High rate of Clostridioides difficile colonization in patients admitted to intensive care: A prospective cohort study.

Here, we evaluated the frequency of C. difficile colonization and its impact on clinical outcomes in patients admitted to intensive care units in Brazil. From ninety-two patients screened 16 (17.3%) were colonized by C. difficile. Colonized patients had higher Simplified Acute Physiology Score III (SAPS III), however there was no association between C. difficile colonization with diarrhea or mortality. The C. difficile strains sequenced belonged to clade 1 and presented high vancomycin-resistant rates.

Nutritional therapy and outcomes in underweight critically ill patients.

BACKGROUND & AIMS: Critically ill patients with body mass index (BMI) < 20 kg/m2 have worse outcomes than normal/overweight patients possibly because underweight is a marker of malnutrition. To assess the effects of nutrition therapy in this population during the first week of an ICU stay. METHODS: Prospective, 2-centre, observational study. Nutritional evaluations were performed between days 2 and 3 (first) and between days 5 and 7 (second) of ICU admission. In the first evaluation, patients were divided into non-fed (without nutritional support) and early-fed (those already receiving nutritional support) groups. In the second evaluation, patients were divided according to caloric intake (≥or<20 kcal/kg) and protein intake (≥or<1.3 g of protein/kg). RESULTS: Of the 4236 patients screened and 342 were included in the cohort. Mortality was 58.5% (median 21 [11-38.25] days of follow-up). Unadjusted patient survival was worse in the non-fed group than in the early-fed group (HR 1.66; 95%CI, 1.18 to 2.32). There was no difference in mortality between groups after adjusting for the SOFA score on the day of the evaluation. At the second evaluation, unadjusted analysis showed better in-hospital survival in patients with higher caloric (HR0.58; 95%CI, 0.40 to 0.86) and protein intake (HR0.59; 95%CI, 0.42 to 0.82); there was no association between mortality and caloric or protein intake after adjusting for the SOFA score on the day of the evaluation. CONCLUSION: Nutritional therapy in the first week of ICU stay did not affect vital outcome after adjusting for the SOFA score on the day of the evaluation in underweight critically ill patients. CLINICAL TRIAL REGISTRY: ClinicalTrials.gov number NCT03398343.

Is red blood cell distribution width a marker of severity in patients discharged from the ICU?

We have read the study about the association between high red blood cell distribution width and higher ward mortality after intensive care unit discharge. The study increases the evidence that RDW may be a marker of severity for patients discharged from the ICU. However, in this letter, we comment on issues that need further discussion.

Elevated red blood cell distribution width at ICU discharge is associated with readmission to the intensive care unit.

BACKGROUND: Red blood cell distribution width (RDW) is a predictor of mortality in critically ill patients. Our objective was to investigate the association between the RDW at ICU discharge and the risk of ICU readmission or unexpected death in the ward. METHODS: A secondary analysis of prospectively collected data study was conducted including patients discharged alive from the ICU to the ward. The target variable was the RDW collected at ICU discharge. Elevated RDW was defined as an RDW > 16%. Outcomes of interest included readmission to the ICU, unexpected death in the ward and in-hospital death. Variables with a p-value <0.1 in the univariate analysis or with biological plausibility for the occurrence of the outcome were included in the Cox proportional hazards model for adjustment. RESULTS: We included 813 patients. A total of 138 readmissions to the ICU and 44 unexpected deaths in the ward occurred. Elevated RDW at ICU discharge was independently associated with readmission to the ICU or unexpected death in the ward after multivariable adjustment (HR: 1.901; 95% CI 1.357-2.662). Other variables associated with this outcome included age, tracheostomy and mean corpuscular volume (MCV) at ICU discharge. Similar results were obtained after the exclusion of unexpected deaths in the ward (HR 1.940; CI 1.312-2.871) and for in-hospital deaths (HR 1.716; 95% CI 1.141-2.580). CONCLUSIONS: Elevated RDW at ICU discharge is independently associated with ICU readmission and in-hospital death.

Ventilation strategy and its influence on the functional performance of lung grafts in an experimental model of single lung transplantation using non-heart-beating donors.

OBJECTIVE: To compare the influence of two different ventilation strategies-volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV)-on the functional performance of lung grafts in a canine model of unilateral left lung transplantation using donor lungs harvested after three hours of normothermic cardiocirculatory arrest under mechanical ventilation. METHODS: The study comprised 40 mongrel dogs, randomized into two groups: VCV and PCV. Of the 20 recipients, 5 did not survive the transplant, and 5 died before the end of the post-transplant assessment period. The remaining 10 survivors (5 in each group) were evaluated for 360 min after lung transplantation. The functional performance of the grafts was evaluated regarding respiratory mechanics, gas exchange, and lung graft histology. RESULTS: There were no significant differences between the groups regarding respiratory mechanics (peak inspiratory pressure, plateau pressure, mean airway pressure, dynamic compliance, and static compliance) or gas exchange variables (PaO2, venous oxygen tension, PaCO2, venous carbon dioxide tension, and the arterial-venous oxygen content difference). The histopathological findings were consistent with nonspecific acute lung injury and did not differ between the groups. CONCLUSIONS: This model of lung transplantation showed that the functional performance of lung grafts was not influenced by the ventilation strategy employed during the first six hours after reperfusion.

