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J F Timsit

Publications and source records attributed to J F Timsit.

At least 19 recordsLinked to original sources
PubMed2003

[Infections by Candida sp. in intensive care. Survey of French practices].

OBJECTIVE: The isolation of Candida sp in nosocomial infections is on the increase and over the past 10 years many guidelines for "good" practices and recommendations have been published on the modalities for the management of systemic candidiasis. The aim of this paper was to assess the habits in the intensive care units in this domain in France. METHOD: A transversal survey on the habits was conducted from March to May 2001, using a questionnaire mailed to 200 intensive care units. RESULTS: One hundred eighty questionnaires (surgical reanimation: 12%, medical: 18%, medico-surgical: 70%) out of 200 (92.5%) were returned. The indirect diagnostic examinations: serology, search for antigenemia and PCR (Polymerase Chain Reaction) were never used in 21, 35 and 65% of cases. The systematic search for colonisation (a mean of 4 areas sampled) was conducted in all the patients by 19% of the investigators, in some patients by 53%, and never by 28%. An antifungal treatment was prescribed: in the presence of a positive haemoculture alone, once out of twice if the sample had been taken from a central catheter and in 2 cases out of 3 when the sample was peripheral. It was prescribed 6 times out of 10 after isolation of Candida sp following surgery or on needle aspiration of an intra-abdominal abscess, varyingly in the case of cadiduria, isolation of a Candida sp in a broncho-pulmonary sample or in abdominal draining and positive culture of a catheter, depending on the intensity of the colonisation, the severity of the clinical picture and the presence of factors of risk for Candida infection. It is still prescribed empirically depending on the same elements and the absence of explanation for worsening. When faced with candidemia in a non-neutropenic patient, a central catheter is not changed in 18% of cases. Depending on the microbiology, fluconazole is prescribed in: the identification of yeast without further precision (78% of cases), Candida sp without further precision (86% of cases), Candida non albicans without further precision (57% of cases), C. albicans (93% of cases), Candida non albicans other than C. krusei and C. glabrata (62% of cases), C. glabrata (36% of cases) with an increase in dose in 1 out of 2 cases. In the presence of C. glabrata or C. krusei, amphotericin B is the choice in respectively 51 and 75% of cases. To adapt the treatment.

Adult↗
PubMed2001

Usefulness of a strategy based on bronchoscopy with direct examination of bronchoalveolar lavage fluid in the initial antibiotic therapy of suspected ventilator-associated pneumonia.

OBJECTIVES: To evaluate (a) the routine accuracy of bronchoalveolar lavage by direct examination (BAL-D) in diagnosing ventilator-associated pneumonia (VAP), and (b) the impact of a diagnostic strategy including clinical judgment, bronchoscopy, and BAL-D on the initial diagnosis and appropriateness of treatment when VAP is suspected. DESIGN AND SETTING: Prospective cohort study in two academic ICUs in Paris, France. PATIENTS AND PARTICIPANTS: Mechanically ventilated patients with suspected VAP underwent bronchoscopy with BAL and protected specimen brush (PSB). BAL-D results were available within 2 h, BAL on culture and PSB results after 24 h, and antibiotic susceptibility after 48 h. At each step in the strategy the senior and the resident in charge of the patient were asked their diagnosis and their therapeutic plan on the basis of presently available data. Definite diagnosis of suspected VAP was based on histology, appearance of cavitation, positive pleural fluid culture, results of PSB and BAL culture, and follow-up. MEASUREMENT AND RESULTS: A total of 110 episodes of suspected VAP were studied; 94 definite diagnoses were made (47 VAP, 47 no VAP). Using a threshold 1% of infected cells, BAL-D discriminated well between patients with and those without VAP (sensitivity 93.6%, specificity 91.5%, area under the receiver-operating characteristic curve 0.953). The senior clinical judgment was correct in 71% cases. It was correct in 78% and 94% of cases after airway visualization and BAL-D findings, respectively. After BAL-D the positive and negative predictive values in diagnosing VAP were 90% and 98%, respectively. However, the therapeutic plan was correct in only 65% using clinical judgment (15 untreated patients, 3 ineffective treatment, 15 useless treatment), 66% using airway visualization (14 untreated VAP, 4 ineffective treatment, 14 useless treatment), and 88% using BAL-D results (1 untreated patients, 6 ineffective, 4 useless), according to definite diagnosis and final antibiotic susceptibility testings. CONCLUSIONS: A strategy based on bronchoscopy and BAL-D generally leads to a rapid and appropriate treatment of nosocomial pneumonia in ventilated patients.

