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J C Farkas

Publications and source records attributed to J C Farkas.

17 recordsLinked to original sources
PubMed1998

Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis.

OBJECTIVE: To evaluate the incidence and risk factors for catheter-related central vein thrombosis in ICU patients. DESIGN: Observational prospective multicenter study. SETTING: An 8-bed surgical ICU, a 10-bed surgical cardiovascular ICU, and a 10-bed medical-surgical ICU. PATIENTS: During an 18-month period, 265 internaljugular or subclavian catheters were included. Veins were explored by duplex scanning performed just before or < 24 h after catheter removal. Suspected risk factors of catheter-related central vein thrombosis were recorded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifty-seven catheters were excluded from the analysis. Therefore 208 catheters were analyzed. Mean age of patients was 64+/-15 years, simplified acute physiologic score was 12+/-5, organ system failure score at insertion was 1+/-1, and mean duration of catheterization was 9+/-5 days. A catheter-related internal jugular or subclavian vein thrombosis occurred in 33% of the cases (42% [95% confidence interval (CI), 34 to 49%] and 10% [95% CI, 3 to 18%], respectively). Thrombosis was limited in 8%, large in 22%, and occlusive in 3% of the cases. Internal jugular route (relative risk [RR], 4.13; 95% CI, 1.72 to 9.95), therapeutic heparinization (RR 0.47; 95% CI, 0.23 to 0.99), and age >64 years (RR, 2.44; 95% CI, 2.05 to 3.19) were independently associated with catheter-related thrombosis. Moreover, the risk of catheter-related sepsis was 2.62-fold higher when thrombosis occurred (p=0.011). CONCLUSIONS: Catheter-related central vein thrombosis is a frequent complication of central venous catheterization in ICU patients and is closely associated with catheter-related sepsis.

APACHE↗
PubMed1996

Effect of subcutaneous tunneling on internal jugular catheter-related sepsis in critically ill patients: a prospective randomized multicenter study.

OBJECTIVE: To evaluate the effect of catheter tunneling on internal jugular catheter-related sepsis in critically ill patients. DESIGN: A prospective randomized controlled study involving 3 intensive care units (ICUs), stratified by number of catheter lumina (1 or 2) and center. SETTING: The 10-bed medical-surgical and 10-bed surgical ICUs at Saint Joseph Hospital and 8-bed surgical ICU at Clinique de la Défense, Paris, France. PATIENTS: Every patient older than 18 years admitted to the ICUs between March 1, 1993, and July 17,1996, who required a jugular venous catheter for more than 48 hours. INTERVENTION: Random allocation to tunneled or nontunneled catheters. MEASUREMENTS: Times to occurrence of systemic catheter-related sepsis, catheter-related septicemia, or a quantitative catheter-tip culture with a cutoff of 103 colony-forming units per milliliter. RESULTS: A total of 241 patients were randomized. Ten patients in whom jugular puncture was not achieved were subsequently excluded. The proportion of patients receiving mechanical ventilation (87%) and mean+/-SD age (65+/-4 years), Simplified Acute Physiologic Score (13.3+/-4.9), Organ System Failure score (1.5+/-1.0), and duration of catheterization (8.7+/-5.0 days) were similar in both groups. Taking into account the first 231 catheters (114 nontunneled [control], 117 tunneled), we found that tunnelization decreased catheter-related sepsis (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.13-0.83; P=.02), catheter-related septicemia (OR, 0.23; 95% CI, 0.07-0.81; P=.02), and, though not statistically significant, positive quantitative tip-culture rate (OR, 0.62; 95% CI, 0.35-1.10; P=.10). These results were slightly modified after adjustment on parameters either imbalanced between both groups (duration of catheter placement and cancer at admission) or prognostic (insertion by a resident, use of antibiotics at catheter insertion, cancer, and sex). CONCLUSION: The incidence of internal jugular catheter-related infections in critically ill patients can be reduced by using subcutaneous tunnelization.

Aged↗
PubMed1993

Long-term follow-up of positive cultures in 500 abdominal aortic aneurysms.

Routine aneurysm culture is frequently performed as it is thought that a positive culture could be a risk factor for secondary graft infection. Five hundred aneurysms, in a series of 796 patients, had microbiologic examination of the thrombus and/or aneurysm wall. Cultures were positive in 185 cases (37%), mostly due to normal skin flora microorganisms (80%), whereas 16 patients (3.2%) had infectious aortitis. Gram-stained smears were positive in nine of these 16 patients compared with two of the other 169. Of the 185 patients with positive culture, after a mean length of follow-up of 35 months, only one had a graft infection that occurred 6 years later and was not due to the same microorganism. Graft sepsis was diagnosed in six of the 296 patients who did not have a positive culture, and was related to clinically obvious locoregional or systemic foci. In this series, positive cultures from aneurysm without rupture or signs of infection were not a risk factor for secondary graft sepsis. Therefore, in cases of asymptomatic unruptured aneurysm, routine culturing is not necessary as a positive result has no pathogenic significance or therapeutic implication.

