Executive Summary Introduction Methodology Used to Prepare the Guideline Epidemiology Incidence Etiology Major Epidemiologic Points Pathogenesis Major Points for Pathogenesis Modifiable Risk Factors Intubation and Mechanical Ventilation Aspiration, Body Position, and Enteral Feeding Modulation of Colonization: Oral Antiseptics and Antibiotics Stress Bleeding Prophylaxis, Transfusion, and Glucose Control Major Points and Recommendations for Modifiable Risk Factors Diagnostic Testing Major Points and Recommendations for Diagnosis Diagnostic Strategies and Approaches Clinical Strategy Bacteriologic Strategy Recommended Diagnostic Strategy Major Points and Recommendations for Comparing Diagnostic Strategies Antibiotic Treatment of Hospital-acquired Pneumonia General Approach Initial Empiric Antibiotic Therapy Appropriate Antibiotic Selection and Adequate Dosing Local Instillation and Aerosolized Antibiotics Combination versus Monotherapy Duration of Therapy Major Points and Recommendations for Optimal Antibiotic Therapy Specific Antibiotic Regimens Antibiotic Heterogeneity and Antibiotic Cycling Response to Therapy Modification of Empiric Antibiotic Regimens Defining the Normal Pattern of Resolution Reasons for Deterioration or Nonresolution Evaluation of the Nonresponding Patient Major Points and Recommendations for Assessing Response to Therapy Suggested Performance Indicators

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia the official statement of the American Thoracic Society and the Infectious Disease Society of America (特集 救急診療ガイドライン) -- (海外のガイドライン)

International study of the prevalence and outcomes of infection in intensive care units

Background
Sepsis poses a global threat to millions of lives. The Surviving Sepsis Campaign (SSC) guidelines provide evidence-based recommendations on the recognition and management of sepsis and its complications.
Methods
We formed a panel of 60 experts from 22 countries and 11 members of the public. The panel prioritized questions that are relevant to the recognition and management of sepsis and septic shock in adults. New questions and sections were addressed, relative to the previous guidelines. These questions were grouped under 6 subgroups (screening and early treatment, infection, hemodynamics, ventilation, additional therapies, and long-term outcomes and goals of care). With input from the panel and methodologists, professional medical librarians performed the search strategy tailored to either specific questions or a group of relevant questions. A dedicated systematic review team performed screening and data abstraction when indicated. For each question, the methodologists, with input from panel members, summarized the evidence assessed and graded the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. The panel generated recommendations using the evidence-to-decision framework. Recommendations were either strong or weak, or in the form of best practice statements. When evidence was insufficient to support a recommendation, the panel was surveyed to generate “in our practice” statements.
Results
The SSC panel issued 93 statements: 15 best practice statements, 15 strong recommendations, and 54 weak recommendations and no recommendation was provided for 9 questions. The recommendations address several important clinical areas related to screening tools, acute resuscitation strategies, management of fluids and vasoactive agents, antimicrobials and diagnostic tests and the use of additional therapies, ventilation management, goals of care, and post sepsis care.
Conclusion
The SSC panel issued evidence-based recommendations to help support key stakeholders caring for adults with sepsis or septic shock and their families.

/pdf/surviving-sepsis-campaign-international-guidelines-for-1trp1tl9am.pdf

Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021.

The aims of severe perioperative bleeding management are three-fold. First, preoperative identification by anamesis and laboratory testing of those patients for whom the perioperative bleeding risk may be increased. Second, implementation of strategies for correcting preoperative anaemia and stabilisation of the macro- and microcirculations in order to optimise the patient’s tolerance to bleeding. Third, targeted procoagulant interventions to reduce the amount of bleeding, morbidity, mortality and costs. The purpose of these guidelines is to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthetists throughout Europe to integrate this knowledge into daily patient care wherever possible. The Guidelines Committee of the European Society of Anaesthesiology (ESA) formed a task force with members of scientific subcommittees and individual expert members of the ESA. Electronic databases were searched without language restrictions from the year 2000 until 2012. These searches produced 20 664 abstracts. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. At the suggestion of the ESA Guideline Committee, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was initially used to assess the level of evidence and to grade recommendations. During the process of guideline development, the official position of the ESA changed to favour the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This report includes general recommendations as well as specific recommendations in various fields of surgical interventions. The final draft guideline was posted on the ESA website for four weeks and the link was sent to all ESA members. Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

https://epub.ub.uni-muenchen.de/24023/1/oa_24023.pdf

Management of severe perioperative bleeding Guidelines from the European Society of Anaesthesiology

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021.

Aims Systolic dysfunction in septic shock is well recognized and, paradoxically, predicts better outcome. In contrast, diastolic dysfunction is often ignored and its role in determining early mortality from sepsis has not been adequately investigated.

