A comparative study of ceftazidime/avibactam-based and fosfomycin plus meropenem-based regimens for managing infections caused by carbapenem-resistant Klebsiella pneumoniae in critically ill patients.

The main aim of this study was to compare and analyze the effectiveness of treatment regimens using ceftazidime/avibactam (CAZ/AVI) versus fosfomycin plus meropenem (FOS/MER) for managing bloodstream infections (BSI) or ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) in critically ill patients. Between 4 January 2019, and 16 July 2023, adult patients (≥18 years old) diagnosed with BSI or VAP due to culture confirmed CRKP in ICU of a tertiary care hospital were investigated retrospectively. A total of 71 patients were categorized into two groups: 30 patients in CAZ/AVI-based, and 41 patients in FOS/MER-based group. No substantial disparities were found in the total duration of ICU hospitalization, as well as the 14- and 30-day mortality rates, between patients treated with CAZ/AVI-based and FOS/MER-based therapeutic regimens. We consider that our study provides for the first time a comprehensive understanding of treatment outcomes and associated risk factors among patients with CRKP-related infections.

Sepsis episodes caused by pressure injuries in critical illness: a retrospective observational cohort study.

BACKGROUND: Critically-ill patients (CIPs) with pressure injuries (PIs) may develop bloodstream infections (BSIs). PURPOSE: To identify predisposing factors and discuss diagnosis and management of sepsis-related PIs in CIPs. METHODS: The records of CIPs in the intensive care unit (ICU) between January 1, 2014, and January 1, 2020, with PI with sepsis-diagnoses and with different site cultures that were positive concurrent with bloodstream-cultures were retrospectively reviewed. RESULTS: Ninety-one sepsis episodes were included in the study. Low albumin level (U = 382.00, P = .006), renal failure (odds ratio [OR], 0.108 [95% CI, 0.015-0.783]; P = .025), and length of ICU stay (U = 130.00, P < .001) were identified as risk factors of BSIs due to PIs. The probability of BSI during a sepsis episode was lower in CIPs with PIs with higher C-reactive protein levels (U = 233.00, P < .001) and whose injury resulted from trauma or surgery (OR, 0.101 [95% CI, 0.016-0.626]; P = .014). The mortality was higher in CIPs with PI-induced BSIs (OR, 0.051 [95% CI, 0.008-0.309]; P = .001). CONCLUSIONS: Pressure injury-induced sepsis was associated with a high risk of 28-day mortality. The findings suggest that CIPs with PI are at increased risk of BSIs if they have low albumin levels, renal-failure, and prolonged ICU stay during sepsis episodes.

OXA-48 Dominance Meets Ceftazidime-Avibactam: A Battle Against Life-Threatening Carbapenem-Resistant Klebsiella pneumoniae Infections in the Intensive Care Unit.

Objective In this study, we aimed to describe the outcomes in ICU patients with bloodstream infection (BSI) or ventilatory-associated pneumonia (VAP) due to carbapenem-resistant Klebsiella pneumoniae (CRKP) who received ceftazidime-avibactam treatment at a tertiary care university hospital. Methods Patients aged 18 years or older who were admitted to the Anesthesiology and Reanimation ICU at Bursa Uludag University Faculty of Medicine Hospital between June 13, 2021, and July 16, 2023, and diagnosed with BSI or VAP due to CRKP were included in this study. Results A total of 42 patients treated with ceftazidime-avibactam were included. Total crude mortality rates were 33.3% on day 14 and 54.8% on day 30. Mortality rates on the 14th and 30th days were 37.5% and 62.5% in patients with BSI and 27.8% and 44.4% in patients with VAP, respectively. There was no statistically significant difference between monotherapy and combination therapy in terms of mortality rates on days 14 and 30, respectively (3/11 vs. 11/31, p=0.620; 5/11 vs. 18/31, p=0.470). Immunosuppression (10/11 vs. 13/31, p=0.005), the Sequential Organ Failure Assessment (SOFA) score ≥8 (at the initiation of treatment; 19/25 vs. 4/17, p<0.001), INCREMENT-CPE score ≥10 (12/16 vs. 3/10, p=0.024) and longer duration (in days) from culture collection to treatment initiation (5.0 ± 0.61 vs. 3.11 ± 0.48, p=0.024) were found to have a statistically significant effect on 30-day mortality. In multivariate analysis, a SOFA score ≥8 at the initiation of treatment (p=0.037, OR: 17.442, 95% CI: 1.187-256.280) was found to be a significant risk factor affecting mortality (30-day). Conclusion The mortality rates of patients with CRKP infection who were followed up in the ICU were found to be high, and it was observed that whether ceftazidime-avibactam treatment was given as a combination or monotherapy did not affect mortality. Further multicentre studies with a larger number of patients are needed to gain a comprehensive understanding of the topic, given that this treatment is typically reserved for documented infections.

