Tracheal Blood Research Articles

Comparison of endotracheal tube cuff inflation techniques by stethoscope and “just seal” method in patients undergoing surgeries under general anesthesia

Background: Overinflation of the endotracheal tube cuff affects tracheal mucosa blood supply that causes postoperative complications like cough, sore throat and hoarseness. There is no standard cuff inflation technique that produces appropriate cuff pressure. The aim of this study was to find out better technique of cuff inflation that will produce adequate pressure with limited complication using stethoscope guided and “just seal”.
 Methods: This was prospective, randomized single blinded study of 100 American Society of Anesthesiologists Physical Status (ASA PS) I and II patients of 18-65 years undergoing elective surgery under general anesthesia requiring endotracheal intubation. Group J (n=50) received ‘just seal’ method of tracheal cuff inflation where air was introduced into cuff until audible leak at mouth disappeared and Group S (n=50) received stethoscope-guided tracheal cuff inflation where air was introduced into cuff until harsh breath sound changed to soft while listening with stethoscope bell over the thyroid cartilage. Volume of air in endotracheal tube cuff, cuff pressure following inflation and post-operative sore throat, hoarseness and cough at 24 hour were assessed.
 Results: Demographic details, mean volume of air in cuff, mean cuff pressure and incidence of postoperative adverse effects like sore throat, hoarseness and cough at 24 hours between the groups were comparable.
 Conclusion: Both the stethoscope guided and “just seal” cuff inflation techniques were equally effective in producing adequate cuff pressure of 20-30 cmH2O with limited complication.

Use of bronchial blocker in emergent thoracotomy in presence of upper airway hemorrhage, and cervical spine fracture: a difficult decision

Female, 85 y.o., weighting 60kg, multiple trauma patient. After an initial laparotomy, an emergent thoracotomy was performed using a bronchial blocker for lung isolation (initial active suction was applied). During surgery, bronchial cuff was deflated, causing a self-limited tracheal blood flooding. A second lung isolation was attempted but it was not as effective as initially. Probably, a lung collapse with the same bronchial blocker was impaired in the second attempt because of the obstruction of bronchial blocker lumen by intraoperative endobronchial hemorrhage. Bronchial blocker active suction may contribute to obtain or accelerate lung collapse, particularly in patients that do not tolerate ventilator disconnection technique or lung surgical compression. The use of bronchial blockers technology was a valuable alternative to double lumen tubes in this case of emergent thoracotomy in the context of a patient having thoracic, abdominal trauma, severe laceration of tongue and apophysis odontoid fracture associated to massive hemorrhage, despite several pitfalls that could compromise its use. The authors intend to discuss the advantages and disadvantages of bronchial blockers comparing to double-lumen tubes for lung isolation, and the risks of our approach, in this complex multitrauma case.

Microbiological Etiologies of Pneumonia Complicating Stroke: A Systematic Review.

Identifying the causal pathogens of pneumonia complicating stroke is challenging, and antibiotics used are often broad spectrum, without recourse to the microbiological cause. We aimed to review existing literature to identify organisms responsible for pneumonia complicating stroke, before developing a consensus-based approach to antibiotic treatment. A systematic literature review of multiple electronic databases using predefined search criteria was undertaken, in accordance with Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. Published studies of hospitalized adults with ischemic stroke, intracerebral hemorrhage, or both, which identified microbiological etiologies for pneumonia complicating stroke up to January 1, 2017, were considered. Analysis included summary statistics and random-effects meta-analysis where appropriate. Fifteen studies (40% ischemic stroke, 60% ischemic stroke and intracerebral hemorrhage) involving 7968 patients were included. Reported occurrence of pneumonia varied considerably between studies (2%-63%) with a pooled frequency of 23% (95% confidence interval, 14%-34%; I2=99%). Where reported (60%), the majority of pneumonia occurred within 1 week of stroke (78%). Reported frequency of positive culture data (15%-88%) varied widely. When isolated, aerobic Gram-negative bacilli (38%) and Gram-positive cocci (16%) were most frequently cultured; commonly isolated organisms included Enterobacteriaceae (21.8%: Klebsiella pneumoniae, 12.8% and Escherichia coli, 9%), Staphylococcus aureus (10.1%), Pseudomonas aeruginosa (6%), Acinetobacter baumanii (4.6%), and Streptococcus pneumoniae (3.5%). Sputum was most commonly used to identify pathogens, in isolation (40%) or in conjunction with tracheal aspirate (15%) or blood culture (20%). Although the analysis was limited by small and heterogeneous study populations, limiting determination of microbiological causality, this review suggests aerobic Gram-negative bacilli and Gram-positive cocci are frequently associated with pneumonia complicating stroke. This supports the need for appropriately designed studies to determine microbial cause and a consensus-based approach in antibiotic usage and further targeted antibiotic treatment trials for enhanced antibiotic stewardship.

