Introduction: Aeromonas hydrophila gastroenteritis is rare in humans and common amongst fish, reptiles and amphibians. In humans, infections caused by Aeromonas species usually occur with increased frequency during warmer months. The organism is frequently isolated from meat products and its transmission is by feco-oral route.
Clinical picture: We report 2 cases of Aeromonas hydrophila gastroenteritis in elderly, diabetic patients. Both patients had severe diarrhea and stool cultures grew Aeromonas hydrophila.
Treatment and outcome: Both responded to intravenous ceftriaxone and were discharged well.
Clinical implication: It is self limiting in immunocompetent hosts. In elderly, immunocompromised or pediatric patients, it can cause bacteremia and high mortality if not treated early.

Purpose: Positioning mechanically ventilated patients in an adequate semi-recumbent position is a low cost and apparently easy applied measure to prevent new VAP. We performed an unannounced
audit to compare the actual backrest angle with the target backrest angle of 30-45 degrees, assess whether compliance was better in patients whose bed had a built-in bedside protractor, and document
diffi culties reported when failing to achieve the target backrest angle.
Methods: From 1/3/2007 to 30/6/2007, unannounced ad hoc inspections were made on patients receiving mechanical ventilation in the intensive care unit. During inspections, the angle of elevation of bed was formally measured by a manual technique using a hand-held protractor. The nurse at bed-side was also asked to estimate the angle of elevation of bed without referring to the built-in protractor and interviewed with a structured questionnaire.
Results: From 1/3/2007 to 30/6/2007, inspections were made on 295 occasions. The median angle of backrest elevation was 25 degrees (interquartile range [IQR]: 20 to 30 degrees). The median angle of elevation estimated by the nurse at the bed-side was 30 (IQR: 20 to 30 degrees), (p <0.001). Semi-recumbent positions meeting the 30 degree minimum target angle were observed on only 120 (41%) occasions. Reasons provided for failing to achieve the target angle included incorrect estimation of the backrest angle and interference of the semi-recumbent position with nursing procedures and nursing inconvenience.
Conclusions: This audit showed that the minimum target semi-recumbent position of 30 degrees was achieved only 40% of the time in an academic intensive care unit. Nurses at bedside consistently
overestimated the angle of elevation of bed, and the presence of a built-in bedside protractor was not associated with a greater compliance with the target backrest elevation angle. Strictly enforced protocols, education programs for nurses and doctors
and regular audit may improve compliance with backrest elevation targets.

Objective: Study the survival-to-hospital discharge rate for veterans who underwent Advanced Cardiac Life Support (ACLS) and reach a better understanding of the variables that infl uence their
survival after cardiac arrest. To aid in developing strategies directed towards decreasing the risks related to the event.
Design: A retrospective record review of advanced resuscitative attempts during the period of January 1st to December 31st, 2006.
Setting: VA Caribbean Health Care System, San Juan.
Patients: Veterans admitted during the study period who suffered cardiac arrest.
Measurements: Patient’s age, sex, diagnosis, initial rhythm, location, time of event and duration of the resuscitation efforts (downtime), were collected.
Main results: There were 128 arrests documented during the study period: 122 (95%) were inhospital events and 6 involved patients brought to the emergency department during the course of resuscitation. The mean age was 72 years and 98% were males; most events occurred at general medical/surgical wards (61%). Events were mostly of cardiac origin (82.78%), with asystole (AS) and pulseless electrical activity (PEA) being the most common initial rhythms (61%). The most frequent pre-arrest diagnoses were sepsis, communityacquired pneumonia, renal failure and malignancy.
Survival-to-hospital discharge was 7.38%; most survivors suffered primarily respiratory arrests while at the general wards. Arrest events were evenly distributed throughout the 24-hour day, and the average downtime in survivors was lower than in non-survivors (12 vs. 22.35 mins respectively, p=0.03).
Conclusions: We found a substantially lower survival rate for in-hospital cardiac arrests than has been previously reported. Possible explanations for this phenomenon include the high incidence
of arrhythmias associated with poor outcome (AS, PEA), the frequency of unwitnessed events occurring in general wards, patient’s age and underlying diagnoses. Measures for the timely
identifi cation of admitted patients who are at risk for poor resuscitative outcomes with these characteristics should be instituted.

