ACE DD genotype: an independent predisposition factor to venous thromboembolism

BACKGROUND: The renin angiotensin system affects haemostasis through different mechanisms; data on the possible role of angiotensin-converting enzyme I/D polymorphism in the pathogenesis of deep venous thrombosis are conflicting, and no information is available regarding the A1166C polymorphism of the angiotensin type 1 receptor gene. In order to investigate this issue, angiotensin-converting enzyme and AT1R polymorphisms were genotyped in 336 consecutive venous thromboembolism patients and 378 controls. MATERIALS AND METHODS: Haemostasis-related risk factors have been evaluated by routine tests. Factor V Leiden, Factor II (G20210A), angiotensin-converting enzyme (I/D), and angiotensin type 1 receptor (A1166C) polymorphisms have been identified by molecular analysis. RESULTS: We documented a significant association between angiotensin-converting enzyme DD genotype and venous thromboembolism (OR=2.19 95%CI 1.51-3.17 adjusted for acquired and haemostasis-related risk factors, P<0.0001); in patients with haemostasis-related risk factors, angiotensin-converting enzyme DD genotype modified the risk of venous thromboembolism in hyperhomocysteinaemic and Factor V Leiden patients and was associated with the risk of recurrent venous thromboembolism (OR=1.83 95%CI 1.06-3.17 P=0.03). In patients without haemostasis-related risk factors the angiotensin-converting enzyme DD genotype was still an independent predictor of venous thromboembolism (OR=3.29 95%CI 2.17-4.98 adjusted for acquired risk factors, P<0.0001). No significant association between the angiotensin type 1 receptor CC genotype and venous thromboembolism was found. CONCLUSIONS: This study shows that angiotensin-converting enzyme DD genotype represents a susceptibility marker of thrombosis in subjects apparently without predisposing factors and traditional thrombophilic alterations, and increases the risk of venous thromboembolism in subjects in whom a thrombogenic condition occurs. Moreover, angiotensin-converting enzyme DD genotype may be considered a new predisposing factor to venous thromboembolism recurrence.     

基于Caprini评分的肝切除术患者静脉血栓栓塞风险因素分析

目的以Caprini风险评估模型评分为参考分析肝切除术患者术后发生静脉血栓栓塞症的危险因素。方法采用回顾性研究方法,收集本院310例接受肝切除手术患者的临床资料,以Caprini风险评估模型进行评分,并通过单因素及多因素分析,对Caprini风险评估模型中的危险因素及肝切除手术相关因素进行筛选,发现影响肝切除术患者静脉血栓栓塞症风险的危险因素。结果单因素及多因素Logistic回归分析显示,手术时间3h、肝恶性肿瘤、深静脉血栓和(或)肺栓塞史为肝切除手术患者发生静脉血栓栓塞症的独立危险因素。Caprini风险评估模型评分静脉血栓栓塞症组患者得分(6.77±1.81)分,非静脉血栓栓塞症组得分(3.62±2.25)分(P=0.02)。Caprini风险评估模型评分≥7分时,发生静脉血栓栓塞症的风险明显增加。结论肝切除术患者术后静脉血栓栓塞症发生的危险因素是手术时间3h、肝恶性肿瘤、深静脉血栓和(或)肺栓塞史,随着Caprini评分的增加静脉血栓栓塞症的风险逐渐升高。     

Prevention of venous thromboembolism in critically ill surgery patients: a cross-sectional study

