Constipation is independently associated with delirium in critically ill ventilated patients

International audienceDelirium is a central nervous system (CNS) dysfunction reported in up to 80 % of intensive care unit (ICU) patients associated with negative short- and long-term outcomes [1, 2]. Gastrointestinal motility disorders are frequent in ICU patients leading to frequent delayed passage of stools [3]. Because there is a bi-directional communication between the CNS and the digestive tract [4], we believed it relevant to test the hypothesis that constipation and delirium are related in ICU patients

Prise en charge des épanchements pleuraux parapneumoniques compliqués de l'adulte par ponctions pleurales itératives au CHU de Rennes au cours de la période 2001-2010

Les patients atteints d'EPP compliqués traités par PPR au CHU de Rennes entre 2011 et 2010 ont été évalués de façon rétrospective. L'échec des PPI était défini par le recours à un traitement évacuateur complémentaire, l'absence de guérison clinique ou radiologique ou le décès en rapport avec l'épisode infectieux. Soixante-dix-neuf patients consécutifs ont été pris en charge par PPR. Le taux de succès était de 81% (N=64). Seuls 3 patients (4%) ont été opérés. En analyse multivariée, la positivité de l'examen direct de la ponction pleurale exploratrice et un volume supérieur à 450mL lors de la première ponction étaient significativement associé à un échec. Les Odds-ratios ajustés respectifs étaient de 7,65 (IC 95%=1,44-40,67) et de 6,97 (IC 95%=1,86-26,07). Les complications des PPR les plus fréquentes étaient les ponctions blanches (N=23, 29%), les pneumothorax iatrogènes (N=5, 6%) et les malaises vagaux (N=3, 4%). Aucun pneumothorax iatrogène n'a nécessité un drainage thoracique. Aucun hémothorax ou œdème de ré-expansion n'a été mis en évidence. Bien que non présentes dans les recommandations internationales, les PPR représentent une option thérapeutique peu invasive, sûre et efficace pour la prise en charge des EPP compliqués.Patients with CPE managed by SST in Rennes university hospital between 2001 and 2010 were retrospectively evaluated. STT failure was defined by the need of complementary evacuation treatment, absence of clinical or radiological control or death due to the sepsis. Seventy-nine consecutive patients were managed with STT. The success rate was 81% (N=64). Only 3 patients (4%) were referred to thoracic surgery. In multivariate analysis, the gram-positive for bacteria and the volume of first therapeutic thoracentesis higher than 450 mL were significantly associated with STT failure. Adjusted Odds-ratios were 7,65 (CI 95%=1,44-40,67) and 6,97 (CI 95%=1,86-26,07) respectively. The main complications of STT were white thoracentesis (N=23, 29%), iatrogenic pneumothorax (N=5, 6%) and vasovagal reactions (N=3, 4%). None of these pneumothoraces required chest tube drainage. No hemothorax or re-expansion pulmonary edema was observed. Although not reported in the international recommendations, STT represents a less invasive, safe and effective therapeutic option for management of CPE.RENNES1-BU Santé (352382103) / SudocSudocFranceF

Repeated therapeutic thoracentesis to manage complicated parapneumonic effusions:

International audienceno abstrac

Massive intra-alveolar hemorrhage caused by leptospira serovar djasiman in a traveler returning from laos

International audienceLeptospirosis is one of the most common pathogens responsible for life-threatening tropical disease in travelers. We report a case of massive intra-alveolar hemorrhage caused by Leptospira serovar Djasiman in a 38-year-old man returning from Laos, who was cured with antibiotics and salvage treatment with extra-corporeal membrane oxygenation

Le syndrome des ongles jaunes : présentation de cinq cas. [The yellow nail syndrome: a series of five cases].

