Biomedical subjects
Publications and source records attributed to F Blot.
We report a case of a spontaneous rupture of a normal stomach after therapeutic oxygen administration. In this case, early treatment precluded the need for a laparotomy. This rare complication highlights the importance of the right positioning of a nasal catheter and leads us to question its role compared to other means of oxygen delivery (nasal cannulae, Hudson mask, Venturi mask).
GOALS: To describe an acute respiratory distress syndrome (ARDS) occurring after chemotherapy for non-seminomatous germ-cell tumors (NSGCT) with diffuse lung metastases, we conducted a retrospective study in a 15-bed intensive care unit (ICU) in a comprehensive cancer center. PATIENTS AND METHODS: During a 10-year period, 16 consecutive patients with diffuse lung metastases from a NSGCT were admitted to the ICU for respiratory distress and high-risk chemotherapy. MAIN RESULTS: Nine patients developed acute respiratory failure requiring mechanical ventilation (MV) within 3 days of the initiation of chemotherapy, while the respiratory status of the seven other patients improved. The evolution was independent of tumor marker levels and the type of chemotherapy regimen. The SAPS II score did not accurately describe the severity of this population. The only predictor of intubation was the initial PaO2/FiO2 ratio upon admission to the ICU. Six out of seven patients who did not require MV were discharged alive from the hospital, whereas all but one patient requiring MV died. Refractory hypoxemia and ventilator-associated pneumonia were the leading causes of death. CONCLUSIONS: Acute respiratory distress in patients with lung metastases from NSGCT is a rare cause of ARDS. Chemotherapy could be responsible for triggering the respiratory worsening. Patients with severe respiratory insufficiency (PaO2 <70 mmHg on room air) on admission to hospital should be promptly transferred to the ICU for the first chemotherapy course.
Isospora belli infection is frequent in patients with acquired immunodeficiency syndrome in tropical areas. It has also been reported in other immunodepressive diseases, such as lymphoblastic leukemia, adult T-cell leukemia, and Hodgkin's disease. To date, no case of non-Hodgkin's lymphoma-related isosporiasis has been reported in a non-HIV-infected patient. We describe a case of non-Hodgkin's lymphoma with chronic diarrhea due to I. belli. In Europe, I. belli can cause severe chronic diarrhea in patients with malignancies whose country of origin is in an endemic area. Trimethoprim-sulfamethoxazole can provide rapid and prolonged clinical and parasitologic cure.
BACKGROUND: Several complications are associated to mechanical ventilation (MV), especially if the duration of MV is prolonged: nosocomial pneumonias and sinusitis, laryngeal and tracheal complications (such as stenosis or granuloma). Pneumonias, en particular, seem to be associated to an increased mortality risk. Overall, the hospital mortality rate of patients undergoing MV for more than 7 days is 45%. Early tracheostomy could allow to reduce some of these complications; however, the actual value of this procedure has never been proven. AIM OF THE STUDY: The aim of this multicenter randomized trial is to assess the potential interest of early tracheostomy (before the 4th day of MV) compared to translaryngeal intubation, in critically ill patients undergoing MV for more than 7 days, in reducing mortality rate, incidence of pneumonias, and duration of MV. METHODS: Inclusion criteria are: MV since<4 days, forseable duration of MV>7 days, age>18-yr, and informed consent obtained. Exclusion criteria are: MV since > 4 days, presence of tracheostomy, major risk of bleeding, cervical infectious disease, "moribund" state (according to SAPS II and OSF scores), MV or CPAP at home, non reversible neurologic disease, intracranial hypertension. The randomization is performed before the end of the 4th day of MV. EXPECTED RESULTS: A decrease of mortality rate on d.28 from 45% to 32% is expected (two-sided test, alpha=0.05, B=0.80); overall, 468 patients should be included over a 3-yr period in at least 50 centers. In addition, a decrease of the incidence of pneumonias and of duration of MV during the first 28 days is expected. Secondary endpoints are mortality rate on d.60, hospital mortality, total duration of MV, infectious complications (other than pneumonias), laryngeal and tracheal complications, duration of sedation, duration of stay in intensive care unit, hospital costs, and comfort of patients.
