[Prevalence of dysphosphoremia in patients admitted in intensive care unit with an impaired renal function]. / Prévalence des dysphosphorémies chez les patients admis en réanimation avec une altération de la fonction rénale.

OBJECTIVE: To assess the frequency of dysphosphoremia in patients admitted in intensive care unit with an impaired renal function and to determine the associated risks factors. Study design. - Epidemiological prospective study. PATIENTS AND METHODS: The creatinine clearance and the phosphoremia were measured in 134 consecutive patients admitted in intensive care unit over a six-month period. Patients with chronic renal failure were excluded. Known risk factors for hypophosphoremia in intensive care unit were recorded. RESULTS: Seventy-nine out of one hundred thirty-four patients (59%) had an impaired renal function (arbitrarily defined by a creatinine clearance < 60 ml/min). The proportion of patients with impaired renal function that where hypo-, normo- (0.8 to 1.2 mmol/l) or hyperphosphoremic was 16, 34 and 50% respectively. Hypophosphoremia was severe (< 0.5 mmol/l) in 5 patients, all with impaired renal function. No risk factors usually associated with hypophosphoremia could be identified. CONCLUSION: As opposed to chronic renal failure patients who are mainly hyperphosphoremic, patients admitted in intensive care unit with an impaired renal function may present with a normo-, or hypophosphoremia. These dysphosphoremias are sometimes severe. Phosphate status should be promptly determined at admission.

[Preoperative screening and nutritional support of nutritional deficiencies]. / Dépistage et stratégies préventives préopératoires des carences nutritionnelles.

Nutritional deficiencies have to be considered as an independent risk factor for postoperative morbidity. Peri-operative nutritional support reduce this risk in elective abdominal surgery for cancer and cardiac surgery. Preoperative nutritional support for 7-10 days reduce postoperative complications in undernourished patients by 10% but is not operant when administered after surgery. Enteral route is as effective. Recent studies using immunonutrients conclude that a short preoperative oral intake is able to reduce complications even in well-nourished patients. Then, a preoperative nutritional screening must be routinely performed leading to a nutritional programme.

Total parenteral nutrition enriched with arginine and glutamate generates glutamine and limits protein catabolism in surgical patients hospitalized in intensive care units.

OBJECTIVES: To study the effect of a parenteral nutrition solution enriched with potential precursors of glutamine, i.e., arginine and glutamate, on plasma glutamine concentrations and protein metabolism. DESIGN: Prospective, randomized, single-blind, comparative study. SETTING: Two intensive care units in two different hospitals. PATIENTS: Fifteen surgical patients. INTERVENTIONS: Patients were randomized to receive total parenteral nutrition for 5 days with the enriched glutamine precursor solution (GlnP+ group) or a conventional solution (control group), both total parenteral nutrition providing 0.25 gN/kg per day and 35 kcal/kg per day (glucose/lipids, 70%:30%). MEASUREMENTS AND MAIN RESULTS: Plasma amino acid concentrations before (T0) and after 3 hrs (T3) of perfusion, nitrogen balance (daily and cumulated), and urinary excretion of 3-methylhistidine were measured daily from day 1 to day 5. The two groups were identical for age, weight, severity score, and nitrogen and energy intakes. After a 3-hr perfusion, plasma concentrations of arginine, ornithine, and glutamine increased, and the differences (T3 - T0) were significantly higher in the GlnP+ group: arginine, 107.6+/-7.0 vs. 51.9+/-3.3 (mean over 5 days; p < .001); ornithine, 78.9+/-7.1 vs. 43.6+/-3.1 (p < .001); and glutamine, 32.4+/-8.6 vs. 6.7+/-5.0 micromol/L (p < .05), respectively. A positive correlation was found between arginine and glutamine plasma increases only in the GlnP+ group: r = .45; p < .01 (Spearman's rank-correlation test). Daily and cumulated nitrogen balances were not significantly different between the two groups but were positive (difference from 0) only in the GlnP+ group. The urinary 3-methylhistidine/creatinine ratio decreased significantly from day 1 to day 5 only in the GlnP+ group: 24.5+/-2.7 vs. 18.8+/-2.7 micromol/mmol (p < .05). CONCLUSIONS: Total parenteral nutrition enriched with arginine and glutamate promotes a better nitrogen balance, limits protein myofibrillar catabolism, and generates glutamine, with arginine (not glutamate) probably being the main contributor to the glutamine-generating effect of the solution through the formation of ornithine.

[Severe pulmonary embolism with two indications for inferior vena cava filter placement]. / Une embolie pulmonaire grave avec deux indications à la mise en place d'un filtre dans la veine cave inférieure.

A case of severe pulmonary embolism, treated with thrombolysis, and complicated by a haemorrhagic shock (peritoneal bleeding after a spleen trauma) is reported. A paradoxical renal artery embolism occurred, due to a patent foramen ovale. The benefit of a inferior vena cava filter insertion in case of paradoxical embolism is discussed.

[Nutrition in acute pancreatitis]. / Nutrition des pancréatites aiguës.

