Biomedical subjects

Pierre-François Laterre

Publications and source records attributed to Pierre-François Laterre.

18 recordsLinked to original sources

PubMed2006

Prolonged unconsciousness in a patient on automated peritoneal dialysis.

A 79-year-old man with end-stage renal disease treated by automated peritoneal dialysis was referred to the emergency department for altered consciousness. The first investigations, including toxicology screening, failed to reveal the precise etiology. The patient was treated for a possible seizure. After the progression of central nervous system depression with bradypnea, the patient was intubated and mechanically ventilated. It appeared later on that he had ingested by mistake one of his wife's medications, baclofen. Baclofen was detected in the blood sampled on admission at a level above the therapeutic range. Baclofen is mainly excreted by the kidney. A short-term administration of low-dose of baclofen is not effectively removed by peritoneal dialysis and may result in prolonged but reversible coma.

Aged↗

PubMed2005

Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death.

BACKGROUND: In November 2001, the Food and Drug Administration (FDA) approved drotrecogin alfa (activated) (DrotAA) for adults who had severe sepsis and a high risk of death. The FDA required a study to evaluate the efficacy of DrotAA for adults who had severe sepsis and a low risk of death. METHODS: We randomly assigned adult patients with severe sepsis and a low risk of death (defined by an Acute Physiology and Chronic Health Evaluation [APACHE II] score <25 or single-organ failure) to receive an intravenous infusion of placebo or DrotAA (24 microg per kilogram of body weight per hour) for 96 hours in a double-blind, placebo-controlled, multicenter trial. The prospectively defined primary end point was death from any cause and was assessed 28 days after the start of the infusion. In-hospital mortality within 90 days after the start of the infusion was measured, and safety information was collected. RESULTS: Enrollment in the trial was terminated early because of a low likelihood of meeting the prospectively defined objective of demonstrating a significant reduction in the 28-day mortality rate with the use of DrotAA. The study enrolled 2640 patients and collected data on 2613 (1297 in the placebo group and 1316 in the DrotAA group) at the 28-day follow-up. There were no statistically significant differences between the placebo group and the DrotAA group in 28-day mortality (17.0 percent in the placebo group vs. 18.5 percent in the DrotAA group; P=0.34; relative risk, 1.08; 95 percent confidence interval, 0.92 to 1.28) or in in-hospital mortality (20.5 percent vs. 20.6 percent; P=0.98; relative risk, 1.00; 95 percent confidence interval, 0.86 to 1.16). The rate of serious bleeding was greater in the DrotAA group than in the placebo group during both the infusion (2.4 percent vs. 1.2 percent, P=0.02) and the 28-day study period (3.9 percent vs. 2.2 percent, P=0.01). CONCLUSIONS: The absence of a beneficial treatment effect, coupled with an increased incidence of serious bleeding complications, indicates that DrotAA should not be used in patients with severe sepsis who are at low risk for death, such as those with single-organ failure or an APACHE II score less than 25.

APACHE↗

PubMed2005

Electrocardiographic changes after head trauma.

We report the case of a patient who developed, a few days after a closed head injury, marked electrocardiographic changes mimicking an acute coronary event, in the absence of actual cardiac damage. The electrocardiographic changes were fully reversible, paralleling the neurologic status. Neuroimaging examinations excluded subarachnoid hemorrhage or space-occupying hematoma, but demonstrated diffuse axonal injury using susceptibility-weighted magnetic resonance techniques. This kind of traumatic brain injury thus may be responsible for a pseudo-acute myocardial ischemic syndrome.

Adult↗

PubMed2005

Recurrent seizure and sustained encephalopathy associated with dimethylsulfoxide-preserved stem cell infusion.