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BACKGROUND: Peritoneal carcinomatosis (PC) is fatal, despite standard systemic chemotherapy. A new approach that combines maximal surgery with maximal regional chemotherapy has potential to cure selected patients who have colorectal PC. The authors have reported the oncologic results of this combined treatment. METHODS: The authors performed a retrospective study of 64 patients who had PC arising from colorectal adenocarcinomas, 19 (29.6%) of whom also had other metastases. These patients were treated by complete resection of all detectable tumors and by a 5-day course of early intraperitoneal chemotherapy (EPIC) with mitomycin C, then by 5-fluorouracil (n = 37), or by intraoperative intraperitoneal chemohyperthermia (IPCH) with mitomycin C, alone or combined with cisplatin (n = 27), in 2 separate trials. In the trial of IPCH, aimed at selecting the most reliable procedure in terms of spatial diffusion and thermal homogeneity, the 27 patients were treated with 7 different procedures. The extent of PC was assessed precisely by using a peritoneal index. The median follow-up period for the entire patient population was 51.7 months. RESULTS: The postoperative mortality and morbidity rates were 9.3% and 54.6%, respectively. Most severe complications occurred in patients who required extensive cytoreductive surgery. Global and disease-free survival rates were respectively 60.1% and 54.7% at 2 years and were 27.4% and 18.4% at 5 years. Results were significantly better (P = 0.04) when patients were metastasis-free (apart from PC) and when the peritoneal index was lower than 16 (P = 0.005). IPCH seemed to be more effective than EPIC for treatment of PC. CONCLUSION: This treatment plan, which combined maximal surgery with maximal regional chemotherapy, cured approximately 25% of patients. This strategy was mainly applicable to patients with limited intraperitoneal cancer volume and no extraperitoneal involvement. IPCH proved to be more effective than EPIC but more difficult to use correctly. Future results should improve through routine use of the optimal hyperthermia procedure, with improvements in the composition of instillate, better patient selection, and the reduction in the rate of complications that occurs with physician experience.
Gonococcal infection can be associated with septic shock leading to multiple organ failure and death.
Pulmonary artery catheters (PACs) are typically inserted for short periods, and the extra-luminal route is assumed to be the overriding source of contamination and/or infection. Our aim was to assess the incidence of PAC and introducer colonization in cancer patients, and to study the mechanisms and risk factors for infection. Patients with a Swan-Ganz catheter admitted to an intensive care unit were prospectively analyzed over 14 months. As soon they were no longer necessary, PACs and introducer sheaths were removed and cultured. We recorded the mean duration of placement, the number of times PACs were handled and the site of insertion. Seventy-nine catheters were inserted in 68 patients. The median (range) duration was three days (0-10) for PACs, and 3.6 days (0-18) for introducers. PAC and/or percutaneous introducer sheath colonization was diagnosed in seven patients (8.9%), but in only one case were both colonized. Colonization rates were 15.5 per 1000 days for PACs and 14.1 per 1000 days for introducers. Introducers were mainly colonized before the 5th day, while PACs were mainly colonized after the 5th day. No PAC or introducer-related local infection or bacteraemia was diagnosed. Colonization was more frequent on catheters inserted into the internal jugular vein. The colonization rate was 5% for PACs and introducers. Our findings suggest that contamination of introducers and PACs may be dissociated and could result from either extraluminal or endoluminal colonization. As three of four PAC colonizations occurred after 5 days, the duration of catheter placement should be considered important. There was little clinical impact of microbial colonization.
