Procalcitonin kinetics – prognostic and diagnostic significance in septic patients

Introduction

Severe sepsis and septic shock are advanced clinical conditions representing the patient''s response to infection and having a variable but high mortality rate. Early evaluation of sepsis stage and choice of adequate treatment are key factors for survival. Some study results suggest the necessity of daily procalcitonin (PCT) monitoring because of its prognostic and discriminative value.

Material and methods

An observational and prospective study was conducted to evaluate the prognostic and discriminative value of PCT kinetics in comparison to PCT absolute value measurements. In a group of 50 intensive care unit patients with diagnosis of severe sepsis or septic shock, serum PCT measurements were performed on admission, and on the 2^nd, 3^rd and 5^th day of therapy. The level of PCT was determined with a commercially available test according to the manufacturer''s protocol.

Results

The kinetics of PCT assessed by ΔPCT was statistically significant in the survivors vs. the non-survivors subgroup (ΔPCT_3/1, p = 0.022; ΔPCT_5/1, p = 0.021). ΔPCT has no statistical significance in the severe sepsis and septic shock subgroups for all analyzed days. Only the 5^th day PCT level was significantly higher in the non-survivors vs. survivors group (p = 0.008). The 1^st day PCT level in the severe sepsis vs. septic shock group has a discriminative impact (p = 0.009).

Conclusions

According to the results, single serum PCT measurement, regardless of absolute value, has a discriminative impact but no prognostic significance, during the first 2 days of therapy. The PCT kinetics is of prognostic value from the 3^rd day and is of earlier prognostic significance in comparison to changes in the patient''s clinical condition evaluated by SOFA score kinetics.     

Procalcitonin levels in salmonella infection

Aim:

Procalcitonin (PCT) as a diagnostic marker for bacteremia and sepsis has been extensively studied. We aimed to study PCT levels in Salmonella infections whether they would serve as marker for early diagnosis in endemic areas to start empiric treatment while awaiting blood culture report.

Materials and Methods:

BACTEC blood culture was used to isolate Salmonella in suspected enteric fever patients. Serum PCT levels were estimated before starting treatment.

Results:

In 60 proven enteric fever patients, median value of serum PCT levels was 0.22 ng/ml, values ranging between 0.05 and 4 ng/ml. 95% of patients had near normal or mild increase (<0.5 ng/ml), only 5% of patients showed elevated levels. Notably, high PCT levels were found only in severe sepsis.

Conclusion:

PCT levels in Salmonella infections are near normal or minimally increased which differentiates it from other systemic Gram-negative infections. PCT cannot be used as a specific diagnostic marker of typhoid.     

Cytokine profile in elderly patients with sepsis

Context:

Sepsis is a serious health problem in the elderly with a high degree of mortality. There is very limited data available in elderly subjects regarding the markers for sepsis. Development of good markers will help in overall management and prediction of sepsis.

Objectives:

Serial estimation of Interleukin-6 (IL-6) and Tumor Necrosis Factor-Alpha (TNF-α) and their correlation with mortality in sepsis in elderly patients and to determine the influence of gender on cytokine production and mortality in elderly patients with sepsis.

Settings and Design:

The prospective study was conducted at our tertiary care center from April 2007 to September 2008. Elderly Patients satisfying the Systemic Inflammatory Response Syndrome (SIRS) criteria were included.

Methods and Material:

TNF-α and IL-6 were estimated in 30 elderly patients admitted to our intensive care unit with SIRS and sepsis. The estimations were done on day 1, 3 and 7 of admission.

Statistical Analysis Used:

Student and paired ‘t’ tests, and ANOVA, which were further followed up by post-hoc ‘t’ tests with Bonferroni correction using SPSS.

Results:

Reducing levels of IL-6 levels from day 1 to 7 was found in the survivor group. TNF-α level was significantly low on day 1 in the nonsurvivor female group.

Conclusions:

Serial estimation of cytokines in elderly patients with sepsis will help in prediction of mortality. Female gender was an independent predictor of increased morality in critically ill patients with sepsis.     

