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

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

Smoking cessation: guidelines for the busy clinician

Cigarette smoking is a preventable cause of morbidity and mortality. Recognizing and treating nicotine dependence is the most important intervention for successful smoking cessation. Available strategies range from behavioral modification and counseling to pharmacologic therapies

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

Boerhaave's syndrome: a diagnostic dilemma in the emergency room

Boerhaave's syndrome is a potential lethal condition which presents not only a diagnostic but also a therapeutic challenge. Errors in diagnosis are usually caused by unawareness of its varied and atypical presentations. All clinicians need to be aware of this lethal disease, its frequent unusual presentations and the importance of early diagnosis

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