Is C-reactive protein a good prognostic marker in septic patients?

Rationale  Several studies have shown that C-reactive protein (CRP) is a marker of infection. The aim of this study was to evaluate CRP as marker of prognosis outcome in septic patients and to assess the correlation of CRP with severity of sepsis. Methods  During a 14-month period, we prospectively included all patients with sepsis admitted to an intensive care unit (ICU). Patients were categorized into sepsis, severe sepsis and septic shock. Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA) score, CRP, body temperature and white cell count (WCC) of the day of sepsis diagnosis were collected. Results  One hundred and fifty-eight consecutive septic patients (mean age 59 years, 98 men, ICU mortality 34%) were studied. The area under the receiver operating characteristics curves of APACHE II, SAPS II, SOFA, CRP, body temperature and WCC as prognostic markers of sepsis were 0.75 [95% confidence interval (CI) 0.67–0.83], 0.82 (95% CI 0.75–0.89), 0.8 (95% CI 0.72–0.88), 0.55 (95% CI 0.45–0.65), 0.48 (95% CI 0.38–0.58) and 0.46 (95% CI 0.35–0.56), respectively. In the subgroup of patients with documented sepsis we obtained similar results. The ICU mortality rate of septic patients with CRP < 10, 10–20, 20–30, 30–40 and >40 mg/dL was 20, 34, 30.8, 42.3 and 39.1%, respectively (P = 0.7). No correlation was found between CRP concentrations and severity of sepsis. Conclusions  In septic patients, CRP of the day of sepsis diagnosis is not a good marker of prognosis.     

Multislice computed tomography coronary angiography in patients admitted with a suspected acute coronary syndrome

Objectives The aim of this prospective clinical study was to assess the accuracy and clinical relevance of multislice computed tomography coronary angiography (MSCTCA) in patients presenting with acute chest pain. Background Multislice computed tomography coronary angiography has shown ability to detect accurately coronary artery disease (CAD) in selected elective patient groups. Methods One hundred and twenty patients presenting with acute chest pain (<24 h) underwent MSCTCA (Siemens Sensation 16) before a scheduled inpatient conventional coronary angiogram (CCA). Exclusion criteria included patients with STEMI, non-sinus rhythm, contraindication to β blockers and renal impairment. Blinded visual assessment of MSCTCA to detect CAD was performed on an 11-segment model. The accuracy of MSCTCA was compared to CCA to detect significant stenoses (≥50%). Results One hundred and thirteen patients underwent both investigations. The prevalence of significant CAD was 74%. 1,243 native segments were assessed by MSCTCA. The overall ability of MSCTCA to detect the presence of ≥1 significant stenosis in all native segments had a sensitivity of 92% (95%CI 83–97%), specificity of 55% (95%CI 35–74%), positive predictive value of 86% (95%CI 76–93%) and negative predictive value of 70% (95%CI 47–87%). 22% of all segments (mostly distal) were non-analyzable. Coronary calcification was a major cause of false positivity. Conclusion In a prospective study of unselected patients presenting with acute chest pain, the diagnostic accuracy of 16-slice CT coronary angiography was moderate and less than reported from studies in elective patients. The clinical relevance of this technology to screen patients with acute chest pain is limited.

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Condensed Abstract Multislice CT coronary angiography (MSCTCA) and conventional coronary angiography (CCA) were used to assess 120 patients presenting with acute chest pain. MSCTCA was compared to CCA to detect significant stenoses (≥50%). In 113 directly comparable patients MSCTCA had a sensitivity of 92% (95%CI 83–97%) and specificity of 55% (95%CI 35–74%) to detect the presence of ≥1 significant stenosis in all native segments. In this patient cohort with a high prevalence of coronary disease and coronary calcification, the accuracy and clinical relevance of 16 slice MSCTCA to screen and risk stratify patients with acute chest pain is limited.