Anti-Bacterial Agents↗
PubMed2001

Accuracy of a composite score using daily SAPS II and LOD scores for predicting hospital mortality in ICU patients hospitalized for more than 72 h.

UNLABELLED: In most databases used to build general severity scores the median duration of intensive care unit (ICU) stay is less than 3 days. Consequently, these scores are not the most appropriate tools for measuring prognosis in studies dealing with ICU patients hospitalized for more than 72 h. PURPOSE: To develop a new prognostic model based on a general severity score (SAPS II), an organ dysfunction score (LOD) and evolution of both scores during the first 3 days of ICU stay. DESIGN: Prospective multicenter study. SETTING: Twenty-eight intensive care units (ICUs) in France. PATIENTS: A training data-set was created with four ICUs during an 18-month period (893 patients). Seventy percent of the patients were medical (628) aged 66 years. The median SAPS II was 38. The ICU and hospital mortality rates were 22.7% and 30%, respectively. Forty-seven percent (420 patients) were transferred from hospital wards. In this population, the calibration (Hosmer-Lemeshow chi-square: 37.4, P = 0.001) and the discrimination [area under the ROC curves: 0.744 (95 % CI: 0.714-0.773)] of the original SAPS II were relatively poor. A validation data set was created with a random panel of 24 French ICUs during March 1999 (312 patients). MEASUREMENTS AND MAIN RESULTS: The LOD and SAPS II scores were calculated during the first (SAPS1, LOD1), second (SAPS2, LOD2), and third (SAPS3, LOD3) calendar days. The LOD and SAPS scores alterations were assigned the value "1" when scores increased with time and "0" otherwise. A multivariable logistic regression model was used to select variables measured during the first three calendar days, and independently associated with death. Selected variables were: SAPS II at admission [OR: 1.04 (95 % CI: 1.027-1.053) per point], LOD [OR: 1.16 (95 % CI: 1.085-1.253) per point], transfer from ward [OR: 1.74 (95 % CI: 1.25-2.42)], as well as SAPS3-SAPS2 alterations [OR: 1.516 (95 % CI: 1.04-2.22)], and LOD3-LOD2 alterations [OR: 2.00 (95 % CI: 1.29-3.11)]. The final model has good calibration and discrimination properties in the training data set [area under the ROC curve: 0.794 (95 % CI: 0.766-0.820), Hosmer-Lemeshow C statistic: 5.56, P = 0.7]. In the validation data set, the model maintained good accuracy [area under the ROC curve: 0.826 (95 % CI: 0.780-0.867), Hosmer-Lemeshow C statistic: 7.14, P = 0.5]. CONCLUSIONS: The new model using SAPS II and LOD and their evolution during the first calendar days has good discrimination and calibration properties. We propose its use for benchmarking and evaluating the over-risk of death associated with ICU-acquired nosocomial infections.

APACHE↗
PubMed2001

Colonization with methicillin-resistant Staphylococcus aureus in ICU patients: morbidity, mortality, and glycopeptide use.

