Retour d’expérience des évacuations par train à grande vitesse de patients en syndrome de détresse respiratoire aiguë sur infection à Covid-19 : les missions Chardon

Lors de la crise Covid-19 en France, il a fallu transférer des patients de zones où les lits de réanimation étaient saturés vers d’autres régions. Tous les moyens ont été utilisés : terrestre, aérien, maritime… Pour la première fois, des trains à grande vitesse (TGV) ont été utilisés. Le transport ferroviaire avait été utilisé largement pendant la Première Guerre mondiale. Ces transferts ont nécessité une collaboration extrêmement importante interservices : ministère, agences régionales de santé, hôpitaux, Samu zonaux, Samu, Smur associations de sécurités civiles, sapeurs-pompiers… L’une des collaborations des plus importantes a été celle avec la SNCF qui a permis une adaptation des rames, sécurisations des itinéraires, adaptation de la conduite… Chaque voiture transporte quatre patients intubés en syndrome de détresse respiratoire aiguë avec un médecin senior, un junior, quatre infirmiers et un logisticien pour la réalisation de la surveillance et des soins. Dans chaque rame, une équipe de régulation médicale est présente pour la coordination. Il y a eu dix évacuations sanitaires, qui ont transporté 197 patients sur 6 600 km (350‒950 km/TGV). Le transport le plus long a été de 7 h 14 min. On n’a pas relevé de complications majeures pendant les transferts. Plusieurs questions restent en suspens comme les critères de sélections des patients, la mise en place d’un train sanitaire aménagé permanent, un stock de matériel. Afin de mieux connaître les conséquences sur les patients, une étude est en cours. Les urgentistes ont une nouvelle corde à leur arc avec la possibilité d’effectuer des évacuations sanitaires en TGV pour des patients médicaux graves sur de longues distances.

SAT0459 EVALUATION OF THE PREVALENCE AND THE MANAGEMENT OF OSTEOPOROTIC FRACTURES IN PATIENTS HOSPITALIZED AT NANCY UNIVERSITY HOSPITAL (FRANCE) IN 2017

Background:

Osteoporotic fractures are a major public health concern because of their consequences in morbidity, costs and mortality. In the meantime, historically postfracture osteoporosis medication use rates have been poor.

Objectives:

The aim is to analyze the management of osteoporosis in patients hospitalized for osteoporotic fractures (OF) at Nancy University Hospital (France) in 2017.

Methods:

Total number of hospitalized patients and hospital stays were extracted by the Department of Medical Information (DIM) which selected departments with at least forty hospitalizations with Medical Unit Summary related to a diagnosis of fracture or osteoporosis. Hospitalizations not concerned by a recent OF were excluded. Data on fractures, patient characteristics, risk factors for OF and fall, management of osteoporosis, discharge status, stay duration, were studied from patient medical records. Prevalence of OF stays, management of osteoporosis and factors associated with duration of stay were analyzed.

Results:

Out of a total of 153,840 hospitalizations, 918 hospitalizations (844 patients, mean age 74.5 years ± 13.6, 74.5% women) concern an OF. The prevalence of hospitalizations for OF was 0.6% of total hospitalizations and 17.9% of total hospitalizations for fractures. Among the 844 patients, 85.7% had a severe fracture (vertebral fracture: 56.2%, hip fracture: 24.1%), 16.5% had a non-severe fracture, and 8.5% had a fracture cascade in the year. At discharge from hospital, 11.7% of patients received a specific treatment for osteoporosis. Longer stay duration was associated with age, severe fractures, Groll index and discharge status.

Conclusion:

Nearly one hospitalized fracture in five is osteoporotic, while only one in ten patients is treated for osteoporosis. Stay duration increased with age and comorbidities. This encourages the development of early prevention, screening and treatment strategies for osteoporosis.

References:

[1]Hernlund E, Svedbom A, Ivergård M, Compston J, Cooper C, Stenmark J, et al. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos. 2013;8:136.

[2]Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006 Oct 19;17(12):1726–33.

[3]Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD. Fragility Fractures and the Osteoporosis Care Gap: An International Phenomenon. Semin Arthritis Rheum. 2006 Apr;35(5):293–305.

