We evaluated the ability of perfusion index (PI) to predict vasopressor requirement during early resuscitation in patients with severe sepsis. All consecutive patients with clinically suspected severe sepsis as defined by the criteria of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference were included. Perfusion variables included PI, arterial lactate level, central venous oxygen saturation, and the difference between central venous carbon dioxide and arterial carbon dioxide pressures, and were recorded before resuscitation and 6 h thereafter. We enrolled 36 patients with severe sepsis. Twenty-one patients required vasopressors, whereas 15 did not. The cut-off of the PI value for predicting vasopressor requirement was ≤0.3. This cut-off value had a sensitivity of 100% and a specificity of 93%; the area under the curve was 0.96 (95% confidence interval 0.8-0.99, P < 0.0001). The cut-off of the arterial lactate level for predicting vasopressor requirement was ≥1.8 mg dL. This cut-off value had a sensitivity of 82% and a specificity of 80%; the area under the curve was 0.84 (95% confidence interval 0.68-0.94, P < 0.0001). Other perfusion variables failed to predict vasopressor requirement in patients with severe sepsis. We concluded that PI and arterial lactate level are good predictors of vasopressor requirement during early resuscitation in patients with severe sepsis. Further studies are warranted to investigate whether monitoring PI during resuscitation improves the outcome of patients with septic shock.

IntroductionThe prevalence of extensively drug resistant gram negative bacilli (XDR-GNB) is rapidly progressing; however in Egypt data are sparse. We conducted the present study to quantify the incidence, risk factors and outcome of patients harboring XDR-GNB.MethodsA one year prospective study was done by collecting all the bacteriological reports for cultures sent from the surgical intensive care unit, Cairo university teaching hospital. XDR-GNB were defined as any gram negative bacilli resistant to three or more classes of antimicrobial agents. Patients with XDR-GNB compared with those sustaining non extensively drug-resistant infection. A multivariate logistic regression model was created to identify independent predictors of multi-resistance.ResultsDuring one-year study period, a total of 152 samples (65%) out of 234 gram negative bacilli samples developed extensively drug resistant infection. XDR strains were significantly higher in Acinetobacterspp (86%), followed by Pseudomonas (63%), then Proteus (61%), Klebsiella (52%), and E coli (47%). Fourth generation cephalosporine (Cefipime) had the lowest susceptibility (10%) followed by third generation cephalosporines (11%), Quinolones (31%), Amikacin (42%), Tazobactam (52%), Carbapinems (52%), and colistin (90%). Relaparotomy was the only significant risk factor for acquisition of XDR infection.ConclusionExtensively drug-resistant gram negative infections are frequent in our ICU. This is an alarming health care issue in Egypt which emphasizes the need to rigorously implement infection control practices.

Introduction:There has been a dramatic recent increase in the incidence of ventilator-associated pneumonia caused by methicillin-resistant Staphylococcus aureus. We investigated the effect of implementation of a ventilator care bundle on the incidence of ventilator-associated pneumonia in a cohort of trauma patients. Methods:A ventilator care bundle was implemented after a 7-month baseline period. Ventilator-associated pneumonia rates, rates of methicillin-resistant Staphylococcus aureus acquisition, rates of vancomycin administration, intensive care unit lengths of stay, and durations of mechanical ventilation were prospectively recorded for 10 months. Results:Use of a ventilator care bundle was associated with a reduced incidence of ventilator-associated pneumonia from 42 cases per 1000 ventilator days (95% confidence interval: 17–83) in the pre-intervention group to 19 (95% confidence interval: 11–34) cases per 1000 ventilator days in the post-intervention group (p = 0.04). The rate of methicillin-resistant S. aureus acquisition was significantly different in the pre-intervention group (27%) and the post-intervention group (3.9%) (p < 0.001). Relative to the pre-intervention period, there was a significant reduction in the duration of mechanical ventilation (p = 0.03) and length of intensive care unit stay during the post-intervention period (p = 0.015). Conclusion:The incidence of methicillin-resistant S. aureus-ventilator-associated pneumonia in trauma patients could be reduced by implementation of a ventilator care bundle.

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Objective Bronchial asthma is a common chronic inflammatory airway disease, which may be associated with pulmonary hypertension and cardiac dysfunction. The aim of this study was to evaluate the ability of 2D‐speckle tracking echocardiography (2D‐STE) and tissue doppler imaging (TDI) to detect subtle cardiac dysfunction in pediatric patients with mild to moderate bronchial asthma. Methodology The study included 30 children with mild to moderate bronchial asthma and 27 age‐matched healthy controls. Both groups underwent pulmonary function tests, TDI and 2D‐STE. Myocardial performance index (MPI), S′, E′, A′ velocities, global strain of left ventricle (LV), right ventricle (RV), and right atrium (RA) were measured. Results RV diastolic function was impaired in the patient group, as the tricuspid E′ velocity was significantly lower in the patients when compared with the controls (16 [14‐17] vs 16 [17‐19] cm/s, P = .044), while the RV‐MPI was significantly higher in patients when compared to controls (0.30 [0.27‐0.36] vs 0.30 [0.30‐0.30], P = .001). The global RV longitudinal strain, RA strain, and LV strain did not show significant differences between the test and the control groups. RV systolic parameters and LV systolic and diastolic parameters did not differ significantly between the two groups. Conclusion Pediatric patients with mild to moderate bronchial asthma may have early RV diastolic dysfunction with preserved other cardiac functions.