Pierrick Le Borgne

Critically ill elderly patients (≥ 90 years): Clinical characteristics, outcome and financial implications

Background Patients aged over 90 are being admitted to intensive care units (ICUs) with increasing frequency. The appropriateness of such decisions still remains controversial due to questionable outcome, limited resources and costs. Our objective was to determine the clinical characteristics and outcome in elderly patients (≥ 90 years) admitted in a medical ICU, with an additional focus on medico-economic implications. Methods We reviewed the charts of all patients (≥ 90 years) admitted to our ICU. We compared them with all other ICU patients (< 90 years), sought to identify ICU mortality predictors and also performed a long-term survival follow-up. Results In the study group of 317 stays: median age was 92 years (IQR: 91–94 years); most patients were female (71.3%.). Acute respiratory failure (52.4%) was the main admission diagnosis; mean SAPS II was 55.6±21.3; half the stays (49.2%) required mechanical ventilation (duration: 7.2±8.8 days); withholding and withdrawing decisions were made for 33.4% of all stays. ICU and hospital mortality rates were 35.7% and 42.6% respectively. Mechanical ventilation (OR = 4.83, CI95%: 1.59–15.82) was an independent predictor of ICU mortality whereas age was not (OR = 0.88, CI95%: 0.72–1.08). Social security reimbursement was significantly lower in the study group compared with all other ICU stays, both per stay (13,160 vs 22,092 Euros, p< 0.01) and per day of stay (p = 0.03). Conclusion Among critically ill elderly patients (≥ 90 years), chronological age was not an independent factor of ICU mortality. ICU care-related costs in this population should not be considered as a limiting factor for ICU admission.

Acute appendicitis as an unexpected cause of inverted takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC), also known as transient left ventricular ballooning syndrome, is a stress-induced-cardiomyopathy. It is precipitated by emotional or physical stress and is characterized by normal coronary arteries and transient regional wall motion abnormalities. Variants of TTC include apical ballooning syndrome and, less commonly, mid, basal, and local variants. New onset heart failure or acute coronary syndromes are a common presentation of TTC. Arrhythmias such as VT, VF, and torsade de pointes have also been reported. We present here a 42-year-old man with an inverted Takotsubo variant with pulmonary edema and transient accelerated idioventricular rhythm. He was initially admitted in the Emergency Department for acute and non-complicated appendicitis. Coronary angiogram showed normal coronary arteries and left ventriculography revealed a reverse variant of TTC. The patient had completely recovered. Myocarditis was ruled out by cardiac magnetic resonance imaging.

Docosahexaenoic acid, but not eicosapentaenoic acid, improves septic shock-induced arterial dysfunction in rats

Introduction Long chain n-3 fatty acid supplementation may modulate septic shock-induced host response to pathogen-induced sepsis. The composition of lipid emulsions for parenteral nutrition however remains a real challenge in intensive care, depending on their fatty acid content. Because they have not been assessed yet, we aimed at determining the respective effects of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) during septic shock-induced vascular dysfunction. Methods In a peritonitis-induced septic shock model, rats were infused with EPA, DHA, an EPA/DHA mixture or 5% dextrose (D5) during 22 hours. From H18, rats were resuscitated and monitored during 4 hours. At H22, plasma, aorta and mesenteric resistance arteries were collected to perform ex vivo experiments. Results We have shown that septic rats needed an active resuscitation with fluid challenge and norepinephrine treatment, while SHAM rats did not. In septic rats, norepinephrine requirements were significantly decreased in DHA and EPA/DHA groups (10.6±12.0 and 3.7±8.0 μg/kg/min respectively versus 17.4±19.3 μg/kg/min in D5 group, p<0.05) and DHA infusion significantly improved contractile response to phenylephrine through nitric oxide pathway inhibition. DHA moreover significantly reduced vascular oxidative stress and nitric oxide production, phosphorylated IκB expression and vasodilative prostaglandin production. DHA also significantly decreased polyunsaturated fatty acid pro-inflammatory mediators and significantly increased several anti-inflammatory metabolites. Conclusions DHA infusion in septic rats improved hemodynamic dysfunction through decreased vascular oxidative stress and inflammation, while EPA infusion did not have beneficial effects.

Bloc auriculoventriculaire complet dans le cadre d’une intoxication sévère au vérapamil

ObservationUn homme de 48 ans s’est presente aux urgences pour malaise avec perte de connaissance. Il ne presentait aucun antecedent notable en dehors d’une algie vasculaire de la face (AVF) (sous Isoptine® 120 mg en traitement de fond et Imiject® en cas de crise). Le patient decrivait par ailleurs une recrudescence de ces douleurs (hemiface gauche) depuis plusieurs jours. A l’admission aux urgences, il etait conscient et oriente, la pression arterielle etait a 70/40 mmHg, [...]

Febrile headache and leg weakness as the initial symptoms of tickborne encephalitis

A 61-year-old woman presented to the emergency department (ED) with a 1-week fever associated with progressive headache. She also reported weakness and paraesthesias in both legs. In the ED, the patient had normal vital parameters and reported no other medical history. Clinical examination showed a slight neck stiffness; the rest of the examination was normal. Laboratory findings showed a mild inflammatory syndrome. The patient had a lumbar punction; the cerebrospinal fluid (CSF) showed moderate pleocytosis (140 leucocytes/μL with a mononuclear …

Hoarseness as the Initial Symptom of Aortic Arch Aneurysm

52-year-old man presented to the emergency Adepartment with progressive hoarseness and trouble breathing for 2 months. The patient had normal vital parameters and no medical history. Clinical examination showed no sign of respiratory failure, but an inspiratory stridor was found on auscultation. A bitonal voice suggestive of recurrent laryngeal nerve palsy was also noted. The rest of the clinical examination was normal. Chest radiography (Fig 1) showed a massive enlargement of the upper and middle mediastinum with tracheal deviation to the right. Contrast-enhanced computed tomography of the chest confirmed an unknown and heavily thrombosed aneurysm of the aortic arch (12.7 cm in maximum diameter). On fiberoptic laryngoscopy (Fig 2), the left vocal

Toxicité pulmonaire induite par l’amiodarone

L’histoireUn homme de 71 ans s’est presente aux urgences pour dyspnee d’aggravation recente dans un contexte d’asthenie inhabituelle evoluant depuis six mois. Ce patient cardiopathe, regulierement suivi en ambulatoire, est traite par amiodarone (dose : 200 mg/jour) et par un nouvel anticoagulant oral (rivaroxaban : 10 mg/jour) dans le cadre d’une fibrillation atriale (FA) permanente. A l’admission aux urgences, le patient etait apyretique, les constantes etaient normales [...]

Thrombophlébite cérébrale et hémorragie intracrânienne : une association sous-estimée

L’histoireUn homme de 51 ans s’est presente aux urgences pour cephalee d’intensite croissante evoluant depuis trois jours. Le patient ne presentait aucun antecedent notable et ne declarait aucun traumatisme recent. L’examen neurologique etait normal ainsi que le reste de l’examen clinique en dehors d’un febricule (37,9 °C) a l’admission. Les examens biologiques preleves ne revelaient aucune anomalie notable. L’ECG etait egalement normal. Apres une antalgie peu [...]