Wen-Kuang Yu

Intensive Care Unit-Acquired Bacteremia in Mechanically Ventilated Patients: Clinical Features and Outcomes

Intensive care unit (ICU)-acquired bacteremia (IAB) is associated with high medical expenditure and mortality. Mechanically ventilated patients represent one third of all patients admitted to ICU, but the clinical features and outcomes in mechanically ventilated patients who develop IAB remain unknown. We conducted a 3-year retrospective observational cohort study, and 1,453 patients who received mechanical ventilation on ICU admission were enrolled. Among patients enrolled, 126 patients who had developed IAB ≧48 hours after ICU admission were identified. The study patients were divided into IAB and no IAB groups, and clinical characteristics of IAB based on specific bacterial species were further analyzed. The multivariate Cox regression analysis showed that ventilator support for chronic obstructive pulmonary disease and congestive heart failure, and patients admitted from nursing home were the independent risk factors for developing IAB. Patients with IAB were significantly associated with longer length of ICU stay, prolonged ventilator use, lower rate of successful weaning, and higher rate of ventilator dependence and ICU mortality as compared to those without IAB. IAB was the independent risk factor for ICU mortality (HR, 1.510, 95% CI 1.054–1.123; p = 0.010). The clinical characteristics of IAB related to specific bacterial species included IAB due to Pseudomonas aeruginosa being likely polymicrobial, lung source and prior antibiotic use; Escherichia coli developing earlier and from urinary tract source; methicillin-resistant Staphylococcus aureus related to central venous catheter and multiple sets of positive hemoculture; and Elizabethkingia meningoseptica significantly associated with delayed/inappropriate antibiotic treatment. In summary, IAB was significantly associated with poor patient outcomes in mechanically ventilated ICU patients. The clinical features related to IAB and clinical characteristics of IAB based on specific bacterial species identified in our study may be utilized to refine the management of IAB.

Hyperbaric oxygen therapy as an adjunctive treatment for sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery

PurposeA retrospective study to evaluate the effect of hyperbaric oxygen (HBO2) therapy on sternal infection and osteomyelitis following median sternotomy.Materials and methodsA retrospective analysis of patients who received sternotomy and cardiothoracic surgery which developed sternal infection and osteomyelitis between 2002 and 2009. Twelve patients who received debridement and antibiotic treatment were selected, and six of them received additional HBO2 therapy. Demographic, clinical characteristics and outcome were compared between patients with and without HBO2 therapy.ResultsHBO2 therapy did not cause any treatment-related complication in patients receiving this additional treatment. Comparisons of the data between two study groups revealed that the length of stay in ICU (8.7 ± 2.7 days vs. 48.8 ± 10.5 days, p < 0.05), duration of invasive (4 ± 1.5 days vs. 34.8 ± 8.3 days, p < 0.05) and non-invasive (4 ± 1.9 days vs. 22.3 ± 6.2 days, p < 0.05) positive pressure ventilation were all significantly lower in patients with additional HBO2 therapy, as compared to patients without HBO2 therapy. Hospital mortality was also significantly lower in patients who received HBO2 therapy (0 case vs. 3 cases, p < 0.05), as compared to patients without the HBO2 therapy.ConclusionsIn addition to primary treatment with debridement and antibiotic use, HBO2 therapy may be used as an adjunctive and safe treatment to improve clinical outcomes in patients with sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery.

Synergistic impact of low serum albumin on intensive care unit admission and high blood urea nitrogen during intensive care unit stay on post-intensive care unit mortality in critically ill elderly patients requiring mechanical ventilation

Aims:  To identify intensive care unit (ICU) risk factors for post‐ICU 6‐month (PI6M) mortality in critically ill elderly patients requiring mechanical ventilation (MV).

Induced pluripotent stem cells reduce neutrophil chemotaxis via activating GRK2 in endotoxin‐induced acute lung injury

We investigated the effect of induced pluripotent stem cells (iPSCs) in moderating neutrophil chemotaxis in endotoxin‐induced acute lung injury (ALI).

Impact and Predictors of Prolonged Chest Tube Duration in Mechanically Ventilated Patients with Acquired Pneumothorax

BACKGROUND: Prolonged chest tube duration is less well studied in patients who are supported by mechanical ventilation and have acquired pneumothorax. We investigated the impact of prolonged chest tube duration on patient outcomes and the risk factors associated with prolonged chest tube duration. METHODS: This retrospective observational study included 106 ventilated subjects who had been treated with thoracostomy for pneumothorax between May 2004 and December 2011. We analyzed 61 subjects and 63 events. The subjects were divided into a prolonged chest tube duration group (> 18 d) and a non-prolonged group (≤ 18 d). RESULTS: Subjects with prolonged chest tube duration had significantly higher ICU mortality (P = .006), longer ICU stay (P = .001), longer hospitalization (P = .004), longer mechanical ventilation after development of pneumothorax (P = .003), higher maximum peak inspiratory pressure (P = .03), and a higher rate of surgical emphysema (P = .009). High peak inspiratory pressure and surgical emphysema remained independent predictors of prolonged chest tube duration after multivariate logistic regression analysis. The probability of chest tube removal within 28 days was significantly lower in subjects with both high peak inspiratory pressure and surgical emphysema, compared to subjects without any risk factors (log rank P = .001). CONCLUSIONS: High peak inspiratory pressure and surgical emphysema are independent predictors of prolonged chest tube duration and negatively impact clinical outcomes in this patient group. These findings may provide information for better chest tube management.

