The computation of fluid balances (FBs) by subtracting fluid outputs from inputs is a common critical care practice. Limited information exists about the accuracy and consistency of nurse-registered ...cumulative FBs and regarding the value of suggested corrections for non-measurable losses.
From 147 ICU patients, we prospectively evaluated the cumulative FBs and their relationship to changes in body weight (BW). Standardised measurements of BW were performed on admission and discharge. FB charts were accurately reviewed and arithmetic errors corrected. Net cumulative FBs and adjusted cumulative FBs (considering sensible or insensible fluid losses/fever/liquid faeces) were analysed for all patients and 3 subgroups (cardiac-cerebral, septic, and others). Agreement between FBs and BW changes was calculated according to the defined subgroups and confounding variables.
Cumulative FBs were inaccurate in 49 cases (33%) with errors ranging from -3606 mL to +2020 mL. The total (average daily) difference between measured BW and FBs (mean ± SD) was 0.185±1.874 kg (0.101±1.020 kg). Correlation (r(2)) and Bland-Altman agreement was poor between BW changes and net cumulative FBs (0.552 and -1.26±5.41 kg) and slightly better between BW changes and adjusted cumulative FBs (0.714 and +0.18±3.68 kg). Standard deviations of the average daily differences between BW changes and FBs were always >1 L. Correction of the net FBs as suggested in the literature were not useful. New multiple regression models only modestly improved correlation.
For a large portion of patients nurse-registered cumulative FBs are neither accurate nor do they agree with standardised BW measurements. Patient care and clinical decision-making should be based on more objective techniques.
Four patients who underwent contrast-enhanced computed tomography (CT) scanning were infected with hepatitis C virus from a contaminated multi-dose vial of NaCl. The outbreak likely occurred due to a ...breach in safe injection practices, resulting in contamination of the vial. Not all patients exposed to the same vial were infected. The uneven distribution of infections could be attributed to a stochastic effect of a low infectious dose. This implies that outbreak investigations need to be extended to all patients scheduled before and after the first identified infected patient to confirm or rule out nosocomial transmission.
OBJECTIVES:In septic patients with acute circulatory failure, reliable predictors of fluid responsiveness are needed at the bedside. We hypothesized that the respiratory change in pre-ejection period ...(ΔPEP) would allow the prediction of changes in cardiac index following volume administration in mechanically ventilated septic patients.
DESIGN:Prospective clinical investigation.
SETTING:A ten-bed hospital intensive care unit.
PATIENTS:Patients admitted after septic shock equipped with an arterial catheter.
INTERVENTIONS:Pre-ejection period (PEP)—defined as the time interval between the beginning of the R wave on the electrocardiogram and the upstroke of the radial arterial pressure curve (PEPKT) or the pulse plethysmographic waveforms (PEPPLET)—and cardiac index (transthoracic echocardiography-Doppler) were determined before and after volume infusion of colloid (8 mL·kg). ΔPEP (%) was defined as the difference between expiratory and inspiratory PEP divided by the mean of expiratory and inspiratory values. Respiratory changes in pulse pressure (ΔPP) was also measured.
MEASUREMENTS AND MAIN RESULTS:Twenty-two volume challenges were done in 20 deeply sedated patients. ΔPEPKT, ΔPEPPLET, and ΔPP (measured in all patients) before volume expansion were correlated with cardiac index change after fluid challenge (r = .73, r = .67, and r = .70, respectively, p < .0001). Patients with a cardiac index increase induced by volume expansion ≥15% and <15% were classified as responders and nonresponders, respectively. Receiver operating characteristic curves showed that the threshold ΔPP value of 17% allowed discrimination between responder/nonresponder patients with a sensitivity of 85% and a specificity of 100%. For both ΔPEPKT and ΔPEPPLET, the best threshold value was 4% with a sensitivity-specificity of 92%–89% and 100%–67%, respectively.
CONCLUSIONS:The present study found ΔPEPKT and ΔPEPPLET to be as accurate as ΔPP in the prediction of fluid responsiveness in mechanically ventilated septic patients.
OBJECTIVEExamine whether a low serum level of apolipoprotein A-I at intensive care unit (ICU) admission is associated with a further increase of the number of systemic inflammatory response syndrome ...(SIRS) criteria.
DESIGNProspective observational study.
SETTINGA 20-bed, university-affiliated, surgical ICU.
PATIENTSPatients admitted after major surgery, multiple trauma, or acute pancreatitis without septic shock.
