Risk factors for early onset pneumonia in trauma patients.

STUDY OBJECTIVES: The aim of the study was to identify risk factors for early onset pneumonia (EOP) in trauma patients, in order to seek possible intervention strategies. STUDY POPULATION: Participants included 124 consecutive trauma patients admitted to a general intensive care unit (ICU) of a university hospital from December 1990 to February 1992 inclusive. DATA COLLECTION: The following data were prospectively collected for each patient: demographics, severity of trauma according to the abbreviated injury scale (AIS), severity of coma according to the Glasgow coma scale (GCS), presence of pneumothorax, pulmonary contusion, rib fractures, hemothorax, and mechanical ventilation. All patients were monitored daily during the ICU stay for the onset of pneumonia, sepsis syndrome, septic shock, and adult respiratory distress syndrome (ARDS). Criteria for the diagnosis of pneumonia were: core temperature of greater than 38.3 degrees C, a WBC count of 10,000 cells/mm3, purulent tracheobronchial secretions, a worsening of pulmonary gas exchange, and persistent pulmonary infiltrates. All patients with suspected pneumonia underwent quantitative bronchoalveolar lavage (BAL) as well as blood cultures; BAL cultures were considered positive when they showed bacterial growth greater than 1 x 10(5) colony-forming unit (cfu)/ml, or less than 10(5), but with the same microorganism isolated in blood cultures. Pneumonia occurring within the first 96 h after trauma was considered EOP. DATA ANALYSIS: A stepwise logistic regression analysis was carried out in order to identify factors independently associated with an increased risk of EOP and late onset pneumonia (LOP). RESULTS: Overall mortality was 43.5 percent: mortality increased by age and AIS score. Forty one patients (33.1 percent) developed pneumonia: 26 (63.4 percent) were EOP and 15 (36.6 percent) were LOP. In the univariate analysis, an age greater than 40 years, the presence of pulmonary contusion, AIS of more than 4 for thorax and of more than 9 for abdomen, and the absence of mechanical ventilation (MV) during the first 4 days of hospitalization or MV lasting less than 24 h were significantly associated with an increased risk of acquiring EOP. Logistic regression analysis showed that the strongest risk factor for EOP was a combined severe abdominal and thoracic trauma, which increased the risk of EOP by 11 times; an age of more than 40 years and MV of less than 24 h during the first 4 days of hospitalization were also independent risk factors for EOP. Factors associated with LOP were an AIS score of more than 4 for abdomen and a length of MV of more than 5 days. CONCLUSION: In a trauma population, a combined severe abdominal and thoracic trauma represents a major risk factor for EOP. Mechanical ventilation administered during the first days after trauma seems to reduce the risk of EOP. As reported in previous studies, mechanical ventilatory support lasting more than 5 days is associated with an increased risk of LOP.

Early and late onset bacteremia have different risk factors in trauma patients.

OBJECTIVE: The aim of this study was to identify risk factors and to describe epidemiological patterns for early-(EOB) and late-onset bacteremias (LOB) after trauma. DESIGN: A prospective study conducted on 141 consecutive trauma patients. SETTING: A general intensive care unit (ICU) of a university hospital. PATIENTS: All multiple trauma patients admitted to our general intensive care unit (ICU) from December 1990 to May 1992 were prospectively enrolled in the study. The following information was collected for each patient and recorded in a computer database: demography, severity of trauma according to the Abbreviated Injury Scale (AIS), severity of coma according to the Glasgow Coma Scale (GCS), presence of pneumothorax, pulmonary contusion, rib fractures, hemothorax, and abdominal trauma, use of mechanical ventilation, and placement of central venous catheters. Bacteremias were defined as EOB when onset occurred within 96 h after trauma, and as LOB when appearing after 96 h from trauma. RESULTS: Thirty-seven patients developed bacteremia during their ICU stay (26%): 11 (29.7%) EOB and 26 (70.3%) LOB. Gram-positive cocci were isolated more frequently in EOB than in LOB (chi 2 = 4.1, P = 0.04). The risk of EOB was significantly increased by the presence of pulmonary contusion [relative risk (RR) 15.0; confidence interval (CI) 1.99-113.25], pneumonia before the onset of bacteremia (RR 3.56; CI 1.17-10.69), AIS score greater than 32 and an abdominal injury score greater than 9 (RR 3.11; CI 1.02-9.49), while intravascular catheters and mechanical ventilation did not represent risk factors for EOB. LOB had a very different pattern and their risk was significantly increased by exposure to intravascular catheters (RR 4.96; CI 1.23-19.94) and to mechanical ventilation lasting more than 7 days (RR 3.6; CI 1.6-8.1). CONCLUSIONS: Scoring with the AIS of the abdominal and thoracic trauma at admission to the ICU appears a useful tool for identifying trauma patients at increased risk of EOB. A rigorous policy of catheter placement and maintenance as a means of reducing late bacteremias in trauma patients is essential.

IL-8, IL-6 and ICAM-1 in serum of paediatric patients undergoing cardiopulmonary bypass with and without cardiocirculatory arrest.

BACKGROUND: The aim of the present study was to evaluate the systemic inflammatory response to CPB in paediatric patients undergoing surgical correction of congenital heart diseases. EXPERIMENTAL DESIGN: comparative investigation. SETTING: paediatric cardiology hospital INTERVENTION: ICAM-1, IL-8, and IL-6 production were analysed before and during CPB, and after surgery in 9 paediatric patients, submitted to cardiocirculatory arrest (Group A); and in 11 without cardiocirculatory arrest (Group B). MEASURES: ICAM-1, IL-8, and IL-6 production were analysed from arterial samples before and during CPB, and after surgery. RESULTS: In group A vs group B a significant increase of IL-8 was detected during (297+/-250 vs 11+/-19 pg x ml(-1), p<0.001) and after (100+/-230 vs n.d. pg x ml(-1)) surgery and was correlated with the duration of operation (r=0.759; p=0.0001) and clamping time (r=0.738; p<0.05). After surgery in group A, IL-6 levels (35+/-43 pg x ml) were higher than those in group B (2+/-5 pg x ml), and a good correlation was observed between IL-6 and duration of aortic clamping (r=0.714; p=0.048), cardiac arrest, (r=0.714; p=0.048), and length of surgery (r=0.867; p=0.04). CONCLUSIONS: In children who underwent CPB with cardiocirculatory arrest cytokine production seems related to duration of operation and amplified by ischemia-reperfusion phenomena.