Two-year follow-up of 196 interstitial lung disease patients after ICU stay

OBJECTIVE: Interstitial lung diseases (ILDs) are associated with poor prognosis in the intensive care unit (ICU). We aimed to assess factors associated with hospital mortality in ILD patients admitted to the ICU and to investigate long-term outcome.MATERIAL AND METHODS: This was a retrospective study in a teaching hospital specialised in ILD management. Patients with ILD who were hospitalised in the ICU between 2000 and 2014 were included. Independent predictors of hospital mortality were identified using logistic regression.RESULTS: A total of 196 ILD patients were admitted to the ICU during the study period. Overall hospital mortality was 55%. Two years after ICU admission, 70 (36%) patients were still alive. Of the 196 patients, 108 (55%) required invasive mechanical ventilation, of whom 21 (20%) were discharged alive from hospital. Acute exacerbation of ILD and multi-organ failure were highly associated with hospital mortality (OR 5.4, 95% CI 1.9-15.5 and OR 12.6, 95% CI 4.9-32.5, respectively).CONCLUSION: Hospital mortality among ILD patients hospitalised in the ICU was high, but even where invasive mechanical ventilation was required, a substantial number of patients were discharged alive from hospital. Multi-organ failure could lead to major ethical concerns.

Rémifentanil-midazolam versus sufentanil-midazolam pour la sédation prolongée en réanimation

OBJECTIVE

Remifentanil has a unique metabolic pathway that holds potential benefits for long-term sedation. We compared remifentanil-midazolam to sufentanil-midazolam in 41 critically ill adults requiring mechanical ventilation.

STUDY DESIGN

Randomized double-blind trial.

PATIENTS AND METHODS

Infusion rates were titrated every 4 hours to achieve the desired Ramsay score. Five fold increases in dose requirement was considered as the development of tolerance. Drugs requirement, development of tolerance and weaning time of ventilation were compared.

RESULTS

The study was stopped after an interim analysis. The remifentanil and sufentanil groups were comparable regarding IGS II: 56+/-22 vs 64+/-26, mean+/-SD, ICU length of stay: 26 (8-45) vs 19 (11-34) days, and sedation duration: 6 (4-19) vs 6 (3-16)days, median [interquartile range, IQR]). There was a shorter weaning time in the remifentanil group as compared to sufentanil group: 22 h (12-53) vs 96 (47-142) h, median [IQR], p=0.04). The daily opioid infusion rate needed to be decreased over time only in sufentanil group, p < 0.001. Tolerance occurred in 6 (30%; CI(95), 10 to 40%) remifentanil and no sufentanil patients (P=0.02).

CONCLUSION

Sufentanil infusion needed to be reduced over time and prolonged the weaning time when compared to remifentanil.

Haemodynamic measurements (continuous cardiac output and systemic vascular resistance) in critically ill patients: transoesophageal Doppler versus continuous thermodilution

Ten critically ill patients underwent this prospective study to assess the reliability of the continuous thermodilution versus transoesophageal Doppler techniques in the determination of continuous cardiac output (CO) and systemic vascular resistance (SVR). A total of 145 pairs of CO and SVR measurements were obtained by both a pulmonary artery catheter with a heated filament and a transoesophageal Doppler apparatus (ODM II). Total CO ranged from 2.4 and 13 l.min-1; the bias of all measurements was 0.01 +/- 0.48 l.min-1, and the 95% confidence limits (mean difference +/- 2 SD) were 0.97/0.96 l.min-1. Total SVR ranged from 309 and 2643 dyn.s.cm-5; the bias of all measurements was 18 +/- 127 dyn.s.cm-5, and the 95%, confidence limits were 272/236 dyn.s.cm-5. Transoesophageal Doppler accurately measures continuous CO and SVR in critically ill patients. It should be viewed as complementary to pulmonary catheterization.

The "hands-off" catheter and the prevention of systemic infections associated with pulmonary artery catheter: a prospective study

The Arrow "Hands-Off" thermodilution catheter (AHO) is completely shielded during balloon testing, preparation, and insertion. To assess the value of the AHO in the prevention of systemic infections associated with pulmonary artery catheterization (SIAPAC), we conducted a randomized prospective study over an 18-mo period. The patients were randomly assigned to two groups, of which one received the thermodilution catheter routinely used in our department and the other, the AHO catheter. The diagnosis of SIAPAC was based on recovery of the same organism from the thermodilution catheter (TC) and blood samples, absence of any other infectious focus, and improvement or resolution of clinical evidence of infection after removal of the TC. A total of 166 TCs were randomized in 150 patients. The two groups (mean +/- SD) were comparable in terms of age, SAPS on admission (15.6 +/- 5.2 versus 15.2 +/- 6.2), SAPS on the day of catheter insertion (17.6 +/- 4.8 versus 17.3 +/- 5.8), duration of catheter insertion (22.8 +/- 11.3 versus 25.3 +/- 19.5 min), insertion site, hemodynamic status, duration of use of the TC (3.6 +/- 1.3 versus 3.5 +/- 1.5 d), and outcome. A total of eight cases of SIAPAC were diagnosed in the standard TC group, versus none in the AHO group (p < 0.002). No cases of SIAPAC occurred in those patients who had their TC for less than four days. This study demonstrates the value of the AHO for preventing systemic infections associated with prolonged pulmonary artery catheterization.

