Pre-emptive contact precautions for intubated patients reduced healthcare-associated meticillin-resistant Staphylococcus aureus transmission and infection in an intensive care unit.

Healthcare-associated infection by meticillin-resistant Staphylococcus aureus (MRSA) is still a great concern in an intensive care unit (ICU). Our surveillance data in the ICU revealed that intubated patients were at eight times higher risk of acquiring MRSA than non-intubated patients, so we hypothesised that pre-emptive contact precautions for all intubated patients would prevent healthcare-associated infection by MRSA in the ICU. Patients staying in our ICU for >2 days were included in this study. The study period was divided into two periods. During 2004 (1st period), contact precautions were performed only for patients with MRSA. During 2005-2007 (2nd period), contact precautions were applied to all intubated patients regardless of MRSA infection status. Patients were defined as MRSA-positive on admission when MRSA was detected by surveillance or clinical culture on enrolment. Other MRSA-positive results were defined as healthcare-associated MRSA (HA-MRSA) transmission. HA-MRSA infection was diagnosed according to the National Nosocomial Infections Surveillance Manual. The 1st period comprised 415 patients, and the 2nd period comprised 1280 patients. In intubated patients, HA-MRSA infection rate decreased significantly in the 2nd period (1st period 12.2%, 2nd period 5.6%; P=0.015). HA-MRSA infection of all patients decreased from 3.6 to 2.3 incidents per 1000 patient-days (P<0.05), despite a significant increase in the rate of patients MRSA positive on admission in the 2nd period (1st period 2.9%; 2nd period 6.1%). Pre-emptive contact precautions for intubated patients would be helpful in reducing HA-MRSA infection in ICU.

Gastrointestinal dysmotility is associated with altered gut flora and septic mortality in patients with severe systemic inflammatory response syndrome: a preliminary study.

BACKGROUND: The gut is an important target organ for injury after severe insult, and resolution of feeding intolerance is crucial for critically ill patients. We investigated gut flora and motility to evaluate the impact of gastrointestinal dysmotility on septic complications in patients with severe systemic inflammatory response syndrome (SIRS). METHODS: Sixty-three ICU patients with severe SIRS were divided into two groups depending on their intestinal condition. Patients with feeding intolerance comprised patients who had feeding intolerance, defined as ≥ 300 mL reflux from nasal gastric feeding tube in 24 h, and patients without feeding intolerance comprised patients with no feeding intolerance. We compared fecal microflora, incidences of bacteremia, and mortality between these groups. KEY RESULTS: Analysis of feces showed that patients with feeding intolerance had significantly lower numbers of total obligate anaerobes including Bacteroidaceae and Bifidobacterium, higher numbers of Staphylococcus, lower concentrations of acetic acid and propionic acid, and higher concentrations of succinic acid and lactic acid than those in patients without feeding intolerance (P ≤ 0.05). Patients with feeding intolerance had higher incidences of bacteremia (86%vs 18%) and mortality (64%vs 20%) than did patients without feeding intolerance (P ≤ 0.05). CONCLUSIONS & INFERENCES: Gut flora and organic acids were significantly altered in patients with severe SIRS complicated by gastrointestinal dysmotility, which was associated with higher septic mortality in SIRS patients.

Vertex epidural hematoma associated with traumatic arteriovenous fistula of the middle meningeal artery: a case report.

BACKGROUND: Vertex epidural hematomas are rare. We describe the features of a vertex epidural hematoma associated with an arteriovenous fistula (AVF) of the meningeal artery created by a laceration of the dura mater underlying a linear skull fracture. Although AVF associated with convexity epidural hematomas has been reported, we know of no such previous report of vertex epidural hematomas. CASE DESCRIPTION: A 65-year-old woman presented with generalized headache following head injury. On hospital day 3, she developed a left hemiparesis. Magnetic resonance imaging (MRI) disclosed a thick epidural hematoma at the vertex. Cerebral angiography showed an AVF between the middle meningeal artery and a venous lake. On hospital day 4, the epidural hematoma was evacuated. CONCLUSION: Although coronal MRI was important for diagnosis of this vertex epidural hematomas, the case particularly illustrates the importance of cerebral angiography. The delayed onset of hemiparesis most likely reflected a continuing increase in hematoma volume because of bleeding from the lacerated meningeal artery.

Cosmetic and functional reconstruction achieved using a split myofascial bone flap for pterional craniotomy. Technical note.

