8138

P83APACHE II SCORE AS A QUALITY CONTROL INDEX: OUR

EXPERIENCE ABOUT 2 YEAR ACTIVITY IN ANCONAUNIVERSITY ICU

E. Adrario M. Valente A. Luzi C. GiovanniniP. ,Pietrop.aoli

The increasing costs in ~he management of ICUrequire the use of a qual1ty control index: ba-sed upon the early 24 hour nospi~alization. APA-CHE II score represent a predict1ve value of thehospital death risk. Such index can be used toevaluate the use of hospital resources and com-pare the efficacy of ineensive care in differenthospitals or over time. Aim of the stUdy 1S theevaluation of the efficacy of our ICU.We computed the APACHE ~I score and hospitaldeath risk (R) by Knaus and ColI. in the wholepatients observed within 2 years activity from1.4.90 to 31.3.92 R=hospital death risk was cal-culated as followed:In(R/1-R)= - 3.517 + (APACHE II Score x 0.146) +

+ (0.603 J.only if. postemergency, surgery])+ ( 1aQnost1c category we1ght)

We evaluated 349 patients, 244" males; 105 fema-les; the mean age resulted 53.45 + - 12.6 OS.The mean value for APACHE II Score was 19.45 +/-21.06 OS and mean R was 31.43 The real death ra-te resulted 36.38 % Therefore teh patients weredivided into groups qased on the1r APACHE IIScore and admission d1agnosis; mean R and realdeath rate were computeafor each group, The va-lues thus obtained were analyzed,stat1sticallyin order to compare obServed versus predicteddeath rate either on the basis of APACHE II Sco-re or on the admission diagnosis. The statisti-cally "t" test ~nd linear regression were per-formed for each group.We observed a statistically significant correla-tioQ between.predicted and observed death rate:an 1ncrease 1n APACHE II Score reflects an 1n-crease ~n R and in real death rate. No statisti-cally s1gnificant difference was evaluated bet-ween the predicted and observed death rate inthe various groups of patients considered.We believe ~hat a more w~de use of APACHE IIScore permits a better rat10nalization of hospi-tal resources in order to control the results ofthe:r;apy and to program a "mUlticentric" organi-zat10n.Istitute Med. Surg. EmergencyUniversity of Ancona

Infections IP85CLINICAL DATA, BACTERIOLOGICAL PROFILES AND OUTCOMEOF SEPTIC SHOCK IN A MEDICAL INTENSIVE CARE U!'o'IT. A tenyear survey.F. Schneider, Ph, Lutun, L Runge, A. Launoy, M, Hasselmann, J.D, Tempe.

P84GAPRIK SCORE IN ABDOMINAL SEPSIS. A N~W METHOD TO ASSESSTHE OUTCOME IN A SURGICAL INTENSIVE CARE UNIT.A. Vicens-Justo, E. Zavala, A. Bertran, M.A. Lopez-Baado,X. Sarmiento, L. Fernandez-Cruz

APACHE II SCore has been widely employed as an objectivemethod of stratifying and predicting the outcome in critically ill patients. The challenges in severity indexes areeither to improve the accuracy or to simplify their calculation. AIM: to determine the accuracy of a new score in -predicting the outcome in patients with abdominal sepsis(AS). PATIENTS AND METHODS: 100 patients with AS (peritonitis and/or abscess) were engaged. APACHE II and GAPRIK-SCores were calculated using data available on the day ofadmittance. GAPRIK Score includes five independent variables: G(Glasgow.Coma 5core),A (age),P (sistolic arterial-pressure),RI(respiratory index Fi02/Pa02) and K (kaliemia).The index is calculated as follows: 1,58 - (Fi02/Pa02 x48,97) - (age x 0,06) - (0,71 x K) + (0,57 x GCS) + (0,02x sistolic arterial pressure). Probability of survival =(2,72 x GAPRIK) / 1 + (2,72 x GAPRIK). Probability of mortality = 1 - probability of survival.This study representsan independent and prospective validation of this model ina group of patients with AS. RESULTS: the results obtainedwith APACHE II SCore taking a cut off level of 0,7 were:sensibility 100%, specificity 87,8% and predictive accuracy 91%. The goodness of fit values obtained with GAPRIK -Score were: sensibility 93,8%, specificity 86,3% and predictive accuracy 89%. CONCLUSION: the new index highly -correlates with outcome and results are comparable to thoseobtained with APACHE II Score. 50, it provides an usefultool in predicting the risk of death. In addition, theGAPRIK index simplifies this evaluation by reducing thenumber of data required.

Surgical Intensive Care Unit (SICU). Department of SurgeryHospital Clinic. Villarroel 170. Barcelona 08036. SPAIN

P8GPREDICTION OF SURVIVING IN CRITICALLY ILLSEPTIC PATIENTSA.Sipria, R.Talvik

In an attempt to evaluate the actual incidence, the clinical characteristics, theinfectious agents inducing septic shock (SS) and the outcome of the patientshospitalized during the last decade, we have studied the data concerning patientsadmitted for sepsis syndrome with hypotension (Bone KC" Crit. Care Med.1989; 17:389) from January 1982 to December 199LPatients and methods : 466 patients (227 women, 239 men), mean age64,3 ± 16.4 years, mean SAPS 17,7 ± 6.2, out of 11 582 admitted during thesame period fulfilled Bone's criteria, They all required hemodynamic supportand mechanical ventilation ; 26.6 % of them underwent haemodialysis. Only7.8 % out of them had a surgical cause to sepsis. Steroids were given to 182patients for their underlying illness ; 146 out of them presented withoncohaematologic diseases. Nosocomial infection was observed in 46,7 % ofthe patients. Patients were classified into 3 categories based on Me Cabe'scriteria (Mc Cabe W.R, el ai, Arch. Inter, Med. 1962; 110:845),Rm!le:L Bacteriological data : hemocultures were found positive at onset of sepsis

syndrome in only 71 % of the patients. One single bacterial strain wasinvolved in 78,1. % of the blood samples (Gram negative bacilli 46,S %,Gram positive cocci 42,3 %, fungi 5,8 %, others 5,4 %), E.coli andS.pneumoniae were the commonest strains met in home infection. whereasP.aeruginosa and S,aureus were mainly responsible for nosocomialinfections. .

2. Survival rales : over-all mortality was 76,5 %, nosocomial infectionproviding 89,7 % death, home infection 68,8 %, In patients with cancermortality was 90 %, in those given steroids for theirs underlying diseases77,8 %. Annual mortality rates did not decrease significantly from 1982 to1991.

3. Role of the underlying host disease: 23 out of 57 patients developped amortal sepsis syndrome in the absence of any medical antecedent. Mortalityrate increased from 68,2 % in patients with non fatal underlying diseases, to79.75 % in ultimately fatal diseases and to 9L5 % -when a rapidly fatalillness was present

Conclusion: these data obtained before monoclonal antibodies were routinelyincluded in the medical full treatment of severe sepsis demonstrate that mortalityrate have not improved in our ICU during the past decade. Furtherbreakthrough in this -field will require a better prevention of sepsis in patientswith ultimately and rapidly fatal underlying diseases,

Service de Reanimation Medicale,67098 STRASBOURG Cede", France,

Hopital de Hautepierre,

We studied 125 septio patients treated in ICU.Ninety nine (78.4%) of them had multiple (~2)

organ failure. The mean age of patients was 50.2yr (range 20 to 80 yr) and mortality rate 67.2%.The prediotive value of variables of central he-modynamf.oa , oxygen balance, pulmonary shunting(Os/Qt) and blood endogenous middle molecules(MY) during intensive therapy were estimated.All the variables taken in 1-3 days before dis-oharge from the ICU were ohanged in the direo-tion of physiological normalization. Beforedeath stroke index (SI) in oomparison with 2first days was significantly decreased andQs/Qt, MM were inoreased. At the same time lowoxygen delivery (DOz) was inadequate for highoxygen oonsumption ('9'02) that is shown by higharteriovenous oxygen content difference (Ca-vDqvand oxygen extraction coefficient.With the help' of stepwise disoriminant analysisdisoriminant funotion for prediotion of survivalor death were oaloulated. The best predictorswere sr, V02 and Qs/Qt. When 81 inoreased and Vcf.with Qs/Qt deoreased survival in patients whotreated more than 15 days was most probable.Aocuraoyof this prediotion was 97.4% (89.7% byJaokknifed olassification). sensitivity 92%,speoifity 100% and false positive value O. Infirst two days aoouraoy, sensitivity, speoifityand false positive values of prediotion were93%, 79%. 100% and 0 respeotively.

Department of anesthesiology and intensive care,Tartu University, 8 Puusepa Street, EE2400 TartuEstonia.

P87POSTNEUROSURGICAL BACTERIAL MENINGITIS (PNBM) IN ADULTSJ•Maeeebo, P.Domsogo, P.Coll, A.Net

Aim of the amity: To analyze the incidence, clinical characteristics, and prognostic factorsin patients with PNBM.

Methods: We have studied those adult patients (older than 14 yr) who presented an acutebacterial meningitis (BM) in the poaoperative period of a neurosurgical procedure. Diagnosisof BM was made on the basis of a positive cerebrospinal fluid (CSF) culture (obtained froma lumbar puncture). The period of the study is between 1980 and 1990. Statistical analysis wasperformed by means of ANOVA and discriminant analysis.