OBJECTIVE: To assess the prognostic value of two severity of illness scores, commonly used for critically ill patients, Simplified Acute Physiology Score (SAPS II) and Organ Dysfunctions and Infection (ODIN), in predicting mortality in febrile neutropenic patients in hematology wards. DESIGN: A 2-month prospective multicenter study. SETTING: Thirty-six hematologic and/or stem cell transplant units in France. PATIENTS: All adult patients with a first febrile neutropenic episode (polymorphonuclear cells <500/mm(3)) were included. INTERVENTIONS: SAPS II was calculated on day 1 of fever, and ODIN on days 1 and 8. The end point was the mortality rate on day 28. MEASUREMENTS AND MAIN RESULTS: Twenty-eight (6.6%) of the 421 patients included died before day 28. The mortality rate predicted by SAPS II was 23.8%, indicating a poor calibration. The SAPS II score at day 1 was greater in nonsurvivors than in survivors (44 +/- 11 vs. 38 +/- 7, p <.0001), as was the number of patients with one or more organ failures at day 1 (14 vs. 2%, p <.0001), and day 8 (42 vs. 3%, p <.0001). The pattern of change in the scores over the first 8 days differed significantly between survivors and nonsurvivors. In multivariate analysis, only ODIN on day 1 and day 8, and spontaneous neutropenia were independent predictors for death. CONCLUSIONS: SAPS II and ODIN scores are inaccurate for predicting individual outcome of febrile neutropenic patients in hematology wards. Serial measurements of these scores during the first week of hospitalization could be more accurate than a single measurement. Besides severity scores and organ failures, the type of neutropenia is at least as important in assessing the prognosis.
Infection remains a major complication of central veinous catheters. A clinically or bacteriologically proven infection is identified in 5 to 10% of the cases although the actual risk varies from less than 1 to more than 30 episodes of infection per 1000 catheter-days. Systemic spread follows colonization of the catheter tip via the skin or the connectors, less frequently via hematogenous seeding from a distant focus of infection. Excepting emergency situations, search for proof of catheter-related infection or noninfection without removing the catheter now appears to be acceptable for selected intensive care patients if appropriate safety measures are taken; the reasonable choice is between maintaining the catheter while performing tests susceptible of determining the reality of catheter-related infection (in this case there remains a certain doubt concerning the respective performance of the different methods proposed for early diagnosis) and catheter exchange on a metal or plastic guide-wire. Rigorous application of the rules of hygiene, asepsis, and local care is crucial: systematic and repeated hand washing is by far the best antiinfectious prophylaxis. Three types of future developments susceptible of improving the current situation can be identified: better knowledge of host defense mechanisms against foreign bodies, reduction of hand-transmitted contamination by wider use of hydro-alcohol solutions for decontamination of the hands, and elaboration of new connectors, and most importantly, biomaterials capable of inhibiting colonization by the growing number of increasingly virulent strains. Discussions concerning the real clinical efficiency, ecological risk and the cost-effectiveness of catheters impregnated with antiseptics and/or antibiotics is a perfect illustration of the current debate.
Because of the lack of specificity of gastrointestinal tract symptoms and of imaging studies findings in one hand, and because of a presumed high risk of complications in the other hand, surgical management of acute abdomen in neutropenic patients remains very controversial. The purpose of the study is to review our experience with management of acute abdomen. The records of 21 neutropenic patients admitted in the intensive care unit for postoperative management or for evaluation and diagnosis of abdominal symptoms were reviewed. Thirteen patients underwent surgery, 8 did not. Peritoneal signs on physical examination were correlated with positive laparotomies, the sensitivity was 71% and the specificity was 50%. Seven of the 13 operated patients survived the surgical procedure (54%); while 37,5% of the non operative group survived. The surgical treatment may be safely carried out in neutropenic patients with an acute abdomen and represent sometimes the only way to assure proper treatment.
