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P386 The prognosis of acute renal failure in an intensive care unit
Abstracts P385 Carotid artery-internal jugular vein fistula: nal jugular vein catheterisation M. Kunert, R. Schmidt, B. Gremmler, H. (Bottrop, Herdecke, D)
I European
Journal
a complication Schleiting,
of Internal
of interL.J.
Ulbricht
Background: Arteriovenous fistulas in the neck are very rare and can be observed as a result of traumatic injuries or as iatrogenic fistula after internal jugular vein catheterisation. Case report: A 60-year-old woman ( 160 cm, 100 kg) was transferred to our cardiac intensive care unit with massive pulmonary oedema due to severe arterial hypertension (RR 260/130 mmHg). Because of insufficient peripheral vein access internal jugular vein catheterisation was performed. Jugular access was very complex because of anatomic conditions (short neck, obesity) and required repetitive punctions. Finally correct positioning of a trilumen catheter could be achieved. After cardio-pulmonary recompensation and antihypertensive treatment the central catheter was removed 4 days after admission. 2 days later the patient complained of pain and swelling at the puncture site. Clinical examination revealed at the puncture site minimal hematoma and slight systolic murmur. Colour Doppler sonography showed a direct communication between carotid artery and jugular internal vein with a turbulent, high-velocity flow spectrum at the junction of artery and vein with a high-velocity arterialised waveform in the jugular internal vein. Successful operative revision of the fistula was performed. Summary: The internal jugular vein is increasingly being used as a temporary route for central catheter placement. It is thought to be safer than the subclavian or femoral vein sites. It is important to point out that internal jugular vein cannulation can be associated with serious complications. Colour Doppler sonography is not only useful in guidance of central vein access via the internal jugular vein but is also first choice in locating puncture complications like fistulas or arterial pseudoaneurysms
P386 The prognosis of Acute Renal Failure in an Intensive Care Unit A.C. Sousa, F. Rodrigues, C.A. Pereira, C. Ltlis, J. Nobrega, J. Jardim, G. Silva, A. Teixeira, J.A. Aratijo, E.R. Maul (Funchal, P) Acute Renal Failure (ARF) is a complication affecting up to 25% of patients admitted to Intensive Care Units (ICU). There are several factors that contribute to the high mortality rate (3788%) for which this clinical entity is responsible. Objective: To analyze the factors that contribute to the prognosis of ARF in an ICU. Material and methods: The authors made a retrospective analysis of the hospital records of 53 patients that developed ARF, among the 243 patients admitted to this Unit between January 1st 2002 and December 3 1st 2002. Two groups were established, one comprising non-surviving patients (n=26) and another comprising patients discharged from 1CU (N=27). A comparative analysis of the two groups was performed. Statistics: Data were analyzed with the SPSS software, version 10. Results: The average age among surviving patients was 61.77, being 61.85 among non-surviving patients, not significant (ns). ICU stay was 12.63 days for surviving patients and 8.5 days for non-surviving patient (ns). 12 surviving patients and 16 non-surviving patients had previous pathologies (ns). Upon admittance to the ICU the average creatinine level in the group of surviving patients was 1.55 mg/dl, being 1.95 mg/dl in the group of non-surviving patients (p =0.020). The average urea level upon admittance to the ICU was 59.15 mg/dl in surviving patients and 79.04 mg/dl in non-surviving patients (p=O.O17). Maximum creatinine peak average was 2.81 mg/dl in surviving patients, whereas in nonsurviving patients it was 4.35 mg/dl (p
Medicine
14 (2003)
SILT159
s139
patients in the group of survivors presented oligoanuria, a symptom that was only observed in 14 patients of the other group (ns). The APACHE II index was 18.67 for surviving patients and 23.35 for non-surviving patients (p=O.O27). The SAPS index was 47.26 for surviving patients and 60.96 for non-surviving patients (p=O.O04).
P387 Streptococcus pyogenes - agent associated with high despiste appropriate treatment M.J. Marta, A. Pais de Lacerda, C. Franca (L&boa, P)
mortality
Necrotising fasciitis is a rare disease characterized by extensive and rapidly spreading death of skin and deeper tissues, caused by streptococcus pyogenes (group A streptococcus). In most cases, it begins after an inapparent trauma. Immunosuppressor predisponent factors are unknown. Two cases of necrotising fasciitis by streptococcus rapidly evoluting to septic shock with multiorgan failure, despiste adequate empirical treatment are presented. The first case refers to a 32-year-old woman with a submaxilar cutaneous lesion who developed blisters from the toracic wall to the inguinal region with edema and vaginal necrosis. It was treated empirically with G-penicillin (24 MU/day) and clindamycin (900 mg every 6 hours). In the second case, a 80.year-old woman was admitted with an i&amatory cervical swelling with dyspnea. Orotraqueal intubation was done. Bloody blisters developed in right mamary region and quickly progressed over large areas with necrosis, despiste therapy with flucloxacilin (12 g/day) and clindamycin (900 mg every 6 hours). In both cases streptococcus pyogenes was isolated from blood cultures, the results of which were only available after the patients died. In necrotising fasciitis death rates are elevated even with adequate treatment. In the presence of a high clinical suspition surgery (when appropriate) with removal of dead tissues and antibiotic therapy should be initiated promptly.
