Does positioning affect tracheal aspiration of gastric content in ventilated infants?

OBJECTIVES: Gastroesophageal reflux and aspiration can occur in premature infants who are supported with mechanical ventilation. The relation between physical positioning and gastric aspiration in ventilated infants has not been studied. Pepsin measured in tracheal aspirate (TA) emerged as a specific marker for aspiration. The objective of our study was to assess pepsin in TA of ventilated infants at 2 different positions: supine and right lateral. METHODS: We conducted a randomized controlled trial on premature infants who were enterally fed and supported with mechanical ventilation. Patients were randomized into intervention and control groups. In the intervention group, infants were placed supine for 6 hours before a sample of TA was obtained. A second sample was collected 6 hours later while lying in the right lateral position. In the control group, the 2 samples of TA were obtained while infants remained in the supine position during the entire study time. Pepsin in TA was measured while blinded to the group assignment. RESULTS: A total of 34 patients were enrolled and randomized to intervention (n = 17) and control (n = 17) groups. Gestational age was 32.7 ± 2.7 weeks, and birth weight was 1617 ± 526 g; both groups had similar demographic and clinical characteristics. Pepsin concentration did not differ between groups at baseline. In the intervention group, pepsin concentration significantly declined from 13 ng/mL (interquartile range [IQR] 11.9-38.7) to 10 ng/mL (IQR 7-12; P < 0.001), whereas it did not change in the control group (P = 0.42). CONCLUSIONS: The right lateral positioning is associated with decreased TA pepsin. The implications of the present study on hospital practice and clinical outcomes need further investigations.

Genetic and Biochemical Predictors of Neonatal Bronchopulmonary Dysplasia.

Bronchopulmonary dysplasia (BPD) is a common complication of prematurity with a multifactorial etiology, influenced by both genetic susceptibility and environmental factors on the immature lung. Fibroblast growth factor receptor-3 and -4 (FGFR-3 and FGFR-4) are abundantly expressed in both the epithelium and mesenchyme in the developing mammalian lung. FGFR-4 may play a role in developing BPD as it is associated with airway inflammation and remodeling; studies showed a link between BPD and a polymorphism in the FGFR-4 gene. The aim of this study was to study the significance of FGFR-4 in developing BPD and to investigate the correlation between its serum level and its genetic polymorphism in relation to development of BPD in preterms. This case-control study was performed on 80 preterm neonates (<32 weeks) divided into two groups: group I included 50 preterms with respiratory distress syndrome (RDS) who developed BPD and group II included 30 preterms with RDS only. The mean serum level of FGFR-4 was significantly lower in group I than in group II ( p -value < 0.05). There was no significant correlation between the serum levels of FGFR-4 and the degree of severity of BPD. Allele variation in the FGFR-4 gene was similar in both groups. The serum level of FGFR-4 was significantly lower in preterms with BPD, although the gene polymorphism was not significantly different in the studied groups.

Renal function in small for gestational age preterm infants.

OBJECTIVE: The objective of this study is to compare glomerular and tubular functions in small for gestational age (SGA) and appropriate for gestational age (AGA) preterm infants. STUDY DESIGN: A prospective controlled study was conducted on SGA and AGA infants with gestational ages between 320/7 and 366/7 weeks, who received gentamycin in the first 72 h of life. Glomerular and tubular functions were assessed on days 1 and 5. RESULTS: Fifty (25 SGA and 25 AGA) infants were included. On day of life 1, SGA group had higher serum sodium, serum urea, and urinary creatinine. On day 5, SGA infants had significant increase in serum creatinine (p = 0.04). Urinary NAG and FeNa were comparable among the two groups on days 1 and 5. CONCLUSIONS: Glomerular functions were compromised in SGA preterm infants. Tubular functions were comparable.

Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA).

[This corrects the article DOI: 10.1186/s13017-016-0089-y.].

Reduction of vancomycin-resistant enterococcal infections by limitation of broad-spectrum cephalosporin use in a trauma and burn intensive care unit.

