Year in review 2009: Critical Care - metabolism

Novel insights into the metabolic alterations of critical illness were published in Critical Care in 2009. The association between early hypoglycaemia/high glycemic variability and poor outcome was confirmed. Improvements in the understanding of the pathophysiological mechanisms of stress hyperglycemia and potential progress in the bedside management of glucose control were presented. With regard to enteral nutrition, some alterations of gastrointestinal physiology were better delineated. The relationship between the achievement of nutritional goals and outcomes was further investigated. Finally, understanding of some critical-illness-related endocrine and neuromuscular disorders improved through new experimental and clinical findings

Multiple organ failure after an overdose of less than 0.4 mg/kg of colchicine: role of coingestants and drugs during intensive care management.

INTRODUCTION: Although the ingestion of a dose of colchicine lower than 0.5 mg/kg is usually complicated by a mortality rate less than 5%, severe complications may be associated with drug-drug interactions in case of overdose combining other drugs. CASE REPORT: A 33-year-old previously healthy woman was admitted after a drug overdose combining colchicine, atorvastatin, ibuprofen, diclofenac, and furosemide. The amount of colchicine ingested was exactly 20 mg, corresponding to 0.33 mg/kg. Despite this relatively low dose, she presented the clinical course that is usually seen with much larger colchicine ingestions. She developed acute renal and liver failure, acute lung injury, pancytopenia with sepsis, rhabdomyolysis, hypertriglyceridemia, and ultimately died on Day 14 from hyperammonemic encephalopathy, refractory hypoxemia, and cardiac arrhythmias. DISCUSSION: Serious drug-drug interactions may have complicated colchicine poisoning. In particular, atorvastatin, an inhibitor of P-glycoprotein and cytochrome P450 3A4, was likely responsible for an increased severity of rhabdomyolysis. In addition, propofol used for sedation during mechanical ventilation may have induced symptoms consistent with "propofol infusion syndrome," with further muscular injury and hypertriglyceridemia. The mechanism of death was unusual and similar to Reye's syndrome

Lipid emulsion as rescue therapy in lamotrigine overdose.

BACKGROUND: Lamotrigine is a sodium channel blocking agent that is widely prescribed for treatment of seizure. Although life-threatening effects are rarely observed in overdose, some previous reports have described the occurrence of cardiac toxicity. The management of sodium channel blocking agent-induced cardiotoxicity conventionally requires sodium bicarbonate administration. Recent case reports describe intravenous lipid administration as a successful treatment for refractory cardiovascular collapse induced by sodium channel blocking medications. OBJECTIVE: The objective of this study is to report the use of intravenous lipid emulsion as adjunctive therapy in a case of lamotrigine overdose in which electrocardiographic changes were unresponsive to bicarbonate therapy. CASE REPORT: We report a case of intentional lamotrigine overdose in a 50-year-old woman who lost consciousness and developed electrocardiographic aberrations, including widening of QRS with occurrence of left bundle branch block. The patient was initially treated with sodium bicarbonate without effect. Recovery of cardiac conduction was rapidly achieved after infusion of a 20% lipid emulsion. The exact mechanism of action of lipid emulsion is not fully understood. The lipophilic properties of lamotrigine suggest that it was partially removed by the plasmatic lipid emulsion. CONCLUSION: This case provides additional insight into the potential benefit of using lipid emulsion in refractory sodium channel blocking intoxications

Application of a Hyaluronic Acid Gel after Intrauterine Surgery May Improve Spontaneous Fertility: A Randomized Controlled Trial in New Zealand White Rabbits

