Jean-Claude Bertrand

Serum and ascitic procalcitonin levels in cirrhotic patients with spontaneous bacterial peritonitis: diagnostic value and relationship to pro-inflammatory cytokines.

Objective: To assess the potential role of procalcitonin and pro-inflammatory cytokines, TNF-α, and IL-6, in the diagnosis of spontaneous bacterial peritonitis (SBP). Design: Prospective study. Setting: The emergency unit of a teaching hospital. Patients: We included 21 patients with SBP and 40 patients with sterile ascitic fluid. Interventions: None. Measurements and main results: For the diagnosis of SBP, the best markers were serum levels of procalcitonin with a cut-off value of 0.75 ng/ml, a sensitivity of 95 %, a specificity of 98 %, and ascitic fluid levels of IL-6 with a cut-off value of 5000 ng/ml, a sensitivity of 100 %, and a specificity of 88 %. C-reactive protein and serum polymorphonuclear count have low sensitivity/specificity at 62/92 % and 57/90 %, respectively. From 21 patients with SBP, ascitic fluid to serum ratio of TNF-α and IL-6 was greater than to 2 in all cases with a mean at 6.2 ± 6.5 and 34 ± 31, respectively. By contrast, this ratio for procalcitonin was less than 1 in all cases with a mean at 0.31 ± 0.25. We found no correlation between procalcitonin levels and cytokine levels in either ascitic fluid or serum. Conclusions: Serum procalcitonin level may become a useful marker for the diagnosis of SBP in cirrhotic patients. The low ratio of ascitic fluid to serum procalcitonin supports the hypothesis that procalcitonin is not produced intraperitoneally.

Weaning from mechanical ventilation with pressure support in patients failing a T-tube trial of spontaneous breathing.

ObjectiveEvidence that PS may facilitate weaning from mechanical ventilation (MV), although not confirmed by randomized trials, prompted us to investigate whether patients could be weaned with PS after failing a T-tube trial.Design and settingThis was a prospective, non-randomized study in two French intensive care units.Patients and participantsOne hundred eighteen patients were enrolled and underwent a T-tube trial, after which 87 were extubated. Thirty-one underwent a further trial with PS, after which 21 were extubated.InterventionsAll patients under MV >24xa0h meeting the criteria for a weaning test underwent a 30-min T-tube trial. If this was successful, they were immediately extubated. Otherwise, a 30-min trial with +7xa0cm H2O PS was initiated with an individualized pressurization slope and trigger adjustment. If all weaning criteria were met, the patients were extubated; otherwise, MV was reinstated.Measurements and Results The extubation failure rate at 48xa0h did not differ significantly between the groups: 11/87 (13%) versus 4/21 (19%), P=0.39. The groups were comparable with regard to endotracheal tube diameter, MV duration, the use of non-invasive ventilation (NIV) after extubation, initial severity score, age and underlying pathology, except for COPD. A significantly higher percentage of patients with COPD was extubated after the trial with PS (8/21–38%) than after a single T-tube trial (11/87–13%) (P=0.003).ConclusionsOf the patients, 21/118 (18%) could be extubated after a trial with PS, despite having failed a T-tube trial. The reintubation rate was not increased. This protocol may particularly benefit patients who are most difficult to wean, notably those with COPD.

Endotoxaemia in patients with severe sepsis or septic shock

Objective: To examine the incidence and the bacteriological and clinical significance of endotoxaemia in ICU patients with severe sepsis or septic shock. Design: Prospective review. Setting: A 15-bed general ICU in a university hospital. Patients: One hundred sixteen patients hospitalised in our ICU fulfilling Bones criteria for severe sepsis or septic shock and with an available early endotoxin assay (chromogenic limulus assay). Interventions: None. Measurements and results: The clinical characteristics of the population were: age 63.6 ± 11.4 years; SAPS II: 45.4 ± 15.6; mechanical ventilation: 72.4 %; septic shock: 51.7 % (n = 60); bacteraemia: 28.4 % (n = 33); gram-negative bacteria (GNB) infection 47.4 % (n = 55); ICU mortality: 39.6 % (n = 46). Detectable endotoxin occurred in 61 patients (51.2 %; mean level: 310 ± 810 pg/ml). There was no relationship between detectable endotoxin and severity of infection at the moment of the assay. Endotoxaemia was associated with a higher incidence of bacteraemia (39.3 % vs 16.3 %; p = 0.01). There was a trend (p = 0.09) towards an association between positive endotoxin and gram-negative bacteraemia or GNB infection but this was non-significant. This relationship became significant only in the case of bacteraemia associated with GNB infection irrespective of the site of infection. Conclusion: Early detection of endotoxaemia appeared to be associated with GNB infection only in cases of bacteraemic GNB infection. Early endotoxaemia correlated neither to occurrence of organ dysfunction nor mortality in patients with severe sepsis or septic shock. This study suggests that the use of endotoxaemia as a diagnostic or a prognostic marker in daily practice remains difficult.

