Patterns and dynamics of airway colonisation in mechanically-ventilated patients.

The aim of this study was to investigate the patterns and dynamics of the microbiota in the airways of ventilated patients. Seventy-four mechanically-ventilated patients were recruited consecutively, and oropharyngeal, tracheal and bronchoalveolar (BAL) fluid specimens were collected 48 h after intubation, and every 72 h thereafter until the patient was extubated or a total of five sample sets had been collected. Ventilator-associated pneumonia (VAP) pathogens were identified, quantified and genotyped. Microbial findings were highly correlated both between airway locations and over time when samples were taken no more than 72 h apart. If no VAP pathogen was present in the oral flora, it was unlikely to be found in a lower airway sample; i.e., the positive predictive value of the oropharyngeal sample was 0.73 (95% CI 0.67-0.80), and the negative predictive value was 0.95 (95% CI 0.92-0.99). Colonisation with Enterobacteriacae, non-fermentative bacteria and Staphylococcus aureus was monoclonal in the airways and over time, whereas colonisation with microbes normally found in the oropharynx, i.e., Haemophilus influenzae, Haemophilus parainfluenzae and Streptococcus pneumoniae, was polyclonal. When antibiotics were used, the chance of recovering VAP pathogens from all sampling sites was reduced three-fold. No correlation was observed between a bacterial count of > or =10(4) CFU/mL in BAL fluid and chest X-rays compatible with VAP.

Does Pseudomonas aeruginosa colonization influence morbidity and mortality in the intensive care unit patient? Experience from an outbreak caused by contaminated oral swabs.

BACKGROUND: Contaminated oral swabs caused a nationwide monoclonal Pseudomonas aeruginosa outbreak involving 27 Norwegian hospitals. The aim of the study was to study the consequences on mortality and morbidity of the introduction of this P. aeruginosa strain to intensive care unit (ICU) patients. METHODS: Forty-four out of 96 patients admitted to the general ICU of Akershus University Hospital during the outbreak, ventilated for more than 24 h and with at least one microbiological sample, were included and followed until death or hospital discharge. All isolated P. aeruginosa strains were genotyped. Demographic data, admission diagnosis, Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA) score, comorbidities, and antibiotics used in the first week were recorded. RESULTS: The outbreak strain was found in 18 patients (41%) of whom seven became infected. Median time to the first positive culture was 4 days. These 18 patients spent a significantly longer time on mechanical ventilation (P =0.03) and had a significantly higher hospital mortality, 55.5% vs. 19.2% (P =0.03), than non-colonized patients. The number of patients with severe underlying disease was significantly higher (P =0.01) and the decline in SOFA score was significantly slower in the pseudomonas group (P =0.02). Irrespective of colonization status, patients with severe underlying disease had a significantly higher mortality (58%) than those without (16%) (P =0.009). CONCLUSION: Use of contaminated oral swabs led to a high rate of early airways colonization. Patients with severe underlying disease were more likely to become colonized, but whether colonization has any influence on hospital mortality requires further study.

Cholesterol-lowering effects of plant sterol esters differ in milk, yoghurt, bread and cereal.

OBJECTIVE: To measure the relative effects of each of four phytosterol ester-enriched low-fat foods (bread, breakfast cereal, milk and yoghurt) on serum lipids, plasma phytosterols and carotenoids. DESIGN: : Three research centres undertook a randomised, incomplete crossover, single-blind study consisting of four treatment periods of 3 weeks each, one of which was a control period. Each sterol-enriched test food provided 1.6 g/day of phytosterols as sterol esters. SETTING: General Community. SUBJECTS: In all 58, free-living men and women with mean age (s.d.) 54 (8) y, moderately elevated plasma total cholesterol 6.2 (0.7) mmol/l and body mass index 26.2 (3.0) kg/m(2). MAIN OUTCOME MEASURES: Serum lipids, plasma phytosterols and carotenoids. RESULTS: Serum total and LDL cholesterol levels were significantly lowered by consumption of phytosterol-enriched foods: milk (8.7 and 15.9%) and yoghurt (5.6 and 8.6%). Serum LDL cholesterol levels fell significantly by 6.5% with bread and 5.4% with cereal. They were both significantly less efficacious than sterol-enriched milk (P<0.001). Plasma sitosterol increased by 17-23% and campesterol by 48-52% with phytosterol-enriched milk and bread. Lipid-adjusted beta-carotene was lowered by 5-10% by sterols in bread and milk, respectively. CONCLUSIONS: This is the first study to demonstrate that cholesterol-lowering effects of plant sterol esters may differ according to the food matrix. Plant sterols in low-fat milk was almost three times more effective than in bread and cereal. Despite phytosterol-enriched cereal products resulting in lower serum cholesterol reductions compared to sterol-enriched milk, the detection of similar changes in plasma phytosterols demonstrated that such products still delivered and released phytosterols to the gut.

