[The role of hyperbaric oxygen therapy in radiation-induced digestive disorders. 36 cases]. / Intérêt de l'oxygènothérapie hyperbare dans la pathologie digestive post-radique. 36 observations.

OBJECTIVES: Study the effect of hyperbaric oxygen on chronic irradiation induced digestive disorders. PATIENTS AND METHODS: A retrospective study was conducted in 36 patients (mean age 66 +/- 11 years) with chronic digestive tract necrosis which had developed a mean 42 months after irradiation therapy. Hyperbaric oxygen therapy was given a mean 17 months after symptom onset: failing healing (n = 9), rectal bleeding (n = 19), profuse diarrhea (n = 9), recurrent anal abscess (n = 1). The severity of the digestive tract radionecrosis was quantified using the Soma-Lent scale. Hyperbaric oxygen therapy was grade 1 (n = 1), grade 2 (n = 11), grade 3 (n = 16), grade 4 (n = 8). RESULTS: Thirty-six patients underwent a mean 67 hyperbaric sessions (100% O2, 2.5 atm, 90 min). Three patients died within one month of the first session due to radiation enteritis, a neoplastic process or another concomitant cause. Immediate outcome after hyperbaric oxygen therapy was cure (n = 3) or improvement (n = 16) in 19 patients (53%) and failure in 17 (47%). Long-term results evaluated in 32 subjects with a mean 52 months follow-up were: cure (n = 9) or improvement (n = 12) in 21 patients (66%) and failure in 11 (34%). Nine patients died within a mean 25 months after the end of the hyperbaric sessions. Death was related to digestive tract radionecrosis in 1 case and neoplasia in 5. CONCLUSION: Hyperbaric oxygen therapy provides clinical relief in 2 out of 3 patients and can be a useful alternative to conventional treatment in patients with chronic radiation-induced necrosis of the digestive tract.

Nosocomial infections: prospective survey of incidence in five French intensive care units.

OBJECTIVE: To assess the incidence and to evaluate the feasibility of inter-unit continuous surveillance of intensive care unit (ICU)-acquired infections. DESIGN: Prospective multicentre, longitudinal, incidence survey. SETTING: Five ICUs in university hospitals in western France. PATIENTS: All patients admitted to the ICU during two 3-month periods (1994-1995). MEASUREMENTS AND RESULTS: The main clinical characteristics of the patients, ICU-acquired infections, length of exposure to invasive devices and the micro-organisms isolated were analysed. The study included 1589 patients (16970 patient-days) and the infection rate was 21.6 % (13.1 % of patients). The ventilator-associated pneumonia rate was 9.6 %, sinusitis 1.5 %, central venous catheter-associated infection 3.5 %, central venous catheter-associated bacteraemia 4.8 %, catheter-associated urinary tract infection 7.8 % and bacteraemia 4.5 %. The incidence density rate of ICU-acquired infections was 20.3% patient-days. Ventilator-associated pneumonia and sinusitis rates were 9.4 and 1.5% ventilation-days, respectively. Central venous catheter-associated infection and central venous catheter-associated bacteraemia rates were 2.8 and 3.8% catheter-days, respectively. The catheter-associated urinary tract infection rate was 8.5% urinary catheter-days and the bacteraemia rate 4.2% patient-days. Six independent risk factors for ICU-acquired infection were found by stepwise logistic regression analysis: absence of infection on admission, age > 60 years, length of stay, mechanical ventilation, central venous catheter and admission to one particular unit. A total of 410 strains of micro-organisms were isolated, 16.8 % of which were Staphylococcus aureus (58.0% methicillin-resistant). CONCLUSION: This prospective study using standardised collection of data on the ICU-acquired infection rate in five ICUs identified six risk factors. It also emphasized the difficulty of achieving truly standardised definitions and methods of diagnosis of such infections.

Short and longterm outcomes for patients with systemic rheumatic diseases admitted to intensive care units: a prognostic study of 181 patients.

