K Vandewoude

Development and validation of a model for prediction of mortality in patients with acute burn injury

The objective was to develop a user‐friendly model to predict the probability of death from acute burns soon after injury, based on burned surface area, age and presence of inhalation injury.

Clinical impact of nosocomial Klebsiella bacteremia in critically ill patients.

Abstract.In order to determine the clinical impact of Klebsiella bacteremia on critically ill patients, a matched cohort study was conducted between January 1992 and December 2000. During the study period, all intensive care unit (ICU) patients with nosocomial Klebsiella bacteremia were defined as cases (n=52), but two of these patients were excluded from the matched cohort due to incomplete medical records. The remaining 50 patients were matched at a ratio of 1:2 with control patients (n=100) on the basis of the APACHE II severity of disease classification system. Patients with Klebsiella bacteremia experienced acute renal failure and hemodynamic instability more often than controls. They also had a longer ICU stay and longer ventilator dependence. In-hospital mortality rates for cases and controls were nearly equal (36% vs. 37%, respectively; P=0.905). In conclusion, after adjusting accurately for severity of underlying disease and acute illness, no difference in mortality was found between ICU patients with Klebsiella bacteremia and their matched control subjects.

Acute isoniazid intoxication: seizures, acidosis and coma.

Isoniazid (INH) is the most widely used of the antituberculosis drugs. An acute overdose is potentially fatal and is characterized by the clinical triad of repetitive seizures unresponsive to the usual anticonvulsants, metabolic acidosis with a high anion gap and coma. The diagnosis of INH overdose should be considered in any patient who presents with an unexplained metabolic acidosis and convulsions. The cornerstone of therapy consists in pyridoxine (vitamin B6) and the dose should be equal to the amount of INH ingested. When conservative therapy fails or in case of renal insufficiency, dialysis must be considered. Severe central nervous toxicity can also be caused by chronic ingestion of higher than therapeutic doses of INH. In those cases pyridoxine-therapy can be useful as well. In the present paper a case of acute overdose of INH is reported, followed by a review of the literature.

Two cases of disseminated mucormycosis in patients with hematological malignancies and literature review

Abstract Two cases of disseminated mucormycosis in patients with underlying hematological disease are described. Both patients presented with fever and pulmonary infiltrates which did not respond to empirical treatment with broad-spectrum antibiotics and antifungal agents, and in both patients there was rapid progression with a fatal outcome. All cultures were negative and the diagnosis was made postmortem. A review of the literature revealed only three recent reports of successful treatment of disseminated mucormycosis. Survival correlated with control of the underlying disease and early diagnosis based on histological examination of biopsy specimens from suspected lesions. Therapy consisted of surgical debridement and amphotericin B. Standard therapeutic schedules need to be defined for this infection.

Prevalence and risk factors for colonisation with gram-negative bacteria in an intensive care unit.

Abstract Objective: To investigate prevalence and determine risk factors for colonisation with Gram-negative bacteria in ICU patients. Design: Prospective, surveillance study. Setting: 26-bed surgical and paediatric ICU. Patients: 159 patients - whereof 22 infants - admitted to the surgical/paediatric ICU over a two-month period. Intervention: In all patients routine microbiological monitoring was performed by thrice weekly oral swabs, urine sampling and, additionally, tracheal aspirates in patients on mechanical ventilation (MV) and by anal swabs once weekly. Results: Population characteristics: Mean age of the adult population was 51.1 ± 17.6 year. Mean age of the paediatric population was 6.3 ± 5.3 year. The mean APACHE II-score was 18 ± 9.1. The mean PRISM-score was 9.7 ± 5.4. The mean ICU stay was 7.5 ± 11.4 days. 43.4 percent of patients received mechanical ventilation (MV). The mean number of mechanical ventilation days was 11.1 ± 14.7 days. 32.1% of patients experienced colonisation with Gram-negative bacteria. Prevalence of colonisation increased with length of ICU stay. The probability of colonisation was 24% after an ICU stay of 3 days (=median ICU stay). Time to colonisation was not different between the controlled sites (p>0.05). 47% of colonisations were due to multiresistant strains. Higher APACHE II-scores and MV were associated with a higher prevalence of colonisation (p<0.01). The ICU mortality was 8%among adult and 4% among paediatric patients. Conclusion: Patients with high APACHE II-scores, on mechanical ventilation and with an ICU stay of more than 3 days are most at risk for colonisation with Gram-negative bacteria. These patients should be cared with the optimal precautions in the prevention of colonisation and infection.