International audienceOBJECTIVE:Intrauterine adhesions (IUAs) are the most common complication after hysteroscopy in patients of reproductive age. Intra-abdominal anti-adhesion gel reduces the incidence of adhesions, but effects on fertility after uterine surgery are not known. The objective of our work was to evaluate the effect of intrauterine anti-adhesion gel on spontaneous fertility after repeated intrauterine surgery with induced experimental synechiae in the rabbit model.MATERIALS AND METHODS:Twenty New Zealand White rabbits underwent a double uterine curettage 10 days apart and were randomized into two groups. Each rabbit served as its own control: one uterine tube was the treatment group (A), the second uterine tube was the control group (B) to avoid bias through other causes of infertility. Group A received a post curettage intrauterine instillation of anti-adhesion gel whereas group B, the control group, underwent curettage without instillation of the gel. After a recovery period, the rabbits were mated. An abdominal ultrasound performed 21 days after mating allowed us to diagnose pregnancy and quantify the number of viable fetuses.RESULTS:There was a significant difference in total fetuses in favor of group A, with an average of 3.7 (range, 0-9) total fetuses per tube against 2.1 (0-7) in group B (p = .04). The number of viable fetuses shows a trend in favor of group A, with an average of 3.4 (0-7) viable fetuses per tube against 1.9 (0-6) viable fetuses per tube in group B (p = .05).CONCLUSION:The use of immediate postoperative anti-adhesion gel improved fertility in an animal model after intrauterine surgery likely to cause uterine synechiae. This experimental model will permit comparison of different anti-adhesion solutions, including assessment of their tolerance and potential mucosal toxicity on embryonic development

Impact of systematic urinary catheterization protocol in delivery room on covert postpartum urinary retention: a before-after study

International audienceWe investigated whether implementation of a routine catheterization procedure in labor improves covert postpartum urinary retention (cPUR) rates. We conducted a prospective before-after study. 121 women admitted to delivery room in the observational group, and 82 in the intervention group, in a tertiary university hospital in Southern France were included. All patients in the intervention group were systematically catheterized 2 hours after delivery. cPUR was screened for in both groups. The primary end-point was cPUR (post-void residual bladder volume >150 ml when voided volume is >150 mL). The rate of cPUR decreased from 50% (60 out of 121 patients) in the observational group to 17% (14/82) in the intervention group (OR = 0.21; 95% Confidence Interval [0.13;0.58]; p < 0.001). Similarly, in the subgroup of patients who underwent instrumental delivery, the rate of cPUR was lower in the intervention group (18%, 2/11) than in the observational group (65%, 15/23) (p = 0.02). Systematic intermittent bladder catheterization immediately postpartum could decrease cPUR. Further studies are necessary to assess the long-term outcomes and improve understanding of postpartum voiding dysfunction

El Diario de Pontevedra : periódico liberal: Ano XIV Número 3910 - 1897 xullo 14

Synthetic mesh surgery for both abdominal and urogenital hernia repair is often unsatisfactory in the long-term due to postoperative complications. We hypothesized that a semi-degradable mesh hybrid may provide more appropriate biocompatibility with comparable mechanical properties. The aim was to compare its in vivo biocompatibility with a commercial polypropylene (PP) mesh.72 rats were randomly allocated to either our new composite mesh (monofilament PP mesh knitted with polylactic-acid-fibers (PLA)) or to a commercially available PP mesh that was used as a control. 15, 90, and 180 days after implantation into the rat abdomen mesh tissue complexes were analysed for erosion, contraction, foreign body reaction, tissue integration and biomechanical properties.No differences were seen in regard to clinical parameters including erosion, contraction or infection rates between the two groups. Biomechanical properties including breaking load, stiffness and deformation did not show any significant differences between the different materials at any timepoint. Macrophage staining did not reveal any significant differences between the two groups or between timepoints either. In regard to collagen I there was significantly less collagen I in the PP group compared to the PP/ PLA group at day 180. Collagen III did not show any significant differences at any timepoint between the two groups.A PP/PLA hybrid mesh, leaving a low amount of PP after PLA degradation seems to have comparable biomechanical properties like PP at 180 days due to enhanced collagen production without significant differences in erosion, contraction, herniation or infection rates