Arnaud Geffroy

Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial.

CONTEXT Use of a chlorhexidine gluconate-impregnated sponge (CHGIS) in intravascular catheter dressings may reduce catheter-related infections (CRIs). Changing catheter dressings every 3 days may be more frequent than necessary. OBJECTIVE To assess superiority of CHGIS dressings regarding the rate of major CRIs (clinical sepsis with or without bloodstream infection) and noninferiority (less than 3% colonization-rate increase) of 7-day vs 3-day dressing changes. DESIGN, SETTING, AND PATIENTS Assessor-blind, 2 x 2 factorial, randomized controlled trial conducted from December 2006 through June 2008 and recruiting patients from 7 intensive care units in 3 university and 2 general hospitals in France. Patients were adults (>18 years) expected to require an arterial catheter, central-vein catheter, or both inserted for 48 hours or longer. INTERVENTIONS Use of CHGIS vs standard dressings (controls). Scheduled change of unsoiled adherent dressings every 3 vs every 7 days, with immediate change of any soiled or leaking dressings. MAIN OUTCOME MEASURES Major CRIs for comparison of CHGIS vs control dressings; colonization rate for comparison of 3- vs 7-day dressing changes. RESULTS Of 2095 eligible patients, 1636 (3778 catheters, 28,931 catheter-days) could be evaluated. The median duration of catheter insertion was 6 (interquartile range [IQR], 4-10) days. There was no interaction between the interventions. Use of CHGIS dressings decreased the rates of major CRIs (10/1953 [0.5%], 0.6 per 1000 catheter-days vs 19/1825 [1.1%], 1.4 per 1000 catheter-days; hazard ratio [HR], 0.39 [95% confidence interval {CI}, 0.17-0.93]; P = .03) and catheter-related bloodstream infections (6/1953 catheters, 0.40 per 1000 catheter-days vs 17/1825 catheters, 1.3 per 1000 catheter-days; HR, 0.24 [95% CI, 0.09-0.65]). Use of CHGIS dressings was not associated with greater resistance of bacteria in skin samples at catheter removal. Severe CHGIS-associated contact dermatitis occurred in 8 patients (5.3 per 1000 catheters). Use of CHGIS dressings prevented 1 major CRI per 117 catheters. Catheter colonization rates were 142 of 1657 catheters (7.8%) in the 3-day group (10.4 per 1000 catheter-days) and 168 of 1828 catheters (8.6%) in the 7-day group (11.0 per 1000 catheter-days), a mean absolute difference of 0.8% (95% CI, -1.78% to 2.15%) (HR, 0.99; 95% CI, 0.77-1.28), indicating noninferiority of 7-day changes. The median number of dressing changes per catheter was 4 (IQR, 3-6) in the 3-day group and 3 (IQR, 2-5) in the 7-day group (P < .001). CONCLUSIONS Use of CHGIS dressings with intravascular catheters in the intensive care unit reduced risk of infection even when background infection rates were low. Reducing the frequency of changing unsoiled adherent dressings from every 3 days to every 7 days modestly reduces the total number of dressing changes and appears safe. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00417235.

Early onset pneumonia: Risk factors and consequences in head trauma patients

BackgroundEarly onset pneumonia occurs frequently in head trauma patients, but the potential consequences and the risk factors of this event have been poorly studied. MethodsThis prospective observational study was undertaken in the surgical intensive care unit of a university teaching hospital in Clichy, France. Head trauma patients requiring tracheal intubation for neurologic reasons and ventilation for at least 2 days were studied to assess the risk factors and the consequences of early onset pneumonia. ResultsDuring a 2-yr period, 109 head trauma patients were studied. The authors found an incidence of early onset pneumonia of 41.3%. Staphylococcus aureus was the most common bacteria involved in early onset pneumonia. Patients with early onset pneumonia had a lower worst arterial oxygen tension:fraction of inspired oxygen ratio, more fever, more arterial hypotension, and more intracranial hypertension, factors known to worsen the neurologic prognosis of head trauma patients. Nasal carriage of S. aureus on admission (odds ratio, 5.1; 95% confidence interval, 1.9–14.0), aspiration before intubation (odds ratio, 5.5; 95% confidence interval, 1.9–16.4) and barbiturate use (odds ratio, 3.9; 95% confidence interval, 1.2–12.8) were found to be independent risk factors of early onset pneumonia. ConclusionsThe results suggest that early onset pneumonia leads to secondary injuries in head-injured patients. Nasal carriage of S. aureus, aspiration before intubation, and use of barbiturates are specific independent risk factors for early onset pneumonia and must be assessed to find and evaluate strategies to prevent early onset pneumonia.