Background: The risk for venous thromboembolism (VTE) and the risk for bleeding among critically ill surgical patients are both important in the early postoperative period. Materials and Methods: To record VTE prophylaxis prescribed for surgical patients in the intensive care unit (ICU) within the first postoperative week. We conducted a prospective observational cross-sectional study of Canadian university affiliated ICUs. Results: Of 29 ICU Directors approached, 28 (96.6%) participated, representing 34 ICUs and 589 ICU beds across Canada. Among 89 patients, surgical procedures were 32 abdominal (36.0%), 19 vascular (21.3%), 10 orthopedic (11.2%), 9 trauma (10.1%), 8 neurologic (9.0%), 5 thoracic (5.6%), 5 gynecologic (5.6%), and 1 for necrotizing fasciitis (1.1%). VTE prophylaxis with unfractionated heparin, low molecular weight heparin, and intermittent pneumatic compression was used in 35 of 89 (39.3%), 8 of 89 (9.0%), and 9 of 89 (10.1%) patients, respectively, whereas 8 of 89 (9.0%) patients were receiving therapeutic anticoagulation. Two methods of VTE prophylaxis were prescribed for 20 of 89 (22.5%) patients. Prophylaxis with unfractionated or low molecular weight heparin was significantly less likely to be prescribed for postoperative ICU patients requiring mechanical ventilation compared with those weaned from mechanical ventilation (odds ratio [OR] 0.36, P = .03). The use of intermittent pneumatic compression devices was significantly associated with current hemorrhage (OR 13.5, P = .02), and risk for future hemorrhage (OR 19.3, P = .001). Conclusions: VTE prevention for surgical ICU patients within the first postoperative week appear to be individualized, and influenced by current and future risks of thrombosis and bleeding. Copyright © 2002 by W.B. Saunders Company     

Differential value of risk factors and clinical signs for diagnosing pulmonary embolism according to age

INTRODUCTION: The diagnostic value of clinical presentation of pulmonary embolism (PE) is uncertain in the elderly, who often have concomitant cardiopulmonary diseases that may mimic PE. The aim of our study was to assess the differential value of risk factors, symptoms and clinical signs of venous thromboembolism, results of electrocardiogram and chest X-ray for the diagnosis of PE in suspected patients according to age. METHODS: We analyzed data from two outcome studies which enrolled 1721 consecutive patients presenting in the emergency department with clinically suspected PE defined as acute onset of new or worsening shortness of breath or chest pain without any other obvious etiology. All patients underwent a sequential diagnostic work-up and a 3-month follow-up. RESULTS: The proportion of confirmed PE was 24.2% (416 of 1721). Strength of the association with PE did not differ according to age group for history of venous thromboembolism (VTE), recent surgery, tachypnea at admission or right ventricular strain on electrocardiogram. Active malignancy, hemoptysis, tachycardia, hemidiaphragmatic elevation and pleural effusion at chest X-ray were no more associated with PE in the patients aged of 75 years or more. Finally, symptoms and signs of deep venous thrombosis, and an alternative diagnosis less probable than PE were associated with PE in all age groups, but the strength of this association decreased significantly with advancing age. CONCLUSION: Some risk factors, symptoms and signs of VTE are less strongly or even not at all associated with PE in the elderly. Physicians should take this into account when attending elderly patients suspected of PE and when assessing their clinical probability of PE.     

老年住院患者经外周静脉穿刺中心静脉置管相关深静脉血栓危险因素分析

目的分析老年住院患者经外周静脉穿刺中心静脉置管(PICC)相关深静脉血栓形成(PICC-DVT)的危险因素。方法选取行上肢PICC置管的老年住院患者564例,PICC术后发生上肢深静脉栓塞的141例为PICC-DVT组,未发生上肢深静脉血栓的423例为对照组。通过回顾性分析两组患者临床数据,探讨老年住院患者PICC-DVT的相关危险因素。结果老年住院患者PICC-DVT发生率为25%;多因素Logistic回归分析显示:心房颤动(OR=2.15,95%CI:1.298~3.433),动脉粥样硬化(OR=2.72;95%CI:1.715~4.372),置管期间手术史(OR=3.23,95%CI:1.358~7.584),静脉血栓史(OR=7.68,95%CI:4.513~13.311),是老年住院患者PICC-DVT的独立危险因素。结论老年住院患者是PICC-DVT的高危人群,心房颤动、动脉粥样硬化、置管期间手术史、静脉血栓史是PICC-DVT的独立危险因素。     