[Organization and management of Norwegian intensive care units]. / Organisering og ledelse av norske intensivavsnitt.

BACKGROUND: A survey of organisational and managerial aspects in Norwegian intensive care units (ICU) was made six months after Standards for Intensive Care, a document setting out guidelines for the organisation and management of intensive care units, had been issued by the Norwegian Medical Association to Norwegian hospitals. MATERIAL AND METHODS: 298 questionnaires were sent to hospital managers and heads of clinical departments in 58 Norwegian hospitals. RESULTS: The overall response rate was 77%. 60% of the respondents had heard about Standards, 44% had read them, 15% used them. The majority of ICUs were run by the Department of Anaesthesia. 75% answered that the admitting department had the overall responsibility for the individual patient; 23% of respondents claimed that the ICU doctor was responsible. More than half of these worked in secondary and tertiary care hospitals. INTERPRETATION: Standards of Intensive Care is poorly known and read by less than half of the respondents. Only a few have started to implement them. Some uncertainty about patient responsibility may exist particularly in secondary and tertiary care hospitals. There seems to be a need for better role clarification and definitions of responsibility for all participants in intensive care, with more focus on organisational and managerial aspects.

[Fulminant influenza pneumonia]. / Fulminant influensapneumoni.

Severe community acquired pneumonia is a common cause of acute respiratory failure requiring ventilator support. Bacteria are by far the most common pathogens, necessitating initial coverage with antibacterial agents. When influenza virus is involved in the aetiology of severe pneumonia, its role in the pathogenesis is most often that of facilitating secondary bacterial pneumonia. The influenza virus itself can, however, cause a severe and rapidly evolving viral pneumonia. We describe two cases of fulminant pneumonia with multiorgan failure, in which extensive microbiologic and serologic diagnostic test did not reveal other causes for the pneumonia than influenza virus. Different clinical lung manifestations of influenza are discussed. Influenza must be considered as an aetiologic possibility in acute respiratory failure.

Clinical outcome and economic impact of aminoglycoside peak concentrations in febrile immunocompromised patients with hematologic malignancies.

The aim of this study was to investigate the clinical and economic significance of aminoglycoside peak concentrations in febrile neutropenic patients with hematologic malignancies. Sixty-one patients were treated according to protocol II of the Paul-Ehrlich-Gesellschaft: initial application of gentamicin or tobramycin in combination with a cephalosporin or ureidopenicillin and, after 3 days, a potential change of antibiosis to be decided in case of nonresponse. At the same time, samples were collected by an independent controller. We found a significant dependence of clinical outcome on aminoglycoside peak concentrations (P = 0.004). Twelve of 17 patients with peak concentrations > 4.8 mg/L, but only 13 of 44 patients with concentrations < or = 4.8 mg/L, responded to initial therapy. Average infection-related costs per patient with peak values > 4.8 mg/L were US$1429, $1790, and $1701 for nursing, diagnostics, and therapeutics, respectively (total $4920). Expenses for patients with peak concentrations < or = 4.8 mg/L were approximately 1.8-fold higher (average total $8718). If all 61 patients had achieved peaks > 4.8 mg/L, the potential savings would have totalled $167,112. We conclude that neutropenic patients form a target group for successful pharmacokinetic intervention and cost saving.

Accuracy of infrared ear thermometry in adult patients.

