Adverse events in critical care: Search and active detection through the Trigger Tool

AIM

To investigate the incidence of disadvantageous events by using the Global Trigger Tool in an intensive care unit (ICU).

METHODS

A retrospective descriptive study was performed in a 12-bed university ICU in the city of Medellin, Colombia. Clinical charts of hospitalized patients were reviewed, between January 1 and December 31, 2016, with the following inclusion criteria: subjects aged over 18 years, with at least 24 h of hospitalization and who had a complete medical history that could be accessed. Interventions: Trained reviewers conducted a retrospective examination of medical charts searching for clue events that elicit investigation, in order to detect an unfavorable event. Measurements: Information was processed through SPSS software version 21; for numerical variables, the mean was reported with standard deviation (SD). Percentages were calculated for qualitative variables.

RESULTS

Two hundred and forty-four triggers occurred, with 82.4% of subjects having presented with at least one and an average of 3.37 (SD 3.47). A total of 178 adverse events (AEs) took place in 48 individuals, with an incidence of 52.1%. On average, four events per patient were recorded, and for each unfortunate event, 1.98 triggers were presented. The most frequent displeasing issues were: pressure ulcers (17.6%), followed by complications or reactions to medical devices (4.3%), and lacerations or skin defects (3.7%); the least frequent was delayed diagnosis or treatment (0.56%). Thirty-eight point four percent of mishap events caused temporary damage that required intervention, and 48.9% of AEs were preventable. Comparison between AEs and admission diagnoses found that hypertension and sepsis were the only diagnoses that had statistical significance (P = 0.042 and 0.022, respectively).

CONCLUSION

Almost half of the unfavorable issues were classified as avoidable, which leaves a very wide field of work in terms of preventative activities.

Greywater treatment in an aerobic SBR: sludge structure and kinetics

In order to have an efficient operation, sequencing batch reactors (SBR) must support granular biomass with high conversion rates, settling properties, and be able to deal with the inherent variability of the composition of real wastewaters. In this study, the effect of the influent composition and the specific organic loading rate (Bx) on the granulation process was evaluated in two SBRs, fed with greywater (GW) and a synthetic medium (SM). The feeding with SM led to the formation of compact granular biomass, with a sludge volume index (SVI) of 22.4 mL g^-1, and a zone settling velocity (ZSV) of 13.1 m h^-1. In contrast, feeding with GW induced the formation of filamentous granules, with lower settling properties (SVI = 165 mL g^-1 and ZSV = 10 m h^-1), when the system was operated at high Bx (4.4 kg COD kg VSS^-1 d^-1). However, the reduction of the average Bx to 2 kg COD kg VSS^-1 d^-1 induced an improvement in the morphology and properties of the granules (SVI = 98 mL g^-1 and ZSV = 13 m h^-1). Furthermore, the kinetic analysis indicated that granules cultivated with SM were formed by fast growing microorganisms with a high cell yield, whereas those cultivated in GW presented a much lower cell yield.

The effect of vinyl acetate in acetoclastic methanogenesis

The influence of vinyl acetate (VA) in the methanogenesis was evaluated, by using an upflow anaerobic sludge blanket reactor of 1.5L. The reactor was operated at 33.5 g/L volatile suspended solids to 30±2 °C, a hydraulic residence time of 1 day, an organic loading rate of 1 kgCOD/m3/d of two different mixtures of VA and glucose. The VA was methanized to 81% when its proportion was of 10% into reactor loading rate, when VA proportion increased to 25%, the methane production rate decreased to 62% and the acetate production rate increased almost 8 times. These results indicated that VA was only hydrolyzed and glucose was not used as a co-substrate. The effect of glucose on VA methanogenic degradation was evaluated through batch reactors of 60 mL, concluding that the glucose supported the methanogenesis without favoring the VA elimination. On the other hand, the results of the sludge from the reactor in the presence of VA demonstrated that VA caused an irreversibly inhibition of acetoclastic methanogenesis when the anaerobic sludge was exposed to this compound.

