Christopher Veremakis

Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: The NASCENT randomized trial

CONTEXT Ventilator-associated pneumonia (VAP) causes substantial morbidity. A silver-coated endotracheal tube has been designed to reduce VAP incidence by preventing bacterial colonization and biofilm formation. OBJECTIVE To determine whether a silver-coated endotracheal tube would reduce the incidence of microbiologically confirmed VAP. DESIGN, SETTING, AND PARTICIPANTS Prospective, randomized, single-blind, controlled study conducted in 54 centers in North America. A total of 9417 adult patients (> or = 18 years) were screened between 2002 and 2006. A total of 2003 patients expected to require mechanical ventilation for 24 hours or longer were randomized. INTERVENTION Patients were assigned to undergo intubation with 1 of 2 high-volume, low-pressure endotracheal tubes, similar except for a silver coating on the experimental tube. MAIN OUTCOME MEASURES Primary outcome was VAP incidence based on quantitative bronchoalveolar lavage fluid culture with 10(4) colony-forming units/mL or greater in patients intubated for 24 hours or longer. Other outcomes were VAP incidence in all intubated patients, time to VAP onset, length of intubation and duration of intensive care unit and hospital stay, mortality, and adverse events. RESULTS Among patients intubated for 24 hours or longer, rates of microbiologically confirmed VAP were 4.8% (37/766 patients; 95% confidence interval [CI], 3.4%-6.6%) in the group receiving the silver-coated tube and 7.5% (56/743; 95% CI, 5.7%-9.7%) (P = .03) in the group receiving the uncoated tube (all intubated patients, 3.8% [37/968; 95% CI, 2.7%-5.2%] and 5.8% [56/964; 95% CI, 4.4%-7.5%] [P = .04]), with a relative risk reduction of 35.9% (95% CI, 3.6%-69.0%; all intubated patients, 34.2% [95% CI, 1.2%-67.9%]). The silver-coated endotracheal tube was associated with delayed occurrence of VAP (P = .005). No statistically significant between-group differences were observed in durations of intubation, intensive care unit stay, and hospital stay; mortality; and frequency and severity of adverse events. CONCLUSION Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00148642.

Red blood cell transfusions and nosocomial infections in critically ill patients.

Objective:A previous retrospective evaluation of Project Impact data demonstrated an association between red blood cell transfusions, nosocomial infections, and poorer outcomes in critically ill patients, independent of survival probability or patient age. The objective of this study was to determine whether transfused patients, independent of survival probability based on Mortality Prediction Model scores, have higher nosocomial infection rates, longer intensive care unit and hospital lengths of stay, and higher mortality rates than nontransfused patients. Design:Prospective, observational, cohort study. Setting:A single-center, mixed medical/surgical, closed intensive care unit. Patients:Adults admitted to St. John’s Mercy Medical Center between August 2001 and June 2003 (n = 2,085) were enrolled using Project Impact software. Both nonoperative and postoperative populations were represented, and transfusion decisions were made independently of patient study inclusion. Patients whose nosocomial infection was diagnosed before transfusion were counted as nontransfused. Interventions:None. Measurements and Main Results:Nosocomial infections, mortality rates, and intensive care unit and hospital length of stay were the main outcome measures. Of the 2,085 patients enrolled, 21.5% received red blood cell transfusions. The posttransfusion nosocomial infection rate was 14.3% in 428 evaluable patients, significantly higher than that observed in nontransfused patients (5.8%; p < .0001, chi-square). In a multivariate analysis controlling for patient age, maximum storage age of red blood cells, and number of red blood cell transfusions, only the number of transfusions was independently associated with nosocomial infection (odds ratio 1.097; 95% confidence interval 1.028–1.171; p = .005). When corrected for survival probability, the risk of nosocomial infection associated with red blood cell transfusions remained statistically significant (p < .0001). Leukoreduction tended to reduce the nosocomial infection rate but not significantly. Mortality and length of stay (intensive care unit and hospital) were significantly higher in transfused patients, even when corrected for illness severity. Conclusions:Red blood cell transfusions should be used sparingly, bearing in mind the potential risks of infection and poor outcomes in critically ill patients. LEARNING OBJECTIVESOn completion of this article, the reader should be able to: Explain the influence of red cell transfusions on nosocomial infection (NI) in critically ill patients. Describe the impact of transfusions on patient outcomes. Use this information in a clinical setting. Dr. Trottier has disclosed that he is an Airway Consultant for Smith’s Medical. Mr. Fu has disclosed that he is an employee of John & Johnson Pharmaceutical. All remaining authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to this educational activity. Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity. Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.

Femoral deep vein thrombosis associated with central venous catheterization: results from a prospective, randomized trial.

OBJECTIVE To determine the frequency of central venous catheter-induced deep vein thrombosis of the femoral vein. DESIGN Prospective, randomized, controlled trial. SETTING Tertiary care center. PATIENTS Forty-five patients in a medical-surgical intensive care unit who required central venous catheterization. INTERVENTIONS Patients were randomized to receive central venous catheterization in either upper (subclavian or internal jugular veins) or lower (femoral vein) catheterization sites. Lower extremity duplex ultrasound examinations were performed before central venous catheter placement, after removal of the catheter, and 7 days after catheter removal. Ultrasound examinations were reported as positive, nondiagnostic, or negative for deep vein thrombosis. MEASUREMENTS AND MAIN RESULTS Of the 21 patients randomized to upper access sites, none developed positive or nondiagnostic duplex ultrasound examinations. Six (25%) of 24 patients randomized to the femoral access site developed lower extremity deep vein thrombosis (p = .02). In addition, seven (29%) patients randomized to the lower access site sustained non-diagnostic ultrasound examinations. A total of 13 (54%) of 24 patients from the lower access group developed abnormal ultrasound examinations (p < .001). Age, duration of catheterization, coagulation profile, deep vein thrombosis prophylaxis, and Acute Physiology and Chronic Health Evaluation II scores were similar between the upper and lower access groups. CONCLUSIONS Based on the data from this study, we concluded that femoral vein catheterization is associated with a 25% frequency of lower extremity deep vein thrombosis compared with similar patients receiving subclavian or internal jugular vein catheters. The femoral vein remains an important emergency venous access route. Physicians inserting femoral vein catheters should be aware of the risk of lower extremity deep vein thrombosis and should consider performing lower extremity duplex ultrasound examinations on removal of femoral vein catheters.

