Spread of Tst-Positive Staphylococcus aureus Strains Belonging to ST30 Clone among Patients and Healthcare Workers in Two Intensive Care Units.

Staphylococcus aureus is a major cause of infections. Toxic shock syndrome toxin (TSST-1) and Panton-Valentine leukocidin (PVL) are associated with severe clinical syndromes. S. aureus colonizing isolates recovered from healthcare workers and patients in the intensive care unit (ICU) of a university hospital comprising Group A were compared with those from adult non-ICU carriers (Group B). mecA, lukS/lukF-PV (Panton-Valentine leukocidin, PVL), and tst (toxic shock syndrome toxin) gene carriage was detected by PCR. Clones were identified in all methicillin-resistant S. aureus (MRSA) and toxin-positive methicillin-susceptible strains (MSSA) by pulsed-field gel electrophoresis (PFGE), agr groups, and multi locus sequencing typing (MLST). Group A included 90 S. aureus isolates, whereas Group B 53. PVL was more frequently found among MRSA vs. MSSA (p < 0.001) and in strains of Group B as compared to Group A (p < 0.001), consistent with the spread of ST80-IV. Higher incidence of tst gene carriage was identified among MSSA vs. MRSA (P 0.005) belonging mainly to ST30, and Group A vs. Group B (P 0.002). The wide dissemination of ST80-IV mainly in the community is responsible for a high percentage of PVL-positive MRSA, while silent spread of tst-positive S. aureus clones among ICU patients and personnel poses a threat of hospital transmission and possible severe infections.

Association of KPC-producing Klebsiella pneumoniae colonization or infection with Candida isolation and selection of non-albicans species.

Clinical specimens from 565 patients hospitalized in 2 intensive care units (ICUs A and B) during a 28-month period were cultured on appropriate media for isolation of Candida. Forty-nine (9%) patients had at least a Candida spp.-positive sample. Candida albicans was the predominant species isolated from 26 (53%) patients. Seventeen patients (3%) developed candidemia. Multivariate analysis showed that obesity, female gender, hospitalization during summer months, admission at ICU B, parenteral nutrition, administration of metronidazole, transplantation, and KPC-producing Klebsiella pneumoniae (KPC-Kp) infection were independently associated with Candida spp. isolation. Candidemia was associated with cortisone administration, KPC-Kp infection, and presence of colostomy or abdominal catheter. Administration of fluconazole was a protective factor for both Candida spp. isolation and infection, leading to selection of Candida non-albicans species. Among several risk factors, KPC-Kp infection and colonization are identified as statistically significant factors associated with Candida isolation, especially of non-albicans species.

Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment.

Airway injuries are life threatening conditions. A very little number of patients suffering air injuries are transferred live at the hospital. The diagnosis requires a high index of suspicion based on the presence of non-specific for these injuries symptoms and signs and a thorough knowledge of the mechanisms of injury. Bronchoscopy and chest computed tomography with MPR and 3D reconstruction of the airway represent the procedures of choice for the definitive diagnosis. Endotracheal intubation under bronchoscopic guidance is the key point to gain airway control and appropriate ventilation. Primary repair with direct suture or resection and an end to end anastomosis is the treatment of choice for patients suffering from tracheobronchial injuries (TBI). The surgical approach to the injured airway depends on its location. Selected patients, mainly with iatrogenic injuries, can be treated conservatively as long as the injury is small (<2 cm), a secure and patent airway and adequate ventilation are achieved, and there are no signs of sepsis. Patients with delayed presentation airway injuries should be referred for surgical treatment. Intraoperative evaluation of the viability of the lung parenchyma beyond the site of stenosis/obstruction is mandatory to avoid unnecessary lung resection.

Risk factors for infection and predictors of mortality among patients with KPC-producing Klebsiella pneumoniae bloodstream infections in the intensive care unit.

