Acute respiratory distress syndrome: the Berlin Definition

The acute respiratory distress syndrome (ARDS) was defined in 1994 by the American-European Consensus Conference (AECC); since then, issues regarding the reliability and validity of this definition have emerged. Using a consensus process, a panel of experts convened in 2011 (an initiative of the European Society of Intensive Care Medicine endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition, focusing on feasibility, reliability, validity, and objective evaluation of its performance. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min). The draft Berlin Definition was empirically evaluated using patient-level meta-analysis of 4188 patients with ARDS from 4 multicenter clinical data sets and 269 patients with ARDS from 3 single-center data sets containing physiologic information. The 4 ancillary variables did not contribute to the predictive validity of severe ARDS for mortality and were removed from the definition. Using the Berlin Definition, stages of mild, moderate, and severe ARDS were associated with increased mortality (27%; 95% CI, 24%-30%; 32%; 95% CI, 29%-34%; and 45%; 95% CI, 42%-48%, respectively; P < .001) and increased median duration of mechanical ventilation in survivors (5 days; interquartile [IQR], 2-11; 7 days; IQR, 4-14; and 9 days; IQR, 5-17, respectively; P < .001). Compared with the AECC definition, the final Berlin Definition had better predictive validity for mortality, with an area under the receiver operating curve of 0.577 (95% CI, 0.561-0.593) vs 0.536 (95% CI, 0.520-0.553; P < .001). This updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition. The approach of combining consensus discussions with empirical evaluation may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.

Drotrecogin alfa (activated) in adults with septic shock

BACKGROUND

There have been conflicting reports on the efficacy of recombinant human activated protein C, or drotrecogin alfa (activated) (DrotAA), for the treatment of patients with septic shock.

METHODS

In this randomized, double-blind, placebo-controlled, multicenter trial, we assigned 1697 patients with infection, systemic inflammation, and shock who were receiving fluids and vasopressors above a threshold dose for 4 hours to receive either DrotAA (at a dose of 24 μg per kilogram of body weight per hour) or placebo for 96 hours. The primary outcome was death from any cause 28 days after randomization.

RESULTS

At 28 days, 223 of 846 patients (26.4%) in the DrotAA group and 202 of 834 (24.2%) in the placebo group had died (relative risk in the DrotAA group, 1.09; 95% confidence interval [CI], 0.92 to 1.28; P=0.31). At 90 days, 287 of 842 patients (34.1%) in the DrotAA group and 269 of 822 (32.7%) in the placebo group had died (relative risk, 1.04; 95% CI, 0.90 to 1.19; P=0.56). Among patients with severe protein C deficiency at baseline, 98 of 342 (28.7%) in the DrotAA group had died at 28 days, as compared with 102 of 331 (30.8%) in the placebo group (risk ratio, 0.93; 95% CI, 0.74 to 1.17; P=0.54). Similarly, rates of death at 28 and 90 days were not significantly different in other predefined subgroups, including patients at increased risk for death. Serious bleeding during the treatment period occurred in 10 patients in the DrotAA group and 8 in the placebo group (P=0.81).

CONCLUSIONS

DrotAA did not significantly reduce mortality at 28 or 90 days, as compared with placebo, in patients with septic shock. (Funded by Eli Lilly; PROWESS-SHOCK ClinicalTrials.gov number, NCT00604214.).

ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure

PURPOSE

To assess whether partitioning the elastance of the respiratory system (E (RS)) between lung (E (L)) and chest wall (E (CW)) elastance in order to target values of end-inspiratory transpulmonary pressure (PPLAT(L)) close to its upper physiological limit (25 cmH(2)O) may optimize oxygenation allowing conventional treatment in patients with influenza A (H1N1)-associated ARDS referred for extracorporeal membrane oxygenation (ECMO).

METHODS

Prospective data collection of patients with influenza A (H1N1)-associated ARDS referred for ECMO (October 2009-January 2010). Esophageal pressure was used to (a) partition respiratory mechanics between lung and chest wall, (b) titrate positive end-expiratory pressure (PEEP) to target the upper physiological limit of PPLAT(L) (25 cmH(2)O).

RESULTS

Fourteen patients were referred for ECMO. In seven patients PPLAT(L) was 27.2 ± 1.2 cmH(2)O; all these patients underwent ECMO. In the other seven patients, PPLAT(L) was 16.6 ± 2.9 cmH(2)O. Raising PEEP (from 17.9 ± 1.2 to 22.3 ± 1.4 cmH(2)O, P = 0.0001) to approach the upper physiological limit of transpulmonary pressure (PPLAT(L) = 25.3 ± 1.7 cm H(2)O) improved oxygenation index (from 37.4 ± 3.7 to 16.5 ± 1.4, P = 0.0001) allowing patients to be treated with conventional ventilation.

CONCLUSIONS

Abnormalities of chest wall mechanics may be present in some patients with influenza A (H1N1)-associated ARDS. These abnormalities may not be inferred from measurements of end-inspiratory plateau pressure of the respiratory system (PPLAT(RS)). In these patients, titrating PEEP to PPLAT(RS) may overestimate the incidence of hypoxemia refractory to conventional ventilation leading to inappropriate use of ECMO.

Bridging to lung transplantation by extracorporeal support

Ideally, bridging patients with end stage severe respiratory failure to lung transplantation should significantly extend the pretransplant life expectancy to increase the chances to receive a suitable organ, as well as efficiently preserve the post-transplant long-term life expectancy by maintaining physiological homeostasis and avoiding multi-organ dysfunction. Various advanced strategies of extracorporeal circulation can replace at least in part the respiratory function of the lung and can potentially provide the appropriate mode and level of cardiopulmonary support for each patient's physiologic requirements. Therefore, patients on the lung transplant waiting list developing severe hypoxemic and/or hypercapnic respiratory failure can be supported for a prolonged period of time before the transplant, preserving a satisfactory post-transplant life expectancy. However, a more systematic clinical study on this issue is warranted in order to define the actual efficacy of these treatments in reducing the mortality rate on the waiting transplant list, and eventually improve the outcome of patients with end stage respiratory failure.