[Initial evaluation of thoracic injuries. Comparison of pulmonary radiography and x-ray computed tomography]

OBJECTIVES

To investigate the contribution of computed tomography scan (CTS) to the initial évaluation of chest trauma.

PATIENTS AND METHODS

We carried out a two-year prospective study in all the chest trauma patients admitted to ICU. They underwent both Chest X-ray (CXR) and CTS within 24 jours of admission. CXR and CTS images were read by achieving a consensus between two radiologists who were unaware of the results of the other investigation. Then we compared these findings with the treatment received by the patients in the ICU.

RESULTS

From July 1, 1991 through July 1, 1993, 56 patients were included (21 with conventional CTS and 35 with helicoidal CTS). CTS demonstrated a significant number of pleural (p < 0.001), parenchymatous (p < 0.001), and mediastinal (p < 0.01) lesions that escaped detection on CXR (CTS+/CXR- lesions). Thoracic drainage was done in 16 patients because of abnormalities CTS+/CXR- (p < 0.01); six patients with CTS+/CXR- pulmonary contusions received Pressure Positive Ventilation (p < 0.01); and four CTS+/CXR- lesions were treated surgically (p < 0.05).

CONCLUSION

CTS adds significantly to the evaluation of chest trauma by allowing prompt, accurate assessment of lesions. In this study, over 50% of these lesions required specific treatment during the ICU stay.

[Modification of C-reactive protein after instillation of natural exogenous surfactants]

BACKGROUND

Blood C-reactive protein levels have been frequently found to be increased after Curosurf instillation. These variations have been compared to the values after Surfexo therapy and after absence of surfactant therapy.

POPULATION AND METHODS

The files of not infected premature babies, aged 25 to 36 weeks of gestational age, under mechanical ventilation for a hyaline membrane disease (HMD), admitted in our unit between January 1990 to June 1995, have been retrospectively studied. They were separated into three groups: A: 67 infants ventilated for more than 5 days for HMD without surfactant therapy; B: 23 infants treated by Surfexo; C: 60 infants treated by Curosurf. CRP was measured daily between day 0 (DO) and D5. Means and standard deviations were calculated for each day and each group. The mean values of CRP at D1 to D5 in group C were compared to DO. The daily CRP values were compared in the three groups. For group C, the results were studied daily according to the gestational age, dosage and age of the neonate at the first instillation. The statistical results have been given according to the Student t test.

RESULTS

After Curosurf, the mean CRP value rose significantly from D1 to D4 compared to D0. There was no difference of CRP between groups A and B from D0 to D5, Group C had higher values in comparison to group A (between D1 to D5) and to group B (between D1 and D3). There was no significant difference of the CRP values in group C according to the number of instillations or the amount instilled, but CRP was lower in early treated infants (< H6).

DISCUSSION

Curosurf instillation is followed by a significant increase in CRP, maximum at D2. This is not seen after Surfexo. This increase seems less important at D2-D3 when Curosurf is administered early. The CRP increase after Curosurf therapy could be due to an inflammatory reaction to the heterologous proteins it contains.

[Use of EMLA cream in premature and full-term newborn infants. Study of efficacy and tolerance]

BACKGROUND

Mild methemoglobinemia is a known side-effect of one of the constituents of EMLA cream, this topical local anesthetic is used with great caution in neonates.

POPULATION AND METHODS

One hundred and sixteen neonates admitted from January to July 1994 in an intensive care unit were included in the study. All required skin punctures which were performed 1 h 30-2 hours after EMLA had been applied on the skin. A reaction score (0 to 5) to skin puncture was established 157 times (120 after and 37 without local anesthesia); methemoglobin (Met Hb) concentrations were measured in 47 blood samples, 18-24 hours (40.4% of samples) or 2-3 days (36.2%) after application of EMLA.

RESULTS

Ninety-four neonates were quiet before puncture (score 0-1). Among them, 57% of those who were given EMLA had a low score (2 or less) vs 18% without EMLA. A low reaction was observed in 65% when the dressings had been kept in place for at least 90 minutes vs 15% with a shorter application. A lower reaction was noted in 78.8% of cases after venopuncture (41% after arterial puncture). No Met Hb level was above 5% and 7 (15%), in five neonates, were between 3 and 5%. There was no clear relationship between methemoglobinemia and gestational age or duration of dressing.

CONCLUSION

EMLA cream is effective and safe in neonates including preterms, when it is applied in a small amount once a day.

Optimal dose of lignocaine for preventing pain on injection of propofol

The purpose of this study was to define the optimum dose of lignocaine required to reduce pain on injection of propofol. We conducted a prospective, randomized, double-blind trial on 310 patients undergoing anaesthesia. Patients were allocated to four groups according to the lignocaine dosage: group A (control), no lignocaine; group B, lignocaine 0.1 mg kg-1; group C, lignocaine 0.2 mg kg-1; group D, lignocaine 0.4 mg kg-1. Our results showed that a dose of lignocaine 0.1 mg kg-1 significantly reduced the incidence of pain and that there was no improvement when the dose was increased.