SlideShare ist ein Scribd-Unternehmen logo
1 von 35
Did my patient have VAP?.

Dr. Andrés Esteban
Servicio de Cuidados Intensivos y Grandes Quemados
84 patients with more than 72 h. of MV
suspected of having nosocomial pneumonia.
Definitive bacterial pneumonia

● Positive pleural fluid culture (n=4)
● Rapid cavitation of lung infiltrates (n=4)
● Histopathologic demonstration (n=9)
27 patients with ultimately pneumonia
J. Y. Fagon, J. Chastre, et al
Chest 1993;103:547
Patients
without
Pneumonia

Patients
with
Pneumonia

9±7

9±6

Temperature

38.3 ± 0.8

38.4 ± 1.1

Change in temperature

+ 0.1 ± 1.0

+0.5 ± 1.0

Blood Leukocytes (103)

15.2 ± 5.8

14.5 ± 5.4

Change in Leukocytes

+2.0 ± 7.0

+2.0 ± 5.6

Radiologic score

6±2

6±2

Change in Radiologic score

+2 ± 1

+2 ± 2

Duration prior ventilation

J. Y. Fagon, J. Chastre, et al
Chest 1993;103:547
The reliability coefficient (Kappa)
among the four pathologists
was ……………… 0.916
The 6 months later resulted in
reclassification of 3 patients

S. H. Kirtland,D.E.Corley et al.
Chest 1997;112:458
39 patients died after a mean 14 d. M.V.
Mechanical ventilation

14 d. (mean)

Airspace disease (Chest radiograph) 36 / 39
Antimicrobial treatment

38 / 39

With Pneumonia (Hist)

9 / 39

Without Pneumonia (Hist)

30 / 39

S.H. Kirtland, D. Corley, et al
Chest 1997;112:445
Correlation (Kappa) with Clinical Findings
(during the 48 h. prior to death)
Histologic
diagnosis of
Pneumonia

Temperature >38.5 ºC

0.15

WBC count ≥ 15,000

-0.03

Bacterial or fungal on
sputun cultive

-0.06

Chest Radiograph

0.04

Decrease PaO2/FiO2

0.11
S.H. Kirtland, D. Corley, et al
Chest 1997;112:445
25 patients with MV >72 h.

16 biopsy speciement per patient

N. Fabregas, S. Ewing et al.
Thorax 1999;54:867
Sensitivity

Specificity

PPV

NPV

Chest
radiography

0.92

0.33

0.60

0.80

Leukocytosis

0.77

0.58

0.67

0.70

Fever

0.46

0.42

0.46

0.42

Purulent
secretions

0.69

0.42

0.56

0.56

Johanson 2/3

0.69

0.75

0.75

0.69

Johanson 3/3

0.23

0.92

0.75

0.52

Pugin
score >6

0.77

0.42

0.67

0.42

N. Fabregas, S. Ewing et al.
Thorax 1999;54:867
9906
Patients admitted to ICU
1633 (16.5 %)
Died

497 (35 %)
Obtained consent and
Performed a clinical autopsy

253
Patients included
(VM >48 h.)

120
Organ donor
101
Patients with legally
mandated autopsies

30
Lost information

A.Esteban,F.Frutos,et al. (submitted)
253 patients with autopsy

> 48 hours of MV

Following during the preceding
14 days of death
Clinical suspicion of pneumonia according
to the LOOSE DEFINITION

Infiltrate on the chest radiograph and
at least two of the folloving
● Leucocytosis >12 x 109/ml
● Fever >38.5 ºC
● Presence of purulent tracheobronquial
secretions
Clinical suspicion of pneumonia according
to the RIGOROUS DEFINITION
Infiltrate on the chest radiograph and
all three of the folloving
● Leucocytosis >12 x 109/ml
● Fever >38.5 ºC
● Presence of purulent tracheobronquial
secretions
Clinical Pulmonary Infection Score (CPIS)
Clinical suspicion of pneumonia in the presence
of a positive score at different cut offs (1-12 points)
which include the following variables.
● Body temperature

● Blood leucocyte count and number of band forms
● Tracheobronchial secretions (purulen or not and
quanty)
● Microscopic examination of bronchial secretions
(Gram and semiquantitative culture)

● PaO2/FiO2
● Chest radiograph
n = 253 patients
Age, mean ± SD
66.2 ± 13.5
157 (62.1 %), 96 (37.9 %)
Sex (Male and female), n %
SAPS II, mean ± SD
49.5 ± 15.8
Length of ICU stay d. mean ± SD
16.7 ± 17.9
Cause of ICU admission, n (%)
● Medical
142 (56.1 %)
● Surgical
88 (34.8 %)
● Coronary
23 (9.1 %)
Temperature (ºC), mean ± SD
37.63 ± 1.13
Leucocytes (x 109/L) mean ± SD
16.16 ± 12.21
PaO2 / FiO2, mean ± SD
182.86 ± 85.94
Chest x-ray findings, n (%)
● No infiltrates
● Localizated

8 (3.2 %)
76 (30 %)
The Kappa statistict
agreement between the two
intensivist in the chest
radiographies was 0.382
Chest Radiography

76 / 253 (30 %)
169 / 253 (66.8 %)

Localized infiltrates
Diffuse infiltrates
Sensibility

Specificity

(%, CI 95%)

(%, CI 95%)

Loose
Definition

64.8
(56.6–72.2)

Rigurous
Definition

Definition

CPIS

LR (+)

LR (-)

36
(27.7-45.3)

1.01
(0.84-1.22)

0.98
(0.72-1.32)

15.5
(10.5-22.3)

91
(84.2-95)

1.72
(0.85-3.48)

0.93
(0.82-1.06)

45.8
(37.8-54)

60.4
(51.1-69)

1.15
(0.86-1.54)

0.90
(0.72-1.11)

