INTRODUCTION:In 2015, the International Society for Heart and Lung Transplantation (ISHLT) published a consensus document for the selection of lung transplant candidates. In the absence of recent French recommendations, this guideline is useful in order to send lung transplant candidates to the transplantation centers and to list them for lung transplantation at the right time. BACKGROUND:The main indications for lung transplantation in adults are COPD and emphysema, idiopathic pulmonary fibrosis and interstitial diseases, cystic fibrosis and pulmonary arterial hypertension (PAH). The specific indications for each underlying disease as well as the general contraindications have been reviewed in 2015 by the ISHLT. For cystic fibrosis, the main factors are forced expiratory volume in one second, 6-MWD, PAH and clinical deterioration characterized by increased frequency of exacerbations; for emphysema progressive disease, the BODE score, hypercapnia and FEV1; for PAH progressive disease or the need of specific intravenous therapy and NYHA classification. Finally, the diagnosis of fibrosing interstitial lung disease is usually a sufficient indication for lung transplantation assessment. OUTLOOK AND CONCLUSION:These new recommendations, close to French practices, help clinicians to find the right time for referral of patients to transplantation centers. This is crucial for the prognosis of lung transplantation.

Background:Many deaths are now preceded by an end of life decision, particularly in the intensive care unit (ICU), but such practices vary considerably between countries, ICUs and individuals, depending on many factors including cultural and religious background, family and peer pressure and local practice. Aims:In this review, we will discuss the application of the four key ethical principles-beneficence, nonmaleficence, autonomy and distributive justice - to withdrawing/withholding decisions. Methods: Drawing data from several national and international studies, we then summarize the current situation across Europe regarding such practices before making some suggestions as to how we could facilitate the often difficult decision making process by improved communication between staff, patient and relatives.

Disseminated aspergillosis is an uncommon but frequently fatal disease in critically ill populations. With studies suggesting that the incidence of this disease is increasing, and with relatively few epidemiological data available in this population, we evaluated cases of disseminated aspergillosis identified at autopsy over a one-year period on a 31-bed mixed medico-surgical intensive care unit (ICU) of an academic university hospital. In 1999, there were 489 deaths out of 2984 ICU admissions, and 222 autopsies were performed. Post-mortem examination demonstrated disseminated aspergillosis involving non-contiguous organs in 6 (2.7%) autopsies and, of these, five patients (2.3% of total) had had chronic obstructive pulmonary disease (COPD) and had been treated with corticosteroids and mechanical ventilation for pulmonary infection. One patient also had granulocytopenia. In each patient, sputum and bronchoalveolar lavage (BAL) cultures had been positive for Aspergillus fumigatus after ICU admission but this was considered as colonization and the patients were given fluconazole for suspected candidal infection. In conclusion, COPD patients treated with corticosteroids and presenting with pulmonary infection should be considered at risk for disseminated aspergillosis. The rapidly fatal outcome after ICU admission suggests that colonization with Aspergillus can occur before ICU admission.

SOCIETY OF CRITICAL CARE MEDICINE 32ND CRITICAL CARE CONGRESS SAN ANTONIO, TEXAS, USA JANUARY 28-FEBRUARY 2, 2003: ORAL/SANDWICH PRESENTATIONS: Poster Presentation: Clinical Science: Sepsis Endocrinology/Vasopressin: PDF Only

Purpose: To determine the neurologic outcome of patients with intracranial hypertension treated with barbiturate-induced coma. Materials and Methods: The records of 49 patients who were admitted to a 31-bed medicosurgical intensive care unit over a 5-year period in whom a barbiturate coma was induced to control intracranial hypertension were analyzed retrospectively. Analysis included assessment of the response to barbiturate coma and evaluation of the long-term neurologic outcome according to the Glasgow Outcome Scale (GOS). Results: Intracranial hypertension was caused by head trauma in 28 patients and subarachnoid hemorrhage in 21 patients. Eight of the head trauma patients and 5 of the patients with subarachnoid hemorrhage survived their hospital stay. The survivors were younger than the nonsurvivors, and had a good neurologic status after 1 year (except for 2 patients who died 1 and 3 months after discharge, respectively). There was no significant difference in the Glasgow Coma Score (GCS) on admission between the survivors and the nonsurvivors. The long-term outcome at 1 year was markedly better in the patients who had experienced a subarachnoid hemorrhage than in the trauma patients. Copyright 2002, Elsevier Science (USA). All rights reserved.

