Les medecins utilisent souvent des medicaments diminuant l’etat de conscience et/ou les douleurs des patients de reanimation (surtout ceux qui sont sous ventilation artificielle). L’agression liee a la pathologie ou aux soins au sens large (mais en fait surtout la douleur) peut etre pourvoyeuse de consequences physiologiques nefastes et bien sUr d’un inconfort non acceptable. Neanmoins, la necessite d’une absence de conscience en soi n’est pas forcement souhaitable, contrairement a une periode per-operatoire chirurgicale. En effet, la perte de conscience n’est pas synonyme de confort (et d’ailleurs elle diminue le depistage des douleurs). En fait, les hypnotiques les plus souvent utilises dans ce contexte (benzodiazepine, propofol) ont des effets nefastes sur la qualite du sommeil. De plus, l’immobilisation liee a la sedation pourrait participer a un deconditionnement musculaire et favoriser la survenue de neuromyopathies acquises en reanimation. Les benzodiazepines sont pourvoyeuses de delire (facteur de risque de mortalite). L’absence totale de souvenirs serait de plus un facteur de risque de syndrome de stress post-traumatique ulterieur. Les sedatifs ont par ailleurs des effets hemodynamiques non negligeables. Des etudes prospectives etudiant une strategie d’absence ou l’arret journalier de la sedation ont montre une diminution de la duree de ventilation artificielle avec une tendance a la diminution de la mortalite. Une strategie d’epargne de la sedation compatible avec l’obtention d’un etat calme et confortable pour le patient de reanimation est faisable et probablement souhaitable tant pout eviter des effets deleteres « immediats » que pour ameliorer la qualite de vie apres la reanimation.
Studies on head injury-induced pituitary dysfunction are limited in number and conflicting results have been reported.To further clarify this issue, 29 consecutive patients (24 males), with severe (n = 21) or moderate (n = 8) head trauma, having a mean age of 37 ± 17 years were investigated in the immediate post-trauma period.All patients required mechanical ventilatory support for 8-55 days and were enrolled in the study within a few days before ICU discharge.Basal hormonal assessment included measurement of cortisol, corticotropin, free thyroxine (fT4), thyrotropin (TSH), testosterone (T) in men, estradiol (E2) in women, prolactin (PRL), and growth hormone (GH).Cortisol and GH levels were measured also after stimulation with 100 µg human corticotropin releasing hormone (hCRH) and 100 µg growth hormone releasing hormone (GHRH), respectively.Cortisol hyporesponsiveness was considered when peak cortisol concentration was less than 20 µg/dl following hCRH.TSH deficiency was diagnosed when a subnormal serum fT4 level was associated with a normal or low TSH.Hypogonadism was considered when T (males) or E2 (women) were below the local reference ranges, in the presence of normal PRL levels.Severe or partial GH deficiencies were defined as a peak GH below 3 µg/l or between 3 and 5 µg/l, respectively, after stimulation with GHRH.Twenty-one subnormal responses were found in 15 of the 29 patients (52%) tested; seven (24%) had hypogonadism, seven (24%) had cortisol hyporesponsiveness, five (17%) had hypothyroidism, and two patients (7%) had partial GH deficiency.These preliminary results suggest that a certain degree of hypopituitarism occurs in more than 50% of patients with moderate or severe head injury in the immediate post-trauma period, with cortisol hyporesponsiveness and hypogonadism being most common.Further studies are required to elucidate the pathogenesis of these abnormalities and to investigate whether they affect long-term morbidity.
The aim of the present study was to determine the relationship between tracheotomy and ventilator-associated pneumonia (VAP). The study used a retrospective case–control study design based on prospective data. All nontrauma immunocompetent patients, intubated and ventilated for >7 days, were eligible for inclusion in the study. A diagnosis of VAP was based on clinical, radiographical and microbiological criteria. Four matching criteria were used, including duration of mechanical ventilation (MV). The indication and timing of tracheotomy were at the discretion of attending physicians. Univariate and multivariate analyses were performed to determine risk factors for VAP in cases (patients with tracheotomy) and controls (patients without tracheotomy). In total, 1,402 patients were eligible for inclusion. Surgical tracheotomy was performed in 226 (16%) patients and matching was successful for 177 (78%). The rate of VAP (22 versus 14 VAP episodes·1,000 MV-days −1 ) was significantly higher in controls than in cases. The rate of VAP after tracheotomy in cases, or after the corresponding day of MV in controls, was also significantly higher in control than in case patients (9.2 versus 4.8 VAP episodes·1,000 MV-days −1 ). In multivariate analysis, neurological failure (odds ratio (95% confidence interval) 2.7 (1.3–5)), antibiotic treatment (2.1 (1.1–3.2)) and tracheotomy (0.18 (0.1–0.3)) were associated with VAP. In summary, the present study demonstrates that tracheotomy is independently associated with decreased risk for ventilator-associated pneumonia.
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