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Biomedical subjects

R N Juste

Publications and source records attributed to R N Juste.

7 recordsLinked to original sources
PubMed2000

Central venous blood culture: a useful test for catheter colonisation?

OBJECTIVE: To evaluate the widespread practice of using qualitative culture of venous blood taken through central venous catheters (CVCs) as a means of diagnosing catheter colonisation in situ. DESIGN: A prospective clinical study. PATIENTS: Three hundred fifty-one CVCs were inserted into 228 critically ill patients. INTERVENTIONS: Prior to CVC removal, blood was taken for qualitative culture from the CVC and a peripheral site. All catheter tips underwent semi-quantitative analysis of bacterial colony count [1]. MEASUREMENTS AND RESULTS: One hundred eighteen (33.6%) CVCs were found to be colonised on removal. A positive central blood culture had a sensitivity and specificity of 50.8% and 78.9% when compared with the 'gold standard' of catheter tip culture. This gives a positive predictive value of 47.7% and a negative predictive value of 76.5%. The sensitivity and specificity of a positive peripheral blood culture were 41.5% and 77.7% with positive and negative predictive values of 48.8% and 72.9%, respectively. When only those catheters removed because of systemic sepsis (n = 139) were considered, a positive central blood culture had a sensitivity of 58.8% and a specificity of 69.3%. CONCLUSION: Our results indicate that the use of central blood culture confers a small advantage in sensitivity compared with peripheral blood culture. This advantage was further improved by only considering the catheters removed because of systemic sepsis but at the cost of a loss of specificity. Qualitative blood culture is a poor tool for the diagnosis of in-situ CVC colonisation.

Adult↗
PubMed1999

Antiseptic-bonded central venous catheters and bacterial colonisation.

This study was undertaken to evaluate the impact of chlorhexidine/silver sulphadiazine-bonded catheters on the incidence of colonisation and catheter-related sepsis in critically ill patients. Threehundred and fifty-one catheters were inserted into 228 patients during the study period, 174chlorhexidine/silver sulphadiazine-bonded catheters and 177 standard catheters. Indications for catheter removal were: death, clinical redundancy and clinical evidence of local or systemic infection. All catheter tips were sent to the microbiology laboratory for semiquantitative analysis of bacterial colony count. Seventy-one (40.2%) of the standard catheters and 47 (27.2%) of the antiseptic-bonded catheters were found to be colonised on removal (p < 0.01). Eight cases (4.7%) of catheter-related sepsis were associated with standard catheters and three cases (1.7%) with antiseptic-bonded catheters, however, this reduction was not statistically significant. Our results indicate that the use of antiseptic-bonded catheters in critically ill patients significantly reduces the incidence of bacterial colonisation.

Adult↗
PubMed1998

The effects of low-dose dopamine infusions on haemodynamic and renal parameters in patients with septic shock requiring treatment with noradrenaline.

OBJECTIVE: To investigate whether low-dose dopamine (LDD) has a significant effect on systemic haemodynamic variables and renal function when used in conjunction with high-dose noradrenaline in optimally volume-resuscitated patients with septic shock. DESIGN: A prospective clinical study in which each patient acted as his/her own control. SETTING: Teaching hospital Intensive Care Unit. PATIENTS: Twenty-one patients with septic shock treated with high-dose noradrenaline were studied, 17 patients completed the study. INTERVENTIONS: Fluid loading to an optimal left ventricular stroke work index (LVSWI) whilst on more noradrenaline than 10 mcg/min and dopamine of 2.5 mcg/kg per min. Three study periods each of 2 h with LDD present, withdrawn and restarted. During each period a complete haemodynamic profile and measurement of urine flow rate, creatinine clearance and sodium excretion was performed. MEASUREMENT AND RESULTS: Removing and restarting LDD caused marked changes in cardiac index (CI, 17% fall, p < 0.01: 23% rise, p < 0.01), stroke volume (SV, 11% fall, p < 0.05: 14% rise, p < 0.05) and systolic blood pressure (SBP, 11% fall, p < 0.05: 14% rise, p < 0.05). Urine volume fell by 40% (p < 0.05) when dopamine was withdrawn. Significant reductions in sodium excretion (p < 0.05) and fractional sodium excretion (p < 0.05) also occurred on stopping LLD. Changes in creatinine clearance were not statistically significant. CONCLUSION: Low-dose dopamine causes significant increases in SBP SV, cardiac output and urine flow during treatment with noradrenaline.

Adrenergic alpha-Agonists↗
PubMed1998

Dopamine clearance in critically ill patients.

OBJECTIVE: To examine the validity of the low-dose "renal" dopamine regimen in critically ill patients by investigating the steady-state clearance of dopamine. DESIGN: A prospective clinical study. SETTING: Teaching hospital intensive care unit. PATIENTS: 48 haemodynamically stable patients receiving a dopamine infusion. INTERVENTIONS: Sampling of arterial blood and dopamine infusates. MEASUREMENT AND RESULTS: Plasma and infusate dopamine levels were measured by liquid chromatography with electrochemical detection. Steady-state clearance was determined by dividing the actual infusion rate by the steady-state plasma concentration. Dopamine clearance for the whole group was 46.4 +/- 35.9 ml/kg per min (mean +/- SD), which is significantly lower than 70 +/- 15.2 ml/kg per min reported for elective surgical patients (p = 0.01). Twelve patients with renal dysfunction had significantly lower dopamine clearances (36 +/- 16.6 ml/kg per min) than the remaining 36 patients (61 +/- 38.5 ml/kg per min, p = 0.022). There was a very poor correlation between plasma dopamine level and infusion rate for the group as a whole (r = 0.47), and this worsened (r = 0.31) when only those patients on a "renal" dose of 2-5 microg/kg per min were considered (n = 30). CONCLUSION: Plasma dopamine clearance is lower in critically ill patients and there is a large interindividual variation. It is therefore impossible to predict the plasma level from the infusion rate. Consequently, the concept of a selective renovascular low-dose dopamine infusion is invalid in critically ill patients.

Adult↗
PubMed1997

Endoluminal brushing for detection of central venous catheter colonization--a comparison of daily vs. single brushing on removal.

The fibrin assay system (FAS) has been designed to address the problem of in-situ diagnosis of central venous catheter (CVC) colonization. The FAS was evaluated in 12 critically ill patients with daily brushings, comparing results with culture of the catheter tip and blood. Data analysis of the FAS showed a sensitivity of 0 with a specificity of 1.0. The study was repeated in a further 12 high-risk patients with a single terminal brushing on catheter removal. This gave a sensitivity of 0.14 and a specificity of 0.8. Differences in sensitivity may be due to daily disruption of the endoluminal fibrin clot. Our results do not support the routine use of the FAS to detect CVC colonization in the intensive care unit.

Adult↗
PubMed1996

Minimising cardiac anaesthetic risk: the tortoise or the hare?

There is no doubt that a group of patients at increased risk of peri-operative cardiac morbidity exists and must be managed with the emphasis on the prevention of myocardial ischaemia. It is also clear that a potentially far larger group are at risk of failing to meet the increased cardiovascular and metabolic demands of surgery and therefore suffering the consequences of a relative hypoperfusion injury. Pre-operative assessment must address both groups and management regimens sought to provide optimal outcome for both. At present there is no consistent strategy for their identification, assessment or management of the high risk surgical population despite the fact that they probably consume a disproportionate share of hospital resources. The first and most important step is the recognition that this high risk group exists. Only then can this population be given similar consideration to those currently thought to be at risk of ischaemia.

Anesthesia↗