Tracheal release maneuvers.

Tracheal resection and reconstruction has been slow to develop in the field of thoracic surgery. The ability to perform a low tension, well-vascularized anastomosis with good outcomes has improved with understanding of tracheal blood supply and the ability to perform tracheal release maneuvers. Laryngeal and suprahyoid release maneuvers can be helpful for cervical tracheal resections, while hilar and pericardial release maneuvers can be beneficial in thoracic tracheal resections. Simple maneuvers such as neck flexion and dissection of the avascular pretracheal plane can also be used to improve anastomotic tension. In this paper, we will review the indications, technical considerations and results of performing cervical and intrathoracic tracheal release maneuvers during tracheal resection and reconstruction.

Successful control of outbreak caused by clonally related extensively-resistant Acinetobacter baumannii in an intensive care unit

Objective: Worldwide drug resistance in Acinetobacter baumannii is on the rise. We report outbreak of extensivelyresistant (XDR) A. baumannii in a medical intensive care unit (MICU) at a tertiary care referral hospital in Pakistan. During subsequent survey, 10 extensively-resistant A. baumannii were isolated from 8 environmental samples and hands of 2 healthcare workers (HCWs). Methods: In January 2013, XDR A. baumannii (Ab1, Ab2, and Ab3) were isolated from tracheal aspirate, blood and sputum of three patients with ventilator associated pneumonia. The isolates were resistant to piperacillin, ampicillinsulbactam, piperacillin-tazobactam, ticarcillin-clavulanic acid, ceftazidime, cefipime, ceftriaxone, imipenem, meropenem, gentamicin, amikacin, doxycycline, minocycline, ciprofloxacin and trimethoprim-sulphamethoxazole.. Pulsed Field Gel Electrophoresis (PFGE) revealed that isolates from HCWs were similar to the genotype initially isolated from patients’ samples. Results: Control of the outbreak was attained with requisite infection control practices and fumigation of the Medical ICU unit. From February 2013 to April 2013 there were no new cases of extensively-resistant isolates in medical ICU. However, two more cases with similar antibiogram MICs and genotype of extensively-resistant isolates emerged in June 2013 from the same MICU. Conclusion: Stringent infection control measures were implemented this time with continuous monitoring and regular surveillance. Follow up for the next two years has been successful as no clustering of XDR A. baumannii were detected from medical and surgical ICUs. J Microbiol Infect Dis 2017; 7(1): 1-6

A Fatal Case of Community Acquired Cupriavidus Pauculus Pneumonia.

