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Clin Infect Dis 2002 Dec 15;35(12):1477-83
Service d'Anesthesie-Reanimation Chirurgicale, Hopital Henri Mondor, and Universite Paris XII, Creteil, France.
To evaluate the colonization of Candida species and the importance of cross-contamination with Candida albicans, we prospectively screened clinical specimens obtained from surgical patients in the intensive care unit (ICU) who had a high risk of yeast colonization. Genotyping of C. albicans was performed using microsatellite markers. Thirty-six of 94 patients acquired nosocomial yeast colonization and/or infection. A total of 1126 specimens were cultured, 167 (15%) of which yielded yeasts. All 122 isolates of C. albicans recovered from the 30 C. albicans-positive patients were genotyped. Twenty-four different genotypes were identified. No genotype was systematically associated with a specific room or time. Isolates recovered from different body sites of patients at different times had identical genotypes. Acquisition of C. albicans in the surgical ICU seems to be mainly endogenous. Microsatellite markers should also be developed for typing non-albicans Candida species to learn whether their epidemiology differs from that of C. albicans.
PMID: 12471566, UI: 22358523
Other Formats:
Crit Care Med 2002 Nov;30(11):2610
Publication Types:
PMID: 12441788, UI: 22328853
Intensive Care Med 2002 Aug;28(8):1181; discussion 1182
PMID: 12400512, UI: 22285740
Intensive Care Med 2002 Aug;28(8):1168-71
Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, Greece. idimo@otenet.gr
OBJECTIVE: To investigate the adrenal function in non-septic, long-stay critically ill patients. DESIGN: Prospective, consecutive study. SETTING: General intensive care unit in a university hospital. PATIENTS: Forty-three non-septic patients with protracted critical illness. INTERVENTIONS: A morning blood sample was first obtained to measure baseline plasma cortisol. Subsequently, 1 micro g of corticotropin (ACTH, Synacthene) was injected intravenously and 30 min later a second blood sample was drawn to determine stimulated plasma cortisol. Patients having a stimulated cortisol level of at least 18 micro g/dl were defined as responders. In 36 patients, morning interleukin-6 (IL-6) was also measured. MEASUREMENTS AND RESULTS: Baseline and stimulated plasma cortisol were 16.8+/-4.1 micro g/dl and 21.2+/-5.1 micro g/dl, respectively. Interleukin-6 was high (median 39.3 pg/ml, interquartile range 24.9-86.6 pg/ml) and correlated negatively with stimulated plasma cortisol (r=-0.40, p<0.05). Of the 43 patients studied, 31 patients (72%) were responders and 12 patients (28%) were non-responders to the ACTH stimulation test. Overall, 18 patients died and 25 patients survived to hospital discharge. Non-responders had significantly higher IL-6 levels compared to responders (106+/-73 versus 48+/-42 pg/ml, p<0.05), whereas mortality rate was comparable in the two groups (50% versus 38%, p=0.74). CONCLUSIONS: Circulating plasma IL-6 levels are high during protracted critical illness, and are partially responsible for the relative adrenal insufficiency found in a subset of severely ill patients.
PMID: 12185444, UI: 22172738
Intensive Care Med 2002 Aug;28(8):1157-60
Abteilung fur Anasthesiologie und Intensivmedizin, Evangelisches und Johanniter Klinikum, Fahrner Strasse 133-135, 47169 Duisburg, Germany. andreas.sander@ejk.de
OBJECTIVES: To describe the efficacy and safety of quinupristin-dalfopristin (Q-D) as rescue therapy in critically ill patients with severe infections caused by methicillin-resistant staphylococci unresponsive to vancomycin treatment. DESIGN: Observational study in the context of the compassionate use programme for Q-D. METHODS: Twelve mechanically ventilated patients suffering from severe staphylococcal infections, pretreated unsuccessfully with vancomycin despite in vitro sensitivity, were included. Patients received, intravenously, Q-D 7.5 mg/kg body weight 3 times daily. The duration of Q-D therapy averaged 11.8 days (range: 1-26 days). The outcome variables were clinical efficacy and bacteriological eradication. RESULTS: Methicillin-resistant Staphylococcus aureus (MRSA) and Staphylococcus epidermidis (MRSE) were isolated in three patients each, and both bacteria were isolated from six patients. Eradication of pathogen(s) was achieved in 7 of 12 patients (66%). Five patients (42%) died due to severe co-morbidity. Adverse events related to Q-D were not observed and neither renal nor liver function was adversely affected. CONCLUSIONS: Quinupristin-dalfopristin appears to be an efficient and safe antimicrobial drug for the rescue treatment of staphylococcal infections in critically ill patients. It may be considered as a treatment option in cases of vancomycin treatment failure.