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CONTEXT: Invasive life-support techniques are a major risk factor for nosocomial infection. Noninvasive ventilation (NIV) can be used to avoid endotracheal intubation and may reduce morbidity among patients in intensive care units (ICUs). OBJECTIVE: To determine whether the use of NIV is associated with decreased risk of nosocomial infections and improved survival in everyday clinical practice among patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) or hypercapnic cardiogenic pulmonary edema (CPE). DESIGN AND SETTING: Matched case-control study conducted in the medical ICU of a French university hospital from January 1996 through March 1998. PATIENTS: Fifty patients with acute exacerbation of COPD or severe CPE who were treated with NIV for at least 2 hours and 50 patients treated with mechanical ventilation between 1993 and 1998 (controls), matched on diagnosis, Simplified Acute Physiology Score II, Logistic Organ Dysfunction score, age, and no contraindication to NIV. MAIN OUTCOME MEASURES: Rates of nosocomial infections, antibiotic use, lengths of ventilatory support and of ICU stay, ICU mortality, compared between cases and controls. RESULTS: Rates of nosocomial infections and of nosocomial pneumonia were significantly lower in patients who received NIV than those treated with mechanical ventilation (18% vs 60% and 8% vs 22%; P<.001 and P =.04, respectively). Similarly, the daily risk of acquiring an infection (19 vs 39 episodes per 1000 patient-days; P =.05), proportion of patients receiving antibiotics for nosocomial infection (8% vs 26%; P =.01), mean (SD) duration of ventilation (6 [6] vs 10 [12] days; P =.01), mean (SD) length of ICU stay (9 [7] vs 15 [14] days; P =.02), and crude mortality (4% vs 26%; P =.002) were all lower among patients who received NIV than those treated with mechanical ventilation. CONCLUSIONS: Use of NIV instead of mechanical ventilation is associated with a lower risk of nosocomial infections, less antibiotic use, shorter length of ICU stay, and lower mortality. JAMA. 2000;284:2361-2367.
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OBJECTIVE: To verify the accuracy of totally implanted ports, tunnelled central venous catheters (CVC), widely used in cancer patients, and multi-lumen catheters, used in intensive care units (ICUs), in measuring central venous pressure (CVP), using right atrial pressure (RAP) measured in a Swan-Ganz catheter as the reference standard. DESIGN: A prospective study, over a 10-month period. SETTING: A medical-surgical ICU in a comprehensive cancer centre. PATIENTS AND PARTICIPANTS: Patients who had both (1) a Swan-Ganz catheter and (2) either a tunnelled catheter, a single or a multi-lumen catheter, or a totally implanted port. INTERVENTIONS: RAP and CVP were measured simultaneously in each patient. MEASUREMENTS AND RESULTS: Fifty-six pairs of RAP-CVP measurements were performed in 35 patients: 6 tunnelled catheters, 6 non-tunnelled single-lumen catheters, 26 multiple-lumen catheters and 18 totally implanted ports were studied. RAP measured in the Swan-Ganz catheter and CVP measured in the CVC were strongly correlated (r = 0.94, p < 0.01), whatever the type of catheter studied. The mean difference between RAP and CVP was -0.39 +/- 1.73 (SD) mmHg. In 51 cases (91%), the difference was within the limits of agreement (-3.78 to 3.00 mmHg, Bland and Altman method). For the five cases with a difference of 4 mmHg (three totally implanted ports, one double- and one triple-lumen catheter), CVP was greater than RAP. CONCLUSIONS: CVP can be accurately measured in totally implanted ports, tunnelled or non-tunnelled single-lumen and multiple-lumen catheters. When the difference exceeds the limit of agreement, the discrepancy between the two measurements has limited significance in most cases.