Results: From 1980 to 1990 were performed 3500 neurosurgical procedure,, and 30 patientsdeveloped a PNBM; this represents an incidence of 0.8%. Mean tige of the patient. was 45+4yr: Seventeen patients (57%) had a gmmnegative BM (GNBM) and thirteen patients (43%)had a grompoaitive cocci BM (GPCBM). Microorganisms most frequently "using GNBMwere Pseudoosorws (8 patients), and that most frequently causing GPCBM wereSraphylococne (1 patients). Overall mortality rate was 16.6 % (5 patients died). Mortality wassignificantly higher in the GNBM group (30%) than in the GPCBM group (0%), P= 0.03.The following parameters were not significantly different between survivors (S) andnonaurvivors (NoS): age, predisposing disease, positive blood culture, CSF proteins,CSFlplasma glucose ratio, number of cells in CSF, CSF gram stain, fever, previous antibiotictreatment, attend mental status, focal aigns or number of neurologie complications. Theparameters significantly different between S and Nos were the following: conicoaeroidtreatment (16% S vem a 60% NoS, P=0.03), coma (4% S versus 100% Nos, P<0.0001),seizures (0% S versus, 40% Nos, P<0.001), and number of extranemologic complications(0.04 S versus 0.8 NoS, P<0.001). To determine the prognostic factor aasociated with apoor outcome we analyzed 12 of the above mentioned variables; after a stepwise selection,the variables roauining in the function were in order of statistical significancy coma (C),previous antibiotic treatment (PATB) and number of extraneurologic complications (ENC).The discriminant function is the following:D= -10.6 + C5.2 + PATB•1.06 - 5C•115The overall efficiency of this equation in predicting S and Nos is 96.6 % (29 of 30 patientswere correctly classified; one patient who was S was predicted as Nos).

Conclusion: PNBM is a clinical entity with a high mortality rate when the causativeorganism. are gram negative bacilli. Factors which predict a poor prognosis are the presenceof coma (which may reflect a more severe cerebral damage), the previous treatment withantibiotics (which may select resistant microorganisms), and the number of extraneurologiccomplications (which may reflect the severity of the patients' illness).

Serreis de Mediciva Iatensiva, Medicioa Intern and Microbiologia. Hospital de SantPan. Av.S.A.M. Claret 167. Barcelona 08025. SPAIN.

P89Ilfl.N LOGICAL Pt'D I1-FEC1II115 CU•PLICATIQJS IN POLYTR U44 PATIENTS: SIG-

NIFICANCE OF HYPOVOLIMIC SH X.M. Ibarz, J. Santo*, A. Sitges-Serra*.

It has been suggested that the presence of hypovolardc shock (EH) is abad prognostic factor anmg polytraurla patients because of its associa-ted risk of bacterial infection. This increased susceptibility to infec-tion has been attributed to HS by at least two media'tisls: gastrointes-tinal isol-ania leading to tnroosal darege and subsequent txansiocation ofendotoxin and bacteria and depression of the inflametory and imnne

To investigate all potential factors associated with an increased riskof infection in polytrauna patients, 51 such patients (44(1, 7F, meanage: 29 years) aluitted to our Intensive Care Unit were followed during3 weeks. P>esa-lce of HS (12 patients) was associated with the highestseverity scares at adttission (mean ISS 37112 vs.24t9, p= 0,001; heartSAPS 1233 vs.9f 2, p= 0,(002 for patients with and without H5 respecti-vely) irrespective of their age or sex. The p )ce of shock ras asso-ciated with a significant decrease ai prpoortion of CO3+ T cells (4\vs 6CP6, paü 02) and I3 levels (694 vs.914 mg/dl, poO,(l3). Patients with1-6 also tended to have cuse indexes in biocha ti al nutritional parate-

tars at atthtjssicrt, althouh the difference was Ixet statistically sigtifi-cant. Pn irnxeased incidence of septic ornplicatia>,s was observed anaigpatients with 16, whictl was more evident in the overall incidencee ofbactelaellia (6m vs 22%, p= 0,(13) and specially in that of prineay bacte-ienia (45% vs 5%, p= 0,001).CaicLxsicns: 1)Preseice of HS in polytralma patients increases the riskof severe septic craplictions 2)This increased risk could be the resultof a decrease in inn,ne function and an increase in bacterial ttansloca-tien as suggested by the significantly higher incidence of prinar y bac-teremas 3)Polytfatma patients with FS should be regularly monitored byblood and stool cultures for early detection of bactetenia.

Departolalts of Intensive Care, Hospital Metes de ferrassa and Surgezy*,Hospital llhivelsitario del Mar.Barcelona. Spain.

S139

P88ANALYSIS OF PROGNOSTIC FACTORS IN ADULT PATIENTS WITHCOMMUNITY -ACQUIRED ACUTE BACTERIAL MENINGITISP. Domingo, J. Mancebo, P. Coll, A. Net

Aim of the study: To determine which factors mostly influence prognosis in adult patients withcommunity-acquired acute bacterial meningitis (ABM).Patients and methods: Patients were included in the present study provided thatthey were aged14 years or older and that they had been diagnosed of ABM on the basis of consistent clinicalfindings, characteristic CSF abnormalities, and/or isolation of a pathogenic microorganism eitherfrom CSF or from blood cultures. The statistical analyses were performed by means of the StatviewIITM statistical package for Macintosh PC .Results: From 1974 to 1991, 275 adult patients with community-acquired acute bacterialmeningitis had been attended at our hospital. There were 126 men (45.8%) and 149 women(54.2%), with a mean age of 44.4±20.8 years (range: 15-87 years). Ninety seven patients (35.3%)had one or more underlying diseases predisposing them for acquiring ABM. One hundred and sixtyeight patients (61.1%) presented with a primary extrameningeal focus of infection. Eighty onepatients (29.4%) had received antibiotic therapy prior to admission to the hospital. Eighty sevenpatients (31.7%) had a normal level of concioussness on admission, whereas 53 (19.3%) had focalneurologic signs, and 12(4.4%) presented with seizures. The mean interval from the beginning ofsymptoms to diagnosis was 56.6 t 50.2 hours (range: 3-360 hours). The mean CSF values were 4.3± 3.5 g/1 for proteins, .27 t .32 for CSF glucose/blood glucose ratio, and 2377 ± 4155 cells/mm'.Tha CSF Gram stained smear showed pathogenic microorganisms in 131 patients (48.2%). andblood cultures were positive in 110 patients (44.3%). hundred and twenty six patients (45.8%)had a meningococcic meningitis, 65 (23.6%) a pneumococcic meningitis, 15 (5.4%) a listericmeningitis, 18 (6.5%) a meningitis caused by grantnegative bacil li,13 (4.7%) a non-pneumococcalgrampositive coccal meningitis, 4(1.5%) a meningitis caused by H. influenzae, one (0.4%). mixedmeningitis, and 33 (12%) a meningitis of unknown origin. Twenty-four patients (8.9%) presentedneurologic complications, and 22(8.1%) had extraneurologic complications. The overall mortalityrate was 17.1% (47 patients). A stepwise regression analysis of the outcome vs. sex, age, underlyingdisease, extrameningeal infection, prior antibiotic therapy, presence of fever and meningeal signs,level of concioussness, interval between symptoms and diagnosis, presence of focalneurologicsigns or sizures on admission, biochemical and cytological CSF parameters, positivity of CSFGram stained smear and bloodeultures. presence of neurologic and extraneurologic complications,etiology of the apisode of ABM, and adequacy of the empiric antibiotic therapy. Factors found tobe associated with a fatal outcome were in decreasing order of importance: development of coma(F= 171:1), shock (F = 135), acute renal failure (F=98.9), advanced age (F=79.7), inadequateempiric therapy (F= 67.6), seizures (F=51.6) or focal neurologic signs (F=42.3) on admission tothe hospital.Conclusions: Our study shows that ABM in adult patients is still significantly associated with ahigh mortality rate, and that facors associated with an increased risk of death are the developmentof coma, shock or acute renal failure after admission, and advanced age, institution of inadequateempiric antibiotic therapy, and the presence of focal neurologic signs or seizures on or beforeadmission to the hospital.

Department of Internal Medicine and Intensive Care Unit. Hospital de la Santa Creu i Sant Pau.Universitat Autonoma de Barcelona. Avgda. Sant Antoni M Claret, 167. 08025 BARCELONA .SPAIN.

P90MULTI PURPOSE USE OF CENTRAL VENOUS NUTRITIONCATHETERS INCREASES INFECTION RATEA.J.J. Woittiez, J. Kaan, P. Goldhoorn

One of the risks of long term central venouscatherisation ( C.V.C.) used for totalparenteral nutrition ( TPN ) is catheterinfection. We analysed C.V.C. infections in ourhospital during 1 year. C.V.C. infection wasdiagnosed by blood culture and tip culture.21% out of 104 catheters, placed in 100patients, were infected. Cultures yielded 17Staph. aureus, 3 Klebt. pneum, 1 Pseudom. aer.We found no correlation between infection rateand localisation of the catheter ( subclavian,jugular or femoral vein), kind of catheter

i single or double lumen ), staff memberntroducing the catheter ( anaesthesiologistor intensive care staff ) and length of stay ofthe C.V.C. ( 10,3 ± 7,05 days in non infectedvs 11,7 ± 4,7 in infected ). However more than56 % of the catheters that served multiplepurposes such as central venous pressuremeasurement or administration of medicationwere infected. After restricting the use ofC.V.C. for TPN only, infection rate declined to11% in the follow-up of h year ( 48 patients )We conclude, that in our series , infection ofCVC used for TPN can be diminshed byrestricting multi purpose use.

Departments bf Intensive Care, Pharmacy andmicrobiology, Twenteborg Hospital, Postbus7600,7600 SZ Almelo, The Netherlands.

S140

P91INTRAVASCULAR CATHETER RELATED INFECTIONS IN

CRITICALLY ILL PATIENTS. MULTICENTRIC STUDY.

(492 cases).

Working group on infectious diseases. Espanish

Society of Intensive Care Medicine.

PURPOSE. We prospectively studied catheter

infectious complications in intensive care unit

(ICU) patients. Incidence, clinical

sintomatology, risk factors, site of entry for

infection, microorganisms isolated and

complications were analized.

