Search

OBJECTIVE: To determine the predictive factors, clinical manifestations, and the outcome of patients with posttraumatic pulmonary embolism (PE) admitted in the intensive care unit (ICU). METHODS: During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each trauma patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study period, all trauma patients admitted to our ICU were classified into two groups. The first group included all patients with confirmed PE; the second group included patients without clinical manifestations of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or its branches. RESULTS: During the study period, 1067 trauma patients were admitted in our ICU. The diagnosis of PE was confirmed in 34 patients (3.2%). The mean delay of development of PE was 11.3 ± 9.3 days. Eight patients (24%) developed this complication within five days of ICU admission. On the day of PE diagnosis, the clinical examination showed that 13 patients (38.2%) were hypotensive, 23 (67.7%) had systemic inflammatory response syndrome (SIRS), three (8.8%) had clinical manifestations of deep venous thrombosis (DVT), and 32 (94%) had respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 32 cases (94%) and low molecular weight heparin was used in two cases (4%). The mean ICU stay was 31.6 ± 35.7 days and the mean hospital stay was 32.7 ± 35.3 days. The mortality rate in the ICU was 38.2% and the in-hospital mortality rate was 41%. The multivariate analysis showed that factors associated with poor prognosis in the ICU were the presence of circulatory failure (Shock) (Odds ratio (OR) = 9.96) and thrombocytopenia (OR = 32.5). Moreover, comparison between patients with and without PE showed that the predictive factors of PE were: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO2/FiO2 < 200 mmHg, the presence of spine fracture, and the presence of meningeal hemorrhage. CONCLUSION: Despite the high frequency of DVT in post-traumatic critically ill patients, symptomatic PE remains, although not frequently observed, because systematic screening is not performed. Factors associated with poor prognosis in the ICU are the presence of circulatory failure (shock) and thrombocytopenia. Predictive factors of PE are: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO2/FiO2 < 200, the presence of a spine fracture, and the presence of meningeal hemorrhage. Prevention is highly warranted. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Damak et al.(2011) Clinical features, complications and mortality in critically ill patients with 2009 influenza A(H1N1) in Sfax,Tunisia. Influenza and Other Respiratory Viruses 5(4), 230-240 Africa, as the rest of the world, was touched by the 2009 pandemic influenza A(H1N1). In the literature, a few publications covering this subject emerged from this continent. We prospectively describe baseline characteristics, treatment and outcomes of consecutive critically ill patients with confirmed 2009 influenza A(H1N1) in the intensive care unit (ICU) of Sfax hospital. From 29 November 2009 through 21 January 2010, 32 patients with confirmed 2009 influenza A(H1N1) were admitted to our ICU. We prospectively analysed data and outcomes of these patients and compared survivors and dead patients to identify any predictors of death. Patients were young (mean, 36·1 [SD], 20·7 years) and 21 (65·6%) of whom had co-morbidities. During ICU care, 29 (90·6%) patients had respiratory failure; among these, 15 (46·9%) patients required invasive ventilation with a median duration of 9 (IQR 3-12) days. In our experience, respiratory dysfunction can remain isolated but may also be associated with other dysfunctions or complications, such as, septic shock, seizures, myasthenia gravis exacerbation, Guillan-Barre syndrome, acute renal failure, nosocomial infections and biological disturbances. The nine patients (28·1%) who died had greater initial severity of illness (SAPS II and sequential organ failure assessment (SOFA) scores) but also a higher SOFA score and increasing severity of organ dysfunction during their ICU evolution. Critical illness from the 2009 influenza A(H1N1) in Sfax occurred in young individuals and was associated with severe acute respiratory and additional organ system failure. SAPS II and SOFA scores at ICU admission, and also during evolution, constitute a good predictor of death. [ABSTRACT FROM AUTHOR]