Venous thromboembolism in the ICU: main characteristics,diagnosis and thromboprophylaxis

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep venous thrombosis (DVT), is a common and severe complication of critical illness. Although well documented in the general population, the prevalence of PE is less known in the ICU, where it is more difficult to diagnose and to treat. Critically ill patients are at high risk of VTE because they combine both general risk factors together with specific ICU risk factors of VTE, like sedation, immobilization, vasopressors or central venous catheter. Compression ultrasonography and computed tomography (CT) scan are the primary tools to diagnose DVT and PE, respectively, in the ICU. CT scan, as well as transesophageal echography, are good for evaluating the severity of PE. Thromboprophylaxis is needed in all ICU patients, mainly with low molecular weight heparin, such as fragmine, which can be used even in cases of non-severe renal failure. Mechanical thromboprophylaxis has to be used if anticoagulation is not possible. Nevertheless, VTE can occur despite well-conducted thromboprophylaxis.     

Prévention de la maladie veineuse thromboembolique en réanimation : Quand ? Pourquoi ? Comment ?

The occurrence of venous thromboembolism(VTE) in critically ill patients represents an important cause of increased morbidity and mortality. Because the incidence of VTE in the intensive care unit (ICU) is about 30% without thromboprophylaxis, patients hospitalized in these units should be considered at high risk for thrombosis and should receive a prophylactic treatment. Besides conventional risk factors for VTE (age, cancer, surgery, obesity…), specific factors present in ICU patients may also contribute to VTE, including mechanical ventilation, vasopressors, and central venous lines. Despite these observations, there are few rigorous studies evaluating thromboprophylaxis specifically in the ICU. Low-molecular weight heparins and unfractionated heparin appear effective in preventing VTE. However, the impact of certain clinical characteristics of critically ill patients (oedema, renal insufficiency, or vasopressor) on the risk/benefit of these drugs needs to be clarified. Mechanical devices, elastic stockings, and intermittent pneumatic compression are recommended for critical care patients who are at high risk for bleeding; however, they have never been evaluated in any clinical trial in ICU patients. Further studies are needed to better understand the reasons of VTE occurrence in ICU patients in order to improve management of their thromboprophylaxis.     

Thrombocytopenia in medical-surgical critically ill patients: prevalence, incidence, and risk factors

OBJECTIVE: The purpose of this study is to describe the prevalence, to analyze the incidence and independent risk factors for thrombocytopenia, and to examine the impact of thrombocytopenia developing in the intensive care unit (ICU) on patient outcome in a well-defined cohort of critically ill patients in a medical-surgical ICU. MATERIALS AND METHODS: As part of a prospective cohort study examining the frequency and clinical importance of venous thromboembolism in the ICU, we enrolled consecutive patients older than 18 years expected to be in the ICU for more than 72 hours. Exclusion criteria were an admitting diagnosis of trauma, orthopedic surgery or cardiac surgery, pregnancy, and life support withdrawal. Patients had platelet counts performed as directed by clinical need. We defined thrombocytopenia as a platelet count of less than 150 x 10(9)/L and severe thrombocytopenia as a platelet count of less than 50 x 10(9)/L. Protocol-directed care included routine thromboprophylaxis and twice weekly screening ultrasonography of the legs. Patients were followed to hospital discharge. RESULTS: Of the 261 enrolled patients, 121 (46%, 95% confidence interval [CI], 40%-53%) had thrombocytopenia (62 on ICU admission and 59 acquired during their ICU stay). Patients who developed a platelet count less than 150 x 10(9)/L during their ICU stay had higher ICU and hospital mortality (P = .03 and .005, respectively), required longer mechanical ventilation (P = .05), and were more likely to receive platelets (P < .001), fresh frozen plasma (P = .005), and red blood cell transfusions (P = .004) than patients who did not develop thrombocytopenia. The only independent risk factors for thrombocytopenia developing during the ICU stay were administration of nonsteroidal anti-inflammatory drugs before ICU admission (hazard ratio, 2.8; 95% CI, 1.3-6.0) and dialysis during the ICU stay (hazard ratio, 3.1; 95% CI, 1.2-7.8). Of the 33 patients who underwent 36 tests for heparin-induced thrombocytopenia, none tested positive. CONCLUSIONS: We found that about 50% of the patients admitted to the ICU had at least one platelet count of less than 150 x 10(9)/L during their ICU stay. Patients who developed thrombocytopenia were more likely to die, required longer duration of mechanical ventilation, and were more likely to require blood product transfusion. Heparin-induced thrombocytopenia was frequently suspected but did not develop in these critically ill patients.     