Evaluation of the combination treatments with intravenous fosfomycin for carbapenem-resistant Klebsiella pneumoniae.

OBJECTIVE: The aim of this study was to evaluate the combination treatments with intravenous fosfomycin for carbapenem-resistant Klebsiella pneumoniae infections in a tertiary-care center. METHODS: Between December 24, 2018 and November 21, 2022, adult patients diagnosed with bloodstream infection or ventilator-associated pneumonia due to culture-confirmed carbapenem-resistant Klebsiella pneumoniae in the anesthesiology and reanimation intensive care units were investigated retrospectively. RESULTS: There were a total of 62 patients fulfilling the study inclusion criteria. No significant difference was recorded in 14- and 30-day mortality among different types of combination regimens such as fosfomycin plus one or two antibiotic combinations. Hypokalemia (OR:5.651, 95%CI 1.019-31.330, p=0.048) was found to be a significant risk factor for 14-day mortality, whereas SOFA score at the time of diagnosis (OR:1.497, 95%CI 1.103-2.032, p=0.010) and CVVHF treatment (OR:6.409, 95%CI 1.395-29.433, p=0.017) were associated with 30-day mortality in multivariate analysis. CONCLUSION: In our study, high mortality rates were found in patients with bloodstream infection or ventilator-associated pneumonia due to carbapenem-resistant Klebsiella pneumoniae, and no significant difference was recorded in 14- and 30-day mortality among different types of combination regimens such as fosfomycin plus one or two antibiotic combinations.

Prognostic Risk Factors in Ventilator-Associated Pneumonia.

BACKGROUND Ventilator-associated pneumonia (VAP) is a nosocomial infection commonly seen in patients in intensive care units (ICU). This study aimed to analyze factors affecting prognosis of patients diagnosed with VAP. MATERIAL AND METHODS Critically ill patients with VAP were retrospectively evaluated between June 2002 and June 2011 in the ICU. VAP diagnosis was made according to 2005 ATS/IDSA (Infectious Diseases Society of America/American Thoracic Society) criteria. First pneumonia attacks of patients were analyzed. RESULTS When early- and late-onset pneumonia causes were compared according to ICU and hospital admittance, resistant bacteria were found to be more common in pneumonias classified as early-onset according to ICU admittance. APACHE II score of >21 (p=0.016), SOFA score of >6 (p<0.001) on admission to ICU and SOFA score of >6 (p<0.001) on day of diagnosis are risk factors affecting mortality. Additionally, low PaO2/FIO2 ratio at onset of VAP had a negative effect on prognosis (p<0.001). SOFA score of >6 on the day of VAP diagnosis was an independent risk factor for mortality [(p<0.001; OR (95%CI): 1.4 (1.2-1.6)]. CONCLUSIONS Resistant bacteria might be present in early-onset VAP. Especially, taking LOS into consideration may better estimate the presence of resistant bacteria. Acinetobacter baumannii, Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus (MRSA) were the most frequent causative microorganisms for VAP. SOFA score might be more valuable than APACHE II score. Frequently surveilling SOFA scores may improve predictive performance over time.

