Rapid Point-of-Care PCR Testing of Drug-Resistant Strains on Endotracheal Aspirate Samples: A Repurposed Effective Tool in the Stepwise Approach of Healthcare-Acquired Pneumonia-A Pilot Study.

Healthcare-associated pneumonia (HCAP) is a common nosocomial infection with high morbidity and mortality. Culture-based detection of the etiologic agent and drug susceptibility is time-consuming, potentially leading to the inadequate use of broad-spectrum empirical antibiotic regimens. The aim was to evaluate the diagnostic capabilities of rapid point-of-care multiplex polymerase chain reaction (PCR) assays from the endotracheal aspirate of critically ill patients with HCAP. A consecutive series of 29 intensive care unit (ICU) patients with HCAP and a control group of 28 patients undergoing elective surgical procedures were enrolled in the study. The results of the PCR assays were compared to the culture-based gold standard. The overall accuracy of the PCR assays was 95.12%, with a sensitivity of 92.31% and a specificity of 97.67%. The median time was 90 min for the rapid PCR tests (p < 0.001), while for the first preliminary results of the cultures, it was 48 h (46-72). The overall accuracy for rapid PCR testing in suggesting an adequate antibiotic adjustment was 82.98% (95% CI 69.19-92.35%), with a specificity of 90% (95% CI 55.50-99.75%), a positive predictive value of 96.77% (95% CI 83.30-99.92%), and a negative predictive value of 56.25 (95% CII 29.88-80.25%). This method of rapid point-of-care PCR could effectively guide antimicrobial stewardship in patients with healthcare-acquired pneumonia.

Trends in Molecular Diagnosis of Nosocomial Pneumonia Classic PCR vs. Point-of-Care PCR: A Narrative Review.

Nosocomial pneumonia is one of the most frequent hospital-acquired infections. One of the types of nosocomial pneumonia is ventilator-associated pneumonia, which occurs in endotracheally intubated patients in intensive care units (ICU). Ventilator-associated pneumonia may be caused by multidrug-resistant pathogens, which increase the risk of complications due to the difficulty in treating them. Pneumonia is a respiratory disease that requires targeted antimicrobial treatment initiated as early as possible to have a good outcome. For the therapy to be as specific and started sooner, diagnostic methods have evolved rapidly, becoming quicker and simpler to perform. Polymerase chain reaction (PCR) is a rapid diagnostic technique with numerous advantages compared to classic plate culture-based techniques. Researchers continue to improve diagnostic methods; thus, the newest types of PCR can be performed at the bedside, in the ICU, so-called point of care testing-PCR (POC-PCR). The purpose of this review is to highlight the benefits and drawbacks of PCR-based techniques in managing nosocomial pneumonia.

Intraoperative Right Colic Graft Ischemia, Followed by Delayed Oesophagoplasty Including an Ileo-Transverse Anastomosis and the Cervical Revascularisation of the Ileum: Case Report.

The ischemic complications during the isolation of the substituting oesophageal graft placement and after its placement may lead to graft necrosis and to the need to find a different reconstructive procedure. The most frequent reports of graft necroses occur in the days following the reconstruction. We are presenting the case of a 27-y.o. with full dysphagia as a result of caustic stenosis, in whose case the oesophageal reconstruction was abandoned following the irreversible ischemia of the right colic graft during the vascular isolation, followed by right-side hemicolectomy and ileo-transverse anastomosis. 4 years post the ingestion of a caustic substance and 2 years post the right colic graft ischemic necrosis, we performed an oesophageal reconstruction using a pediculated, cervically revascularized, ileo-colic graft on the left colic vessels. The graft's particularity is that is formed from left and transverse colon and ileum portions, including the ileo-transverse anastomosis performed 2 years prior to the oesophageal reconstruction.

Monitoring Anticoagulation with Unfractionated Heparin on Renal Replacement Therapy. Which is the Best aPTT Sampling Site?

