Tube Aspirates Research Articles

Connection of capnography sampling tube to an intravenous cannula

There are many connectors on a variety of devices used with a single patient. It is not surprising therefore that misconnections are made either inadvertently or due to confusion because of the large number of potential connections. During a routine anaesthetic the Luer lock sidestream capnograph sampling tube was inadvertently connected to an intravenous cannula. We noticed that blood had contaminated the sampling tube, which led us to find the misconnection and immediately rectify it. Fortunately, the side stream capnograph sampling tube aspirates gas and as a result no injury occurred to the patient, although blood from the patient would eventually have entered the sampling port of the capnograph. A much more serious event would have occurred if the gases leaving the capnograph and returning to the patient circuit had been inadvertently connected to an intravascular cannula leading to air entering directly into an artery or vein. The original purpose of the Luer fitting was to connect a hypodermic needle to a syringe. However, the connector has been so successful that it is now used in a wide range of medical devices, raising the possibility of accidental cross connection between devices [1]. Mistaken connection between a scavenging tube and a facemask has been previously reported [2], as has a misconnection between the common gas outlet and the scavenging port [3]. The European Union has a regulatory framework for market access, international trade relations and regulatory convergence, and industry competitiveness for market devices. There are three European Directives which regulate marketing and putting into service of medical devices. These are the Active Implantable Medical Devices Directive (AIMDD), the Medical Devices Directive (MDD) and the In-Vitro Diagnostic Directive (IVDD). Since 1998 the Medical Devices Directive [4] has provided for a harmonised regulatory environment for all medical devices sold within the European Economic Area. All products which fall within the scope of the Directive must meet certain essential safety and administrative requirements and are CE marked to show that they comply. The European Directive for Medical Devices requires the manufacturer to design and construct devices in accordance with safety principles that ‘eliminate or reduce any risk to the patient as far as possible. If the device is intended for use in combination with other devices or equipment, the whole combination, including the connector system must be safe’. A task force (CEN/BT/TF 123) has been set up to produce non-interchangeable connectors for enteral feeding, respiratory connectors, NIBP hoses, urinary catheters, endoscopes and tourniquets [5]. Fundamentally, the problem results from the application of a single connector design to a number of incompatible applications and a global solution that addresses all aspects of the problem is urgently required. Hopefully, the European Task Force will provide a satisfactory solution as a matter of some urgency.

Gastric vs Small-Bowel Feeding in Critically Ill Children Receiving Mechanical Ventilation: A Randomized Controlled Trial

To determine the effect of feeding tube position (gastric vs small bowel) on adequacy of nutrient delivery and feeding complications, including microaspiration, in critically ill children. Randomized controlled trial. Pediatric ICU in a university teaching hospital. Seventy-four critically ill patients < 18 years of age receiving mechanical ventilation were randomized to receive gastric or small-bowel feeding. All feeding tubes were inserted at the bedside. Color, pH, and bilirubin concentration of the feeding tube aspirates were used to guide placement. Final tube position was confirmed radiographically. Continuous feedings were advanced to achieve a caloric goal based on age and body weight. Tracheal secretions were collected daily and tested for gastric pepsin by immunoassay. Thirty-two patients were randomized to the gastric group, and 42 patients were randomized to the small-bowel group. Twelve patients exited the study because a small-bowel tube could not be placed at the bedside, leaving 30 patients in the small-bowel group. Gastric and small-bowel groups were similar at baseline in age, sex, percentage of ideal body weight, serum prealbumin concentration, and pediatric risk of mortality score. The percentage of daily caloric goal achieved was less in the gastric group compared to the small-bowel group (30 +/- 23% vs 47 +/- 22%, p < 0.01). No difference was found in the proportion of tracheal aspirates positive for pepsin between the gastric and small-bowel groups (50 of 146 aspirates vs 50 of 172 aspirates, respectively; p = 0.3). No differences were found in the frequency of feeding tube displacement, abdominal distension, vomiting, or diarrhea between groups. Small-bowel feeds allow a greater amount of nutrition to be successfully delivered to critically ill children. Small-bowel feeds do not prevent aspiration of gastric contents.

