Benefits of the tranexamic acid in head trauma with no extracranial bleeding: a prospective follow-up of 180 patients.

INTRODUCTION: Tranexamic acid (TXA) is one of the debated therapies in the management of traumatic brain injury (TBI). We conducted this study to evaluate the benefits of TXA in TBI on the mortality and its safety in these patients. METHODS: This was a prospective randomized open-label trial including all patients, aged at 18 years or older, hospitalized in the emergency room during a 13-month period, for TBI. After the realization of the body CT scan, the patients were included if they had intracranial bleeding, and were then randomized according to their medical file number to receive or not the TXA. The eligibility criteria were based on the uncertainty principle, patients with significant extracranial bleeding were excluded since there was evidence that TXA improve their outcome. RESULTS: We enrolled 180 patients aged at 42 ± 20 years, with an 88% men-proportion. Subarachnoid haemorrhage was the most frequent lesion in the brain CT-scan (67.5%). After randomization, 96 patients were in the TXA group (53%). Demographic data, clinical, biological and radiological features were statistically comparable in the two groups of patients ('TXA' and 'noTXA'). The needs of transfusion or neurosurgery, the mortality rate, the in-hospital length of stay and the dependency at 28-post-traumatic day were similar in the two groups of patients. However, pulmonary embolism was statistically more frequent in 'TXA' group (11.5 versus 2.4%, p = 0.02). CONCLUSION: TXA is an interesting treatment in haemorrhagic shock. Its efficiency in head trauma is still debated and controversial. Its impact on the mortality and the needs of transfusion or surgery were not demonstrated in this study. Nevertheless, its safety worth to be studied in larger samples as we found a higher rate of pulmonary embolism in the treated group.

Update on the Epidemiology of Scorpion Envenomation in the South of Tunisia.

INTRODUCTION: Scorpion envenomation is still a frequent occurance in tropical and subtropical regions. In Tunisia, multiple studies on scorpion envenoming have contributed to an improved understanding of cardiac dysfunction and factors predictive of poor prognosis. These previous studies have contributed to the current standardized management of envenomed patients. However, the epidemiology of scorpion envenoming in Tunisia has not been updated for more than 10 years. The aim of this study was to report an update of the epidemiological features of scorpion envenomation in the southern region of Tunisia. METHODS: This is a retrospective monocentric study including all patients admitted in the emergency room for scorpion envenomation. Cases were collected from emergency medical files during a 3-year period (2013-2015). The diagnosis of scorpion envenomation was made by history of a scorpion sting. All files in which scorpion envenomation was not certain were excluded. Data are presented as mean±SD with range or percentages, as appropriate. RESULTS: We enrolled 282 patients aged 27.4±22.8 years with a 1:1 sex ratio. During surveillance in the emergency room, 39 patients developed cardiac dysfunction. Overall, 42 patients (14.9%) were at stage 3 of severity, and 240 patients (85.1%) had moderate scorpion envenomation (stage 2). Only 1 patient died a few hours after admission. In the remaining cases, the outcome was good. Our results show the improvement in mortality rates even in severe presentations. CONCLUSION: This study found that the outcome of scorpion-stung patients has clearly improved. This enhancement can be explained by early medical consultation and standardized management of patients with predictive factors for cardiac dysfunction.

Epidemiological features of stress hyperglycemia in elderly at emergency department.

UNLABELLED: 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 ≤ 6,9 mmol/l).   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.

Prediction value of the Canadian CT head rule and the New Orleans criteria for positive head CT scan and acute neurosurgical procedures in minor head trauma: a multicenter external validation study.

