Analysis of Incidence, Risk Factors and Outcomes Associated With Abdominal Hypertension in Major Burn Patients.

The objective of this study is to analyze incidence and risk factors for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in major burn patients. Aprospective cohort study was conducted at a Burns Treatment Center, including all patients with a burned body surface area ≥20% admitted from August 2015 to January 2018. Intra-abdominal pressure was measured periodically during the first week of ICU stay. Sixty-four patients were analyzed, with median age of 39 years (interquartile range ITQ: 28-53) and 66% were male. Median burned body surface area was 30% (ITQ: 20-46). Twenty-eight (56%) patients presented criteria for IAH and seven (14%) developed clinical signs compatible with ACS. Burn severity was greater in the group that developed IAH, represented by the ABSI score. This group also presented higher values of creatinine and positive fluid balance. The group of patients with ACS showed a higher frequency of alterations in renal and respiratory functions. The organ systems most frequently affected in groups with diagnostic criteria for IAH and ACS were renal, cardiovascular and respiratory. Mortality rate at hospital outcome was 56%. In conclusion, the incidence of IAH during the study period was high in patients with extensive burns. The occurrence of ACS was associated with organic dysfunctions of the respiratory, cardiovascular and renal systems. The factors associated with intra-abdominal hypertension were age, extension of burned body surface, inhalation injury, and need for mechanical ventilation.

Cette étude a pour objectifs d'analyser l'incidence de l'hyperpression abdominale (HPA) et du syndrome du compartiment abdominal (SCA) chez les brûlés graves. Il s'agit d'une étude monocentrique prospective conduite auprès des 64 patients admis avec une brûlure >20% SCT entre août 2015 et janvier 2018. La préssion intraabdominale (PIA) était régulièrement mesurée pendant la première semaine. L'âge médian des patients était de 39 ans (IQR 28-53) et les 2/3 d'entre eux étaient des hommes. La SCT médiane était de 30% (IQR 20-46). Vingt huit (56%) patients avaient des critères d'HPA et 7 (14%) ont présenté des signes de SCA. Le score ABSI et la créatininémie étaient plus élevés chez les patients avec HPA, qui avaient aussi un bilan entrées-sorties positif. Les patients avec un SCA avaient plus de défaillances rénale et respiratoire. Les défaillances les plus fréquemment observées chez les patients avec HPA/SCA étaient rénales, cardio-vasculaires et respiratoires. La mortalité était de 56%. En conclusion, l'incidence de HPA est élevée chez les patients gravement brûlés. La survenue de SCA est une cause de défaillances rénale, cardio-vasculaire et respiratoire. Les facteurs prédicitifs de HPA étaient l'âge, la surface brûlée, l'inhalation de fumées et le recours à la ventilation mécanique.

Core competencies in critical care for general medical practitioners in South Africa: A Delphi study.

Background: Despite a high burden of disease that requires critical care services, there are a limited number of intensivists in South Africa (SA). Medical practitioners at district and regional public sector hospitals frequently manage critically ill patients in the absence of intensivists, despite these medical practitioners having had minimal exposure to critical care during their undergraduate training. Objectives: To identify core competencies in critical care for medical practitioners who provide critical care services at public sector hospitals in SA where intensivists are not available to direct patient management. Methods: A preliminary list of core competencies in critical care was compiled. Thereafter, 13 national and international experts were requested to achieve consensus on a final list of core competencies that are required for critical care by medical practitioners, using a modified Delphi process. Results: A final list of 153 core competencies in critical care was identified. Conclusion: The core competencies identified by this study could assist in developing training programmes for medical practitioners to improve the quality of critical care services provided at district and regional hospitals in SA. Contribution of the study: The study provides consensus on a list of core competencies in critical care that non-intensivist medical practitioners managing critically ill patients in healthcare settings in South Africa, especially where intensivists are not readily available, should have. The list can form the core content of training programmes aimed at improving critical care competence of general medical practitioners, and in this way hopefully improve the overall outcomes of critically ill patients in South Africa.