Cosmetic deformities that appear following pterional craniotomy are usually caused by temporal muscle atrophy, injury to the frontotemporal branch of the facial nerve, or bone pits in the craniotomy line. To resolve these problems during pterional craniotomy, an alternative method was developed in which a split myofascial bone flap and a free bone flap are used. The authors have used this method in the treatment of 40 patients over the last 3 years. Excellent cosmetic and functional results have been obtained. This method can provide wide exposure similar to that achieved using Yasargil's interfascial pterional craniotomy, without limiting the operative field with a bulky temporal muscle flap.

[Surgical treatment of unruptured cerebral aneurysms and complications in patients with ischemic cerebrovascular disease].

Patients who have unruptured intracranial aneurysms associated with ischemic cerebrovascular disease are a high-risk group for surgery. We have done clipping surgery in 15 patients among 40 with ischemic cerebrovascular disease. The criteria for surgery included an age below 65 years, CBF of more than 35 ml/100 g/min, and favorable ADL comparable to Rankin score 0-III. Two patients received simultaneous aneurysm clipping and superficial-middle cerebral artery anastomosis. Only one patient suffered from ischemia-related permanent neurological worsening, and one had direct optic nerve injury. Surgical mortality was 0%, and morbidity was 15%. There were two patients who had transient neurological worsening. These results suggest that surgical treatment of unruptured cerebral aneurysms is not contraindicated in patients with ischemic brain disease, but careful selection and careful perioperative management are mandatory for preventing surgical complications.

Cerebral aneurysm associated with an anomalous hyperplastic anterior choroidal artery.

An unruptured internal carotid artery (ICA) aneurysm arising at the origin of a hyperplastic anomalous AchoA was identified together with a second unruptured middle cerebral artery aneurysm during angiography performed to investigate a striatal and intraventricular haemorrhage in a 55-years-old woman. The anomalous hyperplastic AchoA supplied the left temporal and occipital lobes, and the aneurysm arose proximal to its origin. The patient underwent clipping of the aneurysms, and intra-operative observation revealed that several perforating branches arose directly from the ICA between the AchoA and the ICA bifurcation.

The dimer and trimer of 3-hydroxybutyrate oligomer as a precursor of ketone bodies for nutritional care.

BACKGROUND: Ketone bodies have been considered as a means of providing energy because of their good penetration and rapid diffusion in peripheral tissues. However, because the currently available form of 3-hydroxybu-tyrate is the sodium salt, the sodium load is problematic. To avoid it, a mixture of dimer and trimer has been prepared as a precursor of D-3-hydroxybutyrate. The purpose of this study was to investigate whether and how the solution would be converted to monomers. METHODS: The plasma concentration of 3-hydroxybutyrate monomer was measured in 10 rats during infusion of dimer and trimer. Stepwise dilutions of the solution were incubated with serum and liver homogenates from five rats, serum samples from five volunteers, and a liver sample from one patient with liver injury. The solution also was incubated with carboxylesterase and triacylglycerol lipase. The concentration of monomer in the medium was measured after incubation. RESULTS: The plasma concentration of 3-hydroxybutyrate monomer reached 572 +/- 11 micromol/L 15 minutes after beginning infusion of the mixture at a rate of 25 micromol x kg(-1) x min(-1) and 270 +/- 40 micromol/L at a rate of 12.5 micromol x kg(-1) min(-1). The solution was converted completely to monomers when incubated with rat serum or liver homogenate for 10 minutes. The mixture also was hydrolyzed by human liver homogenate but not by serum. CONCLUSIONS: The dimer and trimer of 3-hydroxybutyrate can be converted rapidly to monomer in rat and human tissues. 3-Hydroxybutyrate oligomers could be an energy substrate for injured patients.

[Cigarette smoking increases the risk of developing a cerebral aneurysm and of subarachnoid hemorrhage].

Despite recent advances in diagnostic and therapeutic techniques, subarachnoid hemorrhage (SAH) is still a serious condition associated with high mortality and morbidity. There are no effective treatments other than surgical intervention. However, another option for decreasing the occurrence of SAH may be prevention of aneurysms formation and of their rupture by controlling risk factors. Cigarette smoking has been recently shown to be one of the major risk factors for SAH. We investigated whether cigarette smoking increased the risk of developing cerebral aneurysms and of SAH. Degree of smoking was investigated in 182 patients with SAH and in 123 patients with an unruptured cerebral aneurysm incidentally detected during investigation of other diseases. Sixty-nine patients with other diseases who were shown to be free of cerebral aneurysms through MR angiography served as controls. Smoking significantly increased the risk of both aneurysm formation and SAH; The odds ratio for SAH was 2.4, and for unruptured cerebral aneurysm 1.7. Smoking especially increased the occurrence of SAH in women and in youngsters. However, smoking did not influence the occurrence of cerebral vasospasm and multiplicity of aneurysms. These data suggest the importance of avoiding smoking to prevent the occurrence of cerebral aneurysms and of SAH.

