Ultrasonographic evaluation of diaphragmatic function

International audienc

First Report of Lamotrigine-Induced Drug Rash with Eosinophilia and Systemic Symptoms Syndrome with Pancreatitis

OBJECTIVE To report a case of lamotrigine-induced drug rash with eosinophilia and systemic symptoms (DRESS) syndrome with pancreatitis as the initial visceral involvement.CASE SUMMARY A 75-year-old man was admitted to the local hospital for generalized tonic-clonic seizures. Results of the clinical examination and neurologic investigations were unremarkable. Lamotrigine treatment was initiated and the patient was discharged a few days later. Forty days after lamotrigine initiation, he developed an exanthematous maculopapular rash with fever, peripheral lymphadenopathies, and hypereosinophilia. Lamotrigine hypersensitivity was suspected and the drug was suspended on day 45. On day 47, the patient presented with acute abdominal pain with an elevated lipase level. Acute pancreatitis was confirmed on computed tomography scan. The patient\u27s condition worsened and he was transferred to the intensive care unit with multiorgan failure. The diagnosis of lamotrigine-induced DRESS syndrome was confirmed by a compatible skin histology and concomitant human herpesvirus-6 infection. DISCUSSION This observation has 2 points of interest. First, pancreatic toxicity of lamotrigine has been rarely reported in the literature. Secondly, pancreatitis is uncommon at the early stage of DRESS syndrome. Only 1 other case of DRESS syndrome, secondary to allopurinol, reports pancreatitis along with an Epstein-Barr virus infection. The Naranjo probability scale indicated a probable causality between lamotrigine and DRESS syndrome in this patient. CONCLUSIONS This is the first reported case of lamotrigine-induced DRESS syndrome with pancreatitis as the initial visceral involvement. Clinicians should be aware of this mode of presentation of DRESS syndrome

Validation of a predictive method for an accurate assessment of resting energy expenditure in medical mechanically ventilated patients

Objective: Use comparison with indirect calorimetry to confirm the ability of our previously described equation to predict resting energy expenditure in mechanically ventilated patients.Design: Prospective, validation study. Setting: Eighteen-bed, medical intensive care unit at a teaching hospital. Patients: All adult patients intubated >24 hrs were assessed for eligibility. Exclusion criteria were clinical situations that could contribute to erroneous calorimetric measurements. Interventions: Resting energy expenditure was calculated using the original Harris-Benedict equations and those corrected for usual stress factors, the Swinamer equation, the Fusco equation, the Ireton-Jones equation, and our equation: resting energy expenditure (kcal/day) = 8 × weight (kg) + 14 × height (cm) + 32 × minute ventilation (L/min) + 94 × temperature (°C) − 4834. Measurements and Main Results: Resting energy expenditure was measured by indirect calorimetry for the 45 included patients. Resting energy expenditure calculated with our predictive model correlated with the measured resting energy expenditure (r2 = .62, p < .0001), and Bland-Altman analysis showed a mean bias of −192 ± 277 kcal/day, with limits of agreement ranging from −735 to 351 kcal/day. Resting energy expenditure calculated with the Harris-Benedict equations was more weakly correlated with measured resting energy expenditure (r2 = .41, p < .0001), with Bland-Altman analysis showing a mean bias of 279 ± 346 kcal/day between them and the limits of agreement ranging from −399 to 957 kcal/day. Applying usual stress-correction factors to the Harris-Benedict equations generated wide variability, and the correlation with measured resting energy expenditure was poorer (r2 = .18, p < .0001), with Bland-Altman analysis showing a mean bias of −357 ± 750 kcal/day and limits of agreement ranging from −1827 to 1113 kcal/day. The use of the Swinamer, Fusco, or Ireton-Jones predictive methods yielded weaker correlation between calculated and measured resting energy expenditure (r2 = .41, p < .0001; r2 = .38, p < .0001; r2 = .39, p < .0001, respectively) than our equation, and Bland-Altman analysis showed no improvement in agreement and variability between methods. Conclusions: The Faisy equation, based on static (height), less stable (weight), and dynamic biometric variables (temperature and minute ventilation), provided precise and unbiased resting energy expenditure estimations in mechanically ventilated patients

Screening for elderly patients admitted to the emergency department requiring specialized geriatric care

