Olivier Martinet

Effects of norepinephrine on the distribution of intestinal blood flow and tissue adenosine triphosphate content in endotoxic shock.

Objective To investigate, during endotoxic shock, the effect of a treatment of norepinephrine (NE) administration on the distribution of blood flow and adenosine triphosphate (ATP) content in the intestinal wall. Design Randomized controlled trial. Setting Animal laboratory. Subjects Domestic pigs. Intervention A total of 18 pigs were anesthetized with ketamine and pentobarbital, mechanically ventilated, hemodynamically monitored, and then challenged with a continuous infusion of Escherichia coli endotoxin (ET) (15 &mgr;g/kg) for 2 hrs. Three groups of six animals were studied; one served as time control, one group received ET and fluid resuscitation, and a third group received ET, fluid resuscitation, and a perfusion of NE to maintain constant mean arterial pressure (MAP). Measurements and Main Results Cardiac output, mesenteric arterial blood flow, MAP, pulmonary pressure, and portal pressure were measured. Intestinal mucosal intracellular pH (pHi) was determined with saline-filled balloon tonometers. Tissue blood flows to the intestinal mucosa and to the muscular layer were independently measured with fluorescent microspheres, using the arterial reference sample method. Measurements were performed before and 3 hrs after the start of the ET challenge. At the end of the experiments, muscularis and mucosal samples were quickly frozen for further enzymatic ATP measurements. ET administration with fluid resuscitation induced a distributive shock with increased mucosal blood flow and decreased muscularis blood flow, whereas pHi decreased and mucosal ATP content was significantly lower than in the control group. In the group receiving ET plus NE, MAP remained constant, mucosal blood flow did not increase, and mucosal ATP content was equal to the time control group. Meanwhile, mucosal acidosis was not prevented. Conclusions Normodynamic endotoxic shock may induce an alteration in mucosal oxygenation, despite an increased tissue blood flow. A treatment of NE combined with fluid resuscitation has complex effects on tissue blood flow, ATP content, and pHi.

Profile of the Risk of Death After Septic Shock in the Present Era: An Epidemiologic Study

Objectives:To investigate mortality of ICU patients over a 3-month period after an initial episode of septic shock and to identify factors associated with mortality. Design:Prospective multicenter observational cohort study. Setting:Fourteen ICUs from 10 French nonacademic and university teaching hospitals. Patients:All consecutive adult patients with septic shock admitted between October 2009 and September 2011 were eligible. Intervention:None. Measurements and Main Results:Multivariable analyses were performed using a Cox proportional hazard model and a flexible extension of the Cox model. In total, 1,495 of 10,941 patients (13.7%) had septic shock and 1,488 patients (99.5%) were included. Median age was 68 years (range, 58–78 yr). The majority of admissions (84%) were medical. Median (interquartile range) Simplified Acute Physiological Score II and Sequential Organ Failure Assessment were, respectively, 56 (45–70) and 11 (9–14). ICU and hospital mortality were, respectively, 39.4% and 48.6%. At 3 months, 776 patients (52.2%) had died. Factors significantly associated with increased risk of death in the multivariable Cox model were older age, male sex, comorbidities (immune deficiency, cirrhosis), Knaus C/D score, and high Sequential Organ Failure Assessment score. Flexible analyses indicated that the impact of Sequential Organ Failure Assessment score was greatest early after septic shock, while the onset of the effect of age, nosocomial infection, and cirrhosis was later. Conclusions:This is the most recent large-scale epidemiological study to investigate medium-term mortality in nonselected patients hospitalized in the ICU for septic shock. Advances in early management have improved survival at the initial phase, but risk of death persists in the medium term. Flexible modeling techniques yield insights into the profile of the risk of death in the first 3 months.

Case Report: Delayed Hemoperitoneum Following Large-Volume Paracentesis in a Patient with Cirrhosis and Ascites

Large-volume paracentesis is widely used in the management of refractory ascites (1). It is important to be aware that significant hemorrhage occurs in approximately 1% of these patients (2). Bleeding is usually from abdominal wall vessels or internal organs injured during puncture, and the diagnosis is made at the time of the procedure or shortly thereafter. The occurrence of delayed intraperitoneal hemorrhage is far less common, and its mechanisms are not completely understood. Most reported cases have been related to drainage of large volumes of ascitic fluid. It has been postulated that a rapid and substantial decrease in intraperitoneal pressure results in overdistension and eventual rupture of hypertensive portal collaterals. We report a case of hemoperitoneum several days after large-volume paracentesis that strengthens this hypothesis.

