Anis Chaari

Scorpion Envenomation Among Children: Clinical Manifestations and Outcome (Analysis of 685 Cases)

Our objective was to characterize both epidemiologically and clinically manifestations after severe scorpion envenomation and to define simple factors indicative of poor prognosis in children. We performed a retrospective study over 13 years (1990-2002) in the medical intensive care unit (ICU) of a university hospital (Sfax-Tunisia). The diagnosis of scorpion envenomation was based on a history of scorpion sting. The medical records of 685 children aged less than 16 years who were admitted for a scorpion sting were analyzed. There were 558 patients (81.5%) in the grade III group (with cardiogenic shock and/or pulmonary edema or severe neurological manifestation [coma and/or convulsion]) and 127 patients (18.5%) in the grade II group (with systemic manifestations). In this study, 434 patients (63.4%) had a pulmonary edema, and 80 patients had a cardiogenic shock; neurological manifestations were observed in 580 patients (84.7%), 555 patients (81%) developed systemic inflammatory response syndrome (SIRS), and 552 patients (80.6%) developed multi-organ failure. By the end of the stay in the ICU, evolution was marked by the death in 61 patients (8.9%). A multivariate analysis found the following factors to be correlated with a poor outcome: coma with Glasgow coma score ≤ 8/15 (odds ratio [OR] = 1.3), pulmonary edema (OR = 2.3), and cardiogenic shock (OR = 1.7). In addition, a significant association was found between the development of SIRS and heart failure. Moreover, a temperature > 39°C was associated with the presence of pulmonary edema, with a sensitivity at 20.6%, a specificity at 94.4%, and a positive predictive value at 91.7%. Finally, blood sugar levels above 15 mmol/L were significantly associated with a heart failure. In children admitted for severe scorpion envenomation, coma with Glasgow coma score ≤ 8/15, pulmonary edema, and cardiogenic shock were associated with a poor outcome. The presence of SIRS, a temperature > 39°C, and blood sugar levels above 15 mmol/L were associated with heart failure.

Pulmonary edema following scorpion envenomation: Mechanisms, clinical manifestations, diagnosis and treatment

Scorpion envenomation is common in tropical and subtropical regions. Cardio-respiratory manifestations, mainly cardiogenic shock and pulmonary edema, are the leading causes of death after scorpion envenomation. The mechanism of pulmonary edema remains unclear and contradictory conclusions were published. However, most publications confirm that pulmonary edema has been attributed to acute left ventricular failure. Cardiac failure can result from massive release of catecholamines, myocardial damage induced by the venom or myocardial ischemia. Factors usually associated with the diagnosis of pulmonary edema were young age, tachypnea, agitation, sweating, or the presence of high plasma protein concentrations. Treatment of scorpion envenomation has two components: antivenom administration and supportive care. The latter mainly targets hemodynamic impairment and cardiogenic pulmonary edema. In Latin America, and India, the use of Prazosin is recommended for treatment of pulmonary edema because pulmonary edema is associated with arterial hypertension. However, in North Africa, scorpion leads to cardiac failure with systolic dysfunction with normal vascular resistance and dobutamine was recommended. Dobutamine infusion should be used as soon as we have enough evidence suggesting the presence of pulmonary edema, since it has been demonstrated that scorpion envenomation can result in pulmonary edema secondary to acute left ventricular failure. In severe cases, mechanical ventilation can be required.

Pulmonary embolism in intensive care unit: Predictive factors, clinical manifestations and outcome