Procalcitonin kinetics as a prognostic marker in severe sepsis/septic shock

Background and Aims:

To evaluate the prognostic value of change (fall) in serum procalcitonin level (PCT) in critically ill adults with severe sepsis/septic shock.

Methods:

This was a prospective observational study in a general purpose Intensive Care Unit of a teaching Institute. PCT was measured at admission (D0) and after 72–96 h (D4) by electrochemi-luminescence immunoassay (BRAHMS PCT kit) in adults (>18 years) admitted with severe sepsis or septic shock. Change in procalcitonin values from D0 to D4 was correlated with the primary outcome, that is, 28 days mortality. All results are reported as median (interquartile range).

Results:

A total of 171 (100 males) of 181 patients were included. The median age was 46 years (range 19–79). 137 patients were in septic shock and 34 in severe sepsis. The sequential organ failure assessment (SOFA) score in all patients was 11 (9–14).91 (53.2%) patients survived at 28 days (survivors). The baseline procalcitonin was similar in two groups (3.48 [1.04–15.85] vs. 5.27 [1.81–23.57] ng/ml in survivors and nonsurvivors [NS] respectively). The procalcitonin change was 1.58 (0.20–8.52) in survivors and 0.28 (–1.38–6.17) in NS (P = 0.01). The C-statistic of percentage change in procalcitonin from D0 to D4 to predict survival was 0.73 (95% confidence interval [CI]: 0.65–0.82) when compared to 0.78 (95% CI: 0.71–0.86) for change of SOFA score. For an absolute fall in procalcitonin of >1 ng/ml, a 70% fall predicted survival with 75% sensitivity and 64% specificity.

Conclusions:

In critically ill-patients with severe sepsis/septic shock, change (fall) in procalcitonin is associated with good outcome.     

Could a protocol based on early goal-directed therapy improve outcomes in patients with severe sepsis and septic shock in the Intensive Care Unit setting?

Context:

Sepsis is a disease with high incidence and mortality. Among the interventions of the resuscitation bundle, the early goal-directed therapy (EGDT) is recommended.

Aims:

The aim was to evaluate outcomes in patients with severe sepsis and septic shock using EGDT in real life compared with patients who did not undergo it in the Intensive Care Unit (ICU) setting.

Settings and Design:

retrospective and observational cohort study at tertiary hospital.

Subjects and Methods:

All the patients admitted to ICU were screened for severe sepsis or septic shock and included in a registry and followed. The patients were allocated in two groups according to submission or not to EGDT.

Results:

A total of 268 adult patients with severe sepsis or septic shock were included. EGDT was employed in 97/268 patients. The general mortality was higher in no early goal-directed therapy (no-EGDT) then in EGDT groups (49.7% vs. 37.1% [P = 0.04] in hospital and 40.4% vs. 29.9% [P = 0.08] in the ICU, respectively. The general length of stay [LOS] in the no-EGDT and EGDT groups was 45.0 ± 59.8 vs. 29.1 ± 30.1 days [P = 0.002] in hospital and 17.4 ± 19.4 vs. 9.1 ± 9.8 days [P < 0.001] in the ICU, respectively).

Conclusions:

Our study shows reduced mortality and LOS in patients submitted to EGDT in the ICU setting. A simplified EGDT without central venous oxygen saturation is an important tool for sepsis management.     

Clinical outcomes after utilizing surviving sepsis campaign in children with septic shock and prognostic value of initial plasma NT-proBNP

Background and Objective:

The surviving sepsis campaign treatment guideline (SSC) implementation is associated with improved outcome in adults with severe sepsis. The effect on outcome of pediatric sepsis is less clear.

Purpose:

To determine the clinical outcomes of SSC implementation and to investigate the prognostic value of initial plasma NT-proBNP and procalcitonin in children.

Materials and Methods:

Infants and children (aged 1month/0-15 years with severe sepsis or septic shock) were prospectively enrolled and treated according to the guidelines. Initial blood drawn was saved for NT-pro-BNP, procalcitonin measurements and clinical data were also recorded.

