Decreased Risk of Ventilator-Associated Pneumonia in Sepsis Due to Intra-Abdominal Infection
François PhilippartGaëlle BourocheJean-François TimsitMaïté Garrouste-OrgeasÉlie AzoulayMichaël DarmonChristophe AdrieBernard AllaouchicheClaire Ara-SomohanoStéphane RucklyAnne-Sylvie DumenilBertrand SouweineDany Goldgran-TolédanoLila BouadmaBenoît Misset
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Abstract:
Rationale Experimental studies suggest that intra-abdominal infection (IAI) induces biological alterations that may affect the risk of lung infection. Objectives To investigate the potential effect of IAI at ICU admission on the subsequent occurrence of ventilator-associated pneumonia (VAP). Methods We used data entered into the French prospective multicenter Outcomerea database in 1997–2011. Consecutive patients who had severe sepsis and/or septic shock at ICU admission and required mechanical ventilation for more than 3 days were included. Patients with acute pancreatitis were not included. Measurements and Main Results Of 2623 database patients meeting the inclusion criteria, 290 (11.1%) had IAI and 2333 (88.9%) had other infections. The IAI group had fewer patients with VAP (56 [19.3%] vs. 806 [34.5%], P<0.01) and longer time to VAP (5.0 vs.10.5 days; P<0.01). After adjustment on independent risk factors for VAP and previous antimicrobial use, IAI was associated with a decreased risk of VAP (hazard ratio, 0.62; 95% confidence interval, 0.46–0.83; P<0.0017). The pathogens responsible for VAP were not different between the groups with and without IAI (Pseudomonas aeruginosa, 345 [42.8%] and 24 [42.8%]; Enterobacteriaceae, 264 [32.8%] and 19 [34.0%]; and Staphylococcus aureus, 215 [26.7%] and 17 [30.4%], respectively). Crude ICU mortality was not different between the groups with and without IAI (81 [27.9%] and 747 [32.0%], P = 0.16). Conclusions In our observational study of mechanically ventilated ICU patients with severe sepsis and/or septic shock, VAP occurred less often and later in the group with IAIs compared to the group with infections at other sites.Keywords:
Ventilator-associated Pneumonia
The clinical usefulness of the APACHE II and SAPS systems in the early prognostic classification of patients with acute pancreatitis has been evaluated in a prospective multicenter study. We aimed to identify early those patients with acute pancreatitis who should be monitored closely to expedite the detection and treatment of complications. One hundred eighty-two patients with acute pancreatitis were included; 28 were classified as severe, having developed at least one major complication of the disease. The scores obtained through the APACHE II and SAPS systems in these severe cases were significantly higher than the scores in the mild cases of acute pancreatitis (p < 0.001). The sensitivity of these systems in the prognostic classification of acute pancreatitis was 70.4% for APACHE II and 66.7% for SAPS, and the specificity was 79.1% for both. When applying APACHE II and SAPS systems in the early phase of acute pancreatitis, the possibility of misdiagnosing the severity exists, thus limiting the application of these systems in the initial assessment of prognostic classification. In conclusion, APACHE II and SAPS systems are of limited clinical utility in the early prognostic evaluation of acute pancreatitis because of their low positive predictive value.
SAPS II
Limiting
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Acute pancreatitis (AP) is an inflammatory disease of the pancreas that causes local damage and systemic inflammatory response. Some of the numerical scoring systems used in the intensive care unit for the assessment of critically ill patients such as APACHE II and MEWS score could be used for AP, beside the scoring systems specific to AP (Ranson score, Pancreas score, BISAP). Therefore, the aim of this study was to examine the significance of inflammatory biomarkers and scoring systems in the evaluation of the severity of AP and outcomes. The study was conducted as a cohort prospective study, examining patients with AP, of both sexes. Laboratory analyses, as well as the scoring systems: Ranson, Pancreas score, Bedside Index of Severity in Acute Pancreatitis (BISAP), and Acute Physiology and Chronic Health Evaluation II (APACHE II) were collected on day zero and 48h after admission. The study included 50 patients of whom 8 died. The most reliable score for predicting AP severity was APACHE II0 and 48AUROC (0.753; 0.768) in relation to the inflammatory biomarkers. For initial prediction of the treatment outcome, APACHE II0, BISAP0, and CRP0 AUROC (0.813; 0.807; 0.753) had the highest discrimination rates and after 48h, APACHE II48, Ranson48, BISAP48, and Pancreas48 AUROC (0.917; 0.856; 0.789; 0.729). There was a statistically significant correlation between CRP0 and BISAP0 (p=0.006) and between PCT and all day-zero scores. All tested screening systems showed reliability in predicting AP severity and treatment outcomes. The best predictive power was demonstrated by the APACHE II score.
