Publications

Introduction: The development of ventilator-associated pneumonia (VAP) is sometimes used as an index of the quality of care. However, the criteria used to diagnose VAP are variable. Using more strict criteria to diagnose VAP may result in a lower reported incidence of VAP and misleadingly suggest better quality of care. Methods: We included all adult patients who were treated with mechanical ventilation for more than 48 hours over a 7-month period (January-July 2012), and who had no lung infection during the first 48 hours of ventilation. We applied 89 algorithms composed of different criteria, including respiratory deterioration, inflammatory response, purulent tracheal secretions, abnormal chest radiography, and positive microbiologic findings. Results: Of 1806 patients admitted during the study period, 144 (8%) were treated with mechanical ventilation for more than 48 hours; 91 of these patients had no evidence of lung infection during the first 48 hours of mechanical ventilation. The application of the 89 algorithms resulted in a highly variable incidence of VAP, ranging from 0 to 44%. The mortality rate increased with increasing strictness of the criteria used, from 50 to 80% Conclusions: Applying different diagnostic criteria in a given patient population can result in a wide variation in the apparent incidence of VAP, and even eliminate it completely. The inverse correlation between the incidence of VAP and mortality, suggests that stricter criteria are more specific for VAP.

Division of Respiratory Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium

Comment

info:eu-repo/semantics/published

info:eu-repo/semantics/published

info:eu-repo/semantics/published

To be able to give a clear name or label to a specific collection of signs and symptoms is important for physicians and patients alike. Having an exact diagnosis helps to identify particular groups of patients, to better understand the underlying disease process, and provides a more defined target for appropriate treatment. However, to be able to reach an accurate diagnosis, and hence, offer optimal medical therapy, a precise definition of the disease process in question is required. Over the years many disease processes have become well defined and are fairly easy to diagnose with the appropriate set of symptoms and test results. For example, acute myocardial infarction is associated with typical symptoms (eg, chest pain), signs (eg, abnormal electrocardiogram), and biomarkers (eg, raised blood troponin levels); patients meeting these criteria can be offered immediate and appropriate therapy. Imprecise definitions of disease limit the ability to form a specific, correct diagnosis and attempts to institute or study therapies in such situations are unlikely to be of benefit and may cause harm. In sepsis, attempts have also been made to provide clear and accurate definitions, but these efforts have not met with universal support. In 2004, a survey of 1058 physicians, including 529 intensivists, noted that only 17% of those interviewed agreed on any one definition. Sepsis is a complex process that can affect any individual and can originate from multiple sites and be caused by multiple microorganisms. Sepsis can present with a multitude of signs and symptoms, none of which are specific for sepsis and all of which can vary among patients and within the same patient over time. These symptoms can vary in severity from a mild, short-lived fever to fatal septic shock. Faced with such complexity and variation, it may be that a single, simple definition for sepsis will never be possible and we should focus on types of infection rather than on sepsis per se.

Selective V1aR agonism appears to be superior to the V1aR/V2R agonist arginine vasopressin and single norepinephrine infusion for hemodynamic support in septic shock.

info:eu-repo/semantics/published