https://www.chpso.org/sites/main/files/file-attachments/chest-2008-geerts-381s-453s.pdf

Prevention of Venous Thromboembolism* American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th Edition)

Health care-associated infections (HAI) are a major public health problem with a significant impact on morbidity, mortality and quality of life. They represent also an important economic burden to health systems worldwide. However, a large proportion of HAI are preventable through effective infection prevention and control (IPC) measures. Improvements in IPC at the national and facility level are critical for the successful containment of antimicrobial resistance and the prevention of HAI, including outbreaks of highly transmissible diseases through high quality care within the context of universal health coverage. Given the limited availability of IPC evidence-based guidance and standards, the World Health Organization (WHO) decided to prioritize the development of global recommendations on the core components of effective IPC programmes both at the national and acute health care facility level, based on systematic literature reviews and expert consensus. The aim of the guideline development process was to identify the evidence and evaluate its quality, consider patient values and preferences, resource implications, and the feasibility and acceptability of the recommendations. As a result, 11 recommendations and three good practice statements are presented here, including a summary of the supporting evidence, and form the substance of a new WHO IPC guideline.

/pdf/core-components-for-effective-infection-prevention-and-3u3wxoewdq.pdf

Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations

Objective. —To evaluate the potential efficacy of pressure limitation with permissive hypercapnia in the treatment of acute respiratory failure/adult respiratory distress syndrome on the basis of current theories of ventilator-induced lung injury, potential complications of systemic hypercarbia, and available human outcome studies. Data Sources. —Articles were identified through MEDLINE, reference citations of published data, and consultation with authorities in their respective fields. Study Selection. —Animal model experimentation and human clinical trials were selected on the basis of whether they addressed the questions of pressure limitation with or without hypercapnia, the pathophysiologic effects of hypercapnia, or the concept of ventilator-induced parenchymal lung injury. Frequently cited references were preferentially included. Data Extraction. —Data were analyzed with particular emphasis on obtaining the following variables from the clinical studies: peak inspiratory pressures, tidal volumes, minute ventilation, and Pco2. Quantitative aspects of respiratory physiology were used to analyze the theoretical effects of permissive hypercapnia on ventilatory requirements in normal and injured lungs. Data Synthesis. —Extensive animal model data support the hypothesis that ventilator-driven alveolar overdistention can induce significant parenchymal lung injury. The heterogeneous nature of lung injury in adult respiratory distress syndrome, with its small physiologic lung volume, may render the lung susceptible to this type of injury through the use of conventional tidal volumes (10 to 15 mL/kg). Permissive hypercapnia is an approach whereby alveolar overdistention is minimized through either pressure or volume limitation, and the potential deleterious consequences of respiratory acidosis are accepted. Uncontrolled human trials of explicit or implicit permissive hypercapnia have demonstrated improved survival in comparison with models of predictive mortality. Conclusions. —Avoidance of alveolar overdistention through pressure or volume limitation has significant support based on animal models and computer simulation. Deleterious effects of the associated hypercarbia in severe lung injury do not appear to be a significant limiting factor in preliminary human clinical trials. Although current uncontrolled studies suggest benefit, controlled trials are urgently needed to confirm these findings before adoption of the treatment can be endorsed. (JAMA. 1994;272:957-962)

Permissive hypercapnia in acute respiratory failure.

Background: Patients with acute pulmonary embolism (APE) present with a broad spectrum of prognoses. Computed tomographic pulmonary angiography (CTPA) has progressively been established as a first line test in the APE diagnostic algorithm, but estimation of short term prognosis by this method remains to be explored.