Spontaneous rupture of the spleen during malaria treated with transcatheter coil embolization of the splenic artery

tation and blood transfusion. An abdominal CT scan disclosed a grade 3 splenic rupture with hemoperitoneum (Fig. 1A). Transcatheter coil embolization of the splenic artery was performed 2 h later (Fig. 1B and C), followed by rapid hemodynamic improvement and disappearance of the abdominal pain. Evolution was uneventful and the patient was discharged after 10 days, remaining free of symptoms at follow-up visit. Spontaneous rupture of the spleen is a rare complication of malaria [1,2]. While splenectomy represents the usual treatment to control active bleeding related to splenic rupture, the loss of the immunologic role of the spleen may result in lifelong septic complications [3], beside complications directly related to surgery. Transcatheter embolization of the splenic artery, which allows spleen preservation, has become an alternative to surgery for obtaining splenic hemostasis in hemodynamically stable patients with blunt splenic injury, with success rates ranging from 93% to 97% [4]. On the basis of the present report, we propose that transcatheter embolization of the splenic artery may also represent a suitable procedure to treat splenic rupture complicating malaria, thus avoiding the detrimental consequences of splenectomy. References

Isolated granulomatous phlebitis: Rare cause of ischemic necrosis of the colon

Isolated phlebitis of the gastrointestinal tract is rare and potentially life threatening. We report on a patient who developed peritonitis, requiring emergency laparotomy, total colectomy, and ileostomy because of colon necrosis. The specimen displayed multiple ulcerations and erosions. Histology showed a predominantly lymphocytic infiltrate of small-sized and middle-sized veins in the submucosa and subserosa, associated with granulomas and foci of vein wall necrosis. Arteries were spared. No local recurrence or systemic vasculitis developed during a follow-up period of two years. Isolated granulomatous phlebitis seems to be self-limited, and its cause is unknown. Surgical resection of the diseased intestine is usually curative.

Ten thousand kilometre transfer of cardiogenic shock patients on venoarterial extracorporeal membrane oxygenation for emergency heart transplantation: Cooperation between Reunion Island and Metropolitan France

Background: There is no heart transplantation centre on the French overseas territory of Reunion Island (distance of 10,000 km). The aim of this study was to describe the characteristics of cardiogenic shock adult patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) who were transferred from Reunion Island to mainland France for emergency heart transplantation. Methods: This retrospective observational study was conducted between 2005 and 2015. The characteristics and outcome of cardiogenic shock patients on VA-ECMO were compared with those of cardiogenic shock patients not on VA-ECMO. Results: Thirty-three cardiogenic shock adult patients were transferred from Reunion Island to Paris for emergency heart transplantation. Among them, 19 (57.6%) needed mechanical circulatory support in the form of VA-ECMO. Median age was 51 (33–57) years and 46% of the patients had ischaemic heart disease. Patients on VA-ECMO presented higher Sequential Organ Failure Assessment score (p = 0.03). No death occurred during the medical transfer by long flight, while severe complications occurred in 10 patients (30.3%). Incidence of thromboembolic events, severe infectious complications and major haemorrhages was higher in the group of patients on VA-ECMO than in the group of patients not on VA-ECMO (p <0.01). Seven patients from the VA-ECMO group (36.8%) and six patients from the non-VA-ECMO group (42.9%, p=0.7) underwent heart transplantation after a median delay of 10 (4–29) days on the emergency waiting list. After heart transplantation, one-year survival rates were 85.7% for patients on VA-ECMO and 83.3% for patients not on VA-ECMO (p=0.91). Conclusions: This study suggests the feasibility of very long-distance medical evacuation of cardiogenic shock patients on VA-ECMO for emergency heart transplantation, with acceptable long-term results.

Leptospirosis in ICU: A Retrospective Study of 134 Consecutive Admissions

Objectives: Leptospirosis causes reversible multiple organ failure, and its mortality remains high. The aim of this study was to determine the mortality rate of leptospirosis in an ICU offering all types of organ support available nowadays and to compare it with mortality in bacterial sepsis. Design: Retrospective, descriptive, and single-center cohort study. Settings: The largest ICU of Reunion Island (Indian Ocean) in a teaching hospital. Patients: Consecutive patients hospitalized in ICU for leptospirosis from January 2004 to January 2015. Interventions: None. Measurements and Main Results: We report 134 cases of patients with leptospirosis hospitalized in ICU. The median age was 40 years (interquartile range, 30–52 yr), with a Simplified Acute Physiology Score II of 38 (27–50) and a Sequential Organ Failure Assessment score of 10 (8–12). Forty-one patients (31%) required mechanical ventilation and 76 (56%) required renal replacement therapy. The door-to-renal replacement therapy time was 0 (0–1) day after admission with a median urea of 25 mmol/L (17–32 mmol/L). Five patients required extracorporeal membrane oxygenation. The mortality rate was 6.0% (95% CI, 2.6–11.4). Among patients hospitalized for sepsis, the standardized mortality ratio of patients with leptospirosis with regards to Simplified Acute Physiology Score II was dramatically low: 0.40 (95% CI, 0.17 – 0.79). Conclusions: The mortality of severe leptospirosis is lower than for other bacterial infection, provided modern resuscitation techniques are available. Prompt organ support ensures very low mortality rates despite high severity scores.

Iatrogenic Tracheal Rupture Caused by Emergency Intubation: A Case Report

BACKGROUND Iatrogenic tracheal rupture is a rare but life-threatening complication. If suspected by clinical examination or chest radiograph, a computed tomography scan can confirm the diagnosis, but the criterion standard is a bronchoscopy. There is no consensus on its management. CASE REPORT A 52-year-old woman was intubated in a prehospital setting after cardiac arrest. A gradual appearance of subcutaneous emphysema was observed after intubation. A computed tomography scan revealed a complicated tracheal rupture, pneumomediastinum, and pneumothorax. The management was surgical. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intubation in emergency conditions increases the risk of tracheal rupture and a delay in management is an important prognostic factor.