Jérôme Fichet

Prognosis and 1-year mortality of intensive care unit patients with severe hepatic encephalopathy ☆

PURPOSE Data regarding outcome of patients with chronic liver disease with severe hepatic encephalopathy in intensive care unit are currently scarce. METHODS This study is a retrospective observational case series in a medical intensive care unit (ICU) in a university hospital from 1995 to 2005. Patients with hepatic encephalopathy (HE) (admitted with or developing) were identified. Clinical and laboratory parameters were analyzed to determinate predictors of ICU and 1-year mortality. RESULTS Seventy-one patients were included (53 male). Median Simplified Acute Physiology Score was 56 with Child-Pugh score 11 +/- 2. Seventy-six percent of patients were admitted with coma (Glasgow Coma Scale, 7.7 +/- 4). Eighty-two percent of patients required intubation, and 28% vasopressors. Thirty-five percent died during ICU stay. At 1 year, mortality was 54%. Univariate analysis identified arterial hypotension, mechanical ventilation, vasopressors at any time, acute renal failure, Simplified Acute Physiology Score, and sepsis associated with ICU mortality. In multivariate analysis, vasopressor use or acute renal failure was the main independent predictor of ICU death and 1-year mortality. Patients free of these risk factors, even requiring intubation, were identified as isolated HE, with lower mortality rates. CONCLUSION Predictors of outcome were similar to other groups of patients with liver disease admitted for other reasons. Intensive care unit mortality was lower than reported for other groups of patients with similar illness. Patients with severe HE admitted to ICU with no organ dysfunction other than mechanical ventilation had a better outcome and may require ICU admission.

Aborted Sudden Cardiac Death Revealing Isolated Noncompaction of the Left Ventricle in a Patient with Wolff-Parkinson-White Syndrome

Isolated noncompaction of the left ventricle (INLV) is a rare congenital disorder associated with multiple cardiac arrhythmias. We report a case of INLV revealed by ventricular fibrillation in a patient with Wolff‐Parkinson‐White syndrome. Because of the persistence of inducible ventricular arrhythmias after ablation of the accessory pathway, implantation of an ICD was decided.

Comparison of Degree of Stenosis and Plaque Volume for the Assessment of Carotid Atherosclerosis Using 2-D Ultrasound

The degree of carotid stenosis (%ST) remains the most frequently used parameter for identifying patients with high risk of stroke but the relationship between %ST and the occurrence of stroke remains controversial. The objectives of this study were to check (1) the relationship between the %ST and the plaque volume index (PVI) as measured by echography and Doppler, (2) the relationship between the intima media thickness (IMT), a vessel wall remodeling index and the PVI an atheromatous growth index. For each of the 128 patients, (165 carotid stenosis), we measured the % ST (section or diameter), the max stenosis velocity (V(max)), the PVI and the common carotid IMT. The %ST (section) ranged from 10% to 93% (mean 66+/-18), V(max) from 0.3m/s to 3m/s (mean 1.2+/-0.8), PVI from 0.61cm(3) to 1.17cm(3) (mean 0.41+/-0.21) and the IMT from 0.08cm up to 0.31cm (mean 0.12+/-0.03). There was no significant correlation between either PVI and %ST (section or diameter), PVI and minimal stenosis section area (S1) or between PVI and V(max). There was no significant correlation between IMT and both %ST area and PVI. PVI was significantly correlated with the whole artery section area (S2) and the plaque length (L). The %ST (section or diameter) was significantly correlated with S1 but not with S2. The absence of correlation between the PVI and the %ST confirm that these two parameters describe two different processes of the atheromatous development.

Reducing risk of stroke in patients with acute coronary syndrome: is screening for asymptomatic carotid disease useful?

Stroke is a rare but severe event after acute coronary syndrome. Relations between both arterial territories are still discussed but prevalence of asymptomatic carotid stenosis potentially implicated in the mechanism of stroke is under-investigated. This study aimed to determine the prevalence of asymptomatic carotid stenosis in that population and review the value of screening in a view to potential surgical correction or other preventive therapies. Systematic carotid Doppler ultrasound screening was implemented on 152 consecutive patients admitted to the intensive care unit due to acute coronary syndrome. Fifty-two percent of patients had at least one carotid artery stenosis determined using the NASCET method. Forty-three percent had at least one carotid stenosis <30%, 6% had mild (30–60%) stenosis, and 2.6% had high-grade (>60%) stenosis. Existence of carotid stenosis was associated with age, diabetes mellitus, hypertension, and with the extent of the coronary atherosclerosis (left main artery stenosis). In multivariate analysis, age and diabetes were independently associated with existence of a carotid stenosis. When ultrasound screening was restricted to patients identified by multivariate analysis, the prevalence of carotid stenosis potentially requiring surgical treatment rose to 4.6%. The frequency of asymptomatic carotid atherosclerosis was high in this population but lesions were mild. While the small number of high-grade lesions indicates that systematic screening is not to be recommended, screening of patients aged >65 years or with diabetes, or both, with a view to surgery may be envisaged, since the role of mild stenosis in the occurrence of stroke remains debatable.

