Mikrobiološki profil i antibiotska osjetljivost uzročnika ventilacijske pneumonije u Jedinici intenzivnog liječenja Kliničkog bolničkog centra "Sestre milosrdnice", Zagreb, Hrvatska

Ventilator-associated pneumonia (VAP) is very common in many intensive care Units, but there are still many uncertainties about VAP, especially about the choice of initial empiric antibiotics. The incidence of specific pathogens with different susceptibility patterns causing VAP varies from hospital to hospital. This is the reason why empiric initial antibiotic treatment for VAP should be based not only on general guidelines (that recommend therapy according to the presence of risk factors for multidrug-resistant bacteria), but also on up-to-date information on local epidemiology. The aim of this study was to determine the microbial profile of pathogens causing VAP and their antibiotic susceptibility patterns. The study was conducted in the 15-bed surgical and neurosurgical Intensive Care Unit, Department of Anesthesiology and Intensive Care, Sestre milosrdnice University Hospital Center, Zagreb, Croatia. Retrospective data were collected from September 2009 to March 2013. All patients that developed VAP during the study period were eligible for the study. According to study results, the incidence of VAP was 29.4%. The most commonly isolated bacterium was Staphylococcus aureus (21.1%), followed by Pseudomonas aeruginosa (19.0%) and Acinetobacter species (13.6%). All Staphylococcus aureus isolates were susceptible to vancomycin and linezolid. Pseudomonas aeruginosa showed 100% susceptibility to cefepime and very high susceptibility to piperacillin-tazobactam (96%), ceftazidime (93%) and ciprofloxacin (89%). Ampicillin-sulbactam was highly effective for Acinetobacter species, showing resistance in only 8% of isolates. In conclusion, according to study data, appropriate empiric antibiotic therapy for patients with VAP without risk factors for multidrug-resistant bacteria is ceftriaxone and for patients with risk factors for multidrug-resistant bacteria ampicillin-sulbactam plus cefepime plus vancomycin or linezolid.Ventilacijska pneumonija (VAP) je vrlo česta u jedinicama intenzivnog liječenja, ali još uvijek postoje mnoge nedoumice vezane uz VAP, osobito što se tiče početnog empirijskog odabira antibiotika za liječenja VAP-a. Učestalost pojedinih patogena s različitom osjetljivošću na antibiotike razlikuje se od bolnice do bolnice. To je razlog zbog kojeg bi se empirijska antibiotska terapija trebala temeljiti ne samo na općim smjernicama (koje preporučuju terapiju na temelju prisutnosti rizičnih čimbenika za bakterije rezistentne na više lijekova), nego i na podacima o lokalnoj epidemiologiji. Cilj ovoga istraživanja je bio utvrditi mikrobiološki profil patogena koji uzrokuju VAP i njihovu osjetljivost na antibiotike. Istraživanje je provedeno u 15-krevetnoj Jedinici intenzivnog liječenja Odjela za anesteziologiju, reanimatologiju i intenzivno liječenje Kliničkog bolničkog centra “Sestre milosrdnice”, Zagreb, Hrvatska. Podaci su skupljani retrospektivno od rujna 2009. do ožujka 2013. godine. Svi bolesnici kod kojih se razvila VAP tijekom navedenog razdoblja su uključeni u istraživanje. Prema našim rezultatima, incidencija VAP-a bila je 29,4%. Najčešće izolirana bakterija je bila Staphylococcus aureus (21,1%), iza koje slijede Pseudomonas aeruginosa (19,0%) i Acinetobacter sp. (13,6%). Svi izolati bakterije Staphylococcus aureus su bili osjetljivi na vankomicin i linezolid. Pseudomonas aeruginosa je u 100% izolata bio osjetljiv na cefepim te visoko osjetljiv na piperacilin-tazobaktam (96%), ceftazidim (93%) i ciprofloksacin (89%). Ampicilin-sulbaktam se pokazao vrlo učinkovitim za Acinetobacter sp. s rezistencijom u samo 8% izolata. U zaključku, prema našim rezultatima, empirijska antibiotska terapija za bolesnike s VAP-om bez rizika za bakterije rezistentne na više lijekova je ceftriakson, a za bolesnike s rizičnim čimbenicima za bakterije rezistentne na više lijekova je ampicilin-sulbaktam plus cefepim plus vankomicin ili linezolid

Clinical significance of intraabdominal pressure and abdominal perfusion pressure in patients with acute abdominal syndrome

Elevated intraabdominal pressure (IAP) has been claimed to play a role in abdominal compartment syndrome. We assessed the correlation between the values of IAP, abdominal perfusion pressure (APP) and clinical scoring systems including SIRS, MODS and APACHE II and the patients\u27 survival rate in patients admitted to the ICU with acute abdomen due to ileus, intestinal perforation, peritonitis and trauma. We measured IAP and APP in 50 surgical patients. In this study the IAP was measured in a non-invasive manner via urinary bladder pressure. The APP was calculated as the difference between mean arterial pressure and IAP values. A significantly higher IAP was found in the non-survivors\u27 group in comparison with the survivors\u27 group. On the other hand, the APP inversely correlated with disease severity scores including SIRS, MODS and APACHE II, whereas IAP values did not show any correlation to these clinical parameters. These findings suggest that IAP and APP may be useful tools in the clinical evaluation of patients with acute abdomen

Stalni nadzor srčanog izbačaja metodama Picco i Lidco prema Pak-u u septičnih bolesnika: kalibrirati ili ne ?