BACKGROUND: Controlled anticoagulation is key to maintaining continuous blood filtration therapies. Objective: The study aimed to compare different blood sampling sites for activated partial thromboplastin time (aPTT) to evaluate anticoagulation with unfractionated heparin (UFH) in continuous renal replacement therapy (CRRT) and identify the most appropriate sampling site for safe patient anticoagulation and increased filter life span. METHOD: The study was a prospective observational single-centre investigation targeting intensive care unit (ICU) patients on CRRT using an anticoagulation protocol based on patient characteristics and a weight-based modified nomogram. Eighty-four patients were included in the study. Four sampling sites were assessed: heparin free central venous nondialysis catheter (CVC), an arterial line with heparinised flush (Artery), a circuit access line (Access), and a circuit return line (Postfilter). Blood was sampled from each of four different sites on every patient, four hours after the first heparin bolus. aPTT was determined using a rapid clot detector, point of care device. RESULTS: A high positive correlation was obtained for aPTT values between CVC and Access sampling sites (r (84) =0.72; p <0 .05) and a low positive correlation between CVC and Arterial sampling site (r (84) =0.46, p < 0.05). When correlated by artery age, the young Artery (1-3 day old) correlates with CVC, Access and Postfilter (r (45) = 0.74, p >0.05). The aPTT values were significantly higher at Postfilter and Arterial sampling site, older than three days, compared to the CVC sampling site (p<0.05). CONCLUSION: Considering patient bleeding risks and filter life span, the optimal sampling sites for safe assessment of unfractionated heparin anticoagulation on CRRT during CVVHDF were the central venous catheter using heparin free lavage saline solution, a heparinised flushed arterial catheter not older than three days, and a circuit access line.

Hemodynamic Predictors for Sepsis-Induced Acute Kidney Injury: A Preliminary Study.

The aim of our study was to assess the association between the macrohemodynamic profile and sepsis induced acute kidney injury (AKI). We also investigated which minimally invasive hemodynamic parameters may help identify patients at risk for sepsis-AKI. We included 71 patients with sepsis and septic shock. We performed the initial fluid resuscitation using local protocols and continued to give fluids guided by the minimally invasive hemodynamic parameters. We assessed the hemodynamic status by transpulmonary thermodilution technique. Sequential organ failure assessment (SOFA score) (AUC 0.74, 95% CI 0.61-0.83, p < 0.01) and cardiovascular SOFA (AUC 0.73, 95% CI 0.61-0.83, p < 0.01) were found to be predictors for sepsis-induced AKI, with cut-off values of 9 and 3 points respectively. Persistent low stroke volume index (SVI) ≤ 32 mL/m2/beat (AUC 0.67, 95% CI 0.54-0.78, p < 0.05) and global end-diastolic index (GEDI) < 583 mL/m2 (AUC 0.67, 95% CI 0.54-0.78, p < 0.05) after the initial fluid resuscitation are predictive for oliguria/anuria at 24 h after study inclusion. The combination of higher vasopressor dependency index (VDI, calculated as the (dobutamine dose × 1 + dopamine dose × 1 + norepinephrine dose × 100 + vasopressin × 100 + epinephrine × 100)/MAP) and norepinephrine, lower systemic vascular resistance index (SVRI), and mean arterial blood pressure (MAP) levels, in the setting of normal preload parameters, showed a more severe vasoplegia. Severe vasoplegia in the first 24 h of sepsis is associated with a higher risk of sepsis induced AKI. The SOFA and cardiovascular SOFA scores may identify patients at risk for sepsis AKI. Persistent low SVI and GEDI values after the initial fluid resuscitation may predict renal outcome.

Preoperative difficult airway prediction using suprahyoid and infrahyoid ultrasonography derived measurements in anesthesiology.