BACKGROUND: Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp) infections in intensive care units (ICUs) are associated with increased mortality. We aimed to determine risk factors for infection and predictors of 30-day mortality in ICU patients with KPC-Kp bloodstream infections (BSI). METHODS: During a 26-month period, patients (n = 273) who stayed more than 6 days in the ICU of the University Hospital of Patras, Greece, were divided into 2 groups, those who developed KPC-Kp BSI and those who did not. K. pneumoniae was identified by Vitek 2 technology. Antibiotic susceptibility testing was performed by agar disk diffusion method. Minimum inhibitory concentrations were determined by Etest. The presence of the blaKPC gene was confirmed by PCR. Molecular typing was performed by pulsed-field gel electrophoresis of XbaI-restricted genomic DNA. Epidemiological data were collected by patient chart review. RESULTS: Five patients had bacteraemia upon admission, while in 48 (17.6%) the BSI developed after 6 days of hospitalization. Risk factors for KPC-Kp BSI in the latter group were the administration of aminoglycosides, number of invasive catheters inserted after the third day, and tracheostomy. The 30-day mortality was 43.4% (23/53 patients). Multivariate analysis revealed that age, SAPS II score at onset of BSI, resistance to colistin, gentamicin, or tigecycline, and septic shock were independently associated with mortality. Treatment with at least 2 appropriate antibiotics was identified as a predictor of a good prognosis. CONCLUSIONS: Many risk factors are involved in KPC-Kp BSI among ICU patients. The high mortality in patients with KPC-KP BSI in the ICU requires the implementation of appropriate infection control measures.

Does epidural morphine loading in addition to thoracic epidural analgesia benefit the postoperative management of morbidly obese patients undergoing open bariatric surgery? A pilot study.

BACKGROUND: Insufficient data exist regarding postoperative thoracic epidural analgesia for morbidly obese patients undergoing open bariatric surgery. This study evaluated the effectiveness of morphine loading in a postoperative thoracic epidural analgesic regimen of patient-controlled epidural analgesia (PCEA) with levobupivacaine combined with continuously administered epidural morphine in this patient group. METHODS: In this prospective randomized controlled trial, 48 superobese patients (body mass index of ≥ 50 kg/m(2)) undergoing open bariatric surgery were randomly allocated to three groups of 16 patients each. Postoperatively, all groups received a continuous epidural morphine infusion of 0.2 mg/h with 0.1 % levobupivacaine via PCEA. Group A did not receive intraoperative epidural morphine loading, while groups B and C received an intraoperative 1- and 2-mg morphine bolus, respectively. Levobupivacaine consumption via PCEA (primary outcome), pain scores at rest and on cough, the time to return of bowel function and ambulation, and arterial blood gas levels (secondary outcomes) were recorded. RESULTS: The increase in perioperative morphine administration (groups B and C) led to a significantly prolonged return to normal bowel function and delayed ambulation (P<0.05 to 0.01, respectively), without an improvement in postoperative analgesia or a reduction in local anesthetic consumption. Although the prevalence of obstructive sleep apnea (OSA) was high in all groups, no respiratory depression was observed. CONCLUSIONS: Thoracic PCEA with 0.1 % levobupivacaine combined with continuous epidural morphine administration of 0.2 mg/h without morphine loading is an effective postoperative analgesic regimen that provides adequate pain control, early ambulation, and early return of bowel function in superobese patients, particularly those with OSA.

KPC-producing Klebsiella pneumoniae enteric colonization acquired during intensive care unit stay: the significance of risk factors for its development and its impact on mortality.

A prospective observational study of 226 intensive care unit (ICU) patients was conducted during a 25-month period. Rectal samples were taken at day 1, 4, and 7 and, afterwards, once weekly. Klebsiella pneumoniae was identified using standard techniques, whereas the presence of bla(KPC) gene was confirmed by PCR. During ICU stay, 72.6% of the patients were colonized with Klebsiella pneumoniae carbapenemases (KPC)-producing K. pneumoniae (KPC-Kp). Male gender, prior bed occupants, and patients in nearby beds colonized with KPC-Kp, tracheotomy, number of invasive catheters inserted, and number of antibiotics administered were the major risk factors for KPC-Kp colonization. ICU mortality (35.4%) was significantly related to Simplified Acute Physiology II score and respiratory insufficiency upon admission, cortisone administration, aminoglycoside administration, confirmed KPC-Kp infection, and severe sepsis or septic shock. The high prevalence of KPC-Kp enteric carriage in ICU patients and the significant mortality associated with KPC-Kp infection dictate the importance of early identification and isolation of such carriers.