Selectin blockade worsened lipopolysaccharide-induced lung injury in a swine model.

BACKGROUND: Polymorphonuclear leukocytes have been reported to play an important role in various acute lung injuries. Neutrophil recruitment into tissues is a multistep process involving sequential engagement of adhesion molecules. The objective of this study was to determine the effect of selectin inactivation with Sulfo Lewis C (SO3-3betaGal1-3betaGlcNAc-O(CH2)8-COOMe) on the pulmonary response to lipopolysaccharide (LPS) infusion. METHODS: All animals (n = 11) were pretreated with an intramuscular injection of a priming dose of Escherichia coli LPS (10 microg/kg). Eighteen hours later, animals received an intravenous infusion of LPS (20 microg/kg) over 20 minutes. All animals were resuscitated with a lactated Ringer's solution. Group I (G1; n = 5) received no additional treatment. Group II (G2; n = 6) received a bolus injection of Sulfo Lewis C (10 mg/kg) 10 minutes before LPS insult followed by a continuous infusion (1 mg/kg per hour) for the rest of the study. Animals were observed for 5 hours from initiation of the LPS infusion and killed. Cardiopulmonary variables and blood gases were measured serially. The multiple inert gas elimination technique (MIGET) was used to evaluate the matching of air flow and blood flow in the lung 5 hours after LPS infusion. Histologic evaluation of the parenchymal injury was performed by using light microscopy. The number of polymorphonuclear leukocytes and red blood cells in the alveolar spaces per field at 400x magnification were counted in 10 randomly selected fields. RESULTS: Hypoxemia, indexed as Pao2/FIO2, was exacerbated by the administration of Sulfo Lewis C (G1:437+/-33 vs. G2: 241+/-63 mm Hg at 5 hours, p<0.03). This finding is supported by the multiple inert gas elimination technique analysis, which demonstrated significantly greater blood flow to true shunt in G2 (G1:4.42+/-1.75 vs. G2:23.2+/-5.69, p<0.02). There was no difference between the two groups in red blood cell counts in the alveolar spaces. However, polymorphonuclear leukocyte counts were significantly greater in G2 (G1:1.8+/-0.58 vs. G2:9.9+/-2.34, p<0.01). CONCLUSION: Selectin blockade significantly worsened lung injury induced by LPS infusion, and greater numbers of neutrophils were observed in alveolar spaces in the group treated with Sulfo Lewis C. These findings are supported by the multiple inert gas elimination technique analysis, which demonstrated significantly greater blood flow to the true shunt compartment in treated animals. Further studies are required to determine the role of selectins in sepsis-induced lung injury.

Biphasic changes in left ventricular function during hyperdynamic endotoxemia.

Cardiac contractility was studied in a clinically relevant conscious swine model simulating human hemodynamics during endotoxemia. The slope of the end-systolic pressure-volume relationship [end-systolic elastance (EES)] was used as a load-independent contractility index. Chronic instrumentation in 10 pigs included two pairs of endocardial ultrasonic crystals for measuring internal major and minor axial dimensions of the left ventricle, a micromanometer for left ventricular pressure measurement, and a thermodilution pulmonary artery catheter. After a 10-day recovery period, control measurements of cardiac hemodynamic function were obtained. The following week, Escherichia coli endotoxin (10 micrograms . kg-1. h-1) was administered intravenously for 24 h. EES increased 1 h after endotoxin infusion and decreased beyond 7 h. The later hemodynamic changes resembled human cardiovascular performance during endotoxemia more closely than the changes during the acute phase. EES decreased in the later phase. A similar biphasic response of EES has been reported during a tumor necrosis factor-alpha (TNF) challenge. Even though plasma TNF was highest at 1 h and declined thereafter in this study, no consistent relationship between TNF and EES was identified, and TNF levels did not correlate directly with the changes in EES.

Effects of long-term hemofiltration on circulating mediators and superoxide production during continuous endotoxin administration.