PMID: 12185441, UI: 22172735
Intensive Care Med 2002 Aug;28(8):1084-8
Department of Anesthesiology and Intensive Care Medicine, Friedrich Schiller University, Bachstrasse 18, 07740 Jena, Germany. Egbert.Huettemann@med.uni-jena.de
OBJECTIVE: To evaluate the impact of transesophageal echocardiographic (TEE) studies on further patient management and incidence and degree of left ventricular (LV) dysfunction in patients with lethal severe brain injury. DESIGN AND SETTING: Retrospective, clinical study in two surgical intensive care units in a university hospital. PATIENTS: In 51 patients with severe brain injury ultimately leading to brain death, the results of TEE studies were reviewed for evidence of newly developed LV dysfunction (i.e., regional wall motion abnormalities) and its impact on patient management. MEASUREMENTS AND RESULTS: Seven patients (13.7%) had a diminished LV function global (fractional area change <50%). Four of these patients (7.8%) exhibited a severely reduced LV function (fractional area change <35%). Regional wall motion abnormalities and preserved global function were found in eight patients (15.7%). Patient management was altered in all patients with diminished LV function: implementation of advanced hemodynamic monitoring (n=5), institution or adjustment of inotropes and adjustment of fluid management (n=7). In patients exhibiting a severely reduced LV function and deteriorating cardiovascular status, brain death diagnosis was established by one clinical examination in conjunction with laboratory tests, thus shortening the interval required for brain death diagnosis by about 12 h. CONCLUSIONS: Severe LV dysfunction occurred in about 8% of our patients with severe brain injury ultimately leading to brain death. TEE may be helpful in guiding cardiovascular resuscitation ultimately leading to improved organ procurement rates.
PMID: 12185429, UI: 22172723
Intensive Care Med 2002 Aug;28(8):1049-57
Intensive Care Unit, Paris 12 Universite and INSERM U 492, Henri Mondor Hospital, Creteil, France.
OBJECTIVE: The new generations of intensive care ventilators tend to be more innovative and sophisticated than previous ones, but little is known about their respective performance for delivering pressure support ventilation (PSV) and how they compare to previous generations. DESIGN: Active lung model bench test. APPARATUS: Twenty-two commercially available ventilators classified into three categories: new generation ventilators (after 1993, n=7), previous generation (before 1993, n=6), and recent piston or turbine-based ventilators ( n=9). MEASUREMENTS AND RESULTS: During PSV, the unloading efficacy of the assistance depends on the ventilator's ability to meet inspiratory flow demand. Three levels of flow (0.1 l/s, 0.6 l/s, and 1.2 l/s) were used to simulate inspiratory demand and the net area of the inspiratory airway pressure-time trace was calculated over the first 0.3 s, 0.5 s, and 1 s (Area (0.3), Area (0.5), and Area (tot)) with three levels of PSV (5 cmH(2)O, 10 cmH(2)O, and 15 cmH(2)O). To assess the respective role of pressure support delivery and triggering function, triggering sensitivity was assessed independently by measuring the time delay ( TD (tg)) and the pressure fall (Delta Paw (tg)) with two levels of inspiratory drive. All the new generation ventilators exhibited significantly better results than most of the previous generation ventilators regarding Area (0.3) and TD (tg), indicating large improvements in terms of triggering and pressurisation. CONCLUSION: Regarding PSV and trigger performance, the new generation ventilators - but also some piston and turbine-based ventilators - outperform most of previous generation ventilators.
