[Severity of illness explains the inadequacy between diagnosis-related groups and intensive care patients. Groupe GHM]. / La gravité de l'atteinte explique l'inadéquation entre le système des groupes homogènes de malades et les patients de réanimation. Groupe GHM.

OBJECTIVE: To assess the relationship between diagnosis related groups (DRG) and severity of illness in intensive care unit (ICU) patients in semf1tical and economical terms. STUDY DESIGN: Prospective, multicentric study including 13 medical and surgical ICUs for adults. MATERIAL: Discharge reports of 3,215 ICU admissions including age, gender, diagnosis, organ system failures, length of stay (LOS) and severity of illness evaluated with severity scores (SS): simplified acute physiological score (SAPS). Apache II, Glasgow score and physiological score (PS). METHODS: Semantical homogeneity was evaluated from the percentage of well-classified patients established from the comparison between the official computerized method and a non-computerized method applied by three clinical experts. Economical homogeneity was evaluated from the relationship between SS and LOS. RESULTS: In total, 88% (CI: 87.7-88.2) of ICU stays were classified in eight main categories of diagnosis (MCD). According to the MCD, the percentage of well-classified patients varied from 28% (CI: 27.6-28.3) to 97% (CI: 96.8-97.1), decreasing with the association of several diagnoses and organ system failures. There was a large variability in the LOS of DRG and a significant correlation between LOS and SS was found in only 8/16 DRG. CONCLUSION: The fact that the severity of illness is not taken into account in the elaboration of DRGs explains the inadequacy of the DRG system in intensive care.

[Compressive hematoma complicating percutaneous catheterization of the axillary vein]. / Hématome compressif compliquant le cathétérisme percutané de la veine axillaire.

A 41-year-old woman was admitted in the intensive care unit with ruptured oesophageal varices. She had already had two similar events, six and four months previously. She had a haemoglobin concentration of 56 g.l-1, 20% prothrombin, 228 s activated cephalin time for a control time of 60 s, 0.9 g.l-1 of fibrinogen and a platelet count of 53 G.l-1. Because of the poor condition of her peripheral veins, it was decided to insert a central venous catheter. The axillary vein was chosen because of the coagulopathy. The axillary artery was accidentally punctured during the second attempt. Despite manual compression for 15 min, a small haematoma arose. The catheter was inserted in the right internal jugular vein. At the same time, a very large oedema of the left arm was noticed. The axillary haematoma had spread to the breast and lumbar fossa. The humeral and radial pulse amplitudes were decreased, and the patient complained of paraesthesiae. At phlebography, a vast haematoma was seen to compress the axillary vein. The patient's condition rapidly worsened, and she died 19 hours after admission with a probable cerebral haemorrhage. Although complications of axillary venous catheterization are rare, this case demonstrates that, in patient with very abnormal coagulation tests, central venous access should be obtained via a peripheral vein.

[The use of buprenorphine for peroperative analgesia]. / Utilisation de la buprénorphine pour l'analgésie peropératoire.

In an open study, buprenorphine was used as the sole analgesic agent in sixty patients undergoing orthopedic or abdominal surgery. The average dose used was 5 micrograms.kg-1. The level of peroperative analgesia was of good quality and was maintained during the recovery period in the majority of cases. The occurrence of side effects such as nausea, vomiting, respiratory depression was low.

[Comparison of 2 anesthetic protocols in colonoscopy on a series of 100 patients]. / Comparaison de deux protocoles anesthésiques pour coloscopies sur une série de 100 patients.

The quality of the anaesthesia and of the recovery (appreciated by Newman's test) of two anesthetic technics for colonoscopies are compared on two homogeneous groups from 50 patients each: propofol alone versus midazolam-alfentanyl association. The differences registered during anaesthesia, particularly concerning the breathing depression might be attributed to alfentanyl which has been used often at important doses. The recovery is delayed in the midazolam + alfentanyl's group in comparison with the propofol's group. The difference is very significant at 15 and 60 minutes. The use's safety and the fast recovery with propofol incite to advocate it as an unique+ anaesthetic agent for colonoscopies.