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Here, we evaluated the frequency of C. difficile colonization and its impact on clinical outcomes in patients admitted to intensive care units in Brazil. From ninety-two patients screened 16 (17.3%) were colonized by C. difficile. Colonized patients had higher Simplified Acute Physiology Score III (SAPS III), however there was no association between C. difficile colonization with diarrhea or mortality. The C. difficile strains sequenced belonged to clade 1 and presented high vancomycin-resistant rates.

Background Red blood cell distribution width (RDW) is a predictor of mortality in critically ill patients. Our objective was to investigate the association between the RDW at ICU discharge and the risk of ICU readmission or unexpected death in the ward. Methods A secondary analysis of prospectively collected data study was conducted including patients discharged alive from the ICU to the ward. The target variable was the RDW collected at ICU discharge. Elevated RDW was defined as an RDW > 16%. Outcomes of interest included readmission to the ICU, unexpected death in the ward and in-hospital death. Variables with a p -value univariate analysis or with biological plausibility for the occurrence of the outcome were included in the Cox proportional hazards model for adjustment. Results We included 813 patients. A total of 138 readmissions to the ICU and 44 unexpected deaths in the ward occurred. Elevated RDW at ICU discharge was independently associated with readmission to the ICU or unexpected death in the ward after multivariable adjustment (HR: 1.901; 95% CI 1.357–2.662). Other variables associated with this outcome included age, tracheostomy and mean corpuscular volume (MCV) at ICU discharge. Similar results were obtained after the exclusion of unexpected deaths in the ward (HR 1.940; CI 1.312–2.871) and for in-hospital deaths (HR 1.716; 95% CI 1.141–2.580). Conclusions Elevated RDW at ICU discharge is independently associated with ICU readmission and in-hospital death.

OBJETIVO: Comparar a influência de duas estratégias ventilatórias - ventilação controlada a volume (VCV) e ventilação controlada a pressão (VCP) - no desempenho funcional de enxertos pulmonares em um modelo canino de transplante pulmonar unilateral esquerdo, utilizando-se doadores cujos pulmões foram captados após três horas de parada cardiocirculatória em temperatura ambiente e sob ventilação mecânica. MÉTODOS: O estudo incluiu 40 cães mestiços randomizados nos grupos VCV e VCP. Dos 20 receptores, 5 não sobreviveram ao transplante, e 5 não sobreviveram ao período de avaliação pós-transplante. Os 10 receptores sobreviventes (5 em cada grupo) foram avaliados durante 360 min após o término do transplante pulmonar. O desempenho funcional dos enxertos foi estudado através da avaliação da mecânica respiratória, trocas gasosas e histologia do enxerto. RESULTADOS: Não houve diferenças significativas entre os grupos quanto às variáveis de mecânica respiratória (pressão de pico inspiratória, pressão de platô, pressão média de vias aéreas, complacência dinâmica e complacência estática) e de trocas gasosas (PaO2, pressão venosa mista de oxigênio, PaCO2, pressão venosa mista de CO2 e diferença arteriovenosa de oxigênio). As alterações histopatológicas foram compatíveis com o padrão de lesão pulmonar aguda não específica e não diferiram entre os grupos. CONCLUSÕES: Este modelo de transplante pulmonar mostrou que o desempenho funcional do enxerto não foi influenciado pela estratégia ventilatória utilizada até seis horas após a reperfusão. OBJECTIVE: To compare the influence of two different ventilation strategies-volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV)-on the functional performance of lung grafts in a canine model of unilateral left lung transplantation using donor lungs harvested after three hours of normothermic cardiocirculatory arrest under mechanical ventilation. METHODS: The study comprised 40 mongrel dogs, randomized into two groups: VCV and PCV. Of the 20 recipients, 5 did not survive the transplant, and 5 died before the end of the post-transplant assessment period. The remaining 10 survivors (5 in each group) were evaluated for 360 min after lung transplantation. The functional performance of the grafts was evaluated regarding respiratory mechanics, gas exchange, and lung graft histology. RESULTS: There were no significant differences between the groups regarding respiratory mechanics (peak inspiratory pressure, plateau pressure, mean airway pressure, dynamic compliance, and static compliance) or gas exchange variables (PaO2, venous oxygen tension, PaCO2, venous carbon dioxide tension, and the arterial-venous oxygen content difference). The histopathological findings were consistent with nonspecific acute lung injury and did not differ between the groups. CONCLUSIONS: This model of lung transplantation showed that the functional performance of lung grafts was not influenced by the ventilation strategy employed during the first six hours after reperfusion.

To assess the accuracy of direct examination and quantitative cultures of BAL to diagnose pneumonia with or without antibiotic treatment.Experimental rat models.Pneumonia was induced by intratracheal inoculation of S. pneumoniae (10(9) cfu/ml) or P. aeruginosa (10(8)cfu/ml). Controls (n = 10) received sterile inoculum. Study animals received penicillin (n = 19) or saline (n = 18) (pneumococcal model); amikacin (n = 13), ceftazidime (n = 11), or saline (n = 13) (Pseudomonas model). BAL was assessed 48 h after infection. The animals were killed for histopathological analysis.All study animals developed pneumonia, which was more extensive in the pneumococcal than in the Pseudomonas model. In pneumococcal pneumonia the sensitivity of BAL cultures (10(3) cfu/ml or higher) was 77.8% with saline and 21.0% with penicillin. In the Pseudomonas ceftazidime group all specimens were negative, precluding diagnosis. The sensitivity of cultures with amikacin was 23.1% vs. 30.8% with saline. In the pneumococcal model intracellular organism (ICO) count of 2% or higher had a sensitivity of 100% for detecting pneumonia with saline and 57.9% with penicillin. In the Pseudomonas model the sensitivity of ICO was 69.2% with both amikacin and saline and 36.3% with ceftazidime. The sensitivity of neutrophil count above 50% in pneumococcal pneumonia was 77.8% and 64.7% with saline and penicillin, respectively, and 69.2%, 61.5%, and 81.8% with saline, amikacin, and ceftazidime, respectively, in Pseudomonas pneumonia.BAL-positive intracellular organisms were more accurate than cultures for the diagnosis of recent pneumonia, and were less affected by antibiotic treatment.

