Do antibiotics administered at the time of central venous catheter removal interfere with the evaluation of colonization?

Objective Catheter colonization is commonly used as an end point in studies on central venous catheter (CVC) infections. This study aimed at comparing the rates of catheter colonization in patients according to the administration of antibiotics at removal. Design Prospective study over a 5-year period. All patients with a CVC removed without suspicion of CVC infection were included. Setting An adult medical/surgical intensive care unit at a university teaching hospital. Patients A total of 472 patients with CVC inserted for a mean CVC duration of 6.0 ± 3.7 days were included. Methods Antibiotics at removal was defined as antibiotics administered within 48 h before CVC removal, and CVC colonization as catheter tip culture yielding ≥ 10³ colony-forming units per milliliter. Interventions None. Measurements and results Of 472 patients, 302 (64%) were receiving antibiotics at removal. The number of CVC colonizations per number of CVCs inserted was 4.7% (22 of 472) and the number of CVC colonizations per 1000 CVC days was 8.0. Administration of antibiotics at removal was associated with a lower risk of CVC colonization. Irrespective of CVC duration, CVC colonization rate differed between patients with or without antibiotics at removal (Kaplan–Meier test, p = 0.04). Conclusions The proportion of patients with antibiotics at time of removal should be taken into account when interpreting the results of surveys and trials using the quantitative CVC tip culture to define CVC colonization as an end point.     

Incidence, risk factors, and outcome of aspiration pneumonitis in ICU overdose patients

Objective To assess the incidence and outcome of clinically significant aspiration pneumonitis in intensive care unit (ICU) overdose patients and to identify its predisposing factors.Design Retrospective cohort study.Setting Medical ICU of an academic tertiary care hospital.Patients A total of 273 consecutive overdose admissions.Measurements and results Clinically significant aspiration pneumonitis was defined as the occurrence of respiratory dysfunction in a patient with a localised infiltrate on chest X-ray within 72 h of admission. In our cohort we identified 47 patients (17%) with aspiration pneumonitis. Importantly, aspiration pneumonitis was associated with a higher incidence of cardiac arrest (6.4 vs 0.9%; p = 0.037) and an increased duration of both ICU stay and overall hospital stay [respectively: median 1 (interquartile range 1–3) vs 1 (1–2), p = 0.025; and median 2 (1–7) vs 1 (1–3), p < 0.001]. In multivariate logistic regression analysis, Glasgow Coma Scale (GCS) score [odds ratio (OR) for each point of GCS 0.8; 95% confidence interval (CI) 0.7–0.9; p = 0.001], ingestion of opiates (OR 4.5; 95% CI 1.7–11.6; p = 0.002), and white blood cell count (WBC) (OR for each increase in WBC of 10⁹/l 1.05; 95% CI 1.0–1.19; p = 0.049) were identified as independent risk factors.Conclusions Clinically relevant aspiration pneumonitis is a frequent complication in overdose patients admitted to the ICU. Moreover, aspiration pneumonitis is associated with a higher incidence of cardiac arrest and increased ICU and total in-hospital stay.     

Antibiotic management of suspected nosocomial ICU-acquired infection: Does prolonged empiric therapy improve outcome?