METHODS. On every patient suspecting catheter

related bacteremia (CRB), cultures at the exit

site skin, cultures of hub, catheter tip, and

peripheral blood were performed. Catheters were

classified as: aseptic, colonized, infected,

catheter probably related bacteremia, non-

catheter related infection, and CRB, in

accordance with a preestablished protocol.

Eighteen hospitals entered into this study

performed in 1991.RESULTS. An overall amount of 492 catheters was

studied. Culture at exit site skin was positive

in 34% of cases, catheter hub in 19%, catheter

tip in 34%, and blood-culture in 19.9% The

incidence of CRB was 8.1%. Predominant pathogens

isolated were: Staphylococcus epidermidis 17

(43%) cases, Staphylococcus aureus 5 (12%),Candida parapsilosis 5 (12%) and Estreptococcus

faecalis 4 (10%). The idendified source of

organisms was exit site skin in 11 (27%) cases,

catheter hub 13 (32 %), and both (skin and hub)

in 16 (40%).CONCLUSIONS. We found a significant relationship

of duration of catheterization and use for

parenteral nutrition to CRB. There was a lack of

correlation among three way stop-cock use,

catheter-lumen's number, catheterization setting

(ICU, operating or emergency room) and CRB.

P93SEVERE COMMUNITY ACQUIRED PNEUMONIA (CAP) IN INTENSIVE

CARE UNIT (ICU). EPIDEMIOLOGY AND PROGNOSIS FACTORS.

C. Santrd, 0. Leroy, C. Beuscart, B. GuEry, H. Georges,

G. Beaucaire.

Over a period of 5 consecutive years (1987-91), 299 non

AIDS patients (111 women and 188 men, mean age - 63.2 y)

with CAP in ICU (clinical and radiographic signs) were

studied retrospectively. According to the McCabe's class,

111 were ultimately fatal (UF) and 8 rapidly fatal (RF).

On admission, the mean SAPS was 12 ± 3, 44 patients

exhibited septic shock, 46 a bacteremia and 130 needed

mechanical ventilation. A total of 260 organisms was

identified in 197 patients (S. pneumoniae n-80,

Staphylococcus app n=57, Gram negative bacilli n=81, other

n=8). Antimicrobial therapy was monotherapy in 117. Death

occured in 85 cases. In monovariate analysis, the poor

prognosis factors were : ineffective initial antibiotics

(p<0.0001), septic shock (p<0.001), mechanical ventilation

(p<O.,001), bacteremia (p<0.001), non pneumonia related

complications (p<0.001), neutrophils count < 3500/mm3

(p<0.005), serum protein < 45 g/l (p<0.01), age 60 years

(p<0.02) and McCabe's OF+RF (p<0.02).

The results of multivariate analysis (sensitivity - 49 Z,specificity - 94 2) were :

Variable OR 95 2 CI pNon pneumonia related'

complications 10.70 5.00 -20.00 .0001

Ineffective initial

antibiotics 4.71 2.58 - 8.58 .0001

MacCabe's OF + RF 3.09 1.63 - 5.87 .0007

Septic shock 2.85 1.23 - 6.61 .016

Bacteremia 2.63 1.18 - 5.87 .019

Conclusion : Among all factors influencing the prognosis

of CAP in ICU, the unique one depending on medical

management was effective initial - antibiotherapy.

Intensive Care and Infectious Diseases Unit - Tourcoing -

Lille University Medical School. - F 59208 FRANCE

P92SEVERE PNElM ONIA. EPIDEMIOLOGY AND PROGNOSTIC FACTORS.

J. Almirall(*), E. Mesalles, J. Klamburg, S. Armenpol, A. Agudo (*1,

C.A. GonzAlez (*), A. Tomasa.

A prospective study was carried out over a period of three

consecutive years in adult patients with acute connKnity-acquired or

hospital acquired pneumonia treated in the intensive care unit of the

hospital. The main objective was to determine wich factors available

at the hospital admission preditc a fatal outcome among such patients,

as well as to assess the value of the causative agent and the clinical

and radiological criteria as predictors of the evolution.

A total of 127 patients were included (105 men and 22 women), with

mean age of 58 years (age range between 17 and 83). The most frequent

underlying clinical condition was chronical obstructive pulmonary

disease (54%). A total of 86 patients (68%) required mechanical

ventilation. A. causal microorganism was identified in 70 patients

(55%), the most frequent being Legionella pneumoniae (20%),

Streptococcus pneumoniae (10%) and Pseudomona aeruginosa (9%).

Mortality.due to severe pneumonia was 42.5% (54 patients).

The association between death and each potential prognostic factors

was first examined in an univariate way and then assesed by means of

the the stepwise logistic regression with mortality as the dependent

variable. The factors wich showed an independent value as predictors

of mortality were radiogrphic spread of the pneumonia (bilateral

afectation), old age (n70 years), presence of septic shok at

beginning, SAPS>12, requirement of mechanical ventilation and P.

aeruginosa as the causative agent.

Intensive Care Unit, Hospital Germans Trias i Pujol, BadaLona (Spain).

(*) Hospital S. Jaume i S. Magdalena, Matar6 (Spain).

Supported in part by Grant FIS 90/0315.

P94NOSOCOMIAL INFECTIONS IN A NEUROLOGICAL AND NEUROSURGICAL INTENSIVE CARE

UNIT (ONE YEAR PROSPECTIVE STUDY).

F.Salord, J.Grando, M.Verges, C.Desgaches, R.Chacornac.

From may 1991 to may 1992, a one year prospective evaluation of the

frequency of nosocomial infections (NI) has been conducted in our intensive

care unit ((CU). During this period 900 adult patients were hospitalized in

the unit (12 beds) for a mean duration of 3.5 days. Out of these 900 pts,

111 (12.3 p.cent) received an antibiotic therapy for a suspected infection.

In ninety-five pts (10.5 p.cent) a NI was proved, in 16 pts the treatment

was rapidly discontinued because of a Lack of NI evidence.

Patients with NI : mean age= 50±17 y-o, mean ICU stay= 19111 days (2-58), 80

were hospitalized after neurosurgery, 15 for medical reasons.

Nineteen pts died in ICU (20 p.cent), 76 were discharged.

In the infected group of pts, 146 episodes of NI were recorded : septicemia=

20, pneumonia= 25, urinary tract infections= 40, acute maxillary sinusitis=

23, meningitis=22, scars infection= 11, other= 5. Forty pts suffered one NI

episode, 55 more than one.

The isolated pathogens were

- septicemia staph. (12), strepto.(4), gram negative bacilli (4)

- pneumonia : staph. (9), haemophilus inf. (5), pseudomonas seruginosa (4),

strepto. (3),. other gram netative bacilli (2), candida alb. (2).

- sinusitis : staph. (7), gram negative bacilli (5),. strepto. (6), candida

alb. (1), aspergillus (1), negative cultures (3).

- urinary tract infections : E. Coli (23), GNB (9), strepto. (6), candidaalb. (2).

- meningitis : staph. (5), candida alb. (2), strepto. (1), gram negative

bacilli (1), negative CST culture (13).

- scars : ps. aeruginosa (3), staph. (3), strepto. (3), klebsiena (2).- other staph. (3), strepto (2).

Considering the high frequency of urinary tract infections (40/146) and

respiratory infection (20 • 23/146), preventive measures have been modified

or introduced in the operating room and in the ICU. A six monthes propectivestudy is on-going to evaluate the impact of these measures on NI.

ICU. HBpital P.Wertheimer 59 bd Pinel 69003 Lyon - France

P95NOSOCOMIAL INFIECTION IN INTENSIVE CARE UNIT (NI-ICU) - ANONGOING AND INTENSIVE CARE METHOD.

E.Maravi; J.Garcia-Jalön; I.Sänchez-Nicolay; JJ.Saenz;J.Maynar; F.Fohseca and I.Jimenez.An Factual" rnacocrrjal infectien (NI) in an intensive care unit posesdata collection problems. If overall solutions are not found for the en-tire hospital, this data will not be correctly understood and any mea-sures would provide little asistance.The objective of the study is an "real" understanding of NI-ICU, alongwith an un erstand ng of NI-Entire hospital.We studied prospective 1991 data on NI for the Hospital and ICU that we-re collected in a000rdance with the following protocolo:1. Intensive data collection by a specific team.2. Voluntary medical report by the physician an a Blue Card.3. SPINE (Spanish Study an the Prevalence of Ncsocxmial Infection).4. EPIHJS (Epidemilogy of Hospital Infection): A threemcnth, rotating

study.These protocols will be approved by: The Comissicn on Infections, andtute Central Ccmissicn of Quality Assurance.Results and Ccnclusions : a) In the ICU-General: 18% of NI, mostly respi-ratory infections (8,9/a), sepsis (3%) and urinary infections (3%). 13%of patients en a respirator developed respiratory infections.afther thethird day. Urinary infections and infections associated with a centralvenous catheter were foundd in patients using a catheter more than threedays.b) 1W-Coronary: 4,28% of N.I., mostly respiratory infections, urinaryinfections and phlebitis.c) The Overall ixspital-NI rate was 3,181 mostly urinary infections(1,81), surgical infections (0,82Y) and respiratory infections (0,48%).d) 87,5% of the Iili physicians submitted voluntary medical reports, withalmost all the NI and lOCP/ of the serious NI being reported prcorptly,versus 51,8% of the medical staff in the rest of the Hospital.Conclusions : It is sl-awn that an understanding of the "actual" rate ofN.I. in an ICU sft,uid be a overall objective for the "entire" hospital.A simple report is not sufficient. However, N.I. identification in theICU was prompt and hip (87,5%). It was observed that some types of N.I.are easier to identify than others.

Intensive Care Unit. Hospital Virgen del Camino?rimya, at 8 --31ffiB - PAMPLONA - SPAIN

P97MORTALITY, EXTRACHARGES AND PROLONGATION OFSTAY ATTRIBUTABLE TO NOSOCOMIAL INFECTION (NI)IN ICU. A ONE-YEAR SURVEY. S.NOUIRA; S.EL4TROUS;F.ABROUG; M.JAAFOURA; S.B000HOUCHA.