Infectious risk associated with arterial catheters compared with central venous catheters

Background:Scheduled replacement of central venous catheters and, by extension, arterial catheters, is not recommended because the daily risk of catheter-related infection is considered constant over time after the first catheter days. Arterial catheters are considered at lower risk for catheter-related infection than central venous catheters in the absence of conclusive evidence. Objectives:To compare the daily risk and risk factors for colonization and catheter-related infection between arterial catheters and central venous catheters. Methods:We used data from a trial of seven intensive care units evaluating different dressing change intervals and a chlorhexidine-impregnated sponge. We determined the daily hazard rate and identified risk factors for colonization using a marginal Cox model for clustered data. Results:We included 3532 catheters and 27,541 catheter-days. Colonization rates did not differ between arterial catheters and central venous catheters (7.9% [11.4/1000 catheter-days] and 9.6% [11.1/1000 catheter-days], respectively). Arterial catheter and central venous catheter catheter-related infection rates were 0.68% (1.0/1000 catheter-days) and 0.94% (1.09/1000 catheter-days), respectively. The daily hazard rate for colonization increased steadily over time for arterial catheters (p = .008) but remained stable for central venous catheters. Independent risk factors for arterial catheter colonization were respiratory failure and femoral insertion. Independent risk factors for central venous catheter colonization were trauma or absence of septic shock at intensive care unit admission, femoral or jugular insertion, and absence of antibiotic treatment at central venous catheter insertion. Conclusions:The risks of colonization and catheter-related infection did not differ between arterial catheters and central venous catheters, indicating that arterial catheter use should receive the same precautions as central venous catheter use. The daily risk was constant over time for central venous catheter after the fifth catheter day but increased significantly over time after the seventh day for arterial catheters. Randomized studies are needed to investigate the impact of scheduled arterial catheter replacement. (Crit Care Med 2010; 38:1030–1035)

Anti-PF4/heparin antibodies associated with repeated hemofiltration-filter clotting: a retrospective study

IntroductionHeparin-induced thrombocytopenia is an immune-mediated adverse drug reaction that is associated with a procoagulant state and both arterial and venous thrombosis. After observing two cases of repeated hemofiltration-filter clotting associated with high anti-PF4/heparin antibody concentrations, we systematically measured the anti-PF4/heparin antibody concentration in all cases of unexpected and repeated hemofiltration-filter clotting during continuous veno-venous hemofiltration (CVVH). The aim of this study was to identify factors associated with positive anti-PF4/heparin antibody in the case of repeated hemofiltration-filter clotting.MethodsWe reviewed the charts of all patients who had an anti-PF4/heparin antibody assay performed for repeated hemofiltration-filter clotting between November 2004 and May 2006 in our surgical intensive care unit. We used an enzyme-linked immunoabsorbent assay (heparin-platelet factor 4-induced antibody) with an optical density (OD) of greater than 1 IU considered positive.ResultsDuring the study period, anti-PF4/heparin antibody assay was performed in 28 out of 87 patients receiving CVVH. Seven patients were positive for anti-PF4/heparin antibodies (OD 2.00 [1.36 to 2.22] IU) and 21 were antibody-negative (OD 0.20 [0.10 to 0.32] IU). Baseline characteristics, platelet counts, and activated partial thromboplastin time ratios were not different between the two groups. CVVH duration was significantly decreased in antibody-positive patients (5.0 [2.5 to 7.5] versus 12.0 [7.5 to 24.0] hours; P = 0.007) as was CVVH efficiency (urea reduction ratio 17% [10% to 37%] versus 44% [30% to 52%]; P = 0.04) on heparin infusion. Anti-PF4/heparin antibody concentration was inversely correlated with CVVH duration. The receiver operating characteristic curve showed that a 6-hour cutoff was the best CVVH session duration to predict a positive antibody test (sensitivity 71%, specificity 85%, and area under the curve 0.83). CVVH duration (32 [22 to 37] hours; P < 0.05) and urea reduction (55% [36% to 68%]; P < 0.03) were restored by danaparoid sodium infusion.ConclusionRepeated hemofiltration-filter clotting in less than 6 hours was often associated with the presence of anti-PF4/heparin antibodies, regardless of the platelet count. In antibody-positive patients, replacement of heparin by danaparoid sodium allowed the restoration of CVVH duration and efficiency.

