ABSTRACT
Ventilator-associated pneumonia is a life-threatening disease causing an increased morbidity, cost and length of stay in the intensive care unit. This document is an evidence based consensus which discusses preventive measures including medical recommendations and practices for cleaning and handling mechanical ventilators. Standard and contact precautions are critical preventive measures
Subject(s)
Humans , Pneumonia/prevention & control , Respiration, Artificial/adverse effects , Antibiotic Prophylaxis , Sterilization/methods , Gastrointestinal Hemorrhage , Intubation, Intratracheal/methods , Pneumonia/etiology , Risk FactorsABSTRACT
Splanchnic hypoperfusion, with pathogenic implications for multiple organ failure, can occur during septic shock. We report four patients with septic shock in whom regional hepatosplenic splanchnic perfusion was monitored through suprahepatic vein catheterization and gastric tonometry. Suprahepatic lactate and oxygen saturation showed splanchnic hypoperfusion in all patients. These parameters improved only in the patient that survived. Gastric tonometry was more inconsistent. We conclude that suprahepatic vein catheterization could have a role in the management of septic shock
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Catheterization , Shock, Septic/therapy , Manometry , Multiple Organ Failure/complications , Splanchnic Circulation/physiology , Shock, Septic/etiology , Hepatic VeinsABSTRACT
Cardiopulmonary extracorporeal assistance is a high complexity procedure for patients with acute respiratory failure, who have failed conventional ventilatory support. A 30 years old female patient with bacterial endocarditis and congestive cardiac failure subjected to cardiac surgery presented severe hypoxemia, right heart failure and pulmonary hypertension, and failed conventional treatment. Cardiopulmonary support with extracorporeal membrane oxygenation (ECMO) reverted the pathophysiologic alterations allowing a successful recovery
Subject(s)
Humans , Adult , Female , Endocarditis , Extracorporeal Circulation/methods , Respiratory Distress Syndrome/surgery , Rheumatic Diseases/complications , Mitral Valve Insufficiency/surgery , Cardiopulmonary Resuscitation/methodsABSTRACT
Lung computed tomography (CT) is being used increasingly to assess lung morphology in patients on mechanical ventilation. Lung CT under known levels of airway pressure (dynamic CT) can also assess the response of lung parenchyma to ventilatory therapy. We report a patient with acute respiratory distress syndrome secondary to descending necrotizing mediastinitis, in whom lung dynamic CT oriented ventilatory management. Independent lung ventilation improved gas exchange and helped patient recovery
Subject(s)
Humans , Male , Adult , Mediastinitis , Respiratory Distress Syndrome/etiology , Respiration, Artificial/methods , Respiratory Distress Syndrome/therapy , Tomography, X-Ray Computed/methodsABSTRACT
Background: Amphotericin B is efficacious for the treatment of systemic candidiasis, however it has potentially serious toxic effects. Administration as lipid emulsions has been advocated to decrease its toxicity. Aim: To compare the safety and tolerance of amphotericin B administered as lipid emulsion or dissolved in dextrose in water. Patients and methods: Forty five patients with confirmed or highly suspected systemic candidiasis were studied. Between January 1996 and June 1997 amphotericin B was administered in dextrose in water to 17 patients (group 1). Between July 1997 and December 1998, the drug was delivered in lipid emulsions (Intralipid, group 2). Clinical and laboratory parameters (serum creatinine, urea nitrogen and potassium), were assessed daily. Results: Both treatment groups were clinically comparable and had the same survival. Accumulative amphotericin B dose administered was 343.2 ñ 197 and 414.6 ñ 518 mg respectively. Hypokalemia was more frequent in group 2 (52 and 25 percent respectively, p < 0.05). There were no differences in the outcome of renal function or other adverse reactions. Conclusions: Administration of amphotericin B as lipid emulsions did not reduce its toxicity in critical patients
Subject(s)
Humans , Female , Male , Adult , Middle Aged , Candidiasis/drug therapy , Amphotericin B/pharmacology , Drug-Related Side Effects and Adverse Reactions/prevention & control , Candida/isolation & purification , Candida/drug effects , Amphotericin B/administration & dosage , Amphotericin B/adverse effects , Drug Tolerance , Hypokalemia/chemically induced , Critical IllnessABSTRACT