Aged↗
PubMed1993

High levels of portal TNF-alpha during abdominal aortic surgery in man.

During shock or multiple organ dysfunction syndrome, translocation of bacteria and/or lipopolysaccharide (LPS) from the ischaemic gut might occur and could explain the excess of cytokine production detectable in plasma. To test this hypothesis, we studied a model of mild gut ischaemia due to bowel manipulation and aortic clamping in patients undergoing abdominal aortic surgery (n = 14). Per-operative levels of LPS and cytokines were measured before clamping and after reperfusion, and compared in systemic and portal blood. Systemic levels of LPS and cytokines were measured in a control group of patients undergoing internal carotid surgery (n = 7). Portal LPS was detectable (i.e., > 12 pg/ml) in 36% of the patients undergoing aortic surgery after bowel manipulation, and in 71% after clamp release. Similar levels of LPS were observed in portal and systemic blood after clamp release. Circulating tumour necrosis factor alpha (TNF-alpha) was observed in all patients undergoing aortic surgery. Levels of portal TNF-alpha were higher than those in systemic blood after bowel manipulation as well as after reperfusion (P = 0.02 and 0.007, respectively). LPS was never detected in control patients and TNF-alpha was detectable in only two out of seven patients. Mean levels of IL-6 were similar in the two groups, with a peak on the day following surgery, confirming that circulating IL-6 is associated with any surgical procedures. Our data indicate that bowel manipulation, aortic clamping and reperfusion lead to similar levels of portal and systemic circulating LPS.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1993

A randomised controlled trial of a low-molecular-weight heparin (Enoxaparin) to prevent deep-vein thrombosis in patients undergoing vascular surgery.

The incidence of postoperative deep vein thrombosis (PDVT) after aortic surgery and lower limb revascularisation has not been assessed by a large prospective study. In a prospective randomised trial the effect of a low-molecular-weight heparin fragment, Enoxaparin (ENX) 4200 anti factor Xa IU once daily was compared to that of unfractionated heparin (UFH) 7500 IU twice daily. Two hundred and thirty-three consecutive patients were classified into three groups, aortic or aortoiliac and aneurysmectomy (n = 75), aorto-femoral bypass for atherosclerotic disease (n = 71), and femoropopliteal or femorodistal bypass (n = 87). Patients were analysed for development of deep vein thrombosis by Duplex scanning and, if positive, by venography between the seventh and tenth postoperative day. PDVT was present in 10 patients in the ENX group and in four patients in the UFH group (8.2 and 3.6% respectively, NS). The incidence of PDVT was 8% after aortic or aortoiliac aneurysmectomy, 7% after aortofemoral revascularisation, and 3.4% after femoropopliteal or femorodistal bypass. The overall incidence of PDVT after aortic surgery was 7.5% (95% CI 5.4-9.7). There was no pulmonary embolism. Intra-operative blood loss and postoperative bleeding events did not differ significantly between the ENX and UFH groups. After 1 month follow-up, no clinical event or death could be related to PDVT or pulmonary embolism. In conclusion, in vascular surgery ENX is as safe and effective in the prevention of PDVT as is UFH.

Aged↗
PubMed1993

Infected infrarenal aortic aneurysms: when is in situ reconstruction safe?

Twenty-five infected infrarenal aortic aneurysms operated on between 1968 and 1989 were reviewed. They were classified into post-embolic (mycotic) aneurysms (group I), infective aortitis (group II), and infected atherosclerotic aneurysms (group III). Aortoduodenal fistulas were found in eight patients and aortocaval in two. Five patients were operated on in a state of shock, and 12 had preoperative positive blood cultures. Surgical procedures included in situ reconstruction of the aorta (n = 21) and extra-anatomic bypass associated with aneurysmal resection (n = 4). In 19 patients, prostheses were covered with omental flaps, and antibiotics were continued for more than 6 weeks in all patients. In patients who underwent in situ reconstruction, three deaths were related to the initial surgery. All surviving patients were regularly followed up, and none showed any sign of late septic recurrence. In patients who underwent extra-anatomic bypass, two died in the postoperative period, one underwent reoperation 2 years after the initial surgery, and the last patient is doing well. Positive postoperative blood cultures (n = 4) revealed persistent sepsis: two cholecystitis, one spondylitis, and one aortic infection. An exhaustive review of the literature was performed; clinical, bacteriologic, and operative features and results were analyzed; prognostic factors were evaluated; and a practical therapeutic approach was suggested. The importance of preoperative diagnosis, complete resection, debridement of infected tissues, omental flap coverage, and long-term antibiotic therapy with regular computerized tomographic scanning follow-up is stressed.

