[Meningitis to Candida albicans at the adult, use of the new diagnosis methods]. / Méningite à Candida albicans chez l'adulte, apport des nouveaux moyens diagnostiques.

Candida albicans or non-albicans are a frequent source of infection but seldom displayed in cerebrospinal fluid although responsible of an important number of nosocomial meningitis. Diagnosis is difficult which often delays treatment, which in turn hinders prognostic. This clinical case shows a patient afflicted with a deadly C. albicans meningitis and allows us to focus on new diagnostic tools and advice against this infection.

Glucose-lipid ratio is a determinant of nitrogen balance during total parenteral nutrition in critically ill patients: a prospective, randomized, multicenter blind trial with an intention-to-treat analysis.

OBJECTIVE: Protein sparing, the major goal of nutritional support, may be affected by the glucose/lipid ratio. This study in critically ill patients compared the efficacy and tolerance of two isocaloric isonitrogenous total parenteral nutritions (TPN) having different glucose/lipid ratios. DESIGN: Multicentric prospective randomized study. PATIENTS: 47 patients with SAPS I score higher than 8 and requiring exclusive TPN. INTERVENTIONS: Patients received glucose/lipid ratios of 50/50 or 80/20. For 7 days all patients received 32 glucidolipidic kcal/kg and 0.27 g/kg nitrogen daily. All-in-one bags were prepared using industrial mixtures and a fat emulsion. MEASUREMENTS AND RESULTS: We determined TPN efficacy by nitrogen balance, urinary 3-methylhistidine/creatinine ratio, transthyretin and tolerance by glycemia, and liver enzymes. After controlling for five variables with significant effects, patients receiving the 50/50 ratio during TPN had significantly higher nitrogen balance than those receiving the 80/20 ratio. The daily difference in mean nitrogen sparing effect in favor of the latter group was 1.367 g (95% CI 0.0686-2.048). Glycemia on day 4 and gamma-glutamyltranspeptidase on day 8 were higher in group receiving the the 80/20 ratio. CONCLUSIONS: In critically ill patients TPN at a glucose/lipid ratio of 80/20 ratio induces a small nitrogen sparing effect compared to the ratio of 50/50, at the expense of poorer glycemic control. The clinical significance is unclear.

[The effects of midazolam on oxygen consumption and the level of vigilance. The possibility of the sedative effect of the plexiglas dome (canopy) of the Deltatrac indirect calorimetry device]. / Effets du midazolam sur la consommation d'oxygène et le niveau de vigilance. Possibilité d'un effet sédatif de la bulle de plexiglas (canopy) du calorimètre indirect deltatrac.

OBJECTIVE: To assess the effects of midazolam on oxygen consumption (VO2) and the level of vigilance. To search for a possible "sedative effect" of the canopy of the Deltatrac (Datex) when a placebo is administered instead of midazolam. STUDY DESIGN: Prospective, comparative, randomized, double-blinded, cross-over study. PATIENTS: Eight healthy volunteers of ASA physical class 1, not under stress, fasting and at rest. METHODS: The volunteers were administered at T0 either midazolam (0.07 mg.kg-1, IM), or a placebo at a one week interval in an order at random. The VO2 was measured with a Deltatrac. Circulatory status was monitored with non invasive methods and the level of vigilance assessed using the Ramsay scale. Statistical analysis was obtained with Anova for repeated measurements with two within factors (drug and time). RESULTS: VO2 decreased similarly and significantly between T0 and T45 min (P < 0.05). The decrease continued only after midazolam until T60 min. However the variation of VO2 between the midazolam and placebo group was not significant. The haemodynamic variables remained unchanged. Midazolam had a stronger sedative effect at T120 min.

[Nutritional aspects of cranial trauma]. / Nutrition artificielle du traumatisé crânien.

In head-injured patients the nutritional support is aimed to prevent denutrition status usually observed. The adequate amount of calories depends on the basal metabolism (as calculated with the Harris Benedict equation). It has to be increased in case of fever (by a 0.1 factor per degree above 37 degrees C), sepsis (by a 0.1 to 0.2 factor) or when sedation is discontinued (by a 0.3 factor). The increased proteolysis is not modified by the associated treatment and results in an inevitable protein loss, whatever the qualitative change in nutritional support. In clinical practice, the nutritional support has to be adjusted continuously to the needs of the patient, to avoid a more pronounced denutrition due to the summation of daily nutritional deficits.

