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Background The calcaneus secundarius (CS) is an accessory ossicle of the anterior facet of the calcaneus and is usually asymptomatic. This accessory bone can be frequently mistaken for a fracture of the anterior process of the calcaneus. Few reports of symptomatic CS have been published, and physicians need to be familiar with imaging strategies when encountering chronic ankle pain or in case of suspicion of fracture of the anterior process of the calcaneus. Case presentation We describe the case of symptomatic CS in a professional soccer player injured during a match. First, computed tomography showed a large CS. Second, magnetic resonance imaging (MRI) demonstrated synchondrosis between the CS and the calcaneus, as well as edema (high MR T2 signal) within it, corresponding to posttraumatic edema. The patient was successfully treated with nonsteroidal anti-inflammatory drugs and physiotherapy; no surgical management was necessary. At the 4-week follow-up, he was pain-free and returned to activity. Conclusion This case illustrates the role of imaging for the diagnosis of CS in cases of acute pain of the foot. CT, as well as MRI, helped to confirm the diagnosis of CS traumatized synchondrosis, which can be mistaken for a fracture.

To measure the effects of increasing mean arterial pressure on oxygen variables and renal function in septic shock.Prospective, open-label, randomized, controlled study.Medical-surgical intensive care unit of a tertiary care teaching hospital.Twenty-eight patients with a diagnosis of septic shock who required fluid resuscitation and pressor agents to increase and maintain mean arterial pressureor =60 mm Hg.Patients were treated with fluid and norepinephrine to achieve and maintain a mean arterial pressure of 65 mm Hg. Then they were randomized in two groups: In the first group (control group, n = 14), mean arterial pressure was maintained at 65 mm Hg, and in the second group (n = 14), mean arterial pressure was increased to 85 mm Hg by increasing the dose of norepinephrine.Hemodynamic variables (mean arterial pressure, heart rate, mean pulmonary artery pressure, pulmonary artery occlusion pressure, cardiac index, systemic vascular resistance index, pulmonary vascular resistance index, left and right ventricular stroke indexes), metabolic variables (oxygen delivery, oxygen consumption-calorimetric method, arterial lactate), and renal function variables (urine flow, serum creatinine, creatinine clearance) were measured. After introduction of norepinephrine, similar values of hemodynamic, metabolic, and renal function variables were obtained in both groups. No changes were observed in group 1 during the study period. Increasing mean arterial pressure from 65 to 85 mm Hg with norepinephrine in group 2 resulted in a significant increase in cardiac index from 4.8 (3.8-6.0) to 5.8 (4.3-6.9) L.min.m. Arterial lactate and oxygen consumption did not change. No changes were observed in renal function variables: urine flow, 63 (14-127) and 70 (15-121) mL; serum creatinine, 170 (117-333) and 153 (112-310) mumol.L; and creatinine clearance, 50 (12-77) and 67 (13-89) mL.min.1.73 m.Increasing mean arterial pressure from 65 to 85 mm Hg with norepinephrine neither affects metabolic variables nor improves renal function.

To determine the independent risk factors for late-onset ventilator-associated pneumonia (VAP) in trauma patients receiving selective digestive decontamination (SDD). A 4-year, prospective cohort study of trauma patients meeting the following criteria: injury severity score >15, and duration of mechanical ventilation >5 days. Predictors of late-onset VAP occurrence were assessed by logistic regression analysis. All patients received SDD consisting of polymixin E, gentamicin, and amphotericin B applied in nostrils, mouth, and gut with a 3-day course of parenteral cefazolin. VAP was suspected on clinical and radiological signs, and confirmed by the presence of at least one microorganism at a concentration of at least 104 CFU/ml on the broncho-alveolar lavage. Independent risk factors for late-onset VAP. A late-onset VAP was diagnosed in 90 (56%) out of 159 patients. Predicting factors for late-onset VAP were: use of non-depolarizing muscle relaxant agents for intubation [3.4 (CI 1.08–10.73)], duration of intubation [1.06 (CI 1.01–1.17)], length of intensive care unit (ICU) stay [1.05 (CI 1.02–1.09)], and prior tracheal colonization [1.03 (CI 1.02–1.21)]. Exposure to prior antimicrobial treatment, except SDD, conferred protection [0.3 (0.12–0.74)]. This study confirms the role of duration of intubation, length of ICU stay, and prior tracheal colonization in the development of late-onset VAP. The results also highlight the importance of the initial management on the development of late-onset VAP. The type of neuromuscular blocking agents to intubate trauma patients should be evaluated in future studies.

