Lung transplantation (LT) is a recognized procedure for selected patients with end-stage respiratory failure. We performed 123 LT, including 32 single lung, 84 double lung, and 7 heart-lung transplantations in 48 patients with chronic obstructive pulmonary disease (COPD), 13 patients with pulmonary hypertension (PH), 33 with cystic fibrosis (CF), and 29 with interstitial lung disease (ILD) between July 1990 and January 2008. Survival was compared for periods before and after December 2001. The mean age of patients was 44.4 years (range 16-66.5 years); 84 (69%) were men. Before LT, 1 second forced expiratory volume was 28.7% +/- 18.1% and PaCO(2) = 6.3 kPa. Fifty-five patients were on noninvasive ventilation. Cold ischemia time was 320 +/- 91 minutes. Cardiopulmonary bypass (CPB) was used in 77 patients (64%). There were 18 early surgical reinterventions, 8 extracorporeal membrane oxygenations, and 38 bronchial stent insertions among 206 at-risk bronchial sutures. Crude survivals were 69%, 58%, 41%, and 18% at 1, 2, 5, and 10 years, respectively. Comparing before (n = 70 with 15 CF) vs after December 2001 (n = 53 with 17 CF), survivals were 63% vs 78%, 51% vs 71%, and 33% vs 60% at 1, 2, and 5 years, respectively (P = .01) and for CF patients, 52% vs 100%, 52% vs 94%, and 25% vs 94% at 1, 2, and 5 years, respectively (P = .005). There was significant improvement in survival before and after 2001 in 123 LT and particularly among CF patients. Improvement in survival after LT may be related to the sum of numerous changes in our practice since December 2001, including the use of pulmonary rehabilitation pre-LT, extracellular pneumoplegia, statins, macrolides for chronic rejection, monitoring of Epstein-Barr blood load, changes in maintenance immunosuppressants, as well as position movement up the coordinator nurse and learning curve.

OBJECTIVE:Few studies have shown that aged packed red blood cells (RBC) transfusion negatively influenced the outcome of ICU patients, probably related to storage lesions which could be decreased by leukodepletion of RBC. The purpose of this study was to evaluate the impact of aged leukodepleted-RBC pack, on the outcome of ICU patients. DESIGN:Retrospective, observational, cohort study in a Medical Intensive Care Unit. PATIENTS:Consecutive patients admitted during the years 2005 and 2006, and requiring a transfusion. We recorded patient's demographic data, number of RBC unit and age of each RBC, length of ICU, mortality during ICU stay. RESULTS:Five hundred and thirty-four patients were included with global mortality was 26.6%, length of stay in ICU six days (3-14) and SAPS II 48 (35-62). RBC equaling to 5.9 were transfused per patients (22.7%<14 days and 57.3%<21 days). The number of RBC was significantly higher in the dead patients group, but the rate of RBC stored less than 21 days was not different (54% versus 60%; p=0.21). In a multivariate logistic model, independent predictors of ICU death were SAPS II (OR=1.02 per point, p<0.001), number of RBC (OR=1.08 per RBC, p<0.001), length of stay in ICU (p<0.001). Similar results were obtained while introducing the age of RBC as time dependent covariates in a multivariate Cox's model. CONCLUSIONS:RBC transfused in our ICU are old. The ICU outcome is independently associated with the number of leucodepleted RBC transfused, but not with their age.

Blood measurements of BNP and NT-proBNP, its catabolite, improve diagnosis for patients admitted to emergency departments with dyspnoea. In this paper, we have compared the BNP to the NT-proBNP for 119 dyspnoeic patients using at random clear clinical status. Among the test group of 119 patients, 57 showed coherent biological results for the 2 markers. These results confirm the final clinical diagnosis. Nine patients with congestive heart failure had abnormally low BNP and NT-proBNP rates. Six of these patients experienced long delays (longer than 48 hours and less than 72 hours) between their admission in emergency and the biological measurement of the natriuretic biomarkers. Three of the other patients could be not only flash OAP cases with a fast growth and a fast normalisation of BNP but also could have existing genetical factors. These genetical factors leading to high variability in BNP synthesis are not related to physiological or cardiac factors. 43 patients showed a mismatch between BNP and NT-proBNP. BNP appeared to be unstable in vitro. The lack of stability in whole blood or plasma samples is increased by sampling in a glass EDTA collection tube and too long delays in transferring the samples from the emergency area and the laboratory in a big hospital. Ten patients showed a mismatch with abnormally high NT-proBNP or false positive results. Among these 10 patients, 5 had renal dysfunction with a high level of creatinine concentration. It is clear that all Diagnostics Manufacturers should now propose different cut-off for natriuretic peptides tests according to the degree of patients' renal impairment.