[Prolonged neuromuscular block after mivacurium injection]. / Bloc neuromusculaire prolongé après injection de mivacurium.

Mivacurium, a new short acting non depolarizing neuromuscular blocker, is metabolized, as suxamethonium, by plasma cholinesterase. Therefore its duration of action is increased in patients with reduced plasma cholinesterase activity. We report a case of prolonged neuromuscular block after an i.v. bolus of mivacurium (0.20 mg.kg-1) in a 69 year-old ASA II woman with an unrecognized cholinesterase deficiency undergoing a lumbar sympathectomy for arteriopathy of the lower limbs. The duration of the block was 6 h and plasma cholinesterase concentrations were very low (540 and 610 UI.L-1), as well as the dibucaine number (16%), which suggests an homozygous enzymatic deficiency. Mechanical ventilation and sedation were continued until spontaneous return of full neuromuscular function.

Evolution of energy expenditure and nitrogen excretion in severe head-injured patients.

OBJECTIVE: The aim of the study was to estimate the influence of therapeutic changes on the level of energy expenditure (EE) and N excretion in a homogeneous group of patients usually considered hypermetabolic. DESIGN: EE and N excretion of head-injured patients were measured simultaneously at phases 1 and 2 (patients treated 4 +/- 3 and 18 +/- 8 days after injury, respectively). SETTING: Acute care hospital. PATIENTS: Eight severe head-injured patients, mean weight 63.1 +/- 6.1 (SD) kg, mean age 21 +/- 3.8 (SD) yr. INTERVENTIONS: At phase 1, all patients were sedated with fentanyl (6.7 +/- 1.9 micrograms/kg.hr) plus flunitrazepam (9.1 +/- 4.8 micrograms/kg.hr) and were mechanically ventilated. All patients received continuous total parenteral nutrition. The nonprotein caloric intake averaged 1092 +/- 200 kcal/day, including 77% glucose and 23% fat (Intralipid 20%). The total N intake averaged 7 +/- 5 g/day, consisting of crystalline amino acids. At phase 2, no patient received any sedative and all were breathing spontaneously via tracheostomy. All patients received parenteral and/or enteral nutrition. The nonprotein caloric intake averaged 1929 +/- 200 kcal/day consisting of 65% carbohydrates and 35% fat. The total N intake averaged 13 +/- 2 g/day. MEASUREMENTS AND MAIN RESULTS: The EE was significantly higher at phase 2 than at phase 1 (2121 vs. 1737 kcal), but the interindividual variability was low at both phases. N excretion was high at the two periods of the study and not correlated to the level of EE. The RQ was 0.75 at both periods, indicating predominant fat oxidation. CONCLUSIONS: We could not demonstrate any parallelism in the evolution of EE and protein catabolism in head-injured patients. The therapeutics (mechanical ventilation, sedation, and nutrition) have a major effect on EE but little on N excretion.

Neuroleptic malignant syndrome induced by metoclopramide.

Neuroleptic malignant syndrome (NMS) associated with metoclopramide is rare. NMS probably results from neuroleptic-induced dopamine receptor blockade. We describe a case and have found only seven reports of metoclopramide-induced NMS in the literature.

[Hypokalemic quadriplegia and coma in renal tubular acidosis]. / Quadriplégie hypokaliémique et coma au cours d'une acidose tubulaire rénale.

A case is reported of an acute episode of severe hypokalaemia (K+ = 1.1 mmol.l-1) associated with hyperchloraemic acidosis and simultaneous high urine pH (pH = 7) in a 24 year old woman with type I distal tubular acidosis and nephrocalcinosis. The flaccid paralysis involved the trunk, neck, facial and pharyngeal muscles. She was in areflexic quadriplegia, coma and respiratory failure requiring endotracheal intubation and positive pressure ventilation. There were no cardiac disturbances, presumably because of the chronic potassium depletion, the patient's youth and healthy myocardium. Despite the usually recommended maximal potassium infusion rate (0.25 mmol.kg-1.h-1), there was a transient worsening of her neuromuscular status. Only 12 h later, the first movements were noticed. In order to prevent such a deterioration, a more rapid potassium infusion could have been used. However, in our case, the occurrence of hypokalaemic extrasystoles was reduced and the patient was still intubated and ventilated. It was therefore decided not to run the risk of myocardial inexcitability carried out with supramaximal infusion rates and to keep the usual protocol. Besides, several pitfalls have to be avoided during the treatment of the numerous metabolic disorders coexisting with severe hypokalaemia, such as metabolic acidosis and hyperglycaemia.

