[Outbreak of influenza A(H1N1)/2009: description of cases and crisis management in a ICU in Reunion Island]

OBJECTIVES

to describe the characteristics, treatment and outcome of critically ill patients with influenza A(H1N1) infection at St Pierre Hospital in Reunion Island during the 2009 outbreak, as well as the measures of care reorganization implemented to face them.

PATIENTS AND METHODS

prospective observational study of probable and confirmed cases of influenza A (H1N1)/2009 infection concerning hospitalized patients in a polyvalent intensive care unit (ICU).

RESULTS

thirteen patients have been included between August and September 2009. Three (23 %) didn't have any medical history. The median age was 42 [22-69]. Eleven have required pulmonary ventilation for 10.3 days (± 8). Three (23 %) have developed an ARDS. Three patients (23 %) died. To cope with the influx of cases and considering our situation of geographic isolation, it has been needed to totally rework the organization of care: set-up of a specific welcoming channel, division into sectors of the department, opening of additional beds, new on-duty assignment, inter and intra hospital cooperation.

CONCLUSION

reunion Island has been an experimental lab of crisis management during the H1N1/2009 epidemic, several months ahead of the mother country. To anticipate the reorganization of care in intensive care units during an outbreak period, particularly in small units or units isolated like ours, looks to us a must so to quietly face a sharp influx of patients.

[Severe head injuries: effects of pre-hospital mechanical ventilation on capnia]

OBJECTIVE

To assess the effect on PaCO2 of mechanical ventilation during prehospital management of severely head-injured patients.

STUDY DESIGN

Retrospective observational study.

PATIENTS

Severely head-injured patients with Glasgow coma score < or = 8. All patients were sedated, with the trachea intubated and the lungs mechanically ventilated.

METHODS

According to the capnia measured at the admission in the neurosurgical intensive therapy unit they were allocated into one of the following three groups: hypocapnia group (PaCO2 < 30 mmHg), recommended capnia group (PaCO2 = 30-38 mmHg) and hypercapnia group (PaCO2 > 38 mmHg).

RESULTS

Out of the 42 patients with similarly severe head injuries, 19% were included in the recommended capnia group (PaCO2: 34 +/- 2 mmHg), 38% in the hypocapnia group (PaCO2: 23 +/- 3 mmHg) and 43% in the hypercapnia group (PaCO2: 47 +/- 7 mmHg). In all except three, PaO2 was above 95 mmHg. The settings of ventilatory parameters on the ventilators were similar.

CONCLUSION

In 81% of patients, mechanical ventilation was inadequate as far as PaCO2 levels are concerned. Major hypocapnia and hypercapnia carry a potential risk for cerebral ischaemic. Therefore it is recommended to monitor PETCO2 during prehospital transport in medical ambulances and to determine arterial blood gases at arrival of severely head-injured patients in the admission unit for emergencies.

[Severe hemorrhage from rupture of an intra-oral arteriovenous malformation]

We report the case of a 47-year-old woman with a sudden, spontaneous exsanguinating haemorrhage from an arteriovenous malformation of the mandible. The diagnosis was obtained with a contrast enhanced CT-scan and a digital subtraction angiography. As arterial embolisation was not available the lesion was treated surgically.

[Interscalenic block: accidental catheterization of the epidural space]

A case is reported of inadvertent insertion of a brachial plexus catheter into the cervical epidural space, at the sitting of an interscalene block for postoperative analgesia, during the recovery from general anaesthesia after surgical repair of a rupture of the rotator cuff of the shoulder. No features of cervical epidural anaesthesia were seen after the first injection of local anaesthetic, as it was made through the catheter insertion cannula. Once inserted, the catheter position was checked prior to the second injection of local anaesthetic. The X-ray obtained after catheter opacification showed the penetration of contrast medium into the epidural space. In our case, two out of the three means of prevention of this complication were not possible: a) sitting of the interscalene block before induction of anaesthesia, as the insertion conditions of the catheter are better in a conscious, sitting patient; b) adequate cannula orientation (namely medial, dorsal and slightly caudal); c) routine X-ray control of the catheter position before the first injection, associated with careful clinical monitoring for 30 min after each local anaesthetic injection.

[Fatal streptococcus A shock after thoracic surgery]

A 23-year-old man with relapsing pneumothorax underwent surgical removal of left apical lung bullae and pleural rubbing down. Forty-eight hours later, he suddenly developed a state of shock together with tachypnoea, oliguria, and a scarlet-like erythema of the face and trunk. Haemodynamic and other investigations led to the diagnosis of septic shock, although no portal of entry could be found. Despite antibiotics (vancomycin, gentamycin and pefloxacine) and symptomatic treatment, the patient's condition continued to worsen. He had a fever (40 degrees C) with abdominal tenderness. Exploratory laparotomy failed to disclose a septic foyer. On aspiration of the left thoracic cavity, a large pyothorax was found and 600 mls of pus were drained. Gram-positive cocci were found on staining and pefloxacine was replaced by mezlocillin. Nevertheless, the patient died within 24 h. Blood and pus cultures confirmed that the infection was due to a pyrogenic penicillin-sensitive group A Streptococcus. Similar cases have been described recently. Group A Streptococcus is suspected to cause severe infections with multiple organ failure, termed "toxic shock-like syndrome". The clinical similarity between the streptococcal and staphylococcal shocks calls for a precise bacteriological diagnosis, and treatment with antibiotics active on both germs.