The accuracy of cardiac output measurement by two most widely used methods of less invasive hemodynamic monitoring and by the standard technique of thermodilution with pulmonary catheter was assessed. The measurements were carried out in septic surgical patients immediately after and between system calibrations. Study results showed satisfactory compatibility of measurements performed by the two methods and by pulmonary catheter in both phases, thus system calibration being recommendable in hemodynamically unstable septic patients.U ovom radu uspoređivala se točnost mjerenja srčanog izbačaja pomoću dviju najčešće upotrebljavanih metoda manje invazivnog hemodinamskog nadzora i standardnom tehnikom termodilucije plućnim kateterom. Mjerenje je provedeno kod septičnih kirurških bolesnika u razdoblju neposredno nakon i između kalibracija sustava. Rezultati su pokazali zadovoljavajuću podudarnost mjerenja u obje faze primjenom obiju metoda i pomoću plućnog katetera, pa se kalibriranje sustava preporuča u hemodinamski nestabilnih septičnih bolesnika

Ventilator-associated pneumonia in patients requiring percutaneous tracheotomy

Pneumonija povezana s mehaničkom ventilacijom jedna je od najčešćih infekcija u jedinicama intenzivnog liječenja. Postoji mnogo podataka o incidenciji i etiologiji pneumonije povezane s mehaničkom ventilacijom među bolesnicima koji se mehanički ventiliraju preko endotrahealnog tubusa, no malo je podataka o pneumoniji povezanoj s mehaničkom ventilacijom među perkutano traheotomiranim bolesnicima. Nedavna istraživanja su utvrdila visoku incidenciju (18–25 %) ove pneumonije nakon traheotomije. Cilj ovog osmogodišnjeg retrospektivnog istraživanja bio je utvrditi incidenciju i etiologiju pneumonije povezane s mehaničkom ventilacijom među perkutano traheotomiranim bolesnicima. U istraživanje je uključeno 98 bolesnika. Dijagnoza pneumonije se postavljala na temelju Clinical Pulmonary Infection Score (CPIS). Incidencija pneumonije povezane s mehaničkom ventilacijom nakon izvođenja traheotomije u naših perkutano traheotomiranih bolesnika iznosila je 15,4 %. Najčešći uzročnici među gram-negativnim bakterijama nakon izvođenja perkutane traheotomije su prema našim podacima Pseudomonas aeruginosa (14,7 %) i Acinetobacter spp (14,7 %), a među gram-pozitivnim bakterijama Staphylococcus aureus (9,7 %) i MRSA (9,7 %).Ventilator-associated pneumonia (VAP) is one of the most common infections in the Intensive Care Units (ICUs). There are a lot of data about the incidence and etiology of VAP in patients who are receiving invasive mechanical ventilation through the endotracheal tube, but there is little data about VAP among percutanoues tracheotomised patients. Recent studies reported a high incidence (18–25 %) of VAP after tracheotomy. The aim of this 8-year retrospective study was to determine the incidence and etiology of VAP among percutanoues tracheotomised patients. In our study we enrolled 98 percutanoues tracheotomised patients. The diagnosis of VAP was defined by Clinical Pulmonary Infection Score (CPIS). The incidence of VAP among percutanoues tracheotomised patients in our study was 15,4 %. The most common gram-negative causative pathogens of VAP after performing percutaneous tracheotomy according to our results were Pseudomonas aeruginosa (14,7 %) and Acinetobacter spp. (14,7 %), and the most common gram-positive causative pathogens of VAP were MRSA (9,7 %) and Staphylococcus aureus (9,7 %)

Korelacija između zbira Glasgowske ljestvice za komu i intrakranijskog tlaka u bolesnika s teškom ozljedom glave

