Design and Implementation of the Intensive Care Unit Quality Management Registry: Monitoring Quality and Cost of an Adult Intensive Care Unit in a Greek State Hospital.

Intensive care electronic registries have been instrumental in quality measurement, improvement, and assurance of intensive care. In this article, the development and pilot implementation of the Intensive Care Unit Quality Management Registry are described, with a particular focus on monitoring the quality and operational cost in an adult ICU at a northern Greek state hospital. A relational database was developed for a hospital ICU so that qualitative and financial data are recorded for further analysis needed for planning quality care improvement and enhanced efficiency. Key features of this database registry were low development cost, user friendliness, maximum data security, and interoperability in existing hospital information systems. The database included patient demographics, nursing and medical parameters, and quality and performance indicators as established in many national registries worldwide. Cost recording was based on a mixed approach: at patient level ("bottom-up" method) and at department level ("top-down" method). During the pilot phase of the database operation, regular monitoring of quality and cost data revealed several fields of quality excellence, while indicating room for improvement for others. Parallel recording and trending of multiple parameters showed that the database can be utilized for optimum ICU quality and cost management and also for further research purposes by nurses, physicians, and administrators.

Bloodstream infections and sepsis in Greece: over-time change of epidemiology and impact of de-escalation on final outcome.

BACKGROUND: Choice of empirically prescribed antimicrobials for sepsis management depends on epidemiological factors. The epidemiology of sepsis in Greece was studied in two large-periods. METHODS: Sepsis due to bloodstream infections (BSI) from July 2006 until March 2013 was recorded in a multicenter study in 46 departments. Patients were divided into sepsis admitted in the emergencies and hospitalized in the general ward (GW) and sepsis developing after admission in the Intensive Care Unit (ICU). The primary endpoints were the changes of epidemiology and the factors related with BSIs by multidrug-resistant (MDR) pathogens; the secondary endpoint was the impact of de-escalation on antimicrobial therapy. RESULTS: 754 patients were studied; 378 from 2006-2009 and 376 from 2010-2013. Major differences were recorded between periods in the GW. They involved increase of: sepsis severity; the incidence of underlying diseases; the incidence of polymicrobial infections; the emergence of Klebsiella pneumoniae as a pathogen; and mortality. Factors independently related with BSI by MDR pathogens were chronic hemofiltration, intake of antibiotics the last three months and residence into long-term care facilities. De-escalation in BSIs by fully susceptible Gram-negatives did not affect final outcome. Similar epidemiological differences were not found in the ICU; MDR Gram-negatives predominated in both periods. CONCLUSIONS: The epidemiology of sepsis in Greece differs in the GW and in the ICU. De-escalation in the GW is a safe strategy.

Hemoptysis due to a mycotic pulmonary artery aneurysm in an injecting drug user.

Infected aneurysms of the pulmonary artery are a rare consequence of injected drug use. Hemoptysis of pulmonary arterial origin is also infrequent; however, the mortality is as high as 50%. We report here a case of hemoptysis in an intravenous drug user, caused by a pulmonary artery aneurysm due to septic microemboli, originating from a groin abscess. We highlight the importance of recognizing and treating thromboembolic complications associated with deep venous thrombosis in injecting drug users.

Procalcitonin and procalcitonin kinetics for diagnosis and prognosis of intravascular catheter-related bloodstream infections in selected critically ill patients: a prospective observational study.

