Introduction La contusion pulmonaire est un facteur de risque de SDRA lors d’un traumatisme thoracique, qui peut survenir avec un intervalle libre de 24 a 48 h suivant l’admission. Le score Thoracic Trauma Severity (TTS) est un score composite qui considere des lesions thoraciques (contusion, fracture de cote, hemo/pneumothorax), mais aussi le terrain (PaO 2 , âge) [1] . L’objectif principal de cette etude etait d’evaluer la performance du score TTS pour predire la survenue de SDRA dans une population de traumatise thoracique ferme porteurs d’une contusion pulmonaire. Materiel et methodes L’ensemble des traumatises severes presentant un traumatisme thoracique ferme consecutivement admis entre 2005 et 2009 ont ete retrospectivement inclus s’ils avaient beneficie d’un scanner thoracique a l’admission. Pour chaque patient, l’ensemble des donnees cliniques et gazometriques ont ete collectees et le score TTS (0 a 30) a ete calcule apres relecture des scanners. Le critere de jugement principal etait la survenue d’un SDRA modere ou severe (PaO2/FiO2 ≤ 200) d’une duree ≥ 48 h pendant les 10 premiers jours d’hospitalisation. La performance predictive du score TTS pour la survenu de SDRA a ete specifiquement etudiee par courbe ROC avec une analyse de seuil en utilisant une approche de type « zone grise ». Enfin, une regression lineaire etait realisee entre le rapport PaO2/FiO2 minimal et le score TTS. Resultats Des 329 patients traumatises thoracique porteurs d’une contusion pulmonaire etudies (75 % d’hommes, âge moyen 36,9 ± 17,1 ans, ISS moyen 22,1 ± 15,2), 82 (25 %) ont presente un SDRA de plus de 48 h (34 a j0, 15 a j1, 11 a j2, 6 a j3 et 16 apres j3). Parmi ces SDRA, 22 (7 %) etaient moderes et 60 (18 %) severes, avec un rapport PaO2/FiO2 minimal de 131,4 ± 33,6. Le score TTS moyen etait significativement plus eleve chez les patients ayant developpe un SDRA (12,2 ± 3,6 vs 8,2 ± 6,7, p p p Tableau 1 ). Discussion Un score TTS ≥ 12 predit des l’admission la survenue d’un SDRA chez les traumatises thoraciques fermes atteints de contusion pulmonaire. Chez les patients non hypoxiques, un TTS ≥ 13 etait aussi predictif de SDRA. Ce score simple et evaluable des l’entree, aide a mieux definir la prise en charge la plus appropriee pour ces patients.

Background: The indications of renal angioembolization for patients with high-grade renal trauma (HGRT) are based on angiographic criteria to reduce the failure rate of conservative management (CM). There is no consensus to predict or exclude an indication of renal angioembolization with a computed tomography (CT) scan. The aim of this study was to evaluate CT-specific criteria to predict or exclude the need for renal embolization. Methods: All traumatized patients admitted with renal injury were considered between 2005 and 2009. We included all patients who had an HGRT (classified by American Association for the Surgery of Trauma Organ Injury Scale grade ≥3) treated by CM. We collected the demographic, CT, angiographic, management, and outcome data for these patients. CT criteria were retrospectively studied to define their predictive values for renal embolization. Results: Among 101 patients with renal injury, 58 were HGRT, and 53 of them were treated by CM. Ten patients (19%) received renal embolization because of an ongoing renal hemorrhage. There was no significant difference for urologic interventions (2 [20%] vs. 7 [16%]), CM failure rate (1 [10%] vs. 2 [5%]), and during hospital stay between these patients and those who did not received embolization. None of the CT criteria had a negative predictive value for renal embolization to 100%, only the absence of intravascular contrast extravasation associated with a perirenal hematoma rim distance <25 mm excludes an indication for embolization. Conclusions: In patients with HGRT who had bleeding, a strategy of targeted angiography can be realized safely in using specific CT scan criteria that can predict with high accuracy and exclude the need for embolization, without reducing the success rate of CM.