OBJECTIVE: To determine the impact of methicillin-resistant Staphylococcus aureus (MRSA) colonization on the occurrence of S. aureus infections (methicillin-resistant and methicillin-susceptible), the use of glycopeptides, and outcome among intensive care unit (CU) patients. DESIGN: Prospective observational cohort survey. SETTING: A medical-surgical ICU with 10 single-bed rooms in a 460-bed, tertiary-care, university-affiliated hospital. PATIENTS: A total of 1,044 ICU patients were followed for the detection of MRSA colonization from July 1, 1995, to July, 1 1998. METHODS: MRSA colonization was detected using nasal samples in all patients plus wound samples in surgical patients within 48 hours of admission or within the first 48 hours of ICU stay and weekly thereafter. MRSA infections were defined using Centers for Disease Control and Prevention standard definitions, except for ventilator-associated pneumonia and catheter-related infections, which were defined by quantitative distal culture samples. RESULTS: One thousand forty-four patients (70% medical patients) were included in the analysis. Mean age was 61+/-18 years; mean Simplified Acute Physiologic Score (SAPS) II was 36.4+/-20; and median ICU stay was 4 (range, 1-193) days. Two hundred thirty-one patients (22%) died in the ICU. Fifty-four patients (5.1%) were colonized with MRSA on admission, and 52 (4.9%) of 1,044 acquired MRSA colonization in the ICU. Thirty-five patients developed a total of 42 S. aureus infections (32 MRSA, 10 methicillin-susceptible). After factors associated with the development of an S. aureus infection were adjusted for in a multivariate Cox model (SAPS II >36: hazard ratio [HR], 1.64; P=.09; male gender: HR, 2.2; P=.05), MRSA colonization increased the risk of S. aureus infection (HR, 3.84; P=.0003). MRSA colonization did not influence ICU mortality (HR, 1.01; P=.94). Glycopeptides were used in 11.4% of the patients (119/1,044) for a median duration of 5 days. For patients with no colonization, MRSA colonization on admission, and ICU-acquired MRSA colonization, respectively, glycopeptide use per 1,000 hospital days was 37.7, 235.2, and 118.3 days. MRSA colonization per se increased by 3.3-fold the use of glycopeptides in MRSA-colonized patients, even when an MRSA infection was not demonstrated, compared to non-colonized patients. CONCLUSIONS: In our unit, MRSA colonization greatly increased the risk of S. aureus infection and of glycopeptide use in colonized and non-colonized patients, without influencing ICU mortality. MRSA colonization influenced glycopeptide use even if an MRSA infection was not demonstrated; thus, an MRSA control program is warranted to decrease vancomycin use and to limit glycopeptide resistance in gram-positive cocci.

Adult↗
PubMed2001

Continuous versus intermittent infusion of vancomycin in severe Staphylococcal infections: prospective multicenter randomized study.

A continuous infusion of vancomycin (CIV) may provide an alternative mode of infusion in severe hospital-acquired methicillin-resistant staphylococcal (MRS) infections. A multicenter, prospective, randomized study was designed to compare CIV (targeted plateau drug serum concentrations of 20 to 25 mg/liter) and intermittent infusions of vancomycin (IIV; targeted trough drug serum concentrations of 10 to 15 mg/liter) in 119 critically ill patients with MRS infections (bacteremic infections, 35%; pneumonia, 45%). Microbiological and clinical outcomes, safety, pharmacokinetics, ease of treatment adjustment, and cost were compared. Microbiological and clinical outcomes and safety were similar. CIV patients reached the targeted concentrations faster (36 +/- 31 versus 51 +/- 39 h, P = 0.029) and fewer samples were required for treatment monitoring than with IIV patients (7.7 +/- 2.2 versus 11.8 +/- 3.9 per treatment, P < 0.0001). The variability between patients in both the area under the serum concentration-time curve (AUC(24h)) and the daily dose given over 10 days of treatment was lower with CIV than with IIV (variances, 14,621 versus 53,975 mg(2)/liter(2)/h(2) [P = 0.026] and 414 versus 818 g(2) [P = 0.057], respectively). The 10-day treatment cost per patient was $454 +/- 137 in the IIV group and was 23% lower in the CIV group ($321 +/- 81: P < 0.0001). In summary, for comparable efficacy and tolerance, CIV may be a cost-effective alternative to IIV.

Adult↗
PubMed2001

[Nosocomial pneumopathy acquired under mechanical ventilation. Suspicion criteria, bacteriologic diagnosis, and remission criteria].

In intensive care patients, pneumonia acquired under ventilatory assistance is the second most frequent nosocomial infection after urinary tract infection. Duration of ventilatory assistance and stay in the intensive care unit are both increased in this leading cause of death due to nosocomial infection. A large number of studies and national and international consensus conferences have been devoted to determining precise criteria leading to clinical suspicion of pneumonia acquired under ventilatory assistance and the appropriate elements for bacteriological diagnosis. The criteria retained in these different studies are neither precise nor reproductable. Based on data in the literature and our their clinical experience the members of the Outcomerea association constituted working groups to elaborate a set of guidelines that could be applied in routine clinic in response to three questions: 1) what criteria are suggestive of pneumonia acquired under ventilatory assistance, 2) what bacteriological tools are needed to confirm diagnosis, 3) how and why should cure be defined. We present a review of the literature and the conclusions of the working groups.

Cross Infection↗
PubMed2000

A one-year prospective study of nosocomial bacteraemia in ICU and non-ICU patients and its impact on patient outcome.

