Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.

OBJECTIVE: To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock," published in 2004. DESIGN: Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. METHODS: We used the GRADE system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost), or clearly do not. Weak recommendations indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. RESULTS: Key recommendations, listed by category, include: early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures prior to antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for post-operative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B) targeting a blood glucose < 150 mg/dL after initial stabilization ( 2C ); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper GI bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include: greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); a recommendation against the use of recombinant activated protein C in children (1B). CONCLUSION: There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Neurally adjusted ventilatory assist can improve arterial oxygenation

INTRODUCTION. Neurally Adjusted Ventilatory Assist (NAVA) [1] is a new spontaneousassisted ventilatory mode which uses the diaphragmatic electrical activity (Eadi) to pilot the ventilator. Eadi is used to initiate the ventilator's pressurization and cycling off. Delivered inspiratory assistance is proportional to Eadi. NAVA can improve patient-ventilator synchrony [2] compared to pressure support (PS), but little is known about its effect on minute ventilation and oxygenation. OBJECTIVES. To compare the effects of NAVA and PS on minute ventilation and oxygenation and to analyze potential determinant factors for oxygenation. METHODS. Comparison between two 20-min periods under NAVA and PS. NAVA gain (proportionality factor between Eadi and delivered pressure) set as to obtain the same peak pressure as in PS. FIO2 and positive end-expiratory pressure (PEEP) were the same in NAVA and PS. Blood gas analyses were performed at the end of both recording periods. Statistical analysis: groups were compared with paired t tests or non parametric Wilcoxon signed-rank tests. p\0.05 was considered significant. RESULTS. [Mean ± SD]: 22 patients (age 66 ± 12 year, 7 M/15F, BMI 23.4 ± 3.1 kg/m2), 8 patients with COPD. Initial settings: PS 13 ± 3 cmH2O, PEEP 7 ± 2 cmH2O, NAVA gain 2.2 ± 1.8. Minute ventilation and PaCO2 were the same with both modes (p = 0.296 and 0.848, respectively). Tidal volume was lower with NAVA (427 ± 102 vs. 477 ± 102 ml, p\0.001). In contrast respiratory rate was higher with NAVA (25.6 ± 9.5 vs. 22.3 ± 8.9 cycles/min). Arterial oxygenation was improved with NAVA (PaO2 85.1 ± 28.9 vs. 75.8 ± 11.9 mmHg, p = 0.017, PaO2/FIO2 210 ± 53 vs. 195 ± 58 mmHg, p = 0.019). Neural inspiratory time (Tin) was comparable between NAVA and PS (p = 0.566). Among potential determinant factors for oxygenation, mean airway pressure (Pmean) was lower with NAVA (10.6 ± 2.6 vs. 11.1 ± 2.4 cmH2O, p = 0.006), as was the pressure time product (PTP) (6.8 ± 3.0 vs. 9.2 ± 3.5 cmH2O 9 s, p = 0.004). There were less asynchrony events with NAVA (2.3 ± 2.0 vs. 4.4 ± 3.8, p = 0.009).Tidal volume variability was higher with NAVA (variation coefficient: 30 ± 19.5 vs. 13.5 ± 8.6, p\0.001). Inspiratory time in excess (Tiex) was lower with NAVA (56 ± 23 vs. 202 ± 200 ms, p = 0.001). CONCLUSION. Despite lower Pmean and PTP in NAVA, arterial oxygenation was improved compared to PS. As asynchronies may be associated with an increased work of breathing and a higher oxygen consumption, their decrease in number with NAVA could be an explanation for oxygenation improvement. Another explanation could be the increase in VT variability. Further studies should now be performed to confirm the potential of NAVA in improving arterial oxygenation and explore the underlying mechanisms.

Video-assisted right supradiaphragmatic thoracic duct ligation for non traumatic recurrent chylothorax

