L’infection liée aux cathéters veineux centraux, événement grave en grande partie évitable, est la principale cause de bactériémie nosocomiale. Les bactériémies associées aux cathéters et liées aux cathéters doivent être bien distinguées. En l’absence de signes locaux patents, de sepsis sévère, d’immunodépression ou de matériel prothétique en place, la réalisation d’hémocultures qualitatives comparatives par le cathéter et en périphérie peut faire le diagnostic d’implication du cathéter sans obliger à son ablation. Des taux de bactériémies liées aux cathéters (définition du consensus français) supérieurs à 1 pour 1000 journéescathéters doivent être considérés comme inacceptables. La mise en place d’un programme de prévention en réanimation est réalisable et le plus souvent efficace pour faire diminuer les taux d’infections, motiver et restructurer les équipes de soins. Si les taux d’infections sont élevés, la mise en place de mesures simples (renforcement de l’hygiène des mains, asepsie chirurgicale à la pose, solutions antiseptiques contenant de l’alcool, voie sous-clavière préférentielle, procédure d’entretien des cathéters et des lignes de perfusion, réfection immédiate des pansements souillés ou décollés, ablation des cathéters inutiles) et adaptées au mode de fonctionnement du service sont efficaces. Une gouvernance claire et une rétroinformation sont indispensables au succès de ces programmes d’amélioration de la qualité des soins. Si les taux restent élevés, ou si l’on veut aller plus loin, les pansements imprégnés de chlorhexidine permettent de diminuer encore le risque d’infection. L’utilisation des cathéters imprégnés d’agents antimicrobiens doit être limitée aux situations d’échec de la politique globale de prévention.
To estimate the rate of pulmonary embolism among mechanically ventilated patients and its association with deep venous thrombosis.Prospective cohort study.Medical intensive care unit of a university-affiliated teaching hospital.mechanically ventilated patients requiring a thoracic contrast-enhanced computed tomography scan for any medical reason.a diagnosis of pulmonary embolism before intensive care unit admission, an allergy to contrast agents, and age younger than 18 yrs.All the mechanically ventilated patients requiring a thoracic computed tomography underwent the standard imaging protocol for pulmonary embolism detection. Therapeutic anticoagulation was given immediately after pulmonary embolism diagnosis. All the included patients underwent a compression ultrasound of the four limbs within 48 hrs after the computed tomography scan to detect deep venous thrombosis.Of 176 included patients, 33 (18.7%) had pulmonary embolism diagnosed by computed tomography, including 20 (61%) with no clinical suspicion of pulmonary embolism. By multiple logistic regression, independent risk factors for pulmonary embolism were male gender, high body mass index, history of cancer, past medical history of deep venous thrombosis, coma, and high platelet count. Previous prophylactic anticoagulant use was not a risk factor for pulmonary embolism. Of the 176 patients, 35 (19.9%) had deep venous thrombosis by compression ultrasonography, including 20 (57.1%) in the lower limbs and 24 (68.6%) related to central venous catheters. Of the 33 pulmonary embolisms, 11 (33.3%) were associated with deep venous thrombosis. The pulmonary embolism risk was increased by lower-limb deep venous thrombosis (odds ratio 4.0; 95% confidence interval 1.6-10) but not upper-limb deep venous thrombosis (odds ratio 0.6; 95% confidence interval 0.1-2.9). Crude comparison of patients with and without pulmonary embolism shows no difference in length of stay or mortality.In mechanically ventilated patients who needed a computed tomography, pulmonary embolism was more common than expected. Patients diagnosed with pulmonary embolism were all treated with therapeutic anticoagulation, and their intensive care unit or hospital mortality was not impacted by the pulmonary embolism occurrence. These results invite further research into early screening and therapeutic anticoagulation of pulmonary embolism in critically ill patients.
Being able to better predict risk and optimal care for patients presenting with acute dyspnea is critical. Prognostic biomarkers are well known: amino-terminal pro-B-type Natriuretic Peptide, troponin, C-reactive protein, procalcitonin. Some were more recently developed: mid-regional pro-A-type natriuretic peptide (Mid Pro-ANP), mid-regional-pro-adrenomedullin (MR-proADM), pro-endothelin, copeptin. The aim of the paper was to evaluate prognostic value of clinical findings and 8 biomarkers in patients with severe acute dyspnea.We designed a prospective cohort study targeting patients admitted in the Emergency Department and in Intensive Care Unit of a University Hospital. Inclusion criteria were acute dyspnea with SpO2 less than 92% and/or respiratory rate (RR) greater than or equal to 25 bpm. Clinical and biological data, including biomarker levels, were recorded. The contribution of the biomarkers in the prognosis was assessed using AUC-ROC curves and by multiple logistic regression.Three hundred and eighty four patients (median age 74 years, 28-day mortality 17%) were enrolled. All biomarkers were available for 317 patients. Main diagnoses were sepsis in 141 cases (36.7%), and acute heart failure in 84 (21.9%) cases. All biomarkers were correlated with prognosis. Pro-ADM (AUC-ROC=0.731; 95% CI: 0.658-0.804) showed the best accuracy. The parameters independently associated with prognosis led to a clinical/biological model with an AUC=0.809 and a good calibration (P (HLchi2)=0.9). Three biomarkers added prognostic information to the model: MR-proADM (P=0.005), copeptin (P=0.006) and troponin (P=0.05).Biomarkers can contribute to determine the day-28 outcome of patients with acute severe dyspnea.