Mechanical ventilation during acute lung injury: current recommendations and new concepts

Despite a very large body of investigations, no effective pharmacological therapies have been found to cure acute lung injury. Hence, supportive care with mechanical ventilation remains the cornerstone of treatment. However, several experimental and clinical studies showed that mechanical ventilation, especially at high tidal volumes and pressures, can cause or aggravate ALI. Therefore, current clinical recommendations are developed with the aim of avoiding ventilator-induced lung injury (VILI) by limiting tidal volume and distending ventilatory pressure according to the results of the ARDS Network trial, which has been to date the only intervention that has showed success in decreasing mortality in patients with ALI/ARDS. In the past decade, a very large body of investigations has determined significant achievements on the pathophysiological knowledge of VILI. Therefore, new perspectives, which will be reviewed in this article, have been defined in terms of the efficiency and efficacy of recognizing, monitoring and treating VILI, which will eventually lead to further significant improvement of outcome in patients with ARDS.

Are guidelines for non-invasive ventilation during weaning still valid?

Noninvasive ventilation (NIV) has gained increasing acceptance over the years to reduce endotracheal intubation, pneumonia and to prevent or treat respiratory failure in patients with different diagnoses. The international consensus conference, and the British society guidelines on NIV ventilation have analyzed its use during the weaning phase concluding that there were still conflicting results of its use. However, recent clinical trials have shown clear clinical benefits on the use of NIV in several patient populations during the weaning period. Acute respiratory failure (ARF) during the weaning process is the main object of recently published studies. The latest published randomized trials on the application of NIV for acute respiratory failure following extubation failed to demonstrate any favorable outcome. Even so, the use of NIV during the process of weaning in patients experiencing multiple weaning failure or as a preventive therapy in patients at higher risk of respiratory deterioration showed improved clinical outcomes only in chronic obstructive pulmonary disease and in particular in hypercapnic patients. Reduced invasive mechanical ventilation, tracheostomy and lower mortality rate at 90 days were the major advantages.

The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks

PURPOSE

In view of the expected 2009 influenza A(H1N1) pandemic, the Italian Health Authorities set up a national referral network of selected intensive care units (ICU) able to provide advanced respiratory care up to extracorporeal membrane oxygenation (ECMO) for patients with acute respiratory distress syndrome (ARDS). We describe the organization and results of the network, known as ECMOnet.

METHODS

The network consisted of 14 ICUs with ECMO capability and a national call center. The network was set up to centralize all severe patients to the ECMOnet centers assuring safe transfer. An ad hoc committee defined criteria for both patient transfer and ECMO institutions.

RESULTS

Between August 2009 and March 2010, 153 critically ill patients (53% referred from other hospitals) were admitted to the ECMOnet ICU with suspected H1N1. Sixty patients (48 of the referred patients, 49 with confirmed H1N1 diagnosis) received ECMO according to ECMOnet criteria. All referred patients were successfully transferred to the ECMOnet centers; 28 were transferred while on ECMO. Survival to hospital discharge in patients receiving ECMO was 68%. Survival of patients receiving ECMO within 7 days from the onset of mechanical ventilation was 77%. The length of mechanical ventilation prior to ECMO was an independent predictor of mortality.

CONCLUSIONS

A network organization based on preemptive patient centralization allowed a high survival rate and provided effective and safe referral of patients with severe H1N1-suspected ARDS.

Invasive and non-invasive long-term mechanical ventilation in Italian children

BACKGROUND

To date, few studies have been published regarding the number of children in Italy who require long-term mechanical ventilation (LTV) and their underlying diagnoses, ventilatory needs and hospital discharge rate.

METHODS

A preliminary national postal survey was conducted and identified 535 children from 57 centers. Detailed data were then obtained for 378 children from 30 centers.

RESULTS

The estimated prevalence in Italy of this population was 4.3/100000. The majority of children (72.2%) were followed in pediatric units. The primary physicians who cared for these patients were either pediatric intensivists or pediatric pulmonologists. Neurological patients (78.2% of cases) represented the principal disorder category. 57.2% of the patients were non-invasively ventilated, with a nasal mask being the most common interface (85% of cases). The presence of clinical symptoms that were associated with abnormal findings on diagnostic testing was the primary indication for ventilatory support, whereas weaning failure was the primary indication for tracheotomy. Invasive ventilation was significantly related to younger age, longer daily hours on ventilation and cerebral palsy. Ventilatory modes with guaranteed minimal tidal volume were more often used in patients with tracheotomy. Despite their age, illness severity and need for technological care, 98% of the study population were successfully home discharged.

CONCLUSION

Managing pediatric home LTV requires tremendous effort on the part of the patient's family and places a significant strain on community financial resources. In particular, neurological patients require more health care than patients in other categories. To further improve the quality of care for these patients, it is essential to establish a dedicated national database.

Sleep disturbances in the critically ill patients: role of delirium and sedative agents

BACKGROUND

Impairment of sleep quality and quantity has been described in critically ill patients. Delirium, an organ dysfunction that affects outcome of the critically ill patients, is characterized by an acute onset of impaired cognitive function, visual hallucinations, delusions, and illusions. These symptoms resemble the hypnagogic hallucinations and wakeful dreams seen in patients with neurological degenerative disorders and suffering of disorders of rapid eye movement (REM) sleep. We assessed the characteristics of sleep disruption in a cohort of surgical critically ill patients examining the hypothesis that severe impairments of rapid eyes movement (REM) sleep are associated to delirium.

METHODS

Surgical patients admitted to the intensive care units of the San G. Battista Hospital (University of Turin) were enrolled. Once weaning was initiated, sleep was recorded for one night utilizing standard polysomnography. Clinical status, laboratory data on admission, co-morbidities and duration of mechanical ventilation were recorded. Patients were a priori classified as having a "severe REM reduction" or "REM reduction" if REM was higher or lower than 6% of the total sleep time (TST), respectively. Occurrence of delirium during intensive care unit (ICU) stay was identified by CAM-ICU twice a day. Multivariate forward stepwise logistic regression analysis was performed with sleep ("severe REM reduction" vs. "REM reduction") as the a priori dependent factor.

