Showing papers in "Intensive Care Medicine in 2013"

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012

Abstract: To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008. A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7–9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pao 2/Fio 2 ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a Pao 2/Fi o 2 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven “absolute”’ adrenal insufficiency (2C). Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome

Abstract: Purpose To update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS).

Lower tidal volume strategy (≈3 ml/kg) combined with extracorporeal CO2 removal versus 'conventional' protective ventilation (6 ml/kg) in severe ARDS: the prospective randomized Xtravent-study.

Abstract: Acute respiratory distress syndrome is characterized by damage to the lung caused by various insults, including ventilation itself, and tidal hyperinflation can lead to ventilator induced lung injury (VILI). We investigated the effects of a low tidal volume (V T) strategy (V T ≈ 3 ml/kg/predicted body weight [PBW]) using pumpless extracorporeal lung assist in established ARDS. Seventy-nine patients were enrolled after a ‘stabilization period’ (24 h with optimized therapy and high PEEP). They were randomly assigned to receive a low V T ventilation (≈3 ml/kg) combined with extracorporeal CO2 elimination, or to a ARDSNet strategy (≈6 ml/kg) without the extracorporeal device. The primary outcome was the 28-days and 60-days ventilator-free days (VFD). Secondary outcome parameters were respiratory mechanics, gas exchange, analgesic/sedation use, complications and hospital mortality. Ventilation with very low V T’s was easy to implement with extracorporeal CO2-removal. VFD’s within 60 days were not different between the study group (33.2 ± 20) and the control group (29.2 ± 21, p = 0.469), but in more hypoxemic patients (PaO2/FIO2 ≤150) a post hoc analysis demonstrated significant improved VFD-60 in study patients (40.9 ± 12.8) compared to control (28.2 ± 16.4, p = 0.033). The mortality rate was low (16.5 %) and did not differ between groups. The use of very low V T combined with extracorporeal CO2 removal has the potential to further reduce VILI compared with a ‘normal’ lung protective management. Whether this strategy will improve survival in ARDS patients remains to be determined (Clinical trials NCT 00538928).

Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort

Abstract: Brain injury is well established as a cause of early mortality after out-of-hospital cardiac arrest (OHCA), but postresuscitation shock also contributes to these deaths. This study aims to describe the respective incidence, risk factors, and relation to mortality of post-cardiac arrest (CA) shock and brain injury. Retrospective analysis of an observational cohort. 24-bed medical intensive care unit (ICU) in a French university hospital. All consecutive patients admitted following OHCA were considered for analysis. Post-CA shock was defined as a need for infusion of vasoactive drugs after resuscitation. Death related to brain injury included brain death and care withdrawal for poor neurological evolution. None. Between 2000 and 2009, 1,152 patients were admitted after OHCA. Post-CA shock occurred in 789 (68 %) patients. Independent factors associated with its onset were high blood lactate and creatinine levels at ICU admission. During the ICU stay, 269 (34.8 %) patients died from post-CA shock and 499 (65.2 %) from neurological injury. Age, raised blood lactate and creatinine values, and time from collapse to restoration of spontaneous circulation increased the risk of ICU mortality from both shock and brain injury, whereas a shockable rhythm was associated with reduced risk of death from these causes. Finally, bystander cardiopulmonary resuscitation (CPR) decreased the risk of death from neurological injury. Brain injury accounts for the majority of deaths, but post-CA shock affects more than two-thirds of OHCA patients. Mortality from post-CA shock and brain injury share similar risk factors, which are related to the quality of the rescue process.

The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome

Abstract: Purpose This study was designed to identify factors associated with death by 6 months post-intensive care unit (ICU) discharge and to develop a practical mortality risk score for extracorporeal membrane oxygenation (ECMO)-treated acute respiratory distress syndrome (ARDS) patients. We also assessed long-term survivors’ health-related quality of life (HRQL), respiratory symptoms, and anxiety, depression and post-traumatic stress disorder (PTSD) frequencies.

Sonographic evaluation of the diaphragm in critically ill patients. Technique and clinical applications.