A.Esteban,F.Frutos,et al. (submitted)
N. Fabregas
Thorax 1999
(n= 25)
Definition

A. Esteban
(n = 253)

Sensibility

Specificity

Sensibility

Specificity

Johanson 2/3

0.69

0.75

0.65

0.46

Johanson 3/3

0.23

0.92

0.15

0.91

CPIS

0.77

0.42

0.46

0.61
Sensitivity

Specificity

LR (+)

LR (-)

(%, CI 95 %)

(%, CI 95 %)

(CI 95 %)

(CI 95 %)

Loose

64.9
(56.5 – 72.2)

36
(27.7 – 45.3)

1.01
(0.84– 1.22)

0.98
(0.72 – 1.32)

Loose
+ localized
infitrates

11.3
(7.1 – 17.5)

91.9
(85.3 – 95.7)

1.39
(0.64 – 3.03)

0.97
(0.85 – 1.1)

Rigorous

15.5
(10.5 – 23.6)

91
(84.2 – 95)

1.72
(0.85 – 3.48)

0.93
(0.82 – 1.06)

2.1
(0.7 – 6)

100
(96.7 – 100)

-

0.98
(0.96 – 1.0)

45.8
(37.8 – 54)

60.4
(51.1 – 69)

1.15
(0.86– 1.54)

0.90
(0.72 – 1.11)

Definition

Rigorous
+ localized
infiltrates

CPIS

A.Esteban,F.Frutos,et al. (submitted)
OVERALL
GROUP

PPV
NPV
Sensitivity
Specificity
Likelihood
(+)
Likelihood
(-)

RISK
FACTOR

PULMON.
RISK
FACTOR

EXTRAPU
L. RISK
FACTOR

75 %
84 %
66 %
89 %
6.02

76 %
75 %
66 %
83 %
3.85

61 %
69 %
59 %
72 %
2.07

85 %
78 %
70 %
90 %
6.83

0.38

0.41

0.58

0.55

A.Esteban,P.Fdez-Segoviano,F.Frutos,et al.
Ann Intern Med 2004;141:440
Decisions based on clinical criteria
resulted in inappropriate treatment
of many patients without pneumonia

J. Y. Fagon, J. Chastre, et al
Chest 1993;103:547
Early diagnosis
Fast cultures
(microarray based(-4h)detection of
ten significant bacterial species)

Procalcitonin (High NPV)
s-TREM-1( in BAL or in plasma)

Early treatments
Lipopolysacharide
Late proinflam . Mediators
Complements cascade
Apoptosis
Inducible NO synthasa
● Clinical criteria may lead to underdiagnosis, which
result an increase risk of death in patients with
ventilator-associated pneumonia not receiving
antibiotic treatment.

● Also the clinical criteria may lead to overdiagnosis
which result in overuse of antibiotics that favour
colonization with potentially resistant pathogenic
microorganisms and superinfection.
MANUEL

JULIO

DATE

376

1999

DIAGNOSIS

Craneal
Stab wound

Craneal
Stab wound

TREATMENT

Catholic Church
Bishop

University Hospital
ICU

OUTCOME

Saint Manuel
Altar of the Church

Neurosurgery bill
ICU bill
Chart number
124123
Psychiatric Nursery
Did my patient have VAP?

Weitere ähnliche Inhalte

Was ist angesagt?

Secondary gastric varices in hepatic cirrhosis
Secondary gastric varices in hepatic cirrhosisSecondary gastric varices in hepatic cirrhosis
Secondary gastric varices in hepatic cirrhosisSamiullah Shaikh
 
Chicago classification version 4.0: HRM classification of esophageal motility...
Chicago classification version 4.0: HRM classification of esophageal motility...Chicago classification version 4.0: HRM classification of esophageal motility...
Chicago classification version 4.0: HRM classification of esophageal motility...Yasir Arafat
 
Complications Following Antireflux Surgery: Recognition and Management
Complications Following Antireflux Surgery: Recognition and ManagementComplications Following Antireflux Surgery: Recognition and Management
Complications Following Antireflux Surgery: Recognition and ManagementGeorge S. Ferzli
 
Anaesthesia for septic patient
Anaesthesia for septic patientAnaesthesia for septic patient
Anaesthesia for septic patientArun Gupta
 
Bibliografía pa grave y stent biliar
Bibliografía pa grave y stent biliarBibliografía pa grave y stent biliar
Bibliografía pa grave y stent biliarFrancisco Gallego
 
Imaging con Scintigrafia
Imaging con ScintigrafiaImaging con Scintigrafia
Imaging con ScintigrafiaCTEPH
 
Timing of surgery in mild biliary pancreatitis
Timing of surgery in mild biliary pancreatitisTiming of surgery in mild biliary pancreatitis
Timing of surgery in mild biliary pancreatitisAravind TK
 
Optimzing sepsis management
Optimzing sepsis managementOptimzing sepsis management
Optimzing sepsis managementEM OMSB
 
Characterization of sialoadenitis after administration of continuous sialogog...
Characterization of sialoadenitis after administration of continuous sialogog...Characterization of sialoadenitis after administration of continuous sialogog...
Characterization of sialoadenitis after administration of continuous sialogog...Michael
 
Normal & abnormal swallows in chicago classification version 3.0
Normal & abnormal swallows in chicago classification version 3.0Normal & abnormal swallows in chicago classification version 3.0
Normal & abnormal swallows in chicago classification version 3.0Samir Haffar
 
Gastro Esophageal Reflux Disease
Gastro Esophageal Reflux DiseaseGastro Esophageal Reflux Disease
Gastro Esophageal Reflux DiseaseApollo Hospitals
 
Sepsis easy: strategy to improve outcome
Sepsis easy: strategy to improve outcomeSepsis easy: strategy to improve outcome
Sepsis easy: strategy to improve outcomeandychamp
 