STUDY OBJECTIVE: The New Orleans Criteria and the Canadian CT Head Rule have been developed to decrease the number of normal computed tomography (CT) results in mild head injury. We compare the performance of both decision rules for identifying patients with intracranial traumatic lesions and those who require an urgent neurosurgical intervention after mild head injury. METHODS: This was an observational cohort study performed between 2008 and 2011 on patients with mild head injury who were aged 10 years or older. We collected prospectively clinical head CT scan findings and outcome. Primary outcome was need for neurosurgical intervention, defined as either death or craniotomy, or the need of intubation within 15 days of the traumatic event. Secondary outcome was the presence of traumatic lesions on head CT scan. New Orleans Criteria and Canadian CT Head Rule decision rules were compared by using sensitivity specifications and positive and negative predictive value. RESULTS: We enrolled 1,582 patients. Neurosurgical intervention was performed in 34 patients (2.1%) and positive CT findings were demonstrated in 218 patients (13.8%). Sensitivity and specificity for need for neurosurgical intervention were 100% (95% confidence interval [CI] 90% to 100%) and 60% (95% CI 44% to 76%) for the Canadian CT Head Rule and 82% (95% CI 69% to 95%) and 26% (95% CI 24% to 28%) for the New Orleans Criteria. Negative predictive values for the above-mentioned clinical decision rules were 100% and 99% and positive values were 5% and 2%, respectively, for the Canadian CT Head Rule and New Orleans Criteria. Sensitivity and specificity for clinical significant head CT findings were 95% (95% CI 92% to 98%) and 65% (95% CI 62% to 68%) for the Canadian CT Head Rule and 86% (95% CI 81% to 91%) and 28% (95% CI 26% to 30%) for the New Orleans Criteria. A similar trend of results was found in the subgroup of patients with a Glasgow Coma Scale score of 15. CONCLUSION: For patients with mild head injury, the Canadian CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher negative predictive value. The question of whether the use of the Canadian CT Head Rule would have a greater influence on head CT scan reduction requires confirmation in real clinical practice.

Post-traumatic pulmonary embolism in the intensive care unit.

OBJECTIVE: To determine the predictive factors, clinical manifestations, and the outcome of patients with post-traumatic pulmonary embolism (PE) admitted in the intensive care unit (ICU). METHODS: During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each trauma patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study period, all trauma patients admitted to our ICU were classified into two groups. The first group included all patients with confirmed PE; the second group included patients without clinical manifestations 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 its branches. RESULTS: During the study period, 1067 trauma patients were admitted in our ICU. The diagnosis of PE was confirmed in 34 patients (3.2%). The mean delay of development of PE was 11.3 ± 9.3 days. Eight patients (24%) developed this complication within five days of ICU admission. On the day of PE diagnosis, the clinical examination showed that 13 patients (38.2%) were hypotensive, 23 (67.7%) had systemic inflammatory response syndrome (SIRS), three (8.8%) had clinical manifestations of deep venous thrombosis (DVT), and 32 (94%) had respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 32 cases (94%) and low molecular weight heparin was used in two cases (4%). The mean ICU stay was 31.6 ± 35.7 days and the mean hospital stay was 32.7 ± 35.3 days. The mortality rate in the ICU was 38.2% and the in-hospital mortality rate was 41%. The multivariate analysis showed that factors associated with poor prognosis in the ICU were the presence of circulatory failure (Shock) (Odds ratio (OR) = 9.96) and thrombocytopenia (OR = 32.5).Moreover, comparison between patients with and without PE showed that the predictive factors of PE were: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO(2)/FiO(2) < 200 mmHg, the presence of spine fracture, and the presence of meningeal hemorrhage. CONCLUSION: Despite the high frequency of DVT in post-traumatic critically ill patients, symptomatic PE remains, although not frequently observed, because systematic screening is not performed. Factors associated with poor prognosis in the ICU are the presence of circulatory failure (shock) and thrombocytopenia. Predictive factors of PE are: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO(2)/FiO(2) < 200, the presence of a spine fracture, and the presence of meningeal hemorrhage. Prevention is highly warranted.

Outcome analysis and outcome predictors of traumatic head injury in childhood: Analysis of 454 observations.

