Physical and rehabilitation medicine (PRM) care pathways: adults with severe traumatic brain injury.

This document is part of a series of guidelines documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These reference documents focus on a particular pathology (here patients with severe TBI). They describe for each given pathology patients' clinical and social needs, PRM care objectives and necessary human and material resources of the pathology-dedicated pathway. 'Care pathways in PRM' is therefore a short document designed to enable readers (physician, decision-maker, administrator, lawyer, finance manager) to have a global understanding of available therapeutic care structures, organization and economic needs for patients' optimal care and follow-up. After a severe traumatic brain injury, patients might be divided into three categories according to impairment's severity, to early outcomes in the intensive care unit and to functional prognosis. Each category is considered in line with six identical parameters used in the International Classification of Functioning, Disability and Health (World Health Organization), focusing thereafter on personal and environmental factors liable to affect the patients' needs.

An evaluation of a post-acute rehabilitation unit after five years of operations.

INTRODUCTION: The Hospital Organization Guidelines (HOG) recently recommended that Reference Hospitals create Post-Acute Rehabilitation Units (PARU). The authors describe the quality process of a PARU in a University Hospital (UH); this quality process had previously been used in a private rehabilitation hospital. GOALS: The authors wanted to evaluate the organization of the care provided in their PARU and compare the evaluation results with the results expected at the unit's creation five years earlier. METHODS: The evaluation indicators were set when the unit was created. These indicators allowed the evaluation of the appropriateness of admissions, the efficiency of the care path and the response to the patients' rehabilitation and intensive care needs. RESULTS: The appropriateness of admission was found to be coherent with the typology of patients admitted (i.e., brain and spinal cord injured patients just discharged from intensive care units). The brain-injured care path was streamlined. The evaluation results raised several questions about the resources provided and about the different needs of post-acute care and rehabilitation. DISCUSSION AND CONCLUSION: Patient needs must be identified precisely if the weak links of the care path are to be reinforced. The indicators used must be capable of assessing both the quantity and the quality of care. If these indicators lack relevance, or if the health care organization responds incompletely to patient needs, it puts the efficiency of the whole system at stake.

[Intensive care handling: specific expectations of rehabilitation]. / Attentes spécifiques du médecin rééducateur sur la prise en charge en réanimation.

For the severe head injured patients, the way of going from coma to arousal is considerably different from one patient to the other, and it is not always easy to determine the appropriate moment for taking them out of intensive care, into rehabilitation. This is the reason why, instead of considering these two treatments as successive phases, it is better to consider them as a collaboration process. The objective of this paper is to describe the needs of this type of patients, by using the data gathered on a weekly basis in the medical data department of the Centre Médical de l'Argentière, on patients admitted in 2002 in the rehabilitation and post-intensive care departments. A typology can be defined with the association of three characteristics: several disabilities; physical, behavioural and relational impairments; need for a multidisciplinary rehabilitation team. This typology requires a specific rehabilitation treatment as from the acute phase of intensive care.

[Ethical and legal points concerning minimally conscious state and permanent vegetative state]. / Aspects éthiques et juridiques posés par les états paucirelationnels et l'état végétatif chronique.

The ethical and legal problems posed by severe outcome of coma are complex and their analysis requires a multi-disciplinary approach. Three aspects have been particularly studied in this paper. The first is a reminder of the medical definitions of the concepts of vegetative state and minimally conscious state. The second focuses on the analysis of the ethical and legal debate of these conditions at an international level. Finally, the third concerns the wealth prospects, proposed, in France, by the circular letter dated May 3, 2002.

[Management of infectious risk associated with therapeutic pools]. / Gestion des risques infectieux liés aux piscines et bains collectifs à usage médical.

UNLABELLED: There is no specific legislation concerning pools and others medical hydrotherapy equipments relating hygiene and security rules. For this reason, the hydrotherapy pools use the public swimming pools legislation. METHOD: This article is based on literature review (database Medline and Embase--manual research). RESULTS: This article offers a review of pool associated infections along with the description of the measures designed to minimise the possible transmission of infection during hydrotherapy activities such as: Technical measures: pool and premises conception, water treatments, feed tanks, air quality. Hygiene rules for patients and hospital staff and pathologies which are contra-indications to hydrotherapy activities. Microbiological and physico-chemical monitoring. DISCUSSION: The infectious risk remains low with therapeutic pools. However, the development of specific legislation and surveillance should be enhanced. CONCLUSION: All these measures are part of the quality assurance program that must be implemented to control the safety of these installations.