Both vancomycin and third-generation cephalosporin use are believed to contribute to a rise in vancomycin-resistant enterococci (VRE) infections. In 1998, the largest number of VRE infections in our hospital occurred in the trauma/burn intensive care unit (TBICU), accounting for nearly 20% of hospital infections. In an attempt to control the VRE infection rate, antibiotic protocols for prophylaxis, empiric, and definitive therapy were initiated during the final quarter of 1998 to minimize cephalosporin use by the introduction of piperacillin/tazobactam. Therefore, we undertook a study of the VRE infection rate for the TBICU in relation to vancomycin, piperacillin/tazobactam, piperacillin, third-generation cephalosporin, and total cephalosporin use before and after efforts to limit cephalosporins. These data were compared to those in the medical and surgical intensive care units. During 1998, seven VRE infections occurred in the TBICU. Following initiation of antibiotic protocols, one case of VRE infection occurred in the subsequent month and no cases in the 17 months since. The decrease in the VRE infection rate corresponded with a significant increase in the use of piperacillin/tazobactam and a reduction in third-generation and total cephalosporin use. In contrast, cephalosporin use in the medical and surgical intensive care units remains significantly higher than in the TBICU, and neither unit has had a reduction in their VRE infection rates.

Anti-tumor necrosis factor antibody reduces mortality in the presence of antibiotic-induced tumor necrosis factor release.

The systemic tumor necrosis factor (TNF) response has been extensively studied during infection. In addition, antibiotics that cause cell-wall lysis have been associated with endotoxinemia and, therefore, could trigger TNF release. We studied the effects of pretreatment with cefoxitin and/or anti-TNF antibody on mortality and early (90 minutes) and delayed (6 hours) serum TNF levels in a murine model of mixed Escherichia coli/Bacteroides fragilis peritonitis. At low and intermediate inocula levels, cefoxitin, but not anti-TNF antibody, prevented death, and low serum TNF levels were noted in all groups. At the highest inoculum level, mortality was uniform in control, cefoxitin, and anti-TNF antibody groups, and a significant elevation in serum TNF levels was seen only at the 6-hour point in animals receiving cefoxitin. The addition of anti-TNF antibody to cefoxitin at this inoculum level abrogated the 6-hour rise in serum TNF levels and reduced mortality to 40%. These results emphasize that the cytokine response in disease is dependent on both the nature of the insult and other forms of therapeutic interventions.

Emerging evidence of selection of fluconazole-tolerant fungi in surgical intensive care units.

OBJECTIVE: To determine whether increased use of fluconazole has coincided with a shift in the relative proportion of fluconazole-tolerant species isolated from critically ill surgical patients in 2 university hospitals. DESIGN: Microbiological data and fluconazole administration frequencies were reviewed among patients treated in the surgical intensive care units (SICUs) from January 1, 1990, through December 31, 1995. SETTING: The SICUs of the University of Virginia Medical Center, Charlottesville, and the Hospital of the University of Pennsylvania, Philadelphia. MAIN OUTCOME MEASURES: The number and species types of all fungal isolates and the number of patients treated with fluconazole for each of the 6 years were determined. RESULTS: A sharp increase in the use of fluconazole among critically ill surgical patients has occurred at both medical centers from 1990-1995. The culture results of most patients treated with fluconazole were negative for fungi (73% and 63% at the University of Virginia Medical Center and the Hospital of the University of Pennsylvania, respectively); there was a greater tendency to use fluconazole at the University of Virginia Medical Center compared with the Hospital of the University of Pennsylvania (2.2% vs 1.8% of patients admitted to the SICU received it, respectively; P = .007). There was a significant increase in the proportion of Candida glabrata isolated at the University of Virginia Medical Center (P < .01) from 1990-1995, but a similar change was not detectable at the Hospital of the University of Pennsylvania. CONCLUSIONS: These data justify concern that the increased use of fluconazole in SICUs may be promoting a shift in the fungal flora that cause nosocomial infections toward species that are more difficult to treat. Prospective studies about the use of fluconazole for prophylaxis and empirical therapy among SICU patients are warranted before its widespread use in these settings continues.

