Diagnosis of ventilator-associated pneumonia.

peer reviewe

The significance of distal bronchial samples with commensals in ventilator-associated pneumonia: colonizer or pathogen?

STUDY OBJECTIVE: To investigate the role of oropharyngeal and cutaneous commensal microorganisms (OCCs) as a cause of ventilator-associated pneumonia (VAP). DESIGN: Retrospective analysis of the medical and microbiological records. SETTING: One medical-surgical ICU. PATIENTS: All VAP episodes recorded during a 10-year period were reviewed. All patients with suspected VAP underwent bronchoscopy with protected-specimen brush (PSB) sampling and BAL before any change in antibiotic therapy was made. OCC-VAP was defined as VAP with significant growth in quantitative cultures (PSB yielded > or = 10(3) cfu/mL and/or BAL yielded > or = 10(4) cfu/mL) of OCCs only. Three experts reviewed the episodes. Exposed patients (ie, those with OCC-VAP) and unexposed patients (ie, patients without VAP) matched on condition severity at ICU admission and mechanical ventilation duration were compared. RESULTS: Twenty-nine episodes in 28 patients with > or = 10(4) cfu/mL OCCs in BAL fluid and/or > or = 10(3) cfu/mL OCCs in PSB specimens were found. All patients in these episodes had new radiologic lung infiltrates, with 26 episodes involving purulent tracheal aspirates, 23 episodes involving temperatures > or = 38.5 degrees C, and 18 episodes involving > or = 11,000 leukocytes/ microL. The main OCCs found were non-beta-hemolytic Streptococcus spp (n = 12), Neisseria spp (n = 7), and coagulase-negative Staphylococcus spp (n = 6). Other possible reasons for fever and the presence of new chest infiltrates were found in 20 and 17 patients, respectively. Histologic evidence of pneumonia was found in 2 of the 10 patients who died. The three experts agreed on the diagnosis for 23 patients. In the OCC-VAP group only, the mean (+/- SD) logistic organ dysfunction (LOD) scores increased significantly (LOD score, 2 +/- 4; p = 0.008) during the 3 days before bronchoscopy, and ICU stay duration was longer than in the unexposed group. The exposed/unexposed study found no difference in mortality. CONCLUSION: OCCs may behave like classic nosocomial pathogens in critically ill patients

Triaging patients to the ICU: a pilot study of factors influencing admission decisions and patient outcomes.

peer reviewedOBJECTIVE: To assess the appropriateness of ICU triage decisions. DESIGN. Prospective descriptive single-center study. SETTING: Ten-bed, medical-surgical ICU in an acute-care 460-bed, tertiary care hospital. PATIENTS: All patients triaged for admission were entered prospectively. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, underlying diseases, admission diagnoses, Mortality Probability Model (MPM0) score, information available to ICU physicians, and mortality were recorded. Of the 334 patients (96% medical), 145 (46.4%) were refused. Reasons for refusal were being too-sick-to-benefit (48, 14%) and too-well-to-benefit (93, 28%). Factors independently associated with refusal were patient location, ICU physician seniority, bed availability, patient age, underlying diseases, and disability. Hospital mortality was 23% and 27% for patients admitted to our ICU and other ICUs, respectively, and 7.5% and 60% for patients too well and too sick to benefit, respectively. In the multivariate Cox model, McCabe = 1 [hazard ratio (HR), 0.44 (95% CI, 0.24-0.77), P=0.001], living at home without help (HR, 0.440, 95% CI, 0.28-0.68, P=0.0003), and immunosuppression (HR, 1.91, 95% CI, 1.09-3.33, P=0.02) were independent predictors of hospital death. Neither later ICU admission nor refusal was associated with cohort survival. MPM0 was not associated with hospital mortality. CONCLUSIONS: Refusal of ICU admission was related to the ability of the triaging physician to examine the patient, ICU physician seniority, patient age, underlying diseases, self-sufficiency, and number of beds available. Specific training of junior physicians in triaging might bring further improvements. Scores that are more accurate than the MPM0 are needed

Fatal septic shock caused by Corynebacterium D2.

BACKGROUND: Septic shock remains one of the leading causes of mortality in critically ill patients. Optimal management depends on prompt diagnosis with identification of the causative organisms to allow appropriate antibiotic therapy. PATIENT: We report the first case of septic shock caused by Corynebacterium D2, a micro-organism that can cause encrusted cystitis and pyelitis of transplanted kidneys or, more rarely, native kidneys. Diagnosis rests on identification of risk factors, positive urine cultures, and computed tomography results. Despite optimal treatment our patient died with persistent encrusted pyelitis. CONCLUSIONS: Corynebacterium D2 is known to cause chronic inflammation of the bladder and proximal urinary tract but can also cause severe septic shock in immunocompetent patients

Staff perceptions of family access and visitation policies in Australian and New Zealand Intensive Care Units: The WELCOME ICU survey

Background: Family-centred critical care recognises the impact of a loved one's critical illness on his relatives. Open visiting is a strategy to improve family satisfaction and psychological outcomes by permitting unrestricted or less restricted access to visit their family member in the intensive care unit (ICU). However, increased family presence may result in increased workload and a risk of burnout for ICU staff. Objectives: The objective of this study was to evaluate ICU staff perceptions regarding visiting hours and family access in Australian and New Zealand ICUs. Secondary outcomes included an evaluation of current visiting policies, witnessed events in ICUs, and barriers to implementing open visiting policies. Design: A web-based survey open to all healthcare workers in Australia and New Zealand ICUs was distributed through local, state-based, and national critical care networks. Open visiting was defined as ICUs open for visiting >14 h per day. Main results: We received 1255 valid responses. Most respondents were nurses (n = 930, 74.1%) with a median critical care experience of 10 y. Most worked in open visiting ICUs (n = 749, 59.7%). Reported visiting hours varied greatly with a median of 20 h per day (interquartile range: 10–24 h). Open visiting was perceived as beneficial for the relatives, but less so for patients and staff (relatives: n = 845, 67.3%, patients: n = 561, 44.7%, staff: n = 257, 20.5%, p < 0.0001). Respondents from closed visiting units and nurses identified more risks from open visiting than other professional groups. Generally, staff preferred not to change from their current practice. Conclusion: We report that staff perceived open visiting as beneficial for relatives, but also identified risks to themselves, including increased workload, a risk of burnout, and a risk of occupational violence. Reluctance to change highlights the importance of addressing staff perceptions when implementing an open visiting policy.</p