Influência da estratégia ventilatória no desempenho funcional de enxertos pulmonares em um modelo experimental de transplante pulmonar unilateral de doadores após parada cardiocirculatória / Ventilation strategy and its influence on the functional performance of lung grafts in an experimental model of single lung transplantation using non-heart-beating donors

OBJETIVO: Comparar a influência de duas estratégias ventilatórias - ventilação controlada a volume (VCV) e ventilação controlada a pressão (VCP) - no desempenho funcional de enxertos pulmonares em um modelo canino de transplante pulmonar unilateral esquerdo, utilizando-se doadores cujos pulmões foram captados após três horas de parada cardiocirculatória em temperatura ambiente e sob ventilação mecânica. MÉTODOS: O estudo incluiu 40 cães mestiços randomizados nos grupos VCV e VCP. Dos 20 receptores, 5 não sobreviveram ao transplante, e 5 não sobreviveram ao período de avaliação pós-transplante. Os 10 receptores sobreviventes (5 em cada grupo) foram avaliados durante 360 min após o término do transplante pulmonar. O desempenho funcional dos enxertos foi estudado através da avaliação da mecânica respiratória, trocas gasosas e histologia do enxerto. RESULTADOS: Não houve diferenças significativas entre os grupos quanto às variáveis de mecânica respiratória (pressão de pico inspiratória, pressão de platô, pressão média de vias aéreas, complacência dinâmica e complacência estática) e de trocas gasosas (PaO2, pressão venosa mista de oxigênio, PaCO2, pressão venosa mista de CO2 e diferença arteriovenosa de oxigênio). As alterações histopatológicas foram compatíveis com o padrão de lesão pulmonar aguda não específica e não diferiram entre os grupos. CONCLUSÕES: Este modelo de transplante pulmonar mostrou que o desempenho funcional do enxerto não foi influenciado pela estratégia ventilatória utilizada até seis horas após a reperfusão.

OBJECTIVE: To compare the influence of two different ventilation strategies-volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV)-on the functional performance of lung grafts in a canine model of unilateral left lung transplantation using donor lungs harvested after three hours of normothermic cardiocirculatory arrest under mechanical ventilation. METHODS: The study comprised 40 mongrel dogs, randomized into two groups: VCV and PCV. Of the 20 recipients, 5 did not survive the transplant, and 5 died before the end of the post-transplant assessment period. The remaining 10 survivors (5 in each group) were evaluated for 360 min after lung transplantation. The functional performance of the grafts was evaluated regarding respiratory mechanics, gas exchange, and lung graft histology. RESULTS: There were no significant differences between the groups regarding respiratory mechanics (peak inspiratory pressure, plateau pressure, mean airway pressure, dynamic compliance, and static compliance) or gas exchange variables (PaO2, venous oxygen tension, PaCO2, venous carbon dioxide tension, and the arterial-venous oxygen content difference). The histopathological findings were consistent with nonspecific acute lung injury and did not differ between the groups. CONCLUSIONS: This model of lung transplantation showed that the functional performance of lung grafts was not influenced by the ventilation strategy employed during the first six hours after reperfusion.

Partial liquid ventilation with perfluorodecalin following unilateral canine lung allotransplantation in non-heart-beating donors.

BACKGROUND: The purpose of this study was to evaluate canine lungs obtained from non-heart-beating donors after unilateral lung transplantation subjected to partial liquid ventilation with perfluorodecalin. METHODS: Twelve donor dogs were killed and kept under mechanical ventilation for 3 hours. Heart-lung blocks were harvested after retrograde pulmonary hypothermic flush with Perfadex. Left lung grafts were randomly transplanted into 12 weight-matched recipient animals. Animals were divided into 2 groups: control (standard mechanical ventilation, n = 6) and PLV (partial liquid ventilation, n = 6). Forty-five minutes after transplantation, the animals in the PLV group received perfluorodecalin (15 ml/kg) via orotracheal tube. All animals received volume-controlled ventilation (FIO2) 1.0, PEEP 5 cm H(2)O) over 6 consecutive hours. Thereafter, blood-gas analysis, ventilatory mechanics and hemodynamics were registered at 30-minute intervals. After 6 hours of reperfusion the animals were killed and the transplanted lungs were extracted to obtain the wet/dry weight ratio. RESULTS: There were significant differences in pulmonary arterial pressure, which were higher in control group animals (p < 0.009). The control animals also showed higher arterial PaO(2) than those in the PLV group (p < 0.00001), but lower PaCO(2) (p < 0.008). The peak and plateau pressures were higher in the PLV group (p < 0.00001). Neither static compliance nor wet/dry weight ratios were different in between groups. CONCLUSIONS: PLV with perfluorodecalin yields functional results compatible with life in this model. Nonetheless, pulmonary gas exchange and mechanics were superior after reperfusion in animals given conventional mechanical ventilation up to 6 hours after left lung allotransplantation.