P388 The epidemiology of microbiologic agents in a ICU and tion between anatomic sites T. Sequeira, A. Raimundo, M. Sousa, J. Martins, M. Coelho, F. Lacerda Nobre (Lisboa, P)
the correlaA. Quintino,
Introduction: Severe sepsis and septic shock are important causes of admission to intensive care units and represents a major cause of death. The mortality rate can reach 60%. Some studies reported a change in the epidemiology of the isolated agents, referring a higher number of Gram positive as well as fungi infections. Objective: To evaluate the pattern and type of infections in our unit. Methods and results: We studied 48 patients (36 male) that were admitted to the1 intensive care unit between 1998 and 2002 with the diagnosis of sepsis or septic shock. The median length of stay was 33.5f51.4 days and mortality rate of 64.6%. A total of 24 patients (50%) had positive blood cultures, 14 of them with more than one agent identified (at the same or different times). Twenty had Gram+ agents with 7 methicillin-resistant Staphilococcus aureus (MRSA), 4 methicillinsensitive Staphilococcus aureus (MSSA), 15 had Gramagents and 4 had fungi. Eight had concomitant infection of the central catheter, in a total of 13 infections identified in the catheters. In the bronchic secretions the agents identified were 18: 9 Gram - , 5 Gram + (MRSA 4 and MSSA 1) and 4 fungi. Only three patients had the same agent isolated in both places, and other three, positive cultures also in both, with different agents. In the urine (8), pleural liquid (2) peritoneal liquid (1) and feces (1) were also isolated some agents. Summing up all the agents isolated, 13 patients had no isolation at all, they all died except for two that were moved to other departments with stays inferior to one day in our unit. Discussion: The changing in the spectrum of agents in ICU is also
I European
Journal
a complication Schleiting,
of Internal
of interL.J.
Ulbricht
Background: Arteriovenous fistulas in the neck are very rare and can be observed as a result of traumatic injuries or as iatrogenic fistula after internal jugular vein catheterisation. Case report: A 60-year-old woman ( 160 cm, 100 kg) was transferred to our cardiac intensive care unit with massive pulmonary oedema due to severe arterial hypertension (RR 260/130 mmHg). Because of insufficient peripheral vein access internal jugular vein catheterisation was performed. Jugular access was very complex because of anatomic conditions (short neck, obesity) and required repetitive punctions. Finally correct positioning of a trilumen catheter could be achieved. After cardio-pulmonary recompensation and antihypertensive treatment the central catheter was removed 4 days after admission. 2 days later the patient complained of pain and swelling at the puncture site. Clinical examination revealed at the puncture site minimal hematoma and slight systolic murmur. Colour Doppler sonography showed a direct communication between carotid artery and jugular internal vein with a turbulent, high-velocity flow spectrum at the junction of artery and vein with a high-velocity arterialised waveform in the jugular internal vein. Successful operative revision of the fistula was performed. Summary: The internal jugular vein is increasingly being used as a temporary route for central catheter placement. It is thought to be safer than the subclavian or femoral vein sites. It is important to point out that internal jugular vein cannulation can be associated with serious complications. Colour Doppler sonography is not only useful in guidance of central vein access via the internal jugular vein but is also first choice in locating puncture complications like fistulas or arterial pseudoaneurysms
P386 The prognosis of Acute Renal Failure in an Intensive Care Unit A.C. Sousa, F. Rodrigues, C.A. Pereira, C. Ltlis, J. Nobrega, J. Jardim, G. Silva, A. Teixeira, J.A. Aratijo, E.R. Maul (Funchal, P) Acute Renal Failure (ARF) is a complication affecting up to 25% of patients admitted to Intensive Care Units (ICU). There are several factors that contribute to the high mortality rate (3788%) for which this clinical entity is responsible. Objective: To analyze the factors that contribute to the prognosis of ARF in an ICU. Material and methods: The authors made a retrospective analysis of the hospital records of 53 patients that developed ARF, among the 243 patients admitted to this Unit between January 1st 2002 and December 3 1st 2002. Two groups were established, one comprising non-surviving patients (n=26) and another comprising patients discharged from 1CU (N=27). A comparative analysis of the two groups was performed. Statistics: Data were analyzed with the SPSS software, version 10. Results: The average age among surviving patients was 61.77, being 61.85 among non-surviving patients, not significant (ns). ICU stay was 12.63 days for surviving patients and 8.5 days for non-surviving patient (ns). 