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The use of low-energy laser (LEL) for the prevention of chemotherapy- and/or radiotherapy-induced oral mucositis in cancer patients: results from two prospective studies

Background  Low-energy laser (LEL) treatment has been suggested as an effective and safe method to prevent and/or treat oral mucositis induced by chemotherapy and/or radiotherapy; however, it has not gained wide acceptance so far. Materials and methods  We conducted two clinical trials testing the LEL technique: firstly, as a secondary prevention in patients with various solid tumors treated with chemotherapy who all developed severe mucositis after a previous identical chemotherapy and, secondly, as therapeutic intervention (compared to sham illumination in a randomized way) in patients with hematological tumors receiving intensive chemotherapy and having developed low-grade oral mucositis. Results  We entered 26 eligible patients in the first study and 36 were randomized in the second study. The success rate was 81% (95%CI = 61–93%) when LEL was given as a preventive treatment. In the second study, in patients with existing lesions, the therapeutic success rate was 83% (95%CI = 59–96%), which was significantly different from the success rate reached in the sham-treated patients (11%; 95%CI = 1–35%); the time to development of grade 3 mucositis was also significantly shorter in the sham-treated patients (p < 0.001). Conclusion  Our results strongly support the already available literature, suggesting that LEL is an effective and safe approach to prevent or treat oral mucositis resulting from cancer chemotherapy.     

Renal and perirenal space involvement in acute pancreatitis: spiral CT findings

Background: This study was conducted to estimate the prevalence and morphologic computed tomographic (CT) features of renal and perirenal space abnormalities in acute pancreatitis in correlation with the severity of pancreatitis. Methods: One hundred fifty-nine contrast-enhanced CT scans of 100 consecutive patients with acute pancreatitis were retrospectively and independently reviewed by three observers. All CT images were obtained using contrast-enhanced helical CT (collimation width = 5 mm, table increment = 7 mm/s, reconstruction interval = 5 mm, scan delay time = 30–50 s). Additional maximized images (field of view = 260 mm) of the perirenal space were available for review. All CT scans were scored with the CT Severity Score Index: pancreatitis was graded as mild (0–2 points), moderate (3–6 points), and severe (7–10 points). Interobserver agreement for both the severity score and the presence of renal and perirenal involvement was calculated. Correlation between the prevalence of complications and the degree of pancreatitis was estimated. Results: CT scans were graded as mild (n= 59), moderate (n= 82), and severe (n= 18). Abnormalities detected included perirenal stranding (n= 37 patients, 26 bilateral), perirenal fluid collections (n= 10 patients, one bilateral), ureteral encasement (n= 2 patients), renal vein thrombosis (n= 1 patient), and renal parenchymal abnormalities (n= 1 patient). The interobserver agreement range for scoring the degree of pancreatitis and the overall presence of abnormalities was 75.5–79.2% and 59.8–100%, respectively. Except for stranding of the perirenal fat, no statistically significant differences between the presence of abnormalities and the severity of pancreatitis (moderate or severe) was observed with Fisher's exact test. Also, no preferential left-sided localization of complications was observed. Conclusions: The incidence of renal and perirenal complications from acute pancreatitis is higher than previously estimated (7%). We found no significant correlation between the prevalence of major complications and the severity of pancreatitis. These findings are important because these complications may have an impact on therapeutic strategy and can affect prognosis. Received: 31 March 1999/Revision accepted: 25 August 1999     

Chemotherapy-induced nausea and vomiting—incidence and impact on patient quality of life at community oncology settings

Goals of work The present study sought to determine the prevalence of acute and delayed chemotherapy-induced nausea and vomiting (CINV) across ten community oncology settings. The effect of CINV on quality of life (QOL) was also evaluated. Materials and methods Cancer patients who were scheduled for their first cycle of a new chemotherapy regimen were recruited from ten community oncology clinics. Study participants recorded occurrence of CINV by completing a daily diary each day for the first 8 days after treatment during each cycle and the Functional Living Index-Emesis (FLIE) before chemotherapy, at the end of day 1 and day 6 after chemotherapy. Mixed model regression analysis was used to explore the association between occurrence of CINV at cycle 1 and subsequent cycles and its impact on patient QOL. Main results One hundred and fifty-one patients provided information for at least one cycle. During cycle 1, only 33% had neither acute nor delayed CINV. Of the 36% patients who developed acute CINV, 8% developed acute CINV only. Of the 59% who developed delayed CINV, 53% reported delayed only and 47% reported acute and delayed CINV. A similar pattern was seen at cycles 2 and 3. Experience of CINV at cycle 1 was associated with the development of CINV at cycles 2 and 3. Occurrence of CINV significantly interfered with patient QOL as assessed by the FLIE. Conclusions CINV remained a substantial problem for patients receiving chemotherapy in this community-based sample, especially delayed CINV. CINV significantly interfered with patient QOL and daily functioning. Work presented at the 39th Annual Meeting of the American Society of Clinical Oncology (poster discussion)—Chicago, IL, May 31–June 3, 2003 Work performed at California Cancer Care, CA Henry Hu and Eileen E. Ming were employed by Merck & Co., Inc. during this study. L. Cohen and Carl A. de Moor were consultants with Merck & Co., Inc. during this study.     

