Weight: 79.30 Paper Topics: steroid purpose study demonstrate efficacy of suggest regimen for oral treatment csu patients refractory high dosage antihistamines conducted retrospective chart review patients diagnosed urticaria feburary 1 2012 december 31 2014 total 98 patients csu included these 16 patients 163% antihistamineresistant prescribed 2-week course steroid thirteen patients 812% successfully controlled antihistamines stopping course second course steroid induced remission additionally patients 125% adverse events complications associated oral steroid observed study period study demonstrated excellence 2-week course oral corticosteroid antihistamine-resistant csu propose standardized corticosteroid treatment regimenthe altered distribution follicular helper cells predict pronounced clinical course primary sjogren's syndrome margit zeher division
Weight: 52.80 Paper Topics: passed cords bougie used 46 technique does use bronchoscopic control bougie tracheal tube tt trachea tt withdrawn cuff vocal cuff fully inflated tt advanced using bougie guide cuff impacts vocal cords gas- table complications type numbervisible cut bougie tt pulled far bougie murphy eye tt failure advance blue rhino bleeding late complication case seldinger needle blocked bougie material patient hard collar case seldinger needle perforated tt cuff tt prevented tracheostomy cuff sealing case seldinger wire passed murphy eye tt dilation process caused tt advance trachea second passage
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Conclusion Tolerance to IPV treatment was good early after cardiac surgery. In this study, use of IPV during the first three postoperative days reduces hospital LOS after cardiac surgery. However, a larger study is necessary to confirm these results. To measure it we used a direct method with certain technical innovations. The subjects breathed through an oronasal mask and one-way valve. Expired air was collected in a 5-l balloon in order to provide adequate mixture of dead space and alveolar air. The concentration of CO 2 on the end of the balloon (PECO 2 ) was measured with an RGM 'Ohmeda' capnograph (infrared technique) together with minute ventilation. Arterial oxygen partial pressure (PaO 2 ) was measured simultaneously from arterial blood using a conventional method.
Weight: 49.93 Paper Topics: plasma role introduction extracellular release atp important modulator immune response atp concentration increased sepsis 1 ifnγ plays critical host defense promoting th1 phenotype bacterial clearance low ifnγ levels associated th2 phenotype consistent critical illness anergy 2 reported 100 300 mm atp increased lps/pha-stimulated il-10 secretion human blood 3 higher il-10/ifnγ ratio shifts immune phenotype th1 th2 response studied effect atp lps-stimulated il-10 ifnγ secretion standardized ex-vivo human blood culture methods venous blood 10 healthy volunteers drawn tubes containing 10 ng lps/ml ilcso edi gmbh reutlingen germany incubated 100 mm atp respectively 37°c 24 hours supernates separated frozen
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P76Impact of a selective digestive decontamination and nasal mupirocin on the incidence of ventilatory-associated pneumonia and the emergence of bacterial resistance Introduction Selective digestive decontamination (SDD) can reduce the incidence of ventilatory-associated pneumonia (VAP). Some concerns have been raised about the risk of selection of resistant bacteria. We evaluated the impact of a SDD regimen on the incidence of VAP and the development of resistant pathogens. Methods In a polyvalent eight-bed ICU, a retrospective analysis was performed of two periods of 8 months before (no-SDD, 178 patients, mean SAPS II 44.8) and after (SDD, 110 patients, mean SAPS II 48.9) the use of SDD with amphotericin, tobramycin and colistin for oropharyngeal and gastric decontamination and mupirocin for nasal decontamination. The results were analyzed with the chi-square test. Results The incidence of VAP was reduced in the SDD group, even though it was not statistically significant (26.9% vs 16.3%, P = 0.138). The mortality of VAP and septic shock was reduced respectively from 39.6% to 16.7% (P = 0.312) and from 60% to 37.5% (P = 0.835). During the SDD period, Gram-positive infections increased while Gram-negative infections and Candida infections showed a reduction. The percentage of resistant species showed a reduction from 49.1% to 30.5% in all the categories of pathogens (Table 1) . Results Ninety-three CT critical care patients received a tunnelled subclavian CVC. The indications were inotropes (n = 40 (43%)), antibiotic administration (n = 27 (29%)), RRT (n = 14 (15.1%)) and unknown (n = 10 (10.8%)). The mean duration of the catheter remaining in situ was 36 days (SD 44.0, range 1-164). Culture results are presented in Table 1 . Twelve patients had an established CVC-related BSI. The mean infection rate/1,000 catheter-days was 3.6. Results Of 120 catheters inserted, 100 could be evaluated for colonization and CR-BSI. Forty-nine in the uncoated group and 51 in the coated group. Clinical characteristics of patients and risk for infection were similar in the two groups, use of propofol was more frequent in the uncoated group and the presence of a vascular device, other than the study catheter, was more frequent in the antibiotic-coated group. Three RM-coated catheters (5.9%) were colonized compared with nine (18.4%) control catheters (relative risk, 0,28; 95% confidence interval, 0.07-1.096; P = 0.05). Three cases of CR-BSI (5.9%) occurred in patients who received RM catheters compared with five in the control group (10.2%). There was no significant differences in the incidence of CR-BSI between RM-coated and uncoated catheters. Uncoated catheters were more frequently colonized but this difference just failed to show statistical significance. When the duration of catheter placement were taken into consideration, Kaplan-Meier analysis showed no significant differences in the risk of colonization or CR-BSI between RM-coated and uncoated catheters. Rates of CR-BSI were seven per 1,000 catheter-days in the RM-coated group compared with 11.4 per 1,000 catheter-days in the uncoated group (P = 0.7). Gram-positive and Gram-negative organisms were similarly responsible for colonizing catheters in our study; there was no difference in rates of colonization by Candida species. Conclusion In this pilot study, we showed a trend toward lower rates of colonization in RM-coated catheters when compared with uncoated control catheters. The incidence and rates of CR-BSI were similar in the two groups, probably because of a small number of catheters studied. Development of a prospective randomized trial with a larger number of patients is underway to confirm or refute these results.
