Effects of hyperoxemia in patients with sepsis - A post-hoc analysis of a multicentre randomized clinical trial

BACKGROUND

Administration of supplemental oxygen is a life-saving treatment in critically ill patients. Still, optimal dosing remains unclear during sepsis. The aim of this post-hoc analysis was to assess the association between hyperoxemia and 90-day mortality in a large cohort of septic patients.

METHODS

This is a post-hoc analysis of the Albumin Italian Outcome Sepsis (ALBIOS) randomized controlled trial (RCT). Patients with sepsis who survived the first 48 h since randomization were included and stratified into two groups according to their average PaO2 levels during the first 48 h (PaO2 0-48 h). The cut-off value was established at 100 mmHg (average PaO2 0-48  h >100 mmHg: hyperoxemia group; PaO2 0-48h≤100: normoxemia group). The primary outcome was 90-day mortality.

RESULTS

1632 patients were included in this analysis (661 patients in the hyperoxemia group, 971 patients in the normoxemia group). Concerning the primary outcome, 344 (35.4%) patients in the hyperoxemia group vs. 236 (35.7%) in the normoxemia group had died within 90 days from randomization (p = 0.909). No association was found after adjusting for confounders (HR 0.87; CI [95%] 0.736-1.028, p = 0.102) or after excluding patients with hypoxemia at enrollment, patients with lung infection or including post-surgical patients only. Conversely, we found an association between lower risk of 90-day mortality and hyperoxemia in the subgroup including patients who had the lung as primary site of infection (HR 0.72; CI [95%] 0.565-0.918). Mortality at 28 days, ICU mortality, incidence of acute kidney injury, use of renal replacement therapy, days to suspension of vasopressor or inotropic agents, and resolution of primary and secondary infections did not differ significantly. Duration of mechanical ventilation and length of stay in ICU were significantly longer in patients with hyperoxemia.

CONCLUSIONS

In a post-hoc analysis of a RCT enrolling septic patients, hyperoxemia as average PaO2>100 mmHg during the first 48 h was not associated with patients' survival.

Exploring the association between happy hypoxia and Coronavirus disease 2019 in the triage phase

BACKGROUND

Patients with severe coronavirus disease 2019 (COVID-19) have been reported to show hypoxia without displaying typical clinical signs or symptoms, called "happy hypoxia." To explore the potential of happy hypoxia as a distinctive symptom of COVID-19, we compared vital signs in the triage phase between patients with and without COVID-19.

METHODS

We retrospectively identified emergency patients with and without COVID-19 admitted to Rakuwakai Marutamachi Hospital, Kyoto, Japan, between January 2021 and December 2021.

RESULTS AND CONCLUSIONS

317 patients were analyzed. Multivariate logistic regression analysis, including all vital signs, demonstrated that the respiratory rate was not statistically associated with COVID-19 (odds ratio, 0.94, p = 0.058), suggesting that happy hypoxia may not be a distinct hallmark of COVID-19.

Plasma Trough Concentrations of Beta-Lactam Antibiotics in the Early Phase of Septic Shock

INTRODUCTION

Septic shock necessitates timely antibiotic therapy, often with broad-spectrum beta-lactam antibiotics (ß-LA). To our knowledge, no previous study has examined antibiotic concentrations repeatedly during the initial phase of treatment. This observational study aimed to assess early-phase plasma concentrations of ß-LA in patients with septic shock.

METHOD

Prospective observational study of patients with septic shock, according to the SEPSIS-3 criteria, who received cefotaxime, piperacillin/tazobactam, or meropenem in accordance with Swedish practice. Demographic and clinical data were recorded for each patient. Consecutive blood samples were obtained during the first 24 h of treatment, and total antibiotic concentrations were measured using liquid chromatography mass spectrometry. Target concentrations were defined as 100% of the time that free (unbound) antibiotic concentrations remained above the minimal inhibitory concentration (fT > MIC).

RESULTS

Twenty-two patients were included, 15 (68%) were male and the median age was 65.5 years (IQR 46.3-65.5). In-hospital mortality was 7/22 (32%). Antibiotic exposure exceeding 100% fT > MIC was achieved in 16 (73%) of the patients. Four patients did not receive the recommended additional dose between the first and second doses of antibiotics; two of them still achieved 100% fT > MIC, whereas the other two attained 66% and 33% fT > MIC, respectively. Among the patients who received the additional dose, four did not achieve 100% fT > MIC. No relationship between mortality and fT > MIC was observed. Significant associations with achieving 100% fT > MIC were observed for older age (p = 0.045) and illness severity (SAPS3, p = 0.025).

CONCLUSION

Our findings demonstrate considerable variability in antibiotic exposure during the initial 24 h of septic shock treatment, highlighting a critical gap in understanding the clinical relevance of sub-optimal serum antibiotic concentrations and their potential impact on patient outcomes.

EDITORIAL COMMENT

Therapeutic drug monitoring of antimicrobials is increasingly being used in research and clinical practice.

Impact of laser acupuncture on gastrointestinal function recovery in patients after acute appendicitis surgery: A retrospective clinical study

BACKGROUND

Laparoscopic surgery has emerged as the preferred treatment for acute appendicitis, a common acute abdominal condition. Despite surgical advances, postoperative gastrointestinal dysfunction and delayed recovery continue to negatively impact rehabilitation outcomes and patient quality of life. Laser acupuncture represents a promising emerging complementary therapy with potential benefits for promoting functional recovery.

AIM

To evaluate the clinical efficacy of laser acupuncture in enhancing gastrointestinal function recovery following laparoscopic appendectomy and to investigate its potential applications in postoperative rehabilitation.

METHODS

This retrospective controlled clinical study selected 120 acute appendicitis patients who underwent laparoscopic appendectomy from January 2022 to December 2023 at a tertiary hospital. Patients were randomly divided into two groups: Routine treatment group (n = 60) and laser acupuncture intervention group (n = 60). There were no significant statistical differences in baseline characteristics (age, gender, body mass index, appendicitis severity) between the two groups. The routine treatment group received standard postoperative care, while the laser acupuncture intervention group received additional laser acupuncture treatment on top of standard care. Key observation indicators included time to first exhaust, time to first bowel movement, time to gastrointestinal function recovery, and postoperative complication rates.

RESULTS

Patients in the laser acupuncture intervention group showed significantly faster gastrointestinal function recovery compared to the routine treatment group. Specifically, time to first exhaust was significantly shortened (intervention group: 12.5 ± 2.3 hours vs control group: 18.7 ± 3.1 hours, P < 0.05), time to first bowel movement was earlier (intervention group: 36.4 ± 4.6 hours vs control group: 48.2 ± 5.7 hours, P < 0.05), postoperative complication rate was significantly reduced (intervention group: 8.3% vs control group: 20.0%, P < 0.05), postoperative pain score was significantly lower (intervention group: 3.2 ± 1.1 vs control group: 4.7 ± 1.5, P < 0.05), and intestinal motility recovery was faster and more effective.

CONCLUSION

Laser acupuncture, as an auxiliary treatment method, can significantly promote gastrointestinal function recovery in patients after laparoscopic appendectomy, reduce complications, and improve postoperative comfort. This technique has advantages such as minimal invasiveness, rapid recovery, and few side effects, making it worthy of further clinical promotion and application.

Decoding portal vein pulsatility: hemodynamic determinants in a post-hoc analysis of a prospective observational trial

BACKGROUND

The portal vein pulsatility index (PVPI) reflects systemic congestion and is influenced by both volume status and right ventricular (RV) function. The mean systemic filling pressure analogue (Pmsa), derived from a mathematical model, estimates the interaction between stressed blood volume and systemic vascular compliance, serving as surrogate marker of volume status. This post-hoc analysis of an observational trial investigates the combined role of Pmsa and RV function as determinants of PVPI using echocardiography. Fifty-five mechanically ventilated patients with circulatory failure were included within 6 h of ICU admission following elective open-heart surgery. Fluid-tolerant patients (PVPI < 50%) underwent a passive leg raising (PLR) test; fluid-responsive patients subsequently received 7 mL/kg of Ringer's lactate. PVPI and Pmsa were measured at five timepoints: baseline (T1), after PLR (T2), upon returning to baseline (T3), after fluid administration (T4), and 20 min post-infusion (T5). RV function parameters, including RV to LV end-diastolic area ratio (RVEDA/LVEDA), tricuspid lateral annular systolic velocity (RV S'), RV fractional area change (RVFAC), pulmonary acceleration time (PAT), and right myocardial performance index (RIMP)-were assessed at T1, T4, and T5. Only fluid-responsive patients were evaluated beyond T3.

RESULTS

At T1, robust multilinear regression including all patients identified RVEDA/LVEDA (β = 10.38; p < 0.001), RIMP (β = - 6.54; p = 0.002), and RV S' (β = - 0.60; p = 0.002) as significant determinants of squared PVPI. In all patients, repeated measures correlation between Pmsa and PVPI was strong across T1-to-T3 (ρ = 0.785; p < 0.001), increasing from a non-significant correlation at T1 (ρ = 0.215; p = 0.115). Generalized estimating equations conducted only in fluid-responsive patients across T1, T4, and T5 identified Pmsa (β = 4.19; p < 0.001), RV S' (β = - 5.84; p < 0.001), RVEDA/LVEDA (β = 34.85; p = 0.018), and RIMP (β = - 35.28; p = 0.039) as significant determinants of PVPI.

CONCLUSION

RV function and Pmsa are key determinants of PVPI. Their combined assessment may support an individualized congestion management by guiding interventions toward volume status, RV function, or both. Trial registration Primary Trial Registration: NCT06440772. Registered 30 May 2024. Retrospectively registered.

Venous excess ultrasound: A mini-review and practical guide for its application in critically ill patients

Advancements in healthcare technology have improved mortality rates and extended lifespans, resulting in a population with multiple comorbidities that complicate patient care. Traditional assessments often fall short, underscoring the need for integrated care strategies. Among these, fluid management is particularly challenging due to the difficulty in directly assessing volume status especially in critically ill patients who frequently have peripheral oedema. Effective fluid management is essential for optimal tissue oxygen delivery, which is crucial for cellular metabolism. Oxygen transport is dependent on arterial oxygen levels, haemoglobin concentration, and cardiac output, with the latter influenced by preload, afterload, and cardiac contractility. A delicate balance of these factors ensures that the cardiovascular system can respond adequately to varying physiological demands, thereby safeguarding tissue oxygenation and overall organ function during states of stress or illness. The Venous Excess Ultrasound (VExUS) Grading System is instrumental in evaluating fluid intolerance, providing detailed insights into venous congestion and fluid status. It was originally developed to assess the risk of acute kidney injury in postoperative cardiac patients, but its versatility has enabled broader applications in nephrology and critical care settings. This mini review explores VExUS's application and its impact on fluid management and patient outcomes in critically ill patients.

