Jean-Pierre Fulgencio

Risk and protective factors for major complications after pneumonectomy for lung cancer.

Pneumonectomy carries a high-risk for postoperative complications. The aim of the study was to identify factors that may predispose to the development of major postoperative complications after pneumonectomy for lung cancer. All consecutive patients from January 2000 to December 2005 were retrospectively studied. Major postoperative complications were defined by respiratory failure, pulmonary embolism, pneumonia, shock, cardiogenic pulmonary oedema, myocardial ischaemia or symptomatic cardiac arrhythmia. One hundred and twenty-nine patients were included. The overall hospital mortality rate was 10.8%, and complications occurred in 42.6%. Multivariate analysis revealed that patients with American Society of Anesthesiologist (ASA) class >2 [odds ratio (OR) 8.26; 95% confidence interval (CI), 3.19-36.55] and liberal fluid administration during surgery (OR, 1.96 for each litre; 95% CI, 1.45-3.16) to be risk factor for major cardiopulmonary complication or mortality. Preoperative haemoglobin > or =10 g/dl (OR, 0.19; 95% CI, 0.01-0.91) and low tidal volume administrated during surgery (< or =7.35 ml/kg; OR, 0.36; 95% CI, 0.10-0.92) were identified as protective factors. Pneumonectomy remains a high-risk surgery. Postoperative complications may be influenced by the comorbidities but also the management of fluid infusion and mechanical ventilation during the surgical procedure.

Immune status and apoptosis activation during brain death.

The present study evaluates the role of the inflammatory status and apoptosis activation in the development of organ dysfunction after brain death using plasma assays and macroarray analysis on skeletal muscle biopsies to look for evidence of remote tissue damage in two intensive care units in France and one in Belgium. As controls, we used patients undergoing hip surgery and healthy volunteers. Causes of brain death in the 85 consecutive patients included in the study were cardiac arrest (n = 29; 34%), stroke (n = 42; 49%, with 38 patients having hemorrhagic stroke), and head injury (n = 14; 17%). Of the 85 patients, 45 donated 117 organs. Plasma endotoxin and cytokine levels indicated a marked systemic inflammatory response in brain-dead patients, which was strongest in the cardiac arrest group. Leukocyte dysfunction, as assessed by cytokines production in response to various stimuli, was noted in a subgroup of patients with brain death after stroke. Interestingly, skeletal muscle biopsies showed no increase in mRNAs for genes related to inflammation, whereas mRNAs for both antiapoptotic and proapoptotic genes were increased, the balance being in favor of apoptosis induction. The increased activation of the proapoptotic caspase 9 was further confirmed by Western blot. In conclusion, the presence of inflammation and apoptosis induction may explain the rapid organ dysfunction seen after brain death. Both abnormalities may play a role in organ dysfunction associated with brain death. However, the level of systemic inflammation or the presence of circulating endotoxin was not associated with lower graft survival.

Une nouvelle cause de syndrome confusionnel postopératoire : la prise de néfopam

Resume Nous decrivons un cas d’intoxication probable au nefopam survenu chez une patiente de reanimation souffrant de denutrition avec hypoprotidemie. Le nefopam etait responsable d’un syndrome confusionnel, associe a d’autres symptomes temoignant de son effet anticholinergique tels que tremblement, hypertonie, mydriase et tachycardie. L’ensemble de la symptomatologie a cede a l’arret du traitement. La responsabilite du nefopam doit etre evoquee le cas echeant chez les patients de reanimation presentant un syndrome confusionnel.

Universal versus targeted additional contact precautions for multidrug-resistant organism carriage for patients admitted to an intensive care unit

HIGHLIGHTSAn isolation‐targeted screening is non‐inferior to universal screening‐isolation.This strategy provides similar rates of acquired MDRO colonization or infection.It could be appropriate in some ICU and allow consumption of fewer resources.A hospital stay of more than 5 days is associated with MDRO carriage on admission.The choice of risk factors may influence the suitability of such a strategy. Background: Although additional contact precautions (ACPs) are routinely used to reduce cross‐transmission of multidrug‐resistant organisms (MDROs), the relevance of isolation precautions remains debated. We hypothesized that the collection of recognized risk factors for MDRO carriage on intensive care unit (ICU) admission might be helpful to target ACPs without increasing MDRO acquisition during ICU stays, compared with universal ACPs. Materials and Methods: This is a sequential single‐center observational study performed in consecutive patients admitted to a French medical and surgical ICU. During the first 6‐month period, screening for MDRO carriage and ACPs were performed in all patients. During the second 6‐month period, screening was maintained, but ACP use was guided by the presence of at least 1 defined risk factor for MDRO. Results: During both periods, 33 (10%) and 30 (10%) among 327 and 297 admissions were, respectively, associated with a positive admission MDRO carriage. During both periods, a second screening was performed in 147 (45%) and 127 (43%) patients. Altogether, the rate of acquired MDRO (positive screening or clinical specimen) was similar during both periods (10% [n = 15] and 11.8% [n = 15], respectively; P = .66). Conclusions: The results of our study contribute to support the safety of an isolation‐targeted screening policy on ICU admission compared with universal screening and isolation regarding the rate of ICU‐acquired MDRO colonization or infection.