We report the case of a patient who received two infusions of dimethylsulfoxide (DMSO) cryopreserved autologous peripheral blood progenitor cells (PBPCs) after myeloablative chemotherapy for a relapsing lymphoma. A 49-year-old man presented an episode of tonic-clonic seizure over a few minutes after the start of each infusion and developed a profound and sustained but reversible encephalopathy with coma after the second infusion. The patient's neurological condition correlated well with the electrophysiological findings (electroencephalogram and multimodality evoked potentials) and, to a lesser extent, with the radiological abnormalities (magnetic resonance imaging). Severe but reversible neurological complications may occur with the infusion of PBPCs cryopreserved with DMSO.

Cryopreservation↗

PubMed2005

Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study.

OBJECTIVE: Intraabdominal hypertension is associated with significant morbidity and mortality in surgical and trauma patients. The aim of this study was to assess, in a mixed population of critically ill patients, whether intraabdominal pressure at admission was an independent predictor for mortality and to evaluate the effects of intraabdominal hypertension on organ functions. DESIGN: Multiple-center, prospective epidemiologic study. SETTING: Fourteen intensive care units in six countries. PATIENTS: A total of 265 consecutive patients admitted for >24 hrs during the 4-wk study period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Intraabdominal pressure was measured twice daily via the bladder. Data recorded on admission were the patient demographics with Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation II score, and type of admission; during intensive care stay, Sepsis-Related Organ Failure Assessment score and intraabdominal pressure were measured daily together with fluid balance. Nonsurvivors had a significantly higher mean intraabdominal pressure on admission than survivors: 11.4 +/- 4.8 vs. 9.5 +/- 4.8 mm Hg. Independent predictors for mortality were age (odds ratio, 1.04; 95% confidence interval, 1.01-1.06; p = .003), Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.1; 95% confidence interval, 1.05-1.15; p < .0001), type of intensive care unit admission (odds ratio, 2.5 medical vs. surgical; 95% confidence interval, 1.24-5.16; p = .01), and the presence of liver dysfunction (odds ratio, 2.5; 95% confidence interval, 1.06-5.8; p = .04). The occurrence of intraabdominal hypertension during the intensive care unit stay was also an independent predictor of mortality (relative risk, 1.85; 95% confidence interval, 1.12-3.06; p = .01). Patients with intraabdominal hypertension at admission had significantly higher Sepsis-Related Organ Failure Assessment scores during the intensive care unit stay than patients without intraabdominal hypertension. CONCLUSIONS: Intraabdominal hypertension on admission was associated with severe organ dysfunction during the intensive care unit stay. The mean intraabdominal pressure on admission was not an independent risk factor for mortality; however, the occurrence of intraabdominal hypertension during the intensive care unit stay was an independent outcome predictor.

APACHE↗

PubMed2005

Compartmentalization of the protease-antiprotease balance in early severe acute pancreatitis.

OBJECTIVE: To assess the balance between trypsin and protease inhibitors simultaneously in the systemic circulation and in the thoracic lymph and peritoneal exudate. METHODS: Twenty patients with early severe acute pancreatitis were studied. Enzymatically active and immunoreactive trypsin in conjunction with its major inhibitors were measured in the 3 compartments at the onset of end-organ failure(s). The molecular forms of trypsin were determined in the lymph and ascites by gel filtration chromatography to separate trypsinogen and free-and inhibitor-bound trypsin. RESULTS: Both enzymatically active trypsin and immunoreactive trypsin levels were highest in ascites and lymph compared with the systemic circulation. Intracompartmental alpha1- protease inhibitor gradient moved in the opposite direction, whereas alpha2 macroglobulin concentration was highest in ascites and lowest in the lymph. Although most of the enzymatically and immunoreactive material in ascites and lymph consisted of trypsin complexed with alpha2 macroglobulin and trypsinogen, respectively, free active trypsin was detected in more than 80% of the samples. CONCLUSIONS: In patients with early severe acute pancreatitis, there is a significant trypsinogen activation resulting in protease-antiprotease imbalance and thereby free enzymatically active trypsin in the 2 body fluid compartments in close vicinity to the inflammatory process. This may be involved in the pathophysiology of local and distant tissue damage.