Fatal QT interval.

A 21-year-old woman, without medical history, was admitted after cardiac arrest. Cardiopulmonary resuscitation and use of semiautomatic defibrillator quickly restored sinus rhythm. Clinical examination was normal with no cardiac murmur or abnormal heart sound. Electrocardiogram revealed sinus rhythm with short QT interval. Serum electrolytes and arterial blood gazes were normal. One hour after admission, lethal ventricular fibrillation occurred. Factors that shorten QT interval including increase in heart rate, hyperthermia, increased calcium, or potassium plasma levels and acidosis were excluded. Short-QT syndrome has been recently recognized as a genetic ion channel dysfunction leading to an abbreviation of action potential and a potential substrate for arrhythmias. This syndrome is characterized by a short QT interval (typically <320 milliseconds), associated with a high incidence of sudden death, syncope, or atrial fibrillation in individuals with an apparently normal heart. Implementation of an internal cardiac defibrillator remains the only effective preventive treatment.

Major ST-segment elevation hiding acute severe pancreatitis

A 78-year-old woman presented with abdominal pain in a suspicion of ethanol intoxication. Baseline 12-lead electrocardiogram showed a major ST-segment elevation suggestive of an acute myocardial infarction. Troponin I was 6.6 ng/mL. Transthoracic echocardiography found normal left ventricular ejection fraction, with no wall motion abnormality or pericardial effusion. Then, amylase and lipase serum levels were 1199 and 3873 IU, respectively, and primary coronary angiography was cancelled. At 48 hours, abdominal CT scan confirmed the diagnosis of severe acute pancreatitis. At 8 days, electrocardiogram showed inverted T waves without Q wave. Delayed cardiac magnetic resonance imaging showed no signs of myocarditis or ischemic sequelae, normal segmental wall motion, and preserved left ventricular ejection fraction (70%). Coronary angiography was also normal. Electrocardiographic (ECG) ST-segment elevation in a suspicion of acute thoracoabdominal pain may lead to rapid primary coronary angiography. We report a case of a pancreatitis mimicking an acute myocardial infarction, where transthoracic echocardiography was carried out, showing normal left ventricular function and thus postponing a potentially deleterious angiography. A 78-year-old woman with a history of chronic alcoholism, with no risk factor for coronary artery disease, was transferred to emergency department for abdominal pain. She had been found lying on the ground at her home in a suspicion of acute ethanol intoxication. At admission, she presented with global dehydration and anuria. Mean arterial blood pressure was 90 mm Hg, and heart rate was 100 beats per minute. Glasgow Coma Scale score was 15. Cardiopulmonary examination result was normal. A 12-lead ECG showed a sinus rhythm with narrow QRS complexes (short QRS duration was especially visible in lead V1) and a major ST-segment elevation in the infero-antero-lateral territory with a mirror image in leads aVR and aVL (Fig. 1A). Standard laboratory workup showed elevated myocardial necrosis markers (creatine phosphokinase [CPK], 7091 IU; troponin I, 6.6 ng/mL), normal serum 0735-6757/

Bi-ventricular failure following methadone overdose.

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Transpulmonary thermodilution and pulse pressure variations in a septic patient with heterotopic cardiac transplantation

Sir: We report the case of a 37year-old man admitted to intensive care unit for coma and hypotension following methadone reintroduction as opioid substitution. He was treated by methadone 60 mg daily, 3 years previously, and treatment was interrupted since opioid consumption recidivism. Incarcerated during 12 weeks, addiction was suspended and decision of methadone substitution was finally decided. Three hours after administration of 60 mg methadone, the patient presented with calm hyporeflexic coma with myosis, hypoventilation, bilateral pulmonary

Calcium-Channel Blockers: An increasing cause of pulmonary edema during tocolytic therapy

55-year-old man was admitted to the inten-sive care unit for shock. He had a history ofsevere coronary artery disease and arterialhypertension, and had undergone heterotopic car-diac transplantation 14 years ago for refractive con-gestive heart failure. Persistent ventricular arrhyth-mia attributed to native heart dysfunction wasinitially treated medically. A cardioverter defibril-lator was implanted after recurrence of syncopalventricular tachycardia 2 years ago. On admission,severe hypotension was noted (73/53 mm Hg).Physical examination at the time of admissionshowed no cardiac murmur or abnormal heartsounds. The patient’s heart rate was 90 beats/minand temperature was 38.6°C. Mechanical ventilation(controlled mode, tidal volume 9 mL/kg, respiratoryrate 20 breaths/min, F