A one-year, prospective, two-observational cohort study was performed to evaluate the incidence and outcome in hospitalized patients (ICU and non-ICU) of nosocomial bacteraemia, and to assess its prognostic value in the ICU group. A group of 18 098 hospitalized patients and a group of 291 consecutive ICU patients were followed. Prognostic factors were determined using single and multivariable analyses. 109 (90 non-ICU and 19 ICU) patients developed 118 nosocomial bacteraemic episodes. The incidence of nosocomial bacteraemia was 6.0 per 1000 admissions (95% confidence interval (CI): 5-7%) and 65 per 1000 admissions in ICU patients (95% CI: 4.5-8.5%). Gram-positive and Gram-negative bacteria were 63/133 (47%) and 70/133 (53%) of the isolated micro-organisms respectively. Crude mortality rates were 41/109 (38%) with adverse outcome associated with mechanical ventilation (OR: 3.6; 95% CI: 1.4-9.2, P =0.01), neutropenia (OR: 7.7; 95% CI: 0.8-73.1;P =0.07) while gastro-intestinal surgery was associated with an improved outcome (OR: 0.4; 95% CI: 0.16-0.96;P =0.04). Of the 291 ICU patients, 19 acquired 22 episodes of nosocomial bacteraemia, and 18 were referred from the wards with documented nosocomial bacteraemia. Of these 37 bacteraemic patients, 17 (46%) died. When adjusting for predictors of death (SAPS II>/=40, cardiac and neurological failure), nosocomial bacteraemia markedly influence the outcome in ICU patients (OR: 3.4; 95% CI: 1.3-8.7;P =0.010). This study suggests that the outcome of nosocomial bacteraemia in hospitalized patients is poor in ventilated and neutropenic patients and that nosocomial bacteraemia per se influenced outcome in ICU patients.

Aged↗
PubMed2000

Scheduled replacement of central venous catheters is not necessary.

Although half of intensivists routinely replace their central venous catheters (CVCs), this practice is not supported by data from randomized control studies or by pathophysiology of CVC infection. The daily risk of CVC infection is considered to be a constant; the risk of catheter infection is directly related to the duration of catheter insertion. Consequently, the routine change of the catheter is able to decrease the number of infections per catheter but not to modify the number of infections per day of catheter insertion. This assertion is supported by evidence-based medicine: scheduled replacement every 3 or 7 days has not been shown to alter the infectious risks of CVCs in randomized studies or a meta-analysis. Moreover, routine replacement at a new site exposes the patient to an increased risk of mechanical complications. The overall rate of mechanical complications per catheter inserted is approximately 3%. Guidewire exchange of the catheters may reduce the risk of mechanical complications, but unfortunately is associated with a higher rate of catheter colonization and catheter-related bacteremia. Routine replacement of CVCs is not necessary.

Animals↗
PubMed2000

Short-term effect of inhaled nitric oxide and prone positioning on gas exchange in patients with severe acute respiratory distress syndrome.

OBJECTIVE: To compare the short-term effects of inhaled nitric oxide (NO) and prone positioning in improving oxygenation in acute respiratory distress syndrome (ARDS). METHODS: Charts of consecutive ARDS patients (lung injury score >2) during a 2-yr period, tested for both inhaled NO and prone positioning efficacy were retrospectively reviewed. Variations in the Pao2/Fio2 ratio induced by inhaled NO and prone positioning were evaluated. MEASUREMENTS AND MAIN RESULTS: Twenty-seven patients (age, 42+/-17 yrs) were included. Simplified Acute Physiology Score II was 45+/-14. Mortality rate in the intensive care unit was 63%. The causes of ARDS were pneumonia (n = 14), extra-lung infection (n = 5), and noninfectious systemic inflammatory response syndrome (n = 8). Lung injury score was 2.7+/-0.3. At baseline, before the initiation of inhaled NO, the Pao2/Fio2 ratio was 97+/-46 torr and before prone positioning, 92+/-26 torr. Variations in the Pao2/Fio2 ratio were lower at start of NO therapy (11+/-4 ppm) than that observed at prone positioning initiation (23+/-31 vs. 62+/-78 torr, p<.05). An increase in variations in the Pao2/Fio2 ratio of >15 torr was associated with prone positioning in 16 patients (59%) and with NO inhalation in 13 patients (48%) (not significant). An increase in variations in the Pao2/Fio2 ratio of >15 torr was associated with both techniques in only six patients (22%). There was no correlation between the response to prone positioning and the response to inhaled NO (r2 = .005; p = .73). CONCLUSIONS: Prone positioning improves hypoxemia significantly better than does inhaled NO. The response to one technique is not predictive of the response to the other technique.

