Comparison of antral tap with endoscopically directed nasal culture.

OBJECTIVES/HYPOTHESIS: The diagnosis of acute bacterial rhinosinusitis continues to generate controversy in critically ill patients. The efficacy of endoscopically directed cultures in these patients is unknown. We compared antral tap (AT) with endoscopic tissue culture (ETC) of the osteomeatal complex in an intensive care unit (ICU) setting. METHODS: Twenty patients admitted to a surgical/trauma ICU were evaluated by AT and ENB for the presence of rhinosinusitis. All patients had 1) a fever of unknown origin without resolution on empiric antibiotic therapy for > or =48 hrs; 2) other sources of fever ruled out; 3) computed tomography scan evidence of mucoperiosteal thickening +/- sinus air/fluid levels; and 4) attempt at conservative treatment with topical decongestants and removal of all nasal intubation. Microbiologic data were collected and analyzed for any statistical difference between groups. RESULTS: A total of 29 sides underwent simultaneous tap and endoscopically directed tissue culture. The mean age was 40 years (range, 23-77 y) with 85% being males. Fifteen of 20 (75%) patients in the AT group were culture-positive. Of the 49 isolates from the AT, 55% yielded Gram-negative bacilli (Acinetobacter sp. 37%) and 45% yielded Gram-positive cocci. The ETC group was culture-positive in 18 of 20 (90%) patients. Of the 52 isolates from the ETC, Gram-negative bacilli were found in 58% (Acinetobacter sp. 33%) and 42% yielded Gram-positive cocci. The ETCs were culture-positive in all but 1 patient with positive taps. There appeared to be a concordance between AT and ETC in 60% of the patients. In five instances (25%), results of the AT or ETC changed ICU management. Two patients ultimately required sinus surgery. CONCLUSIONS: Sinus taps and/or endoscopically directed tissue cultures led to a change in ICU care in 25% of ICU patients studied. In patients with fever of unknown origin and computed tomography evidence of sinusitis, an antral tap continues to provide important information concerning maxillary sinusitis. However, ETC may give as good a representation of the microbiology and secondary inflammatory changes responsible for bacterial ICU rhinosinusitis causing fever of unknown origin. Further study on a larger group of patients is needed.

Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomized, prospective trial.

BACKGROUND: Critically ill trauma patients frequently require prolonged endotracheal intubation and ventilator support. After extubation, swallowing difficulties may exist in < or = 50% of patients. We sought to determine whether performing a swallowing evaluation would reduce the incidence of postextubation aspiration and subsequent pneumonia. DESIGN: Randomized, prospective clinical trial of fiberoptic endoscopic evaluation of swallowing (FEES) vs. routine clinical management in patients after prolonged intubation. METHODS: Seventy patients who were intubated for > 48 hrs were randomized. FEES examinations were performed within 24 +/- 2 hrs after extubation. Silent aspiration was defined as the appearance of liquid or puree bolus below the true vocal cords without coughing during a FEES examination. Clinical aspiration was defined as the removal of enteral content from below the vocal cords, usually during endotracheal tube placement. RESULTS: There were five episodes of aspiration and pneumonia in the FEES group (14%, two silent) and two in the clinical group (6%, not significant, Fisher exact test). Patients aged > 55 yrs and those with vallecular stasis on FEES examination were at significantly higher risk of postextubation aspiration. All patients with pneumonia had an associated aspiration episode. CONCLUSIONS: Patients with prolonged orotracheal intubation are at risk of aspiration after extubation. The addition of a FEES examination did not change the incidence of aspiration or postextubation pneumonia.

Effect of trauma system maturation on mortality rates in patients with blunt injuries in the Finger Lakes Region of New York State.

BACKGROUND: New York State instituted a statewide trauma system beginning in 1990. By 1993, that system included uniform emergency medical system triage guidelines, designated trauma centers, transfer agreements between trauma centers and noncenters, and a trauma registry containing data on seriously injured patients in each region and the state as a whole. We reviewed the first 4 years of registry data for the Finger Lakes Region to determine what effects the institution of a trauma system has had on the outcome of trauma care in this region. DESIGN: Retrospective review of a regional trauma database. METHODS: All qualifying injured patients in the region were entered into the registry beginning in 1993. Data from 1993 through 1996 for patients with blunt injuries were analyzed by both Trauma and Injury Severity Score (TRISS) methodology and logistic regression analysis. For comparison, two time periods were defined: 1993-1994 and 1995-1996. Outcomes for the two time periods were stratified by Revised Trauma Score and the presence or absence of head and/or cervical spine injury, and then compared by hospital type (regional trauma center, area trauma center, and noncenters). RESULTS: In the later time period, there was a statistically significant decrease in the region-wide mortality rate. This was associated with a marked improvement in performance of the noncenters and with an increase in the proportion of patients who received definitive care at a trauma center. CONCLUSIONS: Improved outcomes for patients with blunt trauma can occur early in the implementation of a trauma system. This improvement may be attributable in part to changes in field triage and early transport to trauma centers.

Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash.