Studies on estimates of costs and prolongation of hospital stay due toNI in ICU's patients are scarce. We report on the results of a one-yearprospective survey conducted in the medical ICU of a 700 bedsteaching hospital. Among 216 patients admitted during 48 hours orlonger, those who developped NI during their ICU stay, were assessedfor extracharges and mortality. Diagnosis of urinary tract infection(UTI) relied on standard criteria whereas diagnostic of nosocomialpneumonia relied on quantitative culture of bronchial secretionsretrieved by plugged telescoping catheter. Estimates of prolongation ofstay and extracharges of NI were made according to the physician'sestimate method (HALEY. J.Infect.Dis. 141. 1980 . For each patientwith confirmed NI, it was daily judged by the medical staff of the ICUwhether continued hospitalization should be attributed to NI. Then, allextra-ancillary charges attributable to diagnostic and therapeuticservices in the care of NI were counted and added to the extra dayscharges. Causes of death were systematically analyzed and death wasattributed to NI when the infection was not controlled at the time ofdeath and was associated with significant morbidity.Fifty five episodes of NI were identified in 35 patients (incidence:25,5%). NP developped in 43 episodes, UTI in 11 episodes andsepticemia in one patient. Each episode of NI was responsible for 6.3days of prolongation of stay and 600 US$ of extra-ancillary charges.Total extracharges attributable to each episode of NI were 1400 US$.Mortality among patients who developped NI was 65% with 48%causally related to the occurrence of NI.

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P96BLOOD INFECTIONS IN CRITICALLY ILL PATIENTS: A 8-YEARS STUDY.V Emil S Mencherini. N Barzaohi P Marone' 6 Sala Gallini.M Olivei. A hascht

Background and purpose. Ne undertook a retrospective chart review in order toevaluate incidence and changing pattern of etiology of blood infections at our ICUbetween July, 1,. 1984 and May, 31, 1992.Patients and methods. All patients with positive blood cultures were identified.Bactere.ia was defined as the presence of pathogens in blood accompanied by signsof sepsis syndrome. When it occurred within 48 h from admission, it was defined asICU-acquired. A data analysis was performed in order to establish the clinicalsetting in which the blood samples were obtained, as well as the more coo'-'onisolated microrganisns.Results. 2218 patients were admitted during the study period, the number of

admissions being similar each year (277±23, mean value ± s.d.). Overall, 297

positive blood cultures were detected in 252 patients. In 12 occasions bloodisolates were considered pseudobacteremias. 285 true infections occurred in 240subjects, with a cumulative infection rate of about 13%. However, when dataanalysis was performed separately for the first two and the following years,infection rate was found to rise from 9 to 14%. Bacteria were the causative agentsin all but 12 occasions, in which fungenias (mainly candidemias) occurred.Multiple and polimicrobial bacteremias occurred in 9-17% and 8.2!3.1% casesrespectively, without significant modifications throughout the study period. Withrespect to the clinical setting in which blood infection occurred, about one thirdbacteremias has been found to be acquired outside our ICU. 20B bacteremias (77% ofall infections) were ICU-acquired. Aerobic G+ cocci were identified in 125occasions, 6- and anaerobic agents in 85 and 1l cases respectively; fungi accountedfor further 7 infections. 6+ pathogens accounted for 55% of isolatedn icrorganisas, the most frequently detected agent being M-R Staphylococcus aureus(3B cases), followed by H-S Staphylococcus aureus (29 observations) and C-NStaphylococci (36 isolates), whose frequence has been found to rise progressivelyduring the last few years. Pseudomonas spp and E. coli were the most frequentlyidentified 6- pathogens, whose occurrence remained unchanged during the studyperiod, as well as that of anaerobes. At the contrary, an increasing number offungesias (Candida spp.) have been identified in the last two years. Primarybacteremias accounted for about 57% cases. Vascular catheter-related and lowrespiratory tract infections together caused up to 56% secondary bacteremias,the remaining 44% being caused by peritonitis and surgical wound infections.Conclusions. Bacteremias caused by M-R strains of Staphylococcus aureus and, Acrerecently, C-N Staphylococci and Candida spp. represent a major problem in our ICU.Servizio di Anestesia e Rianimazione I e + Clinica di Malattie Infettiie, IFCCS

Policlinico San Matten, 27100 Pavia, Italy.

P98EPIDEMIOLOGY AND PROGNOSIS OF SEPSIS SYNDROMEIN PATIENTS ADMITTED TO A MEDICAL ICUH. Thabet, A. Rauss, C. Brun-Buisson

In a 14--months period, 76 of 918 patients (8%) admitted to ourICU presented with the sepsis syndrome (SS) as defined by Boneet al, within the first 3 days of admission. Patients having SS wereaged 53 ± 16 yrs. There were 56 males. Their mean SAPS andAPACHE II were 16 ± 6 and 23 ± 8 respectively. The distributionof acute organ system failures (OSF) on admission (Knaus) wereas follow : 0=4, 1=30, 2=26, >_ 3= 16; 46 (60%) had a rapidly fatalor ultimately fatal underlying disease (McCabe). 70/76 (92%) hada confirmed diagnosis of infection, of which 29 were community-acquired and 41 hospital-acquired. Gram-positive infections (GPC)predominated (30 cases, 43%), Gram-negatives (GNB) represented32% and mixed infection 11%, other organisms (fungi, mycobac-teria, parasitic) accounted for 11%. The primary source of infectionwas the respiratory tract in 31/70 (44%), intra-vascular orendocarditis in 11 (16%), the central nervous system in 6 (8.5%),urinary in 7 (10%), skin and soft tissue in 8 (11.5%), abdominal in4, and unknown in 3 cases. Overall mortality was 45%, 60% in the35 patients presenting with shock on admission). Factors associatedwith mortality (by univariate analysis) were a rapidly or ultimatelyfatal underlying disease (p<0.02), OSF>I (p=0.03), SAPS (p<0.01) and APACHE II (p<0.01), major chronic organ dysfunction(p<0.01). Factors not associated with a poor outcome were age,nosocomial infection, bacteremia, shock (p = 0.08), delay from onsetof sepsis to admission, organisms (GPC vs GNB) involved.Conclusion : This ongoing study indicates that GPC arepredominant in patients admitted with SS in a medical ICU. SSpatients have an overall mortality similar to that described in otherseries. Major prognostic factors are chronic health status (McCabeclass and preexisting organ dysfunction) and severity of illness onadmission (APACHE II, SAPS).

Service de Rdanimation Polyvalente. CHU F.BOURGUIBA.MONASTIR 5019. TUNISIA Medical ICU, Henri Mondor Univ. Hospital, 94010 Creteil France

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P99MULTICENTRE SURVEY OF HAND HYGIENE PRACTICE IN INTENSIVECARELa Sproat, TJJ Inglis

A detailed multicentre survey of hand hygiene policy,comprehension and practice was conducted following onfrom a national survey of infection control practice inIntensive Care Units'.A wide variation from recommended practice was found,In some units hand washing was not required forprocedures such as tracheal suction or mouth care, and in

some units there was no formal policy on optimal hygienepractice during these procedures.Nurses' self-reported non-compliance with hand hygienepolicy was poorest before tracheal aspiration(27%), butwas also reported during line care, unrinary catheter bagemptying and mouth care. Some categories of visitinghospital staff did not comply with hand hygiene recom-mendations during the majority of instances of patientcontact.Our results show that some Intensive. Care Units haveunsatisfactory hand hygiene policies. In those unitswhere satisfactory policies exist, self-reportedcompliance was variable and, at times, poor. Furtherresearch is required in this area, particularly intostaff motivation to comply with recommended infectioncontrol practice.

1 Inglis TJJ, Sproat LJ . , Hawkey PM et al.B J Anaes 199268:216-220.

Department of Microbiology, University of Leeds,LS2 9JT, United Kingdom.

P101VIRAL NASOPHARYNGEAL (NP) CARRIAGE (CAR) IN ADULT ICUPATIENTS (PTS). G. Leleu•, J. Le Junter, S. Villiers, M.T. Garrouste, A.Rabbat, B. Schremmer, J.R. Le Gall, F. Morinet and B. Schlemmer.

As opposed to pediatric units, the impact of viral NP-CAR is unknown inadult ICU pts. The aim of this study was to determine the incidence ofpositive NP viral samples (VS) in such pts and its association withrespiratory diseases (RD). Methods: prospective survey of adult medicalICU pts, with an expected ICU stay over 24h. VS were collected on entryand weekly. RD on entry and nosocomial bacterial pneumonia (NBP)were identified through previously strictly selected criteria. Viraldiagnosis was assessed on NP secretions. Herpes simplex- (HSV), rhino-(RV) and enteroviruses (EV) were detected by immunoperoxydasestaining on infected diploid cell culture (MRC-5). Detection of adeno-(AdV), parainfluenzae (type 1, 2, 3)- (PIV), myxo- (MxV) andrespiratory syncitial (RSV) viruses used a direct immunofluorescenceassay. Results: from Feb.91 to Jan.92, out of 289 VS in 160 evaluablepts/174 total patients, virus detection was positive for 25 pts (HSV: 18,RV: 2, AdV: 3, EV: 3, PIV: 0, RSV: 0, MxV: 0). 16 VS were positive atentry: 11 from transferred pts, 5 from directly admitted pts.results all pts virus + (V+) virus - (V-) pn (%) 160 25 (16) 135 (84) -age, years 51±18 52±17 51±18 NSseverity on entry, SAPS 13±5 14±7 12±7 NSdirectly admitted pts % 55 39 60 0.0083days on ICU, median (range) 12 (1-109) 17 (1-109) 8 (1-74) 0.0184immunosuppression % 44 58 41 NSmechanical ventilation (MV) % 53 58 41 NSdays on MV, median (range) 13 (I-103) 22 (2-103) 11(1-70) 0.0034mortality % 31 54 27 0.008RD % 76 65 78 NSAdmission RD were [n (%)I: asthma 17 (15), pneumonia 44 (39), COPD 10(9), P. carinii pneumonia 12 (11), leukemic lung involvement 8 (7) andmiscellaneous 18 (16). Distribution of RD was the same in both groups.NBP occured in 11 pts: 8 in the V- group, 3 in the V+ group. Conclusions:viral NP-CAR is detected in pts with high mortality, transfered fromother wards, but is not associated with lung diseases in adult ICU pts.

