Prise en charge des troubles du rythme en réanimation

Arrhythmias are frequent in intensive care unit patients, subsequent to hypoxia, hypokaliemia or acidosis. Specific treatment is required if correction of such disturbances is not sufficient. Electrical or pharmacological cardioversion is mandatory in case of a life-threatening arrhythmia. Thereafter, it is a challenge to maintain sinus rhythm and prevent recurrences. Skill in anti-arrhythmic therapy is essential to avoid proarrhythmias and other deleterious effects.     

Competencias en enfermeras Especialistas y en Enfermeras de Práctica Avanzada

ObjectiveTo analyse the distribution of advanced competences in specialist nurses and advanced practice nurses and to evaluate their association with some characteristics of their professional profile.MethodMulticentre analytical cross-sectional study. Nurses who worked as advanced practice nurses and specialist nurses were included. Their level of perceived advanced competences was measured, as well as sociodemographic and professional characterization variables.ResultsA total of 277 nurses participated (149 practised as advanced practice nurses and 128 as specialists), with an average of 13.88 (11.05) years as a specialist and 10.48 (5.32) years as an advanced practice nurse. In the sample, 28.8% had a master's or doctorate level qualification, 50.2% worked in Primary Care, 24.9% in hospitals and 22.7% in Mental Health. The self-perceived global level was high in the different competences, the lowest dimensions being research, evidence-based practice, quality and safety management and leadership and consulting. The advanced practice nurses obtained a higher level of competence globally and in the dimensions of leadership and consulting, interprofessional relations, care management, and health promotion. There were no differences based on experience or possession of a master's degree or doctorate. In the advanced practice nurses, the practice context did not influence competence levels, although in the specialist nurses it did, in favour of those practicing in Mental Health.ConclusionsSpecialist and advanced practice nurses have different competences that should be adequately managed for the development of advanced and specialist nursing services.     

L'héliox en réanimation et en médecine d'urgence

• 1.-Theoretical foundations

• 1.⊎Physical properties of helium
• 2.⊎Airway gas flow
• 3.⊎Consequences for medical technology
• 4.-Clinical applications

• 1.⊎Upper airway obstruction
• 2.⊎Asthma
• 3.⊎Chronic obstructive pulmonary disease
• 4.⊎Others:
  • 4.1.-bronchiolitis of the newborn
  • 4.2.-aerosol therapy
  • 4.3.-tracheal gas insufflation
  • 4.4.-bronchoscopy
  • 4.5.-high-frequency jet ventilation
• 5.-Logistical and technical aspects
  • 5.1.⊎Administration in spontaneous breathing
  • 5.2.⊎Administration in mechanical ventilation
  • 5.3.⊎Aerosols
• 6.-Cost

     

Transfusion érythrocytaire en urgence

Indication of blood transfusion is frequent in only some of the clinical situations encountered in emergency departments: severe trauma, gastrointestinal bleeding, and peripartum hemorrhage. In most situations, the usual recommendations concerning blood transfusion must be applied. In the emergency setting, some modifications are thought to be required but they are usually not evidence-based. The clinical conditions in which the transfusion triggers might be increased are those with a high rate of hemorrhage requiring anticipated blood transfusion, those where hematocrit can play a key role in hemostasis (severe head trauma, retroperitoneal hematoma), and those where cerebral circulation is crucial (severe head trauma with uncontrolled intracranial hypertension). Many recommendations (choice of donor’s blood group, distant blood storage) come from regulatory agencies. Lastly, to prevent blood transfusion has become an important objective even in emergency conditions (limitation of hemodilution, treatment of hypotensive factors non-related to hypovolemia, early embolization, damage control surgery), and autotransfusion is the only alternative therapy yet available.     

Probiotiques en réanimation

An acknowledgment of the crucial role of intestinal tract and digestive flora has aroused growing interest in the use of probiotics (defined as “live microorganisms that, when administered in adequate amount, confer a beneficial health effect”) during various intestinal disorders such as chronic inflammatory bowel disease, antibiotic-associated diarrhea, and extra-digestive diseases, namely atopic dermatitis, allergy, and asthma. However, clinical data related to their use in the intensive care unit, especially with the aim to prevent ventilator-associated pneumonia, are scarce and conflicting. We hereby review and discuss the usefulness of probiotics in critically ill patients.     