Results:

A total of 47 subjects were recruited. Since the application of the SSC, our mortality rate had significantly decreased from 42-19% (P = 0.003) as compared to the data in the previous 3 years. Clinical factors that significantly increased the mortality rate were: Initial central venous oxygen saturation < 7 0% after fluid resuscitation [odds ratio (OR) = 23.3; 95% confidence interval (CI) 3.7-143; P = 0.001], and initial albumin level (≤ 3 g/dl, OR = 6.7; 95% CI 1.2-37.5, P = 0.03). There was asignificant difference between the initial NT-proBNP levels between survivors and non survivors, (6280.3 ± 9597 ng/L, P < 0.001), but not for procalcitonin (12.7 ± 24.8, 29.3 ± 46 μg/L, P = 0.1), respectively. An initial NT-proBNP level of more than 11,200 pg/ml predicted Pediatric Intensive Care Unit (PICU) mortality with a sensitivity of 85.7% and a specificity of 90%.

Conclusions:

A modified SSC for severe sepsis and septic shock significantly reduced the mortality rate in our PICU. High initial NT-ProBNP level was associated with mortality.     

An evaluation of serial blood lactate measurement as an early predictor of shock and its outcome in patients of trauma or sepsis

Context:

Attainment of hemodynamic parameters to within a normal range may leave patients in compensatory shock. In such patients, serial blood lactate evaluation can be useful in predicting shock.

Aims:

To ascertain the role of serum lactate as a predictor of shock and its outcome in patients of trauma and sepsis.

Settings and Design:

A prospective, non-interventional study.

Materials and Methods:

The study included 50 patients (5 to 60 years old) of trauma admitted within 12 hours of injury and patients of suspected or proven sepsis. Those with chronic medical illnesses, alcohol intoxication, or poisoning were excluded. Blood lactate levels were analyzed at admission and 12, 24, and 36 hours of inclusion with records of corresponding hemodynamic variables, investigations, and interventions. The outcome was recorded as survival or non-survival.

Statistical Analysis Used:

Statistical analysis was done with a student''s t test and repeated measure ANOVA (Analysis of Variance).

Results:

An analysis revealed higher mean lactate levels in non-survivors as compared with survivors. Mean lactate levels in non-survivors did not attain normal levels, while that of survivors reached normal levels by 24 hrs in trauma patients and 36 hrs in sepsis patients. The predicted mortality rates by a lactate level >40 mg/dl at admission, 12, 24, and 36 hours were 52.6%, 61.5%, 83.3%, and 100%, respectively for both the subgroups combined. Non-survivors had a higher incidence of MODS (Multi Organ Dysfunction Syndrome).

Conclusions:

Serial lactate values followed over a period of time can be used to predict impending complications or grave outcome in patients of trauma or sepsis. Interventions that decrease lactate values to normal early may improve chances of survival and can be considered effective therapy. Lactate values need to be followed for a longer period of time in critical patients.     

Prediction of outcome and prognosis of patients on mechanical ventilation using body mass index, SOFA score, C-Reactive protein, and serum albumin

Context:

Body mass index (BMI), serum albumin, and C-reactive protein (CRP) appear to be major determinants of hospitalization.

Aim:

To determine the predictive ability of BMI, Sequential Organ Failure Assessment (SOFA score), serum albumin, and CRP to assess the duration and outcome of mechanical ventilation (MV).

Materials and Methods:

Thirty patients aged >18 years who required mechanical ventilation (MV) were enrolled for the study. They were divided into two groups; patients who improved (Group 1), patients who expired (Group 2). Group 1 was further divided into two groups: patients on MV for <5 days (Group A), and patients on MV for >5days (Group B). BMI and SOFA score were calculated, and serum albumin and CRP were estimated.

Results and Discussion:

Out of the 30 patients, 18 patients successfully improved after MV (Group 1) and 12 patients expired (Group 2). Among the 18 patients in group 1, ten patients improved within 5 days (Group A) and 8 patients after 5 days (Group B). SOFA score and CRP were significantly increased (P value 0.0003 and 0.0001, respectively) in group 2 when compared to group 1. CRP >24.2 mg/L or SOFA score >7 at the start of MV increases the probability of mortality by factor 13.08 or 3.92, respectively The above parameters did not show any statistical difference when group A was compared to group B.

