Metformin-associated lactic acidosis in an intensive care unit

International audienceIntroduction Metformin-associated lactic acidosis (MALA) is aclassic side effect of metformin and is known to be a severedisease with a high mortality rate. The treatment of MALA withdialysis is controversial and is the subject of many case reportsin the literature. We aimed to assess the prevalence of MALA ina 16-bed, university-affiliated, intensive care unit (ICU), and theeffect of dialysis on patient outcome.Methods Over a five-year period, we retrospectively identifiedall patients who were either admitted to the ICU with metforminas a usual medication, or who attempted suicide by metforminingestion. Within this population, we selected patientspresenting with lactic acidosis, thus defining MALA, anddescribed their clinical and biological features.Results MALA accounted for 0.84% of all admissions duringthe study period (30 MALA admissions over five years) and wasassociated with a 30% mortality rate. The only factorsassociated with a fatal outcome were the reason for admissionin the ICU and the initial prothrombin time. Although patientswho went on to haemodialysis had higher illness severity scores,as compared with those who were not dialysed, the mortalityrates were similar between the two groups (31.3% versus28.6%).Conclusions MALA can be encountered in the ICU severaltimes a year and still remains a life-threatening condition.Treatment is restricted mostly to supportive measures, althoughhaemodialysis may possess a protective effect

The relationship between CD4+CD25+CD127- regulatory T cells and inflammatory response and outcome during shock states

International audienceINTRODUCTION: Although regulatory T lymphocytes (Tregs) have a pivotal role in preventing autoimmune diseases and limiting chronic inflammatory conditions, they may also block beneficial immune responses by preventing sterilizing immunity to certain pathogens. METHODS: To determine whether naturally occurring Treg cells have a role in inflammatory response and outcome during shock state we conducted an observational study in two adult ICUs from a university hospital. Within 12 hours of admission, peripheral whole blood was collected for the measurement of cytokines and determination of lymphocyte count. Sampling was repeated at day three, five and seven. Furthermore, an experimental septic shock was induced in adult Balb/c mice through caecal ligation and puncture. RESULTS: Forty-three patients suffering from shock (26 septic, 17 non septic), and 7 healthy volunteers were included. The percentage of Tregs increased as early as 3 days after the onset of shock, while their absolute number remained lower than in healthy volunteers. A similar pattern of Tregs kinetics was found in infected and non infected patients. Though there was an inverse correlation between severity scores and Tregs percentage, the time course of Tregs was similar between survivors and non survivors. No relation between Tregs and cytokine concentration was found. In septic mice, although there was a rapid increase in Treg cells subset among splenocytes, antibody-induced depletion of Tregs before the onset of sepsis did not alter survival. CONCLUSIONS: These data argue against a determinant role of Tregs in inflammatory response and outcome during shock states

A Soluble Form of the Triggering Receptor Expressed on Myeloid Cells-1 Modulates the Inflammatory Response in Murine Sepsis

The triggering receptor expressed on myeloid cells (TREM)-1 is a recently discovered receptor expressed on the surface of neutrophils and a subset of monocytes. Engagement of TREM-1 has been reported to trigger the synthesis of proinflammatory cytokines in the presence of microbial products. Previously, we have identified a soluble form of TREM-1 (sTREM-1) and observed significant levels in serum samples from septic shock patients but not controls. Here, we investigated its putative role in the modulation of inflammation during sepsis. We observed that sTREM-1 was secreted by monocytes activated in vitro by LPS and in the serum of animals involved in an experimental model of septic shock. Both in vitro and in vivo, a synthetic peptide mimicking a short highly conserved domain of sTREM-1 appeared to attenuate cytokine production by human monocytes and protect septic animals from hyper-responsiveness and death. This peptide seemed to be efficient not only in preventing but also in down-modulating the deleterious effects of proinflammatory cytokines. These data suggest that in vivo modulation of TREM-1 by sTREM peptide might be a suitable therapeutic tool for the treatment of sepsis

Les accidents et incidents en canyoning (pathologies, prévention et organisation des secours)

NANCY1-SCD Medecine (545472101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Traumatisme crânien grave et transport héliporté (étude prospective lorraine)

NANCY1-SCD Medecine (545472101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Complications graves de la coelioscopie (revue de la littérature, à propos d'un cas d'embolie gazeuse)

La cœlioscopie est une technique développée initialement par les gynécologues depuis la fin des années soixante permettant l'exploration de la cavité péritonéale à l'aide d'un fibroscope, après y avoir insufflé un gaz sous pression, du CO2 le plus souvent. Le développement de ses indications en fait une technique chirurgicale réputée sûre, présente dans tous les domaines de la chirurgie, pour des interventions de plus en plus complexes. Ce travail précise l'histoire de cette technique, ses indications, les méthodes d'anesthésie, la technique de la cœlioscopie et les soins post-opératoires. La phase d'installation de la cœlioscopie, commune à toutes les interventions, comporte un risque de complications, illustré par un cas d'embolie gazeuse décrit chez une jeune femme de 17 ans qui subit une cœlioscopie gynécologique à visée diagnostique sous anesthésie générale. L'analyse de la littérature révèle que les complications de la cœlioscopie sont corrélées à l'importance de l'intervention, mais qu'un tiers de celles-ci se produisent lors de la phase d'installation. Une revue de cas cliniques d'embolie gazeuse lors de cœlioscopies gynécologiques à visée diagnostique est présentée.NANCY1-SCD Medecine (545472101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF