Corynebacterium jeikeium native valve endocarditis following femoral access for coronary angiography.

We present a unique case of rapidly fatal native aortic-valve endocarditis due to Corynebacterium jeikeium, with inoculation as a complication of repeated femoral vascular access for coronary angiography.

Persistent hypoxia after diagnosis and treatment of pulmonary thromboembolism.

Acute respiratory failure in the perioperative period represents a frequent challenge to the anesthesiologist. The differential diagnosis is extensive and includes alterations on the pulmonary parenchyma, pulmonary vessels, airway, and cardiac system. Occasionally, two or more pathophysiological process superimpose. We present a patient who suffered from a left pulmonary embolism that was appropriately diagnosed and treated. However, the hypoxemia persisted and a second pathology was suspected. After careful evaluation and differential diagnosis, we drained a right pleural effusion, which had been present preoperatively, with resolution of the hypoxemia. There is controversy in the literature as to the role of drainage of pleural effusions on improving oxygenation. We present this case as an example of successful management of perioperative respiratory failure by thoracentesis in the presence of a second concurrent pathologic process.

An evaluation of a new continuous blood pressure monitoring system in critically ill patients.

STUDY OBJECTIVE: To determine if the DxTek monitor, which is a device that measures blood pressure (BP) noninvasively and continuously by means of pulse velocity and wave shapes derived from the pulse oximeter optical plethysmograph and electrocardiogram is as accurate as an oscillometric cuff device when compared with intraarterial BP measurement. DESIGN: Prospective, comparative study. SETTING: University Medical Center. PATIENTS: 28 intensive care unit patients. INTERVENTIONS: Blood pressures were reported every minute by intraarterial catheters and DxTek and every 10 minutes by an oscillometric monitor for 2 to 5 hours. DxTek calibration was performed initially and when specified patient manipulations by caretakers were performed (on average, every 100 minutes). Comparisons with intraarterial pressure included: 1) DxTek calibrated with arterial catheter pressure, 2) DxTek calibrated with oscillometric pressure, and 3) oscillometric pressure. MEASUREMENTS AND MAIN RESULTS: When comparing oscillometric pressure to intraarterial pressure, the averages of the mean differences (bias) were -4.0 mmHg for systolic (SBP) and < 1.5 mmHg for diastolic (DBP) and mean (MAP) pressures. The averages of the standard deviation of the differences (precisions) were 9.6, 6.4, and 6.3 mmHg, respectively. With the DxTek device calibrated to intraarterial pressure, comparison of the DxTek pressure to intraarterial pressure resulted in a bias < OR = 0.5 mmHg for all three pressures and an average precision of 10.1 mmHg for SBP, 6.0 mmHg for DBP, and 6.7 mmHg for MAP. With the DxTek device calibrated to the oscillometric pressure, the DxTek pressure compared to the intraarterial pressure resulted in average biases of -5.1, -0.8, and -2.2 mmHg and average precisions of 11.1, 7.7, and 8.1 mmHg for SBP, DBP, and MAP, respectively. CONCLUSIONS: The DxTek monitor provides continuous, noninvasive BP measurements with an accuracy comparable to oscillometric devices.

Surgical ICU recidivism after cardiac operations.

