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.
1
Catheter-related bloodstream infection has a significant effect on morbidity, mortality, and health care costs.
2
–
4
The risk of short-term catheter-related bloodstream infection is influenced mainly by extraluminal microbial colonization of the insertion site,
5
and such colonization is also associated with thrombosis.
6
,
7
Although the importance of catheter-related deep-vein thrombosis has been debated,
1
all thromboses have the potential to embolize. In addition, catheter-related deep-vein thrombosis
7
–
9
and pulmonary embolism
10
may remain undiagnosed in critically ill patients undergoing mechanical ventilation.
11
We conducted the 3SITES multicenter study to . . .
Purpose
To compare the efficacy of an antibiotic protocol guided by serum procalcitonin (PCT) with that of standard antibiotic therapy in severe acute exacerbations of COPD (AECOPDs) admitted to the ...intensive care unit (ICU).
Methods
We conducted a multicenter, randomized trial in France. Patients experiencing severe AECOPDs were assigned to groups whose antibiotic therapy was guided by (1) a 5-day PCT algorithm with predefined cutoff values for the initiation or stoppage of antibiotics (PCT group) or (2) standard guidelines (control group). The primary endpoint was 3-month mortality. The predefined noninferiority margin was 12%.
Results
A total of 302 patients were randomized into the PCT (
n
= 151) and control (
n
= 151) groups. Thirty patients (20%) in the PCT group and 21 patients (14%) in the control group died within 3 months of admission (adjusted difference, 6.6%; 90% CI − 0.3 to 13.5%). Among patients without antibiotic therapy at baseline (
n
= 119), the use of PCT significantly increased 3-month mortality 19/61 (31%) vs. 7/58 (12%),
p
= 0.015. The in-ICU and in-hospital antibiotic exposure durations, were similar between the PCT and control group (5.2 ± 6.5 days in the PCT group vs. 5.4 ± 4.4 days in the control group,
p
= 0.85 and 7.9 ± 8 days in the PCT group vs. 7.7 ± 5.7 days in the control group,
p
= 0.75, respectively).
Conclusion
The PCT group failed to demonstrate non-inferiority with respect to 3-month mortality and failed to reduce in-ICU and in-hospital antibiotic exposure in AECOPDs admitted to the ICU.
In this multicenter, open-label trial, patients with septic shock were treated to maintain a mean arterial pressure target of either 80 to 85 mm Hg or 65 to 70 mm Hg. There were no significant ...between-group differences in 28-day mortality or in 90-day mortality.
Septic shock is characterized by arterial hypotension despite adequate fluid resuscitation. The guidelines of the Surviving Sepsis Campaign
1
recommended initial resuscitation with vasopressors to reverse hypotension, with a mean arterial pressure target of at least 65 mm Hg (grade 1C, indicating a strong recommendation with a low level of evidence). This recommendation is based on the findings of small studies, which showed no significant differences in lactate levels or regional blood flow when the mean arterial pressure was elevated to more than 65 mm Hg in patients with septic shock.
2
,
3
However, as emphasized by the Surviving Sepsis Campaign guidelines, . . .
Background
Evaluation of the inferior vena cava (IVC) is not always possible through the subcostal (SC) window.
Methods
Inferior vena cava diameters measured by transhepatic (TH) and SC views were ...compared by Bland and Altman analysis.
Results
131 patients were enrolled, including 88 (67%) under mechanical ventilation. The echogenicity was statistically poorer through the TH view in comparison with the SC view (P = .002). The correlation between the SC and TH views was good and better for respiratory variation than for end‐expiratory or end‐inspiratory diameter measurements (r = 0.86). Despite low bias, the limits of agreement were wide (−7.5 and 7.7 mm for end‐expiratory diameter, −8.7 and 8.5 mm for end‐inspiratory diameter, and −5.3 and 5.8 mm for respiratory variation). Complementary analysis showed that the concordance between the SC and the TH views was better when the IVC was distended. However, the limits of agreement remained broad.
Conclusions
Although feasible in almost all patients, the TH view does not provide better echogenicity in comparison with the SC view. Despite a good correlation with the SC view and a low bias, the limits of agreement were wide, especially when the IVC has an ellipsoidal shape, suggesting caution in the interpretation of data obtained by the TH view.
Chimeric antigen receptor T cells are a promising new immunotherapy for haematological malignancies. Six CAR-T cells products are currently available for adult patients with refractory or relapsed ...high-grade B cell malignancies, but they are associated with severe life-threatening toxicities and side effects that may require admission to ICU.
The aim of this short pragmatic review is to synthesize for intensivists the knowledge on CAR-T cell therapy with emphasis on CAR-T cell-induced toxicities and ICU management of complications according to international recommendations, outcomes and future issues.
A 63-year-old man with no history of alcohol abuse presented with sudden, severe epigastric pain. The serum lipase level was elevated, a finding consistent with acute pancreatitis. Despite supportive ...care with fluid hydration, pain medication, and bowel rest, the patient's condition deteriorated.