Cupriavidus pauculus is a rarely isolated non-fermentative, aerobic bacillus, which occasionally causes severe human infections, especially in immunocompromised patients. Strains have been isolated from various clinical and environmental sources. A 67-year-old man was admitted to the Intensive Care Unit with acute respiratory failure. The patient was diagnosed with bilateral pneumonia, pulmonary sepsis and underwent invasive mechanical ventilation. Examination revealed diminished bilateral vesicular breath sounds, fever, intense yellow tracheal secretions, a respiratory rate of 24/minute, a heart rate of 123/minute, and blood pressure of 75/55 mmHg. Vasoactive treatment was initiated. Investigations revealed elevated lactate and C-reactive protein levels. A chest X-ray showed bilateral infiltration. Parenteral ciprofloxacin and ceftriaxone were administered. Tracheal aspirate culture and blood culture showed bacterial growth of Cupriavidus pauculus. Colistin was added to the treatment. There was a poor clinical response despite repeated blood culture showing negative results. The diagnosis of multiple organ dysfunction syndrome (MODS) caused by C. pauculus was made. The patient died eleven days after admission. Clinical improvement cannot always be expected in spite of targeted antibiotic therapy. This pathogen should be considered responsible for infections that usually develop in immunocompromised patients.

Prevalence, antibiotic susceptibility profiles and ESBL production in Klebsiella pneumoniae and Klebsiella oxytoca among hospitalized patients

Background and Purpose: Klebsiella pneumoniae and Klebsiella oxytoca are the two most common pathogens causing nosocomial infections in humans and are of great concern for developing multidrug resistance. In the present study, K. pneumoniae and K. oxytoca from clinical samples were evaluated for their antibiotic sensitivity patterns against commonly used antibiotics and production of extended-spectrum beta-lactamase (ESBL). Materials and Methods: The isolates were obtained from tracheal swabs, sputum, wound swabs, pus, blood and urine samples of hospitalized patients. Klebsiella pneumoniae and Klebsiella oxytoca were identified by cultural and biochemical methods. Antibiotic sensitivity test was performed by modified Kirby-Bauer disc diffusion technique. ESBL production in Klebsiella spp. was confirmed by double disc synergy test. Results and Conclusion : Out of 500 clinical isolates, 120 were found positive for Klebsiella among which 108 were K. pneumoniae and 12 were K. oxytoca based on indole test. Prevalence rate of Klebsiella was found more prominent in males aged over 50 years, mostly in urine samples. Overall resistance pattern of Klebsiella isolates to Ampicillin, Amoxicillin, Ceftriaxone, Ciprofloxacin, Co-trimoxazole, Gentamicin, Nalidixic acid, Tetracycline was 100%, 90%, 45%, 40%, 45%, 25%, 50%, 35% respectively. Multidrug resistance was found more common in K. pneumoniae (56%) than in K. oxytoca (50%). Prevalence rate of ESBL producing Klebsiella was found 45% among which K. pneumoniae (50%) were found more prominent than K. oxytoca (25%). All the ESBL producing Klebsiella isolates were found to be multidrug resistant, showing 100% resistance to Ampicillin, Amoxicillin, Ceftriaxone and Ciprofloxacin. Keywords : Multi-drug resistant, Klebsiella , extended-spectrum beta-lactamase.

In this issue – April 2016

In this issue – April 2016

Prevalence, antibiotic susceptibility profiles and ESBL production in Klebsiella pneumoniae and Klebsiella oxytoca among hospitalized patients

Background and Purpose: Klebsiella pneumoniae and Klebsiella oxytoca are the two most common pathogens causing nosocomial infections in humans and are of great concern for developing multidrug resistance. In the present study, K. pneumoniae and K. oxytoca from clinical samples were evaluated for their antibiotic sensitivity patterns against commonly used antibiotics and production of extended-spectrum beta-lactamase (ESBL). Materials and Methods: The isolates were obtained from tracheal swabs, sputum, wound swabs, pus, blood and urine samples of hospitalized patients. Klebsiella pneumoniae and Klebsiella oxytoca were identified by cultural and biochemical methods. Antibiotic sensitivity test was performed by modified Kirby-Bauer disc diffusion technique. ESBL production in Klebsiella spp. was confirmed by double disc synergy test.Results and Conclusion: Out of 500 clinical isolates, 120 were found positive for Klebsiella among which 108 were K. pneumoniae and 12 were K. oxytoca based on indole test. Prevalence rate of Klebsiella was found more prominent in males aged over 50 years, mostly in urine samples. Overall resistance pattern of Klebsiella isolates to Ampicillin, Amoxicillin, Ceftriaxone, Ciprofloxacin, Co-trimoxazole, Gentamicin, Nalidixic acid, Tetracycline was 100%, 90%, 45%, 40%, 45%, 25%, 50%, 35% respectively. Multidrug resistance was found more common in K. pneumoniae (56%) than in K. oxytoca (50%). Prevalence rate of ESBL producing Klebsiella was found 45% among which K. pneumoniae (50%) were found more prominent than K. oxytoca (25%). All the ESBL producing Klebsiella isolates were found to be multidrug resistant, showing 100% resistance to Ampicillin, Amoxicillin, Ceftriaxone and Ciprofloxacin. Keywords: Multi-drug resistant, Klebsiella, extended-spectrum beta-lactamase.