Cardiac contusion is frequently found in patients with blunt chest trauma. It is important to note that even if there is a low incidence of pericardial effusion, iterative echocardiography should be used to provide essential information for the diagnosis of cardiac tamponade which can be life-threatening during hospitalisation. The case has been reported of a 17-year-old patient with blunt thoracic trauma in whom the introduction of anticoagulant treatment induced a delayed cardiac tamponade with myocardiac failure 3 weeks after a cardiac contusion. Thoracic computed tomography confirmed the diagnosis and moreover, revealed a pleural effusion with pulmonary embolism. The drainage of the pericardial effusion (700 ml) rapidly restored haemodynamic stability and as such has been proved to be life-saving. (c) 2007 Elsevier Masson SAS. Tous droits reserves.

UNLABELLED:Prolonged use of sedative drugs frequently leads to oversedation of intensive care patients. Clinical assessment scales are not reliable in deeply sedated patients. Parameters obtained from spectral and bispectral analysis of electroencephalogram (EEG) records have been combined to create an index (BIS) to monitor anesthesia depth. The role of such parameters in monitoring the depth of the sedation in intensive care unit (ICU) patients has yet to be determined. We designed the present prospective study to redefine and calculate available spectral and bispectral parameters from raw EEG records and estimate their clinical relevance for the diagnosis of under- or oversedation levels in ICU patients. Forty adult patients receiving continuous midazolam and morphine sedation were included. We obtained 167 clinical evaluations of sedation level using Ramsay and COMFORT scales along with an EEG record of 300 s. Six spectral parameters-relative power of 4 frequency bands (beta, alpha, Theta, and delta), 95th percentile of the power spectrum (SEF95), and 50th percentile of the power spectrum (SEF50) and four bispectral parameters, real triple product, bispectrum (Bispectrum), bicoherence, and ratio 10-were calculated. The relevance of each of these parameters and combinations in predicting too light (Ramsay 1 and 2) or deep (Ramsay 5 and 6) sedation levels was assessed. These calculations were performed before and after exclusion of the agitated patients, whose COMFORT 4 score was above 2. The most relevant parameters for predicting levels of deep sedation (Ramsay 5 and 6) were ratio 10 (area under the curve = 0.763; 95% confidence interval, 0.679-0.833) and SEF95 (area under the curve = 0.687; 95% confidence interval, 0.597-0.767). The most relevant parameters for predicting light levels of sedation (Ramsay 1 and 2) were also ratio 10 (area under the curve = 0.829; 95% confidence interval, 0.695-0.917) and SEF95 (area under the curve = 0.798; 95% confidence interval, 0.650-0.898). There is a modest improvement in relevance of their linear combination in predicting sedation level. Results were similar after exclusion of agitated patients. We conclude that various calculated EEG descriptive parameters exhibited large interindividual variability. There was a strong correlation between EEG spectral and bispectral parameters. Bispectral analysis slightly improves the predictive power of simple spectral analysis in distinguishing too light or deep sedation levels in ICU patients. IMPLICATIONS:Spectral edge frequency 95 and Ratio 10 are the most relevant electroencephalogram (EEG) indexes for monitoring the level of sedation in intensive care unit patients but calculated EEG values exhibited large interindividual variability. Bispectral analysis of EEG provides a slight improvement over simple spectral analysis.

Parneix, M.; Ryckwaert, Y.; Roustan, J. P.; Valette, S.; Jaber, S.; Capdevila, X. Author Information