Objective To characterize empiric antibiotic use in patients with suspected nosocomial ICU-acquired infections (NI), and determine the impact of prolonged therapy in the absence of infection. Design and setting Multicenter prospective cohort, with eight medical-surgical ICUs in North America and Europe. Patients 195 patients with suspected NI. Methods The diagnosis of NI was adjudicated by a blinded Clinical Evaluation Committee using retrospective review of clinical, radiological, and culture data. Results Empiric antibiotics were prescribed for 143 of 195 (73.3%) patients with suspected NI; only 39 of 195 (20.0%) were adjudicated as being infected. Infection rates were similar in patients who did (26 of 143, 18.2%), or did not (13 of 52, 25.0%) receive empiric therapy ( p = 0.3). Empiric antibiotics were continued for more than 4 days in 56 of 95 (59.0%) patients without adjudicated NI. Factors associated with continued empiric therapy were increased age ( p = 0.02), ongoing SIRS ( p = 0.03), and hospital ( p = 0.004). Patients without NI who received empiric antibiotics for longer than 4 days had increased 28-day mortality (18 of 56, 32.1%), compared with those whose antibiotics were discontinued (3 of 39, 7.7%; OR = 5.7, 95% CI 1.5–20.9, p = 0.005). When the influence of age, admission diagnosis, vasopressor use, and multiple organ dysfunction was controlled by multivariable analysis, prolonged empiric therapy was not independently associated with mortality (OR = 3.8, 95% CI 0.9–15.5, p = 0.07). Conclusions Empiric antibiotics were initiated four times more often than NI was confirmed, and frequently continued in the absence of infection. We found no evidence that prolonged use of empiric antibiotics improved outcome for ICU patients, but rather a suggestion that the practice may be harmful. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Junctional ectopic tachycardia after surgery for congenital heart disease in children

Objective To determine incidence, predictors and outcome [intensive care unit (ICU) mortality and length of stay (LOS)] after postoperative junctional ectopic tachycardia (JET) in an unselected paediatric population. Design Patients with JET (n = 89) were compared with non-JET controls (n = 178) in a nested case–control study. Setting Tertiary ICU at Skejby Sygehus, Aarhus University Hospital, Denmark. Patients The patient records of all children (n = 874) who underwent corrective cardiac surgery on cardio-pulmonary bypass (CPB) between 1998 and 2005 were reviewed for postoperative JET. Methods and results The association between JET and its potential predictors was examined with multivariate conditional regression analyses. The overall incidence of JET was 10.2%. CPB duration > 90 min [adjusted odds ratio (OR) 2.6; 95% confidence interval (CI) 1.1–6.5], high inotropic requirements (adjusted OR 2.6; CI 1.2–5.9) and high postoperative levels of creatine kinase (CK)-MB (adjusted OR 3.1; CI 1.3–7.1) were associated with an increased risk of JET. ICU mortality was higher for patients with JET (13.5%; CI 7.2–22.4%) than for controls (1.7%; CI 0.3–4.8%), and LOS in ICU was 3 times higher in JET patients (median 2 vs. 7 days, p < 0.001). Conclusions JET occurred in approximately 10% of children following cardiac surgery and was associated with higher mortality and longer ICU stay. Risk factors included high inotropic requirements after surgery and extensive myocardial injury in terms of high CK-MB values and longer CPB duration.     

Significant cognitive dysfunction in non-delirious patients identified during and persisting following critical illness

Objective Recent studies have shown significant cognitive problems some months after critical illness. However there has been no research examining cognitive function within the intensive care unit (ICU) in non-delirious patients.Design and setting A prospective study in an ICU.Patients and participants Using the Cambridge Neuropsychological Test Automated Battery (CANTAB), 30 long-stay, tracheal-intubated ICU patients were tested. Prior to testing on ICU the Confusion Assessment Measure (CAM-ICU) was administered and only those patients clearly not delirious and off sedation for several days were tested. The CANTAB tests were repeated a week after ICU discharge on the general ward and then again at 2 months. Sixteen patients completed the follow-up.Results While on ICU all 30 patients showed significant problems with strategic thinking and problem solving; 20 patients had some problems with memory. The degree of difficulty with problem solving on ICU was correlated with length of ICU stay (p = 0.011), age (p = 0.036) and length of hospital stay post ICU (p = 0.044). Problems with memory in ICU and on the general ward were correlated with admission APACHE II score (p = 0.004 and p = 0.005 respectively). At the 2-month follow-up 5 of 16 patients (31%) scored below the 25 percentile for memory and 8 of 16 (50%) below the 25 percentile for problem solving (Slater TA, Jones C, Griffiths RD, Wilson S, Benjamin K (2004) Cognitive impairment during and after intensive care: a pilot study. Intensive Care Med 30 [Suppl 1]:S199).Conclusions Difficulties with problem solving and poor memory remained a significant issue for 2 months after ICU discharge.     