A 63-year-old man with no history of alcohol abuse presented with sudden, severe epigastric pain. The serum lipase level was elevated (1380 U per liter; normal range, 22 to 51 U per liter), a finding consistent with acute pancreatitis. Abdominal ultrasonography revealed cholelithiasis without evidence of choledocholithiasis. The patient received supportive care with fluid hydration, pain medication, and bowel rest. His condition deteriorated, and he was transferred to the intensive care unit 2 days after hospital admission. Physical examination at the time of the transfer revealed jaundice, with an elevated total serum bilirubin level (4.2 mg per deciliter 71 μmol . . .
Background
Right ventricular (RV) failure is a common complication in moderate-to-severe acute respiratory distress syndrome (ARDS). RV failure is exacerbated by hypercapnic acidosis and ...overdistension induced by mechanical ventilation. Veno-venous extracorporeal CO
2
removal (ECCO
2
R) might allow ultraprotective ventilation with lower tidal volume (
V
T
) and plateau pressure (
P
plat
). This study investigated whether ECCO
2
R therapy could affect RV function.
Methods
This was a quasi-experimental prospective observational pilot study performed in a French medical ICU. Patients with moderate-to-severe ARDS with PaO
2
/FiO
2
ratio between 80 and 150 mmHg were enrolled. An ultraprotective ventilation strategy was used with
V
T
at 4 mL/kg of predicted body weight during the 24 h following the start of a low-flow ECCO
2
R device. RV function was assessed by transthoracic echocardiography (TTE) during the study protocol.
Results
The efficacy of ECCO
2
R facilitated an ultraprotective strategy in all 18 patients included. We observed a significant improvement in RV systolic function parameters. Tricuspid annular plane systolic excursion (TAPSE) increased significantly under ultraprotective ventilation compared to baseline (from 22.8 to 25.4 mm;
p
< 0.05). Systolic excursion velocity (
S’
wave) also increased after the 1-day protocol (from 13.8 m/s to 15.1 m/s;
p
< 0.05). A significant improvement in the aortic velocity time integral (VTIAo) under ultraprotective ventilation settings was observed (
p
= 0.05). There were no significant differences in the values of systolic pulmonary arterial pressure (sPAP) and RV preload.
Conclusion
Low-flow ECCO
2
R facilitates an ultraprotective ventilation strategy thatwould improve RV function in moderate-to-severe ARDS patients. Improvement in RV contractility appears to be mainly due to a decrease in intrathoracic pressure allowed by ultraprotective ventilation, rather than a reduction of PaCO
2
.
CONTEXT Based on concerns about the risk of infection, the jugular site is often preferred over the femoral site for short-term dialysis vascular access. OBJECTIVE To determine whether jugular ...catheterization decreases the risk of nosocomial complications compared with femoral catheterization. DESIGN, SETTING, AND PATIENTS A concealed, randomized, multicenter, evaluator-blinded, parallel-group trial (the Cathedia Study) of 750 patients from a network of 9 tertiary care university medical centers and 3 general hospitals in France conducted between May 2004 and May 2007. The severely ill, bed-bound adults had a body mass index (BMI) of less than 45 and required a first catheter insertion for renal replacement therapy. INTERVENTION Patients were randomized to receive jugular or femoral vein catheterization by operators experienced in placement at both sites. MAIN OUTCOME MEASURES Rates of infectious complications, defined as catheter colonization on removal (primary end point), and catheter-related bloodstream infection. RESULTS Patient and catheter characteristics, including duration of catheterization, were similar in both groups. More hematomas occurred in the jugular group than in the femoral group (13/366 patients 3.6% vs 4/370 patients 1.1%, respectively; P = .03). The risk of catheter colonization at removal did not differ significantly between the femoral and jugular groups (incidence of 40.8 vs 35.7 per 1000 catheter-days; hazard ratio HR, 0.85; 95% confidence interval CI, 0.62-1.16; P = .31). A prespecified subgroup analysis demonstrated significant qualitative heterogeneity by BMI (P for the interaction term < .001). Jugular catheterization significantly increased incidence of catheter colonization vs femoral catheterization (45.4 vs 23.7 per 1000 catheter-days; HR, 2.10; 95% CI, 1.13-3.91; P = .017) in the lowest tercile (BMI <24.2), whereas jugular catheterization significantly decreased this incidence (24.5 vs 50.9 per 1000 catheter-days; HR, 0.40; 95% CI, 0.23-0.69; P < .001) in the highest tercile (BMI >28.4). The rate of catheter-related bloodstream infection was similar in both groups (2.3 vs 1.5 per 1000 catheter-days, respectively; P = .42). CONCLUSION Jugular venous catheterization access does not appear to reduce the risk of infection compared with femoral access, except among adults with a high BMI, and may have a higher risk of hematoma. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00277888
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