BACKGROUND: Procalcitonin (PCT) has emerged as a valuable marker of sepsis. The potential role of PCT in diagnosis and therapy monitoring of intravascular catheter-related bloodstream infections (CRBSI) in intensive care unit (ICU) is still unclear and was evaluated. METHODS: Forty-six patients were included in the study, provided they were free of infection upon admission and presented the first episode of suspected CRBSI during their ICU stay. Patients who had developed any other infection were excluded. PCT was measured daily during the ICU hospitalization. Primary endpoint was proven CRBSI. Therapy monitoring as according to infection control was also evaluated. RESULTS: Among the 46 patients, 26 were diagnosed with CRBSI. Median PCT on the day of infection suspicion (D0) was 7.70 and 0.10 ng/ml for patients with and without proven CRBSI, respectively (p < 0.001). The area under the curve (AUC) for PCT was 0.990 (95% CI; 0.972 - 1.000), whereas a cut-off value of 0.70 ng/ml provided sensitivity and specificity of 92.3 and 100% respectively. In contrast, the AUC for white blood cells (WBC) was 0.539 (95% CI; 0.369 - 0.709), and for C-reactive protein (CRP), 0.603 (95% CI; 0.438 - 0.768). PCT was the best predictor of proven infection. Moreover, an increase >0.20 ng/ml of PCT between the D0 and any of the 4 preceding days was associated with a positive predictive value exceeding 96%. PCT concentrations from the D2 to D6 after suspected infection tended to decrease in controlled patients, whereas remained stable in non-controlled subjects. A PCT concentration exceeding 1.5 ng/ml during D3 was associated with lack of responsiveness to therapy (p = 0.028). CONCLUSIONS: We suggest that PCT could be a helpful diagnostic and prognostic marker of CRBSI in critically ill patients. Both absolute values and variations should be considered.

Temperature variability analysis using wavelets and multiscale entropy in patients with systemic inflammatory response syndrome, sepsis, and septic shock.

BACKGROUND: Even though temperature is a continuous quantitative variable, its measurement has been considered a snapshot of a process, indicating whether a patient is febrile or afebrile. Recently, other diagnostic techniques have been proposed for the association between different properties of the temperature curve with severity of illness in the Intensive Care Unit (ICU), based on complexity analysis of continuously monitored body temperature. In this study, we tried to assess temperature complexity in patients with systemic inflammation during a suspected ICU-acquired infection, by using wavelets transformation and multiscale entropy of temperature signals, in a cohort of mixed critically ill patients. METHODS: Twenty-two patients were enrolled in the study. In five, systemic inflammatory response syndrome (SIRS, group 1) developed, 10 had sepsis (group 2), and seven had septic shock (group 3). All temperature curves were studied during the first 24 hours of an inflammatory state. A wavelet transformation was applied, decomposing the signal in different frequency components (scales) that have been found to reflect neurogenic and metabolic inputs on temperature oscillations. Wavelet energy and entropy per different scales associated with complexity in specific frequency bands and multiscale entropy of the whole signal were calculated. Moreover, a clustering technique and a linear discriminant analysis (LDA) were applied for permitting pattern recognition in data sets and assessing diagnostic accuracy of different wavelet features among the three classes of patients. RESULTS: Statistically significant differences were found in wavelet entropy between patients with SIRS and groups 2 and 3, and in specific ultradian bands between SIRS and group 3, with decreased entropy in sepsis. Cluster analysis using wavelet features in specific bands revealed concrete clusters closely related with the groups in focus. LDA after wrapper-based feature selection was able to classify with an accuracy of more than 80% SIRS from the two sepsis groups, based on multiparametric patterns of entropy values in the very low frequencies and indicating reduced metabolic inputs on local thermoregulation, probably associated with extensive vasodilatation. CONCLUSIONS: We suggest that complexity analysis of temperature signals can assess inherent thermoregulatory dynamics during systemic inflammation and has increased discriminating value in patients with infectious versus noninfectious conditions, probably associated with severity of illness.

Study of multiparameter respiratory pattern complexity in surgical critically ill patients during weaning trials.

BACKGROUND: Separation from mechanical ventilation is a difficult task, whereas conventional predictive indices have not been proven accurate enough, so far. A few studies have explored changes of breathing pattern variability for weaning outcome prediction, with conflicting results. In this study, we tried to assess respiratory complexity during weaning trials, using different non-linear methods derived from theory of complex systems, in a cohort of surgical critically ill patients. RESULTS: Thirty two patients were enrolled in the study. There were 22 who passed and 10 who failed a weaning trial. Tidal volume and mean inspiratory flow were analyzed for 10 minutes during two phases: 1. pressure support (PS) ventilation (15-20 cm H2O) and 2. weaning trials with PS: 5 cm H2O. Sample entropy (SampEn), detrended fluctuation analysis (DFA) exponent, fractal dimension (FD) and largest lyapunov exponents (LLE) of the two respiratory parameters were computed in all patients and during the two phases of PS. Weaning failure patients exhibited significantly decreased respiratory pattern complexity, reflected in reduced sample entropy and lyapunov exponents and increased DFA exponents of respiratory flow time series, compared to weaning success subjects (p < 0.001). In addition, their changes were opposite between the two phases of the weaning trials. A new model including rapid shallow breathing index (RSBI), its product with airway occlusion pressure at 0.1 sec (P0.1), SampEn and LLE predicted better weaning outcome compared with RSBI, P0.1 and RSBI* P0.1 (conventional model, R(2) = 0.874 vs 0.643, p < 0.001). Areas under the curve were 0.916 vs 0.831, respectively (p < 0.05). CONCLUSIONS: We suggest that complexity analysis of respiratory signals can assess inherent breathing pattern dynamics and has increased prognostic impact upon weaning outcome in surgical patients.

