Emad H. Ibrahim

Experience with a clinical guideline for the treatment of ventilator-associated pneumonia.

Objective To evaluate a clinical guideline for the treatment of ventilator-associated pneumonia. Design Prospective before-and-after study design. Setting A medical intensive care unit from a university-affiliated, urban teaching hospital. Patients Between April 1999 and January 2000, 102 patients were prospectively evaluated. Interventions Prospective patient surveillance, data collection, and implementation of an antimicrobial guideline for the treatment of ventilator-associated pneumonia. Measurements and Main Results The main outcome evaluated was the initial administration of adequate antimicrobial treatment as determined by respiratory tract cultures. Secondary outcomes evaluated included the duration of antimicrobial treatment for ventilator-associated pneumonia, hospital mortality, intensive care unit and hospital lengths of stay, and the occurrence of a second episode of ventilator-associated pneumonia. Fifty consecutive patients with ventilator-associated pneumonia were evaluated in the before period and 52 consecutive patients with ventilator-associated pneumonia were evaluated in the after period. Severity of illness using Acute Physiology and Chronic Health Evaluation II (25.8 ± 5.7 vs. 25.4 ± 8.1, p = .798) and the clinical pulmonary infection scores (6.6 ± 1.0 vs. 6.9 ± 1.2, p = .105) were similar for patients during the two treatment periods. The initial administration of adequate antimicrobial treatment was statistically greater during the after period compared with the before period (94.2% vs. 48.0%, p < .001). The duration of antimicrobial treatment was statistically shorter during the after period compared with the before period (8.6 ± 5.1 days vs. 14.8 ± 8.1 days, p < .001). A second episode of ventilator-associated pneumonia occurred statistically less often among patients in the after period (7.7% vs. 24.0%, p = .030). Conclusions The application of a clinical guideline for the treatment of ventilator-associated pneumonia can increase the initial administration of adequate antimicrobial treatment and decrease the overall duration of antibiotic treatment. These findings suggest that similar types of guidelines employing local microbiological data can be used to improve overall antibiotic utilization for the treatment of ventilator-associated pneumonia.

Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial

BACKGROUND This study sought to compare 2 strategies for the administration of enteral feeding to mechanically ventilated medical patients. METHODS The prospective, controlled, clinical trial was carried out in a medical intensive care unit (19 beds) in a university-affiliated, urban teaching hospital. Between May 1999 and December 2000, 150 patients were enrolled. Patients were scheduled to receive their estimated total daily enteral nutritional requirements on either day 1 (early-feeding group) or day 5 (late-feeding group) of mechanical ventilation. Patients in the late-feeding group were also scheduled to receive 20% of their estimated daily enteral nutritional requirements during the first 4 days of mechanical ventilation. RESULTS Seventy-five (50%) consecutive eligible patients were entered into the early-feeding group and 75 (50%) patients were enrolled in the late-feeding group. During the 5 five days of mechanical ventilation, the total intake of calories (2370 +/- 2000 kcal versus 629 +/- 575 kcal; p < .001) and protein (93.6 +/- 77.2 g versus 26.7 +/- 26.6 g; p < .001) were statistically greater for patients in the early-feeding group. Patients in the early-feeding group had statistically greater incidences of ventilator-associated pneumonia (49.3% versus 30.7%; p = .020) and diarrhea associated with Clostridium difficile infection (13.3% versus 4.0%; p = .042). The early-feeding group also had statistically longer intensive care unit (13.6 +/- 14.2 days versus 9.8 +/- 7.4 days; p = .043) and hospital lengths of stay (22.9 +/- 19.7 days versus 16.7 +/- 12.5 days; p = .023) compared with patients in the late-feeding group. No statistical difference in hospital mortality was observed between patients in the early-feeding and late-feeding groups (20.0% versus 26.7%; p = .334). CONCLUSIONS The administration of more aggressive early enteral nutrition to mechanically ventilated medical patients is associated with greater infectious complications and prolonged lengths of stay in the hospital. Clinicians must balance the potential for complications resulting from early enteral feeding with the expected benefits of such therapy.