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.     

Internal jugular venous catheter-related bacteremia according to central and posterior accesses

Background Although there are many studies about central venous catheter-related infection, we have not found any analysis of the incidence of internal jugular venous catheter-related bacteremia associated with different accesses. Objective The objective of this study was to test whether the position of the internal jugular venous catheter, central or posterior, influences the incidence of bacteremia. Design A cohort study. Setting A 12-bed polyvalent medical–surgical intensive care unit (ICU). Patients Patients admitted to ICU between 1 May 2000 and 30 April 2004 who received one or more internal jugular venous catheters. Measurements and results A total of 1,483 patients were admitted to the polyvalent ICU, of whom 1,311 underwent central venous catheterization. A total of 547 patients received 684 internal jugular venous catheters, 169 by posterior and 515 by central access. There were no significant differences between central and posterior access patients in sex, age, APACHE II (14.1 ± 5.0 vs. 13.9 ± 5.2, p = 0.40), diagnosis, order of catheter insertion, use of mechanical ventilation, use of antimicrobials, use of total parenteral nutrition or use of pulmonary artery catheter. We found a higher incidence of internal jugular venous catheter-related bacteremia with central (4.8 per 1000 catheter-day) than with posterior (1.2 per 1000 catheter-day) access (odds ratio 3.9; 95% confidence interval 1.1–infinite; p = 0.03). Conclusion Posterior access has a lower incidence of internal jugular venous catheter-related bacteremia than central access in non-severely ill patients (according to the low APACHE II score values of the study patients). Competing interests: none declared     

Impact of piperacillin resistance on the outcome of Pseudomonas ventilator-associated pneumonia

Background The impact of antibiotic resistance on the outcome of infections due to Gram-negative bacilli, especially Pseudomonas, remains highly controversial.Study objective, design, and patients We evaluated the impact of piperacillin resistance on the outcomes of Pseudomonas aeruginosa ventilator-associated pneumonia (VAP) for patients who had received appropriate empiric antibiotics before enrollment in the PNEUMA trial, a multicenter randomized study comparing 8 vs 15 days of antibiotics.Results Despite similar characteristics at intensive care unit (ICU) admission, patients infected with piperacillin-resistant Pseudomonas strains were more acutely ill at VAP onset and had a higher 28-day mortality rate (37 vs 19%; P = 0.04) than those with piperacillin-susceptible Pseudomonas VAP. Factors associated with 28-day mortality retained by multivariable analysis were: age (OR: 1.07; 95% CI: 1.03–1.12); female gender (OR: 4.00; 95% CI: 1.41–11.11); severe underlying comorbidities (OR: 2.73; 95% CI: 1.02–7.33); and SOFA score (OR: 1.17; 95% CI: 1.03–1.32), but piperacillin resistance did not reach statistical significance (OR: 2.00; 95% CI: 0.72–5.61). The VAP recurrence rates, either superinfection or relapse, and durations of mechanical ventilation and ICU stay did not differ as a function of Pseudomonas-resistance status.Conclusions For patients with Pseudomonas VAP benefiting from appropriate empiric antibiotics, piperacillin resistance was associated with increased disease severity at VAP onset and higher 28-day crude mortality; however, after controlling for confounders, piperacillin-resistance was no longer significantly associated with 28-day mortality. The VAP recurrence rates and durations of ICU stay and mechanical ventilation did not differ for susceptible and resistant strains.     