Recurrent trauma in elderly patients.

HYPOTHESIS: Older patients (those aged > or = 70 years) who have experienced trauma have an increased risk of recurrent trauma. Demographic, medical, and functional factors are potential contributors to the risk of subsequent trauma among injured elderly patients. DESIGN: Retrospective follow-up study. PARTICIPANTS: Study participants were derived from the Longitudinal Study of Aging, an extension of the 1984 National Health Interview Survey focusing on persons who were aged 70 years and older in 1984. A cohort of elderly patients participating in the Longitudinal Study of Aging and hospitalized for injury in 1985 (n = 100) was identified using Medicare hospital discharge data. An uninjured cohort (n = 401) was also identified from the Longitudinal Study of Aging and matched for age (1 year) and sex. MAIN OUTCOME MEASURES: Risk of admission for trauma among the injured cohort compared with the uninjured cohort and associations between demographic, medical, and functional characteristics and trauma recurrence. RESULTS: Following adjustment for potential confounding factors, the injured cohort was 3.25 times more likely (95% confidence interval, 1.99-5.31) to be hospitalized for injury during the follow-up period compared with the uninjured cohort. Among the injured cohort, those at greatest risk of subsequent trauma included women and those with chronic medical conditions or functional impairments, the latter being the only factor independently associated with recurrence. CONCLUSIONS: Elderly patients who have experienced trauma are at increased risk of subsequent injury. Interventions to reduce the likelihood of trauma recurrence should focus on those with chronic illnesses and functional impairments.

Endovascular therapy of traumatic injuries of the extracranial cerebral arteries.

The field of neuroendovascular therapy is rapidly growing. New technology and operators' expertise are developing at a pace that will make this discipline progressively more available and successful. For patients who have traumatic injuries of the extracranial arteries, endovascular therapy offers a new dimension to the treatment of these injuries and the prevention of stroke. Because many of these patients are likely to be critically ill, it is important to keep in mind the principles of their management before, during, and after the procedure, thus assuring the best chance for a successful outcome. Furthermore, some of the issues related to their neurointensive care will serve as guides for the need for endovascular therapy, as well as its timing.

Diagnosis of blunt rupture of the right hemidiaphragm by technetium scan.

Traumatic rupture of the diaphragm, particularly of the right hemidiaphragm, may be occult and can be difficult to diagnose if laparotomy is not required for concomitant injury. Missed or delayed diagnosis of such injuries can produce life-threatening complications, such as intestinal herniation, ischemia, and necrosis. We present a case of traumatic rupture of the right hemidiaphragm that demonstrates the typically occult nature of this injury. The majority of right-sided injuries are diagnosed during laparotomy performed for other injuries. In those patients not requiring laparotomy, the diagnosis is usually delayed because this injury seldom produces clinical or radiographic findings that are either sensitive or specific. In this case, intraperitoneal injection of technetium sulfur colloid was used to establish the diagnosis of right diaphragm rupture, and an uncomplicated repair was undertaken.

Management of hepatic artery injury: case report.

The trauma surgeon encounters hepatic arterial injury only rarely. The majority of these injuries appear to be due to penetrating trauma, with few cases of hepatic artery injury secondary to blunt trauma reported in the literature. In the setting of blunt trauma, hepatic artery injury is generally accompanied by other severe injuries, and mortality remains high. We present two patients who sustained an avulsion of the left hepatic artery complicating severe blunt trauma to the abdomen and pelvis. Surgical management included ligation of the involved vessel. Both patients required management in the intensive care unit, one eventually succumbing to multisystem organ failure. The cases highlight management principles in these injuries, and treatment options are discussed.

The role of Candida albicans in the pathogenesis of experimental fungal/bacterial peritonitis and abscess formation.