Acute Disease↗

PubMed2005

A pilot-controlled study of a polymyxin B-immobilized hemoperfusion cartridge in patients with severe sepsis secondary to intra-abdominal infection.

Endotoxin is an important pathogenic trigger for sepsis. The polymyxin B-immobilized endotoxin removal hemoperfusion cartridge, Toraymyxin (hereafter PMX), has been shown to remove endotoxin in preclinical and open-label clinical studies. In a multicenter, open-label, pilot, randomized, controlled study conducted in the intensive care unit in six academic medical centers in Europe, 36 postsurgical patients with severe sepsis or septic shock secondary to intra-abdominal infection were randomized to PMX treatment of 2 h (n = 17) or standard therapy (n = 19). PMX was well tolerated and showed no significant side effects. There were no statistically significant differences in the change in endotoxin levels from baseline to 6 to 8 h after treatment or to 24 h after treatment between the two groups. There was also no significant difference in the change in interleukin (IL)-6 levels from baseline to 6 to 8 h after treatment or to 24 h after treatment between the two groups. Patients treated with PMX demonstrated significant increases in cardiac index (CI; P = 0.012 and 0.032 at days 1 and 2, respectively), left ventricular stroke work index (LVSWI, P = 0.015 at day 2), and oxygen delivery index (DO2I, P = 0.007 at day 2) compared with the controls. The need for continuous renal replacement therapy (CRRT) after study entry was reduced in the PMX group (P = 0.043). There was no significant difference between the groups in organ dysfunction as assessed by the Sequential Organ Failure Assessment (SOFA) scores from day 0 (baseline) to day 6. Treatment using the PMX cartridge is safe and may improve cardiac and renal dysfunction due to sepsis or septic shock. Further studies are needed to prove this effectiveness.

Adult↗

PubMed2004

Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study.

OBJECTIVE: Although intra-abdominal hypertension (IAH) can cause dysfunction of several organs and raise mortality, little information is available on the incidence and risk factors for IAH in critically ill patients. This study assessed the prevalence of IAH and its risk factors in a mixed population of intensive care patients. DESIGN: A multicentre, prospective 1-day point-prevalence epidemiological study conducted in 13 ICUs of six countries. INTERVENTIONS: None. PATIENTS: Ninety-seven patients admitted for more than 24 h to one of the ICUs during the 1-day study period. METHODS: Intra-abdominal pressure (IAP) was measured four times (every 6 h) by the bladder pressure method. Data included the demographics, medical or surgical type of admission, SOFA score, etiological factors such as abdominal surgery, haemoperitoneum, abdominal infection, massive fluid resuscitation, and ileus and predisposing conditions such as hypothermia, acidosis, polytransfusion, coagulopathy, sepsis, liver dysfunction, pneumonia and bacteraemia. RESULTS: We enrolled 97 patients, mean age 64+/-15 years, 57 (59%) medical and 40 (41%) surgical admission, SOFA score of 6.5+/-4.0. Mean IAP was 9.8+/-4.7 mmHg. The prevalence of IAH (defined as IAP 12 mmHg or more) was 50.5 and 8.2% had abdominal compartment syndrome (defined as IAP 20 mmHg or more). The only risk factor significantly associated with IAH was the body mass index, while massive fluid resuscitation, renal and coagulation impairment were at limit of significance. CONCLUSION: Although we found a quite high prevalence of IAH, no risk factors were reliably associated with IAH; consequently, to get valid information about IAH, IAP needs to be measured.

Abdomen↗

PubMed2003

Clinical review: Drotrecogin alfa (activated) as adjunctive therapy for severe sepsis--practical aspects at the bedside and patient identification.

Administration of drotrecogin alfa (activated) has been demonstrated to reduce mortality in patients with severe sepsis who are at high risk for death or who have multiple organ dysfunction. This benefit was associated with an increased incidence of bleeding events, but the latter were mainly procedure related. Drug infusion interruptions should be instituted, in accordance with recent recommendations. Monitoring coagulation parameters may help in identifying patients at higher risk for bleeding but it is not indicated to adjust drug dosage. Acute renal failure and hemodialysis are not contraindications to this therapy, and no drug dosage adjustment is indicated. Finally, the type and source of infection, and its anticipated natural history, may determine whether drotrecogin alfa (activated) is indicated as well as the timing of its administration.

