M. Cupa

Diagnostic and prognostic value of procalcitonin in patients with septic shock.

Objective:To determine whether procalcitonin is a reliable diagnostic and prognostic marker in septic shock compared with nonseptic shock. Design:Prospective controlled trial. Setting:Intensive care unit of the Avicenne Teaching Hospital, Bobigny, France. Patients:All patients admitted to our intensive care unit over a 12-month period with clinical evidence of shock. Interventions:None. Measurements and Main Results:Echocardiography or pulmonary artery flotation catheter measurements were used to assess hemodynamics, and multiple specimens were obtained for micro-biological studies. Standard criteria were used to diagnose septic shock. Serum concentrations of procalcitonin, C-reactive protein, and lactate were determined on the day of shock onset (day 1) and on days 3, 7, and 10. Seventy-five patients were included, 62 in the septic shock group and 13 in the cardiogenic shock group. Serum procalcitonin on day 1 was significantly higher in patients with than without septic shock (median, 14 [0.3–767] ng/mL vs. 1 [0.5–36] ng/mL, p < .01). A cutoff value of 1 ng/mL had 95% sensitivity and 54% specificity for separating patients with and without sepsis. C-reactive protein failed to discriminate between these two groups. Among patients with sepsis, procalcitonin concentrations were significantly higher in those who died than in the survivors, at all four measurement time points (median, 16 [0.15–767] ng/mL vs. 6 [0.2–123] ng/mL, p = .045 on day 1; 6.5 [0.3–135] ng/mL vs. 1.05 [0.11–53] ng/mL, p = .02 on day 10). A cutoff value of 6 ng/mL on day 1 separated patients who died from those who survived with 87.5% sensitivity and 45% specificity. C-reactive protein was not helpful for predicting mortality. Serum lactate was a nonspecific prognostic marker. Conclusions:These data indicate that procalcitonin may be a valuable early diagnostic and prognostic marker in patients with septic shock.

Randomized Study Comparing the "Sniffing Position" with Simple Head Extension for Laryngoscopic View in Elective Surgery Patients

BackgroundThe “sniffing position” is recommended for optimization of glottic visualization under direct laryngoscopy. However, no study to date has confirmed its superiority over simple head extension. In a prospective, randomized study, the authors compared the sniffing position with simple head extension in orotracheal intubation. MethodsThe study included 456 consecutive patients. The sniffing position was obtained by placement of a 7-cm cushion under the head of the patient. The extension position was obtained by simple head extension. The anesthetic procedure included two laryngoscopies without paralysis: the first was used for topical glottic anesthesia. During the second direct laryngoscopy, intubation of the trachea was performed. The head position was randomized as follows: group A was in the sniffing position during the first laryngoscopy and the extension position during the second; group B was in the extension position during the first laryngoscopy and the sniffing position during the second. Glottic exposure was assessed by the Cormack scale. ResultsThe sniffing position improved glottic exposure (decreased the Cormack grade) in 18% of patients and worsened it (increased the Cormack grade) in 11% of patients, in comparison with simple extension. The Cormack grade distribution was not significantly modified between the two groups. Multivariate analysis showed that reduced neck mobility and obesity were independently related to improvement in laryngoscopic view with application of the sniffing position. ConclusionsRoutine use of the sniffing position appears to provide no significant advantage over simple head extension for tracheal intubation in this setting. The sniffing position appears to be advantageous in obese and head extension–limited patients.