OBJECTIVE This study examined, using noninvasive means, the changes in breathing pattern and inspiratory muscle pressure-time indices during difficult progressive withdrawal of pressure-support ventilation. DESIGN A prospective analysis of the temporal evolution of several respiratory variables in difficult-to-wean patients. SETTING A university hospital intensive care unit. PATIENTS A heterogeneous group of 17 patients receiving prolonged mechanical ventilation. INTERVENTIONS Daily measurements of breathing pattern and respiratory muscle performance parameters in difficult-to-wean patients. MEASUREMENTS AND MAIN RESULTS We examined breathing pattern variables, rapid shallow breathing (respiratory rate/tidal volume), tracheal occlusion pressure, maximal inspiratory pressure (P(I)max), and the tension-time index of the inspiratory muscles (TTmus = P(I)/P(I)max x Ti/Ttot) (where Ti/Ttot is inspiratory fraction of the cycle). All measurements were repeated at 24-hr intervals throughout the difficult weaning period. The patients were extubated on satisfying ten of 12 classical weaning criteria. Eleven patients were successfully weaned from mechanical ventilation while six patients were not. Weaning failure was associated with the following: a) longer periods of mechanical ventilation before weaning; b) high values of tracheal occlusion pressure, respiratory rate, minute ventilation, and effective impedance maintained throughout the difficult weaning period; and c) persistent high PaCO2 and intrinsic positive end-expiratory pressure values. As the weaning failure patients' inspiratory muscles confronted an increasing inspiratory load, values of the tension-time index of the inspiratory muscles entered or remained in the fatigue zone. In contrast, weaning success patients normalized their breathing pattern and decreased their tracheal occlusion pressure, effective impedance, and tension-time index values. CONCLUSIONS Breathing pattern alterations and respiratory muscle performance impairments lead to ventilator dependency after prolonged mechanical ventilation. The measurement of variables such as the noninvasive tracheal occlusion pressure, inspiratory power of breathing, and tension-time index of the inspiratory muscles facilitate the management of difficult-to-wean patients.

Better understanding of the physiopathology of ventilatory mechanisms associated with ARDS and the recent re evaluation of the iatrogenic potential of mechanical ventilation (MV) brings us closer to the best suited ventilatory mode for these patients. In severely ill ARDS patients, only a small lung volume is ventilated, and remains available for the totality of the gas exchanges (baby lung concept). The goal of MV is to restore and maintain an optimal exchange volume while limiting mechanical agression of the lung tissue. Analysis of the ARDS related pressure-volume relationship (P/V) is helpful in specifying the tolerable limits of the ventilatory pressure regimen. The lower limit (end expiratory pressure) must be kept above the lower inflexion point of the curve, in order to increase the ventilated lung volume and avoid distal airway collapse. Under this limit, gas exchanges are altered by the shunt effect, and shear stress lesions result from the repeated opening and closing of the distal airways. The upper limit (end inspiratory pressure) must be situated below the upper inflexion point of the curve, in order to avoid lesions resulting from surdistension of the alveolocapillary membranes and barotraumatisms. The only way to position MV in such a narrow pressure window, is to greatly reduce the tidal volume (VT). Though CO2 retention would inevitably occur under conventional MV conditions, high frequency ventilation (HFV) seems better adapted to these theoretical objectives; small VT's are injected under a limited amplitude pressure regimes and a satisfactory CO2 clearance is maintained. This ventilatory mode, existing since more than 15 years, has recently benifited from many technical improvements as well as the concept of oscillating the ventilation around a selected mean pressure in the central region of the PN curve. In the past, HFV was applied using low pressure regimens, situated below the lower inflexion point of the curve. The resulting failures are, a posteriori, explained by insufficient lung volumes, unable to maintain adequate gas exchanges. Current work is aimed at re-evaluating HFV, using higher mean airway pressure levels. Combined HFV is another advance towards the theoretical goal of restoring and maintaining optimally ventilated lung volumes. Though HFV alone ran maintain lung volumes oscillating around a mean value, it cannot re-expand atelectatic areas. The small VT's used are insufficient to overcome these area's elevated opening pressures. Volume recruitement by periodic hyperinflations, or sighs, though generally considered useless in conventional MV, have been shown to be of great benefit in HFV. The atelectatic areas opening pressures are reached with the sighs, and ventilation of the newly recruited territory is maintained by the immediate succession of HFV. Combined HFV exploits the hysteresis between the expiratory and inspiratory limbs of the PN curve, as well as the lung's visco-elastic properties. The pressure necessary to maintain an airway open once recruited is, in fact, lower than the required opening pressure. As well, the lung's visco-elastic properties introduce a notion of time dependence : as the pulmonary stress and strain are out of phase, the rapid succcession of the HFV cycles does not provide the time necessary for the unstable alveoli to collapse.As such, combined HFV establishes a double airway pressure regimen; a high frequency component produced by a high frequency jet ventilator and low frequency component produced by a conventional ventilator. This relatively complex mode of ventilation requires heavy sedation and administration of muscle relaxants, and strict surveillance by a trained staff.A simplified procedure for setting and adjusting the respiratory parameters is described. Though further studies are necessary to confirm the interest of HFV, the first evaluations on small patient populations are quite encouraging. In the future, this technique might well find its place between the most sophisticated conventional ventilatory modes and the extra-pulmonary gas exchange techniques which represent the ultimate treatment of gas exchange failure.

