Central venous catheter replacement in the ICU: new site versus guidewire exchange.

AIM: Catheter infection (central venous catheter, CVC-I) and catheter-related bacteremia (CRB) are of particular interest with ICU patients; more than 40-60% of them require a CVC. This prospective observational study was performed to determine if a second episode of catheterization and guidewire exchange was related to increased CRB and CVC-I rates in the ICU. METHODS: Over a period of 3 years, patients requiring a CVC, with catheter care, tip and peripheral blood cultures, were observed. RESULTS: A total of 898 non-tunneled CVCs were examined. The infection rates for 707 first-positioned CVCs were 4.3/1 000 catheter-day (c.d.) for CVC-I and 1.62 for CRB. Replacement was carried out for 191 CVCs: 7 of 103 CVCs inserted in a new site (4.81/1 000 c.d.) and 2 of 88 guidewire exchanged CVCs (1.75/1 000 c.d.) were infected; 2 replaced CVCs were related to CRB (1.38/1 000 c.d.). A cannulation time of over 7 days was related to a higher infection risk with its progressive reduction after the third week: the absolute risk increase was from 5.3 to 1.01 and the relative risk increased from 2.39 to 0.45 for CVC-I. CONCLUSION: Prolonged indwelling time is a significant risk factor for catheter-related infections; the second episode of cannulation and guidewire exchange did not present significant risk factors for catheter-related infections. A strict stable protocol for catheter insertion, care and proper treatment are necessary to reduce both the catheter-related infection rate and cost.

Procalcitonin, C-reactive protein, white blood cells and SOFA score in ICU: diagnosis and monitoring of sepsis.

AIM: To determine in critically ill patients the value of procalcitonin (PCT), C-reactive protein (CRP), sequential organ failure assessment (SOFA) score and white blood cell count in diagnosis and monitoring of sepsis. METHODS: Patients admitted to a medicosurgical intensive care unit in a prospective, observational study, were observed consecutively. According to ACCP/SCCM Consensus Conference definition were defined 4 groups: SEPSIS/SS (sepsis, severe sepsis, septic shock), SIRS, No-SIRS and TRAUMA. RESULTS: Two hundred and fifty five clinical events on a total of 1 826 observation days were observed: 111 SEPSIS/SS, 49 TRAUMA, 45 SIRS and 50 No-SIRS. ROC values, in the diagnosis of sepsis, were 0.88 for PCT, 0.74 for CRP, 0.8 for Sepsis score, 0.74 for SOFA, 0.62 for neu-throphils granulocytes (p<0.05). The best cut-off values in the diagnosis of sepsis were 0.47 ng/mL for PCT and 128 mg/L for CRP. PCT and SOFA were higher in septic shock than in severe sepsis and sepsis (p<0.05 in all cases). The maximum CRP level in SEPSIS/SS was reached only after 24-48 h of observation. Admission PCT value of TRAUMA patients whom evolving in septic complication was higher than patients with a favourable course: 3.4 ng/mL (range 2.63-12.71) vs 1.2 ng/mL (range 0.5-5.2) (p<0.05). TRAUMA patients with septic complications present an early and quick significant increase of PCT (p<0.05). CONCLUSIONS: PCT and CRP may be useful together with bacteriological data in sepsis diagnosis; PCT and SOFA closer correlate with the infection severity; PCT is the better parameter to estimate severity, prognosis or further course of the disease.