The effect of an algorithm-based sedation guideline on the duration of mechanical ventilation in an Australian intensive care unit

Objective To examine the effect of an algorithm-based sedation guideline developed in a North American intensive care unit (ICU) on the duration of mechanical ventilation of patients in an Australian ICU.Design and setting The intervention was tested in a pre-intervention, post-intervention comparative investigation in a 14-bed adult intensive care unit.Patients Adult mechanically ventilated patients were selected consecutively (n = 322). The pre-intervention and post-intervention groups were similar except for a higher number of patients with a neurological diagnosis in the pre-intervention group.Intervention An algorithm-based sedation guideline including a sedation scale was introduced using a multifaceted implementation strategy.Measurements and results The median duration of ventilation was 5.6 days in the post-intervention group, compared with 4.8 days for the pre-intervention group (P = 0.99). The length of stay was 8.2 days in the post-intervention group versus 7.1 days in the pre-intervention group (P = 0.04). There were no statistically significant differences for the other secondary outcomes, including the score on the Experience of Treatment in ICU 7 item questionnaire, number of tracheostomies and number of self-extubations. Records of compliance to recording the sedation score during both phases revealed that patients were slightly more deeply sedated when the guideline was used.Conclusions The use of the algorithm-based sedation guideline did not reduce duration of mechanical ventilation in the setting of this study.     

Acute disseminated encephalomyelitisin the intensive care unit:clinical features and outcome of 20 adults

Objective Because acute disseminated encephalomyelitis (ADEM) is a rare disease in adults admitted to the intensive care unit (ICU), we describe its characteristics and patient outcomes. Design and setting A retrospective (2000–2006), observational, multicenter study was conducted in seven medical ICUs. Clinical, biological and neuroimaging features of patients diagnosed with ADEM were evaluated. Functional prognosis was graded using the modified Rankin (mR) scale. Interventions None. Measurements and results At ICU admission, the 20 patients' median (25th–75th percentile) Glasgow coma score (GCS) was 7 (4–13), temperature 39 (38–39) °C. Six (30%) patients had seizures, 17 (85%) had a motor deficit and 14 (70%) required mechanical ventilation. Fifteen (75%) patients had cerebrospinal fluid pleocytocis. All patients had white-matter lesions on their magnetic resonance images. All patients received high-dose steroids. Five (25%) patients died. Fourteen (70%) patients were able to walk without assistance (mR ≤ 3) at follow-up [7 (3–9) months]. Compared to the latter, patients who died or were severely disabled at the follow-up evaluation [6 (30%) patients, mR > 3] had significantly lower GCS (4 (3–4) vs. 12 (7–13), p = 0.002) and more frequent seizures [4 (67%) vs. 2 (14%), p = 0.02] at admission. Conclusions Unlike previous reports, our results showed that ADEM requiring ICU admission is a severe disease causing high mortality, and 35% of the patients had persistent functional sequelae. Intensivists should be aware of ADEM's clinical features to initiate appropriate immunomodulating therapy. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

A Bayesian decision-support system for diagnosing ventilator-associated pneumonia

Objective To determine the diagnostic performance of a Bayesian Decision-Support System (BDSS) for ventilator-associated pneumonia (VAP). Design A previously developed BDSS, automatically obtaining patient data from patient information systems, provides likelihood predictions of VAP. In a prospectively studied cohort of 872 ICU patients, VAP was diagnosed by two infectious-disease specialists using a decision tree (reference diagnosis). After internal validation daily BDSS predictions were compared with the reference diagnosis. For data analysis two approaches were pursued: using BDSS predictions (a) for all 9422 patient days, and (b) only for the 238 days with presumed respiratory tract infections (RTI) according to the responsible physicians. Measurements and results 157 (66%) of 238 days with presumed RTI fulfilled criteria for VAP. In approach (a), median daily BDSS likelihood predictions for days with and without VAP were 77% [Interquartile range (IQR) = 56–91%] and 14% [IQR 5–42%, p < 0.001, Mann–Whitney U-test (MWU)], respectively. In receiver operating characteristics (ROC) analysis, optimal BDSS cut-off point for VAP was 46%, and with this cut-off point positive predictive value (PPV) and negative predictive value (NPV) were 6.1 and 99.6%, respectively [AUC = 0.857 (95% CI 0.827–0.888)]. In approach (b), optimal cut-off for VAP was 78%, and with this cut-off point PPV and NPV were 86 and 66%, respectively [AUC = 0.846 (95% CI 0.794–0.899)]. Conclusions As compared with the reference diagnosis, the BDSS had good test characteristics for diagnosing VAP, and might become a useful tool for assisting ICU physicians, both for routinely daily assessment and in patients clinically suspected of having VAP. Empirical validation of its performance is now warranted. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Vascular erosion by central venous catheters used for total parenteral nutrition

