Double-lumen central venous catheters impregnated with chlorhexidine and silver sulfadiazine to prevent catheter colonisation in the intensive care unit setting: a prospective randomised study.

Antimicrobial- and antiseptic-impregnated catheters are strategies recommended to prevent central venous catheter (CVC) colonisation. Few data regarding chlorhexidine/silver sulfadiazine-impregnated catheters in intensive care unit (ICU) patients have been reported. We performed a prospective, randomised study comparing the colonisation rates of chlorhexidine/silver sulfadiazine-impregnated CVCs (group 1) against standard CVCs (group 2). In order to assess catheter colonisation rates, a 4cm segment from the tips of aseptically removed catheters was cultured by the roll-plate method. In all, 109 patients were enrolled with successful catheter insertion, 51 of them in group 1 and 58 in group 2. There were no statistically significant differences between the two groups with regards to age, Sequential Organ Failure Assessment (SOFA) score, ICU admission diagnosis, infection risk, catheter insertion sites or catheter length of stay. The colonisation rates were 29.4% (15 catheters) for group 1 and 34.5% (20 catheters) for group 2 (P=0.50). Double-lumen CVCs impregnated with chlorhexidine and silver sulfadiazine were not effective in reducing the incidence of catheter colonisation in ICU patients.

Red blood cell transfusion does not increase oxygen consumption in critically ill septic patients.

BACKGROUND: Red blood cell (RBC) transfusion is commonly used to increase oxygen transport in patients with sepsis. However it does not consistently increase oxygen uptake at either the whole-body level, as calculated by the Fick method, or within individual organs, as assessed by gastric intra-mucosal pH. AIM: This study evaluates the hemodynamic and oxygen utilization effects of hemoglobin infusion on critically ill septic patients. METHODS: Fifteen septic patients undergoing mechanical ventilation whose hemoglobin was <10 g% were eligible. Ten patients (APACHE II: 25.5 +/- 7.6) received an infusion of 1 unit of packed RBC over 1 h while sedated and paralyzed. The remaining five control patients (APACHE II: 24.3 +/- 6.0) received a 5% albumin solution (500 ml) over 1 h. Hemodynamic data, gastric tonometry and calorimetry were obtained prior to and immediately after RBC transfusion or 5% albumin infusion. RESULTS: Transfusion of RBC was associated with an improvement in left ventricular systolic work index (38.6 +/- 12.6 to 41.1 +/- 13.0 g/min/m2; P = 0.04). In the control group there was no significant change in the left ventricular systolic work index (37.2 +/- 14.3 to 42.2 +/- 18.9 g/min/m2). An increase in pulmonary vascular resistance index (203 +/- 58 to 238 +/- 49 dyne/cm5/m2; P = 0.04) was also observed, while no change was produced by colloid infusion (237 +/- 87.8 to 226.4 +/- 57.8 dyne/cm5/m2). Oxygen utilization did not increase either by Fick equation or by indirect calorimetry in either group. Gastric intramucosal pH increased only in the control group but did not reach statistical significance. CONCLUSION: Hemoglobin increase does not improve either global or regional oxygen utilization in anemic septic patients. Furthermore, RBC transfusion may hamper right ventricular ejection by increasing the pulmonary vascular resistance index.

Structural models for intermediate care areas.

OBJECTIVE: To describe structural models of intermediate care units used for critically ill patients. DATA SOURCES: Three multidisciplinary units with varying structures and functions of intermediate care areas (ICAs) are described. DATA SYNTHESIS: Advantages and limitations for each of the three models are outlined. The structural models described are the conventional isolated ICA model, the parallel model, and the integrated model of ICA. CONCLUSION: Each structural model has advantages and limitations. Selection of the appropriate ICA model for an institution depends on the specific circumstances and needs of the institution. Each of the three models can facilitate improved utilization of critical care resources.

Cardiac troponin: a new serum marker of myocardial injury in sepsis.