Writing in and reading ICU diaries: qualitative study of families' experience in the ICU.

PURPOSE: Keeping an ICU patient diary has been reported to benefit the patient's recovery. Here, we investigated the families' experience with reading and writing in patient ICU diaries kept by both the family and the staff. METHODS: We conducted a qualitative study involving 32 semi-structured in-depth interviews of relatives of 26 patients (34% of all family members who visited patients) who met our ICU-diary criterion, i.e., ventilation for longer than 48 hours. Grounded theory was used to conceptualise the interview data via a three-step coding process (open coding, axial coding, and selective coding). RESULTS: Communicative, emotional, and humanising experiences emerged from our data. First, family members used the diaries to access, understand, and assimilate the medical information written in the diaries by staff members, and then to share this information with other family members. Second, the diaries enabled family members to maintain a connection with the patient by documenting their presence and expressing their love and affection. Additionally, families confided in the diaries to maintain hope. Finally, family members felt the diaries humanized the medical staff and patient. CONCLUSIONS: Our findings indicate positive effects of diaries on family members. The diaries served as a powerful tool to deliver holistic patient- and family-centered care despite the potentially dehumanising ICU environment. The diaries made the family members aware of their valuable role in caring for the patient and enhanced their access to and comprehension of medical information. Diaries may play a major role in improving the well-being of ICU-patient families

A case of daptomycin-induced immune thrombocytopenia.

We report a case of severe daptomycin-induced immune thrombocytopenia in a patient treated for methicillin-resistant Staphylococcus epidermidis and ampicillin-resistant Enterococcus faecalis bacteremia acquired in an intensive care unit. Serum antibodies bound to platelets in the presence of daptomycin on flow cytometry. There was no evidence of other causes of thrombocytopenia. The patient died of brain herniation complicating extensive cerebral hemorrhage. To our knowledge, this is the first described case of daptomycin-induced thrombocytopenia

Decision-making process, outcome, and 1-year quality of life of octogenarians referred for intensive care unit admission.

OBJECTIVE: To describe triage decisions and subsequent outcomes in octogenarians referred to an ICU. DESIGN AND SETTING: Prospective observational study in the medical ICU in a tertiary nonuniversity hospital. PARTICIPANTS: Cohort of 180 patients aged 80 years or over who were triaged for admission. MEASUREMENTS: Age, underlying diseases, admission diagnoses, Mortality Probability Model score, and mortality were recorded. Self-sufficiency (Katz Index of Activities of Daily Living) and quality of life (modified Perceived Quality of Life scale and Nottingham Health Profile) were measured 1year after triage. RESULTS: In 132 patients (73.3%) ICU admission was refused, including 79 (43.8%) considered too sick to benefit. Factors independently associated with refusal were nonsurgical status, age older than 85 years, and full unit. Greater self-sufficiency was associated with ICU admission. Hospital mortality was 30/48 (62.5%), 56/79 (70.8%), 9/51 (17.6%), and 0/2 in the admitted, too sick to benefit, too well to benefit, and family/patient refusal groups, respectively; 1-year mortality was 34/48 (70.8%), 69/79 (87.3%), 24/51 (47%), and 0/2, respectively. Self-sufficiency was unchanged by ICU stay. Quality of life (known in only 28 patients) was significantly poorer for isolation, emotional, and mobility domains compared to the French general population matched on sex and age. CONCLUSIONS: More than two-thirds of patients aged over 80 years referred to our ICU were denied admission. One year later self-sufficiency was not modified and quality of life was poorer than in the general population. These results indicate a need to discuss patient preferences before triage decisions

Mortality of patients with heatstroke admitted to intensive care units during the 2003 heat wave in France: a national multiple-center risk-factor study.

OBJECTIVE: Heatstroke requires active body cooling and organ failure supportive care. Although heat waves are expected to recur over the next decades, little is known about the risk factors for mortality in heatstroke patients. We examined the prognosis and risk factors for hospital mortality in patients with heatstroke admitted to an intensive care unit (ICU) during the heat wave in France in August 2003. DESIGN: A questionnaire was sent to the physicians leading an ICU in France to identify the patients admitted with heatstroke during August 2003. Data included demographics, factors predisposing to heatstroke, severity during the first day in the ICU, air conditioning in the ICU, and hospital mortality. Risk factors for mortality were determined in multivariate Cox proportional hazards analysis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were obtained for 345 patients. Hospital mortality was 62.6%. Occurrence of heatstroke at home or in a healthcare facility rather than in a public location, high Simplified Acute Physiology Score II, high body temperature, prolonged prothrombin time, use of vasoactive drugs within the first day in the ICU, and patient management in an ICU without air conditioning were independently associated with an increased risk of death. CONCLUSIONS: Mortality of patients admitted to the ICU with heatstroke is high. Predictors of mortality are available within the first 24 hrs after admission. Furthermore, in this study, air conditioning in the ICU was associated with improved outcome