Continuous infusion of ceftazidime in critically ill patients undergoing continuous venovenous haemodiafiltration: pharmacokinetic evaluation and dose recommendation

IntroductionIn seriously infected patients with acute renal failure and who require continuous renal replacement therapy, data on continuous infusion of ceftazidime are lacking. Here we analyzed the pharmacokinetics of ceftazidime administered by continuous infusion in critically ill patients during continuous venovenous haemodiafiltration (CVVHDF) in order to identify the optimal dosage in this setting.MethodSeven critically ill patients were prospectively enrolled in the study. CVVHDF was performed using a 0.6 m2 AN69 high-flux membrane and with blood, dialysate and ultrafiltration flow rates of 150 ml/min, 1 l/hour and 1.5 l/hour, respectively. Based on a predicted haemodiafiltration clearance of 32.5 ml/min, all patients received a 2 g loading dose of ceftazidime, followed by a 3 g/day continuous infusion for 72 hours. Serum samples were collected at 0, 3, 15 and 30 minutes and at 1, 2, 4, 6, 8, 12, 24, 36, 48 and 72 hours; dialysate/ultrafiltrate samples were taken at 2, 8, 12, 24, 36 and 48 hours. Ceftazidime concentrations in serum and dialysate/ultrafiltrate were measured using high-performance liquid chromatography.ResultsThe mean (± standard deviation) elimination half-life, volume of distribution, area under the concentration-time curve from time 0 to 72 hours, and total clearance of ceftazidime were 4 ± 1 hours, 19 ± 6 l, 2514 ± 212 mg/h per l, and 62 ± 5 ml/min, respectively. The mean serum ceftazidime steady-state concentration was 33.5 mg/l (range 28.8–36.3 mg/l). CVVHDF effectively removed continuously infused ceftazidime, with a sieving coefficient and haemodiafiltration clearance of 0.81 ± 0.11 and 33.6 ± 4 mg/l, respectively.ConclusionWe conclude that a dosing regimen of 3 g/day ceftazidime, by continuous infusion, following a 2 g loading dose, results in serum concentrations more than four times the minimum inhibitory concentration for all susceptible pathogens, and we recommend this regimen in critically ill patients undergoing CVVHDF.

Analgesic efficacy of orodispersible paracetamol in patients admitted to the emergency department with an osteoarticular injury.

Introduction Acute pain still persists in patients under treatment after admission to emergency departments (ED). The objective of this study was to determine the efficacy of 1u2009g of paracetamol in patients presenting an osteoarticular injury. Materials and methods This prospective study included all patients admitted to the ED with an osteoarticular injury and a pain score above 30 on the visual analogue scale (VAS). Patients were selected on admission by the reception nurse and given paracetamol within 5u2009min of admission. VAS scores were recorded 30 and 60u2009min after admission. On discharge from the ED, the patients underwent a further VAS assessment and were asked a question about pain relief (yes/no answer). The primary endpoint was the VAS score at 60u2009min. The secondary endpoint was the pain relief expressed by the patient on discharge from the ED. Results Five hundred and seventy-one patients were included. The median stay in the ED was 90u2009min (75–120u2009min). The diagnoses at discharge were sprain or dislocation (ankle, knee, and wrist) for 287 patients, fracture for 102 patients, and other injury for 182 patients. In 69% of the patients, the injured limb was immobilized. The median VAS score on admission was 57. A significant difference was seen between the median VAS on admission and at 1u2009h after admission (57±18 vs. 30±18; P<0.0001), and between the median VAS score at admission and the score at discharge from the ED (57±18 vs. 26±18, P<0.0001). Finally, 81% of the patients expressed pain relief. On discharge from the ED, a gain of 20u2009mm on the VAS had a positive predictive value of 93% [area under curve (AUC): 89; CI: 86–92; P=0.001], for the endpoint ‘patients stating pain relief’. Conclusion A simple and easily applicable protocol of pain management permits the achievement of satisfactory analgesia during a patients stay in the ED.

