RESUMEN
We report the case of a 55-year-old man without significant medical history admitted to the ICU for a progressive paralysis mimicking life-threatening tetanus. Evolution with classical tetanus treatment was negative, with the need for ventilator support and worsening condition being life threatening. Uncommon evolution revealed a rare glycin antibody-associated hyperekplexia (progressive encephalomyelitis with rigidity syndrome). Patient dramatically improved with immunosuppressive therapy including plasmatic exchanges, cyclophasmid and high dose corticoid infusions. Intensivists should be aware of this very rare syndrome whose treatment is the opposite of tetanus while presentation is very close. Optimal and treatment could lead to prolonged survival.
Asunto(s)
Encefalomielitis/diagnóstico , Encefalomielitis/terapia , Rigidez Muscular/diagnóstico , Rigidez Muscular/terapia , Tétanos/diagnóstico , Cuidados Críticos , Diagnóstico Diferencial , Encefalomielitis/inmunología , Glicina/inmunología , Humanos , Terapia de Inmunosupresión , Masculino , Persona de Mediana Edad , Rigidez Muscular/inmunología , Intercambio Plasmático , Respiración Artificial , Esteroides/uso terapéutico , Síndrome , Tétanos/inmunologíaRESUMEN
PURPOSE: The Berlin definition for acute respiratory distress syndrome (ARDS) is a new proposal for changing the American-European consensus definition but has not been assessed prospectively as yet. In the present study, we aimed to determine (1) the prevalence and incidence of ARDS with both definitions, and (2) the initial characteristics of patients with ARDS and 28-day mortality with the Berlin definition. METHODS: We performed a 6-month prospective observational study in the ten adult ICUs affiliated to the Public University Hospital in Lyon, France, from March to September 2012. Patients under invasive or noninvasive mechanical ventilation, with PaO2/FiO2 <300 mmHg regardless of the positive end-expiratory pressure (PEEP) level, and acute onset of new or increased bilateral infiltrates or opacities on chest X-ray were screened from ICU admission up to discharge. Patients with cardiogenic pulmonary edema were excluded. Patients were further classified into specific categories by using the American-European Consensus Conference and the Berlin definition criteria. The complete data set was measured at the time of inclusion. Patient outcome was measured at day 28 after inclusion. RESULTS: During the study period 3,504 patients were admitted and 278 fulfilled the American-European Consensus Conference criteria. Among them, 18 (6.5 %) did not comply with the Berlin criterion PEEP ≥ 5 cmH2O and 20 (7.2 %) had PaO2/FiO2 ratio ≤200 while on noninvasive ventilation. By using the Berlin definition in the remaining 240 patients (n = 42 mild, n = 123 moderate, n = 75 severe), the overall prevalence was 6.85 % and it was 1.20, 3.51, and 2.14 % for mild, moderate, and severe ARDS, respectively (P > 0.05 between the three groups). The incidence of ARDS amounted to 32 per 100,000 population per year, with values for mild, moderate, and severe ARDS of 5.6, 16.3, and 10 per 100,000 population per year, respectively (P < 0.05 between the three groups). The 28-day mortality was 35.0 %. It amounted to 30.9 % in mild, 27.9 % in moderate, and 49.3 % in severe categories (P < 0.01 between mild or moderate and severe, P = 0.70 between mild and moderate). In the Cox proportional hazard regression analysis ARDS stage was not significantly associated with patient death at day 28. CONCLUSIONS: The present study did not validate the Berlin definition of ARDS. Neither the stratification by severity nor the PaO2/FiO2 at study entry was independently associated with mortality.