Study of the "sniffing position" by magnetic resonance imaging

BackgroundThe “sniffing position” is widely considered essential to the performance of orotracheal intubation and has become the cornerstone of training in anesthesiology. However, the anatomic superiority of this patient head position has not been established. MethodsEight healthy young adult volunteers underwent magnetic resonance imaging scanning in three anatomic positions: head in neutral position, in simple extension, and in the “sniffing position” (neck flexed and head extended by means of a pillow). The following measurements were made on each scan: (1) the axis of the mouth (MA); (2) the pharyngeal axis (PA); (3) the laryngeal axis (LA); and (4) the line of vision. The various angles between these axes were defined: &agr; angle between the MA and PA, &bgr; angle between PA and LA, and &dgr; angle between line of vision and LA. ResultsBoth simple extension and sniffing positions significantly improved (P < 0.05) the &dgr; angle associated with best laryngoscopic view. Our results show that the &bgr; value increases significantly (P < 0.05) when the head position is shifted from the neutral position (&bgr; = 7 ± 6°) to the sniffing position (&bgr; = 13 ± 6°), and the &agr; value slightly (but significantly) decreases (from 87 ± 10° to 63 ± 11°;P < 0.05). Anatomic alignment of the LA, PA, and MA axes is impossible to achieve in any of the three positions tested. There were no significant differences between angles observed in simple extension and sniffing positions. ConclusionsThe sniffing position does not achieve alignment of the three important axes (MA, PA, and LA) in awake patients with normal airway anatomy.

In-hospital and long-term prognosis of elderly patients requiring endotracheal intubation for life-threatening presentation of cardiogenic pulmonary edema.

ObjectiveWe studied the in-hospital course, long-term prognosis, and functional status of elderly patients with life-threatening cardiogenic pulmonary edema requiring mechanical ventilation. DesignSemiprospective evaluation. SettingTwelve intensive care units and one emergency prehospital medical department in university hospitals. PatientsPatients, aged >75 yrs, with life-threatening cardiogenic pulmonary edema requiring invasive airway management during the prehospital phase between January 1994 and January 1999 were included. InterventionNone. Measurements and Main Results A total of 79 patients were studied, of which 55 were included in the prospective phase and 24 during the retrospective phase. The age range was 75–99 yrs, with a mean age of 82.4 ± 5.9. The male/female ratio was 35:44. The in-hospital mortality was 26.6%. The mean follow-up time for all 58 survivors was 23 months (range, 2–56 months). Among those discharged, survival at 1 yr was 69%. At 3 months after hospital discharge, 49 (87%) patients lived at home, 46 (82%) were able to bathe themselves, 35 (62%) could walk at least one block, and 34 (61%) could climb one flight of stairs. ConclusionsMortality after severe pulmonary edema requiring endotracheal intubation in a very elderly cohort has a predictably high mortality, although not related directly to the degree of presenting respiratory compromise. However, approximately 50% of the overall cohort returned to relatively good functional status, despite advanced age and a severely compromised presentation. Aggressive airway management appears, therefore, justified in this select group of patients.

Aminoglycoside and glycopeptide renal toxicity in intensive care patients studied by proton magnetic resonance spectroscopy of urine.

ObjectiveAminoglycoside and glycopeptide antibiotics are responsible for renal toxicity. In most cases, the nephrotoxicity is limited to a reversible tubular injury, but an acute and sustained renal failure may occur. The aim of our study was to explore the renal function of patients given these antimicrobial agents with proton magnetic resonance spectroscopy of urine. This technique is able to detect, in urine samples, a wide range of metabolites reflecting renal tubular function. The variables assessed by magnetic resonance spectroscopy were compared with the routine markers of renal function: creatinine, urea, and 24-hr urine volume. DesignProspective clinical study. SettingIntensive care unit. PatientsAll patients in an intensive care unit receiving an aminoglycoside and/or a glycopeptide were included in the study if they presented with signs of renal dysfunction. All experiments were performed on urine samples collected for the routine follow-up of these patients. InterventionProton spectra were acquired with water suppression, and the peak intensity of each metabolite was reported in relationship to the intensity of the creatinine peak. Measurements and Main ResultsThe ratio values obtained by magnetic resonance spectroscopy were compared with the values of creatininemia and blood urea obtained routinely by biochemistry and with the value of the 24-hr urine volume by logistic regression and general linear models. This statistical analysis showed that the ratio of dimethylamine to creatinine was highly correlated with creatininemia. ConclusionsDimethylamine is an osmolyte released from the medullar region of the kidney. Thus, our study demonstrated that nephrotoxicity from aminoglycosides and glycopeptides is not limited to proximal tubular toxicity but also may involve the medullar region (Henle loop and collecting duct) of the nephron.

