Australian and New Zealand practice in intensive care (ANZPIC II: The spectrum of practice in the diagnosis and management of pneumonia in patients requiring mechanical ventilation

This study of ventilated patients investigated current clinical practice in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units (ICUs) within Australia and New Zealand. Diagnostic methods and confidence, disease severity, microbiology and antibiotic use were assessed. All pneumonia types had similar mortality (community-acquired pneumonia 33%, hospital-acquired pneumonia 37% and ventilator-associated pneumonia 24%, P = 0.15) with no inter-hospital differences (P = 0.08-0.91). Bronchoscopy was performed in 26%, its use predicted by admission hospital (one tertiary: OR 9.98, CI 95% 5.11-19.49, P < 0.001; one regional: OR 629, CI 95% 3.24-12.20, P < 0.001), clinical signs of consolidation (OR 3.72, CI 95% 2.09-662, P < 0.001) and diagnostic confidence (OR 2.19, CI 95% 1.29-3.72, P = 0.004). Bronchoscopy did not predict outcome (P = 0.11) or appropriate antibiotic selection (P = 0.69). Inappropriate antibiotic prescription was similar for all pneumonia types (11-13%, P = 0.12) and hospitals (0-16%, P = 0.25). Blood cultures were taken in 51% of cases. For community-acquired pneumonia, 70% received a third generation cephalosporin and 65% a macrolide. Third generation cephalosporins were less frequently used for mild infections (OR 0.38, CI 95% 0.16-0.90, P = 0.03), hospital-acquired pneumonia (OR 0.40, CI 95% 0.23-0.72, P < 0.01), ventilator-associated pneumonia (OR 0.04, CI 95% 0.02-0.13, P < 0.001), suspected aspiration (OR 0.20, CI 95% 0.04-0.92, P = 0.04), in one regional (OR 0.26, CI 95% 0.07-0.97, P = 0.05) and one tertiary hospital (OR 0.14, CI 95% 0.03-0.73, P = 0.02) but were more commonly used in older patients (OR 1.02, CI 95% 1.01-1.03, P = 0.01). There is practice variability in bronchoscopy and antibiotic use for pneumonia in Australian and New Zealand ICUs without significant impact on patient outcome, as the prevalence of inappropriate antibiotic prescription is low. There are opportunities for improving microbiological diagnostic work-up for isolation of aetiological pathogens.

Successful use of recombinant factor VII in massive hemoptysis due to community-acquired pneumonia

Recombinant activated factor VII (rFVIIa) is a powerful hemostatic agent developed for use in hemophilia. It has been used increasingly in life-threatening hemorrhage in a variety of other settings in which conventional medical or surgical therapy is unsuccessful. This report describes the successful use of rFVIIa for pulmonary hemorrhage due to a focal bleeding source in a regional hospital where bronchial artery embolization or surgery were not available. rFVIIa may be a useful temporizing measure in the unstable patient with pulmonary hemorrhage without coagulopathic bleeding when conventional treatment. is not immediately available.

Double-heater-wire circuits and heat-and-moisture exchangers and the risk of ventilator-associated pneumonia

Objective: To compare the incidence of ventilator-associated pneumonia (VAP) in patients ventilated in intensive care by means of circuits humidified with a hygroscopic heat-and-moisture exchanger with a bacterial viral filter (HME) or hot-water humidification with a heater wire in both inspiratory and expiratory circuit limbs (DHW) or the inspiratory limb only (SHW). Design: A prospective, randomized trial. Setting: A metropolitan teaching hospital's general intensive care unit. Patients: Three hundred eighty-one patients requiring a minimum period of mechanical ventilation of 48 hrs. Interventions: Patients were randomized to humidification with use of an HME (n = 190), SHW (n = 94), or DHW (n = 97). Measurements and Main Results. Study end points were VAP diagnosed on the basis of Clinical Pulmonary Infection Score (CPIS) (1), HME resistance after 24 hrs of use, endotracheal tube resistance, and HME use per patient. VAP occurred with similar frequency in all groups (13%, HME; 14%, DHW; 10%, SHW; p = 0.61) and was predicted only by current smoking (adjusted odds ratio [AOR], 2.1; 95% confidence interval [CI], 1.1-3.9; p =.03) and ventilation days (AOR, 1.05; 95% Cl, 1.0-1.2; p =.001); VAP was less likely for patients with an admission diagnosis of pneumonia (AOR, 0.40; 95% Cl, 0.4-0.2; p =.04). HME resistance after 24 hrs of use measured at a gas flow of 50 L/min was 0.9 cm H2O (0.4-2.9). Endotracheal tube resistance was similar for all three groups (16-19 cm H2O min/L; p =.2), as were suction frequency, secretion thickness, and blood on suctioning (p =.32, p =.06, and p =.34, respectively). The HME use per patient per day was 1.13. Conclusions: Humidification technique does not influence either VAP incidence or secretion characteristics, but HMEs may have air-flow resistance higher than manufacturer specifications after 24 hrs of use.

Preterm infants with video-EEG confirmed seizures:outcome at 30 months of age

Our aim was to identify early predictors of poor neurodevelopmental outcome and of subsequent epilepsy in very early preterm and late preterm newborns with neonatal seizures.

Optical coherence tomography confirmed resolution of macular edema in a diabetic patient after hemodialysis

Purpose: The authors report the first case, to their knowledge, of resolution of diffuse macular edema after hemodialysis, which has been confirmed by optical coherence tomography. Methods: A 53-year-old white woman with type 2 diabetes developed worsening macular edema and was examined in the ophthalmology clinic and scheduled for macular grid laser photocoagulation. The laser, however, was deferred for 4 weeks because she had also developed end-stage renal failure and required hemodialysis. Results: When she was reviewed in the ophthalmology clinic 4 weeks later for laser therapy, it was found that her macular edema had resolved, vision had improved, and laser was unnecessary. Review at 6 months showed that the macular edema remains resolved. Conclusion: Ophthalmologists should be aware that hemodialysis may reduce macular edema in such patients. Copyright © by Ophthalmic Communications Society Inc.

Orthodoxy confirmed, but at what cost?

Examines the Court of Appeal ruling in Mexfield Housing Co-operative Ltd v Berrisford on whether a periodic tenancy agreement concluded by a housing association, which purported to prohibit the landlord from seeking possession unless the tenant was in arrears of rent, or otherwise in breach, could be terminated by way of a notice to quit, even where no breach had occurred, on the ground of uncertainty of term. Considers whether the agreement could be enforced under the rules of equity.