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Impact of a Low-Pressure Polyurethane Adult Endotracheal Tube on the Incidence of Ventilator-Associated Pneumonia: A before and after Concurrence Study

Background. Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality in intensive care unit (ICU) patients, encompassing up to 15% of all hospital acquired infections. Our hospital implemented a facility-wide conversion from a low-volume high-pressure polyvinyl cuffed endotracheal tube (PV-cuffed ETT) to a high-volume low-pressure (HVLP) polyurethane-cuffed endotracheal tube (PU-cuffed ETT) in an effort to reduce the incidence of VAP. Methods. We completed an IRB approved, retrospective chart review comparing the number of episodes of VAP 12 months preceding and following the introduction of a new ETT. A diagnosis of VAP was made based upon the guidelines of our institution, consistent with the Center of Disease Control and Prevention definition. Results. The number of patients developing VAP the year after the ETT conversion reduced to 32 (16.3%) from 68 (24.7%) the year before the conversion (). The rate of VAP was reduced by 56% per ventilator day after the implementation of the PU-cuffed ETT (). No significant differences were observed in length of hospital stay, length of mechanical ventilation, or mortality before or after the conversion. Conclusions. We found that HVLP PU-cuffed ETTs were associated with a statistically significant reduction of VAP in the adult ICUs.

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Risk Factors for Acute Delirium in Critically Ill Adult Patients: A Systematic Review

Background. Delirium is characterized by disturbances of consciousness, attention, cognition, and perception. Delirium is a serious but reversible condition associated with poor clinical outcomes. This has implications for the critically ill patient; the effects of delirium cause long term sequelae, principally cognitive deficits, and functional decline. Objectives. The objective of the paper was to describe risk factors associated with delirium in critically ill adult patients. Methods. Published and unpublished literature from 1990 to 2012, limited to English, was searched using ten databases. Results. Twenty-two studies were included in this paper. A large number of risk factors were presented in the literature; some of these were common across all settings whilst others were exclusive to the type of setting. Benzodiazepines and opioids were shown to be risk factors for delirium independent of setting. Conclusion. With regard to patients admitted to medical and surgical intensive care units, risk factors of older age and comorbidity were common. In the cardiac ICU, older age and lower Mini-Mental Status Examination scores were cited most often as risk factors for delirium, but other risk factors exclusive to the setting were also significant. Benzodiazepines were identified as the most significant pharmacological risk factor for delirium.

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Continuation or Discontinuation of Statin Therapy Did Not Influence Patient Outcomes after the Development of Acute Respiratory Distress Syndrome

Background. The anti-inflammatory effects of statin therapy may be beneficial in the treatment and prevention of acute respiratory distress syndrome (ARDS). Objectives. Determine if continuation or discontinuation of prior statin therapy is associated with ventilator-free days (VFDs) at day 28 in patients with ARDS. Methods. Patients with ARDS admitted to the intensive care units of a tertiary care medical center were evaluated in this retrospective cohort study. Included patients were allocated to three groups: patients in whom statin therapy was given before and continued after ARDS diagnosis (Group 1), patients with statin therapy only before ARDS diagnosis (Group 2), and patients never exposed to statins (Group 3). Results. Of 244 patients evaluated, 187 were included; 17 (9.1%) patients in Group 1, 20 (10.7%) in Group 2, and 150 in Group 3. There were no differences among groups in APACHE II or SOFA scores. VFDs were not significantly different among groups (median 0 versus 4.5 versus 13.5 days, P=0.21). After adjustment for baseline characteristics, including propensity for statin administration, statin therapy was not associated with increased VFDs on linear regression. Conclusions. Exposure to statins before or after ARDS diagnosis was not associated with improved VFDs in this cohort of patients with ARDS.

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Rescue High-Frequency Oscillatory Ventilation for Congenital Diaphragmatic Hernia: What about Lung Histopathology and Necropsy Findings?

Introduction. It is not yet a resolved issue whether HFOV (high-frequency oscillatory ventilation), used as primary mode or as rescue ventilation, has benefit over conventional mechanical ventilation for CDH (congenital diaphragmatic hernia) patients treatment. Purpose. To evaluate the success rate of rescue HFOV for CDH, and the histological characteristics of the lungs, at the autopsy of the deceased patients. Material and Methods. Out of 80 CDH patients, 10 were treated with rescue HFOV. The success of HFOV, histological exam of the lungs of deceased patients, and data on the followup of discharged patients were assessed. Results. Rescue HFOV was started between two hours and four days of life. The success rate of rescue HFOV was 20% (2/10). Autopsy findings along with pulmonary hypoplasia included coarctation of aorta (n=1), pneumonia (n=3), meconium aspiration (n=2), hyaline membranes (n=2), severe muscular hypertrophy of medium and small diameter lung arteries (n=1), severe lung hypoplasia (n=1), pleural effusions (n=2), haemorrhagic diatesis (n=2), and signs of overwhelming sepsis (n=1). The five-years follow up of the two survivors revealed normal growth and neurodevelopment. Conclusions. The results of this study support the idea that rescue HFOV may increase survival of CDH patients, when conventional mechanical ventilation fails.

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Comparing Drug-Drug Interaction Severity Ratings between Bedside Clinicians and Proprietary Databases

Purpose. The purpose of this project was to compare DDI severity for clinician opinion in the context of the patient’s clinical status to the severity of proprietary databases. Methods. This was a single-center, prospective evaluation of DDIs at a large, tertiary care academic medical center in a 10-bed cardiac intensive care unit (CCU). A pharmacist identified DDIs using two proprietary databases. The physicians and pharmacists caring for the patients evaluated the DDIs for severity while incorporating their clinical knowledge of the patient. Results. A total of 61 patients were included in the evaluation and experienced 769 DDIs. The most common DDIs included: aspirin/clopidogrel, aspirin/insulin, and aspirin/furosemide. Pharmacists ranked the DDIs identically 73.8% of the time, compared to the physicians who agreed 42.2% of the time. Pharmacists agreed with the more severe proprietary database scores for 14.8% of DDIs versus physicians at 7.3%. Overall, clinicians agreed with the proprietary database 20.6% of the time while clinicians ranked the DDIs lower than the database 77.3% of the time. Conclusions. Proprietary DDI databases generally label DDIs with a higher severity rating than bedside clinicians. Developing a DDI knowledgebase for CDSS requires consideration of the severity information source and should include the clinician.

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