Description of Streptococcus pneumoniae infections in burn patients

Background

Longer survival in burn patients has resulted in more infectious complications, typically with Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, and Staphylococcus aureus. Although Streptococcus pneumoniae infections are common in the community and can cause nosocomial infections, the incidence and risk factors for pneumococcal infections in burn patients is unclear.

Methods

We performed an electronic retrospective chart review to collect rates of and risk factors for S. pneumoniae infections in patients with thermal burns from March 2003 through June 2008.

Results

Of the 1838 patients admitted to the burn center, 10 were infected (0.54% incidence). Patients presented with pneumonia (seven patients, 0.38% incidence) and bacteremia (three patients, 0.16% incidence) within a week of initial burn (median 1 day, range 0–8), often in the setting of bacterial co-infection (five patients). This group was mainly young males with median 28.8% total body surface area burns; 60% had concomitant inhalational injury. Most did not have traditional risk factors for pneumococcal infection but had objective signs of infection at time of positive culture and were treated with appropriate antibiotics. Two patients in this series died, although no mortality was attributed to S. pneumoniae.

Conclusions

Pneumococcal disease is not common in burn patients and generally occurs early on in hospitalization after burn making it more likely to be a community-acquired pathogen rather than nosocomial in the burn population. It should be considered in the setting of sepsis or new pulmonary infiltrates within a week after burn, but typical empiric antibiotics against the usual burn pathogens should be adequate to also treat for pneumococcal infection.     

Impact clinique et économique d’une politique de contrôle de la sédation par protocole dans un service de réanimation médicochirurgicale

Objective

Since the last consensus conducted by Sfar/SRLF, the use of protocol for sedation became the reference in our ICUs. Decrease in length of stay and length of mechanical ventilation with used of these protocols have been already described. We would like to investigate the economic impact associated.

Study design

Using the PMSI data, we studied retrospectively, the economic effect, one year before and one year after protocol implementation in our ICU.

Method

The economic evaluation compared the cost of sedation but also the cost of mechanical ventilation and length of stay in ICU.

Results

Characteristic and number of patients were equivalent during the two years. We described a significant decrease in length of mechanical ventilation (8.8 vs. 8.4; p < 0.05) but not in length of stay (11.4 vs. 11.7; NS) between the two periods. We described a decrease of sedation cost of 11 412 euros and a decrease of mechanical ventilation cost of 27 360 Euros between the two years.

Conclusion

We confirm in this study that use of sedation protocol in ICU is associated with a clinical impact but also with an economic effect.     

PCT as a diagnostic and prognostic tool in burn patients. Whether time course has a role in monitoring sepsis treatment

Objective

To evaluate the diagnostic and prognostic performance of inflammatory markers for septic and non septic (localized) bacterial infections in patients with severe burn.

Methods and results

Data of 145 patients were prospectively included in this study. Serum procalcitonin and other inflammatory markers were measured within 24 h after burn and daily thereafter. Maximum procalcitonin (p = 0.004) was independent predictors of outcome in logistic regression analysis. PCT thresholds of 1.5 ng/ml, 0.52 ng/ml and 0.56 ng/ml had adequate sensitivity and specificity to diagnose sepsis, respiratory tract and wound infections respectively. A threshold value of 7.8 ng/ml in PCT concentration on day 3 was associated with the effectiveness of the sepsis treatment with an AUC of 0.86 (95% CI 0.69–1.03, p = 0.002). C-reactive protein levels and WBCs showed no significant change over the first 3 days in the patients with successfully treated sepsis (p = 0.93).

Conclusion

The maximum procalcitonin level has prognostic value in burn patients. PCT can be used as a diagnostic tool in patients with infectious complications with or without bacteremia during ICU stay. Daily consecutive PCT measurements may be a valuable tool in monitoring the effectiveness of antibiotic therapy in burn ICU patients.     

Central nervous system infections in patients with severe burns

Background

Central nervous system (CNS) infections develop in 3–9% of neurosurgical ICU patients and 0.4–2% of all patients hospitalized with head trauma. CNS infection incidence in burn patients is unknown and this study sets out to identify the incidence and risk factors associated with CNS infections.