BACKGROUND: Decreasing the ICU length of stay (LOS) after cardiac operations may increase ICU recidivism, obviating the benefit of early discharge. METHODS: From January 1, 1994 to January 1, 1998, there were 2,388 consecutive cardiac operations, from which 2,228 patients were discharged alive from the ICU and had sufficient information to determine their incidence of ICU return, the reasons for their return, their ICU LOS (initial and secondary LOS), and mortality. RESULTS: A decrease occurred in the initial ICU LOS from 1994 through 1997 (medians for 1994, 1995, 1996, and 1997, respectively: 31 h, 26.4 h, 24.5 h, and 24 h; and means, respectively: 69.4 +/- 139.8, 62.8 +/- 114.1, 52.5 +/- 104.0, and 56.2 +/- 103.4 h; p = 0.048). In association with this, however, ICU recidivism increased (as percentage of discharges, respectively: 3.9%, 4.2%, 6.1%, and 8.4%; p = 0.005). Inclusive of secondary ICU LOS, the total ICU LOS hours still decreased over the 4-year period. Most notably, the incidence of readmission increased with longer initial LOS (initial LOS quartiles from shortest to longest: 3.9%, 5.2%, 4.7%, and 9.2%; p = 0.0008). Predictors of ICU recidivism included preoperatively, a history of congestive heart failure, and a lower mean left ventricular ejection fraction (52.7 +/- 19.3% vs 49.8 +/- 21.5%; p = 0.0080); and, postoperatively, an increased mean weight gain (8.5 +/- 5.6 kg vs 10.3 +/- 4.7 kg; p = 0.040) and longer mean initial ventilator time (157 +/- 299 h vs 35 +/- 107 h; p = 0.038). The most common reason for readmission was pulmonary problems. CONCLUSIONS: Over the years studied, the initial ICU LOS after cardiac operations has decreased in association with a significant increase in ICU recidivism. Importantly, however, patients readmitted to the ICU are those with longer initial LOSs. Decreased initial stay does not account for our increased ICU recidivism, and efforts to decrease ICU recidivism can focus on the patients with poor preoperative cardiac function and longer initial ICU stays.

Physicians' own preferences to the limitation and withdrawal of life-sustaining therapy.

While limiting and forgoing therapy at the end of life is now accepted on medical, ethical, moral and legal grounds, many Americans continue to die with heroic measures being taken to prevent their death. Recent studies have demonstrated that physicians frequently attend to their patients without knowledge of their preferences with regards to end-of-life issues. It is postulated that a physician's personal preferences with regard to the limitation and withdrawal of life support and active euthanasia would effect the discussion they had with their patients. The purpose of this study was to analyze end-of-life preferences of a diverse group of practicing physicians. The participants were active attending physicians at a community hospital, a rural referral center, a large tertiary care referral academic complex, and a specialized tertiary care referral center all within the United States. A questionnaire was developed which was mailed to attending physicians at the four participating medical centers. The respondents provided basic demographic data, do-not-resuscitate (DNR) preferences under various clinical circumstances as well as responses to a number of case vignettes. Six hundred and forty physicians responded to the survey. The mean age of the respondents was 46 years; 72% were male. In the event of a cardiac arrest less than 20% of respondents would want to undergo cardiopulmonary resuscitation in the setting of chronic end stage organ failure; the positive response rate was 5% for metastatic cancer and 2% for Alzheimer's disease. If death was imminent, 87% of physicians indicated they would want treatment withdrawn. Similarly, 95% of respondents indicated that they would want treatment withdrawn should they be in a persistent vegetative state. Only 1% of respondents believed that health care providers should never remove or withhold life-sustaining therapy. Should they have advanced motor neuron disease, 38% of physicians indicated they would request that their life be ended. The majority of physicians surveyed volunteered that they would want life-sustaining measures to be limited at the end of their life. A significant number were in favor of active euthanasia. This study suggests that it is unlikely that physicians' personal beliefs in regards to end-of-life care result in the failure to discuss these issues with their patients.

Non-operating room emergency airway management and endotracheal intubation practices: a survey of anesthesiology program directors.

Airway management in the operating room is the responsibility of anesthesiologists, although a variety of personnel may be responsible for airway management outside the operating room. We conducted a survey of anesthesia program directors regarding emergency airway management practices at their institutions. A questionnaire was sent to anesthesia program directors listed in the Graduate Medical Education Directory for 1995-1996. Of the 153 programs surveyed, 134 (88%) responded. In 45% of institutions, intubations in the emergency ward (EW) were performed by emergency medical physicians, 32% by anesthesiology personnel, and 19% by both. Most intubations performed on the hospital ward were performed by anesthesiologists. Neuromuscular blocking drugs and sedative/hypnotics were used 90% and 95% of the time, respectively, by emergency medical physicians in hospitals in which they managed the airway independently. Our data serve as a snapshot of current practices. EW physicians are prominently involved in airway management in the emergency room both independently and with anesthesiologists. Airway management in trauma patients remains the domain of anesthesiologists. Anesthesiologists are most represented in airway management on hospital floors.