BACKGROUND: There is a need for a brief geriatric assessment (BGA) tool to screen elderly patients admitted to the Emergency Department (ED) for their risk of a long hospital stay. OBJECTIVE: To examine whether a BGA administered to elderly patients admitted to the ED may predict the risk of a long hospital stay in the geriatric acute care unit. METHODS: This study had a prospective cohort study design, enrolling 424 elderly patients (mean age 84.0 +/- 6.5 years, 31.6% male) who were evaluated in the ED using a BGA composed of the following items: age, gender, number of medications taken daily, history of falls during the past 6 months, Mini-Mental State Examination (MMSE) score, and non-use of home-help services (i.e., living alone without using any formal or informal home services or social help). The length of stay (LOS) was calculated in days. Patients were separated into three groups based on LOS: low (<8 days), intermediate (8-13 days), and high (>13 days). RESULTS: The prevalence of male gender was higher among patients with the longest LOS compared to those with intermediate LOS (p = 0.002). There were more patients with a history of falls in the high LOS group compared to the intermediate LOS group (p = 0.001) and the low LOS group (p < 0.001). The classification tree showed that male patients with an MMSE score <20 who fell with age under 85 years formed the end node with the greatest relative risk (RR) of a long hospital stay (RR = 14.3 with p < 0.001). CONCLUSIONS: The combination of a history of falls, male gender, cognitive impairment, and age under 85 years identified elderly ED patients at high risk of a long hospital stay

Syndrome de détresse respiratoire aiguë secondaire à une infection à Toxocara cati

Human toxocarosis is a helminthozoonosis due to the migration of toxocara species larvae throughout the human body. Lung manifestations vary and range from asymptomatic infection to severe disease. Dry cough and chest discomfort are the most common respiratory symptoms. Clinical manifestations include a transient form of Loeffler\u27s syndrome or an eosinophilic pneumonia. We report a case of bilateral pneumonia in an 80 year old caucasian man who developed very rapidly an acute respiratory distress syndrome, with a PaO2/FiO2 ratio of 55, requiring mechanical ventilation and adrenergic support. There was an increased eosinophilia in both blood and bronchoalveolar lavage fluid. Positive toxocara serology and the clinical picture confirmed the diagnosis of the "visceral larva migrans" syndrome. Intravenous corticosteroid therapy produced a rapid rise in PaO2/FiO2 before the administration of specific treatment. A few cases of acute pneumonia requiring mechanical ventilation due to toxocara have been published but this is, to our knowledge, is the first reported case of ARDS with multi-organ failure

Pharmacokinetics of epinephrine in patients with septic shock: modelization and interaction with endogenous neurohormonal status

Introduction In septic patients, an unpredictable response to epinephrine may be due to pharmacodynamic factors or to non-linear pharmacokinetics. The purpose of this study was to investigate the pharmacokinetics of epinephrine and its determinants in patients with septic shock. Methods Thirty-eight consecutive adult patients with septic shock were prospectively recruited immediately before epinephrine infusion. A baseline blood sample (C0) was taken to assess endogenous epinephrine, norepinephrine, renin, aldosterone, and plasma cortisol levels before epinephrine infusion. At a fixed cumulative epinephrine dose adjusted to body weight and under steady-state infusion, a second blood sample (C1) was taken to assess epinephrine and norepinephrine concentrations. Data were analyzed using the nonlinear mixed effect modeling software program NONMEM. Results Plasma epinephrine concentrations ranged from 4.4 to 540 nmol/L at steady-state infusion (range 0.1 to 7 mg/hr; 0.026 to 1.67 μg/kg/min). A one-compartment model adequately described the data. Only body weight (BW) and New Simplified Acute Physiologic Score (SAPSII) at intensive care unit admission significantly influenced epinephrine clearance: CL (L/hr) = 127 × (BW/70)0.60 × (SAPS II/50)-0.67. The corresponding half-life was 3.5 minutes. Endogenous norepinephrine plasma concentration significantly decreased during epinephrine infusion (median (range) 8.8 (1 – 56.7) at C0 vs. 4.5 (0.3 – 38.9) nmol/L at C1, P < 0.001). Conclusions Epinephrine pharmacokinetics is linear in septic shock patients, without any saturation at high doses. Basal neurohormonal status does not influence epinephrine pharmacokinetics. Exogenous epinephrine may alter the endogenous norepinephrine metabolism in septic patients

Use of Doppler ultrasound renal resistive index and neutrophil gelatinase-associated lipocalin in prediction of acute kidney injury in patients with septic shock