AIM: To determine factors associated with poor outcome in children suffering traumatic head injury (HI). MATERIALS AND METHODS: A retrospective study over an 8-year period including 454 children with traumatic HI admitted in the Intensive Care Unit of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay. Prognosis was defined according Glasgow outcome scale (GOS) performed after hospital discharge by ICU and pediatric physicians. RESULTS: There were 313 male (68.9%) and 141 female patients. Mean age (±SD) was 7.2±3.8 years, the main cause of trauma was traffic accidents (69.4%). Mean Glasgow coma scale (GCS) score was 8±3, mean injury severity score (ISS) was 26.4±8.6, mean pediatric trauma score (PTS) was 4±2 and mean pediatric risk of mortality (PRISM) was 11.1±8. The GOS performed within a mean delay of 7 months after hospital discharge was as follow: 82 deaths (18.3%), 5 vegetative states (1.1%), 15 severe disabilities (3.3%), 71 moderate disabilities (15.6%) and 281 good recoveries (61.9%). Multivariate analysis showed that factors associated with poor outcome (death, vegetative state or severe disability) were: PRISM ≥24 (P=0.03; OR: 5.75); GCS ≤8 (P=0.04; OR:2.42); Cerebral edema (P=0.03; OR:2.23); lesion type VI according to Traumatic Coma Data Bank Classification (P=0.002; OR:55.95); Hypoxemia (P=0.02; OR:2.97) and sodium level >145 mmol/l (P=0.04; OR: 4.41). CONCLUSIONS: A significant proportion of children admitted with HI were found to have moderate disability at follow-up. We think that improving prehospital care, establishing trauma centers and making efforts to prevent motor vehicle crashes should improve the prognosis of HI in children.

Isolated traumatic head injury in children: Analysis of 276 observations.

BACKGROUND: To determine predictive factors of mortality among children after isolated traumatic brain injury. MATERIALS AND METHODS: In this retrospective study, we included all consecutive children with isolated traumatic brain injury admitted to the 22-bed intensive care unit (ICU) of Habib Bourguiba University Hospital (Sfax, Tunisia). Basic demographic, clinical, biochemical, and radiological data were recorded on admission and during ICU stay. RESULTS: There were 276 patients with 196 boys (71%) and 80 girls, with a mean age of 6.7 ± 3.8 years. The main cause of trauma was road traffic accident (58.3%). Mean Glasgow Coma Scale score was 8 ± 2, Mean Injury Severity Score (ISS) was 23.3 ± 5.9, Mean Pediatric Trauma Score (PTS) was 4.8 ± 2.3, and Mean Pediatric Risk of Mortality (PRISM) was 10.8 ± 8. A total of 259 children required mechanical ventilation. Forty-eight children (17.4%) died. Multivariate analysis showed that factors associated with a poor prognosis were PRISM > 24 (OR: 10.98), neurovegetative disorder (OR: 7.1), meningeal hemorrhage (OR: 2.74), and lesion type VI according to Marshall tomographic grading (OR: 13.26). CONCLUSION: In Tunisia, head injury is a frequent cause of hospital admission and is most often due to road traffic injuries. Short-term prognosis is influenced by demographic, clinical, radiological, and biochemical factors. The need to put preventive measures in place is underscored.

Clinical features, complications and mortality in critically ill patients with 2009 influenza A(H1N1) in Sfax,Tunisia.

PURPOSE: Africa, as the rest of the world, was touched by the 2009 pandemic influenza A(H1N1). In the literature, a few publications covering this subject emerged from this continent. We prospectively describe baseline characteristics, treatment and outcomes of consecutive critically ill patients with confirmed 2009 influenza A(H1N1) in the intensive care unit (ICU) of Sfax hospital. METHODS: From 29 November 2009 through 21 January 2010, 32 patients with confirmed 2009 influenza A(H1N1) were admitted to our ICU. We prospectively analysed data and outcomes of these patients and compared survivors and dead patients to identify any predictors of death. RESULTS: Patients were young (mean, 36·1 [SD], 20·7 years) and 21 (65·6%) of whom had co-morbidities. During ICU care, 29 (90·6%) patients had respiratory failure; among these, 15 (46·9%) patients required invasive ventilation with a median duration of 9 (IQR 3-12) days. In our experience, respiratory dysfunction can remain isolated but may also be associated with other dysfunctions or complications, such as, septic shock, seizures, myasthenia gravis exacerbation, Guillan-Barre syndrome, acute renal failure, nosocomial infections and biological disturbances. The nine patients (28·1%) who died had greater initial severity of illness (SAPS II and sequential organ failure assessment (SOFA) scores) but also a higher SOFA score and increasing severity of organ dysfunction during their ICU evolution. CONCLUSION: Critical illness from the 2009 influenza A(H1N1) in Sfax occurred in young individuals and was associated with severe acute respiratory and additional organ system failure. SAPS II and SOFA scores at ICU admission, and also during evolution, constitute a good predictor of death.

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

BACKGROUND: 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. AIM: To search for the microbiological characteristics of catheter-related bacteremia in a Tunisian ICU. METHODS: 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 1st, 2001 to March 31st, 2002), and who submitted to a central venous catheter for more than 24 hours. Catheter-tip specimens were cultured using a semiquantitative method. RESULTS: 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 catheter-related 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. CONCLUSION: 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.

Scorpion envenomation among children: clinical manifestations and outcome (analysis of 685 cases).

Our objective was to characterize both epidemiologically and clinically manifestations after severe scorpion envenomation and to define simple factors indicative of poor prognosis in children. We performed a retrospective study over 13 years (1990-2002) in the medical intensive care unit (ICU) of a university hospital (Sfax-Tunisia). The diagnosis of scorpion envenomation was based on a history of scorpion sting. The medical records of 685 children aged less than 16 years who were admitted for a scorpion sting were analyzed. There were 558 patients (81.5%) in the grade III group (with cardiogenic shock and/or pulmonary edema or severe neurological manifestation [coma and/or convulsion]) and 127 patients (18.5%) in the grade II group (with systemic manifestations). In this study, 434 patients (63.4%) had a pulmonary edema, and 80 patients had a cardiogenic shock; neurological manifestations were observed in 580 patients (84.7%), 555 patients (81%) developed systemic inflammatory response syndrome (SIRS), and 552 patients (80.6%) developed multi-organ failure. By the end of the stay in the ICU, evolution was marked by the death in 61 patients (8.9%). A multivariate analysis found the following factors to be correlated with a poor outcome: coma with Glasgow coma score ≤ 8/15 (odds ratio [OR] = 1.3), pulmonary edema (OR = 2.3), and cardiogenic shock (OR = 1.7). In addition, a significant association was found between the development of SIRS and heart failure. Moreover, a temperature > 39°C was associated with the presence of pulmonary edema, with a sensitivity at 20.6%, a specificity at 94.4%, and a positive predictive value at 91.7%. Finally, blood sugar levels above 15 mmol/L were significantly associated with a heart failure. In children admitted for severe scorpion envenomation, coma with Glasgow coma score ≤ 8/15, pulmonary edema, and cardiogenic shock were associated with a poor outcome. The presence of SIRS, a temperature > 39°C, and blood sugar levels above 15 mmol/L were associated with heart failure.

Risk factors and outcomes of intensive care unit-acquired infections in a Tunisian ICU.

BACKGROUND: ICU-acquired infections constitute an important world-wide health problem. Our aim was to determine the incidence, predictive factors and impact of ICU-AIs in ICU patients in Tunisia. MATERIAL/METHODS: We conducted a prospective observational cohort study over a 3 month period in the medical surgical intensive care unit of Habib Bourguiba University Hospital (Sfax-Tunisia). RESULTS: During the study period 261 patients were surveyed; 44 of them (16.9%) developed 55 episodes of ICU-AI (34.7 ICU-AI/1000 days of hospitalization). The most frequently identified infections were ventilator-associated pneumoniae (58.2%), and primary bloodstream infection (18.2%). The most frequently isolated organisms were multidrug-resistant P. aeruginosa (44.7%), and A. baumannii (21.3%). The initial antibiotic prescription for ICU-AI was inadequate in 9 cases (16.4% of episodes of ICU-AI). At ICU discharge, overall mortality was 29.9%. Independent risk factors for acquiring infection in ICU were the use of central venous catheter (p=0.014) and antibiotic prescription on admission for more than 24 hours (p=0.025), those of mortality in ICU were SAPS II of more than 35 points (p<0.001) and ICU-AI (p=0.002), and those of mortality at 28 days after an episode of ICU-AI were septic shock (p=0.004) and inadequate initial antimicrobial treatment (p=0.011). CONCLUSIONS: We conclude that the occurrence of ICU-AI is significantly related to increased mortality, and that focusing interventions on better use of antibiotics would have a benefit in terms of prevention and consequences of ICU-AI.