Relation of tricuspid annular displacement and tissue Doppler imaging velocities with duration of weaning in mechanically ventilated patients with acute pulmonary edema.

BACKGROUND: Liberation from the ventilator is a difficult task, whereas early echocardiographic indices of weaning readiness are still lacking. The aim of this study was to test whether tricuspid annular plane systolic excursion (TAPSE) and right ventricular (RV) systolic (Sm) and diastolic (Em & Am) tissue Doppler imaging (TDI) velocities are related with duration of weaning in mechanically ventilated patients with acute respiratory failure due to acute pulmonary edema (APE). METHODS: Detailed quantification of left and right ventricular systolic and diastolic function was performed at admission to the Intensive Care Unit by Doppler echocardiography, in a cohort of 32 mechanically ventilated patients with APE. TAPSE and RV TDI velocities were compared between patients with and without prolonged weaning (> or = or < 7 days from the first weaning trial respectively), whereas their association with duration of ventilation and left ventricular (LV) echo-derived indices was tested with multivariate linear and logistic regression analysis. RESULTS: Patients with prolonged weaning (n = 12) had decreased TAPSE (14.59 +/- 1.56 vs 19.13 +/- 2.59 mm), Sm (8.68 +/- 0.94 vs 11.62 +/- 1.77 cm/sec) and Em/Am ratio (0.98 +/- 0.80 vs 2.62 +/- 0.67, p <0.001 for all comparisons) and increased Epsilon/e' (11.31 +/- 1.02 vs 8.98 +/- 1.70, p <0.001) compared with subjects without prolonged weaning (n = 20). Logistic regression analysis revealed that TAPSE (R2 = 0.53, beta slope = 0.76, p < 0.001), Sm (R2 = 0.52, beta = 0.75, p < 0.001) and Em/Am (R2 = 0.57, beta = 0.32, p < 0.001) can predict length of weaning > or = 7 days. The above measures were also proven to correlate significantly with Epsilon/e' (r = -0.83 for TAPSE, r = -0.87 for Sm and r = -0.79 for Em/Am, p < 0.001 for all comparisons). CONCLUSIONS: We suggest that in mechanically ventilated patients with APE, low TAPSE and RV TDI velocities upon admission are associated with delayed liberation from mechanical ventilation, probably due to more severe LV heart failure.

Down-regulation of the inhibitor of growth family member 4 (ING4) in different forms of pulmonary fibrosis.

BACKGROUND: Recent evidence has underscored the role of hypoxia and angiogenesis in the pathogenesis of idiopathic fibrotic lung disease. Inhibitor of growth family member 4 (ING4) has recently attracted much attention as a tumor suppressor gene, due to its ability to inhibit cancer cell proliferation, migration and angiogenesis. The aim of our study was to investigate the role of ING4 in the pathogenesis of pulmonary fibrosis both in the bleomycin (BLM)-model and in two different types of human pulmonary fibrosis, including idiopathic pulmonary fibrosis (IPF) and cryptogenic organizing pneumonia (COP). METHODS: Experimental model of pulmonary fibrosis was induced by a single tail vein injection of bleomycin in 6- to 8-wk-old C57BL/6mice. Tissue microarrays coupled with qRT-PCR and immunohistochemistry were applied in whole lung samples and paraffin-embedded tissue sections of 30 patients with IPF, 20 with COP and 20 control subjects. RESULTS: A gradual decline of ING4 expression in both mRNA and protein levels was reported in the BLM-model. ING4 was also found down-regulated in IPF patients compared to COP and control subjects. Immunolocalization analyses revealed increased expression in areas of normal epithelium and in alveolar epithelium surrounding Masson bodies, in COP lung, whereas showed no expression within areas of active fibrosis within IPF and COP lung. In addition, ING4 expression levels were negatively correlated with pulmonary function parameters in IPF patients. CONCLUSION: Our data suggest a potential role for ING4 in lung fibrogenesis. ING4 down-regulation may facilitate aberrant vascular remodelling and fibroblast proliferation and migration leading to progressive disease.