Prophylactic drain placement after emergency general surgery procedures? A scoping review of the literature challenging common practice

BACKGROUND

This scoping review aims to map the existing literature on the use of prophylactic drainage (PD) after Emergency General Surgery procedures (EGS) and to change the current practice according to evidence.

METHODOLOGY

Data from an exhaustive literature search conducted across Embase (Ovid), Medline(R) ALL (Ovid), Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials was summarized. Literature published between January 2013 and December 2024 was included.

RESULTS

Most studies found better outcomes for the no-drain group. Implementing a drain after EGS procedures potentially increases hospital stays, postoperative pain, and surgical site infection rates. For conditions such as peritonitis and perforated ulcers, only a few studies were available, with some showing benefits of PD.

CONCLUSION

For some conditions, like colorectal emergencies, there is a scarcity of evidence. The outcomes suggest that PD is not recommended in most EGS cases. In high-risk cases, there are some reports on improved outcomes for PD use. Further research is imperative to create science-based clinical guidelines, especially for less-researched conditions.

Development and Validation of a High-Performance Liquid Chromatography-Ultraviolet Spectrometry Method for Ampicillin and Its Application in Routine Therapeutic Drug Monitoring of Intensive Care Patients

BACKGROUND

Ampicillin/sulbactam, a combination of a β-lactam and β-lactamase inhibitor, is widely used in clinical settings. However, therapeutic drug monitoring (TDM) of ampicillin is not commonly performed, particularly in intensive care units (ICUs). The purpose of this study was to develop and validate a rapid and cost-effective high-performance liquid chromatography (HPLC)-ultraviolet spectrometry method to quantify ampicillin in human serum and evaluate its clinical application in ICU patients.

METHODS

Sample cleanup included a protein precipitation protocol, followed by chromatographic separation on a C18 reverse-phase HPLC column within 12.5 minutes using gradient elution of the mobile phase. The assay was validated according to the German Society of Toxicology and Forensic Chemistry criteria. Clinical applications involved the retrospective analysis of TDM data from ICU patients receiving continuous infusion of ampicillin/sulbactam, including the attainment of target ranges and individual predicted and observed pharmacokinetics.

RESULTS

The method was robust, with linear relations between the peak area responses and drug concentrations in the range of 2-128 mg/L. The coefficient of variation for precision and the bias for accuracy (both interday and intraday) were less than 10%. Clinical application revealed variable pharmacokinetics of ampicillin in ICU patients (clearance of 0.5-31.2 L/h). TDM-guided dose adjustments achieved good therapeutic drug exposure, with 92.9% of the samples being within the optimal (16-32 mg/L) or quasioptimal (8-48 mg/L) range.

CONCLUSIONS

This method provides a practical solution for the routine TDM of ampicillin, facilitating individualized dosing strategies to ensure adequate therapeutic drug exposure. Given its simplicity, cost-effectiveness, and clinical relevance, HPLC-ultraviolet spectrometry holds promise for broad implementation in hospital pharmacies and clinical laboratories.

Microcirculation properties of 20 % albumin in sepsis; a randomised controlled trial

INTRODUCTION

Sepsis and septic shock are associated with microcirculatory dysfunction, significantly impacting patient outcomes. This study aimed to evaluate the effects of a 20 % albumin bolus on microcirculation compared to crystalloid resuscitation in fluid-responsive patients (ClinicalTrials.govID:NCT05357339).

METHODS

We conducted a single-centre randomised controlled trial, enrolling 103 patients (Albumin n = 52, Control n = 51). Fluid responsiveness was assessed, and fluid was administered in boluses of 100 ml to clinical effect. Microcirculation was measured using the Side stream Dark Field camera and AVA 4.3 software. Baseline characteristics, macrohaemodynamics, and microcirculation parameters were recorded. Three patients were excluded from analysis.

RESULTS

The final cohort comprised 100 patients, 35 (35 %) females with a mean age of 58 years (range: 18-86). The mean APACHE score was 28 (range: 7-45), and the mean SOFA score was 9.4 (range: 1-17). No significant differences in APACHE (26.24 vs. 29.4, p = 0.069) or SOFA (9.08 vs. 9.78, p = 0.32) scores were found for albumin and control group respectively. The albumin group had worse microcirculation at baseline but demonstrated significant improvements in microvascular density and activity at 15 min and 60 min (p < 0.005), while the control group exhibited no significant changes. Additionally, both groups were fluid responsive, with a mean pulse pressure variability of 17 % at admission. There were no significant differences in overall fluid balances, vasopressor days, length of ICU stay, or mortality between groups.

CONCLUSION

This study demonstrates that a 20 % albumin bolus significantly enhances microcirculation in fluid-responsive patients with septic shock. These findings underscore the potential benefits of targeted microcirculation therapy in critically ill patients.

[Specialty-specific knowledge as prerequisite for effective treatment of critically ill patients]

Since the last meeting of the German Medical Association in May 2024, there has been a discussion in Germany about the shortening of primary specialty training and a transfer of the contents of additional supra-specialty training to the existing primary specialty training. This also affects intensive care medicine, with the prospect of creating a subspecialty for subspecialties in intensive care medicine (e.g., a specialty in surgical intensive care medicine). We consider the associated reduction of general specialty-specific contents to be inappropriate for several reasons. Knowledge of the specialty-specific trigger factors (foci) of a critical illness (organ dysfunction) as well as knowledge of the respective trigger factor-specific symptoms, diagnostics and pathways for initiating a causal treatment, are decisive for the prognosis. Recent evidence suggests that in the case of septic foci a time span between making the diagnosis and treatment of the focus should not exceed ca. 6h in order to avoid a worsening of the prognosis. To ensure that the time between symptom onset and effective treatment of the causal factors is not too long, an in-depth expertise in the primary specialty is required throughout the process. This expertise is independent of training in intensive care medicine and can only be acquired through adequate training in the specialty, followed by additional training in intensive care medicine. Expertise in the primary specialty is a prerequisite for the effective treatment of critically ill patients. Maintaining the training specific to the primary specialty and the associated acquisition of specific knowledge in the respective specialty also enables a wider deployment of specialists in clinical practice and a more economical use of diagnostic and therapeutic resources. The additional training in intensive care medicine (supraspecialty) should not be at the expense of content specific to the primary specialty and must remain accessible to all surgical specialties in the field of surgery in the next revision of the training regulations. Due to the unavoidable extent, the additional training in intensive care medicine can itself only be provided on a full-time basis.

Positive End-Expiratory Pressure Titration Based on Lung Mechanics May Improve Pulse Pressure Variation Interpretation in Acute Respiratory Distress Syndrome Patients

OBJECTIVES

To evaluate the effects of positive end-expiratory pressure (PEEP) on pulse pressure variation (PPV) in patients with moderate/severe acute respiratory distress syndrome (ARDS).

DESIGN

Prospective interventional self-controlled study.

SETTING

University Hospital of Larissa.

PATIENTS

ARDS patients admitted intubated in the ICU (from August 2020 to March 2022).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

PPV and inferior vena cava (IVC) respiratory variability were evaluated at two PEEP levels (first value mainly based on PEEP/Fio2 and second value based on respiratory system compliance). Additionally, respiratory mechanics, hemodynamics, and echocardiographic indices assessing right ventricular (RV) size (RV end-diastolic area/left ventricular end-diastolic area [RVEDA/LVEDA]), RV systolic function, and RV afterload (pulmonary artery systolic pressure [PASP] and PASP/left ventricular outflow tract velocity time integral [PASP/VTILVOT]) were recorded. Ninety-five patients were evaluated. PPV decreased after PEEP reduction (11.7 ± 0.2 to 7.9% ± 0.2%), whereas IVC respiratory variability increased (9.1 ± 0.9 to 14.6% ± 0.1%) and central venous pressure decreased (all p < 0.0001). RV afterload indices decreased (p < 0.0001), simultaneously with RV size (< 0.0001) and systolic function indices' improvements (< 0.05); shock warranted less noradrenaline doses. The change in PPV correlated significantly to respiratory variability in IVC diameter distensibility (p < 0.0001) and moderately to changes in RV size and systolic function (change in RVEDA/change in LVEDA, change in tricuspid annular plane systolic excursion); RV afterload (change in PASP [ΔPASP], ΔPASP/VTILVOT); and change in Paco2 (all p < 0.05).

CONCLUSIONS

PPV alteration with PEEP decrease, associated with IVC distensibility increases, may indicate the presence of RV dysfunction and increased pulmonary vascular resistances. Whether the patients are in need for fluid loading, fluid responsiveness assessment may be further warranted.

A Plant-Based Dietary Supplement Exhibits Significant Effects on Markers of Oxidative Stress, Inflammation, and Immune Response in Subjects Recovering from Respiratory Viral Infection: A Randomized, Double-Blind Clinical Study Using Vitamin C as a Positive Control

