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Biomedical subjects

L Brazzi

Publications and source records attributed to L Brazzi.

At least 19 recordsLinked to original sources
PubMed2006

Antibiotic prophylaxis to prevent nosocomial infections in patients in intensive care units: evidence that struggle to convince practising clinicians.

BACKGROUND: Pneumonia is an important cause of mortality in intensive care units. The incidence of pneumonia in such patients ranges between 7 and 40%, and the crude mortality from ventilator associated pneumonia may exceed 50%. Although not all deaths in patients with this form of pneumonia are directly attributable to pneumonia, it has been shown to contribute to mortality in intensive care units independently of other factors that are also strongly associated with such deaths. OBJECTIVES: The objective of this review was to assess the effects of antibiotics for preventing respiratory tract infections and overall mortality in adults receiving intensive care. Search strategy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 3, 2003), which contains the Acute Respiratory Infections (ARI) Group specialised trials register; MEDLINE (January 1966 to September 2003); EMBASE (January 1990 to September 2003); proceedings of scientific meetings and reference lists of articles from January 1984 to December 2002. We also contacted investigators in the field. Selection criteria. Randomised trials of antibiotic prophylaxis for respiratory tract infections and deaths among adult intensive care unit patients. Data collection and analysis. At least two reviewers independently extracted data and assessed trial quality. RESULTS: Overall 36 trials involving 6922 people were included. There was variation in the antibiotics used, patient characteristics and risk of respiratory tract infections and mortality in the control groups. In 17 trials (involving 4295 patients) that tested a combination of topical and systemic antibiotic, the average rates of respiratory tract infections and deaths in the control group were 36% and 29% respectively. There was a significant reduction of both respiratory tract infections (odds ratio 0.35, 95% confidence interval [CI] 0.29-0.41) and total mortality (odds ratio 0.78, 95% CI 0.68-0.89) in the treated group. On average 5 patients needed to be treated to prevent one infection and 21 patients to prevent one death. In 17 trials (involving 2664 patients) that tested topical antimicrobials alone (or comparing topical plus systemic versus systemic alone) the rates of respiratory tract infections and deaths in the control groups were 30 and 26% respectively. There was a significant reduction of respiratory tract infections (odds ratio 0.52, 95% CI 0.43-0.63), but not in total mortality (odds ratio 0.97, 95% CI 0.81-1.16) in the treated group. CONCLUSIONS: A combination of topical and systemic prophylactic antibiotics reduces respiratory tract infections and overall mortality in adult patients receiving intensive care. A treatment based on the use of topical prophylaxis alone reduces respiratory infections, but not mortality. The risk of occurrence of resistance as a negative consequence of antibiotic use was appropriately explored only in the most recent trial by de Jonge, which did not show any such effect.

Adult↗
PubMed2004

Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care.

BACKGROUND: Pneumonia is an important cause of mortality in intensive care units. The incidence of pneumonia in such patients ranges between 7% and 40%, and the crude mortality from ventilator associated pneumonia may exceed 50%. Although not all deaths in patients with this form of pneumonia are directly attributable to pneumonia, it has been shown to contribute to mortality in intensive care units independently of other factors that are also strongly associated with such deaths. OBJECTIVES: The objective of this review was to assess the effects of antibiotics for preventing respiratory tract infections and overall mortality in adults receiving intensive care. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 3, 2003), which contains the Acute Respiratory Infections (ARI) Group specialised trials register; MEDLINE (January 1966 to September 2003); EMBASE (January 1990 to September 2003); proceedings of scientific meetings and reference lists of articles from January 1984 to December 2002. We also contacted investigators in the field. SELECTION CRITERIA: Randomised trials of antibiotic prophylaxis for respiratory tract infections and deaths among adult intensive care unit patients. DATA COLLECTION AND ANALYSIS: At least two reviewers independently extracted data and assessed trial quality. MAIN RESULTS: Overall 36 trials involving 6922 people were included. There was variation in the antibiotics used, patient characteristics and risk of respiratory tract infections and mortality in the control groups. In 17 trials (involving 4295 patients) that tested a combination of topical and systemic antibiotic, the average rates of respiratory tract infections and deaths in the control group were 36% and 29% respectively. There was a significant reduction of both respiratory tract infections (odds ratio 0.35, 95% confidence interval 0.29 to 0.41) and total mortality (odds ratio 0.78, 95% confidence interval 0.68 to 0.89) in the treated group. On average 5 patients needed to be treated to prevent one infection and 21 patients to prevent one death. In 17 trials (involving 2664 patients) that tested topical antimicrobials alone (or comparing topical plus systemic versus systemic alone) the rates of respiratory tract infections and deaths in the control groups were 30% and 26% respectively. There was a significant reduction of respiratory tract infections (odds ratio 0.52, 95% confidence interval 0.43 to 0.63) but not in total mortality (odds ratio 0.97, 95% confidence interval 0.81 to 1.16) in the treated group. REVIEWER'S CONCLUSIONS: A combination of topical and systemic prophylactic antibiotics reduces respiratory tract infections and overall mortality in adult patients receiving intensive care. A treatment based on the use of topical prophylaxis alone reduces respiratory infections but not mortality. The risk of occurrence of resistance as a negative consequence of antibiotic use was appropriately explored only in the most recent trial by de Jonge which did not show any such effect.