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Sepsis and acute pancreatitis, which bear a significant morbidity and mortality, are two diseases frequently encountered in intensive care units. Twenty percent of patients with acute pancreatitis have a severe form of the disease and 15-20% of them will die [1]. The mortality in septic shock varies from 40 to 60% [2]. Interestingly, both diseases have several features in common: the occurrence of multiple organ dysfunction over time and the involvement of mediators such as cytokines in the pathogenesis of the disease [3, 4, 5]. While numerous therapeutic clinical trials have been carried out in patients suffering from septic shock, only a small number of trials were done in patients with acute pancreatitis. In septic shock, the results of such trials have been disappointing for several reasons, all of which have been emphasized in recent literature. However, such treatments, which failed during septic shock, might be of interest in patients with severe acute pancreatitis. This hypothesis will be the focus of our article.
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Ventilator-associated Pneumonia
Mechanical ventilator
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To evaluate the influence of Acute Physiology and Chronic Health Evaluation (APACHE II) score on the choice of mechanical ventilation method and treatment outcome.A prospective, randomized trial was carried out at the multidisciplinary Intensive Care Unit over 22 months. Research sample consisted of 129 patients who required mechanical ventilation, divided in two groups: APACHE II < or = 20 and APACHE II > 20. Both groups were than randomized for either noninvasive or invasive mechanical ventilation. Comparison was made based on patient characteristics, objective parameters and influence of APACHE II score on treatment success and failure.APACHE II scoring was shown to have statistical significance on outcome assessment. Statistical significance was in favour of patients with APACHE II score < or = 20 vs > 20 (ventilator associated pneumonia 0 vs. 10, tracheotomy 0 vs. 16, Intensive Care Unit mortality 0 vs 12). Furthermore, in the group with APACHE II score > 20, after randomization, there was a statistical significance in favour of noninvasive mechanical ventilation in need for tracheotomy 2 (4%) vs. 14 (28%) (p < 0.001).Using good patient selection and applying strict protocols, in the group of patients with APACHE II < or = 20 all patients had successful mechanical ventilation, while in the group of patients with APACHE II > 20, noninvasive mechanical ventilation can be applied.
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Objective: To explore the possible causes of ventilator-associated pneumonia and the corresponding nursing strategy. Methods: To review the clinical characteristics and bacterial spectra of 17 cases of ventilator-associated pneumonia(VAP) in the respiratory intensive care u-nit. Results: Among the 36-case mechanical ventilation patients, 17casessuffered from VAP, and 4 patients died, The morbidity and mortality was 47. 22% , and 23. 52% respectively. Conclusion: In addition to practicing the routine nursing, masting strictly the indication of mechanical ventilation, combining noninvasive and invasive mechanical ventilation in the early stage may reduce in incidence of VAP in the RICU.
Ventilator-associated Pneumonia
Respiratory care
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Our aim was to prospectively compare the Accuracy of Acute Physiology and Chronic Health Evaluation (APACHE) II, Bedside Index of Severity in Acute Pancreatitis (BISAP), Ranson's score and modified Computed Tomography Severity Index (CTSI) in predicting the severity of acute pancreatitis based on Atlanta 2012 definitions in a tertiary care hospital in northern India.
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Objective:To discuss the characteristic and risk factors of ventilator-associated pneumonia in mechanical ventilation patients. Methods: The clinical data of patients with mechanical ventilation in ICU from Jan. 2001 to Jun. 2003 were retrospectivly analyzed. Totaly 63 cases were collected,31 patients of them have VAP. The number of non-VAP patients is 32. Results:①The VAP group has a obviously longer period of mechanical ventilation than the non-VAP group[ 17. 3 ± 15. 3)d vs (6. 1 ±. 8)d P0. 01], In the VAP group,41. 9% patients has a period of mechanical ventilation over 10 days, while 9.4% patients of non VAP group has an over 10 days ventilation period. The difference between their is significant. ②31.8% patients in the VAP group were administrated with nutrition support, which is significantly different from the non VAP group (71. 8%)(P = 0. 004).③Logistic analysis suggests that mechanical ventilation time and nutrition support are two risk factors of VAP (using occurrence of VAP as variable). Conclusion:Compared with the non-VPA group.the VAP group has relativly longer period of mechanical ventilation,and lower proportion of proper nutrition support. These may be the two risks factors of VAP.
Ventilator-associated Pneumonia
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Objective To exploring methods of care for reducing the incidence of VAP by investigating the cause of ventilator-associated pneumonia( VAP). Methods From January 2009 to December 2011,90 cases of VAP paitents were ventilated mechanically in the ICU ward,and the nursing strategy was taken. Relation between age,underlying diseases,mechanical ventilation time and pathway creating the artificial airway and the occurred VAP were analyzed retrospectively. Results 21 case occurred VAP,the ratio was 23. 33%,the age,underlying diseases and mechanical ventilation time were relevant to the occurrence of VAP( P 0. 01),the occurred VAP weren't significant differences among 3 pathway creating the artificial airway( P 0. 05). Conclusion We should reduce the incidence of VAP by strengthening nurse,dealing with the related factors of occurrence VAP,shortening the duration of mechanical ventilation time as far as possible.
Ventilator-associated Pneumonia
Artificial ventilation
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