Ventilator-associated pneumonia or endotracheal tube-associated pneumonia? An approach to the pathogenesis and preventive strategies emphasizing the importance of endotracheal tube.

Ventilator-associated pneumonia is the most common nosocomial infection in the intensive care unit, and it is associated with prolonged hospitalization, increased health care costs, and high attributable mortality. During the past several decades, numerous studies focused on the crucial role of the endotracheal tube (ETT) in the pathogenesis of ventilator-associated pneumonia. Tracheal intubation thwarts the cough reflex, compromises mucocilliary clearance, injures the tracheal epithelial surface, provides a direct conduit for rapid access of bacteria from upper into the lower respiratory tract, and allows the formation of biofilm on the ETT surface. The combination of these factors puts the mechanically ventilated patient at great jeopardy of developing ventilator-associated pneumonia. Many preventive strategies have arisen from this understanding: control of intracuff pressure, aspiration of subglottic secretions, decontamination of subglottic area, use of antiseptic impregnated ETTs, and elimination or prevention of the ETT biofilm formation. The authors review the role of ETT management for the prevention of the ventilator-associated pneumonia.

Risk factors for nasopharyngeal carriage of drug-resistant Streptococcus pneumoniae: data from a nation-wide surveillance study in Greece.

BACKGROUND: A nation-wide surveillance study was conducted in Greece in order to provide a representative depiction of pneumococcal carriage in the pre-vaccination era and to evaluate potential risk factors for carriage of resistant strains in healthy preschool children attending daycare centers. METHODS: A study group was organized with the responsibility to collect nasopharyngeal samples from children. Questionnaires provided demographic data, data on antibiotic consumption, family and household data, and medical history data. Pneumococcal isolates were tested for their susceptibility to various antimicrobial agents and resistant strains were serotyped. RESULTS: Between February and May 2004, from a total population of 2536 healthy children, a yield of 746 pneumococci was isolated (carriage rate 29.41%). Resistance rates differed among geographic regions. Recent antibiotic use in the last month was strongly associated with the isolation of resistant pneumococci to a single or multiple antibiotics. Serotypes 19F, 14, 9V, 23F and 6B formed 70.6% of the total number of resistant strains serotyped. CONCLUSION: Recent antibiotic use is a significant risk factor for the colonization of otherwise healthy children's nasopharynx by resistant strains of S pneumoniae. The heptavalent pneumococcal conjugate vaccine could provide coverage for a significant proportion of resistant strains in the Greek community. A combined strategy of vaccination and prudent antibiotic use could provide a means for combating pneumococcal resistance.

Negative-pressure acute tracheobronchial hemorrhage and pulmonary edema.

Negative-pressure pulmonary edema is a well-known complication of an acute upper airway obstruction, which may rarely present as acute alveolar hemorrhage in cases of severe capillary stress failure. Hemorrhage from the central airways has also been reported as a rare manifestation of acute tracheobronchial injury, associated with severe disruption of the bronchial vasculature due to highly negative inspiratory pressure. In this clinical report, we describe a case of both acute tracheobronchial and alveolar hemorrhage in a young man, occurring immediately after extubation due to laryngospasm, diagnosed by bronchoscopy with bronchoalveolar lavage (BAL), measurement of the pulmonary edema fluid/plasma protein ratio, and by thoracic computed tomography (CT) scan. We propose that the patient experienced severe postobstructive negative-pressure pulmonary edema, related to increased permeability of the alveolar capillary membrane and a parallel loss of integrity of the bronchial vascular network. Our findings suggest that both changes in the bronchial circulation and mechanical stress failure of the more distal alveolar-capillary system may be induced by severe and acute upper-airway obstruction.