APACHE↗
PubMed2000

Outcome, functional autonomy, and quality of life of elderly patients with a long-term intensive care unit stay.

OBJECTIVE: To examine the outcome, functional autonomy, and quality of life of elderly patients (> or = 70 yrs old) hospitalized for >30 days in an intensive care unit (ICU). DESIGN: Prospective cohort study. SETTING: A ten-bed, medical-surgical ICU in a 460-bed, acute care, tertiary, university hospital. PATIENTS: A consecutive cohort of 75 patients, >70 yrs old, admitted to the ICU from January 1, 1993, to August 1, 1998, for >30 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Severity at admission and of the underlying disease was estimated according to the Simplified Acute Physiologic Score (SAPS II), the Organ Dysfunction and/or Infection (ODIN) score, the McCabe score, and the Knaus classification. Therapeutic intensity was measured through the French Omega scoring system. All patients were mechanically ventilated during their ICU stay. Outcome measurements were made by two cross-sectional studies using telephone interviews on the first week of September 1996 and 1998 with a questionnaire including measures of functional capacity by Katz's Activities of Daily Living, modified Patrick's Perceived Quality of Life score, and the Nottingham Health Profile. The survival rate was 67% in the ICU and 47% in the hospital. A total of 30 patients were alive and able to participate in at least one of the cross-sectional studies. Independence in activities of daily living was decreased significantly after the ICU stay, except for feeding. However, most of the 30 patients remained independent (class A of the Activities of Daily Living index) with the possibility of going home. Perceived Quality of Life scores remained good, even if the patients estimated a decrease in their quality of life for health and memory. Return to society appeared promising regarding patient self respect and happiness with life. The estimated cost by survivor was of 55,272 EUR ($60,246 US). CONCLUSIONS: This study suggests that persistent high levels of ICU therapeutic intensity were associated with a reasonable hospital survival in elderly patients experiencing prolonged mechanical ventilatory support. These patients presented a moderate disability that influenced somewhat their perceived quality of life. These results are sufficient to justify prolonged ICU stays for elderly patients.

APACHE↗
PubMed1999

Use of tunneled femoral catheters to prevent catheter-related infection. A randomized, controlled trial.

BACKGROUND: The risk for catheter-related infection seems higher with femoral catheters than with catheters inserted at other sites. OBJECTIVE: To evaluate the effect of catheter tunneling on femoral catheter-related infection in critically ill patients. DESIGN: Randomized, controlled trial. SETTING: Three intensive care units at academic hospitals in Paris, France. PATIENTS: 345 adult patients requiring a femoral venous catheter for more than 48 hours. INTERVENTION: Tunneled or nontunneled femoral catheters. MEASUREMENTS: Time to occurrence of systemic catheter-related sepsis, catheter-related bloodstream infection, and quantitative catheter tip culture with a cutoff of 10(3) colony-forming units/mL. RESULTS: Of 345 randomly assigned patients, 336 were evaluable. Probable systemic catheter-related sepsis occurred in 15 of 168 patients who received a nontunneled femoral catheter (controls) and in 5 of 168 patients who received a tunneled femoral catheter (estimated absolute risk reduction, 6% [95% CI, 0.9% to 11%]). Time to occurrence of catheter-related bloodstream infection was not significantly modified (relative risk, 0.28 [CI, 0.03 to 1.92]; P = 0.18); 3 events occurred in the control group and 1 event occurred in the tunneled-catheter group. After stratification by treatment center and adjustment for variables that were prognostic (use of broad-spectrum antimicrobial agents at catheter insertion) or imbalanced between both groups (mechanical ventilation at insertion), tunnelized catheterization reduced the proportion of patients who developed systemic catheter-related sepsis (relative risk, 0.25 [CI, 0.09 to 0.72]; P = 0.005) and positive quantitative culture of the catheter tip (relative risk, 0.48 [CI, 0.23 to 0.99]; P = 0.045). CONCLUSION: The incidence of femoral catheter-related infections in critically ill patients can be reduced by using subcutaneous tunneling.

Catheterization, Peripheral↗
PubMed1999

Relationship between blood lactate and early hepatic dysfunction in acute circulatory failure.