Introduction : Un chylothorax est une pathologie comprenant des manifestations respiratoires, nutritionnelles et immunologiques. La récidive du chylothorax ou l'échec du traitement conservateur imposent un traitement chirurgical. Ce travail rapporte notre expérience de ligature supra-diaphragmatique, vidéo-assistée du canal thoracique, pour chylothorax récurrent non traumatique. Patients et méthodes : Entre 1999 et 2004, nous avons recensé six observations (quatre du côté droit, un du côté gauche et un bilateral) Le chylothorax s'est développé chez trois patients traités par radio et chimiothérapie pour tumeur (deux lymphomes et une tumeur du sein) un dans le contexte d'une lymphangioléiomatose et un après greffe cardiaque. Résultats : Les patients ont bénéficié sous anesthésie générale, d'une ligature du canal thoracique supra-diaphragmatique, vidéo-assistée. Le temps opératoire moyen a été de 102 minutes. Le chylothorax a régressé chez cinq des six patients en sept jours. Un patient a été repris par thoracotomie droite au huitième jour pour chylothorax persistant. Dans la phase post-opératoire, un patient a développé une détresse respiratoire nécessitant une ventilation mécanique. Un autre patient a présenté un chylopéritoine important traité par un stent de Le Veen®. Le séjour moyen a été de quatorze jours sans mortalité péri-opératoire. Conclusion : Le traitement du chylothorax non traumatique récurrent est, en première intention, un traitement médical. En cas de récidive ou d'échec du traitement conservateur, le traitement chirurgical par ligature du canal thoracique supra- diaphragmatique, vidéo-assistée, permet de traiter avec succès le chylothorax récurrent non traumatique. -- Background: Chylothorax is an uncommon disorder with respiratory, nutritional and immunological manifestations. Surgical management is indicated in case of recurrence or failure after conservative treatment. We report our experience with video-assisted right-sided supradiaphrag¬matic thoracic duct ligation for non-traumatic, non-postoperative persistent or recurrent chylothorax. Patients and methods: The medical records of six patients operated at our institution between 1999 and 2004 were retrospectively reviewed. A right-sided chylothorax was found in four patients, a left-sided in one, and a bilateral in one. Three patients developed chylothorax after chemotherapy and chest irradiation for malignant diseases (lymphoma in two patients and breast cancer in one), one in the context of lymphangioleiomyomatosis, one due to a non-diagnosed lymphoma, and one after heart transplantation. Results: The mean operative time was 102 min, with an average length of hospital stay of 14 days. Persistent cessation of chylous effusion within 7 days after surgery was observed in 5/6 patients without recurrence during a mean follow-up time of 41 months. One patient with undiagnosed mediastinal lymphoma required re-operation and thoracic duct ligation on day 8 by right-sided thoracotomy due to persistent chylothorax. No 30-day mortality was recorded. Two patients presented postoperative complications including respiratory insufficiency requiring mechanical ventilation in one, and chylous ascites development requiring peritoneo-venous LeVeen shunting in one patient. Conclusions: Recurrent or persistent non-traumatic chylothorax may be successfully treated by video-assisted right supradiaphragmatic thoracic duct ligation.

Small airways function declines after allogeneic haematopoietic stem cell transplantation.

Bronchiolitis obliterans (BO) following allogeneic haematopoietic stem cell transplantation (HSCT) affects peripheral airways. Detection of BO is presently delayed by the low sensitivity of spirometry. We examined the relationship between peripheral airway function and time since HSCT, and compared it with spirometry and clinical indices in 33 clinically stable allogeneic HSCT recipients. The following measurements were performed: lung function, exhaled nitric oxide, forced oscillatory respiratory system resistance and reactance, acinar (S(acin)) and conductive airways ventilation heterogeneity and lung clearance index (LCI) measured by multiple breath nitrogen washout. 22 patients underwent repeat visits from which short-term changes were examined. Median time post HSCT was 12 months. Eight patients were clinically diagnosed as having BO. In multivariate analysis, time since HSCT was predicted by S(acin) and forced expiratory volume in 1 s % predicted. 20 patients had abnormal S(acin) with normal spirometry, whereas none had airflow obstruction with normal S(acin). S(acin) and LCI were the only measures to change significantly between two visits, with both worsening. Change in S(acin) was the only parameter to correlate with change in chronic graft-versus-host disease grade. In conclusion, peripheral airways ventilation heterogeneity worsens with time after HSCT. S(acin) may be more sensitive than spirometry in detecting BO at an early stage, which needs confirmation in a prospective study.