Conclusion:

Simple, economic and easily accessible markers like CRP and assessment tools of critically ill patients with SOFA score are important determinants of possible outcomes of a patient from MV.     

A comparative study of complications and long term outcomes of Surgical Tracheostomy and two techniques of Percutaneous Tracheostomy

Context:

The operative technique for surgical tracheostomy has remained unchanged, but different techniques for percutaneous tracheostomy have evolved due to interest in minimally invasive procedures for the critically ill patient.

Aims:

To compare the periprocedural complications and long term outcomes of bedside surgical tracheostomy (ST) with two percutaneous tracheostomy (PCT) techniques, namely serial guide wire dilating forceps (GWDF) and PercuTwist (PT).

Settings and Design:

This prospective observational study was carried out in ICU of a tertiary referral centre over three year period on adult intubated patients needing elective tracheostomy.

Materials and Methods:

Patients with anticipated difficult neck anatomy were assigned for ST based on discretion of intensivist. Patients included for PCT were randomly assigned to the GWDT and PT technique. 90 patients underwent either bedside ST (n = 30), PCT by GWDF technique (n = 30) or PCT with PercuTwist (n = 30) and were followed up with fibreoptic bronchoscopy monthly for 06 months.

Statistical Analysis Used:

Data was analyzed by applying chi square tests for categorical variables.

Results:

Periprocedural complications during PCT included major bleeding (>100ml) in two patients in GWDF group which required conversion to ST. Periprocedural bleeding was also the main complication in ST. Increased incidence of granulation tissue and tracheal narrowing in long term was seen in both ST and PCT groups. All of the P values analysed for the intra operative, post operative complications or long term outcomes were >0.05.

Conclusions:

There was no statistically significant difference in incidence of complications of ST and two techniques of PCT. Proper case selection makes PCT as safe as ST.     

An evaluation of the Charlson co-morbidity score for predicting sepsis after elective major surgery

Background and Aims:

Severe sepsis is a significant cause of morbidity and mortality following major surgery. The Charlson co-morbidity score (CCS) has been shown to be associated with severe sepsis following major surgery for cancer. This prospective observational study investigated the effect of patient factors (CCS, gender, age and malignancy) and intraoperative factors (duration of surgery and allogeneic blood transfusion) on the incidence of sepsis after elective major surgery, and the impact of patient co-morbidities on length of stay in critical care.

Materials and Methods:

We prospectively identified a cohort of 101 patients undergoing elective major surgery in a university teaching hospital. The CCS was calculated before surgery, and the incidence of sepsis was documented following surgery. We investigated whether age, malignancy, intraoperative allogeneic blood transfusion, length of surgery or gender were associated with sepsis following surgery.

Results:

Twenty-seven (27%) patients developed sepsis. Using multivariate logistic regression, the duration of surgery was associated with the development of sepsis after surgery (P = 0.054, odds ratio 1.2). The CCS was not associated with sepsis in this population of cancer and non-cancer patients undergoing elective major surgery, but was associated with longer length of stay in the intensive care unit (P = 0.016).

Conclusions:

Duration of surgery, but not patient co-morbidity as assessed by the CCS, may predict the postoperative incidence of sepsis. CCS could be used as a guide to predict consumption of critical care resources by elective surgical patients. A higher CCS was associated with a longer ICU stay. Resources, such as postoperative goal directed therapy, may be useful in reducing length of stay, hospital costs and risks of infective complications in this subgroup of patients with higher CCS.     

Clinical outcome and predictors of mortality in children with sepsis,severe sepsis,and septic shock from Rohtak,Haryana: A prospective observational study

Background:

Information regarding early predictive factors for mortality and morbidity in sepsis is limited from developing countries.

Methods:

A prospective observational study was conducted to determine the clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock. Children aged 1 month to 14 years admitted to a tertiary care pediatric intensive care unit (PICU) with a diagnosis of sepsis, severe sepsis, or septic shock were enrolled in the study. Hemodynamic and laboratory parameters which discriminate survivors from nonsurvivors were evaluated.

