Réanimation Urgences最新文献

• •

  - Pharmacology of methadone

• •

  - Specific antagonist

• •

  - Toxicity of methadone in adults

• •

  - Therapeutic use in children

• •

  - Methadone poisoning in children

A case of recurrent hemothorax following accidental puncture of a normal aorta has been recorded. The patient was admitted for chronic bronchitis with subsequent dyspnea, and edema in the left lower leg. After clinical investigation, treatment included pleural drainage, during which arterial bleeding occurred. CT scan showed the absence of any aneurysm, but it revealed an accidental puncture of the descending aorta, which was directly in contact with the thoracic wall and situated very posteriorly. To the authors' knowledge, this is the only report in the literature on an accidental puncture of a normal aorta. However, one case of aneurysmal descending thoracic aorta and accidental puncture has already been reported.

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.

Experts designated by the Société de réanimation de langue française had to audit the 1988 French consensus about upper gastrointestinal bleeding in critically ill patients. In the last decades the incidence of this nosocomial complication has dramatically decreased. A high-risk population has to be defined. H2 antagonists and sucralfate seemed to be more effective than antacids and prostaglandins. Proton pump inhibitors and enteral nutrition could be alternative prophylaxis. The cost-effectiveness ratio wasn't completely defined but implantation of clinical guidelines may reduce costs and limit such treatment for high-risk patients.

The ventral seat belt in the rear seats of motor vehicles is supposed to protect the passenger who uses it. In this study, however, the case is examined of a seat belt-associated injury involving a teenager. The ‘two-point’ seat belt held the teenager in place during a head-on collision between two vehicles travelling at high speed, and prevented him from being thrown forwards by the impact; but although the safety belt saved his life, he almost lost it afterwards due to the severe abdomino-rachidian injuries that it caused. In conclusion, it has been observed that the standard ‘three-point’ seat belt has significantly reduced the morbidity and mortality rate connected with road accidents; however, the ‘two-point’ version used in the middle part of the back seat can cause serious injury in accidents that occur at high speed. It is recommended that after the appropriate safety tests have been carried out, the ‘two-point’ seat belt should be replaced by an officially approved ‘four-point’ version.

Workload in emergency departments is known to be heavy, and may lead to “burn out” of the medical staff. Although the quantitative factors have been much studied, very few studies on qualitative factors interfering with medical activities are available.

Method: From April to June 1998, eight physicians working in five emergency departments of the south-east of France answered a self-7-day activity evaluation. Quantity of workload, duration and nature of necessary and unjustified breaks were registered.

Results: During the 631 hours of activity, these eight seniors saw 3,961 patients (21.2% of the emergency departments patients, two patients/hour/senior). Time for clinical work was 70%, for administrative work 6.5%, for authorized breaks 16.7%, and for unexpected breaks 6.2%. Unexpected breaks (UB) were justified in 66% and unjustified in 34%, and happened every 132 minutes. They are due to a resident (20.8% of UB), a secretary (14.7% of UB), another patient (13% of UB), a nurse (12.1% of UB), commercial representatives (12.3% of UB), and other people (21% of UB). Medical directors (two physicians) had a heavier administrative workload, and were more frequently interrupted than other physicians (p < 0.01, and p < 0.05).

Conclusion: Qualitative factors should be considered as important as quantitative ones in the evaluation of emergency department physician's workload.

Aim: The aim of this study was to evaluate current practices for gastrointestinal bleeding prophylaxis in intensive care units (ICU) in France.

Methods: A descriptive transversal one given day survey was performed based on a national sample of adult ICUs. This survey focused on usual practices of gastrointestinal bleeding prophylaxis, and also on the type of preventive treatment in patients on prolonged mechanical ventilation (over 48 hours). A one-way analysis of variance was conducted, followed by a multivariate analysis, the results of which showed the main factors involved.

Results: One hundred and twenty-two ICUs participated in the survey, representing about 19% of the total amount of adult ICU beds. Of the 404 patients described, 268 (66.3%) received gastrointestinal bleeding prophylaxis on the day of the survey (omeprazole, 36.9%; ranitidine, 32.8%, or sucralfate, 30.2%). Preventive treatment was more common in medical or polyvalent units than in surgical ICUs (70.3% versus 55.2%; p < 0.01). The results did not show any association between the severity of the disease (estimated on an IGS II score basis) and the use of preventive treatment. Conversely, the latter was associated with the following factors: parenteral nutrition, shock, coagulopathy, history of gastrointestinal bleeding, and treatment with corticosteroids.

Conclusion: It was found that most ICUs in France use prophylactic treatment for the prevention of gastrointestinal bleeding. This probably helps to reduce the incidence of such cases.

The cost of intensive care is poorly documented in France, despite its contribution to the global hospital expenditures

Objectives: 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.