OBJECTIVE: To assess (1) the agreement between infrared ear thermometry and core reference temperature (in the pulmonary artery). (2) the agreement between measurements in the right and left ears, and (3) the screening validity of infrared tympanic thermometry in detecting rectal fever. DESIGN: Temperatures were measured in both ears with an infrared thermometer, in one group of patients by simultaneous measurements with thermistors inserted in the pulmonary artery, esophagus, and rectum, and in the other group with a rectal glass-mercury thermometer. SETTING: An intensive care unit and a department of internal medicine in a secondary care hospital. PATIENTS AND PARTICIPANTS: Two samples: 16 adult patients admitted to the intensive care unit and 103 consecutive patients admitted to the department of medicine. MEASUREMENTS: The major outcome measures were (a) the agreement between infrared ear thermometry and thermistor pulmonary artery temperature and (b) the sensitivity and specificity for detecting fever, using rectal measurement as reference. RESULTS: Both rectal and esophageal thermistor measurements showed better agreement with the pulmonary artery reference temperature than single ear tympanic thermometry. The sensitivity and specificity of ear thermometry for detecting fever (> or = 38.0 degrees C rectal reference) were 0.58 and 0.94, respectively. Double ear thermometry had a sensitivity of 0.61 and a specificity of 0.95, when using the mean value. CONCLUSIONS: Both rectal and esophageal thermistor measurements showed better agreement with pulmonary artery temperature than single ear themometry. Using the mean of two ear measurements improves the agreement and screening validity for detecting fever by rectal temperature. If temperature measurements are critical, esophageal measurements achieve excellent agreement with pulmonary artery temperatures.

Organ function during early acute renal failure does not predict survival in long-term intensive care.

OBJECTIVE: To examine outcome in relation to organ function variables during early acute renal failure (ARF). DESIGN: Retrospective inception cohort. SETTING: General intensive care unit (ICU). PATIENTS: 69 consecutive ARF cases verified to have a creatinine clearance below 50 ml/min with no history of previous renal disease. MAIN OUTCOME MEASURE: ICU survival. MEASUREMENTS AND RESULTS: Septic severity score (SSS), creatinine clearance, thrombocyte count, bilirubin concentration, cardiac inotropic support, PaO2/FIO2 ratio and oliguria were measured. No differences related to outcome were observed in patients surviving more than 7 days after ARF diagnosis. Patients dying within 7 days of ARF had a significantly higher (worse) SSS. Organ dysfunction was established at the time of ICU admission in the majority of cases. CONCLUSION: The organ function variables tested in this study are of limited predictive value during the early stage of ARF.

[Percutaneous gallbladder drainage in acute cholecystitis]. / Perkutan galleblaeredrenasje ved akutt kolecystitt.

12 high-risk patients underwent percutaneous cholecystostomy for serious acute cholecystitis using a transhepatic approach under ultrasonic guidance. Eight patients had acute acalculous cholecystitis, and four had acute calculous cholecystitis. Following the drainage procedure a mean decrease in body temperature of 0.7 degrees centigrade was noted in 11 patients and a reduction of pain and defence in five out of nine patients. Two patients had a perforated gallbladder and pericholecystic abscess; both cases were successfully treated by percutaneous drainage. Four patients with acute acalculous cholecystitis died while in hospital for reasons unrelated to the procedure. The catheter became dislodged in three patients.

Effects of heparin on proteolytic activities in human plasma.

The influence of unfractionated heparin [average molecular weight (MW) 10,000-15,000 kD] and low-molecular-weight heparin (average MW 400-600 kD) on the plasma kallikrein-kinin and the fibrinolytic system was studied in vitro. Unfractionated heparin added to plasma gave an increase in kallikrein-like activity with a corresponding decrease of prekallikrein and functional kallikrein inhibition values. Plasmin-like activity was also increased, but minor changes in plasminogen and no change in antiplasmin values occurred. The changes were less pronounced with low molecular heparin compared with unfractionated heparin. The proteolytic changes were reversed by protamine sulfate but not influenced by the protease inhibitor aprotinin. Gel filtration yielded proteolytic activities able to split the plasma kallikrein substrate S-2305 and, to a minor degree, the plasmin substrate S-2251. The proteolytic activities were not due to complex formation with alpha 2-macroglobulin. We speculate that heparin binds to prekallikrein to form a heparin-prekallikrein complex which undergoes conformational changes and displays a kallikrein-like activity with the ability to split small synthetic substrates. Whether it is capable to split natural substrates remains unresolved.

Haemodynamic effects of heparin during coronary bypass surgery.

Heparin has been suggested as an activator of the plasma kallikrein-kinin system, with possible formation of bradykinin, a potent vasodilator. Haemodynamic effects and changes in the kallikrein-kinin system were studied after heparin- and saline-injections in ten patients undergoing coronary bypass surgery. A moderate decrease in mean arterial pressure was found in all patients in the observation period, but significantly more at 2 and 3 min after heparin-injection compared with saline-injection. None of the other haemodynamic variables measured were significantly different when comparing heparin- to saline-injection. Heparin-injection resulted in significant changes in the kallikrein-kinin system, with a marked increase in spontaneous kallikrein-like activity as the most prominent feature, while no changes were found after saline-injection. Liberation of bradykinin would be expected to give a decrease in systemic vascular resistance with an increase in cardiac output. The results indicate that the plasma kallikrein-kinin system, though apparently activated after heparin-injection, does not contribute significantly to the decrease in arterial pressure in the patients studied.

