Search

Resume Objectifs Verifier l’adequation entre les posologies de vancomycine recommandees par les societes savantes et les objectifs pharmacologiques a atteindre chez des patients de reanimation : concentration a l’equilibre (CE) et rapport CE/CMI (concentration minimale inhibitrice). Des facteurs de variabilite des CE de vancomycine ont egalement ete recherches. Patients et methode Etude monocentrique observationnelle retrospective portant sur 66 patients de reanimation sous antibiotherapie incluant la vancomycine, seule ou en association, en traitement d’une infection severe a cocci Gram positif. Les posologies utilisees etaient de 15 mg/kg sur une heure (avec pour vitesse maximale 1 g/h) pour la dose de charge, puis de 40 a 60 mg/kg chaque 24 heures en injection veineuse continue. Les CE de vancomycine et les CMI des germes impliques ont ete recueillies. Le rapport CE/CMI etait considere comme efficace si superieur a 8. Resultats Quarante-deux pour cent des CE de vancomycine etaient efficaces. Vingt-trois pour cent des rapports CE/CMI etaient superieurs a 8. Le taux de guerison clinique etait de 71 % des patients. La duree de l’antibiotherapie a ete identifiee comme interagissant de facon positive avec l’efficacite biologique de la vancomycine, et le sepsis severe comme un facteur d’interaction negative. Conclusion Moins de la moitie des CE et moins du quart des rapports CE/CMI sont efficaces dans notre etude. Vingt-neuf pour cent des patients sont en echec therapeutique, malgre l’utilisation des posologies recommandees, posant la question de la revision des posologies, de l’administration et du dosage de la vancomycine.

Resume Objectifs Verifier l’adequation entre les posologies d’aminosides recommandees et les objectifs de quotient inhibiteur (QI) a atteindre chez des patients de reanimation. Patients et methode Etude monocentrique observationnelle retrospective de 87 patients de reanimation places sous double antibiotherapie incluant obligatoirement un aminoside (amikacine ou gentamicine), en traitement d’une infection severe. Les posologies utilisees etaient de 15 mg/kg pour l’amikacine et de 5 mg/kg pour la gentamicine. Les concentrations maximales (Cmax) d’aminosides et les concentrations minimales inhibitrices (CMI) des germes impliques ont ete recueillies. Le rapport Cmax/CMI (ou QI) a ete calcule. Un QI est considere comme efficace s’il est superieur a 10. Les Cmax du premier pic d’aminosides ont ete comparees aux Cmax theoriques a atteindre. Des facteurs de variabilite des concentrations plasmatiques au pic d’aminosides (Cmax) ont ete recherches : index de gravite standardise 2 (IGS2), âge, sexe, poids, gravite du sepsis. Resultats Parmi les Cmax, 50,3 % etaient efficaces, soit 59,6 % pour l’amikacine et 38,9 % pour la gentamicine. Quarante-six pour cent des premiers QI etaient efficients ; 12,6 % des premieres Cmax atteignaient les valeurs theoriques. Une efficacite clinique etait observee a 72 heures chez 67,8 % des patients. Les facteurs interagissant negativement avec l’efficacite biologique des aminosides etaient les infections a cocci Gram positif et a anaerobies, et les patients de chirurgie programmee. Conclusion Parmi les QI de notre etude, 49,7 % etaient inefficaces et 32,2 % des patients etaient en echec therapeutique, malgre l’utilisation des posologies d’aminosides recommandees, posant la question de la revision des modalites d’administration des aminosides et surtout des doses recommandees.

Sleep behaviour has been extensively studied with questionnaires in industrialised countries to investigate the epidemiology of sleep-wake disorders. However, only few attempts have yet been made to examine sleep behaviour of people living in Africa. Although, a large number of studies in hot or cold environments have used short-term exposures, reporting disrupted sleep for most of them, long-term exposures to stressful thermal environments are rare in the literature. Prior to the present investigation, we used questionnaires to analyse the effects of seasonal heat increase on perceived sleep behaviour and sleep quality in young native African students in Niger [7], even though these methods of investigation are by no means as accurate as polysomnographic recordings. The hypothesis was that sleep behaviour may be influenced by climatic variations in a hot dry tropical climate. Such climatic variations have been shown to induce seasonal heat acclimatisation marked by changes in body temperature rhythms in the hot versus the cool season [13]. Sleep behaviour was examined during two 7-day periods in January ("cool-dry" season, 88 subjects) and May ("hot-dry" season, 53 subjects). The questionnaire was completed after night sleep and/or naps. The subjects slept an average of 7 1/2 hours a day, most of them having afternoon naps. They experienced no major seasonal variation in their sleep behaviour, but for an increased number of awakenings during the hot season. Restorative quality of sleep scored lower after a nap than after nocturnal sleep. Therefore, general sleep characteristics were not modified by seasonal temperature variations in African native students, perhaps because of the limited changes in daylight under the low latitude of Niamey. Another investigation was carried out using the same 12-item questionnaire in Abidjan on 78 medical students who did not have a nap [9]. Contrary to the Niamey students, the Abidjan subjects adopted short duration sleep schedules, without any effect on the subjective quality of the restorative properties of their sleep.

Ultrasound guidance is useful for venipuncture and placement of central venous access catheters; however, anatomical variants may complicate catheter insertion. A 52-yr-old female patient was admitted to the intensive care unit with acute respiratory distress due to bilateral pneumonia. Her respiratory status worsened rapidly and she required mechanical ventilation. For cardiovascular monitoring, an ultrasound-guided cannulation of her left subclavian vein was performed uneventfully using an Acuson CV70 cardiovascular ultrasound system (Siemens , Erlangen, Germany), and a central venous catheter (CVC) was inserted. A chest x-ray revealed a left-sided paramediastinal course of the CVC (Figure, Panel A), at which point, we considered the potential for arterial placement, accidental venous placement in normal structures (superior intercostal vein or internal thoracic vein), or a malformed left superior vena cava. Subsequently, the diagnosis of persistent left superior vena cava (PLSVC) was confirmed by thoracic computed tomography with contrast injection. Reconstructed computer tomography scan imaging (Figure, Panel B) showed the left subclavian vein give rise to the PLSVC, which drains into in the left atrium, and the brachiocephalic vein that forms the right superior vena cava. The CVC was then removed, and another was inserted uneventfully into the right internal jugular vein using ultrasound guidance. The patient’s respiratory status improved progressively, and her trachea was extubated 21 days later. Persistent left superior vena cava is the most common major anomaly of the systemic venous system. This anatomic variant, which is asymptomatic, results from persistence of an embryological vessel that normally involutes into the coronary sinus. Persistent left superior vena cava is not an absolute contraindication for subclavian vein cannulation if adequate drainage into the right atrium exists. Nevertheless, difficulties can arise during CVC insertion, transjugular intrahepatic portosystemic shunt insertion, and pulmonary artery catheter and pacemaker insertion. The etiology of the CVC false tracking in patients with PLSVC is usually established by chest x-ray and can be confirmed by echocardiography. This case illustrates that thoracic computed tomography is an important diagnostic imaging modality to delineate variant central venous anatomy.