Determining rhythmicity and determinism of temperature curves in septic and non-septic critically ill patients through chronobiological and recurrence quantification analysis: a pilot study.

BACKGROUND: A few studies have demonstrated that critically ill patients exhibit circadian deregulation and reduced complexity of different time series, such as temperature. RESULTS: In this prospective study, we enrolled 21 patients divided into three groups: group A (N = 10) included subjects who had septic shock at the time of ICU entry, group B (N = 6) included patients who developed septic shock during ICU stay, and group C consisted of 5 non-septic critically ill patients. Core body temperature (CBT) was recorded for 24 h at a rate of one sample per hour (average of CBT for that hour) and during different occasions: upon ICU entry and exit in groups A and C and upon entry, septic shock development, and exit in group B. Markers of circadian rhythmicity included mean values, amplitude that is the difference between peak and mean values, and peak time. Furthermore, recurrence quantification analysis (RQA) was employed for assessing different markers of complexity of temperature signals. Patients from group C exhibited higher temperature amplitude upon entry (0.45 ± 0.19) in relation with both groups A (0.28 ± 0.18, p < 0.05) and B (0.32 ± 0.13, p < 0.05). Circadian features did not differ within all groups. Temperature amplitude in groups B and C upon entry was negatively correlated with SAPS II (r = - 0.72 and - 0.84, p < 0.003) and APACHE II scores (r = - 0.70 and - 0.63, p < 0.003), respectively, as well as duration of ICU and hospital stay in group B (r = - 0.62 and - 0.64, p < 0.003) and entry SOFA score in group C (r = - 0.82, p < 0.003). Increased periodicity of CBT was found for all patients upon exit related to entry in the ICU. Different RQA features indicating periodic patterns of change of entry CBT were negatively correlated with severity of disease and length of ICU stay for all patients. CONCLUSIONS: Increased temperature rhythmicity during ICU entry was related with lower severity of disease and better clinical outcomes, whereas the more deterministic CBT patterns were found in less critically ill patients with shorter ICU stay.

Saccharomyces boulardii fungaemia in an intensive care unit patient treated with caspofungin.

We describe a case of Saccharomyces boulardii fugaemia in a critically ill patient with septic shock treated with a probiotic agent containing this yeast. We attributed this fugaemia to gut translocation. Our use of caspofugin yielded excellent results.

Pleural effusions in critically ill patients.

Pleural effusions (PEs) are common in critically ill patients mainly as a consequence of severe cardiopulmonary disorders frequently encountered in these patients. Their impact on the pathophysiology of acute respiratory failure remains unknown. They are usually small and uncomplicated transudates that are easily overlooked on a supine portable chest X-ray and do not require drainage or infectious exudates that always require thoracocentesis. The diagnosis of PEs in critically ill patients has been revolutionized with the advent of chest ultrasound allowing easy bedside quantification of pleural fluid and making thoracocentesis a safe procedure especially in high-risk patients on mechanical ventilation. CT provides a much more accurate evaluation of the size and location of PEs and is extremely helpful in the guidance of catheters into loculated fluid collections. Hemothorax in critically ill patients is usually related to trauma or surgical interventions and requires early drainage and possibly surgical exploration.

Pleural involvement in systemic autoimmune disorders.

Systemic autoimmune diseases, a heterogeneous group of immunologically mediated inflammatory disorders including multiorgan involvement, can affect the pleura with various frequencies, either as a single presenting feature or as part of multisystem involvement. Rheumatoid arthritis and systemic lupus erythematosus represent the most common immunological diseases that affect the pleural cavity; however, there is considerable variation regarding the reported prevalence, natural history and prognosis of pleural involvement in both conditions. The definition of pleural disease in the remaining systemic autoimmune disorders is unquestionably imprecise and assumptive, since it is risky to support premises based on single case reports or retrospective data from very small series. In this article, we will review the manifestations of pleural disease caused by rheumatoid arthritis, systemic lupus erythematosus, scleroderma, polymyositis/dermatomyositis, mixed connective tissue disease, ankylosing spondylitis, Sjogren's syndrome and Wegener's granulomatosis.