Effect of thermal alkaline pretreatment on the anaerobic digestion of wasted activated sludge

The effect of alkaline pretreatment of waste-activated sludge, using two models to study the sequential hydrolysis rates of suspended (Sanders' surface model) and dissolved (Goel's saturation model) solids, on the mesophilic and thermophilic anaerobic digestion rate is evaluated. The pretreatment, which reduces the size of the solids, increases the reaction rate by increasing the surface area and the specific surface hydrolysis constant (K(SBK)); at thermophilic conditions from 0.45 x 10(-3) kg m(-2) d(-1) for the fresh sludge to 0.74 x 10(-3) kg m(-2) d(-1) for the pretreated sludge and at mesophilic conditions these values are 0.28 x 10(-3) kg m(-2) d(-1) and 0.47 x 10(-3) kg m(-2) d(-1) confirming the usefulness of a pretreatment for solids reduction. But for soluble solids, the thermoalkaline pretreatment decreases the reaction rates by inducing a competitive inhibition on the thermophilic anaerobic digestion rate while in the mesophilic range, a non-competitive inhibition is observed. A mathematical simulation of the consecutive reactions, suspended solids to dissolved solids and to methane in staged anaerobic thermophilic-mesophilic digestion, shows that with 4% suspended solids concentration it is better not to use a thermoalkaline pretreatment because overall solids reduction and total methane production are not as good as without pretreatment.

The impact of ammonia nitrogen concentration and zeolite addition on the specific methanogenic activity of granular and flocculent anaerobic sludges

This work presents the effect of ammonia nitrogen concentration and zeolite addition on the specific methanogenic activity (SMA) of different anaerobic sludges with various physical structures (granular and flocculent), operating in batch conditions. Piggery, malting production and urban sludges derived from full-scale anaerobic reactors were tested in the experiment as the source of inoculum in batch digesters. It was found that piggery sludge was the most affected by the increase of ammonia nitrogen concentration while malting producing and municipal sludges were less affected. In general, the addition of zeolite at doses in the range of 0.01-0.1 g/g VSS reduced the inhibitory effect of N-NH(4)(+) for piggery sludge (P.S.). For this sludge, the propionic:acetic ratio increased when the concentration of N-NH(4)(+) increased, indicating that methanogenesis was affected. Finally, a study of the microbial population involved in this study for P.S. by using 16S rRNA based molecular techniques revealed a presence of microorganisms following the order: Methanococcaceae > Methanosarcina > Methanosaeta.

Biological degradation of a mixture of municipal wastewater and organic garbage leachate in expanded bed anaerobic reactors and a zeolite filter

Municipal wastewater was amended with organic garbage leachates at a concentration around 700 mgCOD(soluble)/L and fed to three different anaerobic systems to compare their performance: a down flow fluidized bed (DFFB), an expanded granular sludge bed (EGSB) and a zeolite-packed anaerobic filter reactor (ZPF). The DFFB and EGSB reactors were operated at HRT of 6 and 4 h and the ZPF reactor at 12 and 36 h. Organic loads rate for the DFFB reactor were 2.3+/-0.9 and 4.8+/-1.8 gCOD/L.d, with removal efficiencies around 40% and a methane productivity of 0.2+/-0.03 L/L(reactor).d. For the EGSB reactor, organic loads tested were 2.1+/-0.9 and 4.3+/-1.3 gCOD/L.d, removal efficiencies attained were of 77.6+/-12.7% and 84.4+/-4.9%, respectively at both conditions and total suspended solids were removed in 54.6+/-19.3%, while methane productivity at 4 h HRT was of 1.29+/-0.4 L/L(reactor).d. The ZPF reactor was operated at lower organic loading rates, 1.4+/-0.27 and 0.42+/-0.13 gCOD/L.d and attained removal efficiencies of 48+/-18% and 83+/-8%, respectively, reaching a methane productivity of 0.21+/-0.09 and 0.12+/-0.04 L/L(reactor).d, 83+/-8.0% of total suspended solids were retained in the reactor and as HRT was increased ammonium concentrations increased in 39%. Specific methanogenic activity in all systems was around 0.2 gCOD-CH(4)/gVSS d.

Biological wastewater treatment for removal of polymeric resins in UASB reactor: influence of oxygen

The biological elimination of polymeric resins compounds (PRC) such as acrylic acid and their esters, vinyl acetate and styrene under methanogenic and oxygen-limited methanogenesis conditions was evaluated. Two UASB reactors (A and B) were used and the removal of the organic matter was studied in four stages. Reactor A was used as methanogenic control during the study. Initially both reactors were operated under methanogenic conditions. From the second stage reactor B was fed with 0.6 and 1 mg/L.d of oxygen (O2). Reactor A had diminution in chemical oxygen demand (COD) removal efficiency from 75+/-4% to 37+/-5%, by the increase of PRC loading rate from 750 to 1125 mg COD/L.d. In this reactor there was no styrene elimination. In reactor B the COD removal efficiency was between 73+/-5% and 80+/-2%, even with the addition of O2 and increase of the PRC loading rate, owing to oxygen being used in the partial oxidation of these compounds. In this reactor the yields were modified from 0.56 to 0.40 for CH4 and from 0.31 to 0.60 for CO2. The O2 in low concentrations increased 40.7% the consumption rates of acrylic acid, methyl acrylate and vinyl acetate, allowing styrene consumption with a rate of 0.103 g/L.d. Batch cultures demonstrated that under methanogenic and oxygen-limited methanogenesis conditions, the glucose was not used as an electron acceptor in the elimination of PRC.