We describe the first case of thrombotic thrombocytopenic purpura (TTP) in a patient with Legionnaires' disease. TTP was demonstrated by the low level of adams TS13 activity that resolved after plasmapheresis and remained normal in the long-term follow up.
Une enquête de prévalence menée un jour donné en France a montré que les antifongiques sont utilisés chez 7,5 % des patients présents en réanimation [1]. Il convient donc pour les réanimateurs d'approfondir les connaissances sur les propriétés pharmacocinétiques et pharmacodynamiques de ces molécules. Cette revue ne reprendra pas l'efficacité respective de chacun des produits en fonction des indications. Après un bref rappel des spectres d'activité des molécules disponibles (tableau I), nous décrirons les particularités pharmacologiques, pharmacocinétiques et pharmacodynamiques utiles pour le réanimateur et les principaux problèmes auxquels ils peuvent être confrontés. Les antifongiques appartiennent à quatre grandes familles : les azolés, les polyènes, la 5-fluorocytosine et les candines.
Many patients with severe acute respiratory distress syndrome (ARDS) caused by influenza A(H1N1) infection receive extracorporeal membrane oxygenation (ECMO) as a rescue therapy.To analyze factors associated with death in ECMO-treated patients and the influence of ECMO on intensive care unit (ICU) mortality.Data from patients admitted for H1N1-associated ARDS to French ICUs were prospectively collected from 2009 to 2011 through the national REVA registry. We analyzed factors associated with in-ICU death in ECMO recipients, and the potential benefit of ECMO using a propensity score-matched (1:1) cohort analysis.A total of 123 patients received ECMO. By multivariate analysis, increasing values of age, lactate, and plateau pressure under ECMO were associated with death. Of 103 patients receiving ECMO during the first week of mechanical ventilation, 52 could be matched to non-ECMO patients of comparable severity, using a one-to-one matching and using control subjects only once. Mortality did not differ between the two matched cohorts (odds ratio, 1.48; 95% confidence interval, 0.68-3.23; P = 0.32). Interestingly, the 51 ECMO patients who could not be matched were younger, had lower Pa(o(2))/Fi(o(2)) ratio, had higher plateau pressure, but also had a lower ICU mortality rate than the 52 matched ECMO patients (22% vs. 50%; P < 0.01).Under ECMO, an ultraprotective ventilation strategy minimizing plateau pressure may be required to improve outcome. When patients with severe influenza A(H1N1)-related ARDS treated with ECMO were compared with conventionally treated patients, no difference in mortality rates existed. The unmatched, severely hypoxemic, and younger ECMO-treated patients had, however, a lower mortality.
Rationale Experimental studies suggest that intra-abdominal infection (IAI) induces biological alterations that may affect the risk of lung infection. Objectives To investigate the potential effect of IAI at ICU admission on the subsequent occurrence of ventilator-associated pneumonia (VAP). Methods We used data entered into the French prospective multicenter Outcomerea database in 1997–2011. Consecutive patients who had severe sepsis and/or septic shock at ICU admission and required mechanical ventilation for more than 3 days were included. Patients with acute pancreatitis were not included. Measurements and Main Results Of 2623 database patients meeting the inclusion criteria, 290 (11.1%) had IAI and 2333 (88.9%) had other infections. The IAI group had fewer patients with VAP (56 [19.3%] vs. 806 [34.5%], P<0.01) and longer time to VAP (5.0 vs.10.5 days; P<0.01). After adjustment on independent risk factors for VAP and previous antimicrobial use, IAI was associated with a decreased risk of VAP (hazard ratio, 0.62; 95% confidence interval, 0.46–0.83; P<0.0017). The pathogens responsible for VAP were not different between the groups with and without IAI (Pseudomonas aeruginosa, 345 [42.8%] and 24 [42.8%]; Enterobacteriaceae, 264 [32.8%] and 19 [34.0%]; and Staphylococcus aureus, 215 [26.7%] and 17 [30.4%], respectively). Crude ICU mortality was not different between the groups with and without IAI (81 [27.9%] and 747 [32.0%], P = 0.16). Conclusions In our observational study of mechanically ventilated ICU patients with severe sepsis and/or septic shock, VAP occurred less often and later in the group with IAIs compared to the group with infections at other sites.