Venous thromboembolism in patients undergoing rehabilitation for stroke.

OBJECTIVE: To determine the incidence of venous thromboembolism during rehabilitation for stroke and to identify factors that alter its risk. DESIGN: Cohort. SETTING: Tertiary care stroke rehabilitation program. PATIENTS: 102 consecutive patients undergoing rehabilitation for stroke. INTERVENTIONS: Impedance plethysmography (IPG) as routine screening and in patients with symptoms of deep venous thrombosis (DVT). MAIN OUTCOME MEASURES: DVT, pulmonary embolism (PE), death from PE. RESULTS: Venous thromboembolism was documented in 11 patients (11%) an average of 60 days after stroke onset (range 14-138 days); 2 patients (2%) died from PE. DVT was found on routine IPG screening in six patients and verified by IPG in two clinically symptomatic patients. The odds of developing venous thromboembolism was 17.6 (95% confidence interval: 2.2-143.5) in patients who were bedridden or wheelchair-bound at the time of admission. CONCLUSIONS: The incidence of venous thromboembolism is high and greatest in bedridden or wheelchair-bound patients undergoing stroke rehabilitation; randomized trials evaluating the safety and efficacy of screening and/or prophylaxis in such patients are required.     

Risk assessment of recurrence of venous thromboembolism

Recurrent venous thromboembolism is associated with increased mortality in 5-9% of the patients. On the other hand prolonged anticoagulation can increase the bleeding risk which can also be responsible for an increased mortality. Therefore, it is necessary to validate the recurrence risk of venous thromboembolism on an individual basis. In this review the most relevant risk factors for recurrent venous thromboembolism are analyzed. Spontaneous thrombosis is associated with significantly increased recurrence rates in comparison to risk associated venous thrombosis. In addition, a positive D-dimer result after stop of anticoagulation, an increased amount of residual thrombus in proximal veins analyzed by compression sonography, a proximal localization of thrombosis, symptomatic pulmonary embolism and male sex are clinically relevant risk factors for increased recurrence rates. While mild thrombophilic defects like heterozygous factor V Leiden mutation are not associated with a clinically relevant recurrence risk, inherited inhibitor deficiencies and the antiphospholipid-syndrome are known to be responsible for an increased recurrence rate of venous thromboembolism. A new recurrence risk-score (RR-Score) for individual judgement of patients with a first spontaneous venous thrombosis is introduced.     

术后下肢深静脉血栓形成的临床危险因素及护理

目的:探讨术后下肢深静脉血栓(DVT)形成的临床危险因素及护理方法。方法:将术后患者233例根据彩色Dopp ler检查结果分为血栓组111例和无血栓组122例。所有入选患者进行危险因素评估,分别记录危险因素的个数、手术种类、手术时间、体重指数及术后应用抗凝剂低分子量肝素情况。同时选择57名健康志愿者行双下肢血管超声检查作为正常对照组。结果:111例患者发生DVT,发生率为47.6%,且年龄越大,体重指数增加、危险因素个数越多,DVT发生率越高。结论:DVT发生与多种因素有关,对DVT高危患者应积极采取预防措施。     