Abstract: The use of ultrasonography has become increasingly popular in the everyday management of critically ill patients. It has been demonstrated to be a safe and handy bedside tool that allows rapid hemodynamic assessment and visualization of the thoracic, abdominal and major vessels structures. More recently, M-mode ultrasonography has been used in the assessment of diaphragm kinetics. Ultrasounds provide a simple, non-invasive method of quantifying diaphragmatic movement in a variety of normal and pathological conditions. Ultrasonography can assess the characteristics of diaphragmatic movement such as amplitude, force and velocity of contraction, special patterns of motion and changes in diaphragmatic thickness during inspiration. These sonographic diaphragmatic parameters can provide valuable information in the assessment and follow up of patients with diaphragmatic weakness or paralysis, in terms of patient–ventilator interactions during controlled or assisted modalities of mechanical ventilation, and can potentially help to understand post-operative pulmonary dysfunction or weaning failure from mechanical ventilation. This article reviews the technique and the clinical applications of ultrasonography in the evaluation of diaphragmatic function in ICU patients.

Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM.

Abstract: Recommendations for EEG monitoring in the ICU are lacking. The Neurointensive Care Section of the ESICM assembled a multidisciplinary group to establish consensus recommendations on the use of EEG in the ICU. A systematic review was performed and 42 studies were included. Data were extracted using the PICO approach, including: (a) population, i.e. ICU patients with at least one of the following: traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, stroke, coma after cardiac arrest, septic and metabolic encephalopathy, encephalitis, and status epilepticus; (b) intervention, i.e. EEG monitoring of at least 30 min duration; (c) control, i.e. intermittent vs. continuous EEG, as no studies compared patients with a specific clinical condition, with and without EEG monitoring; (d) outcome endpoints, i.e. seizure detection, ischemia detection, and prognostication. After selection, evidence was classified and recommendations developed using the GRADE system. The panel recommends EEG in generalized convulsive status epilepticus and to rule out nonconvulsive seizures in brain-injured patients and in comatose ICU patients without primary brain injury who have unexplained and persistent altered consciousness. We suggest EEG to detect ischemia in comatose patients with subarachnoid hemorrhage and to improve prognostication of coma after cardiac arrest. We recommend continuous over intermittent EEG for refractory status epilepticus and suggest it for patients with status epilepticus and suspected ongoing seizures and for comatose patients with unexplained and persistent altered consciousness. EEG monitoring is an important diagnostic tool for specific indications. Further data are necessary to understand its potential for ischemia assessment and coma prognostication.

Incidence, risk factors and 90-day mortality of patients with acute kidney injury in Finnish intensive care units: the FINNAKI study

Abstract: Purpose We aimed to determine the incidence, risk factors and outcome of acute kidney injury (AKI) in Finnish ICUs.

High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicentre randomized controlled trial

Abstract: Purpose Septic shock is a leading cause of death among critically ill patients, in particular when complicated by acute kidney injury (AKI). Small experimental and human clinical studies have suggested that high-volume haemofiltration (HVHF) may improve haemodynamic profile and mortality. We sought to determine the impact of HVHF on 28-day mortality in critically ill patients with septic shock and AKI.

Use of high flow nasal cannula in critically ill infants, children, and adults: a critical review of the literature

Abstract: Background High flow nasal cannula (HFNC) systems utilize higher gas flow rates than standard nasal cannulae. The use of HFNC as a respiratory support modality is increasing in the infant, pediatric, and adult populations as an alternative to non-invasive positive pressure ventilation.

Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis

Abstract: Choice of renal replacement therapy (RRT) modality may affect renal recovery after acute kidney injury (AKI). We sought to compare the rate of dialysis dependence among severe AKI survivors according to the choice of initial renal replacement therapy (RRT) modality applied [continuous (CRRT) or intermittent (IRRT)]. Systematic searches of peer-reviewed publications in MEDLINE and EMBASE were performed (last update July 2012). All studies published after 2000 reporting dialysis dependence among survivors from severe AKI requiring RRT were included. Data on follow-up duration, sex, age, chronic kidney disease, illness severity score, vasopressors, and mechanical ventilation were extracted when available. Results were pooled using a random-effects model. We identified 23 studies: seven randomized controlled trials (RCTs) and 16 observational studies involving 472 and 3,499 survivors, respectively. Pooled analyses of RCTs showed no difference in the rate of dialysis dependence among survivors (relative risk, RR 1.15 [95 % confidence interval (CI) 0.78–1.68], I 2 = 0 %). However, pooled analyses of observational studies suggested a higher rate of dialysis dependence among survivors who initially received IRRT as compared with CRRT (RR 1.99 [95 % CI 1.53–2.59], I 2 = 42 %). These findings were consistent with adjusted analyses (performed in 7/16 studies), which found a higher rate of dialysis dependence in IRRT-treated patients [odds ratio (OR) 2.2–25 (5 studies)] or no difference (2 studies). Among AKI survivors, initial treatment with IRRT might be associated with higher rates of dialysis dependence than CRRT. However, this finding largely relies on data from observational trials, potentially subject to allocation bias, hence further high-quality studies are necessary.

Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study

Abstract: To ascertain the relationship among early (first 48 h) deep sedation, time to extubation, delirium and long-term mortality. We conducted a multicentre prospective longitudinal cohort study in 11 Malaysian hospitals including medical/surgical patients (n = 259) who were sedated and ventilated ≥24 h. Patients were followed from ICU admission up to 28 days in ICU with 4-hourly sedation and daily delirium assessments and 180-day mortality. Deep sedation was defined as Richmond Agitation Sedation Score (RASS) ≤−3. The cohort had a mean (SD) age of 53.1 (15.9) years and APACHE II score of 21.3 (8.2) with hospital and 180-day mortality of 82 (31.7 %) and 110/237 (46.4 %). Patients were followed for 2,657 ICU days and underwent 13,836 RASS assessments. Midazolam prescription was predominant compared to propofol, given to 241 (93 %) versus 72 (28 %) patients (P < 0.0001) for 966 (39.6 %) versus 183 (7.5 %) study days respectively. Deep sedation occurred in (182/257) 71 % patients at first assessment and in 159 (61 %) patients and 1,658 (59 %) of all RASS assessments at 48 h. Multivariable Cox proportional hazard regression analysis adjusting for a priori assigned covariates including sedative agents, diagnosis, age, APACHE II score, operative, elective, vasopressors and dialysis showed that early deep sedation was independently associated with longer time to extubation [hazard ratio (HR) 0.93, 95 % confidence interval (CI) 0.89–0.97, P = 0.003], hospital death (HR 1.11, 95 % CI 1.05–1.18, P < 0.001) and 180-day mortality (HR 1.09, 95 % CI 1.04–1.15, P = 0.002), but not time to delirium (HR 0.98, P = 0.23). Delirium occurred in 114 (44 %) of patients. Irrespective of sedative choice, early deep sedation was independently associated with delayed extubation and higher mortality, and thus was a potentially modifiable risk in interventional trials.

Blood oxygenation and decarboxylation determinants during venovenous ECMO for respiratory failure in adults

Abstract: Purpose This study was designed to optimize the latest generation venovenous (vv)-extracorporeal membrane oxygenation (ECMO)-circuit configuration and settings based on the evaluation of blood oxygenation and CO2 removal determinants in patients with severe acute respiratory distress syndrome (ARDS) on ultraprotective mechanical ventilation.

Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome.

Abstract: Pulmonary vascular dysfunction is common during acute respiratory distress syndrome (ARDS), but there is controversy concerning prevalence and prognosis of cor pulmonale during protective ventilation for ARDS. This was a prospective observational study in an academic medical intensive care unit in France. Two hundred and twenty-six consecutive patients with moderate to severe ARDS (Berlin definition) ventilated with plateau pressure limited at 30 cmH2O (mean PEEP of 8.8 ± 3.6 cmH2O) underwent transesophageal echocardiography (TEE) within the first 3 days after the diagnosis of ARDS. Cor pulmonale was defined as a dilated right ventricle associated with septal dyskinesia. Cor pulmonale was detected in 49 patients (prevalence of 22 %; 95 % confidence interval, 16–27 %). Multivariate logistic regression identified infectious causes of lung injury and higher driving pressures as independent factors associated with cor pulmonale. Patients with cor pulmonale exhibited a higher incidence of shock (need for vasoactive drug) at the time of TEE and were more often managed with prone positioning and/or nitric oxide as adjunctive therapy for severe hypoxemia during ARDS course. The 28-day mortality rate was significantly higher in the group with cor pulmonale (60 vs. 36 %, p < 0.01). Multivariate logistic regression identified McCabe and Jackson class, lung injury not related to pneumonia, aspiration, or sepsis, lactic acidosis, driving pressure, and cor pulmonale as independent risk factors for 28-day mortality. Cor pulmonale occurrence is not negligible in ARDS patients ventilated with airway pressure limitation. Cor pulmonale was associated with sepsis and higher values of driving pressure and was an independent risk factor for 28-day mortality in our series.

