Individualised, perioperative open-lung ventilation strategy during one-lung ventilation (iPROVE-OLV): a multicentre, randomised, controlled clinical trial

BACKGROUND

It is uncertain whether individualisation of the perioperative open-lung approach (OLA) to ventilation reduces postoperative pulmonary complications in patients undergoing lung resection. We compared a perioperative individualised OLA (iOLA) ventilation strategy with standard lung-protective ventilation in patients undergoing thoracic surgery with one-lung ventilation.

METHODS

This multicentre, randomised controlled trial enrolled patients scheduled for open or video-assisted thoracic surgery using one-lung ventilation in 25 participating hospitals in Spain, Italy, Turkey, Egypt, and Ecuador. Eligible adult patients (age ≥18 years) were randomly assigned to receive iOLA or standard lung-protective ventilation. Eligible patients (stratified by centre) were randomly assigned online by local principal investigators, with an allocation ratio of 1:1. Treatment with iOLA included an alveolar recruitment manoeuvre to 40 cm H2O of end-inspiratory pressure followed by individualised positive end-expiratory pressure (PEEP) titrated to best respiratory system compliance, and individualised postoperative respiratory support with high-flow oxygen therapy. Participants allocated to standard lung-protective ventilation received combined intraoperative 4 cm H2O of PEEP and postoperative conventional oxygen therapy. The primary outcome was a composite of severe postoperative pulmonary complications within the first 7 postoperative days, including atelectasis requiring bronchoscopy, severe respiratory failure, contralateral pneumothorax, early extubation failure (rescue with continuous positive airway pressure, non-invasive ventilation, invasive mechanical ventilation, or reintubation), acute respiratory distress syndrome, pulmonary infection, bronchopleural fistula, and pleural empyema. Due to trial setting, data obtained in the operating and postoperative rooms for routine monitoring were not blinded. At 24 h, data were acquired by an investigator blinded to group allocation. All analyses were performed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT03182062, and is complete.

FINDINGS

Between Sept 11, 2018, and June 14, 2022, we enrolled 1380 patients, of whom 1308 eligible patients (670 [434 male, 233 female, and three with missing data] assigned to iOLA and 638 [395 male, 237 female, and six with missing data] to standard lung-protective ventilation) were included in the final analysis. The proportion of patients with the composite outcome of severe postoperative pulmonary complications within the first 7 postoperative days was lower in the iOLA group compared with the standard lung-protective ventilation group (40 [6%] vs 97 [15%], relative risk 0·39 [95% CI 0·28 to 0·56]), with an absolute risk difference of -9·23 (95% CI -12·55 to -5·92). Recruitment manoeuvre-related adverse events were reported in five patients.

INTERPRETATION

Among patients subjected to lung resection under one-lung ventilation, iOLA was associated with a reduced risk of severe postoperative pulmonary complications when compared with conventional lung-protective ventilation.

FUNDING

Instituto de Salud Carlos III and the European Regional Development Funds.

Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies

Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.

Towards the personalization of septic shock resuscitation: the fundamentals of ANDROMEDA-SHOCK-2 trial

Septic shock is a highly lethal and prevalent disease. Progressive circulatory dysfunction leads to tissue hypoperfusion and hypoxia, eventually evolving to multiorgan dysfunction and death. Prompt resuscitation may revert these pathogenic mechanisms, restoring oxygen delivery and organ function. High heterogeneity exists among the determinants of circulatory dysfunction in septic shock, and current algorithms provide a stepwise and standardized approach to conduct resuscitation. This review provides the pathophysiological and clinical rationale behind ANDROMEDA-SHOCK-2, an ongoing multicenter randomized controlled trial that aims to compare a personalized resuscitation strategy based on clinical phenotyping and peripheral perfusion assessment, versus standard of care, in early septic shock resuscitation.