Prolonged right ventricular failure after relief of cardiac tamponade.

PurposeTo report a case of severe and fatal cardiac complication following pericardiotomy to relieve a malignant tamponade. Right ventricular (RV) failure was responsible for major hypoxemia and for a persistent shunt through a patent foramen ovale. In the absence of pulmonary embolism and coronary occlusion, possible pathophysiologic mechanisms are discussed.Clinical featuresThis 53-yr-old patient presented with oropharyngeal carcinoma previously treated by chemotherapy. One month later, he showed clinical and echocardiographic signs of cardiac tamponade. He had a circumferential pericardial effusion with complete end-diastolic collapse of the right cavities. After an emergent pericardiotomy, he rapidly presented severe hypoxemia. Transesophageal echocardiography showed an akinetic and dilated right ventricle, paradoxical septal wall motion and a normal left ventricular function. A contrast study revealed a right-to-left shunt. No residual pericardial effusion was detectable. Pulmonary angiography excluded a pulmonary embolism and the coronary angiogram was normal. Troponin Ic was elevated postoperatively and peaked on day two (3.78 μg·L−1). The patient died of refractory shock with persistent intracardiac shunt and RV akinesia on day nine.ConclusionAlthough pulmonary embolism or thrombus of a coronary vessel are the most common causes of prolonged RV failure after pericardiotomy, other mechanisms may be invoked. The possibility is raised that a rapid increase in RV tension may induce the development of muscular injury and impair coronary blood flow, despite a normal coronary angiogram. These could result in a stunned myocardium and opening of a patent foramen ovale. We hypothesize that gradual decompression of a chronic pericardial effusion might be beneficial in patients at risk.RésuméObjectifRapporter un cas de complication cardiaque grave après drainage péricardique d’une tamponnade. Une défaillance ventriculaire droite était associée à une hypoxémie profonde et un shunt permanent à travers un foramen ovale perméable. En l’absence d’embolie pulmonaire et de thrombose coronaire, différents mécanismes physiopathologiques sont discutés.Éléments cliniquesUn homme de 53 ans était atteint d’un cancer de l’oropharynx préalablement traité par chimiothérapie. Un mois plus tard, il a présenté des signes cliniques et échocardiographiques de tamponnade cardiaque. L’épanchement péricardique volumineux était circonférentiel et associé à un collapsus télédiastolique majeur des cavités droites. Après drainage chirurgical du péricarde en urgence, le patient a rapidement présenté une hypoxémie. L’échographie cardiaque transoesophagienne objectivait un ventricule droit akinétique et dilaté, un septum interventriculaire paradoxal et une fonction ventriculaire gauche normale. Une épreuve de contraste a permis de révéler un shunt droit- gauche permanent à travers un foramen ovale perméable. Aucun épanchement péricardique résiduel n’a été retrouvé. Une embolie pulmonaire ainsi qu’une thrombose coronaire ont été éliminées. Une mise en circulation de troponine Ic a été notée avec un pic au deuxième jour à 3,78 μg·L− 1. Le patient est décédé au neuvième jour, dans un tableau d’état de choc réfractaire avec persistance du shunt intracardiaque et de l’akinésie du ventricule droit.ConclusionBien que l’embolie pulmonaire ou la thrombose coronaire soit les causes les plus fréquentes d’une défaillance ventriculaire droite prolongée après drainage péricardique, d’autres mécanismes peuvent être impliqués. Une augmentation rapide de la tension du ventricule droit a pu entraîner une atteinte du muscle cardiaque et détériorer le flux sanguin coronaire, malgré une coronarographie normale. L’état de sidération du myocarde pourrait alors permettre l’ouverture d’un foramen ovale perméable. Chez les patients à risque, une évacuation progressive des épanchements péricardiques chronique pourrait être proposée.