Low yield of ancillary diagnostic studies in neonates infected with Candida.

Fungal infection can be a significant complication for the critically ill neonate. However, the usefulness of extensive radiologic and ophthalmologic investigations in this population has not been thoroughly elucidated. To report the incidence of organ fungal involvement diagnosed by ancillary testing (echocardiogram, ophthalmologic examination, brain imaging, and renal ultrasound (RUS)) among neonatal intensive care unit (NICU) patients with Candida infection. This was a single center review of all NICU patients with Candida-positive cultures of blood, urine, peritoneal fluid, endotracheal tube aspirate, or cerebrospinal fluid from January 1, 1997 to June 1 2002. Data regarding the number of positive cultures, species isolated, and presence of specific risk factors and clinical symptoms were recorded for each case, as well as occurrence, timing and results of ancillary testing. In all, 66 patients had at least one positive culture for Candida. The majority (71%) were <1500 g at birth, and mean gestational age was 29.5+/-5.6 weeks. Echocardiograms were obtained in 54/66 (82%), and ophthalmology examinations were obtained in 36/66 (55%); none of these was consistent with fungal involvement. Brain imaging was performed in 50/66 (76%), only one of which was positive, in a patient with 16 positive blood cultures for Candida albicans. RUS were performed in 58/66 (88%) of patients, with concerning findings for fungal involvement in seven of the studies. RUS findings alone did not appear to consistently influence the length of therapy. Ancillary evaluations to investigate for fungal dissemination were undertaken frequently, but were of overall low yield. Although ancillary testing may be of limited additional value in centers with a low threshold for suspecting fungal infections and an aggressive approach to therapy, potentially important findings, which could impact management, may occur.

Epidemiology of respiratory viruses in patients hospitalized with near-fatal asthma, acute exacerbations of asthma, or chronic obstructive pulmonary disease

Purpose We compared the prevalence and spectrum of common respiratory viruses among patients with near-fatal asthma, acute exacerbations of asthma, or chronic obstructive pulmonary disease (COPD), and the relation of these findings to acute respiratory symptoms. Methods We obtained adequate samples of respiratory secretions from 17 patients hospitalized with near-fatal asthma, 29 with acute asthma, and 14 with COPD. We used a polymerase chain reaction–based method to test for six common respiratory viruses in samples from endotracheal tube aspirates from patients with near-fatal asthma, and from induced sputum specimens from patients with acute asthma or COPD. Respiratory symptoms (runny nose, sore throat, fever, chills, malaise, and cough) were recorded. Quiescent-phase induced sputum specimens were examined from patients who were initially virus positive. Results Viral nucleic acids were detected in 52% (31/60) of acute-phase specimens and 7% (2/29) of quiescent-phase specimens examined ( P <0.001), with similar proportions of virus-positive patients during the acute phase in the three groups: 59% (10/17) of those with near-fatal asthma, 41% (12/29) with acute asthma, and 64% (9/14) with COPD. Picornavirus (47% [n = 8]) and adenovirus (24% [n = 4]) were most commonly identified in near-fatal asthma, whereas influenza virus (36% [n = 5]) predominated in COPD. Virus-positive patients had a significantly increased frequency of runny nose, sore throat, fever, chills, and malaise (odds ratio = 4.1 to 18; P = 0.02 to 0.001). Conclusion Respiratory viruses are associated with hospitalizations for near-fatal asthma, acute asthma, and COPD, with some differences in the spectrum of viruses involved in the different groups of patients. Respiratory viruses are a target for the prevention and perhaps the treatment of these conditions.

Ureaplasmapneumonien und Nachweis von Ureaplasma urealyticum im Tubussekret bei Früh- und Neugeborenen