EDITOR: The review made by Fàbregas and Gomar about the monitoring in neuroanaesthesia is interesting but omits to mention some available monitoring tools [1]. Indeed, the authors did not mention the measurement of cerebral blood flow using the jugular thermodilution technique, which has been used since 1970 [2-4]. This technique has been validated by comparison with the Kety-Schmidt reference method [4] and allows for repeated measurements at the bedside [5]. By comparison with the double-indicator dilution technique [6], the jugular thermodilution is more reliable especially for low cerebral blood flow (<30 mL min−1 100 g−1) [7]. This point is of crucial importance for a technique proposed to monitor patients with brain lesions often presenting with low cerebral blood flow. C. Mélot J. J. Moraine J. Berré Department of Intensive Care; Erasme University Hospital, Brussels, Belgium

Intensive Care Departments are designed for the care of the critically ill, and are equipped with all the material necessary for monitoring and treatment, as well as specially trained medical, nursing, and paramedical staff. With a team of more than 170 highly qualified staff, the Department of Intensive Care at Erasme Hospital, has acquired a national and international reputation in the fields of clinical and experimental research and education, as well as for its standards of clinical practice. Clinical and experimental studies have been high in quantity and quality, and have covered all the key areas in the field of intensive care medicine: severe sepsis, multiple organ failure, transport and metabolism of oxygen, systemic and regional hemodynamic alterations (pulmonary, cerebral, hepato-splanchnic,...), metabolic disorders,... not forgetting issues associated with the complexities of medical ethics. The quality of care, clinical, scientific and personal, offered by the Department of Intensive Care at Erasme Hospital has earned it the high level reputation for which it is renowned in Belgium, and indeed worldwide.

s and Programme: European Society of Anaesthesiologists; 9th Annual Meeting with the Swedish Society of Anaesthesiology; Gothenburg, Sweden, 7-10 April 2001: Intensive Care Medicine

s and Programme: European Society of Anaesthesiologists; 9th Annual Meeting with the Swedish Society of Anaesthesiology; Gothenburg, Sweden, 7-10 April 2001: Intensive Care Medicine

OBJECT:Head elevation as a treatment for lower intracranial pressure (ICP) in patients with intracranial hypertension has been challenged in recent years. Therefore, the authors studied the effect of head position on cerebral hemodynamics in patients with severe head injury.METHODS:The effect of 0 degrees, 15 degrees, 30 degrees, and 45 degrees head elevation on ICP, cerebral blood flow (CBF), systemic arterial (PsaMonro) and jugular bulb (Pj) pressures calibrated to the level of the foramen of Monro, cerebral perfusion pressure (CPP), and the arteriovenous pressure gradient (PsaMonro - Pj) was studied in 37 patients who were comatose due to severe intracranial lesions. The CBF decreased gradually with head elevation from 0 to 45 degrees, from 46.3+/-4.8 to 28.7+/-2.3 ml x min(-1) x 100 g(-1) (mean +/- standard error, p<0.01), and the PsaMonro - Pj from 80+/-3 to 73+/-3 mm Hg (p< 0.01). The CPP remained stable between 0 degrees and 30 degrees of head elevation, at 62+/-3 mm Hg, and decreased from 62+/-3 to 57+/-4 mm Hg between 30 degrees and 45 degrees (p<0.05). A simulation showed that the 38% decrease in CBF between 0 degrees and 45 degrees resulted from PsaMonro - Pj changes for 19% of the decrease, from a diversion of the venous drainage from the internal jugular veins to vertebral venous plexus for 15%, and from CPP changes for 4%.CONCLUSIONS:During head elevation the arteriovenous pressure gradient is the major determinant of CBF. The influence of CPP on CBF decreases from 0 to 45 degrees of head elevation.