Disclosure of Interests:

None declared

Prise en charge d'une réaction anaphylactique en extrahospitalier et aux urgences: revue de la littérature

Care and therapy of patients experiencing an anaphylactic reaction should be known by the physicians working in the emergency medical unit or in pre-hospital care. The epidemiology of these reactions varies according to the countries. The main aetiologies are due to food, hymenoptera or drugs. The clinical scale proposed by Ring and Messmer aims to classify the reactions in 4 grades according to their severity and is useful to stratify therapy. According to the grade of the reaction, the drug of choice for the treatment of anaphylaxis is epinephrine associated to vascular expansion. Anaphylaxis during pregnancy is described. Patients who experienced an immediate hypersensitivity reaction should undergo an allergological investigation to prove the immune mechanism and to identify the culprit allergen. Reporting to the Drug Safety Monitoring Authorities when a drug is implicated should not be forgotten.

Parenteral with enteral nutrition in the critically ill

OBJECTIVE

To determine whether nutrient intake by early enteral nutrition with parenteral nutrition improves levels of retinol-binding protein and prealbumin (primary endpoint) and reduce morbidity and mortality (secondary endpoint) in ICU patients.

DESIGN

Prospective, double-blind, and randomized, placebo-controlled study.

SETTING

Two intensive care units in a tertiary institution.

PATIENTS AND PARTICIPANTS

120 patients in two groups of 60.

INTERVENTIONS

Patients received either enteral plus parenteral nutrition (treatment group) or enteral nutrition plus placebo (placebo group) for 4-7 days after initiation of nutritional support.

MEASUREMENTS AND RESULTS

Retinol-binding protein (P = 0.0496) and prealbumin (P = 0.0369) increased significantly in the treatment group from day 0 to day 7. There was no reduction in morbidity in ICU. There was no difference in OMEGA score (263 vs. 244) and length of stay in the ICU (16.9 vs. 17.3), but a reduction in length of stay at hospital (31.2+/-18.5 vs. 33.7+/-27.7, P = 0.0022). Mortality on day 90 (17 vs. 18) and after 2 years (24 vs. 24) was identical.

CONCLUSIONS

Although it enhances nutrient intake and corrects nutritional parameters such as RBP and prealbumin more rapidly, within 1 week, supplemental parenteral nutrition has no clinically relevant effect on outcome in ICU patients at the early phase of nutritional support.

Comparison of systemic and regional effects of dobutamine and dopexamine in norepinephrine-treated septic shock

OBJECTIVES

To compare the effects of dobutamine and dopexamine on systemic hemodynamics, lactate metabolism, renal function and the intramucosal-arterial PCO(2) gap in norepinephrine-treated septic shock.

DESIGN

A prospective, interventional, randomized clinical trial.

SETTING

Adult medical/surgical intensive care unit in a university hospital.

PATIENTS

After volume resuscitation, 24 patients were treated with norepinephrine alone titrated to obtain a mean arterial pressure of 75 mmHg and a cardiac index greater than 3. 5 l/min(-1). m(-2).

INTERVENTIONS

Patients were randomized to receive an infusion of dobutamine (n = 12) (5 microg/kg per min) or dopexamine (n = 12) (1 microg/kg per min).

MEASUREMENTS AND MAIN RESULTS

Baseline measurements included: hemodynamic parameters, renal parameters (diuresis, creatinine clearance and urinary sodium excretion), gastric mucosal-arterial PCO(2) gap, arterial and mixed venous gases and arterial lactate and pyruvate levels. These measurements were repeated after 1 (H(1)), 4 (H(4)) and 24 (H(24)) h. No difference was found between dobutamine and dopexamine among H(0) and H(1), H(4) and H(24) values for hemodynamics. Dobutamine and dopexamine at low doses had no significant effect on mean arterial pressure, heart rate, cardiac index, oxygen delivery, oxygen consumption and pulmonary artery occlusion pressure. No patients developed arrhythmia or electrocardiographic signs of myocardial ischemia. After 4 and 24 h lactate concentration decreased in the dobutamine group from 2.4 +/- 1 mmol/l to 1.7 +/- 0. 7 mmol/l and 1.5 +/- 0.4 mmol/l, respectively, while it increased in the dopexamine group from 2.3 +/- 1 mmol/l to 2.7 +/- 1 mmol/l after 4 h and returned to baseline values after 24 h (2.2 +/- 0.6). After 24 h the lactate/pyruvate ratio decreased in the dobutamine group from 15 +/- 5 to 12 +/- 3 (p < 0.05) while it was unchanged in the dopexamine group (from 16 +/- 6 to 17 +/- 4). Arterial pH increased in the dobutamine group from 7.35 +/- 0.05 to 7.38 +/- 0.07 (p < 0. 05) while it was unchanged in the dopexamine group (from 7.34 +/- 0. 01 to 7.35 +/- 0.10). The PCO(2) gap decreased after 1 and 4 h in both the dobutamine and dopexamine groups (p < 0.05 with respect to baseline). When looking at individual responses, however, patients from both groups exhibited an increased gastric PCO(2) gap. No difference was found between dobutamine and dopexamine for renal parameters.

