Estimation of the diameter and cross-sectional area of the internal jugular veins in adult patients

International audienceINTRODUCTION: Unawareness of an asymmetry between the right and left internal jugular vein (IJV) and methodological pitfalls in previous studies raise concerns about such asymmetry. Hence the aim of this prospective non-interventional study was to validate the hypothesis that right IJV diameter is greater than those of left IJV and to determine the cross-sectional area of the IJVs using computed tomography (CT)-scans and original automatic software. METHODS: All consecutive adult outpatients who underwent a thoracic contrast-enhanced (TCE) helical CT-scan during a 5-month period were included. To determine diameter and cross sectional area of the IJVs, we used Advanced Vessel Analysis software integrated in a CT-scan (Advanced Vessel Analysis on Advantage Workstation Windows 4.2; General Electrics) allowing automatic segmentation of vessels and calculation of their diameters and cross-sectional areas. RESULTS: A total of 360 TCE CT-scans was performed; 170 were excluded from the analysis. On the remaining 190 CT scans, the diameter and cross-sectional area of the right IJV were significantly greater than those of the left IJV (17 +/- 5 mm [median: 17 mm, range: 13 to 20 mm] vs. 14 +/- 5 mm [median: 13 mm, range: 10 to 16 mm], P < 0.001; and 181 +/- 111 mm2 [median: 160 mm2, range: 108 to 235 mm2] vs. 120 +/- 81 mm2 [median: 102 mm2, range: 63 to 168 mm2], P < 0.001, respectively). CONCLUSIONS: In a general population of adult outpatients, the diameter and cross-sectional area of the right IJV were significantly greater than those of the left IJV. This could be an additional argument to prefer right over left IJV cannulation

Dopexamine and norepinephrine versus epinephrine on gastric perfusion in patients with septic shock: a randomized study [NCT00134212]

INTRODUCTION: Microcirculatory blood flow, and notably gut perfusion, is important in the development of multiple organ failure in septic shock. We compared the effects of dopexamine and norepinephrine (noradrenaline) with those of epinephrine (adrenaline) on gastric mucosal blood flow (GMBF) in patients with septic shock. The effects of these drugs on oxidative stress were also assessed. METHODS: This was a prospective randomized study performed in a surgical intensive care unit among adults fulfilling usual criteria for septic shock. Systemic and pulmonary hemodynamics, GMBF (laser-Doppler) and malondialdehyde were assessed just before catecholamine infusion (T(0)), as soon as mean arterial pressure (MAP) reached 70 to 80 mmHg (T(1)), and 2 hours (T(2)) and 6 hours (T(3)) after T(1). Drugs were titrated from 0.2 μg kg(-1 )min(-1 )with 0.2 μg kg(-1 )min(-1 )increments every 3 minutes for epinephrine and norepinephrine, and from 0.5 μg kg(-1 )min(-1 )with 0.5 μg kg(-1 )min(-1 )increments every 3 minutes for dopexamine. RESULTS: Twenty-two patients were included (10 receiving epinephrine, 12 receiving dopexamine–norepinephrine). There was no significant difference between groups on MAP at T(0), T(1), T(2), and T(3). Heart rate and cardiac output increased significantly more with epinephrine than with dopexamine–norepinephrine, whereas. GMBF increased significantly more with dopexamine–norepinephrine than with epinephrine between T(1 )and T(3 )(median values 106, 137, 133, and 165 versus 76, 91, 90, and 125 units of relative flux at T(0), T(1), T(2 )and T(3), respectively). Malondialdehyde similarly increased in both groups between T(1 )and T(3). CONCLUSION: In septic shock, at doses that induced the same effect on MAP, dopexamine–norepinephrine enhanced GMBF more than epinephrine did. No difference was observed on oxidative stress

Near-Fatal Multiple Organ Dysfunction Syndrome Induced by Plasmodium malariae

International audienc

Empiric antimicrobial therapy for ventilator-associated pneumonia after brain injury