Was ist angesagt? (20)

Secondary gastric varices in hepatic cirrhosis
Secondary gastric varices in hepatic cirrhosisSecondary gastric varices in hepatic cirrhosis
Secondary gastric varices in hepatic cirrhosis
 
Caso clinico 37 2015 nejm
Caso clinico 37 2015 nejmCaso clinico 37 2015 nejm
Caso clinico 37 2015 nejm
 
Scleroderma Associated Lung Disease
Scleroderma Associated Lung DiseaseScleroderma Associated Lung Disease
Scleroderma Associated Lung Disease
 
Chicago classification version 4.0: HRM classification of esophageal motility...
Chicago classification version 4.0: HRM classification of esophageal motility...Chicago classification version 4.0: HRM classification of esophageal motility...
Chicago classification version 4.0: HRM classification of esophageal motility...
 
Sepsis Guidelines 2016-2017
Sepsis Guidelines 2016-2017Sepsis Guidelines 2016-2017
Sepsis Guidelines 2016-2017
 
Complications Following Antireflux Surgery: Recognition and Management
Complications Following Antireflux Surgery: Recognition and ManagementComplications Following Antireflux Surgery: Recognition and Management
Complications Following Antireflux Surgery: Recognition and Management
 
Anaesthesia for septic patient
Anaesthesia for septic patientAnaesthesia for septic patient
Anaesthesia for septic patient
 
Leukocytosis in appendicitis
Leukocytosis in appendicitisLeukocytosis in appendicitis
Leukocytosis in appendicitis
 
Bibliografía pa grave y stent biliar
Bibliografía pa grave y stent biliarBibliografía pa grave y stent biliar
Bibliografía pa grave y stent biliar
 
Imaging con Scintigrafia
Imaging con ScintigrafiaImaging con Scintigrafia
Imaging con Scintigrafia
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Timing of surgery in mild biliary pancreatitis
Timing of surgery in mild biliary pancreatitisTiming of surgery in mild biliary pancreatitis
Timing of surgery in mild biliary pancreatitis
 
Optimzing sepsis management
Optimzing sepsis managementOptimzing sepsis management
Optimzing sepsis management
 
Characterization of sialoadenitis after administration of continuous sialogog...
Characterization of sialoadenitis after administration of continuous sialogog...Characterization of sialoadenitis after administration of continuous sialogog...
Characterization of sialoadenitis after administration of continuous sialogog...
 
Normal & abnormal swallows in chicago classification version 3.0
Normal & abnormal swallows in chicago classification version 3.0Normal & abnormal swallows in chicago classification version 3.0
Normal & abnormal swallows in chicago classification version 3.0
 
Gastro Esophageal Reflux Disease
Gastro Esophageal Reflux DiseaseGastro Esophageal Reflux Disease
Gastro Esophageal Reflux Disease
 
Update on Scleroderma and the Lung
Update on Scleroderma and the LungUpdate on Scleroderma and the Lung
Update on Scleroderma and the Lung
 
Sepsis easy: strategy to improve outcome
Sepsis easy: strategy to improve outcomeSepsis easy: strategy to improve outcome
Sepsis easy: strategy to improve outcome
 
1 prevalencia tep covid abril 2020
1 prevalencia tep covid abril 20201 prevalencia tep covid abril 2020
1 prevalencia tep covid abril 2020
 
"Biomarkers in sepsis and septic shock" by Prof. Jérôme Pugin
"Biomarkers in sepsis and septic shock" by Prof. Jérôme Pugin"Biomarkers in sepsis and septic shock" by Prof. Jérôme Pugin
"Biomarkers in sepsis and septic shock" by Prof. Jérôme Pugin
 

Ähnlich wie Did my patient have VAP?

Ultrasound assisted thrombolysis for vte turkish experience
Ultrasound assisted thrombolysis for vte turkish experienceUltrasound assisted thrombolysis for vte turkish experience
Ultrasound assisted thrombolysis for vte turkish experienceuvcd
 
Nfhk2011 birthe dinesen_parallel17
Nfhk2011 birthe dinesen_parallel17Nfhk2011 birthe dinesen_parallel17
Nfhk2011 birthe dinesen_parallel17NFHK2011
 
H A P& V A P
H A P& V A PH A P& V A P
H A P& V A PMed Bee
 
Excerise Tolerance and Post-Operative Outcomes in Patients with Pulmonary Hyp...
Excerise Tolerance and Post-Operative Outcomes in Patients with Pulmonary Hyp...Excerise Tolerance and Post-Operative Outcomes in Patients with Pulmonary Hyp...
Excerise Tolerance and Post-Operative Outcomes in Patients with Pulmonary Hyp...Aalap Shah
 
Mark Richards - High sensitivity troponins in chest pain
Mark Richards - High sensitivity troponins in chest painMark Richards - High sensitivity troponins in chest pain
Mark Richards - High sensitivity troponins in chest painRahul Goswami
 
Topic Review(Trauma Cholesyctitis)
Topic Review(Trauma Cholesyctitis)Topic Review(Trauma Cholesyctitis)
Topic Review(Trauma Cholesyctitis)Vincent Wang
 
Mantenimiento ca pulmón 2013-05
Mantenimiento ca pulmón 2013-05Mantenimiento ca pulmón 2013-05
Mantenimiento ca pulmón 2013-05Martín Lázaro
 
Roberta Lattes - Argentina - Tuesday 29 - Donor Risk
Roberta Lattes -  Argentina - Tuesday 29 - Donor RiskRoberta Lattes -  Argentina - Tuesday 29 - Donor Risk
Roberta Lattes - Argentina - Tuesday 29 - Donor Riskincucai_isodp
 
05 2019 manila pleural infection final pdf
05 2019 manila pleural infection final pdf05 2019 manila pleural infection final pdf
05 2019 manila pleural infection final pdfipmslmc
 