PMID: 12185424, UI: 22172718
Intensive Care Med 2002 Aug;28(8):1036-41
Department of Anesthesiology, Critical Care and of Emergency, University Hospital of Nimes, 5 rue Hoche, 30 029 Nimes Cedex 04, France. jean.yves.lefrant@chu-nimes.fr
OBJECTIVE: To identify the risk factors of failure and immediate complication of subclavian vein catheterization (SVC). DESIGN: Prospective observational study. SETTING: Surgical critical care unit of a tertiary university hospital. PATIENTS: Critically ill patients requiring a first SVC. INTERVENTION: Subclavian vein catheterization was attempted in 707 patients without histories of surgery or radiotherapy in the subclavian area. Failed catheterizations, arterial punctures, pneumothoraces and misplacements of the catheter tip were recorded. Risk factors of failure and immediate complication were isolated among patients' characteristics, procedure parameters (side and number of venipunctures) and the operator's experience using a univariate +/- multivariate analysis. MEASUREMENTS AND MAIN RESULTS: Five hundred sixty-two SVCs (79.5%) were achieved without adverse events. Among the remaining 145 catheterizations, 67 (9.5%) failures, 55 (7.8%) arterial punctures, 22 (3.1%) pneumothoraces and 30 (4.2%) misplacements of the catheter tip occurred. More than one venipuncture was the only risk factor of failed catheterization [2 venipunctures, odds ratio =7.4 (2.1-26); >2 venipunctures, odds ratio =49.1 (16.8-144.1)]. More than one venipuncture and age 77 years or more were predictive of the occurrence of immediate complications [2 venipunctures, odds ratio =3.6 (1.8-7.0); >2 venipunctures, odds ratio =14 (7.7-25.3); age >or=77, odds ratio =1.8 (1.0-3.1)]. The operator's training was not predictive of failed catheterization or immediate complication. CONCLUSION: For SVC, more than one venipuncture is predictive of failed catheterization and immediate complication. Age 77 years or more was predictive of immediate complications.
PMID: 12185422, UI: 22172716
Intensive Care Med 2002 Aug;28(8):1012-23
University of Dundee, Department of Anaesthesia, Ninewells Hospital, Dundee DD1 9SY, UK. csmacmillan@doctors.org.uk
Cardiac injury and pulmonary oedema occurring after acute neurological injury have been recognised for more than a century. Catecholamines, released in massive quantities due to hypothalamic stress from subarachnoid haemorrhage (SAH), result in specific myocardial lesions and hydrostatic pressure injury to the pulmonary capillaries causing neurogenic pulmonary oedema (NPO). The acute, reversible cardiac injury ranges from hypokinesis with a normal cardiac index, to low output cardiac failure. Some patients exhibit both catastrophic cardiac failure and NPO, while others exhibit signs of either one or other, or have subclinical evidence of the same.Hypoxia and hypotension are two of the most important insults which influence outcome after acute brain injury. However, despite this, little attention has hitherto been devoted to prevention and reversal of these potentially catastrophic medical complications which occur in patients with SAH. It is not clear which patients with SAH will develop important cardiac and respiratory complications. An active approach to investigation and organ support could provide a window of opportunity to intervene before significant hypoxia and hypotension develop, potentially reducing adverse consequences for the long-term neurological status of the patient. Indeed, there is an argument for all SAH patients to have echocardiography and continuous monitoring of respiratory rate, pulse oximetry, blood pressure and electrocardiogram. In the event of cardio-respiratory compromise developing i.e. cardiogenic shock and/or NPO, full investigation, attentive monitoring and appropriate intervention are required immediately to optimise cardiorespiratory function and allow subsequent definitive management of the SAH.
