Mortality in sepsis and its relationship with gender

Sepsis remains a leading cause of death across the world, carrying a mortality rate of 20-50%. Women have been reported to be less likely to suffer from sepsis and to have a lower risk of mortality from sepsis compared to men. The objective of this study was to determine the relationship between gender and mortality in sepsis, and compare cytokine profiles of male and female patients. This was a prospective case series on 97 patients admitted with sepsis. Clinical and microbiological data was gathered, blood samples were collected for cytokine [IL-10, IL-6 and TNFalpha] levels and patients were followed up for clinical outcome. There were 54% males and 46% females, with no significant difference of age or comorbids between genders. Respiratory tract infection was the commonest source of sepsis, and was more common in females [60%] compared to males [39%] [p=0.034]. Males had a higher mortality [p=0.048, RR 1.73] and plasma IL-6 level [p=0.040] compared to females. Mean IL-6 plasma level was significantly [p<0.01] higher in patients who died vs. who recovered. Our study shows that males with sepsis have a 70% greater mortality rate, and mortality is associated with a higher IL-6 plasma level

Industrially important hydrolytic enzyme diversity explored in stove ash bacterial isolates

Extreme environments merit special attention and significance because of the possible existence of thermophilic microorganisms in such ecological niches. Keeping this in mind indigenous stove ash samples were explored for extremophilic bacteria in term of their biodiversity. Accordingly, this study reports 37 bacterial isolates from the local wood run oven [Tandoor] ash samples. All the isolated strains belong to genus Bacillus on the bases of morphocultural and biochemical considerations. The average temperature tolerance profile was >45[degree]C thereby, indicating towards the thermophilic nature of the isolated strains. The Bacillus isolates were screened for 10 different hydrolytic enzymes [cellulase, xylanase, amylase, pectinase, caseinase, keratinase, lipase, esterase, dextranase and beta-galactosidase] by plate screening method using the medium incorporated with specific substrate[s]. It was found that keratinase was produced by all the isolates while, 36 [97.2%] isolates showed caseinase and esterase production. Amylase was produced by 35[94.6%] isolates and 34 [91.8%] isolates were able to degrade Tween-80 and xylan as substrate for lipase and xylanase respectively. The enzyme, beta-galactosidase was produced by 31 [89.1%] of the isolates. Cellulase and dextranase were produced by 26 [70.2%] and 22 [59.4%] isolates respectively. None of the isolates could [under the existing conditions] produce pectin-hydrolyzing enzyme. According to the tukey's post hoc test, significant difference was found between the mean enzyme index of all the [screened] enzymes. Thus, the isolated bacterial strains with diverse hydrolytic potential may be of great value and relevance for the existing [national] industrial setups

The use of laryngeal mask airway Supreme™ in rescue airway situation in the critical care unit

We herein report a witnessed cardiopulmonary collapse of a patient with difficult mask ventilation and near-impossible laryngoscopy-cum-intubation in the critical care unit. The airway was successfully rescued with a laryngeal mask airway Supreme™, followed by an open, crash tracheostomy by the otolaryngologist.

Apache-II score correlation with mortality and length of stay in an intensive care unit

To correlate the APACHE-II score system with mortality and length of stay in ICU. Cohort study. The Intensive Care Unit [ICU] of the Aga Khan University Hospital, Karachi, from May 2005 to May 2006. All adult patients who were admitted in the ICU were included. APACHE-II score was calculated at the second and seventh days of admission in the ICU. Patients who were discharged alive from the ICU or died after first APACHE-II Score [at 2nd day] were noted as the primary outcome measurement. Second APACHE-II score [at 7th day] was used to predict the length of stay in the ICU. Pearson's correlation coefficient [r] was determined with significance at p < 0.05. In the lowest score category 3-10, 27 out of 30 patients [90%] were discharged and only 3 [10%] died. Out of those 39 patients whose APACHE-II score was found in high category 31 - 40, 33 [84.6%] deaths were observed. This revealed that there might be more chances of death in case of high APACHE-II score [p=0.001]. Insignificant but an inverse correlation [r = -0.084, p < 0.183] was observed between APACHE-II score and length of ICU stay. The APACHE-II scoring system was found useful for classifying patients according to their disease severity. There was an inverse relationship between the high score and the length of stay as well higher chances of mortality

How early do antibiotics have to be to impact mortality in severe sepsis? A prospective, observational study from an emergency department

