Background: We compared the incidence of ventilator associated pneumonia (VAP) among patients treated with comprehensive oral care to those treated with conventional methods of oral care. Methods: We conducted a prospective, controlled study in an intensive care unit of 90 ventilated patients. Patients in the study group received a comprehensive oral hygiene treatment regimen that involved tooth brushing, suctioning, sodium bicarbonate, rinsing with an antiseptic solution containing 1.5% hydrogen peroxide and a mouth moisturiser. Patients in the control group received a more conventional treatment that included cleaning with a sponge and atraumatic clamp, and rinsing with a 0.2% solution of chlorhexidine gluconate. Results: Among the 90 patients admitted to the ICU, 8.9% of the study group developed VAP compared with 33.3% of the control group ( p< 0.004). The development of VAP per 1,000 ventilation days was 10.2 in the study group, and 29.5 in the control group ( p< 0.06). The mean number of ventilation days and the mean number of hospitalisation days were also lower in the study group. Conclusions: In patients who are ventilated, a comprehensive oral hygiene treatment regimen that includes tooth brushing, suctioning and rinsing with an antiseptic is more effective in preventing VAP than more conventional protocols.

Critically ill patients, eligible for admission into intensive care units (ICUs), are often hospitalized in other wards due to a lack of ICU beds. Differences in morbidity between patients managed in ICUs and elsewhere are unknown, specifically the morbidity related to hospital-acquired infection. Patients fitting ICU admission criteria were identified by screening five entire hospitals on four separate days. Hospital infections within a 30-day follow-up period were compared in ICU patients and in patients on other wards using Kaplan–Meier curves. Residual differences in the patients' case mix between ICUs and other wards were adjusted for utilizing multivariate Cox models. Of 13415 patients screened, 668 were critically ill. The overall infection rates (per 100 patient-days) were 1.2 for bloodstream infection (BSI) and 1.9 for urinary tract infection (UTI). The adjusted hazard ratios in ICU patients compared with patients on regular wards were 3.1 (P<0.001) for BSI and 2.5 (P<0.001) for UTI. This increased risk persisted even after adjusting for the disparity in the number of cultures sent from ICUs compared with ordinary wards. No interdepartmental differences were found in the rates of pneumonia, surgical wound infections and other infections. Minimizing the differences between characteristics of patients hospitalized in ICUs and in other wards, and controlling for the higher frequency of cultures sent from ICUs did not eliminate the increased risk of BSI and UTI associated with admission into ICUs.

OBJECTIVE:The demand for intensive care beds far exceeds their availability in many European countries. Consequently, many critically ill patients occupy hospital beds outside intensive care units, throughout the hospital. The outcome of patients who fit intensive care unit admission criteria but are hospitalized in regular wards needs to be assessed for policy implications. The object was to screen entire hospital patient populations for critically ill patients and compare their 30-day survival in and out of the intensive care unit.DESIGN:Screening teams visited every hospital ward on four selected days in five acute care Israeli hospitals. The teams listed all patients fitting a priori developed study criteria. One-month data for each patient were abstracted from the medical records.SETTING:Five acute care Israeli hospitals.PATIENTS:All patients fitting a priori developed study criteria.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Survival in and out of the intensive care unit was compared for screened patients from the day a patient first met study criteria. Cox multivariate models were constructed to adjust survival comparisons for various confounding factors. The effect of intensive care unit vs. other departments was estimated separately for the first 3 days after deterioration and for the remaining follow-up time. Results showed that 5.5% of adult hospitalized patients were critically ill (736 of 13,415). Of these, 27% were admitted to intensive care units, 24% to specialized care units, and 49% to regular departments. Admission to an intensive care unit was associated with better survival during the first 3 days of deterioration, after we adjusted for age and severity of illness (p =.018). There was no additional survival advantage for intensive care unit patients (p =.9) during the remaining follow-up time.CONCLUSIONS:The early survival advantage in the intensive care unit suggests a window of critical opportunity for these patients. Under economic constraints and dearth of intensive care unit beds, increasing the turnover of patients in the intensive care unit, thus exposing more needy patients to the early benefit of treatment in the intensive care unit, may be advantageous.

