Pascal Reper

High-frequency percussive ventilation and initial biomarker levels of lung injury in patients with minor burns after smoke inhalation injury

BACKGROUND Several biological markers of lung injury are predictors of morbidity and mortality in patients with acute respiratory distress syndrome (ARDS). Some lung-protective ventilation strategies, such as low tidal volume, are associated with a significant decrease in plasma biomarker levels compared to the high tidal volume ventilation strategy. The primary objective of this study was to test whether the institution of high-frequency percussive ventilation (HFPV) to patients with respiratory distress after smoke inhalation injury influenced initial biomarker levels of lung injury (just before and after using percussive ventilation). MATERIALS AND METHODS A prospective observational cohort study was conducted in the intensive care unit of the Brussels Burn Center. Fifteen intubated, mechanically ventilated patients with minor burns and ARDS following smoke inhalation were enrolled in our study. Physiologic data and serum samples were collected before intubation and at four different time points within the first 48h after intubation to measure the concentration of interleukin (IL)-6, IL-8, and tumor necrosis factor-α (TNF alpha). The differences in biomarker levels before and after starting HFPV were analyzed using repeated measure analysis of variance and a paired t test with correction for multiple comparisons. RESULTS Before starting HFPV under endotracheal intubation, all biological markers (IL-6, IL-8, and TNF alpha) were elevated in the spontaneously breathing patients with acute lung injury (ALI). After intubation and institution of a positive pressure ventilation with HFPV (tidal volume 5.6-6.6ml/kg per ideal body weight), none of the biological markers were increased significantly at either an early (3±2h) or a later point in time. However, the levels of IL-8 had decreased significantly after intubation at a later point in time. During the post-intubation period, the PaO2/FiO2 (partial pressure of arterial oxygen/fraction of the inspired oxygen) ratio increased significantly and the plateau airway pressure decreased significantly. CONCLUSION Levels of IL-6, IL-8, and TNF alpha are elevated in spontaneously ventilating patients with minor burns and ARDS following smoke exposition prior to endotracheal intubation. The institution of HFPV with percussive positive pressure ventilation enhances blood oxygenation and could not further increase the initial levels of these biological markers of lung injury after smoke inhalation injury.

Open source electronic health record and patient data management system for intensive care.

BACKGROUND AND OBJECTIVES In Intensive Care Units, the amount of data to be processed for patients care, the turn over of the patients, the necessity for reliability and for review processes indicate the use of Patient Data Management Systems (PDMS) and electronic health records (EHR). To respond to the needs of an Intensive Care Unit and not to be locked with proprietary software, we developed a PDMS and EHR based on open source software and components. METHODS The software was designed as a client-server architecture running on the Linux operating system and powered by the PostgreSQL data base system. The client software was developed in C using GTK interface library. The application offers to the users the following functions: medical notes captures, observations and treatments, nursing charts with administration of medications, scoring systems for classification, and possibilities to encode medical activities for billing processes. RESULTS Since his deployment in February 2004, the PDMS was used to care more than three thousands patients with the expected software reliability and facilitated data management and review processes. Communications with other medical software were not developed from the start, and are realized by the use of the Mirth HL7 communication engine. Further upgrade of the system will include multi-platform support, use of typed language with static analysis, and configurable interface. CONCLUSION The developed system based on open source software components was able to respond to the medical needs of the local ICU environment. The use of OSS for development allowed us to customize the software to the preexisting organization and contributed to the acceptability of the whole system.

Peroperative cardiogenic shock suggesting acute coronary syndrome as initial manifestation of Lyme carditis.

Carditis can complicate Lyme disease in an estimated <5% of cases, and cardiogenic shock and severe cardiac arrhythmias are described with electrocardiographic abnormalities that could be suggestive of coronary manifestations. We report a case of severe persistent biventricular heart failure complicated by cardiac arrhythmias as initial manifestation of a Lyme disease developing peroperatively electrocardiographic abnormalities suggesting acute transmural myocardial infarction.

Electronic Health Record for Intensive Care based on Usual Windows Based Software

Background and objectives: In Intensive Care Units, the amount of data to be processed for patients care, the turn over of the patients, the necessity for reliability and for review processes indicate the use of Patient Data Management Systems (PDMS) and electronic health records (EHR). To respond to the needs of an Intensive Care Unit and not to be locked with proprietary software, we developed an EHR based on usual software and components. Methods: The software was designed as a client–server architecture running on the Windows operating system and powered by the access data base system. The client software was developed using Visual Basic interface library. The application offers to the users the following functions: medical notes captures, observations and treatments, nursing charts with administration of medications, scoring systems for classification, and possibilities to encode medical activities for billing processes. Results: Since his deployment in September 2004, the EHR was used to care more than five thousands patients with the expected software reliability and facilitated data management and review processes. Communications with other medical software were not developed from the start, and are realized by the use of basic functionalities communication engine. Further upgrade of the system will include multi-platform support, use of typed language with static analysis, and configurable interface. Conclusion: The developed system based on usual software components was able to respond to the medical needs of the local ICU environment. The use of Windows for development allowed us to customize the software to the preexisting organization and contributed to the acceptability of the whole system.

Fatal multiple coronary involvements in a young woman with systemic lupus erythematosus

Abstract We report a rare case of fulminant congestive heart failure with fatal outcome in a 21-year-old girl with systemic lupus erythematosus (SLE). A young woman was admitted in the intensive care unit for pericardial tamponade associated with disseminated coagulopathy and refractory shock secondary to multiple coronary aneurysms. Post-mortem examination revealed significant multiple coronary lesions with aneurysms of the interventricular and right coronary arteries, responsible of muscular necrosis, thrombosis of the coronary sinus, and significant pericardial infiltration with hemorrhagic fluid. We describe a refractory cardiac failure with extensive coronary artery involvements, which is very uncommon in young patients with SLE: few cases have been previously described in the literature. We report a rare case of fulminant congestive heart failure with fatal outcome in a young woman with SLE related to extensive coronary involvements.