Decrease in Mortality after the Implementation of a Hospital Model to Improve Performance in Sepsis Care: Princess Sepsis Code

Sepsis is a time-dependent disease whose prognosis is influenced by early diagnosis and therapeutic measures. Mortality from sepsis remains high, and for this reason, the guidelines of the Surviving Sepsis Campaign recommend establishing specific care programs aimed at patients with sepsis. We present the results of the application of a hospital model to improve performance in sepsis care, called Princess Sepsis Code, with the aim of reducing mortality. A retrospective study was conducted using clinical, epidemiological, and outcome variables in patients diagnosed with sepsis from 2015 to 2022. A total of 2676 patients were included, 32% of whom required admission to the intensive care unit, with the most frequent focus of the sepsis being abdominal. Mortality in 2015, at the beginning of the sepsis code program, was 24%, with a declining rate noted over the study period, with mortality reaching 17% in 2022. In the multivariate analysis, age > 70 years, respiratory rate > 22 rpm, deterioration in the level of consciousness, serum lactate > 2 mmol/L, creatinine > 1.6 mg/dL, and the focus of the sepsis were identified as variables independently related to mortality. The implementation of the Princess Sepsis Code care model reduces the mortality of patients exhibiting sepsis and septic shock.

Sepsis Stewardship: The Puzzle of Antibiotic Therapy in the Context of Individualization of Decision Making

The main recent change observed in the field of critical patient infection has been universal awareness of the need to make better use of antimicrobials, especially for the most serious cases, beyond the application of simple and effective formulas or rigid protocols. The increase in resistant microorganisms, the quantitative increase in major surgeries and interventional procedures in the highest risk patients, and the appearance of a significant number of new antibiotics in recent years (some very specifically directed against certain mechanisms of resistance and others with a broader spectrum of applications) have led us to shift our questions from "what to deal with" to "how to treat". There has been controversy about how best to approach antibiotic treatment of complex cases of sepsis. The individualized and adjusted dosage, the moment of its administration, the objective, and the selection of the regimen are pointed out as factors of special relevance in a critically ill patient where the frequency of resistant microorganisms, especially among the Enterobacterales group, and the emergence of multiple and diverse antibiotic treatment alternatives have made the appropriate choice of antibiotic treatment more complex, requiring a constant updating of knowledge and the creation of multidisciplinary teams to confront new infections that are difficult to treat. In this article, we have reviewed the phenomenon of the emergence of resistance to antibacterials and we have tried to share some of the ideas, such as stewardship, sparing carbapenems, and organizational, microbiological, pharmacological, and knowledge tools, that we have considered most useful and effective for individualized decision making that takes into account the current context of multidrug resistance. The greatest challenge, therefore, of decision making in this context lies in determining an effective, optimal, and balanced empirical antibiotic treatment.

Research priorities in perioperative fluid therapy and hemodynamic monitoring: A Delphi Consensus Survey from the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR)

BACKGROUND

Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance.

METHODS

Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care.

RESULTS

77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus.

CONCLUSIONS

The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.

Outcomes of a multidisciplinary mechanical circulatory support network in cardiogenic shock in a centre without heart transplant program: A successful interprofessional coordination model

BACKGROUND AND OBJECTIVE

Cardiogenic shock (CS) mortality remains very high and mechanical circulatory support (MCS) may provide an effective alternative of treatment in selected patients. The aim of this study is to analyse the results of a multidisciplinary team care program (including anaesthesiologists, cardiologists, cardiothoracic surgeons, and intensivists) in CS patients who required MCS, in a tertiary centre without a heart transplant (HT) program.

METHODS

Prospective observational study that sought to analyse the characteristics and survival to discharge predictors in a consecutive CS patients cohort treated with MCS.

RESULTS

A total of 48 patients were included. Mean age was 61 ± 14 years. Before MCS, 45.8% of the patients presented with cardiac arrest. A 54.2% 30-day survival and 45.8% overall survival to discharge, was found. Age and vasoactive-inotropic score were independent predictors of mortality.

CONCLUSIONS

A multidisciplinary team-care based MCS program in CS patients is feasible and may achieve favourable results in a centre without HT program.

Sepsis Code: dodging mortality in a tertiary hospital

Introducción

En el hospital de La Princesa comienza el “Código Sepsis” (CSP) en el año 2015, como un grupo multidisciplinar que dota al personal sanitario de herramientas clínicas, analíticas y organizativas, con el objetivo de la detección y el tratamiento precoz del paciente con sepsis. El objetivo de este estudio es evaluar el impacto de la implantación de CSP en la mortalidad y determinar las variables asociadas con un aumento de la misma.