P97Decrease in intravenous antibiotic use with adjunctive aerosolized amikacin treatment in intubated mechanically ventilated patients with Gram-negative pneumonia S39 safety and i.v. antibiotic use with inhaled amikacin (AMK) during adjunctive treatment of intubated patients with Gram-negative pneumonia. Methods A double-blind, placebo-controlled, study of aerosol AMK delivered via the Pulmonary Drug Delivery System (PDDS ® ; Nektar Therapeutics) in ventilated patients with Gram-negative pneumonia as an adjunctive to i.v. therapy per ATS guidelines. Patients were randomized to receive aerosol containing 400 mg AMK daily with placebo (normal saline) 12 hours later, 400 mg AMK twice daily or placebo twice daily. The i.v. antibiotics (agent and duration) were determined by the attending physician. The AMK peak serum concentration, trough concentrations and tracheal aspirates were drawn. Results The mean number of i.v. antibiotics at the end of the study (mean 7 days) were two times greater with placebo than with twice-daily AMK (P < 0.02) ( Figure 1 ). For daily and twice-daily AMK, the serum C max were 1.3 and 1.8 µg/ml (respectively) on day 1, and 2.3 and 3.2 µg/ml on day 3. Mean trough levels were 0.87 and 1.49 µg/ml. Tracheal aspirate levels (mean) on day 3 were 6.9 mg/ml (daily) and 16.2 mg/ml (twice daily). Aerosol AMK was well tolerated with no difference in adverse events across treatment groups. Conclusion Repeated doses of adjunctive inhaled AMK to mechanically ventilated patients with Gram-negative pneumonia was safe, well tolerated, and associated with less i.v. antibiotic use than placebo. Despite isolation, MRAB spread over and infected eight more patients in separate rooms and different sections of the ICU 32 days later. Further transmission occurred within a few days: three male patients with multiple trauma (42, 20, and 62 years old; patients 2, 3, and 4), cardia carcinoma (female, 66 years old; patient 5), necrotizing pancreatitis (female, 78 years old; patient 6), splenomegaly owing to polycythaemia vera (male, 74 years old; patient 7 -MRAB diagnosis postmortem), rectal carcinoma (female, 76 years old; patient 8 -isolation because of MRSA infection even before) and respiratory failure after gastric banding (female, 41 years; patient 9). All patients suffered from septic shock with high fever, needed high volume replacement and catecholamines several times and prolonged mechanical ventilation. MRAB was isolated in the tracheal secretion or BAL in all patients, in abdominal drainage (patient 6), and in central venous catheter (patient 5). Environmental investigations showed no problematic circumstances. Colistin i.v. is not available in Germany so it had to be procured from the USA, which caused a delay of treatment for a few days. Another delay occurred because of the rapid growing number of patients who needed Colistin. Patients were treated with an adjusted dosage for 16 days. All patients of the ICU were isolated to avoid new infections as a precaution. After convalescence of two patients, all MRAB patients were moved to the IMC, which was converted to an ICU for this period, to isolate infected patients from uninfected. Three out of nine patients died. All these laborious measures with a great expenditure of logistics worked well; no further transmissions were observed. Objectives Gram-negative bacilli including multidrug-resistant Acinetobacter baumannii (MDR-AB) are responsible for severe ICU-acquired infections, mainly pneumonia and bacteraemia. The aim of this study was to determine the incidence and mortality of this multiresistant strain of Acinetobacter in patients undergoing cardiac surgery, to elucidate the effectiveness of treatment with colistin and to identify whether additional measures were able to prevent and control the dissemination of MDR-AB isolates in our institution. Methods A total of 1,451 patients attended the surgical ICU (SICU) after cardiovascular surgery from 1 September 2005 to 31 August 2006. We reviewed the prophylactic measures of the SICU and tried to identify epidemiological links between MDR-ABinfected patients. We implemented a two-scale multiple program. Scale 1 included classical infection control measures (that is, strict contact and droplet isolation, surveillance of throat, nasal and anal flora for MDR pathogens on all patients transferred from other hospitals, separate nursing staff for each infected or colonized case and strict antibiotic policy), while Scale 2 referred to geographic isolation of MDR-AB cases with exclusive medical and nursing personnel, use of separate supplies and facilities and intense environmental surveillance. Results Fifteen patients were infected by MDR-AB, of which 13 presented respiratory tract infection, one suffered deep surgical site infection and bacteraemia and one from catheter-related infection. They were all treated with intravenous and aerolized colistin in combination with rifampicin or ampicillin and sulbactam.
Figure 1 (abstract P316)Patients and methods Ten healthy subjects (seven females, three males; age 27.3 ± 4.5 years) were investigated in a supine position before and after application of continuous positive airways pressure (CPAP) of 10 cmH 2 O by nasal mask. The study was performed using sonographic equipment with a multiprobe (convex 3.5-5 MHz; sector 2.5-3.5 MHz) and color-Doppler capability (Hitachi H 21) . IVC was visualized by a two-dimensional echographic sector probe and M-mode was used to measure the inspiratory and expiratory diameters at the origin of the suprahepatic veins. HF is composed of portal flow (PF) and hepatic artery flow (HAF). Portal velocity, assessed near the liver hilum, was used as a measure of PF, and the left intrahepatic branch resistivity index (RI) was used as a measure of HAF. Measures were repeated twice for each value of intrathoracic pressure by two different examiners and the mean value was given for the statistical analysis. Results are given as the mean ± SD. Data were evaluated by paired t test and P < 0.05 was taken as statistically significant.
P414Results Twenty-nine (82.9%) out of a total of 35 possible hospitals answered, including 113 (57.7%) answers out of a total of 196 possible answers. Ninety-seven per cent of the physicians were specialists in anaesthesiology. Eighty-seven per cent of the nurses were certified intensive care nurses. Forty-seven per cent were from university hospitals. Twenty-six per cent had a sedation protocol, 37% of the physicians and 14% of the nurses. Only one-third of the ICUs had a protocol for sedation. Sixty-eight per cent having a protocol used it always or often, whereas 32% never use it. Sixtyseven per cent had a sedation scoring system in their departments. The scoring systems used was: Ramsay 49%, Sedation Agitation Score 10% and own (locally made) scoring system 41%. Twentytwo per cent answered that the scoring systems was always used, 58% often and in 20% the scoring systems was seldom used. Forty per sent use the 'wake-up call' test, 63% physicians and 37% nurses. Sixty per cent answered 'no we do not use' the wake-up call test, 47% physicians and 53% nurses. Withdrawal symptoms were experienced more than three times as frequently by nurses compared with physicians (31% vs 9%). Five times as many experienced withdrawal symptoms in the group not having a sedation and analgesia protocol (84% vs 16%). Conclusions There is still a great educational potential for improving the use of sedation protocols and implementing sedation scoring systems and the wake up test in Danish ICUs. This potential could perhaps reduce the incidence of withdrawal symptoms. Effort should also be placed in implementing the sedation protocol in the ICU, illustrated by the differences in numbers of doctors and nurses having a sedation protocol. We compare the efficacy, adverse events, and recovery duration of etomidate and propofol for use in procedural sedation in the emergency department (ED). A randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED was made. Patients received either propofol or etomidate. Doses, vital signs, nasal end-tidal CO 2 (etco 2 ), pulse oximetry, and bispectral electroencephalogram analysis scores were recorded. Subclinical respiratory depression was defined as a change in etco 2 greater than 10 mmHg, an oxygen saturation of less than 92% at any time, or an absent etco 2 waveform at any time.