St Louis Hospital and University Paris 7, 75010 Paris, France.

P100RAPID MANAGEMENT IN THE EMERGENCY DEPARTMENT (ED) OFHEALTH CARE WORKERS (HCW) AT OCCUPATIONAL RISK OF HIV-INOCULATION. D. Elkharrat', Ph. Mauboussin, P. Bodossian, M. Porche, M.Pdnicaud, A. Le Corre and C. Caulin.Introduction. Occupational risk of HIV inoculation (ORHIV) is small (0.3-0.4%) but its consequences are serious. Based on experimental studies,Zidovudine (AZT) has been prophylactically recommended. However, AZTshould be given within 4 hours of the accident if a benefit is to be expected,and, due to its potential toxicity, it is advised to reserve it for HCW whosecontact patient is definitely seropositive (CP+). In order to meet these 2imperatives, CP+ should be promptly identified. The study purpose is todemonstrate the feasibility of management within 4 hours of HCW withORHIV. The setting. The AIDS Committee of our 3-hospital, 1200-bed,2700-HCW Institution has decided in Jan. 91 that 1) the ED will be in chargeof coordinating this problem, the reason being the presence there of seniordoctors around the clock 2) the so-called HIV rapid test and, if required, AZTwould be immediately available for ORHIV situations 3) procedures will befree of charge. Methods. All personnel were informed that in possibleORHIV cases they should immediately 1) wash site of injury 2) have CP ofunknown HIV status tested 3) present to the ED where, the senior physicianin charge will provide explanations and eventualljr AZT. Information wascirculated by•means of personal letters in february and monthly meetingsthereafter. ED senior physicians were regularly briefed on ORHIV and AZTand how to deal with HCW. Also, an algorythm was displayed in the ED, for alldoctors on duty to follow. Results, From March 91 to May 92, 85 HCW,sexe-ratio 67% F, aged 33.6±9.7years, were examined for potential ORHIV.The time between accident and consultation in the ED was 1.35±1.5 h for76, 12 h to 5 days for 7, unknown for 2. There were 45 (53%) nurses, 16(19%) auxiliary nurses, 14 medical staff (16.5%), 6 radiology and 3 lab.technicians, 1 cleaning personnel. The main accident was a needlestickinjury (76%of cases). Patients HIV status was : CP+in 15 (1 was common to2 HCW) at the time of the accident, CP- in 58 who were tested within thehour; it was not identified in 11 ‚All HCW tested subsequently seronegative.AZT was offered to 11 HCW, 3 of whom (1 nurse, 2 doctors) refused it ; in 4,ORHIV was deemed unlikely and AZT not advised. At one year follow-up allHCW remained seronegative. Conclusions. 1) Our approach is original inthat it makes HIV-testing and AZT available at all times. This enables us toreassure the great majority of HCW. Prescription of AZT is limited to HCW atthe highest risk.2) Efficacy of prophylactic AZT has not been clinicallydocumented, therefore prevention of occupational accidents should bestressed.

'Service Urgences. HSpital Lariboisicre. 2, rue A. Pare. 75475 Paris Cedex10. France

P102IN-VITRO STUDY OF GRAM NEGATIVE ISOLATES IN BLOOD CULTURES OF ICUPATIENTS IN PORTUGALRibeiro C .,Moreira J.,Costa D.,Costa M.,Pina E.,Salgado M.J.

As part of an ICU "in vitro" Surveillance Study on Gram negativebacilli, 74 Blood cultures were studied between 1990 and 1991.A detailed analysis of the bacterial population cultured and thesusceptibility by species and antibiotic, will be presented. The presentevaluation will consider the susceptibility, at NCCLS breakpoints,of the five more frequent species isolated to seven antibiotics - 5beta-lactams, 1 aminoglycoside and 1 quinolone. MICs were measured bymicrodilution technique, using a commercial system (Baxter).We obtained the following results (%):

NR IMP CAT AZT CAX PIP AMK CIK. pneumon ae 22 95 41 45 86 VPI 55 95E. .coli 13 100 92 92 92 38(6 100 100P. aeruginosa 12 100 92 100 8 75(16. 92 83Enterobacter spp 8 100 64 73 77 59(1G 96 95Acinetobacter spp 6 100 50 17 33 33(15 100 33All agents 74 97(4) 70(8) 69(8) 69(8) 36(*) 8200 86(1)IMF-Imjpenem;CAZ-Ce taz ime: - ztreonam- - e triaxone,AMK-Amikacin;CIP-Ciprofloxacin

% Susceptibility at (NCCLS breakpoints)* Different breakpoints for P. aeruginosa

HOSPITAL S. JOAO - LABORATORIO DE BACTERIOLOCIA4lameda Prof.,Hernani Monteiro4200 PORTOPORTUGAL

P103MULTICENTER STUDY OF IN-VITRO SUSCEPTIBILITY OF GRAM-NEGATIVE BACTERIAIN I.C.U. PATIENTS IN PORTUGALMoreira J .,Costa D.,Costa M.,Pina E.,Ribeiro C.,Salgado M.J.

In follow-up of a study initiated in 1990, we present the results ofan ICU Surveillance during the year of 1991. We have studied thesusceptibility to 16 antimicrobial agents of Gram-negative bacilliisolated from patients hospitalized in medical and surgical I.C.U.S.,of 6 hospitals, 4 of which were University, plus Neonatal ICU.We studied 592 isolates, with predominance of Pseudomonas aeruginosa(n,258),Acinetobacter s (rn85),Escherichia coli ‚ Klebstellaneumontae and Serrat.ia marcescens n= 1 .

MICs were determined by the microdilution techniques, using a comercialsystem (Baxter).We tested 12 beta-lactams, 3 aminoglicosides and 1 quinolone.We have evaluated: the prevalence of the various species; percentsusceptibility at NCCLS breakpoints to the tested agents, both withinspecies and through the overall sample; susceptibility to the variousdilutions. We obtained the following results (%):

IMP CAZ AlT CAX PIP AMR CIP79 74 1 64 75 77

Acinetobacter 97 66 23 30 20(16 77 45E. coli 99 97 96 97 54(56 96 100K. pneumoniae 99 48 72 84 13(16 88 92S. marcescens 97 91 91 97 27(16 61 39All agents 88(4) 74(8) 69(8) 50(8) 49(** 80(16 76 (1)MP-Imipenem;CAZ-Ceftazidime;AZT-Aztreonam;CAX-Ceftriaxone;

A.MK-Amikacin;ClP-Ciprofloxacin.

% Susceptibility at (NCCLS breakpoints)** Different breakpoint for P. aeruginosa

This study will be continued in 1992 as we consider the updating ofthis data important in terms of-epidemiologic information and guidelinesto therapy.

CENTRO HOSPITALAR DE COIMBRA - LABORATORIO DE B.ACTERIOLOGIAQta. dos Vales3000 COIMBRAPORTUGAL

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P104TRENDS IN SUSCEPTIBILITY OF AEROBIC GRAM NEGATIVE ISOLATES IN ICUPATIENTS IN PORTUGALPins E. ,Moreira J. ‚Costa D. ‚Costa M.,Ribeiro C.,Salgado M.J.

In 1990 a study of antibiotic susceptibility in serial Gram negativeisolates from ICU patients in 6 hospitals was undertaken and repeatedin 1991. A total of 1350 isolates were studied (758 in 1990 and 592in 1991)MICs were measured by a microdilution technique using a commercialsystem (Baxter). 12 beta-lactams, 3 aminoglycosides and a quinolonewere tested. Ps. aeruginosa , Acinetobacter spp , E. coli , K1. pneumoniae ,and Serratia marcescens were the predominant isolates and therespiratory tract the most frequent site. Variations in susceptibility(increase or decrease in resistance) were observed with the most ofthe isolates and for most of the antimicrobials tested but were mostsignificant in Serratia, Acinetobacter and Psudomonas isolates, probablyreflecting the selective pressure exerted by antibiotics withinindividual ICUs. A detailed analysis of susceptibility of the isolatesfrom the LRT by species/antibiotic/hospital will be presented.

ALL Pseudomonas Acinetobacter E. K. Serratia

BACTERIA aeruginosa . spp coli mzseiae marcescens

N.BACTERIA 758 592 261 228 106 85 101 69 98 90 28 33YEAR 90 91 90 91 90 91 90 91 90 91 90 91

IMP 88 88 84 77 96 97 100 99 99 99 96 97CAZ 75 74 82 79 42 66 96 97 74 48 82 91CAX 53 50 26 18 26 23 97 97 89 84 82 97AZT 68 69 75 74 17 30 96 96 80 72 79 91PIP 49 49 69 77 23 20 42 54 28 13 54 27CIP 80 76 73 77 60 45 100100 95 92 96 39AMK 82 80 76 75 89 77 99 96 86 88 82 61

IMP-Imipenem;CAZ-Ceftazidime;AZT-Aztreonam;CAX-Ceftriaxone;AMK-Amikacin;CIP-Ciprofloxacin.