Objective To establish the incidence of central venous catheter erosion in a patient cohort receiving total parenteral nutrition and to examine risk factors and complications of vascular erosion. Design and setting Review of prospectively collected intravenous nutrition service audit records in a tertiary university hospital. Results Records of 1,499 patients (2,992 catheters) were studied over the 14 year period 1991–2005. Fisher's exact test was used to determine statistical significance. Five erosions occurred, representing an incidence of 0.17% per catheter or 0.28 per 1,000 catheter days. One of the five patients died from ensuing complications. Mean time to onset of symptoms was 3.6 days following catheter insertion. Symptoms/signs included dyspnoea (n = 5), chest pain (n = 2) and pleural effusion (n = 5). Diagnosis was delayed by a mean of 1.6 days. Three erosions occurred in left subclavian catheters (n = 583); two in left internal jugular catheters (n = 453). None occurred in right-sided catheters (n = 1956). The relative risk of erosion occurring in left-sided catheters compared to right was 2.9 (95% CI 2.76–3.00; p = 0.009). There was no statistically significantly greater risk of vascular erosion in subclavian than internal jugular catheters (relative risk 0.9; p = 1.0). Older age was a statistically significant risk factor (p = 0.009); female sex was not (p = 0.18). Conclusion In patients receiving total parenteral nutrition via central venous catheters, erosion has an incidence per catheter of 0.17% and is more likely to occur in left-sided catheters and elderly patients.     

Single rooms may help to prevent nosocomial bloodstream infection and cross-transmission of methicillin-resistant <Emphasis Type="Italic">Staphylococcus aureus</Emphasis> in intensive care units

Objective Nosocomial infections remain a major problem in intensive care units. Several authorities have recommended housing patients in single rooms to prevent cross-transmission of potential pathogens, but this issue is currently debated. The aim of the present study was to compare the rate of nosocomial cross-contamination between patients hosted in single rooms versus bay rooms. Design Prospective observational data acquisition over 2.5 years. Setting A 14-bed medico-surgical ICU, composed of six single-bed rooms plus a six-bed and a two-bed bay room served by the same staff. Patients and participants All patients admitted from 1 July 2002 to 31 December 2004. Interventions None. Measurements and results Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in admitted patients was 1.1% and acquisition rate 2.4%. The incidence density of MRSA acquisition was 4.1 [95% CI 2.7–6.3]/1,000 patient-days in bay rooms versus 1.3 [0.5–3.4]/1,000 patient-days in single rooms (p < 0.001). Pseudomonas spp. acquisition rate was 3.9 [2.5–6.1]/1,000 patient-days in bay rooms versus 0.7 [0.2–2.4]/1,000 patient-days in single rooms (p < 0.001), and Candida spp. colonization was 38.4 [33.3–44.1]/1,000 patient-days in bay rooms versus 13.8 [10.2–18.6]/1,000 patient-days (p < 0.001). By multivariate analysis, the relative risk of MRSA, Pseudomonas aeruginosa and Candida spp. acquisition in single rooms or cubicles versus bay rooms was 0.65, 0.61 and 0.75 respectively. Conclusions These data suggest that in an institution where MRSA is not hyperendemic, infection control measures may be more effective to prevent cross-transmission of microorganisms in patients housed in single rooms. Conflict of interest: None     