Abstract: The aim of this retrospective descriptive study was to describe both epidemiologically and clinically manifestations following severe scorpion envenomation and to define simple predictive factors which can be used in routine practice in general Intensive Care Units (ICU) as an indicator of poor prognosis. Cases were collected from hospital patients'' files during 13-year (1990–2002) period in the medical Intensive Care Unit of a university hospital (Sfax – Tunisia). The diagnosis of scorpion envenomation was based on a history of scorpion sting. Nine hundred fifty-one patients, who were admitted for a scorpion sting, were analyzed. There were 769 patients (80.8%) in the grade III group (with cardiogenic shock and/or pulmonary edema or severe neurological manifestation (coma and/or convulsion)) and 182 patients (19.2%) in the grade II group (with systemic manifestations). Scorpion envenomation is more frequent in summer; indeed 82.3% of our patients were admitted between June and September. The mean age (±SD) was 14.7 ± 17.4 years, ranging from 0.5 to 90 years. In this study 739 patients (77.8%) had neuromuscular signs, 700 patients (73.6%) had gastrointestinal signs and 585 patients (61.5%) had a pulmonary edema, while 195 patients (20.5%) had a cardiogenic shock. The mean blood sugar on admission was at 11.32 ± 5.66 mmol/l, a high blood sugar level (>11 mmol/l) was observed in 39% of cases. The mean blood urea was at 7.1 ± 3.2 mmol/l, it was above 10 mmol/l in 10.7% of cases. The mean of leucocytes was at 17 418 ± 7833 cells/mm3, it was above 11 000/mm3 in 80% of cases. In the end of the stay in ICU, evolution was marked by the improvement of 879 patients (92.5%) while 72 patients (7.5%) died. A multivariate analysis found the following factors to be correlated with a poor outcome: age less than 5 years (OR = 2.27), fever >38.5 °C (OR = 2.79), coma with Glasgow coma score ≤8/15 (OR = 9.87), pulmonary edema (OR = 8.46), leucocytes >25 000 cells/mm3 (OR = 2.35) and blood urea >8 mmol/l (OR = 4.02). Moreover, in children group, a significant association was found between PRISM score and mortality rate, this model had a high discriminative power with an area under the ROC curve at 0.93. In the adult patients a significant association was found between SAPS II score and mortality rate, this model had a high discriminative power with an area under the ROC curve at 0.82. In summary, in severe scorpion envenomation, age less than 5 years, fever >38.5 °C, coma with Glasgow coma score ≤8/15, pulmonary edema, leucocytes >25 000 cells/mm3 and blood urea >8 mmol/l were associated with a poor outcome. [Copyright &y& Elsevier]

Scorpion envenoming is a frequent and deadly event in Tunisia. It is caused mainly by Androctonus australis and Buthus occitanus. Pulmonary edema and shock following scorpion envenoming are related to adrenergic cardiomyopathy, and are the main symptoms leading to death. Our aim was to search for the effect of dobutamine on "scorpion myocardiopathy" and to define the optimal dose of dobutamine to start with. This study was conducted in the medical surgical ICU of Habib Bourguiba University Hospital in Sfax - Tunisia. We included 21 patients with pulmonary edema or hemodynamic shock following scorpion envenoming. All patients were monitored using Swan-Ganz catheter. After a first check of the hemodynamic parameters (baseline), all patients received dobutamine infusion at 5, 10, and 15 μg/kg/min. The median age of patients was 19 years (IQR: 14–26) and 12 patients (57.1%) were males. On ICU admission, 11 patients (52.4%) had shock, all patients (100%) had pulmonary edema, 20 patients (95.2%) had neurologic manifestations, and 16 patients (76.2%) had gastro-intestinal manifestations. During ICU stay, 18 patients (85.7%) received mechanical ventilation (MV). The median duration of MV was 3 days (IQR: 2–4). The median duration of dobutamine administration was 4 days (IQR: 3–5). Cardiac index at baseline was 2.7 L/min/m2 (IQR: 2.3–3.2). Under dobutamine at 5, 10 and 15 μg/kg/min, it was 3.6 (IQR: 3.2–3.9), 4.0 (IQR: 2.9–4.8), and 4.1 (IQR: 3.6–4.9) respectively. Arterio-venous oxygen difference at baseline was 6.0 ml/dl (IQR: 5.0–7.0). Under dobutamine at 5, 10 and 15 μg/kg/min, it was 6.1 (IQR: 4.7–6.4), 3.9 (IQR: 3.4–4.3), and 3.9 (IQR: 3.1–4.7) respectively. The length of stay in ICU was 4 days (IQR: 4–5) and 2 patients died during ICU stay (9.5%). Our study confirms that cardiac dysfunction following scorpion envenomation in Tunisia improved well and safely under dobutamine infusion. The optimal dose of dobutamine to start with was between 5 and 10 μg/kg/min. • Pulmonary edema in scorpion envenoming is related to adrenergic cardiomyopathy. • Adrenergic cardiomyopathy in scorpion envenoming improves well under dobutamine. • The optimal dose of dobutamine to start with is between 5 and 10 μg/kg/min. [ABSTRACT FROM AUTHOR]