Association of tracheal mucus or blood and airway neutrophilia with racing performance in Thoroughbred horses in an Australian racing yard.

To determine the variation of tracheal mucus scores, tracheal blood scores and transendoscopic tracheal wash (TW) cytology in a population of Thoroughbred (TB) racehorses and assess their association with racing performance. A total of 220 endoscopic examinations were performed and TWs obtained from 155 TB racehorses. Samples were collected 60-120 min following gallop work. Tracheal mucus score, tracheal blood score and TW cytology were analysed and their association with racing performance assessed. Of the total examinations and samples, 194 from 135 horses fitted the criteria for inclusion. The overall prevalence of visible tracheal mucus was 2.5% (5/194) and of increased tracheal mucus was 0%. The prevalence of visible tracheal blood was 8.8% (17/194) and of increased tracheal blood was 4.6% (9/194). A total of 36% (70/194) of TWs contained elevated percentages of neutrophils and of these, 96% (67/70) occurred in the absence of any visible tracheal mucus. There was no significant association between tracheal mucus score or TW cytology and subsequent racing performance. There was a statistically significant association (P = 0.004) between increased tracheal blood scores and poor racing performance. Visible tracheal blood seen after strenuous exercise in clinically normal TB racehorses was a risk factor for poor racing performance, but the presence of airway neutrophilia was not. No horses in this study were found to have increased tracheal mucus, so the association of increased tracheal mucus with racing performance could not be assessed.

Factors associated with nosocomial infection in the elderly in the Intensive Care Unit

Background: The elderly have increased vulnerability to disease and exposure to hospital infections. Aims: The study aims to evaluate the clinical and epidemiological factors associated with nosocomial infection in the elderly. Methods: A retrospective study with a population of 625 elderly patients admitted to intensive care units and a sample of 308 elderly who developed nosocomial infection from January 2012 to June 2015. Results: A total of 49.7% of the elderly presented a growth of micro-organisms in tracheal aspirates. The diseases classified as increased likelihood of tracheal infection (3.61, 95% - CI 1.84 to 7.10; p = 0.005) and the probability of growth of micro-organism in the culture performed elsewhere - general (8.96, 95% - CI 3.03 to 26.49; p = 0.005). Surgical procedures increased the chance of growth of micro-organisms in tracheal secretion culture (OR 1.96, 95% CI 1.11 to 3.48) and surgical site culture (OR 5.06, 95% CI 1, from 76 to 14.55). The neurological disease increased the chance of growth of micro-organisms in the cultures of tracheal secretions, blood and general (OR 3.80, 95% CI 1.22 to 11.83; OR 3.27, 95% CI 1.24 - 8.66; OR 15.61, 95% CI 4.78 to 50.98). The pneumothorax increases by four times the probability of growth of micro-organisms in the catheter tip (OR 4.17, 95% CI 1.24 to 13.97). Chronic and acute renal failure and other diagnoses increased by eighteen times the chance of growth of micro-organisms in general culture (OR 18.06, 95% CI 3.63 to 89.86). Conclusion: The main risk factors for nosocomial infection of elderly in the Intensive Care Unit are chronic and acute renal failure, neurological diseases and surgical procedures and must be adopted a policy of prevention and control of nosocomial infection in the treatment of the elderly. Keywords: Elderly, Cross infection, Intensive care.

