Evaluating the usefulness of the estimated glomerular filtration rate for determination of imipenem dosage in critically ill patients.

BACKGROUND: Antibiotic dosing in critically ill patients is complicated by variations in the pharmacokinetics of antibiotics in this group. The dosing of imipenem/cilastatin is usually determined by severity of illness and renal function. OBJECTIVES: To determine the correlation between estimated glomerular filtration rates (eGFRs) calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and imipenem trough levels in critically ill patients. METHODS: This prospective observational study was done in the surgical intensive care unit (ICU) at Steve Biko Academic Hospital, Pretoria, South Africa. Imipenem trough levels were measured by high-performance liquid chromatography and compared with eGFRs calculated with the CKD-EPI equation. Correlation was evaluated by the Pearson product-moment correlation coefficient. RESULTS: The study population consisted of 68 critically ill patients aged between 18 and 81 years; 43 (63%) were male, and the mean weight was 78 kg (range 40 - 140). On admission, 30 patients (44%) had sepsis, 16 (24%) were admitted for trauma, and 22 (32%) were admitted for miscellaneous surgical conditions. Acute Physiology and Chronic Health Evaluation II (APACHE II) scores ranged from 4 to 39 (mean 18). The 28-day mortality rate was 29%. The mean albumin level was 16 g/L (range 7 - 25), the mean creatinine level 142 µmol/L (range 33 - 840), and the mean eGFR 91 mL/min/1.73 m2 (range 6 - 180). Imipenem trough levels ranged between 3.6 and 92.2 mg/L (mean 11.5). The unadjusted Pearson product-moment correlation coefficient between eGFR and imipenem trough level was -0.04 (p=0.761). CONCLUSION: Considering the high mortality rate of sepsis in ICUs and the rapid global increase in antimicrobial resistance, it is crucial to dose antibiotics appropriately. Owing to the variability of antibiotic pharmacokinetics in critically ill patients, this task becomes almost impossible when relying on conventional dosing guidelines. This study found that eGFRs do not correlate with imipenem blood levels in critically ill patients and should not be used to determine the dose of imipenem/cilastatin. Instead, the dose should be individualised for patients through routine therapeutic drug monitoring.

Investigating the need for therapeutic drug monitoring of imipenem in critically ill patients: Are we getting it right?

BACKGROUND: The drug levels and clearances of imipenem in critically ill patients are not comprehensively described in current literature, yet it is vital that adequate levels be achieved for therapeutic success. OBJECTIVES: To determine the proportion of critically ill patients treated with imipenem/cilastatin with sub-therapeutic imipenem plasma levels, and to compare the clinical outcomes of those patients with therapeutic levels with those who had sub-therapeutic levels. METHODS: Trough imipenem plasma levels of 68 critically ill patients from a surgical intensive care unit were measured using a validated high-performance liquid chromatography method. Imipenem trough levels were compared with the minimum inhibitory concentration (MIC) of the causative bacterial agents, based on a target value of 100% time above MIC (¦T >MIC). RESULTS: The proportion of participants with sub-therapeutic imipenem levels was 22% (95% confidence interval (CI) 13% - 34%). The 14- and 28-day mortality rates in the sub-therapeutic group were 33% and 40%, respectively, compared with 19% (p=0.293) and 26% (p=0.346), respectively, in the therapeutic group. Sub-therapeutic imipenem plasma levels are associated with adjusted hazard ratio of 1.47 (95% CI 0.55 - 3.91). CONCLUSIONS: The lower proportion of critically ill patients with sub-therapeutic imipenem plasma levels in this study compared with previous studies may be attributed to the practice of higher dosages and the administration method of extended infusions of imipenem/cilastatin in our setting. The results demonstrate a trend of higher mortality in patients with sub-therapeutic imipenem levels, although the results were not statistically significant at this sample size.

Starvation ketoacidosis in pregnancy presenting as euglycaemic, high anion gap metabolic acidosis: A case report highlighting the significance of early recognition and prompt intervention.