A 48 year old man was admitted to the intensive care unit with septicaemic shock associated with febrile jaundice and anuric renal failure. Within hours, he developed cardiogenic shock with multi-organ failure due to an acute myocarditis refractory to catecholamines and requiring intra-aortic balloon pumping. The diagnosis was an ictero-haemorrhagic leptospirosis, the outcome of which was finally favourable. Myocarditis is an underestimated complication of leptospirosis because it is often symptomless. The main signs are arrhythmias, conduction defects and ST-T wave abnormalities which have little clinical expression. The disease may progress and is sometimes fatal. Leptospirosis myocarditis should therefore be carefully considered because of its potential severity and its reversibility with appropriate antibiotic therapy and also the necessity of initial management in a specific infrastructure.

The nosocomial infections and multiresistant bacteria increase is a tremendous problem, particularly in intensive care units. Lot of procedures are set in hospitals, in order to obtain the best antimicrobial regimens. We report the results of a systematic infectious advisory consultation, in the intensive care unit of our Universitary hospital. The study was prospective, collecting data before and after the intervention of an infectious diseases expert. The expert visited the Intensive Care Unit daily, for discussion and validation of all anti-infections treatments. We compared antimicrobial drugs quantities during two 3 months periods (without and with the expert’s visit). 190 patients were analyzed. The expert’s visit led to a 15938.30 Q (19.56%) saving. It was mainly obtained by reducing antifungal treatments. These results compared to other studies realized in France or anglo-saxon countries. The obtained saving was reported to be between 15 and 30%, whatever the type and duration of the intervention were. Other interventions are possible: setting guidelines and teaching program, antibiotics turn-over, restrictions for prescribing antimicrobials... The ecological effect is slower than the economical one. In order to maintain a bacterial flora as sensitive to antibiotics as possible, it’s necessary to set sophisticated antibiotics policies. © 2005 Société de réanimation de langue française. Publié par Elsevier SAS. Tous droits réservés. * Auteur correspondant. Adresse e-mail : PPavese@chu-grenoble.fr (P. Pavese). Réanimation 14 (2005) 281–287 http://france.elsevier.com/direct/REAURG/ 1624-0693/$ see front matter © 2005 Société de réanimation de langue française. Publié par Elsevier SAS. Tous droits réservés. doi:10.1016/j.reaurg.2005.03.002 Mots clés : Consultation d’infectiologie ; Maîtrise antibiothérapie

L'augmentation des infections nosocomiales et des bactéries multirésistantes est un problème majeur notamment dans les services de réanimation. De nombreuses interventions sont mises en place au sein des centres hospitaliers pour optimiser l'usage des traitements anti-infectieux. Nous rapportons une expérience de consultation systématique d'infectiologie que nous avons réalisée au centre hospitalo-universitaire de Grenoble dans le service de réanimation médicale. Nous avons réalisé une étude prospective de type avant–après intervention d'un expert infectiologue. L'intervention consistait en un passage quotidien du référent dans l'unité pour discussion et validation de tous les traitements anti-infectieux. Nous avons comparé les consommations d'anti-infectieux pour deux périodes consécutives de trois mois (sans puis avec intervention). L'étude a concerné au total 190 patients. L'intervention du référent a permis l'économie de 15 938,30 €, soit 19,56 %. Cette économie a surtout été réalisée grâce aux traitements antifongiques. Ces résultats sont comparables à la plupart des expériences menées en France et dans les pays anglo-saxons. L'économie générée par l'intervention d'un référent se situe entre 15 et 30 % quels que soient le mode et la durée de l'intervention. Plusieurs autres types d'intervention peuvent être réalisés : implémentation de recommandations et programme de formation, restriction de la prescription des traitements anti-infectieux, rotation des antibiotiques. L'impact écologique est plus lent et nécessite des politiques de maîtrise de l'antibiothérapie complexes et multidisciplinaires associant plusieurs de ces actions.

