Thursday September 18, 2008
Increased mortality of ventilated patients with endotracheal Pseudomonas aeruginosa without clinical signs of infection

The patients who have Pseudomonas aeruginosa colonization do worse compared to patients who have ventilator associated pneumonia, according to this prospective study in Journal of CCM 1.

Objective: To investigate the frequency and outcomes of ventilated patients with newly acquired large burdens of Pseudomonas aeruginosa and to test the hypothesis that large quantities of bacteria are associated with adverse patient outcomes. It was a prospective, single-center, observational, cohort study in a medical-surgical intensive care units in a tertiary care university hospital.

Patients: All adult patients requiring more than/ =48 hrs of mechanical ventilation and identified as having newly acquired P. aeruginosa in their lower respiratory tracts.

Results:

• Of 45 patients with high P. aeruginosa burdens ( more than/=1,000,000 cfu/mL in endotracheal aspirates; more than/=10,000 cfu/mL in bronchoalveolar-lavage), 17 (37.8%) patients did not meet clinical criteria for ventilator-associated pneumonia and had a statistically significant higher risk of death (p = 0.002) when compared with the patients who had P. aeruginosa ventilator-associated pneumonia.
• When excluding the ten patients who had ventilator-associated pneumonia attributed to bacteria other than P. aeruginosa or attributed to multiple bacteria including P. aeruginosa, the risk of death remained statistically significant (p = 0.006).

Furthermore, more patients with high P. aeruginosa burdens secreted the type III secretion facilitator protein, PcrV (p = 0.01).

Conclusions: A group of patients with large burdens of P. aeruginosa who did not meet clinical criteria for ventilator-associated pneumonia had an increased risk of death when compared with patients who had high P. aeruginosa burdens and met ventilator-associated pneumonia criteria. Patients with high P. aeruginosa burden seemed to possess more virulent strains.

Trivia: Do you know that P. aeruginosa is capable of growth in Diesel and Jet fuel where it is known as a hydrocarbon utilizing microorganism ("HUM bug") and also has the ability to grow at 42 degree Celsius?


References: Please click to get abstract

1. Increased mortality of ventilated patients with endotracheal Pseudomonas aeruginosa without clinical signs of infection - Critical Care Medicine. 36(9):2495-2503, September 2008

Tuesday September 16, 2008
No update due to Hurricane Ike

Monday September 15, 2008
No update due to Hurricane Ike

Sunday September 14, 2008
Digoxin Toxicity

Q: Once patient receive Digoxin Fragmented Antibody (DIGIFAB or Digibind), how frequent digoxin level should be measured ?

A: Digoxin level after giving Digibind will rise and will remain distorted for about 7 days. This is due to ability of Digibind to pull all of the digoxin into blood stream. These are inactive fragments and not toxic. There is no need to follow Dig level after administration of Digibind as it may be misleading.

Thursday September 11, 2008
Does Restraint has any influence on unplanned Extubation

Background: Unplanned extubation commonly occurs in ICUs. Various physical restraints have been used to prevent patients from removing their endotracheal tubes. However, physical restraint not only does not consistently prevent injury but also may be a safety hazard to patients
.
Objective:To evaluate the effect of physical restraint on unplanned extubation in adult intensive care patients.

Methods:

• 100 patients with unplanned extubations and
• 200 age-, sex-, and diagnosis-matched controls

Results:The incidence rate of unplanned extubation was 8.7%. Factors associated with increased risk for unplanned extubation included

• Physical restraints: 3.11 times
• Nosocomial infection: 2.02 times
• Glasgow coma scale more than 9: 1.98 times

Episodes of unexplained extubation were also associated with increase ICU stay.

Conclusions: An impaired level of consciousness on admission to the intensive care unit and the presence of nosocomial infection intensify the risk for unplanned extubation, even when physical restraints are used.


Reference: click to get abstract/article

Chang LY, Wang KWK, Chao YF. Influence of physical restraint on unplanned extubation of adult intensive care patients: A case-control study. American Journal of critical Care 2008; 17:408-415

Wednesday September 10, 2008
Amiodarone Neurotoxicity

Amiodarone neurotoxicity has been reported in up to 40% of patients and may easily get miss or misdiagnosed when an elderly patient presents with multiple symptoms. Major manifestation are peripheral neuropathy causing proximal motor weakness, ataxia and fine resting tremor. It may also present as neuromyopathy. A case has been described with autonomic dysfunction presented as incapacitating orthostatic hypotension. Cases has been reported with Amiodarone-Induced Delirium .

Most neurotoxicities are dose related and resolved with discontinuation of Amiodarone. Being an intensivist it may be important to keep this very common dose related toxicity in mind while evaluating patient with neurologic symptoms.

Related: Amiodarone pulmonary toxicity.


References: Click to see abstract/article

1. Amiodarone-Induced Neuromyopathy: Three Cases and a Review of the Literature - Journal of Clinical Neuromuscular Disease. 3(3):97-105, March 2002.

2. Severe Ataxia Caused by Amiodarone - Volume 96, Issue 10, Pages 1463-1464 (15 November 2005) - Am J of Card

3. Amiodarone toxicity presenting as pulmonary mass and peripheral neuropathy: the continuing diagnostic challenge - Postgraduate Medical Journal 2006;82:73-75

4. Amiodarone: Guidelines for Use and Monitoring - aafp.org - Vol 68, No. 11, Dec., 2003

5. Atypical pulmonary and neurologic complications of amiodarone in the same patient. Report of a case and review of the literature - Vol. 147 No. 10, October 1, 1987 - Archive of Int Med.

6. Amiodarone-Induced Delirium - Am J Psychiatry 156:1119, July 1999

Tuesday September 9, 2008
Procalcitonin, C-reactive protein and now Chromagranin A in Sepsis. JUST ADD IT ON

Dan Zhang from France studied the link between Chromagranin A (CGA) and systemic inflammatory response syndrome (SIRS). CGA is a stress marker released along with catecholamine by adrenal medulla.

They measured CGA, procalcitonin, and C-reactive protein level in 53 patients and 14 controls. They also assessed Simplified acute physiological score (SAPS).

Results: Serum CGA level was significantly elevated in patients where infection is associated with SIRS with a median value of 138.5mcg/L as compared to controls (p<0.001).
CGA concentration also positively with procalcitonin and C-reactive protein.

Conclusion: Patients with CGA concentration higher then 71 mcg/L have a significantly shorter survival and was independent of SAPS score.


Reference: Click to get abstract/article

Zhang D, Lavaux T, Lavigne T, Castelain V, et al. Serum concentration of chromogranin A at admission: An early biomarker of severity in critically ill patients. Annals of Medicine, 21 August 2008