OBJECTIVE: To determine short and longterm outcomes and prognostic factors for patients with systemic rheumatic diseases admitted to intensive care units in 4 teaching hospitals. METHODS: All adult intensive care unit admissions over a 12 year period for systemic rheumatic diseases were retrospectively assessed. One hundred and eighty-one patients with a mean age of 57 +/- 17 years were studied. RESULTS: The death rate in intensive care units was 33% (59/181) and in-hospital mortality was 43% (77/181). One hundred and four patients were discharged alive from hospital; 40 died during followup (mean 105 +/- 7 mo). The estimated 5 year survival rate for the discharged patients was 69%. The 4 factors significantly associated with in-hospital mortality by multivariate analysis were simplified acute physiologic score (p = 10(-4)), poor prior health status (p = 10(-4)), corticosteroid administration (p = 0.005), and the reason for admission; mortality was higher in the group admitted to intensive care for infectious complication (55 versus 34% for others; p = 0.006). In contrast, in-hospital mortality was not influenced by age or by systemic rheumatic diseases. Using Cox's model, only age over 60 years was a prognostic factor significantly associated with an increase in longterm mortality (p = 10(-4)). CONCLUSION: The short term outcome for patients with systemic rheumatic diseases in intensive care units was poor. The longterm prognosis after hospital discharge appeared fair, although the standardized mortality ratio was 5-fold that of a nonselected population. Short and longterm prognoses were similar for different systemic rheumatic disease groups.

Gastric intramucosal pH: an indicator of weaning outcome from mechanical ventilation in COPD patients.

The aim of this study was to determine whether gastric intramucosal pH (pHim) and/or gastric intramucosal carbon dioxide tension (PCO2,im) measured by tonometry can be used to predict the success of weaning in chronic obstructive pulmonary disease (COPD) patients. Twenty six consecutive COPD patients, undergoing mechanical ventilation for acute respiratory failure and satisfying the criteria of weaning from mechanical ventilation with nasogastric tonometer in place, were studied. Arterial blood gas values and PCO2,im were measured 24 h before (H-24), just before (H0), and after 20 min of a weaning trial on T-piece (H20min). Weaning failure was defined as the development of respiratory distress and/or arterial blood gas impairments during the first 2 h of spontaneous breathing on T-piece, or reintubation within 24 h after extubation. Between the weaning failure (n = 6) and weaning success (n = 20) groups, there were no differences in blood gas analysis readings at H-24 and H0 before the weaning period, age, Simplified Acute Physiology Score (SAPS) on admission, SAPS on the day of weaning trial, and duration of ventilation. Clinical status, tonometric and arterial gasometric data were similar at H-24 and H0 in all patients. During mechanical ventilation, pHim was < or = 7.30 in patients who failed weaning and > 7.30 in patients who were successfully weaned (p < 0.001; 100% sensitivity and specificity). The threshold value for PCO2,im of 8.0 kPa (60 mmHg) represents a clear demarcation with respect to outcome before the weaning trial. PCO2,im values during mechanical ventilation are significantly different (p < 0.001) between patients who were successfully weaned and those who were not (6.9 +/- 0.9 vs 9.9 +/- 1.1 kPa (51.9 +/- 6.7 vs 74.3 +/- 8.0 mmHg, respectively)). At H20min, pHim and PCO2,im were still statistically different between the weaning failure and the weaning success group. We conclude that measurement of gastric intramucosal pH (or gastric intramucosal carbon dioxide tension) represents a simple and accurate index to predict weaning outcome in chronic obstructive pulmonary disease patients before attempting weaning.

Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial.

