Microbiology, time course and clinical characteristics of infection in critically ill patients receiving packed red blood cell transfusion.

BACKGROUND AND OBJECTIVES: Packed red blood cell transfusion has been associated with increased infection in a variety of critically ill patient populations. We evaluated the microbiology and time course of infection in transfused patients in the intensive care unit (ICU) as no data exist on these parameters. MATERIALS AND METHODS: We performed a retrospective review of data for all patients admitted to a 24-bed medical-surgical ICU at Cooper University Hospital from July 2003 to September 2006 and entered in the Project Impact database. RESULTS: A total of 2432 patients were admitted during the study period, of which 609 underwent transfusion. Transfused patients were more likely to develop a nosocomial infection (10.5% vs. 4.9%, P < 0.001). ICU and hospital length of stay were longer in the transfused group (P < 0.001 for both). Mortality was also greater (13.1% vs. 8.7%, P = 0.001). Transfused patients had a shorter time from hospital admission to first infection (P < 0.001) and ICU admission to first infection (P < 0.001). Multivariate analysis confirmed transfusion as an independent risk factor for infection, mortality, hospital and ICU length of stay. Methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus and Acinetobacter occurred more often in transfused patients. Acinetobacter accounted for a disproportionate share of infections among transfused patients (P < 0.001). CONCLUSIONS: Transfused ICU patients have a higher incidence of nosocomial infection and worse outcomes. Transfused patients had a shorter onset of infection. Acinetobacter infection appears to be particularly common among these patients. Further investigation is merited to better elucidate the mechanism for these findings and their therapeutic and clinical implications.

Malignant thymoma. A complicated triad of SVC syndrome, cardiac tamponade, and DIC.

A patient presented with multisystem disease due to a very aggressive malignant thymoma. The case was complicated by the triad of cardiac tamponade, superior vena cava (SVC) syndrome, and disseminated intravascular coagulation (DIC). A review of the English literature reveals this to be a unique constellation of clinical symptoms and that DIC was heretofore unreported.

Comparison of wire-guided and nonwire-guided radial artery catheters.

OBJECTIVE: To determine if either wire-guided-catheters (WGC) or nonwire-guided catheters (non-WGCs) are associated with a higher rate of successful arterial cannulation overall or when evaluated by a variety of patient and operator characteristics. DESIGN: Prospective clinical trial in a ten-bed adult medical-surgical ICU in a 500-bed university hospital. PATIENTS: Adults requiring arterial cannulation for hemodynamic monitoring or frequent blood sampling. A total of 116 attempted arterial cannulations were recorded, and 112 in 67 patients were acceptable for statistical analysis. RESULTS: Overall, no difference in success rates could be demonstrated between WGC and non-WGC. WGCs were associated with a higher success rate in patients with pulses characterized as absent or weak (78% vs 37%; p=0.01). WGCs also had a greater success rate than non-WGCs for more experienced operators, whether defined by seniority (83% vs 44%; p=0.02) or by experience at arterial catheterization (81% vs 48%; p=0.02). CONCLUSION: WGCs were not associated with better success rates overall than were non-WGCs, although there were higher success rates in several subsets of patients and/or operators. Because of their significantly higher costs, WGCs cannot be recommended for routine use for arterial catheterization. In cases where successful catheterization is essential, however, there are circumstances under which they may be the preferred equipment, depending on patient characteristics and operator experience.

Peritoneal catheterization.

Procedures involving invasion of the peritoneal cavity are often performed on critically ill or injured patients. Like any invasive procedure, they require a thorough understanding not only of their techniques and indications, but also of their contraindications and complications. Used appropriately, these procedures may serve as invaluable diagnostic or therapeutic tools in the care of acutely ill patients.

Malignant hyperthermia.

Malignant hyperthermia is a pharmacogenetic disease of skeletal muscle characterized by hypermetabolism that occurs on exposure to a triggering agent or agents. The most common agents are halogenated inhalational anesthetics and succinylcholine, a depolarizing muscle relaxant. Patients who experience malignant hyperthermia are generally transferred to the ICU for ongoing treatment and monitoring for secondary complications of the disorder. Critical care practitioners must be both knowledgeable and competent to prevent and treat perioperative episodes of malignant hyperthermia. A thorough preoperative interview should be done to determine risk factors and susceptible patients. This article provides critical care nurses with sound information on the pathophysiology of malignant hyperthermia, the ability to assess the disease properly and treat the patient both before and after the crisis, and the ability to provide support and teaching to patients and patients' families to prevent the recurrence of malignant hyperthermia.