Predicting mortality risk in patients undergoing venovenous ECMO for ARDS due to influenza A (H1N1) pneumonia: the ECMOnet score.

Abstract: Purpose The decision to start venovenous extracorporeal membrane oxygenation (VV ECMO) is commonly based on the severity of respiratory failure, with little consideration of the extrapulmonary organ function. The aim of the study was to identify predictors of mortality and to develop a score allowing a better stratification of patients at the time of VV ECMO initiation.

Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department.

Abstract: Purpose We analyzed the efficacy of a point-of-care ultrasonographic protocol, based on a focused multiorgan examination, for the diagnostic process of symptomatic, non-traumatic hypotensive patients in the emergency department.

Clinical implications of antibiotic pharmacokinetic principles in the critically ill

Abstract: Successful antibiotic therapy in the critically ill requires sufficient drug concentrations at the site of infection that kill or suppress bacterial growth. The relationship between antibiotic exposure and achieving the above effects is referred to as pharmacokinetics/pharmacodynamics (PK/PD). The associated indices therefore provide logical targets for optimal antibiotic therapy. While dosing regimens to achieve such targets have largely been established from studies in animals and non-critically ill patients, they are often poorly validated in the ICU. Endothelial dysfunction, capillary leak, altered major organ blood flow, deranged plasma protein concentrations, extremes of body habitus, the application of extracorporeal support modalities, and a higher prevalence of intermediate susceptibility, independently, and in combination, significantly confound successful antibiotic treatment in this setting. As such, the prescription of standard doses are likely to result in sub-therapeutic concentrations, which in turn may promote treatment failure or the selection of resistant pathogens. This review article considers these issues in detail, summarizing the key changes in antibiotic PK/PD in the critically ill, and suggesting alternative dosing strategies that may improve antibiotic therapy in these challenging patients.

Is treatment with a high flow nasal cannula effective in acute viral bronchiolitis? A physiologic study.

Abstract: The high flow nasal cannula (HFNC) has recently been proposed to support infants with respiratory syncytial virus (RSV)-related respiratory distress. However, in this disease, no physiologic data are currently available on the effects of this device. We assessed the capacity of HFNC to generate positive airway pressure, as well as the resulting effects on breathing pattern and respiratory effort. Twenty-one infants less than 6 months old with acute RSV bronchiolitis were studied prospectively in the pediatric intensive care unit of a university hospital. Pharyngeal pressure (PP) and esophageal pressure (Pes) were measured simultaneously at four increasing flows of 1, 4, 6 and 7 L/min delivered through HFNC. The PP was correlated with flow rate (r = 0.65, p ≤ 0.0001), reaching mean and end-expiratory values of, respectively, 4 (95% CI 3–5) cmH2O and 6.5 (95% CI 5–8) cmH2O at 7 L/min. A flow ≥2 L/kg/min was associated with the generation of a mean pharyngeal pressure ≥4 cmH2O with a sensitivity of 67 %, a specificity of 96 %, a positive predictive value of 75 %, and a negative predictive value of 94.5%. Only flows ≥6 L/min provided positive PP throughout the respiratory cycle. From baseline to maximal flow rate, breathing frequency (p < 0.01), T i/T tot (p < 0.05), Pes swing (p < 0.05) and PTPesinsp/min (p < 0.01), an index of respiratory effort, were reduced. HFNC with a flow rate equal to or above 2 L/kg/min generated a clinically relevant PP, with improved breathing pattern and rapid unloading of respiratory muscles, in young infants with acute RSV bronchiolitis.

A universal definition of ARDS: the PaO2/FiO2 ratio under a standard ventilatory setting—a prospective, multicenter validation study

Abstract: Purpose The PaO2/FiO2 is an integral part of the assessment of patients with acute respiratory distress syndrome (ARDS). The American-European Consensus Conference definition does not mandate any standardization procedure. We hypothesized that the use of PaO2/FiO2 calculated under a standard ventilatory setting within 24 h of ARDS diagnosis allows a more clinically relevant ARDS classification.