Poster PresentationThis journal suppl. contain meeting abstracts of the 31st International Symposium on Intensive Care and Emergency MedicineINTRODUCTION: Acute kidney injury (AKI) is common in septic shock and there is no good marker to predict it. Neutrophil gelatinase-associated lipocalin (NGAL) is a novel renal biomarker showing promising results in prediction of AKI in patients across diff erent clinical settings. Another potential marker is the resistive index (RI) of renal interlobar artery (calculated as (peak systolic velocity – end diastolic velocity) / peak systolic velocity), which has been shown to be useful in identifying those who will develop AKI in patients with septic shock. The aim of this study is to evaluate the usefulness of RI and NGAL in the early detection of AKI. METHODS: A prospective, observational study in a 20-bed medical/surgical ICU of a university teaching hospital. All patients with septic shock were recruited, excluding those with chronic renal failure (serum creatinine >120 μmol/l). Within the fi rst 24 hours after the introduction of vasopressor, urine and serum were collected for NGAL measurement and RI was determined by two independent operators. The occurrence of AKI was measured at day 3, according to RIFLE criteria. RI and NGAL were compared between patients with (RIFLE-F) and without (RIFLE-0/R/I) AKI. RESULTS: During the period from August to November 2010, 20 patients (age 58 ± 16) with septic shock were recruited. Eleven patients were classifi ed as having AKI. No signifi cant diff erence in baseline characteristics such as APACHE II score and baseline creatinine was shown at enrollment. RI, serum-NGAL and urine-NGAL were all higher in patients with AKI (RI: 0.749 ± 0.0697 (mean ± SD) vs. 0.585 ± 0.0983, P <0.001; serum-NGAL: 2,182 ± 838 ng/ml (mean ± SD) vs. 1,075 ± 1,006, P = 0.015; urine-NGAL: 2,009 ± 3,370 vs. 993 ± 1,789 (median ± IQR), P = 0.025). Area under the ROC curve for RI and serum-NGAL was 0.909 (±0.088, P = 0.002) and 0.808 (±0.113, P = 0.02), respectively. For RI, using 0.65 as the cut-off , sensitivity and specifi city was 1 and 0.89, respectively. For serum-NGAL, using a cut-off of 1,200 ng/ml, it had a sensitivity of 1 and specifi city of 0.67. Inter-observer diff erence of RI was low (0.0015 ± 0.0074 (mean ± SD)). CONCLUSIONS: Doppler ultrasound renal RI is non-invasive, rapidly available and easily reproducible, and is at least as good as NGAL as a predictor of AKI in patients with septic shock.link_to_OA_fulltextThe 31st International Symposium on Intensive Care and Emergency Medicine, Brussels, Belgium. 22-25 March 2011. In Critical Care, 2011, v. 15 suppl 1, p. 539, abstract no. P10

Increased intensity of treatment and decreased mortality in elderly patients in an intensive care unit over a decade

Objectives: Data collected from two cohorts of patients aged ≥80 yrs and admitted to an intensive care unit in France were compared to determine whether intensive care unit care and survival had evolved from the 1990s to the 2000s.Design: Retrospective cohort study on patient data attained during intensive care unit stays. Setting: 18-bed intensive care unit in an academic medical center. Patients: Two cohorts of patients aged ≥80 yrs, admitted to an intensive care unit at a 10-yr interval. Interventions: None. Measurements and Main Results: The first cohort comprised 348 patients admitted between January 1992 and December 1995, and the second cohort, 373 patients admitted between January 2001 and December 2004. There was no difference in age between the two cohorts, but patients in the second had significantly less history of functional limitation and significantly more acute illness (Simplified Acute Physiology Score II 43 ± 18 vs. 57 ± 25, respectively, p &lt; .0001). Patients in the second cohort had a significantly higher Omega Score, had a higher occurrence of renal replacement therapy, and received vasopressors more frequently than the patients in the first cohort, even when adjusted for age, sex, Knaus classification, Simplified Acute Physiology Score II, and intensive care unit admission cause. Intensive care unit mortality was 65% and 64% for the first and second cohorts, respectively. In multivariate analysis (including age, Knaus classification, Simplified Acute Physiology Score II and first vs. second period) for association with intensive care unit survival, the 2001–2004 period was associated with a near tripling of chances of survival (odds ratio 2.9; 95% confidence interval, 1.92–4.47, p &lt; .0001). Conclusions: The characteristics and intensity of treatment for elderly people admitted to the intensive care unit changed significantly over a decade. The intensity of treatments has increased over time and survival has improved over time as well. A potential link between increased treatment and improved survival in the elderly may be evoked

Target blood pressure in sepsis: between a rock and a hard place

The optimal target blood pressure in septic shock is still unknown. Therefore, in a long-term, resuscitated porcine model of fecal peritonitis-induced septic shock, Correa and colleagues tested whether different titrations of mean arterial pressure (50 to 60 and 75 to 85 mm Hg) would produce different effects on sepsis-related organ dysfunction. The higher blood pressure window was associated with increased needs for fluid resuscitation and norepinephrine support. However, titrating the lower blood pressure range coincided with an increased incidence of acute kidney injury. In contrast, neither the inflammatory response nor tissue mitochondrial activity showed any difference. This research paper in a clinically relevant model elegantly demonstrates that any standard resuscitation strategy may be a double-edged sword with respect to various therapeutic endpoints. Furthermore, it adds an important piece to the puzzle of the complex pathophysiology of sepsis-related acute kidney injury