Severe acute pancreatitis is a two-phase systemic disease. The first phase is a clinical response resulting from systemic effects of proinflammatory mediators called SIRS (systemic inflammatory response syndrome), that may lead to multiple organ failure and death. The second phase, if the process is not reversed by natural defences or treatment, may be accompanied by local complications such as infected pancreatic necrosis. The severity of the disease must be established early to identify patients requiring intensive monitoring and support. The clinico-biochemical score (Ranson score) is about 80% accurate at 48 hours but is not accurate before this time; the APACHE II system has the sensitivity to predict severe pancreatitis in 61% of patients on admission. Although not perfect, the prognostic systems of severity remain better than clinical judgement. SIRS followed by local complications is accompanied by increased energy requirements and, with the absence of oral intake, a persistently negative nitrogen balance and mineral and micronutrient deficiencies. Thus, early nutritional support is indicated. Formerly, total parenteral nutrition was the standard practice for providing exogenous nutrients avoiding pancreatic stimulation. The use of early enteral feeding has recently been evaluated. Gastric atony and obstruction of the duodenum by pancreatic oedema or necrosis have been overcome by delivering enteral nutrition to the jejunum, distal to the ligament of Treitz; in this position, regular diets do not stimulate pancreatic secretions. The efficacy, tolerance, clinical outcome and cost of enteral nutrition suggest that this feeding route should be preferred in patients with severe acute pancreatitis.

Acute pancreatitis and preeclampsia-eclampsia: a case report.

A case of preeclampsia-eclampsia leading to acute edematous pancreatitis is reported, probably related to microvascular abnormalities and splanchnic ischemia. Recovery was uneventful.

Efficacy of 2-month total parenteral nutrition in AIDS patients: a controlled randomized prospective trial. The French Multicenter Total Parenteral Nutrition Cooperative Group Study.

OBJECTIVE: To evaluate the efficacy of total parenteral nutrition in AIDS patients. DESIGN: A prospective, randomized, controlled, multicentre trial. METHODS: Over a period of 2 months, 31 malnourished and severely immunodepressed AIDS patients were assigned to receive either dietary counselling (n = 15) or home total parenteral nutrition (TPN; n = 16) via a central venous access after an educational program. Results were analysed by intent-to-treat basis. RESULTS: Bodyweight change was +8 kg (+13 +/- 3%) in the TPN group and -3 kg (-6 +/- 2%) in the control group (P < 0.0006). Lean body mass increased in the TPN group (+9 +/- 3%) and decreased in the control group (-5 +/- 3%; P < 0.004) while body cell mass increased in the former (+15 +/- 4%) and decreased in the latter (-12 +/- 6%; P < 0.002). Nutritional subjective global assessment, subjective self-reported health feeling and Karnofsky index were also improved by TPN. Infection line sepsis incidence remained low (0.26 per 100 patient-days). However, no difference in survival rate was exhibited between the two groups by the log-rank test. CONCLUSION: We conclude that home TPN is an efficient treatment of malnutrition in severely immunodepressed AIDS patients.

Renal effects of low-dose dopamine in patients with sepsis syndrome or septic shock treated with catecholamines.

OBJECTIVE: To evaluate the renal effects of low-dose dopamine in patients with sepsis syndrome or septic shock treated with catecholamines. DESIGN: Prospective, clinical study using sequential periods. SETTING: A 12-bed surgical intensive care unit in a university hospital. PATIENTS: 14 patients with sepsis syndrome and 15 patients with septic shock treated with exogenous catecholamines were studied. They had no diuretic treatment. INTERVENTION: Two periods of 2 h each with and without 2 micrograms.kg-1.min-1 of dopamine infusion. Hemodynamic and renal data were obtained at the end of each period. Measurements were repeated after 48 h of dopamine infusion in patients with sepsis syndrome. All data were evaluated by the Wilcoxon rank test. MEASUREMENTS AND RESULTS: In patients with sepsis syndrome, diuresis and creatinine clearance increased significantly by 100% and 60%, respectively, during low-dose dopamine infusion without any change in systemic hemodynamics. The renal response to dopamine decreased significantly after 48 h of dopamine infusion (P < 0.01). In patients with septic shock treated with catecholamines, no variation of either systemic hemodynamics or renal function was noted during low-dose dopamine infusion. CONCLUSION: The renal effects of low-dose dopamine in patients with sepsis syndrome decrease with time. No renal effect of low-dose dopamine was observed in patients with septic shock treated with catecholamines. These findings suggest a desensitization of renal dopaminergic receptors.

High incidence of hypophosphatemia in surgical intensive care patients: efficacy of phosphorus therapy on myocardial function.