Salvage pharyngolaryngectomy with total esophagectomy following definitive chemoradiotherapy.

Historically, total pharyngolaryngectomy with total esophagectomy has been the standard radical surgical treatment for synchronous cancer of the thoracoabdominal esophagus and pharyngolaryngeal region, and for cancer of the cervical esophagus that has invaded as far as the thoracic esophagus. Although definitive chemoradiotherapy that enables preservation of the larynx has often been the first choice of treatment for cancers involving the cervical esophagus, total pharyngolaryngectomy with total esophagectomy is required as a salvage therapy for cases involving failure of complete remission or locoregional recurrence after chemoradiotherapy. However, salvage esophageal surgery after definitive high-dose chemoradiotherapy is generally associated with high morbidity and mortality. The aim of this study was to examine the short-term outcome of salvage total pharyngolaryngectomy with total esophagectomy. From 2001 to 2014, nine patients underwent salvage total pharyngolaryngectomy with total esophagectomy at the Department of Gastroenterological Surgery, Nagoya University. The mortality and morbidity rates were high at 22% and 89%, respectively. Four patients (44%) developed tracheal necrosis, which in two patients eventually led to lethal hemorrhage. Salvage total pharyngolaryngectomy with total esophagectomy is an uncommon and highly demanding surgical procedure that should be carefully planned and conducted in selected centers of excellence. Measures must be taken to preserve the tracheal blood supply, thus avoiding fatal complications.

Investigation of the presence of class 1, 2, 3 integrons and their relationships with antibiotic resistance in clinical Stenotrophomonas maltophilia isolates

Stenotrophomonas maltophilia is an opportunistic emergent pathogen causing hospital-acquired infections. It is resistant to majority of the broad spectrum antibiotics due to several mechanisms which significantly limit the treatment options. Although the relationship between integrons, mobile genetic elements which play role in transferring resistance genes, and the antibiotic resistance in different gram-negative bacteria have been investigated, the data are limited in Turkey especially for S.maltophilia. The aims of this study were to detect the presence of different classes of integrons and plasmids in clinical isolates of S.maltophilia and to investigate the antibiotic resistance profiles of those isolates. One hundred S.maltophilia strains isolated from various clinical samples (32 sputum, 25 tracheal aspirates, 9 urine and blood, 7 exudates and catheters, 4 sterile body fluids and wounds, 2 CSF, 1 conjunctiva) in our microbiology laboratory during January 2011-September 2012, were included in the study. The isolates were identified by VITEK2 Compact (BioMerieux, France) or Phoenix 100 (BD, USA) automatized systems, and the susceptibilities of the strains to levofloxacin, chloramphenicol, ceftazidime and trimethoprim/sulfamethoxazol (SXT) were evaluated via broth microdilution method according to the CLSI recommendations. Class 1 (intI-1), class 2 (intI-2), class 3 (intI-3) integron gene cassettes and integron 5'-3' conserved gene regions (intI-5'-3'CS) were investigated by polymerase chain reaction (PCR) using specific primers in all of the strains. Nucleotide sequence analysis of PCR products was performed in case of positive result, and the presence and size of plasmids were further investigated. The susceptibility rates of S.maltophilia strains to ceftazidime, chloramphenicol, SXT and levofloxacin were found as 24%, 66%, 93% and 95%, respectively, while MIC(50) and MIC(90) values were 64-128 µg/ml, 8-16 µg/ml, 1/19-2/38 µg/ml and 1-2 µg/ml, respectively. In PCR amplification with intI-1, intI-2 and intI-3 primers, 12%, 2% and 10% of the isolates yielded expectative bands, respectively. DNA sequence analysis of the amplified products revealed five isolates to harbour intI-1 gene, while intI class 2 and class 3 genes were not detected in any of the strains. Furthermore in PCR amplification with intI-5'CS and 3'CS primers, 20% of the strains yielded expected bands. Sequence analysis of these amplicons revealed the presence of quaternary ammonium compound resistance protein genes (qacL) in two, aminoglycoside adenyltransferase gene (aadA) in one and integron-associated recombination site (attI1) genes in five strains. Additionally, the presence of plasmids have been detected in 9 (9%) of the strains, however all of them was integron-negative. The sizes of plasmids were 2340, 1350, 2760, 18600, 20000, 3570-2540, 2510 and 5000-2540 base pairs, respectively. When the antibiotic susceptibility patterns of strains were compared with the presence of intI gene regions, no statistically significant relationship was observed (p> 0.05). In conclusion, the demonstration of integron class 1 genes and plasmids among clinical S.maltophilia strains is regarded as a warning data to indicate the potential for spread of those resistant strains in our hospital.

