Fever in trauma patients: evaluation of risk factors, including traumatic brain injury.

BACKGROUND: The role of fever in trauma patients remains unclear. Fever occurs as a response to release of cytokines and prostaglandins by white blood cells. Many factors, including trauma, can trigger release of these factors. OBJECTIVES: To determine whether (1) fever in the first 48 hours is related to a favorable outcome in trauma patients and (2) fever is more common in patients with head trauma. METHOD: Retrospective study of trauma patients admitted to the intensive care unit for at least 2 days. Data were analyzed by using multivariate analysis. RESULTS: Of 162 patients studied, 40% had fever during the first 48 hours. Febrile patients had higher mortality rates than did afebrile patients. When adjusted for severity of injuries, fever did not correlate with mortality. Neither the incidence of fever in the first 48 hours after admission to the intensive care unit nor the number of days febrile in the unit differed between patients with and patients without head trauma (traumatic brain injury). About 70% of febrile patients did not have a source found for their fever. Febrile patients without an identified source of infection had lower peak white blood cell counts, lower maximum body temperature, and higher minimum platelet counts than did febrile patients who had an infectious source identified. The most common infection was pneumonia. CONCLUSIONS: No relationship was found between the presence of fever during the first 48 hours and mortality. Patients with traumatic brain injury did not have a higher incidence of fever than did patients without traumatic brain injury. About 30% of febrile patients had an identifiable source of infection. Further studies are needed to understand the origin and role of fever in trauma patients.

Comparing outcomes of HIV versus non-HIV patients requiring mechanical ventilation.

BACKGROUND: Mechanical ventilation (MV) is a predictor of mortality in patients infected with human immunodeficiency virus (HIV) in the intensive care unit (ICU). Patients with HIV-infections are admitted to the ICU for a variety of reasons that frequently require intubation. While survival rates for HIV-infected patients continue to improve, ICU admission rates have remained consistent. METHODS: To observe the consequences of MV in HIV-infected patients, we conducted a retrospective chart review on patients with HIV (n=55) vs. matched HIV-negative patients (n=55) who required MV over a one-year period and compared the groups for differences in outcome and complications. RESULTS: The HIV group had twice the number of deaths (44% vs. 22%, all-cause mortality) (P=0.01). Among the HIV-positive group, 5 of 55 patients required tracheostomy and prolonged MV, compared to 15 of 55 in the control group (9% and 27%, respectively). Successful extubation was virtually identical (47% MV vs. 50% control). Ventilator-associated pneumonia (VAP) was significantly higher among HIV-positive cases (39 of 55 HIV vs. 14 of 55 non-HIV) (P=0.05). Regression analysis revealed that hypotension, hypoalbuminemia, and fever predicted a poorer outcome. Low CD4 cell counts were strongly associated with mortality. CONCLUSION: HIV-infected patients requiring MV have significantly higher mortality and VAP rates than HIV-negative patients. Since VAP is associated with a poor prognosis, discovering ways to prevent it in the HIV-infected patient may improve outcome.

Recurrent negative pressure pulmonary edema.

An African-American man, aged 34 years, underwent an elective uncomplicated right wrist laceration repair while under general anesthesia. Following extubation, the patient developed hypoxemia, tachypnea, shortness of breath, pulmonary rales, frothy sputum, decreased oxygen saturation, and evidence of upper airway obstruction. Chest radiograph showed pulmonary edema. The patient was diagnosed with post-extubation pulmonary edema (aka. negative pressure pulmonary edema [NPPE]) and was treated with intravenous furosemide and oxygen therapy; he improved remarkably within a few hours. Once stabilized, the patient described a similar episode 10 years earlier following surgery for multiple gunshot wounds. Negative pressure pulmonary edema following tracheal extubation is an uncommon (0.1%) and life-threatening complication of patients undergoing endotracheal intubation and general anesthesia for surgical procedures. The common pattern in these cases is the occurrence of an episode of airway obstruction upon emergence from general anesthesia, usually caused by laryngospasm. Patients who are predisposed to airway obstruction may have an increased risk of airway complications upon extubation after general anesthesia. Prevention and early relief of upper airway obstruction should decrease incidence. Recurrent NPPE has not been previously described in the literature. Herein, we describe the first case of recurrent NPPE in the same patient following extubation.

Comparison of levalbuterol and racemic albuterol in hospitalized patients with acute asthma or COPD: a 2-week, multicenter, randomized, open-label study.

BACKGROUND: The National Heart, Lung, and Blood Institute guideline recommends that dosing racemic albuterol be administered every 1 to 4 hours for treating patients with asthma or chronic obstructive pulmonary disease (COPD) in the hospital. Previously published preliminary and retrospective studies suggested that levalbuterol can be administered every 8 hours for the treatment of bronchoconstriction in hospitalized patients. However, it is unclear how the different dosing regimens affect the total number of nebulizations (scheduled plus as-needed treatments) and the costs of treatment of bronchoconstriction in a hospital setting. Moreover, it is not clear how the different dosing regimens affect symptom outcomes and health status in hospitalized patients with asthma or COPD. OBJECTIVE: The aim of this study was to evaluate these issues in hospitalized patients with acute asthma or COPD. METHODS: In this prospective, multicenter, randomized, open-label study, hospitalized patients aged > or = 18 years were randomly assigned to receive 14-day treatment with levalbuterol 1.25 mg q6-8h or racemic albuterol 2.5 mg q1-4h, administered per routine hospital practice at each institution. The primary efficacy end point was total number of nebulizations during hospitalization. Pulmonary function, symptom evaluation (subject general well-being score [SGWB], disease symptom assessment [DSA], and beta-mediated adverse effect scores), hospital costs (excluding medication costs) and hospital length of stay (LOS) were also evaluated. RESULTS: In the intent-to-treat population (n = 479; levalbuterol, 241;racemic albuterol, 238), the mean (SE) age was 55.3 (16.9) years, the majority of patients were white (57.8%), and the mean (SE) weight was 80.9 (24.5) kg. Demographic characteristics were similar between the 2 treatment groups, except that there were more females with COPD in the levalbuterol treatment group (63.88%) compared with the racemic albuterol treatment group (45.5%) (P = 0.005). Patients treated with levalbuterol required significantly fewer median total nebulizations (10 vs 12; P = 0.031) and scheduled nebulizations (9 vs 11; P = 0.009) compared with those in the racemic albuterol group. The 2 treatment groups required 0 rescue nebulizations. Mean (SD) forced expiratory volume in 1 second improved from baseline with both levalbuterol and racemic albuterol (0.06 [0.43] and 0.10 [0.37] L, respectively); these improvements were maintained throughout the hospital stay (0.11 [0.48] and 0.16 [0.52] L). DSA and SGWB scores improved significantly from baseline in both treatment groups, and beta-mediated adverse effects mean scores were significantly greater with levalbuterol versus racemic albuterol (P < 0.001). In the levalbuterol and racemic albuterol treatment groups, hospital LOS (70.6 and 65.7 hours, respectively), time to discharge (66.0 and 62.8 hours), and total hospital costs (least squares mean [SE], US $4869.30 [$343.58] and $4899.41 [$343.20]) were similar. CONCLUSIONS: In these hospitalized patients with acute asthma or COPD treated with levalbuterol every 6 to 8 hours or racemic albuterol every 1 to 4 hours, significantly fewer total nebulizations were required with levalbuterol, without an increased need for rescue nebulizations during 14 days of hospitalization. Both treatments were associated with improvements from baseline in symptoms and health status. The costs of treating bronchoconstriction in hospitalized patients were similar between the levalbuterol and racemic albuterol groups.