Bei wie vielen Frühgeborenen ≤1250 g und bei wie vielen Neugeborenen >1250 g mit klinischer Symptomatik Ureaplasma urealyticum im Tubussekret nachweisbar war und bei wie vielen eine Pneumonie auftrat. Methodik: Die Patienten wurden in zwei Gruppen unterteilt (Gruppe 1: Geburtsgewicht ≤1250 g, n = 25; Gruppe 2: Geburtsgewicht >1250 g, n = 45) und diese wiederum in zwei Subgruppen (Subgruppe a: U. urealyticum im Tubussekret ohne Pneumonie; Subgruppe b: U. urealyticum im Tubussekret mit Pneumonie). Ergebnisse: Bei 9 Patienten der Gruppe 1 (36%) konnte U. urealyticum nachgewiesen werden, und 5 dieser Patienten (20%) hatten eine Pneumonie (Gruppe 1b). Frühgeborene mit einer Ureaplasmapneumonie hatten im Vergleich zu jenen mit einer blossen Ureaplasmabesiedelung signifikant höhere Beatmungsparameter, eine längere Beatmungsdauer und einen grösseren Sauerstoffbedarf. Bei 6 Patienten der Gruppe 2 (13%) konnte U. urealyticum nachgewiesen werden, und 2 von ihnen (4,4%) hatten eine Pneumonie. Schlussfolgerungen: Bei neonatalen Pneumonien bei sehr kleinen Frühgeborenen, aber auch bei reifen Neugeborenen, sollte stets U. urealyticum in die Differentialdiagnose miteinbezogen werden.

PH and concentration of bilirubin in feeding tube aspirates as predictors of tube placement.

Currently available bedside methods for determining feeding tube placement often provide inconclusive results. Therefore, additional data are needed to assist nurses in making decisions regarding tube location. To describe the usual concentration of bilirubin in aspirates from newly inserted feeding tubes and to determine the extent to which these measures can contribute to pH alone in correctly predicting feeding tube location. Gastrointestinal samples for concurrent pH and bilirubin testing were obtained from adult, acutely ill patients with newly inserted small-bore feeding tubes (nasogastric, n = 209; nasointestinal, n = 228) within 5 minutes of radiographs taken to determine tube location. Respiratory samples were tested (tracheobronchial, n = 126; pleural, n = 24). pH was measured with a pH meter, and bilirubin content was assayed spectrophotometrically. Results from the pH and bilirubin tests were compared with tube location as determined by radiography. Mean pH levels in the lung (7.73) and intestine (7.35) were significantly higher than the mean pH level in the stomach (3.90; p < .001 for each comparison). Mean bilirubin levels in the lung (.08 mg/dl) and stomach (1.28 mg/dl) were significantly lower than the mean bilirubin level in the intestine (12.73 mg/dl; p < .001 for each). By visually inspecting distribution overlap and mean differences by tube site, results were dichotomized so that a combination of pH and bilirubin values could be used to develop a predictive algorithm. A pH of >5 and a bilirubin value of <5 mg/dl correctly identified all respiratory cases, whereas a pH >5 coupled with a bilirubin level of > or =5 mg/dl correctly identified three fourths of the intestinal cases. A pH of < or =5 coupled with a bilirubin value of <5 correctly identified more than two thirds of the gastric cases. Preliminary laboratory-based data indicate that appropriate use of the proposed algorithm could significantly reduce the number of x-rays needed to exclude respiratory placement and to distinguish between gastric and intestinal placement.

Detection of Ureaplasma urealyticum in endotracheal tube aspirates from neonates by PCR.

A PCR-based test was optimized for the detection of Ureaplasma urealyticum from neonatal respiratory specimens, with primers directed against the multiple-banded antigen gene (L. J. Teng, X. Zheng, J. I. Glass, H. Watson, J. Tsai, and G. H. Cassell, J. Clin. Microbiol. 32:1464-1469, 1994). Endotracheal tube aspirates (225) from 103 low-birth-weight neonates (<1,250 g) were taken, when possible, at days 0, 4, and 14 after birth and examined by culture and by PCR. Of 77 specimens positive by either method, 73 were detected by PCR and 60 were detected by culture. Overall, 36% of the neonates were positive for U. urealyticum by either method. Of 16 patients with PCR-positive-culture-negative results, 13 had positive cultures at another sampling point, and one additional patient had a twin with positive cultures. Of 11 patients with day 0 specimens positive by PCR alone, 9 subsequently became culture positive, demonstrating the utility of this test in early detection. Multiple serovars were present in over 50% of positive specimens, with serovars 3 and 14 in combination being most prevalent. The amplicon size generated from the specimen by PCR correctly predicted the biovars isolated in over 85% of positive specimens. Thus, this PCR test was valuable in allowing early detection of U. urealyticum in neonatal respiratory specimens, as well as in providing biovar information.