BACKGROUND: The purpose of this study was to test whether continuous hemofiltration eliminates cytokines and eicosanoids, or stimulates granulocyte function. METHODS: Nineteen pigs were divided into a control group (n = 7), a hemofiltration group (n = 7), and an extracorporeal circuit only group (n = 5). All animals received the same amount of intravenous endotoxin and resuscitation fluid. Zero-balanced hemofiltration was started 30 minutes after initiation of endotoxemia and continued throughout the experiment. Plasma endotoxin, tumor necrosis factor-alpha, eicosanoids, superoxide production, and other physiologic parameters were measured before challenge and at scheduled intervals thereafter. RESULTS: Eicosanoids were filtered but plasma concentrations were not reduced. Tumor necrosis factor-alpha was not filtered or adsorbed. There were no significant differences between groups in any measured parameters. CONCLUSION: Continuous hemofiltration could not efficiently remove tumor necrosis factor-alpha or eicosanoids. Also, continuous hemofiltration did not stimulate production of the proinflammatory mediators measured, nor improve respiratory distress.

Inhaled nitric oxide prevents left ventricular impairment during endotoxemia.

We evaluated the effect of long-term inhalation of nitric oxide (NO) on cardiac contractility after endotoxemia by using the end-systolic elastance of the left ventricle (LV) as a load-independent contractility index. Chronic instrumentation in 12 pigs included implantation of two pairs of endocardial dimension transducers to measure LV volume and a micromanometer to measure LV pressure. One week later, the animals were divided into a control group (n = 6) or a NO group (n = 6). All animals received intravenous Escherichia coli endotoxin (10 micrograms. kg-1. h-1) and equivalent lactated Ringer solution. NO inhalation (20 parts/million) was begun 30 min after the initiation of endotoxemia and was continued for 24 h. In both groups, tachycardia, pulmonary hypertension, and systemic hyperdynamic changes were noted. The end-systolic elastance in the control group was significantly decreased beyond 7 h. NO inhalation maintained the end-systolic elastance at baseline levels and prevented its impairment. These findings indicate that NO exerts a protective effect on LV contractility in this model of endotoxemia.

Effect of Sulfo Lewis C on smoke inhalation injury in an ovine model.

OBJECTIVE: To evaluate the effect of Sulfo Lewis C (SO3-3âGal1-3GlcNAc-O(CH2)8-COOMe), a putative ligand of selectins, on smoke inhalation injury. DESIGN: Prospective animal study with concurrent controls. SETTING: An animal laboratory. SUBJECTS: Twelve 1-yr-old female sheep, weighing 24 to 33 kg. INTERVENTIONS: Twelve sheep received nine exposure units of smoke generated by thermolysis of pine woodchips (80 g). Group 1 (n = 6) was untreated. Group 2 (n = 6) was treated with an intravenous infusion of Sulfo Lewis C after smoke exposure. Animals were killed 48 hrs after injury. MEASUREMENTS AND MAIN RESULTS: Cardiopulmonary variables and blood gases were measured serially. Granulocyte free-radical production was measured before smoke exposure and at 4 and 48 hrs after injury. Ventilation/perfusion distribution (VA/Q) was analyzed using the multiple inert gas elimination technique. Granulocyte free-radical production was increased after smoke exposure in both groups. Oxygenation was significantly improved by the administration of Sulfo Lewis C. VA/Q analysis demonstrated significantly less blood flow to low VA/Q lung segments in treated animals. CONCLUSIONS: Selectin blockade attenuated lung injury after smoke exposure. These data support the hypothesis that neutrophils play a pivotal role in smoke inhalation injury.

Effects of burns on inhalation injury.

BACKGROUND: There are few studies of smoke injury combined with thermal burn. METHODS: Seven sheep (G1) received smoke injury alone; eight (G2) received a 40% full-thickness scald burn immediately after smoke injury. All animals were resuscitated with lactated Ringer's solution and killed 48 hours after injury. Cardiopulmonary variables and blood gases were measured serially. Ventilation perfusion distribution was analyzed using the multiple inert gas elimination technique. Lung wet to dry weight ratio and malondialdehyde levels were determined. RESULTS: G2 resulted in early significant hemodynamic changes. Serum total protein concentration was significantly lower and malondialdehyde significantly higher in G2. However, PaO2, lung wet to dry weight ratio, and ventilation perfusion mismatching in G2 did not differ from those in G1. CONCLUSIONS: Although the addition of burn injury exaggerated the lung lipid peroxidation and hypoproteinemia in the presence of more pronounced hemodynamic changes, the pulmonary dysfunction was not accentuated.

Paradoxical positive nitrogen balance in burn patients receiving high-dose administration of insulin for nutritional care.