The value of lumbar puncture in the evaluation of critically ill, non-immunosuppressed, surgical patients: a retrospective analysis of 70 cases.

OBJECTIVE: To evaluate the diagnostic value of lumbar puncture (LP) in surgical intensive care unit (SICU) patients. DESIGN: Retrospective chart review. SETTING: Surgical intensive care unit at a major tertiary care medical center. PATIENTS: All patients admitted to the SICU during the period 1987-1995 who had a lumbar puncture, excluding those with a history of recent head trauma or a neurosurgical procedure. MEASUREMENTS: Cerebral spinal fluid (CSF) results, indication for lumbar puncture; admitting service, length of ICU stay, presence of fever and use of antibiotics. RESULTS: Of 7,555 admissions to the SICU over the period 1987-1995, 204 patients underwent LP during the hospital admission. Four charts could not be located and 75 patients underwent LP in locations other than the SICU. Of the remaining 125 cases, 55 carried a neurosurgical diagnosis and 70 had non-neurosurgical problems. Fifty-three (75%) of the patients had received antibiotics prior to the procedure. Among the 70 cases without a primary neurosurgical diagnosis, LP was performed to rule out infective meningitis suggested by fever and mental status changes (30 patients), mental status changes alone (7 patients), systemic illness with fever and/or mental status changes (10 patients), seizures (10 patients), meningismus (+/- fever, 4 patients), or a combination of neurological findings (8 patients). There were no cases in which meningitis was positively diagnosed. Medical management was altered in only two patients based upon the results obtained by LP. CONCLUSIONS: We conclude that LP in SICU patients without a recent history of head trauma or a neurosurgical operation is a low yield procedure, especially for the diagnosis of bacterial meningitis.

15 (R)-15-methyl prostaglandin E2 does not prevent gastrointestinal bleeding in seriously ill patients.

A prospective, randomized trial was designed to compare the relative efficacy of 15 (R)-15-methyl prostaglandin E2 with antacid (usually Mylanta II) in 46 patients admitted to a respiratory-surgical intensive care unit. Bleeding was assessed by a modification of the Hemoccult slide test. Three of 22 patients in the antacid group bled, and 12 of 24 patients in the prostaglandin group bled, for a highly significant difference (p = 0.008). Patients in whom prophylaxis failed tended to have a greater number of risk factors. Other prostaglandin analogues that do not require conversion from an inactive to an active form, may be more useful than the agent we studied. Based on currently available data, the hourly titration of the gastric juice to a pH of greater than 3.5 remains the preferred method of prophylaxis for acute bleeding from the stomach in seriously ill patients.

Aspiration of gastric bacteria in antacid-treated patients: a frequent cause of postoperative colonisation of the airway.

The gastric and upper-airway flora of 60 consecutive patients treated with antacids or cimetidine in a respiratory/surgical intensive-therapy unit were studied. In 52 (87.0%) patients one or more organisms were cultured simultaneously from both upper airway and stomach. A sequence of transmission was clear in 17 of these patients. Pneumonia due to gram-negative bacilli developed in 31 patients; in most cases the causative organisms were of gastric origin. No pneumonia developed in the 8 patients whose gastric and upper-airway flora were different. The number of gram-negative bacilli in gastric aspirates correlated with the pH of the gastric aspirate. Treatment of seriously ill patients with antacids or cimetidine may encourage airway colonisation and predispose the patients to pneumonia caused by gram-negative bacilli.