Adult↗
PubMed1993

Arterial thrombosis: a rare complication of the nephrotic syndrome.

Arterial thrombosis is a rare complication of the nephrotic syndrome, occurring mainly in men. Two cases of arterial thrombosis are described, the first affecting a 54-year-old man in whom aortic thrombosis initiated the nephrotic syndrome and who relapsed 1 year later resulting in graft thrombosis, the second affecting a 15-year-old male patient with extensive popliteal and distal arterial thrombosis, followed by recurrent venous bypass thrombosis. A review of the literature shows that arterial thrombosis occurs primarily in the femoropopliteal, renal and coronary arteries. The genesis of arterial thrombosis in patients with nephrotic syndrome involves increased blood viscosity, platelet adhesion and aggregation, high levels of fibrinogen, low levels of serum antithrombin III, diuretic agents and steroid therapy. For high-risk patients with low levels of plasma albumin or those receiving steroids, anticoagulation therapy should be introduced to prevent thrombosis. Urine protein should be evaluated in patients with arterial thrombosis of unknown origin.

Adolescent↗
PubMed1992

Renal revascularization in high-risk patients: the role of iliac renal bypass.

Between 1984 and 1989, 29 iliac renal artery bypasses were performed in 29 patients (mean age 67.8 years) with severe renovascular disease due to atheroma. The indication for renal artery reconstruction was hypertension in all patients, which was associated with kidney failure in 16 cases. In six cases, reconstruction was performed after failure or complications of percutaneous transluminal angioplasty. The bypass was constructed with polytetrafluoroethylene in 24 cases (83%) and vein graft in five cases (17%). There was no postoperative mortality. All bypasses were found to be patent on duplex scanning or digital subtraction arteriograms. One patient was lost to follow-up. Mean follow-up was 23.2 months. One patient died of acute kidney failure, probably related to occlusion of the bypass. Hypertension improved in 22 cases (79%), was cured in two cases (7%), and remained unchanged in four (14%). Renal function remained unchanged in six cases (40%) and improved in nine (60%). Iliac-to-renal artery bypass seems to be the surgical renal revascularization modality best adapted to high-risk patients or those who have severe atheroma. Additionally, this technique enables rapid treatment of failures or complications of percutaneous transluminal angioplasty of the renal artery.

Aged↗
PubMed1992

Acute colorectal ischemia after aortic surgery: pathophysiology and prognostic criteria.

Acute colorectal ischemia is a rare though potentially lethal complication of aortic surgery. We reviewed our recent experience with 16 cases in order to analyze its causative and prognostic factors. The incidence was 2.8%, and the inferior mesenteric artery was occluded in all cases. All patients also had severe occlusive disease of at least two of the hypogastric or deep femoral arteries. Hypoperfusion due to arterial ligation, prosthetic occlusion or embolism was responsible in half the cases. Ischemia and perfusion due to aortic cross-clamping or perioperative hemorrhage were involved in the rest of the cases. Postoperative mortality was 31%. The mortality was lower for partial, nontransmural necrosis, and for elective operations. Recurrent intestinal ischemia, transmural necrosis, surgery for ruptured aneurysm, intestinal hemorrhage and pulmonary edema were associated with a higher mortality rate. All patients with anuria or extrarenal epuration and hepatic cytolysis died. Although reconstruction of the inferior mesenteric artery might lessen the incidence of postoperative colonic ischemia due to hypoperfusion, the role of oxygen free radicals should be investigated in humans, in order to afford colonic protection against the consequences of ischemia-reperfusion.

Acute Disease↗
PubMed1992

Single- versus triple-lumen central catheter-related sepsis: a prospective randomized study in a critically ill population.

