Clinical impact of lung ultrasound monitoring for diagnosis of ventilator associated pneumonia: A diagnostic randomized controlled trial.

PURPOSE: Studies have shown that lung-ultrasound may be superior to chest x-ray (CXR) in diagnosing ventilator-associated pneumonia (VAP). This study investigated whether the use of lung-ultrasound monitoring could detect VAP earlier and improve patient outcome. METHODS: This was a single-center diagnostic randomized controlled trial. In the control group, VAP was diagnosed using a combination of CXR and clinical findings. In the intervention group, VAP was diagnosed using a combination of lung-ultrasound and clinical findings. The primary outcome measured was ventilator free days (VFD). Secondary outcomes were ICU mortality, length of stay in ICU, change in Sequential Organ Failure Score at day 4 compared to day 0 (delta SOFA), antibiotic duration and ventilator days. RESULTS: We randomized intubated patients until 44 VAP diagnosis was made in each group. VFD was higher in the intervention group than in the control group (7.80+/- 9.7 days versus 3.7+/- 6.4 days, p = .044). There were no differences between the groups in terms of ICU mortality (p=.104), ICU length of stay, (p = .058), ventilator days, (p = .081), delta SOFA (p = .10) and antibiotic duration (p = .70). CONCLUSION: The use of lung-ultrasound monitoring for diagnosis of VAP improves patient outcome when compared to the standard diagnostic strategy that relies on CXR.

Effect of Head Elevation to Different Heights in Laryngeal Exposure with Direct Laryngoscopy.

BACKGROUND: The purpose of this study was to determine the optimal pillow height for the best laryngoscopic view in adult patients scheduled for elective surgery under general anaesthesia. METHODS: 150 adult patients undergoing surgery under general anaesthesia with endotracheal intubation with no features suggestive of difficult airway were enrolled for the study. After induction of anaesthesia the assessment of direct laryngoscopic views was done at head positions without a pillow and with non-compressible pillows of heights 5cm and 10cm. RESULTS: The laryngoscopic view with the 5cm pillow was significantly superior to other head position (p<0.01). The incidence of difficult laryngoscopy (Cormack and Lehane grade III) was 32.7% without a pillow which improved to (Cormack and Lehane grade III) 4% with 10cm pillow and there were no cases of difficult laryngoscopy with 5cm pillow. CONCLUSIONS: The use of 5cm pillow in the 'sniffing' position obtains the best laryngoscopic view during direct laryngoscopy.

Olanzapine overdose presenting with acute muscle toxicity.

Olanzapine is an atypical antipsychotic drug that is being increasingly used as an intentional overdose. It usually presents with reduced and fluctuating level of consciousness and coma. It may rarely present with muscle toxicity by binding to HT2A receptor in skeletal muscle and increasing its permeability. We report a case of such poisoning which had no obvious symptoms but was brought to emergency due to overdose and was found to have acute muscle toxicity as evidenced by raised creatine phosphokinase (CPK) levels. From this, we also want to emphasize that CPK levels should be checked in all the patient's prescribed olanzapine to look for muscle toxicity.

Comparison of outcome predictions by the Glasgow coma scale and the Full Outline of UnResponsiveness score in the neurological and neurosurgical patients in the Intensive Care Unit.

Assessment of level of consciousness is very important in predicting patient's outcome from neurological illness. Glasgow coma scale (GCS) is the most commonly used scale, and Full Outline of UnResponsiveness (FOUR) score is also recently validated as an alternative to GCS in the evaluation of the level of consciousness. We carried out a prospective study in 97 patients aged above 16 years. We measured GCS and FOUR score within 24 h of Intensive Care Unit admission. The mean GCS and the FOUR scores were lower among nonsurvivors than among the survivors and were statistically significant (P < 0.001). Discrimination for GCS and FOUR score was fair with the area under the receiver operating characteristic curve of 0.79 and 0.82, respectively. The cutoff point with best Youden index for GCS and FOUR score was 6.5 each. Below the cutoff point, mortality was higher in both models (P < 0.001). The Hosmer-Lemeshow Chi-square coefficient test showed better calibration with FOUR score than GCS. A positive correlation was seen between the models with Spearman's correlation coefficient of 0.91 (P < 0.001).

Colistin and tigecycline for management of external ventricular device-related ventriculitis due to multidrug-resistant Acinetobacter baumannii.

Acinetobacter baumannii is an important cause of nosocomial ventriculitis associated with external ventricular device (EVD). It is frequently multidrug resistant (MDR), carries a poor outcome, and is difficult to treat. We report a case of MDR Acinetobacter ventriculitis treated with intravenous and intraventricular colistin together with intravenous tigecycline. The patient developed nephrotoxicity and poor neurological outcome despite microbiological cure. Careful implementation of bundle of measures to minimize EVD-associated ventriculitis is valuable.

Apnea testing with continuous positive airway pressure for the diagnosis of brain death in a patient with poor baseline oxygenation status.

Apnea testing is a key component in the clinical diagnosis of brain death. Patients with poor baseline oxygenation may not tolerate the standard 8-10 min apnea testing with oxygen insufflation through tracheal tube. No studies have assessed the safety and feasibility of other methods of oxygenation during apnea testing in these types of patients. Here, we safely performed apnea testing in a patient with baseline PaO2 of 99.1 mm Hg at 100% oxygen. We used continuous positive airway pressure (CPAP) of 10 cm of H2O and 100% oxygen at the flow rate of 12 L/min using the circle system of anesthesia machine. After 10 min of apnea testing, PaO2 decreased to 75.7 mm Hg. There was a significant rise in PaCO2 and fall in pH, but without hemodynamic instability, arrhythmias, or desaturation. Thus, the apnea test was declared positive. CPAP can be a valuable, feasible and safe means of oxygenation during apnea testing in patients with poor baseline oxygenation, thus avoiding the need for ancillary tests.