Material y métodos

Se realizó un estudio analítico retrospectivo de los pacientes con activación de la alerta CSP de 2015 a 2018. Se recogieron variables clínico-epidemiológicas, parámetros analíticos y factores de gravedad como el ingreso en Unidades de Cuidados Críticos (UCC) y la necesidad de aminas. La significación estadística se estableció en una p < 0,05.

Resultados

Se incluyeron 1.121 pacientes. La estancia media fue de 16 días y un 32% requirieron ingreso en UCC. La mortalidad mostró una tendencia lineal descendente estadísticamente significativa del 24% en 2015 hasta el 15% en 2018. Las variables predictivas de mortalidad con asociación estadísticamente significativa fueron el lactato > 2 mmol/L, la creatinina > 1,6 mg/dL y la necesidad de aminas.

Conclusiones

La implementación de Código Sepsis disminuye la mortalidad de los pacientes con sepsis y shock séptico. La presencia de una cifra de lactato > 2 mmol/L, los niveles de creatinina > 1,6 mg/dL y/o la necesidad de administrar aminas en las primeras 24 horas, se asocian con un aumento de la mortalidad en el paciente con sepsis.

Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study

Background

Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone.

Methods

Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP.

Results

A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53–1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0–2.5) vs 2 IQR 1.0–3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40–2.72), p = 0.92].

Conclusion

In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: A prospective, cohort, multicentre study

Background

The clinical course of COVID-19 critically ill patients, during their admission in the intensive care unit (UCI), including medical and infectious complications and support therapies, as well as their association with in-ICU mortality has not been fully reported.

Objective

This study aimed to describe clinical characteristics and clinical course of ICU COVID-19 patients, and to determine risk factors for ICU mortality of COVID-19 patients.

Methods

Prospective, multicentre, cohort study that enrolled critically ill COVID-19 patients admitted into 30 ICUs from Spain and Andorra. Consecutive patients from March 12th to May 26th, 2020 were enrolled if they had died or were discharged from ICU during the study period. Demographics, symptoms, vital signs, laboratory markers, supportive therapies, pharmacological treatments, medical and infectious complications were reported and compared between deceased and discharged patients.

Results

A total of 663 patients were included. Overall ICU mortality was 31% (203 patients). At ICU admission non-survivors were more hypoxemic [SpO₂ with non-rebreather mask, 90 (IQR 83–93) vs 91 (IQR 87–94); p < 0.001] and with higher sequential organ failure assessment score [SOFA, 7 (IQR 5–9) vs 4 (IQR 3–7); p < 0.001]. Complications were more frequent in non-survivors: acute respiratory distress syndrome (ARDS) (95% vs 89%; p = 0.009), acute kidney injury (AKI) (58% vs 24%; p < 10⁻¹⁶), shock (42% vs 14%; p < 10⁻¹³), and arrhythmias (24% vs 11%; p < 10⁻⁴). Respiratory super-infection, bloodstream infection and septic shock were higher in non-survivors (33% vs 25%; p = 0.03, 33% vs 23%; p = 0.01 and 15% vs 3%, p = 10⁻⁷), respectively. The multivariable regression model showed that age was associated with mortality, with every year increasing risk-of-death by 1% (95%CI: 1–10, p = 0.014). Each 5-point increase in APACHE II independently predicted mortality [OR: 1.508 (1.081, 2.104), p = 0.015]. Patients with AKI [OR: 2.468 (1.628, 3.741), p < 10⁻⁴)], cardiac arrest [OR: 11.099 (3.389, 36.353), p = 0.0001], and septic shock [OR: 3.224 (1.486, 6.994), p = 0.002] had an increased risk-of-death.

Conclusions

Older COVID-19 patients with higher APACHE II scores on admission, those who developed AKI grades II or III and/or septic shock during ICU stay had an increased risk-of-death. ICU mortality was 31%.

Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: A prospective, cohort, multicentre study

Antecedentes

No se ha reportado plenamente la evolución clínica de los pacientes críticos de COVID-19 durante su ingreso en la unidad de cuidados intensivos (UCI), incluyendo las complicaciones médicas e infecciosas y terapias de soporte, así como su asociación con la mortalidad en UCI.

