Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study.

OBJECTIVES: To assess the compliance of Asian intensive care units and hospitals to the Surviving Sepsis Campaign's resuscitation and management bundles. Secondary objectives were to evaluate the impact of compliance on mortality and the organisational characteristics of hospitals that were associated with higher compliance. DESIGN: Prospective cohort study. SETTING: 150 intensive care units in 16 Asian countries. PARTICIPANTS: 1285 adult patients with severe sepsis admitted to these intensive care units in July 2009. The organisational characteristics of participating centres, the patients' baseline characteristics, the achievement of targets within the resuscitation and management bundles, and outcome data were recorded. MAIN OUTCOME MEASURE: Compliance with the Surviving Sepsis Campaign's resuscitation (six hours) and management (24 hours) bundles. RESULTS: Hospital mortality was 44.5% (572/1285). Compliance rates for the resuscitation and management bundles were 7.6% (98/1285) and 3.5% (45/1285), respectively. On logistic regression analysis, compliance with the following bundle targets independently predicted decreased mortality: blood cultures (achieved in 803/1285; 62.5%, 95% confidence interval 59.8% to 65.1%), broad spectrum antibiotics (achieved in 821/1285; 63.9%, 61.3% to 66.5%), and central venous pressure (achieved in 345/870; 39.7%, 36.4% to 42.9%). High income countries, university hospitals, intensive care units with an accredited fellowship programme, and surgical intensive care units were more likely to be compliant with the resuscitation bundle. CONCLUSIONS: While mortality from severe sepsis is high, compliance with resuscitation and management bundles is generally poor in much of Asia. As the centres included in this study might not be fully representative, achievement rates reported might overestimate the true degree of compliance with recommended care and should be interpreted with caution. Achievement of targets for blood cultures, antibiotics, and central venous pressure was independently associated with improved survival.

Experience with 224 percutaneous dilatational tracheostomies at an adult intensive care unit in Bahrain: a descriptive study.

UNLABELLED: Tracheostomy is one of the most commonly performed procedures in critically ill patients. Over the past 15 years, many large university hospitals have reported their experience with percutaneous dilatational tracheostomy (PDT). We have described and compared our experience with 224 PDTs that we performed in the last four and a half years. We have also compared PDT performed with and without bronchoscopic guidance at our setting and PDT verses surgical tracheostomy. OBJECTIVE: The purposes of this study are to evaluate the safety of PDT in our hospital setting and to compare our results with those published in the literature. DESIGN: A retrospective study for our experiences about safety and efficacy of 224 PDTs in an intensive care unit (ICU) setting. SETTING: A 11-bedded adult medical, surgical, neuro-trauma ICU at Salmaniya Medical Complex, Bahrain. MATERIALS AND METHODS: This is based on our experiences about complications/timings of all PDTs performed from October 2002 to February 2007. A retrospective chart analysis. RESULTS: There were 15 mechanical complications in total, including nine patients developing bleeding during or post-procedure, three patients developing pneumothorax and two patients developing cellulitis; in one procedure, a tracheostomy tube was misplaced. The proportion of total complications was 6.6% and no death. CONCLUSIONS: From our experience, bronchoscope can be used during PDTs performed in ICU by inexperienced intensivists who do not have good exposure to procedures, but after gaining adequate experience, PDT can be performed safely without using bronchoscope.

Acquired tracheoesophageal fistula due to high intracuff pressure.

High-compliance endotracheal tube cuffs are used to prevent gas leak and also pulmonary aspiration in mechanically ventilated patients. However, the use of the usual cuff inflation volumes may cause tracheal damage and lead to tracheoesophageal fistula.Tracheostomy tube cuffs seal against the tracheal wall and prevent leakage of air around the tube, assuring that the tidal volume is delivered to the lungs. In the past, high-pressure cuffs were used, but these contributed to tracheal injury and have been replaced by high-volume, low-pressure cuffs. For long-term applications, some newer tubes have low-profile (tight to shaft) cuffs that facilitate the tracheostomy tube changes by eliminating the lip that forms when standard cuffs are deflated.

Use of noninvasive positive pressure ventilation during pregnancy: case series.

Mechanical ventilation is commonly required in critically ill pregnant patients, requiring ICU admission, with higher morbidity and mortality related to airway management. Alternatively, noninvasive positive pressure ventilation (NIPPV) is increasingly used to treat nonpregnant patients. Pregnancy has been a contraindication to its use. We would like to report a case series of successful use of NIPPV in pregnancy.NIPPV is increasingly used to treat hypoxemic respiratory failure. It has rarely been used during pregnancy. On the other hand, acute respiratory failure (ARF) remains a leading cause of ICU admission in obstetric patients. The use of NIPPV in managing ARF in pregnant patients was not investigated. We report the outcome of treatment with NIPPV of four sickle cell disease pregnant patients with ARF caused by acute chest syndrome. Median APACHE II score for the four cases was 27. Intubation was avoided in all cases. None had aspiration. Mean duration of NIPPV was 40 h with ICU discharge after a mean of 4 days.