Pulmonary Embolism
Pulmonary EmbolismPulmonary Embolism
Pulmonary Embolismcairo1957
 
Liver transplantation vs Resection in cholangiocarcinoma on cirrhosis
Liver transplantation vs Resection in cholangiocarcinoma on cirrhosisLiver transplantation vs Resection in cholangiocarcinoma on cirrhosis
Liver transplantation vs Resection in cholangiocarcinoma on cirrhosisEric Vibert, MD, PhD
 
DR. GHIZAL PRESENTATION
DR. GHIZAL PRESENTATIONDR. GHIZAL PRESENTATION
DR. GHIZAL PRESENTATIONdrammarmehdi
 
endoscopic CSF rhinorrhea
endoscopic CSF rhinorrheaendoscopic CSF rhinorrhea
endoscopic CSF rhinorrheamadan gupta
 

Ähnlich wie Did my patient have VAP? (20)

Ultrasound assisted thrombolysis for vte turkish experience
Ultrasound assisted thrombolysis for vte turkish experienceUltrasound assisted thrombolysis for vte turkish experience
Ultrasound assisted thrombolysis for vte turkish experience
 
Ventilatory Modes.
Ventilatory Modes. Ventilatory Modes.
Ventilatory Modes.
 
Nfhk2011 birthe dinesen_parallel17
Nfhk2011 birthe dinesen_parallel17Nfhk2011 birthe dinesen_parallel17
Nfhk2011 birthe dinesen_parallel17
 
Radiologieinterventionnellechctdebaere
RadiologieinterventionnellechctdebaereRadiologieinterventionnellechctdebaere
Radiologieinterventionnellechctdebaere
 
H A P& V A P
H A P& V A PH A P& V A P
H A P& V A P
 
Septic shock with no diagnosis at 24 hours
Septic shock with no diagnosis at 24 hoursSeptic shock with no diagnosis at 24 hours
Septic shock with no diagnosis at 24 hours
 
Excerise Tolerance and Post-Operative Outcomes in Patients with Pulmonary Hyp...
Excerise Tolerance and Post-Operative Outcomes in Patients with Pulmonary Hyp...Excerise Tolerance and Post-Operative Outcomes in Patients with Pulmonary Hyp...
Excerise Tolerance and Post-Operative Outcomes in Patients with Pulmonary Hyp...
 
Weaning final (3).ppt
Weaning final (3).pptWeaning final (3).ppt
Weaning final (3).ppt
 
MCC 2011 - Slide 14
MCC 2011 - Slide 14MCC 2011 - Slide 14
MCC 2011 - Slide 14
 
Mark Richards - High sensitivity troponins in chest pain
Mark Richards - High sensitivity troponins in chest painMark Richards - High sensitivity troponins in chest pain
Mark Richards - High sensitivity troponins in chest pain
 
Topic Review(Trauma Cholesyctitis)
Topic Review(Trauma Cholesyctitis)Topic Review(Trauma Cholesyctitis)
Topic Review(Trauma Cholesyctitis)
 
Mantenimiento ca pulmón 2013-05
Mantenimiento ca pulmón 2013-05Mantenimiento ca pulmón 2013-05
Mantenimiento ca pulmón 2013-05
 
Roberta Lattes - Argentina - Tuesday 29 - Donor Risk
Roberta Lattes -  Argentina - Tuesday 29 - Donor RiskRoberta Lattes -  Argentina - Tuesday 29 - Donor Risk
Roberta Lattes - Argentina - Tuesday 29 - Donor Risk
 
05 2019 manila pleural infection final pdf
05 2019 manila pleural infection final pdf05 2019 manila pleural infection final pdf
05 2019 manila pleural infection final pdf
 
Antiagregación en los pacientes con Cardiopatía Isquémica
Antiagregación en los pacientes con Cardiopatía IsquémicaAntiagregación en los pacientes con Cardiopatía Isquémica
Antiagregación en los pacientes con Cardiopatía Isquémica
 
Pulmonary Embolism
Pulmonary EmbolismPulmonary Embolism
Pulmonary Embolism
 
Liver transplantation vs Resection in cholangiocarcinoma on cirrhosis
Liver transplantation vs Resection in cholangiocarcinoma on cirrhosisLiver transplantation vs Resection in cholangiocarcinoma on cirrhosis
Liver transplantation vs Resection in cholangiocarcinoma on cirrhosis
 
Section21
Section21Section21
Section21
 
DR. GHIZAL PRESENTATION
DR. GHIZAL PRESENTATIONDR. GHIZAL PRESENTATION
DR. GHIZAL PRESENTATION
 
endoscopic CSF rhinorrhea
endoscopic CSF rhinorrheaendoscopic CSF rhinorrhea
endoscopic CSF rhinorrhea
 

Mehr von Dr.Mahmoud Abbas

EGYPTIAN IMPRINT IN SPAIN Lecture by Dr Abeer Zahana
EGYPTIAN IMPRINT IN SPAIN Lecture by Dr Abeer ZahanaEGYPTIAN IMPRINT IN SPAIN Lecture by Dr Abeer Zahana
EGYPTIAN IMPRINT IN SPAIN Lecture by Dr Abeer ZahanaDr.Mahmoud Abbas
 
Technologies for the Fashion Industry_ What’s new_ (1).pdf
Technologies for the Fashion Industry_ What’s new_  (1).pdfTechnologies for the Fashion Industry_ What’s new_  (1).pdf
Technologies for the Fashion Industry_ What’s new_ (1).pdfDr.Mahmoud Abbas
 
Natural Dyes Greener ways to color textiles.pdf
Natural Dyes Greener ways to color textiles.pdfNatural Dyes Greener ways to color textiles.pdf
Natural Dyes Greener ways to color textiles.pdfDr.Mahmoud Abbas
 
