intensive care unit who were studied had been receiving epidural analgesia for a median of 4 days (interquartile range, 3.5 to 5 days). Twenty-seven patients had signs of local inflammation (erythema or local discharge), and nine of these had infections. All the patients who had both local signs also had infection. All nine infections were local (12%), but four patients also had epidural catheter infections (5.3%). No patient with erythema alone or without local signs had a positive epidural catheter culture. No spinal space infection was diagnosed. Staphylococcus epidermidis was the most frequently cultured microorganism. Local infection was treated by removing the epidural catheter without any antibiotics. Concomitant infection at other sites (21 of 75 patients, or 28%), antibiotic therapy (64 of 75 patients, or 85%), the duration of epidural analgesia, and the insertion site level of the epidural catheter were not identified as risk factors for epidural analgesia-related infections. CONCLUSIONS: The risk of epidural analgesia-related infection in patients in the intensive care unit seems to be low. The presence of two local signs of inflammation is a strong predictor of local and epidural catheter infection.

Increased lung clearance of 99mTcDTPA in allograft lung rejection. The Paris-Sud Lung Transplant Group.

To investigate whether lung 99mTc-DTPA clearance is altered during allograft lung rejection, a group of four double lung and 24 heart-lung transplant patients was studied using serial measurement of the clearance rate of aerosolized 99mTc-DTPA (DTPA-Cl), in association with pulmonary function tests, bronchoalveolar lavage, and transbronchial lung biopsies. Using histologic diagnosis as a standard, we compared 56 episodes with normal lung histology to 32 episodes with allograft lung rejection. A control group of 20 healthy nonsmokers was used to define normal DTPA-Cl. In patients with normal lung histology, DTPA-Cl was higher than in control subjects (2.62 +/- 0.25 versus 1.20 +/- 0.12 %/min; p less than 0.001). In the episodes of allograft lung rejection, DTPA-Cl increased to 3.65 +/- 0.41 %/min (p less than 0.02) as compared with episodes of normal lung histology. The change in DTPA-Cl during allograft lung rejection was correlated (r = 0.3, p less than 0.01) with the increased percentage of lymphocytes in bronchoalveolar lavage (27.8 +/- 3.5% in rejection versus 19.9 +/- 2.2% in normal histology; p less than 0.02). Sensitivity and specificity of DTPA-Cl measurement in detecting lung rejection were 69 and 82%, respectively, versus 45 and 85% for FEV1 measurement. These results suggest that DTPA-Cl monitoring could be used in conjunction with pulmonary function testing as a noninvasive approach for the detection of lung rejection.

Long-term follow-up after prosthetic replacement of the superior vena cava combined with resection of mediastinal-pulmonary malignant tumors.

The contraindication to curative excision of mediastinal and pulmonary cancers because of invasion of the superior vena cava is now challenged by the existence of vascular prostheses that are suitable for venous replacement. Between 1979 and 1990 22 patients underwent resection of lung cancer (n = 6) or malignant mediastinal tumors (n = 16) involving the superior vena cava. Resection was done with concomitant venous reconstruction, and polytetrafluorethylene grafts were used. All bronchogenic carcinomas necessitated right pneumonectomy, whereas the excision of mediastinal tumors had to include pulmonary resections in nine patients (five lobectomies and four sublobar resections) and the right phrenic nerve in 12 patients. Venous reconstruction was performed by interposition of a large polytetrafluoroethylene graft between the proximal and cardiac ends of the superior vena cava (n = 8), or between one (n = 10) or both brachiocephalic veins (n = 4) and the right atrium. One patient died postoperatively (4.5%), and another had mediastinitis that was successfully treated by omentopexy. Chemotherapy was administered preoperatively to five patients and postoperatively to seven patients; radiotherapy was administered to two and 10 patients, respectively. The overall actuarial survival rate is 48% at 5 years, with 11 patients presently alive. The survival rate of patients with mediastinal tumors is 60% at 5 years. Among the patients with lung cancer, two with N1 disease are alive at 16 and 51 months, and one died at 38 months; the two patients with N2 disease died at 6 and 8 months. Only one graft occlusion occurred in the postoperative period; another occurred 14 months after operation and was precipitated by insertion of a central venous catheter. The patency of all remaining grafts was demonstrated after an average time of 23 (1 to 98) months. On the basis of these results, polytetrafluoroethylene graft replacement of the superior vena cava should be part of the planning and execution of radical excision with curative intent of mediastinal and right pulmonary malignant tumors that are not present with other contraindications, such as pleural or distant metastasis and severe systemic disease.

