重症监护病房呼吸机相关性肺炎病原学以及耐药性分析

目的:探讨重症监护病房呼吸机相关性肺炎病原学以及耐药性。方法:对我院2007年2月-2011年7月ICU内出现呼吸机相关性肺炎的患者99例作为研究对象,并对取痰液标本进行病原学以及耐药性分析。结果:革兰阴性菌的检出明显高于其他菌属,在G-杆菌中铜绿假单胞菌以及大肠埃希菌最为常见,G+球菌中以金黄色葡萄球菌以及肺炎链球菌最为常见;所有菌属均对常规抗菌药物有一定的耐药性,但其对万古霉素的敏感性仍然较高。结论:加强对ICU呼吸机相关肺炎进行分离致病菌并对其进行耐药性检测,以指导合理使用抗菌药物,有助于改善患者预后。     

Aspergillus in the Intensive Care Unit

Invasive aspergillosis (IA), the most life-threatening form of aspergillosis, has become a major opportunistic fungal disease in immunocompromised patients. In high-risk patients with hematologic malignancies, IA appears to decline with the use of mold-active antifungal prophylaxis, but the situation is less clear in other patient groups at risk for IA, and precise epidemiologic data from patients treated in intensive care units (ICUs) are lacking. Most Aspergillus culture isolates from nonsterile body sites do not represent disease, but isolation of Aspergillus in critically ill patients is a marker of poor prognosis and is associated with high mortality regardless of invasion or colonization. This review presents current information on epidemiology, risk factors, and diagnosis, and discusses treatment options for patients with IA in the ICU.     

Early Standard Electroencephalogram Abnormalities Predict Mortality in Septic Intensive Care Unit Patients

IntroductionSepsis is associated with increased mortality, delirium and long-term cognitive impairment in intensive care unit (ICU) patients. Electroencephalogram (EEG) abnormalities occurring at the acute stage of sepsis may correlate with severity of brain dysfunction. Predictive value of early standard EEG abnormalities for mortality in ICU septic patients remains to be assessed.MethodsIn this prospective, single center, observational study, standard EEG was performed, analyzed and classified according to both Synek and Young EEG scales, in consecutive patients acutely admitted in ICU for sepsis. Delirium, coma and the level of sedation were assessed at the time of EEG recording; and duration of sedation, occurrence of in-ICU delirium or death were assessed during follow-up. Adjusted analyses were carried out using multiple logistic regression.ResultsOne hundred ten patients were included, mean age 63.8 (±18.1) years, median SAPS-II score 38 (29–55). At the time of EEG recording, 46 patients (42%) were sedated and 22 (20%) suffered from delirium. Overall, 54 patients (49%) developed delirium, of which 32 (29%) in the days after EEG recording. 23 (21%) patients died in the ICU. Absence of EEG reactivity was observed in 27 patients (25%), periodic discharges (PDs) in 21 (19%) and electrographic seizures (ESZ) in 17 (15%). ICU mortality was independently associated with a delta-predominant background (OR: 3.36; 95% CI [1.08 to 10.4]), absence of EEG reactivity (OR: 4.44; 95% CI [1.37–14.3], PDs (OR: 3.24; 95% CI [1.03 to 10.2]), Synek grade ≥ 3 (OR: 5.35; 95% CI [1.66–17.2]) and Young grade > 1 (OR: 3.44; 95% CI [1.09–10.8]) after adjustment to Simplified Acute Physiology Score (SAPS-II) at admission and level of sedation. Delirium at the time of EEG was associated with ESZ in non-sedated patients (32% vs 10%, p = 0.037); with Synek grade ≥ 3 (36% vs 7%, p< 0.05) and Young grade > 1 (36% vs 17%, p< 0.001). Occurrence of delirium in the days after EEG was associated with a delta-predominant background (48% vs 15%, p = 0.001); absence of reactivity (39% vs 10%, p = 0.003), Synek grade ≥ 3 (42% vs 17%, p = 0.001) and Young grade >1 (58% vs 17%, p = 0.0001).ConclusionsIn this prospective cohort of 110 septic ICU patients, early standard EEG was significantly disturbed. Absence of EEG reactivity, a delta-predominant background, PDs, Synek grade ≥ 3 and Young grade > 1 at day 1 to 3 following admission were independent predictors of ICU mortality and were associated with occurence of delirium. ESZ and PDs, found in about 20% of our patients. Their prevalence could have been higher, with a still higher predictive value, if they had been diagnosed more thoroughly using continuous EEG.     