Asunto(s)
Lesión Pulmonar Aguda/clasificación , Lesión Pulmonar Aguda/epidemiología , Hospitales Universitarios , Síndrome de Dificultad Respiratoria/clasificación , Síndrome de Dificultad Respiratoria/epidemiología , Lesión Pulmonar Aguda/terapia , Anciano , Conferencias de Consenso como Asunto , Europa (Continente) , Femenino , Mortalidad Hospitalaria , Humanos , Incidencia , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Respiración con Presión Positiva , Prevalencia , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Respiración Artificial , Síndrome de Dificultad Respiratoria/terapia , Estados UnidosAsunto(s)
Estenosis de la Válvula Aórtica/cirugía , Cateterismo Cardíaco/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Anciano , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Cateterismo Cardíaco/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Masculino , Radiografía , UltrasonografíaAsunto(s)
Aspergilosis/diagnóstico , Encefalopatías/diagnóstico , Neoplasias Encefálicas/terapia , Cuerpo Calloso/patología , Imagen de Difusión por Resonancia Magnética , Lóbulo Frontal/patología , Interpretación de Imagen Asistida por Computador , Imagen por Resonancia Magnética , Infecciones Oportunistas/diagnóstico , Aspergilosis Pulmonar/diagnóstico , Tomografía Computarizada por Rayos X , Corticoesteroides/efectos adversos , Corticoesteroides/uso terapéutico , Adulto , Encéfalo/patología , Terapia Combinada , Diagnóstico Diferencial , Progresión de la Enfermedad , Resultado Fatal , Femenino , HumanosRESUMEN
OBJECTIVE: To assess quality of life (QOL), mortality rate and renal function 6 months after onset of renal replacement therapy (RRT) for acute kidney injury (AKI) in the ICU. PARTICIPANTS AND SETTING: This prospective observational study was conducted in seven ICUs in France over 9 months. Inclusion criteria were: age > or =18 years, RRT delivered for AKI and informed consent signed. AKI was defined from the RIFLE score. Recipients of kidney grafts or patients undergoing chronic RRT were not included. MEASUREMENTS AND RESULTS: QOL was assessed using the Short Form Health Survey (SF-36) questionnaire together with the Index of Activities of Daily Living (ADL) (0: full assistance to 6: no assistance). SF-36 was compared to a reference age- and sex-matched French population. Patient status, place of residence, and persistence of RRT, ADL and SF-36 were assessed at 28 days, 3 months and 6 months from inclusion. In the study period, 205 patients were included and 1 withdrew. At 6 months, 77/204 were alive (mortality 62%). SF-36 and ADL significantly increased from day 28 to 6 months. In the survivors at 6 months, SF-36 items were significantly lower than in the reference population, with the physical items more severely affected than the mental items; 64% were fully autonomous (ADL score = 6); 69% were living in their homes, and 12% were still undergoing RRT; 94% would agree to undergo the same management again. CONCLUSIONS: ICU survivors from RRT for AKI have an impaired QOL at 6 months, but sustained autonomy in their daily lives.
Asunto(s)
Lesión Renal Aguda , Calidad de Vida , Terapia de Reemplazo Renal , Actividades Cotidianas/psicología , Lesión Renal Aguda/mortalidad , Lesión Renal Aguda/psicología , Lesión Renal Aguda/terapia , Anciano , Análisis de Varianza , Comorbilidad , Cuidados Críticos/métodos , Cuidados Críticos/estadística & datos numéricos , Femenino , Francia/epidemiología , Estado de Salud , Encuestas Epidemiológicas , Humanos , Tiempo de Internación/estadística & datos numéricos , Modelos Lineales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Calidad de Vida/psicología , Terapia de Reemplazo Renal/métodos , Terapia de Reemplazo Renal/estadística & datos numéricos , Encuestas y Cuestionarios , Tasa de Supervivencia , Resultado del TratamientoAsunto(s)
Síndrome Antifosfolípido/complicaciones , Insuficiencia Multiorgánica/etiología , Complicaciones Posoperatorias/etiología , Síndrome de Dificultad Respiratoria/etiología , Corticoesteroides/uso terapéutico , Anciano , Antibacterianos/uso terapéutico , Anticuerpos Anticardiolipina/sangre , Anticoagulantes/uso terapéutico , Síndrome Antifosfolípido/diagnóstico , Coma/etiología , Infección Hospitalaria/complicaciones , Infección Hospitalaria/tratamiento farmacológico , Diagnóstico Diferencial , Femenino , Heparina/uso terapéutico , Humanos , Obstrucción Intestinal/cirugía , Neumonía Bacteriana/complicaciones , Neumonía Bacteriana/tratamiento farmacológico , Infecciones por Pseudomonas/complicaciones , Infecciones por Pseudomonas/tratamiento farmacológico , Tromboflebitis/tratamiento farmacológico , Tromboflebitis/etiologíaRESUMEN