The recovery of Candida albicans along with bacteria from the abdomen in the setting of peritonitis is becoming increasingly common. It is not known whether the interactions between the fungal and bacterial elements of these infections are synergistic, competitive, or neutral. To study this question, we have examined the effects of both the addition of C. albicans to a solely bacterial infection caused by Escherichia coli and Bacteroides fragilis, and the deletion of various components of this system using directed antimicrobial therapy. In a mixed infection, both C. albicans and bacteria contributed to mortality, since only the combination of cefoxitin and amphotericin B improved survival (from 50% to 90%). The addition of C. albicans to the bacterial inoculum increased the recovery of abscesses, but only to the number seen with fungal infection alone, implying two fairly independent processes. Although the number of bacteria recovered from abscesses at 10 days postinfection was unchanged with the addition of fungi, the deletion of the bacterial component of mixed infections led to the overgrowth of C. albicans. We conclude that this model of mixed C. albicans/E. coli/B. fragilis peritonitis is best characterized as two nonsynergistic, parallel infections with incomplete competition, allowing the survival of all three organisms to eventual abscess formation.

Coagulopathy in severe closed head injury: is empiric therapy warranted?

Closed head injuries account for a significant portion of the morbidity and mortality following blunt trauma. Severe closed head injuries can be complicated by the development of a coagulopathy that may worsen blood loss and delay invasive neurosurgical procedures. Awaiting the results of coagulation studies prior to initiating treatment of such a coagulopathy introduces an inherent delay that may allow worsening of the coagulation disturbance and negatively influence outcome. This study was undertaken to see if a subgroup of patients with severe closed head injuries had a high probability of developing a coagulopathy and would warrant empiric treatment with fresh frozen plasma. The records of adult patients admitted to our trauma center with a Glasgow coma score (GCS) of < or = 8 and an extracranial abbreviated injury score of < or = 2 during a 9-month period were reviewed. Patients with penetrating trauma or whose altered level of consciousness was due to sedation or shock were excluded. The presence of coagulation abnormalities was determined according to prothrombin time and partial thromboplastin time obtained on admission. The time to invasive neurosurgical procedures for both coagulopathic and noncoagulopathic patients was determined as well as the mean number of hospital days, intensive care unit days, and the mortality for each group. Eighty-one per cent of the patients with a GCS < or = 6 were coagulopathic on admission, and all patients with a GCS of 3 or 4 were coagulopathic. In contrast, no patient with a score of 7 or 8 was coagulopathic. The coagulopathic patients tended to have a higher mortality than the noncoagulopathic patients (53 versus 22%) as well as longer intensive care unit and hospital stays. The mean time to neurosurgical intervention for the coagulopathic group was 226.0 +/- 190.9 minutes versus 84.8 +/- 38.4 minutes for the noncoagulopathic patients. We conclude that patients with closed head injuries who present with a GCS of 6 or less are candidates for empiric treatment for coagulopathy. Such treatment will negate the delay of awaiting coagulation studies. Whether or not such therapy shortens the interval between admission and neurosurgical procedures or alters outcome will require prospective study.

Prognostic factors in patients with inferior vena cava injuries.

