José María Barrio

Continuous Aspiration of Subglottic Secretions in the Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery

OBJECTIVEnAspiration of endotracheal secretions is a major step in the prevention of ventilator-associated pneumonia (VAP). We compared conventional and continuous aspiration of subglottic secretions (CASS) procedures in ventilated patients after major heart surgery (MHS).nnnMATERIALS AND METHODSnRandomized comparison during a 2-year period.nnnRESULTSnA total of 714 patients were randomized (24 patients were excluded from the study; 359 CASS patients; 331 control subjects). The results for CASS patients and control subjects (per protocol and intention-to-treat analysis) were as follows: VAP incidence, 3.6% vs 5.3% (p = 0.2) and 3.8% vs 5.1%, respectively; incidence density, 17.9 vs 27.6 episodes per 1,000 days of mechanical ventilation (MV) [p = 0.18] and 18.9 vs 28.7 episodes per 1,000 days of MV, respectively; hospital antibiotic use in daily defined doses (DDDs), 1,213 vs 1,932 (p < 0.001) and 1,392 vs 1,932, respectively (p < 0.001). In patients who had received mechanical ventilation for > 48 h, the comparisons of CASS patients and control subjects were as follows: VAP incidence, 26.7% vs 47.5% (p = 0.04), respectively; incidence density, 31.5 vs 51.6 episodes per 1,000 days of MV, respectively (p = 0.03); median length of ICU stay, 7 vs 16.5 days (p = 0.01), respectively; hospital antibiotic use, 1,206 vs 1,877 DDD (p < 0.001), respectively; Clostridium difficile-associated diarrhea, 6.7% vs 12.5% (p = 0.3), respectively; and overall mortality rate, 44.4% vs 52.5% (p = 0.3), respectively. Reintubation increased the risk of VAP (relative risk [RR], 6.07; 95% confidence interval [CI], 2.20 to 16.60; p < 0.001), while CASS was the only significant protective factor (RR, 0.40; 95% CI, 0.16 to 0.99; p = 0.04). No complications related to CASS were observed. The cost of the CASS tube was 9 vs 1.5 euro for the conventional tube.nnnCONCLUSIONSnCASS is a safe procedure that reduces the use of antimicrobial agents in the overall population and the incidence of VAP in patients who are at risk. CASS use should be encouraged, at least in patients undergoing MHS.

Incidence and risk factors for ventilator-associated pneumonia after major heart surgery

PurposeMajor heart surgery (MHS) patients are a particularly high-risk population for nosocomial infections. Our objective was to identify risk factors for ventilator-associated pneumonia (VAP) in patients undergoing MHS.MethodsProspective study including 1,844 patients operated from 2003 to 2006.ResultsOverall 106 patients (140 episodes) developed one or more episodes of VAP (5.7%, 22.2 episodes per 1,000xa0days of mechanical ventilation). VAP incidence was 45.9% in those patients requiring more than 48xa0h of MV. Enterobacteriaceae (32.8), Pseudomonas aeruginosa (28.6%) and Staphylococcus aureus (27.1%, of which 65.8% were methicillin resistant) were the principal microorganisms causing VAP. The independent risk factors for VAP were: age >70, perioperative transfusions, days of mechanical ventilation, reintubation, previous cardiac surgery, emergent surgery and intraoperative inotropic support. Median length of stay in the ICU for patients who developed VAP or not was, respectively, 25.5 versus 3xa0days (Pxa0<xa00.001), and mortality was, respectively, 45.7 versus 2.8% in both populations (Pxa0<xa00.001). We developed a predictive preoperative score with a sensitivity of 93% and a specificity of 40%.ConclusionsVAP is common in patients undergoing MHS that require more than 48xa0h of MV. In that “high-risk” population, innovative preventive measures should be developed and applied.

Pre-emptive broad-spectrum treatment for ventilator-associated pneumonia in high-risk patients

PurposePatients requiring mechanical ventilation (MV) for >48xa0h after major heart surgery (MHS) are at a high risk of acquiring ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT). Most non-pharmacological interventions to prevent VAP in such patients are usually already implemented. The objective of this study was to evaluate the efficacy in preventing lower respiratory infections of antibiotics active against multidrug-resistant pathogens in this very high-risk population.MethodsWe performed a prospective randomized open-label study of MHS patients requiring MV for >48xa0h. Patients were randomly allocated to one of two groups: the intervention group, which received a 3-day course of linezolid and meropenem, and the control group, which received the standard of care. The main outcome was the development of VAP or VAT.ResultsOverall, of the 78 patients included in the study, 40 were in the intervention group and 38 in the control group. Both groups were comparable. Data for the intervention and control groups respectively were as follows: VAPxa0+xa0VAT/1,000xa0days was 31.79 vs 64.78 (pxa0=xa00.03), median length of MV before the first episode of VAP or VAT 9 vs 4.5xa0days (pxa0=xa00.02). No significant differences were observed in median length of stay in the intensive care unit, median length of hospital stay, antibiotic use, Clostridium difficile infection, and overall mortality rate. We detected linezolid-resistant coagulase-negative and coagulase-positive staphylococci in the MHS intensive care unit after the study period.ConclusionsA pre-emptive approach with broad-spectrum antibiotics may be effective in reducing the incidence and delaying the onset of VAPxa0+xa0VAT after MHS. The ecological consequences have to be carefully evaluated in future trials.