OBJECTIVE: Echocardiogram-derived left ventricular ejection fraction (LVEF) is usually utilized to evaluate left ventricular function, including that of septic patients. However, LVEF is greatly influenced by afterload. The aim of this study was to test the hypothesis that troponin I, a serum marker of myocardial injury, may be able to detect left ventricular involvement by the septic process, being at least as sensitive an indicator of left ventricular dysfunction as LVEF in these patients. DESIGN: Comparison of echocardiogram-derived LVEF with serum levels of troponin I in ten critically ill septic patients. SETTING: General intensive care unit in a tertiary care private hospital. PATIENTS: Ten critically ill septic patients with no previous documented heart disease. MEASUREMENTS AND RESULTS: Patients were simultaneously submitted to a two-dimensional echocardiogram and troponin I determinations. LVEFs and troponin I levels were analyzed in a two-by-two table in order to validate troponin I as a new biochemical marker of myocardial injury in sepsis. All the patients whose LVEF was < 0.5 had elevated troponin I levels (kappa = 0.61, p = 0.035). CONCLUSIONS: Identification of myocardial dysfunction in septic patients has been a challenging task. Troponin I, a serum marker of myocardial injury, may be of great help in the recognition of myocardial involvement by sepsis in a noninvasive and readily available way.

Stressors in ICU: perception of the patient, relatives and health care team.

OBJECTIVE: To compare the evaluation of the stressors present in the intensive care unit (ICU) from the point of view of the patient, relatives and the multiprofessional team and to identify differences and similarities with regard to the perception of stressors in order to optimize patient care. DESIGN: Cross-sectional analytical survey. SETTING: General ICU of a private hospital. PATIENTS AND PARTICIPANTS: From April 1st to June 30th, 1996, 50 ICU patients during the first week of their ICU stay, 50 of their respective relatives and 50 members of the professional team directly involved in the care of these patients. MEASUREMENTS AND RESULTS: The Intensive Care Unit Environmental Stressor Scale (ICUESS) was administered to all patients. The relatives and health care professionals were asked to complete the ICUESS on the basis of their perception of the patient's stressors. Being in pain, having tubes in the nose or mouth, being restrained by tubes and being unable to sleep were considered by the patients, relatives and health care professionals as the main stressors. The professional team evaluated the intensity of the stressors higher than either the family or the patient. No statistical significance was detected between the intensity of the stressors as evaluated by the patient and the intensity evaluated by relatives and by the professional team. CONCLUSIONS: Being in pain, being unable to sleep and having tubes in the nose and/or mouth were pointed out as the major stressors by the three groups. There was no statistically significant correlation between the total stress scores of the patients and their relatives (r = 0.193), between the patients and the team (r = -0.002), or between the total scores of the team and the relatives (r = -0.185). The results suggest that the views of the relatives and the professional team concerning the stressors have some similar points compared to the evaluation made by the patient himself, although the intensity of the evaluation for each group corresponds to its own perception.

Alteraçöes cardiocirculatórias na sepse / Cardiovascular abnormalities in sepsis

O choque séptico é uma grave síndrome clínica, responsável, nos Estados Unidos, por aproximadamente 400 mil internaçöes em Unidades de Terapia Intensiva e 100 mil óbitos por ano. Em cerca de 15 'por cento' dos pacientes com hipotensão refratária constata-se quadro de depressão miocárdica, responsável por importantes alteraçöes hemodinâmicas. Vários estudos "in vitro" e "in vivo" demostraram que, após a introdução de endotoxinas existentes na parede de algumas bactérias, ocorre a indução de substâncias mediadoras e moduladoras presentes na circulação, desencadeando o processo séptico. O estudo anatomopatológico desses coraçöes demostrou diferentes graus de acometimento, variando desde inflamatória local até quadros de miocardite intersticial, abscesso intramiocárdico e necrose celular. As mais recentes pesquisas neste assunto são relacionadas às interaçöes do óxido nítrico com as estruturas celulares. O TNF, a IL-1 e outros mediadores atuam provavelmente de forma sinérgica, determinando as alteraçöes que acarretam a depressão do miocárdio nos pacientes sépticos. O uso de inibidores das enzimas formadoras de óxido nítrico tem sido motivo de estudos randomizados, com o intuito de avaliar seu benefício na reversão dessas alteraçöes cardiovasculares nos quadros sépticos.

Tromboembolismo pulmonar: anticoagulação ou trombólise? / Pulmonary thromboembolism: anticoagulation or thrombolysis?