BACKGROUND: Nitrogen balance in patients who need high-dose administration of insulin has not been evaluated clinically. The purpose of this study was to compare the difference in nitrogen balance between burn patients who received high-dose administration of insulin and those who did not. METHODS: This study was performed in 19 severely burned adults with no liver or kidney failure. Patients were divided into two groups on the basis of the mean ratio of administered insulin and calorie intake (I/C) for the initial 4 weeks, a high I/C group (n = 9) and a low I/C group (n = 10). There were no significant differences between the two groups regarding age, percentage of area burned, and body weight. Nitrogen balance, blood urea nitrogen, and urine urea nitrogen were measured in all patients. Plasma concentrations of glucose, insulin, glucagon, cortisol, and urinary excretion of 3-methyl-histidine were measured in 12 patients (six in each group). RESULTS: Until day 10 both groups exhibited similar changes in plasma concentrations of glucose, insulin, glucagon, and cortisol. Subsequently, plasma concentrations of insulin and glucagon began to decrease in the low I/C group, whereas a high level was sustained in the high I/C group (p < 0.05). Plasma glucose and cortisol measurements showed no significant differences between the two groups. Blood urea nitrogen levels and urinary excretion of 3-methyl-histidine were not different between the two groups. Urine urea nitrogen excretion in the high I/C group, however, was significantly lower than that in the low I/C group from day 8 (p < 0.05). Thus the high I/C group achieved positive nitrogen balance more quickly than the low I/C group. Paradoxically, however, the high I/C group was at higher risk of septic complications and exhibited higher mortality than the low I/C group (p < 0.05). CONCLUSIONS: These results indicate that an improvement in nitrogen balance, which is accepted as a good thing in the management of critically ill patients, is not necessarily good in the high I/C group and that residual nitrogen was retained within the body in the high I/C group.

Low oxygen extraction despite high oxygen delivery causes low oxygen consumption in patients with burns recovering slowly from operative hypothermia.

BACKGROUND: Patients with burns who eventually succumbed to their injuries tended to recover more slowly from operative hypothermia than those who survived. Slower recovery was associated with a lower postoperative oxygen consumption (VO2). We have now investigated whether this was due to impairment of oxygen delivery or extraction. METHODS: This study was performed in 13 adult patients with severely burns. One hundred four measurements of VO2 by indirect calorimetry were made during recovery from 23 episodes of operative hypothermia in 11 patients. Sixty-six measurements of oxygen transport variables by balloon-tipped pulmonary artery catheter were made after 17 episodes of operative hypothermia in six patients. Body temperature was monitored in the urinary bladder. RESULTS: The rate of temperature rise (T) showed a strong positive correlation with VO2 measured both by indirect calorimetry (r = 0.91, p < 0.001) and by balloon-tipped pulmonary artery catheter (r = 0.83, p < 0.001). Oxygen delivery (DO2) was above normal in nearly all patients. Oxygen extraction was low in patients recovering slowly (T < 1.0 degree C/hr) and high in those recovering quickly (T > or = 1.0 degree C/hr). During fast recovery VO2 (373 +/- 77 ml.min-1.m-2; mean +/- SD) was approximately three times normal and was independent of DO2. In contrast, a strong linear relationship existed between VO2 and DO2 during slow recovery (r = 0.76, p < 0.001). CONCLUSIONS: Patients with burns with slow recovery from operative hypothermia exhibited impaired oxygen extraction and dependence of VO2 on DO2 over a wide range. This picture resembles that in patients with critical illness.

Differences in body temperature changes during dressing change in surviving and non-surviving burned patients.

Change in body temperature (delta BT) while dressings were being changed was measured in 52 extensively burned adults. The patients were divided into four groups based on outcome and the prognostic burn index (PBI; age + burn index): group I (15 survivors, PBI less than or equal to 80), group II (15 survivors, PBI between 80 and 120), group III (14 non-survivors, PBI between 80 and 120), and group IV (eight non-survivors, PBI greater than 120). The body temperature before the change of dressings was the same in the four groups. The mean(s.d.) delta BT in all patients was -0.5(0.8) degrees C. The magnitude of delta BT was not related to the time required for changing dressings (r = 0.04) or to the non-epithelialized area present at each change of dressings (r = -0.05). All groups showed a similar increase in delta BT during the early period after the burn, but in group I it began to decrease progressively after the 16th day after the burn (P < 0.05). A reduction in delta BT was noted in group II from day 25, whereas it was unchanged in groups III and IV (P < 0.05). It also significantly increased 2 days before the diagnosis of sepsis (P < 0.05). These results emphasize that delta BT may provide useful information about prognosis and the development of sepsis.