Objetivo

El objetivo de este estudio es describir las características clínicas y la evolución de los pacientes ingresados en UCI por COVID-19 y determinar los factores de riesgo de la mortalidad en UCI de dichos pacientes.

Métodos

Estudio prospectivo, multicéntrico y de cohorte, que incluyó a los pacientes críticos de COVID-19 ingresados en 30 UCI de España y Andorra. Se incluyó a los pacientes consecutivos del 12 de marzo al 26 de mayo del 2020 si habían fallecido o habían recibido el alta de la UCI durante el periodo de estudio. Se reportaron los datos demográficos, los síntomas, los signos vitales, los marcadores de laboratorio, las terapias de soporte, terapias farmacológicas y las complicaciones médicas e infecciosas, realizándose una comparación entre los pacientes fallecidos y los pacientes dados de alta.

Resultados

Se incluyó a un total de 663 pacientes. La mortalidad general en UCI fue del 31% (203 pacientes). Al ingreso en UCI los no supervivientes eran más hipoxémicos (SpO₂ con mascarilla de no reinhalación, de 90 [RIC 83-93] vs. 91 [RIC 87-94]; p < 0,001] y con mayor puntuación en la escala SOFA-Evaluación de daño orgánico secuencial (SOFA, 7 [RIC 5-9] vs. 4 [RIC 3-7]; p <0,001]). Las complicaciones fueron más frecuentes en los no supervivientes: síndrome de distrés respiratorio agudo (SDRA) (95% vs. 89%; p = 0,009), insuficiencia renal aguda (IRA) (58% vs. 24%; p < 10^–6), shock (42% vs. 14%; p < 10^–13) y arritmias (24% vs. 11%; p < 10^–4). Las superinfecciones respiratorias, infecciones del torrente sanguíneo y los shock sépticos fueron más frecuentes en los no supervivientes (33% vs. 25%; p = 0,03, 33% vs. 23%; p = 0,01 y 15% vs. 3%, p = 10^–7, respectivamente). El modelo de regresión multivariable reflejó que la edad estaba asociada a la mortalidad y que cada año incrementaba el riesgo de muerte en un 1% (IC del 95%: 1-10, p = 0,014). Cada incremento de 5 puntos en la escala APACHE II predijo de manera independiente la mortalidad (odds ratio [OR]: 1,508 [1,081, 2,104], p = 0,015). Los pacientes con IRA (OR: 2,468 [1,628, 3,741], p < 10^–4)], paro cardiaco (OR: 11,099 [3,389, 36,353], p = 0,0001] y shock séptico [OR: 3,224 [1,486, 6,994], p= 0,002) tuvieron un riesgo de muerte incrementado.

Conclusiones

Los pacientes mayores de COVID-19 con puntuaciones APACHE II más altas al ingreso, que desarrollaron IRA en grados ii o iii o shock séptico durante la estancia en UCI tuvieron un riesgo de muerte incrementado. La mortalidad en UCI fue del 31%.

Initial clinical outcomes and prognostic variables in the implementation of a Code Sepsis in a high complexity University Hospital

OBJECTIVE

To assess the impact of the first months of application of a Code Sepsis in a high complexity hospital, analyzing patient´s epidemiological and clinical characteristics and prognostic factors.

METHODS

A long-term observational study was carried out throughout a consecutive period of seven months (February 2015 - September 2015). The relationship with mortality of risk factors, and analytic values was analyzed using uni- and multivariate analyses.

RESULTS

A total of 237 patients were included. The in-hospital mortality was 24% at 30 days and 27% at 60 days. The mortality of patients admitted to Critical Care Units was 30%. Significant differences were found between the patients who died and those who survived in mean levels of creatinine (2.30 vs 1.46 mg/dL, p <0.05), lactic acid (6.10 vs 2.62 mmol/L, p <0.05) and procalcitonin (23.27 vs 12.73 mg/dL, p<0.05). A statistically significant linear trend was found between SOFA scale rating and mortality (p<0.05). In the multivariate analysis additional independent risk factors associated with death were identified: age > 65 years (OR 5.33, p <0.05), lactic acid > 3 mmol/L (OR 5,85, p <0,05), creatinine > 1,2 mgr /dL (OR 4,54, p <0,05) and shock (OR 6,57, P <0,05).