Results:

A total of 50 patients (30 [60%] males) were enrolled in the study, of whom 21 (42%) were discharged (survivors) and rest 29 (58%) expired (nonsurvivor). Median (interquartile range) age of enrolled patients were 18 (6, 60) months. Mortality was not significantly predicted individually by any factor including age (odds ratio [OR] [95% confidence interval [CI]]: 0.96 [0.91-1.01], P = 0.17), duration of PICU stay (OR [95% CI]: 1.18 [0.99-1.25], P = 0.054), time lag to PICU transfer (OR [95% CI]: 1.02 [0.93-1.12], P = 0.63), Pediatric Risk of Mortality (PRISM) score at admission (OR [95% CI]: 0.71 [0.47-1.04], P = 0.07) and number of organ dysfunction (OR [95% CI]: 0.03 [0.01-1.53], P = 0.08).

Conclusion:

Mortality among children with sepsis, severe sepsis, and septic shock were not predicted by any individual factors including the time lag to PICU transfer, duration of PICU stay, presence of multiorgan dysfunction, and PRISM score at admission.     

Attitudes and Beliefs About Chronic Pain Among Nurses–Biomedical or Behavioral? A Cross-sectional Survey

Context:

Studies have documented that nurses and other health care professionals are inadequately prepared to care for patients in chronic pain. Several reasons have been identified including inadequacies in nursing education, absence of curriculum content related to pain management, and attitudes and beliefs related to chronic pain.

Aims:

The objective of this paper was to assess the chronic pain-related attitudes and beliefs among nursing professionals in order to evaluate the biomedical and behavioral dimensions of their perceptions on pain.

Settings and Design:

Cross-sectional survey of 363 nurses in a multispecialty hospital.

Materials and Methods:

The study utilized a self-report questionnaire – pain attitudes and beliefs scale (PABS) – which had 31 items (statements about pain) for each of which the person had to indicate the level at which he or she agreed or disagreed with each statement. Factor 1 score indicated a biomedical dimension while factor 2 score indicated a behavioral dimension to pain.

Statistical Analysis Used:

Comparisons across individual and professional variables for both dimensions were done using one-way ANOVA and correlations were done using the Karl–Pearson co-efficient using SPSS version 11.5 for Windows.

Results:

The overall factor 1 score was 52.95 ± 10.23 and factor 2 score was 20.93 ± 4.72 (P = 0.00). The female nurses had a higher behavioral dimension score (21.1 ± 4.81) than their male counterparts (19.55 ± 3.67) which was significant at P < 0.05 level.

Conclusions:

Nurses had a greater orientation toward the biomedical dimension of chronic pain than the behavioral dimension. This difference was more pronounced in female nurses and those nurses who reported very “good” general health had higher behavioral dimension scores than those who had good general health. The study findings have important curricular implications for nurses and practical implications in palliative care.     

Microalbuminuria: A novel biomarker of sepsis

Context:

Diffused endothelial dysfunction in sepsis leads to an increase in systemic capillary permeability, the renal component manifesting as microalbuminuria. The degree of microalbuminuria correlates with the severity of the acute insult, the quantification of which may serve to predict sepsis and mortality in critically ill patients.

Aims:

To evaluate whether the degree of microalbuminuria could differentiate patients with sepsis from those without and predict mortality in critically ill patients.

Settings and Design:

Prospective, non-interventional study in a 20-bed Intensive Care Unit (ICU) of a tertiary care hospital.

Methods and Materials:

After exclusions, between Jan-May 2007, 94 consecutive adult patients were found eligible. Albumin-creatinine ratio (ACR, mg/g) was measured in urine samples collected on ICU admission (ACR1) and at 24 hours (ACR2).

Results:

Patients were classified into two groups: those with sepsis, severe sepsis and septic shock (n = 30) and those without sepsis [patients without systemic inflammatory response syndrome (SIRS) and with SIRS due to noninfectious causes] (n = 64). In the sepsis group, median ACR1 [206.5 (IQR129.7-506.1)] was significantly higher compared to the non sepsis group [76.4 (IQR29-167.1)] (P = 0.0016, Mann Whitney). The receiver operating characteristics (ROC) curve analysis showed that at a cut off value 124 mg/g, ACR1 may be able to discriminate between patients with and without sepsis with a sensitivity of 80%, specificity of 64.1%, positive predictive value (PPV) of 51.1% and negative predictive value (NPV) of 87.3%. The median ACR2 [154 (IQR114.4-395.3)] was significantly higher (P = 0.004) in nonsurvivors (n = 13) as compared to survivors [50.8 (IQR 21.6-144.7)]. The ROC curve analysis revealed that ACR2 at a cut-off of 99.6 mg/g could predict ICU mortality with sensitivity of 85%, specificity of 68% with a NPV of 97% and PPV of 30%.