Respiratory viruses continue to present serious health challenges to human wellness. Growing evidence suggests that the more severe and damaging effects and symptoms of influenza, rhinovirus (RV), respiratory syncytial virus (RSV), and COVID-19 may primarily result from their common ability to disorganize the body's healthy immune response. The simultaneous over-stimulation of several reactive oxygen species (ROS) pathways and concurrent suppression of bioavailable Nitic Oxide (NO) contribute to an immune disbalance that can lead to cellular oxidative distress and an excessive inflammatory response. This study evaluated the real-time, acute ability of a single, orally administered 50 mg encapsulated dose of a plant-based dietary supplement ("PB-Blend"), compared to 1000 mg of Vitamin C as a positive control, to modulate multiple ROS associated with a dampened immune response, as well as NO and other markers of inflammation, in a cohort recovering from a moderate course of COVID-19. This randomized, double-blind study was performed on 28 individuals 18-24 days after a moderate COVID-19 infection. Participants were orally supplemented with a single encapsulated dose of either 50 mg of PB-Blend or 1000 mg Vitamin C as a positive control. Changes in the levels of bioavailable NO (measured as circulating NOHb) were assessed, as well as the ex vivo cellular formation of mitochondrial, NOX2-, iNOS-, and TNFα-dependent ROS. All parameters were measured in real time before ingestion (baseline), and then at 30, 60, 120, and 180 min after administration. ROS were measured using a portable electron paramagnetic resonance (EPR) spectrometer. Inflammatory, immunity (hsCRP and TNFα plasma levels), interleukin (IL1, IL6, IL8, and IL10), cytokine (IFNγ, TNFα, and NF-κB), and immunoglobulin (IgA, IgM, IgG, and IgE) profiles were also followed. In addition to laboratory and cell function investigations, we performed clinical cardio ergometry, blood O2 saturation, and respirometry examinations. As hypothesized, the collected baseline data from this study group confirmed that mitochondrial, NOX2, and iNOS enzymatic systems were strongly involved in the generation of ROS at 18-24 days following a positive COVID-19 PCR test. Acute single-dose supplementation of 50 mg PB-Blend had a multifunctional impact on ROS and significantly inhibited the following: (a.) mitochondrial ROS levels by up to 56%; (b.) iNOS by up to 60%; and (c.) NOX2-dependent ROS generation by up to 49%. Moreover, 1000 mg Vitamin C supplementation exhibited narrower ROS-mitigating activity by solely inhibiting NOX2-dependent ROS generation by 45%. Circulating NOHb levels were significantly increased after PB-Blend administration (33%), but not after Vitamin C administration. PB-Blend and Vitamin C exhibited similar potential to reduce ex vivo high dose TNFα (200 ng/mL)-induced H2O2 formation. These results suggest that 50 mg of PB-Blend has the potential to modulate disbalanced mitochondria, iNOS, and NOX2 enzymatic systems that can be engendered during respiratory viral infection and subsequent recovery. Moreover, PB-Blend, but not Vitamin C, showed potential to upregulate bioavailable NO, which is known to decline under these conditions. Based upon these observations, PB-Blend could be considered an alternative to, or to be used in tandem with Vitamin C in applications that promote immune support and recovery during seasons of heightened respiratory viral risk (e.g., "flu season").

Left Atrial Strain-Current Review of Clinical Applications

Left atrial strain has gained significant attention in recent years due to its potential to provide valuable insights into the function and mechanics of the left atrium. This review aims to evaluate the current applications of LA strain in clinical practice, particularly in assessing various cardiac conditions, including heart failure, atrial fibrillation, valvular heart disease, and coronary artery disease. We summarize the latest evidence regarding the role of left atrial strain in assessing left atrial remodeling, predicting outcomes, and its potential use as a prognostic tool. Unlike previous reviews focusing on single disease states, this review synthesizes emerging data across multiple cardiac conditions, highlighting novel implications for clinical practice. Left atrial strain emerges as a promising non-invasive marker for evaluating atrial function and guiding clinical decision-making. However, further research must fully establish its role across diverse patient populations and clinical settings.

First dose target attainment with extended infusion regimens of piperacillin and meropenem

BACKGROUND

Standard dosing regimens of meropenem and piperacillin-tazobactam frequently fail to achieve targeted plasma concentrations in critically ill patients. Extended or continuous regimens are often used to improve target attainment. Although prompt antibiotic initiation is a major determinant of survival, few studies have reported systemic concentrations early after treatment initiation. No prior study has reported concentrations immediately after the loading dose and first extended infusion. This study aimed to evaluate plasma target attainment during the first dosing interval with an extended infusion regimen in a general intensive care unit (ICU).

METHODS

Adult ICU patients were prospectively included in conjunction with the first administration of meropenem or piperacillin-tazobactam. Treatment was initiated with a 0.5 h loading dose immediately followed by a 3 h extended infusion; typically 4 + 4 g piperacillin or 1(- 2)g + 1(- 2)g meropenem, in line with the local ICU protocol. Patients requiring renal replacement therapy were excluded. Plasma concentrations were measured post-loading dose (Cmax), near the end of the first extended infusion, and at the end of the first dosing interval (Cmin). Samples were analyzed using validated tandem mass spectrometry (UHPLC-MS/MS) methods. The primary endpoint was the proportion of patients achieving 100% time above minimum inhibitory concentrations (fT > MIC) during the first dosing interval. This was evaluated using observed Cmin above 2 mg/L (meropenem) and 20 mg/L (piperacillin). Additionally, published pharmacokinetic models were applied to the observed data for %fT > MIC estimation, using an a posteriori Bayesian approach.

RESULTS

We included 65 meropenem and 142 piperacillin measurements from 22 and 48 patients, respectively. Many patients (45% meropenem, 38% piperacillin) failed to reach 100% fT > MIC with the standard regimens used. Target non-attainment was associated with high estimated glomerular filtration rates (eGFR) and suspected augmented renal clearance (ARC). All meropenem patients that failed to reach target had eGFR > 90 mL/min/1.73 m2, as did 76% of corresponding piperacillin patients. Patients with suspected ARC frequently exhibited a tenfold or greater peak-to-trough decline (Cmin/Cmax < 0.1).

CONCLUSIONS

Despite aggressive dosing, plasma concentrations often fail to reach 100% fT > MIC during the first dosing interval. Alternative regimens and early plasma concentration measurements followed by adaptive dose adjustments should be considered to improve target attainment.

Vacuum-assisted closure or primary closure with relaparotomy on-demand in patients with secondary peritonitis: a systematic review and meta-analysis

BACKGROUND

Secondary peritonitis is a serious condition with significant morbidity and mortality. Its management requires emergency laparotomy for source control. Vacuum-assisted closure (VAC) and primary abdominal closure (PAC) are the main strategies for managing the laparostomy after source control. Despite the increasing use of VAC, concerns persist regarding its complications and long-term outcomes compared with PAC.

METHODS

This systematic review followed PRISMA 2020 and MOOSE. The Cochrane Risk of Bias (RoB 2) tool, MINORS and GRADE framework assessed study quality and evidence certainty. The protocol was registered in PROSPERO (CRD42022304724). A comprehensive search of MEDLINE, Embase, and the Cochrane Library from January 2004 to August 2024 identified studies reporting postoperative outcomes following VAC or PAC after laparotomy for secondary peritonitis. The included studies had to report at least two key outcomes: mortality, postoperative complications, incisional hernia, secondary fascial closure, and hospital or intensive care unit (ICU) length of stay.

RESULTS

Thirty-three studies including 4,520 patients were analyzed. Mortality was 31.1% in VAC and 22.2% in PAC (p = 0.327). Postoperative complications were higher with VAC (71.0% vs. 39.3%, p = 0.001). Incisional hernia rates were similar (21.3% vs. 20.8%, p = 0.958). Secondary fascial closure rate was significantly lower with VAC (58.1% vs. 85.9%, p < 0.001). VAC patients had longer ICU stays (21.1 vs. 9.7 days, p = 0.04), while hospital stay did not differ. Most studies had a high risk of bias, and GRADE assessment showed low to very low evidence certainty.

CONCLUSION

VAC therapy was associated with more postoperative complications, a lower fascial closure rate, and a longer ICU length of stay compared with PAC. Thirty-day mortality rates did not differ between the approaches. However, most of studies included were subject to serious risk of bias and a low level of certainty in evidence.

Fluid management strategies in critically ill patients with ARDS: a narrative review

Hypervolemia is associated with worse outcomes in critically ill patients with acute respiratory distress syndrome (ARDS), with early positive fluid balance linked to longer intensive care unit (ICU) stays, prolonged ventilatory support, and increased mortality risk due to cardiopulmonary complications, lung edema, and extrapulmonary organ dysfunction. However, a restrictive fluid management strategy is associated with hypoperfusion and distal organ dysfunction, including acute renal failure and cognitive impairment. Indeed, fluid administration in patients with ARDS represents a challenge, as it must take into account the underlying condition, such as sepsis or acute brain injury (ABI), where optimal fluid management is a major determinant of disease outcome. In such cases, the approach to fluid administration should be individualized based on hemodynamic and clinical parameters according to the course of the disease. The strategy of "salvage, optimization, stabilization, and de-escalation" can guide fluid administration in the initial therapeutic approach, whereas negative fluid balance with the use of diuretics or renal replacement therapy (RRT) should be the goal once hemodynamic stabilization has been achieved.

A disproportionality analysis of adverse events associated with ertapenem using the FAERS database from 2004 to 2024

Through an in-depth analysis of ertapenem-associated adverse events (AEs) in the FDA Adverse Event Reporting System (FAERS) database, this study provides a reference for monitoring and safety management of ertapenem. Data from the FAERS database from Q1 2004 to Q1 2024 were analyzed via four nonproportional analysis techniques, including the reporting odds ratio (ROR). Gender, age, and sensitivity analyses were conducted for a more detailed assessment of ertapenem-associated signals. A total of 2,931 reports with ertapenem as the primary suspected drug were collected, covering 27 system organ classes (SOCs). The two SOCs with the strongest signals were nervous system disorders and psychiatric disorders, with overall stronger signals in individuals aged ≥ 65 years. The most frequently reported AEs were confusional state (n = 265) and convulsions (n = 214). Among the strongest signals were oropharyngeal edema (ROR = 191.05, 95% CI: 60.76-601.35) and granulomatous dermatitis (ROR = 150.49, 95% CI: 55.9-405.15). Eleven AEs not listed on the FDA label were identified. The top 20 AEs were predominantly associated with nervous system and psychiatric disorders, with a median time to onset ranging from 3.5 to 8.5 days. This study highlights the neuropsychiatric risks of ertapenem, providing strong evidence for its safety assessment and emphasizing the need for monitoring and individualized management in high-risk patients. Ertapenem, FAERS, Adverse events, Drug safety, Disproportionality analysis.

Distribution and drug resistance analysis of pathogens in early-stage digestive tract perforation complicated with peritonitis

To investigate the distribution and drug resistance of pathogens associated with early-stage digestive tract perforation with peritonitis. A retrospective analysis was conducted on patients with digestive tract perforation and peritonitis at Huadu District People's Hospital of Guangzhou from Jan. 2020 to Aug. 2024. The selected patients were divided into two groups: the upper digestive tract (UDT) group and the lower digestive tract (LDT) group. General clinical characteristics and intraoperative secretions culture results were compared and analyzed. The study included 831 patients; 41.28% were in UDT group followed 58.72% in LDT group. 694 strains that isolated comprised 503 Gram-negative bacteria (GNB), 93 g-positive bacteria (GPB) and 98 fungi. Compared to LDT group, the UDT group had a higher positive rate of GPB and fungi but a lower positive rate of GNB. The most common pathogens among GNB were E.coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae; among GPB were Streptococcus anginosus, Enterococcus aviae, and Streptococcus constellations; among fungi were Candida albicans, Candida glabrata, and Candida Cruxalis. We further analyzed drug susceptibility results to related antibacterial drugs. The findings from this study have significant implications for guiding initial empirical antimicrobial therapy for patients with digestive tract perforation and peritonitis.