Background: in 1992, a consensus conference defined the terms systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock. Since then, numerous reports have validated the prognostic usefulness of these operative definitions. Aim: to evaluate if sepsis severity criteria, as defined by the Consensus Conference, can be applied to noninfectious SIRS. Patients and methods: five hundred eighteen patients admitted to 5 intensive care units (ICU) from 4 hospitals were prospectively evaluated during a 3 months period. Patients that met at least one severity criteria were included. SIRS etiology, organ dysfunction and evolution were recorded in each patient. Results: One hundred two patients were included: 79 with sepsis (group I) and 23 with noninfectious SIRS (group II). ICU and hospital mortality were comparable (43 and 48 percent in sepsis compared to 43 and 51 percent in non infectious SIRS). The most common sources of sepsis were pneumonia and peritonitis. Group II patients had a wide variety of diseases. ICU stay, APACHE score and number of organs with dysfunction were not different among groups. Only the incidence of renal dysfunction was higher in the septic group. Conclusions: The Consensus sepsis severity criteria can be applied to noninfectious SIRS, defining a population subset with similar high mortality and organ dysfunction incidence, although with greatly heterogeneous etiologies
Subject(s)
Humans , Male , Female , Adolescent , Adult , Middle Aged , Sepsis/diagnosis , Systemic Inflammatory Response Syndrome/diagnosis , Peritonitis/complications , Sepsis/etiology , Gram-Negative Bacteria/pathogenicity , Intensive Care Units , Clinical Evolution , Pneumonia/complications , Prognosis , Systemic Inflammatory Response Syndrome/etiologyABSTRACT
Splanchnic ischemia is frequent in sepsis and septic shock and is related to impairment in intestinal permeability, derangement in mucosal barrier functions and translocation of proinflammatory mediators. These changes can contribute to the pathogenesis of multiple organ failure. Vasoactive drugs such as dobutamine and dopexamine can improve splanchnic perfusion and gastric intramucosal pH during sepsis. However, contradictory results have been obtained with dopamine and norepinephrine. On the other hand, epinephrine further impairs splanchnic perfusion. In view of the contradictory effects of different vasoactive drugs, gastric tonometry must be measured during their use, to find the optimal drug combination that optimizes splanchnic blood flow
Subject(s)
Catecholamines/pharmacology , Sepsis/complications , Splanchnic Circulation , Catecholamines/classification , Dopamine/pharmacology , Norepinephrine/pharmacology , Dobutamine/pharmacology , Hydrogen-Ion Concentration , Shock, SepticABSTRACT
Patients with severe head injury are prone to pulmonary complications that result in hypoxemia or hypercarbia, which could worsen their neurological condition. A rational ventilatory approach requires a good knowledge of respiratory and neurological pathophysiology. Airway management is of prime importance in neurological patients. Prophylactic chronic hyperventilation in head trauma is no longer recommended since it could impair cerebral perfusion, although transient hypocarbia could be of benefit to some patients. The use of low or moderate positive and expiratory pressure levels apparently improves oxygenation without worsening intracranial pressure. Ventilatory management should be closely monitored and adjusted to hemodynamic, respiratory and neurological status to achieve a good outcome
Subject(s)
Central Nervous System Diseases/therapy , Respiration, Artificial/methods , Brain Injuries/complications , Brain Injuries/therapy , Ventilator Weaning , Central Nervous System Diseases/complications , Hyperventilation/etiology , Hyperventilation/physiopathology , Lung Diseases/etiologyABSTRACT