International audienceIssues regarding recommendations on empiric antimicrobial therapy for ventilator-associated pneumonia (VAP) have emerged in specific populations.To develop and validate a score to guide empiric therapy in brain-injured patients with VAP, we prospectively followed a cohort of 379 brain-injured patients in five intensive care units. The score was externally validated in an independent cohort of 252 brain-injured patients and its extrapolation was tested in 221 burn patients.The multivariate analysis for predicting resistance (incidence 16.4%) showed two independent factors: preceding antimicrobial therapy ≥48 h (p\textless0.001) and VAP onset ≥10 days (p\textless0.001); the area under the receiver operating characteristic curve (AUC) was 0.822 (95% CI 0.770-0.883) in the learning cohort and 0.805 (95% CI 0.732-0.877) in the validation cohort. The score built from the factors selected in multivariate analysis predicted resistance with a sensitivity of 83%, a specificity of 71%, a positive predictive value of 37% and a negative predictive value of 96% in the validation cohort. The AUC of the multivariate analysis was poor in burn patients (0.671, 95% CI 0.596-0.751).Limited-spectrum empirical antimicrobial therapy has low risk of failure in brain-injured patients presenting with VAP before day 10 and when prior antimicrobial therapy lasts \textless48 

Severe Sepsis Associated with Lemierre's Syndrome: A Rare but Life-Threatening Disease

International audienceBackground. The incidence of Lemierre's syndrome has increased in the past decade. This posttonsillitis complication may be life threatening. Case Presentation. A 19-year-old patient was admitted to Surgical Intensive Care Unit of a French University Hospital for high fever, low blood pressure, and haemoptysis following a sore throat episode. Blood analysis revealed a thrombopenia, an acute renal failure, and an elevated lactate serum. Fusobacterium necrophorum was found in blood cultures. Computed tomography of the neck and lungs confirmed the diagnosis of Lemierre's syndrome: pleural effusions, bilateral lung infiltrates, and an internal jugular vein thrombosis. Fluid administration and antibiotic treatment were quickly initiated. Patient left the unit four days after his admission without any organ dysfunction. Conclusion. Lemierre's syndrome may lead to multiorgan dysfunction and should be rapidly identifie

Clinical review: Fever in septic ICU patients - friend or foe?

International audienceIn recent years, fever control in critically ill patients by medications and/or external cooling has gained widespread use, notably in patients suff ering from neurological injuries. Nevertheless, such a strategy in septic patients is not supported by relevant data. Indeed, in response to sepsis, experimental and clinical studies argue that fever plays a key role in increasing the clearance of microorganisms, the immune response and the heat shock response. Moreover, fever is a cornerstone diagnostic sign in clinical practice, which aids in early and appropriate therapy, and allows physicians to follow the infection course. After discussing the physiological aspects of fever production, the present review aims to delineate the advantages and drawbacks of fever in septic patients. Finally, the treatment of fever by pharmacological and/ or physical means is discussed with regards to their drawbacks, which argues for their careful use in septic patients in the absence of clinical relevance

Effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization.

International audiencePURPOSE: To evaluate the effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization, and impact on infection rates. METHODS: A prospective, before-after study in a surgical intensive care unit. All consecutive patients who had a central venous catheter (CVC) and/or urinary tract catheter (UTC) were included during two consecutive periods. Period 1 (August 2005 to May 2006) served as the control period. During Period 2 (July 2006 to April 2007), a red square, added to the patient's daily care sheet, questioned the physician about the utility of the CVC and/or UTC. If the response was "No", the CVC and/or the UTC were removed by a nurse. RESULTS: A total of 1,271 patients were analyzed (Period 1, n = 676; Period 2, n = 595). The duration of catheterization (median [interquartile range]) was significantly reduced in Period 2 compared to Period 1 (from (5 [3-9] to 4 [3-7] days, p < 0.001, for CVC, and from 5 [3-11] to 4 [3-8] days, p < 0.001, for UTC). The incidence and density incidence of CVC infection decreased in Period 2 compared to Period 1 (from 1.8% to 0.3%, p = 0.010, and from 2.8 to 0.7/1,000 CVC-days, p = 0.051) whereas UTC infections were not significantly different (4.3 to 3.0%, p = 0.230, and 5.0 to 4.9/1,000 UTC-days, p = 0.938, respectively). CONCLUSIONS: A simple daily reminder to physicians on the patients' care sheets decreased the duration of central venous and urinary tract catheterization, and tended to decrease CVC infection rate without affecting UTC infection