Background: Prevalence of catheter-related bacteremia in intensive care units is increasing as central venous catheters (CVC) are used more frequently. In the most of the published literature, Gram positive cocci are the leading cause of catheter-related bacteremia and the systemic empiric treatment recommended include the administration of glycopeptides., Aim: To search for the microbiological characteristics of catheter-related bacteremia in a Tunisian ICU., Methods: Prospective observational cohort survey conducted in the ICU of the Habib Bourguiba university hospital, Tunisia (a 22 bed medical-surgical intensive care unit). We had included all patients admitted to the unit over the study period (from August 1st, 2001 to March 31st, 2002), and who submitted to a central venous catheter for more than 24 hours. Catheter-tip specimens were cultured using a semiquantitative method., Results: During the study period 218 central venous catheters (CVC) were assessed. The mean length of time the catheter was kept in place was 8±6.7 days (range; 2 and 46 days). The CVC insertion site was the subclavian vein in 156 cases (71.6%), the jugular vein in 35 cases (16%), and the femoral vein in 27 cases (12.4%). Seventy four catheters (33.9%) were removed because of suspicion of catheter-related sepsis. The catheter-related bacteremia rate was 6.1 infections/1000 days-CVC. Unlike Gram-positive cocci which caused only one case of catheter-related bacteremia, Gram-negative rods, namely Klebsiella pneumoniae and Serratia marcescens were responsible for 91.7% of cases of catheter-related bacteremia., Conclusion: Our findings translate a specific microbiological flora in our Tunisian intensive care unit and highlight the importance of a treatment strategy based on local epidemiology in patients with catheter related bacteremia.

Background: ICU-acquired infections constitute an important world-wide health problem. Our aim was to determine the incidence, predictive factors and impact of ICU-AIs in ICU patients in Tunisia., Material/methods: We conducted a prospective observational cohort study over a 3 month period in the medical surgical intensive care unit of Habib Bourguiba University Hospital (Sfax-Tunisia)., Results: During the study period 261 patients were surveyed; 44 of them (16.9%) developed 55 episodes of ICU-AI (34.7 ICU-AI/1000 days of hospitalization). The most frequently identified infections were ventilator-associated pneumoniae (58.2%), and primary bloodstream infection (18.2%). The most frequently isolated organisms were multidrug-resistant P. aeruginosa (44.7%), and A. baumannii (21.3%). The initial antibiotic prescription for ICU-AI was inadequate in 9 cases (16.4% of episodes of ICU-AI). At ICU discharge, overall mortality was 29.9%. Independent risk factors for acquiring infection in ICU were the use of central venous catheter (p=0.014) and antibiotic prescription on admission for more than 24 hours (p=0.025), those of mortality in ICU were SAPS II of more than 35 points (p<0.001) and ICU-AI (p=0.002), and those of mortality at 28 days after an episode of ICU-AI were septic shock (p=0.004) and inadequate initial antimicrobial treatment (p=0.011)., Conclusions: We conclude that the occurrence of ICU-AI is significantly related to increased mortality, and that focusing interventions on better use of antibiotics would have a benefit in terms of prevention and consequences of ICU-AI.

Unlabelled: THE AIM of the study was to type Serratia marcescens responsible for nosocomial outbreaks in an intensive care unit in Sfax -Tunisia., Methods: The relatedness between S. marcescens isolates was studied by Pulsed field gel electrophoresis (PFGE). We included 56 strains of Serratia marcescens isolated from patients hospitalized in the intensive care unit during 2003 and 2004. Seven epidemiological unrelated strains of Serratia marcescens were also tested. Samples from environment and hands of the nursing and medical staff were collected and cultured to identify the source of contamination., Results: All strains showed a wild type of antimicrobial susceptibility. PFGE typing revealed that three different clones were present. None of the cultures taken from hands of unit staff and from environmental samples yielded positive results for S. marcescens., Conclusion: We have confirmed the presence of three consecutive outbreaks caused by three genetically unrelated bacterial clones of Serratia marcescens in the intensive care unit ward. These outbreaks are closely related to the frequent use of colistin and the lack of measures of hygiene in this ward.