PMID: 12185419, UI: 22172713
J Hosp Infect 2002 Dec;52(4):259-62
Department of Microbiology and Clinical Microbiology, University of Istanbul, 34303, Aksaray, Istanbul, Turkey
[Medline record in process]
During a three-month period in 1999, 25 strains of carbapenem resistant Acinetobacter baumannii were isolated from 12 of 170 hospitalized intensive care unit (ICU) patients, of which 16 were considered to be clinically significant. These strains were indistinguishable by biotyping and antibiograms, but genotyping was not performed. Appropriate antibiotic treatment, isolation precautions, and infection control education of the staff failed to halt the outbreak. Environmental contamination was therefore investigated, and A. baumannii was found out in 22 (39.3%) of 56 environmental samples obtained by swabbing. Different antibiotic sensitivity patterns were obtained in the majority of these isolates, but four (7.1%) of the strains were found to have the same sensitivity pattern as the strain causing the outbreak. As a result the ICU was closed, equipment and the environment cleaned, with hypochlorite and terminal disinfection carried out. No bacteria were grown on repeat environmental cultures. Environmental contamination has an important reservoir role in outbreaks ofA. baumannii in ICUs and must be eradicated in order to overcome such outbreaks.
PMID: 12473469, UI: 22361586
J Hosp Infect 2002 Dec;52(4):250-8
Department of Clinical Microbiology and Infectious Diseases, Institute of Medical and Veterinary Science, The Queen Elizabeth Hospital, Adelaide, South Australia
During a nine-day period, five patients in a 14-bed intensive care unit (ICU) were shown to have seroconverted with a four-fold or greater rise in serum antibody titre to Legionella longbeachae serogroup 1. A further two patients were observed to have high titres consistent with previous exposure but earlier serum samples were not available for comparison. No patients had antibody responses to Legionella pneumophila serogroups 1 and 2. L. longbeachae was not cultured from respiratory secretions from patients or from the environment within the unit. Legionella anisa was recovered from one cooling tower on the ninth floor of the tower block. The ICU is located on the first floor of the same tower and receives external air from two vents, one on the eastern and the other on the western aspect. All patients with serological evidence of L. longbeachae infection were concomitantly infected with multiresistant Staphylococcus aureus, and were located in bays on the eastern side of the unit. A large pigeon nest was discovered within 1-2m of the eastern vent. Following removal of the birds' nest, no further cases were seen on routine screening of all patients within the unit over the next eight weeks. Alternatively, seroconversion may have been related to demolition of the adjacent nine-storey nurses home. This was begun one month before the first case was diagnosed and was completed four months later. The periodic northerly winds could have carried legionellae from the demolition site directly over the block housing the ICU and may have concentrated them near the eastern air vent. All patients had pneumonia, which was probably multifactorial in origin. There is some uncertainty whether the serological responses seen were an epiphenomenon or were truly indicative of infection with L. longbeachae.