Methods

A retrospective electronic chart review was performed from 1 July 2003 to 30 June 2008 evaluating inpatient medical records along with cerebrospinal fluid (CSF) microbiological results for the presence of CNS infection. The presence of facial and head injuries and burns, along with intracranial interventions were reviewed for association with CNS infections.

Results

There were 1964 admissions with 2 patients (0.1%) found to have CNS infection; 1 each with MRSA and Acinetobacter baumannii. Both patients had facial burns and trauma to their head that required intracranial surgery. Of note, both patients had bacteremia with the same microorganisms isolated from their CSF and both survived. Of all patients, 29% had head or neck trauma and burns; 0.35% of those had a CNS infection. Scalp harvest for grafts or debridement of burned scalp was performed on 125 patients of which 9 had an invasive surgical procedure that involved penetration of the skull. The 2 infected patients were from these 9 intracranial surgical patients revealing a 22% infection rate.

Conclusion

The incidence of CNS infections in patients with severe burns is extremely low at 0.1%. This rate was low even with head and face burns with trauma unless the patient underwent an intracranial procedure.     

Pancreatitis aguda durante la gestación,experiencia de 7 años en un centro de tercer nivel

Introduction

Acute pancreatitis is a common cause of acute abdomen in pregnant women. The purpose of this study was to determine the frequency at our institution and its management and outcomes.

Methods

A retrospective analysis of a database of cases presented in 7 consecutive years at a tertiary center was performed.

Results

Between December 2002 and August 2009, there were 19 cases of acute pancreatitis in pregnant women, 85% with a biliary etiology. The highest frequency was in the third trimester of pregnancy (62.5% cases). In cases of gallstone pancreatitis, 43.6% of pregnant women had had previous episodes before pregnancy. A total of 52.6% of the patients were readmitted for a recurrent episode of pancreatitis during their pregnancy. Overall, 26.3% of the patients received antibiotic treatment and 26.3% parenteral nutrition. Laparoscopic cholecystectomy was performed during the 2nd trimester in two patients (10.5%). There was no significant maternal morbidity.

Conclusion

Acute pancreatitis in pregnant women usually has a benign course with proper treatment. In cases of biliary origin, it appears that a surgical approach is suitable during the second trimester of pregnancy.     

Organisation de la ventilation artificielle dans les unités de réanimation en France

Objectives

To clarify the procedures related to mechanical ventilation in the intensive care unit setting: allocation of ventilators, team education, maintenance and reference documents.

Study design

Declarative survey.

Methods

Between September and December 2010, we assessed the assignment and types of ventilators (ICU ventilators, temporary repair ventilators, non-invasive ventilators [NIV], and transportation ventilators), medical and nurse education, maintenance of the ventilators, presence of reference documents. Results are expressed in median/range and proportions.

Results

Among the 62 participating ICUs, a median of 15 ventilators/ICU (range 1−50) was reported with more than one trademark in 47 (76%) units. Specific ventilators were used for NIV in 22 (35%) units, temporary repair in 49 (79%) and transportation in all the units. Nurse education courses were given by ICU physicians in 54 (87%) units or by a company in 29 (47%) units. Medical education courses were made by ICU senior physicians in 55 (89%) units or by a company in 21 (34%) units. These courses were organized occasionally in 24 (39%) ICU and bi-annually in 16 (26%) units. Maintenance procedures were made by the ICU staff in 39 (63%) units, dedicated staff (17 [27%]) or bioengineering technicians (14 [23%] ICU). Reference documents were written for maintenance procedures in 48 (77%) units, ventilator setup in 22 (35%) units and ventilator dysfunction in 20 (32%) ICU.

Conclusions

This first survey shows disparate distribution of ventilators and practices among French ICU. Education and understanding of the proper use of ventilators are key issues for security improvement.     

Nosocomial infection characteristics in a burn intensive care unit: Analysis of an eleven-year active surveillance

Aims

The objective of this study was to describe nosocomial infection (NI) rates, risk factors, etiologic agents, antibiotic susceptibility, invasive device utilization and invasive device associated infection rates in a burn intensive care unit (ICU) in Turkey.