To determine the effects on hemodynamics, laboratory parameters, and renal function of terlipressin used in septic-shock patients with hypotension not responsive to high-dose norepinephrine (>2.0 microg x kg(-1) x min(-1)) and dopamine (25 microg x kg(-1) x min(-1)), a prospective, open-label study was carried out in 17 patients. Patients received one or two boluses of 1 mg of terlipressin. In all patients terlipressin induced a significant increase in mean arterial pressure (MAP), systemic vascular resistance, pulmonary vascular resistance, and left and right ventricular stroke work. The increase in MAP was accompanied by a significant decrease in heart rate and cardiac index, but stroke volume remained unchanged. Oxygen delivery and consumption were significantly decreased. Blood lactate concentrations significantly decreased over the study period. Bilirubin, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were significantly increased. Thrombocytes were significantly decreased. No change in prothrombin time was observed. Renal function, assessed by urine flow and creatinine clearance, was significantly improved. Pulmonary function assessed by Pao2/Fio2 ratio was not affected. A significant reduction in norepinephrine and dopamine infusion rates was observed in all patients. Eight patients died during their ICU stay from late multiple organ failure. Within the limitations of the present study (open-label design, small group of patients), it can be concluded that in septic shock patients with hypotension nonresponsive to fluid resuscitation and high-dose vasopressors, terlipressin can be effective to restore MAP. Cardiac index should be closely monitored because it was significantly decreased by terlipressin. Renal function was significantly improved. Mesenteric circulation was not evaluated, but hepatic function was altered during the study period. Further studies are required to determine whether terlipressin is safe in terms of outcome in septic shock patients.

The purpose of this review is to analyze literature concerning the diagnosis, prevention, and management of catheter-associated urinary tract infection (CAUTI) occurring in patients hospitalized in the intensive care unit (ICU). Analysis was performed from personal and “Pubmed” data, crossing the following keywords: “urinary tract infection”, “catheter', and “intensive care unit”. Few clinical trials including ICU patients were found despite the abundance of expert opinions. There is no consensus on the use of urinary reagent tests for diagnosis. The prevention of CAUTI in ICU patients does not require expensive devices. Neither complex closed drainage systems nor silver-coated urinary catheters have demonstrated efficacy in comparative randomized clinical trials. Bladder irrigation should not be used, except when an obstruction of the catheter is highly likely. The administration of prophylactic antimicrobial therapy, although effective in reducing the incidence of urinary bacteria, cannot be recommended in ICU patients. The management of CAUTI in ICU patients has not been evaluated in clinical trials. The level of evidence provided in this field is weak, and underlines the need for randomized studies to improve management of patients.

To determine the risk factors for catheter-associated urinary tract infection in a polyvalent intensive care unit (ICU).Prospective cohort study.Sixteen-bed polyvalent ICU in a French university hospital.Prospective patient surveillance of patients included in two successive studies of two urine drainage systems.Bacteriuria occurrence in 553 ICU patients requiring a bladder catheter for longer than 48 h. The following variables were analyzed as possible risk factors: age, sex, severity score at admission, diagnosis on admission, duration of bladder catheterization, length of ICU stay, prior exposure to antibiotics, and system of urine drainage.The frequency of catheter-associated bacteriuria was 9.6%. From the multivariate analysis, five independent risk factors were determined: female sex, length of ICU stay, use of an antimicrobial therapy, severity score at admission, and duration of catheterization.In our study, the drainage system did not influence the occurrence of bacteriuria. To decrease the rate of catheter-associated bacteriuria in polyvalent ICU patients, removal of the bladder catheter must be performed as soon as possible.