BACKGROUND:Glucose absorption from starchy food has only been described with small amounts ingested ( approximately 20-75 g). OBJECTIVE:Our aim was to describe total plasma (Ra) and exogenous glucose (Ra(exo)) appearance, glucose release from the liver (HGP), and the metabolic response after ingestion of 5 g polished or parboiled rice/kg body mass. DESIGN:Gas exchange and urea excretion were monitored in 8 healthy subjects before (3.5 h) and after (8 h) ingestion of rice intrinsically labeled with (13)C; [6,6-(2)H(2)]glucose was infused for the measurement of Ra, Ra(exo), and HGP. RESULTS:Changes in plasma glucose, insulin, lactate, and free fatty acids and the increase in Ra(exo) and Ra ( approximately 200%) and the decrease in HGP ( approximately 90%) were not significantly different (P > 0.05) after ingestion of either rice. Glucose oxidation was not significantly different (111.6 +/- 8.2 compared with 89.0 +/- 11.3 g; P = 0.13), but fat oxidation was significantly lower (9.9 +/- 1.7 compared with 21.3 +/- 4.0 g; P < 0.05) after parboiled than after polished rice. The percentage of the glucose load that appeared in the circulation over 8 h was not significantly different after ingestion of polished (70.4 +/- 4.5%) or parboiled (63.8 +/- 2.0%) rice (P > 0.05). CONCLUSION:Although the starch in parboiled rice is less susceptible to digestion in vitro, exogenous glucose availability was not significantly different after ingestion of large amounts of polished or parboiled rice. Glucose absorption remains incomplete 8 h after ingestion of both types of rice.

Uterine sarcomas comprise a small percentage of uterine malignancies. The most common uterine sarcoma is leiomyosarcoma (LMS). Early stage uterine LMS is curable with complete hysterectomy with removal of an intact uterus. Patients with metastatic disease may achieve tumor responses with improvements in quality of life, but long-term remissions are rare. In this review article, I outline adjuvant therapies for early stage resected uterine LMS, as well as treatment of metastatic disease.

La varicelle de l'adulte peut se compliquer d'une atteinte pulmonaire virale dont le diagnostic est parfois difficile en raison de la classique discordance radio-clinique décrite au cours de cette affection.Nous rapportons les résultats d'une étude rétrospective portant sur 101 patients varicelleux immunocompétents dont 24 ont une pneumonie varicelleuse (PV) définie par l'association de signes fonctionnels pulmonaires et de signes radiologiques évoquant une atteinte pulmonaire parenchymateuse.La comparaison des groupes de patients avec ou sans PV a mis en évidence l'existence de paramètres significativement associés à la PV. Parmi eux, trois sont faciles à identifier au moment de la première consultation du patient (tabagisme, hyperthermie > 38,3 °C et présence d'un énantlième buccal) alors que la cytolyse hépatique semble plus difficile à contrôler en pratique de ville dans le contexte de l'urgence générée par la survenue d'une varicelle de l'adulte. De plus, ces paramètres sont corrélés à l'existence d'une image radiologique compatible avec une PV même chez les patients ne présentant pas de signes d'appel pulmonaires.En raison de la population étudiée qui correspond à des patients sélectionnés par le critère « hospitalisation », on ne peut pas préjuger de leur intérêt pour aider le praticien à décider ou non l'hospitalisation du patient, et des études ultérieures menées en ville avec le concours des médecins généralistes sont nécessaires. © 2000 Éditions scientifiques et médicales Elsevier SASVaricella occurring in healthy adults may extend to the lungs. Diagnosing this complication is sometimes difficult because of the typical discrepancy usually reported in this affection.The authors report the results of a retrospective study on 101 patients including 24 cases of varicella pneumonia. This condition is defined as the presence of clinical signs ofpneumonia and radiographic abnormalities consistent with a viral pneumonitis.Comparison of the patients with and without varicella pneumonia (VP) showed the existence of several parameters significantly associated with VP. Among them, three were easy to identify on the initial examination (tobacco use, fever > 38.3° Cand enanthem of the mouth) whereas hepatitis seemed to be more difficult to assess in general practice. Moreover, these parameters were associated to radiographic abnormality of the lungs even in patients who did not exhibit any sign ofpulmonary involvement.Since the patients in our study were selected by the “hospitalization” criterion, we can not speculate on the interest of these parameters to help the general practitioner decide whether or not to refer the patient to hospital. Therefore, further studies made in collaboration with general practitioners are necessary. © 2000 Éditions scientifiques et médiceies Elsevier SAS