Weight: 44.55 Paper Topics: issue personal thefts theft tampering controlled drugs cds remains prevalent patient safety sadly numerous reports critical care staff stealing cds use fi nancial gain notably cases cds substituted medications order delay detection theft creates hazard medication errors potentially exposes patients opioid intoxicated healthcare workers critical care staff access cds drugs missing diffi cult identify perpetrators implementation deterrent improves methods detection warranted methods limpet device incorporates proximity sensor camera unit installed cd cupboard critical care unit cupboard accessed date time recorded photograph taken identify staff member mock subsequently undertaken designated staff member random times allowed testing product determine number times 'thief'
5. P1 Comparison of carbamylated versus recombinant erythropoietin during spinal cord ischemia/reperfusion injury P2 Sodium 4-phenylbutylate protects against myocardial ischemia-reperfusion injury by reducing unfolded protein response-mediated apoptosis in mice P3 Time-dependent eff ects of intravenous H 2 S during long-term, resuscitated porcine hemorrhagic shock
Weight: 40.62 Paper Topics: ischemia-reperfusion inhibiting introduction unfolded protein response upr-mediated apoptosis plays pivotal role injury sodium 4-phenylbutyrate pba reported act chemical chaperone upr-mediated apoptosis triggered ischemia various organs heart investigated pba reduces upr-mediated apoptosis protects myocardial ischemia-reperfusion injury mice methods c57bl/6 mice subjected 30 minutes lad ischemia followed reperfusion pba 100 mg/kg pbs control administrated intraperitoneally just ischemia apoptosis infarct size tissue protein levels grp78 caspase-12 upr-mediated apoptosisassociated protein evaluated tunel ttc stain western blot analyses respectively 48 hours ischemia n group echocardiography performed weeks ischemia survival ratio observed n group results compared pbs pba reduced apoptotic cells
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IntroductionIntroduction In our murine model of infl uenza, signifi cant weight loss occurs up to day 7 post-infection  . We sought to determine whether weight loss from infl uenza could be altered by rehydration and whether this aff ects pulmonary immune responses. Methods Adult BALB/c mice were infected with X31 (H3N2) infl uenza (1:80) via the intranasal route and randomized to intraperitoneal rehydration with 20 ml/kg compound sodium lactate (CSL), normal saline (NS) or no rehydration (NR) starting on day 3 following infection and continued for 4 days (n = 5/group). On day 7, mice were challenged with 1 x 10 6 Streptococcus pneumoniae (serotype 2). Two further cohorts of mice were challenged with diff erent doses of infl uenza and rehydrated from day 3 to 7 to investigate pulmonary immune responses in the absence of bacteria. Mice were infected with 1:80 (n = 10/group) infl uenza and rehydrated once daily or 1:60 (n = 5/group) infl uenza and rehydrated twice (1:60) daily with 20 ml/kg CSL or not. Daily weight, survival following secondary bacterial pneumonia, number of colony-forming units (48 hours after bacterial challenge) from peripheral blood, lung, and nasal wash and cellularity in lung compartments were measured. Results Rehydration did not aff ect weight loss following 1:80 infl uenza infection (naïve mice (+0.3 ± 0.4 g), infl uenza plus NR (-1.58 ± 0.4 g), infl uenza plus CSL (-1.1 ± 0.7 g) and infl uenza with NS (-1.3 ± 0.4 g)). A repeat experiment with CSL once daily or twice daily did not alter weight loss compared with NR (P >0.05). Survival or CFU counts following bacterial pneumonia did not diff er between the groups (P >0.05). The total number or activational status of bronchoalveolar, lung macrophages/monocytes and lymphocytes was not aff ected by rehydration following infl uenza infection or 48 hours following bacterial pneumonia (P >0.05; P <0.05 vs naïve mice).
We have shown that a the combination of selective digestive decontamination with topical antibiotics (SDD) and a decontamination regimen using nasal mupirocin with chlorhexidine bodywashing (M/C) markedly reduced acquired infections (AI) in intubated patients as compared with SDD alone, M/C alone or none  . We report the surveillance of AI in our ICU before and after the implementation of multiple site decontamination (MSD) as a routine prevention procedure. Introduction The aim of this study was to analyze the correlation between antiviral therapy effi cacy and the negative profi le of the RT-PCR made on pharyngeal swab, subglottic aspiration, and bronchoalveolar lavage in patient aff ected by ARDS caused by H1N1 infection. Methods A prospective analysis was performed on 11 patients admitted to the ICU of a tertiary referral center (Careggi Teaching Hospital, Florence, Italy). All patients underwent daily RT-PCR monitoring on pharyngeal swab, subglottic aspiration, and bronchoalveolar lavage. All patients were treated with oral administration of oseltamivir (75 mg twice daily) and inhaled zanamivir (10 mg twice daily) since ICU admission. Six patients were treated with extracorporeal membrane oxygenation (ECMO) due to their critical respiratory conditions. Two of them resulted co-infected by legionella pneumophila. Results As shown in Figure 1 , RT-PCR from pharyngeal swab at ICU admission failed to demonstrate the viral infection in four patients, whereas RT-PCR from bronchoalveolar lavage had a sensibility of 100%. Similarly, the time course showed that RT-PCR from pharyngeal swab resulted negative in an average time of 3 days after therapy start, while RT-PCRs from bronchoalveolar lavage continued to permit infection monitoring and therapy regimen conduction. None of RT-PCRs on subglottic aspiration samples resulted positive. All patients recovered and were discharged alive from ICU in spontaneous breathing.