Aim: To determine epidemiological, causes, clinical and Para clinical manifestations and outcome in children with traumatic head injury in south Tunisia., Methods: A retrospective study over a 8 year period (1997-2004) of 454 children's with head injury admitted to the Intensive Care Unit (ICU) of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay., Results: Mean age (+/- SD) was of 7.2 +/-3.8 years. The main cause of trauma was traffic accidents (69.4%). There were a predominance of male patient's with a sex-ratio of 2.21. The Score of coma of Glasgow adapted to the child, was on average from 8 +/- 3 points. Extra-cranial pathology was present were observed in 38.9%. The cerebral CT-Scan performed on admission for all patients was pathological in 86.3% of the cases. The most observed lesions were meningeal Haemorrhage (35.2%) and the cerebral contusion (34.5%). According to the "Traumatic Coma Dated Bank classification" we noted a high proportion of type 2 group (46%). Secondary systemic insults were observed in 377 children (83%). Evolution was marked by the death of 82 children (18%). Among survivors, a good recovery was observed in 229 children (50.4%)., Conclusion: In Tunisia, head injury is a frequent cause of hospitalization. It is essentially involved in traffic accidents. The short term prognosis is poor with a high (18%) mortality. Prevention is highly advised.

Background: To investigate the effect of ventilator-associated pneumonia (VAP) on the prognosis of head trauma patients., Methods: We performed a retrospective case-control study in which 57 head trauma patients with VAP were matched to 57 head trauma patients without VAP. Matching criteria were age (+/-5 years), Glasgow Coma Scale score (+/-2), Injury Severity Score (+/-5), Simplified Acute Physiology Score II (+/-5), and duration of exposure to mechanical ventilation., Results: The most causative organisms of VAP were Pseudomonas aeruginosa, and Acinetobactor baumannii (36.8% and 33.8% of isolated organisms, respectively). The duration of mechanical ventilation, intensive care unit stay, and hospital stay were significantly increased in case patients (13 +/- 8.4, 24.5 +/- 18, and 30.8 +/- 18.6 days, respectively) compared with control patients (8.3 +/- 4.3, 12.3 +/- 8, and 20.3 +/- 18.7 days, respectively). Mortality rate was also higher in case (29.8%) than in control (12.3%) patients (p = 0.02)., Conclusion: We conclude that the occurrence of VAP caused by high-risk organisms in cranial trauma patients may increase the risk of death, the mechanical ventilation duration, the intensive care unit stay, and the hospital stay.

Background: This study aimed to determine predictive factors of mortality after posttraumatic brain injury., Methods: A retrospective study conducted over a 3-year period (1997-1999) involved 437 adult patients with head injury admitted to the intensive care unit of a university hospital in Sfax, Tunisia. Basic demographic, clinical, biologic, and radiologic data were recorded at admission and during the intensive care unit stay., Results: This study included 393 men (90%) and 44 women with a mean age of 36 +/- 17 years. Traffic accidents were the main cause of trauma (85.6%). In 58% of the cases, the injury was serious (Glasgow Coma Score, <8). The mean simplified acute physiology score was 39 +/- 15, and the mean Injury Severity Score was 34.5 +/- 17. Of the 437 patients, 127 (29.1%) died. According to multivariate analysis, the factors that correlated with a poor prognosis were age older than 40 years (p < 0.01), simplified acute physiology score exceeding 40 (p < 0.001), Glasgow Coma Score lower than 7 (p = 0.03), intracranial mass lesion (p = 0.02), a cerebral herniation (p < 0.001), diabetes insipidus (p < 0.001), and blood sugar level higher than 10 mmol/L (p < 0. 001)., Conclusions: In Tunisia, head injury is a frequent cause of hospitalization, comprising 14.4% of all adult admissions. It is observed most often among young patients involved in traffic accidents. The short-term prognosis is poor, with a high (29%) mortality rate, and determined by demographic, clinical, radiologic, and biologic factors. Prevention is highly advised.

Unlabelled: Our aims to determine the incidence, the causes, the nature and the prognosis of acute renal failure (ARF) in an intensive care unit of Habib Bourguiba's university hospital (Sfax Tunisia)., Patients and Methods: We retrospectively included all patients having ARF during a period of one year. Two hundred sixteen patients developed ARF (17%) During the period of study. The causes of ARF were multiple, and dominated by hypovolemia (47% of cases) The Acute renal failure (ARF) is a frequent pathology. It is essentially observed in old patients. The causes are often multiple. The mortality is high and the best treatment remains prophylactic.