Nosocomial Acinetobacter pneumonia: Treatment and prognostic factors in 356 cases.

BACKGROUND AND OBJECTIVE: Acinetobacter baumannii and A. baumannii/calcoaceticus complex are commonly encountered pathogens in nosocomial infections. This study aimed to evaluate the treatment and prognostic risk factors in nosocomial pneumonia caused by these microorganisms. METHODS: The study was conducted retrospectively in Uludag University Hospital and included 356 adult non-neutropenic patients with nosocomial pneumonia. RESULTS: Of the subjects, 94.9% (n = 338) had ventilator-associated pneumonia. The clinical response rate was 57.2%, the 14-day mortality 39.6% and the 30-day mortality 53.1%. The significant independent risk factors for the 30-day mortality were severe sepsis (OR, 2.60; 95% CI: 1.49-4.56; P = 0.001), septic shock (OR, 6.12; 95% CI: 2.75-13.64; P < 0.001), APACHE II score ≥ 20 (OR, 2.12; 95% CI: 1.28-3.50; P = 0.003) and empiric monotherapy (OR, 1.63; 95% CI: 1.00-2.64; P = 0.048). Multi-trauma (OR, 2.50; 95% CI: 1.11-5.68; P = 0.028) was found to be a protective factor. In patients with a clinical pulmonary infection score (CPIS) > 6 on the third day of treatment, both the 14- and 30-day mortality rates were high (P < 0.001, P < 0.001). Also, the 14- and 30-day mortality rates were significantly higher in the patients treated with empiric monotherapy compared with combination therapy (48/93 (51.6%)-46/123 (37.4%), P = 0.037 and 62/93 (66.7%)-65/123 (52.8%), P = 0.041, respectively) in pneumonia caused by imipenem-resistant strains. CONCLUSION: Mortality rates were high in pneumonia caused by imipenem-resistant A. baumannii or A. baumannii/calcoaceticus complex. In the units with a high level of carbapenem resistance, antibiotic combinations should be considered for empiric therapy.

Comparison of blood culture and multiplex real-time PCR for the diagnosis of nosocomial sepsis.

BACKGROUND: In many cases of suspected sepsis, causative microorganisms cannot be isolated. Multiplex real-time PCR generates results more rapidly than conventional blood culture systems. METHODS: In this study, we evaluated the diagnostic performance of multiplex real-time PCR (LightCycler® SeptiFast, Roche, Mannheim, Germany), and compared with blood cultures and cultures from focus of infection in nosocomial sepsis. RESULTS: Seventy-eight nosocomial sepsis episodes in 67 adult patients were included in this study. The rates of microorganism detection by blood culture and PCR were 34.2% and 47.9%, respectively. Sixty-five microorganisms were detected by both methods from 78 sepsis episodes. Nineteen of these microorganisms were detected by both blood culture and PCR analysis from the same sepsis episode. There was statistically moderate concordance between the two methods (κ=0.445, P<0.001). There was no significant agreement between the blood culture and PCR analysis in terms of microorganism detected (κ=0.160, P=0.07). Comparison of the results of PCR and cultures from focus of infection revealed no significant agreement (κ=0.110, P=0.176). However, comparison of the results of PCR and blood cultures plus cultures from focus of infection (positive blood culture and/or positive culture from focus of infection) showed poor agreement (κ=0.17, P=0.026). When the blood culture was used as the gold standard, the sensitivity, specificity, positive and negative predictive value of PCR in patients with bacteremia was 80%, 69%, 57% and 87%, respectively. CONCLUSIONS: SeptiFast may be useful when added to blood culture in the diagnosis and management of sepsis.

Early graft dysfunction and mortality rate in marginal donor liver transplantation.