Cepacia Syndrome in a Non-Cystic Fibrosis Patient.

Burkholderia (formerly Pseudomonas) cepacia complex is a known serious threat to patients with cystic fibrosis, in whom it has the potential to cause the fatal combination of necrotizing pneumonia, worsening respiratory failure, and bacteremia, known as Cepacia syndrome. The potential for this pathogen to infect non-cystic fibrosis patients is limited and its epidemiology is poorly understood. Previously reported cases of severe Burkholderia cepacia complex lung infection in immunocompetent hosts include pneumonia, bronchiectasis, pyopneumothorax, and cavitary lesions. We present a case of a 64-year-old man with Streptococcus pneumoniae community-acquired pneumonia whose hospital course was complicated by developing cavitary lung lesions, bacteremia, and acute respiratory distress syndrome. Repeated tracheal aspirate and blood cultures grew Burkholderia cepacia. Our case appears to be the first report of Cepacia syndrome in a patient without cystic fibrosis. This report raises concern regarding the potential severity of pulmonary Burkholderia cepacia complex infection and the need to broaden clinicians' suspicion for Cepacia syndrome. A framework to help diagnose and treat infected non-cystic fibrosis individuals may be useful.

Chryseobacterium gleum infection in patient with extreme malnutrition and hepatic lesion – case report

Chrysobacterium gleum is a nonmotile, oxidase positive, non-fermentative un-sporulate Gram-negative bacillus, bacteria belonging to the genus Chrysobacterium. Infections caused by Chrysobacterium spp are usually health care associated and the most frequent in immunocompromised patients and neonates.In this report we present a case of a 35-year-old female patient admitted to the hospital for extreme malnutrition and a hepatic le-sion. Chrysobacterium gleum was isolated from tracheal aspirate and blood culture. The strain was identified with Microflex MALDI Biotyper (Bruker Daltonik, Fre-mont, CA). The patient was successfully treated with piperacillin/tazobactam. Em-pirical therapy is difficult due to intrinsic resistance to most antimicrobials which are usually effective against Gram-negative bacteria.

Nosocomial Isolates and Their Drug Resistant Pattern in ICU Patients at National Institute of Neurological and Allied Sciences, Nepal.

Multidrug resistant organisms are increasing day by day and the cause is poorly known. This study was carried out from June 2011 to May 2012 at National Institute of Neurological and Allied Sciences Kathmandu, Nepal, with a view to determining drug resistant pathogens along with detection of extended spectrum β-lactamase (ESBL), AmpC β-lactamase (ABL), and metallo-β-lactamase (MBL) producing bacteria causing infection to ICU patients. A standard methodology was used to achieve these objectives as per recommendation of American Society for Microbiology. ESBL was detected by combined disc assay using cefotaxime and cefotaxime clavulanic acid, ABL by inhibitor based method using cefoxitin and phenylboronic acid, and MBL by imipenem-EDTA combined disk method. Two hundred and ninety-four different clinical samples such as tracheal aspirates, urine, pus, swabs, catheter tips, and blood were processed during the study. Most common bacteria were Acinetobacter spp. Of the total 58 Acinetobacter spp., 46 (79%) were MDR, and 27% were positive for ABL and 12% were for MBL. Of the 32 cases of Staphylococcus aureus, 18 (56%) were MDR. Findings of this study warrant routine β-lactamase testing in clinical isolates.