Infective and thrombotic complications of central venous catheters in patients with hematological malignancy: prospective evaluation of nontunneled devices

Goals  Central venous catheter (CVC)-related bloodstream infection (CR-BSI) is a significant complication in hematology patients. A range of CVC devices may be used, and risks for the development of complications are not uniform. The objectives of this study were to determine the natural history and rate of CVC-related complications and risk factors for CR-BSI and to compare device-specific complications in a hematology population. Patients and methods  An observational cohort of patients with hematologic malignancy was prospectively studied following CVC insertion. Participants were reviewed until a CVC-related complication necessitated device removal, completion of therapy, death, or defined end-of-study date. The National Nosocomial Infection Surveillance definition for CR-BSI was used. Overall and device-specific rates of infective and noninfective complications were calculated and potential risk factors were captured. Main results  One hundred six CVCs (75 peripherally inserted central venous catheters [PICCs], 31 nontunneled CVCs) were evaluated in 66 patients, over 2,399 CVC days. Thrombosis occurred in 16 cases (15.1%), exit-site infection in two (1.9%), and CR-BSI in 18 (7.5 per 1,000 CVC days). No significant differences were found when complication rates in PICC and nontunneled devices were compared. An underlying diagnosis of acute myeloid leukemia was negatively associated with CR-BSI (odds ratio (OR) 0.14, p = 0.046), and a previous diagnosis of fungal infection was associated with infection (OR 22.82, p = 0.031). Conclusions  CR-BSI rates in our hematology population are comparable to prior reports. A low rate of exit-site infection and high proportion of thrombotic complications were observed. No significant differences in thrombotic or infective complications were evident when PICC and nontunneled devices were compared. PICC devices are a practical and safe option for management of hematology patients.     

Continued survival gains in recent years among critically ill myeloma patients

Objective  Therapeutic advances have improved survival in patients with myeloma (MM) over the past decade. We investigated whether survival has also improved in critically ill myeloma patients. Design  Retrospective study. Setting  Intensive care unit. Patient  Consecutive myeloma patients admitted to a teaching hospital ICU between 1990 and 2006. We compared three year-of-admission groups (1990–1995, 1996–2001, and 2002–2006) that matched changes in myeloma treatment (chemotherapy only, stem cell transplantation, and new molecules, respectively). Intervention  None. Measurements and main results  We included 196 patients. Reasons for ICU admission and patient characteristics were similar across groups; however, less use of conventional chemotherapy and radiotherapy and greater use of steroids were noted in the more recent periods. Over time, vasopressors and invasive mechanical ventilation were used decreasingly, and noninvasive ventilation increasingly, to treat acute respiratory failure. Hospital mortality decreased from 75% in 1990–1995 to 49% in 1996–2001 and 40% in 2002–2006 (P = 0.0007). Mortality was associated with poor performance status [OR 2.27, 95% CI (1.04–4.99)], need for mechanical ventilation [OR 4.33, 95% CI (1.86–10.10)], need for vasopressors [OR 2.57, 95% CI (1.12–5.86)], and admission for an event related to myeloma progression [OR 2.77, 95% CI (1.13–6.79)]. ICU admission within 48 h after hospital admission was associated with lower mortality [OR 0.28, 95% CI (0.19–0.89)]. Conclusion  Hospital mortality decreased significantly over the last 15 years in myeloma patients admitted to the ICU. Risk factors for death were organ failure and poor chronic health status. Early ICU admission was associated with lower mortality, suggesting opportunities for further improving survival.     

