IntroductionVenous-to-arterial carbon dioxide difference (Pv-aCO2) may reflect the adequacy of blood flow during shock states. We sought to test whether the development of Pv-aCO2 during the very early phases of resuscitation is related to multi-organ dysfunction and outcomes in a population of septic shock patients resuscitated targeting the usual oxygen-derived and hemodynamic parameters.MethodsWe conducted a prospective observational study in a 60-bed mixed ICU in a University affiliated Hospital. 85 patients with a new septic shock episode were included. A Pv-aCO2 value ≥ 6 mmHg was considered to be high. Patients were classified in four predefined groups according to the Pv-aCO2 evolution during the first 6 hours of resuscitation: (1) persistently high Pv-aCO2 (high at T0 and T6); (2) increasing Pv-aCO2 (normal at T0, high at T6); (3) decreasing Pv-aCO2 (high at T0, normal at T6); and (4) persistently normal Pv-aCO2 (normal at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities at day-28 using a log-rank test to evaluate differences between groups. A Spearman-Rho was used to test the agreement between cardiac output and Pv-aCO2. Finally, we calculated the mortality risk ratios at day-28 among patients attaining normal oxygen parameters but with a concomitantly increased Pv-aCO2.ResultsPatients with persistently high and increasing Pv-aCO2 at T6 had significant higher SOFA scores at day-3 (p < 0.001) and higher mortality rates at day-28 (log rank test: 19.21, p < 0.001) compared with patients who evolved with normal Pv-aCO2 at T6. Interestingly, a poor agreement between cardiac output and Pv-aCO2 was observed (r2 = 0.025, p < 0.01) at different points of resuscitation. Patients who reached a central venous saturation (ScvO)2 ≥ 70% or mixed venous oxygen saturation (SvO2) ≥ 65% but with concomitantly high Pv-aCO2 at different developmental points (i.e., T0, T6 and T12) had a significant mortality risk ratio at day-28.ConclusionThe persistence of high Pv-aCO2 during the early resuscitation of septic shock was associated with more severe multi-organ dysfunction and worse outcomes at day-28. Although mechanisms conducting to increase Pv-aCO2 during septic shock are insufficiently understood, Pv-aCO2 could identify a high risk of death in apparently resuscitated patients.
In 2006, the first isolate of KPC-2-producing Pseudomonas aeruginosa in the world was identified in Colombia. Recently, similar strains have been reported in Puerto Rico. We now report KPC-2-producing P. aeruginosa in Trinidad and Tobago. Surveillance for similar strains is warranted, considering their wide geographic spread and known association with mobile genetic elements. CASE REPORTA 63-year-old male patient was admitted to a hospital in Mount Hope, Trinidad and Tobago, with hematuria, dysuria, fever, and chills. He had no history of travel abroad. Four months prior to his presentation, he had a left hip fracture caused by a fall and was hospitalized at another regional hospital for 10 weeks without any surgical intervention but with conservative care. He had remained bedridden since the fracture.Upon physical examination, he appeared chronically ill, was stuporous, febrile (38°C), severely pale, and dehydrated, had bedsores on the buttocks and sacral area, and had a urinary catheter. He had swelling of the left thigh, which was tender and warm to the touch, with subcutaneous emphysema.Blood and urine specimens were submitted for culture. Radiological investigations of the pelvis and legs revealed a fracture of the neck of the left femur, with subcutaneous emphysema and fluid collection along the lateral compartment of the thigh, extending to the inguinal region, hip joint, and left lower abdominal wall.He was given gentamicin, ceftazidime, and metronidazole. A fasciotomy was performed, revealing gas gangrene. Two liters of greenish yellow pus from the anterior compartment of the left thigh, extending to the left lower abdomen, was drained. This pus was cultured.Blood and urine cultures were negative. However, the culture of the pus from surgery yielded Pseudomonas aeruginosa. Antimicrobial susceptibility testing using the MicroScan WalkAway 96 SI system (Siemens) revealed that the isolate was resistant to all tested antimicrobials, including gentamicin, ceftazidime, ciprofloxacin, and carbapenems. Meropenem monotherapy was given despite in vitro resistance, while efforts were made to procure polymyxin B or colistin; unfortunately, these efforts were unsuccessful, and the patient died 10 days postadmission.The P. aeruginosa isolate was sent to the International Center for Medical Research and Training, Cali, Colombia, where the MIC was determined using the Clinical and Laboratory Standards Institute (CLSI)-approved broth microdilution method (2). Ertapenem, imipenem, and meropenem MICs were Ͼ128 g/ml. This isolate was also resistant to ceftazidime (MIC, 128 g/ml), cefepime (MIC, Ͼ128 g/ml), aztreonam (MIC, Ͼ128 g/ml), piperacillin-tazobactam (MICs, Ͼ256 and 4 g/ml), and ciprofloxacin (MIC, Ͼ8 g/ml) and remained susceptible only to polymyxin B (MIC, 2 g/ml).A three-dimensional test to screen for carbapenemases was performed as reported previously (10) with some modifications. This test uses a carbapenem-susceptible organism as an indicator for carbapenemases in a cellular extract. To detect the carbapenemase...
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