Investigating the failure to aspirate subglottic secretions with the Evac endotracheal tube.

BACKGROUND: Aspiration of subglottic secretions is a widely used intervention for prevention of ventilator-associated pneumonia. However, using the Hi-Lo Evac endotracheal tube (Hi-Lo Evac; Mallinckrodt; Athlone, Ireland) (Evac ETT), dysfunction of the suction lumen and subsequent failure to aspirate the subglottic secretions are common. Our objective in this study was to determine the causes of suction lumen dysfunction experienced with the Evac ETT. METHODS: We studied 40 adult patients intubated with the Evac ETT. In all cases for which dysfunction of the suction lumen was observed, the subglottic suction port was examined visually using a flexible bronchoscope. RESULTS: Dysfunction of the suction lumen occurred in 19 of 40 patients (48%). In 17 of these (43%), it was attributed to blockage of the subglottic suction port by suctioned tracheal mucosa. CONCLUSION: Evacuation of subglottic secretions using the Evac ETT is often ineffective due to prolapse of tracheal mucosa into the subglottic suction port.

Prevention of nosocomial maxillary sinusitis in the ICU: the effects of topically applied alpha-adrenergic agonists and corticosteroids.

OBJECTIVE: We investigated the efficacy of locally applied nasal decongestant agents and corticosteroids for preventing nosocomial maxillary sinusitis in mechanically ventilated patients with multiple trauma. DESIGN AND SETTING: A prospective, open-label randomized study in two intensive care units (ICUs). PATIENTS: 79 consecutive multiple trauma patients admitted to the ICU who were expected to be mechanically ventilated for more than 3 days. INTERVENTIONS: Patients were randomly assigned to receive either a combination of a locally applied nasal decongestant agents: 2 drops twice/day of xylometazoline nasal solution 0.1% and 100microg budesonide (NDCA group, n=39) or placebo (control group, n=40). MEASUREMENTS: For the diagnosis of radiological maxillary sinusitis patients underwent paranasal computed tomography within 48h of admission and thereafter every 4-7 days. Infectious maxillary sinusitis was diagnosed by microbiological analysis of fluid aspirated after transnasal puncture of maxillary sinuses. RESULTS: Radiological maxillary sinusitis was detected in 54% of patients in the NDCA group (n=21) but in 82% of controls (p<0.01), and infectious maxillary sinusitis in 8% of the NDCA group (n=3) but in 20% of controls (n=8; p=0.11). The most common pathogen micro-organisms identified from maxillary aspirates were Acinetobacter (32%) followed by anaerobes (21%). CONCLUSION: Our results indicate that the combination of locally applied xylometazoline hydrochloride and budesonide reduces the incidence of radiological maxillary sinusitis and may reduce also that of nosocomial maxillary sinusitis in mechanically ventilated patients with multiple trauma.

Serum biomarkers in acute respiratory distress syndrome an ailing prognosticator.

The use of biomarkers in medicine lies in their ability to detect disease and support diagnostic and therapeutic decisions. New research and novel understanding of the molecular basis of the disease reveals an abundance of exciting new biomarkers who present a promise for use in the everyday clinical practice. The past fifteen years have seen the emergence of numerous clinical applications of several new molecules as biologic markers in the research field relevant to acute respiratory distress syndrome (translational research). The scope of this review is to summarize the current state of knowledge about serum biomarkers in acute lung injury and acute respiratory distress syndrome and their potential value as prognostic tools and present some of the future perspectives and challenges.

Gut failure in critical care: old school versus new school.

The concept of bacterial translocation and gut-origin sepsis as causes of systemic infectious complications and multiple organ deficiency syndrome in surgical and critically ill patients has been a recurring issue over the last decades attracting the scientific interest. Although gastrointestinal dysfunction seemingly arises frequently in intensive care unit patients, it is usually underdiagnosed or underestimated, because the pathophysiology involved is incompletely understood and its exact clinical relevance still remains controversial with an unknown yet probably adverse impact on the patients' outcome. The purpose of this review is to define gut-origin sepsis and related terms, to describe the mechanisms leading to gut-derived complications, and to illustrate the therapeutic options to prevent or limit these untoward processes.