Conclusion:

Absence of significant microalbuminuria on ICU admission is unlikely to be associated with sepsis. At 24 hours, absence of elevated levels of microalbuminuria is strongly predictive of ICU survival, equivalent to the time-tested APACHE II scores.     

Pediatric Sepsis Guidelines: Summary for resource-limited countries

Justification:

Pediatric sepsis is a commonly encountered global issue. Existing guidelines for sepsis seem to be applicable to the developed countries, and only few articles are published regarding application of these guidelines in the developing countries, especially in resource-limited countries such as India and Africa.

Process:

An expert representative panel drawn from all over India, under aegis of Intensive Care Chapter of Indian Academy of Pediatrics (IAP) met to discuss and draw guidelines for clinical practice and feasibility of delivery of care in the early hours in pediatric patient with sepsis, keeping in view unique patient population and limited availability of equipment and resources. Discussion included issues such as sepsis definitions, rapid cardiopulmonary assessment, feasibility of early aggressive fluid therapy, inotropic support, corticosteriod therapy, early endotracheal intubation and use of positive end expiratory pressure/mechanical ventilation, initial empirical antibiotic therapy, glycemic control, and role of immunoglobulin, blood, and blood products.

Objective:

To achieve a reasonable evidence-based consensus on the basis of published literature and expert opinion to formulating clinical practice guidelines applicable to resource-limited countries such as India.

Recommendations:

Pediatric sepsis guidelines are presented in text and flow chart format keeping resource limitations in mind for countries such as India and Africa. Levels of evidence are indicated wherever applicable. It is anticipated that once the guidelines are used and outcomes data evaluated, further modifications will be necessary. It is planned to periodically review and revise these guidelines every 3–5 years as new body of evidence accumulates.     

Safety and efficacy of polymyxin B in multidrug resistant Gram-negative severe sepsis and septic shock

Background and Aims:

The emergence of multidrug resistant strains of Gram-negative bacteria, especially the lactose nonfermenters like Pseudomonas and Acinetobacter, in the intensive care units have prompted renewed worldwide interest in the polymyxins. However, perceived nephrotoxicity has been a major vexation limiting their early and regular use in severe sepsis. This study was conducted to assess the safety and efficacy of polymyxin B in patients with severe sepsis and septic shock.

Materials and Methods:

Forty-five patients with sepsis admitted in our medical-surgical intensive care units were identified from pharmacy records to have received polymyxin B. We retrospectively reviewed the clinical and microbiologic outcomes as well as occurrence of renal failure temporally related to the use of intravenous polymyxin B.

Results:

polymyxin B was used in severe sepsis and septic shock with the isolated organism being resistant to other available antimicrobials or clinical deterioration despite carbapenem use. Overall mortality was 52% and among patients who received at least eight days of intravenous polymyxin B, 67% patients with initial septic shock and 62% with severe sepsis survived. The target multidrug resistant organism was cleared in 88% of subjects evaluated by repeat microbiologic testing. Acute renal failure developed in only two patients (4%).

Conclusions:

Polymyxin B has acceptable effectiveness against nosocomial multidrug resistant Gram-negative sepsis. The associated nephrotoxicity has been found to be significantly lower than previously reported even in patients with background renal impairment and established risk factors of renal failure.     

Alcohol-based hand rub and ventilator-associated pneumonia after elective neurosurgery: An interventional study

Background:

Interventional studies on the effect of alcohol-based hand rub on ventilator-associated pneumonia (VAP) among neurosurgical patients are scarce.

Aim:

To observe the effect of alcohol-based hand rub on tracheobronchial colonization and VAP after elective neurosurgical procedures.