Better understanding of the physiopathology of ventilatory mechanisms associated with ARDS and the recent re-evaluation of the iatrogenic potential of mechanical ventilation (MV) brings us closer to the best suited ventilatory mode for these patients. In severely ill ARDS patients, only a small lung volume is ventilated, and remains available for the totality of the gas exchanges (baby lung concept). The goal of MV is to restore and maintain an optimal exchange volume while limiting mechanical agression of the lung tissue. Analysis of the ARDS related pressure-volume relationship (P/V) is helpful in specifying the tolerable limits of the ventilatory pressure regimen. The lower limit (end expiratory pressure) must be kept above the lower inflexion point of the curve, in order to increase the ventilated lung volume and avoid distal airway collapse. Under this limit, gas exchanges are altered by the shunt effect, and shear stress lesions result from the repeated opening and closing of the distal airways. The upper limit (end inspiratory pressure) must be situated below the upper inflexion point of the curve, in order to avoid lesions resulting from surdistension of the alveolocapillary membranes and barotraumatisms. The only way to position MV in such a narrow pressure window, is to greatly reduce the tidal volume (VT). Though CO2 retention would inevitably occur under conventional MV conditions, high frequency ventilation (HFV) seems better adapted to these theoreotical objectives; small VT's are injected under a limited amplitude pressure regimen and a satisfactory CO2 clearance is maintained. This ventilatory mode, existing since more than 15 years, has recently benefited from many technical improvements as well as the concept of oscillating the ventilation around a selected mean pressure in the central region of the P/V curve. In the past, HFV was applied using low pressure regimens, situated below the lower inflexion point of the curve. The resulting failures are, a posteriori, explained by insufficient lung volumes, unable to maintain adequate gas exchanges. Current work is aimed at re-evaluating HFV, using higher mean airway pressure levels. Combined HFV is another advance towards the theoretical goal of restoring and maintaining optimally ventilated lung volumes. Though HFV alone can maintain lung volumes oscillating around a mean value, it cannot re-expand atelectatic areas. The small VT's used are insufficient to overcome these area's elevated opening pressures. Volume recruitment by periodic hyperinflations, or sighs, though generally considered useless in conventional MV, have been shown to be of great benefit in HFV.(ABSTRACT TRUNCATED AT 400 WORDS)

The pharmacokinetics of alfentanil were studied after single dose intravenous administration of 125 μg/kg to 19 intensive care unit patients who were divided into 3 groups. Group I was given oral antacid, and groups II and III were given, respectively, cimetidine 1200 mg/day IV and ranitidine 300 mg/day IV for 48 hours before administration of alfentanil. Alfentanil plasma concentrations were determined over the 8 hours following drug administration using a radio-immunoassay. Pharmacokinetic parameters were calculated using a noncompartmental analysis. In group II, alfentanil plasma concentrations were significantly higher than in the other groups. In addition, significant changes involving the elimination half-life (142.3 ± 35 vs 81.14 ± 11 and 88.1 ± 33 minutes), total clearance (1.27 ± 0.5 vs 3.56 ± 1.17 and 2.74 ± 1 ml/kg/min) and total volume of distribution related to the pseudo distribution phase (226 ± 73 vs 336 ± 76 and 271 ± 61 ml/kg) were found in group II vs groups I and III. These results suggest that pretreatment with cimetidine alters alfentanil pharmacokinetics after single dose administration. In contrast, ranitidine does not appear to have a significant effect.