A terapia trombolítica é freqüentemente indicada nos pacientes com tromboembolismo pulmonar grave, principalmente naqueles que se apresentam com instabilidade hemodinâmica, hipoxemia grave e sinais de falência do ventrículo direito ao ecocardiograma. Nas últimas três décadas, vários estudos demonstraram a superioridade da terapia trombolítica, seja com a estreptoquinase, a uroquinase, ou a rt-PA, na restauração precoce da perfusão pulmonar. A rápida lise do trombo é acompanhada pela redução da hipertensão pulmonar e dos achados ecocardiográficos compatíveis com elevação da pós-carga do ventrículo direito. Entretanto, o impacto da terapia trombolítica em relação à heparina na sobrevida dos pacientes sem sinais de instabilidade hemodinâmica, especialmente na mortalidade hospitalar, recorrência e riscos de sangramento, não está esclarecido e tem sido motivo de recentes estudos multicêntricos. Os pacientes com sinais de instabilidade clínica também deverão ser considerados para tratamento trombolítico, respeitando-se as contra-indicaçöes de seu uso geral.

Qualidade e custos em terapia intensiva / Quality and costs at the intensive care units

A qualidade da assitência à saúde tem sido especialmente motivo de muitos debates em todo o mundo e tem envolvido todos os profissionais ligados a essa área. Paralelamente, o interesse por análises de custos, especificamente em Unidade de Terapia Intensiva, tem mostrado aumento crescente. A busca por aquisição, manutenção e melhora da qualidade de forma sistematizada e profissional tem sido uma das metas mais recentes nas instituiçöes hospitalares. Toda qualidade real implica custos razoáveis, não sendo mais permitido conceituar qualidade quando são empregados recursos de grande porte para aquisição da mesma. O princípio "quanto mais se paga, mais se obtém" gradativamente tem sido substituído por "fazer mais com menos", sendo este considerado um bom indicador de qualidade na prática médica diária. Discutiremos, neste artigo, o princípio de escassez, liberdade clínica, custo de oportunidade, eficácia, efetividade, eficiência, adequação, como também os diferentes tipos de custos. Complementarmente, discutiremos itens como racionalidade e tipos de avaliaçöes econômicas, modelo de contenção de custos e destinação de recursos em terapia intensiva. Por fim, serão considerados tópicos relacionados à conceituação e às dimensöes de qualidade, e à medicina intensiva baseada em evidências como instrumento facilitador na obtenção de qualidade.

[Retroesophageal hematoma with severe dysfagia after streptokinase for the treatment of the axillosubclavian vein thrombosis]. / Hematoma retroesofágico com grave disfagia após estreptoquinase para tratamento da trombose venosa axilo-subclávia.

We report the case of a 72 year-old man with advanced, stage IV, prostate cancer who underwent osteosynthesis of the cervical spine for nerve root decompression due to metastasis which was causing severe pain in his right upper limb. After three months in the hospital, he developed occlusive thrombosis of the right axillosubclavian vein as a complication of prolonged catheterization of the right subclavian vein for treatment of septicemia secondary to a hospital acquired pneumonia. The patient received thrombolytic therapy with IV streptokinase in the contralateral arm in the following dosage: 250,000 units in 15 minutes followed by 100,000 units per hour during five days. This led to total recanalization of the thrombus, with significant reduction of the arm edema. Twenty-four hours after the end of the thrombolytic therapy, the patient started to complain of dysfagia to solids and liquids and a contrasted esophagogram revealed extensive extrinsic compression of the esophagus due to a probable retroesophageal hematoma. The patient required enteral nutrition via nasoenteral tube during three months after which swallowing returned to normal and a repeat upper GI series confirmed that the hematoma had been reabsorbed, with normal passage of contrast through the esophagus. On late follow-up, the patient did not show evidence of any sequelae of deep venous thrombosis nor any residual dysfagia and is currently in use of elastic stockings and low molecular weight heparin.

[Use of tissue plasminogen activator factor for acute ischemic stroke]. / Uso do fator ativador do plasminogênio tecidual no acidente vascular cerebral isquêmico agudo.