[Empirical antibiotic therapy in life-threatening infections-current concepts and controversies]

Along with early administration and the selection of the right drug, it is important to consider pharmacokinetic and pharmacodynamic principles, especially in life-threatening infections. Therefore, successful antibiotic therapy requires a clear understanding of the relationship between microbiology, pharmacology, and intensive care medicine. Open and transparent communication among professionals is essential for improving the quality of care. This article discusses current concepts and controversies by presenting a relevant case study of community-acquired pneumonia. It aims to help clinicians select the right drug for each patient, including the correct dose, the appropriate administration, and the right duration of treatment.

Deployable machine learning-based decision support system for tracheostomy in acute burn patients

Background

Airway obstruction is a common emergency in acute burns with high mortality. Tracheostomy is the most effective method to keep patency of airway and start mechanical ventilation. However, the indication of tracheostomy is challenging and controversial. We aimed to develop and validate a deployable machine learning (ML)-based decision support system to predict the necessity of tracheostomy for acute burn patients.

Methods

We enrolled 1011 burn patients from Southwest Hospital (2018-20) for model development and feature selection. The final model was validated on an independent internal cross-temporal cohort (2021, n = 274) and an external cross-institutional cohort (Second Affiliated Hospital of Zhejiang University School of Medicine 2020-21, n = 376). To improve the model's deployment and interpretability, an ML-based nomogram, an online calculator, and an abbreviated scale were constructed and validated.

Results

The optimal model was the eXtreme Gradient Boosting classifier (XGB), which achieved an AUROC of 0.973 and AUPRC of 0.879 in training dataset, and AUROCs of greater than 0.95 in both cross-temporal and cross-institutional validation. Moreover, it kept stable discriminatory ability in validation subgroups stratified by sex, age, burn area, and inhalation injury (AUROC ranging 0.903-0.990). The analysis of calibration curve, decision curve, and score distribution proved the feasibility and reliability of the ML-based nomogram, abbreviated scale (BETS), and online calculator.

Conclusions

The developed system has strong predictive ability and generalizability in cross-temporal and cross-institutional evaluations. The nomogram, online calculator, and abbreviated scale based on ML show comparable prediction performance and can be deployed in broader application scenarios, especially in resource-limited clinical environments.

Antimicrobial Stewardship Impact on the Treatment of Intra-abdominal Infections in the Surgical Intensive Care Unit

Background: Broad-spectrum antibiotic agents are utilized for complicated intra-abdominal infection (cIAI); however, the need for empiric methicillin-resistant Staphylococcus aureus (MRSA) coverage is not clear as the incidence of MRSA cIAI is rare. Patients and Methods: A single-center, retrospective, pre- and post-cohort study of adults admitted to the surgical intensive care unit (SICU) with cIAI between March 1, 2021, to May 1, 2023, was conducted. Historically, the SICU utilized vancomycin for all cIAI; however, in April 2022, the preferred regimen was changed to either piperacillin-tazobactam with vancomycin added for patients with MRSA risk factors or for Enterococcus spp. coverage in cefepime- or levofloxacin-based regimens for penicillin-allergic patients. The primary outcome was number of vancomycin days of therapy (DOT) per 1,000 patient days. Categoric and continuous variables were analyzed with chi-square and Fisher exact tests. Results: A total of 142 SICU encounters were included, 64 in the pre-cohort and 78 in the post-cohort. There was no difference in median vancomycin DOT per 1,000 patient days (14 days [interquartile range or IQR 5-21]; 16 days [IQR 8-17] p = 0.522) between the pre- and post-cohort. There was a significant reduction in the number of patients given vancomycin after the protocol change (90.6%; 76.9%, p = 0.042). A significant increase in piperacillin-tazobactam exposure was also observed (48.4%; 82.1%, p < 0.001) in the post-cohort aligning with our institutional practice change. Conclusions: In critically ill surgical patients with cIAI, the implementation of an antimicrobial stewardship guideline did not reduce vancomycin DOT per 1,000 patient days, however, it did result in a significant reduction in vancomycin exposure.

Predictive performance of population pharmacokinetic models in InsightRX® for model-informed precision dosing for Cefepime

BACKGROUND

Model-informed precision dosing (MIPD) is a promising tool used to ensure therapeutic antimicrobial concentrations. Model selection and sampling strategy might lead to different pharmacokinetic (PK) parameter estimates. Herein, we assess the predictive performance for cefepime PK in two models implemented within the InsightRX software using differing sampling approaches.

METHODS

Historic cefepime PK data and individual Bayesian estimates in predominantly critically ill patients, some of whom had extracorporeal support, served as the reference standard. Two population PK models (A; B) were evaluated using four sampling scenarios: (i) trough only, (ii) midpoint only, (iii) trough + midpoint, and (iv) peak + midpoint + trough. The median prediction error (MPE) and median absolute prediction error (MAPE) were calculated for clearance (CL) and volume of central compartment (Vc). Predicted categorical achievement of ≥70% time that the free drug concentration was greater than the minimum inhibitory concentration [fT>MIC(8/16mg/L)] was compared.

RESULTS

MAPE and MPE for CL and Vc resulted in variability that was dependent on model and sampling strategy. Both models' overall MPE and MAPE for CL were <±20 and <30% for all tested scenarios, respectively, with a low MPE of -2.4% to 4.4% on CL for sampling scenario 4. For Vc, MPE and MAPE were >±20 and >30% for the majority of test scenarios across both models, respectively. When excluding patients with extracorporeal support, MPE/MAPE for Vc decreased to 3.7-4.8/23.3%-34.5% and -7.9-2.5/25.2%-29.6% for model A and B, respectively. Using each model and sampling scheme, only four patients had discordant predicted achievement of ≥70% fT>MIC(8/16mg/L).

CONCLUSIONS

These two population PK models and all sampling scenarios demonstrated acceptable prediction of cefepime PK parameters and pharmacodynamic exposures; therefore, they demonstrated suitability for utilizing MIPD for cefepime therapeutic drug monitoring.

Predictive accuracy of changes in the inferior vena cava diameter for predicting fluid responsiveness in patients with sepsis: A systematic review and meta-analysis

BACKGROUND

Existing guidelines emphasize the importance of initial fluid resuscitation therapy in sepsis management. However, in previous meta-analyses, there have been inconsistencies in differentiating between spontaneously breathing and mechanically ventilated septic patients.

OBJECTIVE

To consolidate the literature on the predictive accuracy of changes in the inferior vena cava diameter (∆IVC) for fluid responsiveness in septic patients.

METHODS

The Embase, Web of Science, Cochrane Library, MEDLINE, PubMed, Wanfang, China National Knowledge Infrastructure (CNKI), Chinese Biomedical (CBM) and VIP (Weipu) databases were comprehensively searched. Statistical analyses were performed with Stata 15.0 software and Meta-DiSc 1.4.

RESULTS

Twenty-one research studies were deemed suitable for inclusion. The sensitivity and specificity of ∆ IVC were 0.84 (95% CI 0.76, 0.90) and 0.87 (95% CI 0.80, 0.91), respectively. With respect to the distensibility of the inferior vena cava (dIVC), the sensitivity was 0.79 (95% CI 0.68, 0.86), and the specificity was 0.82 (95% CI 0.73, 0.89). For collapsibility of the inferior vena cava (cIVC), the sensitivity and specificity values were 0.92 (95% CI 0.83, 0.96) and 0.93 (95% CI 0.86, 0.97), respectively.

CONCLUSION

The results indicated that ∆IVC is as a dependable marker for fluid responsiveness in sepsis patients. dIVC and cIVC also exhibited high levels of accuracy in predicting fluid responsiveness in septic patients.

Inadequate imipenem dosing in patients with decreased kidney function: A clinical pharmacokinetic study

OBJECTIVES

A number of population pharmacokinetic (popPK) models of imipenem in critically ill patients are available for dosing optimisation, but they represent only a narrow range of kidney functions. This study evaluates the target attainment of on-label regimens through popPK modelling and simulation in patients across different kidney functions.

METHODS

A popPK model was built based on two datasets from Switzerland (model development population, 151 patients, 322 concentrations) and externally validated on two datasets from the Czech Republic (19 patients, 111 concentrations) and Vietnam (43 patients, 85 concentrations). Monte Carlo simulations were performed to evaluate the probability of target attainment (PTA) from a minimum inhibitory concentration (MIC) of 0.125 to 32 mg/L. We estimated the cumulative fraction of response (CFR) against Pseudomonas aeruginosa (the epidemiological cut-off value was 4 mg/L) across a broad range of Cockcroft-Gault creatinine clearance values (CLCRCG 15-130 mL/min). Targets of 40% and 100%ƒT>MIC (percentage of dosing interval estimated free concentrations above MIC) were investigated.

RESULTS

Decreased kidney function (eGFRCKD-EPI <90mL/min) was observed in 70/151 patients (46.4%) within the model development population, and in 11/19 (57.9%) and 24/43 (55.8%) patients in the Czech Republic and Vietnam, respectively. CLCRCG significantly influenced the imipenem clearance described by a two-compartment model. For PTA, all regimens achieved 40% ƒT>MIC2mg/L. With a 100%ƒT>MIC target, 500 mg q6h (CLCRCG 30-60 mL/min) could only cover a MIC of up to 1 mg/L, irrespective of infusion time. For CFR, no dosing regimen could cover susceptible P. aeruginosa for 100%ƒT>MIC.

CONCLUSIONS

The highest on-label imipenem dosing regimens failed to attain 100% ƒT>MIC4mg/L in patients with decreased kidney function. Higher dosing may be necessary to cover MIC of 4mg/L. Future trials should explore their efficacy, toxicity, and the utility of model-informed precision dosing in this population.

Predicting in-hospital mortality in patients with alcoholic cirrhosis complicated by severe acute kidney injury: development and validation of an explainable machine learning model

Background

At present, there are no specialized models for predicting mortality risk in patients with alcoholic cirrhosis complicated by severe acute kidney injury (AKI) in the ICU. This study aims to develop and validate machine learning models to predict the mortality risk of this population during hospitalization.

