Réanimation Urgences最新文献

Phospholipase A₂ are enzymes that hydrolyse the sn-2 position of glycerophospholipids, and play a pivotal role in the generation of lipid inflammatory mediators. The type IIA secretory phospholipase A₂ (sPLA₂) is a distal effector of inflammation, produced by a number of cells challenged with inflammatory stimuli such as tumor necrosis factor or interleukin-1. Hydrolysis of the glycerophospholipids generates arachidonic acid, which is implicated in eicosanoid synthesis, and some important lipid mediators such as lyso-platelet activating factor, lysophosphatidic acid (LPA), or lysophosphatidylcholine (LPC). High levels of sPLA₂ are found in the plasma of patients suffering from sepsis, septic shock, adult respiratory distress syndrome and multiple organ failure. The levels are correlated to the intensity of the systemic inflammatory response and possibly to the outcome. This review presents important results concerning the pathophysiological implications of sPLA₂ in inflammatory disorders. We also present the role of LPA and LPC. The utility of the determination of sPLA₂ activity in clinical practice is discussed.

The aim of this study was to assess patients' satisfaction in an emergency unit.

Methods: French-speaking patients and volunteers that came to the emergency unit between 10:00 am and 12:00 pm were included in the study for a two-week period. In order to obtain reliable responses, the investigators interviewed the patients face to face with the assistance of a specific questionnaire.

Results: Fifty-two percent of the 514 interviewed patients agreed to answer the investigators' questions; the major reason for failure to reply was the lack of time. Using the Principal Components Analysis, the data were gathered into six dimensions: reception, waiting room 1, waiting room 2, staff appreciation, communication, and waiting time. Six scores of dissatisfaction were established, ranging from 0 (most satisfied) to 100 (most dissatisfied). The results showed that the most worrying point was the waiting (45 ± 22 min). The perception of the length of waiting time was statistically related (P < 0.0001) to the time spent in the emergency unit, contrary to its tolerance. The second point of dissatisfaction was the location (waiting room 1:30 ± 22; waiting room 2.31 ± 22). Finally, the most motivating point for the staff was the recognition of their work by the patients (28 ± 15).

Conclusion: This study found the reasons for the published dissatisfaction. Its intent was to quantify the degree of dissatisfaction and to treat the problems on a hierarchical basis, thus making it possible to better meet the patients' needs. The assessment of patients' satisfaction in an emergency unit is possible but implies a significant deployment of means to obtain a satisfying response rate.

• 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

Objective: To determine the incidence rate and the indications of red blood cell (RBC) transfusion in a pediatric intensive care unit (PICU).

Patients and methods: A prospective observational cohort study of 303 consecutive patients was carried out in a multidisciplinary PICU in a tertiary care university hospital. All the patients were monitored daily over a three-month period. No interventions were done.

Primary outcome measure: Reasons for and number of RBC transfusions.

Secondary outcome measure: Comparison of the data between the group of transfused patients versus non-transfused patients.

Results: Forty-five patients (5%) received one to 33 RBC transfusions, for a total of 103 transfusions. RBC transfusion was given according to the medical team and also clinical and paraclinical parameters, for the following reasons: respiratory failure ($\text{84}\text{103}$), active bleeding ($\text{67}\text{103}$), hemodynamic instability ($\text{50}\text{103}$), blood lactate level > 2 mmol/L ($\text{10}\text{103}$), or to increase oxygen delivery ($\text{6}\text{103}$). In many cases, more than one reason was specified, but in seven cases, no specific reason was provided. The mean hemoglobin concentration before transfusion was 8.1 ± 1.9 g/dL (median: 7.9; range: 3.8 to 17.1 g/dL). The mean PRISM III score at entry was 9 ± 5. The following data were significantly higher in the transfused group: antecedent of neoplasm or cardiovascular disease, hematologic or cardiovascular disease as primary affection, multiple organ dysfunction syndrome, PRISM III score at entry, death and length of stay in PICU.

Conclusion: In this PICU, 15% of the patients received at least one RBC transfusion. In most instances, the indication for a RBC transfusion was to support a respiratory failure. In 7% of the cases, there was no reported indication to explain the transfusion. Morbidity and mortality rates were higher among transfused patients.

Objective: To evaluate the delay to antibiotic therapy (DA) in acute bacterial meningitis (ABM) in adults admitted to the emergency department (ED) and to identify the clinical factors.

Patients and methods: A four-year retrospective study concerning patients admitted to the ED with a further proven diagnosis of ABM. Inclusion criteria: age > 15 years, non-tuberculous bacteria in cerebrospinal fluid (CSF) or in blood, proteinorrhachia > 0.40 g·L⁻¹, glycorrhachia/glycemia < 0.5, leukocytes > 5 mm⁻³ in CSF (≥ 80% polynuclear neutrophils) or cloudy CSF. Exclusion criteria: tuberculous or non-bacterial or nosocomial meningitis, uncertain diagnosis or established diagnosis of ABM before admission.

Results: Fifty-one patients, 27 males and 24 females, with a mean age of 45 years (range: 16–89 years) were included in the study. The mean DA was 216 min (range: 30–975 min). No patient was treated in less than 30 min. Factors associated with significantly longer DA included: a reason for administration other than “syndrome of meningeal irritation with fever” (P=0.041); unusual clinical features (P=0.032), in particular the absence of meningeal irritation or fever; the presence of a neurological deficiency; an advanced age (elderly); the realization of a cerebral CT scan before antibiotic therapy (P=0.0.27); management by a student instead of a senior in difficult cases (P=0.017); the recourse to the opinion of a specialist (P=0.013); and antibiotic therapy first administered in a department other than the ED (P=0.016).

Conclusion: Initiation of antibiotic therapy in ABM is too long. Interindividual variability of clinical features and fluctuations in time are the principal reasons. A cerebral scan and the opinion of a specialist before antibiotic therapy prolongs DA. The first administration of ATB must be done in the ED. The quality of the city-hospital network and emergency physicians' clinical experience are criteria for a more rapid DA. Therefore, a “too fundamentalist medical knowledge,” to the detriment of a “more pragmatic clinical education,” could explain the DA that we noted.

We report a case of acute respiratory distress syndrome (ARDS) in a 37-year-old man. Hypoxemia was refractory despite conventional treatment of ARDS, but the evolution was satisfactory after corticosteroid therapy. Biological data and the clinical evolution led us to the diagnosis of Churg-Strauss syndrome. This case incites us to reiterate that after having eliminating the usual causes of ARDS, the assumption of a systemic disease should be considered in order to begin the appropriate treatment as rapidly as possible.