ResultsThe use of the pattern classifi cation machine which combines amplitude and spectral features of VF ECG signals shows an improved predictive power as compared with other methods. Conclusions This technique could help to determine which patients should receive shock fi rst and which should receive a period of CPR prior to shock, thereby increasing the probability of survival. The potential impact of this research is high in the direction of generating a new methodology able to increase the probability of survival after a cardiac crisis. References Introduction Recent studies report an increase of asystole and pulseless electrical activity (PEA) as the fi rst monitored cardiac arrest rhythms after arrival of the Emergency Medical Services  . The asystolic patients presumably undergo ischaemia for a longer time and may benefi t from treatment reducing hypoxic brain injury. Therapeutic hypothermia (TH) has expanded into prehospital care to be initiated as soon as possible. Rapid cold crystalloid infusion is the most frequent method; however, severe haemodynamic instability is its contraindication. The aim of the study was to assess the adverse eff ects of prehospital volume expansion in patients with initial nonshockable rhythms when used in a setting with only restricted cardiovascular monitoring. Methods All patients who were deemed eligible for advance cardiac life support (ACLS) were included as long as the arrest was witnessed and cardiopulmonary resuscitation (CPR) was initiated within 20 minutes of collapse. Patients were randomized to treatment or control groups. The trial was designed to determine the safety and eff ectiveness of early cooling initiated at the site of arrest. Survival and time to target temperature were documented. Results Data are presented as the mean ± SD or median (interquartile range (25, 75%)). Mean age was 67.8 ± 14 years in the intervention group and 65.4 ± 13.9 years in the control group. On average, cooling therapy was started in 33 ± 12 minutes in the RhinoChill™ group and 170 ± 97 minutes in the control group. Temperatures at hospital admission were signifi cant lower in the RhinoChill™ group. Time to target tympanic temperature, refl ecting brain temperature, were signifi cant faster in the RhinoChill™ group (211 ± 124 minutes vs 424 ± 217 minutes; P <0.05). Adverse events occurred in 12 patients. None was related to the cooling therapy. In the intervention group fi ve patients (20%) survived and three patients (12%) had a CPC of 1 to 2. In the control group only four patients (12.5%) survived and one patient (3.1%) had a CPC of 1 to 2. Conclusions Using the intranasal cooling method, cooling was much faster and earlier in treated patients. Neurologically intact survival and discharge rates were higher in treated patients. Transnasal cooling for the induction of therapeutic hypothermia during prehospital resuscitation is feasible and highly eff ective in lowering brain temperature rapidly. The method off ers the possibility for immediate introduction and realization of mild hypothermia in the fi eld.  . We sought to investigate whether a hospitalwide approach to TH after CA would reduce delays and result in improved outcomes.
Weight: 36.04 Paper Topics: enteral gastrointestinal introduction healthy bowel function important factor judging advisability early nutrition critically ill patients long-term observation objective evaluation motility diffi cult developed non-invasive monitoring capable quantifying visualizing gastrointestinal motility real time study gastrointestinal motility performed patients severe sepsis using developed bowel sound analysis system correlation bowel sounds changes time blood concentrations il-6 associated sepsis severity evaluated methods study prospective observational pilot study conducted hospital consecutive adult patients severe sepsis mechanical ventilator il-6 blood concentration ≥100 pg/ml acute phase defi ned 28th day illness icu entered study june 2011 december 2012 subjects divided treated steroids steroid treatment group nosteroids group
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IntroductionWe hypothesised that pharyngeal oxygen concentrations would be maintained higher and for longer with transnasal humidifi ed rapid insuffl ation ventilatory exchange (THRIVE) than conventional bag-mask pre-oxygenation (CPO). CPO requires the mask to be removed during laryngoscopy; this means that air may enter the mouth so subsequent apnoeic oxygenation will be less eff ective. Oral suctioning could exacerbate this process. However, if high pharyngeal oxygen concentrations and an open airway are maintained, apnoeic oxygenation could be substantially improved. Methods used have included NO-DESAT  and recently THRIVE  , which has been shown to extend apnoea times for up to 1 hour. Methods A volunteer with a nasopharyngeal sampling catheter underwent simulated emergency airway management (EAM), using both CPO and THRIVE, with and without suction. Following 3 minutes of pre-oxygenation with CPO (FiO 2 = 1, FEO 2 >0.8) or THRIVE (60 l/minute; Optifl ow, Fisher and Paykel), EAM was simulated by voluntary apnoea and pharyngoscopy with the laryngoscope blade tip placed 2 cm from the posterior pharyngeal wall. Capnography at the laryngoscope tip confi rmed apnoea. Pharyngeal gas samples (20 ml) were collected during apnoea, and after 5 seconds of oropharyngeal suctioning. Preoxygenation was repeated between sampling. Samples (n = 100) were analysed using calibrated fuel cells.
Availability of appropriate airway monitoring at UK in-hospitalMethods We performed a prospective observational study examining ETIs at our tertiary care institution from July 2012 to June 2014. All consecutive patients who underwent ETIs in the emergency department and ICU were included. Patients under 18 years of age, intubated with VL not using C-MAC, were excluded. After each ETI eff ort, the operator completed a standardized data collection form. We classifi ed glottic visualization as good (C-L grade 1 or 2), and poor (C-L grade 3 or 4). The primary outcome was the fi rst-attempt success rate. Introduction Rapid sequence induction (RSI) in the ICU, emergency department (ED) and operating room (OR) carries the risk of hypoxemia if laryngoscopy is prolonged especially in high-risk patients. Bag and mask pre-oxygenation is normally used to extend the apnoea time; however, arterial desaturation may still rapidly occur. Transnasal humidifi ed rapid insuffl ation ventilatory exchange (THRIVE) is a new technique that provides modest CPAP during pre-oxygenation and crucially also continuous oxygenation of the pharyngeal space throughout the apnoeic period. In elective surgery, THRIVE provides apnoea times as long as 60 minutes due to apnoeic oxygenation  . We report the fi rst implementation of THRIVE with emergency patients into the ICU, ED and OR. Methods Following training a THRIVE system was installed in each location either as a fi xed system on the anaesthetic machine (OR) or a mobile solution on a wheeled stand (ICU, ER). This was a simplifi ed Optifl ow system (Fisher and Paykel, New Zealand) consisting of a high-fl ow rotameter, a reusable humidifi er, a reusable circuit and a disposable nasal interface. Anaesthetists of all grades were encouraged to use THRIVE (60 l/minute) prior to and during all high-risk intubations. Introduction β-Adrenergic agonists increase the ciliary beat frequency in experimental models, raising the possibility that they may be useful for airway hygiene  . Salbutamol increases large airway mucociliary clearance  , although this may not be true for smaller airways  . There are no data from ICU patients, so we decided to test the eff ectiveness of transtracheal instillation of a mixture of ipratropium and salbutamol, assessing the reduction of the number of aspirations and hours of ventilation.