Methods

A retrospective analysis was conducted on 856 adult patients with alcoholic cirrhosis complicated by severe AKI, utilizing data from the MIMIC-IV database. Within the dataset, 627 patients from the period 2008-2016 were designated as the training cohort, whereas 229 patients from 2017 to 2019 comprised the temporal external validation cohort. Feature selection was conducted utilizing LASSO regression, which was subsequently followed by the development of eight distinct machine learning models. The performance of these models in the temporal external validation cohort was rigorously assessed using the area under the receiver operating characteristic curve (AUROC) to determine the optimal model. The model was interpreted using the SHAP method, and nomograms were subsequently constructed. A comprehensive evaluation was performed from the perspectives of discrimination (assessed via AUROC and AUPRC), calibration (using calibration curves), and clinical utility (evaluated through DCA curves).

Results

LASSO regression identified nine key features: total bilirubin, acute respiratory failure, vasopressin, septic shock, oliguria, AKI stage, lactate, fresh frozen plasma transfusion, and norepinephrine. In the temporal external validation cohort, the Lasso-LR model achieved the highest AUROC value of 0.809, establishing it as the optimal model. We developed both a static nomogram and a web-based dynamic nomogram (https://zhangjingyu123456.shinyapps.io/dynnomapp/) for visualization purposes. In the nomogram model, the AUROC for the training cohort and temporal external validation cohort were 0.836 (95% CI: 0.802-0.870) and 0.809 (95% CI: 0.754-0.865), respectively. The calibration slope and Brier score for the training cohort were 1.000 and 0.146, respectively; for the temporal external validation cohort, these values were 0.808 and 0.177, respectively. The DCA curves indicate that the model has certain clinical application value.

Conclusion

The Lasso-LR model exhibits robust predictive capability for in-hospital mortality among patients with alcoholic cirrhosis complicated by AKI, offering valuable prognostic insights and individualized treatment decision support for healthcare professionals.

Treatment Effect of Early Intravenous Milrinone for Cerebral Vasospasm or Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

This study assessed the effect of intravenous (IV) milrinone as first-line therapy for cerebral vasospasm (CVS) or delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

A retrospective study was performed on consecutive patients with aSAH from 2017 to 2022. We assessed the association of IV milrinone treatment with outcomes graded with modified Rankin Scale score at 6 months. We compared the use of alternative therapies for CVS or DCI between patients who received IV milrinone and those who did not. All statistical analyses were performed using STATA 18.0 (StataCorp, College Station, TX).

RESULTS

Of 336 patients, 130 (39%) developed CVS or DCI. Seventy-three patients received IV milrinone and 57 patients did not. Among symptomatic patients, 59% showed improvement in symptoms after milrinone was started. Twenty percent of patients in the milrinone group required vasopressor therapy, whereas 84% of patients were treated with vasopressors in the nonmilrinone group (p < 0.01). Thirty one percent of patients receiving milrinone and 56% of patients in the non-milrinone group received endovascular therapy (p = 0.02). Univariate analysis showed milrinone was likely associated with good outcome (odds ratio [OR] 2.12 [95% confidence interval [CI] 0.97-4.63]; p = 0.06). Propensity score matching analysis confirmed an association between milrinone and good outcome (coefficient 0.30, standard error 0.13 [95% confidence interval [CI] 0.05-0.55]; p = 0.02).

CONCLUSIONS

Our study showed several potential benefits of early IV milrinone therapy for patients with aSAH with CVS or DCI. Patients who received IV milrinone had better outcome and required vasopressor or endovascular therapy less often. Limitations of the study included several protocol deviations, incomplete documentation of drug effect, and inconsistent assessment of CVS resolution. Early IV milrinone improved outcomes and reduced the use of other therapies to treat CVS and DCI. These results need confirmation in a large clinical trial with stratification of patients by clinical severity, indication, and optimized protocols.

A Systematic Review of Antimicrobial Stewardship Interventions Implemented in Intensive Care Units

Antimicrobial stewardship (AS) is essential to ensure appropriate antimicrobial usage and subsequently reduce the emergence of microbial resistance. The intensive care unit is a crucial place for monitoring antimicrobial usage due the frequent exposure to infections. This review provides an update on the current status of antimicrobial stewardship intervention utilized in intensive care settings. A comprehensive search was performed in Cochrane, Web of Science, and PubMed using keywords grouped into Antimicrobial, Stewardship, and Intensive care unit. The search was restricted to original articles published from April 2015 to November 2024. Out of 1,234 records retrieved from the databases, 55 studies were included in this systematic review. Most of the studies were conducted in the United States (n = 9), followed by China (n = 8), India (n = 5), and Italy (n = 4). We identified seven key antimicrobial stewardship (AS) strategies: multi-interventions ASP (22 studies, 40%), prospective feedback and audit (11 studies, 20%), procalcitonin (PCT) protocols for guiding antimicrobial use (12 studies, 21.8%), protocols for antimicrobial de-escalation (4 studies, 7.3%), antimicrobial restrictions or preapprovals (4 studies, 7.3%), diagnostic stewardship (1 study, 1.8%), and guidelines for antimicrobial prescription (1 study, 1.8%). A reduction in targeted or overall antimicrobial usage was reported in most studies (34/42). Specifically, all studies implementing multi-invention ASPs reported a successful reduction in antimicrobial utilization. Some antimicrobial stewardship interventions significantly enhanced the appropriateness of antimicrobial prescriptions. In addition, patient health outcomes were not compromised by antimicrobial reduction. Nonetheless, future studies at a larger scale over a longer time are recommended to accurately assess the impact of AS programme on patient health outcomes.

Beta-Lactam Antibiotic Concentrations and the Acquisition of Multi-Drug Resistant Bacteria in Critically Ill Patients

Antimicrobial resistance (AMR) is a worldwide healthcare emergency. Whether insufficient beta-lactam antibiotic concentrations can be associated with AMR emergence remains controversial. This is a retrospective single-center cohort study including patients admitted to the intensive care unit of a tertiary university hospital from 2009 to 2014, who required a broad-spectrum beta-lactam antibiotic and had at least one therapeutic drug monitoring (TDM). Patients were categorized as having inadequate drug levels if the trough concentration (Cmin) fell below the clinical breakpoint for Pseudomonas aeruginosa. AMR was defined according to breakpoints recommended by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) using the disk diffusion method. A total of 444 patients (male sex, n = 313, 71%; female sex, n = 131, 29%; mean age 58 ± 15 years) were enrolled in the study. Patients received piperacillin/tazobactam (n = 168), ceftazidime/cefepime (n = 58) or meropenem (n = 218); among them, 65 (15%) had insufficient drug levels. Nine of these 65 (13.8%) patients with insufficient antibiotic levels acquired at least one pathogen with AMR within 15 days of TDM, when compared to 84/379 (22%) in the other group (OR 0.56 [95%CI 0.27-1.19]; p = 0.13). In a multivariable competing-risk analysis including male gender, APACHE score on admission, previous colonization by other MDR bacteria, urinary catheter, central venous catheter, mechanical ventilation, previous hospitalization and previous surgery, insufficient antibiotic levels were not associated with AMR acquisition (sHR 0.84 [95% CI 0.42-1.68]). Similar results were found when a higher threshold was used to define insufficient drug levels (Cmin < 4 times the clinical breakpoint). In conclusion, insufficient beta-lactam levels were not independently associated with AMR acquisition. Future prospective studies are needed to evaluate better the relationship between low drug levels and antibiotic resistance acquisition.

SIGH35 and end-expiratory occlusion test for assessing fluid responsiveness in critically ill patients undergoing pressure support ventilation

BACKGROUND

Assessing fluid responsiveness is problematic for critically ill patients with spontaneous breathing activity, such as during Pressure Support Ventilation (PSV), since spontaneous breathing activity physiologically affects heart-lung interplay. We compared the reliability of two hemodynamic tests in predicting fluid responsiveness in this clinical setting: SIGH35, based on a ventilator-generated sigh applied at 35 cmH2O for 4 s and the end-expiratory occlusion test (EEOT).

METHODS

Prospective study conducted in a general intensive care unit (ICU) and enrolling patients in PSV showing different inspiratory effort [assessed by airway occlusion pressure (P0.1)] and requiring volume expansion (VE). Hemodynamic variables were recorded by means of the MOSTCARE® system, patient received a VE using 4 ml/kg of crystalloids over 10 min and were considered responders if a cardiac output (CO) ≥ 10% was observed. The reliability of SIGH35 and EEOT in discriminating fluid responsiveness was assessed using receiver operating characteristic (ROC) curve approach and the area (AUC) under ROC curves was compared. For the EEOT, we considered the percent changes of CO between baseline the end of the test, while for the SIGH35, the percent changes of pulse pressure (PP) between baseline and the lowest value recorded after SIGH35 application.

RESULTS

Sixty ICU patients were enrolled, and 56 patients analysed. The AUC of PP changes after SIGH35 was 0.93 (0.84-0.99) [sensitivity of 93.1% (78.0-98.7%); specificity of 91.6 (73.0-98.9%)]; best threshold - 25% PP from baseline (grey zone - 15%/35%)]; and greater than the AUC of CO changes after EEOT [0.67 (0.52-0.81); sensitivity of 72.4% (54.3-85.3%) specificity of 70.3% (73.0-98.9%)]; best threshold 4% of CO increase from baseline (grey zone - 1%/10%)]. In the subgroup having a P0.1 < 1.5 cmH2O, the AUC of SIGH35 [0.98 (0.94-0.99)] and of EEOT [0.89 (0.72-0.99] were comparable (p = 0.26).

CONCLUSIONS

In a selected ICU population undergoing PSV, SGH35 reliably predicted fluid responsiveness and performed better than the EEOT, which is, however, still reliable in the subgroup of ICU patients having a small extent of inspiratory efforts.

Impact of Hypothermic Temperature Control on Plasma and Soft Tissue Pharmacokinetics of Penicillin/Beta-Lactamase Inhibitor Combinations in Patients Resuscitated After Cardiac Arrest

BACKGROUND AND OBJECTIVES

Penicillin/beta-lactamase inhibitors are often used to treat aspiration pneumonia in patients resuscitated after cardiac arrest (CA). The impact of hypothermic temperature control on the pharmacokinetics of amoxicillin/clavulanate (AMO/CLAV) and ampicillin/sulbactam (AMP/SULB) has not been studied. Our objective was to evaluate the effects of hypothermic temperature control on the plasma and soft tissue pharmacokinetics of AMO/CLAV and AMP/SULB, including pulmonary concentrations of AMP/SULB, in patients resuscitated after CA.