CT colonography: same-day tagging regimen with iodixanol and reduced cathartic preparation

The purpose of the study was to test the tagging performance and patient’s acceptance of a reduced cathartic preparation, based on iodixanol and PEG, administered to patients 3 h before the exam. One hundred and thirty-two asymptomatic patients were enrolled. As colonic cleansing we used PEG macrogol 3350. For fluid tagging iodixanol was orally administered 3 h before the exam, in a total dose of 50 mL mixed with 34.8 g of PEG in 750 mL of water. Image’s review showed 446 segments (56.4%) clean of feces and 346 segments (43.6%) with feces. Untagged fluid was observed in 74/706 (10.5%) segments; inhomogeneous tagging in 129/706 (16%); the average density of fluid was 1054.74 UH in the cecum–ascending colon and 905.14 UH in the descending–sigmoid colon; the average difference of density between right and left colonic segments was 149 UH, and it was statistically significant (P = 0.016). No side effects related to the consumption of Movicol were reported. Very few side effects related to the tagging solution were reported: mild nausea in 7 (0.05%) patients, mild diarrhea in 10 (0.07%). An average rank of 9 points (SD ± 1) on a 10-point scale (10 = no discomfort, 0 = severe discomfort) resulted from the self-administered questionnaire, showing an excellent acceptance of the preparation. Same day fluid tagging with iodixanol provides an optimal fluid tagging, it is completely tolerated by the patient, and it can be performed under medical control.     

Reversible clopidogrel resistance due to right ventricular myocardial infarction: risk factor of recurrent stent thrombosis?

A 63-year-old male Patient was admitted to the intensive care unit due to acute inferior myocardial infarction with right ventricular dysfunction. He received a loading dose of clopidogrel (600 mg) and aspirin (500 mg) and was immediately revascularized by reopening of the proximal right coronary artery (RCA) and implantation of a bare metal stent. After primary successful intervention the patient suffered from thoracic pain on day 5 of admission. The ECG indicated reinfarction. The proximal RCA was again re-opended by PTCA alone. The following day the patient suffered again from thoracic pain with ST-elevation in the inferior leads, this time complicated by additional total AV-blockade. The angiography showed another time a thrombotic occlusion of the initially implanted stent. He received another intervention with implantation of additional two baremetal stents, an aortic counter-pulsation and a temporary two-chamber pace maker. Tirofiban was administered for 24 h and the IABP was withdrawn after 60 h. The patient was discharged on Aspirin 300 mg/d, Clopidogrel 150 mg/d and Enoxaparin 40 mg/d. Six weeks later the patient demonstrated an improved right ventricular function (TAPSE 18 mm), liver enzymes were normal, and inhibition of platelet aggregation by clopidogrel (150 mg/d) was sufficient. In conclusion this implies that the reversible “clopidogrel-resistance” might have been due to congestion and reduced metabolism due to right ventricular infarction.     

Low-dose continuous-infusion ceftazidime monotherapy in low-risk febrile neutropenic patients

 One hundred and thirty-five cancer patients admitted with low-risk neutropenic fever received a low-dose schedule of ceftazidime as infusional monotherapy over a total of 180 episodes. Ceftazidime was administered as a 1-g bolus followed by a continuous infusion of 2 g per day. In this patient population the ceftazidime was both practical and well tolerated. Sixty-eight percent of patients responded with clinical improvement and complete resolution of fever within 48 h. Overall, 95% of patients responded, although 18% subsequently required antibiotic modification for persistent fever. Only 5% of episodes were considered failures due to clinical deterioration, and over the study period there was only 1 fatality due to respiratory failure. The median duration of hospitalisation was only 4 days (2–20). In conclusion, monotherapy with low-dose infusional ceftazidime appears safe and highly effective in this low-risk population of neutropenic patients and may reduce antibiotic costs appreciably. Published online: 7 March 2000     