% of susceptibility at NCCLS breakpoints

HOSPITAL S. JOSS - LABORATORIO DE MICROBIOLOGIAR. Jose A. Serrano1100 LISBOAPORTUGAL

P105TREATf;ENT OF NOSOCOMIAL PNEUMONIA INPATIENTS WITH SEVERE HEAD INJURES

D.Gasanovic-Popovic,R.Ratkovic, G.Bura- Nikolic,I.Stosic,M.Kaludjerovic,D.Grujicic

Pulmonary infection is a major cause ofmortality in patients hospitalized fortreatment of severe head trauma,whereas therisk factors for nosocomial infections inneurosurgical patients are numerous.Group consisting of 12o patients with seriousisolated craniocerebral injures (GCS47 onadmission) have been treated and hospitalizedduring last three years on Neurosurgicalclinic of Belgrade,out of which an observedgroup of 27 patients suffered from lunginfection as complication in a course ofhospitalization.The patients were initially untreated withantibiotics.Our analysis on observed groupshow that the most frequent agents of heavynosocomial pneumonia are gram-negativebacilli: combinations of Enterobacter (7o.4%),Pseudomonas Aeruginosa (59.3%) and Pz•oviden-tia Stuartii (55.6%).We came to conclusion that these agents showthe best sensitivity to Cephalosporines ofII and III generation (cefotaxime,ceftazidime,ceftriaxone) and to Aminoglycosides.The percentage of recovered in observedgroup was 66.7% ( 18 patients ).

Neurosurgical Clinic, Belgrade UniversityClinic Center, ll000 Belgrade, Visegradska 26Yugoslavia

P106VANCOMYCIN PHARMACOKINETICS IN CRITICALLY ILL PATIENTSDURING CONTINUOUS HEMOFILTRATION. Ch. Santr6, 0. Leroy,M. Simon, B. Guery, H. Georges, C. Beuscart, G. Beaucaire.

Patients-Methods Three patients (mean age 58.7years ; R 6 41-79, mean SAPS : 15.7 ; R - 9-23) underwentcontinuous veno-venous hemofiltration (CVVH). for acuterenal failure. Blood was pumped using a roller pump (BL760 FB, Bellco) at 100-150 ml/mn through a membrane

hemofilter (Hemospal AN 69 S). Every patient received 7.5mg/Kg.IV vancomycin for a documented or suspectednosocomial staphylococcal infection. The vancomycinconcentrations were measured in serum and an aliquot of

filtrate sample by radio-immunofluorescence assay (TDX-Abbott). Samples were collected before infusion and 1, 3,6, 12, 18, 24 hours after the end of infusion.Results . The mean peak serum concentration was 27.3mg/l (15.6 - 45.6) one hour after the end of infusion.The mean remaining vancomycin concentration 24 hoursafter the onset of infusion was 3.6 mg/l (2.6 - 4.5). Themean terminal disposition rate constant and eliminationhalf-life was 0.05 h-1 and 13.9h (SD - 0.7 h)respectively. Mean total body clearance was 38.9 ml/mnand CVVH clearance 4.2 ml/mn. The mean volume ofdistribution was 47.4 1.Conclusion : CVVH is effective for vancomycinelimination and in these patients, the eliminationhalf-life was almost constant. Regarding to vancomycintime-dependant killing, 'this should involve a bidinjection to achieve effective concentrations. Otheradministration regimens, such as continuous infusion,should be evaluated in this group of patients.

*Intensive Care and Infectious Diseases Unit. Tourcoing.Lille University Medical School F-59208 TOURCOING FRANCE.

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P107DOSAGE AND DRUG MONITORING IN ONCE DAILYTREATMENT WITH AMINOGLYCOSIDESF. Konrad, R. Wagner, J. Kilian, M. Georgieff

The once daily (OD) administration of high dose of aminoglycosides ismore frequently considered as state of the art therapeutical approach.The pharmacokinetic data on single dosing have mainly been collectedin voluntary subjects and non-intubated patients. This explains the dif-ference in dosage ranging from 4.1 to 6.6 mg/kg BW for the aminogly-coside netilmicin (J Drug Dev 1988: l(Suppl3) 1-88). In a prospectivestudy we therefore determined the netilmicin serum concentrations un-der OD treatment in intübated patients, beginning with a dosage of6 mg/kg BW. 20 patients of a surgical ICU who suffered severe infec-tions were studied. Concentrations were measured directly before andafter the administration as well as after 0.5, 1, 3, 7 and 12 hours to de-fine the required daily dose and to gain information about a meaningfuldrug monitoring. On the 2. and 3. treatment day individualized adjust-ment of the dosage based on pharmacokinetic calculations was perfor-med to achieve a virtual peak level of 25 mg/1 and a trough level of 0.5mg/l. In patients with serum creatinine levels within the reference ran-ge (< 120 µmoll; n = 13) the median netilmicin dose needed was 7.86mg/kg BW. In patients with elevated serum creatinine levels (n = 7)the concept of OD treatment was applicable, if the dose was adaptedand reduced (2.7 mg; 1.3 - 6.6; median with range). However corre-spondingly high peak levels were not achieved (Table 1).Table 1: Concentration of netilmicin on the 3. treatment day (median)Time: After application 0.5 1 3 7 12 24 (h)Pts. with normal creat. 36.9 20.2 17.2 8.2 3.6 1.3 0.3 (mg/1)Pts. with elevated treat. 15.1 9.2 8.1 6.2 4.9 2.6 1.8 (mg/I)In patients with normal serum creatinine and life-threatening infectionstreatment should be initiated with 7 mg/kg body weight. In case oftrough levels below the detection limit, the daily dose may be increa-sed. Dose reduction should be considered, if the trough level is foundto be above 1 mg/I. In contrast to the conventional thrice daily admini-stration during OD treatment determination of the extremely high peaklevels is not required for therapeutical drug monitoring.Department of Anesthesiology, University of Ulm, Steinhövelstr. 9,7900 Ulm, FRG

P108WITH ALLIMIN TREATING RESPIRATORY TRACT DOUBLE INFECTION

Hou Zhongmin, Zhou Ruping

262 severe patients performed tracheotomy were treated in our SICU

from 1981 to 1991, in which 66 cases occuretrespiratory tract

double infection ( 25.2% ), 23 mycotic Infection, 18 pyocyanicinfection, 5 staphylococcus aureus, 3 collInfection and 17 mixed

infection. In treating group with Altimin ( 41

cases, 2-2.5mg/kg/day ), 32 cases recovered ( 78% ), 3 cases died( 7.3% ) and 6 cases died of primary diseases ( 14.6% ). In other

treating group without Altimin ( 25 cases ), 14 cases were cured

( 56% ) , 7 cases died (28% ) and 4 cases died from primary

diseases ( 16% ). Comparing the cure rate and the mortality in theboth groups, the difference were remarkable ( P< 0.05 ).

The observed advantages of treating with Allimin were as follows:

( 1). Allimin Is a broad-spectrum antibiotic and possesses quite

better bacteriostati caction to common pathogenic bacteria ofdouble Infection e.g.: mycete, bacillus pyocyaneus, etc. (2). It

is a preparation of Chinese medicinal herbs, hasn't toxic-sideeffects to human being and is quite safe. (3). The drugs-resisting

bacterial strain against it hasn't still been found, and may use

it for a long times. Therefore, we consider that treating

respiratory tract double infection with Atlimin has some degree of

clinical value.

Department of Surgery, The First Teaching Hospital, 29

Yejin-Da-Dao, Wuhan 430080, CHINA

P109StVEPE LPCIONELLA PNP.UMOPHILA PNEUMONIA. AN INCRPA3IN0 CAUSEOF ADMISSION TO ICUx.Sarelentolt), R.Tv.asl*1, E.HeselleslH), J. Alslrellls),A.Torres,at), M.90 ler(a), J.Mlllalftl, A.To.aeait)

---------------------- - ------ -------------- ---------------Over a Period of 4 conoecuttve years, 54 patient. (7 women.

47 sen) nenn ewe 55 4 17 years with critical acute respiratoryfailure lanes Pso2.P102 value of 147.5 4 15 am Me) and OSPcauned by severe Leelonelle pneuaophlle pneuaun'a (both

un icy-acquired end voeucv.ial. IS and 39, rnspectively)wore edel teed to ICU. The most frequent underlying clinicalcondition for bot

hno

•lei and nley acquiredpneueonlea chronic obstructive pul aonery diocese (31petlee te,57. 4x ). Nusocoalsl Infected patients had a higherIncidence of liver disease 118.4 x v a 6.2 %1, and DiabetesMellitus 131.6 N cm 12.5%). The mean period of MV see 18 ¤ 3days,coslal pneuaonlas requiring longer Periode ofventilation (23 + 4 vs 7 5. 2). The •can Intro ICU stay ve•wies longer for eosocomlel Infections than for coaannityacquired Infections (26.5!4.1 on 9.5*2.1 days).Mortality due to ae Vera Legions)). pneuaophila infection ((9deaths, 35.2%) van loner-then-expeeted by APACH!-II lesenvein. (18.8 ¤ 1, expected sorteilty 73 x) for Leefonellepneumonia (1),(12.8 ¤ I). According to unlverlate analysis,aortallty es, aeeoclated with bilateral redlole elcalInvolvement during the tetra ICU 0v0lution of pneumonia. IntroICU acquired infection, and presence of shock on admission.Neitherone of the folloving parameter. APACHE-Il. orbilateral redloleelc afecelon et edaleelan, leucocyte count, %of bends, CPK levels, Pe02/PiO2 ratio, presence of pleuraleffusslon, developeaent of renal (allure (even requiringheeaodlalysle),or

I.aunoaupreaeion showed prognosticInfluence on the outcome of pneuaon la. Further loslstIcregression analysis only selected septic shock assignificantly related to the prognosis.Noaocoalel acquired pneumonia, and common lty acquiredpneuaontea showed no significant differences Vieh respect tomortality (36.8% vs. 31.2 x, reap. , APACHE-11 ) 19.1 vs17.7¤ 1), Ps02/F102 ratio 1135.9,12.7 vs 175.5 ±201, number ofOUP (3+0.8 vs 300.7).lapin . treatment sith wry troeiclne soon after diagennie wasuspected improved outcoae compared to patients oho receivederythroalclne only after bacteriologic diagnosis had beencoefir.gJ (50 x among IN patients thee did not receiveerythroalclns until dl..noels eventually died, es 28 % among36 that received erythrneiclne from edalsaloh).It seems Justified to begin treatment promptly once the

diagnosis of Le alonell. pneuaophlia pneusonl. Is suspected.Though Leelonelle pneaaophsla Infection with o9P Is an(screw sing cause of admission to (CU, It has a relatively lowmortality, despite development of renal failure, bilateralradiological involvement, )esunosupre as ion or nosnooaleladqulsltlon. Presence or Shock on admission is the costpowerful proenoet/c factor Indicating an Ominous outcome.

s Hospital Unlver sltnrl Carsana Tries 1 Pujo1, endalonecc Hospital Clinic I Provincial, aercelona

P110CANDIDIASIS IN ICUMA. Lehn, A. Ayuso, R. Diaz, J. Robust6, G. Soria l , C.Torres and M. Nolla.