Unplanned extubation in critically ill adults: clinical review.

AIMS AND OBJECTIVES: To investigate and synthesize the evidence on the incidence and consequences of unplanned extubation (UE) in intensive care unit (ICU) patients, and on risk factors for UE. BACKGROUND: ICU patients generally spend considerable time being intubated via the endotracheal route. Non-planned endotracheal tube removal, either deliberate or accidental, may pose significant safety risks for them. As UE is among the most studied critical incidents in the ICU, evaluation and summary of existing findings could provide important implications for clinical practice. SEARCH STRATEGIES, INCLUSION AND EXCLUSION CRITERIA: Observational studies published between 1990 and 2012 in English-language journals indexed by Cumulative Index for Nursing and Allied Health Literature (CINAHL), PubMed, Web of Science and the Cochrane Library were searched for studies on UE of critically ill adults. Thirty-three articles were considered eligible for inclusion. CONCLUSIONS: UE incidence varies considerably among reports, with self-extubation representing the majority of cases. Agitation, especially when combined with inadequate sedation, and decreased patient surveillance are the major risk factors for UE. Inexperienced personnel and improper tube fixation may also be important, while physical restraint use remains controversial. UE can be followed by serious complications, mainly aspiration, laryngeal oedema and increased risk for pneumonia. Need for re-intubation is a major determinant of patient outcomes. Implementation of educational or quality improvement programs is expected to advance personnel's knowledge about risk factors for UE, promote skills on safe, standardized procedures for patient care and increase compliance with them. RELEVANCE TO CLINICAL PRACTICE: Identifying risk factors for UE and minimizing UE incidence through appropriate preventive strategies are prerequisites for improving nursing care quality and patient safety in the ICU.

Factors influencing linezolid-nonsusceptible coagulase-negative staphylococci dissemination among patients in the intensive care unit: a retrospective cohort study.

BACKGROUND: The aim of the present study was to identify risk factors for linezolid-nonsusceptible coagulase-negative staphylococci (CNS) dissemination in the intensive care unit. METHODS: Among the 246 patients included, 33 revealed a linezolid-nonsusceptible CNS-positive culture specimen, 68 were positive for linezolid-susceptible CNS and 145 served as controls. Isolates were characterized by phenotypic and genotypic methods to species level, susceptibility to antistaphylococcal agents and clones. RESULTS: Among the 33 linezolid-nonsusceptible CNS patients, 29 revealed Staphylococcus epidermidis and 4 Staphylococcus capitis. All S. epidermidis strains belonged to the ST22 clone (by multilocus sequence typing), 26 carried both C2534T and T2504A and 3 strains were C2543T mutations. S. capitis strains were stratified as a common pulsed-field gel electrophoresis type and carried the G2576T mutation. Risk factors for linezolid-nonsusceptible CNS isolation were linezolid administration and mean number of linezolid-nonsusceptible CNS-positive patients in nearby beds per day. CONCLUSIONS: These results reinforce the aspect of rational antibiotic usage, but also highlight the need for strict infection control measures to prevent the dissemination of linezolid-nonsusceptible CNS.

Risk factors for KPC-producing Klebsiella pneumoniae enteric colonization upon ICU admission.