Methods: …

https://heart.bmj.com/content/heartjnl/92/2/254.full.pdf

Computed tomographic pulmonary angiography and prognostic significance in patients with acute pulmonary embolism

Imipenem, the first carbapenem discovered, was developed more than two decades ago in response to an unmet need for a highly potent, broad-spectrum antimicrobial agent with a strong safety profile. It has since been used to treat more than 26 million patients. In an era where antibiotic use has driven antibiotic resistance, choosing appropriate initial therapy for serious infection is critical. Appropriate antibiotic regimens must cover all likely pathogens, be administered promptly at the correct dosage and dosing interval, be well tolerated and prevent the emergence of resistance. While imipenem was initially reserved for use in intractable, serious infections, the benefits of early aggressive therapy are now known, making imipenem a core agent in de-escalation therapy due to proven efficacy and safety for indications such as nosocomial pneumonia, intra-abdominal infection, sepsis and febrile neutropenia. De-escalation therapy with an agent such as imipenem minimizes resistance development by initiating aggressive initial treatment and then tailoring therapy based on patient response and culture results, switching to a less expensive, narrower spectrum antibiotic regimen or shortening the duration of therapy. Imipenem has maintained sustained clinical efficacy, tolerability and in vitro activity against important bacterial pathogens for two decades. We review the factors that continue to make imipenem as appropriate an agent for de-escalation therapy now as it was 20 years ago.

Two decades of imipenem therapy

BACKGROUND The effectiveness of simulation-based training of critical care nurses in sterile techniques has not been determined. OBJECTIVE To evaluate the effectiveness of simulation-based training of critical care nurses to use sterile techniques during central vein catheterization and the effect of such training on infection rates. METHODS A prospective controlled study with 12-month observational follow-up to assess the rate of catheter-related bloodstream infections in a 23-bed medical, surgical, neurological critical care unit. RESULTS Forty-six critical care nurses completed assessment and training in sterile technique skills in the simulation laboratory. Performance scores at baseline were poor: median scores in each category ranging from 0 to 2 out of a maximum score of 4 and a median total score of 7 out of a maximum score of 24. After simulation-based training, nurses' median scores in each ST category and their total scores improved significantly, with the median total score increasing to 23 (P < .01; median difference, 15; 95% CI, 14-16). After completion of the simulation-based training intervention, the mean infection rate in the unit was reduced by 85% from 2.61 to 0.4 infections per 1000 catheter-days (P = .02). The incidence rate-ratio derived from the Poisson regression (0.15; 95% CI, 0.03-0.78) indicates an 85% reduction in the incidence of catheter-related bloodstream infections in the unit after the intervention. CONCLUSION Simulation-based training of critical care nurses in sterile technique is an important component in the strategy to reduce the occurrence of such infections and promote patient safety.

Simulation-Based Training for Nurses in Sterile Techniques During Central Vein Catheterization

Objectives. We conducted a study to answer 3 questions: (1) is CT pulmonary angiography (CTPA) overutilized in suspected pulmonary embolism (PE)? (2) What alternative diagnoses are provided by CTPA? (3) Can CTPA be used to evaluate right ventricular dilatation (RVD)? Methods. We retrospectively reviewed the clinical information of 231 consecutive emergency department patients who underwent CTPA for suspected PE over a one-year period. Results. The mean age of our patients was 53 years, and 58.4% were women. The prevalence of PE was 20.7%. Among the 136 patients with low clinical probability of PE, a d-dimer test was done in 54.4%, and it was normal in 24.3%; none of these patients had PE. The most common alternative findings on CTPA were emphysema (7.6%), pneumonia (7%), atelectasis (5.5%), bronchiectasis (3.8%), and congestive heart failure (3.3%). The sensitivity and negative predictive value of CTPA for (RVD) was 92% and 80%, respectively. Conclusions. PE could have been excluded without CTPA in ~1 out of 4 patients with low clinical probability of PE, if a formal assessment of probability and d-dimer test had been done. In patients without PE, CTPA did not provide an alternative diagnosis in 65%. In patients with PE, CTPA showed the potential to evaluate RVD.

/pdf/utilization-of-ct-pulmonary-angiography-in-suspected-4csuktnasi.pdf

Utilization of CT Pulmonary Angiography in Suspected Pulmonary Embolism in a Major Urban Emergency Department.

