Ventilation in the prone position for about 7 h/d in patients with acute respiratory distress syndrome (ARDS), acute lung injury, or acute respiratory failure does not decrease mortality. Whether it ...is beneficial to administer prone ventilation early, and for longer periods of time, is unknown.
We enrolled 136 patients within 48 h of tracheal intubation for severe ARDS, 60 randomized to supine and 76 to prone ventilation. Guidelines were established for ventilator settings and weaning. The prone group was targeted to receive continuous prone ventilation treatment for 20 h/d.
The intensive care unit mortality was 58% (35/60) in the patients ventilated supine and 43% (33/76) in the patients ventilated prone (p = 0.12). The latter had a higher simplified acute physiology score II at inclusion. Multivariate analysis showed that simplified acute physiology score II at inclusion (odds ratio OR, 1.07; p < 0.001), number of days elapsed between ARDS diagnosis and inclusion (OR, 2.83; p < 0.001), and randomization to supine position (OR, 2.53; p = 0.03) were independent risk factors for mortality. A total of 718 turning procedures were done, and prone position was applied for a mean of 17 h/d for a mean of 10 d. A total of 28 complications were reported, and most were rapidly reversible.
Prone ventilation is feasible and safe, and may reduce mortality in patients with severe ARDS when it is initiated early and applied for most of the day.
To assess the cutoff percentage of cells containing intracellular organisms (ICOs) in the microscopic examination of mini-lavage fluid for the diagnosis of ventilator-associated pneumonia (VAP), and ...to study the accuracy of this diagnostic procedure on patients who have received previous antibiotic therapy (AT).
Prospective clinical investigation.
The medico-surgical ICU of a university hospital.
Eighty-two patients who fulfilled the clinical criteria of first episode of VAP.
Lower airway secretion samples were obtained by a nonbronchoscopic protected bronchoalveolar mini-lavage (mini-PBAL).
A total of 82 mini-PBALs were performed. The fluid obtained was divided into two samples. The first sample underwent direct microscopic examination using centrifugal cytology and Giemsa stain in order to determine the percentage of cells containing ICOs. The second sample was processed for Gram stain and quantitative cultures. VAP was the final diagnosis in 65 patients based on the mini-PBAL results obtained in the quantitative cultures. At least one bacterial species grew in a significant concentration (≥ 103 cfu/mL). The mini-PBAL was performed on 42 patients during AT (≥ 24 h of effective AT at the time of diagnostic procedure) and on another 40 patients with no AT (No AT). The results of the quantitative cultures were compared with the percentage of cells containing ICOs using a receiver operator characteristic (ROC) curve. The cutoff point of ≥ 2% of cells containing ICOs had the highest sensitivity (80%) and specificity (82%) in the studied population (area under the ROC curve AUC, 0.83; 95% confidence interval CI, 0.70 to 0.90). In patients receiving AT, the sensitivity was 70% and specificity was 75% (AUC, 0.73; 95% CI, 0.58 to 0.90); and in No AT-group patients sensitivity was 88% and specificity was 100% (AUC, 0.92; 95% CI, 0.84 to 1.0). The comparative analysis of both ROC curves was statistically significant (p = 0.04).
The cutoff point of ≥ 2% of cells containing ICOs has the highest sensitivity and specificity in the microscopic examination of mini-lavage fluid for the diagnosis of VAP. However, sensitivity is too low to be clinically useful. The direct examination of mini-PBAL fluid is less accurate when previous AT has been administered.
In comatose patients admitted to an ICU, particularly those with head injury, the incidence of early onset pneumonia is exceedingly high. We performed an open, prospective, randomized, and controlled ...clinical trial aiming at the reduction of the incidence of ventilator-associated pneumonia in head-injured patients and patients with stroke requiring mechanical ventilation. One hundred patients were included because of head injury or coma caused by medical stroke and with Glasgow coma scores < or = 12 and mechanical ventilation > 72 h. Patients eligible for the study (n = 50) received cefuroxime intravenously (two 1,500-mg doses 12 h apart after intubation) (the cefuroxime group) and 50 patients not receiving cefuroxime formed the control group. In the former group patients did not receive any other antibiotics before the end-point determination, whereas in the latter, 17 patients received prophylactic antibiotics as prescribed by the attending physician. The global incidence of microbiologically confirmed pneumonia was 37% (n = 37); 12 (24%) belonged to the cefuroxime group, and 25 (50%) belonged to the control group (p = 0.007). Early-onset pneumonia accounted for 70% of all the pneumonia episodes (n = 26), eight (67%) belonging to the cefuroxime group, and 18 (72%) belonging to the control group (p = 0.02). In the control group, four of 17 (23%) patients receiving prior antibiotics developed pneumonia, whereas 21 of 33 (64%) patients who did not receive antibiotics developed pneumonia (p = 0.016). The multivariate analysis revealed that the duration of mechanical ventilation (per each day) was an independent risk factor significantly associated to the development of pneumonia. Furthermore, the use of cefuroxime and/or prior antibiotics in the control group, before the pneumonia episode, had a protective effect against its development. No differences were found with regard to mortality and morbidity when comparing the study population with the control group. Nevertheless, when comparing patients with pneumonia (from both study and control groups) with those without it, there was a decrease in total hospital stay (35 +/- 13 versus 25 +/- 14 d, p = 0.048) and ICU stay (20 +/- 11 versus 11 +/- 7 d, p = 0.001). The study demonstrated that the administration of two single high doses 1,500 mg each of cefuroxime after the intubation of patients comatose because of head injury or medical stroke is an effective prophylactic strategy to decrease the incidence of ventilator-associated pneumonia.