The objective of this study was to assess the promptness of antibiotic administration to patients presenting with sepsis and the effects on survival and length of hospitalization. Consecutive, adult patients presenting with Systemic Inflammatory Response Syndrome [SIRS] to the emergency department of the Aga Khan University hospital were enrolled in a prospective, observational study over a period of 4 months. Univariate, multivariate regression modeling and oneway ANOVA were used to examine the effects of various variables on survival and for significant differences between timing of antibiotic administration and survival, two-sided p values <0.05 were considered significant. One hundred and eleven patients were enrolled. Severe sepsis was present in 52% patients; the most frequent organism isolated was Salmonella typhi [18%]. Overall mortality was 35.1%. One hundred [90.1%] patients received intravenous antibiotics in the Emergency room; average time from triage to actual administration was 2.48 +/- 1.86 hours. The timing of antibiotic administration was significantly associated with survival [F statistic 2.17, p=0.003]. Using a Cox Regression model, we were able to demonstrate that survival dropped acutely with every hourly delay in antibiotic administration. On multivariate analysis, use of vasopressors [adjusted OR 23.89, 95% CI 2.16,263, p=0.01] and Escherichia coli sepsis [adjusted OR 6.22, 95% CI 1.21,32, p=0.03] were adversely related with mortality. We demonstrated that in the population presenting to our emergency room, each hourly delay in antibiotic administration was associated with an increase in mortality

Viral hemorrhagic fever: an icu perspective

We present a series of 5 cases that were admitted to our intensive care unit [ICU] with suspicion of VHF. The first case was a 36 years surgeon, referred from Civil Hospital, Karachi to the emergency room [ER] AKUH. No previous history of comorbids existed. The presenting complaints were epigastric pain, vomiting and fever for 4 days, and shortness of breath for one day. He continued to deteriorate with severe acidosis, acute renal failure and bleeding diffusely. He was placed in isolation, cultures were taken and Ribavirin started. He remained in shock with escalating inotropic support and started bleeding from endotracheal tube and nose. He suffered a bradycardiac arrest with hypoxia and after a prolonged cardiopulmonary resuscitation [CPR], he expired. Microbiology showed Dengue IgM-negative, IgG positive by early spot, while Congo Crimean Hemorrhagic fever [CCHF] RNA was negative. History of exposure to VHF was possible as he had operated on a patient who had died suddenly without explanation. His concluding diagnosis was viral hemorrhagic fever

BIS monitoring in a patient with history of awareness and a difficult airway

We describe a case where bispectral index [BIS] monitoring was used successfully to guide an inhaled induction technique for a difficult airway. The patient was a 34 years old male who had a previous history of awareness during anaesthesia. He was also morbidly obese with a Mallampatti score of III on preoperative examination

Efficiency of Pa catheters in the ICU of a tertiary care hospital

Existing randomized controlled trials on Pulmonary Artery Catheter [PAC]-guided strategies reveal a modest risk reduction that does reach statistical significance. An observational, prospective, controlled study was carried out in the ICU of a tertiary care hospital. Incidence, indications, complication rate and outcome of Pulmonary Artery [PA] catheter over a period of 3 months was looked at, comparing cases to matched controls. Despite being a limited study, it is obvious that the cost effectiveness and outcome of patients with the PA catheter seems ambiguous. In a developing country where resources are limited, thought must be given to the risk and benefit ratio of placing this invasive monitor and use of the information provided properly justified

Retrospective review of the use of Swan Ganz Catheters in our intensive care unit [ICU]: a short report

The widespread and often 'misuse' of the Swan Ganz [SG] or Pulmonary artery catheter has often been seen in intensive care patients. The objective of this preliminary review was to observe the trends and possibly formulate an association with outcome of the use of SG catheters as well as to determine the frequency of use and possible complications.The chart review of ten patients was carried out for the months of January and February 2004 in a retrospective manner. The incidence of SG catheter insertion was 12% per month on average. Nine out of 10 patients received the SG catheters for 'fluid management'; and 1 for 'haemodynamic instability'. Eight out of 10 patients expired and average length of stay was 9 days. There were no complications recorded. The cause of death in all patients was 'severe sepsis'. The overwhelming majority of patients who received these catheters expired at the end of their stay