Objetivo: Avaliar os níveis séricos dos principais fatores que regulam a ativação da zona glomerulosa e a produção de aldosterona em pacientes com choque séptico, assim como sua resposta ao teste de cortrosina em alta dose (250 μg). Sujeitos e métodos: Em 27 portadores de choque séptico, foram aferidos níveis basais de aldosterona, cortisol, ACTH, renina, sódio, potássio e lactato, bem como realizado teste de cortrosina. Resultados: Renina se correlacionou com níveis basais de aldosterona e sua variação após teste de cortrosina. Cortisol basal e sua variação não se correlacionaram com ACTH. Apenas três pacientes apresentaram disfunção concomitante da secreção de aldosterona e cortisol. Conclusões: Ativação das zonas fasciculada e glomerulosa são independentes. Secreção de aldosterona é dependente da integridade do sistema renina-angiotensina-aldosterona, enquanto secreção de cortisol não parece predominantemente dependente do eixo hipotálamo-hipófise-adrenal. Esses resultados sugerem que a ativação da adrenal em pacientes críticos ocorre por múltiplos mecanismos. Objective: To assess serum levels of the main factors that regulate the activation of the zona glomerulosa and aldosterone production in patients with septic shock, as well as their response to a high-dose (250 μg) adrenocorticotropic hormone (ACTH) stimulation test. Subjects and methods: In 27 patients with septic shock, baseline levels of aldosterone, cortisol, ACTH, renin, sodium, potassium, and lactate were measured, followed by a cortrosyn test. Results: Renin correlated with baseline aldosterone and its variation after cortrosyn stimulation. Baseline cortisol and its variation did not correlate with ACTH. Only three patients had concomitant dysfunction of aldosterone and cortisol secretion. Conclusions: Activation of the zona glomerulosa and zona fasciculata are independent. Aldosterone secretion is dependent on the integrity of the renin-angiotensin-aldosterone system, whereas cortisol secretion does not appear to depend predominantly on the hypothalamic-pituitaryadrenal axis. These results suggest that activation of the adrenal gland in critically ill patients occurs by multiple mechanisms.

Delirium is a very prevalent syndrome and an important independent predictor of negative outcome in patients in the intensive-care unit (ICU), but there is no proven pharmacological intervention to prevent or treat this disorder. Therefore, the study by Valerie J Page and colleagues, which provided an assessment of the use of haloperidol in the ICU setting, was needed. However, the results of this trial should not be classed as defi nitive because the study has some limitations. First, haloperidol was used as both a prophylaxis and treatment, and the number of patients with delirium at enrolment was not stated. We would expect that the dose needed to treat a patient with delirium would be higher than the prophylactic dose. Also, the criteria for stopping the drug should be reconsidered, since although patients might be 2 days free of delirium, they still could be at risk of developing delirium. Second, regarding the statistical analysis, the primary outcome was the number of delirium-free and comafree days in the first 14 days after randomisation, but patients who died before day 14 were recorded as having zero days free of delirium and coma, restricting the analysis to survivors, and correcting the incidence of the main outcome (delirium) according to the competing event (death). When analysing time-to-event data and competing outcomes, a technique known as cumulative incidence analysis can be used to assess the actual incidence of delirium. This type of analysis would have provided more accurate results in Page and colleagues’ study, and should be used in future trials that intend to address delirium incidence. Last, the study authors conclude that their results do not support the use of haloperidol in patients needing mechanical ventilation, irrespective of whether patients screen positive for delirium or are in a coma. They believe that haloperidol should be reserved for short-term management of acute agitation; however, we think it is too soon to come to this conclusion.

The purpose of this study was to evaluate canine lungs obtained from non-heart-beating donors after unilateral lung transplantation subjected to partial liquid ventilation with perfluorodecalin.Twelve donor dogs were killed and kept under mechanical ventilation for 3 hours. Heart-lung blocks were harvested after retrograde pulmonary hypothermic flush with Perfadex. Left lung grafts were randomly transplanted into 12 weight-matched recipient animals. Animals were divided into 2 groups: control (standard mechanical ventilation, n = 6) and PLV (partial liquid ventilation, n = 6). Forty-five minutes after transplantation, the animals in the PLV group received perfluorodecalin (15 ml/kg) via orotracheal tube. All animals received volume-controlled ventilation (FIO2) 1.0, PEEP 5 cm H(2)O) over 6 consecutive hours. Thereafter, blood-gas analysis, ventilatory mechanics and hemodynamics were registered at 30-minute intervals. After 6 hours of reperfusion the animals were killed and the transplanted lungs were extracted to obtain the wet/dry weight ratio.There were significant differences in pulmonary arterial pressure, which were higher in control group animals (p0.009). The control animals also showed higher arterial PaO(2) than those in the PLV group (p0.00001), but lower PaCO(2) (p0.008). The peak and plateau pressures were higher in the PLV group (p0.00001). Neither static compliance nor wet/dry weight ratios were different in between groups.PLV with perfluorodecalin yields functional results compatible with life in this model. Nonetheless, pulmonary gas exchange and mechanics were superior after reperfusion in animals given conventional mechanical ventilation up to 6 hours after left lung allotransplantation.