Treatment of a low concentration industrial chemicals mixture in an UASB reactor

A wastewater containing a mixture of methanol, isopropyl alcohol, ethylene glycol, acetic anhydride, methyl, ethyl and isopropyl acetate, acrylic acid, butyl and methyl acrylate, o, m and p-xylene and styrene was fed to an UASB reactor. Isopropanol addition diminished the removal efficiency to 60% and required a long adaptation time for its total mineralization. When acrylic acid was added to the mixture, the removal dropped to 83% and recovered after 40 days. As for the rest of the substrates, p-m-o-xylene addition had no effect on reactor performance, although in batch assays it showed low mineralization. Also the effect of volumetric organic load on removal efficiency was followed up. After diminishing the HRT to 4 and 3 h yielding 4.8 and 6.5 gCOD L(-1) d(-1), removal efficiencies decreased to 79 and 74% respectively.

Phenolic refinery wastewater biodegradation by an expanded granular sludge bed reactor

Refinery spent caustics (SC) were diluted with sour waters (SW) in a ratio 1:7, neutralized with CO2 (SC/SW(CO2)) and 83% of H2S was striped during this procedure, remaining an aromatic portion that contained 2123, 2730 and 1379 mg L(-1) of phenol, p-cresol and o-cresol, respectively. The mixture was teated anaerobically in an EGSB reactor fed with 1.5 gCOD L(-1) d(-1), without mineral supplements causing loss of COD removal efficiency that dropped to 23%, methane production ceased and no phenol or cresols were biodegraded. The EGSB experiments were resumed by feeding the reactor with nutrients and phenol at 1.0 gCOD L(-1) d(-1). The mixture SC/SWco2 added to the phenol load, was step increased from 0.10 to 0.87 gCODL(-1) d(-1) maximum. When total organic load was increased to 1.6, COD removal efficiency was 90% and at the highest load attained, 1.87, efficiency dropped to 23% attributed to the toxic effect produced by cresols.

Sulphide and oxygen inhibition over the anaerobic digestion of organic matter: influence of microbial immobilization type

Two different types of microbial aggregates (granular sludge and biofilm onto a plastic matrix) were evaluated for their susceptibility to sulphide and dissolved oxygen. Their specific methanogenic and sulphate reducing activities were evaluated separately and simultaneously. Total sulphide concentrations that caused 50% loss of methanogenic activity were 800 and 1250 mg l(-1) and for sulphate reduction 750 and 860 mg l(-1) for the granular sludge and the attached biomass, respectively. Simultaneous methanogenesis and sulphate reduction resulted in an increased tolerance of the sulphate reducing process towards sulphide. Results suggest that methanogenesis in granular sludge is less resistant to sulphide than in the attached biomass structure, whereas in sulphate reduction the attached biomass exhibited a better tolerance to high concentrations of total sulphide than the granular sludge. The better sulphate reducing capacity in the attached biomass may suggest that biomass was selectively attached. The dissolved oxygen concentration that inhibited 50% the methanogenic activity was 4.9 and 6.4 mg l(-1) for the granular sludge and attached biomass, respectively. When methanogenesis and sulphate reduction were carried out simultaneously, the whole process was not affected by the supplied oxygen, as produced sulphide was used by sulphide oxidizing microorganisms thus scavenging oxygen. Results showed that the integration of anaerobic/aerobic conditions in a single bioreactor is quite possible and can be used as a good strategy for the complete transformation of sulphate to elemental sulphur.

