Qualité des préparations coliques et délai entre la fin de la préparation et la coloscopie

Aims

Bowel preparation is a key factor in the quality of colonoscopy. The administration of the preparation is now well codified and the importance of a short time between the end of the preparation and examination is known. However, there is still discrepancies concerning this time. The purpose of this study was to investigate the relationship between the quality of preparation and the time between the end of the intake and examination.

Patients and methods

For two consecutive weeks, all patients having a colonoscopy at the Hôpital Privé des Peupliers were studied prospectively. The time of the end of the preparation was noted as well as the quality of bowel preparation, as assessed by the Boston scale. Standard bowel preparation was a split dose of 4 liter PEG. The hours for the preparation were different depending on whether the examination was scheduled in the morning or afternoon.

Results

Of the 171 patients enrolled, 159 were analyzed. There was a significant correlation between the Boston scale and the time between the end of the preparation and colonoscopy. This correlation persisted after exclusion of patients who had not taken all the preparation. By grouping the patients into six classes of time — examination preparation (< 4 h, 4–6 h, 6–8 h, 8–10 h, 10–12 h and >12 h) and two preparation classes (perfect preparation [Boston 8 or 9] or not perfect preparation [Boston < 8]), we noted that the frequency of a perfect preparation was not different between groups with time <4 h (79%) or between four and six hours (80 %), this frequency of a perfect preparation was significantly lower for all other groups within >6 h. The quality of preparation was not different for colonoscopy performed in the morning or afternoon, and there was no difference between the 4 liter PEG preparation and other type of preparation.

Conclusion

This study confirms the correlation between completion of preparation and colonoscopy, and preparation quality. It does not seem to exist such an ideal time but rather a time interval between 0 and 6 hours during which the frequency of a perfect preparation remains high and stable. These results suggest that a colonoscopy should be performed during this time interval.     

Obésité de la personne âgée: définition, phénotypes, épidémiologie et conséquences pour la santé

It is difficult to define what is meant by the term obesity in elderly persons (EPs), as aging is associated with increased body fat and reduced lean body mass. The body mass index (BMI) is thus difficult to interpret, particularly as height also decreases with age. Thus, the percentage of body fat in an EP is around the same level as the threshold at which a young adult would be considered obese (25% for men and 35% for women in the over 60s). Moreover, it would seem important to consider body fat distribution and fat-free mass are situated, rather than just the BMI; in this way, three clinical forms of obesity can be described: abdominal obesity (or central obesity), age-related lipodystrophy and sarcopenia, which all need careful assessment in terms of prognosis. The various complications of obesity are presented, as obesity can cause numerous functional disorders and is a risk factor for metabolic and cardiovascular disease as well as for cancer and cognitive decline. Nevertheless, excess adipose tissue can protect against osteoporosis and wasting disease.     

Comment optimiser la nutrition entérale du patient ventilé ?

Nutritional support is a cornerstone of the care of critically ill patients treated with invasive mechanical ventilation. Guidelines recommend to start nutrition as soon as possible after admission in the intensive care unit and to use the enteral route. However, many critically ill patients experience poor tolerance to early enteral nutrition (EN), which has been ascribed to gastroparesis with increased gastric volume, gastroesophageal reflux, regurgitation or vomiting and subsequent increased risk of aspiration and ventilator-associated pneumonia. Management of intolerance to EN has been reported as a leading cause of hypocaloric feeding. However, both definition and management of gastrointestinal intolerance to enteral feeding should be revisited. Regurgitation and vomiting do not seem to be a leading cause of significant complications including ventilator-associated pneumonia. Thus, prevention of vomiting should not significantly impede the delivery of EN. Monitoring of gastric residual volume should not be routinely performed. In case of vomiting, prokinetic drugs should be administered in first-line before any reduction in the rate of EN delivery. Prophylactic treatment with prokinetic drugs should be promoted in patients at high risk of vomiting. Predetermined protocol on EN delivery should be implemented in all intensive care units with the aim to achieve nutritional goals in most of the patients treated with mechanical ventilation. Because of numerous uncertainties, further studies are required in the field of artificial nutrition in the critically ill patients.     