Venous thromboembolism after trauma

PURPOSE OF REVIEW: The trauma population is at increased risk of venous thromboembolic disease, a potentially preventable cause of mortality and morbidity. Although the association between trauma and venous thromboembolism has been recognized for more than a century, there is still great variability in the clinical practices with respect to prophylaxis. This thorough review of recent literature aims to clarify the incidence and risk factors for deep venous thrombosis and pulmonary embolism after trauma, review options and recommendations for detection of deep venous thrombosis and pulmonary embolism, and give evidence-based recommendations for prophylaxis. Special attention is paid to patients with spinal cord injury, patients with head injury, and pediatric trauma patients. RECENT FINDINGS: Highlights in this field during the past year include stratification of venous thromboembolism risk factors after trauma using a large national database, the expanded use of venous duplex ultrasound surveillance in the ICU and during rehabilitation, and investigations into the safety of low molecular weight heparins in patients with solid organ and traumatic brain injuries. Additionally, two new classes of anticoagulant drugs have been introduced for venous thromboembolism prophylaxis, and there are some preliminary studies on a temporary vena cava filter for the prevention of pulmonary embolism. SUMMARY: Venous thromboembolism remains an area of active clinical research focusing on evolving diagnostic techniques, newer methods of chemical and mechanical prophylaxis, and improved understanding of the etiologic factors of posttraumatic venous thromboembolism. These efforts will undoubtedly decrease the posttraumatic morbidity and mortality associated with venous thromboembolism.     

心脏外科ICU患者术后谵妄的危险因素研究

目的 评估心脏外科重症监护病房（CSICU）患者术后谵妄的发生率,分析其危险因素及各危险因素预测术后谵妄发生的效能。方法 采用横断面调查研究法,选取2019年1—5月于某三级甲等综合医院CSICU住院的心脏手术后患者为研究对象。谵妄评估采用ICU患者意识模糊评估法,采用一般资料调查问卷、急性生理和慢性健康评分（Acute Physiology and Chronic Health Evaluation,APACHEⅡ）、中文版重症监护疼痛观察工具、匹兹堡睡眠质量指数量表和ICU环境压力源量表收集资料。采用单因素分析及多因素Logistic回归分析患者术后谵妄的危险因素,利用受试者工作特征曲线（ROC曲线）描述各危险因素的曲线下面积及最佳临界值。结果 （1）共纳入316例患者,发生谵妄81例（25.6%）, Logistic回归分析结果显示,术后谵妄的独立危险因素包括：APACHEⅡ评分（OR=1.257,95%CI为1.018~1.553）,停循环时间>15 min（OR=6.943,95%CI为1.288~37.429）,术后疼痛平均得分（OR=2.918,95%CI为1.749~4.867）,睡眠质量得分（OR=1.147,95%CI为1.038~1.267）,ICU环境压力源得分（OR=1.161,95%CI为1.110~1.214）。（2）ROC曲线结果显示：APACHEⅡ评分、停循环时间>15 min、术后疼痛平均得分、睡眠质量得分、ICU环境压力源得分的曲线下面积分别为0.745、0.617、0.758、0.837、0.910,APACHEⅡ评分、术后疼痛平均得分、睡眠质量得分、ICU环境压力源得分的最佳截断值分别为9分、3分、14分、72分。结论 CSICU患者术后谵妄的发病率处于一个较高水平,APACHEⅡ评分>9分、停循环时间>15 min、术后疼痛平均得分>3分、睡眠质量得分>14分、ICU环境压力源得分>72分的患者更容易发生术后谵妄。本研究为完善CSICU患者术后谵妄的管理提供参考依据。     

Video laparoscopic surgery: is out-of-hospital thromboprophylaxis necessary?