Invasive Mycosis in Medical Intensive Care Unit Patients with Severe Alcoholic Hepatitis

Background

Severe alcoholic hepatitis (AH) has a poor short-term prognosis often caused by infections. However, the incidence of invasive mycosis in patients with AH treated with corticosteroids and its impact still remains unknown.

Methods

Retrospective analyses of twelve medical ICU patients (out of 120 patients with liver cirrhosis) with histological proven AH.

Results

Twelve patients were diagnosed with histological proven AH during there stay at the ICU. All patients were treated with corticosteroids; three patients were treated with corticosteroids and pentoxifylline. Five patients had invasive aspergillosis (IA); three patients had candidemia; and two had fungal colonization with candida species. Only two patients had no evidence for fungals. IA was associated with death in all cases. Death occured in most cases shortly after diagnosis despite antifungal medication. Two patients with candidemia died; one patient died in the group with fungal colonization. Overall, the mortality rate was 100 % in patients with IA and 70 % in the group with candidemia.

Conclusions

Patients with severe AH have an increased susceptibility to invasive mycosis associated with high mortality. A high level of suspicion of invasive mycosis in AH patients and prophylactic strategies are needed in those patients.     

Antifungal Prophylaxis in the Pediatric Intensive Care Unit

Invasive fungal infections in children have shown a dramatic increase over the last two decades. Their importance and clinical implications are more prominent in selected groups of patients such as critically ill children in the pediatric intensive care unit (PICU). This population constitutes an important target for prophylactic antifungal interventions. While antifungal agents have been studied in various clinical settings, knowledge in this particular setting is rather scant. The current data suggest that antifungal prophylaxis in the PICU setting should be tailored to the needs of each patient guided by the individual’s risk factors and local epidemiology.

     

Disturbance of Circadian Rhythms in Analgosedated Intensive Care Unit Patients with and without Craniocerebral Injury

Melatonin, cortisol, heart rate, blood pressure, spontaneous motor activity, and body temperature follow stable circadian rhythms in healthy individuals. These circadian rhythms may be influenced or impaired by the loss of external zeitgebers during analgosedation, critical illness, continuous therapeutic intervention in the intensive care unit (ICU), and cerebral injury. This prospective, observational, clinical study examined 24 critically ill analgo‐sedated patients, 13 patients following surgery, trauma, or acute respiratory distress (ICU), and 11 patients with acute severe brain injury following trauma or cerebral hemorrhage (CCI). Blood samples for the determination of melatonin and cortisol were obtained from each patient at 2 h intervals for 24 h beginning at 18:00 h on day 1 and ending 16:00 h on day 2. Blood pressure, heart rate, body temperature, and spontaneous motor activity were monitored continuously. Level of sedation was assessed using the Ramsey Sedation Scale. The severity of illness was assessed using the APACHE‐II‐score. The time series data were analyzed by rhythm analysis with the Chronos‐Fit program, using partial Fourier series with up to six harmonics. The 24 h profiles of all parameters from both groups of patients were greatly disturbed/abolished compared to the well‐known rhythmic 24 h patterns in healthy controls. These rhythm disturbances were more pronounced in patients with brain injury. The results of this study provide evidence for a pronounced disturbance of the physiological temporal organization in ICU patients. The relative contribution of analgosedation and/or brain injury, however, is a point of future investigation.     

Customized Reference Ranges for Laboratory Values Decrease False Positive Alerts in Intensive Care Unit Patients

Background

Traditional electronic medical record (EMR) interfaces mark laboratory tests as abnormal based on standard reference ranges derived from healthy, middle-aged adults. This yields many false positive alerts with subsequent alert-fatigue when applied to complex populations like hospitalized, critically ill patients. Novel EMR interfaces using adjusted reference ranges customized for specific patient populations may ameliorate this problem.

Objective

To compare accuracy of abnormal laboratory value indicators in a novel vs traditional EMR interface.

Methods

Laboratory data from intensive care unit (ICU) patients consecutively admitted during a two-day period were recorded. For each patient, available laboratory results and the problem list were sent to two mutually blinded critical care experts, who marked the values about which they would like to be alerted. All disagreements were resolved by an independent super-reviewer. Based on this gold standard, we calculated and compared the sensitivity, specificity, positive and negative predictive values (PPV, NPV) of customized vs traditional abnormal value indicators.

Results

Thirty seven patients with a total of 1341 laboratory results were included. Experts’ agreement was fair (kappa = 0.39). Compared to the traditional EMR, custom abnormal laboratory value indicators had similar sensitivity (77% vs 85%, P = 0.22) and NPV (97.1% vs 98.6%, P = 0.06) but higher specificity (79% vs 61%, P<0.001) and PPV (28% vs 11%, P<0.001).