Predictors of ventricular arrhythmias in patients with mitral valve prolapse

Arrhythmias have been reported to occur frequently in symptomatic patients with mitral valve prolapse (MVP). The mechanisms causing ventricular arrhythmias in patients with MVP have not been fully investigated. The purpose of this study was to determine the clinical, echocardiographic and heart rate variability parameters, and plasma concentrations of electrolytes and inflammatory markers in predicting ventricular arrhythmias in patients with MVP. A total of 58 consecutive patients with MVP were included in this study. We performed electrocardiography, echocardiography, holter analysis, routine biochemical tests including plasma concentrations of electrolytes and inflammatory markers, and evaluated the clinical characteristics. Ventricular arrhythmia defined as occurrence of any of the followings: ventricular premature contractions (VPCs), VPC couplets, and ventricular tachycardia documented by holter analysis, continuous monitoring or by electrocardiography. Twenty patients (34%) had ventricular arrhythmias, and 38 (66%) patients had no ventricular arrhythmias. Seventeen patients had VPC, 2 patients had VPC couplets and 1 patient had ventricular tachycardia. Univariable predictors of ventricular arrhythmias included isovolumetric relaxation time and the occurrence of moderate to severe mitral regurgitation. Multivariable logistic regression analysis showed that occurrence of moderate to severe mitral regurgitation was the only independent predictor of ventricular arrhythmias (relative risk: 8.42, 95% confidence interval: 1.49–47.64, p = 0.01). Present study showed that the only independent predictor of ventricular arrhythmias in patients with MVP is the occurrence of moderate to severe mitral regurgitation.     

Mechanical complications during central venous cannulations in pediatric patients

Objective  Identification of early mechanical complications (EMC) of central venous catheterizations (CVC) in pediatric patients and determination of EMC risk factors. Design  Prospective observational study. Setting  Pediatric intensive-care unit in a university hospital. Patients and measurements  Eight-hundred and twenty-five CVC were performed in 546 patients. Age, weight, gender, mechanical ventilation, analgesia, resident CVC failure, CVC indication, admission diagnosis, emergency or scheduled procedure, type of catheter (diameter, lumen number), catheter final location, number of attempts, and EMC were recorded. Risk factors for EMC were determined by multivariate analysis. Results  Median patient age was 22.0 months (0–216 months). CVC was an emergency procedure in 421 (51%) cases, scheduled in 336 (40.7%), and guide-wire exchanged in 68 (8.2%). There were 293 (35.5%) internal jugular, 116 (14.1%) subclavian, and 416 (50.4%) femoral catheters. CVC was performed by staff physicians in 35.8% cases, supervised residents in 43.4%, and staff after resident failure in 20.8%. 151 EMC occurred in 144 CVC (17.5%). The most commons EMC were arterial puncture (n = 60; 7.2%), catheter malposition (n = 39; 4.7%), arrhythmias (n = 19; 2.3%), and hematoma (n = 12; 1.4%). Resident failure to perform CVC (OR 2.53; CI 95% 1.53–4.16), high venous access (subclavian or jugular) (OR 1.91; CI 95% 1.26–2.88), and number of attempts (OR 1.10; CI 95% 1.03–1.17) were independently associated with EMC. Conclusions  EMC of CVC were common in a teaching university hospital, but severe complications were very uncommon. Resident failure to perform CVC, high venous access, and number of attempts were independent risk factors for EMC of CVC.     

Caspofungin for prevention of intra-abdominal candidiasis in high-risk surgical patients

Purpose  Thirty to forty percent of patients with recurrent gastrointestinal perforation/anastomotic leakage or acute necrotizing pancreatitis develop intra-abdominal invasive candidiasis (IC). A corrected Candida colonization index (CCI) ≥0.4 is a powerful predictor of IC. Fluconazole prevents intra-abdominal IC in this setting, but azole-resistant Candida species are emerging. The aim of this study was to explore the efficacy and safety of caspofungin for prevention of intra-abdominal IC in high-risk surgical patients. Methods  Prospective non-comparative single-center study in consecutive adult surgical patients with recurrent gastrointestinal perforation/anastomotic leakage or acute necrotizing pancreatitis. Preventive caspofungin therapy (70 mg, then 50 mg/day) was given until resolution of the surgical condition. Candida colonization index and CCI, occurrence of intra-abdominal IC and adverse events were monitored. Results  Nineteen patients were studied: 16 (84%) had recurrent gastrointestinal perforation/anastomotic leakage and 3 (16%) acute necrotizing pancreatitis. The median duration of preventive caspofungin therapy was 16 days (range 4–46). The colonization index decreased significantly during study therapy, and the CCI remained <0.4 in all patients. Caspofungin was successful for prevention of intra-abdominal IC in 18/19 patients (95%, 1 breakthrough IC 5 days after inclusion). No drug-related adverse event requiring caspofungin discontinuation occurred. Conclusion  Caspofungin may be efficacious and safe for prevention of intra-abdominal candidiasis in high-risk surgical patients. This needs to be further investigated in randomized trials. This study has been partially presented as poster # M-1163 at the 47th ICAAC (Interscience Conference on Antimicrobial Agents and Chemotherapy), Chicago, 17–20 September 2007.     