PMID: 12473468, UI: 22361585
JAMA 2002 Dec 11;288(22):2884-6
PMID: 12472331, UI: 22361869
JAMA 2002 Dec 11;288(22):2859-67
Service de Reanimation Medicale, Centre Hospitalier de Poissy-Saint-Germain en Laye, 10 rue du Champ-Gaillard, 78300 Poissy, France. bdejonghe@chi-poissy-st-germain.fr
CONTEXT: Although electrophysiologic and histologic neuromuscular abnormalities are common in intensive care unit (ICU) patients, the clinical incidence of ICU-acquired neuromuscular disorders in patients recovering from severe illness remains unknown. OBJECTIVES: To assess the clinical incidence, risk factors, and outcomes of ICU-acquired paresis (ICUAP) during recovery from critical illness in the ICU and to determine the electrophysiologic and histologic patterns in patients with ICUAP. DESIGN: Prospective cohort study conducted from March 1999 to June 2000. SETTING: Three medical and 2 surgical ICUs in 4 hospitals in France. PARTICIPANTS: All consecutive ICU patients without preexisting neuromuscular disease who underwent mechanical ventilation for 7 or more days were screened daily for awakening. The first day a patient was considered awake was day 1. Patients with severe muscle weakness on day 7 were considered to have ICUAP. MAIN OUTCOME MEASURES: Incidence and duration of ICUAP, risk factors for ICUAP, and comparative duration of mechanical ventilation between ICUAP and control patients. RESULTS: Among the 95 patients who achieved satisfactory awakening, the incidence of ICUAP was 25.3% (95% confidence interval [CI], 16.9%-35.2%). All ICUAP patients had a sensorimotor axonopathy, and all patients who underwent a muscle biopsy had specific muscle involvement not related to nerve involvement. The median duration of ICUAP after day 1 was 21 days. Mean (SD) duration of mechanical ventilation after day 1 was significantly longer in patients with ICUAP compared with those without (18.2 [36.3] vs 7.6 [19.2] days; P =.03). Independent predictors of ICUAP were female sex (odds ratio [OR], 4.66; 95% CI, 1.19-18.30), the number of days with dysfunction of 2 or more organs (OR, 1.28; 95% CI, 1.11-1.49), duration of mechanical ventilation (OR, 1.10; 95% CI, 1.00-1.22), and administration of corticosteroids (OR, 14.90; 95% CI, 3.20-69.80) before day 1. CONCLUSIONS: Identified using simple bedside clinical criteria, ICUAP was frequent during recovery from critical illness and was associated with a prolonged duration of mechanical ventilation. Our findings suggest an important role of corticosteroids in the development of ICUAP.
PMID: 12472328, UI: 22361866
JAMA 2002 Nov 27;288(20):2601-3
PMID: 12444869, UI: 22337100
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N Engl J Med 2002 Dec 5;347(23):1893-5; author reply 1893-5
PMID: 12472075, UI: 22358069
PMID: 12472074, UI: 22358068
PMID: 12472073, UI: 22358067
Nurs Crit Care 2002 Sep-Oct;7(5):247-54
Lister Hospital, Stevenage.
This paper explores the clinical significance of sensory alteration within critical care. The factors that lead to inappropriate sensory stimuli such as stress, impact of technology and noise are outlined. Such stimuli can lead to serious complications and an extended stay in hospital. Nurses may help prevent sensory imbalance by thoughtful, compassionate and collaborative nursing care.
PMID: 12448507, UI: 22332294
Nurs Crit Care 2002 Sep-Oct;7(5):235-40
Institute of Health Studies, University of Plymouth. mcornock@plymouth.ac.uk
The issue of legal responsibility around decision-making in critical care units is one that can lead to confusion and uncertainty. This paper aims to examine the nature of decision-making in critical care and the legal basis for decision-making. The roles and responsibilities of doctors and nurses in critical care are explored. Both legal responsibility and legal accountability for decision-making in critical care are considered.
PMID: 12448505, UI: 22332292
Nurs Crit Care 2002 Sep-Oct;7(5):227-34
Thoracic Services, Papworth Hospital NHS Trust, Cambridge. claire.tripp@papworth-tr.anglox.nhs.uk
This article evaluates the establishment and development of the critical care practitioner (CCP) role from 1995 to 1998. The hypothesis was that clinical decisions made by CCPs, for the defined patient group, would result in clinical outcomes and resource usage comparable to those currently experienced. The CCP initiative aimed to provide high quality patient care by expediting the process of making appropriate and timely decisions in the management of routine postoperative cardiac patients. To aid the development and evaluation of the CCP role, data on clinical measures, use of staff time and staff attitudes were collected at baseline, and then at nine months and two years nine months following introduction of the role. The evaluation demonstrated that the introduction of the CCP caused no deterioration in clinical outcomes; there were definite changes in the type of tasks carried out.
PMID: 12448504, UI: 22332291