Trends in Active wear and Athleisure.pdf
Trends in Active wear and Athleisure.pdfTrends in Active wear and Athleisure.pdf
Trends in Active wear and Athleisure.pdfDr.Mahmoud Abbas
 
The Changing Role of the Coronary Care Cardiologist & The Emerging Role of Ca...
The Changing Role of the Coronary Care Cardiologist & The Emerging Role of Ca...The Changing Role of the Coronary Care Cardiologist & The Emerging Role of Ca...
The Changing Role of the Coronary Care Cardiologist & The Emerging Role of Ca...Dr.Mahmoud Abbas
 
Drug Induced Kidney Injury in the ICU.pdf
Drug Induced Kidney Injury in the ICU.pdfDrug Induced Kidney Injury in the ICU.pdf
Drug Induced Kidney Injury in the ICU.pdfDr.Mahmoud Abbas
 
Using Novel Kidney Biomarkers to Guide Drug Therapy.pdf
Using Novel Kidney Biomarkers to Guide Drug Therapy.pdfUsing Novel Kidney Biomarkers to Guide Drug Therapy.pdf
Using Novel Kidney Biomarkers to Guide Drug Therapy.pdfDr.Mahmoud Abbas
 
How Textile Digital Printing Changed Interior Designs.pdf
How Textile Digital Printing Changed Interior Designs.pdfHow Textile Digital Printing Changed Interior Designs.pdf
How Textile Digital Printing Changed Interior Designs.pdfDr.Mahmoud Abbas
 
What makes a design fashionable (prints & fashion).pdf
What makes a design fashionable (prints & fashion).pdfWhat makes a design fashionable (prints & fashion).pdf
What makes a design fashionable (prints & fashion).pdfDr.Mahmoud Abbas
 
Use of Steroids in COVID 19- Egyptian Critical Care Summit.pdf
Use of Steroids in COVID 19- Egyptian Critical Care Summit.pdfUse of Steroids in COVID 19- Egyptian Critical Care Summit.pdf
Use of Steroids in COVID 19- Egyptian Critical Care Summit.pdfDr.Mahmoud Abbas
 
Decorative effects on wool fabrics.pdf
Decorative effects on wool fabrics.pdfDecorative effects on wool fabrics.pdf
Decorative effects on wool fabrics.pdfDr.Mahmoud Abbas
 
Technical textiles the future of textile
Technical textiles the future of textileTechnical textiles the future of textile
Technical textiles the future of textileDr.Mahmoud Abbas
 
The future of the jeans sustainable washing cairo textile week
The future of the jeans sustainable washing cairo textile weekThe future of the jeans sustainable washing cairo textile week
The future of the jeans sustainable washing cairo textile weekDr.Mahmoud Abbas
 
Why Egypt should be competitive in the Global Denim Supply Chain?
Why Egypt should be competitive in the Global Denim Supply Chain?Why Egypt should be competitive in the Global Denim Supply Chain?
Why Egypt should be competitive in the Global Denim Supply Chain?Dr.Mahmoud Abbas
 
Cairo Textile Week 2021 Conference -Egypt Textiles & Home Textiles Export Cou...
Cairo Textile Week 2021 Conference -Egypt Textiles & Home Textiles Export Cou...Cairo Textile Week 2021 Conference -Egypt Textiles & Home Textiles Export Cou...
Cairo Textile Week 2021 Conference -Egypt Textiles & Home Textiles Export Cou...Dr.Mahmoud Abbas
 
Non operative management of blunt abdominal trauma
Non operative management of blunt abdominal traumaNon operative management of blunt abdominal trauma
Non operative management of blunt abdominal traumaDr.Mahmoud Abbas
 
History of critical care center cairo university
History of critical care center cairo universityHistory of critical care center cairo university
History of critical care center cairo universityDr.Mahmoud Abbas
 
Kemet presentation itex cairo 2021
Kemet presentation itex cairo 2021 Kemet presentation itex cairo 2021
Kemet presentation itex cairo 2021 Dr.Mahmoud Abbas
 
Incorporating printed fabrics in interior decoration and acoustic panels
Incorporating printed fabrics in interior decoration and acoustic panelsIncorporating printed fabrics in interior decoration and acoustic panels
Incorporating printed fabrics in interior decoration and acoustic panelsDr.Mahmoud Abbas
 
How digital printing is adding value to active wear and athleisure?
How digital printing is adding value to active wear and athleisure?How digital printing is adding value to active wear and athleisure?
How digital printing is adding value to active wear and athleisure?Dr.Mahmoud Abbas
 

Mehr von Dr.Mahmoud Abbas (20)

EGYPTIAN IMPRINT IN SPAIN Lecture by Dr Abeer Zahana
EGYPTIAN IMPRINT IN SPAIN Lecture by Dr Abeer ZahanaEGYPTIAN IMPRINT IN SPAIN Lecture by Dr Abeer Zahana
EGYPTIAN IMPRINT IN SPAIN Lecture by Dr Abeer Zahana
 
Technologies for the Fashion Industry_ What’s new_ (1).pdf
Technologies for the Fashion Industry_ What’s new_  (1).pdfTechnologies for the Fashion Industry_ What’s new_  (1).pdf
Technologies for the Fashion Industry_ What’s new_ (1).pdf
 
Natural Dyes Greener ways to color textiles.pdf
Natural Dyes Greener ways to color textiles.pdfNatural Dyes Greener ways to color textiles.pdf
Natural Dyes Greener ways to color textiles.pdf
 
Trends in Active wear and Athleisure.pdf
Trends in Active wear and Athleisure.pdfTrends in Active wear and Athleisure.pdf
Trends in Active wear and Athleisure.pdf
 
The Changing Role of the Coronary Care Cardiologist & The Emerging Role of Ca...
The Changing Role of the Coronary Care Cardiologist & The Emerging Role of Ca...The Changing Role of the Coronary Care Cardiologist & The Emerging Role of Ca...
The Changing Role of the Coronary Care Cardiologist & The Emerging Role of Ca...
 