The aim of this study was to assess the efficacy of a disinfectable, needle-free connector in the prophylaxis of catheter-related bloodstream infection.
A randomized controlled trial was performed in ...a polyvalent intensive care unit. Patients who needed multilumen central venous catheters were randomly assigned to a study or a control group. All catheters were inserted and manipulated according to the Centers for Disease Control and Prevention (CDC) recommendations. Study group patients were equipped with catheters with disinfectable, needle-free connectors whereas control group patients were equipped with catheters with 3-way stopcocks. Two peripheral blood cultures and a semiquantitative culture of the catheter tip were performed on removal of the catheter.
The study included 243 patients, with a total of 278 central venous catheters. The catheters' mean insertion duration was 9.9 days. Both groups were comparable regarding patient and catheter characteristics. Incidence rate of catheter-related bloodstream infection was 0.7 per 1000 days of catheter use in the study group, compared with 5.0 per 1000 days of catheter use in the control group (
P
=
.03).
To add a disinfectable, needle-free connector to the CDC recommendations reduces the incidence of catheter-related bloodstream infection in critically ill patients with central venous catheters.
To analyze the colonization of each lumen and the risk factors for triple-lumen central venous catheter-related bloodstream infection (CRBI).
Prospective, observational study in the medical-surgical ...intensive care unit (ICU) of a teaching hospital.
A total of 120 patients requiring the insertion of a triple-lumen catheter.
Cultures of the catheter.
The catheters were removed when CRBI was suspected or at discharge from ICU. At the removal time, blood cultures, a swab of the insertion site and a culture of the catheter tip were performed. Furthermore, we made quantitative cultures of the proximal, medial and distal lumen. We diagnosed CRBI in six patients (3.35 CRBI/1,000 days at risk), and we observed that in these patients colonization of the medial lumen was more frequent (5/6) than in patients without CRBI (9/114; p = 0.0001). The logistic regression analysis showed that colonization of the medial lumen was an independent risk factor for CRBI (OR 28.1, 95% CI 2.2-364.9).
Colonization of the medial lumen is an independent risk factor for triple-lumen catheter-related bloodstream infection, possibly due to the absence of use of this lumen.
A prospective and observational study has been conducted to analyze the efficacious of linezolid compared to vancomycin to eradicate the infecting organism in critically ill patients with ...Gram-positive infections.
Prospective, observational and non-controlled study in a medical-surgical intensive care unit (ICU) in a university hospital. A total number of 53 critically ill patients with therapy to proven Gram-positive bacterial infection were studied. Infected patients were diagnosed and treated according to international guidelines, following standard protocol for the critically ill infected patients. Microbiologic eradication of the infecting organism at the seventh day of treatment and patients' clinical outcome were analysed.
Twenty-seventh patients received linezolid and twenty-six received vancomycin. Infection-site diagnoses were: hospital-acquired pneumonia (21 cases: 39.6%), complicated surgical-site infection (19 cases: 35.8%) and catheter-related bacteraemia (13 cases: 24.5%). The most important isolated microorganism was methicillin-resistant Staphylococcus aureus (MRSA) (28 cases: 52.8%). Clinical success was 20/ 27 (74.1%) in the linezolid group and 16/ 26 (61.5 %) in the vancomycin group, with p = 0.3. The adjusted logistic regression model demonstrated that the treatment with linezolid is associated to microbiologic eradication of the infecting organism at the seventh day of treatment OR = 7.88 (95% CI 1.86-33.52) and p = 0.005. In this model, the length of hospital stay was lower in the group with microbiologic eradication at the seventh day (p = 0.015). Drug-related adverse events were comparable in both groups of treatment.
Treatment with linezolid in critically ill patients with Gram-positive infections was equivalent to vancomycin in terms of efficacy and safety, but linezolid was associated to a higher rate of microbiologic eradication of the infecting organism at the seventh day of treatment.
The treatment of biliary tract infections requires antibiotics and an appropriate surgical procedure. The aim of this study was to evaluate the efficacy and safety of piperacillin/tazobactam versus ...ceftriaxone plus ornidazole in the treatment of biliary tract infections.
This was a randomized, prospective and comparative clinical trial of two antibiotic regimens in the treatment of biliary tract infection. One hundred and fifty three patients were randomly allocated into two groups; three patients were excluded after randomization. One group (n = 75) received piperacillin/tazobactam (4 g/8 h iv) and the other group (n = 75) was administered a combination of ceftriaxone (2 g/24 h iv) plus ornidazole (1 g/24 h iv). In both groups, protocolized surgical or endoscopic procedures were carried out. Clinical efficacy and safety were assessed at the end of treatment.
Demographic data and severity of disease were similar in both groups. Three patients were excluded of the study by deviations from the protocol. Sixty-seven patients (89.3%) out of the piperacillin/tazobactam group and sixty-six patients (88%) out of the ceftriaxone plus ornidazole group were clinically cured (OR = 0.87 95% CI, 0.31-2.4). Twelve patients died, seven in the piperacillin/tazobactam group and five in the ceftriaxone plus ornidazole group. Adverse events were similar in both groups (OR = 1.18 95% CI, 0.37-3.7).
This study suggests that piperacillin/tazobactam is as efficacious and safe as ceftriaxone plus ornidazole in the treatment of biliary tract infections.
We report the rare occurrence of fatal cardiac tamponade due to coronary sinus and right atrial thrombosis associated with central venous catheterization. The clinical course was extremely rapid, ...with death occurring a few minutes after the acute clinical event. Other causes of acute cardiac tamponade were ruled out by the postmortem studies.