Weaning from mechanical ventilation is defi ned as the transition from the ventilatory dependence of the patient to a spontaneous breathing status. Recognizing when a patient is ready to be weaned from mechanical ventilation is greatly infl uences the outcome, and may prevent compromising a patient. Weaning indices were developed to help the physician predict the outcome of weaning trials, a common concern in the intensive care unit (ICU) setting. Many physiological mechanisms explain the reason why many patients fail weaning trial, mostly related to a noncompliant respiratory function
and cardiovascular instability. The primary goal is to reduce failed attempts, and to adopt successful weaning protocols, in order to overcome problems that may arise in the critically ill patients. The ratio of respiratory rate to tidal volume (f/Vt), among other indices, and weaning trials like pressure support ventilation (PSV) or spontaneous breathing with the use of T tube are explained.

Resuscitation from death is not an every day event; however, it is no longer a rarity. Cardiopulmonary resuscitation (CPR) has, therefore, become a common tool in our management of these critically ill patients.
Despite an improved understanding and management of cardiac arrest, and the widespread application of do not resuscitate (DNR) orders in an attempt to prevent the inappropriate use of CPR, the success rate following in-hospital cardiac arrest has remained unchanged
over the last three decades, with return of spontaneous circulation (ROSC) in about 30% with approximately 15% of patients being discharged neurologically intact [1-5].

Brain natriuretic peptide levels (BNP) have been best studied in the heart failure (HF) literature and has been increasingly used in the critical care population as an estimate of cardiac function. BNP
is secreted by cardiomyocytes in response to an increase in transmural ventricular pressure. The measurement of BNP is well known in the cardiac literature. Studies in the critical care population have looked at measuring BNP in different subsets of patients with sepsis, pulmonary embolism (PE), acute respiratory distress syndrome (ARDS), pulmonary hypertension (PH) and non-cardiogenic pulmonary edema (CPE). BNP has been used to differentiate HF syndrome from other causes of respiratory failure both in the acute and chronic settings. The measurement of BNP in the critical care population is fraught with difficulties only one of which is the significant effect of renal failure on our ability to interpret BNP levels effectively. This review summarizes the current literature on the utility and significance of measuring BNP in the critical care population.

Objective: The main goal of this research is to know
a nurse’s attitude to patients that may suffer delirium
during the hospitalization time. A second goal
is to analyze whether relative’s visit time is a factor
to be considered.
Design: Multicentre prospective and observational
study.
Methodology: This study was performed in several
hospitals that belong to the public sanitary health
system of the Principado de Asturias (SESPA) and
one hospital that belongs to Servicio Andaluz de
Salud (SAS). The target populations are general
hospitalization nurses, nurses specialized in
intensive care, and relatives of patients admitted
in intensive care units (ICU). As a tool we used a
Likert questionnaire for validation of attitudes.
This questionnaire included 20 questions about
different situations that the nurses and relatives
maintain in patients with delirium.
Results: 215 questionnaires were sent to the target
population including 87.91% nurses and 12.09%
patient’s relatives. Cabueñes Hospital (SESPA) returned the highest number of questionnaires
(46.51%). Intensive care nurses returned the
highest number of questionnaires (73.02%). We
considered different assistant levels for ICU, that
in mostly corresponded to levels III and IV. The
analysis of the variables studied using a multiple
regression linear model revealed that the answers
to 9 out of 20 possible items were signifi cantly
different. Finally, the differences were highest in 3
of those 9 items.
Conclusions: Nurses don’t fi nd to the patients with
delirium, of more interest than other types of patients,
although they are highly concerned by their health
before and after the delirium. Nurses are partially
but not completely aware that delirium is a very
serious illness. Nurses are not confi dent regarding
whether the patient’s relatives could calm down
the patient and help him to overcome the disease.
Given the heterogeneity of the answers there are no
defi nitive conclusions regarding whether a change
of the visit hours might be important in the recovery
of patients with delirium.

