1,720,965 research outputs found
Hemodynamic and gas exchange response to inhaled nitric oxide and prone positioning in acute respiratory distress syndrome patients
No full textObjective: To analyze the single effect and the interaction of prone position and inhaled nitric oxide (iNO) on lung function and hemodynamic variables.
Design: 2 x 2 factorial trial.
Setting: Department of intensive care medicine at a university hospital.
Patients: Fourteen patients on volume-controlled mechanical ventilation for acute respiratory distress syndrome (ARDS),
Intervention: Four experimental conditions, each one characterized by the patient's position (supine or prone) with iNO or without iNO.
Measurements and Results: Hemodynamic and gas exchange data were collected for each experimental condition. Pao(2) was increased both by positioning (p < .01) and iNO (p < .01); iNO caused also a reduction in venous admixture (p < .01), pulmonary artery pressure (p < .01), and pulmonary vascular resistance index (p < .05). We could not demonstrate any significant interaction between the two treatments. The average effect of prone positioning was the same both with and without iNO, whereas the average effect of iNO was the same in both the prone and the supine position.
Conclusion: In the studied acute respiratory distress syndrome patients the average effects of iNO and positioning on oxygenation were additive and no interaction could be shown. A strategy including both treatments could warrant the best improvement in oxygenation, and should take into account the individual response to each treatment and the possible combination of the two
Value of tracheal aspirate surveillance cultures
No full textAbstract
AIM: The aim of this study was to investigate the hypothesis that periodical sampling of the tracheo-bronchial tree in the absence of clinical suspicion of pneumonia is useful to identify bacteria responsible for subsequent late ventilator associated pneumonia (VAP). This was a retrospective observational human study carried out in two medical-surgical intensive care units of two different hospitals. From January 1999 to December 2000, 559 patients, who received invasive respiratory support for more than 48 hours, were screened.
METHODS: Tracheal aspiration (TA) was performed once or twice weekly in all mechanically ventilated patients. The microbiological findings from TA surveillance cultures done in the eight days before suspicion of VAP were compared to those isolated from the positive diagnostic samples done for late onset VAP (after more than four days of mechanical ventilation). The sensitivity, specificity, and positive/negative predictive values of the ability of the surveillance sample to anticipate the VAP pathogen were calculated.
RESULTS: Among the microorganisms isolated from TA, 68% were retrieved from diagnostic samples. All VAP pathogens previously isolated were from 43% of the TA samples. If TA was collected 2-4 days before the clinical diagnosis of VAP, pathogens were detected in 58% of samples. In contrast, only 27% were collected more than four days earlier (P<0.05). The positive predictive values for Pseudomonas aeruginosa and methicillin resistant Staphylococcus aureus from routine TA samples were 92% and 90%, respectively. The negative predictive values for Pseudomonas aeruginosa and methicillin resistant Staphylococcus aureus from routine TA samples were 75% and 89%, respectively.
CONCLUSIONS: TA cultures in ventilated patients may help to predict pathogens. Early detection may lead to earlier treatment in long term ventilated patients when VAP is suspected
Citrate anticoagulation during CVVH in high risk bleeding patients
No full textBackground: Regional citrate anticoagulation (RCA) is an effective form of anticoagulation for continuous renal replacement therapy (CRRT) in patients with contraindications to heparin. Its use has been very limited, possibly because of the need for special infusion solutions and difficult monitoring of the metabolic effects.
Objective: To investigate the safety and the feasibility of an RCA method for continuous veno-venous hemofiltration (CVVH) using commercially available replacement fluid.
Methods: We evaluated 11 patients at high risk of bleeding, requiring CVVH. RCA was performed using commercially available replacement fluid solutions to maintain adequate acid-base balance. We adjusted the rate of citrate infusion to achieve a post-filter ionized calcium concentration [iCa] 250 ml/min. When needed, we infused calcium gluconate to maintain systemic plasma [iCa] within the normal range.