INTERVENTIONSWe defined as the SIRS Exacerb group patients who presented a further increase of the number of SIRS criteria during their ICU stay or, in the presence of four SIRS criteria at ICU admission, those who presented a further aggravation of organ failure. Other patients were attributed to the SIRS No Exacerb group. From day 1 to 6, we measured apolipoprotein A-I, high-density lipoprotein and total cholesterol, triglycerides, C-reactive protein, procalcitonin, serum amyloid A, interleukin 6, interleukin-1 receptor antagonist, albumin, and other nutrition-linked variables. We looked at laboratory values or factors present at ICU admission according to the two groups.
MEASUREMENTS AND MAIN RESULTSFrom 63 patients analyzed, 29 (46%) were assigned to the SIRS Exacerb group. Age, sex, and SAPS II and SIRS scores at ICU admission did not differ between the groups. Patients in the SIRS Exacerb group presented more often a septic event (5/29 vs. 0/34, p = .02), had a higher hospital mortality (6/29 vs. 0/34, p = .007), and had a longer ICU stay (p = .0023). At admission, inflammatory variables such as the C-reactive protein, serum amyloid A, interleukin 6, interleukin-1 receptor antagonist plasma levels, and other lipid or nutrition-linked variables were similar between the two groups. Apolipoprotein A-I levels were lower in the SIRS Exacerb group (median interquartile range68 56–81 vs. 84 69–94 mg/dL, p = .028).
CONCLUSIONA low serum level of apolipoprotein A-I at ICU admission is associated with an increase of the number of SIRS criteria during the ICU stay.
PURPOSE OF REVIEWTo assess the recent advances in the field of waterborne nosocomial infections.
RECENT FINDINGSIn the last year, many publications have confirmed the importance of well known ...nosocomial waterborne pathogens such as Legionella spp. or other Gram-negative bacteria, especially non-fermentative bacilli. There have also been numerous reports of outbreaks or pseudo-outbreaks caused by Mycobacteria spp. The most intriguing information relates to the possibility that some fungi causing nosocomial infections may originate from the hospital water distribution system.
SUMMARYDespite progress in understanding the pathogenesis of nosocomial waterborne infections, outbreaks, pseudo-outbreaks and sporadic infections still occur. Targeted quality control of hospital water, updated procedures for the appropriate use of sterile and non-sterile water, coupled with surveillance constitute the cornerstones of prevention of these infections.
An increased frequency of nontyphoidal salmonellosis is well established in cancer patients, but it is unclear whether this represents increased susceptibility to exogenous infection or ...opportunistic, endogenous reactivation of asymptomatic carriage. In a retrospective study, a simple case definition was used to identify the probable presence of reactivation salmonellosis in five cancer patients between 1996 and 2002. Reactivation salmonellosis was defined as the development of nosocomial diarrhea >72 h after admission and following the administration of antineoplastic chemotherapy in an HIV-seronegative cancer patient who was asymptomatic on admission, in the absence of epidemiological evidence of a nosocomial outbreak. Primary salmonellosis associated with unrecognized nosocomial transmission or community acquisition and an unusually prolonged incubation period could not entirely be ruled out. During the same time period, another opportunistic infection, Pneumocystis pneumonia, was diagnosed in six cancer patients. Presumably, asymptomatic intestinal Salmonella colonization was converted to invasive infection by chemotherapy-associated intestinal mucosal damage and altered innate immune mechanisms. According to published guidelines, stool specimens from patients hospitalized for longer than 72 h should be rejected unless the patient is neutropenic or >or=65 years old with significant comorbidity. However, in this study neutropenia was present in only one patient, and four patients were <65 years old. Guidelines should thus be revised in order not to reject stool culture specimens from such patients. In cancer patients, nosocomial salmonellosis can occur as a chemotherapy-triggered opportunistic reactivation infection that may be similar in frequency to Pneumocystis pneumonia.
Determination of activated partial thromboplastin time (aPTT) is used in coagulation management after heart surgery. Results from the central laboratory take long to be obtained. We sought to shorten ...the time to obtain coagulation results and the desired coagulation state and to reduce blood loss and transfusions using point of care (POC) aPTT determination.
Randomized, controlled trial.
University-affiliated 20-bed surgical ICU.
Forty-two patients planned for valve surgery (Valves) and 84 for coronary artery bypass grafting (CABG) with cardiopulmonary bypass.