Objective: The objective of the study is to determine
factors that infl uence the outcome of long stay patients
in a general intensive care unit (ICU) and/
or high-dependency unit (HDU) in a New Zealand
teaching hospital.
Setting: 10-bed general ICU and 4-bed surgical
HDU in a 400-bed hospital.
Study type: Population based retrospective cohort
study.
Methods: All patients with prolonged stay in a high
resource area (>7 days in the ICU or >14 days in either
the ICU or HDU) between 2000 and 2003 were
reviewed. Demographic data, co-morbidities, diagnoses,
clinical events, hospital and 1-year mortality
data were obtained using available databases and
patient records. Multiple logistic regression analysis
was performed to identify which variables are associated
with death among patients with a prolonged stay in a high-resource unit (ICU/HDU).
Results: 207 patients were included in the study.
Twenty eight percent died before hospital discharge
and 40% died within one year of their admission.
Univariate analysis showed that increasing age,
APACHE II score, admission post cardiac arrest,
inpatient cardiac arrest, development of sepsis and
requirement for renal support therapy were all risk
factors for increased mortality. However, when adjusted
for age, gender and APACHE II score the
only risk factor strongly associated with death was
having a cardiac arrest in the ICU.
Conclusions: Prolonged ICU and/or HDU stay is associated
with a high mortality rate particularly in
patients with advancing age and increasing severity
of illness. In this study, only cardiac arrest after a
prolonged stay in the ICU and/or HDU is a strong
predictor of death independent of the age and the
APACHE II score.

Background: This study aimed to collect information
about long-term survival and independence of
patients requiring acute hospital admissions and
care in Intensive Care Unit (ICU) and High Dependency
Unit (HDU) in a non tertiary setting.
Setting: An 11-bed multidisciplinary co-located
ICU and HDU, a JFICM level 2 unit, providing all
intensive care services for a non-tertiary (secondary)
New Zealand District Health Board Hospital.
Method: All acute adult admissions presenting to
ICU/HDU between 1 Jan 2001 and 31 Dec 2001
were studied. Admission demographic and physiological
data was collected. From a review of the
hospital records, NZ death registry, and the ICU
database of published obituary notices, dates of
death were identifi ed. After the fi rst anniversary
of their initial ICU admission, discharged patients
in whom death had not been confi rmed, were contacted.
Patients surviving ICU were surveyed to
determine their independence. The age and gender
adjusted annual survival for the general population
was compared to observed survival following ICU/
HDU admission. Main Results: Adult acute admissions comprised
586 (68.5%) of the total of 855 ICU/HDU admissions
in 2001 (86 paediatric [<15 years] and 169 elective
admissions excluded). Acute adult admissions (M
49.9%; F 50.1%) had a median age of 58 years, an
ICU survival of 86.3%, and a hospital survival of
82.7%. Long-term outcome was established in 94%
of admissions. One year post admission 73.2% were
confi rmed as alive. Increased age decreased survivorship,
with only 35.3% of the >85 years old group
surviving one year. After ICU admission, one year
survival was lower than that of the general population.
Age-group matched survival was from 93% to
32% for males and 60.2% to 90.4% for females of
the general population survival rate. 94.4% of survivors
were independent.
Conclusions: Following acute admission, ICU patients
have a lower level of survivorship than the
general population, but the vast majority of the
73.2% patients that survive one year remain independent.
Generally the quality of life at one year is
acceptable to survivors.

A middle age Caucasian gentleman presented to the Emergency Department with fever, chills and hypotension. Chest X-ray revealed consolidation in right lower lobe consistent with pneumonia. A chest radiograph after central line placement revealed a venous anomaly. CT scan with contrast revealed persistent left superior vena cava and absent right superior vena cava.

We present the case and images of a 52 yearold Hispanic gentleman with a history of hepatitis C and chronic liver disease that developed Vibrio vulnifi cus sepsis secondary to eating raw oysters.
His course was complicated by necrotizing fasciitis in the upper extremities and renal failure.

