Anaesthesia and intensive care
-
Anaesth Intensive Care · Mar 2010
The role of admission surveillance cultures in patients requiring prolonged mechanical ventilation in the intensive care unit.
We undertook a prospective observational cohort study in intensive care unit (ICU) patients requiring mechanical ventilation for four days or more to evaluate normal and abnormal bacterial carriage on admission detected by surveillance cultures of throat and rectum. We assessed the importance of surveillance and diagnostic cultures for the early detection of resistance to third generation cephalosporins employed as the parenteral component of the selective decontamination of the digestive tract. Finally, we sought the risk factors of abnormal carriage on admission to the ICU. ⋯ The knowledge of carriage on admission using surveillance cultures may help intensivists to identify patients with abnormal carriage on admission and resistant bacterial strains at an early stage even when diagnostic samples are negative. Third generation cephalosporins covered admission flora in about 80% of the enrolled population and were modified in patients with abnormal flora who received antibiotic therapy before ICU admission. Our finding of overgrowth present on admission may justify the immediate administration of enteral antimicrobials.
-
Anaesth Intensive Care · Mar 2010
Excessive tryptophan catabolism along the kynurenine pathway precedes ongoing sepsis in critically ill patients.
It has recently been shown that an increased plasma level of the tryptophan catabolite kynurenine is an early indicator for the development of sepsis in major trauma patients. We examined the predictive value of kynurenine pathway activity for ongoing sepsis in patients being admitted to a surgical intensive care unit for different reasons. In addition, we asked whether an accumulation of kynurenines in patients' plasma depends on reduced renal clearance. ⋯ In general, non-septic critically ill patients showed activation of the kynurenine pathway, but septic shock coincided with an exacerbation of kynurenine pathway activity even in the absence of renal failure. Importantly, plasma concentrations of quinolinic acid (area under the curve 0.832 [95% confidence interval 0.710 to 0.954]) and the Quin/Trp ratio (area under the curve 0.835 [95% confidence interval; 0.719 to 0.952]) showed the best discrimination between non-septic and pre-septic patients at baseline. These findings open new avenues for further investigations on the pathophysiology of sepsis.
-
Anaesth Intensive Care · Mar 2010
Case ReportsTongue swelling complicating management of a ventilated patient with acute respiratory distress syndrome secondary to novel influenza A (H1N1).
The recently emerged novel influenza A H1N1 virus continues to spread globally. The use of oseltamivir for treatment and prophylaxis of infection is recommended and its use has climbed steeply although there is little data available on its benefit in critically unwell patients with H1N1 influenza. A rare side-effect of oseltamivir treatment reported in post-marketing surveillance is tongue and lip swelling/angioedema. This case report describes the management of a critically ill ventilated patient with severe acute respiratory distress syndrome who developed clinically significant tongue and lip swelling during treatment with oseltamivir.
-
Anaesth Intensive Care · Mar 2010
Perioperative fluid prescription, complications and outcomes in major elective open gastrointestinal surgery.
Perioperative fluid therapy and associated outcomes of patients undergoing major elective open gastrointestinal surgery are poorly understood. This study measured perioperative fluid therapy, complication rates and outcomes for major elective open gastrointestinal surgery in a tertiary care hospital. We obtained demographic data, operative details, fluid prescription, complications and outcomes in 100 patients. ⋯ The most common adverse events were pulmonary oedema (21%), ileus (18%), serious sepsis (17%), pneumonia (17%), arrhythmias (14%), delirium (14%) and wound healing problems (infections 13%, anastomotic leaks 12%). Mortality at 30 days was 2%. This study provides planning data for future interventional studies.
-
Anaesth Intensive Care · Mar 2010
Case ReportsPlasmapheresis treatment in Guillain-Barré syndrome: potential benefit over intravenous immunoglobulin.
Guillain-Barré syndrome includes acute inflammatory demyelinating polyradiculoneuropathy, acute motor axonal neuropathy, acute motor and sensory axonal neuropathy, Miller Fisher syndrome and acute pandysautonomia. Plasma exchange was the first treatment in Guillain-Barrd syndrome proven to be superior to supportive treatment alone and intravenous immunoglobulin was subsequently shown to be equally effective and is now commonly used as first-line treatment. We describe a 78-year-old woman who presented with a two-day history of progressive generalised weakness and left facial nerve palsy, preceded by a flu-like illness lasting for one week. ⋯ A gradual improvement of respiratory function and peripheral muscle strength was observed after the first plasma exchange and on the eighth day the patient was weaned off mechanical ventilation. This case suggests that patients with severe Guillain-Barrd syndrome may benefit from plasma exchange after immunoglobulin treatment in refractory cases. Plasma exchange should be considered early in Guillain-Barrć syndrome cases with axonal involvement, and in the recurrent or familial Guillain-Barré syndrome forms.