Prevalence of microorganism and emergence of bacterial resistance in ICU of Bangabandhu Sheikh Mujib Medical University of Bangladesh

Background Antibiotic resistant bacterial nosocomial infections are a leading problem in intensive care units (ICU). Objective To study the pattern of microorganism and bacterial resistant to antibiotic in ICU of Bangabandhu sheikh Mujib Medical University of Bangladesh. Methods This retrospective study was conducted in ICU of Bangabandhu Sheikh Mujib Medical University, Bangladesh from January 2010 to December 2012. Total number of samples were 448. The samples of tracheal aspirate, blood and urine for culture and sensitivity was collected from the patient admitted in ICU. Analysis of tracheal aspirate, blood and urine culture was done from hospital record. All bacteria was identified by standard microbiological methods, and their antibiotic sensitivity was performed using disk diffusion method. Results Total number of samples 448. Samples of tracheal aspirate was 159, positive culture 121(76%), most frequent identified organism was acenetobacter 45.45%, followed by pseudomonas 32.23%, proteus 11%, klebsiella 10% and E.coli 3%, samples of blood culture was 148, positive culture 22(14.86%), most frequent identified organism was pseudomonas 63.63%, followed by acenetobacter 22.72%, salmonella 4.54% and E.coli 4.54% and samples of urine culture was 141, positive culture 36 (25.53% ) most frequent identified organism was enterococcus 22.22%, followed by acenatobacter 19.44%, candida16.66%, klebsiella 13.88% and E.coli 13.88%. Drug resistant organism of tracheal aspirate was 12(20.33%) in 2010, 2(20%) in 2011 and 13(25%) in 2012. only collistin sensitive organism identified was 28(23.14%). Conclusion From this study we concluded that most common site of infection was respiratory tract and most prevailing organism was acinetobacter & pseudomonas and antibiotic resistant infection is increasing and at present around one fourth organisms were resistant to all antibiotics. DOI: http://dx.doi.org/10.3329/jbsa.v26i1.19811 Journal of Bangladesh Society of Anaesthesiologists 2013; 26(1): 20-26

The Professional Experience of Anaesthesiologists in Proper Inflation of Laryngeal Mask and Endotracheal Tube Cuff.

Cuffs inflated to inappropriately high pressures cause ischemia, reducing tracheal mucosal blood flow, while cuffs inflated at lower pressure than necessary give rise to inadequate ventilation, aspiration of gastric contents, or extubation due to air leakage. In this study, we aimed to investigate the effect of the experience of anaesthesia staff on endotracheal tube and laryngeal mask airway cuff inflation. The study included 348 elective patients scheduled to undergo surgery under general anaesthesia, with 34 anaesthesia technicians, 16 anaesthesia residents, and 12 anaesthesiologists with different years of professional experience. The participants were told to inflate the cuff balloon with air to the level of the pressure that was appropriate for them. No information was provided to the participants about the values of the cuff pressure pending the completion of all measurements. After placement of the laryngeal mask airway and endotracheal tube, the success of the procedure was checked by monitoring square-wave capnograph tracing and thoracoabdominal motion. Each participant performed the procedures on three patients, and the mean cuff pressures were measured. There was no significant correlation between duration of experience of technicians, residents, and experts in using laryngeal mask airway pressure (r=-0.192/p=0.278, r=0.225/p=0.402, r=-0.476/p=0.118, respectively) and endotracheal tube (r=-0.306/p=0.079, r=-0.060/p=0.826, r=-0.478/0.116, respectively). It has been concluded that professional experience does not contribute to achieving normal cuff pressure without monitoring. Introduction of the cuff manometer into routine anaesthesia practice will be useful, irrespective of anaesthesiologists' experience.