International audienceINTRODUCTION: The yellow nail syndrome is a rare disorder described for the first time in 1964. The pathophysiology remains unclear. Its definition is based on a clinical triad of yellow nails, lymphoedema and chronic respiratory disorders including pleural effusions and bronchiectasis. CASES REPORTS: We describe a retrospective series of five patients diagnosed with the yellow nail syndrome. All the patients were male, aged from 52 to 71 years (median=56). Three patients were diagnosed with the classic triad, whereas the other two had only yellow nails and bronchiectasis. Yellow nails and chronic sinusitis were present in all five patients. We also report atypical manifestations such as a transudative pleural effusion and facial oedema. The yellow nail syndrome was associated with cancer in two cases. CONCLUSION: More common alternative diagnoses must be excluded. The association with cancer should be explored. The treatment is only symptomatic

Iterative thoracentesis as first-line treatment of complicated parapneumonic effusion.

International audienceRATIONALE: Optimal management of complicated parapneumonic effusions (CPPE) remains controversial. OBJECTIVES: to assess safety and efficacy of iterative therapeutic thoracentesis (ITTC), the first-line treatment of CPPE in Rennes University Hospital. METHODS: Patients with CPPE were identified through our computerized database. We retrospectively studied all cases of CPPE initially managed with ITTC in our institution between 2001 and 2010. ITTC failure was defined by the need for additional treatment (i.e. surgery or percutaneous drainage), or death. RESULTS: Seventy-nine consecutive patients were included. The success rate was 81% (n = 64). Only 3 patients (4%) were referred to thoracic surgery. The one-year survival rate was 88%. On multivariate analysis, microorganisms observed in pleural fluid after Gram staining and first thoracentesis volume ≥450 mL were associated with ITTC failure with adjusted odds-ratios of 7.65 [95% CI, 1.44-40.67] and 6.97 [95% CI, 1.86-26.07], respectively. The main complications of ITTC were iatrogenic pneumothorax (n = 5, 6%) and vasovagal reactions (n = 3, 4%). None of the pneumothoraces required chest tube drainage, and no hemothorax or re-expansion pulmonary edema was observed. CONCLUSIONS: Although not indicated in international recommendations, ITTC is safe and effective as first-line treatment of CPPE, with limited invasiveness

At-risk drinking is independently associated with ICU and one-year mortality in critically ill nontrauma patients*.

International audienceOBJECTIVES: The impact of at-risk drinking on the outcomes of nontrauma patients is not well characterized. The aim of this study was to determine whether at-risk drinking is independently associated with the survival of nontrauma patients in an ICU and within 1 year following ICU discharge. DESIGN: Observational cohort study. SETTING: A 21-bed mixed ICU in a university hospital. PATIENTS: A total of 662 patients who experienced an ICU stay of 3 days or more and for whom alcohol consumption could be assessed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: ICU-related variables were collected prospectively, and a 1-year follow-up was determined retrospectively. Analyses were adjusted based on prognostic determinants of short- and long-term outcomes, as previously described in ICU patients and alcohol abusers. Two hundred and eight patients (33%) were identified as at-risk drinkers according to the National Institute on Alcohol Abuse and Alcoholism criteria. Additionally, 111 patients (17%) died in the ICU, and 97 (15%) died after ICU discharge. From the ICU admission until the end of the 1-year follow-up period, the at-risk drinkers exhibited poorer survival than the non-at-risk drinkers (p = 0.0004, as determined by the log-rank test). More specifically, 50 at-risk drinkers (24%) versus 61 non-at-risk drinkers (13%) died in the ICU (p = 0.0009 for the comparison). After adjustment, at-risk drinking remained independently associated with mortality in the ICU (adjusted odds ratio of 1.83; 95% CI of 1.16-2.89; p = 0.01) and with mortality within the year following ICU discharge (adjusted hazard ratio of 1.70; 95% CI of 1.15-2.52; p = 0.008). The causes of death in the at-risk and non-at-risk drinkers were similar. CONCLUSIONS: In this population of critically ill nontrauma patients, at-risk drinking was independently associated with death in the ICU and within the year following ICU discharge