Adult↗
PubMed2004

Effectiveness and efficiency of intensive care medicine: variable costs in different diagnosis groups.

BACKGROUND: To establish the effectiveness of ICU treatment and the efficiency in the use of resources in patients stratified according to 10 diagnosis and two levels-of-care. To propose strategies aimed at reducing costs and improving efficiency in each patient group. METHODS: Multicentre prospective observational study. ICUs enrolled two cohorts of up to 10 consecutive patients with ICU stay >/= 48 h. Each with one of these diagnoses: trauma, brain-trauma, brain-hemorrhage, stroke, acute-on-chronic-obstructive-pulmonary disease, lung-injury/acute respiratory distress syndrome, heart failure, and scheduled/unscheduled abdominal surgery. The presence of active-life support divides high from low level-of-care treatments. Variable ICU costs were collected daily (bottom-up) for 21 days. We evaluated effectiveness (hospital survival) and efficiency (hospital-survivors variable-cost as a ratio of overall cost). RESULTS: Forty-two Italian general ICUs recruited 529 patients in 5 months. Mean ICU variable-costs significantly differed with diagnosis and level-of-care. Costs were positively affected by ICU length-of-stay, by duration of active-treatment. Outcome variably influenced costs. Medians of variable-costs per patient (1715 Euro) and patient-groups efficiencies (60.7%) identified four possible combinations between (low and high) cost and (low and high) efficiency groups. Moreover, efficiency was better than effectiveness in stroke, brain-hemorrhage and trauma, while it was worse in heart failure, acute-on-COPD or acute-lung injury. Overall ICU cost attributed only to survivors ranged from 699 (scheduled surgical) to 5906 (unscheduled surgical) Euro. Cost of non-survivors distributed to all patient was between 95 (scheduled-surgical) to 1633 (unscheduled-surgical) Euro. CONCLUSIONS: Analysis of variable patient-specific cost was used as a tool to assess intensive care performance in patient subgroups with different diagnosis and levels-of-care.

Adult↗
PubMed2002

Prone position in acute respiratory distress syndrome.

In the last few years prone positioning has been used increasingly in the treatment of patients with acute respiratory distress syndrome (ARDS) and this manoeuvre is now considered a simple and safe method to improve oxygenation. However, the physiological mechanisms causing respiratory function improvement as well as the real clinical benefit are not yet fully understood. The aim of this review is to discuss the physiological and clinical effects of prone positioning in patients with ARDS. The main physiological aims of prone positioning are: 1) to improve oxygenation; 2) to improve respiratory mechanics; 3) to homogenise the pleural pressure gradient, the alveolar inflation and the ventilation distribution; 4) to increase lung volume and reduce the amount of atelectatic regions; 5) to facilitate the drainage of secretions; and 6) to reduce ventilator-associated lung injury. According to the available data, the authors conclude that: 1) oxygenation improves in approximately 70-80% of patients with early acute respiratory distress syndrome; 2) the beneficial effects of oxygenation reduce after 1 week of mechanical ventilation; 3) the aetiology of acute respiratory distress syndrome may markedly affect the response to prone positioning; 4) extreme care is necessary when the manoeuvre is performed; 5) pressure sores are frequent and related to the number of pronations; 6) the supports used to prone and during positioning are different and nonstandardised among centres; and 7) intensive care unit and hospital stay and mortality still remain high despite prone positioning.

Acute Disease↗
PubMed2001

Effect of prone positioning on the survival of patients with acute respiratory failure.