Valeurs de la troponine I au cours des rhabdomyolyses chez les personnes âgées admises aux urgences

Summary Objective xa0The objective of this study was to assess the utility of determining serum cardiac troponin I (TcI) levels in the elderly. Methods During the nine-month study period, all patients older than 70 years admitted to the emergency department presenting rhabdomyolysis (defined by creatine kinasexa0>xa0500 IU/L) were included in this prospective descriptive study, except for those with acute coronary syndrome or pulmonary embolism. Patients were classified into two groups according to their serum TcI level:xa0>xa00.15 orxa0≤xa00. 15 ng/mL. The groups were compared for clinical, laboratory and treatment variables at inclusion and for mortality at six months. Results The study included 67 patients: 30 in the group with TcIxa0>xa00.15 ng/mL group and 37 in the other group. Clinical and laboratory indicators were similar in the two groups. In contrast, significantly more patients in the TcIxa0>xa00.15 ng/mL group had been treated with a curative dose of heparin (14 versus 2, pxa0=xa00.01). This difference between the two groups was noted in both the emergency department and other hospital units. Serum TcI levels were not correlated with creatine kinase levels. Concordance between emergency department diagnosis and discharge diagnosis was 95%. No patient was discharged with a diagnosis of acute coronary syndrome; one patient, with a serum TcI levelxa0≤xa00.15 ng/mL, was diagnosed with a pulmonary embolism. Fewer than half the patients underwent cardiac ultrasonography. Segmental hypokinesia was observed in only a few cases (6% in the TcIxa0>xa00. 15 ng/mL group versus 8% in the other group). Mortality at six months was higher among patients with an elevated serum TcI level, but the difference was not significant (23% versus 8%, pxa0=xa00.07). Conclusion This study indicated a trend toward higher mortality among patients with elevated serum TcI levels, although the factors underlying these increased concentrations remain unclear.OBJECTIVEnThe objective of this study was to assess the utility of determining serum cardiac troponin I (TcI) levels in the elderly.nnnMETHODSnDuring the nine-month study period, all patients older than 70 years admitted to the emergency department presenting rhabdomyolysis (defined by creatine kinase>500 IU/L) were included in this prospective descriptive study, except for those with acute coronary syndrome or pulmonary embolism. Patients were classified into two groups according to their serum TcI level:>0.15 or<or=0. 15 ng/mL. The groups were compared for clinical, laboratory and treatment variables at inclusion and for mortality at six months.nnnRESULTSnThe study included 67 patients: 30 in the group with TcI>0.15 ng/mL group and 37 in the other group. Clinical and laboratory indicators were similar in the two groups. In contrast, significantly more patients in the TcI>0.15 ng/mL group had been treated with a curative dose of heparin (14 versus 2, p=0.01). This difference between the two groups was noted in both the emergency department and other hospital units. Serum TcI levels were not correlated with creatine kinase levels. Concordance between emergency department diagnosis and discharge diagnosis was 95%. No patient was discharged with a diagnosis of acute coronary syndrome; one patient, with a serum TcI level<or=0.15 ng/mL, was diagnosed with a pulmonary embolism. Fewer than half the patients underwent cardiac ultrasonography. Segmental hypokinesia was observed in only a few cases (6% in the TcI>0. 15 ng/mL group versus 8% in the other group). Mortality at six months was higher among patients with an elevated serum TcI level, but the difference was not significant (23% versus 8%, p=0.07).nnnCONCLUSIONnThis study indicated a trend toward higher mortality among patients with elevated serum TcI levels, although the factors underlying these increased concentrations remain unclear.

Modifiable Risk Factors for Delirium in Critically Ill Trauma Patients: A Multicenter Prospective Study

Objective: Intensive care unit (ICU)–acquired delirium has been associated with increased morbidity and mortality. Prevention strategies including modification of delirium risk factors are emphasized by practice guidelines. No study has specifically evaluated modifiable delirium risk factors in trauma ICU patients. Our goal was to evaluate modifiable risk factors for delirium among trauma patients admitted to the ICU. Design: Prospective observational study. Setting: Two level 1 trauma ICU centers. Patients: Patients 18 years of age or older admitted for trauma including mild to moderate traumatic brain injury were eligible for the study. Interventions and Measurements: Delirium was assessed daily using the confusion assessment method for the ICU (CAM-ICU). The effect of modifiable risk factors was assessed using multivariate Cox regression analysis adjusting for severity of illness and significant nonmodifiable risk factors. Main Results: A total of 58 of 150 recruited patients (38.7%; 95% confidence interval [CI] 30.9-46.5) screened positive for delirium during ICU stay. When adjusting for significant nonmodifiable risk factors, physical restraints (hazard ratio [HR]: 2.13; 95% CI: 1.07-4.24) and active infection or sepsis (HR: 2.12; 95% CI: 1.18-3.81) significantly increased the risk of delirium, whereas opioids (HR: 0.35; 95% CI: 0.13-0.98), episodes of hypoxia (HR: 0.55; 95% CI: 0.31-0.95), access to a television/radio in the room (HR: 0.26; 95% CI: 0.11-0.62), and number of hours mobilized per day (HR: 0.77; 95% CI: 0.68-0.88) were associated with significantly less risk of delirium. Conclusion: We have identified modifiable risk factors for delirium. Future studies should aim at implementing strategies to modify these risk factors and evaluate their impact on the risk of delirium.