Is continuous subglottic suctioning cost-effective for the prevention of ventilator-associated pneumonia?

OBJECTIVE: To establish whether continuous subglottic suctioning (CSS) could be cost-effective. DESIGN: Cost-benefit analysis, based on a hypothetical replacement of conventional ventilation (CV) with CSS. SETTING: A surgical intensive care unit (SICU) of a tertiary care university hospital in France. PATIENTS: All consecutive patients receiving ventilation in the SICU in 2006. METHODS: Efficacy data for CSS were obtained from the literature and applied to the SICU of our hospital. Costs for CV and CSS were provided by the hospital pharmacy; costs for ventilator-associated pneumonia (VAP) were obtained from the literature. The cost per averted VAP episode was calculated, and a sensitivity analysis was performed on VAP incidence and on the number of tubes required for each patient. RESULTS: At our SICU in 2006, 416 patients received mechanical ventilation for 3,487 ventilation-days, and 32 VAP episodes were observed (7.9 episodes per 100 ventilated patients; incidence density, 9.2 episodes per 10,000 ventilation-days). Based on the hypothesis of a 29% reduction in the risk of VAP with CSS than CV, 9 VAP episodes could have been averted. The additional cost of CSS for 2006 was estimated to be €10,585.34. The cost per averted VAP episode was €1,176.15. Assuming a VAP cost of €4,387, a total of 3 averted VAP episodes would neutralize the additional cost. For a low VAP incidence of 6.6%, the cost per averted VAP would be €1,323. If each patient required 2 tubes during ventilation, the cost would be €1,383.69 per averted VAP episode. CONCLUSION: Replacement of CV with CSS was cost-effective even when assuming the most pessimistic scenario of VAP incidence and costs.

Hysterectomy for benign uterine pathology among women without previous vaginal delivery.

OBJECTIVE: To evaluate the feasibility and the complication rate of vaginal hysterectomy in benign uterine pathology (except for uterine prolapse) among patients without previous vaginal delivery. METHODS: A review of the medical records in patients without previous vaginal delivery who underwent hysterectomies between January 1995 and June 2004 was carried out. Patients were divided into two different groups: group 1 included patients with first-intention abdominal hysterectomy; group 2 included patients with vaginal approach further stratified into 2a without and 2b with laparoscopic assistance. RESULTS: Three hundred patients without previous vaginal delivery underwent hysterectomy during this period. Vaginal hysterectomy was planned in 75.7% of cases. Success rate for planned vaginal hysterectomies was 92.1%. The mean weight of uteri extracted by vaginal and abdominal approaches were 326 g and 1,047 g, respectively (P<.001). The mean operative time was significantly longer in the laparoscopic-assisted approach (160 minutes) than in the abdominal approach (120 minutes), and significantly shorter in exclusively vaginal (75 minutes) than in other procedures (P<.001). The use of the laparoscopic assistance in hysterectomy decreased significantly over the period of the study (P<.001). The mean duration of hospital stay was significantly shorter in group 2 than in group 1 (3.8 days compared with 6.2 days, P<.001), but no differences were noted between subgroups 2a and 2b. CONCLUSION: Vaginal hysterectomy should not be contraindicated in patients lacking previous vaginal delivery. In these particular patients, most of the procedures can be performed by vaginal approach, with the benefit of limiting the costs and the duration of hospital stay.

Validity of medical staff assessment at admission of patient's risk of nosocomial infection: a prospective study in a surgical intensive care unit.

OBJECTIVE: To evaluate the ability of a surgical intensive care unit (SICU) medical staff to assess at admission the individual risk of nosocomial infection (NI) during SICU stay in patients admitted for at least 48 h. DESIGN: Prospective observational study. SETTING: A tertiary-care university hospital. PATIENTS AND PARTICIPANTS: 201 admissions to the SICU from November 19, 2003, until April 16, 2004. MEASUREMENTS AND RESULTS: Assessment by medical staff at admission of each patient's estimated risk of NI (pneumonia, venous central catheter-related infection, symptomatic urinary tract infection, and bacteremia) during SICU hospitalization, in order to classify patients into four groups: NI risk very low or absent (group 1), low (group 2), high (group 3), very high or certain (group 4). NI was diagnosed via routine surveillance according to Centers for Disease Control case definitions. RESULTS: 154 patients were assessed; the percentage of patients with NI increased with estimated risk at admission, from 0% in group 1 to 14.3% in group 4. Positive predictive value of medical assessment varied from 8.4% to 14.5%, according to the cutoff value. Negative predictive value varied from 92.1% to 100%. CONCLUSION: Our study suggests that ICU physicians encounter a major difficulty when informing patients or patients' families about the risk of NI occurrence, as they cannot predict this risk accurately. This limitation should be explained to patients and their families.