L Lorenzo

Meropenem by Continuous versus Intermittent Infusion in Ventilator-Associated Pneumonia due to Gram-Negative Bacilli

Background: It is known that β-lactam antibiotics exhibit time-dependent bactericidal activity. Several studies have found continuous infusion of meropenem more effective than intermittent infusion in maintaining constant serum concentrations in excess of the minimum inhibitory concentration. However, limited data exist on the clinical efficacy of meropenem administered by continuous infusion. Objective: To evaluate the clinical efficacy of continuous versus intermittent infusion of meropenem for the treatment of ventilator-associated pneumonia (VAP) due to gram-negative bacilli. Methods: A retrospective cohort study was conducted of patients with VAP caused by gram-negative bacilli who received initial empiric antibiotic therapy with meropenem. We analyzed 2 contemporary cohorts: one group received meropenem by continuous infusion (1 g over 360 min every 6 h), the other by intermittent infusion (1 g over 30 min every 6 h). The administration method was prescribed according to the physicians discretion. Patients received meropenem plus tobramycin for 14 days. Results: There were no significant differences between patient groups with regard to gender, age, APACHE-II at intensive care unit admission, diagnosis, microorganism responsible for VAP, or organ dysfunction severity at the time VAP was suspected. The group receiving medication by continuous infusion showed a greater clinical cure rate than the group treated with intermittent infusion (38 of 42, 90.47%, vs 28 of 47, 59.57%, respectively, with OR 6.44 [95% Cl 1.97 to 21.05; p < 0.001]). Conclusions: Meropenem administered by continuous infusion may have more clinical efficacy than intermittent infusion.

Relative adrenal insufficiency and hemodynamic status in cardiopulmonary bypass surgery patients. A prospective cohort study

BackgroundThe objectives of this study were to determine the risk factors for relative adrenal insufficiency in cardiopulmonary bypass patients and the impact on postoperative vasopressor requirements.MethodsProspective cohort study on cardiopulmonary bypass patients who received etomidate or not during anesthetic induction. Relative adrenal insufficiency was defined as a rise in serum cortisol ≤ 9 μg/dl after the administration of 250 μg of consyntropin. Plasma cortisol levels were measured preoperatively, immediately before, 30, 60, and 90 minutes after the administration of cosyntropin, and at 24 hours after surgery.Results120 elective cardiopulmonary bypass patients were included. Relative adrenal insufficiency (Δcortisol ≤9 μg/dl) incidence was 77.5%. 78 patients received etomidate and 69 (88%) of them developed relative adrenal insufficiency, (P < 0.001). Controlling for clinical characteristics with a propensity analysis, etomidate was the only independent risk factor associated with relative adrenal insufficiency (OR 6.55, CI 95%: 2.47-17.4; P < 0.001). Relative adrenal insufficiency patients showed more vasopressor requirements just after surgery (P = 0.04), and at 4 hours after surgery (P = 0.01). Pre and post-test plasma cortisol levels were inversely associated with maximum norepinephrine dose (ρ = -0.22, P = 0.02; ρ = -0.18, P = 0.05; ρ = -0.21, P = 0.02; and ρ = -0.22, P = 0.02, respectively).ConclusionsRelative adrenal insufficiency in elective cardiopulmonary bypass patients may induce postoperative vasopressor dependency. Use of etomidate in these patients is a modifiable risk factor for the development of relative adrenal insufficiency that should be avoided.

Cost/benefit analysis of chlorhexidine-silver sulfadiazine-impregnated venous catheters for femoral access.

Sixty-four patients with chlorhexidine-silver sulfadiazine-impregnated catheters had a lower rate of catheter-related bloodstream infection and lower central venous catheter-related costs per catheter day than 190 patients with a standard catheter.

Chlorhexidine-silver sulfadiazine-impregnated venous catheters are efficient even at subclavian sites without tracheostomy

BACKGROUND Chlorhexidine-silver sulfadiazine (CHSS)-impregnated catheters have been found to decrease the risk of catheter-related bloodstream infection (CRBSI) and central venous catheter (CVC)-related costs. However, there are no published data about cost-effectiveness of the use of CHSS-impregnated catheters in subclavian venous access without the presence of tracheostomy (thus, with a very low risk of CRBSI). That was the objective of this study. METHODS This was a retrospective study of patients admitted to a mixed intensive care unit who underwent placement of subclavian venous catheters without the presence of tracheostomy. RESULTS Patients with standard catheters (n = 747) showed a higher CRBSI incidence density (0.95 vs 0/1,000 catheter-days; P = .02) and higher CVC-related cost per day (

Lesser accidental arterial catheter removal with the femoral access than with the cubital, dorsalis pedis and brachial arterial accesses

3.78 ± 

Continuous endotracheal tube cuff pressure control system protects against ventilator-associated pneumonia

7.43 vs

Efficiency of chlorhexidine–silver sulfadiazine-impregnated venous catheters at subclavian sites

3.31 ± 

Vasoplegic syndrome after cardiopulmonary bypass surgery – associated factors and clinical outcomes: a nested case-control study