UREAPLASMA UREALYTICUM (UU) SEROTYPING DOES NOT IMPROVE THE ABILITY TO PREDICT CHRONIC LUNG DISEASE OF PREMATURITY (CLD). † 865

BACKGROUND: Colonization of the respiratory tract with UU has been associated with the development of CLD. However, culture positivity alone is a poor predictor of this outcome. Isolation of specific UU serotypes may help identify those babies who are truly at high risk and those that might benefit from antimicrobial therapy. OBJECTIVE: To determine the distribution of UU serotypes isolated from the respiratory secretions of preterm neonates and to assess the association between colonization with specific serotypes and the development of CLD. METHODS: As part of a randomized trial to evaluate Alpha-1 Antitrypsin supplementation for the prevention of CLD, endotracheal tube (ETT) aspirates taken on days 0,4 and 14 were cultured for UU. Isolates were serotyped by immunoperoxide assay. CLD in survivors was defined by the requirement for supplemental oxygen at 36 weeks' corrected gestational age. RESULTS: 106 babies with birth weights of 600-1250 g were enrolled. At least one ETT aspirate was obtained and cultured in 103 cases. UU was isolated from 30/91 (33%) babies surviving to 36 weeks and serotyping was successful in all but one. 29 patients yielded 51 isolates from the 14 known serotypes: 38 (75%) were from the parvum biovar (serotypes 1,3,6 and 14) and 30 (59%) were serotypes 3 or 14. 24/29 (83%) UU positive patients had at least one isolate from the parvum biovar. 26/91 (29%) babies developed CLD. There was a weak association between UU culture positivity and the development of CLD (RR=1.49, CI 0.78-2.84). Confining the analysis to either a specific serotype or biovar did not improve the predictive ability. CONCLUSIONS: UU isolates from the respiratory tracts of very preterm neonates in Toronto are predominantly from the parvum biovar. UU colonization appears to be weakly associated with the development of CLD. Serotyping does not aid in the identification of infants at increased risk for this condition.Funding received from Bayer/Canadian Red Cross Society Research and Development Fund

Evaluation of Expiratory CO2 waveform at a lobar level by fibrobronchocapnography

To evaluate regional pulmonary blood flow, the authors employed fibrobronchocapnography (FBC) which consisted of a flexible bronchoscope (FFB) and a compact infrared CO2 meter (250 mm × 250 mm, 200 mm). A CO2 sampling tube made of teflon and measuring 1.8 m in length, 0.5 mm inner diameter, and 1.0 mm outer diameter, was introduced into a lobar bronchial orifice through the working channel of a FFB. The air from the lobe was constantly aspirated at a rate of 20 ml/min. The CO2 waveform was continuously monitored. This method was used in 13 patients with lung cancer and one with pulmonary embolism. In patients with lung cancer, group A (cases with blood flow disturbances) exhibited decreases in the end-tidal PCO2 (PETCO2) and mean alveolar PCO2 (PMACO2), and the CO2 waveform showed a flat form with a high PCO2 peak at the early inspiratory phase. Group B (cases without blood flow disturbances) demonstrated no differences in PETCO2, PMACO2, and CO2 wave form. In the case of pulmonary embolism, lung scan revealed impaired blood flow through the artery to right lower lobe. Gas sampling from this lobe showed decreased PETCO2 and PMACO2 and the CO2 wave form was flattened but without a peak. Anticoagulant therapy in this patient reversed these abnormalities. As the expired CO2 concentration in the lobe with disturbed blood flow is very low, PETCO2 and PMACO2 will also be low and CO2 wave form is flat. In lobes without disturbances in the blood flow, the end-expiratory gas in the central bronchi and trachea had higher CO2 concentration. During the next inspiration, the sampling tube aspirates the gas with higher CO2 concentration, giving rise to high PCO2 peak in the wave form. The authors conclude that FBC may be a useful method for the diagnosis and localization of blood flow disturbances and in evaluating the efficacy of therapy in pulmonary diseases that are associated with blood flow disturbances.