Methods and results A cohort of 262 intensive care unit patients with severe sepsis or septic shock underwent two echocardiography examinations early in the course of their disease. All clinical, laboratory, and survival data were prospectively collected. Ninety-five (36%) patients died in the hospital. Reduced mitral annular e′-wave was the strongest predictor of mortality, even after adjusting for the APACHE-II score, low urine output, low left ventricular stroke volume index, and lowest oxygen saturation, the other independent predictors of mortality (Cox's proportional hazards: Wald = 21.5, 16.3, 9.91, 7.0 and 6.6, P < 0.0001, <0.0001, 0.002, 0.008, and 0.010, respectively). Patients with systolic dysfunction only (left ventricular ejection fraction ≤50%), diastolic dysfunction only (e′-wave <8 cm/s), or combined systolic and diastolic dysfunction (9.1, 40.4, and 14.1% of the patients, respectively) had higher mortality than those with no diastolic or systolic dysfunction (hazard ratio = 2.9, 6.0, 6.2, P = 0.035, <0.0001, <0.0001, respectively) and had significantly higher serum levels of high-sensitivity troponin-T and N-terminal pro-B-type natriuretic peptide (NT-proBNP). High-sensitivity troponin-T was only minimally elevated, whereas serum levels of NT-proBNP were markedly elevated [median (inter-quartile range): 0.07 (0.02–0.17) ng/mL and 5762 (1001–15 962) pg/mL, respectively], though both predicted mortality even after adjusting for highest creatinine levels (Wald = 5.8, 21.4 and 2.3, P = 0.015, <0.001 and 0.13).

Conclusion Diastolic dysfunction is common and is a major predictor of mortality in severe sepsis and septic shock.

Diastolic dysfunction and mortality in severe sepsis and septic shock

Myocardial infarction after vascular surgery : The role of prolonged, stress-induced, ST depression-type ischemia

Over the past two decades there has been a steady evolution in the practice of adult cardiac surgery with the introduction of "off-pump" surgery. However, respiratory complications remain a leading cause of postcardiac surgical morbidity and can prolong hospital stays and increase costs. The high incidence of pulmonary complications is in part due to the disruption of normal ventilatory function that is inherent to surgery in the thoracic region. Furthermore, patients undergoing such surgery often have underlying illnesses such as intrinsic lung disease (e.g., chronic obstructive pulmonary disease) and pulmonary dysfunction secondary to cardiac disease (e.g., congestive heart failure) that increase their susceptibility to postoperative respiratory problems. Given that many patients undergoing cardiac surgery are thus susceptiple to pulmonary complications, it is remarkable that more patients do not suffer from them during and after cardiac surgery. This is to a large degree because of advances in anesthetic, surgical and critical care that, for example, have reduced the physiological insults of surgery (e.g., better myocardial preservation techniques) and streamlined care in the immediate postoperative period (e.g., early extubation). Moreover, the development of minimally invasive surgery and nonbypass techniques are further evidence of the attempts at reducing the homeostatic disruptions of cardiac surgery. This review examines the available information on the incidences, consequences, and treatments of postcardiac surgery respiratory complications.

/pdf/pulmonary-complications-after-cardiac-surgery-1dl2kgxd6y.pdf

Pulmonary complications after cardiac surgery.

Civilian mass casualty events are becoming an increasingly important security issue all over the world1–3 since terrorism is not an endemic phenomenon, but an epidemic.

Prehospital Trauma Life Support (PHTLS) guidelines state that critically injured, but salvageable patients, should be promptly evacuated and transferred, preferably to a Level I trauma center, immediately following primary triage and resuscitation.4 This approach has been practiced by the rescue teams of the Magen David Adom Israeli National Emergency Medical Services (MDA) since Advanced Trauma Life Support (ATLS) courses were initiated in Israel in 1990.

Thus, PHTLS and ATLS guidelines have been strictly followed in Israel, resulting in admission of most major civilian trauma victims to trauma centers. However, the recent onslaught of terror related mass casualty incidents in this country has forced a change in practice in such circumstances, resulting in a paradigm shift. Both PHTLS and ATLS deal primarily with the treatment of a single patient. In the situation of a mass casualty incorporating multiple and severe civilian injuries, evacuating all critically injured patients to a Level I trauma center may not be applicable, as treatment of a patient population must take priority over treatment of individuals.5 In a mass casualty event, the impositions placed upon prehospital rescue services in regards to evacuation priorities become the most dominant consideration. This phenomenon has been observed during the recent events in Israel.

We undertook to perform a retrospective analysis of medical evacuations carried out by the MDA rescue teams from the scenes of terror related mass casualty incidents to examine whether PHTLS evacuation guidelines remain valid in these circumstances. Our study offers a unique insight into real-life evacuation priorities in such real-time events. This experience has led us to realize that a paradigm change may be necessary in contingency planning for such circumstances, with a shift from the trauma center concept to medical centers in general.

Evacuation Priorities in Mass Casualty Terror-Related Events: Implications for Contingency Planning

Perioperative care is undergoing significant change due to clinical advances and economic pressures. As more emphasis is placed on costcontainment and improved efficiency, current practices should be reviewed and critiqued to determine whether they are actually effective. Common problems, such as postoperative pulmonary complications, should be a focus of these efforts because the “bottom line” is to devise methods to reduce these complications and so decrease the costs of medical care. This requires a multifaceted approach that entails a better understanding of the causes of the complications, devising effective treatments and preventive strategies, and performing outcome studies to determine the success of currently used and new procedures. In this review, I examine the pulmonary changes after surgery involving the thoracic cavity and the consequences of modern pain management techniques. Perioperative Respiratory Function: A

https://www.researchgate.net/profile/Charles_Weissman/publication/6779395_Pulmonary_function_after_cardiac_and_thoracic_surgery/links/0046352cae60b967aa000000.pdf

Charles Weissman

Papers

Diastolic dysfunction and mortality in severe sepsis and septic shock

Myocardial infarction after vascular surgery : The role of prolonged, stress-induced, ST depression-type ischemia

Pulmonary complications after cardiac surgery.

Evacuation Priorities in Mass Casualty Terror-Related Events: Implications for Contingency Planning

Pulmonary function after cardiac and thoracic surgery.