RESULTS

REM sleep amounted to 44 (16-72) minutes [11 (8-55) % of the TST] in 14 patients ("REM reduction") and to 2.5 (0-36) minutes [1 (0-6) % of the TST] in the remaining 15 patients ("severe REM reduction") (P = 0.0004). SAPS II on admission was higher in " severely REM deprived" then in "REM deprived" patients. Delirium was present in 11 patients (73.3%) of the patients with "severe REM reduction" and lasted for a median of 3 (0-11) days before sleep assessment, while only one patient having "REM reduction" developed delirium that lasted for 1 day. The factors independently associated with a higher risk of developing "severe REM reduction" were delirium and daily dosage of lorazepam.

CONCLUSION

The present study shows that while all critically ill patients present a profound fragmentation of sleep with a high frequency of arousals and awakenings and a reduction of REM sleep, a percentage of patients present an extremely severe reduction of REM sleep. Delirium and daily dosage of lorazepam are the factors independently associated to extremely severe REM sleep reduction.

Long-term home ventilation of children in Italy: a national survey

BACKGROUND

Improved technology, as well as professional and parental awareness, enable many ventilator-dependent children to live at home. However, the profile of this growing population, the quality and adequacy of home care, and patients' needs still require thorough assessment.

OBJECTIVES

To define the characteristics of Italian children receiving long-term home mechanical ventilation (HMV) in Italy.

METHODS

A detailed questionnaire was sent to 302 National Health Service hospitals potentially involved in the care of HVM in children (aged <17 years). Information was collected on patient characteristics, type of ventilation, and home respiratory care.

RESULTS

A total of 362 HMV children was identified. The prevalence was 4.2 per 100,000 (95% CI: 3.8-4.6), median age was 8 years (interquartile range 4-14), median age at starting mechanical ventilation was 4 years (1-11), and 56% were male. The most frequent diagnostic categories were neuromuscular disorders (49%), lung and upper respiratory tract diseases (18%), hypoxic (ischemic) encephalopathy (13%), and abnormal ventilation control (12%). Medical professionals with nurses (for 62% of children) and physiotherapists (20%) participated in the patients' discharge from hospital, though parents were the primary care giver, and in 47% of cases, the sole care giver. Invasive ventilation was used in 41% and was significantly related to young age, southern regional residence, longer time spent under mechanical ventilation, neuromuscular disorders, or hypoxic (ischemic) encephalopathy.

CONCLUSIONS

Care and technical assistance of long-term HMV children need assessment, planning, and resources. A wide variability in pattern of HMV was found throughout Italy. An Italian national ventilation program, as well as a national registry, could be useful in improving the care of these often critically ill children.

When pressure does not mean volume? Body mass index may account for the dissociation

Low tidal volume (VT 6 ml/predicted body weight) pressure limited (plateau pressure <30 cmH₂O) protective ventilation as proposed by the ARDS Network was associated with an improvement in mortality and is considered the gold standard for acute respiratory distress syndrome (ARDS) ventilation strategies. Limiting plateau pressure minimizes ventilator-induced lung injury by reducing the trans-pulmonary pressure, which is the real alveolar distending pressure. However, in the presence of chest wall elastance impairment, as observed in obese patients, plateau pressure underestimates the trans-pulmonary pressure and derecrutiment at low distending pressure could occur. Moreover, low tidal volume to keep plateau pressure <30 cmH₂O could be associated with large differences compared to measured total lung capacity. Quantitative bedside techniques that are able to measure lung volumes together with trans-pulmonary pressure could expand our chances to tailor mechanical ventilation in ARDS patients.

Candidemia after cardiac surgery in the intensive care unit: an observational study

Candidemia is a well-recognized complication of hospital stay, especially in critically ill patients. There is not a general consensus that predictors for candidemia in cardiosurgical intensive care unit (cICU) are different from a general ICU and it has been reported that cardiopulmonary bypass time is a specific risk factor in the cICU. We performed a prospective study to evaluate the main predictors for candidemia in patients admitted to the cICU. Included patients were adults admitted between July 2005 and December 2007 with an ICU-length of stay (ICU-LOS) ≥48 hours after cardiac surgery. Exclusion criteria were solid organ or bone marrow transplants, previous diagnosis of candidemia or other invasive infections and ICU stay before surgery. A multiple regression analysis was performed to identify the risk factors. Among 1955 patients admitted to the cICU, 345 were enrolled. Only 26 patients (1.3%) had candidemia after an ICU-LOS of 20 days (inter-quartile range, IQR 8-49 days). Total parenteral nutrition [odds ratio (OR)=9.56; confidence interval (CI)=1.741-52.534], severe sepsis (OR=4.20; CI=1.292-13.667), simplified acute physiology score II (OR=1.16; CI=1.052-1.278) and ICU-LOS >20 days (OR=6.38; CI=1.971-20.660) were independent predictors of candidemia. Patients undergoing cardiac surgery developed candidemia late after cICU admission and the independent predictors were similar to the general ICU.

Effect of a lung protective strategy for organ donors on eligibility and availability of lungs for transplantation: a randomized controlled trial

CONTEXT

Many potential donor lungs deteriorate between the time of brain death and evaluation for transplantation suitability, possibly because of the ventilatory strategy used after brain death.

OBJECTIVE

To test whether a lung protective strategy increases the number of lungs available for transplantation.

DESIGN, SETTING, AND PATIENTS

Multicenter randomized controlled trial of patients with beating hearts who were potential organ donors conducted at 12 European intensive care units from September 2004 to May 2009 in the Protective Ventilatory Strategy in Potential Lung Donors Study. Interventions Potential donors were randomized to the conventional ventilatory strategy (with tidal volumes of 10-12 mL/kg of predicted body weight, positive end-expiratory pressure [PEEP] of 3-5 cm H(2)O, apnea tests performed by disconnecting the ventilator, and open circuit for airway suction) or the protective ventilatory strategy (with tidal volumes of 6-8 mL/kg of predicted body weight, PEEP of 8-10 cm H(2)O, apnea tests performed by using continuous positive airway pressure, and closed circuit for airway suction).

MAIN OUTCOME MEASURES

The number of organ donors meeting eligibility criteria for harvesting, number of lungs harvested, and 6-month survival of lung transplant recipients.