OBJECTIVE: To determine predictive factors, clinical and demographics characteristics of patients with pulmonary embolism (PE) in ICU, and to identify factors associated with poor outcome in the hospital and in the ICU. METHODS: During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study periods, all patients admitted to our ICU were classified into four groups. The first group includes all patients with confirmed PE; the second group includes some patients without clinical manifestations of PE; the third group includes patients with suspected and not confirmed PE and the fourth group includes all patients with only deep vein thromboses (DVTs) without suspicion of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or in its branches. The diagnosis was also confirmed by echocardiography when a thrombus in the pulmonary artery was observed. RESULTS: During the study periods, 4408 patients were admitted in our ICU. The diagnosis of PE was confirmed in 87 patients (1.9%). The mean delay of development of PE was 7.8 ± 9.5 days. On the day of PE diagnosis, clinical examination showed that 50 patients (57.5%) were hypotensive, 63 (72.4%) have SIRS, 15 (17.2%) have clinical manifestations of DVT and 71 (81.6%) have respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 81 cases (93.1%) and low molecular weight heparins were used in 4 cases (4.6%). The mean ICU stay was 20.2 ± 25.3 days and the mean hospital stay was 25.5 ± 25 days. The mortality rate in ICU was 47.1% and the in-hospital mortality rate was 52.9%. Multivariate analysis showed that factors associated with a poor prognosis in ICU are the use of norepinephrine and epinephrine. Furthermore, factors associated with in-hospital poor outcome in multivariate analysis were a number of organ failure associated with PE ≥ 3. Moreover, comparison between patients with and without pe showed that predictive factors of pe are: acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO2/FiO2 ratio <300 and the absence of pharmacological prevention of venous thromboembolism. CONCLUSION: Despite the high frequency of DVT in critically ill patients, symptomatic PE remains not frequently observed, because systematic screening is not performed. Pulmonary embolism is associated with a high ICU and in-hospital mortality rate. Predictive factors of PE are acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO2/FiO2 < 300 and the absence of pharmacological prevention of venous thromboembolism.

Diffuse axonal injury in patients with head injuries: an epidemiologic and prognosis study of 124 cases.

BACKGROUND Diffuse axonal injury (DAI) is usually associated to severe trauma. Recent imaging advances made its diagnosis easier. Its prognosis impact is not yet well established. The aim of this article is to describe the epidemiologic, clinical, and radiologic features of posttraumatic DAI and to study its prognosis impact on mortality and outcome according to Glasgow Outcome Scale. METHODS This is a retrospective study over a 4-year period (2004-2007) of 124 patients admitted for head trauma. Demographic, clinical, biological, and radiologic findings were recorded at admission and during intensive care unit stay. RESULTS Mean age (±standard deviation) was 28 years±15.8 years. Cranial computed tomography scan was sufficient enough to diagnose DAI in 31 patients. Magnetic resonance imaging was performed in 105 patients with a delay of 7.7 days±8.6 days. Most patients were classified as stage II (49.5%) or stage III (44.8%) according to Gentrys classification. In a multivariate analysis, factors associated with higher mortality were dysautonomia (p=0.018; odds ratio [OR]=4.17), hyperglycemia≥8 mmol/L (p=0.001; OR=3.84) on intensive care unit admission, and subdural hematoma (p=0.031; OR=3.99), whereas factors associated to poor outcome according to Glasgow Outcome Scale score were Glasgow Coma Scale score<8 (p=0.032, OR=3.55), secondary systemic injuries score≥3 (p=0.034, OR=2.83), hyperglycemia≥8 mmol/L (p=0.002, OR=5.55), and DAI count≥6 (p=0.035, OR=3.33). In patients with pure DAI, the absence of consciousness recovery was the unique independent factor of mortality (p<0.001, OR=116.4), whereas only transfusion need was an independent factor of poor outcome (p=0.017, OR=4.44). CONCLUSION Dysautonomia, hyperglycemia, and subdural hematoma are the main factors associated to higher mortality when DAIs are diagnosed, whereas a DAI count≥6 is associated to poor outcome. Magnetic resonance imaging classification did not have a prognosis value even in patients with pure DAI.

Post-traumatic pulmonary embolism in the intensive care unit.

