Hospital staff education on severe sepsis/septic shock and hospital mortality: an original hypothesis.

BACKGROUND: Signs of serious clinical events overlap with those of sepsis. We hypothesised that any education on severe sepsis/septic shock may affect the outcome of all hospital patients. We designed this study to assess the trend of the mortality rate of adults admitted to hospital for at least one night in relationship with a hospital staff educational program dedicated to severe sepsis/septic shock. METHODS: This study was performed in six Italian hospitals in the same region. Multidisciplinary Sepsis Teams members were selected by each hospital management among senior staff. The education included the following steps: i) the Teams were taught about adult learning, problem based learning, and Surviving Sepsis guidelines, and provided with educational material (literature, electronic presentations, scenarios of clinical cases for training and booklets); ii) they started delivering courses and seminars each to their own hospital staff in the last quarter of 2007.To analyse mortality, we selected adult patients, admitted for at least one night to the wards or units present in all the study hospitals and responsible for 80% of hospital deaths. We fitted a Poisson model with monthly hospital mortality rates from December 2003 to August 2009 as dependent variable. The effect of the educational program on hospital mortality was measured as two dummy variables identifying a first (November 2007 to December 2008) and a second (January to August 2009) education period. The analysis was adjusted for a linear time trend, seasonality and monthly average values of age, Charlson score, length of stay in hospital and urgent/non-urgent admission. RESULTS: The hospital staff educated reached 30.6% at the end of June 2009. In comparison with the pre-education period, the Relative Risk of death of the patient population considered was 0.93 (95% confidence interval [CI] 0.87-0.99; p 0.025) for in-patients in the first, and 0.89 (95% CI 0.81-0.98; p 0.012) for those in the second period after education. CONCLUSION: Our hypothesis that a program educating hospital staff to early detection and treatment of severe sepsis/septic shock may affect the outcome of all hospital patients is original, but it has to be corroborated by other experiences.

Congenital symptomatic intrahepatic arteriovenous fistulas in newborns: management of 2 cases with prenatal diagnosis.

BACKGROUND: Fetal and neonatal hepatic arteriovenous fistulas are rare and associated with a high mortality rate; they can be prenatally detected by ultrasonography. Management of these malformations can be a challenge for pediatric surgeons. METHODS: Two patients with a prenatal diagnosis of intrahepatic arteriovenous shunts were treated at our institution in the last 2 years. A hepatic complex arteriovenous malformation fed respectively by prominent branches of the hepatic artery and of the celiac trunk rising from dilated suprarenal aortae and draining into suprahepatic veins was detected. In the first case, an embolization was performed; in the second, the surgical resection of the vascular malformation was the treatment of choice. RESULTS: The first patient died after embolization and before surgery for hemodynamic complications. The second patient, at a follow-up of 16 months, is alive and doing well. CONCLUSION: Hepatic resection is the treatment of choice for localized intrahepatic arteriovenous malformation. Theoretically, embolization could be curative or reduce the size of a malformation, making consequent hepatic resection feasible. Results do not support this theory because of the high rate of complications recorded that brought in every case, ours included, to the death of the child.

Removal of an unexpected tracheal foreign body after five months.

Foreign body aspiration can produce serious pulmonary diseases. Timely diagnosis and appropriate treatment is important to prevent long-term complications in affected children. We report the case of a 15-month-old child with a 5-month history of regurgitation, vomiting, recurrent tracheobronchitis, and pneumonia. The diagnosis was gastroesophageal reflux. The laryngotracheal endoscopy revealed a rabbit vertebra partially obstructing the airway at the level of the cricoid cartilage. With a rigid bronchoscope and forceps equipped with a telescope, it was possible to disengage and extract the foreign body. Six months later endoscopic control revealed no residual alterations in the larynx and trachea.

Multicenter, randomized, controlled study of porcine surfactant in severe respiratory syncytial virus-induced respiratory failure.

OBJECTIVE: Recently, natural exogenous surfactant replacement has been used in experimental models and clinical trials for the treatment of severe respiratory syncytial virus (RSV) disease. The present study was aimed at verifying this hypothesis and confirming the results of our previous pilot study by assessing the effect of surfactant treatment in mechanically ventilated infants with severe RSV-induced respiratory failure. DESIGN: Multicenter, randomized, controlled study. SETTING: Six pediatric intensive care units staffed by full-time intensive care physicians. PATIENTS: A total of 40 infants (20 treated and 20 controls) with RSV-induced respiratory failure requiring conventional mechanical ventilation (CMV) were randomly assigned to either exogenous surfactant (treated group) or conventional treatment (control group) over a 1-yr period. INTERVENTIONS: Fifty milligrams per kilogram of body weight of porcine-derived natural surfactant (Curosurf) was administered. The drug was instilled by means of a syringe attached to a small suction catheter inserted into the endotracheal tube down to its tip, momentarily disconnecting the patient from CMV. Main Outcome Measures: The assessment consisted of the following outcome variables: duration of CMV, length of intensive care unit stay, gas exchange, respiratory mechanics, re-treatment need, complications, and mortality. RESULTS: The two groups were similar with regard to demographics, Pediatric Risk of Mortality scores, and baseline Pao(2)/Fio(2), Paco(2), and ventilator settings. A marked increase in Pao(2)/Fio(2) and decrease in Paco(2) were observed in the treated group after surfactant administration. Hemodynamic parameters remained unchanged throughout the study period. Peak inspiratory pressure and static compliance were similar at baseline in the two groups. A decrease in peak inspiratory pressure and increase in static compliance were observed in the treated group after surfactant administration. Among surfactant-treated patients, 15 received the treatment within 24 hrs of admission, whereas the remainder (five patients) were treated later. Among children who were treated later, three needed an additional dose of surfactant. None of the children treated within 24 hrs needed an additional dose. Duration of CMV and length of stay in the intensive care unit were significantly shorter in the treated group (4.6 +/- 0.8 and 6.4 +/- 0.9 days, respectively) compared with the control group (5.8 +/- 0.7 and 8.2 +/- 1.1 days, respectively) (p <.0001). No relevant complications were observed, and all the infants survived. CONCLUSIONS: Consistent with our previous study and others, this study shows that surfactant therapy improves gas exchange and respiratory mechanics and shortens CMV and intensive care unit stay in infants with severe RSV-induced respiratory failure.