Innovative solutions: Standardized concentrations facilitate the use of continuous infusions for pediatric intensive care unit nurses at a community hospital.

The pediatric intensive care unit at a community hospital successfully implemented the use of standardized concentrations. The process included deciding the standardized concentrations, use of titration charts, and integration of smart pump technology. Since the implementation of standardized concentrations, there has been no signal or sentinel events reported. It is safe and efficacious to use standardized concentrations combined with smart pump technology and abandon the use of the rule of 6 in the pediatric population.     

Hospital outbreak caused by a carbapenem-resistant strain of Acinetobacter baumannii: patient prognosis and risk-factors for colonisation and infection

Between October 2001 and August 2002, 30 hospital patients became infected or colonised by a multiresistant (including to carbapenems) epidemic strain of Acinetobacter baumannii (AbMR) in a hospital outbreak. This study analysed the risk-factors associated with acquisition of this epidemic strain and investigated the prognosis of patients infected by AbMR, with the aim of elucidating factors which lead to mortality. A case-control study of the acquisition of AbMR in patients infected or colonised in the hospital outbreak was performed. Independent risk-factors leading to death were studied by logistic regression analysis. Multivariate analysis of the risk-factors for colonisation/infection with AbMR revealed an independent association with the presence of an arterial catheter (OR, 1.13; 95% CI, 1.03-1.25) and administration of imipenem as monotherapy (OR, 11.12; 95% CI, 2.33-53.09). Multivariate analysis of the prognostic features leading to mortality revealed a significant association with hypotension or shock (OR, 24.63; 95% CI, 1.56-387.56) at the time of bacterial isolation.     

Diffuse Axonal Injury (DAI) is not Associated with Elevated Intracranial Pressure (ICP)

Summary Objective. Traditionally, intracranial pressure (ICP) monitoring has been utilized in all patients with severe head injury (Glasgow coma score of 3–8). Ventriculostomy placement, however, does carry a 4 to 10 percent complication rate consisting mostly of hematoma and infection. The authors propose that a subgroup of patients presenting with severe head trauma and diffuse axonal injury without associated mass lesion, do not need ICP monitoring. Additionally, the monitoring data from ICP, MAP, and CPP for a comparison severe head injury group, and subgroups of DAI would be presented. Materials and methods. Thirty-six patients sustaining blunt head trauma and fitting our strict clinical and radiographic diagnosis of DAI were enrolled in our study. Inclusion criteria were severe head injury patients who did not regain consciousness after the initial impact, and whose CT scan demonstrated characteristic punctate hemorrhages of <10 mm diameter at the greywhite junction, basal ganglia, corpus callosum, upper brainstem, or a combination of the above. Patients with significant mass lesions and documented anoxia were excluded. Their intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were compared to a control group of 36 consecutive patients with severe non-penetrating non-operative head injury, using the Analysis for Variance method. Results. Eighteen (50.0%), six (16.7%), and twelve (33.3%) patients had types I, II, and III DAI, respectively. The admission Glasgow Coma Score (GCS) was higher for types I and II than for type III DAI. ICP was monitored from 23 to 165 hours, with a mean ICP for 36 patients of 11.70 mmHg (SEM=75) and a range from 4.3 to 17.3 mmHg. Of all ICP recordings, of which 89.7% (2421/2698) were ≤20 mmHg. Average mean arterial pressure (MAP) was 96.08 mmHg (SEM=1.69), and 94.6% (2038/2154) of all MAP readings were greater than 80 mmHg. Average cerebral perfusion pressure (CPP) was 85.16 mmHg (SEM=1.68), and 90.1% (1941/2154) of all CPP readings were greater than 70 mmHg. This is compared to the control group mean ICP, MAP, and CPP of 16.84 mmHg (p=0.000021), 92.80 mmHg (p=0.18), and 76.49 mmHg (p=0.0012). No treatment for sustained elevated ICP>20 mmHg was needed for DAI patients except in two; one with extensive intraventricular and subarachnoid hemorrhage who developed communicating hydrocephalus, and another with ventriculitis requiring intrathecal and intravenous antibiotic treatments. Two complications, one from a catheter tract hematoma, and another with Staph epidermidis ventriculitis, were encountered. All patients, except type III DAI, generally demonstrated marked clinical improvement with time. The outcome, as measured by Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS) was similarly better with types I and II than type III DAI. Conclusion. The authors conclude that ICP elevation in DAI patients without associated mass lesions is not as prevalent as other severe head injured patients, therefore ICP monitoring may not be as critical. The presence of an ICP monitoring device may contribute to increased morbidity. Of key importance, however, is an accurate clinical history and interpretation of the CT scan.     

Usefulness of different myocardial sampling zones for the postmortem diagnosis of myocardial infarction

Summary The diagnosis of myocardial infarction requires the use of a group of tests that are very efficient, quick and inexpensive. Another important consideration is the choice of myocardial sampling zones, especially in cases of differential diagnosis between a cardiac injury secondary to a trauma or violent asphyxia and others, secondary to myocardial infarction. The aim of this work was to choose, through discriminant analysis, the most useful zones of cardiac tissue for the quantification of free fatty acids and free carnitine and for the performance of the K/Na quotient, as biochemical parameters for the postmortem diagnosis of myocardial infarction. According to the discriminant analysis performed, seven zones of cardiac tissue are necessary to achieve a differential diagnosis among myocardial infarction, other natural deaths, and violent deaths with a 71.9% efficacy. Greater diagnostic efficacy was found (78.1%) for differentiating between natural deaths and violent deaths. Offprint requests to: E. Lachica     

Effect of acute insulin administration on biliary lipid secretion by the diabetic rat.

The insulin-deficient state induces profound changes in bile formation. The present work was to test the effect of acute insulin administration on lipid secretion into bile in diabetic rats. Diabetes was induced by streptozotocin injection (6 mg/100 g body-weight, i.p., 6 days before the experiments). Bile formation was stimulated by taurocholate infusion (0.5 mumol/min/100 g body-weight). Intravenous administration of insulin (bolus: 100 mU/100 g body-weight, plus infusion: 5 mU/min/100 g body-weight) induced choleresis accompanied by a slight and transient enhancement in bile acid output which was similar to that found in lecithin and cholesterol output in the control group. However, insulin induced a rapid and significant (P less than 0.05) reduction in biliary lipid output in the diabetic rats. These results suggest that insulin may play an important role in mechanisms other than synthesis involved in the supply of biliary lipids towards the canaliculi.