Prevalence, clinical consequences and management of acute faecal incontinence with diarrhoea in the ICU: The FIRST™ Observational Study.

There are limited data on the incidence and management of acute faecal incontinence with diarrhoea in the ICU. The FIRST™ Observational Study was undertaken to obtain data on clinical practices used in the ICU for the management of acute faecal incontinence with diarrhoea in Germany, UK, Spain and Italy. ICU-hospitalised patients ≥18 years of age experiencing a second episode of acute faecal incontinence with diarrhoea in 24 h were recruited, and management practices of acute faecal incontinence with diarrhoea were recorded for up to 15 days. A total of 372 patients had complete data sets; the mean duration of study was 6.8 days. At baseline, 40% of patients experienced mild or moderate-to-severe skin excoriation, which increased to 63% in patients with acute faecal incontinence with diarrhoea lasting >15 days. At baseline, 27% of patients presented with a pressure ulcer, which increased to 37%, 45% and 49% at days 5, 10 and 15, respectively. Traditional methods (pads, sheets and tubes) were more commonly used compared to faecal management systems during days 1-4 (76% vs. 47% faecal management system), while the use of a faecal management system increased to 56% at days 5-9 and 61% at days 10-15. At baseline, only 26% of nurses were satisfied with traditional management methods compared to 69% with faecal management systems. For patients still experiencing acute faecal incontinence with diarrhoea after 15 days, 82% of nurses using a faecal management systems to manage acute faecal incontinence with diarrhoea were satisfied or very satisfied, compared to 37% using traditional methods. These results highlight that acute faecal incontinence with diarrhoea remains an important healthcare challenge in ICUs in Europe; skin breakdown and pressure ulcers remain common complications in patients with acute faecal incontinence with diarrhoea in the ICU.

Prevalence, management and clinical challenges associated with acute faecal incontinence in the ICU and critical care settings: the FIRST cross-sectional descriptive survey.

OBJECTIVE: To evaluate the prevalence, awareness and management of acute faecal incontinence with diarrhoea (AFId) in the Intensive Care Unit. DESIGN: Cross-sectional descriptive survey design of intensive care units across Germany, Italy, Spain and the United Kingdom. RESULTS: 962 questionnaires were completed by nurses (60%), physicians (29%) and pharmacists or purchasing personnel (11%). The estimated prevalence of AFId ranged from 9 to 37% of patients on the day of the survey. The majority of respondents reported a low-moderate awareness of the clinical challenges associated with AFId. Patients with AFId commonly had compromised skin integrity, which included perineal dermatitis, moisture lesions or sacral pressure ulcers. Reducing the risk of cross-infection and protecting skin integrity were rated as the most important clinical challenges. 49% had no hospital protocol or guideline for AFId management. There was also a low awareness of nursing time spent managing AFId; 60% of respondents estimated that 10-20 minutes are required for managing an AFId episode by 2-3 healthcare staff. CONCLUSIONS: AFId in the critical care setting may be an underestimated problem which is associated with a high use of nursing time.

Clinical impact of a commercially available multiplex PCR system for rapid detection of pathogens in patients with presumed sepsis.

BACKGROUND: Timely identification of pathogens is crucial to minimize mortality in patients with severe infections. Detection of bacterial and fungal pathogens in blood by nucleic acid amplification promises to yield results faster than blood cultures (BC). We analyzed the clinical impact of a commercially available multiplex PCR system in patients with suspected sepsis. METHODS: Blood samples from patients with presumed sepsis were cultured with the Bactec 9240 system (Becton Dickinson, Heidelberg, Germany) and aliquots subjected to analysis with the LightCycler SeptiFast (SF) Test (Roche Diagnostics, Mannheim, Germany) at a tertiary care centre. For samples with PCR-detected pathogens, the actual impact on clinical management was determined by chart review. Furthermore a comparison between the time to a positive blood culture result and the SF result, based on a fictive assumption that it was done either on a once or twice daily basis, was made. RESULTS: Of 101 blood samples from 77 patients, 63 (62%) yielded concordant negative results, 14 (13%) concordant positive and 9 (9%) were BC positive only. In 14 (13%) samples pathogens were detected by SF only, resulting in adjustment of antibiotic therapy in 5 patients (7,7% of patients). In 3 samples a treatment adjustment would have been made earlier resulting in a total of 8 adjustments in all 101 samples (8%). CONCLUSION: The addition of multiplex PCR to conventional blood cultures had a relevant impact on clinical management for a subset of patients with presumed sepsis.