Clinical criteria alone are insufficient to allow a diagnosis of intravascular catheter-related sepsis (CRS). A definite diagnosis of CRS usually requires removal of the catheter for quantitative catheter tip culture. However, only about 15-25% of central venous catheters (CVC) removed because infection is suspected actually prove to be infected, and the diagnosis is always retrospective. Other diagnostic tests, such as differential quantitative blood cultures from samples taken simultaneously from the catheter and a peripheral vein, have been proposed to avoid unjustified removal of the catheter and the potential risks associated with the placement of a new catheter at a new site: a central-to-peripheral blood culture colony count ratio of 5:1 to 10:1 is considered indicative of CRS. Despite its high specificity, the latter diagnostic technique is not routinely used in clinical practice because of its complexity and cost. The measurement of the differential time to positivity between hub blood (taken from the catheter port) and peripheral blood cultures might be a reliable tool facilitating the diagnosis of CRS in situ. In an in vitro study, we found a strong relationship between the inoculum size of various microorganisms and the time to positivity of cultures. When the times to positivity of cultures of blood taken simultaneously from central and peripheral veins in patients with and without CRS were examined, we found that earlier positivity of central vs peripheral vein blood cultures was highly correlated with CRS. Using a cut-off value of +120 min, the "differential time to positivity" of the paired blood samples, defined as time to positivity of the peripheral blood minus that of the hub blood culture, had 91% specificity and 94% sensitivity for the diagnosis of CRS. This method may be coupled with other techniques that have high negative predictive value, such as skin cultures at the catheter exit site. This diagnostic test can be proposed for routine clinical practice in most hospitals using automatic devices for blood cultures positivity detection. Endoluminal brushing of the catheter is considered sensitive and specific for the diagnosis of CRS, but the risk of embolisation or subsequent bacteraemia should be considered. Gram staining and the acridine-orange leucocyte cytospin test on through-catheter blood culture have been proposed for rapid diagnosis of CRS without catheter removal. The technique, which requires 100 microl catheter blood and the use of light and ultraviolet microscopy, is considered simple, rapid (30 min) and inexpensive. In conclusion, diagnostic tools such as paired blood cultures or Gram staining and the acridine-orange leucocyte cytospin test should allow a diagnosis of CRS without catheter removal in cancer patients.
Except for bronchoalveolar lavage, the value of the Gram stain examination of respiratory tract samples for the diagnosis of hospital-acquired pneumonia (HAP) and their potential impact on empiric antibiotic treatment have rarely been assessed. During a 14-mo period, both plugged telescoping catheter (PTC) and endotracheal aspirate (EA) were performed when an HAP was suspected in mechanically ventilated patients. The results of Gram stain examinations and cultures and previous and subsequent antibiotic treatment were prospectively recorded. Two criteria for pneumonia were considered: (1) clinically diagnosed pneumonia, according to attending physicians, based on clinical and radiological evolution and the PTC culture results, and (2) microbiologically proven pneumonia (solely based on the result of quantitative PTC culture). Of 91 episodes of suspected HAP in 51 patients, 27 (30%) episodes were clinically diagnosed as pneumonia. When considering clinically diagnosed pneumonia, the sensitivity and specificity of Gram stain examination were similar (respectively, 89% and 62% for EA and 67% and 95% for PTC). When considering microbiologically proven pneumonia, the sensitivity and specificity of Gram stain examination were, respectively, 91% and 64% for EA and 70% and 96% for PTC. The negative predictive value of Gram stain examination of EA and the positive predictive value of Gram stain examination of PTC were high. Our results suggest that the combination of Gram stain examination of paired PTC and EA may contribute to the early diagnosis of HAP in about two-thirds of mechanically ventilated patients, and guide the empiric therapy when needed. In the remaining one-third of patients, the Gram stain examination is not helpful in predicting HAP.
Peritoneal carcinomatosis represents the terminal stage of adenocarcinomas of the gastrointestinal tract. A new treatment combining cytoreductive surgery and intraperitoneal chemotherapy-hyperthermia has been used with encouraging results. The purpose of this study was to report the complications associated with this treatment. Fourty procedures were carry out in 37 patients. Death occurred in 3 patients. Major medical complications were 13 pulmonary infections, 11 acute renal failure (with only 3 who needed dialysis) and 10 patients with neutropenia grade 3 and 4 toxicity. Intra-abdominal complications occurred in 16 patients (there were 11 anastomotic leak and/or bowel perforation, and 12 intra-abdominal infections). Some complications like secretory diarrhea or tubulopathia which were related to these treatment need further investigations. Six procedures were without any complications, 6 presented minor ones and 22 major complications. Adverse effects were relatively important with this new treatment strategy. This was maybe due to a learning process; there is no death and only one anastomotic leak in our last study including 30 patients with cytoreductive surgery and intraperitoneal chemotherapy-hyperthermia.