BACKGROUND: Pain from rib fracture pain may affect pulmonary function, morbidity, and length of intensive care unit stay. Previous trials have varied epidural technique within the study and have used several outcome variables. METHODS: The charts of patients who sustained rib fractures after a motor vehicle crash between January 1, 1994, and June 30, 1997, were reviewed. Data were collected from 64 patients who had three or more rib fractures and initiation of intravenous patient-controlled analgesia with morphine or thoracic epidural analgesia with bupivacaine and fentanyl within 24 hours of admission. RESULTS: Injury Severity Score and Acute Physiology and Chronic Health Evaluation II scores were not significantly different between groups. Patients in the epidural group had significantly more rib fractures and were significantly older. Patients who received epidural analgesia had significantly lower pain scores at all times. There were no differences in the lengths of intensive care unit or hospital stays, or the incidence of pulmonary complications or organ failure between groups. CONCLUSION: Thoracic epidural analgesia with bupivacaine and fentanyl provided superior analgesia than intravenous patient-controlled analgesia morphine.

A randomized prospective trial of amphotericin B lipid emulsion versus dextrose colloidal solution in critically ill patients.

BACKGROUND: Amphotericin B is the agent of choice for most invasive fungal infections in critically ill patients. It is associated with at least a 50% incidence of nephrotoxicity, despite prophylactic measures such as sodium loading. Newer formulations of amphotericin B are available but are costly and have unknown bioavailability in critically ill patients. Previous trials in neutropenic and critically ill patients have demonstrated that mixing amphotericin B with 20% lipid solution (Intralipid; Clintec Nutrition, Deerfield, III) may decrease nephrotoxicity. METHODS: In this randomized, prospective clinical trial, patients with positive fungal blood cultures, tracheal/sputum cultures or peritoneal cavity cultures were randomized to receive either 0.5 mg/kg per day of amphotericin B dextrose or 1.0 mg/kg per day of amphotericin B lipid emulsion. Duration of therapy was determined by the primary care team. Weekly 24-hour creatinine clearance was measured until 2 weeks after amphotericin B therapy was completed. RESULTS: The two groups were similar based on age, white blood cell count, serum creatinine, and creatinine clearance at the beginning of therapy. The group receiving amphotericin B lipid emulsion had significantly less decrease in creatinine clearance compared with controls, despite receiving significantly more amphotericin B. CONCLUSION: Amphotericin B lipid emulsion can be given at a higher total cumulative dose than amphotericin B dextrose with less nephrotoxicity.

Central CRF inhibits gastric emptying of a nutrient solid meal in rats: the role of CRF2 receptors.

Corticotropin-releasing factor (CRF)-related peptides exhibit different affinity for the receptor subtypes 1 and 2 cloned in the rat brain. We investigated, in conscious rats, the effects of intracisternal (i.c.) injection of CRF (rat/human) on the 5-h rate of gastric emptying of a solid nutrient meal (Purina chow and water ad libitum for 3 h) and the CRF receptor subtype involved. CRF, urotensin I (suckerfish), and sauvagine (frog) injected i.c. inhibited gastric emptying in a dose-dependent manner, with ED50 values of 0.31, 0.13, and 0.08 microgram/rat, respectively. Rat CRF-(6-33) (0.1-10 micrograms i.c.) had no effect. The nonselective CRF1 and CRF2 receptor antagonist, astressin, injected i.c. completely blocked the inhibitory effect of i.c. CRF, urotensin I, and sauvagine with antagonist-to-agonist ratios of 3:1, 10:1, and 16:1, respectively. The CRF1-selective receptor antagonist NBI-27914 injected i.c. at a ratio of 170:1 had no effect. These data show that central CRF and CRF-related peptides are potent inhibitors of gastric emptying of a solid meal with a rank order of potency characteristic of the CRF2 receptor subtype affinity (sauvagine > urotensin I > CRF). In addition, the reversal by astressin but not by the CRF1-selective receptor antagonist further supports the view that the CRF2 receptor subtype is primarily involved in central CRF-induced delayed gastric emptying.

The impact of antioxidant and splanchnic-directed therapy on persistent uncorrected gastric mucosal pH in the critically injured trauma patient.

BACKGROUND: Critically ill trauma patients with gastric intramucosal acidosis, as measured by gastric tonometry, have an increased incidence of multiple organ dysfunction syndrome despite supranormal O2 delivery. We altered our resuscitation protocol to maximize splanchnic blood flow and decrease oxygen-derived free radical damage. DESIGN: Prospective clinical trial with historical controls. METHODS: The protocol differed from control by including administration of folate, mannitol, and low-dose isoproterenol. All patients had gastric tonometers and pulmonary artery catheters. If the intramucosal pH (pHi) was less than 7.25, splanchnic-sparing inotropic and vasodilatory agents were used to optimize systemic cardiac output. Two groups of trauma patients with persistent intramucosal acidosis at 24 hours (pHi < 7.25) were compared: a control group (n = 7), and patients who received the splanchnic/antioxidant protocol (n = 13). RESULTS: The two groups were similar based on Acute Physiology and Chronic Health Evaluation II score, Injury Severity Score, age, cardiac index, oxygen delivery, and oxygen consumption. The "splanchnic therapy" group had fewer organ system failures as well as shortened length of intensive care unit and hospital stay. Three of 7 patients in the control group and 2 of 13 patients in the splanchnic therapy group had a final pHi < 7.25. CONCLUSION: Gastric tonometry-guided resuscitation and antioxidant/splanchnic therapy in critically ill trauma patients with persistent gastric mucosal acidosis may decrease multiple organ dysfunction syndrome.