OBJECTIVES: To identify risk factors for KPC-producing Klebsiella pneumoniae (KPC-Kp) enteric colonization at intensive care unit (ICU) admission. Recently, the emergence and spread of KPC-producing Enterobacteriaceae in healthcare facilities has become an important issue. Understanding the extent of the reservoir in ICUs may be important for targeted intervention. METHODS: A prospective observational study of all patients (n = 405) admitted to an ICU was conducted during a 22 month period. Rectal samples were taken from each patient within 12-48 h of admission and were inoculated in selective chromogenic agar. K. pneumoniae isolates were characterized by standard methodology. Antibiotic susceptibility testing (agar disc diffusion method), MIC determination (Etest), identification of carbapenemase-producing isolates (Hodge test) and determination of KPC production (boronic acid-imipenem disc test) were performed. The presence of the bla(KPC) gene was confirmed by PCR. Epidemiological data were collected from the ICU computerized database and patient chart reviews. RESULTS: Upon ICU admission, 52/405 (12.8%) patients were colonized with KPC-Kp that was associated with the following risk factors: previous ICU stay (OR 12.5; 95% CI 1.8-86.8), chronic obstructive pulmonary disease (OR 6.3; 95% CI 1.2-31.9), duration of previous hospitalization (OR 1.3; 95% CI 1.1-1.4), previous use of carbapenems (OR 5.2; 95% CI 1.0-26.2) and previous use of ß-lactams/ß-lactamase inhibitors (OR 6.7; 95% CI 1.4-32.9). For patients previously hospitalized on peripheral wards the following risk factors were identified: duration of hospitalization prior to ICU admission (OR 1.1; 95% CI 1.1-1.3), number of comorbidities (OR 1.9; 95% CI 1.1-3.5) and number of antimicrobials administered (OR 2.1; 95% CI 1.3-3.3). CONCLUSIONS: The high prevalence of KPC-Kp enteric carriage in ICU patients at admission dictates the importance of implementation of infection control measures and strict antibiotic policies prior to ICU transfer.

Commonly used severity scores are not good predictors of mortality in sepsis from severe leptospirosis: a series of ten patients.

Introduction. Severe leptospirosis, also known as Weil's disease, can cause multiorgan failure with high mortality. Scoring systems for disease severity have not been validated for leptospirosis, and there is no documented method to predict mortality. Methods. This is a case series on 10 patients admitted to ICU for multiorgan failure from severe leptospirosis. Data were collected retrospectively, with approval from the Institution Ethics Committee. Results. Ten patients with severe leptospirosis were admitted in the Patras University Hospital ICU in a four-year period. Although, based on SOFA scores, predicted mortality was over 80%, seven of 10 patients survived and were discharged from the hospital in good condition. There was no association between SAPS II or SOFA scores and mortality, but survivors had significantly lower APACHE II scores compared to nonsurvivors. Conclusion. Commonly used severity scores do not seem to be useful in predicting mortality in severe leptospirosis. Early ICU admission and resuscitation based on a goal-directed therapy protocol are recommended and may reduce mortality. However, this study is limited by retrospective data collection and small sample size. Data from large prospective studies are needed to validate our findings.

Anicteric leptospirosis-associated severe pulmonary hemorrhagic syndrome: a case series study.

In leptospirosis, severe pulmonary hemorrhagic syndrome has replaced Weil's disease as the main cause of mortality, with rates of up to 75%. Four men, all farmers, were admitted to the intensive care unit between August 2009 and July 2010 with a diagnosis of acute respiratory distress syndrome. All patients presented with fever, hemoptysis, bilateral pulmonary infiltrates in chest radiographs, and thrombocytopenia and had compatible epidemiological history with leptospirosis; 3 patients had anemia, 3 had renal failure, 2 had increased creatine kinase, whereas bilirubin was slightly increased in only 1 patient. Leptospirosis was diagnosed serologically in all cases. Empirical therapy with ceftriaxone was administered immediately to all patients, while implementation of ARDSnet protective mechanical ventilation approach combined with an early goal-directed hemodynamic approach led to a relatively low mortality rate (25%). Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score II and Sepsis-Related Organ Failure Assessment scoring systems were unable to predict the outcome of the patients with leptospirosis-associated severe pulmonary hemorrhagic syndrome.

