N. Libert

Pneumopathie nécrosante à Stapholococcus aureus sécréteur de la leucocidine de Panton-Valentine : traitement avec succès par antibiotiques et immunoglobulines à visée anti-toxinique

We report a patient who presented a severe Panton-Valentine-secreting methicillin-susceptible Staphylococcus aureus pneumonia with threatening multi-organ failure including acute respiratory distress syndrome, cardiac failure, renal failure and disseminated intravascular coagulation. Clinical and biological disease course using empiric therapy with treatment directed against toxin production (linezolid, clindamycin and intravenous immunoglobulins) was found to be quickly effective.

Il y a-t-il une place pour le sérum salé hypertonique dans les états septiques graves ?

Fluid loading is the first step, necessary to care for severe sepsis. Two main classes of solutions are currently available: crystalloids and colloids. The concept of small volume resuscitation with hypertonic saline has emerged these last years in the care of traumatic haemorrhagic shock. The main benefits are the restoration of intravascular volume, improvement of cardiac output and improvement of regional circulations. Many experiments highlight modulation of immune and inflammatory cascades. We report the mechanisms of action of hypertonic saline based on experimental human and animal studies, which advocate its use in septic shock.

Méningoencéphalite aiguë révélatrice d’une maladie de Behçet

We report a 69-year-old man admitted in intensive care unit for aseptic meningoencephalitis. Initially, suspicion of an infectious etiology led to introduce an anti-infectious treatment. Behçets disease was diagnosed during hospitalization incited to screen for noninfectious etiologies. A high dose steroid therapy was rapidly effective. The diagnosis of neuro-Behçets disease was entertained.

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.

Paludisme grave pris en charge sur le terrain et paludisme grave d’importation : une étude cas-témoins rétrospective multicentrique

Introduction La prise en charge de l’acces palustre grave (APG) sur une zone de guerre reste d’actualite pour les medecins militaires. Son efficacite n’a jamais ete evaluee. Materiels et methodes Etude retrospective cas-temoins multicentrique comparant les caracteristiques, les delais de diagnostic, les modalites de traitement et les pronostics des APG pris en charge sur un theâtre d’operation de 1999xa0a 2016xa0et les APG traites pendant la meme periode dans 3xa0hopitaux metropolitains. Resultats Soixante-dix patients ont ete inclus (50xa0hommes, âge median 42,5xa0ans [IQR 32–53]) pour APG a Plasmodium falciparum acquis en Afrique sub-saharienne, 15xa0cas survenus sur les theâtres d’operations exterieures, et 55xa0temoins, ayant presente un APG d’importation, diagnostiques en metropole. Les 15xa0cas ont ete diagnostiques, evalues par un reanimateur dans l’heure et recu un anti-paludeen IV (quinine ou artesunate) sur le terrain. Le delai median entre le diagnostic et l’administration du traitement etait de 4xa0heures [IQR 3–5]. Le transfert vers une reanimation metropolitaine etait realise en moins de 24xa0heures. Cinq etaient intubes avant l’evacuation. Par rapport aux temoins, les militaires etaient plus jeunes (32,4xa0dans le groupe militaire versus 46,1xa0ans dans le groupe civil, p p xa0=xa00,04). Le palusdisme etait dignostique plus rapidement dans le groupe militaire, notamment grâce aux tests diagnostiques rapides (1,9xa0vs. 4,6xa0jours, p xa0=xa00,01). Il n’y avait pas de difference concernant les criteres de gravite OMS entre les deux groupes a l’admission en reanimation. Les evolutions etaient similaires en termes de duree de sejour en reanimation (4xa0jours dans les 2xa0groupes) et en hospitalisation (7xa0et 8xa0jours, p xa0>xa00,05) d’introduction d’amines vasopressives (5xa0vs 15, p xa0>xa00,05), d’epuration extra-renale (5xa0vs 13, p xa0>xa00,05) et d’intubation orotracheale (6xa0vs 15, p xa0>xa00,05). Les pronostics etaient similaires dans les 2xa0groupesxa0: il y avait 4xa0deces (5,7xa0%) dans notre serie (1xa0vs 3, p xa0>xa00,05) Conclusion Malgre des contraintes d’isolement et d’elongation majeurs, la prise en charge des APG en zone de guerre est efficiente sans perte de chance pour les militaires. Des efforts doivent etre portes sur l’observance de la prophylaxie anti-palustre qui aurait pu permettre d’eviter la survenue de la plupart de ces cas graves.