BACKGROUND: Although placing patients with acute respiratory failure in a prone (face down) position improves their oxygenation 60 to 70 percent of the time, the effect on survival is not known. METHODS: In a multicenter, randomized trial, we compared conventional treatment (in the supine position) of patients with acute lung injury or the acute respiratory distress syndrome with a predefined strategy of placing patients in a prone position for six or more hours daily for 10 days. We enrolled 304 patients, 152 in each group. RESULTS: The mortality rate was 23.0 percent during the 10-day study period, 49.3 percent at the time of discharge from the intensive care unit, and 60.5 percent at 6 months. The relative risk of death in the prone group as compared with the supine group was 0.84 at the end of the study period (95 percent confidence interval, 0.56 to 1.27), 1.05 at the time of discharge from the intensive care unit (95 percent confidence interval, 0.84 to 1.32), and 1.06 at six months (95 percent confidence interval, 0.88 to 1.28). During the study period the mean (+/-SD) increase in the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen, measured each morning while patients were supine, was greater in the prone than the supine group (63.0+/-66.8 vs. 44.6+/-68.2, P=0.02). The incidence of complications related to positioning (such as pressure sores and accidental extubation) was similar in the two groups. CONCLUSIONS: Although placing patients with acute respiratory failure in a prone position improves their oxygenation, it does not improve survival.

Female↗
PubMed2001

Mesenteric and renal oxygen transport during hemorrhage and reperfusion: evaluation of optimal goals for resuscitation.

BACKGROUND: Changes in flow to the gut and the kidney during hemorrhage and resuscitation contribute to organ dysfunction and outcome. We evaluated regional and splanchnic oxygen (O2) flow distribution and calculated oxygen supply distribution during hemorrhage and reperfusion and compared them with global measures. METHODS: Seven anesthetized pigs were instrumented to evaluate global hemodynamics, visceral blood flow, and oxygen transport. Tonometric pH probes were positioned in the stomach and jejunum. Animals were bled to 45 mm Hg for 1 hour. Crystalloids and blood were infused during the following 2 hours to normalize blood pressure, heart rate, urine output, and hemo- globin. RESULTS: During hemorrhage, mesenteric flow and O2 consumption were significantly decreased, whereas systemic consumption remained normal. Renal flow was reduced, but renal O2 consumption remained normal. After resuscitation, despite normal hemodynamics, neither systemic, mesenteric, nor renal O2 delivery returned to baseline. Lactate remained significantly increased. Arterial pH, base excess, and gastric and jejunal pH were all decreased. CONCLUSION: During hemorrhage, the gut is more prone than other regions to O2 consumption supply dependency. After resuscitation, standard clinical parameters do not detect residual O2 debt. Lactate, arterial pH, base excess, and intramucosal gut pH are all markers of residual tissue hypoperfusion.

Acid-Base Equilibrium↗
PubMed2001

Use of sedative and analgesic drugs in the first week of ICU stay. A pharmaco-epidemiological perspective.

AIM: To assess the current practice of pharmacological sedation and analgesia in patients admitted in Italian intensive care units. METHODS DESIGN: observational, prospective, cohort study, involving all patients admitted during a one-month period to participating Centers in 1994. All patients were followed-up for vital status until discharge and evaluated for pharmacological sedation and analgesia for the first week of ICU stay. SETTING: 128 Italian, adult, general, intensive care units, approximately representing 1/3 of all Italian Units. PATIENTS: 2932 patients were analyzed. They generated 22612 patient-days of intensive care unit stay, 11221 of which were evaluated. RESULTS: A total of 31 different sedative drugs were used in 1751 patients. On 64% of sedated days only one drug was utilized, whereas two or more drugs were administered in the remaining days. Propofol was the most widely prescribed drug, followed by fentanyl and diazepam, while morphine accounted for 14.8% of sedated days. The analysis of the pattern of sedation over time revealed a trend to linearly reduce the use of this practice. CONCLUSIONS: Our results depict a relatively low prevalence of sedation in Italy, with the use of large number of different agents. We also observed a larger than expected use of some drugs, like propofol and fentanyl, that could be due to the unavailability of new sedative and analgesic drugs in Italy on 1994. In conclusion, Italian intensivists seem to be very conservative about the practice of pharmacological sedation in critically ill patients.

Adult↗
PubMed2001

Pathophysiology of prone positioning in the healthy lung and in ALI/ARDS.

