Increased risk of bloodstream and urinary infections in intensive care unit (ICU) patients compared with patients fitting ICU admission criteria treated in regular wards.

Critically ill patients, eligible for admission into intensive care units (ICUs), are often hospitalized in other wards due to a lack of ICU beds. Differences in morbidity between patients managed in ICUs and elsewhere are unknown, specifically the morbidity related to hospital-acquired infection. Patients fitting ICU admission criteria were identified by screening five entire hospitals on four separate days. Hospital infections within a 30-day follow-up period were compared in ICU patients and in patients on other wards using Kaplan-Meier curves. Residual differences in the patients' case mix between ICUs and other wards were adjusted for utilizing multivariate Cox models. Of 13415 patients screened, 668 were critically ill. The overall infection rates (per 100 patient-days) were 1.2 for bloodstream infection (BSI) and 1.9 for urinary tract infection (UTI). The adjusted hazard ratios in ICU patients compared with patients on regular wards were 3.1 (P<0.001) for BSI and 2.5 (P<0.001) for UTI. This increased risk persisted even after adjusting for the disparity in the number of cultures sent from ICUs compared with ordinary wards. No interdepartmental differences were found in the rates of pneumonia, surgical wound infections and other infections. Minimizing the differences between characteristics of patients hospitalized in ICUs and in other wards, and controlling for the higher frequency of cultures sent from ICUs did not eliminate the increased risk of BSI and UTI associated with admission into ICUs.

Central vein catheterization. Failure and complication rates by three percutaneous approaches.

We prospectively studied the results of 714 attempts at central venous catheterization during an eight-month period in our intensive care department. We compared the rates of failure of catheterization and early complications among three percutaneous approaches: subclavian, anterior jugular, and posterior jugular veins. The procedures were performed by experienced staff or resident physicians and inexperienced interns and residents under teaching supervision. Overall rates of failure and complication were similar for each percutaneous approach within each group of physicians. Overall failure rate was 10.1% for the experienced group and 19.4% for the inexperienced. The complication was 5.4% for experienced and 11% for inexperienced. Among inexperienced physicians, the success rate was 86.7% and the complication rate 7.6% in unconscious patients, whereas in conscious patients these rates were 70.5% and 13.8%, respectively. The inexperienced physicians caused fewer complications in mechanically ventilated than in spontaneously breathing patients. We suggest that inexperienced physicians should first attempt central vein catheterizations in unconscious and mechanically ventilated patients.

Effects on respiratory patterns during bronchoscopy by the Sanders attachment technique.

The purpose of this study was to rationalize the choice of injector and bronchoscope sizes during bronchoscopy under general anesthesia using the Sanders attachment technique. Arterial Po2 and Pco2, FIo2, and peak inspiratory pressure at the tip of the bronchoscope were plotted against the ratio (RI/B) of the internal diameters of the injector and the bronchoscope in seven dogs undergoing bronchoscopy under general anesthesia. Peak inspiratory pressure, FIo2, and PaO2, increased, and PaCO2 decreased with an increase in RI/B. A working table is proposed to predict the optimal RI/B.

Case series: hyponatremia associated with moderate exercise.

Exercise-induced hyponatremia is commonly believed to be associated only with extraordinary physical efforts, or particularly strenuous exercise. Hyponatremia complicating moderate exercise has not been described previously. The authors describe the characteristics of seven patients with life-threatening hyponatremia associated with mild to moderate exercise. All patients suffered from nausea, vomiting, agitation, and confusion, appearing during or after moderate physical activity. Grand mal convulsions occurred in five of the patients. In laboratory results, hyponatremia was as low as 115 mEq/L, with a relatively high sodium concentration in the urine. High serum creatine kinase activity levels were found in most of the patients. All patients were discharged in good condition, without neurologic sequela. The authors conclude that hyponatremia is a possible complication of moderate exercise, and not only of endurance sports, and that exercise-induced hyponatremia can produce severe neurologic manifestations. The mechanism of the hyponatremia is unclear, but may be due to a hemodynamically inappropriate stimulus for antidiuretic hormone secretion.

Anaphylactic shock due to rupture of a hepatic hydatid cyst into a pericystic blood vessel following blunt abdominal trauma.

Partial drainage of a hepatic hydatid cyst into a pericystic blood vessel caused anaphylactic shock following minimal blunt abdominal trauma in a child. A case report including diagnostic procedures and treatment is presented.

Accidental intra-arterial injection of ketamine.

A case of accidental intra-arterial injection of ketamine is reported. Necrosis of the skin proximal to the site of injection and transient foot drop followed the injection.

Effect of positive end-expiratory pressure on intrapulmonary shunt at different levels of fractional inspired oxygen.

In 10 patients undergoing ventilation, venous admixture was measured at different values of positive end-expiratory pressure (PEEP). The measurements were performed at the level of fractional inspired oxygen (FIO2) at which each patient was ventilated, and at FIO2=1. In patients ventilated at FIO2 between 0.21 and 0.3 venous admixture was not modified by PEEP, while in patients ventilated with FIO2 between 0.4 and 0.6, venous admixture decreased significantly (p less than 0.01). With FIO2=1, increased PEEP produced a reduction in venous admixture in all cases (p less than 0.05). These observations suggest that in patients similar to ours, PEEP does not reduce venous admixture at low levels of FIO2 (0.21--0.3), and the observed reduction with PEEP at FIO2=1 may be misinterpreted.

Massive aspiration during surgery for a hydatid cyst of the lung.

A case of massive aspiration of hydatid liquid during an operation for excision of hydatid cyst of the lung is presented. Some considerations about the treatment and the anaesthetic approach to the problem are given. An analysis of 42 operations performed during 1963-1973 in the Rambam Hospital is discussed. Rupture of cyst with cyanosis and fall in blood pressure occurred in only 5 of these cases and among them, only one patient died.

Arterial air embolism after penetrating lung injury.

We present a case of cerebral air embolism after a gunshot wound to the lung, combined with mechanical ventilation. Hyperbaric and pharmacologic therapy resulted in complete recovery. The discussion focuses on hyperbaric therapy as the mainstay of treatment, the importance of prophylactic measures, and prompt diagnosis.