Analysis of readmission rates to the intensive care unit after implementation of a rapid response team in a University Hospital.

OBJECTIVES: To compare readmission rates to the intensive care unit (ICU) before and after the implementation of a rapid response team (RRT), and to identify risk factors for readmission. DESIGN: A quasi-experimental before-after study was carried out. SETTING: A University Hospital. PATIENTS: All patients discharged from the ICU from January to December 2008 (control group) and from January 2010 to December 2012 (intervention group). INTERVENTION: Implementation of an RRT. MAIN VARIABLES OF INTEREST: The data included demographic parameters, diagnoses upon admission, ICU readmission, APACHE II, SOFA, and TISS 28 scores, and routine daily assessment by an RRT of patients discharged from the ICU. RESULTS: During the study interval, 380 patients were analyzed in the period prior to the implementation of the RRT and 1361 after implementation. There was a tendency toward decreased readmission rates one year after RRT implementation. The APACHE II score and SOFA score at ICU discharge were independent factors associated to readmission, as well as clinical referral to the ICU. CONCLUSIONS: The RRT intervention resulted in a sustained decrease in readmission rates one year after implementation of this service. The use of a specialized team in health institutions can be recommended for ICU survivors.

Infectious complications in adult burn patients and antimicrobial resistance pattern of microorganisms isolated.

The objective of this study was to analyze the incidence of hospital acquired infections (HAIs) in burn patients, and to determine the principle infection sites and the sensitivity profile of the microorganisms to antimicrobials. This is a retrospective cohort study, conducted in a specialized centre for the treatment of burns from January 2009 to December 2013. The sample consisted of 404 patients, divided into two groups: the first group comprised 142 patients without infection, and the second group was made up of 262 patients who had acquired HAIs. There was a predominance of males in both groups. Mean age of the patients without infection was 37 years (SD 14.89), and 38 years (SD 15.78) for the patients with HAIs. Of the 523 infections observed in this study, pneumonia was the most frequent with 216 (41%) cases, followed by urinary tract infections with 137 (26%) episodes. The pathogens identified were Acinetobacter baumannii (93, 40%), Pseudomonas aeruginosa (50, 21%) and Klebsiella (pneumoniae/oxytoca) (23, 10%) and were resistant to most common antimicrobials. In the study population, no pathogens resistant to vancomycin were found. The present study describes high rates of infection in burn victims. Pneumonia was the most frequent site of infection, followed by urinary tract infections caused respectively by non-fermenting bacteria with a high frequency of antimicrobial resistance.

L'objectif de cette étude était d'analyser l'incidence des infections nosocomiales chez les patients brûlés, de déterminer les principaux sites infectés et d'analyser les profils de sensibilité des bactéries. Cette étude rétrospective a été conduite dans un CTB entre janvier 2009 et décembre 2013. L'échantillon de 404 patients a été réparti en 2 groupes: le premier, de 142 patients, sans infection (SI) et le second de 262 patients infectés (I). Les hommes prédominaient dans les 2 groupes. L'âge moyen des patients SI était de 37 +/- 14,89 ans, celui des patients I de 38 +/- 15,78 ans. Les 216 pneumonies représentaient la majorité (41%) des 523 infections relevées, suivies par les infections urinaires (137, 26%). Acinetobacter baumannii (93 isolats; 40%), Pseudomonas æruginosa (50; 21%) et Klebsiella sp. (23; 10%) étaient les plus fréquents et les plus résistants. Nous n'avons pas isolé de bactérie VAN R. On constate une prévalence élevée des infections chez les brûlés, principalement en sites pulmonaire et urinaire, souvent par des BGN non fermentants à résistance élevée.

Acute respiratory distress syndrome in burn patients: incidence and risk factor analysis.