Traditionally Pulmonary wedge pressure (PWP) determination with Swan-Ganz catheter has been the gold standard to estimate ventricular preload in critically ill patients. However, the correlation between PWP and left ventricular telediastolic volume is poor, and the tecnique does not allow any estimation of extravascular lung water (EVLW). In the last years, several techniques have been developed to improve assessment of intra and extravascular volumes. Two tracers transcardiopulmonary dilution method was developed by Pearce et al in the early 60ïs. It used a thermal tracer to estimate intrathoracic total volumen (ITTV), and a colorimetric tracer for estimting intrathoracic blood volume (ITBV). The difference between ITTV and ITBV is called EVLW. Recently, the technique has been simplified to use just the thermal tracer. The Pulse Contour Cardiac Output computer (PiCCO, Pulsion Medizintechnik, Germany), allows a continous measurement of cardiac output and an intermittent measurement of ITTV, ITBV and EVLW. The use of this new technique could improve patient management, allowing optimal fluids administration without producing lung edema. Besides the PiCCO computer, both a standard central venous line in an upper body vein and a specially designed femoral artery line to measure thermal tracer dissipation are required. Preliminary experience has shown that it is a reliable method, with low morbidity and easy implementation, and may be a promising and useful tool in critical care patients
Subject(s)
Humans , Extravascular Lung Water , Blood Volume/physiology , Blood Pressure , Cardiac Output , Catheterization, Swan-Ganz , Thermodilution/methodsABSTRACT
Quisimos evaluar la aplicabilidad y eficacia de la ventilación con presión positiva no invasiva (VPPNI) en pacientes con insuficiencia respiratoria aguda (IRA) hipoxémica y aumento del trabajo respiratorio. En un periodo de 10 meses evaluamos a 64 pacientes que ingresaron a nuestro servicio con el diagnóstico de IRA y signos de fatiga muscular, en ausencia de patología crónica. Fueron considerados no aptos para VPPNI quienes tuvieran compromiso de conciencia importante, inestabilidad hemodinámica o más de dos órganos en falla, cirugía reciente de esófago, estómago o duodeno, hemorragia digestiva alta activa, distensión abdominal importante o dificultad en el manejo de secreciones. Luego de aplicar los criterios de exclusión, 14 (23 por ciento) pacientes fueron sometidos a VPPNI por un periodo de 1 a 9 días. La Pa/FiO2, sin cambios significativos en la PaCO2 y frecuencia respiratoria. En 5 pacientes (36 por ciento) fracasó el método, de los cuales 2 fallecieron. Un paciente presentó una escara nasal. Por su mínima invasividad y fácil aplicación, la VPPNI debe ser considerada precozmente en todo paciente con IRA hipoxémica con buen nivel de conciencia y que preserve su ventilación espontánea
Subject(s)
Humans , Male , Female , Respiration, Artificial/methods , Respiratory Insufficiency/therapy , Intermittent Positive-Pressure Ventilation/methods , Hypoxia/therapy , Intermittent Positive-Pressure Ventilation/instrumentationABSTRACT
El entrenamiento de la musculatura inspiratoria durante el weaning ventilatorio es fundamental para aumentar sus capacidades y cualidades motoras a través de una planificación que considere tanto las reservas energéticas aeróbicas como anaeróbicas. Estas últimas son responsables de acciones musculares de alta intensidad y limitadas en el tiempo. La determinación del umbral de disparo máximo, que probablemente corresponda a una de las actividades, y la influencia de esta variable en el volumen corriente son descritas en el presente estudio
Subject(s)
Humans , Male , Female , Aged , Inspiratory Capacity/physiology , Ventilator Weaning , Basal Metabolism , Respiratory Muscles/physiology , Respiratory Function TestsABSTRACT
Acute respiratory distress syndrome (ARDS) secondary to systemic injury has a high mortality. Symptomatic treatment with mechanical ventilation, PEEP and high levels of inspired oxygen is effective for most of the patients. When ventilatory support fails in reversing hypoxemia, extracorporeal respiratory assistance has been advocated as a temporary treatment until lung repair occurs. We described our experience in eleven patients (9M, 2F, 41ñ16 yo) with severe ARDS refractory to conventional treatment and expected to die if not assisted with extracorporeal oxugenation. All patients required invasive monitoring; seven needed continuous renal therapy because of concurrent renal failure. Venous-venous percutaneous cannulation and systemic anticoagulation were performed and axtracorporeal oxygenation and CO2 removal started with blood pump flows of 20 to 30 percent of patient cardiac output. Improved oxygenation and decreased CO2 levels were immediately observed in 10/11 patients. One patient failed to have reversal of hypoxemia because recirculation and died shortly after initiation of extracorporeal therapy. Plasma leak syndrome and bleeding were observed in 3 and 2 patients respectively. Extracorporeal assistance was mantained for 52ñ34 h (19-134). Five (45 percent) patients were weaned off the pump and two (18 percent) survived and were discharged. Despite the high cos, extracorporeal respiratory assistance, when applied to selected patients, can reverse hypoxia and may save some previously unsalvagable patients allowing them to return to a normal life