RESULTS

The trial was stopped after enrolling 118 patients (59 in the conventional ventilatory strategy and 59 in the protective ventilatory strategy) because of termination of funding. The number of patients who met lung donor eligibility criteria after the 6-hour observation period was 32 (54%) in the conventional strategy vs 56 (95%) in the protective strategy (difference of 41% [95% confidence interval {CI}, 26.5% to 54.8%]; P <.001). The number of patients in whom lungs were harvested was 16 (27%) in the conventional strategy vs 32 (54%) in the protective strategy (difference of 27% [95% CI, 10.0% to 44.5%]; P = .004). Six-month survival rates did not differ between recipients who received lungs from donors ventilated with the conventional strategy compared with the protective strategy (11/16 [69%] vs 24/32 [75%], respectively; difference of 6% [95% CI, -22% to 32%]).

CONCLUSION

Use of a lung protective strategy in potential organ donors with brain death increased the number of eligible and harvested lungs compared with a conventional strategy.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00260676.

Early CPAP prevents evolution of acute lung injury in patients with hematologic malignancy

PURPOSE

Although chemotherapy and transplantation improve outcome of patients with hematological malignancy, complications of these therapies are responsible for a 20-50% mortality rate that increases when respiratory symptoms evolve into acute lung injury (ALI). The aim of this study is to determine the effectiveness of early continuous positive airway pressure (CPAP) delivered in the ward to prevent occurrence of ALI requiring intensive care unit (ICU) admission for mechanical ventilation.

METHODS

Patients with hematological malignancy presenting in the hematological ward with early changes in respiratory variables were randomized to receive oxygen (N = 20) or oxygen plus CPAP (N = 20). Primary outcome variables were need of mechanical ventilation requiring ICU admission, and intubation rate among those patients who required ICU admission.

RESULTS

At randomization, arterial-to-inspiratory O(2) ratio in control and CPAP group was 282 ± 41 and 256 ± 52, respectively. Patients who received CPAP had less need of ICU admission for mechanical ventilation (4 versus 16 patients; P = 0.0002). CPAP reduced the relative risk for developing need of ventilatory support to 0.25 (95% confidence interval: 0.10-0.62). Among patients admitted to ICU, intubation rate was lower in the CPAP than in the control group (2 versus 14 patients; P = 0.0001). CPAP reduced the relative risk for intubation to 0.46 (95% confidence interval: 0.27-0.78).

CONCLUSIONS

This study suggests that early use of CPAP on the hematological ward in patients with early changes in respiratory variables prevents evolution to acute lung injury requiring mechanical ventilation and ICU admission.

Endotoxin removal: how far from the evidence? The EUPHAS 2 Project

Since 1994, a polystyrene fiber cartridge used for extracorporeal hemoperfusion, to which polymyxin B is bound and immobilized, has been used in septic patients in order to absorb and remove circulating lipopolysaccharide, thereby neutralizing the effects of this endotoxin. This therapy gradually gained acceptance as the amount of evidence increased from initial small clinical studies to a carefully conducted systematic review, and ultimately to the multicentered randomized clinical trial conducted in Italy, entitled the EUPHAS Study (Early Use of Polymyxin B Hemoperfusion in Abdominal Septic Shock). While the conclusions of this initial randomized controlled trial were in agreement with previous studies, it possessed some important limitations, including a slow accrual rate, enrolling only 64 patients between 2004 and 2007, inability to blind treating physicians, and a premature study termination based on the results of the scheduled interim analysis. These limitations resulted in a modest patient sample size, which may have overestimated the true magnitude of the clinical effect. Apart from Japan, Italy is the current primary user of polymyxin B-hemoperfusion in the treatment of sepsis, with about 600 cartridges being used per year. However, no structured collection of data has been attempted, resulting in the an opportunity to understand the effects of polymyxin B-hemoperfusion on a large, diverse sample size. In response, Italian investigators and users of this treatment have designed a new prospective multicentered, collaborative data collection study, entitled EUPHAS 2. The aim of the EUPHAS 2 project is to collect a large database regarding polymyxin B-hemoperfusion treatments in order to better evaluate the efficacy and biological significance of endotoxin removal in clinical practice. Additionally, this study aims to verify the reproducibility of the data currently available in the literature, evaluate the patient population chosen for treatment and identify subpopulations of patients who may benefit from this treatment more than others.

Protective effects of steroids in cardiac surgery: a meta-analysis of randomized double-blind trials

OBJECTIVE

Cardiac surgery and cardiopulmonary bypass (CPB) induce an acute inflammatory response contributing to postoperative morbidity. The use of steroids as anti-inflammatory agents in surgery using CPB has been tested in many trials and has been shown to have good anti-inflammatory effects but no clear clinical advantages for the lack of an adequately powered sample size. The aim of this study was to evaluate the effects of steroid treatment on mortality and morbidity after cardiac surgery.

DESIGN

A systematic meta-analysis of randomized double-blind trials (RDBs).

SETTING

A university hospital.

PARTICIPANTS

Adult patients who underwent cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

A trial search was performed through PubMed and Cochrane databases from 1966 to January 2009. Among 104 clinical trials reviewed, 31 RDB trials (1,974 patients) were considered suitable to be analyzed. A quality assessment of the trials was performed using the Jadad score. The types of steroid used in these trials were methylprednisolone (51.4%), dexamethasone (34.3%), hydrocortisone (5.7%), prednisolone (2.9%), or a combination of methylprednisolone and dexamethasone (5.7%). Steroid prophylaxis provided a protective effect preventing postoperative atrial fibrillation (odds ratio = 0.56; confidence interval [CI] 0.44-0.72, p < 0.0001), reducing postoperative blood loss (mean difference = -204.2 mL; CI from -287.4 to -121 mL; p < 0.0001), and reducing intensive care unit (mean difference = -6.6 hours; CI from -10.5 to -2.7 hours, p = 0.0007) and overall hospital stay (mean difference = -0.8 days; CI from -1.4 to -0.2 days, p = 0.01). Steroid prophylaxis had no effect on postoperative mortality, mechanical ventilation duration, re-exploration for bleeding, and postoperative infection.

CONCLUSIONS

A systematic review of RDB trials reveals that steroid prophylaxis may reduce morbidity after cardiac surgery and does not increase the risk of postoperative infections.