Hyperbaric Oxygen (HBO) therapy is advocated for the treatment of severe trauma of the limbs in association with surgery because of its effects on peripheral oxygen transport, muscular ischemic necrosis, compartment syndrome, and infection prevention. However, no controlled human trial had been performed until now to specify the role of HBO in the management of crush injuries. Thirty-six patients with crush injuries were assigned in a blinded randomized fashion, within 24 hours after surgery, to treatment with HBO (session of 100% O2 at 2.5 atmosphere absolute (ata) for 90 minutes, twice daily, over 6 days) or placebo (session of 21% O2 at 1.1 ata for 90 minutes, twice daily, over 6 days). All the patients received the same standard therapies (anticoagulant, antibiotics, wound dressings). Transcutaneous oxygen pressure (PtCO2) measurements were done before (patient breathing normal air) and during treatment (HBO or placebo) at the first, fourth, eighth, and twelfth sessions. The two groups (HBO group, n = 18; placebo group, n = 18) were similar in terms of age; risk factors; number, type or location of vascular injuries, neurologic injuries, or fractures; and type, location, or timing of surgical procedures. Complete healing was obtained for 17 patients in the HBO group vs. 10 patients in the placebo group (p < 0.01). New surgical procedures (such as skin flaps and grafts, vascular surgery, or even amputation) were performed on one patient in the HBO group vs. six patients in the placebo group (p < 0.05). Analysis of groups of patients matched for age and severity of injury showed that in the subgroup of patients older than 40 with grade III soft-tissue injury, wound healing was obtained for seven patients (87.5%) in the HBO group vs. three patients (30%) in the placebo group (p < 0.05). No significant differences were found in the length of hospital stay and number of wound dressings between groups. For the patients with complete healing, the PtCO2 values of the traumatized limb, measured in normal air, rose significantly between the first and the twelfth sessions (p < 0.001). No significant change in PtCO2 value was found for the patients whose healing failed. The Bilateral Perfusion Index (BPI = PtCO2 of the injured limb/PtCO2 of the uninjured limb) at the first session increased significantly from 1 ata air to 2.5 ata O2 (p < 0.05). In patients with complete healing, the BPI was constantly greater than 0.9 to 2.5 ata O2 during the following sessions, whereas the BPI in air progressively rose between the first and the twelfth sessions (p < 0.05), reaching normal values at the end of the treatment. In conclusion, this study shows the effectiveness of HBO in improving wound healing and reducing repetitive surgery. We believe that HBO is a useful adjunct in the management of severe (grade III) crush injuries of the limbs in patients more than 40 years old.

Pulmonary toxoplasmosis after allogeneic bone marrow transplantation: case report and review.

We report an isolated case of toxoplasma pneumonitis in a 27-year-old man. This acute infection occurred after induction chemotherapy for AMLo relapsing 3 years post-allogeneic BMT. The detection of Toxoplasma gondii in the bronchoalvolar lavage (BAL), by culture in fibroblast cell line MRC5 enabled us to make the diagnosis. Pyrimethamine and sulfadiazine were effective.

[Prognosis of systemic diseases diagnosed in intensive care units]. / Pronostic des maladies systémiques diagnostiquées en réanimation.

OBJECTIVES: The aims of this study were to evaluate the prognosis of patients with systemic rheumatic disease diagnosed in medical intensive care unit (MICU) and to determine whether the outcome is different for patients with systemic rheumatic disease previously known hospitalized in MICU. METHODS: Retrospective evaluation, over a ten-year period, of 88 cases of systemic rheumatic disease selected in two groups: group I: diagnosed in MICU, group II: previously known and treated. RESULTS: Group I: 18 patients with necrotizing vasculitis (n = 6), extra-intestinal manifestations of inflammatory bowel disease (n = 4), systemic lupus erythematosus (n = 3), miscellaneous (n = 5). Group II: 70 patients with rheumatoid arthritis (n = 31), necrotizing vasculitis (n = 12), systemic lupus erythematosus (n = 12), polymyositis (n = 4), extra-intestinal manifestations of inflammatory bowel disease (n = 5), miscellaneous (n = 6). The main admission diagnoses were infectious diseases (p < 0.005) or iatrogenic complications in the group II (p < 0.01) and acute exacerbation of systemic rheumatic disease in the group I (p < 0.0001). Age; simplified acute physiologic score (SAPS); number of acute organ system failure; number of patients requiring mechanical ventilation, haemodialysis or right heart catheterization were not different between the two groups. The durations of mechanical ventilation and stay in the MICU were shorter in the group II (p < 0.005). MICU mortality rate was higher in the group II (p < 0.05), with a five years cumulative proportion of surviving statistically lower (p < 0.05). Mortality rate of the entire population (37.5%) was similar to that of a non-selected population with comparable SAPS. Multivariate analysis showed that SAPS, number of acute organ system failure and iatrogenic complications were the main prognostic factors (p = 0.05). CONCLUSIONS: The prognosis was better for patients with systemic rheumatic disease diagnosed in MICU. Infectious diseases were the main cause of death, probably in relation with immunosuppressive treatments.