The Challenging Diagnosis of Non-Community-Acquired Pneumonia in Non-Mechanically Ventilated Subjects: Value of Microbiological Investigation

BACKGROUND: Early recognition and an attempt at obtaining microbiological documentation are recommended in patients with non-community-acquired pneumonia (NCAP), whether hospital-acquired (HAP) or health care-associated (HCAP). We aimed to characterize the clinical features and microbial etiologies of NCAP to assess the impact of microbiological investigation on their management. METHODS: This was a prospective 1-y study in a university hospital with 141 non-mechanically ventilated subjects suspected of having HAP (n = 110) or HCAP (n = 31). RESULTS: Clinical criteria alone poorly identified pneumonia (misdiagnosis in 50% of cases). Microbiological confirmation was achievable in 80 subjects (57%). Among 79 microorganisms isolated, 28 were multidrug-resistant aerobic Gram-negative bacilli and group III Enterobacteriaceae and 6 were methicillin-resistant Staphylococcus aureus. Multidrug-resistant aerobic Gram-negative bacilli accounted for one third of the microorganisms in early-onset HAP and for 50% in late-onset HAP. Methicillin-resistant S. aureus was most often recovered from subjects with HCAP. Inappropriate empirical antibiotics were administered to 36% of subjects with confirmed pneumonia. Forty subjects were admitted to the ICU, 13 (33%) of whom died. Overall, 39 subjects (28%) died in the hospital. CONCLUSIONS: Integrating the microbiological investigation in the complex clinical diagnostic workup of patients suspected of having NCAP is mandatory. Respiratory tract specimens should be obtained whenever possible for appropriate management.

Pneumomédiastin spontané chez un homme jeune

Le pneumomédiastin est défini par la présence anormale d’air au niveau du médiastin. Son diagnostic repose sur l’imagerie radiologique (radiographie du thorax et tomodensitométrie permettant de préciser son extension). Les étiologies du pneumomédiastin sont multiples et parfois graves telles que la rupture de la paroi œsophagienne (traumatique, néoplasique ou post-chirurgicale) et l’infection de contiguı̈té à germes anaérobies. Plus récemment, a été décrite la possibilité de survenue d’un pneumomédiastin chez des sujets jeunes effectuant des manœuvres respiratoires forcées [1]. Nous rapportons une observation de ce type, chez un patient hospitalisé en urgence et discutons la démarche diagnostique, le mécanisme et la conduite à tenir. Il s’agit d’un patient de 22 ans, 1 m 77 et 55 kg (IMC = 17,55), ayant des antécédents de syndrome anxiodépressif qui dans la semaine précédent son admission, avait présenté un tableau psychiatrique fait de bouffée délirante aiguë et d’hallucinations visuelles, associées à un sentiment de persécution. Le patient était alors adressé aux urgences pour bilan somatique avant une hospitalisation en secteur psychiatrique. Aux urgences, le patient était agité (peu coopérant) et présentait des hallucinations auditives et visuelles, avec un délire de persécution sans déficit neurologique. L’état hémodynamique était stable (pression artérielle : 143/ 86 mmHg, fréquence cardiaque : 92 b/min, SaO2 98 % en air ambiant). L’auscultation pulmonaire était normale, mais l’attention était attirée par la présence d’un emphysème souscutané cervical modéré. Afin d’éliminer une pathologie organique potentiellement responsable du tableau psychiatrique, on réalisait un examen tomodensitométrique cérébral. Ce dernier était normal mais confirmait la présence d’un emphysème sous-cutané cervical. La radiographie thoracique révélait qu’il était associé à un pneumomédiastin. Un second examen tomodensitométrique, réalisé au niveau thoracique, confirmait le pneumomédiastin circonférentiel, dont le volume était modéré, sans aucune pathologie pleurale