Prone position was initially introduced in healthy anesthetized and paralyzed subjects for surgical specific reasons. Then, it was used during acute respiratory failure to improve gas exchange. The interest on prone position during ALI/ARDS progressively increased, even if the mechanisms leading to a respiratory improvement are not yet completely understood. In normal subjects, during anesthesia and paralysis, prone position determines a more homogeneous distribution of the gravitational gradient of alveolar inflation, a ventilation distributed towards the non dependent lung regions and a reverse of the gravitational distribution of regional perfusion, even if factors other than gravity are involved. Moreover, prone position causes, both in healthy subject and in obese patients, an improvement in oxygenation and in functional residual capacity without affecting respiratory system, lung and chest wall compliance. In ALI/ARDS patients, prone position lead to a reverse of the alveolar inflation and ventilation distribution, due to the reverse of hydrostatic pressure overlying lung parenchyma, the reverse of heart weight, and the changes in chest wall shape and mechanical properties. Little data are available for the modifications in regional lung perfusion. The possible mechanisms involved in oxygenation improvement during prone position in ALI/ARDS patients are: 1) increased lung volumes; 2) redistribution of lung perfusion; 3) recruitment of dorsal spaces with more homogeneous ventilation and perfusion distribution. From a clinical point of view, prone position seems to be a very promising treatment for ALI/ARDS, even if its use is not yet a standard clinical practice. We have recently finished a randomized-controlled trial in order to investigate the clinical impact of this procedure. In the preliminary phase of the study performed in 35 Italian Intensive Care Units, we studied, from 1996 to 1998, 73 patients with a PaO2/FiO2 of 123 +/- 42 and a SAPS (Simplified Acute Physiology Score) of 38 +/- 11. After the first hour of prone positioning, the PaO2/FiO2 ratio of 76% of the patients had increased by more than 20 mmHg (responder) with a mean increase of 78 +/- 53 mmHg. The proportion of responders increased to 85% after 6 hours of prone positioning. The incidence of maneuver-related complications and severe and life-threatening complications was extremely rare. The overall mortality at ICU discharge was 51% and the ICU stay was similar in survivors and non survivors (17.8 +/- 11.6 vs 17.8 +/- 11.4 days).

Anesthesia↗
PubMed2000

Antibiotics for preventing respiratory tract infections in adults receiving intensive care.

OBJECTIVES: Pneumonia is an important cause of mortality in intensive care units. The objective of this review was to assess the effects of antibiotics for preventing respiratory tract infections and overall mortality in adults receiving intensive care. SEARCH STRATEGY: We searched MEDLINE, proceedings of scientific meetings and reference lists of articles from January 1984 to September 1997. We also contacted investigators in the field. SELECTION CRITERIA: Randomised trials of antibiotic prophylaxis for respiratory tract infections and deaths among adult intensive care unit patients. DATA COLLECTION AND ANALYSIS: Trials were assessed for quality and investigators contacted for additional information. MAIN RESULTS: Overall 33 trials involving 5727 people were included. There was variation in the antibiotics used, patient characteristics and the risk of respiratory tract infections and mortality in the control groups. In 16 trials (involving 3493 patients) of a topical and systemic antibiotic combination, the average rates of respiratory tract infections and deaths in the control group were 33% and 28% respectively. There was a significant reduction of both respiratory tract infections (odds ratio 0.36, 95% confidence interval 0.30 to 0. 43) and total mortality (odds ratio 0.80, 95% confidence interval 0. 68 to 0.93). On average five patients needed to be treated to prevent one infection and 23 treated to prevent one death. In 17 trials (involving 2366 patients) of topical antimicrobials the rates of respiratory tract infections and deaths in the control groups were 30% and 24% respectively. There was a significant reduction of respiratory tract infections (odds ratio 0.57, 95% confidence interval 0.46 to 0.69) but not in total mortality (odds ratio 1.01, 95% confidence interval 0.84 to 1.22). REVIEWER'S CONCLUSIONS: A combination of topical and systemic prophylactic antibiotics can reduce respiratory tract infections and overall mortality in adult patients receiving intensive care. [This abstract has been prepared centrally.]

Adult↗
PubMed1998

Predicting outcome in the intensive care unit using scoring systems: is new better? A comparison of SAPS and SAPS II in a cohort of 1,393 patients. GiViTi Investigators (Gruppo Italiano per la Valutazione degli interventi in Terapia Intensiva). Simplified Acute Physiology Score.