Adrenocortical function during septic shock.

OBJECTIVE: To investigate, in patients with severe septic shock, the adrenocortical function assessed by daily plasma cortisol determinations during the first 72 h and by the short synthetic ACTH stimulation test performed within 24 h of the onset of shock. DESIGN: Prospective clinical investigation. SETTING: Medical intensive care unit in a university teaching hospital. PATIENTS: 40 consecutive patients with documented septic shock requiring at least hemodynamic resuscitation and respiratory support. INTERVENTIONS: There were no interventions. MEASUREMENTS AND RESULTS: Basal cortisol concentrations were increased with a mean value of 36.8 micrograms/dl (range 7.9-113). Of the overall cortisol determinations 92% were above 15 micrograms/dl. No statistically significant differences in basal cortisol concentrations were found when survival, type of infection, and positive blood cultures were considered. Patients with hepatic disease had significantly higher cortisol (50.1 (+/- 6.2) micrograms/dl versus 35.9(+/- 3.3) micrograms/dl, p = 0.035) levels compared to other patients. No correlations were found between basal plasma cortisol concentrations and factors such as SAPS, OSF, hemodynamic measurements, duration of shock, and amount of vasopressor and/or inotropic agents. Cortisol concentrations had significant but weak correlation with ACTH levels in survivors (r = 0.4; p = 0.03; n = 28) but not in non-survivors (r = 0.03; p = 0.85; n = 52). Cortisol levels in non-survivors increased significantly from enrollment time to the 72nd hour of the survey (day 1: 38.9(+/- 3.8) micrograms/dl versus day 3: 66.7(+/- 17.1) micrograms/dl; p = 0.046) and were significantly higher than those recorded in survivors. Responses to the short ACTH stimulation test were not significantly different between survivors and non-survivors. According to the different criteria used to interpret the response to the ACTH stimulation test, incidence of adrenocortical insufficiency was highly variable ranging from 6.25-75% in patients with septic shock. Only one patient had absolute adrenocortical insufficiency (basal cortisol level below 10 micrograms/dl; response to the ACTH stimulation test below 18 micrograms/dl). CONCLUSION: Our data suggest that in a selected population of patients with severe septic shock single plasma cortisol determination has no predictive value. The short ACTH stimulation test performed within the first 24 h of onset shock can neither predict outcome nor estimate impairment in adrenocortical function in patients with high basal cortisol level. Adrenal insufficiency is rare in septic shock and should be suspected when cortisol level is below 15 micrograms/dl and then confirmed by a peak cortisol level lower than 18 micrograms/dl during the short ACTH stimulation test.

[Detection of left cardiopathy using echocardiography during acute respiratory failure in chronic respiratory insufficiency]. / Dépistage des cardiopathies gauches par échocardiographie au cours de l'insuffisance respiratoire aiguë des insuffisances respiratoires chroniques.