Outcome in bacteremia associated with nosocomial pneumonia and the impact of pathogen prediction by tracheal surveillance cultures

Objective To assess whether pathogen prediction in bacteremia associated with nosocomial pneumonia (NP) by tracheal surveillance cultures improves adequacy of early antibiotic therapy and impacts mortality.Design and setting A retrospective observational study of a prospectively gathered cohort. This cohort included all adult patients admitted to the ICU of a tertiary care hospital from 1992 through 2001 and who developed bacteremia associated with NP. Measurements and main results 128 episodes of bacteremia associated with NP were identified. In 110 episodes a tracheal surveillance culture 48–96 h prior to bacteremia was available: this culture predicted the pathogen in 67 episodes (61%). Overall rates of appropriate empiric antibiotic therapy within 24 and 48 h were 62 and 87%, respectively. Pathogen prediction was associated with a significantly higher rate of appropriate antibiotic therapy within 24 h (71 vs 45%; p = 0.01), but not within 48 h (91 vs 82%; p = 0.15). Crude in-hospital mortality was 50%. Pathogen prediction was associated with increased survival in univariate (OR 0.43; CI 0.19–0.93; p = 0.04) and multivariate analysis (OR 0.32; CI 0.12–0.82; p = 0.02). Multivariate analysis further identified age (OR 1.04; CI 1.01–1.07; p = 0.02), increasing APACHE II score (OR 1.08; CI 1.02–1.15; p = 0.01), and methicillin-resistant Staphylococcus aureus (OR 5.90; CI 1.36–25.36; p = 0.01) and Pseudomonas aeruginosa (OR 3.30; CI 1.04–10.4; p = 0.04) as independent risk factors for mortality.Conclusion Pathogen prediction in bacteremia associated with NP by tracheal surveillance cultures is associated with a higher rate of adequate empiric antibiotic therapy within 24 h and with increased survival.     

Validation of the SAPS 3 admission prognostic model in patients with cancer in need of intensive care

Objectives To validate the SAPS 3 admission prognostic model in patients with cancer admitted to the intensive care unit (ICU).Design Cohort study.Setting Ten-bed medical–surgical oncologic ICU.Patients and participants Nine hundred and fifty-two consecutive patients admitted over a 3-year period.Interventions None.Measurements and results Data were prospectively collected at admission of ICU. SAPS II and SAPS 3 scores with respective estimated mortality rates were calculated. Discrimination was assessed by area under receiver operating characteristic (AUROC) curves and calibration by Hosmer–Lemeshow goodness-of-fit test. The mean age was 58.3 ± 23.1 years; there were 471 (49%) scheduled surgical, 348 (37%) medical and 133 (14%) emergency surgical patients. ICU and hospital mortality rates were 24.6% and 33.5%, respectively. The mean SAPS 3 and SAPS II scores were 52.3 ± 18.5 points and 35.3 ± 20.7 points, respectively. All prognostic models showed excellent discrimination (AUROC ≥ 0.8). The calibration of SAPS II was poor (p < 0.001). However, the calibration of standard SAPS 3 and its customized equation for Central and South American (CSA) countries were appropriate (p > 0.05). SAPS II and standard SAPS 3 prognostic models tended somewhat to underestimate the observed mortality (SMR > 1). However, when the customized equation was used, the estimated mortality was closer to the observed mortality [SMR = 0.95 (95% CI = 0.84–1.07)]. Similar results were observed when scheduled surgical patients were excluded.Conclusions The SAPS 3 admission prognostic model at ICU admission, in particular its customized equation for CSA, was accurate in our cohort of critically ill patients with cancer.This work was performed at the Intensive Care Unit, Instituto Nacional de Cancer, Rio de Janeiro, Brazil. Financial support: institutional departmental funds. Conflicts of interest: none.     