PURPOSE: In order to evaluate the significance of yeastisolation from septic patients in ICU, we propose ascreening that includes both microbiology and cellularimmunity tests. The usefulness of this classification forpatient management was prospectively assessed.METHODS: Study includes 34 ICU patients. Meean age 58 (17-90) who has yeast isolated from any specimen cultured todocument a sepsis episode were studied. The screeningconsisted of 1) different specimens on selective media foryeast isolation; 2) eye exam; 3) detection of Candidaantigen and antibody in serum; 4) cutaneous tests.RESULTS: The mean ICU stay was 36 days (2-84). The overallmortality was 35%. The mean age was 50 for those patientswho survived, and 72 for those who died (p<0.01). Themortality was 41% for the 29 patients with negativecutaneous tests, and 0% for the 5 patients with positivetests. The first positive specimen triggering the study wasindicative of disseminated Candidiasis in 3 patients (33%mortality), and therefore they were not further screened.A positive blood culture was the triggering specimen in 2patients. In the other 29 patients, the first positivespecimen was one of the traditionally considered non-significant. Overall, 31 patients were included in thescreening protocol. Six of them had high risk ofdisseminated Candidiasis (HRDC) due to a positive bloodculture (17% mortality). Nineteen patients had criteria forHRDC with a negative blood culture (47% mortality), and 6patients had not HRDC (17% mortality).CONCLUSION: In our hands, the definitions of Candidiasisproposed for critically ill patients with a long stay inICU allowed for an easier evaluation of HRDC, and madepossible an adequate instauration of antifungic therapy.

ICU and Microbiology department = . Hospital General deCatalunya, Sant Cugat del Vall6s. Barcelona, Spain.

106

PillEnterococcw+ Jaecium VANCOMYCIN RESISTANT IN ICUPATIENTS.

MJ. Jiment, M. Rosin*, J. Saarar, JA SanchazIzquierdo, A.Mart cz, P. Ai ribas, S. Bermejo, E. Alted.

INTRODUCTION Durinj 1991 we have isolated in several eamplas of ICUpatients Enten000cct•s faecuun resistant to Vanoomycin (V t F). Thisresistance pattern is exceptional in our environment and involves a therapeuticchallenge.

OBBGTIP$The aim of this work is to analyse the clinical relevance of thisfindings and the existence of risk factors for VREF colonization in this patients.PATIENTS and METHODS We have studied 16 ICU patients during 1991who have been isolated VREF. We have recorded Ago; sex; da^§F);

ICU stayIS); income diagnosis; days of stay until VREF was isolated cluucalsam ks (CS); invasive methods: Mechanical ventilation ' days ofMV DMV), pt^eviess guy (PS), type of surgery and time surgery toVREF to was isolated ((1SUR), Swan-Ganz (SO) n° of intravenous catheters(1VC),artczial catheters (ACi,mdwelling bladder catheterdrainages (TI)), and abdominal drainages (AD) in each patient and meanduration for each one (D); antimicrobial therapy (A'7) selective oraldeoontaminatlea (SOD) ummunoanppressive therapy, clinical significance ofisolated (Infection vs. colonization) and mortality.RESULT& Age 56 ± 13; male 62,5%; female 37,5%; income diagnosis:trauma patients 50% surgical and medical non traumaents 50% ( livertransplantation LT 1'x,3%)• IS 48* 32 DSEF 24t 11; CSIlood culture (BC)37,5%• urine 12,S^,, bronel'ua1 as pirate 1875%, surgical wound exudate (SWE)31,25%; Invasive methods: MV -100%, I)MV 43± 27 PS 81 (abdominalsur ry 625% LT 125%) TSVR 22#10 SO 62,5% (1)6* 3), NC 3*17±4), AC Z±1 (t)7±2) TBC j St0 5(D 13±) AD 2±1 (D l03),'TD 10 593)' SOD 100% ; ATEI: Vancomyein 68,75% (1)9f5), aminoglyoosides 62,5%(1) 435), £-Laqm antibiotics 100%, immunosuppressive therapy 12,5%;colonization 87 ,s%, infection 12,5% and mortality 5%.CONCLUSIONS: 1)The mean ICU stay in this patients was v long. 2 ) Thenumber and mean duration of invasive methods was very hit too.3) EFVRwas isolated specially from blood cultures and SWE.4) The clinical meaning ofthis isolates was minimal (87,5% colonization vs. 12,5% infection) 5) The useof vancomycin in SOD may be a risk factor for the VERF appearance

Departments of ICU and Infectious Diseases*,University Hospital "12 deOctubre'. Cira do Andalucia KM 5.4.28041 Madrid, Spain.

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P112EXCHANGE TRANSFUSION IN SEVERE FALCIPARUM MALARIA. ABOUT4 PATIENTS. Ch. Santrt*, 0. Leroy*, F. Fourrier**,H. Georges*, B. Guery*, C. Beuscart*, G. Beaucaire*.

Severe plasmodium falciparum malaria (PFM) mortality rateremains high (from 10 to 44 I according studies), despitewell-known medical treatment. Exchange transfusion (EXT)has been proposed in 1974 as a therapeutic adjunct forthese patients.Patients-Methods Four patients (mean age 52.3years, R - 34-65, mean SAPS : 15, R - 11-20, meanparasitaemia rate : 24.5 1, R - 16-40 1) with severe PFMunderwent EXT due to severity criteria (WHO classification1986) or lack of quick improvement with conventionaltreatment. Two patients were comatose and all exhibitedrenal insufficiency. All patients received IV quinine (38mg/kg.24 h), vibramycine was adjuncted in two cases. EXTwas performed with a blood roller pump. Time to completethe exchange ranged from 1 to 4 hours (mean 2.5 h),needing 14 ± 1.2 units of blood cells.Results All patients were cured without sequellaes.Clinical, especially neurological status, improvedquickly during EXT. Parasitaemia rate decreased below 5 2immediatly after EXT (mean 3.2 Z) and below 1 2 at H24,without dramatical increase after the end of theprocedure. Mean stay in ICU was 13.3 days (R - 5-20). Onepatient exhibited an important hemolysis and renalimpairment probably related to a malarial haemoglobinuria.Conclusion : ' Although the lack of controlled andrandomized studies does not allow final conclusions, EXTappears to be safe, and effective in these type ofpatients, particularly with neurological status and renalimpairment.

* Intensive Care and Infectious Diseases Unit. Tourcoing.** Intensive Care Unit. Hbpital B. LilleLille University Medical School. 59208 TOURCOING - FRANCE.

P113TETANUS IN GREECE: MANAGEMENT, COMPLICATIONS AND MORTALITYIN 22 CASES.L.Gregorakos,C.Katsanos, V.Malessios, J.Nicolopoulos,J.Tsokou, Ch.Nicolaou, M.Kountou-ri.

Tetanus is a disease of the nervus system characterized byintense activity of motor neurons resulting in severe mu-scle spasms. Tetanus is still an important cause of morta-lity in the world (300,000 cases per year, with a mortali-ty approaching 45 percent).In more temperate and econo-mically developed areas such as Europe and North Americathe disease has become extremely rare because of betterhygiene, improved wound care and high immunization rates.Recently the advances in knowledge and management of acuterespiratory failure in the intensive care units and theuse of vital supportive measures have changed the progno-sis of tetanus patients (<15%). In the last decade (1981-1991),in Greece, 354 tetanus pts (171 males and 183 fema-les) were reported with a mortality of 20.5%. In this stu-dy we present 22 pts (15 males-7 females) with tetanus.Mean a ye of the patients was 60 years (range 23-83), 13(58.1%) patients were over 60 years.The incubation periodwas 8 days 22(100%) were mechanically ventilated. Themean duration of MV was 21.6 days while the mean durationof stay in the ICU was 35.5 days. 7(31.8%) died during me-chanical ventilation, 5(71.4%) of them from cardiac arrestand 2 (28.6%) from sepsis. The above data suggest that thehigh mortality rate (31.8%) of tetanus pts in the ICUseems related to age, cardiovascular instability and sepsisdue to nosocomial pneumonia.

P114DISSEMINATED ASPERGILLOSIS IN ICU

P. Velasco, J. A. Moreno, P. Torrabadella, E. Castellä', M. C. Gdmez' andJ. M. Condom"

The disseminated aspergillosis is an unusual diagnostic in the intensivecare unit (ICU). It can clinically manifest as severe respiratory failure,muf iorgan failure and dead.The authors are reporting two cases of disseminated aspergillosis admittedto the ICU with respiratory failure and sepsis. We describe risk factors,clinical evolution and postmortem findings.