IntroductionThe most frequent reasons for hypercapnic respiratory failure (HRF) in ICUs are COPD and in recent years obesity hypoventilation syndrome (OHS) and obstructive sleep apnea (OSA). Even 15 to 30% of COPD patients also have accompanying OSA. Due to increased upper airway resistance, those patients require higher expiratory pressures (EPAP) during noninvasive ventilation (NIV). In order to prescribe optimal mode and pressures during the ICU stay and at discharge, the intensivist should diagnose the underlying OSA. Portable recording devices have been developed and they were approved at least for the diagnosis in high pretest probability patients with results equal to in-laboratory polysomnography. The aim of this study is to assess whether respiratory polygraph (RPLG) can be used for obtaining diagnostic information of OSA in hypercapnic ICU patients. Methods Patients, with HRF requiring NIV, were included in the study. RPLG studies were conducted under nasal oxygen before NIV, using the Philips Respironics Alice PDx® device, which provides the records of pulse oximetry with derived heart rate; snoring and nasal airfl ow with nasal pressure transducer and nasal thermistor; rib cage, abdominal motion and body position with abdominal and thoracic belts. American Academy of Sleep Medicine 2014 recommendations were used for the diagnosis of OSA and OHS. Because of the diagnostic diffi culties of hypopnea in hypoxemic patients, we evaluated only the obstructive apnea index (OAI) instead of the apnea hypopnea index (AHI). Results Thirty-one patients with the mean age of 67 ± 9 years were included in the study. Their mean APACHE II score was 16 ± 5 and BMI was 33 ± 9 kg/m 2 . Admission arterial blood gases were as follows (mean ± SD); pH: 7.33 ± 0.07, PaO 2 : 74 ± 12 mmHg, PaCO 2 : 69 ± 11 mmHg, HCO 3 -: 31 ± 5, O 2 Sat%: 92 ± 4. Admission diagnoses of the patients were OHS (36%) and COPD (68%). Mean OAI was 13 ± 6 in patients with OAI >5. Eighty-one percent (n = 25) of the recordings were interpretable and clinical and RPLG data supported a new diagnosis of OSA in 14 (56%) patients, and EPAP levels were increased. Laboratory sleep study was recommended to 19% of the patients. At the end of the study 56% of the COPD and 72% of the OHS patients were identifi ed to have OSA. Conclusion Although it underestimates AHI, RPLG is important and technically feasible in ICU patients in suggesting the presence of OSA and in providing information for appropriate NIV management. Introduction Respiratory muscle weakness is common in mechanically ventilated patients and impairs liberation from ventilation. Inspiratory muscle training (IMT) might accelerate liberation from mechanical ventilation. We undertook to summarize previously published IMT protocols and the impact of IMT on respiratory muscle function and clinical outcomes. Methods We searched multiple databases using a sensitive search strategy combining MeSH headings and keywords for studies of IMT during MV. Studies were adjudicated for inclusion and data were abstracted independently and in duplicate. Methodological quality was assessed using the GRADE system. Results Eleven studies met the inclusion criteria; of these, six were randomized controlled trials and fi ve were observational studies. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S80 A variety of IMT techniques were employed including inspiratory threshold loading (eight studies), biofeedback to increase inspiratory eff ort (one study), chair-sitting (one study) and diaphragmatic breathing pattern training (one study). Threshold loading was achieved by application of an external device (six studies) or increases in the inspiratory pressure trigger setting (two studies). Most studies implemented IMT in the weaning phase (n = 5) or after diffi cult weaning (n = 5); one study implemented IMT within 24 hours of intubation. IMT was associated with greater increases in maximal inspiratory pressure compared with control (six studies, mean diff erence 7.6 cmH 2 O (95% CI 5.8, 9.3), I 2 = 0%). There were no signifi cant diff erences in the duration of MV (six studies, mean diff erence -1.1 days (95% CI -2.5, 0.3), I 2 = 71%) or the rate of successful weaning (Figure 1 ; fi ve studies, risk ratio 1.13 (95% CI 0.92, 1.40), I 2 = 58%). The GRADE quality of evidence was low for all these outcomes; risk of bias was high for most studies and summary eff ects were imprecise and inconsistent. No serious adverse events related to IMT were reported. Conclusion IMT in mechanically ventilated patients appears safe and well tolerated and improves respiratory muscle function. IMT was not associated with accelerated liberation from mechanical ventilation. However, because the included studies had important methodological limitations and employed varying methods of IMT, we cannot draw fi rm conclusions about the eff ect of IMT on clinical outcomes.
