Severe pneumonia requiring ICU admission: revisited

To describe the aetiology, outcome and management approach for patients with community acquired pneumonia [CAP] and hospital-acquired pneumonia [HAP] who required ICU admission and to determine the predictors of mortality. A prospective observational study of 119 consecutive patients who were admitted to the ICU with diagnoses of CAP [n = 89] or HAP [n = 30] from May 2011 until December 2012. The overall ICU and hospital mortality rates for CAP and HAP were 24.4% and 30.3%, respectively. There were no significant differences between the patients with CAP and HAP in terms of ICU mortality or the average length of hospital stay. The most commonly isolated pathogens were H1N1 [23%] and Streptococcus pneumonia [17%] in the patients with CAP and Acinetobacter baumannii [37%] in the patients with HAP. Multidrug resistant [MDR] organisms were detected in 32 [38.6%] isolates. The median time for receiving antibiotics was 2 h. Most of the patients [82%] received double antibiotic coverage. Multiple regression analysis identified septic shock [beta = 0.43, p < 0.001], acute respiratory distress syndrome [ARDS] [beta = 0.34, p = 0.003], and the pneumonia severity index [PSI] [beta = -0.36, p < 0.024] as significant predictors of mortality. The outcomes of patients with severe pneumonia who were admitted to the ICU were better than those of previous reports. Early administration of combination antibiotics was practiced with vigilance. MDR organisms and respiratory viruses were the commonly isolated pathogens. The presence of septic shock, ARDS and high PSI were independent predictors of mortality

case of near fatal asthma: the role of ECMO as rescue therapy

We report a case of an adolescent with near fatal asthma [NFA]. He presented with severe hypoxemia and lifethreatening acidemia, who failed to respond to conventional therapy. His hospital course was complicated by barotrauma and hemodynamic instability. Early introduction of extracorporeal membrane oxygenation [ECMO] led to dramatic improvement in gas exchange and lung mechanics. This case illustrates the important role of ECMO as salvage therapy in NFA

Bronchoscopy as a rescue therapy in patients with status asthmaticus: two case reports and review of literature

Management of status asthmaticus requires more than guidelines-guided therapy. Occasionally, uncommon therapeutic interventions and procedures may provide significant benefits. The role of bronchoscopy in fatal asthma is still not clearly defined. We illustrate two cases of severe status asthmaticus on mechanical ventilation who showed remarkable improvement after therapeutic bronchoscopy

Venous thromboembolism in a medical intensive care unit. The effect of implementing clinical practice guidelines

To determine the incidence of VTE in medical patients admitted to the intensive care unit [ICU] following the implementation of a standard deep venous thrombosis [DVT] prophylaxis protocol using unfractionated heparin [UFH], and to identify risk factors for DVT in these patients. We prospectively studied 123 consecutive patients admitted to the Medical ICU of King Khalid University Hospital, Riyadh, Saudi Arabia. We excluded patients on anticoagulation or with contraindications for heparin. Patients who were negative for DVT by screening Doppler Ultrasound [U/S] were started on UFH twice a day. The Doppler U/S was repeated twice weekly for 6 weeks. One hundred and four critically ill medical patients were included. A DVT was diagnosed in 10 patients while receiving UFH, an incidence rate of 9.8%. The compliance rate was 98%. Sepsis [p=0.0167], limited mobility [p<0.0001], previous DVT [p=0.024], and nephrotic syndrome [p=0.008] were significantly more common in patients who developed DVT compared with others. However, by backward logistic regression, previous DVT was the only significant factor for the development of DVT [B=-0.439, AOR=5.01, p<0.0001]. The implementation of clinical practice guidelines for VTE prophylaxis in critically ill medical patients using UFH twice daily resulted in a high compliance rate and low incidence of VTE. Previous DVT was a significant risk factor for development of VTE

Yield and complications of flexible fiberoptic bronchoscopy in a teaching hospital

To assess the diagnostic yield and safety of flexible fiberoptic bronchoscopy [FFB]. A retrospective review of bronchoscopy reports and corresponding patients charts over 3 years from January 2004 - December 2006 in King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. Indication for procedure, suspected diagnosis, final diagnosis, and complications were reported. Out of 720 patients, 707 [98.2%] patients had a full follow up. Five hundred and ninety-two [83.7%] underwent FFB for diagnostic purposes and 115 [16.3%] for therapeutic purposes. The mean age was 42 -/+ 18 years. Infection, including mycobacterium tuberculosis, and malignancy were the 2 main indications for FFB [35.9% and 25.9%]. The overall diagnostic yield was 58%. Tuberculosis was diagnosed in 67% of suspected cases, whereas bacterial pneumonia was diagnosed in 40.5%. Malignancy was confirmed in 61.2% of suspected cases. Bronchoscopy diagnosed 37 [43%] of 86 patients with interstitial lung disease. The diagnostic yield was 57% for sarcoidosis, 40% for usual interstitial pneumonia and 88% for bronchiolitis obliterans organizing pneumonia. The overall complication rate was 5%; pneumothorax occurred in 0.56% and was associated exclusively with transbronchial biopsy. No mortality was observed. Flexible fiberoptic bronchoscopy is a useful diagnostic tool with a low rate of complications. The diagnostic yield in our institution is similar to that reported in Western series