CONCLUSIONS

In norepinephrine-treated septic shock, low doses of neither dobutamine nor dopexamine caused significant effects on systemic hemodynamics and renal function and both dobutamine and dopexamine inconsistently improved the PCO(2) gap. The present results support the need for individual measurement of the effects of catecholamine on the PCO(2) gap.

[Collective oxygen therapy and disaster medicine]

The distribution of oxygen to many victims can be necessary all along the medical help chain: operations of extraction, stand up, recovery, transport, life supporting care, surviving and transportation in mobile processing formations installed to proximity of the site, evacuations by road or by fly. Moreover, hospital in situation of crisis has an increased oxygen consumption (especially for ventilators). An estimable need calculation, a census of stocking and distribution ways have to allow to adapt resources to needs. Proposed solutions are the strengthening of vehicles in oxygen tanks, utilization of liquid oxygen tanks in large mobile formations and particular procedures to supply hospital crisis situation.

Assessment of deep vein thrombosis prophylaxis in surgical patients: a study conducted at Nancy University Hospital, France

OBJECTIVE

This retrospective evaluation aimed to assess the adequacy of prophylaxis against thromboembolism prescribed to surgical patients at the authors' institution, and to compare it with generally accepted published guidelines. Aspects considered were indications for prophylaxis, regimens used and monitoring.

METHODS

Eleven units (nine surgical and two surgical intensive care) took part in the survey on a voluntary basis. The clinical audit system used involved developing a set of criteria based on existing guidelines, comparing observed practice with those recommendations, analysing the factors underlying any deviation and developing corrective measures.

RESULTS

When the medical records of 117 patients hospitalized in October 1995 were examined, prophylaxis against deep vein thrombosis was documented in 86 (low molecular weight heparin in 85, dextran in one). No associated physical preventative measures were recorded. Indications and dosage were appropriately handled in 90.7% and 75.2% of patients, respectively. Ninety-five cases were outside the reference criteria: 74 for excluded surgical indications, 13 which involved laparoscopy, and eight in which spinal or epidural anaesthesia was administered. Platelet count was performed in 73.8% of cases before prophylactic treatment, and in 23.10% during its course. Anti-Xa activity was measured in 0.4% of cases. Analysis of causes showed that guidelines were not complied with either because of lack of organization, or because of disagreement with them.

DISCUSSION

In this study, indications for prophylaxis were well established and heparin dosages used were not fundamentally flawed. The weak point in practice was a failure to carry out platelet counts, particularly during the course of treatment. Appropriate corrective action consists of disseminating guidelines and relevant information, and using a preoperative checklist to assess thromboembolic risk.

CONCLUSION

Physicians agree that opportunities to improve preventative practices exist, and that the quality improvement programme should be pursued.

