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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Evaluation of a clinical pulmonary infection score in the diagnosis of ventilator-associated pneumonia

Abstract

The most important dilemma in the diagnosis of ventilator-associated pneumonia (VAP) based on only clinical findings is overdiagnosis. The aim of the study is to prospectively evaluate the Clinical Pulmonary Infection Score (CPIS) in relation to VAP diagnosis.

Design. Prospective, in a cohort of mechanically ventilated patients.

Setting. The intensive care unit of a university hospital.

Patients. Fifty patients, on mechanical ventilation therapy for more than 48 hours, suspected of having VAP were enrolled in the study and bacteriologic confirmation was done by bronchoalveolar lavage (BAL) culture.

Interventions. Bronchoscopy with BAL fluid culture after establishing a clinical suspicion of VAP in patients having no prior antibiotic therapy or no change in current antibiotic therapy within last three days before BAL.

CPIS scores during diagnosis were 6±2 (3-9) (median±QR, maximum-minimum) and it was 7±2 (2-9) at the 72nd hour, in 41 cases with a diagnosis of VAP. In cases with no diagnosis of VAP, the CPIS scores were found to be 6±2 (4-8) and 5±3 (2-7), respectively. There was no significant difference between the VAP group and the non-VAP group at diagnosis, but was significant at 72nd hour (respectively, p=0.551 and p=0.025).

CPIS scores during diagnosis were 6±3 (4-8) (median± QR, maximum-minimum) and 7±4 (2-8) at the 72nd hour, in 14 cases with a diagnosis of early-onset VAP. In cases with a diagnosis of late-onset VAP, the CPIS scores were found to be 6±2 (3-9) and 7±2 (3-9), respectively. There was no significant difference between the early-onset VAP group and the late-onset VAP group. In conclusion, the CPIS results should be evaluated carefully in the clinical setting during the diagnosis.

Key words: ventilator associated pneumonia, CPIS, VAP diagnosis

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Observed versus predicted hospital mortality in general wards patients assisted by a medical emergency team

Abstract

Introduction. In many countries the demand for intensive care beds exceeds their availability. The Medical Emergency Team (MET) can manage critically ill patients outside the intensive care unit (ICU). Hospital mortality rate for patients admitted to general wards and assisted by the MET was never compared to the predicted mortality for the same group of patients in an ICU setting.

Methods. Single-centre, prospective, observational study on consecutive adult patients assisted by the MET in all general wards and in the Emergency Department of a 1100-bed teaching Hospital. Patients with a ‘do-not-attempt-resuscitation’ decision were excluded.

Results. Eighty-two consecutive patients were included. Observed hospital mortality was 34.1% (28 patients), while the Simplified Acute Physiology Score II (SAPS II) predicted a mortality for the first MET visit of 17% (p=0.02). Patients transferred to an ICU, but not during the first MET evaluation (delayed ICU admission), had worse than predicted outcomes, while patients immediately transferred to an ICU showed hospital mortality similar to the predicted one. The fifty patients treated for acute respiratory failure (especially those with pneumonia – 12 patients) had the worst observed/predicted hospital mortality ratio (3.0 for acute respiratory failure, p=0.02; 8.06, p=0.03 for pneumonia patients).

Conclusions. Critically ill patients who remained in general wards or who were admitted to the ICU with some delay had markedly higher hospital mortality than the SAPS II predicted hospital mortality, even if they were assisted by the MET.

Key words: medical emergency team, rapid response system, intensive care unit; critical care

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Intracranial symptomatic giant arachnoid cyst

Introduction

Intracranial arachnoid cysts are congenital compartments. They are frequently localized in the middle fossa and are intimately bordered by the arachnoid membrane. (1,2) Clinical symptoms appear commonly at an early age. Cases of symptomatic arachnoid cysts are rare in the elderly. (1,3,4)

In this case report, we describe clinical and radiological signs of a 66 year old patient presenting with a giant suprasellar arachnoid cyst. Treatment options are discussed.

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High frequency oscillatory ventilation as the most appropriate treatment for life threatening thoracic trauma

Abstract

Acute respiratory failure is common in trauma patients and can be a threat to life in severe thoracic injury. We represent a case of severe respiratory failure after blunt thoracic injury with uncontrollable bleeding and massive air leak which was successfully managed with high frequency oscillatory ventilation. In our opinion high frequency oscillatory ventilation represent a safe and effective treatment of life threatening acute respiratory failure in trauma patients.

Key words: traumatic lung injury, hypoxemic respiratory failure, air leak, cardiac arrest

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Atypical presentation of thrombosis of a permanent pacemaker lead

Abstract

Pacemaker related infective endocarditis (PMIE) and pacemaker lead thrombosis (PMLT) are infrequent but potentially lethal complications of pacemaker (PM) therapy. Differences in clinical presentation, echocardiographic appearance and laboratory findings are usually helpful in making a confident diagnosis.  On the other hand, atypical clinical and echocardiographic findings may complicate their differentiation and result in a therapeutic dilemma. We present a 70-year-old man with a permanent PM hospitalized because of a 7-day history of fever and weakness. Elevated inflammatory parameters and atypical echocardiographic findings resulted in a diagnostic dilemma between PMIE and PMLT. In this paper, we discuss the pathogenesis of these entities, their clinical presentation and therapy.

Key words: echocardiography, endocarditis, pacemaker, lead, thrombosis

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