Intraperitoneal rupture of renal cyst in autosomal dominant polycystic kidney disease.

CONTEXT: To report a rare case of spontaneous rupture of an infected renal cyst into the peritoneal cavity. CASE REPORT: We report a case of 66-year old man with autosomal dominant polycystic kidney disease and kidney dialysis who had suffered from intestinal obstruction and peritoneal syndrome for 2 days associated with purulent urine. An exploratory laparotomy found multiple hepatic cysts and bilaterally enlarged polycystic kidneys. We noted left renal cyst infected and ruptured into the peritoneal cavity causing general peritonitis. The patient died from septic shock and hemodynamic failure. CONCLUSION: The peritoneal rupture of infected renal cyst is an exceptional and serious complication of polycystic kidney disease. Medical and surgical treatments are urgent to prevent lethal complications.

Epidemiological, clinical characteristics and outcome of severe scorpion envenomation in South Tunisia: multivariate analysis of 951 cases.

The aim of this retrospective descriptive study was to describe both epidemiologically and clinically manifestations following severe scorpion envenomation and to define simple predictive factors which can be used in routine practice in general Intensive Care Units (ICU) as an indicator of poor prognosis. Cases were collected from hospital patients' files during 13-year (1990-2002) period in the medical Intensive Care Unit of a university hospital (Sfax - Tunisia). The diagnosis of scorpion envenomation was based on a history of scorpion sting. Nine hundred fifty-one patients, who were admitted for a scorpion sting, were analyzed. There were 769 patients (80.8%) in the grade III group (with cardiogenic shock and/or pulmonary edema or severe neurological manifestation (coma and/or convulsion)) and 182 patients (19.2%) in the grade II group (with systemic manifestations). Scorpion envenomation is more frequent in summer; indeed 82.3% of our patients were admitted between June and September. The mean age (+/-SD) was 14.7 +/- 17.4 years, ranging from 0.5 to 90 years. In this study 739 patients (77.8%) had neuromuscular signs, 700 patients (73.6%) had gastrointestinal signs and 585 patients (61.5%) had a pulmonary edema, while 195 patients (20.5%) had a cardiogenic shock. The mean blood sugar on admission was at 11.32 +/- 5.66 mmol/l, a high blood sugar level (>11 mmol/l) was observed in 39% of cases. The mean blood urea was at 7.1 +/- 3.2 mmol/l, it was above 10 mmol/l in 10.7% of cases. The mean of leucocytes was at 17 418 +/- 7833 cells/mm(3), it was above 11 000/mm(3) in 80% of cases. In the end of the stay in ICU, evolution was marked by the improvement of 879 patients (92.5%) while 72 patients (7.5%) died. A multivariate analysis found the following factors to be correlated with a poor outcome: age less than 5 years (OR = 2.27), fever >38.5 degrees C (OR = 2.79), coma with Glasgow coma score < or =8/15 (OR = 9.87), pulmonary edema (OR = 8.46), leucocytes >25 000 cells/mm3 (OR = 2.35) and blood urea >8 mmol/l (OR = 4.02). Moreover, in children group, a significant association was found between PRISM score and mortality rate, this model had a high discriminative power with an area under the ROC curve at 0.93. In the adult patients a significant association was found between SAPS II score and mortality rate, this model had a high discriminative power with an area under the ROC curve at 0.82. In summary, in severe scorpion envenomation, age less than 5 years, fever >38.5 degrees C, coma with Glasgow coma score < or =8/15, pulmonary edema, leucocytes >25 000 cells/mm3 and blood urea >8 mmol/l were associated with a poor outcome.

