Moshe Hersch

Accuracy and ease of use of a novel electronic urine output monitoring device compared with standard manual urinometer in the intensive care unit

INTRODUCTIONnUrine output (UO) is a critical parameter in the intensive care unit not yet electronically monitored. This study tested the accuracy and ease of use of a new electronic continuous UO monitoring device (Urinfo 2000; Medynamix, Jerusalem, Israel).nnnMETHODSnThis article is a prospective study in a 6-bed intensive care unit. In consecutive patients with indwelling urinary catheter and expected stay of 24 hours or more, hourly UO was measured by either Urinfo or manual urinometer, validated by cylinder measurements. Overall accuracy was assessed comparing each method with the cylinder, using regression analysis, Bland-Altman plots, and, for UO of 40 mL/h or less, standard evaluation of diagnostics. Staff satisfaction was assessed by a short questionnaire.nnnRESULTSnIn 20 patients, 453 measurements were obtained, 167 by urinometer and cylinder and 286 by Urinfo and cylinder. The mean relative percentage deviation from the cylinder measurement was 8% and 26% for the Urinfo and urinometer, respectively (P < .05). Bland-Altman plots of each method vs the cylinder showed a better agreement with the Urinfo. Positive predictive value for UO of 40 mL/h or less (cylinder as criterion standard) was 91% and 77% for the Urinfo and urinometer, respectively. The questionnaire revealed an 87% satisfaction with the Urinfo.nnnCONCLUSIONSnUrinfo is significantly more accurate and user friendly than the urinometer. It promises future incorporation of these data into patient data management systems for the benefit of patients management.

Nicotiana glauca (Tree Tobacco) Intoxication—Two Cases in One Family

We present two cases of rare human poisoning in one family following ingestion of cooked leaves from the tobacco tree plant, Nicotiana glauca. The toxic principle of N. glauca, anabasine (C10H14N2), is a small pyridine alkaloid, similar in both structure and effects to nicotine, but appears to be more potent in humans. A 73-year-old female tourist from France, without remarkable medical history, collapsed at home following a few hours long prodrome of dizziness, nausea, vomiting, and malaise. The symptoms developed shortly after eating N. glauca cooked leaves that were collected around her daughters house in Jerusalem and mistaken for wild spinach. She was found unconscious, with dilated pupils and extreme bradycardia. Following resuscitation and respiratory support, circulation was restored. However, she did not regain consciousness and died 20xa0days after admission because of multi-organ failure. Anabasine was identified by gas chromatography/mass spectrometry method in N. glauca leaves and in the patients urine. Simultaneously, her 18-year-old grandson developed weakness and myalgia after ingesting a smaller amount of the same meal. He presented to the same emergency room in a stable condition. His exam was remarkable only for sinus bradycardia. He was discharged without any specific treatment. He recovered in 24xa0h without any residual sequelae. These cases raise an awareness of the potential toxicity caused by ingestion of tobacco tree leaves and highlight the dangers of ingesting botanicals by lay public. Moreover, they add to the clinical spectrum of N. glauca intoxication.

Routine surveillance blood cultures: Their place in the management of critically III patients

The use of surveillance blood cultures has been advocated as a means to allow earlier detection of septic episodes amongst intensive care patients, and therefore earlier institution of appropriate antibiotic therapy. We compared the results of surveillance cultures and clinically indicated blood cultures for bacterial isolates grown and the influence of culture results on patient management. Blood cultures were obtained from all intensive care unit (ICU) patients over the course of 3 months at a set surveillance time (surveillance group) or according to clinical indications (clinical group). Bacteriological results were compared and real-time chart review performed to assess the influence of the surveillance cultures on patient management, with particular reference to antibiotic therapy. Two hundred and forty-nine blood culture sets were collected over 3 months, 99 in the surveillance group and 150 in the clinical group. A total of 256 bacterial isolates were grown, 95 in the surveillance group and 161 in the clinical group. For the surveillance group 36%, 20%, and 44% of the isolates represented bacteraemia, line colonization and culture contamination, respectively. For the clinical group the distibution was 69%, 7%, and 24% respectively (P<0.001, P<0.01, and P<0.0027 for comparisons of percentages within each classification). On only one occasion was antibiotic therapy started based on the result of a surveillance culture, and on only one occasion was a septic episode detected earlier by a surveillance culture; however, this culture result did not lead to a change in patient management. Surveillance blood cultures are expensive and add very little to the management of patients in the intensive care environment.

Predictors of mortality of mechanically ventilated patients in internal medicine wards.