[How can we define the modalities and clinical levels of coma to wakefulness?]. / Comment définir les modalités et les niveaux cliniques de passage du coma à l'éveil ?

OBJECTIVE: The starting point of the French conference of consensus concerning arousal after coma was to answer the following question: "How can we define the ways of going from coma to arousal and their clinical levels? MATERIALS AND METHOD: A team of readers have picked up in the literature one hundred and fifty papers, out of which fifty six have been analysed. RESULTS: From this analysis, three points emerged: The concepts of coma and arousal; The conditions of evolution from coma to arousal; Various groups of patients depending on their expressing arousal. One could not find any consensual model concerning the different ways of going from coma to arousal. The variability of the technics and the changing validity of all scores did not allow the conditions of arousal to reach a satisfactory level of proof. The Glasgow Coma Scale (GCS) is the recognised standard for severe wakefulness' impairment, but it is not sensitive enough while patients' arousing. The Glasgow Outcome Scale (GOS) takes into account the patients' situations far later and does not include situations such as Minimally Conscious States (MCS). That's why we face multiple scores, either ordinal, or categorial, all tending to evaluate the slow levels of arousal. CONCLUSION: Clinical findings concerning arousal are to be completed by non-clinical data. This would be greatly helpful to define appropriate management concerning individualized groups of patients. At this stage, another challenge for clinicians is to make the difference between emerging wakefulness and growing conscious activity.

[Study of incidence and risk factors of nosocomial urinary tract infection in patients with indwelling urinary catheter in intensive care units]. / Etude de l'incidence et des facteurs de risque de l'infection urinaire nosocomiale chez les malades sondés en réanimation polyvalente.

A prospective study was carried out in a medical and surgical ICU to determine the incidence of nosocomial urinary tract infection (NUTI) and to identify the most important risk factors. Over a 6 month period, 180 patients were included. All had an indwelling catheter. Six risk factors were studied: age, sex, illness (medical, surgical, trauma), hospital or extra-hospital origin, simplified acute physiology score and length of bladder catheterization. Forty three patients developed a NUTI. Length of bladder catheterization was the only significant different risk factor in infected and non-infected patients. Kaplan Meir analysis was used to determine time to development of NUTI. The risk rose from 19% for 5 day long catheterization to 50% for 14 day long catheterization.

[Traumatic rupture of the bladder. Apropos of 11 cases]. / Les ruptures traumatiques de la vessie. A propos de onze cas.

Eleven cases of rupture of bladder were observed within 7 years. Four of them were due to a direct trauma on a full bladder (group I), the other seven occurred during a complex trauma, constantly with a fracture of the pelvis (group II). In group I, the rupture was situated on the apex of the bladder. The symptoms were a suprapubic pain in four patients, a hematuria in two, and an anuria in one. In the four patients, intraperitoneal fluid was clinically evident, and confirmed ultrasonographically. An urography was performed in two patients and showed an intraperitoneal leak in our patient, and intravesical clots in the other one. The four patients were operated on within 48 hours, and were successfully treated by suture and vesical catheter. In group II, the vesical injury was revealed by hematuria (2 patients) hemorragic shock (2 patients) or both (2 patients). In the last patient, an abdominal pain after 10 days was the only symptom. Clinical signs of hemoperitoneum were present in only four patients and were confirmed ultrasonographically in two out of five patients. The urogram was normal in two of four patients. In one patient it showed a small bladder, and in another one a vesical leak. Five patients were operated on among where three in emergency and two after 9 and 10 days. Four patients with intraperitoneal rupture were successfully tread by suture of the bladder. Among three patients with extraperitoneal rupture, one had an additional tear of the mesentery and died from intravascular coagulation, the second was successfully treated by a suture, and the last one by a vesical catheter only.(ABSTRACT TRUNCATED AT 250 WORDS)

[Role of invasive technics in the occurrence of nosocomial infections. At an intensive care unit]. / Place des techniques vulnérantes dans la survenue des infections nosocomiales. En réanimation.