Airway management is one of the most important skills in everyday practice of anesthesia. Improper airway management might contribute to significant morbidity and mortality. In some patients, clinical parameters do not anticipate all difficulties related to airway management. Ultrasonography (US) might confer a potential screening tool for difficult airway. Suprahyoid and infrahyoid US measurements have been investigated for difficult airway prediction in anesthesiology. The most extensively investigated parameter was the anterior neck soft tissue thickness measured at different levels: anterior to the hyoid bone, epiglottis and vocal cords commissure. Hyomental distances measured with the head placed in neutral, sniffing or maximal hyperextended position and the derived hyomental distance ratios have also been evaluated for difficult airway prediction. For the evaluation of the tongue, measurements such as thickness, cross-sectional area, width, volume and tongue-to-oral cavityratio can be used. Thus, anesthesiologists have many available potential US measurements, which could provide information regarding airway anatomy during the preoperative airway assessment and could serve as potential screening parameters for difficult airway. Still, we do not yet know which of these provides optimal predictive accuracy and larger sample size studiesare required to validate their use in the preoperative evaluation of the airway.

Does norepinephrine infusion dose influence the femoral-to-radial mean arterial blood pressure gradient in patients with sepsis and septic shock?

The aim of our study is to determine whether there is a clinically important difference between the femoral and the radial site of blood pressure measurements, and to identify whether the vasoactive infusion dose influences the femoral-to-radial mean arterial blood pressure (MAP) gradient. We included 71 patients with sepsis and septic shock, with no comorbidities that may influence the hemodynamic parameters. Simultaneous measurements were registered at the femoral and radial arteries. The agreement between the two sites of recording was tested in the no-norepinephrine, low-norepinephrine, and high-norepinephrine groups, as well as for the whole group. Results show that 75.4% of paired recordings have a gradient of at least 5 mmHg between the femoral and radial recordings. For the measurements that have a gradient more than 5 mmHg, norepinephrine infusion dose was not found to be a determining factor. A better level of agreement was found after carrying out a separate Bland-Altman analysis for the femoral-to-radial and radial-to-femoral gradients. Norepinephrine infusion rate was not found to be a determining factor for the femoral-to-radial MAP gradient in septic and septic shock patients. Measurement of MAP at the radial or femoral site is clinically interchangeable for most of these patients.

Initial Fluid Resuscitation Following Adjusted Body Weight Dosing in Sepsis and Septic Shock.

INTRODUCTION: Fluid administration is considered a fundamental part of early sepsis treatment. Despite abundant research, fundamental questions about the amount of fluids to be given remain unanswered. Recently, the idea of adjusting the fluid load to the ideal body weight emerged, as obesity rates are increasing, and fluid overload was proven to increase mortality. AIM OF THE STUDY: The study aimed to determine whether advanced haemodynamic monitoring supports the adjustment of the initial fluid load to the ideal body weight (IBW). METHODS: Seventy-one patients with sepsis and septic shock were enrolled in the study. The initial fluid resuscitation was performed using local protocols. The haemodynamic status was assessed after the initial fluid load by transpulmonary thermos-dilution technique and the renal outcome recorded at twenty-four hours. RESULTS: 68.6% of the patients included in the study had weight disorders ranging from BMI+20% to morbid obesity. Before IBW adjustment, only 49.3% received the 30 ml/kg fluid load recommended by Surviving Sepsis Campaign Guidelines (2016) (SSC). After IBW adjustment, 70.4% received the recommended fluid dose. The difference in fluid load/kg before and after the bodyweight adjustment was statistically significant (p<0.01). After the initial fluid load, the majority of the macro haemodynamic parameters were in the targeted range. There was no statistically significant difference between the urinary output outcome at 24 hours or the 28 days mortality rates between the patients resuscitated by the SSC and those who received less fluid. CONCLUSIONS: Advanced haemodynamic monitoring was in favour of adjusting the initial fluid load to the IBW. There were no statistically significant differences either in the urinary output outcome at twenty-four hours, or in the twenty-eight-day mortality rates between the patients who received the 30 ml/kg IBW and those who received less than 30 ml/kg IBW.