Valves and CABG were randomized to postoperative coagulation management monitored either by central laboratory aPTT (Lab group) or by POC aPTT (POC group). Heparin was administered according to guidelines.
POC aPTT results were available earlier than Lab aPTT after venipuncture in Valves (3 +/- 2 vs. 125 +/- 68 min) and in CABG (3 +/- 4 vs. 114 +/- 62 min). Heparin was introduced earlier in the POC group in Valves (7 +/- 23 vs. 13 +/- 78 h, p = 0.01). Valves of the POC group bled significantly less than Valves in the Lab group (647 +/- 362 ml vs. 992 +/- 647 ml, p < 0.04), especially during the first 8 h after ICU admission. There was no difference in bleeding in CABG (1074 +/- 869 ml vs. 1102 +/- 620, p = NS). In Valves, fewer patients in the POC group than in the Lab group needed blood transfusions (1/21 vs. 8/21; p = 0.03). No difference was detected in CABG.
In Valves in the POC group the time to the desired coagulation state was reduced, as was the thoracic blood loss, reducing the number of patients transfused. This improvement was not observed in CABG. Side effects were similar in the two groups.
To determine the factors associated with failure of noninvasive positive pressure ventilation (NPPV) in patients presenting with acute respiratory failure to the emergency department (ED).
The ...authors retrospectively analyzed patients admitted to the ED for acute respiratory failure (defined as a PaCO2 level >45 mm Hg, and pH < or = 7.35 or a PaO2/FiO2 ratio < 250 mm Hg) and who were treated with NPPV. NPPV was delivered routinely according to an institutional protocol. Failure of NPPV was defined as the requirement of endotracheal intubation at any time.
A total of 104 patients were included. NPPV failed in 31% (32/104), and the mortality was significantly higher in this group (12/32 44%) compared with patients who were not intubated (2/72 3%) (p < 0.0001). Factors associated with failure of NPPV were Glasgow Coma Scale score < 13 at ED admission (odds ratio OR, 3.67; 95% confidence interval CI = 1.33 to 10.07), pH < or = 7.35 (OR, 3.23; 95% CI = 1.25 to 8.31), and respiratory rate (RR) > or =20 min(-1) (OR, 3.86; 95% CI = 1.33 to 11.17) after one hour of NPPV. The negative predictive value for NPPV failure was 86% (95% CI = 70% to 95%) for RR > or =20 min(-1). In the multivariate analysis, pH < or = 7.35 and RR > or =20 min(-1) after one hour of NPPV were independently associated with NPPV failure (adjusted ORs, 3.51; 95% CI = 1.29 to 9.62 and 3.55; 95% CI = 1.13 to 11.20, respectively).
Patients with pH < or = 7.35 and an RR > or =20 min(-1) after one hour of NPPV had an increased risk of subsequent endotracheal intubation.
Objectives: To determine the factors associated with failure of noninvasive positive pressure ventilation (NPPV) in patients presenting with acute respiratory failure to the emergency department ...(ED). Methods: The authors retrospectively analyzed patients admitted to the ED for acute respiratory failure (defined as a PaCO2 level >45 mm Hg, and pH ≤ 7.35 or a PaO2/FiO2 ratio < 250 mm Hg) and who were treated with NPPV. NPPV was delivered routinely according to an institutional protocol. Failure of NPPV was defined as the requirement of endotracheal intubation at any time. Results: A total of 104 patients were included. NPPV failed in 31% (32/104), and the mortality was significantly higher in this group (12/32 44%) compared with patients who were not intubated (2/72 3%) (p < 0.0001). Factors associated with failure of NPPV were Glasgow Coma Scale score < 13 at ED admission (odds ratio OR, 3.67; 95% confidence interval CI = 1.33 to 10.07), pH ≤ 7.35 (OR, 3.23; 95% CI = 1.25 to 8.31), and respiratory rate (RR) ≥20 min−1 (OR, 3.86; 95% CI = 1.33 to 11.17) after one hour of NPPV. The negative predictive value for NPPV failure was 86% (95% CI = 70% to 95%) for RR ≥20 min−1. In the multivariate analysis, pH ≤ 7.35 and RR ≥20 min−1 after one hour of NPPV were independently associated with NPPV failure (adjusted ORs, 3.51; 95% CI = 1.29 to 9.62 and 3.55; 95% CI = 1.13 to 11.20, respectively). Conclusions: Patients with pH ≤ 7.35 and an RR ≥20 min−1 after one hour of NPPV had an increased risk of subsequent endotracheal intubation.
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