Réanimation cardio-pulmonaire et travail en équipe : réflexion autour du concept aéronautique de "Crew Resource Management"

La prise en charge intra-hospitalière des arrêts cardio-respiratoires s'appuie sur une application précoce des gestes de base de la réanimation cardio- pulmonaire (massage cardiaque, ventilation pulmonaire, défibrillation) par les soignants. À l'heure actuelle, les formations à la réanimation cardio-pulmonaire impliquent uniquement l'apprentissage de gestes techniques et de connaissances théoriques, mais omettent totalement les aspects relationnels, ainsi que les problèmes de communication et de travail en équipe. Au travers d'une revue critique de la littérature médicale et aéronautique, nous proposons une nouvelle piste de formation dans le domaine de la réanimation cardio-pulmonaire. En s'appuyant sur les travaux réalisés dans l'aviation, dans les domaines de l'erreur humaine et du travail en équipe, nous offrons finalement une adaptation du "Crew Resource Management" ainsi qu'une série de recommandations, visant à intégrer les éléments relationnels et le facteur humain dans les cours de réanimations cardio-pulmonaires.

Isolated limb perfusion with tumor necrosis factor and melphalan for non-resectable soft tissue sarcomas : long-term results on efficacy and limb salvage in a selected group of patients

Rapport de synthèse : Introduction : La perfusion isolée de membre (isolated limb perfusion, ou ILP) par TNF-alpha et melphalan, utilisés en association, est une stratégie de prise en charge chirurgicale des sarcomes non opérables des extrémités. Elle a été en partie développée au CHUV dans les années 1990, sous l'impulsion du Professeur F. Lejeune, ancien Chef du Service d'oncologie médicale (CePO). Les résultats des 31 premiers patients ont été publiés en 2000 dans l'European Journal of Surgical Oncology. Les données dans la littérature manquant sur les résultats à long terme, nous avons revu tous les patients traités au CHUV depuis 1992 pour tenter des de déterminer ces résultats à long terme, en se focalisant sur l'efficacité du traitement, symbolisée par le taux de sauvetage de membres, autrement condamnés à l'amputation ou à une chirurgie mutilante. Matériel et méthode : Etude rétrospective. De 1992 à mars 2006, 51 patients ont été traités par ILP dans notre institution, certains à deux reprises (58 ILP au total). Quatre-vingt-huit pour cent présentaient un sarcome de haut grade de malignité, et 84% une tumeur localement avancée (T2b NO Mo ou plus). Résultats : Le follow-up moyen est de 38.9 mois (4-159, médiane 22 mois), on note 21 % de complications immédiates et 23% de complications tardives ou chroniques. Une réponse complète (nécrose totale ou disparition de la tumeur) a été observée dans 25% des cas, une réponse partielle (>50% de nécrose ou de diminution de taille tumorale) dans 42%, une stabilité de la maladie dans 14% et une progression tumorale dans 14%. Un traitement adjuvant a été entrepris dans 31 % des cas, une résection des résidus tumoraux a pu être effectuée chez 65% des patients. On note un taux de récidive locale de 35% (après 20,3 mois en moyenne) et un taux de récidive à distance de 45% (après 13,4 mois en moyenne). Le disease-free survival est de 14,9 mois et la survie à 5 ans de 43,5%. Le taux d'amputation s'élève à 24%. Conclusion : La perfusion isolée de membre est un traitement grevé d'un taux élevé de complications, mais il peut étre entrepris dans les sarcomes les plus sévères avec un succès significatif. Ainsi, dans notre série, une chirurgie mutilante (en général l'amputation) a pu être épargnée à 76% des patients.

Long-term sequelae in children surviving adult respiratory distress syndrome.

Nine children surviving severe adult respiratory distress syndrome were studied 0.9 to 4.2 years after the acute illness. They had received artificial ventilation for a mean of 9.4 days, with an Fio2 greater than 0.5 during a mean time of 34 hours and maximal positive end expiratory pressure levels in the range of 8 to 20 cm H2O. Three children had recurrent respiratory symptoms (moderate exertional dyspnea and cough), and two had evidence of fibrosis on chest radiographs. All patients had abnormal lung function; the most prominent findings were ventilation inequalities, as judged by real-time moment ratio analysis of multibreath nitrogen washout curves (abnormal in eight of nine patients) and hypoxemia (seven of nine). Lung volumes were less abnormal; one patient had restrictive and two had obstructive disease. A significant correlation between intensive care measures (Fio2 greater than 0.5 in hours and peak inspiratory plateau pressure) and lung function abnormalities (moment ratio analysis and hypoxemia) was found. A possibly increased susceptibility of the pediatric age group to the primary insult or respiratory therapy of adult respiratory distress syndrome is suggested.

