ABSTRACTS 75

randomly allocated to a conventional bed with manual turning or to a KTT. Apache II score was determined on each patient and the following data were recorded: ICU discharge status, initial and final Apache II score, length of stay in ICU, length of time requiring mechanical ventilatory assistance, development of nosocomial pneumonia, fluid balance, PaO,/ FiO,, daily oximetric hemoglobin oxygen saturation and development of new decubitus ulcers.

Overall ICU mortality, length of stay, Apache II score, duration of mechanical ventilation and incidence of nosoco- mial pneumonia were similar in both groups. Patients with sepsis and pneumonia had a 3.48 day shorter adjusted for Apache II score length of ICU stay compared with controls ( p < 0.001). COPD patients on the KTT had a lower Apache II score on discharge and required 6.84 fewer days in the ICU (p < 0.001) and 4.6 days less of assisted ventilation (p < 0.001). Complications of the use of the KTT included: venous lines disconnections (one case of premature ventricu- lar arrhythmia) and one case of facial ulcer. A decrease in length of ICU stay in some clinical settings could result in significant cost-saving. (Reprinted with permission.)

Decision Not to Treat: “Do Not Resuscitate” Order for

the Burn Patient in the Acute Setting. Hammond J, Ward CC. Crit Care Med 17:136, 1989.

A retrospective analysis looked at the course and outcome of 808 acute burn injuries at the University of Miami/ Jackson Memorial Burn Centre. 365 of these 808 met the definition of a major injury. 66 died, 8.2% of total admissions and 18.1% of major injuries. 16 patients had only supportive therapy, directed at overall confort; these made up 4.4% of the major burn admissions and 24.2% of the deaths.

Profile of the patients who had a do not resuscitate order (DNR) was the following: mean age of 52.5 (31-78) years, 79% as a mean of total body surface area (TBSA) burn. 6 out of 23 patients had attempted suicide; those with a DNR had a mean TBSA of 93%. The DNR order was a decision made after meeting with nurses, physicians, patient and family. It was based on experience and not emotion. The process was flexible and if any doubt arose, treatment was instituted.

Retrospective use of the burn injury index showed that DNR patients had a mean score of 13.06 + 2.32 (12- 13 points have probability of survival of ~10%). (Reprinted with permission.)

Efficacy of an Attachable Subcutaneous Cuff for the Preven- tion of Intravascular Catheter-Related Infection. Flowers

RH III, Schwenzer KJ, Kopel RF, et al. JAMA 261:878, 1989.

A randomized controlled trial was undertaken to deter- mine the efficacy of an attachable subcutaneous cuff in preventing central catheter-related infection among critically ill patients. These cuffs are composed of collagen impreg- nated with silver ions. They are positioned subcutaneously and the collagen induces tissue ingrowth that seals the catheter tract. The silver ions act as antimicrobial barrier.

Fifty-five catheters (triple-lumen and pulmonary artery catheter) inserted through new sites in 35 patients were studied. 26 catheters were cuffed, 29 were control. Clinical data on patients were similar except for a greater but

nonsignificant rate of renal failure and neoplasia in the control group. All catheters except for one were inserted through a subclavian vein with similar techniques and were dressed with ointment containing polymyxin, neomycin and bacitracin. The dressing itself was made of transparent polyurethane. Dressings and tubing sets were changed every 48 hours: decision to remove catheters were suspected infec- tion or no further need for the catheter. Blood cultures, catheter insertion site, catheters, catheter hubs and infusates were cultured. Average duration of catheter insertion was not significantly different between the two groups.

Two (7.7%) of 26 cuffed catheters became colonized, compared with ten (34.5%) of 29 control catheters. Estimates of cumulative risk of colonization in the two groups were significantly different. There were no catheter-related blood infection in the cuff group (4 cases in the control group). Candida albicans was responsible for 9 of 12 episodes of colonization. A positive skin site culture had a positive predictive value for positive catheter culture of 60% for bacteria and 81.8% for C. albicans. A positive hub culture had a positive predictive value of 45.5% for a positive- catheter culture with the same organism. There were no significant side effects from cuff placement but extra- cutaneous extrusion occurred in 10.4% of all cuffs. The same incidence of site inflammation was found in both groups but inflamed sites were more often colonized in the control group.

The incidence of catheter-related infection may be reduced by using cuffed catheter. A large proportion of C. albicum

infection may be explained, in part, by the use of non- fungicidal antimicrobial ointment. (Reprinted with permis- sion.)

Peripheral Vascular Resistance in Septic Shock: Its Relation

to Outcome. Groeneveld ABJ, Nauta JJP, Thqs LG. Inten- sive Care Med 14:141, 1988.

Nonsurvivors of septic shock may have primary myocar- dial failure or persistent defect in peripheral vascular tone, irrespective of cardiac index.

Twenty-one records of survivors and 21 non-survivors of septic shock were examined retrospectively. More specifi- cally, systemic vascular resistance index (SVRI), in response to the lowest cardiac index (CI) measured after initial values were examined: in both survivors (Group 1) and non- survivors (Group 2) the single lowest CI (T = 2) after measurement of initial value (T = 1) was selected from each patient’s record. Usual hemodynamic measurements were obtained with a pulmonary artery catheter and a peripheral arterial line. Calculation of SVRI was done according to the formula SVRI = (MAP-CVP)/CI x 80 dynessec . cm ’ m-r. Rank correlation coefficients were calculated for rela- tions between CI, mean arterial pressure and SVRI at T = 1 and T = 2, and compared between the 2 groups using Fisher’s z-test.

Initial hemodynamic metabolic and therapeutic variables did not differ between the two groups. The non-survivor group had a greater number of mechanically ventilated patients and lower arterial pH. Both absolute values and changes in MAP and SVRI significantly differed (p < 0.005); group 2 re- mained hypotensive with subnormal SVRI. In group I. CI significantly correlated with SVRI but the relationship was lost in group 2. MAP and SVRI correlated well in both