Pyrexia - PACT - ESICM

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Task 2. Determining the cause of fever in the critically ill patient Tracheal aspirates: their diagnostic significance is greater if (semi-) quantitative rather than qualitative cultures are performed; this helps to obviate false-positive results by colonisation of upper airways in the absence of lower respiratory tract infection by the bacteria. Usually, a cut-off point of 10 5 cfu/mL is taken. Indeed, some micro-organisms are obligatory pathogens while the lowgrade presence of others, such as Gram-negative bacilli, may merely represent colonisation. Microscopy of the aspirates is necessary to exclude saliva with many epithelial cells, and elastin staining may confirm a lower (versus upper) respiratory tract origin of the aspirate. In the case of VAP, the aspirate typically contains numerous neutrophils. Distal bronchial specimens: tracheal aspirate results are less specific than those of Gram stains, microscopy and cultures of lower (distal) pulmonary secretions obtained by bronchoscopy and bronchoalveolar lavage (BAL) or protected specimen brush (PSB). It remains unclear, however, whether antibiotic guidance based on the latter is associated with lower morbidity and mortality for suspected VAP than antibiotic treatment guided by tracheal aspirates. Nevertheless, utilisation of these invasive tools may prevent overtreatment by antibiotics and reduce antibiotic pressure. This may be increasingly relevant because of the increase in multiresistant pathogens causing VAP. Finally, positive blood or, when present, pleural fluid cultures with the same organism as recovered from the airway can be found in VAP. Before proceeding to the next section, consider searching the Web for evidence that treatment guided by BAL/PSB specimens is superior to that guided by conventional, less invasive techniques and also for more specific clinical indications for the use of the invasive technique. Then assess the views expressed below. The table below outlines a diagnostic approach to VAP when invasive procedures are performed. Criteria for the diagnosis of VAP I Three or more of the following: a) Rectal temperature >38.0 °C or 103 cfu/L) or >5% of leukocytes containing phagocytosed bacteria. b) Positive blood culture with the same micro-organism as that present in the airway c) Positive culture of pleural fluid [16]
Task 2. Determining the cause of fever in the critically ill patient The following reference is in favour of invasive technique for VAP diagnosis to reduce antibiotic usage and to improve outcome. Fagon JY, Chastre J, Wolff M, Gervais C, Parer-Aubas S, Stéphan F, et al. Invasive and noninvasive strategies for management of suspected ventilatorassociated pneumonia. A randomized trial. Ann Intern Med 2000; 132(8): 621–630. PMID 10766680 A CDC paper on the diagnosis of VAP favouring invasive techniques can be found on the following e-reference http://www.cdc.gov/ncidod/eid/vol7no2/mayhall.htm but the following papers oppose this approach: Ruiz M, Torres A, Ewig S, Marcos MA, Alcón A, Lledó R, et al. Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: evaluation of outcome. Am J Respir Crit Care Med 2000; 162(1): 119–125. PMID 10903230 Heyland D, Dodek P, Muscedere J, Day A, Cook D; for the Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006; 355(25): 2619– 2630. PMID 17182987 Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D; VAP Guidelines Committee and the Canadian Critical Care Trials Group. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: diagnosis and treatment. J Crit Care 2008; 23(1): 138–147. PMID 18359431 Hence, choosing among strategies remains hard, is controversial and is dependent in part on local practices. For review: Morehead RS, Pinto SJ. Ventilator-associated pneumonia. Arch Intern Med 2000; 160(13): 1926–1936. PMID 10888967 Q. Look at the chest radiographs of this ICU patient who developed fever of 38.5 °C and a deterioration in his oxygenation. The initial CXR is on the left and shows right lower lobe volume loss and some patchy infiltrate; the CXR on the right was taken 48 hours later. The patient was a 72-year-old male with cerebellar haemorrhage, a [17]
Page 1 and 2: AN ESICM MULTIDISCIPLINARY DISTANCE
Page 3 and 4: LEARNING OBJECTIVES After studying
Page 5 and 6: Introduction INTRODUCTION Thirty pe
Page 7 and 8: Task 1. Assessing and measuring fev
Page 19: Task 2. Determining the cause of fe
Page 23 and 24: Task 2. Determining the cause of fe
Page 35 and 36: Task 3. Fever in specific categorie
Page 39 and 40: Fever in neurological disease Task
Page 43 and 44: Task 4. Understanding and treating
Page 51 and 52: Self-assessment EDIC-style Type A 8
Page 53 and 54: Self-assessment Self-assessment ans
Page 55 and 56: Patient Challenges Q. Outline the p
Page 57 and 58: Patient Challenges A cardiogenic ca
Page 59 and 60: Patient Challenges Cooling techniqu
Page 61 and 62: syndrome was clear and antibiotics,
Page 63 and 64: Patient Challenges An 18-year-old m
Page 65: Patient Challenges often a transien

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