Sunday November 9, 2008

APRV !
(3 part videos - Total time 21.08 minutes)

Saturday November 8, 2008
Do anti-Pseudomonal agents increase the Pseudomonas aeruginosa colonization?

Jose Martinez published a paper in Intensive Care Medicine to clarify the issues.

Setting: Prospective study in two medical ICU.

Measurements: Surveillance cultures from nares, pharynx, rectum and respiratory secretions. Acquisition of resistance was defined as the isolation, after 48 hrs of ICU stay, of an isolate resistant to a given antibiotics.

Results: Forty-four (13%) patients acquired 52 strains of P. aeruginosa.

Administration of piperacillin-tazobactam for more than/= 3 days and use of amikacin for more than/= 3 days were positively associated with acquisition of P. aeruginosa, whereas use of quinolones and antipseudomonal cephalosporins was protective.

Exposure to quinolones and cephalosporins was not associated with the acquisition of resistance, whereas it was linked with usage of all other agents. Neither quinolones nor cephalosporins were a major determinant on the emergence of resistance to themselves, as resistance to these antibiotics developed at a similar frequency in non-exposed patients.

Conclusions: In critically ill patients, quinolones and antipseudomonal cephalosporins may prevent the acquisition of P. aeruginosa and may have a negligible influence on the acquisition and emergence of resistance.



Reference:

Martinez J, Delgado E, Marti S, Marco F et al. Influence of antipseudomonal agents on Pseudomonas aeruginosa colonization and acquisition of resistance in critically ill medical patients.
Intensive Care Medicine 2008 Published online October 21st 2008.

Friday November 7, 2008
Factors predicting successful noninvasive ventilation in acute lung injury

Noninvasive ventilation (NIV) has been successfully used to treat various forms of acute respiratory failure. It remains unclear whether NIV has potential as an effective therapeutic method in patients with acute lung injury (ALI). The aims of this study were to determine factors predicting the need for endotracheal intubation in ALI patients treated with NIV, and to promote the selection of patients suitable for NIV.

Results: A total of 47 patients with ALI received NIV, and 33 patients (70%) successfully avoided endotracheal intubation.

Patients who required endotracheal intubation had a

• significantly higher Acute Physiology and Chronic Health Evaluation (APACHE) II score
• a significantly higher Simplified Acute Physiology Score (SAPS) II
• a significantly lower arterial pH

The respiratory rate decreased significantly within 1 h of starting NIV only in patients successfully treated with NIV.

An APACHE II score of more than 17 (P = 0.022) and a respiratory rate of more than 25 breaths/min after 1 h of NIV (P = 0.024) were independent factors associated with the need for endotracheal intubation.

Patients who avoided endotracheal intubation had a significantly lower ICU mortality rate and in-hospital mortality rate than patients who required endotracheal intubation.

Conclusion: We determined an APACHE II score of more than 17 and a respiratory rate of more than 25 breaths/min after 1 h of NIV as factors predicting the need for endotracheal intubation in ALI patients treated with NIV.


Above pearl is contributed by:

Tony Halat, MD
Clinical Instructor in Medicine
Department of Medicine,
The Methodist Hospital
Weill Medical College, Cornell University



Reference: click to get article

Factors predicting successful noninvasive ventilation in acute lung injury - Journal of Anesthesia, Volume 22, Number 3 / August, 2008, 201-206

Thursday November 6, 2008
Index to Predict death in COPD Patients

The BODE index, a simple multidimensional grading system, is better than the FEV1 at predicting the risk of death from any cause and from respiratory causes among patients with COPD.

BODE index is a 10-point scale - higher scores indicate a higher risk of death.
B = The body-mass index (B),
O = The degree of airflow obstruction
D = Dyspnea (D), and
E = Exercise capacity (E), measured by the six-minute–walk test.

Reference: click to get article

Celli BR, Cote CG, Marin JM, Casanova C, et al. The body mass index, airflow obstruction, dyspnea, and exercise capacity index in COPD. NEJM 2004, 350: 1005-1012..

Wednesday November 5, 2008
Does Transfusion increases length of stay

Joseph Datsha and their colleague published a retrospective study on management of anemia in critically ill patients and their effects in American Journal of Therapeutics.

Study was designed to measure

• to measure packed red blood cell (pRBC) use across different critical care settings;
• to characterize transfused and nontransfused critically ill patients; and
• to identify potential predictors of transfusion use.

A retrospective analysis of critically ill patients from 139 hospitals across the United States was conducted.

Results: A total of 180,221 patients met all inclusion criteria, with 29,331 (16.3%) receiving pRBCs during their ICU stay.There was differential use of pRBCs by ICU/coronary care unit setting (i.e., 23% of general ICU patients versus 7% of intermediate coronary care unit patients).

