Patients in the ICU were assigned to catheter insertion in the subclavian, jugular, or femoral vein. Subclavian catheterization had a lower risk of bloodstream infection and deep-vein thrombosis, and ...a higher risk of pneumothorax, than catheterization in the other two sites.
Subclavian, jugular, and femoral central venous catheterization are associated with infectious, thrombotic, and mechanical complications.
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Catheter-related bloodstream infection has a significant effect on morbidity, mortality, and health care costs.
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The risk of short-term catheter-related bloodstream infection is influenced mainly by extraluminal microbial colonization of the insertion site,
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and such colonization is also associated with thrombosis.
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,
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Although the importance of catheter-related deep-vein thrombosis has been debated,
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all thromboses have the potential to embolize. In addition, catheter-related deep-vein thrombosis
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and pulmonary embolism
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may remain undiagnosed in critically ill patients undergoing mechanical ventilation.
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We conducted the 3SITES multicenter study to . . .
Beta-lactam antibiotics (βLA) are the most commonly used antibiotics in the intensive care unit (ICU). ICU patients present many pathophysiological features that cause pharmacokinetic (PK) and ...pharmacodynamic (PD) specificities, leading to the risk of underdosage. The French Society of Pharmacology and Therapeutics (SFPT) and the French Society of Anaesthesia and Intensive Care Medicine (SFAR) have joined forces to provide guidelines on the optimization of beta-lactam treatment in ICU patients.
A consensus committee of 18 experts from the two societies had the mission of producing these guidelines. The entire process was conducted independently of any industry funding. A list of questions formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes) was drawn-up by the experts. Then, two bibliographic experts analysed the literature published since January 2000 using predefined keywords according to PRISMA recommendations. The quality of the data identified from the literature was assessed using the GRADE® methodology. Due to the lack of powerful studies having used mortality as main judgement criteria, it was decided, before drafting the recommendations, to formulate only "optional" recommendations.
After two rounds of rating and one amendment, a strong agreement was reached by the SFPT-SFAR guideline panel for 21 optional recommendations and a recapitulative algorithm for care covering four areas: (i) pharmacokinetic variability, (ii) PK-PD relationship, (iii) administration modalities, and (iv) therapeutic drug monitoring (TDM). The most important recommendations regarding βLA administration in ICU patients concerned (i) the consideration of the many sources of PK variability in this population; (ii) the definition of free plasma concentration between four and eight times the Minimal Inhibitory Concentration (MIC) of the causative bacteria for 100% of the dosing interval as PK-PD target to maximize bacteriological and clinical responses; (iii) the use of continuous or prolonged administration of βLA in the most severe patients, in case of high MIC bacteria and in case of lower respiratory tract infection to improve clinical cure; and (iv) the use of TDM to improve PK-PD target achievement.
The experts strongly suggest the use of personalized dosing, continuous or prolonged infusion and therapeutic drug monitoring when administering βLA in critically ill patients.
...as noticed by Wieruszewski and Khanna, the pharmacologic response to NE should be characterized individually 1. The weight-based strategy could lead to a delay of AVP initiation in some patients, ...particularly in the growing proportion of obese critically ill patients. Vasopressin in septic shock: an individual patient data meta-analysis of randomised controlled trials.
In patients with convulsive status epilepticus, the addition of cooling to 32 to 34°C for 24 hours did not have a significant effect on the percentage of patients with good outcomes at 90 days as ...compared with standard seizure treatment alone.
Convulsive status epilepticus is among the most challenging life-threatening neurologic emergencies.
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Antiepileptic drug treatment is initiated rapidly and adjusted in response to clinical and electroencephalographic (EEG) findings.
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The in-hospital mortality associated with this condition is approximately 20% and, if status epilepticus remains refractory to treatment, can be as high as 40%.
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Functional impairments after status epilepticus may be due to the effect of seizures on cortical neurons or to cerebral damage due to the underlying process that caused the seizures. In a prospective, multicenter study, 50% of survivors of convulsive status epilepticus who were admitted to an intensive care . . .
Objective
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.
Design
Retrospective analysis of an observational cohort.
Setting
24-bed medical intensive care unit (ICU) in a French university hospital.
Patients
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.
Intervention
None.
Measurements and main results
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.
Conclusions
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.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The occurrence of mediastinitis after cardiac surgery remains a rare and severe complication associated with poor outcomes. Whereas bacterial mediastinitis have been largely described, little is ...known about their fungal etiologies. We report incidence, characteristics and outcome of post-cardiac surgery fungal mediastinitis.
Multicenter retrospective study among 10 intensive care units (ICU) in France and Belgium of proven cases of fungal mediastinitis after cardiac surgery (2009-2019).