Methods

Prospective surveillance of nosocomial infections was performed according to Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) criteria between 2001 and 2012. The data was analyzed retrospectively.

Results

During the study period 658 burn patients were admitted to our burn ICU. 469 cases acquired 602 NI for an overall NI rate of 23.1 per 1000 patient days. 109 of all the cases (16.5%) died. Pseudomonas aeruginosa (241), Acinetobacter baumannii (186) and Staphylococcus aureus (69) were the most common identified bacteria in 547 strains.

Conclusion

Total burn surface area, full thickness burn, older age, presence of inhalation injury were determined to be the significant risk factors for acquisition of NI. Determining the NI profile at a certain burn ICU can lead the medical staff apply the appropriate treatment regimen and limit the drug resistance. Eleven years surveillance report presented here provides a recent data about the risk factors of NI in a Turkish burn ICU.     

Enquête sur les attentes de la famille et/ou des proches d’un patient hospitalisé en réanimation après prise en charge extrahospitalière par une équipe du samu

Introduction

Emergency admission of a patient into an intensive care unit (ICU) is a source of stress for family and/or relatives. Expectations of family and/or relatives are important endpoints for the medical and paramedical team in charge of the patient, to better answer to their questions.

Objective

The aim of this study was to determine family's and/or relatives expectations concerning a patient emergently hospitalized into an ICU after out-of-hospital medical care of by a samu team.

Materials and method

We performed a survey using a questionnaire sent by email to 500 randomly chosen individuals from the French population.

Results

We received 220 responses (44 %). Family and/or relatives expectations are different about short, medium and long terms. Elements perceived as the most important in the short term are severity, diagnosis and prognosis, whereas in the medium and long terms they are hospital-stay and potential sequels. Medical language used is considered as too much complex for more than half of respondents. In case of foreseeable unfavourable outcome, 90 % of respondents would like to receive immediate information using a simple and brief language. At last, nearly two thirds of respondents had been really exposed to such a situation before, and assessed the quality of information received as moderate, with a score of 5/10.

Conclusion

Information of families and/or relatives of a patient hospitalized in ICU is essential. Their expectations concern short, medium and long terms. At last, most of them prefers that information would be delivered by a physician, and using a simple and brief language.     

Description de la prévention et estimation de la fréquence des erreurs de programmation de vitesse d’administration en continu des médicaments en réanimation par une application informatique

Objectives

To assess the usefulness and the feasibility to use a software supervising continuous infusion rates of drugs administered with pumps in ICU.

Study design

Follow-up of practices and inquiry in three intensive care units.

Material

Guardrails software^TM of reassurance of the regulations of the rates of pumps (AsenaGH^TM, Alaris).

Methods

First, evaluation and quantification of the number of infusion-rates adjustments reaching the maximal superior limit (considered as infusion-rate-errors stopped by the software). Secondly, appreciate the acceptance by staffs to such a system by a blinded questionnaire and a quantification of the number of dataset pumps programs performed with the software.

Results

The number of administrations started with the pumps of the study in the three services (11 beds) during the period of study was 63,069 and 42,694 of them (67.7 %) used the software. The number of potential errors of continuous infusion rates was 11, corresponding to a rate of infusion-rate errors of 26/100,000. KCl and insulin were concerned in two and five cases, respectively. Eighty percent of the nurses estimated that infusion-rate-errors were rare or exceptional but potentially harmful. Indeed, they considered that software supervising the continuous infusion rates of pumps could improve safety.

Conclusion

The risk of infusion-rate-errors of drugs administered continuously with pump in ICU is rare but potentially harmful. A software that controlled the continuous infusion rates could be useful.     

Rôle de la génétique dans la variabilité interindividuelle en anesthésie

Objective

This review discusses variability among patients in anesthesia, due to genetic polymorphisms.

Data sources

Articles in French and English languages were retrieved from PubMed database. The initial request was “anesth* and (genotyp* or polymorphism* or genetic*)”.

Study selection

Original articles, general reviews and one case report. Letters were excluded.

Data extraction

Rare genetic diseases were excluded from the scope of this review. We stressed on frequent genetic polymorphisms that may have a daily impact in anesthesiology.