Weight: 31.86 Paper Topics: findings using introduction: igg2 deficiency suggested predispose severe h1n1 infection 1 however contradictory findings reported 2 and therefore replication different cohorts need performed purpose study assess immunoglobulins igg subclasses levels cohort patients influenza methods: studied 137 spanish patients developed flu 803 h1n1pdm virus diagnosis confirmed detection influenza virus nasopharyngeal swabs using real-time polymerase chain reaction immmunoglobulins igg subclasses binding site human igg subclass kits measured acute convalescent phase correlation severity examined analyzed genetic variants ighg2 order evaluated role igg2 levels clinical immunological characteristics compared chi-squared test fisher's exact test needed results: ninety-three patients hospitalized 49 required admission intensive
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Methods:This cross-sectional prospective study was conducted in two ICUs at Loghman-Hakim Hospital, Tehran, Iran, from November 2012 to March 2013. Patient, soil, and hospital environment samples were collected. All isolates were identified using standard bacteriologic and biochemical methods. The phenotypes and genotypes were characterized. The standard disc diffusion method was utilized to test antimicrobial susceptibility. Integron identification was performed by multiplex polymerase chain reaction. Results: There were no A. baumannii bacteria isolated from the hospital environment or soil, although the bacterium was detected around the lip of one patient. Also, a total of 42 A. baumannii clinical strains were isolated from the lower respiratory tract (n = 20), blood (n = 6), urine (n = 8), and wound catheters and nasal swabs (n = 8). 65 % of the isolated species were classified as class 2 integrons. The strains were 100 % resistant to piperacillin, piperacillin-tazobactam, ceftazidime, ceftriaxone, cotrimoxazole, cefepime, ceropenem, and cefotaxime. However, all of the strains were sensitive to polymyxin B Conclusions: Further research is necessary to establish a relationship between A. baumannii and soil, (especially in re¬gards to its bioremediation), as well as to determine its importance in nosocomial infections and outbreaks in the ICU. Introduction: Multi-drug resistant (MDR) Bacteria are a worldwide threat especially for intensive care unit's patients (ICU). In Gram Negative Bacilli, the emergence and spread of Extended-spectrum Beta-lactamase (ESBL) and carbapenemase-producing bacteria (CPB) is one of the common causes of morbidity and mortality associated with ICU-acquired infections (ICU AI). The aim of this study was to determine the epidemiology and risk factors for ESBL and CPB infections as well as the resistance patterns of these bacteria isolated in a Tunisian multidisciplinary intensive care unit. Methods: We conducted a retrospective, case-control study including all patients admitted between January and October 2015. ICU AI were defined as those acquired no less than 48 h after ICU admission. We did not include patients with no bacteriological evidence of infection. Differences in ICU mortality, length of stay and duration of mechanical ventilation (MV) were tested across patients with and without ICU acquired MDR bacteria infections. We also assessed infected sites, most frequent bacteria for each group (ESBL and CPB), and looked for risk factors. Results: In the study period, 184 patients were admitted to the ICU, 67 (34,41 %) had ICU AI. From these 67 patients, 35 had an ESBL infection in 53 isolates, and 21 patients were infected with CPB isolated from 30 cultures. Global mortality in the study period was 44,59 %, the mortality associated to MDR infection was 51,16 %. In fact, mortality of ESBL infections was not so higher than the global one (48,57 %) whereas CPB infection weighed down mortality to reach 71,43 %. In the same way, length of stay was significantly longer in MDR infected patients (18,37 days ± 11.6 STD) than non-MDR infected ones (8,66 ± 4.60 STD, p < 0,001). MV duration was respectively 15,85 days (±12,51 STD) in MDR group and 6,62 days (±5,10 STD, p < 0,001) in the non-MDR infected group. Length of stay and duration of MV were found to be risk factors for acquiring MDR infection in ICU. Ventilator associated pneumonia was the most frequent acquired infection as well in non MDR infected patients as in both ESBL and CPB. Acinetobacter Baumannii was the leading isolate from CPB infection (60 %) followed by Klebsiella Pneumoniae (27 %). Concerning bacilli producing ESBL, Klebsiella Pneumoniae was the most frequently isolated (54,72 %) followed by Escherichia Coli and Enterobacter Cloacae (15,09 % each). Conclusions: The prevalence of ESBL and CPB is increasing day by day in nearly every center of different countries and is responsible for large number of hospital-acquired and nosocomial infections, with very few, if any, therapeutic options. Necessary steps to prevent the spread and emergence of resistance should be taken. The mortality rate was 13 % (n = 4). We found a statistical significant association between the SAPS II score and mortality: higher scores are linked to death (Mann Whitney U test). We also found association between higher leukocyte count and prolonged activated partial thromboplastin time (aPTT) at admission with death (Mann Whitney U test). We did not find association between any other analytical abnormality at admission and at death. We also did not find any bad outcome association with patients' symptoms, physical examination abnormalities, renal or ventilation support (Person's Qui Squared Test).
CasesThe cases occurred amongst three adults (age range 19-49) who presented with clinical and radiographic evidence of pneumonia. Two cases were community -acquired with the third being hospitalacquired. The organisms identified by the TAC were Mycoplasma pneumoniae, Aspergillus spp. Cryptosporidium parvum and Pneumocystis jiroveci (PCJ), with one patient having two organisms detected. M. pneumoniae and PCJ were not identified on standard cultures, whilst Crytposporidum and Aspergillus spp and were both identified on conventional culture/microscopy 5 days after TAC identification. In all three cases, the results of the TAC assay resulted in change in management, with institution of new antimicrobials targeting the organisms identified combined with rationalisation of pre-existing antimicrobial treatments. Discussion These three cases illustrate how conventional cultures may miss important or unexpected pathogens, or return results late on in the course of the disease. We believe that this technology has the potential to significantly impact on the management of critically ill patients with lung infections, and are currently planning a larger scale evaluation of its use in critical care. Introduction: Pneumonia is a major cause for ICU admission and mortality. Prompt investigation facilitates tailored antimicrobial strategy, guides management, and aids prognostication. The British Thoracic Society (BTS)  suggest specific tests are performed for patients with severe pneumonia: Legionella and pneumococcal urinary antigens, sputum and blood cultures, respiratory viral PCR swabs, and atypical serology testing. We suspected these tests were inconsistently undertaken or delayed in our ICU, and introduced a computerised pneumonia screen, 'BUNS' , (Blood cultures and viral serology/Urinary antigens/Nasal +/-endotracheal viral swab/Sputum sample) to consistently investigate this condition. Methods: All patients with a primary diagnosis of pneumonia admitted to a UK district hospital ICU over a one-year period up to 31/ 10/14 were retrospectively reviewed to determine which investigations had been requested within 24 hours of admission. These were compared to the BTS guideline  . We subsequently implemented the 'BUNS pneumonia screen' within our electronic investigation system. A single click auto-generated request labels for all tests in the BTS guidelines. After implementation and staff education, we repeated the data collection between 1/2/15 and 1/11/15. Results: See Table 10 . Conclusions: This study has shown that a computerised autogenerated set of investigation requests, aided by an easily remembered acronym, lead to increased proportion of patients (85 % vs 28 %) receiving prompt and consistent 'gold standard' investigations for pneumonia. We believe this reduced duplication and delay in obtaining diagnostic results, thereby improving patient care. We suggest the 'Bundle of BUNS' could be easily replicated in other ICUs, and a similar system could be introduced for other presenting conditions. Introduction: Despite the significant impact of nosocomial infections on the morbidity and mortality of patients staying in the intensive care unit (ICU), no study over the past 20 years has focused specifically on pneumonia following secondary peritonitis. Our objective is to determine epidemiological features and in-hospital mortality of pneumonia in this kind of patients. Methods: Prospective observational study involved 418 consecutive patients admitted in the ICU, who had undergone a laparotomy because of a secondary peritonitis. Univariate and multivariate analyses were performed to identify risk factors associated with mortality and development of pneumonia. Results: The incidence of pneumonia following secondary peritonitis was 9.6 %. Risk factors associated with the development of pneumonia were hospital-acquired peritonitis, >48 h of mechanical ventilation, and SOFA score. The onset of pneumonia was late in majority of patients (about 16.8 days after the initiation of the peritonitis), and the etiological microorganisms responsible for it were different than for peritonitis. The 90-day in-hospital mortality rate was 47.5 % of pneumonia patients. Independent factors associated with 30-90-day in-hospital mortality were pneumonia and SOFA score Conclusions: Pneumonia in patients who had undergone a surgery because of a secondary peritonitis, increases the 90-day mortality. The onset of pneumonia following secondary peritonitis usually is late (16.8 days) and with etiological microorganisms different than those responsable for secondary peritonitis Introduction: The "CURB-65 score" is a convenient, well validated tool to assess disease severity and aid in the clinical management of community acquired pneumonia (CAP)  . Recent literature however demonstrates that its use is variable and often inaccurate. Failure to use this tool may lead to over or under treatment and may result in inappropriate patient admission thereby increasing healthcare costs  . The aim of the initial audit was to determine the frequency of the use of the score in emergency medical care and correlate this with clinical decision-making. The data was analysed and common pitfalls were identified. After the implementation of various tools designed to address these issues a repeat audit was performed to assess for any improvements.