Inferior vena cava (IVC) injuries are potentially devastating insults that continue to be associated with high mortality despite advances in prehospital and in-hospital critical care. Between 1987 and 1996, 37 patients (32 males and 5 females; average age, 30 years) were identified from the trauma registry as having sustained IVC trauma. Overall mortality was 51 per cent (n = 19), with 13 intraoperative deaths and five patients dying within the first 48 hours. Blunt IVC injuries (n = 8) had a higher associated mortality than penetrating wounds (63% versus 48%). Of the 29 patients with penetrating IVC trauma, the wounding agent influenced mortality (shotgun-100% versus gunshot-43% versus stab-0%). Anatomical location of injury was also predictive of death [suprahepatic (n = 3)-100% versus retrohepatic (n = 9)-78% versus suprarenal (n = 6)-33% versus juxtarenal (n = 2)-50% versus infrarenal (n = 15)-33%]. A direct relationship existed between outcome and the number of associated injuries: nonsurvivors averaged four and survivors averaged three. Eighty per cent of patients sustaining four or more associated injuries died, by contrast to a 33 per cent mortality in those suffering less than four injuries. Physiological factors were also predictive of outcome. Patients in shock (systolic blood pressure < 80) on arrival had a higher mortality than those who were hemodynamically stable (76% versus 30%). Preoperative lactate levels were of prognostic value for death (> or = 4.0-59% versus < 4.0-0%), as was base deficit (< 4-22%, > or = 4, and < 10-36%, > or = 10-73%). Interestingly, neither time from injury to hospital arrival (47.4 minutes versus 33.0 minutes) nor time in the emergency department before surgery (45.6 minutes versus 42.6 minutes) differed between survivors and fatalities. Mortality remained high in the 34 patients who had operative control of their IVC injuries [lateral repair (n = 27)-44% versus ligation (n = 6)-66% versus Gortex graft (n = 1)-0%]. As wounding agent, anatomical location, associated injuries, and physiological status seem to most directly impact mortality, future efforts must focus both on establishing prevention programs directed at reducing the incidence of this injury, as well as on advancing the management of those who do survive to hospitalization, if we are to improve on the outcome of these devastating injuries.

Peritonitis into the 1990s: changing pathogens and changing strategies in the critically ill.

To study the effect of severe illness on the nature of peritonitis and intra-abdominal abscesses, the microbiology and clinical course of patients operated on over a 1-year period with culture-proven intra-abdominal infections whose preoperative Acute Physiology and Chronic Health Evaluation (APACHE) II scores were greater than or equal to 15 (predicted mortality at least 50%) were examined. Twenty-nine patients were enrolled, and overall mortality was 52 per cent, with increasing mortality correlating with higher APACHE II scores. The organism most commonly isolated from the peritoneum was Candida albicans, followed by Enterococcus species, Enterobacter species, and Staphylococcus epidermidis. An increase in the mean of the APACHE II scores on Days 3 and 7 compared to the preoperative score was associated with a 91 per cent mortality, while a decrease was associated with only a 22 per cent mortality. The authors conclude that the microbiology of intra-abdominal infections is inherently different in severely ill patients and that longitudinal clinical scoring may be more useful than a single scoring in predicting outcome. These data suggest that trials to investigate the broadening of standard perioperative antimicrobial coverage in the ill and use of longitudinal clinical scoring to direct aggressive reintervention may be warranted.

Combined blunt cardiac and pericardial rupture: review of the literature and report of a new diagnostic algorithm.

The spectrum of blunt cardiac injury varies from the asymptomatic cardiac concussion to the immediately fatal cardiac rupture. Although the majority of victims sustaining blunt cardiac rupture die before receiving medical attention, some survive to evaluation. The diagnosis of cardiac rupture, if established, typically results from the signs and symptoms of pericardial tamponade. However, some patients may have remarkably few signs and symptoms suggestive of cardiac injury and represent a significant diagnostic challenge. We provide two cases of cardiac rupture in which the diagnosis was delayed by the presence of an associated pericardial tear with decompression into the mediastinum and pleural space. In neither of the cases did existing institutional algorithms for blunt cardiac injury assist in establishing the diagnosis before the acute demise of the patient. The presence of a coexisting pericardial injury in these patients with blunt cardiac rupture obscured the diagnosis, leading to the deaths of these patients. A discussion of these two cases and review of the literature is provided with recommendations for diagnostic algorithms in patients sustaining blunt thoracic trauma with possible cardiac and pericardial injury.

Trauma-specific intensive care units can be cost effective and contribute to reduced hospital length of stay.