Jejunal lymphangioma. An unusual cause of chronic gastrointestinal bleeding.

We discuss a case of lymphangioma of the small bowel that caused chronic anemia secondary to gastrointestinal blood loss. We believe that this is the first jejunal lymphangioma to be diagnosed by Sonde endoscopy. There are several other lymphatic abnormalities of the small intestine that are briefly discussed. In the Western literature, anemia or chronic gastrointestinal blood loss is an unusual presentation of lymphangioma of the small bowel.

Adrenal insufficiency in the surgical intensive care unit patient.

BACKGROUND: Adrenocortical dysfunction is unusual in the unselected critically ill patient. Case reports document a state of corticosteroid responsive vasopressor dependence, resembling the systemic inflammatory response syndrome. The exact incidence of this disorder is unknown. METHODS: We prospectively studied the incidence of adrenal insufficiency during a 9-month period in a surgical intensive care unit (ICU) population. Trauma, general surgery, urology, and gynecologic-oncology patients were included. Patients who met criteria were given a cosyntropin stimulation test. RESULTS: Overall, the incidence of adrenal insufficiency was 0.66%. In the subgroup of patients with greater than 14 days stay in the ICU, 6% were found to have adrenal insufficiency. In patients aged more than 55 years and with ICU stays of 14 days or greater, 11% were adrenally insufficient. CONCLUSIONS: Screening of critically ill patients for adrenal insufficiency, particularly those with prolonged ICU stay and age greater than 55 years, is warranted.

Neuronal pathways involved in abdominal surgery-induced gastric ileus in rats.

The 20-min rate of gastric emptying of a noncaloric solution and c-fos expression detected by immunohistochemistry in the brain were monitored 3 h after abdominal surgery performed under 10-min enflurane anesthesia in rats. Abdominal surgery (laparotomy and 1-min manipulation of the cecum) decreased gastric emptying from 60.8 +/- 3.4 to 25.9 +/- 3.4%. Capsaicin applied to the celiac/superior mesenteric ganglia 2 wk before the experiment reduced the delay in gastric emptying induced by abdominal surgery (46.3 +/- 3.4%), whereas perivagal capsaicin application had no effect (23.6 +/- 7.9%). The corticotropin-releasing factor (CRF) antagonist [D-Phe12, Nle21,38,C alpha MeLeu37]CRF-(12--41) injected intracisternally (10-20 micrograms) prevented postoperative gastroparesis induced by surgery, while having no effect on basal gastric emptying. Abdominal surgery increased the number of Fos-positive cells in brain nuclei regulating autonomic outflow: the nucleus of the solitary tract, locus ceruleus, paraventricular nucleus, and supraoptic nucleus of the hypothalamus. These data indicate that capsaicin-sensitive splanchnic afferent fibers and activation of CRF receptors in the brain are part of the neuronal circuitry mediating gastric stasis 3 h after abdominal surgery.

Abdominal surgery-induced delayed gastric emptying in rats: role of CRF and sensory neurons.

The role of peripheral corticotropin-releasing factor (CRF) and afferent pathways in mediating abdominal surgery-induced delayed gastric emptying was investigated using an intravenous injection of the competitive CRF antagonist alpha-helical CRF9-41 and capsaicin pretreatment in adult fasted rats. Gastric emptying of a non-caloric solution was measured by the phenol red method. Intravenous CRF (0.13 nmol) inhibited by 65% gastric emptying. CRF effect was completely reversed by simultaneous intravenous injection of alpha-helical CRF9-41 (13 nmol). Abdominal surgery under enflurane anesthesia inhibited gastric emptying by 60% measured 3 h postoperatively. Enflurane anesthesia alone had no effect on gastric emptying 3 h after exposure. Abdominal surgery-induced delay of gastric emptying was reversed by 46, 60, and 100% by capsaicin pretreatment (125 mg/kg, -3 wk), intravenous injection of alpha-helical CRF9-41 (13 nmol), and combined pretreatments with capsaicin and CRF antagonist, respectively. Capsaicin and alpha-helical CRF9-41 given alone or in combination did not influence gastric emptying. These results indicate that peripheral CRF receptors along with capsaicin-sensitive afferent neurons contribute to somatovisceral stress (abdominal surgery)-induced delayed gastric emptying.

Polyarteritis nodosa presenting as a biliary stricture.

Polyarteritis nodosa, a disease of the media of small and medium-sized arteries, has protean manifestations and many presenting signs and symptoms. Gastrointestinal involvement is common but involvement of the biliary tree is rare. We report a unique case of polyarteritis presenting as a biliary stricture.