12 surviving patients and 16 non-surviving patients had previous pathologies (ns). Upon admittance to the ICU the average creatinine level in the group of surviving patients was 1.55 mg/dl, being 1.95 mg/dl in the group of non-surviving patients (p =0.020). The average urea level upon admittance to the ICU was 59.15 mg/dl in surviving patients and 79.04 mg/dl in non-surviving patients (p=O.O17). Maximum creatinine peak average was 2.81 mg/dl in surviving patients, whereas in nonsurviving patients it was 4.35 mg/dl (p
Medicine
14 (2003)
SILT159
s139
patients in the group of survivors presented oligoanuria, a symptom that was only observed in 14 patients of the other group (ns). The APACHE II index was 18.67 for surviving patients and 23.35 for non-surviving patients (p=O.O27). The SAPS index was 47.26 for surviving patients and 60.96 for non-surviving patients (p=O.O04).
P387 Streptococcus pyogenes - agent associated with high despiste appropriate treatment M.J. Marta, A. Pais de Lacerda, C. Franca (L&boa, P)
mortality
Necrotising fasciitis is a rare disease characterized by extensive and rapidly spreading death of skin and deeper tissues, caused by streptococcus pyogenes (group A streptococcus). In most cases, it begins after an inapparent trauma. Immunosuppressor predisponent factors are unknown. Two cases of necrotising fasciitis by streptococcus rapidly evoluting to septic shock with multiorgan failure, despiste adequate empirical treatment are presented. The first case refers to a 32-year-old woman with a submaxilar cutaneous lesion who developed blisters from the toracic wall to the inguinal region with edema and vaginal necrosis. It was treated empirically with G-penicillin (24 MU/day) and clindamycin (900 mg every 6 hours). In the second case, a 80.year-old woman was admitted with an i&amatory cervical swelling with dyspnea. Orotraqueal intubation was done. Bloody blisters developed in right mamary region and quickly progressed over large areas with necrosis, despiste therapy with flucloxacilin (12 g/day) and clindamycin (900 mg every 6 hours). In both cases streptococcus pyogenes was isolated from blood cultures, the results of which were only available after the patients died. In necrotising fasciitis death rates are elevated even with adequate treatment. In the presence of a high clinical suspition surgery (when appropriate) with removal of dead tissues and antibiotic therapy should be initiated promptly.
P388 The epidemiology of microbiologic agents in a ICU and tion between anatomic sites T. Sequeira, A. Raimundo, M. Sousa, J. Martins, M. Coelho, F. Lacerda Nobre (Lisboa, P)
the correlaA. Quintino,
Introduction: Severe sepsis and septic shock are important causes of admission to intensive care units and represents a major cause of death. The mortality rate can reach 60%. Some studies reported a change in the epidemiology of the isolated agents, referring a higher number of Gram positive as well as fungi infections. Objective: To evaluate the pattern and type of infections in our unit. Methods and results: We studied 48 patients (36 male) that were admitted to the1 intensive care unit between 1998 and 2002 with the diagnosis of sepsis or septic shock. The median length of stay was 33.5f51.4 days and mortality rate of 64.6%. A total of 24 patients (50%) had positive blood cultures, 14 of them with more than one agent identified (at the same or different times). Twenty had Gram+ agents with 7 methicillin-resistant Staphilococcus aureus (MRSA), 4 methicillinsensitive Staphilococcus aureus (MSSA), 15 had Gramagents and 4 had fungi. Eight had concomitant infection of the central catheter, in a total of 13 infections identified in the catheters. In the bronchic secretions the agents identified were 18: 9 Gram - , 5 Gram + (MRSA 4 and MSSA 1) and 4 fungi. Only three patients had the same agent isolated in both places, and other three, positive cultures also in both, with different agents. In the urine (8), pleural liquid (2) peritoneal liquid (1) and feces (1) were also isolated some agents. Summing up all the agents isolated, 13 patients had no isolation at all, they all died except for two that were moved to other departments with stays inferior to one day in our unit. Discussion: The changing in the spectrum of agents in ICU is also