[Conditions of feasibility and stability in the measurement of protein synthesis using 15N glycine in intensive care patients]. / Conditions de réalisation et stabilité de mesure des synthèses protéiques à l'aide de la 15N glycine chez les patients de réanimation.

The rates of nitrogen flux and protein synthesis in the whole body were measured in two intensive care (ICU) patients on two occasions separated by a period of 24 h. Rates of flux and synthesis were estimated from 15N excretion in urinary ammonia after a slow injection of 15N glycine over a period of 1 h. The aim of the present study was to evaluate the feasibility and the reproducibility of the method. The variation of nitrogen flux was between 6 and 9%, and for synthesis between 7 and 9%. Skeletal muscle protein breakdown was measured from urinary 3, methylhistidine excretion. The muscle contribution to the whole body breakdown rate was 32 and 41% for one patient and 48 and 51% for the other one. The combination of measurement of 15N excretion after a single dose of 15N glycine with that of urinary 3, methylhistidine provided a reproducible method for measuring whole body protein synthesis in ICU patients. It could be repeated at short intervals and gave useful comparative information provided that conditions were carefully standardized.

[Urinary excretion of creatinine and 3-methylhistidine in multiply injured patients]. / Excrétion de créatinine et de 3,méthylhistidine urinaire chez les polytraumatisés.

The daily urinary excretion of 3,methylhistidine (3,MeHis) was measured in eight severely injured patients for periods of at least two weeks to at most one month after the trauma. The patients were fed with 0.20 +/- 0.05 g X kg-1 X 24 h-1 of nitrogen and 25 +/- 5 kcal X kg-1 X 24 h-1 given as glucose. The pattern of 3,MeHis and creatinine excretion as well as the weight loss suggested the following: 1) the muscle protein breakdown in these patients was approximately twice the normal value (the mean 3,MeHis excretions were respectively 7.98, 7.21, 6.26 and 5.14 mumol X kg-1 X 24 h-1 for the four week study period, compared with the normal value of 3.73); 2) the creatinine excretion decreased slowly. This showed the magnitude of muscle wasting in these patients who, in one month, could lose up to 20% of their initial weight. Various factors could be responsible for increasing and extending the muscle protein catabolism: the importance of muscle damage, the metabolic response to neurotrauma, sepsis and prolonged immobilization. In these conditions, it would seem useless and even harmful to try, at all costs, to obtain a positive nitrogen balance. The authors suggest therefore an average intake of 0.2 g X kg-1 X 24 h-1 of nitrogen, which should be sufficient to meet the requirements for protein synthesis.

[Evaluation of protein catabolism in multi-injured patients]. / Evaluation du catabolisme protéique chez les polytraumatisés.

The urinary excretion of nitrogen was calculated, using the daily urinary urea nitrogen output in 19 patients with multiple trauma. The patients were followed for at least two weeks in an intensive care unit. The urinary excretion for each patient was expressed as the average of 7 day periods and the differences were evaluated with the Student's test for paired samples. Protein catabolism (defined as a urinary nitrogen excretion higher than 0.250 g per kilo and per day) was found in 18 of 19 patients during the first week, and in 16 during the second week. Catabolism was still present in 8 of 11 the third week and in 3 of 6 the fourth week after the trauma. Nitrogen excretion remained at the same level for two weeks and decreased significantly afterwards. Protein catabolism was an important contribution to weight loss. The cumulative loss of lean body mass revealed approximately 70% of weight loss over four weeks. The role of factors involved in catabolism and a therapeutic approach are discussed.

[Intrabronchial diffusion of amoxycillin when administered by two different injection modes (author's transl)]. / Diffusion intrabronchique de l'amoxicilline administrée selon deux modalités d'injection différentes.

Twelve ICU patients, all with broncho-pulmonary infection were treated with 50 mg/kg-1/24 h-1 of amoxycillin administered every eight hours, either by one hour perfusion, or by brief IV injection (2'). Both modes were given to all of the patients in order to determine, by comparison, the most efficient treatment. There is no significant difference in serum levels after perfusion or IV injection. However, IV injection is preferable because of a significant difference in bronchial levels after 3 hours (p less than 0.01). In most cases, the bronchial levels and the bronchio/serum concentration ratios, while not significantly different, are higher than after perfusion. None of the results justify the use of perfusion.