PURPOSE: The purpose of this study was to assess the influence of early hepatic dysfunction on lactate level in patients with acute circulatory failure in a retrospective study. MATERIALS AND METHODS: Blood lactate was compared between patients in acute circulatory failure (systolic blood pressure < or = 80 mm Hg despite fluid challenge) with or without early hepatic dysfunction (bilirubin > 60 micromol/L or SGOT > 100 IU/L during the first 48 hours). Univariate and multivariate analysis were performed to assess the effects of early hepatic dysfunction and other clinical and biological data on serum lactate levels in patients with acute circulatory failure. RESULTS: The study included 92 patients, mean age 64+/-15 years, mean simplified acute physiology score (SAPS) 18.4+/-4.1. Early hepatic dysfunction was identified in 29 patients (32%). Mean initial blood lactate was 5.54+/-4.78 mmol/L. Overall intensive care unit mortality was 67.3%. Although patients with and without hepatic dysfunction showed no significant difference in terms of mean SAPS, mean lowest systolic blood pressure, and mortality, serum lactate was higher in the group with hepatic dysfunction than in the group without hepatic dysfunction (8.24+/-6.49 mmol/L v4.29+/-3.09 mmol/L, P < .001). Factors independently associated with serum lactate were the existence of early hepatic dysfunction (P < .01), a nondistributive type of shock (P < .05), and the mean initial amount of epinephrine (P < .05). CONCLUSIONS: This study suggests that early hepatic dysfunction plays an important role in serum lactate elevation in acute circulatory failure.

Aged↗
PubMed1999

Efficiency of inhaled nitric oxide as rescue therapy during severe ARDS: survival and factors associated with the first response.

PURPOSE: The purpose of this study was to determine if the response to inhaled nitric oxide (NO) as salvage therapy is an independent factor for survival in adult respiratory distress syndrome (ARDS) patients and to identify the factors that predict the response to inhaled NO during ARDS. MATERIALS AND METHODS: This was a multicenter, 2-year retrospective, clinical study in five university surgical or medical intensive care units, including all consecutive patients with ARDS in whom inhaled NO was tried. Clinical data (medical history, diagnoses), general severity scores (SAPS II, OSF), biological data, radiological and hemodynamic data at admission, at the beginning of the ARDS, and under treatment with inhaled NO were recorded. The NO response was defined as the variation of PaO2/Fio2 ratio before initiation and after 30 minutes of NO inhalation (VarPaO2/FiO2). RESULTS: Ninety-three patients aged 49 +/- 18 years were studied. Mean SAPS II was 45 +/- 16. Before the beginning of inhaled NO, PaO2/Fio2 ratio was 95 +/- 53 mm Hg and lung injury score 2.7 + 0.3. VarPao2/Fio2 when NO was started (11 +/- 4 ppm) was 26 +/- 44.5 mm Hg (median 17 mm Hg). Intensive care unit mortality was 74%. None of the parameters studied were predictors of response to inhaled NO, although there was a tendency for the youngest patients with the more severe hypoxemia to have a better response. Response to first inhaled NO test (VarPaO2/FiO2) was univariately associated with survival (Survivors: 45 +/- 44 mm Hg vs. Nonsurvivors: 20 +/- 43 mm Hg, P = .01), but this difference disappeared after adjusting for other prognostic factors (P = .16) selected by multivariate analysis. Finally, inhaled NO was continued for more than 1 day for 75 patients, and definitively stopped for 18 patients. Intensive care unit mortality (73% vs. 78%) was not different between these groups (P = .25, Log-rank test). CONCLUSIONS: We conclude that (1) efficacy of inhaled NO in improving oxygenation was moderate and difficult to predict, (2) response to first NO inhalation was not associated with prognosis, and (3) treatment of the most severe ARDS patients with inhaled NO did not influenced their intensive care unit survival.

Adult↗
PubMed1999

Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study.

