Optimización de los aislamientos preventivos en una UCI polivalente mediante la aplicación de un plan de intervención / Optimization of pre-emptive isolations in a polyvalent ICU through implementation of an intervention strategy

ANTECEDENTES: El aislamiento preventivo consiste en la aplicación de medidas de aislamiento de contacto en pacientes con alta sospecha de estar colonizados por bacterias multirresistentes. OBJETIVO: Evaluar el impacto de un programa de intervención basado en la implantación de un Protocolo Consensuado de Aislamiento Preventivo (PCAP) al ingreso en una UCI polivalente de un hospital general. MÉTODO: Análisis comparativo de 2 cohortes de pacientes, una histórica, que incluye pacientes a los que se indicó el aislamiento preventivo a juicio del médico responsable (enero de 2010 a febrero de 2011), y otra prospectiva, que incluye los pacientes a los que se aplicó el PCAP (marzo a noviembre de 2011). El PCAP incluyó la identificación y divulgación de los criterios de aislamiento preventivo, la metodología a seguir en cuanto a toma de muestras, la valoración de los resultados y los criterios de retirada del aislamiento. La indicación del aislamiento fue realizada por el personal médico, y un equipo de enfermería realizó el seguimiento. Se definió el aislamiento preventivo como «adecuado» cuando en alguna de las muestras iniciales se identificó una bacteria multirresistente. Para la comparación de resultados entre los 2 periodos se utiliza la chi cuadrado para variables cualitativas y la t de Student para variables cuantitativas. Se aceptan como significativas diferencias con p < 0,05. RESULTADOS: De los 1.740 pacientes ingresados en UCI (1.055 en el primer periodo y 685 en el segundo) se indicó el aislamiento preventivo en 199 (11,4%), de los que 111 (10,5%) correspondieron a la fase histórica (grupo control) y 88 (12,8%) a la fase posterior a la implantación del PCAP (grupo de intervención). No se han detectado diferencias en la edad, el APACHE II y las características de los pacientes entre los 2 periodos. La aplicación del PCAP se ha relacionado con una disminución de los aislamientos preventivos no indicados (29,7 vs. 6,8%, p < 0,001), una disminución del tiempo en la solicitud de las muestras de vigilancia (1,56 vs. 0,37 días, p < 0,001), y una disminución de la duración en días del aislamiento (4,77 vs. 3,58 días, p < 0,001). En 44 pacientes (22,1%) en los que se indicó el aislamiento preventivo se identificaron más de una bacteria multirresistente, siendo la tasa de «aislamiento preventivo adecuado» del 19,8% en el primer periodo y del 25,0% en el segundo (p < 0,382). CONCLUSIONES: Tras la instauración de PCAP se han reducido significativamente los aislamientos preventivos no indicados correctamente, se ha disminuido el tiempo entre el aislamiento y la toma de muestras, además de reducirse la duración del aislamiento en los casos en que no es necesario, sin que haya aumentado la tasa de «aislamiento preventivo adecuado»

BACKGROUND: Pre-emptive isolation refers to the application of contact precaution measures in patients with strongly suspected colonization by multiresistant bacteria. OBJECTIVE: To assess the impact of an intervention program involving the implementation of a consensus-based protocol of pre-emptive isolation (CPPI) on admission to a polyvalent ICU of a general hospital. METHODS: A comparative analysis of 2 patient cohorts was made: a historical cohort including patients in which pre-emptive isolation was established according to physician criterion prior to starting CPPI (from January 2010 to February 2011), and a prospective cohort including patients in which CPPI was implemented (from March to November 2011). CPPI included the identification and diffusion of pre-emptive isolation criteria, the definition of sampling methodology, the evaluation of results, and the development of criteria for discontinuation of pre-emptive isolation. Pre-emptive isolation was indicated by the medical staff, and follow-up was conducted by the nursing staff. Pre-emptive isolation was defined as "adequate" when at least one multiresistant bacteria was identified in any of the samples. Comparison of data between the 2 periods was made with the chi-square test for categorical variables and the Student t-test for quantitative variables. Statistical significance was set at P < .05. RESULTS: Among the 1,740 patients admitted to the ICU (1,055 during the first period and 685 during the second period), pre-emptive isolation was indicated in 199 (11.4%); 111 (10.5%) of these subjects corresponded to the historical cohort (control group) and 88 (12.8%) to the posterior phase after the implementation of CPPI (intervention group). No differences were found in age, APACHE II score or patient characteristics between the 2 periods. The implementation of CPPI was related to decreases in non-indicated pre-emptive isolations (29.7 vs. 6.8%, P<.001), time of requesting surveillance cultures (1.56 vs. 0.37 days, P<.001), and days of duration of treatment (4.77 vs. 3.58 days, P<.001). In 44 patients (22.1%) in which pre-emptive isolation was indicated, more than one multiresistant bacteria was identified, with an "adequate pre-emptive isolation rate” of 19.8% in the first period and 25.0% in the second period (P<.382). CONCLUSIONS: The implementation of CPPI resulted in a significant decrease in pre-emptive isolations which were not indicated correctly, a decrease in the time elapsed between isolation and collection of samples, and a decrease in the duration of isolation measures in cases in which isolation was unnecessary, without increasing the rate of "adequate pre-emptive isolation"

Optimization of pre-emptive isolations in a polyvalent ICU through implementation of an intervention strategy.

