Abstract: OBJECTIVE: To describe the epidemiology of infections in intensive care units (ICUs), whether present at admission or acquired during the stay. METHODS: Prospective data collection lasting 6 months in 71 Italian adult ICUs. Patients were screened for infections and risk factors at ICU admission and daily during their stay. MAIN RESULTS: Out of 9,493 consecutive patients admitted to the 71 ICUs, 11.6% had a community-acquired infection, 7.4% a hospital-acquired infection, and 11.4% an ICU-acquired infection. The risk curve of acquiring infection in the ICU was higher in patients who entered without infection than in those already infected (log-rank test, p < .0001; at 15 days, 44.0% vs. 34.6%). Hospital mortality (27.8% overall) was higher in patients admitted with infection than in those who acquired infection in the ICU (45.0% vs. 32.4%, p < .0001). Although the presence of infection per se did not influence mortality, the conditions of severe sepsis and septic shock were strong prognostic factors (odds ratio, 2.3 and 4.8, respectively). Apart from ICU-acquired peritonitis, no other site of infection reached statistical significance as an independent prognostic factor for hospital mortality. CONCLUSIONS: Adding specific data on infections and risk factors to a well-established electronic data collection system is a reliable basis for a continuous multicenter infection surveillance program in the ICU. Given the well-established importance of infection prevention programs, our data suggest that the improvement of the treatment of severe sepsis and septic shock is the key to lower infection-related mortality in the ICU. This calls for closer attention to severe infections in surveillance programs.
Abstract: PURPOSE: To evaluate (i) the appropriateness, safety, and patient outcomes after placement of the VenaTech LP caval filter and (ii) the success of filter insertion through various venous access routes. MATERIALS AND METHODS: An open multicenter prospective observational study was conducted in 12 European centers, including an initial part limited to four centers. Patients with common indications were eligible for inclusion after approval by an independent ethics committee. Over a 42-month period, 106 patients (46 men [43.4%], 60 women [56.6%]), 72.2 years +/- 13.3 of age (range, 37-97 y), with poor prognoses were included. Patients were examined 2-5 days after the procedure, then at 30 days +/- 5 and 90 days +/- 15 for clinical follow-up and filter assessment. Evaluation criteria were based on occurrence of pulmonary embolism (PE), adverse events, death, filter position, and caval patency. Data were available in 101 case report forms at days 2-5, in 75 at day 30 +/- 5, and in 60 at day 90 +/- 15. Two patients (1.9%) were lost to follow-up. RESULTS: The overall mortality rate was 20.8%. PE was present in 71 patients (67.0%). History of venous thromboembolic disease (VTED) was noted in 32 patients (30.2%), and recently diagnosed VTED was present in 101 patients (95.3%). Partial caval thrombosis was present before the procedure. Filter tilting of 10-45 degrees was seen in 3.9% of cases at days 2-5, 4.3% of cases at day 30 +/- 5, and 1.9% of cases at day 90 +/- 15. Follow-up evidenced neither clinical signs of PE nor significant device-related events. CONCLUSIONS: In a prospective patient cohort with a projected 3-month mortality rate of nearly 21.0% as a result of severe prognoses, the success of insertion via various venous access routes and the appropriateness and safety of the VenaTech LP caval filter were assessed. Findings at 90-day follow-up were free of symptomatic PE and device-related adverse effects.
Abstract: AIM: The assessment of the quality of intensive care medicine is mandatory in the modern healthcare system. In Italy, the GiViTI (Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva) network is working in this field since 1991 and it now involves 295 out of the about 450 Italian intensive care units (ICU). In 2002 GiViTI launched a project for the continuous quality assessment and improvement that is now joined by 180 ICUs. Data collected in 2005 are analyzed and presented. METHODS: All admitted patients were entered in a validated software, which performs a multitude of validity checks during the data entry. Data were further reviewed by the co-ordinating center; patients admitted in months with more than 10% of incomplete or inconsistent records in each ICU were excluded from the analysis. Each year, a multivariate logistic regression model is fitted to identify predictors of hospital mortality. Starting from the SAPS 2 and the 2004 GiViTI model predictions of hospital mortality, two calibration tables and curves are presented. RESULTS: In 2005, 180 Italian ICUs collected data on 55 246 patients. After excluding those admitted in months with an unjustified lower recruitment rate or with less than 90% of complete and consistent data, we had 52 816 (95.6%) valid cases. Although the rough hospital mortality in 2005 was 1% higher than in 2004 (22.6% vs 21.5%), the adjusted mortality shows a statistically significant 4% reduction (obser-ved-to-expected ratio: 0.96; 95% CI: 0.94-0.97). CONCLUSIONS: Italian ICUs in 2005 performed better than in 2004, at a parity of patient severity.