OBJECTIVE: To determine the attributable risk of death due to catheter-related septicemia (CRS) in critically ill patients when taking into account severity of illness during the intensive-care unit (ICU) stay but before CRS. DESIGN: Pairwise-matched (1:2) exposed-unexposed study. SETTING: 10-bed medical-surgical ICU and an 18-bed medical ICU. PATIENTS: Patients admitted to either ICU between January 1, 1990, and December 31, 1995, were eligible. Exposed patients were defined as patients with CRS; unexposed controls were selected according to matching variables. METHODS: Matching variables were diagnosis at ICU admission, length of central catheterization before the infection, McCabe Score, Simplified Acute Physiologic Score (SAPS) II at admission, age, and gender. Severity scores (SAPS II, Organ System Failure Score, Organ Dysfunction and Infection Score, and Logistic Organ Dysfunction System) were calculated four times for each patient: the day of ICU admission, the day of CRS onset, and 3 and 7 days before CRS. Matching was successful for 38 exposed patients. Statistical analysis was based on nonparametric tests for epidemiological data and on Cox's models for the exposed-unexposed study, with adjustment on matching variables and prognostic factors of mortality. RESULTS: CRS complicated 1.17 per 100 ICU admissions during the study period. Twenty (53%) of the CRS cases were associated with septic shock. CRS was associated with a 28% increase in SAPS II. Crude ICU mortality rates from exposed and unexposed patients were 50% and 21%, respectively. CRS remained associated with mortality even when adjusted on other prognostic factors at ICU admission (relative risk [RR], 2.01; 95% confidence interval [CI95], 1.08-3.73; P=.03). However, after adjustment on severity scores calculated between ICU admission and 1 week before CRS, the increased mortality was no longer significant (RR, 1.41; CI95, 0.76-2.61; P=.27). CONCLUSION: CRS is associated with subsequent morbidity and mortality in the ICU, even when adjusted on severity factors at ICU admission. However, after adjustment on severity factors during the ICU stay and before the event, there was only a trend toward CRS-attributable mortality. The evolution of patient severity should be taken into account when evaluating excess mortality induced by nosocomial events in ICU patients.

APACHE↗
PubMed1998

Aspergillus pericarditis with tamponade: report of a successfully treated case and review.

We report a case of aspergillus pericarditis with tamponade complicating invasive pulmonary aspergillosis in a patient treated for acute lymphocytic leukemia. Prolonged antifungal therapy and aggressive surgical treatment cured the pericarditis, without relapse, despite the fact that the patient underwent autologous bone marrow transplantation. In a review of 28 other cases of aspergillus pericarditis, we found that this condition usually had occurred in severely immunocompromised patients and was always the result of contiguous dissemination of Aspergillus from the lung or myocardium. Tamponade was present in eight of 29 patients. Aspergillus antigen was detected in the pericardial fluid of all three patients whose fluid specimens were tested. Aspergillus pericarditis was diagnosed before death in 10 of 29 patients, all of whom had established premortem diagnoses of invasive aspergillosis at other sites and had received antifungal therapy. Three of the four survivors received combined medical and aggressive surgical therapies. The performance of echocardiography early during the course of invasive pulmonary aspergillosis, together with intensive combined therapies, might lower the high mortality associated with aspergillus pericarditis.

Adult↗
PubMed1998

Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis.

OBJECTIVE: To evaluate the incidence and risk factors for catheter-related central vein thrombosis in ICU patients. DESIGN: Observational prospective multicenter study. SETTING: An 8-bed surgical ICU, a 10-bed surgical cardiovascular ICU, and a 10-bed medical-surgical ICU. PATIENTS: During an 18-month period, 265 internaljugular or subclavian catheters were included. Veins were explored by duplex scanning performed just before or < 24 h after catheter removal. Suspected risk factors of catheter-related central vein thrombosis were recorded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifty-seven catheters were excluded from the analysis. Therefore 208 catheters were analyzed. Mean age of patients was 64+/-15 years, simplified acute physiologic score was 12+/-5, organ system failure score at insertion was 1+/-1, and mean duration of catheterization was 9+/-5 days. A catheter-related internal jugular or subclavian vein thrombosis occurred in 33% of the cases (42% [95% confidence interval (CI), 34 to 49%] and 10% [95% CI, 3 to 18%], respectively). Thrombosis was limited in 8%, large in 22%, and occlusive in 3% of the cases. Internal jugular route (relative risk [RR], 4.13; 95% CI, 1.72 to 9.95), therapeutic heparinization (RR 0.47; 95% CI, 0.23 to 0.99), and age >64 years (RR, 2.44; 95% CI, 2.05 to 3.19) were independently associated with catheter-related thrombosis. Moreover, the risk of catheter-related sepsis was 2.62-fold higher when thrombosis occurred (p=0.011). CONCLUSIONS: Catheter-related central vein thrombosis is a frequent complication of central venous catheterization in ICU patients and is closely associated with catheter-related sepsis.

APACHE↗