Among 73,688 cardiac surgery procedures, 40 patients developed fungal mediastinitis. Five were supported with left ventricular assist device and five with veno-arterial extracorporeal membrane oxygenation before initial surgery. Twelve patients received prior heart transplantation. Interval between initial surgery and mediastinitis was 38 17-61 days. Only half of the patients showed local signs of infection. Septic shock was uncommon at diagnosis (12.5%). Forty-three fungal strains were identified: Candida spp. (34 patients), Trichosporon spp. (5 patients) and Aspergillus spp. (4 patients). Hospital mortality was 58%. Survivors were younger (59 43-65 vs. 65 61-73 yo; p = 0.013), had lower body mass index (24 20-26 vs. 30 24-32 kg/m
; p = 0.028) and lower Simplified Acute Physiology Score II score at ICU admission (37 28-40 vs. 54 34-61; p = 0.012).
Fungal mediastinitis is a very rare complication after cardiac surgery, associated with a high mortality rate. This entity should be suspected in patients with a smoldering infectious postoperative course, especially those supported with short- or long-term invasive cardiac support devices, or following heart transplantation.
There is little descriptive data on Stenotrophomonas maltophilia hospital-acquired pneumonia (HAP) in critically ill patients. The optimal modalities of antimicrobial therapy remain to be determined. ...Our objective was to describe the epidemiology and prognostic factors associated with S. maltophilia pneumonia, focusing on antimicrobial therapy.
This nationwide retrospective study included all patients admitted to 25 French mixed intensive care units between 2012 and 2017 with hospital-acquired S. maltophilia HAP during intensive care unit stay. Primary endpoint was time to in-hospital death. Secondary endpoints included microbiologic effectiveness and antimicrobial therapeutic modalities such as delay to appropriate antimicrobial treatment, mono versus combination therapy, and duration of antimicrobial therapy.
Of the 282 patients included, 84% were intubated at S. maltophilia HAP diagnosis for duration of 11 5-18 days. The Simplified Acute Physiology Score II was 47 36-63, and the in-hospital mortality was 49.7%. Underlying chronic pulmonary comorbidities were present in 14.1% of cases. Empirical antimicrobial therapy was considered effective on S. maltophilia according to susceptibility patterns in only 30% of cases. Delay to appropriate antimicrobial treatment had, however, no significant impact on the primary endpoint. Survival analysis did not show any benefit from combination antimicrobial therapy (HR = 1.27, 95%CI 0.88; 1.83, p = 0.20) or prolonged antimicrobial therapy for more than 7 days (HR = 1.06, 95%CI 0.6; 1.86, p = 0.84). No differences were noted in in-hospital death irrespective of an appropriate and timely empiric antimicrobial therapy between mono- versus polymicrobial S. maltophilia HAP (p = 0.273). The duration of ventilation prior to S. maltophilia HAP diagnosis and ICU length of stay were shorter in patients with monomicrobial S. maltophilia HAP (p = 0.031 and p = 0.034 respectively).
S. maltophilia HAP occurred in severe, long-stay intensive care patients who mainly required prolonged invasive ventilation. Empirical antimicrobial therapy was barely effective while antimicrobial treatment modalities had no significant impact on hospital survival.
clinicaltrials.gov, NCT03506191.
OBJECTIVES:Infectious complications are frequently reported in critically ill patients, especially after cardiac arrest. Recent and widespread use of therapeutic hypothermia has raised concerns about ...increased septic complications, but no specific reappraisal has been performed. We investigated the infectious complications in cardiac arrest survivors and assessed their impact on morbidity and long-term outcome.
DESIGN:Retrospective review of a prospectively acquired intensive care unit database.
SETTING:A 24-bed medical intensive care unit in a French university hospital.
PATIENTS:Between March 2004 and March 2008, consecutive patients admitted for management of resuscitated out-of-hospital cardiac arrest were considered. Patients dying within 24 hrs were excluded. All patientsʼ files were reviewed to assess the development of infection.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:Of the 537 patients admitted after cardiac arrest, 421 were included and 281 patients (67%) presented 373 infectious complications. Pneumonia was the most frequent (318 episodes), followed by bloodstream infections (35 episodes) and catheter-related infections (11 episodes). When grouped together, Gram-negative bacteria were the most frequently isolated infectious germs (64%), but the main pathogen detected was Staphylococcus aureus (57 occurrences). Both application itself (83 vs. 73%; p = .02) and duration (1244 vs. 1176 mins; p = .05) of therapeutic hypothermia were significantly more frequent in infected patients. Infection was associated with increased mechanical ventilation duration (6 2–9 vs. 3 2–5.5 days; p < .001) and intensive care unit length of stay (7 4–10 vs. 3 2–7 days; p < .001). Nonetheless, there was no impact on intensive care unit mortality (174 62% vs. 92 66% patients; p = .45) or on favorable neurologic outcome (cerebral performance category 1–2, 102 36% vs. 47 34% patients; p = .58).
CONCLUSIONS:Infectious complications are frequent after cardiac arrest and may be even more frequent after therapeutic hypothermia. Despite increase in care costs, long-term and clinically relevant outcomes do not seem to be impaired. This should not discourage the use of therapeutic hypothermia in cardiac arrest survivors.
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