METHODS

This prospective clinical study involved ten adult patients after CA receiving either AMO/CLAV 2 g/0.2 g or AMP/SULB 2 g/1 g intravenously every 8 h. Patients underwent hypothermic temperature control (33 ± 1 °C) for 24 h, followed by normothermia. Plasma, urine, muscle, and subcutaneous pharmacokinetics were measured and plasma protein-binding assessed for each subject. Microdialysis determined unbound drug concentrations in soft tissues. The pulmonary concentration of AMP/SULB was analyzed in the epithelial lining fluid.

RESULTS

No significant differences in plasma pharmacokinetics or renal excretion of AMO/CLAV and AMP/SULB were observed between the two temperature conditions. Soft tissue concentrations showed no consistent trend. Pharmacokinetic/pharmacodynamic targets (time that the unbound plasma concentrations were above the minimal inhibitory concentration [MIC] for MIC up to 8 mg/L) were met but not for 16 mg/L. Pulmonary concentrations of AMP/SULB in the epithelial lining fluid showed no clear trend.

CONCLUSION

This study indicates that hypothermic temperature control does not significantly affect plasma concentrations, soft tissue concentrations, or renal excretion of AMO/CLAV and AMP/SULB in patients resuscitated after CA. However, pulmonary concentrations of AMP/SULB exhibited interindividual variability.

Impact of Timing of Beta-Lactam Therapeutic Drug Monitoring and Therapy Adjustment in Critically Ill Patients

Purpose: To assess the impact of beta-lactam therapeutic drug monitoring (TDM) timing and therapy adjustment on clinical cure and 30-day mortality. Methods: This was a prospective study of critically ill patients admitted to the University of Florida Health Shands Hospital intensive care unit (ICU) between 2021 and 2022, ≥18 years old, and requiring beta-lactam therapy for a suspected or confirmed infection. Beta-lactam concentrations were measured per standard of care, pharmacokinetic/dynamic (PK/PD) target attainment was calculated, and therapy was adjusted if needed. Multiple regression and time-to-event (TTE) analyses were performed. Results: A total of 297 infection episodes from 268 patients were included. The mean (SD) age was 56 years (17), weight was 82 kg (32), and 14% received renal replacement therapy. The most common infection source was the lung, and the most common beta-lactam was cefepime. The most common infusion duration was 30 min. The median (IQR) time to first TDM was 2.7 days (1.7-4.7). Fifty-seven percent of patients required therapy adjustment. Increases in beta-lactam dose, frequency, or infusion duration were associated with lower 30-day mortality compared to continuing the same regimen (aOR 0.30, p = 0.015). Delay in performing TDM was associated with lower probability of clinical cure (aOR 0.92, p = 0.0023). Patients who had the regimen increased had shorter hospital stay compared to those who had it decreased. Timing of beta-lactam TDM in ICU patients was a significant predictor of clinical cure, while adjusting beta-lactam therapy to achieve higher exposure was a significant predictor of 30-day mortality.

Passive leg raising test versus rapid fluid challenge in critically ill medical patients

BACKGROUND

The passive leg raising (PLR) test is a simple test to detect preload responsiveness. However, variable fluid doses and infusion times were used in studies evaluating the effect of PLR. Studies showed that the effect of fluid challenge on hemodynamics dissipates in 10 min. This prospective study aimed to compare PLR and a rapid fluid challenge (RFC) with a 300-ml bolus infused within 5 min in adult patients with a hemodynamic compromise.

MATERIALS AND METHODS

Critically ill medical patients with signs of systemic hypoperfusion were included if volume expansion was considered. Hemodynamic status was assessed with continuous measurements of cardiac output (CO), when possible, and mean arterial pressure (MAP) at baseline, during PLR, and after RFC.

RESULTS

A total of 124 patients with a median age of 65.0 years were included. Their acute physiology and chronic health evaluation (APACHE) II score was 19.7 ± 6.0, with a sequential organ failure assessment (SOFA) score of 9.0 ± 4.4. Sepsis was diagnosed in 73.3%, and 79.8% of the patients were already receiving a norepinephrine infusion. Invasive MAP monitoring was established in all patients, while continuous CO recording was possible in 42 patients (33.9%). Based on CO changes, compared with those with RFC, the false positive and false negative rates with PLR were 21.7 and 36.8%, respectively, with positive and negative predictive values of 70.6 and 72.0%, respectively. Based on MAP changes, compared with those with RFC, the false positive and false negative rates with PLR compared to RFC were 38.2% and 43.3%, respectively, with positive and negative predictive values of 64.4 and 54.0%, respectively.

CONCLUSION

This study demonstrated a moderate agreement between PLR and RFC in hemodynamically compromised medical patients, which should be considered when testing preload responsiveness.

[Obesity in intensive care]

The prevalence of obesity and its associated comorbidities are increasing worldwide, leading to a rising proportion of obese patients in hospitals and intensive care units. This trend is causing a significant additional burden on our healthcare system. An obese patient requiring intensive care treatment presents major challenges for the entire team, not only in terms of economic aspects but also medically, in nursing care, and in physiotherapy. Additionally, psychosocial and organizational factors play a role that must be considered. For nursing and physiotherapy, appropriate aids such as lifters, special large hospital beds, suitable rooms, and adequate staffing should be provided. The medical challenges include intubation and airway management, hemodynamic monitoring, vascular access, adequate nutrition, appropriate dosing of medication, and difficult ultrasound conditions at the bedside. Furthermore, this patient population has an increased risk of developing pressure ulcers, pneumonia, and thrombosis, which increase the overall care requirements and further challenge the intensive care setting.

Cytokine Hemoadsorption versus Standard Care in Cardiac Surgery Using the Oxiris Membrane: The OXICARD Single-center Randomized Trial

BACKGROUND

Cardiac surgery can lead to dysregulation with a proinflammatory state, resulting in adverse outcomes. Hemadsorption using the AN-69 membrane (Oxiris membrane, Baxter, USA) has the properties to chelate inflammatory cytokines. The authors hypothesized that in patients at high risk of inflammation, the use of the Oxiris membrane could decrease inflammation, preserve endothelial function, and improve postoperative outcomes.

METHODS

The authors conducted a randomized single-center study at Amiens University Hospital (Amiens, France). The study population consisted of adult patients admitted for scheduled cardiac surgery with an expected cardiopulmonary bypass (CPB) time greater than 90 min. The patients were allocated to either the standard group or the Oxiris group. The intervention consisted of using the Oxiris membrane on a Prismaflex device (Baxter, USA) at a blood flow rate of 450 ml/min during CPB. The primary outcome was the assessment of microcirculation on day 1 after surgery by measuring sublingual microcirculation using the microvascular flow index. Microvascular flow index reflects the microcirculation flow type and is graded from 0 to 3 as follows: 0, no flow; 1, intermittent flow; 2, sluggish flow; 3, continuous flow. The secondary outcome was a composite adverse outcome within 30 days after surgery. Cytokines and endothelial biomarkers were measured in all patients at different time points. An intention-to-treat analysis was performed.

RESULTS

From October 2019 to November 2022, the study included 70 patients. Two patients were excluded from the Oxiris group: one patient did not undergo surgery, and one procedure was performed under deep hypothermia. The microvascular flow index did not differ between groups on day 1 from baseline: difference (95% CI) Oxiris minus standard at -0.17 (-0.44 to 0.10); P = 0.2. The occurrence of a composite adverse outcome did not significantly differ between groups (14 [42%] for the Oxiris group vs. 12 [35%] for the standard group; P = 0.7). The overall variation in cytokines and angiopoietins did not significantly differ between groups.

CONCLUSIONS

In patients scheduled for a cardiac surgery with prolonged CPB, the authors could not demonstrate the benefit on microcirculation and major cardiovascular events.

Role of narrow band imaging in assessing bronchial mucosal hypervascularization in COVID-19 patients

BACKGROUND

SARS-CoV-2 virus which targets the lung vasculature is supposed to affect both pulmonary and bronchial arteries. This study evaluated the tracheobronchial vascularization density observed with narrow band imaging (NBI) in patients hospitalized for COVID-19 pneumonia. To determine if the observed changes were specific of COVID-19 patients, the procedure was also performed in non-COVID-19 patients.

METHODS

Thirty patients included in this monocentric, prospective study underwent videobronchoscopy using both white light and NBI: 10 with a COVID-19 infection, 10 with a non-COVID-19 pulmonary infection and 10 with a peripheral pulmonary nodule. The tracheobronchial vascular density observed through NBI was rated by two blinded pneumologists at three levels (carina, right main bronchus and left main bronchus).

RESULTS

When compared to the two other groups, a significant increase of the tracheobronchial vascularization was found in COVID-19 patients. The median tracheobronchial vascularization global score obtained with NBI (out of 15 points) was: 10 [9 - 13] in the COVID-19 group, 5 [4 - 10] in the non-COVID-19 group (p < 0.001) and 6 in the Nodule group [4 - 9] (p = 0.002). Using a weighted Cohen's Kappa coefficient, we observed a good agreement between the two raters for the evaluation of the tracheobronchial vascularization score (κ = 0.75 [0.65-0.83]); p < 0.001).

CONCLUSION

Videobronchoscopy with NBI in COVID-19 patients showed diffuse changes in tracheobronchial vascularization. We suggest that such bronchial hypervascularisation with dilated vessels contributes, at least in part, to the intrapulmonary right to left shunt that characterized the COVID-19 related Acute Vascular Distress Syndrome (AVDS).

Hospital and Clinician Practice Variation in Cardiac Surgery and Postoperative Acute Kidney Injury

Importance

Approximately 30% of US patients develop acute kidney injury (AKI) after cardiac surgery, which is associated with increased morbidity, mortality, and health care costs. The variation in potentially modifiable hospital- and clinician-level operating room practices and their implications for AKI have not been rigorously evaluated.

Objective

To quantify variation in clinician- and hospital-level hemodynamic and resuscitative practices during cardiac surgery and identify their associations with AKI.

Design, Setting, and Participants

This cohort study analyzed integrated hospital, clinician, and patient data extracted from the Multicenter Perioperative Outcomes Group dataset and the Society of Thoracic Surgeons Adult Cardiac Surgical Database. Participants were adult patients (aged ≥18 years) who underwent cardiac surgical procedures between January 1, 2014, and February 1, 2022, at 8 geographically diverse US hospitals. Patients were followed up through March 2, 2022. Statistical analyses were performed from October 2024 to February 2025.

Exposures

Hospital- and clinician-level variations in operating room hemodynamic practices (inotrope infusion >60 minutes and vasopressor infusion >60 minutes) and resuscitative practices (homologous red blood cell [RBC] transfusion and total fluid volume administration).

