[Aortocoronary bypass, haemodialysis and internal mammary artery steal]. / Pontage aortocoronarien, hémodialyse et vol thoracique interne.

The dramatic occurrence, during haemodialysis sessions, of hemodynamic and cerebral symptoms in a 53-year-old haemodialysed woman with a history of aortocoronary bypass leads to discovery and treatment by percutaneous angioplasty and stenting of a significant stenosis of proximal subclavian artery, ipsilateral to the arteriovenous fistula, with retrograde flow in internal mammary artery graft and vertebral artery. All symptoms resume after interventional radiology. Analysis of literature confirms possibility of coronary artery steal induced by use of the arteriovenous fistula in haemodialysed patients with ipsilateral internal mammary bypass, especially if there is concomitant subclavian artery stenosis, and leading us to discuss the diagnostic and therapeutic implications.

Do antibiotics administered at the time of central venous catheter removal interfere with the evaluation of colonization?

OBJECTIVE: Catheter colonization is commonly used as an end point in studies on central venous catheter (CVC) infections. This study aimed at comparing the rates of catheter colonization in patients according to the administration of antibiotics at removal. DESIGN: Prospective study over a 5-year period. All patients with a CVC removed without suspicion of CVC infection were included. SETTING: An adult medical/surgical intensive care unit at a university teaching hospital. PATIENTS: A total of 472 patients with CVC inserted for a mean CVC duration of 6.0 +/- 3.7 days were included. METHODS: Antibiotics at removal was defined as antibiotics administered within 48[Symbol: see text]h before CVC removal, and CVC colonization as catheter tip culture yielding > or = 10(3) colony-forming units per milliliter. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Of 472 patients, 302 (64%) were receiving antibiotics at removal. The number of CVC colonizations per number of CVCs inserted was 4.7% (22 of 472) and the number of CVC colonizations per 1000 CVC days was 8.0. Administration of antibiotics at removal was associated with a lower risk of CVC colonization. Irrespective of CVC duration, CVC colonization rate differed between patients with or without antibiotics at removal (Kaplan-Meier test, p=0.04). CONCLUSIONS: The proportion of patients with antibiotics at time of removal should be taken into account when interpreting the results of surveys and trials using the quantitative CVC tip culture to define CVC colonization as an end point.

Rapid decrease in plasma D-lactate as an early potential predictor of diminished 28-day mortality in critically ill septic shock patients.

BACKGROUND: Splanchnic ischemia plays a major role in the development of organ failure during septic shock. Plasma D-lactate has been proposed as a better marker of splanchnic hypoperfusion than L-lactate. We studied the prognostic ability of plasma D- and L-lactate levels. METHODS: A prospective study was performed in an intensive care unit and included patients with septic shock. Two samples for plasma D- and L-lactate determination were collected: the first within 6 h after the patient met the criteria for septic shock (day 1) and the second 24 h later (day 2). RESULTS: In univariate analysis, day 1 plasma D- and L-lactate values were associated with 28-day mortality. For plasma D- and L- lactate, the area under the receiver operating characteristic curve was 0.68+/-0.09 and 0.84+/-0.07 on day 1 (p=0.09), and 0.74+/-0.10 and 0.90+/-0.07 on day 2 (p=0.06), respectively. In survivors, D-lactate levels decreased between day 1 and day 2 (p=0.03), but L-lactate did not (p=0.29). In septic shock patients, plasma D- and L-lactate levels reliably discriminate between survivors and non-survivors. The prognostic ability of plasma L-lactate was better than that of plasma D-lactate. CONCLUSION: A rapid decrease in plasma D-lactate during the course of septic shock could indicate reduced 28-day mortality.

Clinical features and outcome of chronic dialysis patients admitted to an intensive care unit.

BACKGROUND: Information about chronic dialysis (CD) patients admitted to intensive care units (ICU) is scant. This study sought to determine the epidemiology and outcome of CD patients in an ICU setting and to test the performance of the Simplified Acute Physiology Score (SAPS II) to predict hospital mortality in this population. METHODS: All consecutive CD patients admitted to an adult, 10 bed medical/surgical ICU at a university hospital between January 1996 and December 1999 were included in this prospective observational study. Demographics, characteristics of the underlying renal disease, admission diagnosis, the number of organ system failures (OSFs) excluding renal failure and SAPS II, both calculated 24 h after admission, the duration of mechanical ventilation, ICU survival and survival status at hospital discharge and 6 months after discharge were recorded. RESULTS: A total of 92 CD patients, 16 on peritoneal dialysis and 76 on haemodialysis, were included. The main reason for ICU admission was sepsis and the mean ICU length of stay 6.2+/-9.9 days. ICU mortality was 26/92 (28.3%) and was associated in multivariate analysis with SAPS II (P<0.001), duration of mechanical ventilation (P<0.01) and abnormal values of serum phosphorus (high or low; P<0.05). Hospital mortality was 35/92 (38.0%) and was accurately predicted by SAPS II [receiver operating characteristics curve: 0.86+/-0.04; goodness-of-fit test: C = 6.86, 5 degrees of freedom (df), P = 0.23 and H = 4.78, 5 df, P = 0.44]. The 6 month survival rate was 48/92 (52.2%). CONCLUSIONS: CD patients admitted to the ICU are a subgroup of patients with high mortality and SAPS II can be used to assess their probability of hospital mortality. The severity of the acute illness responsible for ICU admission and an abnormal value of serum phosphorus are determinants for ICU mortality.