[Acute fatty liver of pregnancy. "Incidence, pathogenesis, diagnosis, treatment and prognosis"]. / La stéatose hépatique aiguë gravidique. "Epidémiologie, physiopathologie, tableau clinique, prise en charge thérapeutique et pronostic".

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 termination and handling in special care or treating complications has lead to good maternofetal results.

End-of-life family conferences: rooted in the evidence.

Critical care clinicians no longer consider family members as visitors in the intensive care unit. Family-centered care has emerged from the results of qualitative and quantitative studies evaluating the specific needs of families of patients dying in the intensive care unit. In addition, interventional studies have established that intensive and proactive communication empowers family members of dying patients, helping them to share in discussions and decisions, if they so wish. In addition to intensive communication, interventional studies have highlighted the role of nurses, social workers, and palliative care teams in reducing family burden, avoiding futile life-sustaining therapies, and providing effective comfort care. End-of-life family conferences are formal, structured meetings between intensivists and family members. Guidelines for organizing these conferences take into account the specific needs of families, including reassurance that the patient's symptoms will be adequately managed; honest clear information about the patient's condition and treatment; a willingness on the part of physicians to listen and respond to family members and to address their emotions; attention to patient preferences; clear explanations about surrogate decision making; and continuous, compassionate, and technically proficient attention to the patient's needs until death occurs. Means of improving end-of-life care have been identified in epidemiologic and interventional studies. End-of-life family conferences constitute the keystone around which excellent end-of-life care can be built.

The effect of ventilator-associated pneumonia on the prognosis of head trauma patients.

BACKGROUND: To investigate the effect of ventilator-associated pneumonia (VAP) on the prognosis of head trauma patients. METHODS: We performed a retrospective case-control study in which 57 head trauma patients with VAP were matched to 57 head trauma patients without VAP. Matching criteria were age (+/-5 years), Glasgow Coma Scale score (+/-2), Injury Severity Score (+/-5), Simplified Acute Physiology Score II (+/-5), and duration of exposure to mechanical ventilation. RESULTS: The most causative organisms of VAP were Pseudomonas aeruginosa, and Acinetobactor baumannii (36.8% and 33.8% of isolated organisms, respectively). The duration of mechanical ventilation, intensive care unit stay, and hospital stay were significantly increased in case patients (13 +/- 8.4, 24.5 +/- 18, and 30.8 +/- 18.6 days, respectively) compared with control patients (8.3 +/- 4.3, 12.3 +/- 8, and 20.3 +/- 18.7 days, respectively). Mortality rate was also higher in case (29.8%) than in control (12.3%) patients (p = 0.02). CONCLUSION: We conclude that the occurrence of VAP caused by high-risk organisms in cranial trauma patients may increase the risk of death, the mechanical ventilation duration, the intensive care unit stay, and the hospital stay.

Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients.

OBJECTIVE: To assess the impact of tracheotomy on sedative administration, sedation level, and autonomy of mechanically-ventilated intensive care unit (ICU) patients. DESIGN, SETTING, AND PATIENTS: In this observational study, the charts of all consecutive patients undergoing mechanical ventilation requiring tracheotomy over a 14-month period in our 18-bed tertiary care ICU were reviewed retrospectively. Patients' sedation levels (according to the Riker's 7-level sedation-agitation score) and intravenous (fentanyl and midazolam) and oral (clorazepate and haloperidol) sedative administration were measured daily during the 7 days before and after tracheotomy. We also recorded patients for whom chair positioning and oral alimentation became possible in the days following tracheotomy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tracheotomy was performed on 72 (23.1%) of the 312 patients undergoing mechanical ventilation for > or = 48 hrs. After tracheotomy, median (25th, 75th percentiles) fentanyl and midazolam administration decreased from 866 (191, 1672) to 71 (3, 426) microg/(patient.day) and from 44 (16, 128) to 7 (1, 42) mg/(patient.day) (p < .001), respectively. Concomitant median time spent heavily sedated decreased from 7 (3, 17) to 1 (0, 6) hrs/day (p < .001), with no increase in agitation time. During the 7 days following tracheotomy, partial oral alimentation became possible for 35 patients (48.6%) and out-of-bed positioning became possible for 16 patients (22.2%). CONCLUSION: On the basis of these observations, we conclude that tracheotomized mechanically ventilated ICU patients required less intravenous sedative administration, spent less time heavily sedated, and achieved more autonomy earlier.