The effects of inhaled nitric oxide after lung transplantation

Primary graft failure (PGF) is one of the major complications that occurs immediately following lung transplantation and greatly contributes to increased morbidity and mortality. The incidence of PGF is correlated with a marked decline in endogenous nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) levels. Therefore, the administration of NO during lung transplantation has been proposed as a possible therapeutic treatment to prevent or attenuate PGF pathogenesis. Despite the initial positive results of experimental and uncontrolled clinical trials, recent randomized clinical trials do not support the prophylactic administration of inhaled nitric oxide (iNO) for the prevention of PGF following lung transplantation under the conditions tested. Nonetheless, there is evidence that iNO administration during PGF can improve oxygenation and reduce pulmonary hypertension without altering systemic vascular resistance. This suggests that iNO may prevent the need for extracorporeal membrane oxygenation (ECMO) during the hypoxic phase of PGF. During the intraoperative phase of transplantation, one-lung ventilation (OLV) and pulmonary artery clamping usually increase PVR, causing decreased right ventricular function and hemodynamic instability. The administration of iNO during these lung transplant procedures could decrease right ventricular dysfunction by reducing PVR and help to avoid the use of cardiopulmonary bypass.

Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial

CONTEXT

Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy. This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources.

OBJECTIVE

To determine the effectiveness of early tracheotomy (after 6-8 days of laryngeal intubation) compared with late tracheotomy (after 13-15 days of laryngeal intubation) in reducing the incidence of pneumonia and increasing the number of ventilator-free and intensive care unit (ICU)-free days.

DESIGN, SETTING, AND PATIENTS

Randomized controlled trial performed in 12 Italian ICUs from June 2004 to June 2008 of 600 adult patients enrolled without lung infection, who had been ventilated for 24 hours, had a Simplified Acute Physiology Score II between 35 and 65, and had a sequential organ failure assessment score of 5 or greater.

INTERVENTION

Patients who had worsening of respiratory conditions, unchanged or worse sequential organ failure assessment score, and no pneumonia 48 hours after inclusion were randomized to early tracheotomy (n = 209; 145 received tracheotomy) or late tracheotomy (n = 210; 119 received tracheotomy).

MAIN OUTCOME MEASURES

The primary endpoint was incidence of ventilator-associated pneumonia; secondary endpoints during the 28 days immediately following randomization were number of ventilator-free days, number of ICU-free days, and number of patients in each group who were still alive.

RESULTS

Ventilator-associated pneumonia was observed in 30 patients in the early tracheotomy group (14%; 95% confidence interval [CI], 10%-19%) and in 44 patients in the late tracheotomy group (21%; 95% CI, 15%-26%) (P = .07). During the 28 days immediately following randomization, the hazard ratio of developing ventilator-associated pneumonia was 0.66 (95% CI, 0.42-1.04), remaining connected to the ventilator was 0.70 (95% CI, 0.56-0.87), remaining in the ICU was 0.73 (95% CI, 0.55-0.97), and dying was 0.80 (95% CI, 0.56-1.15).

CONCLUSION

Among mechanically ventilated adult ICU patients, early tracheotomy compared with late tracheotomy did not result in statistically significant improvement in incidence of ventilator-associated pneumonia.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00262431.

Extracorporeal CO2 removal

The extracorporeal carbon dioxide removal (ECCO(2)R) concept, used as an integrated tool with conventional ventilation, plays a role in adjusting respiratory acidosis consequent to tidal volume (Vt) reduction in a protective ventilation setting. This concept arises from the extracorporeal membrane oxygenation (ECMO) experience. Kolobow and Gattinoni were the first to introduce extracorporeal support, with the intent to separate carbon dioxide removal from oxygen uptake; they hypothesized that to allow the lung to 'rest' oxygenation via mechanical ventilation could be dissociated from decarboxylation via extracorporeal carbon dioxide removal. Carbon dioxide is removed by a pump-driven modified ECMO machine with veno-venous bypass, while oxygenation is accomplished by high levels of positive end-expiratory pressure, with a respiratory rate of 3-5 breaths/min. The focus was that, in case of acute respiratory failure, CO(2) extraction facilitates a reduction in ventilatory support and oxygenation is maintained by simple diffusion across the patient's alveoli, called 'apneic oxygenation'. Concerns have been raised regarding the standard use of extracorporeal support because of the high incidence of serious complications: hemorrhage; hemolysis, and neurological impairments. Due to the negative results of a clinical trial, the extensive resources required and the high incidence of side effects, low frequency positive pressure ventilation ECCO(2)R was restricted to a 'rescue' therapy for the most severe case of acute respiratory distress syndrome (ARDS). Technological improvement led to the implementation of two different CO(2) removal approaches: the iLA called 'pumpless arteriovenous ECMO' and the veno-venous ECCO(2)R. They enable consideration of extracorporeal support as something more than mere rescue therapy; both of them are indicated in more protective ventilation settings in case of severe ARDS, and as a support to the spontaneous breathing/lung function in bridge to lung transplant. The future development of more and more efficient devices capable of removing a substantial amount of carbon dioxide production (30-100%) with blood flows of 250-500 ml/min is foreseeable. Moreover, in the future ARDS management should include a minimally invasive ECCO(2)R circuit associated with noninvasive ventilation. This would embody the modern mechanical ventilation philosophy: avoid tracheal tubes; minimize sedation, and prevent ventilator-induced acute lung injury and nosocomial infections.

Plasma levels of surfactant protein D and KL-6 for evaluation of lung injury in critically ill mechanically ventilated patients

Background

Preventing ventilator-associated lung injury (VALI) has become pivotal in mechanical ventilation of patients with acute lung injury (ALI) or its more severe form, acute respiratory distress syndrome (ARDS). In the present study we investigated whether plasma levels of lung-specific biological markers can be used to evaluate lung injury in patients with ALI/ARDS and patients without lung injury at onset of mechanical ventilation.

Methods

Plasma levels of surfactant protein D (SP-D), Clara Cell protein (CC16), KL-6 and soluble receptor for advanced glycation end-products (sRAGE) were measured in plasma samples obtained from 36 patients - 16 patients who were intubated and mechanically ventilated because of ALI/ARDS and 20 patients without lung injury at the onset of mechanical ventilation and during conduct of the study. Patients were ventilated with either a lung-protective strategy using lower tidal volumes or a potentially injurious strategy using conventional tidal volumes. Levels of biological markers were measured retrospectively at baseline and after 2 days of mechanical ventilation.