BACKGROUND/AIM: To determine the effect of marginal donor livers on mortality and graft survival in liver transplantation (LT) recipients. MATERIALS AND METHODS: Donors with any 1 of following were considered marginal donors: age ≥65 years, sodium level ≥ 165 mmol/L and cold ischemia time ≥ 12 h. Donors were classified according to the donor risk index (DRI) < 1.7 and ≥ 1.7. The transplant recipients' model for end-stage liver disease (MELD) scores were considered low if < 20 and high if ≥ 20. Early graft dysfunction (EGD) and mortality rate were evaluated. RESULTS: During the study period 47 patients underwent cadaveric LT. The mean age of the donors and recipients was 45 years (range: 5-72 years) and 46 years (range: 4-66 years), respectively. In all, there were 15 marginal donors and 18 donors with a DRI > 1.7. In total, 4 LT patients that received livers from marginal donors and 5 that received livers from donors with a DRI ≥ 1.7 had EGD. Among the recipients of marginal livers, 5 died, versus 4 of the recipients of standard livers. There was no significant difference in EGD or mortality rate between the patients that received livers from marginal donors or those with a DRI ≥ 1.7 and patients that received standard donor livers. CONCLUSION: Marginal and DRI ≥ 1.7 donors negatively affected LT outcomes, but not significantly.

Guillain-Barré Syndrome and Human Immunodeficiency Virus.

Guillain-Barré syndrome (GBS) is an acute disease characterised by symmetrical muscle weakness, loss of sensation and reflex. There is usually a viral infection at the beginning of the disease. Here, we report a GBS case which did not respond to any treatment strategy at first and was diagnosed as Human Immunodeficiency Virus positive (HIV+) during the search for the aetiology. A 32-year-old male patient who presented to a medical centre with symptoms of gait disturbance and arm and leg numbness was found to have albuminocytologic dissociation upon cerebrospinal fluid examination. After the diagnosis of GBS, immunoglobulin G (IVIG) therapy (400 mg kg(-1) day(-1) 5 days) was started as a standard therapy. This therapy was repeated due to a lack of improvement of symptoms. During this therapy, the patient was sent to our clinic with symptoms of respiratory failure and tetraplegia. He was conscious, cooperative, haemodynamically stable and his arterial blood gas analyses were: pH: 7.28, PaO2: 74.4 mmHg, PCO2: 63.8 mmHg. He was intubated, mechanically ventilated and underwent plasmapheresis. After the investigation of aetiology, HIV(+), CD4/CD8: 0.17, absolute CD4: 71 cells mL(-1) were detected and antiretroviral therapy was started. The patient died from multiple organ failure due to sepsis on day 35. In conclusion, HIV infection should be kept in mind in GBS patients, especially those not responding to routine treatment. As a result, not only could the patient receive early and adequate treatment, but also HIV infection transmission would be avoided.

Ogilvie's syndrome following bilateral knee arthroplasty: a case report.

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction, is an uncommon but severe postoperative complication of total hip and knee arthroplasty. This syndrome should be borne in mind after arthroplasty surgery. We present a case of this serious postoperative complication and aim to identify the risk factors and alert surgeons to the possibility and appropriate management of Ogilvie's syndrome.

Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study.

RATIONALE: Accurate, early identification of patients at risk for developing acute lung injury (ALI) provides the opportunity to test and implement secondary prevention strategies. OBJECTIVES: To determine the frequency and outcome of ALI development in patients at risk and validate a lung injury prediction score (LIPS). METHODS: In this prospective multicenter observational cohort study, predisposing conditions and risk modifiers predictive of ALI development were identified from routine clinical data available during initial evaluation. The discrimination of the model was assessed with area under receiver operating curve (AUC). The risk of death from ALI was determined after adjustment for severity of illness and predisposing conditions. MEASUREMENTS AND MAIN RESULTS: Twenty-two hospitals enrolled 5,584 patients at risk. ALI developed a median of 2 (interquartile range 1-4) days after initial evaluation in 377 (6.8%; 148 ALI-only, 229 adult respiratory distress syndrome) patients. The frequency of ALI varied according to predisposing conditions (from 3% in pancreatitis to 26% after smoke inhalation). LIPS discriminated patients who developed ALI from those who did not with an AUC of 0.80 (95% confidence interval, 0.78-0.82). When adjusted for severity of illness and predisposing conditions, development of ALI increased the risk of in-hospital death (odds ratio, 4.1; 95% confidence interval, 2.9-5.7). CONCLUSIONS: ALI occurrence varies according to predisposing conditions and carries an independently poor prognosis. Using routinely available clinical data, LIPS identifies patients at high risk for ALI early in the course of their illness. This model will alert clinicians about the risk of ALI and facilitate testing and implementation of ALI prevention strategies. Clinical trial registered with www.clinicaltrials.gov (NCT00889772).