OBJECTIVES: This study sought to compare the performance of the old and new versions of the Simplified Acute Physiology Score, SAPS and SAPS II, in classifying patients according to the risk of hospital mortality. METHODS: To compare the performance of the two systems, measures of association between the scores and observed mortality were adopted, together with discrimination (area under the Receiver Operating Characteristics curve) and calibration (goodness-of-fit statistics) estimates. Subjects were 1,393 eligible patients recruited during 1 month in 1994. The outcome measure was vital status at hospital discharge. RESULTS: SAPS II was associated more strongly with hospital mortality than the earlier version. SAPS II also had better discrimination ability than SAPS (area under Receiver Operating Characteristics curve 0.80 versus 0.74) and predicted an overall number of deaths (416.5) closer to the observed figure (475) than SAPS (267.7). Conversely, neither SAPS nor SAPS II fitted our data. Both P values derived from goodness-of-fit statistics were lower than 0.05. CONCLUSIONS: SAPS II offers a real improvement compared with SAPS in its ability to explain hospital mortality, but its standard parameters do not fit our data from Italy. The role and impact of potential determinants of this lack of fit, such as random errors and confounders related to casemix and/or quality of care should be clarified before this scoring system be used outside formal research projects. Special caution is suggested when SAPS II is adopted to predict mortality to compare intensive care unit performance across different countries and systems of care.

Adult↗
PubMed1998

Prone position in mechanically-ventilated patients.

The prone position, initially introduced into respiratory therapy to improve the drainage of secretions, has been suggested to improve oxygenation in anaesthetized and paralysed subjects. Here we report on the results obtained using the prone position in 17 normal subjects, 10 obese subjects and 16 patients with acute respiratory failure (ARF). In normal subjects, the prone position did not alter respiratory system compliance (Crs,st, 80.9 +/- 16.6 versus 75.9 +/- 13.2 mL.cmH2O-1), while it did improve arterial oxygen tension (Pa,O2, 21.3 +/- 4.9 versus 26.5 +/- 2.1 kPa, p < 0.01), this improvement being paralleled by an increase in functional residual capacity (FRC, 1.935 +/- 0.576 versus 2.921 +/- 0.681 L, p < 0.01). In obese subjects, the FRC (0.894 +/- 0.327 versus 1.980 +/- 0.856 L, p < 0.01) and the lung compliance (CL,st, 91.4 +/- 55.2 versus 109.6 +/- 52.4 mL.cmH2O-1, p < 0.01) increased in the prone position, while the chest wall compliance (Ccw,st, 199.5 +/- 58.7 versus 160.5 +/- 45.4 mL.cmH2O-1, p < 0.01) decreased and the Crs,st remained substantially unaffected (55.4 +/- 9.6 versus 59.6 +/- 12.1 mL.cmH2O-1). In these subjects, the improvements in FRC and CL,st were always paralleled by an increase in Pa,O2 (17.3 +/- 4.1 versus 24.1 +/- 3.7 kPa, p < 0.01). In ARF patients, no difference between the supine and prone position was found either in FRC (1.17 +/- 0.41 versus 1.29 +/- 0.57 L), or in Crs,st (38.4 +/- 13.7 versus 35.9 +/- 10.7 mL.cmH2O-1) or CL,st (52.4 +/- 23.3 versus 53.9 +/- 23.6 mL.cmH2O-1) despite a significant reduction in Ccw,st being observed (204.8 +/- 97.4 versus 135.9 +/- 52.5, p < 0.01). In this group of patients, the use of the prone position resulted in a significant increase in Pa,O2 (13.7 +/- 3.2 versus 17.2 +/- 4.4 kPa, p < 0.05), being the oxygenation improvement induced by the prone position relative to the baseline Ccw,st, according to the relationship: Pa,O2 = -32.4 + (0.24 x Ccw,st); r = 0.82, p < 0.01). The mechanisms which can be hypothesized to justify the modifications reported above are discussed.

Acute Disease↗
PubMed1997

[An index of daily intensive care unit activity].

OBJECTIVE: To set up an index for the evaluation of type of interventions and procedures applied a prerequisite for the evaluation of appropriateness of ICU's activity. DESIGN: Observation prospective study. PATIENTS: 2507 patients out of the 5030 enrolled in the cohort study. MEASUREMENTS: A cross-sectional assessment of the volume and intensity of treatment--level of care--delivered to patients was performed at a preidentified index day. A check list of procedures was utilized. Intensive high level treatment was demonstrated by the application of procedures suggesting one or more organs or vital functions intensively supported. Sub-intensive treatment was defined by the application of procedures indicating monitoring or treatments not exclusively performed in intensive environment. RESULTS: 3955 samples were collected over 9 index days; 2707 (68.3%) resulted in intensive, 1227 (30.7%) subintensive or intermediate and 41 (1%) ward treatments. Out of the intensive samples, 63.4% received only one intensive procedure, while 27.9% two. Ventilatory support was the most frequently (90.4%) utilized intensive procedure. Overall 99% of the samples were characterized by treatments/procedures too invasive for normal ward. CONCLUSIONS: The proposed method gives the opportunity to easily evaluate the level of care and then the appropriateness of ICU care.

Cross-Sectional Studies↗