To assess the usefulness of BAL in diagnosing bacterial pneumonia in mechanically ventilated patients, 80 BAL fluid samples obtained from 72 patients with lung infiltrates were studied using the following parameters: infected cell count (polymorphonuclear leukocytes or macrophages with intracellular organisms), microscopic examination of stained smears, and quantitative culture with the determination of the simplified bacterial index (SBI) and the predominant species index (PSI). Of the 80 BAL samples studied, 56 were performed under antibiotic therapy. Bacterial pneumonia was the final diagnosis in 28 cases. The SBI is the sum of the whole numbers of each bacterial concentration expressed as a common logarithm. The PSI is the whole number of the predominant microorganism's concentration expressed as a common logarithm. The discriminative value of each test was assessed using a receiver operating characteristic (ROC) curve, whereby the possibility of establishing a cutoff value used to discriminate between the presence or absence of pneumonia is evaluated. The percentage of infected cells was higher in the pneumonia group (8.8 +/- 18.1 versus 0.4 +/- 1.1%, p < 10(-3), but no cutoff value could be proposed. Under microscopic examination, the presence of bacteria was noted with a significantly greater frequency in the pneumonia group (sensitivity 67.8% and specificity 82.7%). A total of 58 BAL samples were positive when cultured. The SBI was significantly higher in the pneumonia group (6.5 +/- 2.9 versus 1.6 +/- 1.7, p < 10(-4).(ABSTRACT TRUNCATED AT 250 WORDS)

In mechanically ventilated patients (pts), nosocomial pneumonia (NP) often originates from oropharyngeal (0) and gastric (C) flora. The main bacterial reservoir is not clearly defined. The goal of this study was to establish a relationship between quantitative bacterial culture of salivary (S) and (G) samples and the occurence of NP. We conducted a preliminary prospective survey in 46 ICU medical (n = 33) and surgical In = 13) pts, ventilated on entry, with an ICU stay over 48 H. Gastric pH, S and G samples were studied on entry and twice weekly by quantitative cultures (>100 cfu/ml) on appropriate media for Gram negative bacilli, S aureus, Enterococcus and yeasts. Bacteria were compared by molecular typing (pulsed field gel electrophoresis). Nosocomial pneumonia was strictly defined by the association of clinical, radiologic and microbiologic quantitative criteria. To identify risk factors for NP, baseline characteristics of the infected pts were compared with those of controls, as well as previous occurrence of S or G colonization (> 10 6 cfu/ml), by score test, using Cox's model. Relative risk (RR) of developing NP was estimated by exponentiation of each Cox's regression coefficient. 11 NP (5 Acinetobacter sp., 3 Enterobacter sp., 1 S. aureus, 1 Klebsiella pneumoniae, 1 Enterococcus) were observed. The NP rate wäs estimated at 9 p. cent at day 5, and 29 p. cent at day 10. Pts with NP were more likely than controls to have immunodeficiency (p = .04) and longer previous hospitalization (p = .05), but immunodeficiency was the only independent risk factor for NP selected by the multivariate analysis (RR = 3.6, p = .04). Otherwise, no influence was observed on the risk of developing NP by G colonization (RR = .9, p = .83), while influence, although not significant, was exerted by S colonization (RR = 2, p = .40). Moreover, such influence strongly appeared on the risk of developing Acinetobacter sp. NP: previous salivary culture for Acinetobacter sp. > 106 cfu/ml increased about 14-fold the risk of developing Acinetobacter sp. NP (p = .006).

Inspired gases must be warmed and humidified during mechanical ventilation. In a prospective randomized study we compared the performance of a heated humidifier (HH) (Draegger Aquaport) and a heat and moisture exchanger (HME) (Pall Filter BB 2215). A total of 116 patients requiring mechanical ventilation (Servo 900C Siemens) were enrolled into the study and were randomly assigned to 2 groups. Patients in group I were ventilated with a traditional breathing circuit with HH and patients in group II using a simplified circuit with HME. Pre-existing and hospital acquired atelectasis and pneumonia, occurrence of endotracheal tube (ET) occlusion and ventilatory parameters (respiratory rate, tidal volume) were studied. No statistical difference was found between groups for each parameter except the greater frequency of ET occlusions in the II group (0/61 vs 9/55) (p=0.0008). Pall Filter (PF), a hydrophobic filter, humidifies the dry gases from the condensed water which is put down on the HME surfaces during cooling of saturated expired gases. This purely physical property is linked to the magnitude of the thermic gradient between the expired pried gase and the ambiant temperture. Performance impairment of PF in our study might be due to high ambiant temperature in the intensive care unit (usually around 28°C) which reduces thermic gradient and water exchanges. We conclude that efficiency of PF may be weak in some conditions of ambiant temperature.