P220Nasal high flow oygen for acute respiratory failure: a systematic review R. Pugh, S. Bhandari Glan Clwyd Hospital, Rhyl , UK Critical Care 2016, 20(Suppl 2):P220 Introduction: Nasal high flow oxygen (NHFO) is an attractive therapy for acute hypoxemic respiratory failure (AHRF), with reported comfort, and theoretical wash-out of CO2 and generation of PEEP. However, its clinical efficacy is uncertain. We undertook a systematic review of current evidence to support its use in adults. Methods: Medline and EMBASE were searched using the terms: nasal AND (high-flow OR high flow) AND (oxygen OR oxygen therapy. RCTs were included if comparison was made between NHFO and standard O2 therapy, or NHFO and CPAP or NIV, for AHRF in adults, and primary outcomes (intubation and mortality) reported on. Results: We identified 468 potentially relevant studies. 4 RCTs met inclusion criteria. There were important differences in patient groups, interventions and outcome measurements, precluding meta-analysis. There were no significant differences in intubation rate or mortality between intervention groups, with the exception of Frat (2015) , who demonstrated significantly reduced 90d mortality in NHFO compared with standard O2 and NIV groups, and lower intubation rate on post hoc analysis of patients with lowest PF ratio. Conclusions: There is only limited evidence from RCTs at present to support use of NHFO rather than conventional therapy for acute hypoxemic respiratory failure in adults, and further study of patients at risk of requiring invasive ventilation is needed.
P221Setting optimal flow rate during high flow nasal cannula support: preliminary results T. Mauri 1 , C. Turrini 2 , T. Langer 1 , P. Taccone Introduction: High Flow Nasal Cannula (HFNC) is a non-invasive respiratory support that might impact major clinical outcomes of acute respiratory failure patients  . We present preliminary data from a clinical study that aims to describe physiological effects of HFNC at different flow rates. Methods: We performed a prospective randomized cross-over study on This indicates that each set of data (n = 10) are normally distributed and therefore dosing is consistent. It may be concluded from this study that delivery of aerosol to adults at both high and low gas flow rates via NHF therapy is an efficient and highly reproducible means of administration. Introduction: Here we present an improved theoretical version of a valve for transtracheal ventilation as a bi-directional manual respiratory pump where a combination of low flow during inspiration, by reducing gas supply to the valve, and increased flow during expiration, by increasing gas supply to the valve, permits more effective venturi effect and efficient expiration, with low total gas consumption. Methods: The theoretical performance of the valve was modeled mathematically and the model was tested in vitro with a standard valve but by variable flow rates (Fig. 52) .
P238Conclusions: This study confirmed that EtCO2 is an inadequate proxy for MV in non-intubated patients. EtCO2-based RR is a poor proxy for EtCO2 & an even worse proxy for MV. Introduction: Capnography (EtCO2) is unreliable for monitoring respiratory status in non-intubated patients. We used a noninvasive respiratory volume monitor (RVM), which provides accurate measurements of minute ventilation (MV), tidal volume & respiratory rate (RR) in non-intubated patients, to compare the relationship between EtCO2 & MV in intubated patients with general anesthesia (GA), non-intubated patients with spinal anesthesia (SA) & awake volunteers. Methods: RVM data (ExSpiron, Respiratory Motion Inc., Waltham MA) were collected from 153 patients in 3 groups: Group 1, 54 patients, age:65.2 ± 12.1 yrs, BMI:31.2 ± 6.3 kg/m2, surgery with GA; Group 2, 60 patients, 68.9 ± 9.0 yrs, 30.5 ± 5.8 kg/m2, surgery with SA; Group 3, 39 volunteers, 48.5 ± 13.8 yrs, 27.9 ± 8.6 kg/m2, coached to breathe at varied RRs. Groups 1&2 EtCO2 data were collected via ventilator (Draeger Apollo), with an ET tube in Group 1 & sampling nasal cannula in Group 2. Group 3 EtCO2 data were collected via capnograph (Capnostream20, Covidien) with nasal cannula. Deming regression quantified the relationship between EtCO2&MV. EtCO2 sensitivity&mean EtCO2 were compared across cohorts by unpaired t-tests. Results: The EtCO2 sensitivity was significantly higher in intubated patients vs volunteers (-83.5°± 9.7°vs-30.1°± 16.1°, p < 0.001, Fig. 64a ). In non-intubated patients the sensitivity was not normally distributed & spanned the range of intubated patients & volunteers. Measured EtCO2 values were higher in Group1 than Groups 2&3 (37.2 ± 4.4 mmHg vs 23.0 ± 5.2 mmHg vs 31.0 ± 4.0 mmHg, respectively, p < 0.001, Fig. 64b ). EtCO2 measurements were normally distributed in all groups. Conclusions: Our results show that EtCO2 lacks adequate sensitivity to changes in MV&introduces measurement bias with the nasal cannula.