Our hypothesis was that clinical outcomes are improved and cost and hospital length of stay (LOS) reduced as a result of the opening of a closed trauma intensive care unit (ICU). We conducted a cross-sectional study in a university-affiliated Level I trauma center. Our study population comprised trauma patients admitted to the ICU between June 1, 1996 and July 1, 1998 for at least 24 hours and with an Injury Severity Score (ISS) >16 (excluding those with severe brain injury). The main outcome measures were changes in LOS and number of ventilator days, prevalence of complications, changes in patient charges, and hospital costs. Two hundred four patients were included [trauma ICU (TICU) 60, surgical ICU 144]. The two groups were not statistically different in age, ISS, mechanism of injury, infection rate, and mortality; however, the TICU patients had a lower number of ventilator hours (83.1 vs 100.0; P = 0.007), lower ICU LOS (9.4 vs 12.1 days; P = 0.06), and lower total hospital LOS (15.6 vs 22.3 days; P = 0.01). Although this was not of statistical significance TICU patients had lower hospital charges ($125,383 vs $152,994; P = 0.06) and lower cost per case ($42,306 vs $47,548; P = 0.35) for a net savings of $314,520 during the first 6 months of operation of the TICU. This study suggests that improved clinical outcomes and decreases in cost and LOS are directly related to the opening of a closed trauma ICU.

Pneumothorax in the neonatal intensive care unit in Cairo University Hospital.

Pneumothorax is more frequent in the neonatal period than at any other time in life and the incidence increases in neonates who have concurrent underlying lung disease or who require mechanical ventilation. This cross sectional study was performed in the inborn NICU in Cairo University Hospitals over one year from September 2010 to August 2011. All neonates admitted were included; their data were collected and observed for pneumothorax occurrence. A total of 59 neonates (9.1%) developed pneumothorax with highest incidence in ELBW and gestational ages less than 32 weeks. RDS and MAS were the most common coexisting lung pathologies. 89.83% of the cases with pneumothorax were on mechanical ventilation. Pneumothorax occurred on the right side in 64.4% of cases, on the left in 18.6% and bilateral in 16.95% of the cases. The mortality was higher (62.7%) in the neonates with pneumothorax than the mortality of the total admissions. The mortality was significantly higher with lower birth weights and gestational ages. Apgar score at one and five minutes and the associated medical diagnosis showed no significant differences between the neonates who died and those who survived.

Long-term survival in the elderly after trauma.

BACKGROUND: In the elderly, trauma has been associated with increased, long-term, all-cause mortality. Functional limitations secondary to injury may be responsible for the reduced survival rate. The objective of this study was to test this hypothesis using data from the Longitudinal Study of Aging (LSOA). METHODS: The LSOA is an extension of the 1984 National Health Interview Survey, which focused on 7,527 persons who were 70 years and older in 1984. Using data from the LSOA, a cohort of elderly patients hospitalized for injury in 1985 (N = 102) was identified from Medicare hospital discharge data. An uninjured cohort (N = 408) was also identified using the LSOA and matched by age (within 1 year) and sex. Deaths in both cohorts were identified using the National Death Index. Hazard ratios (HRs) for mortality within 6 years subsequent to injury, adjusted for demographic, health status, and functional characteristics, were calculated. RESULTS: The injured cohort had a significantly reduced rate of survival compared with the uninjured cohort (HR = 1.5; 95% confidence interval [CI] 1.1-2.2), and this relationship persisted after adjusting for demographic and health characteristics (HR = 1.4; 95% CI 1.0-2.0). After additional adjustment for measures of functional decline, the association diminished (HR = 1.2; 95% CI 0.8-1.7). Functional decline remained a strong, independent factor for the risk of mortality. CONCLUSION: Trauma in the elderly has both an acute and long-term influence on mortality; the latter seems to be mediated through a decline in function resulting from the injury. This study suggests that strategies to return the elderly patient to preinjury functional status are of paramount importance. Future research should explore the impact of these interventions on long-term survival.

Anterior lung herniation: another aspect of the seatbelt syndrome.

Shoulder harnesses can be a source of thoracic injury in motor vehicle crashes. Sternal and rib fractures are most commonly reported. We present a case of a traumatic anterior lung herniation secondary to shoulder harness trauma in a motor vehicle crash victim with multiple injuries. A brief review of lung hernias is provided as well as a brief discussion of the thoracic manifestations of the seatbelt syndrome.