PURPOSE: A prospective randomized study was conducted over a 23-month period in an adult medical-surgical intensive care unit to determine whether triple-lumen catheters reduce the need for peripheral vascular access and whether they are associated with a higher rate of infection than single-lumen catheters. PATIENTS AND METHODS: After the insertion route, internal jugular or subclavian, was selected by the physician, patients were randomized either to single-lumen or triple-lumen catheter groups. Complementary peripheral vascular access was allowed in both groups. Catheters were removed according to preestablished defined reasons: suspicion of catheter-related sepsis, uselessness of central venous access, duration of catheterization of more than 21 days, discharge from the intensive care unit, or death. RESULTS: Data on 129 central venous catheters were collected from 91 consecutive patients. Twenty-five of 68 patients from the single-lumen group and 1 of 61 patients from the triple-lumen group needed peripheral vascular access (p less than 0.001). Catheter-related sepsis rates, defined either by clinical signs and positive qualitative tip cultures (8.9% versus 11.5%) or by quantitative tip cultures (16.2% versus 11.5%), were identical in the single-lumen and triple-lumen groups (type II error: 8%). CONCLUSION: In intensive care units, the use of triple-lumen catheters is associated with a dramatic decrease in the need for peripheral vascular access. The incidence of central venous catheter-related sepsis appears identical for single- and triple-lumen catheters.

Adult↗
PubMed1992

Influence of surgery on in-vitro cytokine production by human monocytes.

Surgery leads to significant modulation of the immune system, in which cytokines play a major role. Circulating interleukin 6 (IL-6) and IL-1 have been reported following surgery whereas tumor necrosis factor alpha (TNF-alpha) is only found in gut ischemia-associated surgery. We have investigated the consequences of surgery on in-vitro cytokine production by human monocytes stimulated by lipopolysaccharide (LPS) and staphylococcal toxic shock syndrome toxin-1 (TSST-1). Comparisons were made between the responsiveness of cells obtained the day before (D-1), during (D0) and after (D1, D2, D3) surgery. Patients undergoing abdominal aortic surgery (N = 9), carotid surgery (N = 4) and spinal surgery (N = 4) have been studied. A significant decrease of TNF-alpha, IL-1 beta and IL-1 alpha production by monocytes prepared from blood samples taken during the surgery was noticed, whereas IL-6 production was not significantly modified. On D2 a significant increase of monocyte responsiveness was observed and levels of cytokine productions rose back to initial values by the end of the follow up. The diminished in-vitro cytokine production observed during surgery might be the consequence of the effects of anaesthetic drugs, whereas the enhancement observed on D2 might reflect the surgical stress, leading to in-vivo priming of circulating monocytes.

Aged↗
PubMed1990

[Total pulmonary atelectasis after epidural anesthesia].

A case is reported of a 69-year-old man who sustained a total atelectasis of his right lung while undergoing ilio-tibial bypass surgery. This patient had a history of chronic obstructive pulmonary disease. The plain chest film showed a possible right-sided segmental atelectasis as well as pleural thickening on the same side. Lung function tests showed up a small obstructive syndrome, with mild hypoxaemia (Pao2 60.5 mmHg). The procedure was performed under epidural anaesthesia, carried out with 20 ml of 0.5% bupivacaine and 0.1 mg fentanyl. The upper level of anaesthesia was T4. The patient was sedated with flunitrazepam. He was given oxygen because arterial blood appeared to be somewhat dark. Despite this, the patient became grey, agitated, and had tachypnoea, together with absent breath sounds on the right side. A chest X-ray confirmed the diagnosis of total atelectasis of the right lung. Fiberoptic bronchoscopy was carried out, and a purulent mucous plug was removed. The patient improved and recovered from this episode totally. Blood gases were measured 1 month later; there was no difference with the preoperative values, except for correction of the hypoxaemia (Pao2 76 mmHg). The different factors possibly involved in the pathogenesis of the plug are discussed. It is likely that general anaesthesia would not have avoided this complication.

Aged↗
PubMed1990

[Recurring arterial thrombosis in the adult during a nephrotic syndrome. Report of a case and review of the literature].

A 55 year old male with idiopathic nephrotic syndrome (minimal glomerular changes at light microscopy) developed recurrent arterial thrombosis (aortic, popliteal and prosthetic) combined with recurrent proteinuria. Fourty nine cases of adult arterial thrombosis associated with nephrotic syndrome are reviewed. This complication mainly affects the coronary, iliac and femoral, renal and cerebral arteries. Any type of nephrotic syndrome can be involved. The hypercoagulable state predisposes to thromboembolic events. Corticosteroid induced thrombotic episodes have been described during nephrotic syndrome. Therefore anticoagulant therapy is mandatory when steroid therapy is used.

Arteries↗
PubMedDate not supplied

[Isolated dissecting aneurysm of the superior mesenteric artery. Dysplasia, a rare cause of mesenteric ischemia. Report of a case].

We report a case of successful surgical revascularization of the superior mesenteric artery in a patient presenting with intestinal ischaemia due to fibrodysplasia. This is a rare pathology, with 5 cases operated in our institution and only 16 cases reported in the literature. Angiography may show other sites of arterial dysplasia. In such cases, success depends on early surgical revascularization.

Aortic Dissection↗