Echocardiography was performed in a systematic fashion in 58 patients suffering from on-chronic respiratory failure (IRC) who were admitted to the intensive care unit. The prevalence of left ventricular disease in patients with IRC who were admitted to the intensive care unit was 31%, there were 18 cases of cardiac disease: nine had hypertrophic cardiac disease (two with intraventricular gradients), three had dilated cardiomyopathies, and there were six cases of ischaemic cardiac disease. Among these cases, six had not previously been diagnosed as having cardiac disease (10%). In cases with poor echogenicity by the transthoracic root, oesophageal echocardiography was performed and this improved the feasibility of a good examination with only a five per cent failure rate. Left ventricular disease was implicated in the clinical assessment eleven times (19%), either on admission (nine times) or during the course of the in-patient treatment (twice). In directing the initial assessment and the aetiological treatment, echocardiography directly contributed to better management in six cases (10%). As regards the number of cases of cardiac disease which were detected, the study confirms the value of this technique at the bedside of the patient. The use of the transoesophageal route improves the diagnostic value including those patients who were intubated and ventilated.

Hemodynamic changes in acute adrenal insufficiency.

OBJECTIVE: Acute adrenocortical insufficiency is an unusual cause of isolated shock. The purpose of this study is to describe the cardiovascular changes in 6 patients with acute adrenal insufficiency presenting with hemodynamic instability. DESIGN: Retrospective and prospective study. SETTING: Medical intensive care unit in a university hospital. PATIENTS: 6 patients studied by right cardiac catheterization. MEASUREMENTS AND RESULTS: Results before glucocorticoid treatment show two possible hemodynamic states: 1) myocardial depression with hypovolemia in 3 patients, and 2) hyperdynamic shock with high cardiac output and diminished systemic arterial resistance in 3 other patients. The 3 patients presenting hyperdynamic shock were all given intravenous fluid therapy of over 20 ml/kg before the first hemodynamic measurement. For 2 other patients with low cardiac index and high systemic arterial resistance studied prospectively, 20 ml/kg intravenous fluid therapy transformed the hemodynamic state to hyperdynamic shock. The cardiovascular effect of glucocorticoid treatment studied in 4 patients was resulted in an improvement in the left ventricular systolic work index. CONCLUSIONS: Diagnosis of acute adrenocortical insufficiency must be considered if clinical manifestations are present suggesting septic shock without any obvious infectious cause in patients having undergone considerable intravenous fluid therapy as an initial course of treatment.

Efficacy of 4-methylpyrazole in ethylene glycol poisoning: clinical and toxicokinetic aspects.

Potentially fatal ethylene glycol intoxication in an adult with normal renal function was treated with 4-methylpyrazole administered three hours after the incident occurred. The plasma ethylene glycol concentration was 3.5 g l-1 on admission. The metabolic acidosis present on admission resolved within four hours, and the subsequent clinical course was uneventful. The apparent plasma half-life of ethylene glycol was 16 h and the mean renal and plasma clearances of ethylene glycol were 24 and 25 ml min-1, respectively. These results support the hypothesis that complete blockade of hepatic metabolism of ethylene glycol is achieved by 4-methylpyrazole. The only side-effect observed as a result of treatment was a transient slight increase in serum transaminase activity.

[Echocardiographic abnormalities in the stage IV of HIV infection]. / Anomalies échocardiographiques au stade IV de l'infection par le VIH.

Fifty patients in stage IV of HIV infection (including 41 AIDS patients) were prospectively studied by echocardiography. Thirteen of them showed abnormalities: 4 had pericardial effusion, 1 endocarditis, 7 myocardial disorders and 1 primary pulmonary arterial hypertension. Pericardial effusion, also present in patients who had pleuropulmonary Kaposi's sarcoma, was not specific. Myocardial disorders concerned the diastolic function in 1 case, the segmental kinetics in 2 cases and the whole systolic function in 4 cases (3 had congestive myocardiopathy and 1 had transient systole alteration without left ventricular dilatation). The mechanism of global left ventricular disorders was multifactorial, and several hypotheses were discussed: infectious myocarditis, adrenergic or nutritional deficiency myocarditis, cardiotoxicity of antiviral drugs, common pathology with HIV encephalopathy. The prognosis of congestive myocardiopathy was poor in AIDS patients and undetermined in stage IV non-AIDS patients. Echocardiography is capable of detecting these lesions, and its use may contribute to a better care of these patients.

