Accuracy of delayed cultures of plugged telescoping catheter samples for diagnosing bacterial pneumonia.

OBJECTIVE: It is not always feasible to culture immediately bacteriologic samples of protected pulmonary specimens on a 24-hr basis before starting antibiotic treatment. We have evaluated the effect of delaying the culture of immediate plugged telescoping catheter (PTC) samples performed before starting antibiotherapy. DESIGN: Prospective paired comparisons study. SETTING: Intensive care unit in a university hospital. PATIENTS: Ninety-nine PTCs were performed on 68 intensive care unit patients suspected of nosocomial or community- acquired bacterial pneumonia. INTERVENTION: PTC samples were divided into two aliquots: one for immediate (H0) analysis and one for storage at 4 degrees C (H24) for 24 hrs before being cultured. MEASUREMENTS AND MAIN RESULTS: The results from these delayed cultures (H24) were compared with those from immediate ones (H0). All negative H0 samples (n = 59) were also negative at H24. Forty PTCs yielded one or more microorganisms, with a total of 69 microorganisms in one or both samples. H0 and H24 cultures were concordant in 119 of 128 (97.9%) cases (kappa coefficient value 0.79) with a threshold of 103 colony-forming units (cfu)/mL. Agreement between paired cultures was very good. The bias calculated as the mean difference between paired culture results was 0.128 +/- 1.024 (Deltalog). Concordance using the 103 cfu/mL threshold (102/107 cases, kappa coefficient value 0.82) and agreement were enhanced (0.067 +/- 0.645) when possible contaminants were excluded (n = 21). CONCLUSIONS: Storing PTC specimens for 24 hrs at 4 degrees C is an acceptable alternative when culturing cannot be performed immediately. This allows starting antibiotic treatment without any delay.

Efficiency and safety of mechanical ventilation with a heat and moisture exchanger changed only once a week.

The cost of mechanical ventilation (MV) is high. Efforts to reduce this cost, as long as they are not detrimental for the patients, are needed. MV with heat and moisture exchangers (HME) changed every 48 h is safe, efficient, and cost-effective. Preliminary reports suggest that the life span of these filters may be prolonged. We determined prospectively whether a hygroscopic and hydrophobic HME (Hygrobac-Dar; Mallinckrodt) provided safe and efficient heating and humidification of the inspired gases when changed only once a week. Patients who were considered to require mechanical ventilation for more than 48 h were included in the study. HMEs were initially set for 7 d. Efficient airway heating and humidification were assessed by clinical parameters (number of tracheal suctionings and instillations required, peak airway pressures) and hygrometric measurements performed by psychrometry. Resistance was measured from Day 0 to Day 7. Bacterial colonization of circuits and HMEs was studied. A total of 377 days of mechanical ventilation with 60 HMEs was studied. Clinical parameters and hygrometric measurements did not change between Day 0 and Day 7. Mean absolute humidity was 30.3 +/- 1.3 mg H(2)O/L on Day 0 and 30.8 +/- 1.5 mg H(2)O/L on Day 7 (p = 0.7). Endotracheal tube occlusion never occurred. Three HMEs were replaced prematurely because of insufficient absolute humidity. This rare event occurred only in patients with COPD and after the third day of use. In addition, the absolute humidity delivered by the HMEs was significantly lower in patients with COPD than in the rest of the population. Resistance did not change from Day 0 to Day 7 (2.4 +/- 0.3 versus 2.7 +/- 0.3 cm H(2)O/L/s; p = 0.4). Bacterial samples of both circuits and ventilator sides of HMEs were sterile in most cases. We conclude that mechanical ventilation can be safely conducted in non-COPD patients using an HME changed only once a week, leading to substantial cost savings (about $110,000 per year if these findings were applied to the university-affiliated hospitals in Paris).

Iatrogenic diseases as a reason for admission to the intensive care unit: incidence, causes, and consequences.

BACKGROUND: Data on iatrogenic diseases (IDs) have been recorded for the past 25 years. We determined whether aging of the general population and medical advances, including more powerful drugs and complex procedures, have altered the incidence, causes, and consequences of severe IDs during this period. METHODS: One-year retrospective study was conducted in an adult medical-surgical intensive care unit (ICU) affiliated with a French general hospital in an area of 200 000 inhabitants. All the patients admitted to the ICU during 1994 were screened for IDs. Patients with community or hospital-acquired IDs on admission were included. Follow-up assessed morbidity, mortality, workload, and costs of care for IDs, and the rate of preventable IDs. were included; the cause of the ID was drugs in 41, medical acts in 12, and surgical acts in 15. These 68 patients were in the ICU for 472 days, with a 13% fatality rate (9 patients) and a financial cost of US $688 470. They were not different from the 555 other ICU patients in terms of severity, mortality, workload, and length of stay in the ICU. Risk factors for ID were old age and the number of prescribed drugs. The rate of preventable ID was 51%. CONCLUSIONS: Iatrogenic diseases are a persistent and important reason for admission to the ICU, and the risk factors, causes, and consequences remain unchanged since 1980. Despite 25 years of experience with high-technology medicine, ID still has a negative impact on the health and resources of society.

[Patients admitted to the intensive care unit for iatrogenic disease. Risk factors and consequences]. / Patients admis en réanimation pour pathologie iatrogène: facteurs de risque et conséquences.

PURPOSE: Data pertaining to iatrogenic diseases have been recorded over the last 25 years. Regarding the evolution of medical practice (general ageing, more and more powerful drugs and complex procedures), it is not known whether the incidence and the consequences of iatrogenic diseases have changed since their first evaluation. METHODS: To determine the admission rate to intensive care units for iatrogenic diseases, with the purpose of analyzing risk factors and consequences, and to compare our results with previous data recorded in 1979 (admission rate: 12.6%, mortality: 20%, preventable events: 47%), a 1-year retrospective study was conducted in an intensive care unit (ICU). RESULTS: During 1994, 68 (10.9%) out of 623 patients were admitted to the ICU for iatrogenic diseases (drugs: 41, medical acts: 12, surgical acts: 15). They were not different--in terms of severity, mortality, workload and length of stay in the ICU--from the other 555 patients hospitalized for other reasons. They were hospitalized on average for 472 days in the ICU, with a 13% fatality rate and a financial cost of US $688,470. Risk factors for iatrogenic diseases were the age and the number of prescribed drugs. The rate of preventable events was 51%. CONCLUSIONS: In this study, the occurrence of life-threatening iatrogenic diseases was a persistent and important purpose for admission to the ICU. Risk factors and consequences are still identical to those reported in 1979. Our results emphasize the persistence of the noxious impact of iatrogenic diseases on the quality and cost of medical care.

[Coronary gas embolism after laparoscopic surgery]. / Embolie gazeuse coronaire lors de la chirurgie coelioscopique.

Gas embolism is a severe complication of laparoscopic surgery. We report two cases: one with lethal peroperative cardiac arrest from massive coronary artery gas embolism recognized during open-chest cardiac massage; the second case, also associated with coronary artery gas embolism, resulted in severe but transient abnormal left ventricular anterior wall motion, subepicardial ischaemia and injury in ECG leads V1 to V5, but unremarkable coronary arteriography and full recovery. The pathophysiology of gas embolism occurring during a laparoscopic procedure, the mechanisms of gas entry into the systemic vascular bed, the clinical, ECG, pulse oximetry, end-tidal CO2 concentration changes and alarm signs are discussed. The diagnostic value of Doppler transoesophageal echocardiography when possible is underlined, and emergency management of gas embolism is considered.