Memory in relation to depth of sedation in adult mechanically ventilated intensive care patients

Objective To investigate the relationship between memory and intensive care sedation.Design and setting Prospective cohort study over 18 months in two general intensive care units (ICUs) in district university hospitals.Patients 313 intubated mechanically ventilated adults admitted for more than 24 h, 250 of whom completed the study.Measurements Patients (n = 250) were interviewed in the ward 5 days after discharge from the ICU using the ICU Memory Tool. Patient characteristics, doses of sedative and analgesic agents, and sedation scores as measured by the Motor Activity Assessment Scale (MAAS) were collected from hospital records after the interview.Results Patients with no recall (18%) were significantly older, had higher baseline severity of illness, and experienced fewer periods of wakefulness (median proportion of MAAS score 3; 0.37 vs. 0.70) than those who had memories of the ICU (82%). Multivariate analyses showed that increasing proportion of MAAS 0–2 and older age were significantly associated with having no recall. Patients with delusional memories (34%) had significantly longer ICU stay (median 6.6 vs. 2.2 days), higher baseline severity of illness, higher proportions of MAAS scores 4–6, and more administration of midazolam than those with recall of the ICU without delusional memories.Conclusions Heavy sedation increases the risk of having no recall, and longer ICU stay increases the risk of delusional memories. The depth of sedation during total ICU stay as recorded with the MAAS may predict the probability of having memories of the ICU.     

Adult congenital heart disease: intensive care management and outcome prediction

Objective Improved patient survival and increasingly complex surgery have expanded the requirement for specialist care for patients with adult congenital heart disease (ACHD). Despite the recent publications of management guidelines for ACHD, data concerning optimal patterns of care in the peri-operative/critical care period of this challenging population are sparse. The aims of the current study were to therefore to determine the pattern of intensive care unit (ICU) management, resource utilisation and predictors of mortality in critically ill ACHD patients. Design, setting and patients Data were collected prospectively for patients with ACHD stratified for complexity of disease admitted to the ICU of a tertiary cardiothoracic centre (1997–2002). Multivariate analysis of pre-operative indices as predictors of mortality was performed. Of 342 ACHD admissions (total mortality 4.4%, simple 0%, moderate/complex 10.6%), the requirement for specialist investigations and interventions was high, reflected in ICU admission costs per patient (simple $5391 ± 130, moderate $13218 ± 261, complex $30074 ± 689). Standard severity of illness scoring systems did not accurately predict mortality; however, abnormal pre-operative thyroid function (p = 0.0048), creatinine (p = 0.0032) and bilirubin (p = 0.0021) were highly predictive of mortality. Conclusions Peri-operative mortality in patients with ACHD is low overall but varies with disease complexity. Such patients have a high requirement for specialist ICU investigation/intervention. Although standard severity of illness scoring is unhelpful, simple pre-operative parameters may predict peri-operative mortality. These findings reflect the requirement for specialist care, and have implications for planning service provision, training and operative consent in ACHD patients.     

Colonization of the medial lumen is a risk factor for catheter-related bloodstream infection

Objective To analyze the colonization of each lumen and the risk factors for triple-lumen central venous catheter-related bloodstream infection (CRBI). Design and setting Prospective, observational study in the medical–surgical intensive care unit (ICU) of a teaching hospital.Patients A total of 120 patients requiring the insertion of a triple-lumen catheter.Interventions Cultures of the catheter.Measurements and results The catheters were removed when CRBI was suspected or at discharge from ICU. At the removal time, blood cultures, a swab of the insertion site and a culture of the catheter tip were performed. Furthermore, we made quantitative cultures of the proximal, medial and distal lumen. We diagnosed CRBI in six patients (3.35 CRBI/1,000 days at risk), and we observed that in these patients colonization of the medial lumen was more frequent (5/6) than in patients without CRBI (9/114; p = 0.0001). The logistic regression analysis showed that colonization of the medial lumen was an independent risk factor for CRBI (OR 28.1, 95% CI 2.2–364.9).Conclusions Colonization of the medial lumen is an independent risk factor for triple-lumen catheter-related bloodstream infection, possibly due to the absence of use of this lumen.This study was presented, in part, at the 15th Annual Congress of the European Society of Intensive Care Medicine, Barcelona, Spain, September 2002.     

