Diastolic dysfunction as a predictor of weaning failure: A systematic review and meta-analysis.

PURPOSE: Weaning failure and prolonged mechanical ventilation are associated with increased morbidity, cost of care, and high mortality rates. In the last few years, cardiac performance has been recognized as a common etiology of weaning failure, and growing evidence suggests that left ventricular diastolic dysfunction is a key factor that determines weaning outcomes. Therefore, we performed a systematic review and a meta-analysis to evaluate whether diastolic dysfunction in the critically ill patient subjected to mechanical ventilation is an independent predictor of weaning failure. MATERIALS AND METHODS: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Google Scholar, and ClinicalTrials.gov from inception to September 2014, along with conferences proceeding from January 2005 through September 2014, and included Observational Studies and Randomized Clinical Trials evaluating predictors of weaning failure. RESULTS: Ten studies were included in the systematic review; and 7, in the meta-analysis (6 observational studies and 1 randomized controlled trial). Patients who developed weaning failure had a higher E/e' ratio when compared with those who did not (mean difference, 2.65; 95% confidence interval, 0.52-4.79; P= .01); however, there was no difference in the E/A ratio (mean difference, 0.07; 95% confidence interval, -0.04 to 0.18; P= .22). Both the E/e' and E/A ratios were associated with weaning-induced pulmonary edema at the end of a spontaneous breathing trial. CONCLUSION: A higher E/e' ratio is significantly associated with weaning failure, although a high heterogeneity of diastolic dysfunction criteria and different clinical scenarios limit additional conclusions linking diastolic dysfunction with weaning failure.

Thrombin-activatable Fibrinolysis Inhibitor (TAFI) as a Novel Prognostic Factor After Orthotropic Liver Transplantation: A Pilot Study.

BACKGROUND: Thrombin-activatable fibrinolysis inhibitor (TAFI), a liver-produced coagulation factor, has been associated with higher mortality in cirrhotic patients, but there has not been any description of its role in perioperative care in liver transplantation cases. METHODS: A total of 21 patients were included. Serum TAFI levels were determined at 3 time points: preoperatively (TAFI pre), immediately postoperative (TAFI PO), and 24 hours postoperatively (TAFI 24 h). The main outcome was the physiological pattern of TAFI in the perioperative period of liver transplantation. The secondary outcomes were the association between TAFI and early allograft dysfunction (EAD) as well as that of TAFI and 6-month mortality. RESULTS: TAFI levels increased at the 24-hour time point, compared to the other 2 time points (TAFI pre, P = .007; TAFI PO, P = .0001). Early allograft dysfunction occurred in 2 of 21 patients, both demonstrating lower TAFI 24 h levels compared to those who did not develop this complication (3.0 ± 0.2 vs 1.5 ± 0.3; P = .0001). Three patients who died all demonstrated lower levels of TAFI pre (1.3 ± 0.1 vs 2.5 ± 0.5; P = .001) and TAFI PO (1.2 ± 0.1 vs 2.4 ± 0.4; P = .001) compared to the survivors. CONCLUSIONS: These findings suggest that the determination of TAFI levels-both pre- and postoperatively-may be of clinical relevance in liver transplant recipients.

Risk factors and outcome for nosocomial breakthrough candidaemia.

OBJECTIVES: To describe all cases of nosocomial candidaemia that occurred in patients in use of anti-fungals. METHODS: Retrospective cohort study (1995-2003). Breakthrough candidaemia was defined as the occurrence of candidaemia in a patient receiving at least 3 days of systemic anti-fungal therapy. Patients with breakthrough candidaemia were compared to patients with non-breakthrough candidaemia. RESULTS: During the period of study, 20 patients had breakthrough candidaemia, and 40% of them had cancer. While most of these episodes occurred with amphotericin B, some patients received low-dose regimens of fluconazole or ketoconazole in association with ranitidine. Non-Candida albicans species caused 75% of these infections, mainly Candida parapsilosis (30%). When compared to controls (n=171), the breakthrough group had more frequently mucositis, longer stay in the intensive care unit, and longer periods of hyperalimentation, mechanical ventilation, urinary catheter and broad-spectrum antibiotics. Candida isolation from sites other than blood occurred more frequently in the breakthrough group. Mortality rate and Candida species distribution were similar among groups. CONCLUSIONS: C. parapsilosis was the main aetiology of breakthrough candidaemia. Common risk factors included mucositis, isolation of Candida from sites other than blood, use of broad-spectrum antibiotics, and invasive medical procedures. No difference in the mortality rate was observed.

A 9-year study comparing risk factors and the outcome of paediatric and adults with nosocomial candidaemia.

Although there are numerous studies of candidaemia in adults, data on paediatrics are still limited. The aim of this study was to compare risk factors, aetiology, therapy, and the outcome of nosocomial candidaemia among paediatric and adult patients in a large Brazilian tertiary hospital (1995-2003). During this period, 78 paediatrics and 113 adults were studied. Species other than Candida albicans caused 78.2% of episodes of candidaemia in paediatrics. Compared to adults, paediatrics received more frequently broad-spectrum antibiotics, vasopressors, blood transfusions, arterial catheter, chest tube, cardiothoracic surgery, mechanical ventilation, and parenteral nutrition. Candidaemia caused by Candida parapsilosis was more common in paediatrics, as was the isolation of Candida spp. from catheters. Amphotericin B treatment was more common in paediatrics. Mortality rate was higher in adults than in paediatrics with nosocomial candidaemia. We reinforce the necessity of continuous epidemiologic surveillance to follow the dynamics of candidaemia.

A comparative study of risk factors and outcome among outpatient-acquired and nosocomial candidaemia.

Candidaemia is perceived as a nosocomial infection. The aim of this study was to describe all cases of candidaemia that occurred in the outpatient setting, and to compare risk factors and outcome among patients with outpatient-acquired and nosocomial candidaemia. During 1995 and 2003, 210 patients developed candidaemia at our institution, and 9.0% were outpatient acquired. Major underlying diseases were cancer (47.4%) and chronic renal failure (36.8%). Most occurred within 24 h of hospitalization (63.2%), and 83.7% were caused by species other than Candida albicans, mainly Candida parapsilosis (36.8%). Candida spp. were isolated from catheters in 21% of cases, and 52.6% of patients had been admitted to hospital in the 60 days preceding candidaemia. Compared with patients with nosocomial candidaemia, chronic renal failure was more frequent in the outpatient group, who were also more commonly exposed to haemodialysis. Ileus, gastrointestinal bleeding, previous bacteraemia, use of proton pump inhibitors, previous stay in the intensive care unit and requirement for antibiotics, blood transfusion, vasopressors and invasive medical procedures were more frequent in the nosocomial group. Overall mortality was high in both groups. Candidaemia must be considered as a potential cause of sepsis in the community, and it is associated with a high mortality rate.