BACKGROUND: Pre-emptive isolation refers to the application of contact precaution measures in patients with strongly suspected colonization by multiresistant bacteria. OBJECTIVE: To assess the impact of an intervention program involving the implementation of a consensus-based protocol of pre-emptive isolation (CPPI) on admission to a polyvalent ICU of a general hospital. METHODS: A comparative analysis of 2 patient cohorts was made: a historical cohort including patients in which pre-emptive isolation was established according to physician criterion prior to starting CPPI (from January 2010 to February 2011), and a prospective cohort including patients in which CPPI was implemented (from March to November 2011). CPPI included the identification and diffusion of pre-emptive isolation criteria, the definition of sampling methodology, the evaluation of results, and the development of criteria for discontinuation of pre-emptive isolation. Pre-emptive isolation was indicated by the medical staff, and follow-up was conducted by the nursing staff. Pre-emptive isolation was defined as "adequate" when at least one multiresistant bacteria was identified in any of the samples. Comparison of data between the 2 periods was made with the chi-square test for categorical variables and the Student t-test for quantitative variables. Statistical significance was set at P<.05. RESULTS: Among the 1,740 patients admitted to the ICU (1,055 during the first period and 685 during the second period), pre-emptive isolation was indicated in 199 (11.4%); 111 (10.5%) of these subjects corresponded to the historical cohort (control group) and 88 (12.8%) to the posterior phase after the implementation of CPPI (intervention group). No differences were found in age, APACHE II score or patient characteristics between the 2 periods. The implementation of CPPI was related to decreases in non-indicated pre-emptive isolations (29.7 vs. 6.8%, P<.001), time of requesting surveillance cultures (1.56 vs. 0.37 days, P<.001), and days of duration of treatment (4.77 vs. 3.58 days, P<.001). In 44 patients (22.1%) in which pre-emptive isolation was indicated, more than one multiresistant bacteria was identified, with an "adequate pre-emptive isolation rate" of 19.8% in the first period and 25.0% in the second period (P<.382). CONCLUSIONS: The implementation of CPPI resulted in a significant decrease in pre-emptive isolations which were not indicated correctly, a decrease in the time elapsed between isolation and collection of samples, and a decrease in the duration of isolation measures in cases in which isolation was unnecessary, without increasing the rate of "adequate pre-emptive isolation".

Angiographic features of "brain sag".

OBJECT: Cerebrospinal fluid hypotension, or "brain sag," is a recently described phenomenon most commonly seen following craniotomy for the clipping of ruptured aneurysms along with preoperative lumbar drain placement. The clinical features and CT findings have been previously described. Clinical presentation can be similar to and often mistaken for cerebral vasospasm. In this study, the authors report on the angiographic findings in patients with brain sag. METHODS: Five cases of brain sag were diagnosed (range 1-4 days) after the surgical treatment of ruptured aneurysms at the University of Illinois at Chicago. All patients met the clinical and CT criteria for brain sag. Admission cerebral angiograms and subsequent angiograms during symptoms of brain sag were obtained in all patients. In 3 patients, angiography was performed after the resolution of symptoms. RESULTS: In all 5 patients, the level of the basilar artery apex was displaced inferiorly with respect to the posterior clinoid processes during brain sag. This displacement was significant enough to create a noticeable kink in the basilar artery ("cobra sign") in 3 patients. Other angiographic findings included foreshortening or kinking of the intracranial vertebral artery. In all patients, the posterior cerebral arteries were displaced medially and inferiorly. Three patients were treated for simultaneous severe radiological vasospasm. In 4 patients, the brain sag was recognized, and the patients' conditions improved when they were placed flat or in the Trendelenburg position, at times combined with an epidural blood patch. Patients with follow-up angiography studies after the symptoms had resolved displayed a reversal of the angiographic features. CONCLUSIONS: Brain sag appears to be associated with characteristic angiographic features. Recognizing these features may help to diagnose brain sag as the cause of neurological deterioration in this patient population.

Primitive neuroectodermal tumor after radiation therapy for craniopharyngioma.

The authors report a case of primitive neuroectodermal tumor induced by radiation therapy of craniopharyngioma. This African-American male patient originally presented with craniopharyngioma, for which he underwent resection and whole-brain radiation therapy. Eight years later, at the age of 20 years, he returned with a left facial droop and left hemiparesis. A right basal ganglia mass was identified and resected. Histopathological examination identified the lesion as primitive neuroectodermal tumor. Although radiation therapy has shown to be beneficial in decreasing the recurrence rate in subtotally resected craniopharyngioma, the risks of radiation treatment should be clearly communicated to the patients, their families, and neurosurgeons before starting such treatment. This report expands the spectrum of reported radiation-induced neoplasms in the CNS.

