R Galván

Periodically changing ventilator circuits is not necessary to prevent ventilator-associated pneumonia when a heat and moisture exchanger is used

OBJECTIVE To analyze the efficacy of periodically changing ventilator circuits for decreasing the rate of ventilator-associated pneumonia when a heat and moisture exchanger (HME) is used for humidification. The Centers for Disease Control and Prevention recommended not changing the circuits periodically. DESIGN Randomized, controlled trial conducted between April 2001 and August 2002. SETTING A 24-bed, medical-surgical intensive care unit in a 650-bed, tertiary-care hospital. PATIENTS All patients requiring mechanical ventilation during more than 72 hours from April 2001 to August 2002. INTERVENTIONS Patients were randomized into two groups: (1) ventilation with change of ventilator circuits every 48 hours and (2) ventilation with no change of circuits. Throat swabs were taken on admission and twice weekly until discharge to classify pneumonia as endogenous or exogenous. RESULTS Three hundred four patients (143 from group 1 and 161 from group 2) with similar characteristics (age, gender, Acute Physiology and Chronic Health Evaluation II score, diagnostic group, and mortality) were analyzed. There was no significant difference in the rate of pneumonia between the groups (23.1% vs 23.0% and 15.5 vs 14.8 per 1,000 ventilator-days). There was no significant difference in the incidence of exogenous pneumonia per 1,000 days of mechanical ventilation (1.71 vs 1.25). There was no difference in the distribution of microorganisms causing pneumonia. CONCLUSIONS Circuit change using an HME for humidification does not decrease pneumonia and represents an unnecessary cost.

Influence of tracheostomy on the incidence of central venous catheter-related bacteremia

Although there are many studies on catheter-related infection, there are scarce data about the influence of tracheostomy in the incidence of central venous catheter-related bacteremia (CRB). In this cohort study, we found a higher incidence of CRB in patients with tracheostomy than without (11.25 vs. 1.43 per 1,000 catheter-days; odds ratio [OR] = 7.99; 95% confidence interval [CI] = 4.38–infinite; P < 0.001). Besides, we found a higher incidence of CRB in patients with tracheostomy using the jugular access compared to subclavian access (21.64 vs. 5.11 per 1,000 catheter-days; OR = 4.23; 95% CI = 1.44–infinite; P = 0.0097).

Equivalence of posterior internal jugular and subclavian accesses in the incidence of central venous catheter related bacteremia

Age (years) 57.30 ± 17.29 57.99 ± 16.70 0.63 Male sex 499 (56.9%) 94 (55.6%) 0.80 APACHE II score 13.94 ± 4.97 13.99 ± 5.21 0.89 Diagnosis group Cardiology 202 (23.0%) 36 (21.3%) 0.69 Respiratory 144 (16.4%) 31 (18.3%) 0.57 Digestive 67 (7.6%) 11 (6.5%) 0.64 Neurological 221 (25.2%) 41 (24.3%) 0.85 Traumatology 220 (25.1%) 44 (26.0%) 0.77 Intoxication 23 (2.6%) 6 (3.6%) 0.61 Order of catheter insertion First 712 (81.2%) 133 (78.7%) 0.46 Second 131 (14.9%) 29 (17.2%) 0.48 Third 34 (3.9%) 7 (4.1%) 0.99 Use of mechanical ventilation 655 (78.9%) 129 (76.3%) 0.70 Use of antimicrobials 695 (79.2%) 131 (77.5%) 0.68 Use of total parenteral nutrition 111 (12.7%) 24 (14.20%) 0.61 Use of pulmonary artery catheter 91 (10.4%) 19 (11.24%) 0.78 Reason for catheter removal Death 118 (13.5%) 23 (13.6%) 0.99 Suspicion of catheter-related infection 82 (9.3%) 16 (9.5%) 0.99 Change with guidewire due to longer need 114 (13.0%) 21 (12.4%) 0.90 No longer needed 541 (61.7%) 105 (62.1%) 0.93 Accidental removal 22 (2.5%) 4 (2.4%) 0.99 Duration with the index catheter (days) 8.90 ± 3.74 9.75 ± 3.48 0.007 CVC-RB 8 (0.9%) 2 (1.2%) 0.99 CVC-RB density incidence (per 1,000 catheter-days) 1.02 1.21 0.99 a