Despite widespread use of laparoscopic procedures, no adequate data are available to support specific recommendations for venous thromboprophylaxis in patients undergoing laparoscopic surgery. This prospective, randomized trial is the first to be designed to evaluate a regimen of out-of-hospital thromboprophylaxis after laparoscopic surgery. Consecutive patients admitted for laparoscopic surgery were considered for the study. The thromboprophylaxis regimen used for each patient was based on a risk score. Possible thromboprophylactic measures included elastic stockings and pre- and postoperative Dalteparin or early ambulation. At discharge, patients were randomly allocated either to continue Dalteparin for 1 week, or to receive no further prophylaxis. Patients judged to be at low risk were not randomized. Compression ultrasound of the leg veins was performed in all patients 4 weeks after hospital discharge. Fifty-three patients, all with acute appendicitis, were judged to be at low risk of deep vein thrombosis and were not included in the randomized study. The remaining 209 patients fell into two groups: 104 patients received postdischarge Dalteparin and 105 patients did not. The incidence of deep vein thrombosis was 0% (0 of 104) vs. 0.95% (one of 105), respectively (P = 1.00). The risk of postdischarge venous thromboembolism is low in patients undergoing laparoscopic surgery who receive in-hospital thromboprophylaxis. Given this low risk, a clinical trial powered to determine if extending prophylaxis in such patients reduces the risk of clinically apparent deep vein thrombosis would be unfeasibly large.     

Genetic variations observed in arterial and venous thromboembolism--relevance for therapy, risk prevention and prognosis.

We undertook genetic and biochemical assays in patients with arterial (n = 146) and venous (n = 199) thromboembolism and survivors of pulmonary embolism (n = 58) to study causation and gene-life style interactions. In the clinical material from North Western Russia, factor V Leiden was found to be a risk factor in venous thrombosis (OR = 3.6), while the methylenetetrahydrofolate reductase (MTHFR) C677T mutation was a significant variable in both venous (p = 0.03) and arterial thrombosis (p = 0.004). Homocysteine levels were determined (n = 84) and hyperhomocysteinemia correlated with the T allele of the MTHFR gene, and with smoking and coffee consumption. Vitamin supplementation reduced homocysteine levels dependent on MTHFR genotype (36% TT, 25% CT, 22% CC). In pulmonary embolism patients, frequency of the -455G/A beta-fibrinogen dimorphism was studied. Carriers of this allele were significantly underrepresented (p < 0.02) among pulmonary embolism survivors (34.5%) compared to controls (56.7%). Additionally, -455AA homozygotes were found in 11.7% controls but only 1.7% of pulmonary embolism patients (p = 0.006). In venous and arterial thrombosis cases, MTHFR and homocysteine data led to effective dietary supplementation with a reduced risk of disease progression. Results from the pulmonary embolism study may indicate that screening tests for the -455G/A beta-fibrinogen genetic variation could be of prognostic value, and may point the way for novel anticoagulation strategies.     

Incidence, risk profile and morphological pattern of venous thromboembolism after prostate cancer surgery

Summary.  Background : Venous thromboembolism (VTE) is the most common non-surgical complication after major pelvic surgery. Little is known about the risk factors or the time of development of postoperative venous thrombosis. Methods: A cohort of 523 consecutive patients undergoing radical prostatectomy with lymphadenectomy was prospectively assessed by complete compression ultrasound at days −1, +8 and +21. Results: Complete data were available in 415 patients, while four patients had VTE before surgery and were excluded from the analysis. In the remaining 411 patients, 71 VTE events were found in 69 patients (16.8%). Most were limited to calf muscle veins (56.5%), followed by deep calf vein thrombosis (23.2%), proximal deep vein thrombosis (DVT, 14.5%) and pulmonary embolism (PE, 5.8%). Of the 14 patients with proximal DVT/PE, 11 patients (78.6%) developed VTE between days 8 and 21. Risk factors for VTE were a personal history of VTE (OR 3.0), pelvic lymphoceles (LCs) impairing venous flow (OR 2.8) and necessity of more than two units of red blood cells (OR 2.6). Conclusion: Venous thromboembolism is common after radical prostatectomy. A significant proportion develops after day 8, suggesting that prolonged heparin prophylaxis should be considered. Since LCs with venous flow reduction result in higher rates of VTE, hemodynamically relevant lymphoceles should be surgically treated.     