Bronchoalveolar oxyradical inflammatory elements herald bronchopulmonary dysplasia.

To quantify oxyradical inflammatory markers in serial endotracheal tube aspirates obtained from premature neonates at risk for developing bronchopulmonary dysplasia, and to correlate these parameters with clinical manifestations of the disease. Prospective cohort study. Tertiary neonatal intensive care unit. Twenty-eight intubated, premature infants, with 15 infants displaying simple respiratory distress syndrome and 13 infants eventually developing bronchopulmonary dysplasia. Endotracheal tube aspirates were collected and clinical severity scores were calculated longitudinally from an inception cohort during the first week of life. Diagnosis of bronchopulmonary dysplasia by standard criteria was recorded at 30 days of life. Various biochemical analyses related to pulmonary oxyradical stress were determined on endotracheal tube aspirates and were normalized according to the magnitude of serum/aspirate urea ratios. The demographic, illness severity, and biochemical characteristics of infants with simple respiratory distress syndrome and those characteristics of infants developing bronchopulmonary dysplasia were evaluated by masked comparison. Populations of respiratory distress syndrome and bronchopulmonary dysplasia infants could be differentiated during the first week of life by means of the following parameters: gestational age; birth weight; Score of Neonatal Acute Physiology; Neonatal Therapeutic Intervention Scoring System; epithelial lining fluid leukocytes; elastase; myeloperoxidase; xanthine oxidase and catalase enzyme activities; and total sulfhydryls. Infants with simple respiratory distress syndrome could be segregated from those infants who developed bronchopulmonary dysplasia by the magnitude of the epithelial lining fluid oxyradical inflammation markers. While infants developing bronchopulmonary dysplasia typically exhibited increased concentrations of these markers during the first week of life, those infants with simple respiratory distress syndrome displayed low, uniform, or decreasing values of these markers over this interval. Infants developing bronchopulmonary dysplasia demonstrate an early pulmonary inflammatory response, and one key aspect of this response involves various oxyradical-generating systems.

Hold That X-Ray

We report here a prospective study evaluating an alternative to the roentgenographic confirmation of "fine-bore" nasoenteral feeding tubes. Of 78 nasoenteral intubations in 46 patients using a Dobbhoff (Biosearch Medical Products) weighted enteral feeding tube, gastric aspirates were evaluated in 28. Auscultation was performed in all 78. Data was collected at initial placement prior to x-ray confirmation. Observers used color-coded pH paper to analyze gastric aspirate (pH < or = 4) and/or auscultation of the epigastrium to determine feeding tube position prior to x-rays. Auscultation alone was ineffective as a confirmatory test with only 6.3% specificity (p = 0.31). Aspiration to ascertain tube position was very accurate when pH < or = 4.0 (p = 0.0005) and when it was performed. A pH value of > 4 was not very helpful in predicting malposition (37%) especially when pH altering medications were used. Aspiration of contents was successful in 85% of patients. We conclude that when the pH of the nasogastric tube aspirate is < 4.0, x-ray films are not needed to prove the accuracy of tube placement. In other situations, a film is indicated since auscultation is inaccurate.

Effect of ranitidine on intragastric pH and stress-related upper gastrointestinal bleeding in patients with severe head injury

We conducted a double-blind, placebo-controlled study to evaluate the effects of ranitidine on intragastric pH and upper gastrointestinal tract bleeding in severe head injury patients. Within 24 hr of the precipitating trauma, 34 adults with Glasgow coma scale scores < or = 10 were randomized to a 6.25 mg/hr ranitidine continuous infusion or placebo for a maximum of 72 hr. Intragastric pH was recorded via an intragastric pH electrode. Patients with hematemesis, hematochezia, bright red blood, or "coffee ground" nasogastric tube aspirates plus a 5% decrease from baseline in hematocrit were considered to have gastrointestinal bleeding. Ranitidine patients maintained a significantly greater mean pH than placebo patients (placebo 2.2, ranitidine 4.1; P < 0.01). All patients had at least two bleeding risk factors at study entry. No ranitidine patients (0/16) developed bleeding compared with five (5/18) placebo patients (P < 0.05). Ranitidine continuous infusion provided consistent intragastric pH control and significant protection from stress-related upper gastrointestinal tract bleeding in a high-risk patient population.

