Analgésie contrôlée par le patient brûlé: effet d'épargne de fentanyl par la clonidine

ObjectifTo determine the sparing effect of clonidine (C) on fentanyl (F) demand in burned patients under PCA.Study designProspective, randomized, double blind study versus placebo.PatientsTwelve consecutive patients with mean burn surface area of 20 ± 9%, studied between the third and the eighth day post-burn.MethodsF was delivered by a PCA pump (bolus: 1 mg·kg⁻¹). In the morning, burn patients received additional F (5 mg·kg⁻¹) before hydrotherapy. After randomisation, C or placebo (P) were alternatively infused over 24 hours. Demands for F during the morning, the afternoon and the evening were noted. Pain scores were measured on a visual analogic scale. In eight patients, plasma levels of F (pF) were iteratively measured. Heart rate, arterial pressure, respiratory rate and SpO₂ were monitored.ResultsAnalgesic demands were 19.5/day under P and 9.5 under C (P < 0.0001). Pain reoccurred for pF of 4.1 under C vs 5.7 under P (P < 0.05) with same pain scores in the two groups. After a pain stimulus, pain scores were lower under F, despite lower pF (P < 0.05). Arterial pressure and heart rate were significantly lowered during the first hour of C infusion.ConclusionDoses of F and pF required to reach analgesia were very high. Adding C decreases by 50% the F demand and lowers pF. Minor haemodynamic effects were observed during the first hour of C infusion.     

Protéines nutritionnelles et catabolisme musculaire chez le brûlé grave. Effets comparatifs de petits peptides ou d'acides aminés libres

The beneficial effects of hight caloric and protein enteral diet on wound healing and prevention of infection in severly burned patients is well documented. However, the relative proportion of each nutrient and especially the form of nitrogen supply have not yet been clearly established. The aim of this study was to compare, in severely burned patients, the efficiency of a partial protein hydrolysate and free amino acid formula during a 15-day enteral feeding. Twenty burned patients ranging in age from 18 to 67 years with a mean burn size of 40 ± 12 % of total body surface area, of which 31 ± 14 % was deep dermal, were studied prospectivly and randomised in two groups. Group A received the free amino acid diet which was obtained by hydrolysis of the protein hydrolysate given to Group B (60 % small peptides). All diets contained a nitrogen source of similar amino acid composition. Nitrogen balance was measured daily and serum protein concentrations were determined on days 0, 4, 8, 11 and 15. Anthropometric parameters, urinary 3 methylhistidine/creatinine ratio and plasma amino acid concentration were assessed on days 0, 8 and 15. Daily and cumulative nitrogen balance at D15 did not differ between the two groups. In group A, the circulating visceral proteins increased at all times of the study without decrease of acute phase reactant, whereas only transthyretin and retinol binding protein increased at D11 and D15 with a significant decrease of C-reactive protein at the same time in the other group. In group A, the musculary circumference had decreased at D8 and D15 without change of the 3 methylhistidine/creatinine ratio, whereas in group B the anthropometric parameters did not change with a decrease of the 3 methylhistidine/creatinine ratio at D8. Comparisons of D8 or D15 with D0 values showed that 14 amino acids, from which 6 essential amino acids increased significantly with the free amino acid diet, but only one amino acid increased with the protein hydrolysate diet. We conclude that in severely burned patients, enteral feeding with small peptides decreases muscular breakdown without change in hepatic protein synthesis. The enteral support containing free amino acids is more effective on serum protein levels, probably by increasing the production of endogenous amino acids.     

Estimation du volume de distribution de l’urée chez le patient hémodialysé

BackgroundOn-line urea clearance estimation, currently available on some dialysis monitors, makes it possible to calculate the dialysis dose Kt and thus allows to estimate Kt/V for each session, providing an estimation of urea distribution volume (V) at equilibrium assumed equal to total body water.MethodsThree methods suitable for routinely estimating V, using the anthropometric Watson formula (V_Wat), the body composition monitor (BCM) device (Fresenius Medical Care) based on bio-impedance analysis (V_imp) and the indirect estimation (V_Daug) obtained from measurement of Kt/(Kt/V)_sp ratio respectively are compared during 25 dialysis sessions in 15 patients to a direct estimation (V_DDQ) obtained by direct quantification of dialysis (DDQ) considered as the gold standard in hemodialysis patient..ResultsV_Watson overestimates V_DDQ by about 20%. The values of V_imp (29.1 ± 5.6 L) and V_Daug (29.5 ± 4.6 L) are in agreement with V_DDQ (29.9 ± 5.2 L). Correlation coefficient with V_DDQ is better for V_imp (r = 0.94) than for V_Daug (r = 0.85).ConclusionBio-impedancemetry using BCM and indirect method using the second generation Daugirdas equation are two methods of clinical interest for estimating V. Bio-impedancemetry does not require blood sample, but it needs to have a specific device at disposal.     