Objective: To describe the natural history and risk factors of the cholestatic post-cardiac surgery syndrome.
Methods: We reviewed all cases of patients with hyperbilirubinemia after cardiac surgery admitted to a large metropolitan referral hospital during January 2005 to December 2005 (n=317).
Results: Fourteen patients (11 male, 3 female) developed postoperative hyperbilirubinemia after excluding hyperbilirubinemia secondary to acute cholecystitis, acute pancreatitis, and shock. Sixty four percent of patients have mild and subclinical hepatobiliary disease preoperatively. Preoperative echocardiography showed right ventricular enlargement and/or hypokinesis in most patients. The mean serum total bilirubin peaked at postoperative day 9 and return to normal by postoperative day 18. The highest recorded serum total bilirubin was 13 mg/dL (221 umol/L). The mean serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP) levels were mildly elevated and showed no distinct peak during postoperative period.
Conclusion: In this series, 4.4% of patients undergoing cardiac surgery developed idiopathic post-operative jaundice. Preexisting liver disease and increased right heart pressures were associated with this syndrome. After excluding other causes of hyperbilirubinemia, serum total bilirubin can be expected to normalize in first 18 days after surgery.

Purpose: To measure the degree of physician’s knowledge of the SSC management guidelines in Puerto Rico.
Materials and methods: A questionnaire was administered personally to 231 physicians. It included therapeutic interventions and important elements of the guidelines. Physicians including internal medicine and general surgery from public and private hospitals around the entire island answered the questionnaire.
Results: In general, the sample population performed quite poorly, with a mean of less than 50% correct answers, including the internal medicine attendings. PGY-3 residents had a higher percentage of correct answers than attending (52.5% vs. 47.4%, p =0.21). Correlating directly with the level of training, a trend toward more knowledge was noted (PGY-3 52.5% vs. PGY-1 42.2%, p =0.08). PGY2 and PGY-3 residents in internal medicine demonstrated a significant knowledge of the SIRS criteria compared with the first year residents (p =0.01 for PGY-1 vs. PGY-2, and p =0.02 for PGY-1 vs. PGY-3). Of the questions concerning bundle components, the worst scores were on those focused on use of steroids (21.3%), glucose control (42.6%) and ventilation (40.1%).
Conclusions: Regardless of their levels of training, internists and surgeons fared quite poorly in those questions that specifically address most therapeutic interventions known to reduce sepsis mortality. Our findings revealed no difference in knowledge between physicians in-training and their counterparts in private practice. This is quite unexpected, as one would anticipate improved and updated knowledge in those in the academia.
Considering the morbidity and mortality associated with sepsis, these findings warrant an initiative to correct them.

The care of the critically ill patient in the pediatric intensive care unit (PICU) has remained an important topic for those health care providers dealing with children. The purpose of this article is to introduce to the reader a summary of selected papers which we consider relevant to the care of the pediatric critically ill patient and that were published in the year 2006. These articles were selected on the basis of application to the PICU, overall importance and are not to be solely considered authoritative in their field. There are many other useful articles. We have attempted to choose those articles with scientific merit and rigorous methodology that we believe present interesting data in the field.

Aim: To describe the endotracheal cuff pressure (Pcuff) measurements of patients receiving ventilation via endotracheal tubes in an Intensive Care Unit (ICU).
Method: Pcuff were measured daily using a cuff tonometer and the pressure then adjusted to <30 cmH2O in patients ventilated in the ICU, over fifteen months. Data collected were demographics, the location where intubation occurred, and airway pressures when available (PEEP, peak, and plateau). Data was analysed using Kruskal-Wallis and Dunn’s Multiple Comparison Test.
Results: 1073 data sets were collected from 199 intubated ventilated adults. Of all Pcuff measured 15.7% (169) exceeded 30 cmH2O. The first Pcuff measurements made during ICU stay had median pressure 30 cmH2O (IQR 23.5-40) and 34.5% (68) exceeded 30 cmH2O. Median Pcuff of patients admitted following intubation in the Operating Theatre (OT) were 26 cmH2O (IQR 20-37), those via Emergency Department (ED) were 32 cmH2O (IQR 28-57), and those intubated in ICU were 28 cmH2O (IQR 22-34.25). Pcuff of patients intubated in OT differed significantly from ED patients, as did ICU patients compared to ED (p <0.005). ICU and OT patients did not differ.
Conclusion: Pcuff measurement is not routine at intubation. Described complications of elevated Pcuff include cuff herniation, vocal cord damage, tracheal mucosal ischaemia, and airway obstruction.
Unrecognised elevated Pcuff is common, with a higher incidence in ED than ICU or OT. Skilled intubation assistance from anaesthetic technicians is routine in OT, common in ICU, but less frequent in ED, and may influence the initial Pcuff.