Anti-Infective Agents↗

PubMed2003

Cavocaval adult liver transplantation and retransplantation without venovenous bypass and without portocaval shunting: a prospective feasibility study in adult liver transplantation.

BACKGROUND: The original method of liver transplantation (LT) included recipient inferior vena cava (IVC) resection and the use of extracorporeal venovenous bypass (VVB). Refinements in technique permit transplantation to be done with IVC preservation and without VVB use. MATERIAL AND METHODS: Between November 1993 and November 2000, 202 consecutive grafts were performed in 188 adults (>/=16 years of age). Twelve patients (6.4%) received two and three retransplants (re-LT). Split grafting was performed 19 times (19 of 202 grafts, 9.4%). Risk factors included United Network of Organ Sharing status I (n=30, 16%), previous right upper abdominal surgery (n=32, 17.1%), caudate lobe encirclement of IVC (n=65, 32.2%), IVC (n=24, 11.9%), and splanchnic venous modification (n=58, 30.9%), transjugular intrahepatic portosystemic stent shunt (n=34, 16.8%), giant (>5 kg) liver tumor (n=6, 3%), septic necrosis of the caudate lobe (n=1, 0.5%), and previous cavocaval (n=13, 6.4%) or classical LT (n=5, 2.5%). RESULTS: IVC preservation, avoidance of IVC cross clamping and of VVB use were possible in 98.9%, 93%, and 99.5% of 183 primary LT and in 89.5%, 84.2%, and 89.5% of 19 re-LT. Temporary portocaval shunting was never applied. Perioperative mortality was 1.2%. There was no allotransfusion in 73 (36%) grafts and 45 (22%) patients were immediately extubated. Permanent hepatic vein and caval problems were encountered in three (1.5%) grafts. One patient needed stent placement to treat IVC stenosis. Actual 3- and 12-month patient survival for whole, re-LT, and right-lobe split LT groups were 94.7%, 94.1%, 94.7%, 88.2%, 94.1%, and 89%. Three-month graft survival rates for these groups were 92.6%, 94.7%, and 84.2%. CONCLUSIONS: LT with IVC preservation and without VVB use and portocaval shunting is possible in nearly all primary transplants and in the majority of re-LT.

Adult↗

PubMed2003

Drotrecogin alfa (activated) in the treatment of severe sepsis patients with multiple-organ dysfunction: data from the PROWESS trial.

OBJECTIVE: Based on the results of the PROWESS trial the European Agency for the Evaluation of Medicinal Products has recently approved drotrecogin alfa (activated) for treatment of adult patients with severe sepsis and multiple-organ failure. We report study's data on efficacy and safety in patients with multiple-organ dysfunction. DESIGN AND SETTING: Randomized, double-blind, placebo-controlled, multicenter trial in 164 medical centers. PATIENTS: 1271 patients (75.2% of the intention-to-treat population, n=1690) with multiple-organ dysfunction at study entry. INTERVENTIONS: Drotrecogin alfa (activated) n=634, 24 micro g/kg per hour for 96 h or placebo ( n=637). RESULTS: Observed 28-day mortality was significantly lower with drug treatment than with placebo (26.5%vs. 33.9%), cardiovascular and respiratory organ dysfunction resolved more rapidly over the first 7 days, and serious bleeding events were more frequent (2.4% vs. 1.3%). CONCLUSIONS: Treatment with drotrecogin alfa (activated) significantly reduced 28-day mortality and more quickly resolved cardiovascular and respiratory organ dysfunction. The difference in serious bleeding event rates may be clinically significant; however, the overall benefit-risk profile appears favorable.