Drug Induced Kidney Injury in the ICU.pdf
Drug Induced Kidney Injury in the ICU.pdfDrug Induced Kidney Injury in the ICU.pdf
Drug Induced Kidney Injury in the ICU.pdf
 
Using Novel Kidney Biomarkers to Guide Drug Therapy.pdf
Using Novel Kidney Biomarkers to Guide Drug Therapy.pdfUsing Novel Kidney Biomarkers to Guide Drug Therapy.pdf
Using Novel Kidney Biomarkers to Guide Drug Therapy.pdf
 
How Textile Digital Printing Changed Interior Designs.pdf
How Textile Digital Printing Changed Interior Designs.pdfHow Textile Digital Printing Changed Interior Designs.pdf
How Textile Digital Printing Changed Interior Designs.pdf
 
What makes a design fashionable (prints & fashion).pdf
What makes a design fashionable (prints & fashion).pdfWhat makes a design fashionable (prints & fashion).pdf
What makes a design fashionable (prints & fashion).pdf
 
Use of Steroids in COVID 19- Egyptian Critical Care Summit.pdf
Use of Steroids in COVID 19- Egyptian Critical Care Summit.pdfUse of Steroids in COVID 19- Egyptian Critical Care Summit.pdf
Use of Steroids in COVID 19- Egyptian Critical Care Summit.pdf
 
Decorative effects on wool fabrics.pdf
Decorative effects on wool fabrics.pdfDecorative effects on wool fabrics.pdf
Decorative effects on wool fabrics.pdf
 
Technical textiles the future of textile
Technical textiles the future of textileTechnical textiles the future of textile
Technical textiles the future of textile
 
The future of the jeans sustainable washing cairo textile week
The future of the jeans sustainable washing cairo textile weekThe future of the jeans sustainable washing cairo textile week
The future of the jeans sustainable washing cairo textile week
 
Why Egypt should be competitive in the Global Denim Supply Chain?
Why Egypt should be competitive in the Global Denim Supply Chain?Why Egypt should be competitive in the Global Denim Supply Chain?
Why Egypt should be competitive in the Global Denim Supply Chain?
 
Cairo Textile Week 2021 Conference -Egypt Textiles & Home Textiles Export Cou...
Cairo Textile Week 2021 Conference -Egypt Textiles & Home Textiles Export Cou...Cairo Textile Week 2021 Conference -Egypt Textiles & Home Textiles Export Cou...
Cairo Textile Week 2021 Conference -Egypt Textiles & Home Textiles Export Cou...
 
Non operative management of blunt abdominal trauma
Non operative management of blunt abdominal traumaNon operative management of blunt abdominal trauma
Non operative management of blunt abdominal trauma
 
History of critical care center cairo university
History of critical care center cairo universityHistory of critical care center cairo university
History of critical care center cairo university
 
Kemet presentation itex cairo 2021
Kemet presentation itex cairo 2021 Kemet presentation itex cairo 2021
Kemet presentation itex cairo 2021
 
Incorporating printed fabrics in interior decoration and acoustic panels
Incorporating printed fabrics in interior decoration and acoustic panelsIncorporating printed fabrics in interior decoration and acoustic panels
Incorporating printed fabrics in interior decoration and acoustic panels
 
How digital printing is adding value to active wear and athleisure?
How digital printing is adding value to active wear and athleisure?How digital printing is adding value to active wear and athleisure?
How digital printing is adding value to active wear and athleisure?
 

Kürzlich hochgeladen

All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...Arohi Goyal
 
Most Beautiful Call Girl in Bangalore Contact on Whatsapp
Most Beautiful Call Girl in Bangalore Contact on WhatsappMost Beautiful Call Girl in Bangalore Contact on Whatsapp
Most Beautiful Call Girl in Bangalore Contact on WhatsappInaaya Sharma
 
Top Rated Bangalore Call Girls Majestic ⟟ 9332606886 ⟟ Call Me For Genuine S...
Top Rated Bangalore Call Girls Majestic ⟟  9332606886 ⟟ Call Me For Genuine S...Top Rated Bangalore Call Girls Majestic ⟟  9332606886 ⟟ Call Me For Genuine S...
Top Rated Bangalore Call Girls Majestic ⟟ 9332606886 ⟟ Call Me For Genuine S...narwatsonia7
 
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...narwatsonia7
 
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeTop Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeCall Girls Delhi
 
Model Call Girls In Chennai WhatsApp Booking 7427069034 call girl service 24 ...
Model Call Girls In Chennai WhatsApp Booking 7427069034 call girl service 24 ...Model Call Girls In Chennai WhatsApp Booking 7427069034 call girl service 24 ...
Model Call Girls In Chennai WhatsApp Booking 7427069034 call girl service 24 ...hotbabesbook
 
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls  * UPA...Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls  * UPA...
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...mahaiklolahd
 
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...GENUINE ESCORT AGENCY
 
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service AvailableGENUINE ESCORT AGENCY
 
Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...Dipal Arora
 
Call Girls Tirupati Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 8250077686 Top Class Call Girl Service AvailableCall Girls Tirupati Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 8250077686 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Raipur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Raipur Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Raipur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Raipur Just Call 9630942363 Top Class Call Girl Service AvailableGENUINE ESCORT AGENCY
 
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
Russian Call Girls Service  Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...Russian Call Girls Service  Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...parulsinha
 