CASE 1. A 63-year-old man with an history of diabetes mellitus (DM),idiopathic thrombopenic purpure (ITP) and receiving steroid therapy forone month was admitted to our hospital with respiratory failure. During thehospital stay, he required ICU admission for support of oxygenation andmechanical ventilation. Initially, P. Carinii pneumonia was diagnosed frombronchoalveolar lavage. Sputum culture grew aspergillus and the pacientsubsequently died. At autopsy, necrotizing hemorrhagiabronchopneumonia (NHB) with focal abscesses, renal, thyroid andmyocardial abscesses, endocarditis and oclusion of the pulmonar arterieswere found. Performed cultures were positives for aspergillus fumigatus.

CASE 2: A 65-year-old man with an history of idiopathicencephalomenigoradiculitis and taking chronic steroid therpy was admittedto the ICU for life sustaining support with acute respiratly failure. Chestradiography revealed cavitating right upper lobe pneumonia. There werealso endophtalmitis and nose wing abscess. He requiered mechanicalventilation. Sputum culture grew aspergillus. At Postmortem examination,there were NHB and performed culture of the nose wing abscess waspositive for Aspergillus tumigatus and Pseudoalescheria boydii.

Hospital Universitario " Germans Trias i Pujol " . Servicio de MedicinaIntensiva.Servicio de Anatomia Patolögica'. Servicio de MicrobiologiaCarretera Canyet s/n: 08916.Badalona . Barcelona. Spain.

Hospital for the diseasesof the Chest, Athens-Greece.152 Messogeion Avenue

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P115TRACHEOESOPHAGEAL FISTULA IN A PA1IENf WITH SEPSIS BY

C YTOHEG ALOVIPUS .X.Sarmlento. X. Esquirol. Ch Domingo, J.Perez-Piteira. R.Tombs. 11.Soler.

A. To mass---------------------- ----------------------------------------------

A 64 year old man was admitted to the ICU because or fever and

dyspnea-. He had never drink alcohol nor taken drugs, and had been diagnosedof tuberculosis 30 years before correctly treated with PAS andStreptomycine for one year. About that time he stopped smoking. Heremained asymptomatic until 1989 when he developed hemoptysis secondaryto a cavltated Infiltrate of the right upper lobe, eventually requiringrepeated arterial embolization of the Involved bronchial vessels, He couldnot be operated because of limited respiratory capacity. Repeatedbacteriological controls of the sputum were always negative fortuberculosis. Three months before admission he developed progressivedysphagia and ocasional vomiting, and finally he noticed progressive shortof breath and fever.

He was admitted to the Pulmonary Department with the diagnosis of rightpneumonia and was transferred to the ICU three days later because ofdyspnea at rest. Tests done at admission disclosed a bilateral infiltrationon chest X-ray, arterial hypouemia and hypocapnia, light elevation ofSCOT, anemia. hypoproteinemia, and normal renal function. AFB study ofthe sputum was again negative. The ICU course was complicated by massivehemoptysis requiring Intubation. An emergency fibrobronchosropy showeda tracheoesophageal fistula 2 cm above the carina. the patient developedintractable pneumonia refractory to high oxygen concentrations, and diedon the tenth day of hospitalization.Necropsic study confirmed a tracheoesophageal fistula communicating

with cavitations in the right upper lobe, that were surrounded by pneumonicinfiltrates. Hystopathologic Investigation showed typical microscopicInclusions of cytomegalovirus both In lung and In the liver and the specificimm unofluorescence test for antibodies against cytomegalovirus waspositive.

In this case report we describe how systemic primary infection with thecytomegalovirus In a patient without suspicion of Immunodeficiency wasassociated with the development of a bronchoesophageal fistula. AlthoughThis fistula could be ezpleinad by the previous 'tuberculosis, anemia,hypoproteine.mia and the tracheal incubation, it seems also likely that anesophageal cytomegalic ulcers, that usually Involves deep layers of themucosa and muscularis perfored thru the tracheobronchiel wall causing alarge tracheoesophageal fistula as described.

-------------------------------- - ------------------------------Depertment of Intensive Care Medicine. Hospital Ilniverlstarl Germans TriesI Pujol. Carrelera del Canyet s/n (Can Poti). BADALONA. SPAIN

P116ACUTE RENAL FAILURE DUE TO LEPTOSPIROSISD,Reingardiene, N.A mbrazeviilene

With this analysis we Wish to present thecourse of acute renal failure (ARF) inleptospirosis. There were 8 males and Ifemale, ranging in age from 32 to 62 years,All the patients had either high riskoccupations or a history of exposure toexternal sources of infection. All had fever,myalgia, Jaundice and muscle tenderness. Inall patients was a haemorrhagic diathesis.The diagnosis was confirmed at mean during5,7 days, The common serotype affecting manwas L , icterohaemorrhagiae, In all patients theARF was oliguric. The period from the onset

pof a.ymptoms and signs of the ARF varied onaverage 4,8 days. The concentration ofcreatinine in the serum prior to the firsthaemodialysis ranged from 0,52 to 1,1 mmol/l.In all patients the liver was palpable andtender. Levels of total bilirubine, AST, ALT,alkaline phosphatase were increased. Compli-cations were detected, massive gastrointesti-nal blood loss, arrhyth mlas in 2, hepaticencephalopathy - in 2, thrombocytopenia - in1. All patients were dialyzed. Two of the 9patients died: one from a fulminant hepaticfailure during the oliguric phase ARF, andother from sepsis, after recovering fromrenal dysfunction,In conclusion: it is impor-tant to recognize that many cases of ARF dueleptospirosis with prompt and adequate treat-ment are often favorable clinical outcome.

Department of Anesthesiology and Intensivecare, Kaunas Medical Academy. 3000, Kaunas,Mickevidlaus 9, Lithuania

IntoxicationP117CARDIP.0 TOXICITY' OF 5 FU : A PROSPECTIVE STUDYJY RANCHERE, B.GORDIANI, JF LATOUR *, C.ARDIETS, M.CLAVEL

A prospective clinical study was performed during threemonths in 1990. 301 patients were given combined chemothe-rapy with 5 FU, for 934 cycles. 11 types of combined che-motherapy were used. Associated drugs included Cyclophos-phamide (58,8%), anthracyclin (57%), cisplatin (18,6%),folinic acid (6,3%), and others (6,3%). Continuous infu-sion was used in 112 patients and single injection in 189patients. 5 FU induced cardiac events occured in 13patients. Median age was 64±0,7 y, 7 males and 5 females.5 patients had previous cardiac history (4 mild hyperten-sion, and 1 arteritis). The onset of clinical manifesta-tions was different from the 1st cycle to the 5th cyclebut 7 occured during the ist cycle from day 1 to day 6.Inaugural symptoms were angina pectoris (7), myocardialinfarction (5), arythmias (1). 5 patients died (mean age64±9,7 y) of myocardial infarction with secondary asso-

ciated neurologic symptoms. ECG showed repolarisationchanges in all cases. Myocardial infarction was proven byincreasing cardiac enzymes in 4 cases, and by autopsy inone case. The use of nitrates or calcium channel blockershad poor results. There was no relation between the peakplasma concentrations of 5 FU and occurance of a cardiactoxicity in two cases. During continuous infusion therewere 10 cardiac acute symptoms (9%) and deaths (4,5%), andduring single injections 3 cardiac problems (0,4%). Thedifference between two type of 5 FU use is statisticiallysignifiant for cardiac accidents and cardiac deaths (P =0,00009). A possible explanation is Fluoroacetate (FAC)a Krebs cycle blocker. FAC is a compound recently implica-ted in 5 FU induced cardiotoxicity. FAC is in vivo metabo-lite of fluoroacetaldehyde-acetal, resulting from aceta-lisation of fluoroacetaldehyde (impurity in FU Vials) bytris (the solvent). It may be possible than during time ofcontinuous infusion this product increase in solution.Opt of Anesthesiology and Intensive Care, Opt of OncologyCancer Center Leon Berard 28, Rue Laennec LYON France

P118HEMODYNAMIC COLLAPSE INDUCED BY THE PHARMACOLOGICAL INTER-ACTION BETWEEN AN AMPHETAMINE DERIVATIVE AND DISOPYRAMIDE:A CASE REPORT.

H. GERMANOS, D. DIANA, P. WULLEMAN.

A 29 years old nurse was admitted to our hospital for bru-tal dyspnea. She said to have irrelevant medical history,to be on oral contraceptives and to have absorbed 100 mgof disopyramide for palpitations 1 hour before. Physicalexamination on admission showed : cyanosis, hypotension(systolic blood pressure:70 mmHg), tachycardia (heart rate:120/'),vasoconstriction, tachypnea, anxiety and severe ju-gular veins turgidity,all signs suggesting a massive pul-monary embolism.Arterial blood gases were:pH 7.33, paCO 2

28 mmHg,pa0 2 64 mmHg, base excess-8.5 mmol/1.Routine bloodchemistry showed hypokalemia (3.1 mEq/l;range 3.5-5.0).Routine ECG showed sinus tachycardia and left bundlebranch block (LBBB).Standard chest-X ray and bidimensionalechocardiography were normal.The patient's condition ra-pidly improved after fluid challenge with colloids and o-xygenation with a 40% Venturi mask.The ECG returned tonormal within 10 minutes.The clinical evolution and normalventilation-perfusion lung scans ruled out the initialdiagnosis of massive pulmonary embolism.The hypothesis ofdrug-induced hemodynamical impairment was confirmed by thedetection of large urinary amounts of phentermine resinatean amphetamine derivative.Phentermine resinate can rarelyinduce hypotension,while very little is known about itspharmacological interactions with other drugs.We concludethat, either a direct toxicity of the drug or an interac-tion with the antiarythmic drug disopyramide (whose serumlevel was within therapeutic range)and/or the hypokalemiamight explain the rapidly reversible hemodynamic impair-ment and LBBB experienced by this patient.

Department of Intensive Care Medicine, Hbpital Ixelles-Etterbeek, 63 rue Jean Paquot, 1050 Bruxelles, Belgium.