Results

Plasma levels of CC16 and KL-6 were higher in ALI/ARDS patients at baseline as compared to patients without lung injury. SP-D and sRAGE levels were not significantly different between these patients. In ALI/ARDS patients, SP-D and KL-6 levels increased over time, which was attenuated by lung-protective mechanical ventilation using lower tidal volumes (P = 0.02 for both biological markers). In these patients, with either ventilation strategy no changes over time were observed for plasma levels of CC16 and sRAGE. In patients without lung injury, no changes of plasma levels of any of the measured biological markers were observed.

Conclusion

Plasma levels of SP-D and KL-6 rise with potentially injurious ventilator settings, and thus may serve as biological markers of VALI in patients with ALI/ARDS.

Respiratory management of acute respiratory failure in neuromuscular diseases

Neuromuscular diseases (NMD) can affect all major respiratory muscles, leading to the development of respiratory failure, which is the most common cause of morbidity and mortality in patients affected by those conditions. Based on the clinical onset of acute respiratory failure (ARF), NMD can be classified into two main categories: 1) slowly progressive NMD with acute exacerbations of chronic respiratory failure, and 2) rapidly progressive NMD with acute episodes of respiratory failure. The most common slowly progressive NMDs, such as motor neuron diseases and inherited myopathies, account for the majority of NMD patients developing chronic neuromuscular respiratory failure at risk of acute exacerbations. Conversely, rapidly progressive NMDs, such as Guillain-Barré syndrome and myasthenic crises, are characterized by a sudden onset of ARF, usually in patients with previously normal respiratory function. The patho-physiological mechanisms responsible for ARF in NMD and the variety and complexity of specific challenges presented by the two main categories of NMD will be analyzed in this review, with the aim of providing clinically relevant suggestions for adequate respiratory management of these patients.

Invasive candidiasis and candidemia: new guidelines

Invasive candidiasis (IC) includes candidemia, disseminated candidiasis with deep organ involvement, endocarditis and meningitis. IC has an attributable mortality of 40% to 50% and is increasingly reported in intensive care units (ICUs). Candida albicans and non-albicans strains are both responsible for infections in ICUs, where empirical and targeted treatments especially need to be initially appropriate. This review synthesizes the most recent guidelines for IC and candidemia from an ICU perspective. Essentially, patients who have been previously exposed to azoles have a higher probability of being infected by azole-resistant or non-albicans strains. Infection site, illness severity, neutropenia, hemodynamic status, organ failure and concomitant drug treatments are host-related factors that influence the choice of anti-fungal treatment. In general, echinocandins are currently favored for empiric treatment of candidemia, especially in critically ill patients or those with previous azole exposure. Pharmacokinetic properties and side effects suggest that polyenes should be avoided in patients with renal failure, and that echinocandins and azoles should be avoided in patients with severe hepatic dysfunction.

Filtering out the noise: evaluating the impact of noise and sound reduction strategies on sleep quality for ICU patients

The review article by Xie and colleagues examines the impact of noise and noise reduction strategies on sleep quality for critically ill patients. Evaluating the impact of noise on sleep quality is challenging, as it must be measured relative to other factors that may be more or less disruptive to patients' sleep. Such factors may be difficult for patients, observers, and polysomnogram interpreters to identify, due to our limited understanding of the causes of sleep disruption in the critically ill, as well as the challenges in recording and quantifying sleep stages and sleep fragmentation in the intensive care unit. Furthermore, most research in this field has focused on noise level, whereas acousticians typically evaluate additional parameters such as noise spectrum and reverberation time. The authors highlight the disparate results and limitations of existing studies, including the lack of attention to other acoustic parameters besides sound level, and the combined effects of different sleep disturbing factors.

Epidemiology of mechanical ventilation: analysis of the SAPS 3 database

OBJECTIVE

To evaluate current practice of mechanical ventilation in the ICU and the characteristics and outcomes of patients receiving it.

DESIGN

Pre-planned sub-study of a multicenter, multinational cohort study (SAPS 3).

PATIENTS

13,322 patients admitted to 299 intensive care units (ICUs) from 35 countries.

INTERVENTIONS

None.

MAIN MEASUREMENTS AND RESULTS

Patients were divided into three groups: no mechanical ventilation (MV), noninvasive MV (NIV), and invasive MV. More than half of the patients (53% [CI: 52.2-53.9%]) were mechanically ventilated at ICU admission. FIO2, VT and PEEP used during invasive MV were on average 50% (40-80%), 8 mL/kg actual body weight (6.9-9.4 mL/kg) and 5 cmH2O (3-6 cmH2O), respectively. Several invMV patients (17.3% (CI:16.4-18.3%)) were ventilated with zero PEEP (ZEEP). These patients exhibited a significantly increased risk-adjusted hospital mortality, compared with patients ventilated with higher PEEP (O/E ratio 1.12 [1.05-1.18]). NIV was used in 4.2% (CI: 3.8-4.5%) of all patients and was associated with an improved risk-adjusted outcome (OR 0.79, [0.69-0.90]).

CONCLUSION

Ventilation mode and parameter settings for MV varied significantly across ICUs. Our results provide evidence that some ventilatory modes and settings could still be used against current evidence and recommendations. This includes ventilation with tidal volumes >8mL/kg body weight in patients with a low PaO2/FiO2 ratio and ZEEP in invMV patients. Invasive mechanical ventilation with ZEEP was associated with a worse outcome, even after controlling for severity of disease. Since our study did not document indications for MV, the association between MV settings and outcome must be viewed with caution.

Assessment of sleep in ventilator-supported critically III patients

OBJECTIVES

In critically ill patients, sleep derangements are reported to be severe using Rechtschaffen and Kales (R&K) methodology; however, whether such methodology can reliably assess sleep during critical illness is unknown. We set out to determine the reproducibility of 4 different sleep-assessment methods (3 manual and 1 computer-based) for ventilator-supported critically ill patients and also to quantify the extent to which the reproducibility of the manual methods for measuring sleep differed between critically ill and ambulatory (control) patients.