A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts

Abstract: intra-abdominal candidiasis (IAC) may include Candida involvement of peritoneum or intra-abdominal abscess and is burdened by high morbidity and mortality rates in surgical patients. Unfortunately, international guidelines do not specifically address this particular clinical setting due to heterogeneity of definitions and scant direct evidence. In order to cover this unmet clinical need, the Italian Society of Intensive Care and the International Society of Chemotherapy endorsed a project aimed at producing practice recommendations for the management of immune-competent adult patients with IAC. A multidisciplinary expert panel of 22 members (surgeons, infectious disease and intensive care physicians) was convened and assisted by a methodologist between April 2012 and May 2013. Evidence supporting each statement was graded according to the European Society of Clinical Microbiology and Infection Diseases (ESCMID) grading system. Only a few of the numerous recommendations can be summarized in the Abstract. Direct microscopy examination for yeast detection from purulent and necrotic intra-abdominal specimens during surgery or by percutaneous aspiration is recommended in all patients with nonappendicular abdominal infections including secondary and tertiary peritonitis. Samples obtained from drainage tubes are not valuable except for evaluation of colonization. Prophylactic usage of fluconazole should be adopted in patients with recent abdominal surgery and recurrent gastrointestinal perforation or anastomotic leakage. Empirical antifungal treatment with echinocandins or lipid formulations of amphotericin B should be strongly considered in critically ill patients or those with previous exposure to azoles and suspected intra-abdominal infection with at least one specific risk factor for Candida infection. In patients with nonspecific risk factors, a positive mannan/antimannan or (1→3)-β-d-glucan (BDG) or polymerase chain reaction (PCR) test result should be present to start empirical therapy. Fluconazole can be adopted for the empirical and targeted therapy of non-critically ill patients without previous exposure to azoles unless they are known to be colonized with a Candida strain with reduced susceptibility to azoles. Treatment can be simplified by stepping down to an azole (fluconazole or voriconazole) after at least 5–7 days of treatment with echinocandins or lipid formulations of amphotericin B, if the species is susceptible and the patient has clinically improved. Specific recommendations were elaborated on IAC management based on the best direct and indirect evidence and on the expertise of a multinational panel.

Prognostication of neurologic outcome in cardiac arrest patients after mild therapeutic hypothermia: a meta-analysis of the current literature

Abstract: To assess the sensitivity and false positive rate (FPR) of neurological examination and somatosensory evoked potentials (SSEPs) to predict poor outcome in adult patients treated with therapeutic hypothermia after cardiopulmonary resuscitation (CPR). MEDLINE and EMBASE were searched for cohort studies describing the association of clinical neurological examination or SSEPs after return of spontaneous circulation with neurological outcome. Poor outcome was defined as severe disability, vegetative state and death. Sensitivity and FPR were determined. A total of 1,153 patients from ten studies were included. The FPR of a bilaterally absent cortical N20 response of the SSEP could be calculated from nine studies including 492 patients. The SSEP had an FPR of 0.007 (confidence interval, CI, 0.001–0.047) to predict poor outcome. The Glasgow coma score (GCS) motor response was assessed in 811 patients from nine studies. A GCS motor score of 1–2 at 72 h had a high FPR of 0.21 (CI 0.08–0.43). Corneal reflex and pupillary reactivity at 72 h after the arrest were available in 429 and 566 patients, respectively. Bilaterally absent corneal reflexes had an FPR of 0.02 (CI 0.002–0.13). Bilaterally absent pupillary reflexes had an FPR of 0.004 (CI 0.001–0.03). At 72 h after the arrest the motor response to painful stimuli and the corneal reflexes are not a reliable tool for the early prediction of poor outcome in patients treated with hypothermia. The reliability of the pupillary response to light and the SSEP is comparable to that in patients not treated with hypothermia.

Fluid resuscitation with 6 % hydroxyethyl starch (130/0.4 and 130/0.42) in acutely ill patients: systematic review of effects on mortality and treatment with renal replacement therapy

Abstract: Purpose To determine whether fluid resuscitation of acutely ill adults with 6 % hydroxyethyl starch (6 % HES 130) with a molecular weight of 130 kD and a molar substitution ratio of approximately 0.4 (6 % HES 130) compared with other resuscitation fluids results in a difference in the relative risk of death or treatment with renal replacement therapy (RRT).

Cognitive impairment after intensive care unit admission: a systematic review.