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Respiration, Artificial/methods , Respiratory Distress Syndrome/therapy , Acute Disease , Multiple Trauma/complications , Ventilators, MechanicalABSTRACT
Inhalation therapy with nitric oxide has been suggested as beneficial in the adult respiratory distress syndrome, however there are few reports of its prolonged use. We report a patient with a chronic lymphocytic leukemia that developed an adult respiratory distress syndrome with severe hypoxemia, refractory to conventional therapeutic measures, during the course of a septic shock. The patient received nitric oxide (19 ppm) improving arterial oxygen saturation and allowing the reduction of FiO2 to 40 percent. The patient died 5 days later due to a multiple organ failure
Subject(s)
Humans , Male , Aged , Nitric Oxide/administration & dosage , Respiratory Distress Syndrome/therapy , Hemodynamics , Leukemia, Lymphoid/complications , Blood Pressure , Shock, Septic/complicationsABSTRACT
To assess the acute effects of methylene blue infusion, an inhibitor of nitric oxyde synthesis, on hemodynamic parameters in patients with refractory septic shock. Fourteen patients admitted to intensive care units with septic shock of diverse etiologies and unable to maintain median arterial pressures over 60 mm Hg with the use of at least 2 vasoactive drugs, were studied. All received a 1 mg/kg bolus of methylene blue. Hemodinamic parameters were measured before and 30, 60, 120 and 180 min after the bolus. Systolic and diastolic blood pressure and systemic vascular resistance increased in all patients. There were no significant changes in cardiac output, oxygen consumption or extraction. Methylene blue has an acute pressor effect in patients with septic shock
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Guanylate Cyclase/antagonists & inhibitors , Methylene Blue/pharmacology , Nitric Oxide/antagonists & inhibitors , Systemic Inflammatory Response Syndrome/drug therapy , Vascular Resistance/drug effects , Vasoconstrictor Agents/pharmacology , Hemodynamics , Blood Pressure , Central Venous Pressure , Clinical ProtocolsABSTRACT
Background: Vasoactive drugs used in the reanimation of septic patients, can modify splanchnic perfusion. Aim: To compare the effects of dobutamine and amrinone on gastric intramucosal pH (pHi), lactate levels and hemodynamics in surgical patients with compensated septic shock. Patients and methods: Fourteen postoperative patients with abdominal sepsis and compensated septic shock (pHi <7.32 or lactate >2.5 mmol/l) were studied in a prospective, randomized, unblinded study. Patients were randomized to receive (Group 1, n=7) dobutamine at 5 µg/Kg/min or (Group 2, n=7) amrinone at 5 µg/Kg/min. Hemodynamic data, arterial lactate and pHi were measured before and 30, 60 and 120 minutes after starting drug infusion. Results: Both drugs were associated with a decrease in lactate levels. Dobutamine infusion, but not amrinone, increased gastric pHi, as well as cardiac index and oxygen delivery. Conclusions: An improvement in gastric pHi associated with an increase in oxygen delivery, was observed with dobutamine. Amrinone showed no effect at the fixed, low dose used in the study
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Amrinone/pharmacology , Dobutamine/pharmacology , Shock, Septic/drug therapy , Postoperative Complications/drug therapy , Abdomen, Acute/surgery , Lactates/metabolism , Lactates/blood , Splanchnic Circulation , Hydrogen-Ion Concentration , Shock, Septic/etiologyABSTRACT