Clinical manifestations of systemic paraphenylene diamine intoxication.

BACKGROUND: To report clinical symptoms and outcome of systemic paraphenylene diamine (PPD) intoxication. METHODS: Our study was retrospective. It was conducted over 6 yrs (1994-2000) in the medical intensive care unit (ICU) of a university hospital and it concerned 19 patients hospitalized for systemic PPD intoxication. RESULTS: The mean age (+/- SD) was 27.9 +/- 16.8 yrs, the sex ratio was about 0.58 and the Simplified Acute Physiology Score (SAPS II) was 30 +/- 27. At admission, clinical symptoms were dominated by cervicofacial edema (79%), chocolate brown colored urine (74%), upper airway tract edema (68.4%), oliguria (36.8%), muscular edema (26.3%) and shock (26.3%). The biological results were dominated by rhabdomyolysis (100%), metabolic acidosis (100%), acute renal failure (ARF) (47.4%) and hyperkalemia (26.3%) (biological disturbances were more pronounced in patients with ARF). The therapies used were gastric lavage (100%), fluid infusion (100%), mechanical ventilation (84.2%), alcalinization (80%), corticosteroids (84.2%), vasopressors (26.3%) and renal replacement therapy (26.3%). The intoxication evolution was marked by the death of six patients (31.6%); five of them had developed ARF. The mechanical ventilation duration and the ICU stay were both more prolonged in patients who developed ARF. CONCLUSIONS: Clinical manifestations of systemic PPD intoxication were associated with respiratory, muscular, renal and hemodynamic syndromes. ARF occurrence testifies to the severity of the intoxication.

Suspected acute interstitial nephritis induced by colistin.

We describe a 35-year-old male admitted to the intensive care unit (ICU) for acute exacerbation of chronic obstructive pulmonary disease (COPD). He developed ventilator-associated pneumonia caused by multidrug-resistant Pseudomonas aeruginosa and was treated with imipenem and colistin without any renal toxicity. The patient was readmitted to the ICU for a 2nd and a 3rd exacerbation of COPD and was again treated with imipenem and colistin. In both episodes, he developed rapid worsening in renal function, which improved following colistin withdrawal. Use of the Naranjo ADR probability scale indicated a probable relationship between the renal failure and the colistin therapy. In addition, the time course of events suggested that colistin was the cause of acute interstitial nephritis in this patient. We conclude that our patient had a possible acute allergic reaction to colistin since the 1st introduction was not associated with any renal toxicity and renal failure was observed on the 1st day of the 2nd and the 3rd initiation of colistin therapy, respectively.

Neurological complications secondary to severe scorpion envenomation.

BACKGROUND: The aim was to study the incidence, clinical manifestations, and prognosis of neurological complications secondary to scorpion envenomation. MATERIAL/METHODS: A retrospective study over a 13-year period including all patients admitted to our ICU for scorpion envenomation. RESULTS: During the period of study, 951 patients were admitted due to scorpion envenomation. Mean age was 14.7+/-17.4 years, ranging from 0.5 to 90 years. Neuromuscular signs were observed in 739 patients (78%), coma (Glasgow Coma Score 12) in 15.4% of cases, and convulsions in 6%. The other neurological signs observed were: agitation in 709 patients (74.6%), squint in 119 patients (12.5%), bilateral miosis in 43 patients (5%), and a bilateral mydriasis in 16 patients (1.7%). Brain CT was performed in 10 patients, these being abnormal in 90% of cases. In our study the presence of coma (p<0.001), convulsions (p<0.001), bilateral miosis (P<0.001), and the presence of bilateral mydriasis (P<0.001) correlated with poor outcome. CONCLUSIONS: Neurological manifestations were often observed in severe scorpion-envenomed patients and they correlated with poor outcome. Their mechanisms are complex. Prevention is highly warranted.