[Daily interruption of sedation in intensive care unit patients with renal impairment: remifentanil-midazolam compared to fentanyl-midazolam]. / Arrêt journalier de la sédation en réanimation chez l'insuffisant rénal: rémifentanil-midazolam versus fentanyl-midazolam.

OBJECTIVE: We compared extubation time following daily interruption of sedation in intensive care unit patients with renal impairment with two sedation regimes remifentanil-midazolam and fentanyl-midazolam. STUDY DESIGN: Prospective, randomized double-blind trial. PATIENTS AND METHODS: Patients with renal impairment needing mechanical ventilation for more than 48 hours. Two groups: remifentanil (R) and fentanyl (F), Infusion rates were titrated to achieve the desired Ramsay score. The two groups received midazolam (2.5 mg then 0.1 mg/kg/h). RESULTS: Nineteen patients were included. Patient's characteristics, mean sedation time and sedation quality were comparable. Extubation time was significantly shorter in R group (1480+/-980 versus 2880+/-1280 min, P=0.04). Weaning time was also shorter in R group (220+/-164 versus 720+/-480 min). Agitation on weaning was comparable in the two groups. Group R received significantly more morphine than group F after interruption of sedation. CONCLUSION: Daily interruption of sedation with remifentanil is associated with shorter weaning and extubation time in patients with renal impairment. However further studies are necessary to determine if this issue is associated with lower rate of ventilation induced complications.

[30 microg intrathecal clonidine prolongs labour analgesia, but increases the incidence of hypotension and abnormal foetal heart rate patterns]. / 30 microg de clonidine en intrathécal prolonge l'analgésie du travail, mais augmente l'incidence des hypotensions et des anomalies du rythme cardiaque foetal.

OBJECTIVE: To assess the efficacy of spinal clonidine combined with bupivacaine and sufentanil and its effects on maternal and foetal outcome. STUDY DESIGN: Prospective double-blind randomized study. PATIENTS AND METHODS: One hundred and five patients requesting labour analgesia had combined spinal epidural analgesia with intrathecal bupivacaine 2.5 mg and were randomly assigned to receive in addition either sufentanil 5 microg (S5), sufentanil 5 microg and clonidine 30 microg (C30), or sufentanil 10 microg (S10). Onset time, duration of analgesia, visual analogue scores, blood pressure, ephedrine requirements, heart rate, nausea, pruritus, sedation, motor block, foetal heart rate abnormalities, mode of delivery and Apgar scores were recorded. RESULTS: Mean duration of spinal analgesia was significantly longer in patients receiving spinal clonidine compared to patients in S5 group (144+/-61 min versus 95+/-37 min). The onset time of analgesia was significantly shorter in S10 group (3+/-1 min) versus C30 group (4+/-1 min) and S5 group (4+/-1 min) (P=0.002). Hypotension was significantly more frequent in C30 group (29 versus 3% and 3% in S5 and S10 groups) (p=0,001). Foetal heart rate abnormalities and sedation were also significantly more frequent in C30 group. Mode of delivery (spontaneous, instrumental or caesarean delivery) and Apgar scores were unaffected by clonidine treatment. CONCLUSION: Intrathecal clonidine 30 mug prolongs analgesia. However, it increases the incidence of hypotension, and abnormal foetal heart rate patterns. Thus, this study confirms that the use of 30 mug intrathecal clonidine for labour analgesia is not recommended.

Evaluation of transesophageal echocardiography for diagnosis of traumatic aortic injury.

BACKGROUND: Traumatic aortic injury is a frequent cause of death after blunt trauma, but few patients survive to reach a trauma center. The role of transesophageal echocardiography (TEE) in the diagnosis of traumatic aortic injury remains debated. METHODS: Over a 9-yr period, 209 blunt trauma patients (mean age, 34 +/- 13 yr) were suspected of having traumatic aortic injury because of enlarged mediastinum and/or sudden deceleration, and underwent TEE and angiography (aortography and/or contrast-enhanced computed tomography. RESULTS: Traumatic aortic injury was diagnosed in 42 patients (20%). Angiography (aortography and/or contrast-enhanced computed tomography) was less accurate (sensitivity, 83%; specificity, 100%) than TEE (sensitivity, 98%; specificity, 100%) for the diagnosis of aortic injury because it failed to diagnose most minor injuries (intramural hematoma or limited intimal flap, n = 7). However, when considering only patients with major aortic injury (n = 33; i.e., those who might need surgery), angiography (sensitivity, 97%; specificity, 100%) and TEE (sensitivity, 97%; specificity, 100%) were equivalent. CONCLUSION: Transesophageal echocardiography is an accurate method for diagnosis of traumatic aortic injury. Nevertheless, the clinical implications of limited aortic injuries diagnosed by the technique have yet to be determined.

[Beware of yeast septicemia in intensive care medicine]. / Alerte aux septicémies à levures en réanimation polyvalente.

A retrospective study of 24 cases of systemic candidosis observed in a polyvalent intensive care unit over a 6.5 yr period (1987-1993) led to some constatations: an increasingly high incidence of this type of septicaemia (up to 27.5% of all septicaemias), large responsibility of skin saprophytes Candida ( > 62% vs 21% from intestinal Candida albicans), frequent diagnostic difficulties, and a fatal outcome in 7/24 patients (mainly from severe causal illness). In order to improve the prognosis, a more systematic and often empirical resort to fungicidal agents could be justified whenever patients with very severe surgical or medical conditions develop a protracted fever of unclear origin.