[Iodoform poisoning. 3 cases]. / Intoxication à l'iodoforme. 3 observations.

Three cases of iodoform poisoning are described following dressings with 10% iodoform gauze (0.10 x 5 m) on extended wounds. Five, ten and sixteen days after the beginning of dressings, the patients became confuse, hallucinated, and one of them was subsequently comatose. Vomiting, fever, tachycardia with premature ventricular beats and shortening of P-R interval, slight increase of transaminases and proteinuria were observed. Within a few days (3 to 8) after the iodoform dressings were discontinued, the signs of iodoform toxicity disappeared. The toxicity of iodoform is probably unrecognized if the rarity of the observations published and the amount of iodoform gauzes annually sold are compared.

[Metabolic acidosis in severe acute asthma. Effect of alkaline therapy]. / Acidose métabolique de l'asthme aigu grave. Effet de l'alcalinisation.

Respiratory acidosis of severe acute asthma is a severity factor. In this paper the treatment of associated metabolic acidosis is discussed. Among 34 consecutive episodes of severe acute asthma with acidosis (pH < 7.35) treated with continuous adrenaline perfusion, theophylline and hydrocortisone hemisuccinate, respiratory acidosis was observed in 12, metabolic acidosis in 2 and mixed respiratory and metabolic acidosis in 20. The association of hypercapnic acidosis with hypochloraemic acidosis reflected a time of installation longer than when respiratory acidosis only was present (p < 0.05). Among the 22 patients who had metabolic acidosis on admission, 14 were treated with 168 +/- 82 mmol of sodium bicarbonate, the remaining 8 patients being untreated and acting as controls. The rapidity with which pH was corrected was the same in the treated and untreated groups (9.1 +/- 5.5 hours vs 6.7 +/- 3.7 hours), whereas dyspnoea (respiratory rate < 18/min) was more rapidly corrected in the treated group that in controls (11.6 +/- 5.7 hours vs 5.9 +/- 5.9 hours; p < 0.05). It is concluded that in more than 50% of the cases respiratory acidosis of severe acute asthma is associated with a metabolic acidosis. Correcting this metabolic acidosis with sodium bicarbonate results in improvement of respiration, perhaps by facilitating the action of bronchodilator catecholamines.

[Use of intravenous adrenalin in severe acute asthma]. / Utilisation de l'adrénaline intraveineuse dans l'asthme aigu grave.

The efficacy of and tolerance to intravenous Adrenaline (IV) have been assessed in cases of acute severe asthma (AAG). From January 1983 to March 1990 there were 56 episodes of AAG treated by intravenous Adrenaline using an average dose of 0.33 microgram per kilogramme per minute, in association with intravenous steroid therapy and Aminophylline (0.6 mg/kg per hour). A group of 12 patients were ventilated before admission and were excluded from the study. Two groups were defined on the basis of their admission PaCO2: Group A with 30 episodes of AAG and a PaCO2 above 45 mm of mercury, Group B with 14 episodes of AAG and a PaCO2 of less than 45 mm of mercury. The clinical improvement was equally rapid in both groups on average 8.7 (plus or minus 8.2) hours in Group A and 14.6 (plus or minus 15.7) hours in Group B. Artificial ventilation was only required in 2.3% of cases (7% in Group A and none in Group B). Treatment using intravenous Adrenaline is well tolerated as is shown by the absence of any worsening of the tachycardia, the significant fall in blood pressure after correcting the PaCO2 in Group A and the absence of any raised blood pressure in Group B. In conclusion, treatment with intravenous Adrenaline associated with IV Theophylline and IV corticosteroids based on the fact of its rapid action and that it is well tolerated, means that this drug should be considered as part of the therapeutic arsenal during acute severe asthmatic attacks in patients who are breathing spontaneously.