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.
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
.
Targeted temperature management (TTM) contributes to improved neurological outcome in adults who have been successfully resuscitated after cardiac arrest with shockable rhythm. Endovascular cooling ...catheters are widely used to induce and maintain targeted temperature in the ICU. The aim of the study was to compare the risk of complications with cooling catheters and standard central venous catheters.
In this prospective single-centre cohort study, we included all patients admitted to an intensive care unit for successfully resuscitated cardiac arrest that required endovascular TTM (Coolgard®, Zoll™ Medical corporation, MA, USA), between August 2012 and November 2014, inclusive. We matched the endovascular cooling catheter cohort with a retrospective historical cohort of 512 central femoral venous catheters from the 3SITES trial to compare thrombotic and infectious complications.
Overall, 108 patients were included in the cooling cohort, of which 89 had ultrasound doppler. The duration of catheterization was 4.9 days in the control group versus 4.2 days in the TTM group (p = 0.08). After propensity-score matching, there were significantly more thrombotic complications in the cooling (n = 75) than in the control (n = 75) group (12 of 75 (16%) versus 0 of 75 (0%), respectively, p = 0.005), and 4 patients presented major complications. There were 8 colonized catheters in each group (11%) (p > 0.99), and none of the patients had a catheter-related bloodstream infection.
In our propensity-score matched study, endovascular cooling catheters were associated with an increased risk of venous catheter-related thrombosis compared to standard central venous catheters.
Abstract Purpose The lack of a consensus definition for acute kidney injury (AKI) has led to a great deal of discrepancies and confusion in the literature in this field. Thus, the RIFLE (Risk of ...renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function and End-stage renal disease) and Acute Kidney Injury Network (AKIN) classifications were developed by multidisciplinary collaborative groups and were validated by experts in an international consensus conference in 2007 under an umbrella “acute kidney insufficiency” definition. Methods Search in the MEDLINE and PUBMED databases for relevant literature from January 2000 to June 2011 was performed to assess the accuracy of the novel consensus definitions for AKI. Conclusions Both systems are based on serum creatinine level and urine output criteria and are staged in 3 severity levels. A major difference between these 2 classifications is that smaller and more rapid changes in serum creatinine are considered in the AKIN stage 1. Each AKI classification has demonstrated its ability to stratify patients according to their AKI severity and to predict outcomes. No classification system has been shown to be superior over the others. Their application in clinical studies would benefit from standardization and the new Kidney Disease Improving Global Outcomes definition of AKI was recently proposed to achieve this aim. Because these classifications do not allow earlier AKI diagnosis and do not optimize the timing of RRT initiation, they remain of moderate utility from the patient's point of view.
Background
To assess the ability of procalcitonin (PCT) to distinguish between bacterial and nonbacterial causes of patients with severe acute exacerbation of COPD (AECOPD) admitted to the ICU, we ...conducted a retrospective analysis of two prospective studies including 375 patients with severe AECOPD with suspected lower respiratory tract infections. PCT levels were sequentially assessed at the time of inclusion, 6 h after and at day 1, using a sensitive immunoassay. The patients were classified according to the presence of a documented bacterial infection (including bacterial and viral coinfection) (BAC + group), or the absence of a documented bacterial infection (i.e., a documented viral infection alone or absence of a documented pathogen) (BAC- group). The accuracy of PCT levels in predicting bacterial infection (BAC + group) vs no bacterial infection (BAC- group) at different time points was evaluated by receiver operating characteristic (ROC) analysis.
Results
Regarding the entire cohort (
n
= 375), at any time, the PCT levels significantly differed between groups (Kruskal–Wallis test,
p
< 0.001). A pairwise comparison showed that PCT levels were significantly higher in patients with bacterial infection (
n
= 94) than in patients without documented pathogens (
n =
218) (
p
< 0.001). No significant difference was observed between patients with bacterial and viral infection (
n
= 63). For example, the median PCT-H
0
levels were 0.64 ng/ml 0.22–0.87 in the bacterial group vs 0.24 ng/ml 0.15–0.37 in the viral group and 0.16 ng/mL 0.11–0.22 in the group without documented pathogens. With a c-index of 0.64 (95% CI; 0.58–0.71) at H
0
, 0.64 95% CI 0.57–0.70 at H
6
and 0.63 (95% CI; 0.56–0.69) at H
24
, PCT had a low accuracy for predicting bacterial infection (BAC + group).
Conclusion
Despite higher PCT levels in severe AECOPD caused by bacterial infection, PCT had a poor accuracy to distinguish between bacterial and nonbacterial infection. Procalcitonin might not be sufficient as a standalone marker for initiating antibiotic treatment in this setting.
Cardiac and infectious causes of the patient's difficulties were investigated and excluded, and we diagnosed Radiation Therapy Oncology Group grade 4 radiation-induced lung injury because the ...opacities were located around the site of the vertebral osteosynthesis (figure). ...we estimated that the predictable risk of developing high grade radiation pneumonitis with our protocol of radiotherapy was very low because of the method—stereotactic radiotherapy—limiting the dose of undesired lung radiation to a mean lung dose of 11·2 Gy on a small lung volume. Radiation pneumonitis usually occurs within 4–12 weeks of the radiotherapy and is related to pneumocyte and endothelial cell damage from the radiation and an inflammatory response mediated by cytokines and reactive oxygen species.
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