Main Outcomes and Measures

The primary outcome was consensus guideline-defined AKI (any stage) within 7 days after cardiac surgery. Hospital- and clinician-level variations were quantified using intraclass correlation coefficients (ICCs). Associations of hospital- and clinician-level practices with AKI were analyzed using multilevel mixed-effects models, adjusting for patient-level characteristics.

Results

Among 23 389 patients (mean [SD] age, 63 [13] years; 16 122 males [68.9%]), 4779 (20.4%) developed AKI after cardiac surgery. AKI rates varied across hospitals (median [IQR], 21.7% [15.5%-27.2%]) and clinicians (18.1% [10.1%-23.7%]). Significant clinician- and hospital-level variation existed for inotrope infusion (ICC, 6.2% [95% CI, 4.2%-8.0%] vs 17.9% [95% CI, 3.3%-31.9%]), vasopressor infusion (ICC, 11.7% [95% CI, 8.3%-14.9%] vs 44.5% [95% CI, 11.7%-63.5%]), RBC transfusion (ICC, 1.7% [95% CI, 0.9%-2.6%] vs 4.5% [95% CI, 1.2%-9.4%]), and fluid volume administration (ICC, 2.1% [95% CI, 1.3%-2.7%] vs 23.8% [95% CI, 2.7%-39.9%]). In multilevel risk-adjusted models, the AKI rate was higher for patients at hospitals with higher inotrope infusion rates (adjusted odds ratio [AOR], 1.98; 95% CI, 1.18-3.33; P = .01) and lower among clinicians with higher RBC transfusion rates (AOR, 0.89; 95% CI, 0.79-0.99; P = .03). Other practice variations were not associated with AKI.

Conclusions and Relevance

This cohort study of adult patients found that hospital- and clinician-level variation in operating room practices was associated with AKI after cardiac surgery, suggesting possible targets for intervention.

Improved Prediction of Fluid Responsiveness in Ventilated Patients With Low Tidal Volume: The Role of Preload Variation

OBJECTIVES

To analyze whether two levels of preload, one reduced by the application of tourniquets with sphygmomanometer cuffs and the other increased by passive leg elevation, improve the predictive capacity of pulse pressure variation (PPV) and stroke volume variation (SVV) of fluid responsiveness in patients ventilated with low tidal volume (Vt).

DESIGN

Prospective cohort study.

SETTING

ICU at the University Hospital of Cádiz (Spain).

PATIENTS

Patients diagnosed with septic shock, on controlled invasive mechanical ventilation without spontaneous breathing, with a Vt of 6 mL/kg predicted body weight and considered for an intravascular volume load due to hemodynamic instability.

INTERVENTIONS

Patient position changes: supine position and passive leg raise. Placement of pressure cuff compression at 60 mm Hg in one upper limb and the two lower limbs. Administration of 10 mL/kg of saline solution in 10 minutes.

MEASUREMENTS AND RESULTS

Twenty-eight tests were obtained. The baseline characteristics of the responders and nonresponders were similar. The baseline variables PPV and SVV had a limited ability to predict the response to fluids, with areas under the curve of 0.71 and 0.66, respectively. However, its predictive capacity increases significantly with different maneuvers, with the best prediction of the difference between the PPV value during the application of tourniquets and the PPV value in the supine position, with an area under the receiver operating characteristic curve of 0.97.

CONCLUSIONS

Lowering preload using tourniquets improves the predictive capacity of PPV and SVV for fluid responsiveness in patients ventilated with low Vt.

Postresuscitation pleth variability index-guided hemodynamic management of out-of-hospital cardiac arrest survivors: A randomised controlled trial

Background and purpose

Hypotension and shock after return of spontaneous circulation is harmful. Goal-directed post-resuscitation care aims at maintaining adequate perfusion pressure, but evidence.on strategies to achieve this goal is limited. This study aimed to compare outcomes of pleth variability index (PVi) supported hemodynamic management during early hospital admission with those of standard hemodynamic management.

Methods and trial design

From March 2019 to August 2023, all mechanically ventilated patients adults admitted alive after a non-traumatic out-of-hospital cardiac arrest (OHCA) to the emergency department of Saint-Pierre University Hospital in Brussels, were screened for inclusion in this prospective, parallel, randomised, single-blind study. We enrolled patients with signs of tissue hypoperfusion after cardiac arrest. Patients were randomly allocated (1:1) to undergo hemodynamic treatment based on the PVi (intervention) or standard monitoring (control). Hemodynamic interventions targeted mean blood pressure above 70 mmHg, a capillary refill time below 3 s and urine output above 0.5 ml/kg/minute. The primary outcome was lactate clearance at 3 h. We hypothesized that PVi guided hemodynamic management would result in a faster lactate clearance at 3 h.

Results

96 patients underwent randomization. Due to non-consent and loss to follow-up 82 patients were included in the analysis, 39 in the intervention and 43 in the control group. The median lactate clearance 3 h after inclusion was not different between groups (57.4% [Interquartile range (IQR): 27.7-75.8%] in the control group versus 61.5% [IQR: 39.3-74.7%] in the intervention group), with a mean difference of 4.9% (95% CI, -7.5-17.2; p = 0.44) between the two groups. No side effects were observed.

Conclusion

A pleth variability index-based protocol did not significantly improve the lactate clearance compared with standard care (NCT03841708).

Stop-It Randomized Clinical Trial (RCT) for Intra-Abdominal Infection (IAI) Revisited: Multivariate Analyses To Identify Treatment Effects 4 Days Antibiotic Agents Versus Resolution Signs/Symptoms + 2 Days and Drivers of Outcomes

Background: The STOP-IT randomized clinical trial (RCT) pioneered limiting antibiotic agents in intra-abdominal infection (IAI) with adequate surgical source control, but NIH funding ended before an adequate power sample size was enrolled to determine equivalence between STOP-IT study regimens: four days of antibiotic agents (4-days) after source control versus antibiotic agents until resolution of signs and symptoms of IAI plus two days (standard of care [SOC]). The objective of this investigation was to identify possible significant treatment effects 4-days versus SOC, and independent variables defining and predicting outcomes. Methods: De-identified data from 518 STOP-IT subjects were analyzed retrospectively in two groups: 4-days (n = 258) and SOC (n = 260), and separately as one group (n = 518). Statistics: multivariate regression analysis, chi-squared, and simple Cohen kappa coefficient. Results: No pre-randomization variable predicted protocol FAILURE (surgical site infection, recurrent IAI, or death at 30 d) in 4-day subjects. APACHE II predicted SOC FAILURE, but no cut point determined treatment effect (AUC = 0.608). Both observations implied that FAILURE may not reflect patient outcomes. Additionally, Cohen kappa for FAILURE and hospitalization at 7, 14, and 21 days was weak (0.1154, 0.2084, and 0.1969, respectively) with high numbers of discordant values. Pre-randomization variables associated with hospitalization/discharge at days 7, 14, and 21: extra-abdominal infection 1 (p < 0.0001), APACHE II score (p < 0.0001), age (p = 0.006), and WBC maximum (p < 0.05). However, all of these pre-randomization variables did not predict FAILURE, except APACHE II. Conclusions: Poor Cohen kappa coefficients indicate STOP-IT FAILURE agreed only weakly with hospital/discharge at 7, 14, or 21 days, and is not a valid reliable endpoint in IAI or for determining success or failure of any treatment. Pre-randomization extra-abdominal infection, APACHE II score, age, and WBC maximum strongly predicted hospitalization, but only APACHE II predicted failure. The study should use the appropriate sample size calculation when doing an equivalence on the basis of the Two One-Sided Test design. RCTs in IAI need prospectively validated clinically reliable endpoints that align with known patient outcomes that determine success.

MORTALITY OF SEPTIC SHOCK SECONDARY TO PEDIATRIC PRIMARY PERITONITIS PREDICTED BY RESPIRATORY QUOTIENT COMBINED WITH LACTATE: A SURVEY FROM TWO CHILDREN'S HOSPITALS IN NORTHWEST CHINA

ABSTRACT

Background: Pediatric sepsis is a life-threatening condition, with extremely high incidence and mortality among critically ill children worldwide. Patients with septic shock are susceptible to intestinal complications due to altered blood flow distribution, and these complications often correlate directly with a poor prognosis. Early detection of low perfusion and appropriate resuscitation are critical components in the management of patients experiencing shock. Nevertheless, significant debate persists regarding the comparative value of various resuscitation targets. While central venous oxygen saturation (ScvO2) monitoring is frequently advocated, it remains a subject of scrutiny. All pathophysiological mechanisms are intricately linked to cellular hypoxia and energy metabolism, which is why metabolic-related biomarkers, particularly lactate and lactate clearance rate, are highly regarded by critical care experts. Nonetheless, limited research has been conducted on the association between markers of circulatory shock and metabolic disorders in critically ill patients particularly in the field of pediatrics. Physiological indicators, particularly those associated with cell energy metabolism, have shown potentials in predicting sepsis and septic shock. Methods: This was a retrospective study. A total of 63 patients, comprising 30 males and 33 females, who developed septic shock secondary to pediatric primary peritonitis, were admitted to the Intensive Care Department of the Children's Hospital Affiliated to Xi'an Jiaotong University and the Pediatric Intensive Care Unit of Gansu Provincial Maternity and Child-Care Hospital between December 2016 and December 2021. Based on the primary outcome of 28-day all-cause mortality, patients were assigned into the survival group and nonsurvival group. Demographic and clinical data were compared. Risk factors for the prognosis of septic shock secondary to pediatric primary peritonitis were identified by logistic regression, and their potentials in predicting the 28-day survival were assessed by the receiver operating characteristic and Kaplan-Meier survival curves. Results: Among the 63 eligible patients with septic shock secondary to pediatric primary peritonitis, 47 survived. In comparison to the survival group, the nonsurvival group showed significantly higher proportions of mechanical ventilation, surgical intervention, and use of vasoactive drugs, procalcitonin, activated partial thromboplastin time, respiratory quotient (RQ), lactate (Lac), the Pediatric Sequential Organ Failure Assessment score, and the Pediatric Risk of Mortality III score, but lower platelet count, fibrinogen, and mean arterial pressure (all P's < 0.05). RQ (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.41, 3.22; P < 0.05) and Lac (OR, 2.01; 95% CI, 1.15, 3.21; P < 0.05) were independent prognostic factors for septic shock secondary to pediatric primary peritonitis. Their combination (RQ < 1.6 + Lac < 4 mmol/L) achieved a better accuracy in predicting the 28-day cumulative survival. Conclusion: RQ combined with Lac offers an excellent performance in predicting mortality of septic shock secondary to pediatric primary peritonitis.