Organophosphate poisonings with parathion and dimethoate

Objective Organophosphate toxicity is the leading cause of morbidity and death in poisoning by insecticides. The clinical symptoms of pesticide toxicity range from the classic cholinergic syndrome to flaccid paralysis and intractable seizures. The mainstays of therapy are atropine, oximes, benzodiazepines and supportive care. The toxicokinetics vary not only with the extent of exposure, but also with the chemical structure of the agent. Patients We report two cases of poisoning with parathion-ethyl and dimethoate. The patients developed a cholinergic syndrome immediately, accompanied by bradycardia and hypotension. Interventions The patients were admitted to the intensive care unit (ICU) a few hours after ingestion. Atropine was administered according to the cholinergic symptoms. The patients recovered in the ICU after 10–12 days and were discharged after 3 and 4 weeks. Measurements and results Organophosphate blood and urine levels were determined on admission and during hospitalisation. The pesticides were rapidly distributed and slow elimination rate of the poisons was documented. In the case of parathion-ethyl the distribution half-life estimated was t_1/2α= 3.1 h while the terminal half-life was t_1/2β = 17.9 h. Using a one-compartment model for dimethoate the elimination half-life was t_1/2β =  30.4 h in plasma and 23.8 h in urine. The serum pseudo-cholinesterase activity was below the limit of detection at admission and recovered during the following 3 weeks. Parts of this article were presented at the XIV. GTFCH Symposium in Mosbach (Germany) 2005     

Outcomes and prognostic factors in patients with head and neck cancer and severe acute illnesses

Objectives To evaluate the outcomes of patients with head and neck cancer and severe acute illnesses, and to identify characteristics associated with hospital mortality. Design Cohort study. Setting Ten-bed medical–surgical oncologic intensive care unit (ICU). Patients Consecutive patients admitted to the ICU over a 68-month period. Interventions None. Measurements and results Demographic, clinical and cancer-related data were collected. Multivariate logistic regression analysis was performed to identify predictive factors of hospital mortality. One hundred and twenty-one patients aged 63.3 ± 14.7 years were enrolled in the study. The main sites of primary tumor were oral cavity (30%), larynx (25%), pharynx (14%) and thyroid (9%). The main reasons for ICU admission were sepsis (37%) and acute respiratory failure (20%). The mean SAPS II score was 49.6 ± 17.8 points, and during ICU stay 100 (83%) patients received mechanical ventilation, 70 (58%), vasopressors, and 12 (10%), dialysis. The ICU, hospital and 6-month mortality rates were 39%, 56% and 72%, respectively. A performance status ≥ 2 [odds ratio (OR) = 5.17 (95% confidence interval, CI = 1.84–14.53)], advanced cancer (TNM stage IV) [OR = 3.80 (95% CI = 1.28–11.28)], and the number of organ failures [OR=2.87 (95% CI=1.83–4.50)] were associated with increased mortality in multivariate analysis. Conclusions In conjunction with clinical judgment and taking into consideration the patient's preferences and values, the knowledge of these outcome predictors may be useful in helping physicians to identify patients who might benefit from the intensive care and to improve discussions on patients' prognosis. This work was performed at the Intensive Care Unit, Instituto Nacional de Cancer, Rio de Janeiro, Brazil. This study is original and was not previously submitted to another primary scientific journal. Preliminary data were presented as a poster at the 2005 American Head & Neck Society Annual Meeting in Boca Raton, FL, USA, and at the 9th Congress of the World Federation of Intensive and Critical Care Medicine in Buenos Aires, Argentina, 27–31 August 2005. Financial support: Institutional departmental funds Conflicts of interest: None