Abstract: BACKGROUND: Nonpermanent caval filters are placed in critical thromboembolic situations in which anticoagulation therapy is transiently contraindicated, ineffective, or the source of complications. The purpose of this study was to assess the safety and effectiveness of a second-generation long-duration temporary caval filter in these situations and compare its utility with that of other temporary filters. METHODS: This prospective study, including patients who underwent temporary caval filtration with the Tempofilter II, was conducted in nine European centers. All filters were successfully implanted. The filter was removed when the indication for caval filtration ceased. RESULTS: A total of 104 filters were inserted in 103 patients with an average age of 60 +/- 15.5 years (range, 22-92 years). Most patients (85%) had pulmonary embolism, deep venous thrombosis, or both. The main indications for caval filter placement were complications of or contraindications to anticoagulation therapy (n = 85; 82.5%) or for ineffectiveness of anticoagulation therapy (n = 12; 11.7%). The average duration of implantation was 29.5 +/- 14.0 days (range, 2-86 days). One filter migrated in the right atrium, followed by pulmonary embolism. No other case of pulmonary embolism or of infectious or mechanical complications related to the filter was observed. Thrombus was trapped within the filter in 24 cases (23.3%). All filters but one were removed, regardless of whether thrombus had been trapped. Retrieval was always successful after implantation periods up to 12 weeks. In 16 cases (15.5%), the filter was replaced by a permanent filter. CONCLUSIONS: The Tempofilter II is safe, effective, and useful in critical thromboembolic situations. It offers a valuable alternative to retrievable optional filters.
Abstract: STUDY OBJECTIVES: To evaluate the feasibility of uninterrupted translaryngeal open ventilation delivered through a pediatric, uncuffed endotracheal tube during percutaneous endoscopic tracheostomy (PET).Design and setting: Prospective, observational clinical study in a six-bed ICU of a university hospital. PATIENTS: Forty consecutive adult patients requiring an elective tracheostomy. INTERVENTIONS: We employed the basic Ciaglia technique with multiple dilators (n = 10), a single dilator (n = 15), and the Fantoni method (n = 15). During PET, pressure-controlled ventilation was maintained through an uncuffed, 4-mm inner-diameter pediatric tube. The fraction of inspired oxygen was 1.0. Ventilator settings were as follows: pressure-controlled ventilation, 40 cm H(2)O; respiratory rate, 25/min; inspiratory time, 1.2 s of inspiratory time (inspiratory/expiratory ratio, 1:1); and positive end-expiratory pressure, 0 cm H(2)O. MEASUREMENTS AND RESULTS: Measurements of arterial blood gas (ABG) tensions were obtained before the start of each tracheostomy and every 3 min during the procedure. An average of 8.28 +/- 2.28 ABG measurements were obtained from each patient (+/- SD). All patients were successfully assisted during performance of the tracheostomy, and no patient required ventilation through a cuffed endotracheal tube. The maximum increase in PaCO(2) was 8.49 +/- 5.50 mm Hg, and the maximum decrease in pH related to hypercarbia was 0.04 +/- 0.04. The PaO(2) increased in all patients (maximum change, 69.75 +/- 57.00 mm Hg; p < 0.01), and no patient had desaturation during the procedure. CONCLUSIONS: The technique that we propose for airway management during PET was safe and effective. A mild increase in PaCO(2) was not associated with significant metabolic and hemodynamic consequences, and an adequate PaO(2) was maintained throughout the study.
Abstract: BACKGROUND: Subclavian vein catheterism, a commonly used methodology in ICU, is not devoid of complications, even some serious ones (Pneumothorax 0.5%). METHODS: The authors propose an alternative technique based on the use of an introducer needle bent on its own axis to form an arch with its concavity turned towards the Quincke point. On searching the blood vessel, once the subclavian plane has been reached, the needle advancement towards the jugular fosse happens by following the needle curvature. In this way the operator can keep the needle on a plane parallel to the cutaneous one, and all the complications due to involuntary exceeding of the costal plane are avoided. The response of this new technique in 110 patients (study group) is compared through a retrospective study, to 100 patients with whom the standard technique has been used (control group). RESULTS: The study group has presented a significant reduction both of total complications (p<0.05) and of total failures (p< 0.01). CONCLUSIONS: Such results, although pertinent to a still limited study, testify to an improvement in terms of security and efficacy, with the new alternative technique without an increase in costs.
Abstract: BACKGROUND: Our aim was to check out the advantages of temporary caval filtration in pregnancy with a retrievable filter: Tempofilter (tCF). METHODS: During a period of 2 years we implanted tCF in four patients at the third pregnancy trimester with serious acute deep venous thrombosis (DVT) of the lower limbs for prophylaxis of pulmonary thromboembolic disease (TED) in the pre-partum, during Caesarian section (CS), and in the post-partum period. tCF has been placed percutaneously in local anaesthesia using the Seldinger technique and under image intensifier control. All procedures were performed in a polyvalent ICU. RESULTS: tCF positioning was always easy. No complications linked to the adopted technique occurred. No incidence of pulmonary embolism was reported (PE). The permanence period of tCF in situ was 14 to 29 days (mean+/-SD: 21+/-6). The CS always took place without complications either for the patient or for the foetus. CONCLUSIONS: The combined use of tCF and an anti-coagulating therapy resulted in an effective prophylaxis of TED for the pregnant woman without any interferences with CS and with no consequence as for permanent endovascular prosthesis for the young patient herself.
