[Can one use probabilistic protocols for antibiotic therapy in intensive care units?]. / Peut-on utiliser des protocoles d'antibiothérapie probabiliste en réanimation?

Due to a large spectrum, empiric antibiotics treatments participate to the increase in bacterial resistance. In order to improve its indications, the implementation of therapeutic guidelines in an ICU was studied. Empiric therapy was administered in 30% of the 178 patients receiving antimicrobial agents. Large spectrum drugs were prescribed in 26% of empiric treatments. The mean duration of empiric antibiotics administration was 3.2 days. It was concluded that it was possible to use guidelines of empiric antibiotic in an intensive care unit.

[Acute intestinal ischemia after voluntary drug poisoning]. / Ischémie intestinale aiguë dans les suites d'une intoxication médicamenteuse volontaire.

A case is reported of a patient who suffered from ischaemic enteritis after having taken an overdose of several drugs. The 42-year-old woman was found out no more than 7 h after she had taken a mixture of benzodiazepines, tricyclic antidepressants and barbiturates (4 mg.l-1 blood level on admission). She had been lying against a bedpost, resulting in compression of her anterior abdominal wall below the umbilicus, involving her right femoral nerve. There was a severe rhabdomyolysis. Despite clinical improvement, the patient being extubated the following day, her abdomen remained painful and swollen. A CT abdominal scan showed a peritoneal effusion and a distended small bowel. Laparatomy revealed severe ischaemia of the terminal 80 cm of ileum, with some gangrenous areas. This was resected, and a right-sided ileostomy performed. Histopathological examination demonstrated a mucosal necrosis without mesenteric arterial thrombosis. A bilateral pleural effusion occurred during postoperative course, requiring drainage. Thereafter, the clinical course was uneventful, with intestinal continuity being re-established three months later. The femoral paralysis receded spontaneously. It is likely that this unusual postural complication of coma may be attributed to a transient compression of mesenteric vessels.

[Practical aspects of indirect calorimetry in post-anesthesia recovery]. / Aspects pratiques de la calorimétrie indirecte en réanimation.

The application of indirect calorimetry among intensive care patients is usually considered as a complicate technique, owing to the difficulties to interpret the bulk of obtained data. As a matter of fact, the variability of energy expenditure (EE) among these patients leads to prefer continuous measurements. This variability is related to interindividual variations as well as variations in the same patient (variations due to body temperature, activity state, diet-induced thermogenesis...). A computer program of data storage and calculations was developed. It allows: on-line storage as well as numerical and graphic display of VO2, VCO2, RQ and EE; menu-driven storage of all occurring events; automatic suppression of the recordings made after ventilator alarms; graphic printing and metabolic calculations. The two main indications for indirect calorimetry are the determination of actual EE and VO2 monitoring in acute states.

[Regional anticoagulation with citrate in hemodialysis in patients with a high risk for hemorrhage]. / Anticoagulation régionale par le citrate au cours de l'hémodialyse chez les patients à haut risque hémorragique.

During haemodialysis in the patient at high risk for bleeding, heparin cannot be safely used to prevent clotting in the dialysis assembly. Among numerous procedures proposed to reduce the risk for bleeding, Pinnick et al. (N Engl J Med, 308: 258, 1983) proposed the use of citrate as the sole anticoagulant. Citrate toxicity and efficiency were studied during 44 haemodialyses carried out in thirteen patients with a high risk for bleeding or with active bleeding. Three patients had hepatic failure. Two types of citrate solution were used, the trisodium form of citrate (102 mmol.l-1 citrate) or the monosodium form (306 mmol.l-1 citrate). The solutions were infused with a calibrated, pressure insensitive pump, before the dialysis unit at a flow rate of 600 ml.h-1 and 200 ml.h-1 respectively. Sufficient citrate was infused to maintain a clotting time of the blood line and dialyser of more than 18 min. Standard 10% calcium chloride was infused at a constant rate of 7 mg.min-1 into the blood being returned to the patient. The patients were dialysed for 4 h for each haemodialysis with a single-pass system. The dialyses were uncomplicated; no active bleeding was noted. The patient's clotting time was significantly reduced during haemodialysis (18.1 +/- 8.9 min to 14.5 +/- 6.3 min; p less than 0.001). Two-hundred and twenty serum citrate levels were measured. Only nine were above the toxic value of 2 mmol.l-1. No clinical evidence of a decrease in ionized calcium was found: there was no change in the corrected QT intervals and blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Corynebacterium JK: surgical infections in non-immunosuppressed patients.

Infection caused by Corynebacterium JK (CJK) has been recently described in immunocompromised patients. To evaluate the frequency of CJK infection among surgical and trauma intensive care patients, all patients with CJK isolations at clinical sites were reviewed. The criteria used were the presence of bacterial infection symptoms, isolation from significant sites and the efficiency of a vancomycin treatment. Eight patients were studied; 3 of them were considered infected, while 5 were judged only colonized. It is concluded that CJK infections can be a clinical problem in surgical trauma patients.