Starvation ketoacidosis (SKA) constitutes an important consideration in the pregnant patient who presents with profound metabolic acidosis. Pregnancy-related changes predispose the patient to develop SKA following relatively short periods (12 - 14 hours) of 'starvation'. Patients also typically look clinically well in relation to the significant metabolic derangements that accompany the condition. Prompt recognition and early institution of appropriate therapy is therefore extremely important in terms of optimising maternal and fetal outcome. We describe a pregnant patient with SKA who presented with profound euglycaemic ketoacidosis that resolved rapidly following the early initiation of appropriate therapy. Furthermore, appropriate therapy resulted in our patient avoiding the need for an emergency caesarean section, which is often reported in this scenario. The ensuing discussion addresses SKA in pregnancy, the unique features of our patient, and management considerations from a maternal and fetal perspective. We also discuss the various causes of ketoacidosis such as diabetic ketoacidosis (DKA), euglycaemic DKA, alcohol-induced euglycaemic ketoacidosis and SKA in pregnant patients.

[Treatment of two cases of periodic sleep apnea by maxillo-facial surgery]. / Traitement de deux cas d'apnées périodiques du sommeil par chirurgie maxillo-faciale.

Juvenile temporomandibular bony ankylosis may generate micro- and retroposition of the mandible. Collapse of the upper airway during sleep due to muscle atonia awakens the patient, leading to compensative diurnal hypersomnia. In severe cases, alveolar hypoventilation may result in anoxic seizure, sudden death or development of life threatening cor pulmonale. The corrective surgical procedure for adult is an anterior sagittal osteotomy and in the growing child, costochondral grafting is proposed. Pre and post operative polysomnograms with recording of oxygen saturation are objective measures of good surgical results.

[Basal cell nevus]. / La naevomatose basocellulaire.

The main features of the nevoid basal cell syndrome, also called Gorlin-Goltz-syndrome, are basal cell nevi, jaw cysts, anomalies of the vertebras and ribs, and intracerebral calcifications. The diagnosis is often incidentally made by discovery of bilateral jaw cysts, as it was in the case of our patient and her family. The therapy is the complete enucleation of the cyst. The cavity is filled with homologous cancellous bone graft. Recurrence and little cysts are treated with the solution of Carnoy eliminating remaining microcysts.

[Resection and reconstruction of mandible for treatment of two rare benign tumors]. / Résection et reconstruction de la mandibule pour le traitement de deux tumeurs bénignes rares.

Odontogenic myxoma and particularly juvenile fibromatosis are rare benign tumors in the maxillo-facial region. The aggressive local and sometimes voluminous development of these tumors may necessitate partial mandibulectomy. Autologous bone graft from the iliac crest is the best material for mandibular reconstruction because of its functional and esthetic results. If osteosynthesis of the graft is achieved by means of internal wiring, several weeks of intermaxillary fixation are required, whereas internal rigid fixation with plate and screws allows the patient to open the mouth more rapidly.

[2 rare tumors of the mandible. Removal and reconstruction]. / Deux tumeurs peu fréquentes de la mandibule. Exérèse et reconstruction.

Odontogenic myxoma and particularly juvenile fibromatosis are rare benign tumors in the maxillo-facial region. The aggressive local and sometimes voluminous development of these tumors may necessitate partial mandibulectomy. Autologous bone graft from the iliac crest is the best material for mandibular reconstruction because of its functional and esthetic results. If osteosynthesis of the graft is achieved by means of internal wiring, several weeks of intermaxillary fixation are required, whereas internal rigid fixation with plate and screws allows the patient to open the mouth more rapidly.

[2 infrequent tumors of the mandible. Removal and reconstruction]. / Deux tumeurs peu fréquentes de la mandibule. Exérèse et reconstruction.

Odontogenic myxoma and particularly juvenile fibromatosis are rare benign tumors in the maxillo-facial region. The aggressive local and sometimes voluminous development of these tumors may necessitate partial mandibulectomy. Autologous bone graft from the iliac crest is the best material for mandibular reconstruction because of its functional and esthetic results. If osteosynthesis of the graft is achieved by means of internal wiring, several weeks of intermaxillary fixation are required, whereas internal rigid fixation with plate and screws allows the patient to open the mouth more rapidly.

[Difficult intubation in maxillofacial surgery. Tracheotomy or fibroscopy?]. / L'intubation difficile en chirurgie maxillo-faciale. Trachéotomie ou fibroscopie?

Prior to general anesthesia, some maxillofacial conditions may require tracheostomy or, in recent years, fiberoptic endotracheal intubation. This technic is efficient but delicate and therefore needs a skilled qualified operator. However, fiberoptic endoscope may avoid the inconvenience of tracheostomy. This article presents our method of fiberoptic endotracheal intubation with the specific indications and results.