CONCLUSIONS

The epidemiological, clinical and mortality characteristics of the patients in our series are similar to the best published in the literature. The study has identified several markers that could be useful at a local level to estimate risk of death in septic patients. Studies like this one are necessary to make improvements in the Code Sepsis programs.

Evolution of regional oxygen saturation in the peri-operative of thoracic surgery and its relationship with central venous saturation

OBJECTIVE

To study the relationship between the values of SvcO2 and SrcO2 in lung resection with one lung ventilation (OLV) and changes in these variables and mean arterial pressure (MAP) and arterial oxygen saturation (SpO2) during the perioperative period.

MATERIAL AND METHODS

Prospective, observational study of 25 patients in whom pulmonary resection was performed with OLV. The values of MAP, SpO2, SvO2, and SrcO2 were recorded at 6 different times: 1)baseline; 2)double-lung ventilation before the OLV (VBP1); 3)during OLV; 4)after double-lung ventilation (VBP2); 5)30minutes after surgery, and 6)6hours after surgery.

RESULTS

The SrcO2 showed a significant increase from baseline to starting ventilation (65.72±9.05% vs 70.44±7.24%; P<.01). There were no significant changes in their values at the different intraoperative times. Post-operatively, as in the case of the SvcO2, a significant decrease (P<.001) of its value compared with the previous value was observed.

CONCLUSIONS

SrcO2 showed a significant increase after induction of anaesthesia and initiation of mechanical ventilation compared to baseline, and a significant decrease at the end of surgery after extubation in the immediate postoperative period. Being a tissue monitoring, non-invasive technique and with continuous values it can alert the clinician of changes in the ratio of oxygen consumption (VO2) to oxygen delivery (DO2) at times of greatest risk, such as OLV, extubation, and the early postoperative period.

Rationale and study design for an individualized perioperative open lung ventilatory strategy (iPROVE): study protocol for a randomized controlled trial

BACKGROUND

Postoperative pulmonary and non-pulmonary complications are common problems that increase morbidity and mortality in surgical patients, even though the incidence has decreased with the increased use of protective lung ventilation strategies. Previous trials have focused on standard strategies in the intraoperative or postoperative period, but without personalizing these strategies to suit the needs of each individual patient and without considering both these periods as a global perioperative lung-protective approach. The trial presented here aims at comparing postoperative complications when using an individualized ventilatory management strategy in the intraoperative and immediate postoperative periods with those when using a standard protective ventilation strategy in patients scheduled for major abdominal surgery.

METHODS

This is a comparative, prospective, multicenter, randomized, and controlled, four-arm trial that will include 1012 patients with an intermediate or high risk for postoperative pulmonary complications. The patients will be divided into four groups: (1) individualized perioperative group: intra- and postoperative individualized strategy; (2) intraoperative individualized strategy + postoperative continuous positive airway pressure (CPAP); (3) intraoperative standard ventilation + postoperative CPAP; (4) intra- and postoperative standard strategy (conventional strategy). The primary outcome is a composite analysis of postoperative complications.

DISCUSSION

The Individualized Perioperative Open-lung Ventilatory Strategy (iPROVE) is the first multicenter, randomized, and controlled trial to investigate whether an individualized perioperative approach prevents postoperative pulmonary complications.

TRIAL REGISTRATION

Registered on 5 June 2014 with identification no. NCT02158923 .

A practice-based observational study identifying factors associated with the use of high-dose tigecycline in the treatment of secondary peritonitis in severely ill patients

INTRODUCTION

Based on tigecycline linear pharmacokinetic/pharmacodynamics, dose increases have been advocated to maximise activity especially when severe infections with high bacterial load and/or multidrug resistance are suspected. This practice-based observational study explored factors associated with tigecycline administration (100 mg/12h, 200 mg loading dose) in severely ill patients with complicated intra-abdominal infection (cIAI) admitted to four Surgical Critical Care Units (SCCUs).

