jueves, 5 de marzo de 2015

Más sobre NAV/More on VAP

Procalcitonina como marcador diagnóstico de NAV en cirugía cardiaca
Procalcitonin as a diagnostic marker of ventilator-associated pneumonia in cardiac surgery patients. Jiao J, Wang M, Zhang J, Shen K, Liao X, Zhou X.
Exp Ther Med. 2015 Mar;9(3):1051-1057. Epub 2015 Jan 9.
The aim of the present study was to assess whether procalcitonin (PCT) can be used as a diagnostic marker for ventilator-associated pneumonia(VAP) in cardiac surgery patients. Between January 2012 and June 2013, a total of 92 patients were recruited and divided into non-VAP (59 patients) and VAP (33 patients) groups. The preoperative and postoperative characteristics of the patients were recorded. Serum levels of PCT, interleukin (IL)-6 and C-reactive protein (CRP) were measured using an electrochemiluminescence immunoassay. Subsequently, receiver operating characteristic curves of the PCT, IL-6 and CRP levels were constructed. In addition, associations between the sequential organ failure assessment (SOFA) scores and the serum levels of PCT, IL-6 and CRP in the VAP patients were analyzed. No statistically significant difference was observed between the non-VAP and VAP patients in the occurrence of postoperative complications. However, the SOFA scores (days 1 and 7), the duration of stay in the intensive care unit and the mechanical ventilation time were all significantly higher in the VAP group when compared with the non-VAP group (P<0.05). The optimum PCT cut-off value for VAP diagnosis on day 1 was 5.0 ng/ml, with a sensitivity of 91% and a specificity of 71%. The serum PCT levels on days 1 and 7 were found to correlate positively with the SOFA scores (r=0.54 and r=0.66 for days 1 and 7, respectively). Therefore, the results suggested that serum PCT may be used as diagnostic marker for VAP in patients following cardiac surgery.
KEYWORDS: cardiac surgery; diagnostic marker; procalcitonin; ventilator-associated pneumonia

Una encuesta nacional del diagnóstico y tratamiento de sospecha de neumonía asociada a la ventilación.
A national survey of the diagnosis and management of suspected ventilator-associated pneumonia.
Browne E, Hellyer TP, Baudouin SV, Conway Morris A, Linnett V, McAuley DF, Perkins GD, Simpson AJ.
BMJ Open Respir Res. 2014 Dec 16;1(1):e000066. doi: 10.1136/bmjresp-2014-000066. eCollection 2014.
BACKGROUND: Ventilator-associated pneumonia (VAP) affects up to 20% of patients admitted to intensive care units (ICU). It is associated with increased morbidity, mortality and healthcare costs. Despite published guidelines, variability in diagnosis and management exists, the extent of which remains unclear. We sought to characterise consultant opinions surrounding diagnostic and management practice for VAP in the UK. METHODS: An online survey was sent to all consultant members of the UK Intensive Care Society (n=∼1500). Data were collected regarding respondents' individual practice in the investigation and management of suspected VAP including use of diagnostic criteria, microbiological sampling, chest X-ray (CXR), bronchoscopy and antibiotic treatments. RESULTS: 339 (23%) responses were received from a broadly representative spectrum of ICU consultants. All respondents indicated that microbiological confirmation should be sought, the majority (57.8%) stating they would take an endotracheal aspirate prior to starting empirical antibiotics. Microbiology reporting services were described as qualitative only by 29.7%. Only 17% of respondents had access to routine reporting of CXRs by a radiologist. Little consensus exists regarding technique for bronchoalveolar lavage (BAL) with the reported volume of saline used ranging from 5 to 500 mL. 24.5% of consultants felt inadequately trained in bronchoscopy. CONCLUSIONS: There is wide variability in the approach to diagnosis and management of VAP among UK consultants. Such variability challenges the reliability of the diagnosis of VAP and its reported incidence as a performance indicator in healthcare systems. The data presented suggest increased radiological and microbiological support, and standardisation of BAL technique, might improve this situation.
KEYWORDS: Assisted Ventilation; Pneumonia; Respiratory Infection
Influencia de anestesia con remifentanilo/propofol en NAV después de cirugía cardiaca
Influence of Remifentanil/Propofol Anesthesia on Ventilator-associated Pneumonia Occurence After Major Cardiac Surgery.
Krdzalic A, Kosjerina A, Jahic E, Rifatbegovic Z, Krdzalic G.
Med Arch. 2013 Dec;67(6):407-9. doi: 10.5455/medarh.2013.67.407-409. Epub 2013 Dec 28.
The study is designed to evaluate the influence of remifentanil/propofol anesthesia on ventilator-associated pneumonia (VAP) occurrence and respiratory support (RS) time after major cardiac surgery. MATERIAL AND METHODS: In retrospective-prospective study we investigated the respiratory support time and VAP occurrence in group of 47 patients with remifentanil/propofol and 35 patients with fentanil/midazolam anesthesia after major cardiac surgery in period June 2009-December 2011. Groups are divided in subgroups depending of who underwent cardiac surgery with or without cardiopulmonary by pass (CPB). RESULTS: The time of respiratory support (RS) was the shortest in remifentanil group without CPB (R/Off 63min ± 44.3 vs R/On 94min ± 49.2 p=0,22), but was longer in fentanil group (F/Off 142 min ± 102.2 vs F/On 212 min ± 102.2 p=0.0014). The duration of RS of ON pump remifentanil group was shorter than in ON pump fentanil group (R/On 94 min vs F/On 212 min p=0.0011). The time of RS of OFF pump remifentanil group was lower than in Off pump entangle group (R/Off 63min ± 44,3 vs F/Off 142min ± 102.2 p=0,021) with statistically significance. Ventilator-associated pneumonia was detected in 7 patients (8.5 %). Six patients (17.1%) were from entangle group and one patient (2.1%) from remifentanil group. The most common isolates were Pseudomonas aeruginosa in all patients and both Pseudomonas aeruginosa and Klebsiella pneumonia in one patient. CONCLUSION: The remifentanil anesthesia regimen in cardiac surgery decreases length of respiratory support duration and can prevent development of VAP. The role of remifentanil anesthesia in preventing VAP, as one of the most important risk factor of in-hospital mortality after cardiac surgery is still incompletely understood and should be investigated further.
KEYWORDS: cardiac surgery; remifentanil/propofol anesthesia; ventilator-associated pneumonia
Anestesia y Medicina del Dolor
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