Indicators used by clinicians to assess pain in the brain injured

INTRODUCTION. The assessment of pain in critically ill brain-injured patients is challenging for health professionals. In addition to be unable to self-report, the confused and stereotyped behaviors of these patients are likely to alter their ''normal'' pain responses. Therefore, the pain indicators observed in the general critically ill population may not be appropriate. OBJECTIVES. To identify behavioral and physiological indicators used by clinicians to assess pain in critically ill brain-injured patients who are unable to self-report. METHODS.Amixed-method design was used with the first step being the combination of the results of an integrative literature review with the results of nominal groups of 12 nurses and four physicians. The second step involved a web-based survey to establish content validity. Fourteen experts (clinicians and academics) from three French speaking European countries rated the relevance of each indicator. A content validity index (CVI) was computed for each indicator (I-CVI) and for each category (S-CVI). RESULTS. The first step generated 52 indicators. These indicators were classified into six categories: facial expressions, position/movement, muscle tension, vocalization, compliance with ventilator, and physiological indicators. In the second step, the agreement between raters was high with an Intraclass Correlation Coefficient of 0.88 (95% CI 0.83-0.92). The I-CVIs ranged from 0.07 to 1. Indicators with an I-CVI below 0.5 (n = 12) were not retained, resulting in a final list of 30 indicators. The CVI for this final list was 0.75 with categories ranging from 0.67 (compliance with ventilation) to 0.87 (vocalization). CONCLUSIONS. This process identified specific pain indicators for critically ill braininjured patients. Further evaluation is in progress to test the validity and relevance of these indicators in the clinical setting.

Short-term moderate hypocapnia augments detection of optimal cerebral perfusion pressure.

An autoregulation-oriented strategy has been proposed to guide neurocritical therapy toward the optimal cerebral perfusion pressure (CPPOPT). The influence of ventilation changes is, however, unclear. We sought to find out whether short-term moderate hypocapnia (HC) shifts the CPPOPT or affects its detection. Thirty patients with traumatic brain injury (TBI), who required sedation and mechanical ventilation, were studied during 20 min of normocapnia (5.1±0.4 kPa) and 30 min of moderate HC (4.4±3.0 kPa). Monitoring included bilateral transcranial Doppler of the middle cerebral arteries (MCA), invasive arterial blood pressure (ABP), and intracranial pressure (ICP). Mx -autoregulatory index provided a measure for the CPP responsiveness of MCA flow velocity. CPPOPT was assessed as the CPP at which autoregulation (Mx) was working with the maximal efficiency. During normocapnia, CPPOPT (left: 80.65±6.18; right: 79.11±5.84 mm Hg) was detectable in 12 of 30 patients. Moderate HC did not shift this CPPOPT but enabled its detection in another 17 patients (CPPOPT left: 83.94±14.82; right: 85.28±14.73 mm Hg). The detection of CPPOPT was achieved via significantly improved Mx-autoregulatory index and an increase of CPP mean. It appeared that short-term moderate HC augmented the detection of an optimum CPP, and may therefore usefully support CPP-guided therapy in patients with TBI.

Development of a control banding tool for nanomaterials

Control banding (CB) can be a useful tool for managing the potential risks of nanomaterials. The here proposed CB, which should be part of an overall risk control strategy, groups materials by hazard and emission potential. The resulting decision matrix proposes control bands adapted to the risk potential levels and helps define an action plan. If this plan is not practical and financially feasible, a full risk assessment is launched. The hazard banding combines key concepts of nanomaterial toxicology: translocation across biological barriers, fibrous nature, solubility, and reactivity. Already existing classifications specific to the nanomaterial can be used "as is." Otherwise, the toxicity of bulk or analogous substances gives an initial hazard band, which is increased if the substance is not easily soluble or if it has a higher reactivity than the substance. The emission potential bands are defined by the nanomaterials' physical form and process characteristics. Quantities, frequencies, and existing control measures are taken into account during the definition of the action plan. Control strategies range from room ventilation to full containment with expert advice. This CB approach, once validated, can be easily embedded in risk management systems. It allows integrating new toxicity data and needs no exposure data. [Authors]

La cessation de la chimiothérapie pour le traitement de l'adénocarcinome pancréatique avancé : recherche de facteurs prédictifs de mort imminente