One hundred ECMO retrivals before and during the Covid-19 pandemic: an observational study

ObjectivesPatients with severe acute respiratory distress syndrome may require veno-venous extracorporeal membrane oxygenation (V-V ECMO) support. For patients in peripheral hospitals, retrieval by mobile ECMO teams and transport to high-volume centers is associated with improved outcomes, including the recent COVID-19 pandemic. To enable a safe transport of patients, a specialised ECMO-retrieval program needs to be implemented. However, there is insufficient evidence on how to safely and efficiently perform ECMO retrievals. We report single-centre data from out-of-centre initiations of VV-ECMO before and during the COVID-19 pandemic.Design & settingSingle-centre retrospective study. We include all the retrievals performed by our ECMO centre between January 1st, 2014, and April 30th, 2021.ResultsOne hundred ECMO missions were performed in the study period, for a median retrieval volume of 13 (IQR: 9–16) missions per year. the cause of the acute respiratory distress syndrome was COVID-19 in 10 patients (10 %). 98 (98 %) patients were retrieved and transported to our ECMO centre. To allow safe transport, 91 of them were cannulated on-site and transported on V-V ECMO. The remaining seven patients were centralised without ECMO, but they were all connected to V-V ECMO in the first 24 hours. No complications occurred during patient transport. The median duration of the ECMO mission was 7 hours (IQR: 6–9, range: 2 – 17). Median duration of ECMO support was 14 days (IQR: 9–24), whereas the ICU stay was 24 days (IQR:18–44). Overall, 73 patients were alive at hospital discharge (74 %). Survival rate was similar in non-COVID-19 and COVID-19 group (73 % vs 80 %, p = 0.549).ConclusionIn this single-centre experience, before and during COVID-19 era, retrieval and ground transportation of ECMO patients was feasible and was not associated with complications. Key factors of an ECMO retrieval program include a careful selection of the transport ambulance, training of a dedicated ECMO mobile team and preparation of specific checklists and standard operating procedures.     

The absence of coronary artery calcification does not rule out the presence of significant coronary artery disease in Asian patients with acute chest pain

The absence of coronary artery calcification (CAC) has been used to as an indication to rule out significant coronary artery disease (CAD). However, diagnostic usefulness of ‘zero calcium score criteria’ as a decision-making strategy to rule out significant CAD as the etiology of acute chest pain has not been studied in depth, especially in Asian ethnicity. We prospectively enrolled 136 Korean patients (58% men, 56 ± 13 years) who presented to the emergency department (ED) with acute chest pain and non-diagnostic ECG. All patients underwent 64-slice CT for calcium scoring and coronary CT angiography (cCTA). We investigated the association of CAC with the presence of ≥50% CAD on cCTA and with a final diagnosis of an acute coronary syndrome (ACS). Ninety-two patients out of 136 (68%) did not show detectable CAC, and 14 out of these 92 without CAC (15%) had ≥50% CAD on cCTA. Sensitivity, specificity, positive predictive value and negative predictive value of zero calcium score criteria for the detection of ≥50% CAD were 0.66 (95% confidence interval, 0.50–0.80), 0.83 (0.74–0.90), 0.64 (0.48–0.77), 0.85 (0.75–0.91), respectively. Patients who had ≥50% CAD without detectable CAC were younger (P = 0.001), and had a higher prevalence of smoking (P = 0.048) as compared to patients with a degree of CAC. Most of the patients with ≥50% CAD of non-calcified plaque were younger than 60 years of age (79%, 11/14), however, 3 of them were older than 60 years of age. Forty-five patients (33%) were subsequently diagnosed as having ACS, and 38% (17/45) of them had no CAC. Zero calcium score did not necessarily guarantee the absence of significant CAD, even in patients older than 60 years, in Asian ethnicity presenting to the ED with chest pain.     