Recombinant activated factor VII decreases bleeding without increasing arterial thrombosis in rabbits.

PurposeTo compare the effects of recombinant activated factor VII (rFVIIa) and platelet-rich plasma (PRP) in an experimental model of bleeding and arterial thrombosis.MethodsThe Folts model was used in 60 rabbits. After anesthesia, the carotid artery was exposed and a 75% stenosis was induced. A compression injury of the artery triggered a series of cyclic flow reductions (CFRs). After counting baseline CFRs, animals were assigned randomly to one of four groups (n = 15 in each): control, PRP, rFVIIa and placebo. Control animals received 10 mL · kg−1 of saline while 10 mL · kg−1 of a hydroxyethyl starch solution (200,000/6%/O.S) were infused in the three other groups. CFRs were measured again, followed by treatment with PRP, rFVIIa or placebo and by a final measurement of CFRs. At the end of each observation period, an ear immersion bleeding time (BT) was measured and a blood sample was drawn for the evaluation of hematological variables. Microvascular bleeding was evaluated at the end of the experiment in grams of blood shed from liver and spleen sections. Results are presented as median (range).ResultsrFVIIa shortened the BT and decreased microvascular bleeding as compared with placebo [60 (35–100) sec vs 110 (50–140) sec, P = 0.0019 and 9 (4–24) g vs 17 (5–28) g, P = 0.002, respectively], rFVIIa did not increase CFRs [3(0–9) vs 1(0–5), P = 0.11],ConclusionrFVIIa led to a decrease in BT and microvascular bleeding but did not significantly affect arterial thrombosis in rabbits.RésuméObjectifComparer les effets du facteur VII recombinant activé (rFVIIa) et du plasma riche en plaquettes (PRP) avec un modèle expérimental de saignement et de thrombose artérielle.MéthodeLe modèle de Folts a été utilisé chez 60 lapins. Après l’anesthésie, l’artère carotide a été exposée et une sténose à 75 %a été induite. Une lésion postcompression a déclenché une série de réductions cycliques du flux (RCF). Après avoir fait la numération de base des RCF, les animaux ont été assignés aléatoirement à l’un des quatre groupes (n = 15 chacun): témoin, PRP rFVIIa et placebo. Les témoins ont reçu 10 mL · kg− 1 de solution saline et 10 mL · kg− 1 d’une solution d’amidon hydroxyéthylée (200 000/6 %/0,5) ont été perfusés chez les animaux des trois autres groupes. De nouvelles mesures des RCF ont été faites, suivies du traitement avec PRP rFVIIa ou placebo et par une mesure finale des RCF. À la fin de chaque période d’observation, le temps de saignement (TS) de l’immersion de l’oreille a été mesuré et un échantillon de sang prélevé pour l’évaluation du bilan hématologique. À la fin de l’expérimentation, le saignement microvasculaire a été évalué en grammes de sang provenant de la coupe du foie et de la rate. Les résultats sont présentés par la médiane (valeurs extrêmes).RésultatsLe rFVIIa a raccourci le TS et diminué le saignement microvasculaire, comparativement au placebo [60 (35–100) s vs 110 (50–140) s,P = 0,0019 et 9 (4–24) g vs 17(5–28) g, P = 0,002, respectivement]. Le rFVIIa n’a pas augmenté les RCF [3(0–9) vs 1(0–5), P = 0,11].ConclusionLe rFVIIa a réduit le TS et le saignement microvasculaire, mais n’a pas affecté significativement la thrombose artérielle chez des lapins.

