Athanasios Prekates

The Diagnostic Value of Gram Stain of Bronchoalveolar Lavage Samples in Patients with Suspected Ventilator-associated Pneumonia

Ventilator-associated pneumonia (VAP) is one of the most common causes of morbidity and mortality in intensive care unit patients. However, the diagnosis is quite difficult. Gram stain (GS) of bronchoalveolar lavage (BAL) sample is a time-saving diagnostic method for VAP. However, its clinical significance has not been adequately investigated. The aim of this study was to determine its sensitivity and specificity for VAP diagnosis. We prospectively performed GS and quantitative bacterial cultures (QBC) of BAL samples, obtained through fiberoptic bronchoscope, in 75 consecutive postoperative and/or multiple trauma patients with suspected VAP. We considered BAL-GS as positive for VAP diagnosis when (i) polymorphonuclear neutrophils were > 25 per optic field at a magnification x 100 (p.o.f x 100); (ii) squamous epithelial cells were < 1% p.o.f x 100; and (iii) one or more microorganisms were seen p.o.f. at a magnification x 1,000 (p.o.f. x 1,000). VAP was diagnosed with criteria similar to those used in previous studies. Pneumonia was the final diagnosis in 22/75 (29%) patients. The BAL-GS was positive in 17/22 patients with VAP and in 7/53 patients without VAP. Accordingly, the sensitivity of BAL-GS for VAP diagnosis was 77%, the specificity 87%, the positive predictive value 71% and the negative predictive value 90%. Our data suggest that BAL-GS has good sensitivity and high specificity for VAP diagnosis. It could therefore constitute a useful complementary tool in the task of early diagnosis and treatment of VAP.

Acute myocardial infarction with normal coronary arteries during septic shock from Neisseria meningitidis.

Objective: To investigate a possible additive effect of combined nitric oxide (NO) and almitrine bismesylate (ALM) on pulmonary ventilation-perfusion (▪·VA/▪·Q) ratio.¶Design: Prospective, controlled animal study.¶Setting: Animal research facility of a university hospital.¶Interventions: Three conditions were studied in ten female pigs with experimental acute lung injury (ALI) induced by repeated lung lavage: 1) 10 ppm NO, 2) 10 ppm NO with 1 μg/kg per min ALM, 3) 1 μg/kg per min ALM. For each condition, gas exchange, hemodynamics and▪·VA/▪·Qdistributions were analyzed using the multiple inert gas elimination technique (MIGET).¶Measurement and results: With NO + ALM, arterial oxygen partial pressure (PaO2) increased from 63 ± 18 mmHg to 202 ± 97 mmHg while intrapulmonary shunt decreased from 50 ± 15 % to 26 ± 12 % and blood flow to regions with a normal▪·VA/▪·Qratio increased from 49 ± 16 % to 72 ± 15 %. These changes were significant when compared to untreated ALI (p < 0.05) and NO or ALM alone (p < 0.05), although improvements due to NO or ALM also reached statistical significance compared to ALI values (p < 0.05).¶Conclusions: We conclude that NO + ALM results in an additive improvement of pulmonary gas exchange in an experimental model of ALI by diverting additional blood flow from non-ventilated lung regions towards those with normal▪·VA/▪·Qrelationships.