DESIGN

Observational methodologic study.

SETTING

Academic center.

PATIENTS

Critically ill patients receiving mechanical ventilation and age-matched controls underwent polysomnography.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Reproducibility for the computer-based method (spectral analysis of electroencephalography [EEG]) was better than that for the manual methods: R&K methodology and sleep-wakefulness organization pattern (P = 0.03). In critically ill patients, the proportion of misclassifications for measurements using spectral analysis, sleep-wakefulness organization pattern, and R&K methodology were 0%, 36%, and 53%, respectively (P < 0.0001). The EEG pattern of burst suppression was not observed. Interobserver and intraobserver reliability of the manual sleep-assessment methods for critically ill patients (kappa = 0.52 +/- 0.23) was worse than that for control patients (kappa = 0.89 +/- 0.13; P = 0.03). In critically ill patients, the overall reliability of the R&K methodology was relatively low for assessing sleep (kappa = 0.19), but detection of rapid eye movement sleep revealed good agreement (kappa = 0.70).

CONCLUSIONS

Reproducibility for spectral analysis of EEG was better than that for the manual methods: R&K methodology and sleep-wakefulness organization pattern. For assessment of sleep in critically ill patients, the use of spectral analysis, sleep-wakefulness organization state, or rapid eye movement sleep alone may be preferred over the R&K methodology.

Design, conduct, analysis and reporting of a multi-national placebo-controlled trial of activated protein C for persistent septic shock

The role of drotrecogin alfa (activated) (DAA) in severe sepsis remains controversial and clinicians are unsure whether or not to treat their patients with DAA. In response to a request from the European Medicines Agency, Eli Lilly will sponsor a new placebo-controlled trial and history suggests the results will be subject to great scrutiny. An academic steering committee will oversee the conduct of the study and will write the study manuscripts. The steering committee intends that the study will be conducted with the maximum possible transparency; this includes publication of the study protocol and a memorandum of understanding which delineates the role of the sponsor. The trial has the potential to provide clinicians with valuable data but patients will only benefit if clinicians have confidence in the conduct, analysis and reporting of the trial. This special article describes the process by which the trial was developed, major decisions regarding trial design, and plans for independent analysis, interpretation and reporting of the data.

Polymyxin-B hemoperfusion inactivates circulating proapoptotic factors

Objective

To test the hypothesis that extracorporeal therapy with polymyxin B (PMX-B) may prevent Gram-negative sepsis-induced acute renal failure (ARF) by reducing the activity of proapoptotic circulating factors.

Setting

Medical-Surgical Intensive Care Units.

Patients and interventions

Sixteen patients with Gram-negative sepsis were randomized to receive standard care (Surviving Sepsis Campaign guidelines) or standard care plus extracorporeal therapy with PMX-B.

Measurements and results

Cell viability, apoptosis, polarity, morphogenesis, and epithelial integrity were evaluated in cultured tubular cells and glomerular podocytes incubated with plasma from patients of both groups. Renal function was evaluated as SOFA and RIFLE scores, proteinuria, and tubular enzymes. A significant decrease of plasma-induced proapoptotic activity was observed after PMX-B treatment on cultured renal cells. SOFA and RIFLE scores, proteinuria, and urine tubular enzymes were all significantly reduced after PMX-B treatment. Loss of plasma-induced polarity and permeability of cell cultures was abrogated with the plasma of patients treated with PMX-B. These results were associated to a preserved expression of molecules crucial for tubular and glomerular functional integrity.

Conclusions

Extracorporeal therapy with PMX-B reduces the proapoptotic activity of the plasma of septic patients on cultured renal cells. These data confirm the role of apoptosis in the development of sepsis-related ARF.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-008-1124-6) contains supplementary material, which is available to authorized users.

Helmet ventilation and carbon dioxide rebreathing: effects of adding a leak at the helmet ports

OBJECTIVE

We examined whether additional helmet flow obtained by a single-circuit and a modified plateau valve applied at the helmet expiratory port (open-circuit ventilators) improves CO(2) wash-out by increasing helmet airflow.

DESIGN AND SETTING

Randomized physiological study in a university research laboratory.

PARTICIPANTS

Ten healthy volunteers.

INTERVENTIONS

Helmet continuous positive airway pressure and pressure support ventilation delivered by an ICU ventilator (closed-circuit ventilator) and two open-circuit ventilators equipped with a plateau valve placed either at the inspiratory or at the helmet expiratory port.

MEASUREMENTS AND RESULTS

We measured helmet air leaks, breathing pattern, helmet minute ventilation (Eh)), minute ventilation washing the helmet (Ewh)), CO(2) wash-out, and ventilator inspiratory assistance. Air leaks were small and similar in all conditions. Breathing pattern was similar among the different ventilators. Inspiratory and end-tidal CO(2) were lower, while (Eh) and (Ewh) were higher only using open-circuit ventilators with the plateau valve placed at the helmet expiratory port. This occurred notwithstanding these ventilators delivered a lower inspiratory assistance.

CONCLUSIONS

Additional helmet flow provided by open-circuit ventilators can lower helmet CO(2) rebreathing. However, inspiratory pressure assistance significantly decreases using open-circuit ventilators, still casting doubts on the choice of the optimal helmet ventilation setup.

Diagnosis of ventilator-associated pneumonia: a systematic review of the literature

INTRODUCTION

Early, accurate diagnosis is fundamental in the management of patients with ventilator-associated pneumonia (VAP). The aim of this qualitative review was to compare various criteria of diagnosing VAP in the intensive care unit (ICU) with a special emphasis on the value of clinical diagnosis, microbiological culture techniques, and biomarkers of host response.

METHODS

A MEDLINE search was performed using the keyword 'ventilator associated pneumonia' AND 'diagnosis'. Our search was limited to human studies published between January 1966 and June 2007. Only studies of at least 25 adult patients were included. Predefined variables were collected, including year of publication, study design (prospective/retrospective), number of patients included, and disease group.