Lipopolysaccharide-trap-Fc, a multifunctional agent to battle gram-negative bacteria.

The family of Toll-like receptors (TLRs) plays a pivotal role in host defense against pathogens. However, overstimulation of these receptors may lead to uncontrolled general inflammation and eventually to systemic organ dysfunction or failure. With the intent to control overwhelming inflammation during gram-negative bacterial sepsis, we constructed soluble fusion proteins of the lipopolysaccharide (LPS)-receptor complex to modulate TLR signaling in multiple ways. The extracellular domain of mouse TLR4 and mouse myeloid differentiation factor 2 (MD-2) fusions (LPS-Trap) were linked to human immunoglobulin G Fc domains (LPS-Trap-Fc). In addition to the ability to bind LPS or gram-negative bacteria and to inhibit interleukin-6 secretion of monocytic cells after LPS treatment, LPS-Trap-Fc was able to opsonize fluorescent Escherichia coli particles. This led to enhancement of phagocytosis by monocytic cells which was strictly dependent on the presence of the Fc region. Moreover, only LPS-Trap-Fc- and not LPS-Trap-coated bacteria were sensitized to complement killing. Therefore, LPS-Trap-Fc not only neutralizes LPS but also, after binding to bacteria, enhances phagocytosis and complement-mediated killing and could thus act as a multifunctional agent to fight gram-negative bacteria in vivo.

Continuous non-invasive arterial pressure technique improves patient monitoring during interventional endoscopy.

INTRODUCTION: Close monitoring of arterial blood pressure (BP) is a central part of cardiovascular surveillance of patients at risk for hypotension. Therefore, patients undergoing diagnostic and therapeutic procedures with the use of sedating agents are monitored by discontinuous non-invasive BP measurement (NIBP). Continuous non-invasive BP monitoring based on vascular unloading technique (CNAP, CN Systems, Graz) may improve patient safety in those settings. We investigated if this new technique improved monitoring of patients undergoing interventional endoscopy. METHODS: 40 patients undergoing interventional endoscopy between April and December 2007 were prospectively studied with CNAP(R) in addition to standard monitoring (NIBP, ECG and oxygen saturation). All monitoring values were extracted from the surveillance network at one-second intervals, and clinical parameters were documented. The variance of CNAP values were calculated for every interval between two NIBP measurements. RESULTS: 2660 minutes of monitoring were recorded (mean 60.1+/-34.4 min/patient). All patients were analgosedated with midazolam and pethidine, and 24/40 had propofol infusion (mean 90.9+/-70.3 mg). The mean arterial pressure for CNAP was 102.4+/-21.2 mmHg and 106.8+/-24.8 mmHg for NIBP. Based on the first NIBP value in an interval between two NIBP measurements, BP values determined by CNAP showed a maximum increase of 30.8+/-21.7% and a maximum decrease of 22.4+/-28.3% (mean of all intervals). DISCUSSION: Conventional intermittent blood pressure monitoring of patients receiving sedating agents failed to detect fast changes in BP. The new technique CNAP improved the detection of rapid BP changes, and may contribute to a better patient safety for those undergoing interventional procedures.

Recovery from respiratory failure after decompression laparotomy for severe acute pancreatitis.

We present three cases of patients (at the age of 56 years, 49 years and 74 years respectively) with severe acute pancreatitis (SAP), complicated by intra-abdominal compartment syndrome (ACS) and respiratory insufficiency with limitations of mechanical ventilation. The respiratory situation of the patients was significantly improved after decompression laparotomy (DL) and lung protective ventilation was re-achieved. ACS was discussed followed by a short review of the literature. Our cases show that DL may help patients with SAP to recover from severe respiratory failure.