Severe hyperkalemia induced by a short interruption of barbiturate coma

Dear Editor, A 23-year-old woman was admitted to the ICU division of Tzanion Hospital after a motor vehicle crash. Her clinical diagnosis was severe head injury consisting of cerebral edema and traumatic subarachnoid hemorrhage grade 3. Her Glasgow Coma Score (GCS) at the scene was 7, requiring tracheal intubation for airway protection. On admission, pulse was 100 beats/min and blood pressure was 130/75 mmHg. Complete blood count results were normal. Her physical examination was unremarkable except for the finding related to the pupils, which were 2 mm in size, equal, and nonreactive to light. Initial intensive care management included sedation with propofol 2% (2.8 mg/ kg/h) and midazolam (0.46 mg/kg/ h), both of which were held at continuous constant rate for the first 6 days of hospitalization, along with ventilation to almost normocarbia (pCO2 37–38 mmHg), maintenance of normoglycemia, and core body temperature close to 36 C. Total suppression of brain activity by induction of barbiturate coma therapy (BCT) with sodium thiopental at constant infusion rate (2.14 mg/kg/h, interrupted once for 45 min on day 5) was initiated, and electroencephalogram (EEG) was used to determine the optimal depth of barbiturate coma. On the first day following injury (day 1), the patient required norepinephrine (5 lg/min) to achieve the desired mean arterial pressure (MAP) of about 85–90 mmHg. The patient had mild hypokalemia (3.3 mmol/l) on starting sodium thiopental (admission potassium level was 2.9 mmol/l), which responded to potassium supplementation (total 67.5 mmol over 5 h) (Fig. 1). At day 3, despite her neurologically stable clinical condition, she deteriorated, with marked increase in inotrope requirement (23.4 lg/ml). She received also 135 mmol potassium in 10 h. By the end of day 5, the hemodynamic and potassium instability (42.7 lg/ml and 5.8 mmol/l, respectively) were very remarkable. Blood pH was 7.36, and the other electrolyte values were normal. Blood, sputum, and urine cultures on standard media at day 5 were all sterile. Creatine phosphokinase (CPK) was normal. Whole body computed tomography (CT) scan reevaluation was negative, and head CT scan appeared slightly improved. By the middle of day 6, despite no active bleeding or septic shock identified, the hemodynamic parameters were very disturbing, along with the serum potassium level, which was increased to 7.4 mmol/l. Muscle crush injury and rhabdomyolysis were not present. Electrocardiogram (ECG) abnormalities were not found, and troponin I was normal. The possible medications that could have potentially harmed the patient were propofol and sodium thiopental. Since neither the myocardial enzymes nor ECG and transthoracic echocardiogram (TTE) were abnormal, we ruled out propofol infusion syndrome as the causative factor. The findings of refractory hypotension and otherwise unexplained hyperkalemia raised the possibility that sodium thiopental could be the causative factor. A tapering dose of sodium thiopental was initiated by the end of day 5 and completed in the middle of day 6, and the inotrope dose within the next few hours started to decrease. Continuous venous–venous hemodiafiltration dialysis (CVVHDF) was started to reverse the serious hyperkalemia. Twenty-four hours later, the patient

New-onset atrial fibrillation and clinical outcome in non-cardiac intensive care unit patients

BACKGROUND Data regarding new onset atrial fibrillation (nAF) in general, non-cardiac, intensive care unit (ICU) patients are limited. However, it has been suggested that nAF is associated with worse clinical outcome in these patients. OBJECTIVE The purpose of the present work was to study the prognostic impact of nAF, in this setting. METHODS We prospectively studied all patients admitted to a single ICU for a period of 12 months. Patients admitted for brief post-operative monitoring, patients with chronic, intermittent atrial fibrillation and atrial fibrillation present upon admission, were excluded. Death during ICU stay (ICUD) was the pre-specified study end-point. Length of stay (LOS) for survivors was also reported. A number of factors related to the occurrence of nAF and the present disease were recorded for each patient. RESULTS The study population was comprised of 133 patients. Twenty (15%) of them manifested nAF. The end-point of ICUD was observed in 27.1% of the patients. The median LOS reported was 8 days. Patients with nAF seemed to have significantly worse prognosis, compared to those who did not manifest nAF (OR=3.35, 95%CI:1.26-8.92; P=0.016). Additionally, nAF patients appear to require significantly extended LOS (P=0.01). Nevertheless, when the effect of nAF on ICUD was adjusted for sepsis, there was no statistically significant difference between those that manifested nAF and the rest of the patients. CONCLUSION Patients suffering nAF seem to have worse prognosis during ICU stay. However, a direct impact of nAF on mortality was not documented.

Burkitt lymphoma of the ovaries mimicking sepsis: a case report and review of the literature

BackgroundIt is not unusual for systemic diseases to mimic sepsis and, in any case, the clinician should thoroughly investigate this possibility.Case presentationWe present the case of a 21-year-old Greek woman who presented to the Intensive Care Unit of our hospital with severe septic shock – multiple organ failure as a result of a suspected gynecological infection of the ovaries. An immediate improvement of her clinical condition in combination with strong clinical suspicion and negative cultures led to the differential diagnosis of diseases other than sepsis. Based on the results of the biopsies that were obtained by research laparotomy, our patient suffered from primary Burkitt ovarian lymphoma. Her clinical condition improved with supportive treatment and chemotherapy. Chemotherapy is the dominant treatment for Burkitt’s lymphoma, while surgery or radiotherapy has no place.ConclusionsAll intensivists should be aware of clinical conditions that mimic sepsis as early diagnosis can lead to appropriate therapy and avoid unnecessary diagnostic tests and antibiotic abuse.