Pneumothorax et pneumopéricarde compressifs post-traumatiques en ventilation spontanée

The occurrence of tension pneumopericardium in patient in spontaneous ventilation after blunt trauma is rare. The diagnosis is difficult and it may remain unrecognized. The authors reported the case of a 50 year-old trauma patient with a tension pneumothorax associated with a pneumopericardium. The patient was not mechanically ventilated at any time. Pericardial relief was obtained by insertion of a chest tube.

Postpartum thrombosis of the superior mesenteric artery after vaginal delivery.

BACKGROUND: Several causes of severe and acute postpartum abdominal pain (pelvic infection, complications of pelvic thromboembolism, arterial ischemia) require early diagnosis and prompt therapy. CASE: Eight days after a normal vaginal delivery, a 38-year-old woman presented with severe acute abdominal pain that had been going on for 3 days. Abdominal computed tomography showed a superior mesenteric artery thrombosis with suggested ileal wall ischemia. An emergency thrombectomy associated with ileal resection and ileostomy were performed. No identifiable source of embolism, hemostatic disorder, systemic vasculitis, or systemic disease associated with thrombosis was found. CONCLUSION: Even after a vaginal delivery, the postpartum period is associated with an increased risk of complications of thromboembolism. In the case of acute abdominal pain, abdominal contrast-enhanced computed tomography may be necessary to exclude mesenteric arterial ischemia.

Cas cliniquePneumothorax et pneumopéricarde compressifs post-traumatiques en ventilation spontanéePost-traumatic tension pneumothorax and pneumopericardium in spontaneous ventilation

The occurrence of tension pneumopericardium in patient in spontaneous ventilation after blunt trauma is rare. The diagnosis is difficult and it may remain unrecognized. The authors reported the case of a 50 year-old trauma patient with a tension pneumothorax associated with a pneumopericardium. The patient was not mechanically ventilated at any time. Pericardial relief was obtained by insertion of a chest tube.

Iliac crest bone harvest : Should we really use continuous infusion of ropivacaine?

To the Editor:— We read with interest the study by Scavone et al. that demonstrates the absence of efficacy of a prophylactic epidural blood patch after inadvertent dural puncture. We suggest that two factors could have influenced the negative result of this trial. First, inadvertent dural puncture could have been overdiagnosed, namely when loss of resistance to saline was used to locate epidural space. This could explain the lower incidence of post–dural puncture headache and less frequent realization of therapeutic epidural blood patch reported in this study compared with others. Second, 20 ml may not be the adequate blood volume to test a prophylactic epidural blood patch. This volume has tended to increase over time to 20 ml or more, 23 5 ml in a study by Safat-Tisseront et al. The optimal blood volume may be the volume at which pain in the back, buttocks, or legs occurs, which was only achieved for seven patients in the study of Scavone et al. This higher volume may lead to either a larger patch over the dural tear or a significantly higher increase in lumbar and intracranial pressure, leading to reduced cerebral vasodilation. Olivier Pruszkowski, M.D.,* Orlando Goncalves, M.D., Claude Lentschener, M.D., Alexandre Mignon, M.D., Ph.D. *Hôpital Cochin Maternité Port-Royal, Assistance Publique–Hôpitaux de Paris, Paris, France. olivier.prus@club-internet.fr