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...tanya dube
 
Top Rated Hyderabad Call Girls Chintal ⟟ 9332606886 ⟟ Call Me For Genuine Se...
Top Rated  Hyderabad Call Girls Chintal ⟟ 9332606886 ⟟ Call Me For Genuine Se...Top Rated  Hyderabad Call Girls Chintal ⟟ 9332606886 ⟟ Call Me For Genuine Se...
Top Rated Hyderabad Call Girls Chintal ⟟ 9332606886 ⟟ Call Me For Genuine Se...chandars293
 
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...hotbabesbook
 
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...parulsinha
 
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426jennyeacort
 
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service AvailableGENUINE ESCORT AGENCY
 

Kürzlich hochgeladen (20)

All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
 
Most Beautiful Call Girl in Bangalore Contact on Whatsapp
Most Beautiful Call Girl in Bangalore Contact on WhatsappMost Beautiful Call Girl in Bangalore Contact on Whatsapp
Most Beautiful Call Girl in Bangalore Contact on Whatsapp
 
Call Girls in Gagan Vihar (delhi) call me [🔝 9953056974 🔝] escort service 24X7
Call Girls in Gagan Vihar (delhi) call me [🔝  9953056974 🔝] escort service 24X7Call Girls in Gagan Vihar (delhi) call me [🔝  9953056974 🔝] escort service 24X7
Call Girls in Gagan Vihar (delhi) call me [🔝 9953056974 🔝] escort service 24X7
 
Top Rated Bangalore Call Girls Majestic ⟟ 9332606886 ⟟ Call Me For Genuine S...
Top Rated Bangalore Call Girls Majestic ⟟  9332606886 ⟟ Call Me For Genuine S...Top Rated Bangalore Call Girls Majestic ⟟  9332606886 ⟟ Call Me For Genuine S...
Top Rated Bangalore Call Girls Majestic ⟟ 9332606886 ⟟ Call Me For Genuine S...
 
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
 
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeTop Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
 
Model Call Girls In Chennai WhatsApp Booking 7427069034 call girl service 24 ...
Model Call Girls In Chennai WhatsApp Booking 7427069034 call girl service 24 ...Model Call Girls In Chennai WhatsApp Booking 7427069034 call girl service 24 ...
Model Call Girls In Chennai WhatsApp Booking 7427069034 call girl service 24 ...
 
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls  * UPA...Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls  * UPA...
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...
 
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
 
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service Available
 
Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...
 
Call Girls Tirupati Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 8250077686 Top Class Call Girl Service AvailableCall Girls Tirupati Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 8250077686 Top Class Call Girl Service Available
 
Call Girls Raipur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Raipur Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Raipur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Raipur Just Call 9630942363 Top Class Call Girl Service Available
 
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
Russian Call Girls Service  Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...Russian Call Girls Service  Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
 
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
 
Top Rated Hyderabad Call Girls Chintal ⟟ 9332606886 ⟟ Call Me For Genuine Se...
Top Rated  Hyderabad Call Girls Chintal ⟟ 9332606886 ⟟ Call Me For Genuine Se...Top Rated  Hyderabad Call Girls Chintal ⟟ 9332606886 ⟟ Call Me For Genuine Se...
Top Rated Hyderabad Call Girls Chintal ⟟ 9332606886 ⟟ Call Me For Genuine Se...
 
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
 
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
 
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
 
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
 

Did my patient have VAP?