Intensive care unit utilization and outcome after esophagectomy.

OBJECTIVE: To establish the frequency of intensive care unit (ICU) admission after esophagectomy and to determine the associated outcomes. DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PARTICIPANTS: Four hundred thirty-two patients who underwent esophagectomy between January 2000 and June 2004. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Data relating to demographics, patient co-morbidities, perioperative management, complications, and Acute Physiology and Chronic Health Evaluation (APACHE) III variables were abstracted. Statistical analyses were performed to compare survivors with non-survivors and ICU patients with non-ICU patients. Of 432 patients included in the study, 123 (28.5%) were admitted to the ICU. Arrhythmias, new infiltrates on chest radiograph, and documented aspiration were common reasons for ICU admission. Patients admitted to ICU were of high acuity (mean APACHE III score 54.5, mean prediction of ICU death 6.4%). Of 352 patients originally not sent to the ICU, 43 (12.2%) were subsequently admitted to the ICU, often for aspiration. Overall in-hospital mortality was 3.7% (16 of 432 patients). Fifteen of the 123 ICU patients (12.2%) did not survive to hospital discharge. CONCLUSIONS: A significant minority of patients will require ICU admission after esophagectomy, often for aspiration pneumonitis and arrhythmias. Despite high severity of illness scores, the perioperative mortality rate for patients after esophagectomy at a high-volume center is low.

Evaluation of "Loss" and "End stage renal disease" after acute kidney injury defined by the Risk, Injury, Failure, Loss and ESRD classification in critically ill patients.

PURPOSE: The Risk, Injury, Failure, Loss and ESRD (RIFLE) classification has been widely accepted for the definition of acute kidney injury (AKI); however, no study has described in detail the last two stages of the classification: "Loss" and "ESRD". We aim to describe and evaluate the development of "Loss" and "ESRD" in a group of critically ill patients. METHODS: We conducted a retrospective analysis of cases prospectively collected from the Acute Physiology and Chronic Health Assessment (APACHE III) database. Subjects were consecutive critically ill patients >18 years of age admitted to three ICUs of two tertiary care academic hospitals, from January 2003 through August 2006, excluding those who denied research authorization, chronic hemodialysis therapy, kidney transplant recipients, readmissions, and admissions for less than 12 h for low risk monitoring. RESULTS: 11,644 patients were included in the study. The median age was 66 (interquartile range, 52-76), 90% were Caucasians and 54% of the patients were male. Half of the patients developed AKI, and most of the patients were in the Risk and Injury stages. From the patients that developed AKI, a total of 1,065 (19%) patients required renal replacement therapy (RRT), 415 (39%) underwent continuous renal replacement therapy (CRRT) and 650 (61%) underwent intermittent hemodialysis. A total of 281 patients on RRT did not survive hospital discharge, 97 patients progressed to "Loss", and 282 patients progressed to "ESRD". After multivariable adjustment, the progression to "ESRD" was associated with higher baseline creatinine, odds ratio (OR) 1.19 per every increase in creatinine of 0.1 mg/dl (95% CI, 1.11-1.29) P < 0.001; and less frequent use of CRRT, OR 0.18 (95% CI, 0.11-0.29) P < 0.001. CONCLUSION: In this large retrospective study we found that almost 50% developed some form of AKI as defined by the RIFLE classification. Of these, 19% required RRT, and 4.9% progressed to "ESRD". "ESRD" was more likely in patients with elevated baseline creatinine and those treated with intermittent hemodialysis.

Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage.