The Effect of Tube Thoracostomy on Oxygenation in ICU Patients

Previous research found that in noncritically ill patients, thoracocentesis has an unpredictable effect on oxygenation, possibly due to re-expansion pulmonary edema and systemic hypotension. The authors performed a retrospective analysis to study the effect of tube thoracostomy on oxygenation in ICU patients, and the complications associated with it. The authors reviewed the charts of 58 ICU patients in whom 74 procedures were performed. Demographic data, APACHE II score, and indication for thoracocentesis were retrieved from the patient’s file. The PaO2/FiO2 ratio was calculated before, 12, 24, and 48 hours after tube thoracostomy. PaO2/FiO2 ratios at the mentioned time intervals were compared using 1-way analysis of variances (ANOVA) with repeated measures. Logistic regression analysis was used to identify factors associated with a good response to treatment. Age of the patients was 53 ± 19.0 years (range, 17-88), APACHE II score was 21 ± 8.3 (range, 6-38), and median length of stay was 13.5 days (interquartile range, 7-25). The volume drained during the first 24 hours was 1077 ± 667 ml. PaO2/FiO2 ratio was 185 ± 79.3 before chest drainage, 197 ± 79.1 at 12 hours, 217 ± 88.9 at 24 hours, and 233 ± 99.8 at 48 hours. In only 54% of the procedures, a response to therapy was present. Multivariate analysis identified a PaO2/FiO2 below 180 to be independently associated with improvement in oxygenation. At 24 and 48 hours, the PaO2/FiO2 ratio was significantly higher than before drainage ( P < .001). There were 13 complications in 11 procedures (14.9%). The authors’ results suggest that tube thoracostomy can be used as an adjunct in the treatment of selected patients with hypoxemic respiratory failure in the ICU. A low PaO2/FiO2 seems to be a good predictor of response to therapy. However, the complication rate is considerable, especially in patients with a prolonged ICU stay.

Recurrent pericardial effusion as a result of chronic pancreatitis : Successful treatment with somatostatin

We report a well-documented case of relapsing chronic calcifying pancreatitis with recurrent pleural and pericardial effusions during episodes of clinical and biochemical relapse of the pancreatitis. Pericardial effusions in association with pancreatitis have been reported only very occasionally, almost exclusively in chronic alcoholic pancreatitis with pseudocyst formation. Our successful conservative treatment consisted of parenteral nutrition and a continuous infusion of somatostatin for 6 weeks. We discuss other reported cases and proposed mechanisms of pathogenesis.

Candida infection in surgical patients

Sir: In a recent review article by Vincent et al. [1] published in Intensive Care Medicine on the aEpidemiology, diagnosis and treatment of systemic Candida infection in surgical patients under intensive careo, we were surprised not to find any comment or guideline about the management of central venous lines in this patient population. Catheter-related infections are inherent in the intensive care unit (ICU) and central venous lines are, apart from the gastrointestinal and urogenital tracts, frequently the port of entry for candidemia in these patients (varying between 32 and 70 %). Although there is doubt about the direct pathogenic role of central venous lines in systemic candidal infections and/or candidemia, recent data support the removal of non-surgically implanted lines in patients with candidemia [2, 3]. Nguyen et al. [2] showed that the mortality for patients whose catheters were removed was 21% compared to 41% (p < 0.001) when catheters remained in place. Vascular catheter retention was also a significant risk factor for microbiological failure. On the other hand, Vincent et al. recommend using high doses a fluconazole in all ICU patients infected by Candida species at dosages of 600±800 mg/day for 3 days, followed by 400 mg/day given intravenously, or orally if feasible. The bases for this recommendation are weak and are not supported by important clinical data. The only study which supported higher dosages of fluconazole in ICU patients [4] was seriously biased by the fact that the mortality in patients treated with high doses of fluconazole was dramatically decreased by a rescue treatment with amphotericin B. In the EPIC (European Prevalence of Infection in Intensive Care) study, 50 % of the patients in whom fungi were isolated were treated with antifungals; however, the associated mortality was only 6%, which is low compared to the generally accepted attributable mortality of approximately 30% for nosocomial Candida infections. This suggests that most of the patients were treated for colonisation rather than for infection, and we are concerned that the recommendation to give higher doses of fluconazole will only lead to overtreatment and induction of relative resistance and/or dose-dependent susceptibility to nosocomial strains. The authors showed in Table 3 (referring to the study of Rex et al.) that recurrent candidemia was the main cause of treatment failure. A possible reason for treatment failure could be the occurrence of candidal thrombophlebitis of the central veins. Since catheter-related thrombosis is a frequent but rare clinically significant complication of central venous lines, we think that especially in the ICU candidal thrombophlebitis of the central veins should always been excluded in cases of recurrent candidemia [5]. In conclusion, catheter-related candidemia should always be considered in the ICU, and proper catheter management in the ICU is probably more important and supported by more clinical data than increasing the dose of fluconazole to 600 or 800 mg in the first few days in all ICU patients. Moreover, this review does not address alternative antifungal therapeutic options, such as the development of intraconazole cyclodextrin or nanocrystal solution for intravenous usage, nor the development of new fungicidal drugs like the new triazoles (voriconazole) or echinocandins in the very near future.