Use of transparent plastic tubular retractor in surgery for deep brain lesions: a case series.

Brain tissue retraction is frequently required to reach deep intra-axial lesions, and the quest for an ideal retractor that would protect the underlying brain tissue continues. Despite the availability of multiple retractors, the incidence of brain retraction injury remains high and has been reported to be 5% to 10%. A recently developed transparent tubular retractor appears to provide several advantages in surgery for deep intra-axial tumors and intracerebral hematomas. We used a new commercially available transparent tubular retractor in 16 craniotomies. Fourteen of these patients were operated upon for deep tumors and cysts, including two intraventricular tumors and two for deep intracerebral hemorrhages. In all patients, the tubular retractor was directed toward the lesion through a small corticotomy and guided by a navigation system. Each lesion was completely removed through the retractor's lumen. In all cases, the tubular retractors provided excellent visualization of the underlying pathology and facilitated its surgical removal, dissection, and hemostasis. The tubular nature of the retractor allowed the rotation and changing the angle of approach without putting extra pressure on the brain tissue, which inevitably occurs when malleable or other ribbon-type retractors are used. There were no hematomas on routine postoperative CT scans in this series. Transparent tubular retractors provide a unique means of deep visualization and even force distribution at the retracted brain tissue. Although these retractors were originally designed for the removal of deep subcortical tumors, they may be used to access and evacuate intracerebral hematomas. In our experience, the use of tubular retractors allows one to achieve safe access to deep intracerebral lesions and decreases the rate of retraction-related complications.

CT Ventriculography for diagnosis of occult ventricular cysticerci.

BACKGROUND: Neurocysticercosis is the most common parasitic infection of the central nervous system (CNS). Intraventricular lesions are seen in 7-20% of CNS cysticercosis. Intraventricular lesions can be missed by computed tomography (CT) and magnetic resonance imaging (MRI) as they are typically isodense/isointense to the cerebrospinal fluid. We present our experience with CT ventriculography to visualize occult cysts. CASE DESCRIPTION: Two patients presented with hydrocephalus and suspected neurocysticercosis were evaluated with CT and MRI with and without contrast failing to reveal intraventricular lesions. CT-ventriculography was used: 10 ml of cerebrospinal fluid was drained from the ventriculostomy catheter, and 10 ml of iohexol 240 diluted 1:1 with preservative-free saline was injected through the ventriculostomy catheter. Immediate CT of the brain was performed. The first patient had multiple cysts located throughout the body of the left lateral ventricle. The second patient had a single lesion located in the body of the lateral ventricle. The CT-ventriculography findings helped in identifying the lesions and plan the surgical intervention that was performed with the aid of an endoscope to remove the cysts. CONCLUSIONS: Intraventricular neurocysticercosis is a common parasitic disease which can be difficult to diagnose. We used CT-ventriculography with injection of contrast through the ventriculostomy catheter in two patients where CT and MRI failed to demonstrate the lesions. This technique is a safe and useful tool in the imaging armamentarium when intraventricular cystic lesions are suspected.

Entrapment of the glossopharyngeal nerve in patients with Eagle syndrome: surgical technique and outcomes in a series of 5 patients.

OBJECT: Eagle syndrome is characterized by unilateral pain in the oropharynx, face, and earlobe, and is caused by an elongated styloid process or ossification of the stylohyoid ligament with associated compression of the glossopharyngeal nerve. The pain syndrome may be successfully treated with surgical intervention that involves resection of the styloid process. Although nerve decompression is routinely considered a neurosurgical intervention, Eagle syndrome and its treatment are not sufficiently examined in the neurosurgical literature. METHODS: A review was performed of cases of Eagle syndrome treated in the Department of Neurosurgery at the University of Illinois at Chicago Medical Center over the last 7 years. The clinical characteristics, radiographic imaging, operative indications, procedural details, surgical morbidity, and clinical outcomes were collected and analyzed. RESULTS: Of the many patients with facial pain treated between 2001 and 2007, 7 were diagnosed with Eagle syndrome, and 5 of these patients underwent resection of the elongated styloid process. There were 4 women and 1 man, ranging in age from 20 to 68 years (mean 43 years). The average duration of disease was 11 years. In all patients, a preoperative workup revealed unilateral or bilateral elongation of the styloid process. All patients underwent resection of the styloid process on the symptomatic side using a lateral transcutaneous approach. There were no surgical complications. All patients experienced pain relief immediately after the operation. At the latest follow-up (average 46 months, range 7 months to 7.5 years) all but 1 patient maintained complete pain relief. In 1 patient, the pain recurred 12 months postoperatively and additional interventions were required. CONCLUSIONS: Eagle syndrome may be considered an entrapment syndrome of the glossopharyngeal nerve. It is a distinct clinical entity that should be considered when evaluating patients referred for glossopharyngeal neuralgia. The authors' experience indicates that patients with Eagle syndrome may be successfully treated using open resection of the elongated styloid process, which appears to be both safe and effective in terms of long-lasting pain relief.