Conclusions

Reference ranges for laboratory values customized for an ICU population decrease false positive alerts. Disagreement among clinicians about which laboratory values should be indicated as abnormal limits the development of customized reference ranges.     

Multipurpose Intensive Care Unit in a District General Hospital

The advantages of a four-bedded purpose-built general intensive care unit in a district general hospital are described. In addition to 1,447 inpatients treated between January 1968 and December 1971 the unit was used to conduct outpatient investigations. This has filled an important gap in conventional arrangements, and is practical and economical. The unit has proved to have advantages, not only for seriously ill patients but also has benefited the hospital in other ways. It has been of material assistance in recruiting and training nursing and medical staff and has been welcomed and supported by patients and their relatives. It has also attracted practical support from voluntary organizations whose generosity has enabled much additional equipment to be purchased.     

The Planning and Operation of an Intensive Care Unit

It is desirable that every hospital of 100 beds or more should have an intensive care unit. An attempt is made to outline the more important features to be considered, including the physical aspects, when planning and establishing such a unit. The unit should contain 2-4% of the total number of hospital beds. It should be separate, centrally located and self-contained. Direct observation of all patients must be possible at all times. Efficient and specially trained personnel using modern and special equipment are required. Orientation lectures and demonstrations must be carried out frequently and regularly. The types of patients to be admitted to the unit are discussed, as well as the governing rules and regulations. All doctors should have a right to admit and look after their own patients in the unit; an Intensive Care Unit Committee made up of representatives of the major services is suggested as a means of controlling admissions and discharges and for general administration.     

Management of Hyperglycemia with the Administration of Intravenous Exenatide to Patients in the Cardiac Intensive Care Unit

ObjectiveTo evaluate the feasibility, effectiveness, and safety of intravenous exenatide to control hyperglycemia in the cardiac intensive care unit (CICU).MethodsA prospective, single-center, open-label, nonrandomized pilot study. Forty patients admitted to the CICU with glucose levels of 140 to 400 mg/dL received intravenous exenatide as a bolus followed by a fixed dose infusion for up to 48 hours. Exenatide effectiveness was benchmarked to two historical insulin infusion cohorts, one (INT) with a target glucose of 90 to 119 mg/dL (n = 84) and the other (MOD) with a target of 100 to 140 mg/dL (n = 71).ResultsMedian admission glucose values were 185.5 mg/dL (161.0, 215.5), 259.0 mg/dL (206.0, 343.0), and 189.5 mg/dL (163.5, 245.0) in the exenatide, MOD, and INT groups, respectively (P<.001). Steady state glucose values were similar between the exenatide (132.0 mg/dL [110.0, 157.0]) and the MOD groups (127.0 mg/dL [105.0, P = .15), but lower in the INT group (105.0 mg/dL [92.0, 128.0], P<.001 for exenatide versus INT). Median (IQR) time to steady state was 2.0 hours (1.5, 5.0) in the exenatide group compared to 12.0 hours (7.0, 15.0) in the MOD group (P<.001) and 3.0 hours (1.0, 5.0) in the INT group (P = .80 for exenatide versus INT). Exenatide was discontinued in 3 patients after failure to achieve glycemic control. No episodes of severe hypoglycemia (<50 mg/dL) occurred in patients who received exenatide. Nausea was reported by 16 patients and vomiting by 2 patients.ConclusionIntravenous exenatide is effective in lowering glucose levels in CICU patients, but its use may be limited by nausea. (Endocr Pract. 2013;19:81-90)     

Dermatomyositis and Polymyositis in the Intensive Care Unit: A Single-Center Retrospective Cohort Study of 102 Patients