We report a fatal outcome using 1.5% glycine as distension/irrigation fluid for hysteroscopic myomectomy.During general anaesthesia for transcervical endoscopic resection of myoma, a healthy 35‐year‐old woman developed severe pulmonary hyponatraemia and cerebral oedema, and was declared brain dead. Postmortem findings did not reveal pontine myelinolysis. Through the procedure, the net fluid absorption of 1.5% glycine was 1.6 L plus 1 L of maintenance intravenous Ringer’s lactate solution.Regional anaesthesia is recommended for hysteroscopy, since general anaesthesia may mask neurologic signs, and meticulous attention should be paid to intraoperative fluid balance.

Objective:Hospital mortality of patients with septic multiorgan failure (MOF) is still around 95%. The present study investigates whether this high mortality could be significantly reduced by the addition of sequential hemofiltration (SH) with bicarbonate hemodialysis (HD) to the currently used life supportive measures.Design: 35 (18 surgical and 17 nonsurgical) patients, with 3 or more organ failures, had daily sessions of zero balance SH, for periods ranging from 2-22 days.Measurements and Results: SH induced significant improvement of PaO2/100 FIO2, Apache II score, MAP, as well as blood chemistry in survivors. Dying patients had less marked improvement of blood oxygenation, non-significant changes in other variables, in addition to low MAP before and after SH, as well as marked hemodynamic unstability during the procedure. The observed hospital mortality was 38% for the surgical group, and 35.3% for the medical patients (n.s.).Conclusions: Mortality observed in this retrospective, uncontrolled study was significantly lower than that currently observed with conventional supportive therapy, with or without the addition of other forms of blood purification, e.g. CAVH and CAVHD. This improvement in results appears to be related to the property of SH to completely clear 90% of the blood from mediators of inflammation in only one passage through the hemofilter, and to better tolerance of HD done using bicarbonate buffer. A definite evaluation of this technique will be eventually reached by a programmed, appropriate sample size study, which is out of reach for one individual ICU.

Five patients with sepsis-induced acute organ system failure were treated by sequential plasmafilterdialysis with slow continuous hemofiltration in addition to conventional therapy. In this way, we were able to associate the possible clearance of mediators and toxic substances achieved by plasmapheresis with an improved clearance of nitrogen waste products, since we added diffusion to the convective effect of hemofiltration. The hypercatabolism was well controlled, and there was a significant improvement in cardiorespiratory parameters at the same time. These patients were retrospectively compared with four conventionally treated patients (100% mortality) and with six others treated by association of conventional therapy and continuous arteriovenous hemodialysis (50% mortality). Despite the small numbers of patients treated and the need of additional studies, our good results (all the patients survived) encourage us to use this approach as an adjunct of conventional therapeutic measures in oliguric and hypercatabolic AOSF patients.

Eleven patients suffering severe traumatic respiratory insufficiency were mechanically ventilated using a new system which combined high-frequency positive-pressure ventilation (HFPPV) with low-rate conventional mechanical ventilation (LRCMV). Ten similar patients were ventilated by conventional mechanical ventilation (CMV) with PEEP. HFPPV patients were fully conscious and cooperative during ventilation and did not need sedatives or muscle relaxants. Arterial oxygenation was significantly (p < .005) better in HFPPV than CMV patients (89.91 ± 10.24 vs. 78.43 ± 11.13 torr, respectively), and pulmonary shunt was also better in the HFPPV group (13.1 ± 4.7% vs. 20.4 ± 6.4%, p < .01). Moreover, inspired oxygen concentrations were lower (Pao2/Fio2 197.8 ± 51.3 in the HFPPV group vs. 130 ± 46.6 in the CMV group, p < .005) and the time required for mechanical ventilation was shorter (4.2 ± 0.91 vs. 6.1 ± 0.8 days, p < .1). All HFPPV patients immediately began breathing spontaneously when they were disconnected from the ventilator. We suggest this method as a better ventilatory mode for patients suffering traumatic respiratory insufficiency.

The respiratory parameters of some of the patients with acute respiratory failure deteriorates while using conventional ventilation. These patients suffer unilateral lung disease and the failure to respond favourably to therapy is due to increased intrapulmonary shunt. There is a reflex vasodilation in the injured lung. Functional residual capacity is reduced in the injured lung and the compliance decreases. Gas flow is then deviated to the other lung, thus increases alveolar collapse and decreases regional compliance in the injured lung. These events cause severe hypoxemia. We present here two cases with unilateral lung disease that failed to respond to conventional mechanical ventilation. Asynchronized differential lung ventilation was found to be the therapeutic answer to the problem. We discuss the pathophysiology of unilateral lung injury and the physiology of differential lung ventilation.

