COPD patients with ventilator-associated pneumonia: implications for management.

Data on the occurrence and outcome of patients with chronic obstructive pulmonary disease (COPD) and ventilator-associated pneumonia (VAP) are quite limited. The aim of this study was to determine if COPD intensive care unit (ICU) patients have a higher rate of VAP development, different microbiological aetiology or have worse outcomes than other patients without VAP. A secondary analysis of a large prospective, observational study conducted in 27 European ICUs was carried out. Trauma patients were excluded. Of 2082 intubated patients included in the study, 397 (19.1%) had COPD; 79 (19.9%) patients with COPD and 332 (19.7%) patients without COPD developed VAP. ICU mortality increased by 17% (p < 0.05) when COPD patients developed VAP, remaining an independent predictor of mortality [odds ratio (OR) 2.28; 95% confidence interval (CI) 1.35-3.87]. The development of VAP in COPD patients was associated with a median increase of 12 days in the duration of mechanical ventilation and >13 days in ICU stay (p < 0.05). Pseudomonas aeruginosa was more common in VAP when COPD was present (29.1% vs. 18.7%, p = 0.04) and was the most frequent isolate in COPD patients with early-onset VAP, with a frequency 2.5 times higher than in patients without early-onset VAP (33.3% vs. 13.3%, p = 0.03). COPD patients are not more predisposed to VAP than other ICU patients, but if COPD patients develop VAP, they have a worse outcome. Antibiotic coverage for non-fermenters needs to be included in the empiric therapy of all COPD patients, even in early-onset VAP.

Comparison between CDI-100 continuous SO2, Hb, and Hct monitoring, intermittent ABL-4 saturation and Hb monitoring, and lab Hb and Hct monitoring.

During extracorporeal circulation (ECC) a continuous monitoring of venous oxygen saturation yields a quantitative impression of the equilibrium of oxygen supply and oxygen consumption in steady state conditions. The aim of the investigation was to study whether the measurements of venous oxygen saturation and haemoglobin of a continuous on-line monitor (CDI-100) agree with those of the ABL-4 bloodgasmonitor or the haemoglobincyanid method in hospital laboratory. The study group consisted of 21 patients, with comparable conditions of anesthesia and ECC set-up. Measurements of saturation and haemoglobin were compared at three moments, resulting in a total of 189 measurements. Analysis was based on the Bland Altman method, using the differences between correspondent measurements, which contain all the information needed to decide whether the methods agree. Bias of saturation measurement (CDI-100 versus ABL-4) is -3.4, 3.0 and -3.5% at times 1,2 and 3. All values are situated within the limits of agreement. Bias of haemoglobin measurement (CDI-100 versus ABL-4) is 0.3, 0.3, and 0.2 gr/dl at times 1, 2 and 3. All values (except one value) are situated within the limits of agreement. Bias of hemoglobin measurement (CDI-100 versus hospital laboratory) is 0.2, 0.0 and 0.1 gr/dl, and all values are situated within the limits of agreement. The results confirm that the CDI-100, in the set-up as described, can be used as a reliable instrument to monitor venous oxygen saturation and haemoglobin during ECC.

Haemolytic anaemia caused by piperacillin-tazobactam.

We report a case of haemolytic due to the use of piperacillin-tazobactam in a 50-year-old woman. Since 2002 4 other cases were reported. Either the presence of piperacillin as tazobactam can induce haemolysis. In all cases discontinuating the drugs resolves the haemolysis. Although drug-induced haemolytic anaemia due to piperacillin-tazobactam is rare, the common use of this antibioticum in the critical care setting should alert the physician as a possible culprit in cases of haemolytic anaemia.

Neurological complications in critically ill patients; septic encephalopathy, critical illness polyneuropathy.

Septic encephalopathy and critical illness polyneuropathy are two syndromes, appearing at different stages in critically ill patients. Their aetiology is unclear, but many arguments seem to associate them with respiratory insufficiency in a context of systemic inflammatory response syndrome (S.I.R.S.) and multiple organ dysfunction syndrome (M.O.D.S.). Septic encephalopathy appears early in the course of sepsis, diagnosis is based on clinical picture and electro-encephalogram. The exact pathogenesis is unclear. Prognosis is related to the underlying pathology, and treatment is supportive. Critical illness polyneuropathy is a predominantly motor axonal dysfunction, occurring in a setting of respiratory insufficiency, S.I.R.S., and M.O.D.S. A weaning problem often indicates the presence of critical illness polyneuropathy. Diagnosis is made on history, clinical picture and electromyographic studies. Indeed, motor and sensory conduction studies show a reduction of the amplitude of action potentials. In a later stage fibrillations and positive sharp waves emerge, with a further reduction of action potentials. Follow-up examinations reveal signs of axonal regeneration. The exact aetiology is unknown, but may be related to sepsis and M.O.D.S. Sepsis and M.O.D.S. are associated with the release of "mediator" substances, and somewhere in this cascade, there might be a toxin, influencing the nerve. A differential diagnosis with myopathy and neuromuscular transmission defects has to be made. Specific treatment is absent, and prognosis is related to the underlying pathology.