Ultrasound-based assessment of hyomental distances in neutral, ramped, and maximum hyperextended positions, and derived ratios, for the prediction of difficult airway in the obese population: a pilot diagnostic accuracy study.

BACKGROUND: Ultrasonography-assessed hyomental distance (HMD) ratio has been found to discriminate between obese patients with Cormack-Lehane grades 1 or 2 vs. those with grades 3 or 4. The aim of our study is to evaluate the performance of the HMD evaluated ultrasonographically in neutral, ramped, and maximum hyperextended positions, as well as for the ratios obtained by dividing the HMD in the ramped position to that in the neutral position (HMDR1) and by dividing the HMD in maximum hyperextension to that in the neutral position (HMDR2), in order to predict the occurrence of Cormack-Lehane grades 3 or 4 during direct laryngoscopy. METHODS: Ultrasound measurements were performed preoperatively in 25 patients with morbid obesity, measuring the HMD in the neutral, ramped, and maximum hyperextended positions. Pre-epyglotic soft tissue thickness, Mallampati and upper lip bite test scores were recorded. Cormack-Lehane grading was considered as an outcome variable in the Receiver Operating Characteristics curve analysis. RESULTS: HMD in the neutral, ramped and maximum hyperextended positions presented similar sensitivities, 100% [39.8-100.0]. For HMD, specificity was 42.86% [21.8-66.0] in the neutral position, 61.9% [38.4-81.9] in the ramped postion, and 71.4% [47.8-88.7] in the maximum hyperextended position. For HMDR1, the cut-off value was 1.12. This threshold provides 75% [19.4-99.4] sensitivity and 76.2% [52.8-91.8] specificity. For HMDR2, a cut-off value of 1.23 provides 100% [39.8-100.0] sensitivity and 90.5% [69.6-98.8] specificity. CONCLUSION: HMDR2 seems to have superior diagnostic accuracy in predicting difficult laryngoscopy in the obese population compared to HMDR1, as well as compared to the HMD in the neutral, ramped, and maximum hyperextended positions.

Polyarteritis Nodosa in Pregnancy.

BACKGROUND: Polyarteritis nodosa (PAN) is a rare disease that occurs predominantly in middle-aged males; its onset during pregnancy is exceptional. CASE REPORT: We present a case of PAN with peripartum onset in a patient with a twin pregnancy after ovarian stimulation for primary infertility. The pregnancy outcome was good in terms of the children's health. In the case of the mother, however, the presence of nonspecific signs and symptoms, a noncontributory ovarian biopsy, and mimics of a puerperal infection delayed the diagnosis of PAN. The emergence of a tender subcutaneous nodule on the forearm and its histopathologic findings were diagnostic. Treatment with pulse methylprednisolone and intravenous cyclophosphamide resulted in the patient's prompt recovery. CONCLUSION: We present the case to stress the value of careful physical examination in unveiling the presence of a rare disease.

Assessment of method agreement between two minimally invasive hemodynamic measurements in septic shock patients on high doses of vasopressor drugs. A preliminary study.

BACKGROUND: Minimally invasive hemodynamic monitoring is still controversial among the methods used to assess the hemodynamic profile of the septic shock patient. The aim of this study was to test the level of agreement between two different devices. METHODS: We collected 385 data entries during 12-hour intervals from four critically ill patients with septic shock and high doses of vasoactive therapy using two minimally invasive methods at the same time: Vigileo™ device which uses the pulse contour principle, and EV1000™ monitoring platform which uses the transpulmonary thermodilution principle. The studied parameters were Stroke Volume (SV), Cardiac Output (CO) and Mean Arterial Pressure (MAP). We tested the agreement by performing the visual examination of data patterns using graphs and studying the bias, limits of agreement and creating Bland-Altman plots. For assessing the systematic, proportional and random differences, we computed a Passing-Bablock regression with the CUSUM test for linearity. RESULTS: The one sample t-Test for the differences between the two methods against the null value was statistically significant for the studied parameters (p < 0.0001). The Bland-Altman analysis found no agreement between the data obtained using the two techniques, with calculated error percent as high as 88.28% for SV, 82.02% for CO and 42.06% for MAP. The Passing-Bablock regression analysis tested positive for systematic differences, but this could not be accounted for. CONCLUSION: We found no agreement between data obtained from the studied devices; therefore, these cannot be used interchangeably for critically ill septic shock patients on high doses of vasoactive substances.