After a burn lesion, Acute Respiratory Distress Syndrome (ARDS) may occur via direct lung injury due to inhaled smoke and fumes or mediated by the inflammatory response associated with the burn or its infectious complications. The aim of the present study is to assess the epidemiologic profile of ARDS in adult burn patients admitted to intensive care in a burn unit at a university hospital. A prospective cohort study was performed from January to December 2012. Demographic and diagnostic data, prognostic scores, etiology and data on the extent and depth of burns were collected. Data related to risk factors for ARDS and death were also recorded. A total of 85 patients were included in the study. Patients were aged 41.7 (SD = 15.7) years old; 71.8% were male and the mean total body surface area burned was 28.3% (SD = 19.1%); 35.3% presented inhalation injuries. Invasive ventilatory support was required in 44 ICU inpatients (51.8%). ARDS was diagnosed in 38.6% of patients under invasive mechanical ventilation. In multivariate analysis, the presence of inhalation injuries was a risk factor for ARDS (OR = 9.75; CI 95% 2.79 - 33.95; P < 0.001). ARDS is a common complication in burn patients admitted to specialized intensive care units. Inhalation injuries were an independent risk factor for ARDS. Mortality rate observed in the study patients was high and associated with ARDS diagnosis.

Après une brûlure, un SDRA peut survenir soit en raison d'une atteinte pulmonaire directe (inhalation de fumées) soit en raison de la réaction inflammatoire due à la brûlure ou à une complication infectieuse. Le but de ce travail est d'évaluer l'épidémiologie des SDRA survenus chez des adultes brûlés hospitalisés dans l'unité de réanimation dédiée d'un CHU durant l'année 2012. Les données démographiques, celles concernant la brûlure (cause, étendue, profondeur, scores pronostics) et les facteurs de risque de SDRA ont été relevés. Quatre vingt cinq patients ont été inclus. Les patients étaient âgés de 41,7+/-15,7 ans, 71,8% d'entre eux étaient des hommes, ils étaient brûlés sur 28,3+/-19,1% de la SCT, 35,3% d'entre eux avaient des lésions d'inhalation. Quarante quatre patients (51,8%) ont eu besoin de ventilation mécanique. Un SDRA a été diagnostiqué chez 38,6% des patients ventilés. En analyse multivariée, les lésions d'inhalation sont un facteur de risque de SDRA (OR 9,75 ; IC95 2,79-33,95 ; p<0,001). Le SDRA est une complication fréquente chez les brûlés admis en unité de réanimation spécialisée. Les lésions d'inhalation sont un facteur de risque indépendant de SDRA. La mortalité de la cohorte était élevée, et associée au diagnostic de SDRA.

Impact of the reduction of environmental and equipment contamination on vancomycin-resistant enterococcus rates.

More than 1,500 perirectal swab cultures and 552 environmental and equipment cultures were collected during the study period. Enterococcus faecium was the most frequent species isolated, being responsible for 71% of the positive cultures. Fifty infections were documented, with bloodstream infections (18, 36%) being the most frequent, followed by urinary tract infection (15, 30%). An educational intervention was given to 136 healthcare workers (HCWs), and a questionnaire regarding vancomycin-resistant enterococcus (VRE) transmission was also performed pre- and post-intervention. Overall, 858 opportunities of patient care were evaluated. The compliance with contact precautions did not improve; however, in general, the proportion of correct answers regarding VRE increased significantly when comparing pre- and post-intervention periods (p < 0.05). On the other hand, the proportion of environmental and equipment contaminated by VRE decreased significantly from pre- (23.2%) to post-intervention (8.2%) (p < 0.001) and was associated with a significant decrease in VRE infection from 7.7 to 1.9 when comparing the pre- and post-intervention periods. The use of vancomycin (defined daily dose [DDD]) did not change significantly over the study period (p = 0.970), and the use of teicoplanin increased (p < 0.001). Seventy-six percent of E. faecium belong to type and subtype A by pulsed-field gel electrophoresis (PFGE). This predominant type was found in the environment and caused colonization and infection. In conclusion, the present study showed that reduction of the proportion of environmental and equipment contamination was associated with a decrease of colonization and infection due to VRE, and that the strategy to control VRE dissemination should be based on local problems.