IntroductionPatients with idiopathic inflammatory myopathies (IIMs) are sometimes complicated with life-threatening conditions requiring intensive care unit (ICU) admission. In the past, owing to the low incidence of IIM, little was known about such patients. Our aim was to investigate the clinical features and outcomes of these patients and identify their risk factors for mortality.MethodsA retrospective study was performed of IIM patients admitted over an 8-year period to the medical ICU of a tertiary referral center in China. We collected data regarding demographic features, IIM-related clinical characteristics, reasons for admission, organ dysfunction, and outcomes. Independent predictors of ICU mortality were identified through multivariate logistic regression analysis.ResultsOf the 102 patients in our cohort, polymyositis (PM), dermatomyositis (DM), and clinically amyopathic dermatomyositis (CADM) accounted for 23.5%, 64.7%, and 11.7% respectively. The median duration from the onset of IIM to ICU admission was 4.3 months (interquartile range [IQR], 2.6–9.4 months). Reasons for ICU admission were infection alone (39.2%), acute exacerbation of IIM alone (27.5%), the coexistence of both (27.5%), or other reasons (5.8%). Pneumonia accounted for 97% of the infections; 63.2% of infections with documented pathogens were caused by opportunistic agents. Rapid progressive interstitial lung disease (RP-ILD) was responsible for 87.5% of acute exacerbation of IIM. The median Acute Physiology and Chronic Health Evaluation II (APACHE II) score on ICU day 1 was 17 (IQR 14–20). On ICU admission, acute respiratory failure (ARF) was the most common type (80.4%) of organ failure. The mortality rate in the ICU was 79.4%. Factors associated with increased ICU mortality included a diagnosis of DM (including CADM), a high APACHE II score, the presence of ARF, a decreased PaO₂/FiO₂ ratio, and a low lymphocyte count at the time of ICU admission.ConclusionsThe outcome of IIM patients admitted to the ICU was extremely poor. A diagnosis of DM/CADM, the presence and severity of ARF, and the lymphocyte counts at ICU admission were shown to be valuable for predicting outcome. Opportunistic infections and rapidly progressive interstitial lung disease warrant concern in treating these patients.     

神经外科重症监护室发热及其治疗

发热是神经外科重症监护室(Neurosurgical intensive care unit,NICU)最常见的症状之一,它是人体对损伤的保护性反应,但同时又加重了机体的负担,从而恶化临床结局。NICU发热起因复杂并相互交错,仅少部分有特异性表现,并且总上而言处理困难。因此系统地了解发热的起因、处理以及预后是非常重要的。尽管过去的文献对于发热已有很好的研究,然而缺乏对NICU发热的系统性描述。我们通过回顾文献系统性地总结了NICU发热,旨在进一步增进对NICU发热的认识从而有利于临床诊治。     

Fungal Infections in COVID-19 Intensive Care Patients

Opportunistic fungal infections increase morbidity and mortality in COVID-19 patients monitored in intensive care units (ICU). As patients’ hospitalization days in the ICU and intubation period increase, opportunistic infections also increase, which prolongs hospital stay days and elevates costs. The study aimed to describe the profile of fungal infections and identify the risk factors associated with mortality in COVID-19 intensive care patients. The records of 627 patients hospitalized in ICU with the diagnosis of COVID-19 were investigated from electronic health records and hospitalization files. The demographic characteristics (age, gender), the number of ICU hospitalization days and mortality rates, APACHE II scores, accompanying diseases, antibiotic-steroid treatments taken during hospitalization, and microbiological results (blood, urine, tracheal aspirate samples) of the patients were recorded. Opportunistic fungal infection was detected in 32 patients (5.10%) of 627 patients monitored in ICU with a COVID-19 diagnosis. The average APACHE II score of the patients was 28 ± 6. While 25 of the patients (78.12%) died, seven (21.87%) were discharged from the ICU. Candida parapsilosis (43.7%) was the opportunistic fungal agent isolated from most blood samples taken from COVID-19 positive patients. The mortality rate of COVID-19 positive patients with candidemia was 80%. While two out of the three patients (66.6%) for whom fungi were grown from their tracheal aspirate died, one patient (33.3%) was transferred to the ward. Opportunistic fungal infections increase the mortality rate of COVID-19-positive patients. In addition to the risk factors that we cannot change, invasive procedures should be avoided, constant blood sugar regulation should be applied, and unnecessary antibiotics use should be avoided.     