OBJECTIVE: To determine the predictive factors, clinical manifestations, and the outcome of patients with post-traumatic pulmonary embolism (PE) admitted in the intensive care unit (ICU). METHODS: During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each trauma patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study period, all trauma patients admitted to our ICU were classified into two groups. The first group included all patients with confirmed PE; the second group included patients without clinical manifestations of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or its branches. RESULTS: During the study period, 1067 trauma patients were admitted in our ICU. The diagnosis of PE was confirmed in 34 patients (3.2%). The mean delay of development of PE was 11.3 ± 9.3 days. Eight patients (24%) developed this complication within five days of ICU admission. On the day of PE diagnosis, the clinical examination showed that 13 patients (38.2%) were hypotensive, 23 (67.7%) had systemic inflammatory response syndrome (SIRS), three (8.8%) had clinical manifestations of deep venous thrombosis (DVT), and 32 (94%) had respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 32 cases (94%) and low molecular weight heparin was used in two cases (4%). The mean ICU stay was 31.6 ± 35.7 days and the mean hospital stay was 32.7 ± 35.3 days. The mortality rate in the ICU was 38.2% and the in-hospital mortality rate was 41%. The multivariate analysis showed that factors associated with poor prognosis in the ICU were the presence of circulatory failure (Shock) (Odds ratio (OR) = 9.96) and thrombocytopenia (OR = 32.5).Moreover, comparison between patients with and without PE showed that the predictive factors of PE were: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO2/FiO2 < 200 mmHg, the presence of spine fracture, and the presence of meningeal hemorrhage. CONCLUSION: Despite the high frequency of DVT in post-traumatic critically ill patients, symptomatic PE remains, although not frequently observed, because systematic screening is not performed. Factors associated with poor prognosis in the ICU are the presence of circulatory failure (shock) and thrombocytopenia. Predictive factors of PE are: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO2/FiO2 < 200, the presence of a spine fracture, and the presence of meningeal hemorrhage. Prevention is highly warranted.

Guillain–Barré syndrome related to pandemic influenza A (H1N1) infection

Dear Editor, Since April 2009, the world has been experiencing a pandemic influenza caused by the reasserting virus A (H1N1). Little information about neurological complications induced by this virus is available in the literature. We report the case of a 37-year-old woman who was admitted to our intensive care unit for respiratory distress associated with flaccid tetraplegia. Two weeks ago, she had fever, asthenia, and cough. A nasopharyngeal swab was performed, and reverse-transcription polymerase chain reaction (RT-PCR) confirmed infection with pandemic flu virus A (H1N1). Ten days later, she suffered muscular weakness of the lower limb, then the upper limb. At admission, she had normal consciousness, flaccid tetraplegia with complete areflexia, and symmetric paresthesia of the lower limb. A few hours later, she developed severe dyspnea with impaired coughing, accumulation of airway secretions, nasal voice, swallowing difficulties, and severe hypoxemia (SpO2 at 85% under 10 l oxygen/min) requiring mechanical ventilation. During the first 2 days, episodes of bradycardia and hypertension were recorded on hemodynamic monitoring. Diagnosis of Guillain–Barre syndrome was considered and confirmed by electromyography showing reduction in motor conduction velocity and prolonged distal latencies, which were more severe in the lower limb. On analysis of cerebrospinal fluid, there was no albuminocytologic dissociation. Investigations performed in order to identify another triggering factor were negative. Five consecutive plasma exchanges were performed, and the patient improved progressively. Repeated and prolonged weaning tests were successful, and the patient had a vigorous cough. She was free from mechanical ventilation within 2 weeks, and neither swallowing problems nor dysautonomia abnormalities were reported. The patient was discharged from our intensive care unit within 45 days. Guillain–Barre syndrome is an acute, immune-mediated polyradiculoneuropathy. In 66% of patients, history of respiratory or gastrointestinal infection within 6 weeks preceding onset of the disease is found [1]. Some infectious agents are particularly known as triggering factors of Guillain–Barre syndrome [2]. Sivadon-Tardy et al. [3] reported that influenza virus can also induce Guillain–Barre syndrome, but the majority of infections were due to virus A (H3N2), and clinical course was less severe compared with other infectious agents. For our patient, acute respiratory failure and bulbar dysfunction were the main causes leading to intensive care admission. Bulbar dysfunction can be responsible for autonomic instability and aspiration that worsens respiratory distress [4]. Determining the best time for mechanical ventilation is crucial, and up to 25% of patients with Guillain–Barre syndrome may need mechanical ventilation [1]. Delayed intubation, especially when bulbar dysfunction is considered, may increase the risk of early-onset pneumonia related to aspiration [4]. In adults, plasmapheresis is considered the gold standard for treatment of the most severe cases of Guillain– Barre syndrome. In five randomized trials, plasma exchange reduced the need for prolonged ventilation from 27% to 4% [2]. To the best of our knowledge, there are no available data concerning clinical severity and prognosis of Guillain–Barre syndrome related to pandemic flu virus A (H1N1). Further studies are needed to clarify the incidence of this complication and its prognostic impact.