Liver Cirrhosis is Independently Associated With 90-Day Mortality in ARDS Patients

International audienceBACKGROUND: In a few studies, cirrhosis has been associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). These studies were, however, conducted mostly before 2000. Over the last 15 years, the prognosis of cirrhotic patients admitted to the intensive care unit (ICU) seems to have improved and major changes in the management of mechanical ventilation (MV) of ARDS have appeared. The aim of this study was to determine whether cirrhosis remains a factor for poor prognosis despite improvements in MV techniques and supportive therapies for ARDS. METHODS: Retrospective analysis of data recorded from 232 patients (42 with cirrhosis and 290 without cirrhosis) who received lung-protective ventilation for ARDS defined according to American-European Consensus Conference criteria and admitted from 2006 to 2013. Alcohol was the most common aetiology of the cirrhosis. The end point was mortality at day-90 from the diagnosis of ARDS, survival was calculated using the Kaplan-Meier method, and we used a Cox-proportional hazard model to determine whether cirrhosis remained independently associated with mortality after adjustment for other prognostic variables for ARDS described previously. Organ dysfunctions were assessed based on the Sequential Organ Failure Assessment (SOFA) criteria, pulmonary and nonpulmonary dysfunctions were distinguished and compared between cirrhotic and non-cirrhotic patients on the first 3 days of VM. RESULTS: Comparison of survival curves showed that cirrhotic patients had a poorer 90-day prognosis than non-cirrhotic patients (P = 0.03 by the log-rank test). After adjusted analysis, cirrhosis remained independently associated with mortality at day 90 (adjusted hazard ratio 2.09, 95% CI, 1.27-3.45, P = 0.004). Non-pulmonary SOFA scores were significantly higher in cirrhotic patients than in non-cirrhotic patients on day 1 (P \textless 0.001), day 2 (P = 0.003), and day 3 (P = 0.002) of MV for ARDS whereas pulmonary SOFA scores did not differ significantly. CONCLUSIONS: Despite improvements in the management of cirrhotic patients admitted to the ICU and in the management of MV for the treatment of ARDS, cirrhosis remained associated with a poorer prognosis in ARDS patients. The prognosis of cirrhotic patients with ARDS appears related to extrapulmonary organ dysfunctions rather than pulmonary dysfunctio

Decline of multidrug-resistant Gram negative infections with the routine use of a multiple decontamination regimen in ICU

International audienceObjectives: We have shown that the routine use of a multiple decontamination regimen with oropharyngeal and digestive polymyxin/tobramycin/amphotericin B plus mupirocin/chlorhexidine in intubated patients reduced all-cause acquired infections (AIs) in the intensive care unit (ICU). We now assessed the long-term impact of this strategy on AIs involving multidrug-resistant aerobic Gram negative bacilli (AGNB) and acquired episodes of extended-spectrum betalactamase (ESBL)-producing Enterobacteriaceae rectal carriage. Methods: This was an observational single center study of all patients admitted to an ICU over 5 years (study population). Decontamination was given for the period of intubation and standard care otherwise. AIs and colonization rates were prospectively recorded. AIs rates were compared between the study period and a 1-year pre-intervention period. During study, trends were analyzed by semester using a Poisson regression model. Results: The incidence rate of multidrug-resistant AGNB AIs was lower during the study (1.59 per 1000 patient-days, versus pre-intervention: 5.43 parts per thousand, p < 0.001) and declined with time (adjusted OR = 0.85, 95 percent confidence interval 0.77-0.93, p < 0.001). ESBL-producing Enterobacteriaceae acquired colonization episodes (OR = 0.94 [0.88-1.00] P = 0.04) and the use of five major antibiotics (p < 0.001) also declined. Conclusion: A multiple decontamination regimen did not favor the emergence of multidrug-resistant AGNB. In contrast, infection and colonization rates declined with time. (C) 2016 The British Infection Association. Published by Elsevier Ltd. All rights reserved