Candidoses en réanimation

Invasive candidiasis is a dread complication in hospitalized patients, characterized by mortality rates comparable to that of septic shock (40 to 60%). Its incidence in hospitalized patients is 0.5/1000 admissions, but about 10 per 1000 admissions in critical care where it represents 5 % to 10 % of all nosocomial bloodstream infections. Although a high proportion of hospitalized patients may become colonized with Candida spp, only a minority subsequently develop an infection. Clinical signs of such infection manifest only late rending them particularly difficult to diagnose. Early empiric antifungal treatment may improve the prognosis. However, for economical and epidemiological reasons, such a treatment can not be applied to all patients at risk. For these patients, empiric antifungal treatment could be started only when the colonization index reaches a threshold value that predicts subsequent infection. A better knowledge of the pathophysiology of Candida infections and the availability of triazoles compounds that are less toxic than amphotericin B, allowed the concept of prophylactic and preemptive therapy. However, antifungal prophylaxis is suspected as a major promoter of the emergence of potentially resistant non-albicans Candida, mostly in cancer centers. For critically ill patients, a strict restriction of prophylaxis to selected groups of patients for whom its efficacy is proven may contribute to limit this epidemiology.     

Souffrances et croyances chez 1000 sujets en surpoids ou obèses en France

Abstract

Few studies take into consideration overweight and obese subjects outside the consultation room. This study aims to better understand the experiences of these subjects, their suffering, perceived causes of their weight gain and perception of their weight loss.

Subjects and methods

A telephone survey was conducted of a representative sample of 1000 overweight (OW) (75.8%) or obese OB [24.6%] subjects.

Results

1) Suffering: 58% of the obese subjects and 30% of the OW subjects feel that they are much too fat. The more the subjects believe their excess weight to be an obstacle to their social life, the more they diet. Sadness, loneliness, suffering increase in line with Body Mass Index: suffering is mentioned by 28% of the OW subjects and 52% of the OB (P < 0.001). Obese women are twice as likely to express their suffering as OB men (65 vs 33%, P < 0.001); 2) perceived causes of OW or obesity: diet is the first cause cited (39%), with major differences between the gender: 58% of men as opposed to 22% of women quote diet as the most important factor (P < 0.01). Half of the subjects believe their diet is too rich, although 2/3 consider they have a normal, healthy diet. Eight percent say that their OW is principally caused by a psychological problem; 3) diet and weight loss: weight loss is accompanied by various fears: losing one’s jolly image, losing one’s freedom, fear of becoming irritable or depressive; and above all no longer being able to eat what one wants (61% of OB subjects). The more the subjects diet, the more they are afraid of becoming irritable and aggressive (19% for those who never diet as opposed to 37% for three who have dieted three times or more [P < 0.001]).

Conclusion

Suffering grows in line with weight gain, more so in women than in men. But most subjects are afraid of losing weight because they fear the psychological consequences of restrictive diets…     

Cuidados e implicaciones en los cuidadores de pacientes quirúrgicos en el domicilio

ObjectiveTo identify the care given by informal caregivers to patients who underwent abdominal surgery in the Consorci Hospitalari of Vic (Barcelona). To compare the responsibility burden for those caregivers in all the different stages of the surgical process. To determine the consequences of the care itself on the caregiver's health and to identify the factors that contribute to the need of providing care and the appearance of consequences for the caregivers in the home.MethodologyA longitudinal observational study with follow-up at admission, at discharge and 10 days, of 317 non-paid caregivers of patients who suffer underwent surgery. The characteristics of caregivers and surgical patients were studied. The validated questionnaire, ICUB97-R based on the model by Virginia Henderson, was used to measure the care provided by informal caregivers and its impact on patient quality of life.ResultsMost of the caregivers were women, with an average age of 52.9 ± 13.7 years without any previous experience as caregivers. The greater intensity of care and impact was observed in the time when they arrived home after hospital discharge (p < 0.05). The predictive variables of repercussions were being a dependent patient before the surgical intervention (β = 2.93, p = 0.007), having a cancer diagnosis (β = 2.87, p < .001) and time dedicated to the care process (β = 0.07, p = 0.018).ConclusionsCaregivers involved in the surgical process provide a great amount of care at home depending on the characteristics of patients they care for, and it affects their quality of life.     