[Anesthesia and intensive care for heart-lung transplantation]. / Anesthésie et réanimation pour transplantation coeur-poumons.

Since Shumway carried out the first successful heart-lung transplant (HLT) in Stanford in 1981, HLT has become a new therapeutic means for patients with end-stage pulmonary disease or arterial hypertension. However, it is still rarely carried out because of a lack of donors and the complexity of the surgery and postoperative course. This review described the criteria for proper donor and recipient selection, as well as the anaesthetic and postoperative management of HLT patients at Marie Lannelongue Hospital. The lack of suitable organ grafts results, at least in part, from improper donor management. Pulmonary oedema by fluid overloading and excessive haemodilution should be carefully prevented. Low doses of catecholamines and vasopressin maintain circulatory stability and convenient organ function. The indications for HLT (primary pulmonary hypertension, Eisenmenger's complex, and end-stage bronchopulmonary disease) are all characterized by severe pulmonary hypertension, hypoxaemia and cardiac failure. Careful anaesthetic induction is required to avoid circulatory collapse. Cardiopulmonary bypass (CPB) should be started early, so that mediastinal dissection may be carried out in satisfactory haemodynamic conditions. After unclamping the aorta, circulatory support with fluid and catecholamine infusion is often required. High inspired oxygen fraction and end-expiratory positive pressure may be required because of reperfusion pulmonary oedema. Blood transfusion is often needed as there are major blood losses due to dissection of the posterior mediastinum during CPB. Postoperative catecholamine administration is prolonged over several days. Negative fluid balance is often necessary to reduce pulmonary oedema. Improvement in surgical technique, early extubation, and late prescription of steroids have reduced the incidence of tracheal complications. Acute renal failure often occurs as a result of prolonged CPB, hypovolaemia, drug nephrotoxicity and sepsis. Bacterial complications (pneumonia, mediastinitis) are the main causes of early death. After the 15th postoperative day, opportunistic infections and allograft rejection are the main complications. Since 1981, major advances in HLT recipient management resulted in improved survival rates (70-80% at 1 year, and 60-70% at 2 years for the best teams). Despite the complexity of management, and the longterm threat of obliterative bronchiolitis, HLT is, at present time, the only possibility for these young patients to recover a normal quality of life.

[Heart-lung transplantation and double lung transplantation. 33 cases]. / Transplantations coeur-poumons et bipulmonaires. 33 cas.

Between June 1986 and October 1989, 29 heart lung transplantations and 4 double lung transplantations were performed at the Marie Lannelongue Hospital, Paris. The early and later course of these patients was studied. The actuarial survival rates at one and two years were 65 percent and 55 percent respectively. Bacterial infection was the main cause of early death. Late morbidity was predominantly due to cytomegalovirus infection and episodes of rejection. Respiratory function, evaluated in 19 long-term survivors, was usually normal. Only 3 patients developed a functional pattern of severe obliterative bronchiolitis probably related to uncontrolled rejections. The indications of the different types of lung transplantation are discussed: in cases of primary pulmonary hypertension or Eisenmenger's complex, heart lung transplantation is the only possible procedure. In patients with respiratory failure without cardiac dysfunction, double lung transplantation gives good functional results and makes an extra heart available for transplantation in another patient. Single lung transplantation, which gives worse functional results with a similar mortality rate, must be reserved for patients who are unable to undergo double lung transplantation.

[Anaphylactic shock]. / Choc anaphylactique.

The anaphylactic shock is a life-threatening reaction produced by the release of pharmacologically active substances (histamine, leukotriene...) by most cells and basophils. The release of these mediators may be immunologically mediated (anaphylactic reaction a typical immediate hypersensitivity reaction mediated by IgE) or not (anaphylactic reaction when not mediated by an antigen-antibody process). These mediators in turn specific end-organ responses in the cardio-vascular system, (vasodilatation, change in inotropy, increased capillary permeability), the respiratory system (bronchospasm upper airway oedema) and the skin (urticaria). Because of its etiology (mainly drugs, contrast media and colloids) the treatment of anaphylactic or anaphylactic reactions must be prophylactic. When it occurs, its cure is based upon adrenaline and fluid loading and eventually bronchodilators.