Résultat de la rééducation sur l’évolution motrice et fonctionnelle au cours du traitement de la tuberculose vertébrale

Objectives. – To evaluate the result of rehabilitation on motor and functional improvement in spinal tuberculosis.Methods. – Prospective case study. Data were collected from 47 patients with spinal tuberculosis medically and/or surgically treated, and rehabilitated over a period of 6 months, after spinal decompression and fusion. The main outcome measures were motor development of the patients was evaluated at the beginning, in the 1st week, in the 3rd month, and in the 6th month. Functional development of the patients was evaluated at the beginning and in the 6th month. Functional assessment was made according to Modified Barthel Index (MBI), and motor examination was make according to American Spinal Injury Association (ASIA).Results. – The study population consisted of 47 patients (22 males and 25 females) mean age 37.9 ± 18.3 years (range 5–76 years). The most common site of spinal tuberculosis was the thoracic region. Localized back pain, paraparesis, sensory dysfunction and fever were typical clinical manifestations. Surgical management was performed as anterior or posterior drainage of abscess and/or stabilization of the spine. The rehabilitation program was performed in all patients during the preoperative, early postoperative and late postoperative 6th month periods. Muscle-strengthening exercises on necessary localization such as pectoral, abdominal, lower extremities, truncal and sacrospinal extansors were started for the rehabilitation. The motor score for the lower limbs and the MBI scores for activities of daily living (ADL) and mobility improved significantly (P < 0.001). The self-care and mobility categories of the MBI on admission were 14.8% severely dependent and 10.6% independent. However, at the end of the rehabilitation program, 4.2% were severely dependent and 70.2% independent.Conclusion. – Early diagnosis and appropriate medical and/or surgical treatment together with a rehabilitation program will improve the life quality of patients with spinal tuberculosis.     

Infections nosocomiales dans un service de brûlés. Résultats d'une enquête prospective d'un an

ObjectivesTo assess nosocomial infections in a burn care centre, to identify patients' infection risk factors at the time of admission and factors of monthly variations of infection incidence.Study designProspective survey, from October 1992 to September 1993.Patients and methodThe study included 140 patients staying for more than two days in a 22-bed burn unit. Nosocomial infection criteria were derived from the 1988 CDC critera. Incidence rates of infection were calculated. Infected and noninfected patients were compared. Each monthly infection incidence was compared with six unit activity indicators.ResultsFifty-six patients developed 132 infections. The overall incidence was 94%. Incidence density was 25 infections per 1,000 days of care. The distribution of infected sites was: skin (30%), intravascular catheters (25%), blood (22%), urinary tract (18%), respiratory tract (5%). The most frequent pathogens were Pseudomonas sp (49%), Staphylococcus sp (18%), Escherichia coli (18%), and Streptococcus faecalis (10%). They were characterized by a good antibiotic sensitivity. Each common burn severity index was predictive of nosocomial infections. Facial, perineal and respiratory lesions were also linked to infection. There was a positive correlation between the peak of nosocomial infections in the unit during a month and the peak of activity during the foregoing one.ConclusionIncidence rates of infection were high, as 40% of the population was concerned. Choosing reliable infection criteria was the most difficult problem to solve.     

Effet de l'ondansétron sur la pression intracrânienne et la pression de perfusion cérébrale chez le patient neurochirurgical

ObjectiveTo determine the effect of ondansetron on intracranial pressure (ICP), mean arterial pressure (MAP) and cerebral perfusion pressure (CPP).Study designProspective, comparative, randomized double-blind study.PatientsTwenty-six patients undergoing intracranial surgery.MethodInduction was obtained with propofol (1–2.5 mg·kg⁻¹), fentanyl (1.5 μg·kg⁻¹) and pancuronium (0.1 mg·kg⁻¹), and maintenance was achieved with propofol and fentanyl. Intermittent positive pressure ventilation was used to ensure mild hypocapnia at 35 ± 2 mmHg. Positioning of the patient was followed by 15 minutes steady-state. Patient received thereafter either 8 mg ondansetron or a placebo intravenously. The ICP was measured using a lumbar malleable spinal needle. CPP was calculated using the formula CCP = MAP-ICP. All variables were measured every minute for 15 minutes.ResultsThe ICP, MAP and CPP did not differ between the two groups. There were no differences in the highest ICP values in patients receiving either ondansetron or placebo (11 ± 5 versus 9 ± 5,± SD), respectively.ConclusionIntravenous administration of 8 mg ondansetron affects neither cerebral hemodynamics nor ICP.