MethodsProspective cohort study in patients monitored with continuous EEG after cardiac arrest in two Dutch ICUs. Twice a day a very strict stimulus protocol including five stimulus types (in this order: clapping, yelling patients name, passive eye opening, nasal tickle and sternal rub) was executed. Each stimulus was applied 3 times for 5 s with an interval of 30s. Each stimulus response was individually scored reactive, non-reactive, doubtful or unscorable (e.g. too much noise) by three independent, blinded raters (JH, MvP, MT-C). Reactivity was defined as a change in the amplitude or frequency in the EEG upon stimulation, excluding muscle artifacts. Iso-electric EEGs were excluded beforehand. Stimulus responses on which two out of three raters agreed were included in the analysis.
Weight: 31.86 Paper Topics: myocardial introduction acute myocardial depression septic shock common 1 depression mediated circulating depressant substances incompletely characterized 2 the aim study observe eff ects tnfα model perfused rat heart methods profound anesthesia pentothal wistar rats killed exsanguination sternotomy heart taken connected langendorf column apex heart hooked strength sensor biopac student laboratory software used record analyse heart contractions contractions recorded minutes periods 20 minutes control measurements fi rst recorded measured parameters: heart rate contraction force speeds contraction relaxation control tnfα 20 ng/ml exposure removal tnfα express variations parameters percentage control sem paired test used compare heart rate contraction
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MethodsMethods We enrolled 20 ICUs in 15 states. ICUs collected nasal and perianal swabs on all patients at admission and discharge/transfer. After a 3-month baseline period, 10 units were randomized to the intervention arm and required to wear gloves and gowns for all patient contact. An intervention toolkit was created based on site feedback and compliance reports. Swab collection compliance was fed back and discussed during site conference calls on a weekly basis. Site coordinators monitored compliance with gloves and gowns, hand hygiene and frequency of HCW visits and reviewed patient charts for adverse events.
ResultsMethods A randomized prospective controlled trial was carried out from September 2010 to September 2012. Patients were submitted to block randomization and stratifi ed on the basis of their initial SAPS II exp score. Antibiotic therapy was started on the day of inclusion in the treatment group and only with proven Gr(+) pathogen in the control group. Initial data were gathered on demographics, diagnosis, proven risk factors for sepsis-related mortality, severity of infl ammatory response, ventilator-associated pneumonia and organ dysfunction. Dynamics of SIRS, CPIS and SOFA scores, subsequent infectious isolates, ventilator-free days, length of ICU stay and outcome were followed for each patient. Results A total of 170 patients were enrolled. No statistically signifi cant diff erences in their basal characteristics were found. The subsequent score values, length of ICU stay and the number of ventilator-free days were also comparable between groups. The majority of Gr(+) pathogens were isolated between 6 and 10 days of inclusion. No diff erences were found regarding the concomitant Gr(-) fl ora and the related antibiotic therapy. The new organ dysfunction severity was similar in both groups (P = 0.37). The in-hospital mortality was 26.2% in the treatment group versus 18.6% in the control group (P = 0.56). Signifi cant diff erences between the Kaplan-Meier estimates of survival were also not found (log-rank test P = 0.81). No major adverse reactions were observed. Conclusion The implementation of this new policy failed to reduce the degree of organ dysfunction severity and was not associated with signifi cant survival benefi t. Moreover, even though it did not reach statistical signifi cance, a second peak of Gr(+) isolates was observed as a possible complication of the preemptive therapy. Whether this approach could lead to vancomycin MIC creep or there could still be a niche for it later in the course of treatment and/or in nontrauma patients remains to be further explored. Reference Introduction Acinetobacter baumannii (A. baum) is a leading cause of septicemia of patients hospitalized in the ICU with high mortality rates. The aim of our study is to investigate the risk factors associated with A. baum bacteremia and its mortality rates. Introduction The French military hospital at the Kaboul International Airport (KaIA) base provides surgical care for International Force and Afghan National Army soldiers, and also local patients. The development of multiresistant bacteria (MRB) nosocomial infections has raised a major problem complicating the care of combat casualties  . The aim of this study is to assess the prevalence of MRB carriage on admission to the ICU in this combat support hospital. Methods We used a prospective observation study on patients admitted to the French military ICU in KaIA over 3 months (July to September 2012). All hospitalized patients were assessed for the presence of colonization with MRB: nasal and rectal swabs were performed to identify, respectively, methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum β-lactamases bacteria (ESBLB).
Weight: 23.96 Paper Topics: severe recommendation emergence virus infections decades like dengue west nile wn acute respiratory syndrome sars chikungunya chik middle east respiratory syndrome coronavirus mers-cov ebola ebo zika zik yellow fever yf raised questions quickness reliability laboratory diagnostic tests verification suspected cases important questions arising emerging infection like source route transmission infectivity patients safety measures health care personal distribution animal reservoir vectors require performance laboratory diagnosis investigate patient's infections blood sample taken analysis blood parameters pathogen detection pcr testing presence specific antibodies however sampling blood requires medically trained personal comprises risks patient health care personal particular blood sampling patients highly infectious haemorrhagic
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Severe acute respiratory syndrome (SARS)When SARS emerged in November 2002, it was obvious to analyze samples from the respiratory tract for diagnostic. However, even for the first SARS patients other samples beside blood and nasopharyngeal aspirate samples like feces and urine were found positive with 97% and 42% for viral RNA, respectively  (Table 1 and Additional file 1: Table S7 ). This was confirmed by analysis of throat wash and saliva showing a high virus load up to 6x10 6 and 6x10 8 RNA copies per ml, respectively  . Moreover, the detection of SARS in plasma, sputum, endotracheal aspirates, stool, throat swabs and saliva revealed significant differences between the types of samples  as all samples from the lower respiratory tract were tested positive. Cheng et al. found that death was associated with higher virus load in nasopharyngeal specimens obtained on day 10 after the onset of symptoms  . Different samples like serum, nasopharyngeal aspirates (NPA), throat swabs, nasal swabs, rectal swab, stool and urine were used for analysis of the viral pathogenesis during the course of the disease     .
Weight: 19.35 Paper Topics: example nucleic acid amplification tests naats indispensable tools biology medicine infectious diseases diagnostics naats generally faster sensitive specific current gold standard culture-based techniques fact number dna-and rna-based diagnostics recommended food drug administration fda infectious diseases human immunodeficiency virus hiv 1 2 bringing naats point care poc particularly resource-poor settings envisioned revolutionize healthcare unfortunately naats require access expensive specialized equipment degree expertise highly unlikely decentralized laboratories additional challenge tests typically require extraction step isolate dna rna blood urine sputum purification step eliminate contaminants sample matrix confound actual detection procedure figure procedures necessitate expensive instrumentation add hours sample-to-answer results