Data synthesis

Most results were related to pain studies. We selected various examples to describe how genetic polymorphisms impacts the pharmacology of a given drug, and what are the clinical consequences.

Conclusion

There is a growing field of pharmacogenetic related evidences in anesthesiology. The results from various animal and human studies underline the genetic origin of variability among individuals. How anaesthesists have to integrate these parameters for their daily practice is still unclear, but pharmacogenetic will obviously be a leading field of anesthesia research in the future.     

Variation de kaliémie après une induction en séquence rapide avec la succinylcholine chez les patients de réanimation

Objective

Evaluate the changes in potassium following rapid sequence induction with succinylcholine in critically ill-patients and determine whether hospital length of stay could influence the succinylcholine-induced hyperkaliemia.

Study design

Prospective and observational study.

Patients and methods

After approval by our local ethical committee, we prospectively included 36 patients admitted from more than 24 hours in ICU and who required succinylcholine for rapid tracheal intubation (1 mg/kg). Serum potassium was measured before, 5 and 30 min after succinylcholine. The incidence of life-threatening hyperkaliemia (≥ 6.5 mmol/L) was noted.

Results

We could observe significant and transient increase in serum potassium (median increase of 0.45 [0.20–0.80] mmol/L at five minutes). A significant relationship was observed between the ICU length of stay and arterial potassium increase (r = 0.37, P < 0.05). From the ROC curve, a threshold of 12 days had an 86% sensitivity and 69% specificity in discriminating patients in whom the potassium increase was more than 1.5 mmol/L.

Conclusion

Induction with succinylcholine is followed by significant but transient hyperkaliema. The ICU length of stay before giving succinylcholine could influence significantly the amplitude of potassium increase.     

Avantages décisifs,indications et limites de l’anesthésie au xénon

Objective

To analyze the current knowledge related to xenon anaesthesia.

Data sources

References were obtained from computerized bibliographic research (Medline^®), recent review articles, the library of the service and personal files.

Study selection

All categories of articles on this topic have been selected.

Data extraction

Articles have been analyzed for biophysics, pharmacology, toxicity and environmental effects, clinical effects and using prospect.

Data synthesis

The noble gas xenon has anaesthetic properties that have been recognized 50 years ago. Xenon is receiving renewed interest because it has many characteristics of an ideal anaesthetic. In addition to its lack of effects on cardiovascular system, xenon has a low solubility enabling faster induction of and emergence from anaesthesia than with other inhalational agents. Nevertheless, at present, the cost and rarity of xenon limits widespread use in clinical practice. The development of closed rebreathing system that allowed recycling of xenon and therefore reducing its waste has led to a recent interest in this gas.

Conclusion

Reducing its cost will help xenon to find its place among anaesthetic agents and extend its use to severe patients with specific pathologies.     

Audit of protocols for treatment of paediatric burns in emergency departments in the Île de France

Introduction

The main purpose of this study was to establish the existence and accuracy of protocols for treatment of children with burns in emergency departments (EDs) across the Île de France. In addition, we also analysed the incidence of paediatric burns.

Methods

A postal questionnaire was sent to 91 EDs in the Île de France. Data collected were: number of children with burns in 2005, the absence or presence of specific written protocols. The ED was asked to send a copy of the protocol for analysis.

Results

Forty-six EDs (50.5%) replied to the questionnaire. These EDs treated a total of 3 258 children with burns, corresponding to 0.63% of paediatric pathologies in EDs. Amongst responding EDs, 48% had specific written protocols for the management of children with burns (but only in the larger EDs: >10 000 patient visits/year). A written protocol for managing pain in children was present in 65% of cases. For analgesia, 80% used oxygen/nitrous oxide. Concerning second-step analgesics, six EDs 67% used a combination of paracetamol/codeine and only 22% used non-steroidal antiflammatory drug. Regarding third-step analgesics, 67% used nalbuphine while only 43% used morphine.

Conclusion

3 200 children were registered with burns in half of the region's EDs during 2005 (0.63% of paediatric consultations). The larger the ED the higher was the availability of specific written protocols. International recommendations appeared to be respected concerning dressings, management of pain being marked by an under-utilisation of morphine.     