Clonidine pre-treatment prevents hemorrhagic shock-induced endotoxemia and oxidative stress in the gut, liver, and lungs of the rat.

OBJECTIVES: To study the effect of clonidine pre-treatment on hemorrhagic shock (H/S)-induced endotoxemia and oxidative stress (OS) in three vital organs of the rat. METHODS: The study protocol consisted of two arms: one for the measurement of organic hydroperoxide (LOOH) and superoxide radical (O(2)(-·)) production in the gut, liver, and lungs (n = 32 rats) and one for the measurement of endotoxin in portal and systemic circulation (n = 32 rats). Four animal groups (sham, clonidine, H/S, and clonidine-H/S group) were used in each arm. Three hours after H/S and concominant blood resuscitation, tissues were collected for LOOHs and O(2)(-·) measurement and blood samples were obtained for endotoxin determination. RESULTS: Clonidine pre-treatment prior to H/S resulted in a significant reduction of LOOHs and O(2)(-·) production in all vital organs (P < 0.05-0.001), while additionally, clonidine reduced H/S-induced endotoxemia in portal (P < 0.05) and systemic circulation as well (P < 0.01). DISCUSSION: Clonidine pre-treatment prevents endotoxemia and OS in the gut, liver, and lungs of rats subjected to severe H/S. The improved intestinal barrier function probably stems from the antioxidant effect of clonidine on the intestinal epithelium, whereas the reduced endotoxemia may contribute to a decreased OS observed in the liver and lungs.

Quantification of superoxide radical production in 4 vital organs of rats subjected to hemorrhagic shock.

OBJECTIVE: The aim of this study was to measure the production of superoxide radical (O2-), a direct indicator of oxidative stress, in 4 vital organs of rats subjected to hemorrhagic shock. For this purpose, and for the first time, a new quantitative assay for the ex vivo measurement of O2- via an established 1:1 molar relationship between O2- and 2-OH-ethidium was used. The production of lipid hydroperoxides (LOOHs), a standard method of evaluation of oxidative stress, was also used for reasons of comparison. METHODS: Sixteen male Wistar rats were divided into 2 groups: sham and hemorrhagic shock, targeting to a mean arterial pressure of 30 to 40 mm Hg for 60 minutes. Three hours after resuscitation, tissues were collected for measurement of LOOHs and O2- production. RESULTS: Hemorrhagic shock induced increased production of LOOHs in the gut, liver, and lungs (P<.001), whereas the production of O2- was also increased in the gut (P<.001), liver (P<.001), and, to a lesser extent, in the lungs (P<.05). The oxidative load of the kidneys, as estimated by both techniques, remained unaffected. CONCLUSION: The results of this new O2- assay were comparable with the results of the established LOOHs method, and this assay proved to be accurate and sensitive in the detection and quantification of O2- production in all organs tested. Thus, the proposed direct measurement of O2- in critically ill patients often facing in extremis situations could be used as a prognostic tool and as a method to evaluate therapeutic interventions in the setting of emergency medicine.

Vardenafil effect on ureteric smooth muscle: in vitro study in porcine model.

INTRODUCTION: Phosphodiesrase type 5 inhibitors have been recently reported to induce a relaxing effect on ureteral smooth muscle. We conducted an in vitro study to elucidate the relaxing effect of various doses of vardenafil on the porcine ureter. Moreover, we propose a porcine ureter model for the evaluation of the effect of different substances on the ureter. MATERIALS AND METHODS: A total number of 24 ureters were obtained by domestic pigs. The obtained ureteral specimens were immediately placed in Krebs solution. All specimens were cut into 4- to 5-mm-long tubular segments, which were mounted in 10 mL vertical chambers of an organ bath system. The same specific conditions were set to the organ bath device for all specimens. The tubular segments were connected to a force/pressure transducer device. After automatic ureteral contractions with stable frequency were achieved, different doses of vardenafil (0.1, 1, and 10 µM) were added to the bath chambers. Isometric responses of the tissues throughout the experiment were recorded and statistically analyzed. RESULTS: The administration of vardenafil resulted in reduction of both rate and tension of the ureteral contraction regardless of the dose of vardenafil. Nevertheless, statistical analysis revealed significantly reduced ureteral contraction rate and tension when vardenafil 1 or 10 µM was administered in comparison to the initial steady state. CONCLUSION: Vardenafil concentrations of 1 and 10 µM should be considered as appropriate for ureteral relaxation. The porcine model replicates human ureteral response in vitro at least in the case of phosphodiesrase type 5 inhibitors and probably would be useful for the evaluation of other pharmaceutical agents.