METHODS

Medical records of all consecutive adult patients with cIAI and controlled infection source requiring surgery and admission for ≥ 48 h to SCCU were reviewed and divided into patients treated with a regimen including tigecycline (tigecycline group) and those that not (control group). A logistic regression model was performed using "tigecycline administration" (dependent variable) and variables showing differences (p ≤ 0.1) in bivariate analyses (independent variables).

RESULTS

One hundred and twenty one patients were included. In the tigecycline group, higher percentage of patients (vs. controls) presented colon as surgical site (66.7% vs. 41.8%, p = 0.006), nosocomial infection (55.6% vs. 26.9%, p = 0.001), mechanical ventilation (48.1% vs. 28.4%, p = 0.025), chronic renal replacement therapy (40.7% vs. 19.4%, p =0.008), septic shock (72.2% vs. 46.3%, p = 0.004), and higher values of SAPS II (48.0 ± 15.0 vs. 39.6 ± 15.5, p = 0.003), SOFA at admission (7.0 ± 3.3 vs. 5.5 ± 3.7, p = 0.020), lactate-24h (2.5 ± 2.8 vs. 1.6 ± 0.9, p = 0.029) and CRP-72 h (207.4 ± 87.9 vs. 163.7 ± 76.8, p = 0.021). In the multivariate analysis (R2 = 0.187, p < 0.001) nosocomial infection (OR = 7.721; 95%CI = 2.193, 27.179; p = 0.001), colon as infection site (OR = 4.338; 95%CI = 1.432, 13.145; p = 0.009) and CRP-72 h (OR = 1.009 per-unit; 95%CI = 1.002, 1.016; p = 0.012) were associated with tigecycline administration.

CONCLUSIONS

In severely ill patients with cIAI, high-dose tigecycline administration was associated with nosocomial origin of cIAI and colon as source infection site.

Bugs, hosts and ICU environment: countering pan-resistance in nosocomial microbiota and treating bacterial infections in the critical care setting

ICUs are areas where resistance problems are the largest, and they constitutes a major problem for the intensivist's clinical practice. Main resistance phenotypes among nosocomial microbiota are: i) vancomycin-resistance/heteroresistance and tolerance in grampositives (MRSA, enterococci) and ii) efflux pumps/enzymatic resistance mechanisms (ESBLs, AmpC, metallobetalactamases) in gramnegatives. These phenotypes are found at different rates in pathogens causing respiratory (nosocomial pneumonia/ventilator-associated pneumonia), bloodstream (primary bacteremia/catheter-associated bacteremia), urinary, intraabdominal and surgical wound infections and endocarditis in the ICU. New antibiotics are available to overcome non-susceptibility in grampositives; however, accumulation of resistance traits in gramnegatives has lead to multidrug resistance, a worrisome problem nowadays. This article reviews by microorganism/infection risk factors for multidrug resistance, suggesting adequate empirical treatments. Drugs, patient and environmental factors all play a role in the decision to prescribe/recommend antibiotic regimens in the specific ICU patient, implying that intensivists should be familiar with available drugs, environmental epidemiology and patient factors.

[Description of the hemodynamic and respiratory effects of hemoperfusion treatment with polymyxin B in patients with abdominal septic shock]

The objective of this study is to describe the hemodynamic effects, inotropic and vasoactive drug dependence, and to analyze the PO2/FiO2 ratio in 13 patients with septic shock of abdominal origin after hemoperfusion treatment with polymyxin-B. Treatment with polymyxin hemoperfusion therapy is indicated for patients with severe sepsis/septic shock of abdominal origin who do not respond adequately to conventional therapy. Two complete cycles with polymyxin cartridge were performed on 11 of the 13 patients, and a single cycle on the other O2. After treatment, the mean airway pressure (MAP) was increased (P=.003), the need for norepinephrine decreased (P=.003), and the PO2/FiO2 ratio increased (P=.02). The use of polymyxin hemoperfusion in patients with septic shock of intra-abdominal origin can significantly improve hemodynamic and respiratory functions.