The objective was to evaluate the helical CT (HCT) criteria that could indicate severe pulmonary embolism (PE). In a retrospective study, 81 patients (mean age 62 years) with clinical suspicion of PE explored by HCT were studied. The patients were separated into three different groups according to clinical severity and treatment decisions: group SPE included patients with severe PE based on clinical data who were treated by fibrinolysis or embolectomy ( n=20); group NSPE included patients with non-severe PE who received heparin ( n=30); and group WPE included patients without PE ( n=31). For each patient we calculated a vascular obstruction index based on the site of obstruction and the degree of occlusion in the pulmonary artery. We noted the HCT signs, i.e., cardiac and pulmonary artery dimensions, that could indicate acute cor pulmonale. According to multivariate analysis, factors significantly correlated with the severity of PE were: the vascular obstruction index (group SPE: 54%; group NSPE: 24%; p<0.001); the maximum minor axis of the left ventricle (group SPE: 30.2 mm; group NSPE: 40.4 mm; p<0.001); the diameter of the central pulmonary artery (group SPE: 32.4 mm; group NSPE: 28.3 mm; p<0.001); the maximum minor axis of the right ventricle (group SPE: 47.5 mm; group NSPE: 42.7 mm; p=0.029); the right ventricle/left ventricle minor axis ratio (group SPE: 1.63; group NSPE: 1.09; p<0.0001). Our data suggest that hemodynamic severity of PE can be assessed on HCT scans by measuring four main criteria: the vascular obstruction index; the minimum diameter of the left ventricle; the RV:LV ratio; and the diameter of the central pulmonary artery.

Les dérivés réactifs de lˈoxygène sont impliqués dans de nombreux processus pathologiques. Dans cette revue, nous rapportons les travaux témoignant de lˈexistence dˈun stress oxydatif chez les malades de réanimation et nous discutons les arguments suggérant que les anti-oxydants soient bénéfiques chez ces malades.

Recombinant activated factor VII (rFVIIa-NovoSeven®-Novordisk) was first developed to treat severe bleeding episodes occurring in patients with haemophilia A or B with inhibitor. Complexed with tissue factor, it activates the factor × and allows transformation of prothrombin into thrombin, independently of factors VIII and IX. The success of rFVIIa in controlling haemophilic bleedings has led to use it, punctually for other serious bleedings in liver transplantation, cardiac surgery or in cirrhotic patients. We report five cases of patients hospitalised in intensive care unit, with haemorrhagic shock or severe haemostasis disorder. Despite of massive transfusions and usual resuscitation therapeutics, their clinical course was pejorative. Then, they were given a 90 μg/kg rFVIIa intravenous dose. See Table ​Table11. Table 1 A dramatic improvement occurred in a few hours. The majority of haemorrhages stopped after one or two rFVIIa doses administration. The immediate correction of haemostasis disorders allowed a reduction in blood transfusions amount and a decreasing of amine support requiring. One patient presented a thrombosis of the portal venous system quickly corrected, but no other adverse event could be attributed to rFVIIa. rFVIIa-NovoSeven® appears to be of great interest in the treatment of uncontrolled haemorrhage in intensive care units. It can be considered as an efficient and safe therapy. Nevertheless, because of its high price and of the very preliminary nature of the data we report, further investigations are necessary before using this product as a routine treatment.