APACHE↗

PubMed2003

Re-use of a liver allograft; an exceptional opportunity to enlarge the organ donor pool.

Liver allograft re-use is an exceptional way of enlarging the donor pool. We describe here a case of a re-used liver allograft, originating from an insulin-intoxicated donor and transplanted at first into a recipient presenting with hyperacute liver failure due to paracetamol intoxication. Because the original recipient developed an irreversible cerebral oedema, the allograft was re-implanted electively 55.5 h later into a patient with post-viral C cirrhosis and solitary hepatocarcinoma. Both donor and recipient operations were technically successful; liver function after the second use of the graft was normal.

Acetaminophen↗

PubMed2003

Drotrecogin alfa (activated) administration across clinically important subgroups of patients with severe sepsis.

OBJECTIVE: To assess the effects of drotrecogin alfa (activated) therapy, a recombinant human activated protein C, across clinically relevant subpopulations in a randomized, phase 3, placebo-controlled study of patients with severe sepsis (recombinant human activated protein C worldwide evaluation in severe sepsis [PROWESS]). DESIGN: Univariate and multivariable analysis of prospectively defined subgroups from the PROWESS study. SETTING: A total of 164 medical centers in 11 countries. PATIENTS: A total of 1,690 patients with severe sepsis. MEASUREMENTS AND MAIN RESULTS: We report observed 28-day mortality rates for drotrecogin alfa (activated) and placebo patients for subgroups prospectively defined by demographic data, surgical status, type and site of infection, and clinical and biochemical measures of disease severity. We performed subgroup analyses to explore the consistency of the mortality benefit observed in the overall population and performed tests for both quantitative and qualitative interactions. To examine the magnitude of the treatment benefit with drotrecogin alfa (activated) across the underlying predicted risk of mortality spectrum, we used stepwise logistic regression on PROWESS placebo patients to generate a predicted risk of mortality model that simultaneously included many clinical and biochemical markers of mortality risk. Because drotrecogin alfa (activated) has anticoagulant properties, we also present analyses of bleeding and thrombotic events. Actual mortality rates were lower with drotrecogin alfa (activated) compared with placebo for nearly all prospectively defined subgroups. Both univariate and multivariable regression analyses showed a consistent relative risk reduction in 28-day mortality rates for drotrecogin alfa (activated). Larger absolute risk reductions were found with drotrecogin alfa (activated) in patients with a higher baseline predicted risk of mortality, and actual mortality rates were lower with drotrecogin alfa (activated) in all subgroups defined by disease severity measures where a > or = 20% placebo mortality was observed. Although discriminatory power was limited by few observed events, the increased absolute risk of experiencing a serious bleeding event with treatment did not seem to vary according to the baseline predicted risk of mortality. CONCLUSIONS: The administration of drotrecogin alfa (activated) to patients with severe sepsis was associated with a significant survival benefit that tended to increase with higher baseline likelihood of death. Current data suggest that the increased risk of bleeding does not vary according to likelihood of death.

APACHE↗

PubMed2003

Anticoagulant therapy in acute lung injury.

OBJECTIVE: To review the rationale for evaluating anticoagulant therapies in acute lung injury (ALI) and to review selected data regarding the effectiveness of anticoagulants in animals and human patients with ALI and acute respiratory distress syndrome. DATA SOURCES: Published literature on coagulation alterations and anticoagulant strategies in ALI during the past 25 yrs. DATA EXTRACTION AND SYNTHESIS: In the lung, alveolar and interstitial fibrin deposition are the hallmarks of early phase ALI. Local procoagulant activity and reduced fibrinolysis constitute the rationale for anticoagulant use in the treatment of ALI. An activated complex of tissue factor and factor VIIa triggers procoagulant activity in the lung, with subsequent thrombin formation and fibrin deposition. Increased pulmonary vascular permeability and leukocyte accumulation have been successfully prevented in animals treated with tissue factor/activated factor VII pathway inhibitor. In humans, a phase II study evaluating tissue factor pathway inhibitor in the treatment of severe sepsis suggested that lung function in acute respiratory distress syndrome patients was improved. However, the phase III trial failed to demonstrate a survival benefit; data regarding respiratory dysfunction have not yet been published. Heparin, despite effectively inhibiting thrombin formation, has not shown consistent benefits in reducing lung injury, and its efficacy has not yet been evaluated in a controlled study. Antithrombin administration in animals has shown consistent benefits with ALI, but clinical studies have failed to demonstrate reductions in mortality and lung injury. Activated protein C administration has been shown to improve survival and lung function in both animal and clinical studies. Soluble thrombomodulin has been shown to improve ALI in animals, and it is currently being evaluated in humans with sepsis. Finally, plasminogen activators may improve gas exchange in ALI, but studies in humans are limited.