Telemedicine Intervention Improves ICU Outcomes

Telemedicine for the intensive care unit (Tele-ICU) was founded as a means of delivering the clinical expertise of intensivists located remotely to hospitals with inadequate access to intensive care specialists. This was a retrospective pre- and postintervention study of adult patients admitted to a community hospital ICU. The patients in the preintervention period (n = 630) and during the Tele-ICU period (n = 2193) were controlled for baseline characteristics, acute physiologic scores (APS), and acute physiologic and health evaluation (APACHE IV) scores. Mean APS scores were 37.1 (SD, 22.8) and 37.7 (SD, 19.4) (P = 0.56), and mean APACHE IV scores were 49.7 (SD, 24.8) and 50.4 (SD, 21.0) (P = 0.53), respectively. ICU mortality was 7.9% during the preintervention period compared with 3.8% during the Tele-ICU period (odds ratio (OR) = 0.46, 95% confidence interval (CI), 0.32–0.66, P < 0.0001). ICU LOS in days was 2.7 (SD, 4.1) compared with 2.2 (SD, 3.4), respectively (hazard ratio (HR) = 1.16, 95% CI, 1.00–1.40, P = 0.01). Implementation of Tele-ICU intervention was associated with reduced ICU mortality and ICU LOS. This suggests that there are benefits of a closed Tele-ICU intervention beyond what is provided by daytime bedside physicians.

Therapeutic Hypothermia in Traumatic Brain Injury

Traumatic brain injury (TBI) is a major source of death and severe disability worldwide. In the USA alone, this type of injury causes 290,000 hospital admissions, 51,000 deaths, and 80,000 permanently disabled survivors [1,2]. Intracranial hypertension develops commonly in acute brain injury related to trauma [3,4]. Raised Intracranial pressure (ICP) is an important predictor of mortality in patients with severe TBI, and aggressive treatment of elevated ICP has been shown to reduce mortality and improve outcome [4-11]. Guidelines for the Management of Severe TBI, published in the Journal of Neurotrauma in 2007 [12] make a Level II recommendation that ICP should be monitored in all salvageable patients with a severe TBI (Glasgow Coma Scale [GCS] score of 3–8 after resuscitation) and an abnormal computed tomography (CT) scan. ICP monitoring is also recommended in patients with severe TBI and a normal CT scan if two or more of the following features are noted at admission: age over 40 years, unilateral or bilateral motor posturing, or systolic blood pressure < 90 mm Hg (Level III recommendation). Furthermore, ICP should be maintained less than 20 mmHg and cerebral perfusion pressure (CPP) between 50 and 70 mmHg (Level III).

Using survival analysis to predict septic shock onset in ICU patients

Purpose: To determine the efficacy of survival analysis for predicting septic shock onset in ICU patients. Materials and Methods: We performed a retrospective analysis on ICU cases from Mercy Hospital St. Louis from 2012 to 2016. As part of the procedure for inclusion in the Apache Outcomes database, each case is reviewed by critical care clinicians to identify septic shock patients as well as the time of septic shock onset. We used survival analysis to predict septic shock onset in these cases and employed lagging to compensate for uncertainties in septic shock onset time. Results: Survival analysis was highly effective at predicting septic shock onset, producing AUC values of >0.87. The methodology was robust to lag times as well as the specific method of survival analysis used. Conclusions: This methodology has the potential to be implemented in the ICU for real time prediction and can be used as a building block to expand the approach to other hospital wards or care environments.

Bradycardia Secondary to Cervical Spinal Cord Injury

Acute spinal cord injury (SCI) is most commonly traumatic in origin but may also result from degenerative spine disease, ischemia, demyelination, inflammation, or rapidly expanding neoplastic, hemorrhagic, or pyogenic masses (Ghezzi et al, 2001). In the United States, traumatic SCI with or without bony injury has an annual incidence of 28 to 55 per million, with an average of 10,000 new cases a year and a prevalence of 200,000 (Sekhon & Fehlings, 2001). The average age at the time of injury is 32 years and the male/female ratio is 4:1. More than half (55%) of traumatic SCI involves the cervical cord. The most common causes of SCI are traffic accidents (motor vehicle, bicycle, pedestrian) (40%– 50%), assault (10%–25%), falls (20%), work-related injuries (10%–25%), and sports/recreation-related injuries (10%–25%) (Cheung et al, 2002; Surkhin et al, 2000). In traumatic cervical SCI, 3month mortality is 20% to 21%. The independent predictors of mortality are level of cord injury, Glasgow Coma Scale, respiratory failure, and age. Principal causes of death are respiratory disorders, cardiovascular disorders, pulmonary embolism, infections, and suicide (Claxton et al, 1998; DeVivo et al, 1999, Yeo et al, 1998). Cardiovascular disorders are responsible for 40.5% of deaths, being the most common cause of mortality in patients with SCI (Garshick et al, 2005).