Abstract: Purpose There is increasing evidence that critical illness and treatment in an intensive care unit (ICU) may result in significant long-term morbidity. The purpose of this systematic review was to summarize the current literature on long-term cognitive impairment in ICU survivors.

Neurologic complications in neonates supported with extracorporeal membrane oxygenation. An analysis of ELSO registry data

Abstract: Neurologic complications in neonates supported with extracorporeal membrane oxygenation (ECMO) are common and diminish their quality of life and survival. An understanding of factors associated with neurologic complications in neonatal ECMO is lacking. The goals of this study were to describe the epidemiology and factors associated with neurologic complications in neonatal ECMO. Retrospective cohort study of neonates (age ≤30 days) supported with ECMO using data reported to the Extracorporeal Life Support Organization during 2005–2010. Of 7,190 neonates supported with ECMO, 1,412 (20 %) had neurologic complications. Birth weight <3 kg [odds ratio (OR): 1.3; 95 % confidence intervals (CI): 1.1–1.5], gestational age (<34 weeks; OR 1.5, 95 % CI 1.1–2.0 and 34–36 weeks: OR 1.4, 95 % CI 1.1–1.7), need for cardiopulmonary resuscitation prior to ECMO (OR 1.7, 95 % CI 1.5–2.0), pre-ECMO blood pH ≤ 7.11 (OR 1.7, 95 % CI 1.4–2.1), pre-ECMO bicarbonate use (OR 1.3, 95 % CI 1.2–1.5), prior ECMO exposure (OR 2.4, 95 % CI 1.6–2.6), and use of veno-arterial ECMO (OR 1.7, 95 % CI 1.4–2.0) increased neurologic complications. Mortality was higher in patients with neurologic complications compared to those without (62 % vs. 36 %; p < 0.001). Neurologic complications are common in neonatal ECMO and are associated with increased mortality. Patient factors, pre-ECMO severity of illness, and use of veno-arterial ECMO are associated with increased neurologic complications. Patient selection, early ECMO deployment, and refining ECMO management strategies for vulnerable populations could be targeted as areas for improvement in neonatal ECMO.

Prognostic value of troponins in sepsis: a meta-analysis.

Abstract: Rationale The role of biomarkers such as troponin in risk stratification of sepsis is still debated. The aim of this meta-analysis is to assess the relation between troponin elevation in sepsis and mortality.

Microcirculatory blood flow as a tool to select ICU patients eligible for fluid therapy

Abstract: Purpose The aim of this study is to assess the incidence of sublingual microcirculatory flow alterations, according to a predefined arbitrary cutoff value, in patients with “clinical signs of impaired organ perfusion”. Secondary endpoints were the changes in microvascular flow index (MFI), “clinical signs of impaired organ perfusion”, and stroke volume (SV) after fluid administration, and the differences between groups.

Clinical outcomes of Pseudomonas aeruginosa pneumonia in intensive care unit patients

Abstract: Purpose Our aim was to identify the clinical profile of intensive care unit (ICU) patients with Pseudomonas aeruginosa (PA) pneumonia and the impact on ICU mortality and duration of mechanical ventilation (MV) of multidrug resistance (MDR) in the PA isolate and inadequate initial antibiotic therapy (IIAT).

Effects of dobutamine on systemic, regional and microcirculatory perfusion parameters in septic shock: a randomized, placebo-controlled, double-blind, crossover study

Abstract: Purpose The role of dobutamine during septic shock resuscitation is still controversial since most clinical studies have been uncontrolled and no physiological study has unequivocally demonstrated a beneficial effect on tissue perfusion. Our objective was to determine the potential benefits of dobutamine on hemodynamic, metabolic, peripheral, hepatosplanchnic and microcirculatory perfusion parameters during early septic shock resuscitation.

Therapeutic hypothermia after out-of-hospital cardiac arrest in Finnish intensive care units: the FINNRESUSCI study

Abstract: Purpose We aimed to evaluate post-resuscitation care, implementation of therapeutic hypothermia (TH) and outcomes of intensive care unit (ICU)-treated out-of-hospital cardiac arrest (OHCA) patients in Finland.

Noninvasive mechanical ventilation in patients having declined tracheal intubation

Abstract: Purpose Noninvasive ventilation (NIV) is a treatment option in patients with acute respiratory failure who are good candidates for intensive care but have declined tracheal intubation. The aim of our study was to report outcomes after NIV in patients with a do-not-intubate (DNI) order.