肝硬化合并静脉血栓栓塞症的临床诊治

目的:探讨肝硬化合并静脉血栓栓塞症(venous thromboembolism,VTE)的临床特征及诊治要点。方法:回顾分析复旦大学附属中山医院2004年1月至2015年12月期间收住入院的23例VTE合并肝硬化患者的临床特征及治疗预后。结果:观察期内VTE合并肝硬化患者的发生率为0.8%。23例患者中男性16例,女性7例,年龄43~84岁,平均(55.7±10.1)岁。肝硬化A级患者(n=9)血清蛋白及血红蛋白含量高于肝硬化B级、C级患者(n=14),差异有统计学意义(P0.05);A级患者凝血功能和血肌酐水平优于B级、C级患者,其D-二聚体水平及血小板含量略低于B级、C级患者,但两组间各项指标差异无统计学意义。73.9%的患者也有恶性肿瘤病史。18例患者接受低分子肝素治疗;5例患者未接受抗凝治疗,其中3例死亡。结论:肝硬化患者也有静脉血栓形成风险,需要早期诊断,及时治疗。     

Risk factors for nosocomial pneumonia in critically ill trauma patients

OBJECTIVE: To determine risk factors for nosocomial pneumonia in critically ill trauma patients. DESIGN: Prospective cohort study. SETTING: The trauma intensive care unit (ICU) of a 1500-bed tertiary-care hospital. PATIENTS: All critically ill trauma patients (n = 103) admitted consecutively between November 1995 and October 1996. INTERVENTIONS: A comparison of data recorded at the time of ICU admission and during the clinical evolution in patients with (n = 23) and without (n = 80) nosocomial pneumonia was made. Data referred mainly to possible risk factors were recorded; they also included factors related to pneumonia etiology and evolutive factors. Predictors of nosocomial pneumonia were assessed by logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: The presence of significant growth on quantitative cultures of the protected specimen brush (> or = 103 colony forming units/mL) was required to accept pneumonia as microbiologically proven, as well as the concurrence of a cohort of clinical and radiologic signs. Twenty-three (22.3%) patients developed nosocomial pneumonia. The mean age of these patients was 41.7 yrs; 18 of them (78.3%) were men. The microorganisms isolated in significant concentrations were Acinetobacter baumanii (ten cases), Staphylococcus aureus (11 cases), Pseudomonas aeruginosa (five cases), Haemophilus influenzae (two cases), and Klebsiella pneumoniae, Citrobacter freundii, Serratia marcescens, Enterococcus spp., Enterobacter spp., coagulase-negative Staphylococcus, and Streptococcus intermedius (one case each one). Risk factors for pneumonia by univariate analysis included nasogastric tube; continuous enteral feeding; prolonged mechanical ventilation (>1 day); use of H2-receptor antagonist, sucralfate, muscle relaxants, corticosteroids, barbiturates, and inotropic agents; positive end-expiratory pressure; intense sedation; re-intubation; tracheotomy; urgent brain computed tomography (CT) scan; craniotomy; iatrogenic event; and hyperventilation. The mortality rate was 43.5% (10 of 23) in the nosocomial pneumonia group and 18.8% in patients without nosocomial pneumonia (p =.02). Also, the mean stay in the ICU, the therapeutic charge (measured with total and mean punctuation of the Therapeutic Intervention Scoring System) and the complications, infectious and noninfectious, of the clinical evolution were significantly more frequent in patients with nosocomial pneumonia than in those without pneumonia (p <.05). In the multivariate analysis, continuous enteral feeding, craniotomy, prolonged mechanical ventilation (>24 hrs), use of positive end-expiratory pressure, and corticotherapy were independent predictors of nosocomial pneumonia. CONCLUSIONS: It seems that factors related to the patient's clinical course, rather than variables registered on the first days of ICU admission, are those that would exert an influence on the development of nosocomial pneumonia in critically ill trauma patients. In this way, from our point of view, in our study the main risk factors are the use of prolonged mechanical ventilation (>4 hrs) and positive end-expiratory pressure. At the same time, we can conclude that the reduction of this infection incidence could decrease the mean stay in the ICU, the therapeutic charge, and the prognosis in terms of mortality and morbidity.     