Bridging INTERMACS 1 patients from VA-ECMO to LVAD via Impella 5.0: De-escalate and ambulate

PurposeVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) stabilizes patients in refractory cardiogenic shock. However, ECMO-related complications strongly affect the outcome, especially if a long-term LVAD is needed.Methods and materialsWe describe a new strategy in management of INTERMACS 1 patients consisting in early weaning from VA-ECMO with axillary Impella 5.0 as a bridge to LVAD implantation. Nine patients in two European centres are described.ResultsAll patients were implanted with VA-ECMO for initial hemodynamic and metabolic stabilization. After a median time of 8 days, Impella 5.0 was implanted. Impella support allowed in all patients weaning from inotropes and from VA-ECMO (after a median time of 22 h). No patients had right ventricular failure after ECMO-weaning and most patients were mobilized and orally fed (88.9%) during Impella support. All patient underwent LVAD implantation after a median Impella time of 17 days. Only one patient had right-ventricular failure after LVAD implantation. All patients were discharged from hospital after a median time of 40 days.ConclusionEarly weaning from VA-ECMO with Impella 5.0 as a bridge to LVAD is a safe and effective strategy in management of INTERMACS 1 patients. This approach minimizes ECMO-related complications and allows patient mobilization and right ventricular function optimization before LVAD implantation.     

Efficacy of treatment to relieve mucositis-induced discomfort

 To determine the efficacy of a mouthwash in relieving mucositis-induced discomfort in patients receiving chemotherapy, 31 (16 male, 15 female) with a mean age of 45 (range 16–80) were given an in-house three-drug (lidocaine, diphenhydramine and sodium bicarbonate in normal saline) mouthwash when they developed mucositis of any severity. The complications were assessed on the CALGB (Cancer and Leukemia Group B) scale. The response to the mouthwash was reported on a self-assessment scale. Patients' response data were analyzed with reference to: (1) relief throughout the duration of mucositis and (2) relief during the worst stage (for each episode) of mucositis. Five patients with fungal, viral or bacterial oral infection were excluded from study. Overall, 4 patients had grade I, 16 patients had grade II, 10 patients had grade III and 1 patient had grade IV mucositis. The average duration of mucositis was 7.9 days (range 3–23 days), and the mean duration of the worst stage of mucositis was 4.81 days (range 2–13 days). The mean mucositis severity score was 1.9 (range 1–4), and the average self-assessment (response) score was 0.81 (range 0–2). The mean mucositis score during the worst stage of mucositis was 2.25 (range 1–4), and the average self-assessment (response) score during the worst stage of mucositis was 0.91 (range 0–2.7). These results suggests that this three-drug mouthwash provides effective symptomatic relief in patients with chemotherapy-induced mucositis. Published online: 5 October 1999     

Risk factors of septic shock in bacteremic acute pyelonephritis patients admitted to an ER

Our objective was to identify factors associated with septic shock in patients with bacteremic acute pyelonephritis who were admitted to our emergency department (ER). We performed a retrospective cohort study of 208 adult cases compiled between January 2000 and December 2010. The mean age of the 208 predominantly female (81.3%) adult cases enrolled during the study period was 65.9 ± 15.2 years. The overall mortality rate was 6.7% (14/208), but the mortality rate of 54 patients (26%, 54/208) who initially presented with shock was 25.9% (14/54). Multiple logistic regression analyses revealed that the independent risk factors for the occurrence of septic shock were the presence of a urinary tract obstruction (OR 4.391, 95% CI 1.782–10.821, P = 0.001), healthcare-associated infection (OR 3.491, 95% CI 1.585–7.692, P = 0.002), and liver cirrhosis (OR 4.609, 95% CI 1.395–15.222, P = 0.012). Therefore, physicians should be aware that appropriate early management is necessary to prevent fatal outcomes in patients with risk factors of septic shock.     