[Sleep obstructive apnea syndrome and temporomandibular ankylosis. Maxillofacial correction for adults and children]. / Syndrome d'apnées obstructives du sommeil et ankylose temporo-mandibulaire. Correction maxillo-faciale pour l'adulte et l'enfant.

Juvenile temporomandibular bony ankylosis may generate micro- and retroposition of the mandible. Collapse of the upper airway during sleep due to muscle atonia awakens the patient, leading to compensative diurnal hypersomnia. In severe cases, alveolar hypoventilation may result in anoxic seizure, sudden death or development of life threatening cor pulmonale. The corrective surgical procedure for adult is an anterior sagittal osteotomy and in the growing child, costochondral grafting is proposed. Pre- and post-operative polysomnograms with recording of oxygen saturation are objective measures of good surgical results.

Deliberate, fixed extra-articular obstruction. Treatment of choice for subluxation and true recurrent dislocation of the temporomandibular joint.

Temporomandibular dislocation and subluxation are two pathological situations both characterized by hypermobility of the condyle. We believe that when luxation is recurrent and when subluxation becomes painful or is accompanied by disc dysfunction, surgical intervention is indicated. We are impressed by Gosserez and Dautrey's (1967) method of augmentation of the tubercle, or extra-articular obstruction, which is a modification of Leclerc and Girard's (1943) original procedure. The advantages of this technique are described and results are based on a series of 38 patients.

[Surveys of the treatment and socio-professional future of patients with spondylarthritis. Our impressions in 1986]. / Enquêtes sur le traitement et le devenir socio-professionnel des spondylarthritiques. Nos impressions en 1986.

After a brief historical reminder, the authors emphasize the difficulties of such investigations; difficulties of realization, analysis and synthesis since the results depend on ethnic and socio-cultural origins, socio-professional factors, primary or secondary forms or the length of evolution of the disease. From their experience, the authors draw a certain number of figures which they compare to those from other authors, especially concerning factors which aggravate the functional prognosis of the disease, or condition its complications. As for the therapy, considering the divergent opinions expressed about the results obtained with modern treatments, and used for thirty years, the authors have initiated an opinion survey among the members of the FSR (French Society of Rheumatology). The analysis of personal cases, the synthesis of various publications, the results of their survey, lead them to conclude that the problem of the treatment of ankylosing spondylo-arthritis and its professional consequences, is currently still more medico-social than scientific. The picture of rheumatoid pelvispondylitis seems less severe today than before, but it is necessary to have a longer follow-up to evaluate it statistically.

Homologous cancellous bone grafts for large jaw defects caused by bone cysts.

For more than 10 years homologous bone stored at -20 degrees C has been used to fill large bone cavities after cystectomy. This article outlines the principles of collecting, storing, and preserving the homograft, presents special aspects of the surgical technique, and reports long-term results.

[Solitary plasmocytoma of the mandible]. / Plasmocytome solitaire de la mandibule.

The authors present a case of solitary bony plasmocytoma of the mandibule, with local amyloid deposition. Diagnosis was made at extemporaneous pathological examination, then confirmed by the examination of the fixed surgical sample. Immunoenzymologically the proliferation proved to be monoclonal, with secretion of kappa light chain. The patient was treated by surgical curettage and homologous cancelous bone filling, followed by 5,500 rads of electrontherapy. He was then regularly controlled during 8 years and remained free from local recurrence. All investigations in search of dissemination (Kahler disease) remained negative.

[Centrosomatic tuberculous vertebral osteitis. General review apropos of 4 cases]. / L'ostéite vertébrale tuberculeuse centro-somatique. Revue générale à propos de 4 cas.

Defined by the localisation of tuberculous infection in the vertebral body, centrosomatic tuberculous vertebral osteitis, which is rarer than Pott's spondylodiscitis, is more frequently seen in the cases of multifocal tuberculosis occurring preferentially in male black African immigrants approximately 30 years of age. Central area destruction, which has been the initial and pathognomonic radiological sign since its description by Calve and Galland , may progress towards wedging of the vertebral body, and even to its complete disappearance, accompanied by reactive osteocondensation . Infection from this particular localisation of vertebral tuberculosis may spread via arterial branches posterior to the vertebral bodies.