Severe scorpion envenomation among children: does hydrocortisone improve outcome? A case-control study

BACKGROUND To analyse the efficacy and safety of systemic infusion of hydrocortisone hemisuccinate in children admitted to the intensive care unit with severe scorpion envenomation, we assessed the impact on mortality and length of hospital stay. METHOD We conducted a pair-wise, case-control study with 1:1 matching, reviewing records over a 13-year period (1990-2002) for the intensive care unit (ICU) of the Habib Bourguiba University Hospital, Sfax, Tunisia. A total of 184 children were included in the study (92 cases and 92 controls); cases received hydrocortisone hemisuccinate during hospitalization and controls received no steroids. Patients were matched according to age (±2 years), severity factors at admission (pulmonary edema and grades of severity of scorpion envenomation) and scorpion antivenom administration. RESULTS Cases and controls did not differ significantly in age (4.9 ± 5.5 years vs 6.2 ± 3.8 years; p > 0.05), mean temperature on admission (37.2 ± 1.2 vs 37.2 ± 1.06; p = 0.99) or presence of systemic inflammatory response syndrome (SIRS) (77 vs 70; p = 0.198). The proportion of patients with pulmonary edema was similar in the two groups (77 vs 71; p > 0.05), and in each group 46 patients (50%) received scorpion antivenom (p > 0.05). The use of mechanical ventilation, ICU length of stay and ICU mortality was not significantly different between the studied groups. CONCLUSION We detected no significant difference between patients receiving steroids and steroid-free patients in terms of mortality and ICU length of stay. The hydrocortisone hemisuccinate regimen described here had a limited effect in critically ill envenomated children and, therefore, we suggest that it should not be recommended.

Clinical features, complications and mortality in critically ill patients with 2009 influenza A(H1N1) in Sfax,Tunisia

Please cite this paper as: Damak et al.(2011) Clinical features, complications and mortality in critically ill patients with 2009 influenza A(H1N1) in Sfax,Tunisia. Influenza and Other Respiratory Viruses 5(4), 230–240

Incidence and impact outcome of pulmonary embolism in critically ill patients with severe exacerbation of chronic obstructive pulmonary diseases.

We aimed to determine the incidence and the prognostic impact [mortality and length of intensive care unit (ICU) stay (LOS)] of pulmonary embolism (PE) in critically ill patients with severe acute exacerbation of chronic obstructive pulmonary disease (COPD).

Acute renal failure and pregnancy: a seventeen-year experience of a Tunisian intensive care unit

Abstract Purpose: To describe the epidemiologic features of acute renal failure related to pregnancy (PRARF) and to evaluate its prognostic impact. Methods: Retrospective study conducted in a Tunisian intensive care unit over a period of 17 years (1995–2011). Women were included if they were more than 20 weeks pregnant and were admitted to the ICU during pregnancy or immediately (<7 d) post partum. PRARF was defined by a serum creatinine level >0.8 mg/dL and was classified as mild (0.9 to 1.4 mg/dL), moderate (1.5 to 2.9 mg/dL) or severe (>3 mg/dL). Results: Five hundred and fifty patients were included. Mean age was 31 ± 6 years. Mean SOFA score was 4 ± 3. PRARF was diagnosed in 313 patients (56.9%). ARF was mild in 215 cases (39.1%), moderate in 65 cases (11.8%) and severe in 33 cases (6%). Main causes leading to this complication were preeclampsia (66.5%) and acute hemorrhage (27.8%). Only two patients (0.4%) developed chronic renal failure and needed long-term dialysis. Patients who developed this complication had higher SOFA score (4.7 ± 3.5 vs. 3.2 ± 2.1; p < 0.001). Thirty-three patients (6%) died in the ICU. The rate of ICU mortality was significantly higher in patients with PRARF (9.3 vs. 1.7%; p < 0.001). Conclusions: PRARF is associated with higher mortality. Thus, appropriate monitoring of pregnancies is needed in order to prevent its onset by an early and prompt management of the underlying risk factors.