[Evaluation of the Engstrom metabolic computer]. / Evaluation du calculateur de métabolisme Engstrom.

The Engstrom Metabolic Computer (EMC), in association with the Erica Ventilator, uses indirect calorimetry to carry out continuous on-line gas exchange measurements. A laboratory assessment of the different parts of this equipment is described. The variability of FIO2 was less than 0.05. The accuracy and stability of the inspiratory flowmeter were only slightly modified by changes in the I/E ratio and gas flow rates. The overestimation of flow on increasing FIO2 was taken into account by the computer. The hygrometry of inspiratory and expiratory air samples reached that of room air, with an absence of saturation during prolonged measurements. The CO2 analyser also showed a good stability. The accuracy of the oxygen cell needed to be checked periodically. A global evaluation was carried out using Damask's method: a lung model was used into which CO2 and N2 were insufflated at precise rates to simulate CO2 production and O2 consumption. The measured respiratory quotient was also compared with the known RQ of burning methanol. The difference between measured and real values was less than 5%. Therefore, it was concluded that the EMC was reliable for indirect calorimetry measurements.

[A severe form of heat stroke in a long-distance runner]. / Une forme grave du coup de chaleur chez un coureur de fond.

A case of a severe heat stroke is reported in a 30 yr old white man while running a long-distance race. At the time of admission, moderate hyperthermia (40 degrees C) and coma were two major symptoms found at physical examination. Within 24 h, the clinical picture evolved to multiple organ failure with marked rhabdomyolysis, acute renal failure with hyperkalaemia and lactic acidosis. At this time, were also found a consumptive coagulopathy and acute hepatic failure. After numerous complications, most of them infectious, the patient was discharged after four months in ICU and admitted in a physical rehabilitation department. Muscle biopsy performed three years after the heat stroke showed an abnormal reactivity to caffeine, but a normal reaction to halothane. The relationship between malignant hyperthermia and heat stroke remains uncertain.

[Fibroscopy and pulmonary burns. Preliminary study, apropos of 44 cases]. / Fibroscopie et brûlures pulmonaires. Etude préliminaire, à propos de 44 observations.

A fiberoptic bronchoscopy was performed in 44 out of 1160 burnt patients. The indications for this investigation were dictated by the kind of accident suffered by the patient: explosion or fire; in 16 patients, the face was spared. The clinical, radiological and biological signs could be absent on arrival, and occur later. Four different aspects were seen: very characteristic, although not entirely specific, was the pale white mucosa following blast injury. The degree of obstruction by soot varied, and could be fatal. The aspect of mucosal burn was due to the inhaling of hot gases or burning particles leading to the formation of blisters or crusts on the mucosa. Finally, a non-specific mucosal congestion was seen alone or with either of the preceding forms. The therapeutic interest of this technique was limited to the inhalation of soot and ash, broncho-aspiration not always being easy. The prognostic value was very restricted as it was not possible to investigate the distal ramifications of the bronchial tree. Further studies are necessary to define some more mucosal aspects, as well as the clinical and paraclinical correlations.

[Bacteriologic study of indwelling central venous catheters. Factors influencing the risk of microbial colonization and sepsis (author's transl)]. / Analyse bactédriologique des cathéters centraux. Discussion du mécanisme en cause.

The mechanism of microbial colonization and sepsis is disputed. For many authors, catheter contamination results from poor aseptic technic during insertion or removal or from the descent of organisms along the catheter from the skin puncture site; we think with Michel that endogenous colonization of the thrombus at the tip of the catheter must be considered: a statistical correlation between infected foci remote from the catheter allows this hypothesis; tracheostomy may be considered as well as a percutaneous contaminant as a deep infected focus. The correlation between non specific immunity and contamination is another finding which allows the ability of endogenous colonization.

[Pheochromocytoma and pregnancy. Report of two cases (author's transl)]. / Association phéochromocytome-grossesse. Deux observations.

We found in the literature 119 cases of pheochromocytoma manifested during pregnancy and observed 2 personal cases. Pheochromocytoma and pregnancy show reciprocal influences. Unsuspected diagnosis is frequent and followed by a high maternal mortality. The tumor was surgically removed in 42 cases. There are two different attitudes: when diagnosed in early pregnancy, the tumor can be excised without delay although the foetal risk is high; when the diagnosis is made in the last trimester, foetal maturity has to be awaited to perform a combined caesarean section and excision of the tumor.

[Hysteria: an etiology of post-operative accident (author's transl)]. / L'hystérie. Une cause inhabituelle de réveil anormal.

Hysteria can explain some immediate post-operative accidents. We report some cases observed during these late years; all were troublesome for the anesthesiologist.