RESULTS

Of 572 articles fulfilling the initial search criteria, 159 articles were chosen for detailed review of the full text. A total of 64 articles fulfilled the inclusion criteria and were included in our review. Clinical criteria, used in combination, may be helpful in diagnosing VAP, however, the considerable inter-observer variability and the moderate performance should be taken in account. Bacteriologic data do not increase the accuracy of diagnosis as compared to clinical diagnosis. Quantitative cultures obtained by different methods seem to be rather equivalent in diagnosing VAP. Blood cultures are relatively insensitive to diagnose pneumonia. The rapid availability of cytological data, including inflammatory cells and Gram stains, may be useful in initial therapeutic decisions in patients with suspected VAP. C-reactive protein, procalcitonin, and soluble triggering receptor expressed on myeloid cells are promising biomarkers in diagnosing VAP.

CONCLUSION

An integrated approach should be followed in diagnosing and treating patients with VAP, including early antibiotic therapy and subsequent rectification according to clinical response and results of bacteriologic cultures.

Circulating plasma factors induce tubular and glomerular alterations in septic burns patients

Background

Severe burn is a systemic illness often complicated by sepsis. Kidney is one of the organs invariably affected, and proteinuria is a constant clinical finding. We studied the relationships between proteinuria and patient outcome, severity of renal dysfunction and systemic inflammatory state in burns patients who developed sepsis-associated acute renal failure (ARF). We then tested the hypothesis that plasma in these patients induces apoptosis and functional alterations that could account for proteinuria and severity of renal dysfunction in tubular cells and podocytes.

Methods

We studied the correlation between proteinuria and indexes of systemic inflammation or renal function prospectively in 19 severe burns patients with septic shock and ARF, and we evaluated the effect of plasma on apoptosis, polarity and functional alterations in cultured human tubular cells and podocytes. As controls, we collected plasma from 10 burns patients with septic shock but without ARF, 10 burns patients with septic shock and ARF, 10 non-burns patients with septic shock without ARF, 10 chronic uremic patients and 10 healthy volunteers.

Results

Septic burns patients with ARF presented a severe proteinuria that correlated to outcome, glomerular (creatinine/urea clearance) and tubular (fractional excretion of sodium and potassium) functional impairment and systemic inflammation (white blood cell (WBC) and platelet counts). Plasma from these patients induced a pro-apoptotic effect in tubular cells and podocytes that correlated with the extent of proteinuria. Plasma-induced apoptosis was significantly higher in septic severe burns patients with ARF with respect to those without ARF or with septic shock without burns. Moreover, plasma from septic burns patients induced an alteration of polarity in tubular cells, as well as reduced expression of the tight junction protein ZO-1 and of the endocytic receptor megalin. In podocytes, plasma from septic burns patients increased permeability to albumin and decreased the expression of the slit diaphragm protein nephrin.

Conclusion

Plasma from burns patients with sepsis-associated ARF contains factors that affect the function and survival of tubular cells and podocytes. These factors are likely to be involved in the pathogenesis of acute tubular injury and proteinuria, which is a negative prognostic factor and an index of renal involvement in the systemic inflammatory reaction.

Effectiveness of polymyxin B-immobilized fiber column in sepsis: a systematic review

INTRODUCTION

Severe sepsis and septic shock are common problems in the intensive care unit and carry a high mortality. Endotoxin, one of the principal components on the outer membrane of gram-negative bacteria, is considered important to their pathogenesis. Polymyxin B bound and immobilized to polystyrene fibers (PMX-F) is a medical device that aims to remove circulating endotoxin by adsorption, theoretically preventing the progression of the biological cascade of sepsis. We performed a systematic review to describe the effect in septic patients of direct hemoperfusion with PMX-F on outcomes of blood pressure, use of vasoactive drugs, oxygenation, and mortality reported in published studies.

METHODS

We searched PubMed, the Cochrane Collaboration Database, and bibliographies of retrieved articles and consulted with experts to identify relevant studies. Prospective and retrospective observational studies, pre- and post-intervention design, and randomized controlled trials were included. Three authors reviewed all citations. We identified a total of 28 publications - 9 randomized controlled trials, 7 non-randomized parallel studies, and 12 pre-post design studies - that reported at least one of the specified outcome measures (pooled sample size, 1,425 patients: 978 PMX-F and 447 conventional medical therapy).

RESULTS

Overall, mean arterial pressure (MAP) increased by 19 mm Hg (95% confidence interval [CI], 15 to 22 mm Hg; p < 0.001), representing a 26% mean increase in MAP (range, 14% to 42%), whereas dopamine/dobutamine dose decreased by 1.8 microg/kg per minute (95% CI, 0.4 to 3.3 microg/kg per minute; p = 0.01) after PMX-F. There was significant intertrial heterogeneity for these outcomes (p < 0.001), which became non-significant when analysis was stratified for baseline MAP. The mean arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio increased by 32 units (95% CI, 23 to 41 units; p < 0.001). PMX-F therapy was associated with significantly lower mortality risk (risk ratio, 0.53; 95% CI, 0.43 to 0.65). The trials assessed had suboptimal method quality.

CONCLUSION

Based on this critical review of the published literature, direct hemoperfusion with PMX-F appears to have favorable effects on MAP, dopamine use, PaO2/FiO2 ratio, and mortality. However, publication bias and lack of blinding need to be considered. These findings support the need for further rigorous study of this therapy.

SPIR01 and SPIR02: a two-year 1-day point prevalence multicenter study of infections in intensive care units in Piedmont, Italy

This study reports the results of a one-day point prevalence study of infections performed in 2001 (SPIR01) and 2002 (SPIR02) in a Regional network of ICUs in Piedmont, Italy. The study aims were to illustrate the overall proportion of infected patients and the rate of ICU-acquired infections. Mortality rate was evaluated three weeks after the study days. Resistance pattern of Staphylococcus aureus, coagulase negative Staphylococci and Pseudomonas aeruginosa were recorded. The primary end-point of the study was to document the prevalence and associated risk factors of the ICU-acquired infections, and the impact of infections on mortality. The prevalence of ICU-acquired infection was 30% in SPIR01, and 38.3% in SPIR02. The rate of methicillin-resistance was high among isolates of Staphylococcus aureus and coagulase-negative Staphylococci. The prevalence of ICU-acquired infections was lower than that reported in the EPIC study. In our experience, this Regional survey stimulated further research and collaboration to improve the prophylaxis, diagnosis and treatment of ICU-acquired infections.