Slow-release clomipramine acute poisoning with radio-opaque gastric bezoar

A 48-year-old woman with depression was intubated on admission to the intensive care unit for deep coma of unknown origin. Post-intubation chest X-ray showed the intragastric presence of a radio-opaque pharmacobezoar with 22 tablets (Fig. 1). Toxicology screening results and information from the family confirmed a witnessed intake of a slow-release preparation of clomipramine (AnafranilRetard 75 mg, depot tablets) 12 h before admission. Slow-release clomipramine is known to produce a radio-opaque pharmacobezoar that can be removed by gastroscopic examination [1, 2]. This observation confirms that chest X-ray can disclose the cause of a coma related to severe intoxication.

Response to Letter to the Editor: 'High-frequency percussive ventilation and initial biomarker levels of lung injury after smoke inhalation - Not straightforward to interpret'.

We thank R.S. Shah, M. Vizacaychipis for their thoughts about the published work and would like to describe some important points about our study of biomarkers following high frequency percussive ventilation in patients with acute respiratory failure following inhalation injury without extensive burns [1]. Patients included in this study had no important comorbidities; active smokers were excluded from the study. None had preexisting medical history of chronic pulmonary disease, asthma or medical follow up for respiratory problems and certainly not for documented (severe) COPD history. The patients were recruited consecutively according to the restrictive selection criteria and received systematically mask oxygen, intensive chest physiotherapy and aerosols with bronchodilators before intubation. Oxygenation deterioration is similar in all these patients who requires artificial ventilatory support with High Frequency Percussive Ventilation administered by a VDR4 device less than 6 h after smoke inhalation injury. No patient was intubated and conventionally ventilated before starting HFPV. Sedation practice combines administration of midazolam and morphine derivates like for other burn or non burn ICU patients; fluid administration was adapted for baseline perfusions because instable patients requiring vasoactive support were also not eligible for this study. Gazometric and clinical deterioration after admission leads to rapid artificial ventilatory support. None of the patients were intubated nor ventilated on the fire scene. HFPV parameters were adjusted using the Bicore monitoring which enhances the follow up and monitoring under HFPV giving ventilatory volumes and pressures which are more difficult to determine and not directly available on the VDR4 monitoring. This leads to a better control of ventilatory parameters under HFPV than with the VDR4 monitoring certainly when protective ventilation following the guidelines

Complicated pneumothorax and congenital lung cystic malformation

Congenital cystic adenomatoid malformation, also named congenital pulmonary airway malformation (CPAM), is a congenital lung abnormality which is uncommon in adults. The usual radiological appearance of CPAM is a cystic space-occupying lesion. We present one case of CPAM with unusual clinical and radiological findings, a complicated spontaneous pneumothorax with intracystic haemorrhage with successful conservative initial treatment, despite acute haemodynamic instability.

Cough-induced rupture of the right diaphragm and abdominal herniation

Dear Editor, We report a case of a cough-induced traumatic rupture of the right diaphragm with abdominal herniation. A 49-year-old male patient arrived at the emergency department for severe respiratory distress and carbonarcosis. He had a medical history of chronic respiratory disease (Gold III COPD) and hypertension. This obese smoker was admitted to the intensive care unit for noninvasive ventilation. Clinical examination on ICU admission showed right upper abdominal pain and subcutaneous thoracic emphysema; the patient also presented an uncomplicated umbilical hernia. Two days later the patient still presented dyspnea and abdominal pain with severe and persistent coughing. The ileus resolved once the morphine treatment had been stopped. A chest X-ray and an abdominal CT scan showed no abnormalities at this time. Two days later a chest X-ray control (Fig. 1) showed the intrathoracic presence of abdominal structures suggesting a right diaphragmatic rupture in the thoracic cavity. The thoracic CT scan (Fig. 1) confirmed the presence of a right diaphragmatic rupture with intrathoracic abdominal fat and intestinal structures, which required surgical reparation. The abdominal exploration showed a large herniation of gastrocolic omentum with the colic portion associated with an old rib fracture. The right diaphragmatic hernia was then surgically repaired and covered with a synthetic prosthesis; pleural drainage was performed at the end of the operation. The postoperative chest X-ray and CT scan showed no diaphragmatic hernia yet, and the patient was uneventfully discharged to the ward. The most common cause of diaphragmatic rupture is reported to be trauma, though different percentages have been cited in studies. Seven percent of thoracic injuries and 22 % of thoracoabdominal injuries are associated with diaphragmatic injury, and left-sided ruptures are five times more common than right-sided injuries. Various complications have been related to coughing including pneumothorax, pneumomediastinum and rib fracture [1]. Although autopsy studies have revealed an equal incidence of right and left diaphragmatic ruptures, clinical study reports suggest 88– 95 % of diaphragmatic ruptures occurred on the left side. Right-sided ruptures are associated with high mortality and morbidity, and thus the underdiagnosis of right-sided injuries may be due to greater pre-hospital mortality after trauma injury. Rightsided tears are significantly less likely than left-sided tears because of the protected effect of the liver. This could also be explained by a better visualization of the left diaphragm, on diagnostic laparoscopy, with restricted visualization of the right diaphragm [2]. This observation is the first documented case of a patient developing a right diaphragmatic rupture after persistent cough during his hospital stay that required surgical repair leading to an uneventful recovery.