Deep vein thrombosis during prolonged mechanical ventilation despite prophylaxis

Objective To determine the prevalence of deep vein thrombosis (DVT) among patients requiring prolonged mechanical ventilation in the intensive care unit. Design Prospective cohort study. Setting Medical intensive care unit of a university-affiliated urban teaching hospital. Patients Patients requiring mechanical ventilation for >7 days. Interventions All patients admitted to the medical intensive care unit requiring prolonged mechanical ventilation underwent duplex ultrasonography of their lower extremities and upper extremities every 7 days. The main outcome identified was the presence of DVT. Secondary outcomes included hospital mortality, hospital and intensive care unit lengths of stay, and the occurrence of pulmonary embolism. Measurements and Main Results A total of 110 patients requiring mechanical ventilation for >7 days were enrolled. Prophylaxis against DVT was employed in 110 of the patients (100%). A total of 26 patients (23.6%) developed DVT. Patients with DVT were statistically more likely to have underlying malignancy (30.8% vs. 8.3%;p = .004) and longer durations of central venous catheterization (26.9 ± 22.2 days vs. 14.5 ± 12.1 days;p = .024) compared with patients without DVT. There were no statistically significant differences in hospital mortality or lengths of stay in the hospital and intensive care unit for patients with and without DVT. Patients documented to have DVT by using duplex ultrasonography had a statistically greater frequency of subsequent pulmonary embolism during their hospitalization (11.5% vs. 0.0%;p = .012). Conclusion The occurrence of DVT is common among patients requiring prolonged mechanical ventilation in the intensive care unit setting despite the use of prophylaxis measures. These data suggest that alternative strategies for the prevention of DVT should be evaluated. Additionally, early detection methods should be considered to reduce the potential morbidity associated with untreated DVT in this high-risk population.

USING PROTOCOLS TO IMPROVE THE OUTCOMES OF MECHANICALLY VENTILATED PATIENTS: Focus on Weaning and Sedation

The use of nonphysician-directed protocols and guidelines for the management of sedation and weaning has been shown to reduce the duration of mechanical ventilation for patients with acute respiratory failure when compared with conventional physician-directed practices. Practitioners in ICUs frequently are needed to perform multiple tasks and to evaluate numerous elements of clinical information in the care of the critically ill. In this complex environment, protocols and guidelines are one strategy for ensuring that specific tasks are carried out in a timely manner. Simple-to-employ methods for facilitating changes and improvements in the care of hospitalized patients recently have been proposed. These methods emphasize the importance of developing a culture of cooperation within the ICU so protocols and guidelines can be implemented successfully. Such a culture should embrace changes in medical practices in the ICU if they are associated with improved clinical outcomes. The results of studies evaluating the use of protocols and guidelines have important implications for general critical care practices, because many ICUs do not have physicians who are constantly at the patients bedside. The need for effective communication from the bedside caregiver (e.g., nurse, respiratory therapist, pharmacist, technician) to the physician, so that treatment orders can be changed appropriately, usually results in some delay in the implementation of treatment changes. Protocols are one method for potentially reducing those delays and ensuring that medical care is administered in a more standardized and efficient manner.

Medical thoracoscopy versus image-guided pleural biopsy for diagnosing pleural diseases

Background The diagnostic role of medical thoracoscopy and image-guided pleural biopsy in patients with undiagnosed exudative pleural effusion has increased over the last few years. Objective The aim was to compare the efficacy and safety of medical thoracoscopy versus image-guided [ultrasound (US) and computed tomography] pleural biopsy in the diagnosis of pleural lesions. Patients and methods A total of 40 patients with undiagnosed pleural lesions were divided into two groups. After full investigations, pleural biopsies were taken by medical thoracoscopy and the image-guided technique in groups I and II, respectively. Results In group I, the results of 19 (95%) patients yielded a positive diagnosis, whereas in group II, the results of 17 (85%) patients yielded a positive diagnosis (where results were positive in 80% of US-guided biopsies and 90% in computed tomography-guided biopsies), with no significant difference in the diagnostic yield of the two groups. The US-guided biopsy showed significantly the least duration (P=0.001). Complications were significantly fewer in the image-guided biopsy group (P=0.008). The mean duration of hospital stay was significantly less in the image-guided group than in the medical thoracoscopy group (P=0.001). In conclusion, the overall diagnostic yield is comparably high for medical thoracoscopy and image-guided pleural biopsies, and both are complementary techniques used in different clinical situations. Each diagnostic procedure has its own advantages and disadvantages. Image-guided biopsy is less invasive and can be carried out as an outpatient procedure, whereas medical thoracoscopy provides diagnostic and therapeutic capabilities in one setting.