Sepsis is the commonest complication of small bowel transplantation. These infections are presumibly caused by bacterial translocation, due to splachnic ischemia. To study bacterial translocation in the inmediate postoperative period after small bowel transplantation in dogs and to relate it to splanchnic ischemia. Three groups of dogs were studied. In group A (n=6) spontaneous episodes of splanchnic schemia were monitored in the first 18 hrs of the postoperative period. In group B (n=5) a 60 min ischemia was induced by superior mesenteric artery occlusion, 2 hours after small bowel transplantation. In group C (n=5) a 60 min ischemia was induced by occlusion of mesenteric vein, 2 hrs after transplantation. Bacterial translocation was assessed through bacterial cultures from the mesenteric vein and splanchnic ischemia with intramucosal pH measurement (a pH<7.2 was considered indicative of ischemia). 28 of 83 cultures were positive, specially for Gram negative bacilli. The incidence of positive cultures was 14 percent for group A, 17 percent for group B and 79 percent for group C (p<0.01 cpmpared to groups A and b). The higher incidence of bacterial translocation occurred during the first 2 hours after transplantation, when the lower intramucosal pH recording were obtained. The percentage of positive cultures was 39 percent during periods of ischemia, compared to 24 percent during periods without ischemia (p=NS). Bacterial translocation occurs during the first 2 hours after intestinal transplantation in concomitance with the lower intramucosal pH readings
Subject(s)
Animals , Dogs , Translocation, Genetic/physiology , Transplantation, Autologous/immunology , Intestine, Small/transplantation , Surgical Procedures, Operative , Bacteria/isolation & purification , Endotoxins/isolation & purification , Ischemia/physiopathology , HemodynamicsABSTRACT
Leptospirosis is a world-spread zoonosis that is incidentally acquired by humans. It causes a diphasic febrile illness in which the Weil syndrome is its severest form, with renal, hepatic, clotting and central nervous system involvement. We report a 73 years old male, that was admitted to an intensive care unit with multiple organ failure due to leptospirosis. The clinical picture initially resembled a sepsis due to biliary tract obstruction and was operated, not finding a biliary tract obstruction. Considering the history of a fall to sewed waters, leptospirosis was suspected and treatment with penicillin was started, obtaining a full recovery of the patient
Subject(s)
Humans , Male , Aged , Leptospirosis/complications , Multiple Organ Failure/etiology , Penicillins/administration & dosage , Leptospira/pathogenicity , Leptospirosis/drug therapyABSTRACT
Adult respiratory distress syndrome is highly prevalent in intensive care units and has a high mortality. Lately, nitric oxide has been used as adjuvant therapy. To study the effects of nitric oxide inhalation in patients with adult respiratory distress syndrome, 12 patients were subjected to nitric oxide inhalation at a concentration of 10 parts per million, during 30 minutes. At the end of the nitric oxide inhalation period, there was an improvement of PaO2/FIOa ratio from 89ñ32 to 111ñ43 mm Hg and 16 percent reduction of lung shunting (Qs/Qt). Nitric oxide inhalation at a concentration of 10 parts per million improved arterial oxygenation and reduced pulmonary shunting in patients with adult respiratory distress syndrome
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Nitric Oxide/pharmacokinetics , Respiratory Distress Syndrome/therapy , Respiratory Therapy , Pulmonary Gas Exchange/physiology , Hemodynamics , Respiratory Distress Syndrome/physiopathologyABSTRACT
Background: Acute brain injury is associated with a bimodal hypermetabolic state probably caused by cytokine secretion and high hormone and catecholamine concentrations. In a first stage, the brain would produce these substances and afterwards, another production source, most probably the splanchnic territory, would perpetuate the hypermetabolic state. Aim: To investigate the cytokine production source and to assess intestinal permeability in acute brain injury in the absence of cerebral ischemia and systemic oxygen deficit. Patients and methods: Arterial systemic and cerebral venous bulbar interleukin 1 õ and interleukin 6 levels were measured during the first seven days of evolution in 15 patients with acute brain injury. Serum lactate, the oxygen/lactate ratio, gastric intramucosal pH and intestinal permeability using the lactulose/mannitol test were also assessed in the same period. Results: High arterial and venous interleukin 1 õ and interleukin 6 levels were detected. A positive gradient for interleukin 6 levels was detected throughout the study period with normal intramucosal pH, lactate and oxygen/lactate ratio. There was also an early impairment of intestinal permeability in these patients. Conclusions: High arterial and venous cytokine concentrations were detected in patients with acute brain injury. The positive gradient for interleukin 6 suggests a brain origin for this cytokine. Intestinal permeability is also altered in these patients