Analyse de la variabilité respiratoire de la pression artérielle pulsée en ventilation spontanée

Volume expansion (VE) is one of the main symptomatic treatment of critically ill patients with hemodynamic shock. Although the aim of VE is to increase stroke volume (SV) and organ perfusion, inappropriate administration may lead to poor outcome. During invasive mechanical ventilation, dynamic parameters based on cardiopulmonary interactions have been developed in order to predict the hemodynamic response to VE. Variations in SV and estimates like pulse pressure variation (PPV) can be used in clinical practice in highly selected patients, with regular cardiac rhythm, undergoing mechanical ventilation without spontaneous respiratory cycles. Several studies have tested the diagnostic accuracy of PPV to predict fluid responsiveness in nonintubated, spontaneously breathing patients. Analysis methods for PPV are currently either too complex or inaccurate to be recommended in clinical practice. The aim of this review is to present the rationale for, and the limitations of the use of PPV to predict fluid responsiveness in critically ill spontaneously breathing patients without mechanical ventilation.     

Mécanismes et prise en charge de la tubulopathie liée à la rhabdomyolyse

Severe damage of skeletal muscle, referred to as rhabdomyolysis, is the cause of 10% of acute kidney injury (AKI) cases and AKI complicates 13–50% of traumatic or nontraumatic rhabdomyolysis. Hypovolemia and the direct nephrotoxic effect of myoglobin are thought to be the main factors involved in rhabdomyolysis-induced AKI. Myoglobin promotes kidney injuries through vasoconstrictive properties, proximal tubular injuries, and distal obstruction. Recently, we demonstrated that macrophages influence the long-term prognosis of this disease by exerting proinflammatory as well as profibrotic properties. Clinical management relies on early diagnosis (creatine kinase > 5,000 UI/l) and fluid resuscitation using isotonic sodium chloride. Despite optimal rehydration, patients can develop AKI and require renal replacement therapy (RRT). Severe hyperkalemia or metabolic acidosis is the main cause of RRT. Thus, intermittent hemodialysis rather than continuous RRT should be used as frontline RRT, if available. To date, alkalinization, as well as prophylactic intermittent hemodialysis with high cut-off membrane, did not demonstrate superiority on long-term renal function compared to conventional approach. While global prognosis is depending upon the cause of rhabdomyolysis, mortality increases from 22% to 59% as soon as patients develop AKI. Long-term prognosis is unknown. Animal models demonstrated that rhabdomyolysis can lead to renal fibrosis after several months of followup. This suggests that patients with rhabdomyolysis should be considered as at high risk to develop chronic kidney disease and therefore referred to nephrologists to minimize long-term consequences of chronic kidney disease.     

Évaluation du coût de la réanimation, à partir de la Base nationale de coûts par activité médicale (France)

The cost of intensive care is poorly documented in France, despite its contribution to the global hospital expendituresObjectives: To assess the cost of intensive care in France.Design: To calculate mean costs by type of patients, from the National Hospital Cost Survey (NHCS).Patients: Patients hospitalized in an intensive care unit (ICU) in the public sector in 1997.Results: The average cost of hospitalization in ICU is 20.532 ± 29.262 FF or 5.112 ± 3.256 FF per day (N = 23.029 after trimming). Intensive care represents 46% of medical costs per patient and 38% of their total costs. Daily cost varies according to the mode of hospital discharge and type of stay.Discussion: The NHCS is the best available source of data on hospital costs, but it still underestimates the cost of ICU for sampling reasons, and does not yet include data to refine an analysis.Conclusion: The study confirms that the costs of ICU are significant as compared to other hospital stays, and allows for the computation of plausible orders of magnitudes.     

Douleur et culture: quelques questions de méthode liées à la mesure de la dimension culturelle

Résumé  Les relations entre douleur et culture soulèvent le problème de l’interaction complexe de facteurs biologiques, psychologiques, culturels et sociaux dans la perception et l’expression de la douleur. Elles posent également la question de la manière dont l’expérience douloureuse peut être traduite et communiquée dans le cadre d’une relation thérapeutique. Les questions qui se posent dans le domaine des rapports entre douleur et groupes sociaux et culturels sont donc multiples et de divers ordres. S’il s’agit bien s?r de savoir quelle est l’influence de ces variables sur la perception de la douleur et sur la réponse à la douleur, la question se pose cependant en premier lieu de savoir ce que recouvre la référence à la ?culture? des individus. Cet article propose un bref survol de quelques interrogations que soulève cette dimension ?culturelle?.      

Dyspnée laryngée après extubation: efficacité de la ventilation non invasive à deux niveaux de pression

Endotracheal reintubation for post-extubation acute respiratory distress is sometimes difficult due to the presence of laryngeal edema. In the present study, a report was made on two patients with post-extubation acute respiratory distress syndrome, whose clinical condition deteriorated even with optimal medical treatment. The onset of acute respiratory acidosis and the progressive loss of consciousness could have justified intubation and the use of mechanical ventilation. However, noninvasive bilevel nasal positive pressure ventilation was introduced, thereby avoiding a more aggressive therapeutic option: a rapid positive response was obtained in both cases.     

Intérêt et limites des bases de données médico-administratives: L’exemple de la cardiologie médicale à l’AP-HP

The objective of this work was to test (1) the effect of the quality of administrative data on the comparison of adjusted in-hospital mortality rates, and (2) the effect of additional clinical variables in the French version of the DRG model on the quality of mortality prediction. The study concerned two diseases (acute myocardial ischemy and congestive heart failure), taken care in departments of medical cardiology. Data from the DRG administrative database of cardiologic units of the Assistance Publique-Hôpitaux de Paris system were analysed. Additional clinical variables were defined by a group of cardiologists. The results put in evidence an important underreporting of the comorbidity in the collection made by the clinicians, especially those, which had a minimal impact on the DRG classification. In spite of a 15% rate of wrong DRGs, there was no significant difference in the total amount of Synthetic Index of Activity (ISA) after data reviewing. If the mortality prediction models are stronger after data reviewing and addition of supplementary variables, the impact of these factors in terms of comparison of the standardised mortality rates (SMR) is small.