In a previous nonrandomized study we observed no difference in the rate of acquisition of bacteriuria between a complex closed drainage system (CCDS) and a two-chamber drainage system (TCDS) in ICU patients. To confirm this result we performed a statistically powerful study assessing the effectiveness of the CCDS and the TCDS in ICU patients. Randomized, prospective, and controlled study in the medicosurgical intensive care unit (16 beds) in a teaching hospital. We assigned 311 patients requiring indwelling urinary catheter for longer than 48 h to TCDS or CCDS to compare the rate of acquisition of bacteriuria. Patients did not receive prophylactic antibiotics during placement management or catheter withdrawal. Urine samples were obtained weekly for the duration of catheterization and within 24 h after catheter removal, and each time symptoms of urinary infection were suspected. There was no statistical difference in the rate of bacteriuria between the two groups: 8% with TCDS and 8.5% with CCDS. Rates of urinary tract infection were 12.1 episodes with TCDS and 12.8 episodes with CCDS per 1000 days of catheter. This randomized study on the effectiveness of TCDS and CCDS in ICU patients confirms the findings of our previous study. No differences were noted between the two systems. The higher cost of CCDS is not justified for ICU patients.

Study objectives To determine whether the rate ofacquisition of bacteriuria differs between the use of a complex closeddrainage system (CCDS) with a preattached catheter, antireflux valve, drip chamber, and povidone-iodine releasing cartridge, and atwo-chamber open drainage system (TCOS) in ICU patients. Design Prospective, nonrandomized, controlled trial. Setting Medical/surgical/trauma ICU in a universityhospital. Patients Two hundred twenty-four ICUpatients requiring an indwelling urinary catheter. Intervention We compared the rate of acquisition ofbacteriuria in two groups of consecutive patients (n = 113 andn = 111, respectively) who underwent bladder catheterization with a TCOS during the first 6 months and with a CCDS during the next 6months. Urinary catheters were managed by a team of trained nursesfollowing the same written protocol. No prophylactic antibiotics wereadministered, either during management of catheter placements orcatheter withdrawal, but 75% of patients received one or moreantimicrobial medications for treatment of infected sites other thanthe urinary tract. Urine samples were obtained weekly for the durationof catheterization and within 24 h after catheter removal, andeach time symptoms of urinary infection were suspected. Only patientswho required an indwelling catheter for > 48 h were evaluated. Measurements and results There was no statisticaldifference in the rate of bacteriuria between the two groups. Bacteriuria occurred in 11.5% and 13.5% of patients, and wasdiagnosed on day 14 ± 8 and 13 ± 9 of catheterization(mean ± SD) for the TCOS and the CCDS, respectively. A CCDS cost $3(US dollars) more than the TCOS. Conclusions To ourknowledge, this is the first study to compare the effectiveness of a TCOS and a CCDS in ICU patients. No differences were noted between thetwo systems (α = 0.05). The higher cost of a CCDS is not justifiedfor ICU patients.

To assess the effects of a norepinephrine-induced vasoconstriction on renal function in septic and nonseptic patients.Open-label prospective study.Medical-surgical ICU in an urban teaching hospital.Fourteen patients with septic shock and 12 uninfected patients with head trauma (Glasgow coma score,8).Patients received norepinephrine infusion to increase systemic vascular resistance index (SVRI), and to raise mean arterial BP (MAP) to70 mm Hg in the septic group and cerebral perfusion pressure (CPP) to70 mm Hg in the head trauma group.MAP and SVRI increased in both groups (p0.001), and CPP significantly increased in the head trauma group (p0.001). The cardiac index was not modified in either group. Norepinephrine infusion reestablished urine flow in 12 of the 14 septic patients (p0.001), with a decrease in serum creatinine levels (p0.001) and an increase in creatinine clearance rate (p0.001) after 24 h. Urine parameters were not affected in the head trauma group.Within the limitation of the present study, norepinephrine administration induces a marked vasoconstriction in septic and nonseptic patients. Norepinephrine has positive effects on renal function in septic patients but has no significant effect on the same urinary parameters when administered to uninfected patients with normal renal function.