Visual Characteristics Of Aspirates from Feeding Tubes as a Method for Predicting Tube Location

A sample of 880 feeding tube aspirates were classified as being primarily clear or cloudy and as having one of six colors. Gastric aspirates were most frequently cloudy and green, tan or off-white, or bloody or brown. Intestinal fluids were primarily clear and yellow to bile-colored. In the absence of blood, pleural fluid was usually pale yellow and serous, and tracheobronchial secretions were usually tan or off-white mucus. However, respiratory aspirates often contained blood and therefore failed to have the expected characteristics of respiratory fluid. Staff nurses were shown photographs of a sample of 106 aspirates and asked to predict tube position. Their ability to identify 50 gastric aspirates improved significantly after reading a list of suggested characteristics of feeding tube aspirates (81.33% to 90.47%, p < .0001). Similarly, their ability to identify 50 intestinal aspirates improved from 64.07% to 71.53% after reading the list of criteria. However, nurses were often unable to identify respiratory aspirates; the accuracy of their predictions decreased after reading the list of suggested characteristics (from 56.67% to 46.11%). The appearance of aspirates is often helpful in distinguishing between gastric and intestinal placement, but is of little value in ruling out respiratory placement.

Phosphatidylcholine composition of endotracheal tube aspirates of neonates and subsequent respiratory disease.

The phosphatidylcholine (PC) content of the initial endotracheal tube aspirate was measured in 105 infants intubated for resuscitation or for ventilation for respiratory distress syndrome, using high performance liquid chromatography and postcolumn fluorescence derivitization with diphenyl-1,3,5-hexatriene. Sixty eight had measurable PC. Of the infants who developed respiratory distress syndrome, with or without subsequent chronic lung disease, neither the percentage of dipalmitoylphosphatidylcholine (DPPC) nor the ratio of DPPC to palmitoyloleoylphosphatidylcholine (POPC), showed any correlation with gestational age. However, both parameters were significantly lower overall in this group than in the group of infants who did not develop respiratory distress syndrome. Infants with a ratio of DPPC:POPC less than 3.0 developed respiratory distress syndrome irrespective of gestational age, but there was considerable overlap between groups for values greater than this. The infants with respiratory distress syndrome who went on to develop chronic lung disease had the same initial PC profile as those with respiratory distress syndrome who did not develop chronic lung disease, but differed as a group by being lighter and more premature. The development of chronic lung disease was not associated with a particular initial PC composition. Other factors related to increasing prematurity must therefore be involved in rendering infants vulnerable to developing chronic lung disease.

Endoscopy-negative upper gastrointestinal bleeding in a patient with chronic pancreatitis