PURPOSE: To evaluate thrombolytic therapy with rt-PA for acute stroke within 6h of symptom onset, and assessment of neurologic outcome. METHODS: We studied 6 patients, four women, mean age 63 +/- 18 years, with severe neurologic deficit within 6h of stroke onset, and with no spontaneous improvement. The stroke was embolic in 3, and thrombotic in the others. All patients were submitted to a head CT scan followed by either a cerebral angiography in 3 patients, or a transcranial Doppler, in the other 3 for assessment of arterial obstruction, and patency after thrombolytic therapy. We used 0.9 mg/kg of rt-PA, IV, over 60 min in 5 patients, and 0.5 mg/kg by intra-arterial infusion, over 60 min, in one. At the beginning a bolus of 10% of the total dose was delivered during 1 to 2 min. Head scan was repeated 24h and 7 days after treatment to detect ischemic areas and hemorrhagic complications. RESULTS: Middle cerebral artery occlusion was observed in 5 patients and posterior cerebral artery occlusion in one. The obstruction was cleared in 4 patients with persistence of the patency after 24h. A complete neurologic recovery was found in one patient, and a partial recovery in three. In two patients there was failure of arterial recanalization with no neurologic recovery. Only one patient had hemorrhagic transformation of ischemic tissue, without neurologic worsening. Death occurred in one patient due to pulmonary infection. CONCLUSION: Arterial patency with thrombolytic therapy was effective in 4 of our 6 patients. All 4 patients also disclosed a certain degree of neurologic improvement, rt-PA can be successfully used in selected patients up to 3h of the event onset, as shown in randomized studies.

[Superior vena cava and right atrium thrombosis successfully treated with streptokinase]. / Trombose da veia cava superior e do átrio direito tratada com sucesso com estreptoquinase.

The case of a 56 year-old male with acute lymphoid leukemia and no signs of activity for the last four months is reported. He presented with superior vena cava thrombosis caused by a Hickman catheter, and had positive blood cultures for Candida albicans and Staphylococcus epidermidis. Despite adequate antimicrobial therapy, the fever persisted, and the patient was submitted to surgical thrombectomy. One week following the procedure, the fever returned, and thrombosis of the superior vena cava extending to the right atrium was identified by transesophageal echocardiography (TEE). The patient underwent thrombolytic therapy with streptokinase, and no thrombus could be identified in the control TEE. No hemorrhagic or thromboembolic complication occurred. The patient was discharged with oral anticoagulation.

Stressors in ICU: patients' evaluation.

OBJECTIVE: To study the physical and psychological stressors in the intensive care unit (ICU) and to correlate stressors with different demographic variables. DESIGN: Cross-sectional analytical survey. SETTING: Intensive care unit of a private hospital. PATIENTS AND PARTICIPANTS: 50 randomly selected ICU patients during the first week of their ICU stay. MEASUREMENTS AND RESULTS: The Intensive Care Unit Environmental Stressor Scale was administered to 50 patients. Pain and the impossibility of sleeping due to noise and having tubes in the nose and mouth were considered the most important physical stressors. Loss of self control and lack of understanding about the attitudes and procedures were the main psychological stressors. CONCLUSIONS: Interventions should be aimed at relieving the patient's pain and at controlling the level of noise to make sleep possible. From the psychological standpoint, the independence of the patient should be encouraged, thus stimulating the recovery of self-control. The team should also inform the patient about the procedures which will be carried out.

Noncardiogenic pulmonary edema complicating diabetic ketoacidosis.

OBJECTIVE: To alert physicians to the possibility of pulmonary edema as a complication of diabetic ketoacidosis. METHODS: We report a case of adult respiratory distress syndrome after resuscitative efforts to compensate the first episode of diabetic ketoacidosis in a previously healthy young woman. RESULTS: In a 26-year-old woman with a 3-day history of malaise, polyuria, nausea, and vomiting, severe hypoxia and rales developed, and intubation and mechanical ventilation became necessary. Hemodynamic evaluation and striking electron microscopic findings on open-lung biopsy confirmed the diagnosis of adult respiratory distress syndrome. Despite adequate ventilatory support and hemodynamic management, death ensued and was attributed to irresponsive and progressive acute respiratory failure due to increased pulmonary capillary permeability edema. CONCLUSION: Clinicians should be aware of this possibly fatal pulmonary complication of diabetic ketoacidosis.