[Complications of vascular surgery]

Vascular surgery, which in certain life-threatening situations is the only possible therapeutic option, has progressed considerably since its beginning in the 1950s. Because of the constant progression of vascular diseases, this surgery will present, in the forthcoming years, a major public health problem. Because of advances in medico-surgical management, evermore elderly and frail patients can be treated. Perioperative mortality is constantly decreasing, but much progress remains to be accomplished to prevent, avoid or treat, postoperative complications. They are common and serious in these typical patients with cardiovascular diseases (men over 50 years of age, heavy smokers, atheromatous ...). The AA divide these complications into 3 main groups depending on the surgical procedure: abdominal aortic surgery, carotid surgery and arterial and venous surgery of the lower limbs. There is much data on abdominal aortic surgery because these long and complex procedures produce repercussions often involving many systems. The postoperative complications are treated according to the system they involve: cardiovascular, the most serious, respiratory, the commonest, alimentary, neurological, renal, others, as well as combined systems. The AA do not deal with the specific problems associated with cardiac and cardio-thoracic surgery. The AA discuss the different epidemiological findings of the large surgical series published in the 1970s and 1980s. The more recent literature analyses the relationship between preoperative risk factors (atheroma, COAD, hypertension ...), peroperative problems (surgical difficulties, emergencies, massive transfusions, others) and the corresponding postoperative morbidity. Thus a few general outlines of the physiopathology of these different complications emerge. In the light of these notions the few proposed methods will be evaluated in order to improve the preoperative condition of the vascular patient. The AA also review the relevance of the preoperative investigation in patients for vascular surgery. All these measures aim at reducing the incidence and severity of perioperative morbidity.

[Prevention of venous thromboembolism. Survey of in-hospital medical practice]

OBJECTIVES

In an effort to improve the prevention of venous thromboembolism, the Nancy University Hospitals conducted a survey of medical practice concerning indications for preventive therapy and surveillance of platelet counts and anti Xa activity.

METHODS

The survey involved 163 medical files. Questionnaires were filled out in 6 units (3 medical wards and 3 intensive care units).

RESULTS

Indications for preventive therapy were found to be quite variable with the exception of very low risk of thromboembolism where the treat/do not treat ratio was 0.1/1, indicating a clear tendency for abstention. This ratio was 0.77/1 and 0.38/1 respectively for low and moderate risk and 2/1 for high risk. There was undoubtedly a ward effect. The attitudes in practice tended toward non-prevention in patients without limited mobility. For platelet counts, an initial count was performed in 95% of the cases and during treatment in 38% although the specific rates were not the same for different types of units. Anti-Xa activity, which according to prevention recommendations need not to be determined, was not monitored in 88% of the cases. In accordance with prevention recommendations, anti-Xa activity was not determined in 88% of the cases.

CONCLUSION

Further progress is needed in the prevention of venous thromboembolism and should be based on wider use of existing methods.

Dobutamine improves the adequacy of gastric mucosal perfusion in epinephrine-treated septic shock

OBJECTIVE

To assess the effects of dobutamine at a rate of 5 micrograms/kg/min on hemodynamics and gastric intramucosal acidosis in patients with hyperdynamic septic shock treated with epinephrine.

DESIGN

A prospective, interventional, clinical trial.

SETTING

An adult, 16-bed medical/surgical intensive care unit of a university hospital.

PATIENTS

Twenty septic shock patients with a mean arterial pressure of > 75 mm Hg and a cardiac index of > 3.5 L/min/m2.

INTERVENTIONS

After baseline measurements (H0), each patient received dobutamine at a rate of 5 micrograms/kg/min. Baseline measurements included: hemodynamic parameters, tonometric parameters, arterial and mixed venous gases, and arterial lactate concentrations. These measurements were repeated after 1 (H1), 2 (H2), and 3 (H3) hrs. After H2 measurements, dobutamine was stopped. The patients were separated into two groups according to their PCO2 gap (tonometer PCO2-PaCO2). The increased PCO2 gap group was defined by a PCO2 gap > 8 torr (> 1.1 kPa) (n = 13), and the normal PCO2 gap group by a PCO2 gap < or = 8 torr (< or = 1.1 kPa)(n = 7).

MEASUREMENTS AND MAIN RESULTS

Dobutamine at 5 micrograms/kg/min had no significant effects on mean arterial pressure, heart rate, cardiac index, systemic vascular resistance, oxygen delivery, and oxygen consumption in epinephrine-treated septic shock. No patients developed arrhythmia or electrocardiographic signs of myocardial ischemia. During dobutamine infusion, arterial lactate concentration decreased from 5.1 +/- 0.4 in the increased PCO2 gap group and 4.2 +/- 0.4 in the normal PCO2 gap group to 3.9 +/- 0.3 and 3.5 +/- 0.3 mmol/L, respectively (p < .01). The PCO2 gap decreased and gastric intramucosal pH increased in the increased PCO2 gap group from 12 +/- 0.8 (1.6 +/- 0.1 kPa) to 3.5 +/- 0.8 torr (0.5 +/- 0.1 kPa) (p < .01) and from 7.11 +/- 0.03 to 7.18 +/- 0.02 (p < .01), respectively, and did not change in the normal PCO2 gap group. After stopping dobutamine infusion, the PCO2 gap and intramucosal pH returned to baseline values in the increased PCO2 gap group.