BACKGROUND: Cardiopulmonary complications are common after endoscopy for upper GI (UGI) hemorrhage in the intensive care unit (ICU). OBJECTIVE: To evaluate the practice and outcome of elective prophylactic endotracheal intubation before endoscopy for UGI hemorrhage in the ICU. DESIGN: Retrospective, propensity-matched case-control study. SETTING: A 24-bed medical ICU in a tertiary center. PATIENTS: ICU patients who underwent endoscopy for UGI hemorrhage. MAIN OUTCOME MEASUREMENTS: Cardiopulmonary complications, ICU and hospital length of stay, and mortality. In a propensity analysis, patients who were intubated for airway protection before UGI endoscopy were matched by probability of intubation to controls who were not intubated before UGI endoscopy. RESULTS: Of 307 patients, 53 underwent elective prophylactic intubation before UGI endoscopy. The probability of intubation depended on the Acute Physiology and Chronic Health Evaluation III (APACHE III) score (OR 1.4; 95% CI, 1.2-1.6), age (OR 0.97; 95% CI, 0.95-0.09), the presence of hemetemesis (OR 1.9; 95% CI, 0.8-5.1), previous lung disease (OR 2.1; 95% CI, 0.8-4.9), and the number of transfusions (OR 1.1; 95% CI, 1.0-1.1 per unit). Nonintubated matched controls were identified for all but 4 patients with active massive hemetemesis, who were excluded from matched analysis. Cumulative incidence of cardiopulmonary complications (53% vs 45%, P = .414), ICU length of stay (median 2.2 vs 1.8 days, P = .138), hospital length of stay (6.9 vs 5.9 days, P = .785), and hospital mortality (14% vs 20%, P = .366) were similar. CONCLUSIONS: Cardiopulmonary complications are frequent after endoscopy for acute UGI bleeding in ICU patients and are largely unaffected by the practice of prophylactic intubation.

Statin administration did not influence the progression of lung injury or associated organ failures in a cohort of patients with acute lung injury.

PURPOSE: Preclinical studies suggest that HMG-CoA reductase inhibitors (statins) may attenuate organ dysfunction. We evaluated whether statins are associated with attenuation of lung injury and prevention of associated organ failure in patients with ALI/ARDS. METHODS: From a database of patients with ALI/ARDS, we determined the presence and timing of statin administration. Main outcome measures were the development and progression of pulmonary and nonpulmonary organ failures as assessed by changes in PaO(2)/FiO(2) ratio and Sequential Organ Failure Assessment score (SOFA) between days 1 and 7 after the onset of ALI/ARDS. Secondary outcomes included ventilator free days, ICU and hospital mortality, and lengths of ICU and hospital stay. RESULTS: From 178 patients with ALI/ARDS, 45 (25%) received statin therapy. From day 1 to day 7, the statin group showed less improvement in their PaO(2)/FiO(2) ratio (27 vs. 55, P = 0.042). Ventilator free days (median 21 vs. 16 days, P = 0.158), development or progression of organ failures (median DeltaSOFA 1 vs. 2, P = 0.275), ICU mortality (20% vs. 23%, P = 0.643), and hospital mortality (27 vs. 37%, P = 0.207) were not significantly different in the statin and non-statin groups. After adjustment for baseline characteristics and propensity for statin administration, there were no differences in ICU or hospital lengths of stay. CONCLUSION: In this retrospective cohort study, statin use was not associated with improved outcome in patients with ALI/ARDS. We were unable to find evidence for protection against pulmonary or nonpulmonary organ dysfunction.

Perioperative statin therapy and renal outcomes after major vascular surgery: a propensity-based analysis.