Levels of exhaled carbon monoxide measured during an intervention program predict 1-year smoking cessation: a retrospective observational cohort study

Life-long smoking cessation is a critical public health objective, but it is difficult for numerous people. This study aimed to identify the independent predictors of 1-year abstinence in smokers motivated to quit and participating in an intervention program. This 6-year retrospective observational cohort study was conducted in smokers who participated in an intervention program. The exhaled carbon monoxide (CO) was sequentially measured on day 1, 8, 15, and 22 of the intervention program. The primary outcome measure was smoking status at 1 year of follow-up. A total of 162 participants were enrolled and divided into a successful quit group (n = 52) and unsuccessful quit group (n = 110). Using a multivariate logistic regression analysis, we reported that the intention to quit (adjusted odds ratio [AOR] = 1.475, 95% confidence interval [CI] = 1.169–1.862, P-value = 0.001), varenicline use (AOR = 3.199, 95% CI = 1.290–7.934, P -value = 0.012) and the exhaled CO level on day 8 (AOR = 0.937, 95% CI = 0.885–0.992, P-value = 0.025) independently predicted 1-year smoking cessation. Moreover, the level of exhaled CO < 4.5 parts per million on day 8 significantly predict successful 1-year smoking cessation (area under curve 0.761, sensitivity 88.2%, and specificity 57.8%, P-value < 0.001). These independent predictors including intention to quit, varenicline use, and exhaled CO level on day 8, may help primary care physicians rearrange resources and refine the strategies for intervention programs to achieve a higher rate of long-term smoking cessation.Quitting smoking: Identifying predictors of successResearchers in Taiwan identify key predictors that pinpoint people most likely to quit smoking successfully during intervention programs. Millions are spent each year supporting people to quit smoking. However, successful quitters remain in the minority, with only 9–35 per cent of those in intervention programs abstaining for at least a year. Hsin-Kuo Ko at Taipei Veterans General Hospital and co-workers identified key independent indicators of successful abstinence in 162 smokers attending an intervention program. Alongside having a high intention to quit and using varenicline medication, a potential predictor is having an exhaled carbon monoxide (CO) level of less than 4.5 parts-per-million by day 8 of the course. Exhaled CO is higher in smokers than in non-smokers. Measuring CO levels one week into courses may be a useful biomarker to identify those fully committed to quit.

Prognostic factors of noninvasive mechanical ventilation in lung cancer patients with acute respiratory failure

Introduction Few studies have reported outcomes of lung cancer patients with acute respiratory failure (RF) using noninvasive positive pressure ventilation (NIPPV). The aim of this study was to investigate the prognostic factors in these patients. Materials and methods This retrospective observational study included all hospitalized lung cancer patients who received NIPPV for acute RF. It was conducted at a tertiary medical center in Taiwan from 2005 to 2010. The primary outcome was all cause mortality at 28 days after the initiation of NIPPV. Secondary outcomes included all-cause in-hospital mortality, weaning from NIPPV, intubation rate, tracheostomy rate, duration of NIPPV, hospital stay and intensive care unit stay. Results The all-cause mortality rate at day 28 of the enrolled 58 patients was 39.66%. The 90-day and 1-year mortality rates were 63.79% and 86.21%, respectively. NIPPV as the first line therapy for RF had higher 28-day mortality rate than it used for post-extubation RF (57.6% versus 16.0%, p<0.05). Independent predictors of mortality at 28 days were progressive disease or newly diagnosed lung cancer (OR 14.02 95% CI 1.03–191.59, p = 0.048), combined with other organ failure (OR 18.07 95% CI 1.87–172.7, p = 0.012), and NIPPV as the first line therapy for RF (OR 35.37 95% CI 3.30–378.68, p = 0.003). Conclusion Lung cancer patients using NIPPV with progressive or newly diagnosed cancer disease, combined with other organ failure, or NIPPV as the first line therapy for respiratory failure have a poor outcome.

Paroxysmal Sympathetic Hyperactivity: Two Case Reports

Paroxysmal sympathetic hyperactivity (PSH) is a syndrome characterized by episodes of hyperthermia, diaphoresis, agitation, dystonia, and increased blood pressure (BP), respiratory rate (RR), and heart rate (HR). Most cases are found after brain injury, although a few cases have had no brain injury. The exact mechanism is still not clear, but PSH can be treated by opioids, gabapentin, benzodiazepines, centrally acting α-agonists, and β-antagonists, bromocriptine, and intrathecal baclofen, instead of anti-epileptics, antibiotics, or antipyretics, in most cases. Delayed diagnosis and management of PSH may increase morbidity and mortality. We present 2 cases and review the literature on PSH. Accurate diagnosis and appropriate treatment can reduce the number of ventilator days and shorten the hospital course, and even improve the clinical outcome. Therefore, the differential diagnosis and management of patients presenting with hyperthermia, dystonia, tachypnea, and tachycardia are very important in daily practice in the intensive care unit.

Influence of Intensive Care-Acquired Hypernatremia on the Short-term Mortality of Mechanically Ventilated Patients

Background: ICU-acquired hypernatremia (IAH) is reported to be strongly associated with mortality, and mechanical ventilation (MV) is a risk factor for IAH. However, the incidence of IAH and its impact on ICU mortality among mechanically ventilated patients are unknown.Methods: A retrospective observational study was conducted in a respiratory ICU from December 2008 to December 2009. Patients receiving MV were evaluated. The outcome measurements were the occurrence of IAH and 28-day ICU mortality.Results: Of 161 patients enrolled, 30 (19%) had IAH. Patients with IAH had a higher APACHE II score at admission, lower oxygenation status and longer duration of MV in the ICU compared to those without. In a multivariate logistic regression analysis, IAH was independently associated with 28-day ICU mortality (odds ratio 6.756, 95% confidence interval 1.745-26.164, p=0.006) after adjustment for the APACHE II score at admission, acute kidney injury at admission and a Do Not Resuscitate order.Conclusions: IAH is common among critically ill patients requiring MV and is independently associated with ICU mortality in this patient population.