BACKGROUND: Respiratory variations in pulse oximetry plethysmographic waveform amplitude (DeltaPOP) can predict fluid responsiveness in mechanically ventilated patients but cannot be easily assessed at the bedside. Pleth variability index (PVI) is a new algorithm allowing for automated and continuous monitoring of DeltaPOP. We hypothesized that PVI can predict fluid responsiveness in mechanically ventilated patients under general anaesthesia. METHODS: Twenty-five patients were studied after induction of general anaesthesia. Haemodynamic data [cardiac index (CI), respiratory variations in arterial pulse pressure (DeltaPP), DeltaPOP, and PVI] were recorded before and after volume expansion (500 ml of hetastarch 6%). Fluid responsiveness was defined as an increase in CI > or =15%. RESULTS: Volume expansion induced changes in CI [2.0 (sd 0.9) to 2.5 (1.2) litre min(-1) m(-2); P<0.01], DeltaPOP [15 (7)% to 8 (3)%; P<0.01], and PVI [14 (7)% to 9 (3)%; P<0.01]. DeltaPOP and PVI were higher in responders than in non-responders [19 (9)% vs 9 (4)% and 18 (6)% vs 8 (4)%, respectively; P<0.01 for both]. A PVI >14% before volume expansion discriminated between responders and non-responders with 81% sensitivity and 100% specificity. There was a significant relationship between PVI before volume expansion and change in CI after volume expansion (r=0.67; P<0.01). CONCLUSIONS: PVI, an automatic and continuous monitor of DeltaPOP, can predict fluid responsiveness non-invasively in mechanically ventilated patients during general anaesthesia. This index has potential clinical applications.
Asunto(s)
Fluidoterapia/métodos , Monitoreo Intraoperatorio/métodos , Anciano , Anciano de 80 o más Años , Algoritmos , Anestesia General , Gasto Cardíaco , Puente de Arteria Coronaria , Femenino , Hemodinámica , Humanos , Cuidados Intraoperatorios/métodos , Masculino , Persona de Mediana Edad , Oximetría , Pletismografía , Respiración Artificial , Mecánica RespiratoriaRESUMEN
Acute respiratory distress syndrome (ARDS) is a frequent cause of admission in intensive care unit. The treatment is well codified. Unfortunately some patients die because of hypoxemia despite a well-conducted medical treatment. Extracorporeal oxygenation could be the ultimate treatment for these refractory hypoxemia patients. We report two cases of patients suffering from severe ARDS who beneficiated from extracorporeal oxygenation, pointing out the interest of this technique during severe ARDS as well as the accessibility and the feasibility of the technique even apart from a specialized center.
Asunto(s)
Oxigenación por Membrana Extracorpórea , Síndrome de Dificultad Respiratoria/terapia , Adulto , Humanos , Legionelosis/complicaciones , Masculino , Persona de Mediana Edad , Neumonía Neumocócica/complicaciones , Síndrome de Dificultad Respiratoria/complicacionesRESUMEN
OBJECTIVES: To evaluate the impact of local recommendations on off label use of recombinant activated factor VII. TYPE OF STUDY: Observational, retrospective. MATERIAL AND METHODS: Recommendations have been diffused by a local working group in 2004, concerning seven groups of indications (traumatology, cardiac, hepatic and various surgeries, obstetrics, neurology and haematology). Conformity to recommendations was studied according to 4 axes: respect of prescribing procedure, indication, posology, and pre ones required with the administration. RESULTS: There were thirty-one uses from 2004 to 2006. Thirty patients presented a massive haemorrhage (blood products before administration of recombinant activated factor VII expressed in median [min-max]: red blood cell unit=15 [0-37], fresh frozen plasma=11 [0-21]). Gravity score at the admission: SAPSII=55+/-22 (average+/-SD), 87% patients presented haemorrhagic shock. Prescribing procedure was in conformity with recommendations in 45%, indications were correct in 74%, posology in 55%, and 16% of prescriptions were completely conform. CONCLUSION: With the tariffing to the activity reform, the reimbursement of off label use of expensive molecules will depend on the respect of the evidence-based medicine. According to this study, the observance of local recommendations was insufficient. Rationalizing prescriptions for practice improvement seemed to be difficult and challenging.