Introduction: Escherichia coli meningitis was rarely reported in adult patients. Moreover it is very rare in an adult patient without diabetes mellitus or neurosurgical shunts. In adult patients, it carries a high mortality ranging from 27% to 90% with
treatment, and 100% without treatment.
Case report: We describe a 78 year old lady who presented with altered mental state and neck stiffness. Her cerebrospinal fluid analysis was consistent with bacterial meningitis and she had E.
coli bacteraemia. She was treated with ceftrioxone 2 gm twice a day for 2 weeks. She also developed non-ST elevation myocardial infarction on day 3 of admission. She was treated with aspirin, low molecular weight heparin and monitored on telemetry for 3 days. She remained in hospital for 2 weeks and was discharged well.
Conclusion: E. coli meningitis carries high mortality. E. coli may cause meningitis in adult patients without diabetes mellitus or neurosurgical shunts. Early diagnosis and treatment is key to good outcome as mortality without treatment is 100%.

Clinical presentation of miliary tuberculosis is highly variable. Patients that present with central nervous system disease such as meningitis or tuberculoma is seen in up to 20% of the cases. Meningeal involvement is usually seen in up to 54% of the cases of miliary tuberculosis, and in just a few minority of patients the AFB smears are positive.

BNP may be raised in patient with DF without heart failure. The exact pathogenesis of raised BNP in DF is unclear.

Mechanical ventilation has always been a cornerstone of respiratory support for patients with respiratory muscle paralysis. In selected patients, diaphragm pacing (DP) through electrical stimulation of the phrenic nerves provides an alternative to mechanical ventilation with signifi cant advantages in life quality. We report an interesting case of unilateral diaphragmatic paralysis in which unilateral diaphragmatic pacing produced signifi cant improvement in quality of life.

In the condition of electrolyte unbalance and hypoalbuminemia the Stewart approach is better than the traditional approach. Nevertheless, the calculation of SIG is more timeconsuming, therefore the corrected anion gap (AGcorr) was suggested to use in clinical practice as a combination with SBE.

More than a century after the description of sarcoidosis, the disease remains not well understood. Sarcoidosis is an infl ammatory disease of unknown etiology characterized by noncaseating granulomas with multiple organs affected. The epidemiology reveals lung involvement in 90- 95% of the patients and just 5-13% incidence of neurological involvement. We present an unusual case of a patient with medulla oblongata and retroperitoneal sarcoidosis with no other organ involvement. In addition to the case presentation and extensive up-to-date literature review on extrapulmonary sarcoidosis, we describe the diffi culties in making the diagnosis and the challenge in differentiating sarcoidosis from other illnesses such as tuberculosis.

The roles of lipopolysaccharide (LPS), monocyte chemoattractant protein-1 (MCP-1) and tumor necrosis factor (TNF) in the genesis of endothelial cell injury are being defi ned. Therapy for IPS includes supportive care and immunosuppressive agents. The role of TNF antagonists is being studied in ongoing clinical trials.

Plasmatic biomarkers measurement during the initial phase of sepsis may help to individualize therapy. An evaluation at 24 h based on IL-6/IL-10 ratio may anticipate a more aggressive infl ammatory profi le. These patients would specially benefi t from immunomodulating therapies to improve survival.

TH appears underutilized in our sample of practitioners from two developing countries. Clinicians in these countries are not
familiar with ILCOR TH guidelines. Therapeutic hypothermia is certainly practical in most clinical settings and programs aimed
at educating practitioners about TH are needed in developing countries to improve neurological outcome in comatose victims of
cardiac arrest.