CONCLUSION

The addition of 5 micrograms/kg/min of dobutamine added to epinephrine in hyperdynamic septic shock selectively improved the adequacy of gastric mucosal perfusion without modification in systemic hemodynamics.

Comparison of norepinephrine and dobutamine to epinephrine for hemodynamics, lactate metabolism, and gastric tonometric variables in septic shock: a prospective, randomized study

OBJECTIVES

To compare the effects of norepinephrine and dobutamine to epinephrine on hemodynamics, lactate metabolism, and gastric tonometric variables in hyperdynamic dopamine-resistant septic shock.

DESIGN

A prospective, intervention, randomized clinical trial.

SETTING

Adult medical/surgical intensive care unit in a university hospital.

PATIENTS

30 patients with a cardiac index (CI) > 3.51 x min(-1) x m(-2) and a mean arterial pressure (MAP) < or = 60 mmHg after volume loading and dopamine 20 microg/kg per min and either oliguria or hyperlactatemia.

INTERVENTIONS

Patients were randomized to receive an infusion of either norepinephrine-dobutamine or epinephrine titrated to obtain an MAP greater than 80 mmHg with a stable or increased CI.

MEASUREMENTS AND MAIN RESULTS

Baseline measurements included: hemodynamic and tonometric parameters, arterial and mixed venous gases, and lactate and pyruvate blood levels. These measurements were repeated after 1, 6, 12, and 24 h. All the patients fulfilled the therapeutic goals. No statistical difference was found between epinephrine and norepinephrine-dobutamine for systemic hemodynamic measurements. Considering metabolic and tonometric measurements and compared to baseline values, after 6 h, epinephrine infusion was associated with an increase in lactate levels (from 3.1 +/- 1.5 to 5.9 +/- 1.0 mmol/l;p < 0.01), while lactate levels decreased in the norepinephrine-dobutamine group (from 3.1 +/- 1.5 to 2.7 +/- 1.0 mmol/l). The lactate/pyruvate ratio increased in the epinephrine group (from 15.5 +/- 5.4 to 21 +/- 5.8; p < 0.01) and did not change in the norepinephrine-dobutamine group (13.8 +/- 5 to 14 +/- 5.0). Gastric mucosal pH (pHi) decreased (from 7.29 +/- 0.11 to 7.16 +/- 0.07; p < 0.01) and the partial pressure of carbon dioxide (PCO2) gap (tonometer PCO2-arterial PCO2) increased (from 10 +/- 2.7 to 14 +/- 2.7 mmHg; p < 0.01) in the epinephrine group. In the norepinephrine-dobutamine group pHi (from 7.30 +/- 0.11 to 7.35 +/- 0.07) and the PCO2 gap (from 10 +/- 3.0 to 4 +/- 2.0 mmHg) were normalized within 6 h (p < 0.01). The decrease in pHi and the increase in the lactate/pyruvate ratio in the epinephrine group was transient, since it returned to normal within 24 h.

CONCLUSIONS

Considering the global hemodynamic effects, epinephrine is as effective as norepinephrine-dobutamine. Nevertheless, gastric mucosal acidosis and global metabolic changes observed in epinephrine-treated patients are consistent with a markedly inadequate, although transient, splanchnic oxygen utilization. The metabolic and splanchnic effects of the combination of norepinephrine and dobutamine in hyperdynamic dopamine-resistant septic shock appeared to be more predictable and more appropriate to the current goals of septic shock therapy than those of epinephrine alone.