  • 1. Did my patient have VAP?. Dr. Andrés Esteban Servicio de Cuidados Intensivos y Grandes Quemados
  • 2.
  • 3.
  • 4. 84 patients with more than 72 h. of MV suspected of having nosocomial pneumonia. Definitive bacterial pneumonia ● Positive pleural fluid culture (n=4) ● Rapid cavitation of lung infiltrates (n=4) ● Histopathologic demonstration (n=9) 27 patients with ultimately pneumonia J. Y. Fagon, J. Chastre, et al Chest 1993;103:547
  • 5. Patients without Pneumonia Patients with Pneumonia 9±7 9±6 Temperature 38.3 ± 0.8 38.4 ± 1.1 Change in temperature + 0.1 ± 1.0 +0.5 ± 1.0 Blood Leukocytes (103) 15.2 ± 5.8 14.5 ± 5.4 Change in Leukocytes +2.0 ± 7.0 +2.0 ± 5.6 Radiologic score 6±2 6±2 Change in Radiologic score +2 ± 1 +2 ± 2 Duration prior ventilation J. Y. Fagon, J. Chastre, et al Chest 1993;103:547
  • 6.
  • 7. The reliability coefficient (Kappa) among the four pathologists was ……………… 0.916 The 6 months later resulted in reclassification of 3 patients S. H. Kirtland,D.E.Corley et al. Chest 1997;112:458
  • 8. 39 patients died after a mean 14 d. M.V. Mechanical ventilation 14 d. (mean) Airspace disease (Chest radiograph) 36 / 39 Antimicrobial treatment 38 / 39 With Pneumonia (Hist) 9 / 39 Without Pneumonia (Hist) 30 / 39 S.H. Kirtland, D. Corley, et al Chest 1997;112:445
  • 9. Correlation (Kappa) with Clinical Findings (during the 48 h. prior to death) Histologic diagnosis of Pneumonia Temperature >38.5 ºC 0.15 WBC count ≥ 15,000 -0.03 Bacterial or fungal on sputun cultive -0.06 Chest Radiograph 0.04 Decrease PaO2/FiO2 0.11 S.H. Kirtland, D. Corley, et al Chest 1997;112:445
  • 10. 25 patients with MV >72 h. 16 biopsy speciement per patient N. Fabregas, S. Ewing et al. Thorax 1999;54:867
  • 12. 9906 Patients admitted to ICU 1633 (16.5 %) Died 497 (35 %) Obtained consent and Performed a clinical autopsy 253 Patients included (VM >48 h.) 120 Organ donor 101 Patients with legally mandated autopsies 30 Lost information A.Esteban,F.Frutos,et al. (submitted)
  • 13. 253 patients with autopsy > 48 hours of MV Following during the preceding 14 days of death
  • 14. Clinical suspicion of pneumonia according to the LOOSE DEFINITION Infiltrate on the chest radiograph and at least two of the folloving ● Leucocytosis >12 x 109/ml ● Fever >38.5 ºC ● Presence of purulent tracheobronquial secretions
  • 15. Clinical suspicion of pneumonia according to the RIGOROUS DEFINITION Infiltrate on the chest radiograph and all three of the folloving ● Leucocytosis >12 x 109/ml ● Fever >38.5 ºC ● Presence of purulent tracheobronquial secretions
  • 16. Clinical Pulmonary Infection Score (CPIS) Clinical suspicion of pneumonia in the presence of a positive score at different cut offs (1-12 points) which include the following variables. ● Body temperature ● Blood leucocyte count and number of band forms ● Tracheobronchial secretions (purulen or not and quanty) ● Microscopic examination of bronchial secretions (Gram and semiquantitative culture) ● PaO2/FiO2 ● Chest radiograph
  • 17. n = 253 patients Age, mean ± SD 66.2 ± 13.5 157 (62.1 %), 96 (37.9 %) Sex (Male and female), n % SAPS II, mean ± SD 49.5 ± 15.8 Length of ICU stay d. mean ± SD 16.7 ± 17.9 Cause of ICU admission, n (%) ● Medical 142 (56.1 %) ● Surgical 88 (34.8 %) ● Coronary 23 (9.1 %) Temperature (ºC), mean ± SD 37.63 ± 1.13 Leucocytes (x 109/L) mean ± SD 16.16 ± 12.21 PaO2 / FiO2, mean ± SD 182.86 ± 85.94 Chest x-ray findings, n (%) ● No infiltrates ● Localizated 8 (3.2 %) 76 (30 %)
  • 18. The Kappa statistict agreement between the two intensivist in the chest radiographies was 0.382
  • 19.
  • 20.
  • 21.
  • 22. Chest Radiography 76 / 253 (30 %) 169 / 253 (66.8 %) Localized infiltrates Diffuse infiltrates
  • 23. Sensibility Specificity (%, CI 95%) (%, CI 95%) Loose Definition 64.8 (56.6–72.2) Rigurous Definition Definition CPIS LR (+) LR (-) 36 (27.7-45.3) 1.01 (0.84-1.22) 0.98 (0.72-1.32) 15.5 (10.5-22.3) 91 (84.2-95) 1.72 (0.85-3.48) 0.93 (0.82-1.06) 45.8 (37.8-54) 60.4 (51.1-69) 1.15 (0.86-1.54) 0.90 (0.72-1.11) A.Esteban,F.Frutos,et al. (submitted)
  • 24. N. Fabregas Thorax 1999 (n= 25) Definition A. Esteban (n = 253) Sensibility Specificity Sensibility Specificity Johanson 2/3 0.69 0.75 0.65 0.46 Johanson 3/3 0.23 0.92 0.15 0.91 CPIS 0.77 0.42 0.46 0.61
  • 25. Sensitivity Specificity LR (+) LR (-) (%, CI 95 %) (%, CI 95 %) (CI 95 %) (CI 95 %) Loose 64.9 (56.5 – 72.2) 36 (27.7 – 45.3) 1.01 (0.84– 1.22) 0.98 (0.72 – 1.32) Loose + localized infitrates 11.3 (7.1 – 17.5) 91.9 (85.3 – 95.7) 1.39 (0.64 – 3.03) 0.97 (0.85 – 1.1) Rigorous 15.5 (10.5 – 23.6) 91 (84.2 – 95) 1.72 (0.85 – 3.48) 0.93 (0.82 – 1.06) 2.1 (0.7 – 6) 100 (96.7 – 100) - 0.98 (0.96 – 1.0) 45.8 (37.8 – 54) 60.4 (51.1 – 69) 1.15 (0.86– 1.54) 0.90 (0.72 – 1.11) Definition Rigorous + localized infiltrates CPIS A.Esteban,F.Frutos,et al. (submitted)
  • 26. OVERALL GROUP PPV NPV Sensitivity Specificity Likelihood (+) Likelihood (-) RISK FACTOR PULMON. RISK FACTOR EXTRAPU L. RISK FACTOR 75 % 84 % 66 % 89 % 6.02 76 % 75 % 66 % 83 % 3.85 61 % 69 % 59 % 72 % 2.07 85 % 78 % 70 % 90 % 6.83 0.38 0.41 0.58 0.55 A.Esteban,P.Fdez-Segoviano,F.Frutos,et al. Ann Intern Med 2004;141:440
  • 27. Decisions based on clinical criteria resulted in inappropriate treatment of many patients without pneumonia J. Y. Fagon, J. Chastre, et al Chest 1993;103:547
  • 28. Early diagnosis Fast cultures (microarray based(-4h)detection of ten significant bacterial species) Procalcitonin (High NPV) s-TREM-1( in BAL or in plasma) Early treatments Lipopolysacharide Late proinflam . Mediators Complements cascade Apoptosis Inducible NO synthasa
  • 29. ● Clinical criteria may lead to underdiagnosis, which result an increase risk of death in patients with ventilator-associated pneumonia not receiving antibiotic treatment. ● Also the clinical criteria may lead to overdiagnosis which result in overuse of antibiotics that favour colonization with potentially resistant pathogenic microorganisms and superinfection.
  • 30.
  • 31.
  • 32.
  • 33.
  • 34. MANUEL JULIO DATE 376 1999 DIAGNOSIS Craneal Stab wound Craneal Stab wound TREATMENT Catholic Church Bishop University Hospital ICU OUTCOME Saint Manuel Altar of the Church Neurosurgery bill ICU bill Chart number 124123 Psychiatric Nursery