Multiple Anesthetic Drug Sensitization in a Hairdresser With Previous Immediate-Type Hypersensitivity to Penicillin: A Case Report.

Risk factors for intraoperative immediate-type hypersensitivity reactions may require allergological evaluation. We report the case of a hairdresser with a positive history of penicillin hypersensitivity and anaphylactic shock during previous general anesthesia, whose in vivo and in vitro allergy tests were positive for neuromuscular blocking agents, opioids, and midazolam. Immediate-type hypersensitivity reactions to antibiotics and professional exposure to hairdressing products might induce simultaneous cross-sensitization to multiple drugs that are commonly used during general anesthesia.

Antibiotic-induced immediate type hypersensitivity is a risk factor for positive allergy skin tests for neuromuscular blocking agents.

BACKGROUND: Skin tests for neuromuscular blocking agents (NMBAs) are not currently recommended for the general population undergoing general anaesthesia. In a previous study we have reported a high incidence of positive allergy tests for NMBAs in patients with a positive history of non-anaesthetic drug allergy, a larger prospective study being needed to confirm those preliminary results. The objective of this study was to compare the skin tests results for patients with a positive history of antibiotic-induced immediate type hypersensitivity reactions to those of controls without drug allergies. METHODS: Ninety eight patients with previous antibiotic hypersensitivity and 72 controls were prospectively included. Skin tests were performed for atracurium, pancuronium, rocuronium, and suxamethonium. RESULTS: We found 65 positive skin tests from the 392 tests performed in patients with a positive history of antibiotic hypersensitivity (1 6.58%) and 23 positive skin tests from the 288 performed in controls (7.98%), the two incidences showing significant statistical difference (p = 0.0011). The relative risk for having a positive skin test for NMBAs for patients versus controls was 1.77 (1.15-2.76). For atracurium, skin tests were more often positive in patients with a positive history of antibiotic hypersensitivity versus controls (p = 0.02). For pancuronium, rocuronium and suxamethonium the statistical difference was not attained (p-values 0.08 for pancuronium, 0.23 for rocuronium, and 0.26 for suxamethonium). CONCLUSIONS: Patients with a positive history of antibiotic hypersensitivity seem to have a higher incidence of positive skin tests for NMBAs. They might represent a group at higher risk for developing intraoperative anaphylaxis compared to the general population.

Cerebral salt wasting syndrome in patients with minor head trauma - two case reports.

We describe two polytrauma patients without severe head trauma who developed Cerebral Salt Wasting Syndrome (CSWS) during their stay in our ICU with natriuresis, hyponatremia and hypovolemia. Hyponatremia encountered in CSWS and the syndrome of inadequate antidiuretic hormone secretion (SIADH) is a common electrolyte finding in patients with severe head trauma, subarachnoid hemorrhage, malignancy and infections of the central nervous system. CSWS was an unexpected electrolyte finding in our patients with minor head trauma without neurological or neurosurgical problems. To rule out other causes of hyponatremia (SIADH, secondary adrenal dysfunction and thyroid dysfunction) a correct diagnosis is very important, as proper treatment of CSWS with fluid and salt replacement will decrease mortality and morbidity. In conclusion, CSWS should be suspected in any polytrauma patient with minor head trauma and hyponatremia.

Can APACHE II, SOFA, ISS, and RTS Severity Scores be used to Predict Septic Complications in Multiple Trauma Patients?