Ethanol Lock Therapy (E-Lock) in the Prevention of Catheter-Related Bloodstream Infections (CR-BSI) after Major Heart Surgery (MHS): A Randomized Clinical Trial

Background Lock-therapy with antimicrobials has been used for the treatment and prevention of catheter-related bloodstream infections (CR-BSI). Experiences with Ethanol-Locks (E-locks) have included therapeutic interventions with variable results. Patients undergoing Major Heart Surgery (MHS) are a high-risk population for CR-BSI.The aim of this study was to assess the efficacy and tolerance to E-Locks in the prevention of CR-BSI of patients undergoing MHS. Methods and Findings This is an academic, prospective, randomized, non-blinded and controlled clinical trial assessing the incidence of CR-BSI of patients with E-locks (E-lock) and the tolerance to the procedure in comparison with patients receiving conventional catheter-care (CCC). Patients undergoing MHS with intravascular catheters for more than 48 hours were randomly assigned into treatment or control group by a computer-generated list of randomly assigned numbers. In the treatment group, all their catheter lumens were locked with an ethanol solution at 70% for two hours, every three days (E-Locks). The control group received conventional catheter-care (CCC). Overall, 200 patients with 323 catheters were included in the study, which was stopped after 10 months due to adverse events. Of them, 179 catheters (113 patients) had E-Locks and 144 catheters (87 patients) were CCC. Euroscore Surgical Risk in both groups was 4.04 vs 4.07 pu200a=u200a0.94 respectively. The results for the E-Locks and CCC were as follows: Incidence of CR-BSI/1000 days of exposure 2.1 vs 5.2 (pu200a=u200a0.33), catheter tip colonization 14 (7.8%) vs 6 (4.2%) patients (pu200a=u200a0.17), median length of hospital stay, 15 vs 16 days (pu200a=u200a0.77). Seven patients (6.19%), all in the ethanol branch, had to discontinue the trial due to intolerance or adverse events. Conclusions We do not recommend prophylaxis of CR-BSI with ethanol-lock on a routine basis in patients undergoing Major Heart Surgery. Trial Registration Clinical Trials.gov NCT01229592

Loss of hydroxyl ions from gutta-percha points with calcium hydroxide in their composition: an in vivo study.

The aim of this study was to quantify variations in the pH of calcium-hydroxide, gutta-percha cones that had remained for 1 week inside the root canals of molars or premolars whose endodontic treatment could not be concluded in a single visit. All teeth were instrumented and dried before the placement of the points. The cones were removed, and placed in vials with distilled water. Additional, new gutta-percha cones were also studied as a control. The pH was measured by a pH meter, model CRISON MicropH 2001. The average pH mensurations obtained for new, calcium-hydroxide, gutta-percha points was 10.11; for cones that were used 1 week, it was 7.08. There was a statistically significant difference observed between the two groups by the Students t test (p > 0.001). After 7 days, a significant decrease takes place in the alkalinity of these points.

Impact of four sequential measures on the prevention of ventilator-associated pneumonia in cardiac surgery patients

IntroductionVentilator-associated pneumonia (VAP) is the most frequent infection in patients admitted to intensive care units.The efficacy of individual measures for the prevention of VAP is well documented, and data on the impact of implementing bundle measures have usually been reported from studies in which several measures are implemented simultaneously in the general intensive care unit (ICU).The objective of our work was to evaluate the impact of four sequentially implemented measures for preventing VAP in a major heart surgery ICU. The measures were a specific training program, aspiration of subglottic secretions (ASSs), introduction of an inclinometer to improve the semirecumbent position, and reinforcement of oral care with chlorhexidine.MethodsWe compared rates of VAP, days on mechanical ventilation (MV), and cost of antimicrobial agents before and during implementation.ResultsWe collected data from 401 patients before the intervention and from 1,534 patients during the intervention. Both groups were comparable. No significant differences in EuroSCORE were observed between the patients of both periods (6.4 versus 6.3; Pu2009=u20090.7). The rates of VAP (episodes/1,000xa0days of ventilation) were, respectively, 23.9 versus 13.5 (Pu2009=u20090.005). Mean number of days of MV/1,000xa0days of stay was 507 versus 375 (Pu2009=u20090.001), and the cost of antimicrobial therapy (Euros/1,000xa0days of stay) was €70,612 versus €52,775 (Pu2009=u20090.10). The main effect of sequential application of preventive measures in time achieved a relative-rate reduction of VAP of 41% (IRR, 0.41; 95% CI, 0.28 to 0.62). The mortality rate before and during the intervention was 13.0% and 10.2%, respectively.VAP rate was most significantly reduced by training and the use of the inclinometer.ConclusionsA sequentially applied bundle of four preventive measures reduces VAP rates, days of MV, and the cost of antimicrobial therapy in patients admitted to the major heart surgery ICU.Trial registrationClinical Trials.gov: NCT02060045. Registered 4 February 2014.

