Subject(s)
Anesthesia/methods , Antibiotic Prophylaxis/methods , Carcinoma, Basal Cell/surgery , Carcinoma, Squamous Cell/surgery , Dermatologic Surgical Procedures/adverse effects , Postoperative Complications/prevention & control , Skin Neoplasms/surgery , Xeroderma Pigmentosum/surgery , Adolescent , Adult , Amoxicillin-Potassium Clavulanate Combination/therapeutic use , Androstanols/administration & dosage , Anemia/etiology , Anemia/therapy , Anesthesia/adverse effects , Anesthetics, Inhalation/administration & dosage , Blood Transfusion/statistics & numerical data , Carcinoma, Basal Cell/complications , Carcinoma, Basal Cell/genetics , Carcinoma, Basal Cell/pathology , Carcinoma, Squamous Cell/complications , Carcinoma, Squamous Cell/genetics , Carcinoma, Squamous Cell/pathology , Child , Child, Preschool , Female , Humans , Laryngeal Masks/adverse effects , Male , Methyl Ethers/administration & dosage , Monitoring, Intraoperative/methods , Neuromuscular Nondepolarizing Agents/administration & dosage , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Prospective Studies , Rocuronium , Sevoflurane , Skin Neoplasms/complications , Skin Neoplasms/genetics , Skin Neoplasms/pathology , Xeroderma Pigmentosum/complications , Xeroderma Pigmentosum/genetics , Xeroderma Pigmentosum/pathology , Young AdultABSTRACT
BACKGROUND: Non-ventilator ICU-acquired pneumonia after cardiothoracic surgery is challenging to diagnose, and little is known about its impact on patient outcomes. Here, our primary objective was to compare the sensitivity and specificity of cultures of 2 types of fiberoptic bronchoscopy (FOB) specimens: endotracheal aspirates (FOB-EA) and bronchoalveolar lavage fluid (FOB-BAL). The secondary objectives were to evaluate the sensitivity and specificity of spontaneous sputum cultures and of the modified Clinical Pulmonary Infection Score (CPIS) and to describe patient outcomes. METHODS: We conducted a prospective observational study of consecutive cardiothoracic surgery subjects with suspected non-ventilator ICU-acquired pneumonia. Using FOB-BAL cultures ≥10(4) cfu/mL as the reference standard, we evaluated the accuracy of FOB-EA ≥10(5) cfu/mL and spontaneous sputum ≥10(7) cfu/mL. On the day of FOB, we determined the modified CPIS. Mortality and antibiotic treatments were recorded. RESULTS: Of 105 subjects, 57 (54.3%) received a diagnosis of non-ventilator ICU-acquired pneumonia. FOB-EA cultures had 82% (95% CI 69-91%) sensitivity and 100% (95% CI 89-100%) specificity and were significantly less sensitive than FOB-BAL cultures (P < .004). Spontaneous sputum was obtained from one-third of subjects. Spontaneous sputum cultures had 82% (95% CI 56-95%) sensitivity and 94% (95% CI 68-100%) specificity and were non-significantly less sensitive than FOB-BAL (P = .061). A modified CPIS >6 had 42% (95% CI 29-56%) sensitivity and 87% (95% CI 74-95%) specificity for non-ventilator ICU-acquired pneumonia. Antibiotic therapy was stopped in all subjects without non-ventilator ICU-acquired pneumonia, after 1.6 ± 1.2 d, without deleterious effects. CONCLUSIONS: The modified CPIS has low diagnostic accuracy for non-ventilator ICU-acquired pneumonia. FOB-EA cultures perform less well than do FOB-BAL cultures for diagnosing non-ventilator ICU-acquired pneumonia. Spontaneous sputum is valuable when FOB cannot be performed but could be obtained in only a minority of subjects. When cultures are negative, antibiotic discontinuation is safe.
Subject(s)
Cardiac Surgical Procedures/adverse effects , Cross Infection/diagnosis , Intensive Care Units , Pneumonia/diagnosis , Postoperative Complications/microbiology , Aged , Aged, 80 and over , Anti-Bacterial Agents/therapeutic use , Bronchoalveolar Lavage Fluid/microbiology , Bronchoscopy/methods , Cross Infection/drug therapy , Cross Infection/microbiology , Female , Humans , Male , Middle Aged , Pneumonia/drug therapy , Pneumonia/microbiology , Prospective Studies , Sensitivity and Specificity , Sputum/microbiology , Trachea/microbiologyABSTRACT
BACKGROUND: The diagnosis of heparin-induced thrombocytopenia (HIT) is problematic in the surgical ICU, as there are multiple potential explanations for thrombocytopenia. We conducted a study to assess the incidence, clinical presentation, and outcome of HIT in a cardiothoracic surgical ICU. METHODS: From January 2005 to December 2010, all patients with suspicion of HIT were prospectively identified, and data were collected retrospectively. Detection of anti-PF4/heparin antibodies and functional assays were systematically performed. RESULTS: During the study period, 5,949 patients were admitted to the ICU (2,751 after cardiac surgery and 3,198 after thoracic surgery), of whom 101 were suspected to have HIT(1.7% [95% CI, 1.4%-2.0%]). Suspicion of HIT occurred at a median of 5 (4-9) days after ICU admission. Diagnosis was confirmed in 28 of 5,949 patients (0.47% [95% CI, 0.33%-0.68%]).Thrombosis was detected in 14 patients with HIT (50%) and in 12 patients without HIT (16%)( P 5 .0006). After receiver operating characteristic analysis (area under curve 5 0.78 0.06),a 4Ts score ≥ 5 had a sensitivity of 86% and a specificity of 70%. Course of platelet count was similar between the two groups. Six patients (21%) with HIT and 20 (27%) without died( P 5 .77). CONCLUSIONS: Even with a prospective platelet monitoring protocol, suspicion for HIT arose in <2% of patients in a cardiothoracic ICU. Most were found to have other causes of thrombocytopenia,with HIT confirmed in 28 of 101 suspected cases (0.47% of all patients in the ICU). The 4Ts score may have value by identifying patients who should have laboratory testing performed.The mortality of patients with HIT was not different from other very ill thrombocytopenic patients in the ICU.
Subject(s)
Biomarkers/blood , Cardiac Surgical Procedures , Heparin/adverse effects , Intensive Care Units , Thoracic Surgical Procedures , Thrombocytopenia/diagnosis , Aged , Antibodies/blood , Anticoagulants/adverse effects , Anticoagulants/immunology , Female , Follow-Up Studies , France/epidemiology , Heparin/immunology , Humans , Incidence , Male , Middle Aged , Platelet Count , Prospective Studies , Thrombocytopenia/chemically induced , Thrombocytopenia/epidemiology , Thrombosis/prevention & controlABSTRACT
Prune belly syndrome (PBS) is a rare congenital anomaly of uncertain etiology. Many associations of PBS with other malformations were previously reported, but only few cases of the association with VACTERL have been described. We report a rare case of a Moroccan new born with PBS and complete VACTERL association. The cause of this association is still unknown, but a common etiology is possible, especially when for the two syndromes, a defect in mesodermal differentiation, in early first trimester, has been suggested.