Duration of cardiopulmonary bypass compared with changes in the plasma protease systems.

Forty patients undergoing elective coronary artery bypass grafting were investigated concerning association between duration of cardiopulmonary bypass (CPB) and changes in the plasma protease systems. Spontaneous enzyme activity, proenzymes and functional inhibition capacities in the fibrinolytic, plasma kallikrein-kinin and coagulation systems were measured before, during and after CPB and in the immediate postoperative period. No clear relationship was revealed between changes in the measured variables and the duration of CPB.

[Anaphylactic shock caused by suxamethonium (Curacit)]. / Anafylaktisk sjokk etter suxameton (Curacit).

We describe five cases of anaphylactic shock following the short-acting muscle relaxant succinylcholine (suxamethonium). All the patients recovered uneventfully. Skin prick testing identified succinylcholine as the probable causative agent in four cases. The incidence of anaphylaxis to succinylcholine in our material appears to be 1:1,000. Treatment consisted of volume substitution, adequate oxygenation and adrenergic agents. We discuss the routine use of succinylcholine for intubation in elective surgery, and conclude that the anaesthesiologist must always be prepared for a possible anaphylactic reaction.

Different activation patterns in the plasma kallikrein-kinin and complement systems during coronary bypass surgery.

Components of the plasma kallikrein-kinin and complement systems were determined in patients undergoing open heart surgery with cardiopulmonary bypass. Spontaneous kallikrein activity (KK), plasma prekallikrein (PKK), functional kallikrein inhibition capacity (KKI), C3 activation products (C3-act), and the terminal complement complex (TCC) were measured. A marked, transitory increase in KK and a decrease in PKK were found prior to cardiopulmonary bypass just after heparin injection. An additional decline in PKK and KKI during bypass with a return to near control levels in the postoperative period was observed. C3-act increased in all patients during bypass, reaching a peak value at wound closure. The TCC concentration also increased significantly during cardiopulmonary bypass, returned to control levels in the early postoperative period, and then increased again in the late postoperative period. It is concluded that activation of the kallikrein-kinin system started after injection of heparin, prior to cardiopulmonary bypass. Activation of both the initial and the terminal complement cascade, however, started only after onset of cardiopulmonary bypass.

Changes in the coagulation and fibrinolytic systems during and after cardiopulmonary bypass surgery.

Components of the coagulation and fibrinolytic systems were determined in patients undergoing open heart surgery with cardiopulmonary bypass. The variables studied included prothrombin, antithrombin-III, spontaneous plasmin activity, plasminogen and functional antiplasmin activity. The variables were measured using chromogenic peptide substrate assays. A marked, transitory, increase in spontaneous plasmin activity prior to cardiopulmonary bypass, but after heparin injection was found. A decrease in antiplasmin activity during bypass was observed, while actual plasminogen level, when correcting for hemodilution, was unchanged. Both prothrombin and antithrombin-III paralleled the decrease in hemoglobin concentration during bypass. These findings suggest that the injection of heparin induced a transient activation of the fibrinolytic system, whereas no detectable consumption of the measured coagulation variables was observed.

Changes in the plasma protease systems during open-heart surgery with dextran vs. Ringer acetate as priming solution.

Two different priming solutions for cardiopulmonary bypass (CPB) were studied in regard to possible influence on the plasma protease systems. The study was performed on 20 patients undergoing elective coronary artery bypass grafting. In ten cases the priming solution contained 1,000 ml dextran (MW 70,000) and in ten it consisted only of Ringer's acetate solution. The same level of haemodilution was established during CPB in the two groups. Clinical variables and laboratory data were monitored. Spontaneous kallikrein activity, plasma prekallikrein, functional kallikrein inhibition capacity, spontaneous plasmin activity, plasminogen, functional antiplasmin activity, prothrombin and antithrombin-III were measured, using chromogenic peptide substrate assays before and during CPB as well as in the postoperative period. The antiplasmin activity decreased more in the dextran than in the Ringer group following cardiopulmonary bypass but the difference was without clinical significance. No statistically significant intergroup difference was found in the other measured variables of the kallikrein-kinin, fibrinolytic and coagulation systems.