N-Acetyl Functions and Acetate Detected by Nuclear Magnetic Resonance Spectroscopy of Urine to Detect Renal Dysfunction following Aminoglycoside and/or Glycopeptide Antibiotic Therapy

Background/Aims: N-acetylneuraminidine (NeuNAc), N-acetylglutamine (GIcNAc) and acetate are metabolites present in normal urine. In patients treated with aminoglycosides and/or glycopeptides, elevation of these metabolites in urine suggests renal tubular injury. NeuNAc, GIcNAc and acetate are easily detected by magnetic resonance spectroscopy (MRS), in contrast to other bioanalytical methods. In the present study, these urinary metabolites were detected using MRS and compared with standard biochemical markers of renal injury in intensive care unit patients treated with aminoglycosides and/or glycopeptides. Methods: 16 patients with clinical and biochemical signs of renal dysfunction were included in the study. Proton magnetic resonance spectra were obtained from 134 urine samples. The resonance intensity of NeuNAc, GIcNAc and acetate were reported relative to the resonance intensity of creatinine (ct). These ratios were compared with classical parameters of renal dysfunction, such as plasma creatinine and urea concentration, and 24-hour urine volume, by logistic regression and general linear models. Results: Statistical analysis showed that changes in plasma creatinine and urea concentration were reliably reflected in changes in the NeuNAc/ct ratio, and that plasma urea concentration changes also correlated with the acetate/ct ratio; however, the GIcNAc/ct ratio was not related to these measures of overall renal function. Conclusions: NeuNAc/ct may be a useful marker of renal dysfunction in patients treated with aminoglycosides and glycopeptides; by MRS it can be both straightforward and informative to follow the renal function of patients treated with these antibiotics.

Early indicators of a health crisis: Examination of the records of an emergency medical services call center during the August 2003 heat wave

Summary Objective The aim of this study was to determine, a posteriori, the parameters detecting an event in a French medical emergency dispatching centre (SAMU). Methods Six parameters were retained: total number of medical requests received by the Samu 93-centre 15: the number of decisions to send a mobile intensive care unit (MICU), number of decisions to send a non-medical unit, number of decisions to send a general practitioner and number of deaths observed by the physicians of the MICU. For each parameter, a daily referential was established over the five previous years (1998 to 2002) and compared with the results of August 2003. Results The number of decisions to send a non-medical unit and the number of decisions to send a general practitioner were unchanged. The number of deaths on the 8th of August observed by the MICU physician should have led to an alert being given: 5.0 deaths for a referential of 1.7 (+ 194%). The number of decisions to send an MICU on the 7th of August should have led to an alert being given: 41 interventions for a referential of 25 (+64%). The number of medical interventions on the 6th of August should have led to an alert being given: 351 interventions for a referential of 299 (+17%). Conclusion The total number of medical interventions treated by the SAMU 93-centre 15 is a the most sensitive and earliest marker of a sanitary event, such as that observed in August 2003 with the heat wave.OBJECTIVE The aim of this study was to determine, a posteriori, the parameters detecting an event in a French medical emergency dispatching centre (SAMU). METHODS Six parameters were retained: total number of medical requests received by the Samu 93-centre 15: the number of decisions to send a mobile intensive care unit (MICU), number of decisions to send a non-medical unit, number of decisions to send a general practitioner and number of deaths observed by the physicians of the MICU. For each parameter, a daily referential was established over the five previous years (1998 to 2002) and compared with the results of August 2003 RESULTS The number of decisions to send a non-medical unit and the number of decisions to send a general practitioner were unchanged. The number of deaths on the 8th of August observed by the MICU physician should have led to an alert being given: 5.0 deaths for a referential of 1.7 (+ 194%). The number of decisions to send an MICU on the 7th of August should have led to an alert being given: 41 interventions for a referential of 25 (+64%). The number of medical interventions on the 6th of August should have led to an alert being given: 351 interventions for a referential of 299 (+17%). CONCLUSION The total number of medical interventions treated by the SAMU 93-centre 15 is a the most sensitive and earliest marker of a sanitary event, such as that observed in August 2003 with the heat wave.