Efficacy and safety of bemiparin compared with enoxaparin in the prevention of venous thromboembolism after total knee arthroplasty: a randomized, double-blind clinical trial

Summary.  In this randomized, multicenter, controlled, double-blind, sequential trial, 381 patients undergoing primary total knee replacement were randomly assigned to receive subcutaneous injections of either 3500 IU anti-factor Xa of bemiparin sodium, first dose 6 h after surgery, or 40 mg of enoxaparin, first dose 12 h before surgery, followed by daily doses for 10 ± 2 days, for the prophylaxis of venous thromboembolism. The primary efficacy endpoint was venous thromboembolism up to postoperative day 10 ± 2, defined as deep vein thrombosis detected by mandatory bilateral venography, documented symptomatic deep vein thrombosis and/or documented symptomatic pulmonary embolism. The primary safety endpoint was major bleeding. Eighty-seven percent of all randomized patients (333 of 381 patients) were evaluable for efficacy. The incidence of venous thromboembolism was 32.1% (53 of 165 patients) in the bemiparin group and 36.9% (62 of 168 patients) in the enoxaparin group. The absolute risk difference was 4.8% in favor of bemiparin [95% confidence interval (CI), −15.1% to 5.6%; non-inferiority P -value: 0.02; superiority P -value: 0.36]. The incidence of proximal deep vein thrombosis was 1.8% (three of 165 patients) in the bemiparin group and 4.2% (seven of 168 patients) in the enoxaparin group. Major bleeding occurred in six patients (three in each group). There were no deaths during the study. This trial shows that bemiparin started postoperatively is as effective and safe as enoxaparin started preoperatively in the prevention of venous thromboembolism in patients undergoing total knee replacement.     

Early post-cardiac surgery delirium risk factors

The purpose of this study was to identify the post-cardiac surgery delirium risk factors and to evaluate clinical outcomes. Data on 90 patients with postoperative delirium after cardiac surgery on cardiopulmonary bypass (CPB) were analyzed retrospectively. The patients were divided into two groups by evaluating the severity of the delirium: light and moderate delirium group (n=74) and severe delirium group (n=16). We found that the rate of early post-cardiac surgery delirium was low (4.17%). We have determined that post-cardiac surgery delirium prolonged the length of stay in the Intensive Care Unit (ICU) by (8.4 (8.6)) and the hospital stay by (23.6 (13.0)) days. The patients had higher preoperative risk scores, their age was 71.5 (8.9) years, the body mass index was 28.8 (4.4) kg/m(2), the majority were male (72.2%), and the left ventricular ejection fraction was 46.1(11.9) %. Statistical analysis by multivariable logistic regression has indicated that increasing the dose of fentanyl administered during surgery over 1.4 mg also increased the possibility of developing a severe delirium (OR=29.4, CI 4.1-210.3) and longer aortic clamping time could be independently associated with severe postoperative delirium (OR=8.0, CI 1.7-37.2). After surgery, new atrial fibrillation (AF) episodes amounted to 53.3% and, after distinguishing the delirium severity groups, AF developed in the patients belonging to the severe delirium groups statistically significantly more frequently, 81.8 vs 47.3, where p=0.01. Our data suggest that early post-cardiac surgery delirium is not a common complication, but it prolonged the length of stay at the ICU and in the hospital. The delirium risk factors, such as longer aortic clamping time, the dose of fentanyl and new atrial fibrillation episodes occurring after cardiac surgery, are associated statistically significantly with the development of severe post-cardiac surgery delirium.