Capsaicin-induced Pain and Tourniquet ConstrictionTo the Editor:-Recently, Byas-Smith et al. 1 reported that tourniquet constriction expands and exacerbates pain during intradermal injection of capsaicin in humans.The underlying mechanism was unclear.It is suggested herein that excitation of paravascular nociceptors is involved in expansion of pain.Capsaicin has been shown to evoke pain from skin, 2 muscle, 3 and paravascular tissue, but not from veins. 4 In the latter study, one of the authors had a disconcerting experience.Capsaicin was perfused through a vascularly isolated hand vein segment to test capsaicin for its property to excite vascular nociceptors.It definitively did not, but strong pain occurred distant from the perfusion site and spread to the entire forearm.In fear of spreading pain to the entire body, a tourniquet was installed quickly to the upper arm, which, however, increased pain further, up to an unbearable intensity.It was determined that capsaicin solution had drained via a previously unnoticed side branch of the isolated vein segment into the venous system.From there, capsaicin apparently had gained access to the paravascular space (capsaicin does not evoke pain in veins).The substantial increase in capsaicin-induced pain during tourniquet inflation is unknown.A recruitment of myelinated fibers during ischemia has been discussed; 5 however, fostering by venous congestion of transendothelial crossing of capsaicin to the paravascular tissue also may play a role.Thus, the spread of capsaicin from the site of application to the paravascular space may have contributed, at least in part, to the observations made by Byas-Smith et al.

The use of induced hypertension in head injury patients is controversial. We present the case of a 19-year-old man admitted with severe head trauma after a road accident and describe the beneficial effects that increasing arterial blood pressure had on the cerebral perfusion pressure, cerebral blood flow and jugular bulb oxygen saturation in this patient.

Cerebral blood flow increases on exposure to high altitude, and perhaps more so in subjects who develop acute mountain sickness. We determined cerebral blood flow by transcranial Doppler ultrasound of the middle cerebral artery at sea level, in normoxia (fraction of inspired O2, FIO2 0.21), and during 15-min periods of either hypoxic (FIO2 0.125) or hyperoxic (FIO2 1.0) breathing, in 7 subjects with previous high-altitude pulmonary oedema, 6 climbers who had previously tolerated altitudes between 6000 m and 8150 m, and in 20 unselected controls. Hypoxia increased mean middle cerebral artery flow velocity from 69 (3) to 83 (4) cm · s−1 (P < 0.001) in the controls, from 63 (3) to 75 (3) cm · s−1 (P < 0.001) in the high-altitude pulmonary-oedema-susceptible subjects, and from 58 (4) to 70 (4) cm · s−1 (P < 0.001) in the successful high-altitude climbers. Hyperoxia decreased mean middle cerebral flow velocity to 60 (3) cm · s−1 (P < 0.001), 53 (3) cm · s−1 (P < 0.01), and 49 (3) cm · s−1 (P < 0.01) in the controls, high-altitude pulmonary-oedema-susceptible, and high-altitude climbers, respectively. We conclude that a transcranial Doppler-based estimate of cerebral blood flow is affected by hypoxic and hyperoxic breathing, and that it is not predictive of tolerance to high altitude.

In current clinical practice, it is important to be able to evaluate the evidence supporting each of our actions. Physicians can no longer rely on tradition or habit; however, with the increasing number of journals available, it is impossible for the practicing clinician to keep abreast of all the relevant literature. One valuable method of gathering and summarizing the latest information and opinions is the use of round tables and consensus conferences. Published reports of round table and consensus conference findings can be invaluable in guiding the clinician.

Euro-Neuro '98: First International Update on Neuro-Anaesthesia and Neuro-Intensive Care; Genk, Belgium, 5-7 February 1998