Infectious complications of percutaneous central venous catheterization in pediatric patients

Objective Analysis of infectious complications and risk factors in percutaneous central venous catheters. Design One-year observational, prospective, multicenter study (1998–1999). Setting Twenty Spanish pediatric intensive care units. Patients Eight hundred thirty-two children aged 0–14 years. Intervention None. Measurements and main results One thousand ninety-two catheters were analyzed. Seventy-four (6.81%) catheter-related bloodstream infections (CRBSI) were found. The CRBSI rate was 6.4 per 1,000 CVC days (95% CI 5.0–8.0). Risk factors for CRBSI were weight under 8 kg (p < 0.001), cardiac failure (RR 2.69; 95% CI 1.95–4.38; p < 0.001), cancer (RR 1.66; 95% CI 0.97–2.78; p = 0.05), silicone catheters (RR 2.82; 95% CI 1.49–5.35; p = 0.006), guidewire exchange catheterization (p = 0.002), obstructed catheters (RR 2.67; 95% CI 1.63–4.39; p < 0.001), and more than 12 days' indwelling time (RR 5.9; 95% CI 3.63–9.41; p < 0.001). Multivariate Cox regression identified lower patient weight (HR 2.4; 95% CI 1.11–5.19; p = 0.002), guidewire exchange catheterization (HR 2.2; 95% CI 1.07–4.54; p = 0.049) and more than 12 days' indwelling time (HR 1.97; 95% CI 0.89–4.36; p = 0.089) as significant independent predictors of CRBSI. Factors which protected against infection were the use of povidone–iodine on hubs (HR 0.42; 95% CI 0.19–0.96; p = 0.025) and porous versus impermeable dressing (HR 0.41; 95% CI 0.23–0.74; p = 0.004). Two children (0.24%) died from endocarditis following catheter-related sepsis due to Stenotrophomonas maltophilia in one case and P. aeruginosa in the other. Conclusions Catheter-related sepsis is associated with lower patient weight and more than 12 days' indwelling time, but not with the insertion site. Cleaning hubs with povidone–iodine protects from infection. The named authors wrote this article on behalf of the Spanish Central Venous Catheter Pediatric Study Group, the members of which are listed in the Appendix.     

Prognostic value of midregional pro-atrial natriuretic peptide in ventilator-associated pneumonia

Objective  This study aimed to investigate the correlation of midregional pro-atrial natriuretic peptide (MR-proANP) with severity of septic status in patients with ventilator-associated pneumonia (VAP) and the usefulness of MR-proANP for mortality prediction in VAP. Design  Prospective observational cohort study. Setting  University Hospital. Patients  Seventy-one patients consecutively admitted to ICU who developed VAP. Patients were followed for 28 days after diagnosis, when they were considered survivors. There were no interventions. Results  MR-proANP levels increased from sepsis to severe sepsis and septic shock on D0 and D4 of VAP (0.002 and 0.02 respectively). Median MR-proANP levels on day 0 and day 4 (pmol/L [interquartile range]) were 149.0 (79.8–480.0) and 249.0 (93.6–571.0) in septic patients, 438.5 (229.3–762.0) and 407.5 (197.8–738.0) in severe sepsis, 519.5 (369.5–1282.3) and 632.0 (476.0–1047.5) in septic shock. On day 0 and day 4, MR-proANP levels were significantly higher in non-survivors (525.0 [324.0–957.8] and 679.5 [435.0–879.5], respectively) than in survivors (235.0 [102.0–535.0] and 254.0 [110.0–571.0], respectively; P = 0.004). Univariate logistic regression model for mortality included age, gender, APACHE II score, creatinine, logarithmic transformed MR-proANP (LnMR-proANP). Mortality was directly related to LnMR-proANP on D0 and D4, with odds ratios (OR) of 2.06 (95% CI 1.21–3.51) and 2.63 (1.33–5.23), respectively. In multivariate logistic regression, only LnMR-proANP D0 with OR = 2.35 (1.05–5.26) and LnMR-proANP D4 with OR = 3.76 (1.39–10.18) remained significant. Conclusions  Our data demonstrated that MR-proANP levels increase progressively with the severity of sepsis and are independent predictors of mortality in VAP.