Animals↗

PubMed2003

The clinical evaluation committee in a large multicenter phase 3 trial of drotrecogin alfa (activated) in patients with severe sepsis (PROWESS): role, methodology, and results.

OBJECTIVE: In the multinational PROWESS trial, drotrecogin alfa (activated) significantly reduced mortality rate in patients with severe sepsis compared with placebo. The use of large multiple-center trials can potentially complicate interpretation of results in severe sepsis populations because of variability in medical attitudes and practices and the frequency of confounding events such as protocol violations. The objective of this study was to perform a blinded, critical, integrated review of data from the 1,690 severe sepsis patients from 164 medical centers enrolled in the PROWESS trial using a Clinical Evaluation Committee. DESIGN: Blinded, critical, integrated review of data. SETTING: Participating sites. PATIENTS: The 1,690 severe sepsis patients from 164 medical centers enrolled in the PROWESS trial. INTERVENTIONS: We performed analyses of the optimal cohort, defined as patients who had full compliance with the protocol, had evidence of an infection, and received adequate anti-infective therapy. We also performed other analyses, including significant underlying disorders, life support measures, and causes of death. MEASUREMENTS AND MAIN RESULTS: The optimal cohort of 81.4% of the intention-to-treat population [drotrecogin alfa (activated), n = 695; placebo, n = 680] had similar baseline severity of illness between the two groups, a similar pharmacodynamic effect, and a relative risk of death estimate consistent with that observed in the overall PROWESS trial (0.83, 95% confidence interval 0.69-0.99 vs. 0.806, 95% confidence interval 0.69-0.94). A beneficial effect of drotrecogin alfa (activated) similarly was observed in patients with significant underlying disorders (0.73, 95% confidence interval 0.57-0.93) who were more severely ill and had a higher percentage of patients forgoing life-sustaining therapy. In contrast with the original investigator determinations, a benefit associated with drotrecogin alfa (activated) treatment in urinary tract infection adjudicated by the Clinical Evaluation Committee was observed. CONCLUSIONS: The survival benefit associated with drotrecogin alfa (activated) use was consistent with the results of the overall trial regardless of whether patients met criteria of the optimal cohort or had a significant underlying disorder.

APACHE↗

PubMed2002

Lipopolysaccharide-binding protein serum levels in patients with severe sepsis due to gram-positive and fungal infections.

Lipopolysaccharide-binding protein (LBP) is increased in patients with severe gram-negative infections, but LBP serum levels have not been reported for in patients with gram-positive and fungal infections. LBP serum levels were determined in patients with severe sepsis secondary to gram-positive or fungal infections and were compared with LBP serum levels obtained from patients with gram-negative mixed infections and from healthy volunteers. Thirty-seven episodes of severe sepsis were analyzed among 24 patients. LBP serum levels were significantly increased in patients with severe sepsis (46.4+/-28.3 microg/mL), compared with that of healthy volunteers (5.7+/-1.9 microg/mL; P<.0001). On the other hand, LBP serum levels obtained from patients with gram-negative infections (40.80+/-34.79 microg/mL) did not differ from those obtained from patients with gram-positive (35.55+/-23.95 microg/mL) or fungal (39.90+/-22.19 microg/mL) infections. These data suggest that LBP is an aspecific marker of sepsis, and the response was not clearly correlated with severity. Furthermore, in patients with multiple episodes of sepsis, LBP response seems to be of lesser magnitude after each subsequent episode of severe sepsis.