Interférences hémo-dynamiques entre le diltiazem et le thiopental - étude expérimentale chez le porc

La prescription d’agents bloqueurs calciques connait un développement croissant. Les barbituriques interfèrent sur les mouvements calciques cellulaires. Ce travail étudie l’interaction hémodynamique, chez le porc, entre le Thiopental et le Diltiazem, injecté à la dose de 0,15 mg·kg-1 puis perfusé à débit constant à 0,07 mg-kg1-h-1.De la cinquième à la dixième minute, la diminution de la post charge s’associe à une dépression modérée de la contractilité du ventricule gauche. Ces variables retrouvent leurs valeurs initiales en 30 minutes. La fréquence et le débit cardiaque ne varient pas. Leur stabilité serait le résultat d’interférences complexes entre l’effet de chacune de deux drogues sur le système sympathique et la mécanique ventriculaire.AbstractThe clinical applications of calcium channel blockers are rapidly growing; as barbiturates interfere with intracellular calcium movements, the possibliry of drug interaction at this level must be considered. We have studied the haemodynamic interaction of Thiopentone and Diltiazem in pigs, A loading dose of Diltiazem (0.15 mg·kg-1) was injected followed by a continuous administration of 0.07 mg·kg-1 -hour. From the fifth to the tenth minute, the reduced afterload was associated with a moderate depression of the contractility of the left ventricle. These values returned to the initial level within 30 minutes. Heart rate and cardiac output were not modified. The stability of these two parameters is thought to result from the complex interaction of both drugs on the sympathetic nervous system and the venticular function.

Analgésie péridurale à dose élevée de fentanyl: échec de la méthode pour la kinésithérapie post-opératoire précoce avec chirurgie du genou

RésuméEn post-opératoire immédiat de la chirurgie orthopédique du membre inférieur, 10 patients reçoivent fentanyl 5 μg • kg-1 en une seule injection péridurale. L’analgésie quasi complète (P< 0.001) est très rapidement obtenue. La période d’analgésie maxima est courte (87 ± 8.34 min), ainsi que la durée totale d’analgésie (182.3 ± 32.1 min). Malgré cette dose élevée de fentanyl (245 à 450 μ,g), chez cinq patients, la mobilisation passive du genou après libération de l’appareil extenseur est extrêmement douloureuse, voire impossible chez trois d’entre eux, sans recourir aux anesthésiques locaux. A cette dose, le risque de dépression respiratoire est réel avec diminution de la fréquence respiratoire (P < 0.01) et augmentation de la Pco2 (P < 0.01).En regard de la courte durée de l’analgésie, d’un score analgésique identique aux études ayant utilisées de plus faibles doses de fentanyl ou d’autres morphinoïdes de plus longue durée d’analgésie, de l’incapacité àa calmer des douleurs provoquées intenses, et du risque réel de dépression respiratoire, 1’injection péridurale de fentanyl ne doit pas se faire à doses éevés, si tant est que son emploi soit préférable à celui de la morphine.AbstractFollowing orthopedic surgery of the lower limb, ten patients were given fentanyl 5 ?g ò kg“1 in a single epidural injection. Almost complete analgesia (P < 0.001) was rapidly obtained. The total period of analgesia was rather short (182.3 ± 32.1 min). The maximal analgesia period was 87± 8.34 minutes. Despite this high dose of fentanyl (245 to 450 μ-g), in five patients the passive mobilization of the knee following surgery was extremely painful and, for that matter, impossible in three of them. Such high doses of fentanyl entail the risk of respiratory depression as respiratory rate is decreased (P < 0.01) and the Pco2 is increased (P < 0.01).Fentanyl should not be used at such high dosage and should probably not be preferred to morphine, considering that the duration of analgesia is short, that the analgesic score is identical to that obtained with lower doses or with longer lasting narcotics, that it does not prevent passive mobilization pains and that it entails a definite risk of respiratory depression.