The usability of bedside ultrasound in nursing practice for critically ill patients

OBJECTIVE

To describe the usability of bedside ultrasound (POCUS) as perceived by nurses working in emergency, urgent care, and intensive care units.

METHODS

We conducted an exploratory study using a mixed-methods approach with nurses in the critical care sectors of a university hospital in Paraná, Brazil. Data collection involved mixed questionnaires and semi structured interviews. We analyzed the data through descriptive statistics and thematic content analysis.

RESULTS

Nurses utilized POCUS for procedures such as venous and arterial punctures, bladder assessments and procedures, cardiovascular assessments, and gastrointestinal evaluations and procedures. Perceptions of usability were organized into thematic categories: Qualification for POCUS certification, Impact of the tool on nursing practice, and Use of the equipment in daily activities.

CONCLUSIONS

POCUS was regarded as a significant tool for nursing care, enhancing interventions, clinical decision-making, and professional autonomy.

Target attainment of benzylpenicillin in patients with infective endocarditis

OBJECTIVES

Benzylpenicillin is commonly used to treat infective endocarditis, particularly for streptococcal infections. This study aimed to perform pharmacokinetic/pharmacodynamic analyses of benzylpenicillin to assess the probability of target attainment (PTA) across different pathogens, MIC values, pharmacokinetic/pharmacodynamic targets, and renal function levels.

METHODS

In the Partial Oral Endocarditis Treatment trial, patients with left-sided infective endocarditis were randomly assigned to either conventional intravenous or partial oral antibiotic treatment. This substudy included patients receiving intravenous benzylpenicillin (3000 mg q6h). Pharmacokinetic measurements were conducted, and a population pharmacokinetic model was developed to estimate PTAs through model-based simulations. Pharmacokinetic/pharmacodynamic targets were based on time above MIC (or 4 × MIC) of the free concentration (fT > MIC or fT > 4 × MIC).

RESULTS

A total of 75 patients were included, and 291 plasma concentrations were obtained. MIC values were available for 68 patients. Individual target attainment for 50% fT > MIC and 50% fT > 4 × MIC targets was 100% (56/56) and 94.6% (53/56) for streptococci, 100% (3/3) for staphylococci, but only 66.7% (6/9) and 33.3% (3/9) for Enterococcus faecalis. For more stringent targets of 100% fT > MIC and 100% fT > 4 × MIC, individual target attainment was 89.3% (50/56) and 75.0% (42/56) for streptococci, 100.0% (3/3) and 66.7% (2/3) for staphylococci, but 33.3% (3/9) and 11.1% (1/9) for E. faecalis. Simulations showed PTAs above 90% for MIC values ≤ 0.5 mg/L at the 50% fT > MIC target, and for MIC values ≤ 0.063 mg/L at 50% fT > 4 × MIC or 100% fT > MIC targets. Higher renal clearance was associated with substantially lower PTAs.

DISCUSSION

Intravenous benzylpenicillin achieved target levels in most patients with infective endocarditis, particularly for those infected with streptococci or susceptible staphylococci. However, low individual target attainment in patients with E. faecalis suggests limitations in treating enterococcal endocarditis, especially in patients with preserved renal function.

Intraoperative Lung Ultrasound in the Detection of Pulmonary Nodules: A Valuable Tool in Thoracic Surgery

In the last two decades, there has been an increased interest in the application of lung ultrasound (LUS), especially intraoperatively, owing to its safety and simple approach to detecting and assessing pulmonary nodules. This review focuses on recent advancements in intraoperative lung ultrasound in detecting lung nodules. A systematic search was conducted using databases such as PubMed and Google Scholar. Keywords included "Lung ultrasound", "intraoperative lung ultrasound", and "video-assisted transthoracic surgery (VATS)". Articles published between 1963 and 2024 in peer-reviewed journals were included, focusing on the ones from the 2000s. Data on methodology, key findings, and research gaps were reviewed. Results indicated a significant advantage of intraoperative lung ultrasound (ILU) in the assessment of pulmonary nodules. ILU offers a noninvasive, real-time imaging modality that demonstrates up to 100% accuracy in detecting pulmonary nodules, with shorter time needed compared to other modalities, as well as less intraoperative periods and postoperative complications. However, some disadvantages were detected, such as operator dependency and a lack of specificity and knowledge of specific signs, as well as assisted localization via percutaneous puncture and its correct interpretation. The findings suggest that ILU has a promising future in pulmonary surgeries such as LUS-VATS but needs to be engaged more in clinical applications and modified with new techniques such as artificial intelligence (AI).

Impact of Multiplex PCR on Diagnosis of Bacterial and Fungal Infections and Choice of Appropriate Antimicrobial Therapy

Multiplex Polymerase Chain Reaction (PCR) has significantly impacted the field of infectious disease diagnostics, offering rapid and precise identification of bacterial and fungal pathogens. Unlike traditional culture methods, which may take days to yield results, multiplex PCR provides diagnostic insights within hours, enabling faster, targeted antimicrobial therapy and reducing the delay in treating critical infections like sepsis. The technique's high sensitivity and broad pathogen coverage make it ideal for both single and polymicrobial infections, improving outcomes across respiratory, bloodstream, and bacterial/fungal infections. However, multiplex PCR is not without challenges; initial high costs and the need for specialized training can limit its adoption, especially in low-resource settings. This review discusses the clinical advantages and limitations of multiplex PCR, highlighting its influence on diagnostic accuracy, antimicrobial stewardship, and the global fight against antimicrobial resistance (AMR). Furthermore, recent innovations in multiplex PCR, such as digital PCR and portable devices, are explored as potential tools for expanding access to rapid diagnostics worldwide.

Lactate and CO2-derived parameters are not predictive factors of major postoperative complications after cardiac surgery with cardiopulmonary bypass: a diagnostic accuracy study

Purpose

This study aimed to compare the performance of lactate and CO2-derived parameters in predicting major postoperative complications (MPC) after cardiac surgery with cardiopulmonary bypass.

Methods

Lactate and CO2-derived parameters, including the venous-arterial difference in CO2 partial pressure (Pv-aCO2), the venous-arterial difference in CO2 partial pressure to arterial-venous O2 content ratio (Pv-aCO2/Ca-vO2), and the venous-arterial difference in CO2 content to arterial-venous O2 content ratio (Cv-aCO2/Ca-vO2) at ICU admission, 3 h, 6 h, and 12 h later were collected. Receiver-operating characteristics (ROC) curve analysis was carried out to assess the predictive performance. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of MPC.

Results

MPC occurred in 77 (54.2%) of 142 patients. No significant difference was observed between the MPC and no-MPC groups regarding lactate and CO2-derived parameters. The area under the curves (AUCs) were 0.532 (0.446-0.616) for lactate, 0.559 (0.473-0.642) for Pv-aCO2, 0.617 (0.532-0.697) for Pv-aCO2/Ca-vO2, and 0.625 (0.540-0.705) for Cv-aCO2/Ca-vO2, respectively, and there was no significant difference between the parameters. In the post-hoc analysis, all parameters' AUCs were lower than 0.75 in predicting acute renal failure, and there was no significant difference between these parameters. Cv-aCO2/Ca-vO2 at 12 h yielded the highest AUC of 0.853 (0.784-0.907) in predicting mortality and the highest AUC of 0.808 (0.733-0.869) in predicting delirium. In multivariate analysis, hypertension, surgery duration, and PaO2/FiO2 were identified as independent predictors of MPC, while lactate and CO2-derived parameters lost statistical significance after adjustment for covariates.

Conclusions

Lactate and CO2-derived parameters cannot be used as reliable indicators to predict the occurrence of MPC after cardiopulmonary bypass. Instead, traditional clinical factors such as hypertension, extended surgical duration, and impaired oxygenation emerged as the most reliable risk indicators.

Improving Empiric Antibiotic Selection for Patients Hospitalized With Abdominal Infection: The INSPIRE 4 Cluster Randomized Clinical Trial

Importance

Empiric extended-spectrum antibiotics are routinely prescribed for over a million patients hospitalized annually with abdominal infection despite low likelihoods of infection with multidrug-resistant organisms (MDROs).

Objective

To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates can reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with abdominal infection.

Design, Setting, and Participants

This 92-hospital cluster randomized clinical trial assessed the effect of an antibiotic stewardship bundle with CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults hospitalized with abdominal infection. The trial population included adults (≥18 years) treated with empiric antibiotics for abdominal infection in non-intensive care units (ICUs). The trial periods included a 12-month baseline from January to December 2019 and an intervention period from January to December 2023.

Intervention

CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period if the patient's estimated absolute risk of MDRO abdominal infection was less than 10%, coupled with feedback and education.

Main Outcomes and Measures

The primary outcome was empiric extended-spectrum antibiotic days of therapy. Safety outcomes: days to ICU transfer and hospital length of stay. Analyses compared differences between baseline and intervention periods across strategies.

Results

Among 92 hospitals with 198 480 patients, mean (SD) age was 60 (19) years and 118 723 (59.8%) were female. The trial included 93 476 and 105 004 patients hospitalized with abdominal infection during the baseline and intervention periods, respectively. Receipt of any empiric extended-spectrum antibiotics for the routine care group was 48.2% (22 519 of 46 725) during baseline and 50.5% (27 452 of 54 384) during intervention vs 47.8% (22 367 of 46 751) and 37.6% (19 010 of 50 620) for the CPOE bundle group. The group receiving CPOE prompts had a 35% relative reduction (rate ratio, 0.65; 95% CI, 0.60-0.71; P < .001) in empiric extended-spectrum antibiotic days of therapy vs routine care (raw absolute reduction between baseline and intervention periods was -169 for the CPOE bundle vs -20 for routine care). Hospital length of stay was noninferior to routine care (0.1 days longer during intervention; mean [SD], baseline, 5.4 [3.4] days vs intervention, 5.5 [3.5] days; hazard ratio [HR], 1.02; 90% CI, 0.99-1.06), and mean days to ICU transfer in the CPOE group was indeterminate (both groups 0.2 days longer during intervention; HR, 1.10; 90% CI, 0.99-1.23).

Conclusions and Relevance

CPOE prompts recommending empiric standard-spectrum antibiotics (coupled with education and feedback) for patients admitted with abdominal infection who have low risk for MDRO infection significantly reduced extended-spectrum antibiotics without increasing ICU transfers or length of stay.

Trial Registration

ClinicalTrials.gov Identifier: NCT05423743.