A prospective study was carried out in a polyvalent medical intensive care unit to determine the role played by diagnostic and therapeutic invasive techniques in the development of four nosocomial infections. Over a 6-month period, 206 patients admitted for more than 48 hours were studied; all had undergone one or several invasive techniques: 76 patients (37 per cent) developed a total of 117 nosocomial infections including urinary tract infection (41.8 per cent), purulent bronchitis (37.5 per cent) septicaemia (11.6 per cent) and pneumonia (7.6 per cent). The risk factors were: duration of urinary or vascular catheterization, tracheal intubation, tracheotomy and artificial ventilation. Gram-negative bacilli (59 per cent) predominated over Gram-positive cocci (39.6 per cent).

Norepinephrine therapy has no deleterious renal effects in human septic shock.

We investigated 25 patients (aged 20 to 70 yr) in septic shock with low systemic vascular resistance in order to assess the effects on renal function of prolonged (24 to 240 h) norepinephrine (NE) infusion (range 0.5 to 1.5 micrograms/kg.min). Two sets of renal function tests were made: a) control study before NE therapy after the initial intravascular loading and on dopamine infusion (mean dosage 14 +/- 2 micrograms/kg.min); b) in the last 24 h of NE infusion associated with dopamine (2 to 3 micrograms/kg.min). The following renal function tests were measured: urine flow rate, creatinine, osmolar and free water clearances, and fractional excretion of sodium (FENa). Data were collected only in 22 nonanuric patients: urine flow rate, creatinine, and osmolar clearance increased (p less than .001), and free water clearance (p less than .001) and FENa (p less than .02) decreased. These results suggest that NE (0.5 to 1.5 micrograms/kg.min) may be used in the treatment of human septic shock without deleterious renal effects.

[Bacterial contamination of the inspiratory circuit of artificial ventilation apparatus: influence of the frequency of circuit renewal and the duration of ventilation]. / Etude de la contamination bactérienne du circuit inspiratoire d'appareils de ventilation artificielle: influence de la fréquence de renouvellement du circuit et de la durée de ventilation.

In a study concerning contamination of artificial ventilators (Drager model UV1), the influence of 2 parameters was assessed: the frequency of changing the circuit (2 and 4 days) and the interval between admission of the patient into the intensive care unit and obtaining the sample. As a function of these variables, 4 groups of 15 patients each were constituted. The levels of contamination noted at 4 sites in the inspiratory phase tubing (cascade humidifier, condensate collector, tubing nearest to the patient and tubing nearest to the humidifier) and in the gas flow showed no significant difference between the groups, regardless of whether the circuit was changed after 2 or 4 days, or whether the patient had been recently admitted to the department or had been there for at least 6 days. Quantitative and qualitative study of bacteria showed that the one(s) contaminating the inspiratory phase tubing were the same as the one(s) colonizing the tracheal secretions of the patient, and that the most contaminated areas were those nearest to the patient (proximal tubing, collector), which confirms the retrograde contamination of the circuit.

[Immunologic response in herpes encephalitis: development of the antibody serum/cerebrospinal fluid ratio in 13 cases]. / Réponse immunologique dans les encéphalites herpétiques: évolution du rapport anticorps sériques/rachidiens dans treize observations.

Serological monitoring was performed in 13 cases of herpetic encephalitis (one infant and 12 adults). Samples taken simultaneously from blood and cerebrospinal fluid (CSF) were tested before and after initiation of antiviral treatment. Antiherpesvirus (anti-HSV) antibodies were assayed by an ELISA method. The state of the blood-brain barrier was controlled by assaying other antiviral antibodies. Immune response was studied during the 3-to-4 weeks of the course of the infection. Anti-HSV IgG levels in CSF increased markedly after 12 days. At the same time, antibody serum/CSF ratios dropped below a value of 20, indicating intrathecal secretion of the antibody. Based on results in monitoring these 13 cases, it may be suggested that 3 samples of serum and CSF are required to confirm the herpetic etiology, including 2 samples taken during the second week of the course of encephalitis.