Materials and Methods:

An interventional study using a “before–after” design in a tertiary care center in Kerala. Two 9-month study periods were compared; between these periods, an infection control protocol incorporating an alcohol-based hand rub was implemented for a period of 3 months and continued thereafter. Consecutive patients who required mechanical ventilation after neurosurgery between January and September 2006 and 2007, respectively, were included. Outcome measures included VAP rate, tracheobronchial colonization rate, profile of microorganisms and patient survival.

Results:

A total of 352 patients were on mechanical ventilator for a varying period of 1–125 days. The patients in the control and intervention groups were similar with regard to sex, age and type of neurosurgery. Tracheobronchial colonization was seen in 86 (48.6%) of 177 in the control group and 73 (41.7%) of 175 among the intervention group (P = 0.195). The VAP rates in the control and intervention groups were 14.03 and 6.48 per 1000 ventilator days (P = 0.08). The predominant organisms causing VAP and tracheobronchial colonization were Klebsiella and Pseudomonas aeruginosa, respectively, in both groups. Patient survival rates were 87.6% (control) and 92% (intervention).

Conclusion:

Clinical results indicated a better outcome, showing a reduction in tracheobronchial colonization rate and VAP rate, although this was not statistically significant.     

The impact of packed red blood cell transfusion on clinical outcomes in patients with septic shock treated with early goal directed therapy

Background:

The optimal hemoglobin level and transfusion threshold in patients with septic shock treated with an early, goal oriented approach to resuscitation remains unknown.

Aims:

To assess the impact of packed red blood cell (PRBC) transfusion on clinically relevant outcomes in patients with septic shock treated with early goal directed therapy (EGDT).

Settings and Design:

Retrospective cohort study of 93 patients who presented with septic shock, to a single center academic intensive care unit and received EGDT.

Materials and Methods:

Data were collected on patients identified via the Surviving Sepsis Campaign Chart Review database and linked to Project IMPACT database. The PRBC group and no PRBC group were compared by the Pearson chi-square and Fisher’s exact test to analyze statistical significance.

Results:

The PRBC group had a mortality of 41.2% vs. 33.9% in the no PRBC transfusion group (P = NS). The PRBC group also had more mechanical ventilation days (11.2 days vs. 5.0 days, (P ≤ 0.05), longer hospital length of stay (25.9 days vs. 12.5 days, (P ≤ 0.05), and longer intensive care unit length of stay (11.4 days vs. 3.8 days, (P ≤ 0.05).

Conclusions:

In this retrospective cohort study, transfusion of PRBCs was associated with worsened clinical outcomes in patients with septic shock treated with EGDT. Further studies are needed to determine the impact of transfusion of PRBC within the context of early resuscitation of patients with septic shock, as the beneficial effects gained by an early and goal oriented approach to resuscitation may be lost by the negative effects associated with PRBC transfusion.     

The Effect of Community-Managed Palliative Care Program on Quality of Life in the Elderly in Rural Tamil Nadu,India

Background:

HelpAge India has been facilitating community-managed palliative care program in the villages of Tamil Nadu, India.

Objective:

To evaluate the effect of perceived quality of life in the elderly in the project villages in rural Tamil Nadu.

Materials and Methods:

It was a community-based evaluation study. Considering the mean difference of 0.6, design effect-2, precision-5%, power 80%, and 10% non-response, a sample size of 450 elderly persons (more than 60 years) was adequate. Sample was selected by two-stage cluster sampling. Tamil version of “WHO-Quality of Life-brief questionnaire” was used. Trained interviewers made house-to-house visits and obtained information by personally interviewing the subjects.

Results:

The mean score for perceived physical quality of life in the project area was (10.47 ± 1.80 SD) high than the mean score (10.17 ± 1.82 SD) in the control area (P = 0.013) and the mean score for psychological support (10.13 ± 2.25 SD) in project area was high than the mean score (9.8 ± 2.29 SD) in control area (P = 0.043). There was no effect on domain of social relationship and environment.

Conclusions:

In the project villages, the perceived physical quality of life and psychological support among elderly persons was significantly better than the control villages.