The purpose of this study was to determine the incidence of deep venous thrombosis in medical intensive care unit patients receiving deep venous thrombosis prophylaxis. This was a prospective cohort study of 141 consecutive adult patients anticipated to remain in the medical intensive care unit for >48 hours. Deep venous thrombosis prophylaxis was provided using subcutaneous unfractionated heparin or a sequential compression device according to risk-stratified protocol. Compression ultrasound was performed. Fourteen patients (9.9%) developed deep venous thrombosis on follow-up studies. Incidence of deep venous thrombosis was 7.9% per person year (95% confidence interval, 4.8-12.8). Two of 14 developed pulmonary embolism. Eight patients required full anticoagulation with intravenous heparin or coumadin. In-hospital mortality was similar in both groups. Patients with deep venous thrombosis had a statistically higher risk of pulmonary embolism: 14.2% (95% confidence interval, 2.0-43.0) versus 0.0% (95% confidence interval, 0-3; P = .009). Incidence of deep venous thrombosis is high in medical intensive care unit patients receiving standard prophylaxis. Adherence to strict deep venous thrombosis prophylaxis protocol and exploration of other prophylaxis regimens should be pursued.

Efficacy of deep venous thrombosis prophylaxis in the medical intensive care unit.

Status asthmaticus is a life-threatening episode of asthma that is refractory to usual therapy. Recent studies report an increase in the severity and mortality associated with asthma. In the airways, inflammatory cell infiltration and activation and cytokine generation produce airway injury and edema, bronchoconstriction and mucus plugging. The key pathophysiological consequence of severe airflow obstruction is dynamic hyperinflation. The resulting hypoxemia, tachypnea together with increased metabolic demands on the muscles of respiration may lead to respiratory muscle failure. The management of status asthmaticus involves intensive pharmacological therapy particularly with beta-adrenoceptor agonists (beta-agonists) and corticosteroids. Albuterol (salbutamol) is the most commonly used beta2-selective inhaled bronchodilator in the US. Epinephrine (adrenaline) or terbutaline, administered subcutaneously, have not been shown to provide greater bronchodilatation compared with inhaled beta-agonists. Corticosteroids such as methylprednisolone should be administered early. Aerosolized corticosteroids are not recommended for patients with status asthmaticus. Inhaled anticholinergic agents may be useful in patients refractory to inhaled beta-agonists and corticosteroids. In patients requiring mechanical ventilation, the strategy aims to avoid dynamic hyperinflation by enhancing expiratory time to allow complete exhalation. Complications of dynamic inflation are hypotension and barotrauma. Sedation with opioids, benzodiazepines or propofol is required to facilitate ventilator synchrony but neuromuscular blockade should be avoided as myopathy has been a reported complication. Overall, in the management of patients with status asthmaticus, the challenge to the pulmonary/critical care clinician is to provide optimal pharmacological and ventilatory support and avoid the adverse consequences of dynamic hyperinflation.

/pdf/management-of-respiratory-failure-in-status-asthmaticus-3xs0oh0gah.pdf

Management of Respiratory Failure in Status Asthmaticus

Myopathy is a rare complication that arises during management of status asthmaticus that may be related to administration of corticosteroids and neuromuscular blocking agents. We present 4 patients with myopathy and a review of the 31 previously reported patients in the literature. All patients received corticosteroids, and 33 of the 35 patients received neuromuscular blocking agents. Muscle weakness was often diffuse and, in several patients, involved the muscles of respiration. Creatine kinase values ranged from normal to markedly elevated. Diagnosis was obtained by electromyogram and muscle biopsy in most patients. Resolution of the muscle weakness occurred over a period of days to months. Patients in whom myopathy developed required mechanical ventilation for longer periods than patients intubated for status asthmaticus without myopathy.

Janet M. Shapiro

Papers

Simulation-Based Training for Nurses in Sterile Techniques During Central Vein Catheterization

Utilization of CT Pulmonary Angiography in Suspected Pulmonary Embolism in a Major Urban Emergency Department.

Efficacy of deep venous thrombosis prophylaxis in the medical intensive care unit.

Management of Respiratory Failure in Status Asthmaticus

Myopathy in Status Asthmaticus: Relation to Neuromuscular Blockade and Corticosteroid Administration