Optimized perioperative analgesia reduces chronic phantom limb pain intensity, prevalence, and frequency: a prospective, randomized, clinical trial.

BACKGROUND: Severe preamputation pain is associated with phantom limb pain (PLP) development in limb amputees. We investigated whether optimized perioperative analgesia reduces PLP at 6-month follow-up. METHODS: A total of 65 patients underwent lower-limb amputation and were assigned to five analgesic regimens: (1) Epi/Epi/Epi patients received perioperative epidural analgesia and epidural anesthesia; (2) PCA/Epi/Epi patients received preoperative intravenous patient-controlled analgesia (PCA), postoperative epidural analgesia, and epidural anesthesia; (3) PCA/Epi/PCA patients received perioperative intravenous PCA and epidural anesthesia; (4) PCA/GA/PCA patients received perioperative intravenous PCA and general anesthesia (GA); (5) controls received conventional analgesia and GA. Epidural analgesia or intravenous PCA started 48 h preoperatively and continued 48 h postoperatively. The results of the visual analog scale and the McGill Pain Questionnaire were recorded perioperatively and at 1 and 6 months. RESULTS: At 6 months, median (minimum-maximum) PLP and P values (intervention groups vs. control group) for the visual analog scale were as follows: 0 (0-20) for Epi/Epi/Epi (P = 0.001), 0 (0-42) for PCA/Epi/Epi (P = 0.014), 20 (0-40) for PCA/Epi/PCA (P = 0.532), 0 (0-30) for PCA/GA/PCA (P = 0.008), and 20 (0-58) for controls. The values for the McGill Pain Questionnaire were as follows: 0 (0-7) for Epi/Epi/Epi (P < 0.001), 0 (0-9) for PCA/Epi/Epi (P = 0.003), 6 (0-11) for PCA/Epi/PCA (P = 0.208), 0 (0-9) for PCA/GA/PCA (P = 0.003), and 7 (0-15) for controls. At 6 months, PLP was present in 1 of 13 Epi/Epi/Epi, 4 of 13 PCA/Epi/Epi, and 3 of 13 PCA/GA/PCA patients versus 9 of 12 control patients (P = 0.001, P = 0.027, and P = 0.009, respectively). Residual limb pain at 6 months was insignificant. CONCLUSIONS: Optimized epidural analgesia or intravenous PCA, starting 48 h preoperatively and continuing for 48 h postoperatively, decreases PLP at 6 months.

Peak body temperature predicts mortality in critically ill patients without cerebral damage.

OBJECTIVES: We investigated whether mortality in intensive care unit (ICU) patients without cerebral damage is associated with fever manifestation and characteristics. METHODS: Patients admitted to a medical-surgical ICU between October 2005 and July 2006 were prospectively studied. Exclusion criteria were acute brain injury, intracerebral/subarachnoid hemorrhage, ischemic stroke, and brain surgery. An ear-based or axillary thermometer was used to measure body temperature. The association between fever (ear-based temperature, >38.3 degrees C), fever characteristics, and ICU mortality was evaluated using univariate and multivariate analysis. RESULTS: Two hundred and thirty-nine patients were enrolled. Fever was not associated with ICU mortality after adjustment for confounding patient factors. A significant dose-response increase of ICU mortality according to 1 degree C increments of peak body temperature was demonstrated, whereas peak body temperature was an independent predictor of ICU mortality. CONCLUSION: These findings imply that, although fever is not generally associated with mortality in patients without cerebral damage, it can be harmful and should be suppressed when it becomes very high. Rigorous clinical trials are needed to help establish antipyretic therapy guidelines.