Dans cette étude rétrospective, nous reportons des données relatives à la chimiothérapie chez des patients atteints d'adénocarcinome pancréatique avancé, avec attention à la durée du temps qui passe entre le dernier traitement et la mort. En outre, nous analysons des paramètres cliniques et de laboratoire, enregistrés à la dernière chimiothérapie, avec le but d'identifier des facteurs de risque pour un décès proche. L'analyse rétrospective est effectuée sur des patients avec adénocarcinome pancréatique avancé, qui ont bénéficié au moins d'une ligne de chimiothérapie. Nous avons enregistré les données concernant la chimiothérapie (régimes, lignes et date de la dernière administration) et avons choisi et enregistré des facteurs cliniques et de laboratoire, qui étaient récoltés à la dernière chimiothérapie (performance status, présence d'ascite, hémoglobine, leucocytes, plaquettes, bilirubine totale, albumine, LDH, protéine C-réactive et Ca19-9). Des analyses statistiques (univariée et multivariée) sont effectuées pour étudier la relation entre ces facteurs et le temps de survie, à la recherche de facteurs prédictifs de mort imminente. Nous avons analysé les données de 231 patients: hommes/femmes, 53/47%; métastatique/localement avancé, 80/20%; âge médian 66 ans (gamme 32-85). Tous les patients sont décédés à cause de la progression de la maladie. La survie globale médiane est 6.1 mois (95% Cl 5.1-7.2). Lors de la dernière chimiothérapie, le performance status est 0-1 pour 37% et 2 pour 63% des patients. Cinquante-neuf pour cent des patients reçoivent une ligne de chimiothérapie, 32, 8 et 1% reçoivent des chimiothérapies de deuxième, troisième, quatrième ligne, respectivement. L'intervalle entre la dernière administration de chimiothérapie et le décès est <4 semaines pour 24%, 4-12 semaines pour 47% et >12 semaines pour 29% des patients. La survie médiane à partir de la dernière chimiothérapie jusqu'au décès est 7.5 semaines (95% Cl 6.7-8.4). L'ascite, la leucocytose, des valeurs élevées de bilirubine, LDH, protéine C- réactive et Ca19-9, et des valeurs abaissées d'albumine sont associés à une survie plus courte à l'analyse univariée; néanmoins, aucun de ces facteurs n'est corrélé à la survie de façon significative à l'analyse multivariée. Nous en concluons qu'une proportion significative de patients avec adénocarcinome pancréatique avancé reçoit la chimiothérapie dans le dernier mois de vie, et que les paramètres cliniques et de laboratoire enregistrés à la dernière chimiothérapie ne prédisent pas une survie plus courte.

Clinical review: Update on neurally adjusted ventilatory assist - report of a round-table conference.

ABSTRACT: Conventional mechanical ventilators rely on pneumatic pressure and flow sensors and controllers to detect breaths. New modes of mechanical ventilation have been developed to better match the assistance delivered by the ventilator to the patient's needs. Among these modes, neurally adjusted ventilatory assist (NAVA) delivers a pressure that is directly proportional to the integral of the electrical activity of the diaphragm recorded continuously through an esophageal probe. In clinical settings, NAVA has been chiefly compared with pressure-support ventilation, one of the most popular modes used during the weaning phase, which delivers a constant pressure from breath to breath. Comparisons with proportional-assist ventilation, which has numerous similarities, are lacking. Because of the constant level of assistance, pressure-support ventilation reduces the natural variability of the breathing pattern and can be associated with asynchrony and/or overinflation. The ability of NAVA to circumvent these limitations has been addressed in clinical studies and is discussed in this report. Although the underlying concept is fascinating, several important questions regarding the clinical applications of NAVA remain unanswered. Among these questions, determining the optimal NAVA settings according to the patient's ventilatory needs and/or acceptable level of work of breathing is a key issue. In this report, based on an investigator-initiated round table, we review the most recent literature on this topic and discuss the theoretical advantages and disadvantages of NAVA compared with other modes, as well as the risks and limitations of NAVA.

Modifiable and nonmodifiable risk factors for postoperative delirium after cardiac surgery with cardiopulmonary bypass.