Assessment of central venous catheter colonization using surveillance culture of withdrawn connectors and insertion site skin

BackgroundCulture of catheter hubs and skin surrounding the catheter entry site has a negative predictive value for catheter tip colonization. However, manipulation of the hub for culture requires the hubs to be swabbed, introducing potential dislodging of biofilm and subsequent migration of microorganisms. Hubs are usually closed with needleless connectors (NCs), which are replaced regularly. Our objective was to evaluate whether culture of flushed withdrawn NCs is an alternative to hub culture when investigating central venous catheter colonization.MethodsThe study population comprised 49 intensive care unit patients whose central venous catheters had been in place for at least 7xa0days. Cultures of NCs and skin were obtained weekly.ResultsWe included 82 catheters with more than 7xa0days’ indwelling time. The catheter tip colonization rate was 18.3xa0% (15/82). Analysis of skin and NC cultures revealed a 92.5xa0% negative predictive value for catheter colonization. Three episodes of catheter-related bloodstream infection (C-RBSI) occurred in patients with colonized catheters.ConclusionSurveillance of NC and skin cultures could help to identify patients at risk for C-RBSI.

Routine aspiration of subglottic secretions after major heart surgery: impact on the incidence of ventilator-associated pneumonia

Aspiration of subglottic secretions (ASS) is recommended in patients requiring mechanical ventilation for ≥48h. We assessed the impact of the introduction of ASS routinely in all patients after major heart surgery in an ecological study comparing ventilator-acquired pneumonia (VAP) incidence, days of mechanical ventilation, and cost of antimicrobial agents before and after the implementation of ASS. Before and after the intervention the results (per 1000 days) were: VAP incidence, 23.92 vs 16.46 (Pxa0=xa00.04); cost of antimicrobials, €71,384 vs €63,446 (P = 0.002); and days of mechanical ventilation, 507.5 vs 377.5 (Pxa0=xa00.009). From the moment of induction of anaesthesia all patients undergoing major heart surgery should routinely receive ASS.

Early intravenous immunoglobulin replacement in hypogammaglobulinemic heart transplant recipients: results of a clinical trial.

Immunoglobulin G (IgG) hypogammaglobulinemia (HGG) is a risk factor for development of severe infections after heart transplantation. We performed a clinical trial to preliminarily evaluate the efficacy and safety of early administration of intravenous immunoglobulin (IVIG) for prevention of severe infection in heart recipients with post‐transplant IgG HGG.

Impact of selective digestive decontamination without systemic antibiotics in a major heart surgery intensive care unit

Purpose The incidence density of ventilator‐associated pneumonia (VAP) is higher in patients undergoing major heart surgery than in other populations, despite the introduction of bundles of preventive measures, because many risk factors are not amenable to intervention. Selective digestive decontamination (SDD) has been shown to be efficacious for decreasing the frequency of VAP, although it has not been incorporated into the routine of most intensive care units. The objective of our study was to evaluate the efficacy of SDD without parenteral antibiotics for preventing VAP in a major heart surgery intensive care unit. Methods We compared the incidence of VAP before the introduction of SDD (17 months) and during the 17 months after the introduction of SDD and examined its ecologic influence. Results The rates of VAP in the overall population before and during the intervention were 16.26/1000 days and 6.80 episodes/1000 days of mechanical ventilation, respectively (P = .01). The rates of VAP in the 173 patients remaining under mechanical ventilation > 48 hours after surgery were, respectively, 25.85/1000 days of mechanical ventilation versus 12.06 episodes/1000 days of mechanical ventilation (P = .04). We found a significant reduction in the number of patients with multidrug‐resistant microorganisms (P = .01) in the second period of the study. Conclusions Our study shows that SDD without parenteral antibiotics can reduce the incidence of VAP in high‐risk patients after major heart surgery, with no significant ecologic influence.