[Double lumen tube insertion in awake patients through the AirTraq laryngoscope in 2 cases of expected difficult airway]

The likelihood of difficult airway in thoracic surgery increases in the presence of associated cancer of the pharynx or larynx. The difficulty is greater when a double lumen tube must be inserted in these conditions, and various newly developed optical devices offer solutions for managing such cases. We report on 2 patients with expected difficult airway who were scheduled for lung resection. In both cases, intubation was accomplished through the AirTraq laryngoscope while the patient remained awake. Awake patient tolerance is facilitated by this laryngoscope, because the tube can be inserted without changing the position of the tongue or placing pressure on the vallecula.

Complications related to less-invasive haemodynamic monitoring

BACKGROUND

The aim of this study was to evaluate the type and incidence of complications during insertion, maintenance, and withdrawal of central arterial catheters used for transpulmonary thermodilution haemodynamic monitoring (PiCCO™).

METHODS

We conducted a prospective, observational, multicentre study in 14 European intensive care units (six countries). A total of 514 consecutive patients in whom haemodynamic monitoring by PiCCO™ was indicated were studied.

RESULTS

Five hundred and fourteen PiCCO catheters (475 in femoral, 26 in radial, nine in axillary, and four in brachial arteries) were inserted. Arterial access was obtained on the first attempt in 86.4% of the patients. Minor problems such as oozing after insertion (3.3%) or removal of the catheter (3.5%) were observed, but no episodes of serious bleeding (more than 50 ml) were recorded. Small local haematomas were observed after insertion (4.5%) and after removal (1.2%) of the catheter. These complications were not more frequent in patients with coagulation abnormalities. The incidence of site inflammation and catheter-related infection was 2% and 0.78%, respectively. Other complications such as ischaemia (0.4%), pulse loss (0.4%), or femoral artery thrombosis (0.2%) were rare, transient, and all resolved with catheter removal or embolectomy, respectively.

CONCLUSIONS

In this series of patients, central arterial catheters used for PiCCO™ monitoring were demonstrated to be a safe alternative for advanced haemodynamic monitoring.

[Septic shock due to community-acquired complicated intra-abdominal infection treated with ertapenem: outcome in 25 cases]

OBJECTIVES

To assess the effectiveness of ertapenem in patients admitted to a surgical intensive care unit with septic shock due to community-acquired complicated intra-abdominal infection.

PATIENTS AND METHODS

Patients undergoing emergency surgery for community-acquired complicated intra-abdominal infection were enrolled prospectively. All patients were given intravenous ertapenem at a rate of 1 g/24 h and the guidelines of the Surviving Sepsis Campaign were applied. Outcome measures were duration of antibiotic therapy, mean length of stay in the surgical intensive care unit (ICU), antibiotic failure, and death while in the surgical ICU.

RESULTS

Twenty-five patients with a mean (SD) age of 74 (14) years were enrolled. The origin of infection was the colon in 56% of the cases; most patients (76%) had generalized peritonitis. The mean stay in the surgical ICU was 10 (7) days. The mean duration of antibiotic therapy was 5.8 (1.26) days. Antibiotic failure occurred in 12%. Mortality in the surgical ICU was 28%.

CONCLUSIONS

Our findings suggest that patients with community-acquired intra-abdominal infection and septic shock have a good chance of survival when treated according to the guidelines of the Surviving Sepsis Campaign. Ertapenem seems to give good results when used in this setting.

[Neuraxial hematoma after combined regional anesthesia: conservative resolution]

Epidural hematoma is a rare but serious neurological complication of neuraxial anesthesia. We report the case of a woman in whom this complication presented after knee replacement surgery under combined neuraxial anesthesia. No adverse events occurred during surgery. In the early postoperative period thromboembolic prophylaxis and continuous perfusion of ropivacaine were started through the epidural catheter. Lumbar pain along with sensorimotor alterations in the lower limbs developed on the first day after surgery. Epidural hematoma was suspected and the perfusion of local anesthetic was suspended. A computed tomography scan confirmed the presence of a hematoma with poorly defined margins. The patient was transferred to another hospital for dorsolumbar magnetic resonance, which revealed an extensive hematoma. Surgery was ruled out in favor of conservative treatment. Neurological symptoms resolved slowly over the following days and the patient was discharged partially recovered 51 days after surgery and recovery was complete within 6 postoperative months. We discuss the prevalence, etiology, and treatment of neuraxial hematoma related to local or regional anesthesia.