La pratique de la nutrition artificielle est modifiée en cas d’insuffisance rénale aiguë (IRA). En effet, cette dysfonction viscérale a deux conséquences : 1) un certain nombre de modifications métaboliques sont rattachées soit à l’IRA elle-même, soit à sa cause, au sein de ce qui constitue un état d’agression ; 2) la mise en œuvre des techniques d’épuration extrarénale (EER) interagit avec la situation nutritionnelle, avant tout en rendant possible un apport nutritif normal et adapté à la situation métabolique du patient. De façon relativement marginale, l’EER entraîne la perte de certains nutriments hydrosolubles : glucose, acides aminés, petits peptides, vitamines et oligoéléments ; les molécules lipidiques (triglycérides, vitamines) ne sont pas éliminées. Aucune carence nutritionnelle véritable n’est reliée directement à la pratique de l’EER, si l’on excepte les hypokaliémies et les hypophosphorémies nettement favorisées par la dialyse. Chez le patient sévèrement agressé, les recommandations d’apports nutritionnels ne doivent pas être modifiées en cas d’IRA : apport énergétique représentant 120 à 130 % de la dépense énergétique théorique, ou 100 % de la dépense mesurée ; apports azotés de l’ordre de 1,25 à 1,5 g de protéines par kg et par jour ; calories glucidiques 60 %, lipidiques 40 % de la ration calorique non protéique. Les besoins en micronutriments ne sont que peu modifiés et les apports doivent être conformes aux apports recommandés, ajustés en cas de carence probable ou confirmée préexistante (vitamines B1 et B9, zinc, sélénium). La voie d’administration de la nutrition artificielle doit être entérale en priorité et parentérale uniquement en cas de stricte nécessité.

Nutritional status was studied in lung transplant (LT) candidates. The hypotheses were that nutritional depletion was highly prevalent and lean body mass depletion was a risk factor for a higher mortality both before and after LT. Of 78 consecutive patients listed for LT, 16 (21%) died while on the waiting list, eight (10%) were alive awaiting LT, and 54 (69%) received a graft. Mean age was 42.3+/-4.4 (mean+/-SD). Thirty-eight per cent had a diagnosis of bronchiectasis or cystic fibrosis (BRO/CF), 33% of emphysema, 20% of idiopathic pulmonary fibrosis (IPF) and 8% of primary pulmonary hypertension. Body mass index (BMI) was 20.4+/-4.3 kg.m2, weight was 87.9+/-16.6% of ideal body weight (IBW). Patients were classed into four nutritional groups according to IBW and creatinine height index (CHI): 1: weight <90% IBW and CHI <60% of predicted (28% of cases); II: weight <90% IBW and CHI > or =60% (27%); III: weight > or =90% IBW and CHI <60% (17%); IV: weight > or =90% IBW and CHI > or =60% (28%). Overall, 72% were depleted corresponding to groups 1, II and III. Lean body mass depletion occurred despite normal weight in 17% of the cases (group III). Subjects with BRO/CF were mostly in groups 1, II, III whereas IPF were concentrated in group II. Lean body mass depletion was associated with more severe hypoxaemia, reduced 6-minute walking distance and a higher mortality while awaiting. After LT, duration of mechanical ventilation, time spent in intensive care unit (ICU) was related to initial body composition. Survival after LT was lowest in group III. To conclude, nutritional depletion in lung transplant candidates is highly prevalent and should be more precisely assessed with a special reference to lean body mass since it has specific consequences both while awaiting and after lung transplant. Attempts should be made to increase lean body mass before lung transplant.

The shortage of organ donors has led to progressive softening of selection criteria for organ donation. We report on hepatic transplantation in a 55-year-old woman with primary biliary cirrhosis, whose donor was a 50-year-old heart transplant recipient who became brain stem dead, due to cerebral bleeding 8 months after transplantation. An orthotopic liver transplantation was performed. The postoperative course was uneventful and the recipient was alive and had normal liver function after a 42-month follow-up. Analysis of the literature included ethical consideration, potential hepatotoxic effects of immunosuppressive drugs and modification of the graft immunogenicity. It confirms that transplanted patients should not be a priori excluded from organ donation.