A reappraisal of norepinephrine therapy in human septic shock.

The effectiveness and safety of iv infused norepinephrine (0.5 to 1 microgram/kg X min) were evaluated in 12 hyperdynamic vasodilated septic patients, who remained hypotensive despite iv volume expansion and antimicrobial and dopamine therapy. During norepinephrine infusion, mean arterial pressure and systemic vascular resistance index increased (p less than .001) and heart rate decreased (p less than .02). Cardiac index either increased or was unchanged in ten patients and decreased slightly in the remaining two patients. Urine flow increased (p less than .01) and was more than 0.5 ml/min when a critical renal perfusion pressure was reached if renal damage was not overwhelming. We conclude that norepinephrine may improve arterial BP and urine flow when volume replacement and dopamine therapy have failed to reverse the hypotension of septic shock.

[Comparison of fosfomycin-penicillin M and penicillin M-gentamycin. Apropos of 35 severe infections caused by methicillin-sensitive Staphylococcus aureus]. / Comparaison entre fosfomycine-pénicilline M et pénicilline M-gentamicine. A propos de 35 infections sévères à Staphylococcus aureus méticilline-sensibles.

Two combined antibiotic treatments were compared in 35 cases of methicillin-sensitive Staph. aureus infection. Eighteen patients (including 17 with septicaemia) received penicillin M (methicillin or oxacillin) and gentamicin daily for a mean period of 11 days. Clinical and bacteriological cure was obtained in 14 cases; 2 of these 14 patients developed superinfection with gentamicin-resistant enterobacteria, 1 relapsed and 2 had renal impairment. Seventeen patients (including 15 with septicaemia) were given fosfomycin and penicillin M for a mean period of 17 days. Clinical and bacteriological cure was obtained in 16 patients; the patient with clinical and bacteriological failure died. There was no superinfection or relapse; 3 patients had hypokalaemia and 1 had renal damage caused by methicillin. The clinical and bacteriological results, therefore, were in favour of the fosfomycin-methicillin combination, but the only statistically significant difference between the two groups concerned the complications.

Preoperative acute volume loading in patients with pheochromocytoma.

Ten patients with pheochromocytoma underwent preoperative acute volume loading to determine whether fluid infusion severely increased pulmonary capillary wedge pressure without improving forward flow, and to provide a guide for intraoperative volume replacement. In one patient, volume loading confirmed baseline pressure data suggesting a discrepancy between right and left ventricular filling pressures. In a second patient with normal baseline wedge pressure, volume loading revealed an unsuspected ventricular dysfunction. During subsequent surgery, both volume and speed of fluid infusion were adapted to the preoperative ventricular response.

[Measurement by mass spectrometry of oxygen consumption and carbon dioxide production in mechanically ventilated patients]. / Mesure par spectrométrie de masse de la consommation d'oxygène et de la production de gaz carbonique chez les patients ventilés artificiellement.

The authors present a technique of VO2 and VCO2 measurements by a non invasive method in mechanically ventilated patients. Inspirated and expirated gas are sampled respectively in the inspiratory limb of the patient's breathing circuit and in a mixing chamber. Gas samples are analysed by mass spectrometry in the laboratory. Expiratory flow rate is determined by the ventilator flowmeter. To evaluate this procedure the authors have studied the stability of the inspirated and expirated gas samples and the reproductibility of measurements. In a patient with respiratory and haemodynamic stable status this method measures VO2 within 8,2% and VCO2 within 7%.

[Critical study of the serological diagnosis of herpetic encephalitis. Apropos of 4 cases]. / Etude critique du diagnostic sérologique de l'encéphalite herpétique. A propos de quatre observations.

Virologic study was performed in four cases of Herpes simplex virus encephalitis. Herpes simplex virus type 1 was recovered from surgical brain biopsy specimens taken in three cases. Anti-HSV antibodies were assayed in simultaneous blood and cerebrospinal fluid samples by ELISA. CSF and serum specific antibody ratios were compared to those of antibodies directed against other viral antigens whenever possible. A significant and early increase in this CSF/serum ratio was demonstrated in two patients. The diagnostic value of this serological method is discussed, as an alternative to viral isolation from brain biopsy specimens.