2.72; P < .001) than patients with a CHSS-impregnated catheter (n = 879). Exact logistic regression analysis showed that catheter duration (P = .02) and the type of catheter used (P = .01) were associated with the risk of CRBSI. Kaplan-Meier method showed that CHSS-impregnated catheters were associated with more prolonged CRBSI-free time than standard catheters (log-rank = 9.76; P = .002). Poisson regression analysis showed that CHSS-impregnated catheters were associated with a lower central venous catheter-related cost per day than standard catheters (odds ratio, 0.87; 95% confidence interval, 0.001-0.903; P < .001). CONCLUSIONS The use of CHSS-impregnated catheters is an effective and efficient measure for the prevention of CRBSI even at subclavian venous access sites without the presence of tracheostomy.

Incidence of nosocomial infection in patients with nontraumatic or traumatic coma

Arterial catheterization is a frequent proceeding in critically ill to obtain repetitively blood sampling and continuous monitoring of systemic arterial pressure arterial. The incidence of accidental catheter removal (ACR) in arterial catheters has been scarcely studied, and we did not find studies comparing the ACR incidence between femoral, cubital, dorsalis pedis and brachial arterial sites. The importance of ACR lies in that could cause severe complications, such as severe external haemorrhage and vascular damage, and some could be potentially life-threatening. Thus, due to the scarce published data and the possibility of severe complications in relation to ARC of arterial catheters we proposed this study. The objective of this study was to compare the incidence of ACR in femoral, cubital, dorsalis pedis and brachial arterial sites. We performed a retrospective study over seven years of all patients who were undergoing to femoral, cubital, dorsalis pedis or brachial arterial catheterization during their stay in the polyvalent Intensive Care Unit of the Hospital Universitario de Canarias, Tenerife, Spain. The study was approved by the institutional review board. The following data were collected: age, sex, diabetes mellitus, APACHE-II, diagnosis group, catheter access, catheter insertion and removal dates, and cause of catheter removal (planned or accidental). We considered accidental catheter removal as the presence of an unplanned removal produced by the patient or the staff. The ACR can be performed by the patient, either by taking hold of it with their hands or by making voluntary movements that led directly the removal. The ACR can be performed by the staff as consequence of inadequate handling. The catheters removed due to obstruction of the catheter were not considered as ACR. Statistical analyses were performed with SPSS 12.0.1 (SPSS Inc., Chicago, IL), LogXact 4.1 (Cytel Co., Cambridge, MA) and StatXact 5.0.3 (Cytel Co., Cambridge, MA). Continuous variables are reported as medians and percentiles 25th--75th, and were compared using Mann--Whitney test. Categorical variables are reported as frequencies and percentages, and were compared using Chi-square test. The incidence of ACR between groups was compared using Cox regression. The magnitude of the effects is expressed as Hazard Ratio (HR) and 95% confidence interval (CI). A p-value less than 0.05 was considered statistically significant. Were included a total of 2199 arterial catheters and remain in situ during 13,237 days. We detected 116 ACR, thus the 5.3% arterial catheters were accidentally removed and we had 0.88 ACR per 100 days of arterial catheterization. We found 49 events of ACR in 1250 (3.9%) arterial femoral catheters during 7524 days of catheterization (0.65 events of ACR per 100 days of catheterization), 39 events of ACR in 583 (6.7%) arterial cubital catheters during 3513 days of catheterization (1.11 events of ACR per 100 days of catheterization), 15 events of ACR in 198 (7.6%) arterial dorsalis pedis catheters during 1187 days of catheterization (1.26 events of ACR per 100 days of catheterization) and 13 events of ACR in 168 (7.7%) arterial brachial catheters during 1013 days of catheterization (1.28 events of ACR per 100 days of catheterization), As shown in Table 1, there were no significant differences between femoral, cubital, dorsalis pedis and brachial arterial catheters in age, sex, diabetes mellitus, APACHE-II, diagnosis group and duration of the catheter. However, there were found statistically significant differences in the percentage of catheters with ACR (p = 0.01) and in the ACR incidence per 100 days of catheterization (p = 0.02) between the different arterial sites. Cox regression analysis showed a lower ACR incidence in femoral than in cubital (Hazard Ratio = 0.608; 95% CI = 0.399--0.926; p = 0.02), dorsalis pedis (Hazard Ratio = 0.534; 95% CI = 0.299--0.952; p = 0.03) and brachial (Hazard Ratio = 0.500; 95% CI = 0.271--0.922; p = 0.03) arterial catheters (Table 2). To our knowledge, this is the first study comparing ACR incidence between femoral, cubital, dorsalis pedis and brachial arterial sites. The most relevant finding of our study is that femoral arterial catheter showed a lower ACR incidence that cubital, dorsalis pedis and brachial arterial catheters. In our study, we found that the 5.3% of arterial catheters were accidentally removed and an ACR rate of 0.88 events per 100 days of arterial catheterization. Our ACR rate is