Intracranial hypertension and adult respiratory distress syndrome: usefulness of tracheal gas insufflation

The management of increased intracranial pressure (ICP) in patients with an associated acute lung injury is difficult. High levels of PaCO2 as tolerated for permissive hypercapnia are deleterious for cerebral circulation. In such circumstances, tracheal gas insufflation (TGI), which was recently proposed to reduce PaCO2, may be of benefit. We report the cases of two patients with severe adult respiratory distress syndrome and head trauma complicated with elevated ICP. The introduction of TGI decreased PaCO2 by 17 and 26%, decreased ICP, and increased calculated cerebral perfusion pressure. We conclude that TGI could be added to a pressure-targeted strategy of ventilatory management when severe adult respiratory distress syndrome was associated to an intracranial hypertension.

Hemodynamic and metabolic effects of rapid correction of hypophosphatemia in patients with septic shock

STUDY OBJECTIVE

To examine the hemodynamic and metabolic short-term effects of hypophosphatemia correction in patients with septic shock receiving catecholamine therapy.

DESIGN

Prospective, single cohort study.

SETTING

ICU, university hospital.

PATIENTS

Ten patients with septic shock and hypophosphatemia below 2 mg/dL.

INTERVENTIONS

Infusion of glucose-1-phosphate solution (20 mmol of elemental phosphorus) for 60 min.

MEASUREMENTS AND RESULTS

Hemodynamic, oxygen-derived, acid-base, and electrolyte parameters before and immediately after phosphate infusion. Left ventricular stroke work index increased significantly (22%) from a mean low value of 24 +/- 10 g/m2 without changes in filling pressures. Systolic arterial pressure improved by 12%. Arterial pH improved slightly but significantly. Ionized calcium level slightly decreased within the normal range values. Other parameters remained unchanged.

CONCLUSIONS

Severe hypophosphatemia may be considered as a superimposed cause of myocardial depression, inadequate peripheral vasodilatation, and acidosis in septic shock. A rapid correction of hypophosphatemia is well tolerated and may have both myocardial and vascular beneficial effects. The magnitude of the response, however, is variable and unpredictable on the basis of serum phosphorus levels.

Therapeutic optimization including inhaled nitric oxide in adult respiratory distress syndrome in a polyvalent intensive care unit

OBJECTIVE

To investigate the effects of inhaled nitric oxide (NO) in adult respiratory distress syndrome (ARDS) associated with a therapeutic optimization strategy on oxygen parameters, barotrauma, and evolution in a medical and surgical intensive care unit.

DESIGN

Prospective study.

MATERIALS AND METHODS

Twenty consecutive patients with ARDS were studied (Murray score 3.6 +/- 0.2). Eleven were surgical patients and nine were medical patients. All fulfilled the extracorporeal membrane oxygenation entry criteria. The APACHE II score predicted mortality was 39%. All were ventilated with FiO2 1 with positive end-expiratory pressure (PEEP) of 11 +/- 1 cm H2O. Therapeutic optimization included permissive hypercapnia, tracheal gas insufflation, prone position, continuous hemofiltration, treatment of infection, and pleural drainage. We used NO continuously inhaled at a concentration ranging from 5 to 10 ppm.

MEASUREMENTS AND MAIN RESULTS

After 1 hour, inhaled NO improved PaO2 in all patients except one (78 +/- 11 to 130 +/- 25 mm Hg) (p < 0.05), allowing a reduction of FiO2 and PEEP. After 24 hours, mean pulmonary arterial pressure decreased from 31 +/- 3 to 25 +/- 2 mm Hg (p < 0.05). Systemic hemodynamics were unaffected. Oxygen delivery increased from 531 +/- 135 to 603 +/- 125 mL/minute/m-2 (p < 0.05). Barotraumatic lesions were present in only one patient. Reversal of ARDS was obtained in 16 patients, of whom 14 (70%) were discharged.

CONCLUSIONS

This study was shorter to demonstrate an improvement in the survival rate. Nevertheless, these preliminary results are encouraging. Because of its safety, effectiveness, and easy use, inhaled NO should be used as a part of a therapeutic optimization protocol before considering more invasive and expensive procedures, such as extracorporeal respiratory support or intravascular oxygenation.