OBJECTIVE: To evaluate how the presence and timing of statin therapy affect perioperative renal outcomes after major vascular surgery. DESIGN: Retrospective cohort study. SETTING: Surgical intensive care unit at a single academic medical center. PARTICIPANTS: Patients undergoing major vascular surgery between July 2004 and October 2005. MEASUREMENTS AND MAIN RESULTS: The presence and timing of perioperative statin administration and the propensity for receiving such therapy were noted. Renal outcomes, lengths of stay, and mortality were reviewed. One hundred fifty-one procedures were performed. Eighty-nine patients (59%) received statin therapy. There was no evidence for renal protection with perioperative statin therapy (Delta creatinine 0.2 mg/dL v 0.2 mg/dL, p = 0.41; acute renal injury/acute renal failure 8% v 6%, p = 1.00; renal replacement therapy 3% v 3%, p = 1.00; all statin v no statin, respectively). With the possible exception of early reinstitution of statin therapy in chronic statin users, subgroup analyses failed to confirm an association between statin timing and prevention of postoperative renal dysfunction. CONCLUSIONS: In the present investigation, neither the presence nor timing of perioperative statin therapy was associated with improved renal outcomes in patients undergoing a range of major vascular procedures. A possible exception is early postoperative reinitiation of statin therapy in chronic statin users. The discrepant results of available literature preclude a definitive statement on the use of statin therapy as a means of preventing postoperative renal dysfunction. An adequately powered prospective trial is needed before advocating the routine use of statin therapy for perioperative renal protection.

Risk factors for the development of acute lung injury in patients with septic shock: an observational cohort study.

OBJECTIVE: Almost half of the patients with septic shock develop acute lung injury (ALI). The understanding why some patients do and others do not develop ALI is limited. The objective of this study was to test the hypothesis that delayed treatment of septic shock is associated with the development of ALI. DESIGN: Observational cohort study. SETTING: Medical intensive care unit in a tertiary medical center. PATIENTS: Prospectively identified patients with septic shock who did not have ALI at the outset, excluding those who denied research authorization. MEASUREMENTS AND MAIN RESULTS: High frequency cardio-respiratory monitoring, arterial gas analysis, and portable chest radiographs were reviewed to identify the timing of ALI development. Risk factors present before ALI development were identified by review of electronic medical records and analyzed in univariate and multivariate analyses. Seventy-one of 160 patients (44%) developed ALI at a median of 5 (range 2-94) hours after the onset of septic shock. Multivariate logistic regression analysis identified the following predictors of ALI development: delayed goal-directed resuscitation (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.52-8.63, p = .004), delayed antibiotics (OR 2.39, 95% CI 1.06 -5.59, p = .039), transfusion (OR 2.75, 95% CI 1.22-6.37, p = .016), alcohol abuse (OR 2.09, 95% CI .88-5.10, p = 0.098), recent chemotherapy (OR 6.47, 95% CI 1.99-24.9, p = 0.003), diabetes mellitus (OR .44, 95% CI .17-1.07, p = .076), and baseline respiratory rate (OR 2.03 per sd, 95% CI 1.38-3.08, p < .001). CONCLUSION: When adjusted for known modifiers of ALI expression, delayed treatment of shock and infection were associated with development of ALI.

Impact of a basic nutrition course for residents at a faculty hospital. Did it make a difference in demand for nutrition consultations?

BACKGROUND/AIMS: To assess whether a basic nutrition course for residents at a faculty hospital improves their knowledge of nutrition and increases the number of consultation requests for nutrition by alerting participants to the high prevalence of undernutrition in hospitals. METHODS: The residents from 34 departments of basic, internal and surgical sciences were recruited to take a 1-day course. Questionnaires, designed to assess knowledge of nutrition, were completed at the beginning and at the end of the course. The results of the questionnaires and the number of consultation demands for nutrition before and after the course were compared. RESULTS: The results of 161 participants were evaluated. The mean (+/-SE) numbers of correct answers given to the first and second questionnaires were 14.9 +/- 0.22 and 18.7 +/- 0.21, respectively (p < 0.01). When the number of requests for nutrition consultation during 7-month periods (just before and after the course) were compared, the mean number of requests in each month during these periods were found to be 1.81 +/- 0.58 and 4.06 +/- 1.20, respectively (p < 0.01). CONCLUSIONS: A short course of basic nutrition for residents improves their basic knowledge and leads to an increase in the number of consultation requests for nutritional support.