Celluliti, fasciti, miositi, gangrena gassosa

Le infezioni dei tessuti molli che coinvolgono l’epidermide, il derma, l’ipoderma e, talvolta, anche le fasce e i muscoli possono avere diversi aspetti clinici di gravita variabile a seconda del tipo di lesione. Le dermoipodermiti batteriche non necrotizzanti riuniscono, in particolare, le erisipele e le celluliti superficiali, e lo streptococco e l’agente batterico principalmente implicato. Il trattamento consiste in una terapia antibiotica con una penicillinaxa0G e nell’istituzione di misure di prevenzione secondaria per limitare il rischio di recidiva: trattamento della porta d’ingresso e gestione dei fattori di rischio favorenti. Le dermoipodermiti batteriche necrotizzanti comprendono le celluliti necrotizzanti, le fasciti necrotizzanti, le miositi e le gangrene gassose. Possono essere interessate varie localizzazioni: cervicofacciale, toracica, addominoperineale e agli arti. La ripercussione locale e generale e spesso contrassegnata da un’evoluzione sistematicamente sfavorevole in assenza o in caso di ritardo di trattamento, che va dall’estensione in profondita della necrosi fino al quadro di sindrome da risposta infiammatoria sistemica, che puo compromettere la prognosi vitale. Il tasso di mortalita rimane alto, vicino al 30%. Si tratta di un’urgenza terapeutica tanto medica, attraverso un antibiotico ad ampio spettro a volte in associazione con un antitossinico, che chirurgica senza ritardi, il piu precoce possibile. Il ricorso all’ossigenoterapia iperbarica in alcuni casi e usato come trattamento adiuvante, ma resta ancora discusso.

Celulitis, fascitis, miositis y gangrena gaseosa

Las infecciones de los tejidos blandos, que afectan a la epidermis, la dermis, la hipodermis e incluso las fascias y los musculos, pueden presentar diversos aspectos clinicos de gravedad variable en funcion del tipo de lesion. Las dermohipodermitis bacterianas no necrosantes agrupan sobre todo las erisipelas y las celulitis superficiales; el estreptococo es el principal agente bacteriano causal. El tratamiento consiste en la administracion de penicilina G y la aplicacion de medidas de prevencion secundaria con el fin de limitar el riesgo de recidiva: tratamiento de la puerta de entrada y manejo de los factores de riesgo. Las dermohipodermitis bacterianas necrosantes incluyen las celulitis necrosantes, las fascitis necrosantes, las miositis y las gangrenas gaseosas. Hay varias localizaciones: cervicofacial, toracica, abdominoperineal y de los miembros. La repercusion local y sistemica suele manifestarse frecuentemente por una evolucion desfavorable, en ausencia de tratamiento o si este se retrasa, desde la extension en profundidad de la necrosis hasta el cuadro de sindrome de respuesta inflamatoria sistemica que puede comprometer el pronostico vital. El indice de mortalidad es elevado (casi el 30%). Se trata de una urgencia terapeutica medica (antibioticoterapia de amplio espectro, a veces asociada a una antitoxina) y quirurgica sin demora, lo mas precoz posible. Se recurre a la oxigenoterapia hiperbarica en algunos casos como tratamiento adyuvante, pero su aun se discute.

Thrombus formation in a patent foramen ovale

0750-7658/

Sérum salé hypertonique, quoi de neuf ?

– see front matter 2013 Société française d’anesthésie et de réanimatio http://dx.doi.org/10.1016/j.annfar.2013.02.018 foramen ovale (PFO) (Fig. 1A). A few hours later, hemodynamic state worsened. A new transoesophageal echocardiography revealed an acute cor pulmonale with thrombus in the right pulmonary artery and a thrombus trapped in the PFO (Fig. 1B). The patient subsequently developed bi-atrial thrombus straddling the PFO. As long as the PFO acted as a pressure relief valve, hemodynamic state was stabilized despite ARDS and pulmonary embolism related pulmonary hypertension. When the thrombus occluded PFO, right ventricular overpressure raised, inducing irrecoverable cardiogenic shock. Despite treatment with heparin and thrombolysis, vasopressors, inotropes, and nitric oxide, the patient developed refractory cardiogenic shock with multi organ failure, and died 1 day later. PFO’s prevalence in autopsy studies of general population is 25 to 30% [1]. Higher prevalence has been reported in conditions with elevated right-heart pressures [2]. In the presence of low cardiac output and stasis, co-existence of DIC may have a paradoxical effect of enhancing thrombus formation [3]. This type of non-mobile thrombi (in opposition to mobile thrombi resulting from peripheral venous thrombosis) are normally less likely to cause pulmonary embolism and decrease with anticoagulant therapy [4,5]. Unfortunately things were different for our patient. There are no clear recommendations regarding treatment of entrapped thrombi in PFO. Surgical embolectomy, frequently proposed, might be impossible in case of severe multiorgan failure. Anticoagulant therapy may be an alternative treatment [6]. In case of failure and cardiogenic shock, thrombolysis should probably be considered, even in the presence of DIC.