PURPOSEnBudget restrictions have led to shortage of intensive care unit (ICU) beds in several countries. Consequently, ventilated patients are often kept on the wards. This study examined survival likelihood among patients ventilated on the wards and the predictive value of commonly used severity-of-illness scores.nnnMETHODSnThis study is a prospective observation and characterization of consecutive, mechanically ventilated patients in 3 internal medicine wards of a single hospital who were denied ICU admission. Outcome measures are as follows: 28-day mortality, survival to hospital discharge, and 3 months postdischarge.nnnRESULTSnEighty-six patients were examined. The patients were 78.9 ± 8.9 years old; 53% were independent preadmission. Respiratory insufficiency due to infection was the main reason for mechanical ventilation (58%). Charlson and acute physiology scores (APS) averaged 4 ± 2.2 and 91.8 ± 26.7, respectively. Twenty-eight-day mortality was 71%, whereas in-hospital mortality was 74% and 3 months postdischarge mortality was 79%. Survivors were significantly younger than nonsurvivors (74.4 ± 8.5 years vs 80.4 ± 8.6 years, P < .01), were more likely to be ventilated for cardiac causes (41% vs 11%, P = .04), and had significantly higher initial mean blood pressure (79.4 mm Hg vs 58.2 mm Hg, P = .02) and blood albumin levels (29.8 g/L vs 25.7 g/L, P = .05). Death rate was 10 times more likely, with an APS greater than 90 on the day of intubation as compared with an APS less than 90.nnnCONCLUSIONnMortality in patients ventilated on the ward was high, especially in the subgroup of patients with an APS score greater than 90. The early calculation of APS may assist in focusing therapeutic efforts on patients with better survival chances.

The use of the arterial line as a source for blood cultures

Abstract Objective: To determine the reliability of blood cultures obtained through indwelling arterial lines as compared to that of blood cultures obtained by venipuncture.n Design: A prospective observational study.n Setting: Six-bed mixed medical surgical intensive care unit (ICU) of a 550-bed university-affiliated medical center.n Measurements: During a 3-month period blood culture sets, when clinically indicated, were drawn in parallel from indwelling arterial catheters and one-time venipuncture and the results compared. Each blood sample consisted of 15 ml and was distributed equally between three blood culture bottles: aerobic, anaerobic and one aerobic resin-containing bottle. Blood culture results from the two sources were compared according to preset definitions.n Main results: During the study period 90 parallel blood culture sets (540 bottles) were obtained from 36 patients. Forty-three (16%) venipuncture bottles were positive versus 88 (32%) arterial line culture bottles (p<0.001). Of the parallel sets, 83% yielded equivalent results – either both sterile or both growing the same organism. Amongst the discordant sets, the arterial line cultures grew 37 gram-positive and 18 gram-negative isolates not found in venipuncture sets (i.e. 50% of 109 arterial line isolates), while only two gram-positive isolates were solely grown in venipuncture cultures (4% of all 55 venipuncture isolates, p<0.001). On clinical correlation, all the gram-positive organisms in the discordant cultures were found not to reflect bacteremia, while five of the 18 gram-negative isolates (28%) grown only in arterial line cultures probably did reflect ongoing bacteremia.n Conclusion: The results of blood cultures taken from the arterial line are frequently equivalent to those taken from venipuncture. When discordant, the growth of gram-positive bacteria almost certainly reflects contamination or arterial line colonization, whereas the growth of gram-negative bacteria may have to be considered as reflecting bacteremia.

Dialysis by the book? Treatment of renal failure in a 101-year-old patient

While dialysis historically began as treatment intended for younger patients, it has, over time, increasingly been extended to treat elderly patients with a high comorbidity burden. Data on the outcomes of dialysis in these patients show that in some cases it confers no benefit and may be associated with functional decline. We describe a 101-year-old male patient with chronic kidney disease (CKD), admitted to the intensive care unit (ICU) with exacerbation of heart failure and sepsis. He experienced acute deterioration of renal function, with oliguria and acidosis. The patients healthcare proxy insisted that dialysis be initiated despite his extremely advanced age, citing the patients devout religious beliefs. He underwent 56 dialysis treatments over the course of ∼4 months after which he died as a result of septic and cardiogenic shock. Our case is unique, in that it may represent the oldest individual ever reported to start haemodialysis. It illustrates the ever-growing clinical and ethical challenges posed by the treatment of renal failure in the geriatric population.

Acute rise of PaCO2 as a sign of perforated bowel

ConclusionsAcute respiratory acidosis may be an early ominous sign of a diseased and “starved” bowel perforation in heavily sedated totally ventilator dependant MVE patient. Further attention of intensivists to validate this pilot observation is needed.