Postoperative delirium after cardiac surgery is associated with increased morbidity and mortality as well as prolonged stay in both the intensive care unit and the hospital. The authors sought to identify modifiable risk factors associated with the development of postoperative delirium in elderly patients after elective cardiac surgery in order to be able to design follow-up studies aimed at the prevention of delirium by optimizing perioperative management. A post hoc analysis of data from patients enrolled in a randomized controlled trial was performed. A single university hospital. One hundred thirteen patients aged 65 or older undergoing elective cardiac surgery with cardiopulmonary bypass. None. MEASUREMENTS AND MAINS RESULTS: Screening for delirium was performed using the Confusion Assessment Method (CAM) on the first 6 postoperative days. A multivariable logistic regression model was developed to identify significant risk factors and to control for confounders. Delirium developed in 35 of 113 patients (30%). The multivariable model showed the maximum value of C-reactive protein measured postoperatively, the dose of fentanyl per kilogram of body weight administered intraoperatively, and the duration of mechanical ventilation to be independently associated with delirium. In this post hoc analysis, larger doses of fentanyl administered intraoperatively and longer duration of mechanical ventilation were associated with postoperative delirium in the elderly after cardiac surgery. Prospective randomized trials should be performed to test the hypotheses that a reduced dose of fentanyl administered intraoperatively, the use of a different opioid, or weaning protocols aimed at early extubation prevent delirium in these patients.

Impact of bedside open lung biopsies on the management of mechanically ventilated immunocompromised patients with acute respiratory distress syndrome of unknown etiology.

BACKGROUND: Open lung biopsy (OLB) is helpful in the management of patients with acute respiratory distress syndrome (ARDS) of unknown etiology. We determine the impact of surgical lung biopsies performed at the bedside on the management of patients with ARDS. METHODS: We reviewed all consecutive cases of patients with ARDS who underwent a surgical OLB at the bedside in a medical intensive care unit between 1993 and 2005. RESULTS: Biopsies were performed in 19 patients mechanically ventilated for ARDS of unknown etiology despite extensive diagnostic process and empirical therapeutic trials. Among them, 17 (89%) were immunocompromised and 10 patients experienced hematological malignancies. Surgical biopsies were obtained after a median (25%-75%) mechanical ventilation of 5 (2-11) days; mean (+/-SD) Pao(2)/Fio(2) ratio was 119.3 (+/-34.2) mm Hg. Histologic diagnoses were obtained in all cases and were specific in 13 patients (68%), including 9 (47%) not previously suspected. Immediate complications (26%) were local (pneumothorax, minimal bleeding) without general or respiratory consequences. The biopsy resulted in major changes in management in 17 patients (89%). It contributed to a decision to limit care in 12 of 17 patients who died. CONCLUSION: Our data confirm that surgical OLB may have an important impact on the management of patients with ARDS of unknown etiology after extensive diagnostic process. The procedure can be performed at the bedside, is safe, and has a high diagnostic yield leading to major changes in management, including withdrawal of vital support, in the majority of patients.

Psychotropic drug prescriptions in hospitalized ederly psychiatric patients: comparison with adult psychiatric patients

RÉSUMÉ Comparaison dés habitudes de prescription de médicaments psychotropes dans des cliniques de psychiatrie adulte et de psychogériatrie Afin de pouvoir comparer l'utilisation de médicaments psychotropes et non psychotropes, la proportion des nouveaux et celle des anciens antidépresseurs ou antipsychotiques, ce travail a eu pour but d'étudier les prescriptions médicamenteuses dans deux groupes de patients hospitalisés, l'un en milieu psychiatrique adulte (de 18 à 64 ans), l'autre en milieu psychogériatrique (plus de 64 ans). Lors d'un jour de référence en Mai 2000, toutes les prescriptions médicamenteuses dans deux hôpitaux psychiatriques universitaires abritant l'un une population adulte, l'autre gériatrique, ont été relevées chez tous les patients. Le coût financier total par patient a été comparé en tenant compte de la proportion des médicaments non psychotropes. La médication de 61 patients adultes et de 82 patients gériatriques a ainsi été analysée. Le nombre moyen de médicaments non psychotropes par patient était plus élevé dans la population âgée (p< 0.001), ce qui se reflète également par une prescription totale de médicaments par patient en moyenne plus élevée dans cette population (p<0.001). L'utilisation de benzodiazépines était inférieure dans là population psychogériatrique (p<0.001), même si l'on y additionne celle en association avec les antidépresseurs (p<0.001). Le coût financier du traitement pharmacologique quotidien d'un patient adulte était significativement inférieur à celui d'un patient gériatrique dont la comédication somatique est nécessairement plus importante (9.3 ± 7.2 CHF/patient contre 14.1 ± 9.5 CHF/patient) (p<0.009). En conclusion, cette étude confirme l'importance des habitudes locales dans la prescription médicamenteuse par les médecins, à l'exception de l'utilisation des benzodiazépines pour lesquelles les psychogériâtres semblent moins favorables.