Time course of pro- and anti-inflammatory cytokine levels in patients with burns—Prognostic value of interleukin-10

Introduction

Trends and the prognostic value of cytokine responses to severe burns have not been fully examined in humans. Therefore, the aim of this study was to determine the time course and prognostic value of pro- and anti-inflammatory cytokines in the immediate post-burn period.

Patients and methods

Blood samples were taken for measuring IL-1β, IL-6, IL-8, IL-10, IL-12p70 and TNF-α concentrations from patients with more than 20% burned surface area on admission and on 5 consecutive days. Development of sepsis was assessed using standard criteria twice a day.

Results

IL-12p70 remained under assay detection levels in the study period. IL-1β and TNF-α could be detected in stimulated blood samples with higher levels in survivors (n = 21). IL-6 on days 4–5 and IL-8 on days 4–6 in non-stimulated plasma showed significant elevation in non-survivors (n = 18) whereas in stimulated blood its levels did not differ significantly. IL-10 levels were significantly higher in non-survivors during the study period in non-stimulated, and except day 6 in stimulated blood. Using the cut-off level of 14 pg ml⁻¹ for IL-10 predicted ICU mortality with 85.4% sensitivity and 84.2% specificity on admission.

Conclusion

Early anti-inflammatory excess had a bad prognosis for patients suffering from severe burns.     

Severe and acute pancreatitis admitted in intensive care: a prospective epidemiological multiple centre study using CClin network database

Objectives

To describe the demographic characteristics, incidence of extra-abdominal hospital-acquired infections and outcome of patients admitted to intensive care unit (ICU) with severe acute pancreatitis.

Study design

A retrospective, observational multiple center (65 centers) analysis of prospectively acquired data.

Patients and methods

During 2 years, all consecutive admitted patients to ICU for severe acute pancreatitis in the centers participating in the nosocomial infections surveillance network CClin Sud-Est were included. Patients whose ICU stay was less than 48 hours were not included. Demographic characteristics, extra-abdominal hospital-acquired infections and clinical course were described.

Results

During the study period, 510 patients were included which represented 2 % of patients with a length of stay longer than 48 hours in the 65 participating ICUs. The global attack rate of extra-abdominal hospital-acquired infections (pneumonia, bacteremia, urinary tract or central venous catheter infection) was 23 % in overall patients and it was 33 % in the 294 mechanically ventilated patients. ICU mortality was 20 % in overall patients and it was 34 % in mechanically ventilated patients.

Conclusion

Severe acute pancreatitis represents 2 % of ICU stay longer than 48 hours. Its clinical course is frequently complicated by hospital-acquired infections and is associated with an high ICU mortality rate. This epidemiological observational study may be used for calculating sample size for future multicenter interventional therapeutic studies.     

Amélioration de la perfusion des organes vitaux par la valve d’impédance inspiratoire et le concept de pompe respiratoire : rationnel physiologique et application clinique

Objective

In this article, we review the effects of the respiratory pump to improve vital organ perfusion by the use of an inspiratory threshold device.

Data sources

Medline and MeSH database.

Study selection

All papers with a level of proof of I to III have been used.

Data extraction

The analysis of the papers has focused on the physiological modifications induced by intrathoracic pressure regulation.

Data synthesis

Primary function of breathing is to provide gas exchange. Studies of the mechanisms involved in animals and humans provide the physiological underpinnings for “the other side of breathing”: to increase circulation to the heart and brain. We describe studies that focus on the fundamental relationship between the generation of negative intrathoracic pressure during inspiration through a low-level of resistance created by an impedance threshold device and the physiologic effects of a respiratory pump. A decrease in intrathoracic pressure during inspiration through a fixed resistance resulting in an intrathoracic pressure of −7 cmH₂O has multiple physiological benefits including: enhanced venous return, cardiac stroke volume and aortic blood pressure; lower intracranial pressure; resetting of the cardiac baroreflex; elevated cerebral blood flow oscillations and increased tissue blood flow/pressure gradient.

Conclusion

The clinical and animal studies support the use of the intrathoracic pump to treat different clinical conditions: hemorrhagic shock, orthostatic hypotension, septic shock, and cardiac arrest.