Prise en charge en urgence des corps étrangers ingérés

Foreign body (FB) ingestion is frequent in children. FB can pass through spontaneously in around 80% of cases during the first week, but 20% of them require endoscopic removal, and <1% need surgery. Severe complications (perforation, abscess, fistula, massive haemorrhage) were reported. Radiographs of the neck, chest and abdomen, with anteroposterior and lateral views, are recommended to diagnose and to locate FB. The risk that FB > 2 cm in diameter or > 5 cm in size block in the esophagus, at the pylorus, duodenal curve, ligament of Treitz, Meckel diverticulum, ileocecal valve, appendix and rectosigmoid junction, is important. Like sharp and pointed FB, their endoscopic removal should be performed in emergency. Disk batteries should be removed from the esophagus during the first 2 hours because of the damages they can quickly induce. Concerning magnet ingestion, it is to note that one magnet can pass through spontaneously, but several magnets can attract themselves across intestinal loop inducing necrosis, then perforation or fistula. Esophageal food impaction can be associated with stenosis, motility disorder, or eosinophilic esophagitis that requires endoscopic biopsies for its diagnosis. Patients with small, blunt objects located at the lower third of the esophagus or in the stomach could be observed at home; radiograph should be performed 3 to 4 weeks later if the FB was not found in faeces. In children, it is recommended to perform FB extraction by endoscopy under general anaesthesia and tracheal intubation, using several accessories. This gives good success rate, reduces perendoscopic complications, and enables to diagnose mucosal lesions.     

Prise en charge de la glycémie du patient en état critique

The importance of the control of glycemia in critically ill patients has been recently highlighted by the report of significant reductions in the mortality and morbidity in patients in whom the insulin therapy aimed at maintaining blood sugar below 6.1 mmol/L. This article attempts to review the underlying mechanisms of stress hyperglycemia, and the results of previous clinical studies that have assessed the effects of hyperglycemia and of its management in various circumstances.Under the influence of inflammatory mediators and counter-regulatory hormones, a resistance to insulin appears and induces an increase in the production of glucose and a decrease in glucose utilization in some insulin-dependent tissues. The presence of hyperglycemia at the time of admission has been associated with an increased susceptibility to infection and with a worse outcome following acute myocardial infarction and stroke.Even though the underlying mechanisms are only partially elucidated, a tight control of glycemia is warranted in most critically ill patients.     

La coloscopie en France en 2008: résultats de l’enquête de deux jours d’endoscopie en France

Objectives

Obtaining an evaluation of the number of endoscopies of the lower digestive tract in France in 2008, and the reasons for carrying them out.

Patients and methods

It was a forward-looking survey carried out by sending questionnaires to all the French gastroenterologists (N = 3,125), asking them to forward information about their endoscopy activities over a given period; 1,039 sets of complete, analysable replies were received from 1,039 gastroenterologists, covering 7,247 endoscopies carried out on 6,250 patients.

Results

Sixty-one million four hundred sixty-six thousand nine hundred fifty-one colonoscopies were carried out in 2008, i.e. 2.5% or 30,000 fewer colonoscopies than in 2006. The overall number of endoscopies of the lower digestive tract fell by 5.2%, from 1,323,200 in 2006 to 1,253,002 in 2008. The main therapeutic endoscopic act was polypectomy, which remained stable at 311,757 colonoscopies with polypectomy, i.e. 27% of the 1,148,000 colonoscopies. Six hundred eight thousand (54%) of the 1,253,002 endoscopies of the lower digestive tract, i.e. 57% of the colonoscopies, were carried out within the framework of primary or secondary screening for monitoring and checks after polypectomy or monitoring after treatment of colorectal cancers. The colonoscopies carried out within 24 months after a previous colonoscopy made up 8% of the total of 1,147,951 colonoscopies, i.e. 91,023 examinations, whereas in all 46% of the patients had already had a full prior colonoscopy, 68% of which had been carried out more than three years beforehand. During 1,254,000 lower endoscopies to remove 951,535 polyps on the basis of the largest polyps, 77% lower endoscopies involved removal of at least one polyp measuring less than 10 mm or 29 and 48% measuring between 5 and 10 mm and less than 5 mm respectively.

Conclusions

Ten years after the first survey carried out by the SFED in 1998, the highest level of participation by gastroenterologists was in 2008. The number of colonoscopies carried out in 2008 was lower than in 2006, which shows rationalization of the practice of colonoscopy and the gastroenterologists’ compliance with the indications, together with the various measures implemented to distribute the recommendations. The Acbus (Agreement Covering Rational Use of Care) target of 0.5% for colonoscopy does not seem realistic, as in practice 8% of the colonoscopies were carried out less than two years after a previous colonoscopy on indisputable grounds (insufficient preparation of the examination or risk of haemorrhage due to failure to stop taking anticoagulants, justifying a second procedure for patients to remove polyps) in 3.5% of the cases.