Qualité : du concept à la pratique

Quality approach supposes to measure the discrepancies between reality and recommendations. Then corrective actions can be proposed. A good goal for a specific unit could identify only a few fields that should be investigated yearly. This process should involve not only the ICU director and head nurse but also the whole team. The corrective actions must be evaluated and the results shared in the team. A benchmarking approach in comparison with similar units can also be stimulating.     

Pancréatite aiguë : nutrition artificielle

Severe acute necrotizing pancreatitis is a stressfull disease. Nutritional support is recommended as in any other critical situation. The aim of artificial nutrition is to supply metabolic demands, to prevent wasting, to modulate the inflammatory response, to protect gut barrier function and prevent bacterial translocation which is probably the main cause of necrosis infection. Literature may help to conclude that artificial nutrition, by enteral or parenteral route, does not worsen pancreatitis. Lipid emulsions may be used safely intravenously. Enteral route (in post-pyloric position) is the best way. The effects on stress response are well established as in other critical situations. It is feasible safely and administration must be realized as soon as possible. Finally it is a cost-effective technique. We must not forget early micronutrients and vitamins supplementation.     

Translocation bactérienne : mythe ou réalité ?

Bacterial translocation is defined as the passage of viable enteric bacteria across the intestinal mucosal barrier to the mesenteric lymph nodes and distant organs. Three mechanisms have been suggested to explain the phenomenon: altered intestinal barrier function, bacterial overgrowth, and impaired host defense. In experimental approach, reduced blood flow in the gut, trauma, chronic inflammation or immunosuppression are conditions that enhance bacterial translocation. In humans, bacterial translocation from the intestinal lumen has been demonstrated and some related infections have been identified. However, no data have confirmed the ˈintestinal hypothesisˈ which implicates the bacterial translocation in the systemic inflammatory response syndrome or in the multivisceral organ failure syndrome. Some nutritional variations may experimentally modify the incidence of bacterial translocations and are therefore proposed to clinicians.     

Méningites à pneumocoque : actualités,perspectives

Streptococcus pneumoniae is the most frequent cause of severe meningitis in adults. Effective antibiotic treatment must be given early, before lumbar puncture, even if a CT scan is needed. In France, 40% of pneumococci have a decreased susceptibility to penicillin. As a consequence, the recommended probabilistic treatment is the association of a third-generation cephalosporin and vancomycin. Neurological complications are the consequence of cytotoxic and vasogenic cerebral edema. Until now corticosteroids have failed to improve the prognosis of patients with pneumococcal meningitis. Other treatments, such as anti-TNF antibodies or antioxidants, seem to be able to decrease the risk of cerebral damages in some experimental models.     

Prise en charge du sevrage difficile et prolongé ; expérience du centre médical de Bligny : à propos de 146 cas sur une période de dix ans

In this retrospective study, the authors present their experience in caring for patients with prolonged and difficult weaning from mechanical ventilation. During a period of 10 years, 146 tracheostomised patients with a mean age of 68.2 ± 8.5 were transferred from different intensive care units (ICUs) to the Centre Médical de Bligny for difficult weaning, after a mechanical ventilation duration of 57 ± 33 days. One hundred and one patients were suffering from chronic lung disease (group 1) while 45 remaining patients were not (group 2). Group 1 patients were hospitalised for a mean duration of 25 ± 24 days in the ICU, and for 48 ± 43 days in the Pneumology department. In-hospital mortality was 27%. Complete weaning was obtained in 65% of the survivors. One-year survival was 64%. Group 2 patients were hospitalised for a mean duration of 24 ± 18 days in the ICU, and for 38 ± 31 days in the Pneumology department. In-hospital mortality was 23%. Complete weaning was obtained in 85% of survivors. One-year survival was 74%. The authors conclude on the necessity to develop weaning centers in France.     

Traitements adjuvants du choc septique. « Que reste-t-il de nos amours ? »

Twenty years ago, people thought that mortality of septic shock could be dramatically reduced by compounds like anti-endotoxin and anti-cytokin antibodies. Numerous studies failed to demonstrate any effect and a long period of depression happened. We are probably entering a new therapeutic area with several positive results, including stress doses of corticosteroïds and activated protein C.However the reduction in mortality will be far smaller than anticipated mainly because attribuable mortality of septic shock is more limited than previously thought.     

Prélèvement pulmonaire positif à Candida : infection nosocomiale ou colonisation ?

In intensive care, bronchial specimens positive to Candida are a common finding, even in non-immunocompromised hosts. This may be due to the extension to the lung of a colonization from the mouth and esophagus in intubated patients with diabetes or alcoholism or in patients given antibiotics. Previous studies have underlined two distinct entities: Candida pneumonia may occur in immunocompromised patients, frequently with a long-term catheter, in the context of septicemia; the lung is therefore a secondary localization of the systemic candidosis. Conversely, Candida bronchopneumonia may occur in ICU patients, with or without immunosuppression, and is integrated in a large colonization of the tracheobronchial tree. This colonization could account for positive bronchial specimens beyond or above the threshold and is possibly associated with a colonization of other sites (i.e., urine, digestive tract, and skin). The treatment of Candida bronchopneumonia is integrated into that of the colonization, a feature recognized as independently associated with further systemic candidosis.