Increasing age, Declining hemoglobin concentrations, Mechanical ventilation, dialysis, Presence of acute renal failure, Congestive heart failure and Septicemia were associated with a higher likelihood of pRBC use.

Each pRBC transfusion significantly increased hospital length of stay (1.6, 0.5, and 2.7 additional days for patients with 1, 2, and 3 or more transfusions, respectively, P <>

Conclusions: Multiple factors increased the likelihood of pRBC use in ICU patients. In addition, pRBC transfusion was associated with increased length of stay.



Reference: click to get article

Dasta J, Modt S, McLaughlin T, LeBlanc J et al. Current Management of Anemia in Critically Ill Patients: Analysis of a Database of 139 Hospitals. Journal of Therapeutics. 2008 15(5):423-430.

Tuesday November 4, 2008
Predictors of hospital mortality in a population-based cohort of patients with acute lung injury

Following Pearl is contributed from:

Tony Halat, MD
Clinical Instructor in Medicine
Department of Medicine, The Methodist Hospital
Weill Medical College, Cornell University


Objective: We sought to determine the predictors of mortality in a population-based cohort of patients with acute lung injury and to characterize the performance of current severity of illness scores in this population.

Patients: The cohort included 1,113 patients with acute lung injury identified during the year 1999-2000.

Results: We evaluated physiology, comorbidities, risk factors for acute lung injury, and other variables for their association with death at hospital discharge. Bivariate predictors of death were entered into a multiple logistic regression model. We compared Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, and Simplified Acute Physiology Score II to the multivariable model using area under the receiver operating characteristic curve. The model was validated in an independent cohort of 886 patients with acute lung injury. Modified acute physiology score, age, comorbidities, arterial pH, minute ventilation, Paco2, Pao2/Fio2 ratio, intensive care unit admission source, and intensive care unit days before onset of acute lung injury were independently predictive of in-hospital death. The area under the receiver operating characteristic curve for the multivariable model was superior to that of APACHE III but was no different after external validation.

Conclusions: The predictors of mortality in patients with acute lung injury are similar to those predictive of mortality in the general intensive care unit population, indicating disease heterogeneity within this cohort. Accordingly, APACHE III predicts mortality in acute lung injury as well as a model using variables selected specifically for patients with acute lung injury.


Reference: click to get article

Predictors of hospital mortality in a population-based cohort of patients with acute lung injury - Critical Care Medicine. 36(5):1412-1420, May 2008

Monday November 3, 2008
Impact of Transfusion in Intensive Care Unit

Paul Marik in the article published in Critical care Medicine assessed the independent effect of RBC transfusion on patient outcomes. From 571 articles screened, 45 met inclusion criteria and were included for data extraction.

Study Design: Retrospective study reviews and metaanalysis.

Forty-five studies including 272,596 patients were identified. The overall risks vs. benefits of RBC transfusion on patient outcome in each study were classified as (i) risks outweigh benefits, (ii) neutral risk, and (iii) benefits outweigh risks.

Results:

• In 42 of the 45 studies the risks of RBC transfusion outweighed the benefits.
• The risk was neutral in two studies with the benefits outweighing the risks in a subgroup of a single study (elderly patients with an acute myocardial infarction and a hematocrit <30%).>
• Seventeen of 18 studies demonstrated that RBC transfusions were an independent predictor of death. The pooled odds ratio (12 studies) was 1.7 (95% confidence interval, 1.4-1.9).
• Twenty-two studies examined the association between RBC transfusion and nosocomial infection; in all these studies blood transfusion was an independent risk factor for infection. The pooled odds ratio (nine studies) for developing an infectious complication was 1.8 (95% confidence interval, 1.5-2.2).
• RBC transfusions similarly increased the risk of developing multi-organ dysfunction syndrome (three studies) and ARDS (six studies). The pooled odds ratio for developing acute respiratory distress syndrome was 2.5 (95% confidence interval, 1.6-3.3).

Conclusions: Despite the inherent limitations in the analysis of cohort studies, our analysis suggests that in adult, intensive care unit, trauma, and surgical patients, RBC transfusions are associated with increased morbidity and mortality and therefore, current transfusion practices may require reevaluation. The risks and benefits of RBC transfusion should be assessed in every patient before transfusion.



Reference: click to get article

Marik P, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: A systematic review of the literature. Critical Care Medicine 2008, 36(9): 2667-2674

Sunday November 2, 2008
Hemodynamic Classification of Atrial Septal Defects

Saturday November 1, 2008

Q; What is your diagnosis?

Answer: Atrial fibrillation and complete heart block

In first glance, its hard to miss Atrial fibrillation in above EKG but distinguishing points are

• Fibrillary waves of atrial fibrillation on close look
• No P waves.
• Regular ventricular rhythm

AF with complete heart block is an indication for a permanent pacemaker.