Evaluation of Admission Blood Glucose Levels in The Intensive Care Unit

ObjectiveTo assess the availability and clinical value of blood glucose (BG) testing at the time of admission to the intensive care unit (ICU) after such testing was implemented as routine care in the ICU.MethodsWe studied ICU admission BG testing rates and the prevalence of hyperglycemia. In this effort, we assessed the frequency of baseline BG testing in 330 consecutive patients during a period of 3 months and then implemented routine BG monitoring in 1,147 consecutive ICU patients during a 7-month period.ResultsOf the total study population, 25% had previously diagnosed diabetes (PDD). At baseline, 70% had BG measured within 4 hours before or after ICU admission (99% of patients with and 60% of patients without PDD). After implementation of routine BG monitoring, there was a significant increase in testing (70% before versus 87% after, /40.001; 70% during the baseline 3-month period versus 93% in the final 3 months of the study, P < 0.001). In patients without PDD, 41% had BG levels ≥ 140 mg/dL, and 8% had BG concentrations ≥ 200 mg/dL. Overall in the ICU setting, 57% of BG values ≥ 140 mg/dL and 33% of BG levels > 200 mg/dL were in patients without PDD. Frequencies of BG testing by admission diagnosis included the following (at baseline and during the final 3 months after implementation of routine BG tests): post-surgical status (46%, 85%), peripheral vascular disease (51%, 90%), neurologic disease (52%, 83%), gastrointestinal disease (58%, 91%), infection (69%, 100%), and diabetes (100%, 100%).ConclusionRates of routine BG testing are low in ICU patients without PDD. Elevations in BG levels were detected in 41% of our study patients without PDD, suggesting that routine implementation of BG monitoring in an ICU will identify patients at increased risk for hyperglycemia-associated higher morbidity and mortality. (Endocr Pract. 2007;13:705-710)     

外科重症监护病房革兰阴性杆菌的菌群分布及耐药性分析

目的监测外科重症监护病房(SICU)革兰阴性杆菌的菌群分布及耐药性。方法对中山大学附属第一医院SICU 2007年到2008年分离的革兰阴性杆菌及其耐药性进行回顾性分析。结果共分离到革兰阴性杆菌279株,前5位为大肠埃希菌(21.9%)、铜绿假单胞菌(20.8%)、鲍曼不动杆菌(15.8%)、肺炎克雷伯菌(11.8%)和嗜麦芽窄食单胞菌(11.5%)。肠杆菌科细菌对碳青霉烯类抗生素敏感性最高,尚无耐药株;非发酵菌对阿米卡星耐药率最低,对其他抗生素耐药性高。结论 SICU革兰阴性杆菌的耐药性有上升的趋势,应加强细菌耐药性监测,合理使用抗生素,防止耐药菌株的传播。     

Treatment of Invasive Candida Infections in the Neonatal Intensive Care Unit

Invasive Candida infections are a leading cause of morbidity and mortality in the neonatal intensive care unit (NICU). Extremely preterm and very low birth weight infants are at the highest risk of infection. There are currently no antifungal agents that have FDA-labeling for the treatment of invasive candidiasis in the neonatal population. Based on the current IDSA guidelines, amphotericin and fluconazole are considered first-line options for neonatal candidiasis. The newer antifungal agents (i.e., echinocandins and voriconazole) are currently considered second-line or salvage therapy; however, evidence supporting their use is emerging. This review focuses on the supporting evidence for the selection of antifungal agents for treatment of invasive Candida infections in the NICU.     

Impaired Postoperative Hyperglycemic Stress Response Associated with Increased Mortality in Patients in the Cardiothoracic Surgery Intensive Care Unit

ObjectiveTo describe the association of tight glycemic control with intensive insulin therapy and clinical outcome among patients in the cardiothoracic surgery intensive care unit.MethodsAll patients who underwent cardiothoracic surgery and were admitted to the cardiothoracic surgery intensive care unit between September 13, 2007, and November 1, 2007, were enrolled. Clinical and metabolic data were prospectively collected. All patients received intensive insulin therapy using a nurse-driven dynamic protocol targeting blood glucose values of 80 to 110 mg/dL. Four stages of critical illness were defined as follows: acute critical illness (intensive care unit days 0-2), prolonged acute critical illness (intensive care unit 3 or more days), chronic critical illnesss (tracheotomy performed), and recovery (liberated from ventilator).ResultsOne hundred fourteen patients were enrolled. Seventy-three (64%) recovered during acute critical illness, 26 (23%) recovered during prolonged acute critical illness, and 15 (13%) progressed to chronic critical illness. All 6 deaths were among patients in chronic critial illness. Admission blood glucose and average blood glucose values for the first 12 hours were lower in patients who developed chronic critical illness and died and were higher in patients who developed chronic critical illness and survived (P = .007 and P = .007, respectively). Severe hypoglycemia (blood glucose < 40 mg/dL) occurred once (0.03% of all measurements). Lower initial blood glucose values, which reflect an impaired stress response immediately after surgery, were associated with increased mortality, and a significant delay in achieving tight glycemic control with intensive insulin therapy was associated with prolonged intensive care unit course, but no increase in mortality.ConclusionThe study findings suggest that acute postoperative hyperglycemia and its prompt correction with intensive insulin therapy are associated with favorable outcomes in patients in the cardiothoracic surgery intensive care unit. (Endocr Pract. 2010;16:798-804)