Patients sustaining severe head injury require use of standardized treatment protocols, most of them focused on the maintenance of cerebral perfusion pressure. Among other goals, neurologic recovery can be expected if a satisfactory level of cerebral perfusion pressure has been achieved. The aim of the study was to assess the correlation between neurologic findings expressed as Glasgow Coma Scale (GCS) score, and intracranial cerebral perfusion and mean arterial pressure. Results obtained in 24 study patients pointed to negative correlation between GCS score and intracranial pressure (p=0.006), and positive correlation between GCS score and cerebral perfusion pressure (p=0.016). There was no statistically significant correlation between GCS score and mean arterial pressure, which could be explained by use of iatrogenic procedures for the maintenance of mean arterial pressure. In conclusion, the intracranial and cerebral perfusion pressures appear to correlate well with GCS score, thus monitoring of these pressures may be highly useful in the follow-up of patients with severe brain injury.U bolesnika s teškom ozljedom mozga neophodna je primjena standardiziranih protokola liječenja. Većina ih je usmjerena na održavanje cerebralnog perfuzijskog tlaka. Oporavak neurološkog statusa očekivan je ako se cerebralni perfuzijski tlako država u zadovoljavajućim granicama. Cilj ispitivanja bio je odrediti povezanost neurološkog statusa izraženog kao zbir Glasgowske ljestvice za komu (GCS) s intrakranijskim cerebralnim perfuzijskim i srednjim arterijskim tlakom. Podaci skupljeni tijekom liječenja 24 bolesnika s teškom ozljedom mozga ukazali su na postojanje negativne korelacije zbira GCS i intrakranijskog tlaka (p=0,006) te pozitivne korelacije zbira GCS i cerebralnog perfuzijskog tlaka (p=0,016). Nije bilo statistički značajne korelacije između zbira GCS i srednjeg arterijskog tlaka, što se može tumačiti jatrogenim postupcima održavanja srednjeg arterijskog tlaka. Zaključeno je da su praćeni intrakranijski i cerebralni perfuzijski tlakovi dobro povezani sa zbirom GCS. Promatranje ovih tlakova pouzdan je način praćenja bolesnika s teškom ozljedom mozga

Early complications of percutaneous tracheostomy using the Griggs method

This article presents our observations and experiences with the Griggs method of percutaneous dilation tracheostomy (PTD). We performed 200 tracheostomies on neurosurgical and surgical patients who needed temporary ventilatory support and protection. Early complications were defined and registered. Frequency of early complications was 22,5 %. The majority of complications were minor and improved quickly. Therefore, PTD was shown to be a safe and appropriate technique for patients treated in the intensive care unit (ICU). Unfortunately, lack of standardization and defined criteria deprive the opportunity for good comparisons between the Griggs method and other PTD methods

Microbial Profile and Antibiotic Susceptibility Patterns of Pathogens Causing Ventilator-Associated Pneumonia at Intensive Care Unit, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia

Ventilator-associated pneumonia (VAP) is very common in many intensive care Units, but there are still many uncertainties about VAP, especially about the choice of initial empiric antibiotics. The incidence of specific pathogens with different susceptibility patterns causing VAP varies from hospital to hospital. This is the reason why empiric initial antibiotic treatment for VAP should be based not only on general guidelines (that recommend therapy according to the presence of risk factors for multidrug-resistant bacteria), but also on up-to-date information on local epidemiology. The aim of this study was to determine the microbial profile of pathogens causing VAP and their antibiotic susceptibility patterns. The study was conducted in the 15-bed surgical and neurosurgical Intensive Care Unit, Department of Anesthesiology and Intensive Care, Sestre milosrdnice University Hospital Center, Zagreb, Croatia. Retrospective data were collected from September 2009 to March 2013. All patients that developed VAP during the study period were eligible for the study. According to study results, the incidence of VAP was 29.4%. The most commonly isolated bacterium was Staphylococcus aureus (21.1%), followed by Pseudomonas aeruginosa (19.0%) and Acinetobacter species (13.6%). All Staphylococcus aureus isolates were susceptible to vancomycin and linezolid. Pseudomonas aeruginosa showed 100% susceptibility to cefepime and very high susceptibility to piperacillin-tazobactam (96%), ceftazidime (93%) and ciprofloxacin (89%). Ampicillin-sulbactam was highly effective for Acinetobacter species, showing resistance in only 8% of isolates. In conclusion, according to study data, appropriate empiric antibiotic therapy for patients with VAP without risk factors for multidrug-resistant bacteria is ceftriaxone and for patients with risk factors for multidrug-resistant bacteria ampicillin-sulbactam plus cefepime plus vancomycin or linezolid

Prognostic performance of the Simplified Acute Physiology Score II in major Croatian hospitals: a prospective multicenter study

AIM: To perform an external validation of the original Simplified Acute Physiology Score II (SAPS II) system and to assess its performance in a selected group of patients in major Croatian hospitals. ----- METHODS: A prospective, multicenter study was conducted in five university hospitals and one general hospital during a six-month period between November 1, 2007 and May 1, 2008. Standardized hospital mortality ratio (SMR) was calculated from the mean predicted mortality of all the 2756 patients and the actual mortality for the same group of patients. The validation of SAPS II was made using the area under receiver operating characteristic curve (AUC), 2×2 classification tables, and Hosmer-Lemeshow tests. ----- RESULTS: The predicted mortality was as low as 14.6% due to a small proportion of medical patients and the SMR being 0.89 (95% confidence interval [CI], 0.78-0.98). The SAPS II system demonstrated a good discriminatory power as measured by the AUC (0.85; standard error [SE]=0.012; 95% CI=0.840-0.866; P<0.001). This system significantly overestimated the actual mortality (Hosmer-Lemeshow goodness-of-fit H statistic: χ(2) =584.4; P<0.001 and C statistics: χ(2)(8) =313.0; P<0.001) in the group of patients included in the study. ----- CONCLUSION: The SAPS II had a good discrimination, but it significantly overestimated the observed mortality in comparison with the predicted mortality in this group of patients in Croatia. Therefore, caution is required when an evaluation is performed at the individual level