Decontamination of the digestive tract and oropharynx in ICU patients.

BACKGROUND: Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. METHODS: We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. RESULTS: A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. CONCLUSIONS: In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

Painful Recall in Elective Electrical Cardioversion with Propofol and the Need for Additional Analgesia.

INTRODUCTION: Electrical cardioversion (ECV) is a short but painful procedure for treating cardiac dysrhythmias. There is a wide variation regarding the medication strategy to facilitate this procedure. Many different sedative techniques for ECV are described. Currently, the optimal medication strategy to prevent pain in ECV has yet to be established. The role for additional analgesic agents to prevent pain during the procedure remains controversial, and evidence is limited. METHODS: We conducted a prospective multicenter study to determine the incidence of painful recall in ECV with propofol as a sole agent for sedation, in order to assess the indication for additional opioids. In all patients, sedation was induced with propofol titrated till loss of eyelash reflex and nonresponsiveness to stimuli, corresponding to Ramsay Sedation Score level 5-6. ECV was performed with extracardiac biphasic electrical shocks. The primary outcome was painful recall of the procedure, defined as numeric pain rating scale (NRS) ≥ 1. NRS ≥ 4 is considered inadequately treated pain. Secondary outcome parameters were pain at the side of the defipads and muscle pain after ECV. RESULTS: A total of 232 patients were enrolled in this study. Six patients were excluded due to missing data or violation of study protocol. Three patients reported recall of the procedure, and one patient (0.4%) reported recall of severe pain during the procedure with NRS 7. Two patients (0.9%) reported recall of mild pain with NRS 1-3. Complete amnesia was observed in 223 patients (98.7%), with NRS 0. The mean of the total dose of propofol was 1.1 mg/kg. Fifteen patients (6.6%) experienced pain at the side of the defipads, and six patients (2.7%) complained of muscle pain after the procedure. CONCLUSIONS: In this prospective multicenter study, propofol as a sole agent provided good conditions for ECV with a low incidence of recall. Effective sedation and complete amnesia was achieved in 98.7% of the patients, 0.4% of patients reported recall of severe pain during the procedure, and 0.9% of patients experienced mild pain during the ECV.

A rare stress cardiomyopathy in a patient with Guillain-Barré syndrome.

We report on a 39-year-old woman who was intubated because of progressive respiratory failure due to muscle weakness and mucous plugging because of Guillain- Barré syndrome. Shortly after uncomplicated intubation she developed hypotension and a profound tachycardia. The electrocardiogram showed sinus tachycardia with nonspecific ST-T segment changes. Echocardiography showed akinesia of the apex, septum and inferior left ventricular wall with an estimated left ventricular ejection fraction of 10%. It was concluded that the patient was suffering from takotsubo cardiomyopathy. Following treatment, she experienced a complete recovery. Takotsubo cardiomyopathy is a rare complication in Guillain-Barré syndrome; eight other cases have been reported in the literature.

Preventing ventriculostomy-related infections with antibiotic-impregnated drains in hospitals: a two-centre Dutch study.

This observational cohort study assessed the effect of the introduction of antibiotic-impregnated external ventricular drains (AI-EVDs), as opposed to plain silicone EVDs, on the occurrence of ventriculostomy-related infections (VRIs) in two Dutch hospitals, with no other changes to their clinical practice. VRI was defined using the criteria of the Centers for Disease Control and Prevention, and with a culture-based definition. A propensity-score-adjusted competing risks survival analysis showed that introduction of AI-EVDs did not significantly decrease the risk of VRIs in routine care, nor affect the bacterial aetiology, even after adjustment for confounding and competing events.

Ventilator setting in ICUs: comparing a Dutch with a European cohort.

BACKGROUND: From data collected during the third International Study on Mechanical Ventilation (ISMV), we compared data from a Dutch cohort with a European cohort. We hypothesised that tidal volumes were smaller and applied positive end-expiratory pressure (PEEP) was higher in the Netherlands, compared with the European cohort. We also compared use of non-invasive ventilation (NIV) and outcomes in both cohorts. METHODS: A post-hoc analysis of a prospective observational study of patients receiving mechanical ventilation. RESULTS: Tidal volumes were smaller (7.6 vs. 8.1 ml÷kg predicted bodyweight) in the Dutch cohort and applied PEEP was higher (8 vs. 6 cm H2O). Fewer patients admitted in the Netherlands received NIV as first mode of mechanical ventilation (7.1 vs. 16.7%). Fewer patients in the Dutch cohort developed an ICU-acquired pneumonia (4.5 vs. 12.3%, p < 0.01) and sepsis (5.7 vs. 10.9%, p = 0.03), but more patients were diagnosed as having delirium (15.8 vs. 4.6%, p < 0.01). ICU and in-hospital mortality rates were 19% and 25%, respectively, in Dutch ICUs vs. 26% and 33% in Europe (p = 0.06 and 0.03). CONCLUSION: Tidal volumes were smaller and applied PEEP was higher in the Dutch cohort compared with international data, but both Dutch and international patients received larger tidal volumes than recommended for prevention or treatment of acute respiratory distress syndrome. NIV as first mode of mechanical ventilation is less commonly used in the Netherlands. The incidence of ICU-acquired pneumonia is lower and of delirium higher in the Netherlands compared with international data.

Troponin I in predicting cardiac or pulmonary complications and outcome in subarachnoid haemorrhage.

BACKGROUND: Patients with aneurysmal subarachnoid haemorrhage (SAH) are at risk of cardiac and pulmonary complications. Troponin I (cTnI), a reliable marker of myocardial injury, is frequently raised after SAH. AIMS: To investigate the additional value of (cTnI) in predicting cardiac or pulmonary complications and outcome in patients with SAH. METHODS: Admission cTnI was measured in a prospective series of patients admitted within 24 hours of SAH. By means of univariate and multivariate logistic regression models the additional prognostic value of raised cTnI (>0.3 microg/litre) was investigated compared with established prognosticators (clinical condition on admission, age, and amount of blood on admission computed tomography) for predicting the occurrence of pulmonary oedema, pulmonary gas exchange abnormalities, rhythm disturbances, inadequate cardiac performance, a combination of these complications, and poor outcome. Area under the operator characteristic curve (AUC-ROC) was used to assess additional prognostic value. RESULTS: Abnormal cTnI concentrations were found on admission in 35 of 68 patients. Abnormal cTnI concentrations and poor clinical condition independently predicted cardiac or pulmonary complications. After extending the model with World Federation of Neurological Surgeons scale and age in addition to abnormal cTnI, the AUC-ROC improved from 0.70 (95% confidence interval (CI), 0.57 to 0.83) to 0.83 (95% CI, 0.72 to 0.93). Abnormal cTnI also independently predicted poor outcome. The additional prognostic value of cTnI for poor outcome is limited. CONCLUSIONS: cTnI measurement is a powerful predictor for the occurrence of pulmonary and cardiac complications, but does not carry additional prognostic value for clinical outcome in patients with aneurysmal SAH.