Dr. C. Me1 Wilcox: A 54-year-old man with a history of alcohol-induced chronic pancreatitis presented to the hospita1 with worsening abdominal pain, hematemesis, melena, and postural symptoms. He was in his usual state of health until 3 months before admission, when he underwent esophagogastroduodenoscopy for an exacerbation of chronic epigastric pain after an unsuccessful empirie trial of antiulcer therapy. Endoscopic findings included mild esophagitis and proximal gastritis. At that time, the hemoglobin was 130 g/L (13 g/dL) and the serum amylase concentration was 2.47 pkat/L (148 U/L) [upper limit of normal, 1.83 pkat/L (110 U/L)]. To further evaluate the abdominal pain, abdominal ultrasonography was performed demonstrating a sonolucent structure in the head of the pancreas measuring 5.1 X 3.8 cm, compatible with a pseudocyst. The common bile duet was noted to be 1.2 cm in diameter. Abdominal computed tomography (CT) at that time with IV contrast confirmed the presence of a pancreatic pseudocyst. In addition, abundant pancreatic calcifications were noted. He was begun on H,blocker therapy with some amelioration of pain. Six weeks before admission, a subsequent abdominal ultrasonography showed no change in the size or appearance of the pseudocyst. The pseudocyst was to be observed for another 6 weeks before deciding on therapy. Five days before admission, he noted the onset of worsening epigastric pain characterized as crampy and burning. The following day he noted the presence of black stool. Over the next 3 days, intermittent nausea and vomiting of bright red blood as wel1 as postural symptoms occurred, and he went to the hospital. In the emergency department, a nasogastric tube aspirate showed 50 mL of bright red blood and toffee-grounds material, which cleared after 500 mL of tap water lavage. He was thus admitted. His medical history was notable for alcohol-induced chronic pancreatitis and mild intermittent chronic abdominal pain of 3 years’ duration. Two years before admission, he was found to have an esophageal ulcer by esophagogastroduodenoscopy, presumed to be acid-peptic in origin by endoscopic and histopathological criteria. He underwent a laparotomy for colonic perforation after colonoscopic polypectomy 2 years previously. There was no pancreatie disease in his family history. He smoked one pack of cigarettes per day for more than 20 years. Although previously drinking six or more beers per day, he was currently consuming one to three beers per week. Admission physical examination showed a thin man in no apparent distress with blood pressure 155,/105 mmHg, pulse 104 beats/min, respirations 20 breaths/min, and temperature 37°C. With upright posture, his blood pressure decreased to 140/90 mmHg with a pulse increase to 120 heats/ min. Head and neck examination showed no abnormalities. The lungs were remarkable for an increased expiratory phase. Cardiac examination showed a tachycardia and a soft flow murmur at the base. Soft bruits were present over the femoral arteries. The abdomen was scaphoid with a well-healed midline star. Bowel sounds were present and no abdominal bruits were audible. Mild epigastric tenderness was present with palpation in the absente of any mass lesions; hepatosplenomegaly and rebound

Routine endotracheal cultures for the prediction of sepsis in ventilated babies.

Serial cultures of endotracheal tube aspirates were carried out in 94 neonates who were intubated and had been ventilated for longer than one week. A similar change in bacterial colonisation with duration of ventilation was seen in infants who subsequently developed sepsis and those who did not. In both groups, 177 aspirates (more than 90%) obtained during the first week of ventilation were sterile. Thereafter, colonisation with mixed Gram positive flora emerged followed by growth of Gram negative bacilli. For the infants who developed sepsis, the correlation between pathogens isolated from blood during the episodes of sepsis and those from previous endotracheal tube isolates was poor; in only five of the 26 cases of sepsis (19%) was the same single strain of organism isolated from culture of the blood and of the endotracheal tube aspirate. Other markers of infection such as endotracheal tube aspirate white blood cell counts and changes in bacterial flora were not useful in predicting systemic infection. Routine surveillance cultures of endotracheal tube aspirates in ventilated infants are not helpful in predicting the pathogens that are isolated from the blood during episodes of sepsis.

1355 CHLAMYDIA TRACHOMATIS (Ct) PNEUMONITIS IN PREMATURE INFANTS

Although Ct is recognized as a common etiologic agent in infant pneumonia, its role in pulmonary infection of premature infants has received little attention. Eight premature high risk babies hospitalized in our intensive care nursery over a 9 month period were documented to have Ct pneumonitis by standard McCoy cell tissue culture of endotracheal tube aspirates (7 patients) or nasopbaryngeal swab (1 patient). All patients had negative CMV urine cultures. Birthweights ranged from 610-2200 g. and gestational ages from 26-34 weeks. Six patients were born vaginally and 2 by Caesarean section. Age ranges at time of Ct isolation was 8-83 days (mean 29 days). All patients were cultured during an acute worsening of their respiratory status; 7 showed acute changes on chest X-ray. Seven patients were treated with erythromycin for 3 weeks; the remaining patient died prior to Ct identification. Five patients died of respiratory failure, 1 patient is at home on oxygen therapy for chronic lung disease and 2 patients have no residual lung disease. During this same time period, there were 8 infants of similar gestational age, birthweight, chronological age and mode of delivery whose endotracheal aspirate culture was negative for Ct. All these infants have survived. Chlamydia trachomatis appears to be associated with severe pulmonary disease in premature infants. Ct pneumonitis should be considered in a premature high risk infant with worsening respiratory status.