OBJECTIVE: To determine the incidence of hypophosphatemia in a surgical intensive care unit and to determine whether or not a phosphorus challenge causes a change in cardiac performance in hypophosphatemic patients. DESIGN: Prospective clinical study and case reports. SETTING: Surgical intensive care unit in an university hospital. PATIENTS: A total of 208 consecutive patients admitted to the surgical ICU were evaluated over a 6 months period. INTERVENTIONS: All classical risk factors for hypophosphatemia were recorded. A group of 8 moderate or severe hypophosphatemic patients were evaluated for hemodynamic data before and after a phosphorus load. Glucose phosphate was given over 30 min by the intravenous route. Dosage regimen was 0.4 mmol/kg weight for moderate hypophosphatemia and 0.8 mmol/kg weight for severe hypophosphatemia. RESULTS: Risk factors were present in 134 patients and 60 patients were hypophosphatemic (44.8%). Only 3 risk factors were discriminant for hypophosphatemia: sepsis, diuretics and total parenteral nutrition. The mortality was higher in the hypophosphatemic group than in the normophosphatemic group (30% versus 15.2%; p < 0.05). Cardiac performance improved after phosphatemia normalization in all patients (cardiac index: 3.82 +/- 1.87 versus 4.52 +/- 1.83 1/min.m2; p < 0.01). CONCLUSION: This study underlines the high incidence (28.8%) of hypophosphatemia in surgical intensive care patients and its association with a high mortality rate (30%). A short course of phosphotherapy improves cardiac index (+18%).

Phlegmonous gastritis associated with HIV-1 seroconversion. Endoscopic and microscopic evolution.

A 40-year-old man presented with peritonitis. Diagnosis of phlegmonous gastritis was made by laparotomy. Conservative treatment combined with antibiotics was successful. Multiple endoscopies with biopsies illustrate the natural history of this disease. The patient developed HIV-1 seroconversion during hospital stay. Prompt diagnosis and treatment may improve the prognosis of this often lethal disease.

Predictability of clinicobiochemical scoring systems for early identification of severe gallstone-associated pancreatitis.

Early identification of severe gallstone-associated acute pancreatitis (GAAP) is a prerequisite for treatment with urgent endoscopic sphincterotomy. This study assesses the value of two clinicobiochemical scoring systems to this end. Over the 7-year period from 1983 to 1989, 100 consecutive patients with acute pancreatitis (45 related to gallstones, 36 to alcohol, and 19 of undetermined etiologies) had clinicobiochemical analysis within 48 hours of admission. The final diagnosis and outcome were retrospectively compared with the prediction achieved by the scoring systems. With regard to Blamey's criteria for early identification of gallstones, significant differences were found between the biliary and nonbiliary groups with respect to female sex, serum amylase concentration greater than or equal to 4,000 IU/L, alkaline phosphatase level greater than or equal to 300 IU/L, and alanine aminotransferase level greater than or equal to 100 IU/L (all p values less than 0.001). Age greater than or equal to 50 years was found to be significant (p less than 0.02) only in differentiating gallstone- versus alcohol-associated acute pancreatitis. When three or more positive factors were present, the sensitivity and specificity for predicting gallstones were 60% and 87%, respectively; the predictive value of a positive result was 79%, of a negative result 74%, and the overall accuracy was 75%. At a cutoff level of five, rather than three or more prognostic factors, the modified Ranson's criteria for patients known as having GAAP allowed a suitable discrimination of patients with an expected high risk of complications and mortality. When the two scoring systems (Blamey greater than or equal to 3 and Ranson greater than or equal to 3) were combined, 17 patients were predicted as having severe GAAP: 6 of these 17 patients were misdiagnosed as having biliary pancreatitis, whereas 9 patients with definite severe GAAP were not selected because of a Blamey score less than 3. More specific diagnostic tools are needed, and higher cutoff levels for prognostic scores are required for the prediction of severe GAAP, particularly in view of selecting patients for potentially dangerous approaches such as urgent endoscopic sphincterotomy.

[Perioperative parenteral nutrition. For whom? How?]. / Nutrition parentérale péri-opératoire. Pour qui? Comment?

Preoperative artificial feeding (for 7 to 15 days) through an enteral or parenteral route is justified only in a subgroup of patients suffering form severe denutrition, who are scheduled for surgery with high morbidity or mortality. Postoperatively, the field of indication is broader, and it includes any patients who cannot soon feed themselves enough to catch their resting energy expenditure plus 20%. The administration route should use the technique with the lowest morbidity (enteral feeding) and the lowest costs. The role of new substrates (structured lipids, glutamine, trace elements) on immunity should be specified.

Effect of zinc on the immune status of zinc-depleted AIDS related complex patients.

Zinc deficiency has been recently reported in AIDS patients to be associated with a decrease in T helper cells. The effect of zinc supplementation was evaluated in 5 ARC patients and 5 control subjects using lymphocyte subset counts, blast transformation and chemiluminescence of polymorphonuclear leukocytes. Zinc was analysed by atomic absorption spectrophotometry. T-cell subsets were quantified by cytofluorometry. Chemiluminescence of PMN was measured by phagocytosis of opsonized zymosan. The ARC patients had significantly lower zinc concentrations in the RBC prior to supplementation (p < 0.05). This level increased following the administration of zinc gluconate. This increase was accompanied by (i) an increase in HLA.Dr + cells with no CD4 CD8 ratio alteration; (ii) a stimulation of lymphocyte transformation and PMN chemiluminescence particularly after 15 days' high zinc supplementation. Such a reconstitution in specific and non specific immune functions in ARC patients may warrant further investigation.