Results: Twenty-nine filters ran for a total of 965.5 h. Average filter life was 33.6 +/- 20.5 h. Asymptomatic hypocalcemia was detected in 6.9% of all samples. No [iCa] values < 0.9 mmol/L were observed. Hypercalcemia (1.39 +/- 0.05 mmol/L) occurred in 2.5% of all samples. We observed hypematremia (threshold 153 mmol/L) and alkalosis (threshold 7.51) in only 9.3% and 9.4% respectively of all samples, mostly concomitantly. No patient showed any signs of citrate toxicity.
Conclusions: We developed a protocol for RCA during CVVH using commercially available replacement fluid that proved safe, flexible and applicable in an Intensive Care Unit (ICU) setting
Can routine surveillance samples from tracheal aspirate predict bacterial flora in cases of ventilator-associated pneumonia?
No full textAim. The aim of this study was to investigate the hypothesis that periodical sampling of the tracheo-bronchial tree in the absence of clinical suspicion of pneumonia is useful to identify bacteria responsible for subsequent late ventilator associated pneumonia (VAP). This was a retrospective observational human study carried out in two medical-surgical intensive care units of two different hospitals. From January 1999 to December 2000, 559 patients, who received invasive respiratory support for more than 48 hours, was screened. Methods. Tracheal aspiration (TA) was performed once or twice weekly in all mechanically ventilated patients. The microbiological findings from TA surveillance cultures done in the eight days before suspicion of VAP were compared to those isolated from the positive diagnostic samples done for late onset VAP (after more than four days of mechanical ventilation). The sensitivity, specificity and positive/negative predictive values of the ability of the surveillance sample to anticipate the VAP pathogen were calculated. Results. Among the microorganisms isolated from TA, 68% wae retrieved from diagnostic samples. All VAP pathogens previously isolated were from 43% of the TA samples. If TA was collected 2-4 days before the clinical diagnosis of VAP, pathogens were detected in 58% of samples. In contrast, only 27% were collected more than four days earlier (P<0.05). The positive predictive values for Pseudomonas aeruginosa and methicillin resistant Staphylococcus aureus from routine TA samples were 92% and 90%, respectively. The negative predictive values for Pseudomonas aeruginosa and methicillin resistant Staphylococcus aureus from routine TA samples were 75% and 89%, respectively. Conclusion. TA cultures in ventilated patients may help to predict pathogens. Early detection may lead to earlier treatment in long term ventilated patients when VAP is suspected. Minerva Medic
[Capillary oximetry as an index for determination of the level of positive end expiratory pressure (PEEP)]
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Building a continuous multicenter infection surveillance system in the intensive care unit : findings from the initial data set of 9,493 patients from 71 Italian intensive care units
No full textObjective. To describe the epidemiology of infections in intensive care units (ICUs), whether present at admission or acquired during the stay.
Methods. Prospective data collection lasting 6 months in 71 Italian adult ICUs. Patients were screened for infections and risk factors at ICU admission and daily during their stay.
Main Results. Out of 9,493 consecutive patients admitted to the 71 ICUs, 11.6% had a community-acquired infection, 7.4% a hospital-acquired infection, and 11.4% an ICU-acquired infection. The risk curve of acquiring infection in the ICU was higher in patients who entered without infection than in those already infected (log-rank test, p < .0001; at 15 days, 44.0% vs. 34.6%). Hospital mortality (27.8% overall) was higher in patients admitted with infection than in those who acquired infection in the ICU (45.0% vs. 32.4%, p < .0001). Although the presence of infection per se did not influence mortality, the conditions of severe sepsis and septic shock were strong prognostic factors (odds ratio, 2.3 and 4.8, respectively). Apart from ICU-acquired peritonitis, no other site of infection reached statistical significance as an independent prognostic factor for hospital mortality.
Conclusions. Adding specific data on infections and risk factors to a well-established electronic data collection system is a reliable basis for a continuous multicenter infection surveillance program in the ICU. Given the well-established importance of infection prevention programs, our data suggest that the improvement of the treatment of severe sepsis and septic shock is the key to lower infection-related mortality in the ICU. This calls for closer attention to severe infections in surveillance programs
Relevance of clinical diagnosis of lung infection in ICU patients with acute brain injury
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