Prolonged high-dose intravenous magnesium therapy for severe tetanus in the intensive care unit: a case series.

INTRODUCTION: Tetanus rarely occurs in developed countries, but it can result in fatal complications including respiratory failure due to generalized muscle spasms. Magnesium infusion has been used to treat spasticity in tetanus, and its effectiveness is supported by several case reports and a recent randomized controlled trial. CASE PRESENTATIONS: Three Caucasian Greek men aged 30, 50 and 77 years old were diagnosed with tetanus and admitted to a general 12-bed intensive care unit in 2006 and 2007 for respiratory failure due to generalized spasticity. Intensive care unit treatment included antibiotics, hydration, enteral nutrition, early tracheostomy and mechanical ventilation. Intravenous magnesium therapy controlled spasticity without the need for additional muscle relaxants. Their medications were continued for up to 26 days, and adjusted as needed to control spasticity. Plasma magnesium levels, which were measured twice a day, remained in the 3 to 4.5 mmol/L range. We did not observe hemodynamic instability, arrhythmias or other complications related to magnesium therapy in these patients. All patients improved, came off mechanical ventilation, and were discharged from the intensive care unit in a stable condition. CONCLUSION: In comparison with previous reports, our case series contributes the following meaningful additional information: intravenous magnesium therapy was used on patients already requiring mechanical ventilation and remained effective for up to 26 days (significantly longer than in previous reports) without significant toxicity in two patients. The overall outcome was good in all our patients. However, the optimal dose, optimal duration and maximum safe duration of intravenous magnesium therapy are unknown. Therefore, until more data on the safety and efficacy of magnesium therapy are available, its use should be limited to carefully selected tetanus cases.

Lung dysfunction following cardiopulmonary bypass.

BACKGROUND: It is well known by now that during open heart surgery many detrimental factors are involved in lung injury. The influence mainly of cardiopulmonary bypass (CPB), anesthesia, hypothermia, operation itself, as well as medication and transfusion, can cause a diffuse injury in the lungs, which most often leads to a postoperative pulmonary edema and abnormal gas exchange. METHODS: We performed an unrestricted search of Pubmed Medline and EMBASE from 1966 through 2008. Clinical, experimental, basic science, and review papers were included. RESULTS: The hypothesis that a systemic inflammatory reaction takes place after the use of CPB, could explain most of these effects influences in the lung. On the other hand, the release of various pro-inflammatory cytokines like TNF-á, IL-1, IL-2, IL-6, IL-8, and endotoxin during CPB can lead to the entrapment of neutrophils in the pulmonary capillaries. Consequently, the following chain of reactions is likely to occur: an endothelial cell swelling, plasma and protein extravasation into the interstitial tissue, release of proteolytic enzymes, congestion of the alveoli with plasma, erythrocytes and inflammatory debris. CONCLUSION: In this review we highlight the possible pathophysiological mechanisms implicated in the observed postoperative lung dysfunction.

Sepsis requiring intensive care following intramuscular injections: two case reports.

INTRODUCTION: Intramuscular injections can rarely result in serious infectious complications such as abscesses which may progress to bacteraemia and generalized sepsis. These complications are rare, but can be life threatening, as they can lead to multi-organ failure associated with high morbidity and mortality. CASE PRESENTATION: In this report we present two patients who developed life-threatening infections after intramuscular injections. They were admitted to the hospital, had prompt surgical drainage, required ICU admission for severe sepsis, were treated with an early goal-directed therapy protocol and had a good outcome. CONCLUSION: Sepsis is a rare, potentially life-threatening complication after intramuscular injections. Timely surgical drainage followed by appropriate ICU care and early goal directed therapy is crucial and may contribute to a good outcome in these rare cases.