Field trial of the brucellosis fluorescence polarization assay

Fluorescence polarization assay (FPA) is a homogeneous technique which was applied to the serological diagnosis of bovine brucellosis. Because of its simplicity and because it may be performed very rapidly, it was an ideal test to adapt to field use. The FPA was used to test cattle on six dairy farms in Baja California, Mexico. Anticoagulated blood, serum, and milk were collected from each animal. The anticoagulated blood was tested immediately on the farm while serum and milk were tested subsequently in the laboratory. Cattle on one farm (n = 140) were thought not to be infected with Brucella abortus and the other farms were thought to have high prevalence of the infection. The whole blood FPA (FPA(bld)) did not detect antibody in any of the cattle on the first premise. This finding was confirmed using a number of other serological tests, including the buffered antigen plate agglutination test, the complement fixation test, the indirect and competitive enzyme immunoassays, and the FPA using serum and milk. Cattle on the other premises (n = 1122) were tested in a similar fashion. The sensitivity of the FPA(bld), relative to the serum FPA (considered the definitive test), was 99.1% and the relative specificity of the FPA(bld) was 99.6%. These results compared favourably with those obtained using the other serological tests.

Biodegradation of octylphenol polyethoxylates by denitrification

The biodegradation route of the octylphenol ethoxylates (OPEOs) by denitrification in an upflow anoxic sludge blanket (UASB) reactor was studied. An anaerobic sludge adapted to denitrifying conditions with acetate was adapted with increasing amounts of OPEOs and diminishing amounts of acetate until only 300 mg x L(-1) of OPEOs were fed. Only 70% of stoichiometric NO3- was fed so partial removal was expected. The total OPEOs fed was transformed with 70% COD removal. HPLC and GC-MS analyses showed that octylphenol (OP) was immediately formed but disappeared while other intermediates, the ethoxylated moieties; mono and diethoxylate (OPEO1 and OPEO2 respectively) led to the cleavage of the alkyl chain to form propylphenol triethoxylate (PPEO3) and heptylphenol diethoxylated (HPEO2). These last two compounds are produced due to an attack to both sides of the molecule; the hydrophilic and the hydrophobic. These findings suggest three simultaneous routes of OPEO degradation.

Anaerobic digestion of a nonionic surfactant: inhibition effect and biodegradation

Nonionic surfactants are used worldwide in various industrial and household applications. Since these compounds are used in aqueous solutions, they primarily enter the environment through sewage and industrial wastewater treatment plants. The objective of this work was to evaluate the inhibitory effect of Triton X-100, a commercial nonionic surfactant, on the anaerobic digestion of lactose. Thus non-ionic surfactants acts as a non-competitive inhibitor with K1 = 250 mgL-1 and a inhibition order of 2.4. Nonetheless if give enough time the sludge was able to degrade 79% of Triton at 0.1 gL-1 d-1 in a UASB reactor. An activity test of this sludge showed that Triton inhibited the acetogenic (both propionic and butyric) and acetoclastic activities, while there were high fermentative and hydrogenotrophic activities (80% and 95%, respectively).

Degradation of lineal alkylbenzene sulphonate (LAS) in an acidogenic reactor bioaugmented with a Pseudomonas aeruginosa (M113) strain

The degradation of of lineal alkylbenzene sulphonate (LAS) was studied in a two-stage anaerobic system where the acidogenic reactor was bioaugmented with a strain of Pseudomonas aeruginosa (M113). This is a strain, which under aerobic and denitrifying conditions uses LAS as carbon source. Results show that LAS was only degraded within the acidogenic stage while in the methanogenic reactor there was no degradation and eventually there was an inhibition due to a LAS accumulation in the sludge. During the experiment, the M113 strain remained in the acidogenic conglomerate (at around 10(4) CFU/mL) although there is no evidence of their involvement in LAS degradation.

Influence of Ammonium on the Performance of a Denitrifying Culture Under Heterotrophic Conditions

The effect of ammonium on a denitrifying reactor of the upflow anaerobic sludge blanket type was studied. At a constant nitrate loading rate (2500 mg NO3 --N/[L. d]), using acetate as organic electron donor and at a C/NO3 --N/ ratio of 1.23, an increase in the N2 production rate was observed when the ammonium loading rate was increased (25, 250, and 500 mg NH4 +-N/[L. d]). Dissimilatory nitrate reduction to ammonium (DNRA) was not observed, and the N2 production efficiency was increased from 84 to 100% or higher. Since NH4 + in the output was lower than in the input, it was suggested that it was used for nitrate reduction. At constant NH4 +-N/NO3 --N/ and C/NO3 --N/ ratios of 0.2 and 1.63, respectively, the molecular nitrogen production rate was increased at 300 and 500 mg NH4 +-N/(L. d), whereas at 200 mg NH4 +- N/(L. d) DNRA took place probably owing to culture conditions of low reductive power. Molecular nitrogen production was not observed under autotrophic conditions, and the addition of acetate to the culture recovered its high nitrogen removal rate. Experimental results and balances indicated that the consumed ammonium was used as an additional reductive source.