Eleven patients suffering severe traumatic respiratory insufficiency were mechanically ventilated using a new system which combined high-frequency positive-pressure ventilation (HFPPV) with low-rate conventional mechanical ventilation (LRCMV). Ten similar patients were ventilated by conventional mechanical ventilation (CMV) with PEEP. HFPPV patients were fully conscious and cooperative during ventilation and did not need sedatives or muscle relaxants. Arterial oxygenation was significantly (p less than .005) better in HFPPV than CMV patients (89.91 +/- 10.24 vs. 78.43 +/- 11.13 torr, respectively), and pulmonary shunt was also better in the HFPPV group (13.1 +/- 4.7% vs. 20.4 +/- 6.4%, p less than .01). Moreover, inspired oxygen concentrations were lower (PaO2/FIO2 197.8 +/- 51.3 in the HFPPV group vs. 130 +/- 46.6 in the CMV group, p less than .005) and the time required for mechanical ventilation was shorter (4.2 +/- 0.91 vs. 6.1 +/- 0.8 days, p less than .1). All HFPPV patients immediately began breathing spontaneously when they were disconnected from the ventilator. We suggest this method as a better ventilatory mode for patients suffering traumatic respiratory insufficiency.

Twenty-four patients with high microvascular permeability pulmonary edema were initially treated by means of conventional supportive therapy for 1-12 days. Continued deterioration was treated by predilutional hemofiltration and induced a dramatic improvement in 22/24 patients. Survival was 92%. Sieving coefficients for autacoids and middle molecular weight vasoactive peptides involved in the development of high microvascular permeability pulmonary edema were higher than 0.88 indicating that clearing from blood of these peptides during one pass through the hemofilter is similar to that obtained during one pass through the pulmonary normal microvasculature. Hemofiltration seems to be a significant breakthrough in the treatment of ARDS secondary to severe sepsis.

Two patients, affected by spotted fever, developed low pulmonary capillary wedge pressure (PCWP) pulmonary edema with severe hypoxemia. Conventional specific and supportive therapy, including mechanical ventilation, failed to induce significant respiratory and hemodynamic improvement which was dramatically reached by means of hemofiltration. Removal of circulating middle molecular weight peptides by the convective mass transfer, characteristic of hemofiltration, offers a new and effective therapeutic approach for the adult respiratory distress syndrome secondary to rickettsial diseases.

One case of severe varicella pneumonia with high microvascular permeability pulmonary edema and signs of multiple system organ disfunction was successfully treated by means of hemofiltration. The patient was discharged from the Intensive Care Unit 6 days after admission. Peptides showing molecular weight ranging between 600 (prostaglandins) and 4000 (B-endorphin) daltons were cleared from blood at the same rate as urea. Hemofiltration appears to be a valuable tool for treating septic ARDS.

Pulmonary oedema may be cardiac or non-cardiac in origin: these two forms are clinically indistinguishable and their treatments are completely different. A case of pulmonary oedema is reported. This was believed to be of cardiac origin but did not respond to conventional treatment with diuretics and positive fibrotropic drugs. Insertion of a Swan-Ganz catheter revealed low capillary wedge on pressure. This, in turn, indicates that pulmonary oedema is non-cardiac in origin. The administration of liquids and cortisones led to a rapid improvement in the patient's condition. It is concluded that, whenever conventional treatment of pulmonary oedema fails, the possibility of non-cardiac oedema should be considered. In order to check this, capillary wedge pressure is measured.

Two patients with chest injuries, flail chest and respiratory failure were mechanically ventilated by a system composed of 2 Bennett respirators and an independent source of gas. This system provides high-frequency positive pressure ventilation (HFPPV), low-frequency conventional mechanical ventilation (LFCMV) and high inspiratory flow of fresh gas (HIF), through the independent source. This system made use of the advantages of HFPPV and also solved the problem of possible CO2 retention. Using this system we could ventilate the patients while they were fully conscious and cooperative, thus eliminating the need for sedatives and muscle relaxants. Time of mechanical ventilation was shortened since the internal pneumatic fixation was very good and made it possible for the fractured ribs to unite rapidly. Restoration of spontaneous breathing was immediate after disconnection from the ventilator. We suggest this method as another mode of ventilation for patients with flail chest and respiratory failure.