BACKGROUND: Physiological composite scores are used to predict mortality in multiple trauma patients. Sepsis is the leading cause of late mortality in trauma victims brought about by immune suppression due to homeostasis dysregulation. OBJECTIVE: To determine whether APACHE II, SOFA, ISS and RTS scores can predict the occurrence of sepsis in multiple trauma patients. METHODS: APACHE II, SOFA, ISS, and RTS scores were calculated during the first twenty-four hours after the injury for sixty-four adult poly-traumatic patients. The occurrence of infectious complications was investigated over a fourteen-day period. The infection-free rates for the multiple trauma patients were considered as end-points in the Kaplan-Meier plot analysis. RESULTS: For SOFA, a cutoff score of 4 points was identified as a predictor of the occurrence of sepsis, with 89% of the patients with SOFA<4 being infection-free, while 37% of those with SOFA>4 were infection-free (p<0.01). None of the patients with APACHE II≤5 points developed infections. Eighty-four percent of patients with APACHE II scores of 5-10 did not develop sepsis, while 49% with APACHE II≥11 were infection-free (p<0.01). A cutoff of 7 points was found to be most discriminative for RTS. Eighty-eight percent of the patients with RTS≤7 and 43% of those with RTS<7 were infection-free (p<0.01). Eighty-eight percent of patients with ISS≥22 did not develop sepsis and 56% with ISS>22 did not develop sepsis (p<0.01). CONCLUSION: APACHE II, SOFA, ISS, and RTS functional severity scores can predict mortality as well as the occurrence of sepsis in multiple trauma patients.

Elevated serum total IgE alter the diagnostic performance of radio-immune assays for ß-lactam specific antibody dosing.

BACKGROUND: In vivo allergy tests and the detection of drug-specific antibodies are widely used in the diagnosis of ß-lactam induced immediate-type hypersensitivity reactions. The diagnostic performance of immunoenzymatic tests for the demonstration of serum-specific IgE (IgEs) antibodies is influenced by total IgE values (IgEt). The aim of this study was to investigate whether the result obtained by radioimmunoassays (RIA) for ß-lactams IgEs antibodies is correlated to IgEt. METHODS: 68 paired in vivo and in vitro tests were performed for the culprit drugs in 49 patients with suspected previous hypersensitivity reactions to ß-lactams. 14 controls who tolerated the tested antibiotics were similarly investigated. The dosing of IgEt was performed using the Immulite Immunoassay (Siemens). We detected IgEs using a sandwich-type RIA with sepharose as solid phase (Pathologie Cellulaire et Moléculaire en Nutrition, France) and anti-IgEs I(125)-labelled antibodies (Immunotech, Czech Republic). RESULTS: RIA-IgEs sensitivity was 56.52% in patients with IgEt < 120 IU/mL and 90.90% in patients with IgEt > 120 IU/mL (p = 0.0052). All patients with IgEt > 500 IU/mL had positive RIA results. RIA-IgEs specificity was 90.90% for IgEt < 120 IU/mL and 66.66% for IgEt > 120 IU/mL. The linear equation that fits the relation between IgEt and IgEs is: IgEs = (IgEt + 81.644)/137.94, with a correlation coefficient of 0.4. CONCLUSIONS: Serum total IgE alter the diagnostic performance of radioimmunoassays for ß-lactam specific antibody dosing. Assays for the detection of both IgEt and IgEs need to be performed for each individual investigated, retrospectively, to confirm clinical immediate-type hypersensitivity reactions.

Biomarkers in polytrauma induced systemic inflammatory response syndrome and sepsis - a narrative review.

Polytrauma still represents one of the leading causes of death in the first four decades of life. Septic complications represent the predominant causes of late death in polytrauma patients. Early diagnosis and treatment of infection is associated with an improved clinical outcome and reduced mortality. Several biomarkers have been evaluated for making early diagnosis of sepsis. Current evidence does not support the use of a single biomarker in diagnosing septic complications. Procalcitonin trend was found to be useful in early identification of post-traumatic sepsis.