Apache II score as a predictor of length of stay and outcome in our ICUS

The APACHE II [acute physiology and chronic health evaluation] is used widely for predicting probability of hospital mortality and length of stay in the ICU. APACHE II forms were available to all ICU residents within 24 hours of admission, and a score was assigned to them. Based on our results the APACHE II score has reliably predicted an outcome of the least amount of length of stay [LOS] in the ICU as well as a 100% probability of being shifted out of the ICU for a score of <10 [according to international benchmarks]. This reliable scoring system can be used for predicting mortality and length of stay and therefore, resource allocation, antibiotic use and ethical decisions regarding counseling families about end of life decisions - all within 24 hours of admissions

Outcome of home mechanical ventilation

To determine the outcome of patients discharged home on portable ventilator. The Aga Khan University Hospital, Karachi from January 2000 to December 2004. All ventilator-dependent patients discharged home were contacted. Survivors were administered the EQ-5D Quality-of-Life instrument. SPSS version 13 was used to analyze data. Eleven patients were discharged home on invasive ventilation. Mean age was 49 years [range10-98 years]. Cause of ventilatory failure were cervical spine trauma in 36%, primary neurological disease in 27%, critical illness neuropathy and respiratory failure in 18% each. Survival rate was 73%, with three deaths. Mean duration of ventilation was 9.45 months [95% CI 3.24, 15.67]. Rate of successful weaning after discharge was 36%, with 4 patients off all forms of ventilatory support and 2 on only nocturnal support. A 2.8 [95% CI 0.5, 16.6] relative risk towards successful weaning was associated with the presence of a family member as the primary care giver. Mean scores on the EQ-5D descriptive tool were; mobility 2 [ +/- 0.82], self-care 2 [ +/- 0.82], usual activities 1.86 [ +/- 0.69], pain/discomfort 1.43[ +/- 0.79], anxiety/depression 1.29 [ +/- 0.76]. Mean score on the EQ-VAS was 48.2[ +/- 27.3]. In carefully selected patients, home ventilation is a viable option with the expectation of successful weaning and survival. Patients discharged home on ventilation reported a reasonably good quality of life with proportionately more problems related to independence compared to overall well-being

Apache II score as a predictor of the type or virulence of sepsis

A variety of systems for assessing severity of illness in critically ill patients have been described. The APACHE II [acute physiology and chronic health evaluation] is used widely for predicting probability of hospital mortality. We have looked, in our retrospective review, at the correlation between APACHE II scores of patients admitted to our Intensive care unit [ICU] within twenty four hours and the development and type of infection as well as evidence of hemodynamic involvement [i.e. presence of sepsis] as outlined by the criteria described for systemic inflammatory response syndrome [SIRS]. As evidenced by following these patients with increased APACHE II scores and their cultures, we found that many of them had moderate to severe signs and symptoms of sepsis including hemodynamic complications, increased respiratory rate, temperature changes and mental status changes. They were also eventually found to be culture positive for organisms like Candida, Methicillin-resistant Staphylococcus aureus [MRSA], Pseudomonas sp., E. coli, and Klebsiella sp. in the blood, tracheal cultures and urine -organisms possibly virulent in compromised patients even though these patients were intubated and catheterized

Reduction in ventilator - associated pneumonia using bacterial filters: a prospective, observational study

Nosocomial pneumonias related to mechanical ventilation in patients admitted to intensive care units occur in 25-33% of all hospitalized patients. They are responsible for a growing number of deaths in the ICU and represent enormous costs annually. Although they form only 5-15% of hospitalized beds, ICUs account for 10-25% of health care costs internationally. A large amount of this cost goes in treatment and care of patients with ventilator-associated pneumonia [VAT's]. We undertook a prospective observational study in our intensive care unit where a simple bacterial filter was used in the ventilator circuit of each patient and changed daily. The incidence of VAPs occurring over a period of three months [prior and after the intervention] was observed. This study was carried out in our twelve-bedded multidisciplinary ICU in an urban tertiary care hospital. This is an urban referral center where the incidence of VAPs in the quarter prior to the intervention, Oct-Dec 2002, was 13.6 per 1000 patients. Positive VAP was diagnosed based on results of tracheal secretions correlated with clinical findings. A light weight filter [HME] was used in the ventilator circuit and changed on a daily basis. The incidence of VAP dropped to 2/1000 patients in the next quarter, Jan-Mar 2003. Ventilator associated pneumonias contribute to a great deal of the morbidity, cost and mortality as well as duration of stay in ICU patients. The introduction of bacterial filters [at the minimal cost of Rs. 100 or $1.6 daily] has significantly reduced this incidence, thereby pointing towards a positive trend at a minimal cost. This promising intervention should be tested in a larger cohort of patients