Vikas Koppurapu

A review of the management of complex para-pneumonic effusion in adults

A complex para-pneumonic effusion is a descriptive term for exudative effusions, which complicate or are likely to complicate the anatomy of the pleural space after pneumonia. We performed an online search was performed using the resources PubMed and Google Scholar to provide an update on the management of such effusions based on review of published literature. Search terms including pleural effusion (PE), parapneumonic effusion, and empyema were used. Relevant studies were identified and original articles were studied, compared and summarized. References in these articles were examined for relevance and included where appropriate. Studies involving pediatric patients were excluded. Management of para-pneumonic PE has changed tremendously over the last decade. As we accumulate more evidence in this area, approach to pleural fluid drainage is becoming more specific and guideline based. An example of a practice changing study in this aspect is the Multi-center Intrapleural Streptokinase Trial (MIST) 2 trial which demonstrated that a combination of intra-pleural tPA and DNAse improved outcomes in pleural infections compared to DNase or t-PA alone. More randomized control trials are needed to describe the role of surgical techniques like VATS (video-assisted thoracoscopic surgery) when MIST 2 protocol fails; this combination has revolutionized the management of empyema in recently.

647: DECREASING PREVALENCE OF VAP IN AN ADMINISTRATIVE DATABASE

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP) are potentially fatal infections in ICU patients. The primary aim of our study was to evaluate the combination of biomarkers: Procalcitonin (PCT) for antibiotic stewardship and MR-proADM, CT-proAVP and MRproANP to predict 28-day and 1-year survival. Methods: Single center, retrospective cohort study of ICU patients with CAP and HAP admitted to our ICU from 2009–2011. This study is a pre-planned sub-analysis of the Stop Antibiotics on Procalcitonin guidance Study (SAPS). Demographics, APACHE IV, duration of antibiotic treatment (DOT) in 24 h periods, PCT values, 28-day and 1-year survival were collected. Patients were randomized in 2 groups with daily PCT in the intervention group. Stop antibiotics criteria were PCT ≤ 0,5 μg/L or ≤ 20% peak value. Blood samples on admission were analysed for MRproADM, CT-proAVP and MR-proANP. Data were expressed as median and quartile range. MannWhitney U test compared DOT in both groups. Multiple logistic regression analysis using 28-day and 1-year survival was performed and Odds ratios (OR) were computed. Results: 158 patients were selected, 97 males, age 65 [54–74] years, APACHE IV 73 [53–86], 59 with CAP and 99 with HAP. A pathogen was found in 66 patients, S. pneumoniae, K. pneumoniae and E. coli were most common. There were 111 survivors at 28 days and 95 survivors after 1 year. 79 (50%) patients had daily PCT. DOT was 5 days [4–7] and 6 days [5–10] in PCT and control group (p = 0.03). In a logistic regression model for 28-day survival only APACHE IV made a significant contribution (OR 0.98, p = 0.01), OR for MR-proADM (0.91), CT-proAVP (1.0), MRproANP (1.0), all non-significant. As for 1-year survival APACHE IV OR 0.98 (p = 0.02) and OR for MR-proADM (0.92), CT-proAVP (1.0), MR-proANP (1.0), all non-significant. Conclusions: Antibiotic stewardship with daily PCT resulted in a reduction in antibiotics of 1 day in CAP and HAP patients admitted to the ICU. Novel biomarkers such as MR-proADM, CTproAVP and MR-proANP had no value in predicting 28-day and 1-year survival.

Prevalence and predictors of readmissions among adults with cystic fibrosis in the United States

INTRODUCTION Patients with Cystic Fibrosis (CF) have increasing rates of hospitalization. We analyzed the burden and predictors of thirty-day readmission among patients with CF in the U.S. MATERIAL AND METHODS Nationwide Readmission Database (NRD) 2013 was used to identify adults with CF who were hospitalized. These individuals were followed to determine the prevalence of readmission within thirty days of index discharge. Cox proportional hazard regression was used to identify independent predictors of readmission. RESULTS There were 14,616 index admissions of adults with CF in 2013. Of these, 2,606 (17.8%) patients were readmitted within 30 days of discharge. Female sex and chronic anemia were independent predictors of readmission. The most common causes of readmission were pulmonary exacerbation (31%), lung transplant complications (5.2%), and septicemia (3.4%). CONCLUSION Readmissions are frequent among adults with CF and contribute to significant healthcare burden and cost among this population.

National utilization of different biliary decompression procedures in septic shock due to cholangitis.

Biliary drainage procedure is important in patients with ascending cholangitis [1,2]. These procedures are more difficult to perform among patients who develop septic shock due to technical issues. We sought to examine national trends of utilization and outcomes of endoscopic retrograde cholangiopancreaticography (ERCP), percutaneous transhepatic biliary drainage (PTBD), and surgical drainage (SD) in these patients. We also identify predictors for nonutilization of biliary drainage procedures in this population.