Effects of sodium bicarbonate on striated muscle metabolism and intracellular pH during endotoxic shock

The effects of HCO3Na load on acid-base balance and muscle intracellular bioenergetics have been investigated using 31P-magnetic resonance spectroscopy in an experimental model of endotoxinic shock. Anesthetized, mechanically ventilated, and paralyzed rats (n = 16) were given an intravenous bolus of Escherichia coli lipopolysaccharide (15 mg/kg). When shock was established they were randomly assigned to receive either HCO3Na intravenously (2 mmol/kg in 2 min) or an equimolar saline injection. Lipopolysaccharide induced a significant decrease in the levels of mean arterial pressure (58 +/- 6 vs. 120 +/- 8 mmHg), arterial pH (7.20 +/- .03 vs. 7.35 +/- .01), intracellular pH (6.86 +/- .04 vs. 7.08 +/- .01), a marked hyperlactatemia (7 +/- 3 vs. 1.2 +/- .2 mmol/L) and a drop in the phosphocreatine-inorganic phosphate ratio. In the bicarbonate-loaded rats, mean arterial pressure further decreased whereas it remained unchanged in the saline group. Bicarbonate increased arterial pH and PaCO2 transiently. In the saline group, arterial pH decreased and PaCO2 remained stable. In both groups, intracellular pH and high energy phosphates had a similar evolution. In this model of septic shock, partial correction of arterial pH using HCO3Na did not reduce the metabolic cellular injury in skeletal muscle. Based on these results, HCO3Na may be of limited therapeutic value in severe septic metabolic acidosis.

Prognosis of stroke patients undergoing mechanical ventilation

OBJECTIVE

to determine the outcome of stroke patients undergoing mechanical ventilation.

DESIGN

retrospective chart review and follow-up telephone interview.

SETTING

medical ICU in a multidisciplinary university hospital.

PATIENTS AND PARTICIPANTS

199 stroke patients from 1984-1989 where the final diagnosis was stroke.

INTERVENTIONS

all patients were admitted for the need of mechanical ventilation.

MEASUREMENTS AND RESULTS

demographic information, previous relevant diseases, stroke type, general clinical and neurological data, biochemical variables, severity of illness were recorded for the first 24 h following ICU admission. A 1-year follow-up was performed, including mortality and functional status of survivors. Of 170 eventually analyzable patients, 123 (72.4%) died during their ICU stay and 156 (91.8%) during the first year. Three variables were independently associated with one-year mortality: Glasgow score < 10 (p < 0.03), bradycardia (p < 0.001), absence of brainstem reflexes (p < 0.0004).

CONCLUSION

overall prognosis of stroke needing mechanical ventilation is poor, strongly linked to symptoms of neurological impairment.

Acute unilateral renal failure and contralateral ureteral obstruction

After obstetrical surgery, a young woman developed an acute renal failure of one kidney, the other having been protected by a fortuitous ureteral ligation. The possible effects of a temporary kidney exclusion on itself and on the other kidney are discussed.

[The combination of penicillin G and ofloxacin: a response to the empirical treatment of community acquired pneumonia]

The aim of this study was to assess the clinical efficacy of a combination of penicillin G and ofloxacin in the treatment of community acquired pneumonia. Thirty eight patients (23 males, 15 females, mean age 62.8 years +/- 19.6) were included. They presented a CAP with the following criteria: fever, abnormal chest X-ray pattern. They received the combination of IV penicillin 12 x 10(6) U daily and IV ofloxacin 200 mg bid. After 48 hours of apyrexia, this treatment was followed by oral ofloxacin alone 200 mg bid. In six cases, the etiologic agent was identified: 2 S. pneumoniae, 1 Chlamydiae psittaci, 2 Staphylococcus aureus, 1 Mycoplasma. In 32 cases, the bacteriological investigation was negative. Five patients were excluded: 2 deaths due to heart failure, 3 alterations of treatment. Twenty eight patients recovered: apyrexia was obtained in 3.5 days. Penicillin G was prescribed for 7.5 days +/- 2.65, followed by ofloxacin alone for 11.43 +/- 3 days. Five patients were considered as clinical failures: 2 deaths due to extensive pneumonia, 3 recoveries after alteration of treatment. Side effects were rare: 1 confusion, 2 skin rashes. As a conclusion: penicillin G and ofloxacin in combination for the initial therapy of CAP, rapidly relayed by ofloxacin alone, permitted 84.3% of recovery in our patients.