Six-month survival of patients with acute lung injury: prospective cohort study.

OBJECTIVE: Both short- and long-term outcome studies in acute lung injury (ALI) performed thus far were conducted before the implementation of recent advances in mechanical ventilation and supportive care and/or in the context of clinical trials with restricted inclusion criteria. We sought to determine the outcome of consecutive acute lung injury patients after the implementation of these interventions. DESIGN: Prospective cohort study. SETTING: Three intensive care units of two tertiary care hospitals. PATIENTS: Patients with acute lung injury treated from October 2005 to May 2006, excluding those with no research authorization or do-not-resuscitate order. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The investigators collected detailed information about comorbidities, severity of pulmonary and nonpulmonary organ failures, complications, respiratory support, and other interventions. The main outcome measure was mortality 6 months after the onset of acute lung injury. From 142 patients enrolled over a 6-month period, 24 (17%) died in the intensive care unit, 38 (27%) in the hospital, and 55 (39%) by the end of the 6-month follow-up. Median (interquartile range) intensive care unit length of stay, duration of mechanical ventilation, and number of day 28 ventilator-free days were 7.1 (3.6-11.3), 5.7 (2.6-10.3), and, 19.0 (0-24.2) days. Multiple logistic regression analysis identified underlying Charlson comorbidity score (odds ratio 3.11, 95% confidence interval 2.01-5.05) for each point increase, transfer admission from the floor or outside hospital (odds ratio 3.75, 95% confidence interval 1.41-10.99), day 3 cardiovascular failure (odds ratio 3.30, 95% confidence interval 1.19-9.92), and day 3 Pao2/Fio2 (odds ratio 0.94, 95% confidence interval 0.88-0.99) as significant predictors of 6-month mortality. CONCLUSIONS: With the implementation of recent advances in mechanical ventilation and supportive care, premorbid condition is the most important determinant of acute lung injury survival.

Toward the prevention of acute lung injury: protocol-guided limitation of large tidal volume ventilation and inappropriate transfusion.

OBJECTIVE: We evaluated the effect of two quality improvement interventions (low tidal volume ventilation and restrictive transfusion) on the development of acute lung injury in mechanically ventilated patients. DESIGN: Observational cohort study. SETTING: Three intensive care units in a tertiary academic center. PATIENTS: We included patients who were mechanically ventilated for > or =48 hrs excluding those who refused research authorization or had preexisting acute lung injury or pneumonectomy. INTERVENTIONS: Multifaceted interdisciplinary intervention consisting of Web-based teaching, respiratory therapy protocol, and decision support within computerized order entry. MEASUREMENTS AND MAIN RESULTS: Of 375 patients who met the inclusion and exclusion criteria, 212 were ventilated before and 163 after the interventions. Baseline characteristics were similar between the two groups except for a lower frequency of sepsis (27% vs. 17%, p = .030), trend toward lower median glucose level (140 mg/dL, interquartile range 118-168 vs. 132 mg/dL, interquartile range 113-156, p = .096), and lower frequency of pneumonia (27% vs. 20%, p = .130) during the second period. We observed a large decrease in tidal volume (10.6-7.7 mL/kg predicted body weight, p < .001), in peak airway pressure (31-25 cm H2O, p < .001), and in the percentage of transfused patients (63% to 38%, p < .001) after the intervention. The frequency of acute lung injury decreased from 28% to 10% (p < .001). The duration of mechanical ventilation decreased from a median of 5 (interquartile range 4-9) to 4 (interquartile range 4-8) days (p = .030). When adjusted for baseline characteristics in a multivariate logistic regression analysis, protocol intervention was associated with a reduction in the frequency of new acute lung injury (odds ratio 0.21, 95% confidence interval 0.10-0.40). CONCLUSIONS: Interdisciplinary intervention effectively decreased large tidal volumes and unnecessary transfusion in mechanically ventilated patients and was associated with a decreased frequency of new acute lung injury.