Activité physique dans la prise en charge de l’obésité : effets bénéfiques et modalités pratiques

Regular physical activity is a fully recognized modality in the treatment of obesity and can contribute to decrease cardiovascular and metabolic morbidity. This didactic article focuses on the physiopathological benefits of physical activity in the treatment of obesity. Physical activity recommendations as well as efficient alternate modalities are explored in order to favor the management and treatment of the cardiovascular and metabolic morbidity associated with obesity.     

L'insuffisance respiratoire aiguë du syndrome de Guillain-Barré et de la myasthénie auto-immune. De la détection au sevrage de la ventilation mécanique

Guillain-Barré syndrome (GBS) and myasthenia gravis (MG) are the most common neuromuscular causes of acute respiratory failure. Their prognosis has been considerably improved by the advent of mechanical ventilation. However patients remain at risk of respiratory arrest, because the severity of respiratory failure is often underestimated as patients often have minimal symptoms. Aspiration pneumonia, nonspecific complications of mechanical ventilation and weaning failure may also occur. Respiratory failure may be due to weakness of inspiratory and/or expiratory muscles, which can be assessed by the measurement of vital capacity (VC) and static maximal pressures. Bulbar dysfunction may also be a contributory factor. Patients with respiratory symptoms, especially orthopnoea, a reduction of VC below 60% of the predicted value or bulbar weakness must be referred to intensive care, particularly since GBS follows a progressive course and MG is characterized by fluctuating motor deficit. Criteria for mechanical ventilation include signs of respiratory distress, hypoxemia, hypercapnia or a VC below 20% predicted, but because of the risk of aspiration, major bulbar weakness can also be considered to be an indication. Weaning should only be started if there has been neurological improvement and VC is above 20%. Extubation should be preceded by a prolonged trial of spontaneous ventilation. Measurement of VC is essential at each step of the evolution of neuromuscular respiratory failure.     

Utilité de la différence veinoartérielle en dioxyde de carbone dans la prise en charge du choc septique

Acute circulatory failure in septic shock will produce macro- and microcirculatory disorders leading to tissue hypoxia. The venous-to-arterial carbon dioxide tension difference is the difference between partial pressure of CO₂ in mixed venous (gapPCO₂) or in central venous blood (ΔPCO₂) and in the arterial blood. It depends on the cardiac output, the global CO₂ production, and the relationship between PCO₂ and the CO₂ content (CCO₂). Measuring the ΔPCO₂ during the resuscitation of septic shock patients might be beneficial when determining when to continue reanimation despite a central venous oxygen saturation (ScvO₂) > 70% and a high blood lactate level. Because hyperlactatemia is not a discriminatory factor in determining the source of the cellular stress, an increased ΔPCO₂ (> 6 mmHg) could be used to identify patients who remain inadequately resuscitated. Decreasing the ΔPCO₂ is a therapeutic goal to adjust cardiac output to the metabolic demand. Moreover, ΔPCO₂ can help to titrate inotropes to adjust oxygen delivery (DO₂) toCO₂ production, or to choose between hemoglobin correction and fluid/inotrope infusion in patients with too low ScvO₂. ΔPCO₂ combined with oxygen-derived parameter, arteriovenous oxygen content difference (C(a-cv)O₂), through the calculation of the ΔPCO₂/C(a-cv)O₂ ratio can be a useful hemodynamic tool to detect the activation of global anaerobic metabolism.     

Programme d’amélioration de la qualité de la prise en charge de la douleur des malades hospitalisés pour HIV ou cancer

Résumé  Nous présentons le rapport d’un programme d’assurance qualité réalisé dans deux services hospitaliers de médecine, maladies infectieuses et oncologie (appel d’offres ANDEM ANAES entre 96–98). Le programme a débouché sur des actions qui sont définis (évaluation systématique, élaboration d’un classeur douleur). Les observations réalisées peuvent être utiles pour des projets analogues. Rapport final ANDEM ANAES de Déc. 98