Acute-Phase Proteins↗

PubMed2002

Traumatic injuries: imaging and intervention in post-traumatic complications (delayed intervention).

The nonoperative management (NOM) of abdominal trauma has gained increasing acceptance over the past decade. This approach has been extended to severe trauma patients previously considered as candidates for surgery. Consequently, the incidence of delayed and uncommonly encountered complications has increased. Causes of delayed complications are multiple and include: (a) abnormal or insufficient injury healing process; (b) retention of necrotic tissue; (c) secondary infection of initially sterile collections; and (d) underestimation of injury severity. The purpose of this review article is to explain the role of various imaging modalities in detecting post-traumatic delayed complications and to highlight the usefulness of minimally invasive techniques, including laparoscopy, biliary endoscopy, therapeutic angiography and image-guided drainage. Subsequent complications, which do not necessarily negatively influence the final outcome, are often predictable, virtually obligatory consequences of the successful NOM of high-grade or complex abdominal injuries. Between 50 and 60% of those patients with grade-IV or grade-V liver or splenic lacerations require some type of interventional treatment; therefore, indiscriminate discharge of patients with solid organ injury managed conservatively may be potentially harmful. As the incidence of complications is higher for more severe grade-IV or grade-V liver, spleen, or kidney injuries, scheduled follow-up CT scans may be rational in this subset of patients to identify potential complications amenable to early application of interventional techniques. Follow-up CT scans are unnecessary in stable adults or children with low-grade injury. Delayed splenic or hepatic rupture is one of the major concerns because this type of complication remains difficult to predict and historically often requires emergent surgery. These ruptures may benefit from NOM, should the same criteria as for primary rupture be respected. Conversely, parenchymatous focal pooling of contrast on initial CT is a good predictor for the development of delayed vascular malformation. In children, as a large part of splenic and hepatic vascular malformations resolve spontaneously, expectant observation may be indicated provided that a strict imaging follow-up is performed until complete disappearance of these lesions. If needed, embolization of parenchymal vascular lesions should be performed as selectively as possible in order to avoid functional parenchyma loss and to reduce the risk of secondary infection of hematoma or ischemic tissue. Technical improvements, such as microcatheter systems and direct percutaneous approach to targeted lesions, have widened the potential for safe endovascular management of acquired vascular malformations. Advantages and disadvantages relative to the different embolic agents are explained. Endoscopic retrograde pancreatography is the chief investigational tool for detecting biliary and pancreatic ducts injuries. The respective roles of endoscopic, percutaneous and surgical approaches in the management of these complications are discussed. The CT scan and ultrasound-guided drainage provide effective nonoperative options in the management of post-traumatic parenchymatous and (retro)-peritoneal collections. Treatment modalities of less common complications, such as bowel stricture or perforation, mesenteric vascular injuries and renal trauma-induced hypertension, are reviewed.

Biliary Tract Diseases↗

PubMed2002

Management of patients with severe sepsis, treated by drotrecogin alfa (activated).

A number of management issues confront the clinician treating a critically ill patient with drotrecogin alfa (activated) (Xigris; Eli Lilly and Company, Indianapolis, IN), a compound documented to significantly reduce the risk of 28-day all-cause mortality in patients with severe sepsis. The management issues that will be discussed include differentiating drug effect from the hemostatic changes of sepsis, prevention and management of bleeding during drotrecogin alfa (activated) infusion, treatment considerations in the patient with thrombocytopenia or disseminated intravascular coagulation, thromboprophylaxis in drug-treated patients, and the use of drotrecogin alfa (activated) in patients requiring renal replacement therapy. Proper adherence to principles described in this article can facilitate patient management and reduce the risk of bleeding.

Anti-Infective Agents↗