Exploring the Use of Mothers' Own Milk as Oral Care for Mechanically Ventilated Very Low-Birth-Weight Preterm Infants

The purpose of this study was to explore the use of mothers' own milk (colostrums, transitional milk, and mature milk) as oral care in the ventilator-associated pneumonia (VAP)-prevention bundle of mechanically ventilated preterm infants weighing 1500 g or less. Mechanically ventilated preterm infants weighing 1500 g or less admitted to a regional level III NICU in the Gulf South between January 1, 2006, and December 31, 2009. Retrospective descriptive. Oral care with mothers' own milk was implemented as part of the VAP-prevention bundle in the neonatal intensive care unit in the fourth quarter of 2007. Using retrospective deidentified data retrieved from the electronic medical record, the primary and secondary outcome variables were collected among eligible infants (≤1500 g) admitted January 1, 2006, to December 31, 2007 (before implementation) and January 1, 2008, to December 31, 2009 (after implementation). Sample characteristics, including infant gestational age, birth weight, and gender, as well as maternal age, type of delivery, and incidence of maternal chorioamnionitis, were also collected. Data analysis included frequencies and distributions to summarize sample characteristics and variables of interest. Appropriate tests for differences were conducted on outcome variables between the before and after groups of the human milk oral care intervention. The feasibility outcome variable included nursing compliance with the oral care procedure. The safety outcome variable included record of any adverse events associated with the oral care procedure. The efficacy health outcomes included the rate of positive tracheal aspirates, positive blood cultures, the number of ventilator days, and length of stay. Infant age (26.1-26.6 weeks) and weight (840-863 g) were similar in the before (n = 70) and after (n = 68) sample subjects. There were no statistically significant differences in ventilator days, χ² (46, n = 115) = 46.22, P = .46, and length of stay, χ (75, n = 115) = 78.78, P = .36, between groups. Although the rate of positive tracheal aspirates and positive blood cultures reduced after implementation of oral care with mothers' own milk, these differences were not statistically significant (U(47) = 250, z = -7.1, P = .48; U(47) = 217.5, z = -1.44, P = .15). There were no statistically significant differences in the rates of positive tracheal aspirates and blood cultures after implementation of oral care with mothers' own milk. The findings of this study suggest that using mothers' own milk as part of the VAP-prevention bundle is a feasible and safe practice; however, further research is needed to determine the immunological benefits of this practice.

Multiple versus single injections of fluorescent microspheres for the determination of regional organ blood flow in septic sheep

Determination of regional blood flow by the injection of microspheres in sepsis models is crucial for the experimental evaluation of the influence of experimental treatment strategies on organ perfusion. However, multiple injections may critically increase the total quantity of microspheres, thereby restricting regional microcirculation and altering the results of blood flow measurements. This study was designed to compare the results of multiple versus single injections of microspheres in an established ovine sepsis model. Injury was induced by smoke inhalation and instillation of Pseudomonas aeruginosa into the lungs. Twenty sheep were studied for 4, 8, 12, 18, or 24 h, respectively. Microspheres were injected at the end of the study period and the animals were euthanized and organ tissues were harvested. Another four sheep were studied for 24 h and multiple microsphere injections were performed at the above indicated time points in the same animals. Tracheal blood flow significantly increased and blood flow to the pancreas and ileum significantly decreased versus baseline in both groups (P < 0.05 each). Blood flow to the ileum, renal cortex and skin did not significantly change versus baseline in both groups (P > 0.05). Blood flow was higher to the trachea in the multiple injection group at 18 h (P = 0.048) and to the ileum at 12 h (P = 0.049), and lower to the skin at 18 h (P = 0.015). In conclusion, the results indicate that multiple versus single microsphere injections induced no or negligible alterations during ovine sepsis. This finding may help reduce the quantity of animals needed in future experiments.