Antifungal prophylaxis: update on an old strategy.

Obstructive sleep apnea: screening is the waiting room for preoperative testing, postoperative monitoring, and safety measures

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From bedside to bench: The missing brick for patients with fungal sepsis

We read with great interest the article by Spec et al. [1] investigating the immunophenotype of T cells from patients with Candida spp. sepsis. This is the first observational study describing the altered immune response of patients with candidemia. The authors included non-neutropenic critically ill patients with candidemia and non-septic controls, and excluded patients with human immunodeficiency virus infection, who had undergone solid or bone marrow transplantation or with other known causes of impaired immune response. The authors hypothesized that their findings may help explain why patients with fungal sepsis show a high mortality despite appropriate antifungal therapy. In our opinio…

Should we continue to use prediction tools to identify patients at risk of Candida spp. infection? If yes, why?

Background Given the predominance of invasive fungal disease (IFD) amongst the non-immunocompromised adult critically ill population, the potential benefit of antifungal prophylaxis and the lack of generalisable tools to identify high risk patients, the aim of the current study was to describe the epidemiology of IFD in UK critical care units, and to develop and validate a clinical risk prediction tool to identify non-neutropenic, critically ill adult patients at high risk of IFD who would benefit from antifungal prophylaxis. Methods Data on risk factors for, and outcomes from, IFD were collected for consecutive admissions to adult, general critical care units in the UK participating in the…

Dying with or because of invasive fungal infection? The role of immunity exhaustion on patient outcome

De Rosa et al. considered clinical scores, biomarkers and their combination as useful aids for an early antifungal treatment and advocated the adoption of de-escalation therapy in an antifungal stewardship approach as a possible key for a better management of these patients. Authors considered the high burden of invasive fungal infections in terms of patient outcomes and costs and focused on current strategies for their optimization.

Associations of Antifungal Treatments With Prevention of Fungal Infection in Critically Ill Patients Without Neutropenia

BACKGROUND: Invasive fungal infections are important causes of morbidity and mortality among critically ill patients. Early institution of antifungal therapy is pivotal for mortality reduction. Starting a targeted antifungal therapy after culture positivity and fungi identification requires a long time. Therefore, alternative strategies (globally defined as 'untargeted antifungal treatments') for antifungal therapy institution in patients without proven microbiological evidence of fungal infections have been discussed by international guidelines. This review was originally published in 2006 and updated in 2016. This updated review provides additional evidence for the clinician dealing with …

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Contains fulltext : 252214.pdf (Publisher’s version ) (Open Access) BACKGROUND: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. METHODS: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to defi…

Attitudes towards end-of-life issues in intensive care unit among Italian anesthesiologists: a nation-wide survey

Background: The aim of this paper is to collect data on the practice of palliative care, withholding and withdrawal of life-sustaining therapies, and management of end of life (EOL) in Italian intensive care units (ICUs). Methods: Web-based survey among Italian anesthesiologists endorsed by the Italian Society of Anesthesiology Analgesia Reanimation and Intensive Care (SIAARTI). The survey consists of 27 close-ended and 2 open-ended questions. Results: Eight hundred and five persons responded to the full list of questions. The highest proportion of respondents was of 36–45 years of age (34%) and catholic (66%). Almost 70% of responders declared that palliative/supportive care are applied …

Is it time to consider visual feedback systems the gold standard for chest compression skill acquisition?

ICU-acquired infections: It is not only about the number of patients per room

LETTER TO EDITOR

What Is the Most Recent Evidence on the Prevention and Early Treatment of Invasive Fungal Infections in Nonneutropenic Critically Ill Patients?

: Invasive fungal infections (IFIs) are associated with high morbidity and mortality in intensive care units. Candida species are the most important fungal pathogens and among the most frequent causes of infection in critically ill patients. Studies have evaluated the correlation between the onset of antifungal treatment and survival. However, definitive diagnosis of IFI is time-consuming in clinical practice. Antifungal prophylaxis and preemptive or empirical treatments are among therapeutic strategies to prevent or treat early fungal infections in selected patients. Recently, new evidence from randomized controlled trials and systematic reviews has been published. Moreover, new clinical p…

Procalcitonin as a marker of Candida species detection by blood culture and polymerase chain reaction in septic patients

Background: The aim of our study is to test procalcitonin (PCT) as surrogate marker of identification of Candida spp. by blood culture (BC) and real-time-polymerase chain reaction (PCR), whether alone or in association with bacteria, in septic patients.Methods: We performed a single-centre retrospective study. We reviewed the clinical charts of patients with a diagnosis of severe sepsis or septic shock treated at our general intensive care unit from March 2009 to March 2013. We analysed all diagnostic episodes consisting of BC, real-time PCR assay and dosage of PCT. We registered age, sex, white blood count, sequential organ failure assessment score and type of admission between medical or …

Uncertainty about the evidence on untargeted antifungal treatment

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Is it time to combine untargeted antifungal strategies to reach the goal of 'early' effective treatment?

A recently published retrospective study by Posteraro et al. [1] investigated the use of (1–3)-β-D-glucan (BDG) as a strategy for antifungal drug administration in patients at high risk of candidemia. The strategy consisted of the administration of antifungals (anidulafungin in most cases) to septic patients with a Candida score ≥ 3a nd a positive BDG result (≥80 pg/ml). This untargeted strategy led to better selection of patients, avoiding exposure to antifungals in approximately 73 % of patients with negative BDG results and leading to shortened treatment duration in another 20 % of patients. Untargeted antifungal treatments (including prophylaxis, pre-emptive and empiric approaches) are …

Sigh in Patients With Acute Hypoxemic Respiratory Failure and ARDS

Background Sigh is a cyclic brief recruitment maneuver: previous physiologic studies showed that its use could be an interesting addition to pressure support ventilation to improve lung elastance, decrease regional heterogeneity, and increase release of surfactant. Research Question Is the clinical application of sigh during pressure support ventilation (PSV) feasible? Study Design and Methods We conducted a multicenter noninferiority randomized clinical trial on adult intubated patients with acute hypoxemic respiratory failure or ARDS undergoing PSV. Patients were randomized to the no-sigh group and treated by PSV alone, or to the sigh group, treated by PSV plus sigh (increase in airway pr…

Ten important articles on noninvasive ventilation in critically ill patients and insights for the future: A report of expert opinions

Background Noninvasive ventilation is used worldwide in many settings. Its effectiveness has been proven for common clinical conditions in critical care such as cardiogenic pulmonary edema and chronic obstructive pulmonary disease exacerbations. Since the first pioneering studies of noninvasive ventilation in critical care in the late 1980s, thousands of studies and articles have been published on this topic. Interestingly, some aspects remain controversial (e.g. its use in de-novo hypoxemic respiratory failure, role of sedation, self-induced lung injury). Moreover, the role of NIV has recently been questioned and reconsidered in light of the recent reports of new techniques such as high-fl…

Bloodstream infections in intensive care unit patients: distribution and antibiotic resistance of bacteria

Vincenzo Russotto,1 Andrea Cortegiani,1 Giorgio Graziano,2 Laura Saporito,2 Santi Maurizio Raineri,1 Caterina Mammina,2 Antonino Giarratano1 1Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Paolo Giaccone University Hospital, University of Palermo, Palermo, Italy; 2Department of Sciences for Health Promotion and Mother-Child Care, University of Palermo, Palermo, Italy Abstract: Bloodstream infections (BSIs) are among the leading infections in critically ill patients. The case-fatality rate associated with BSIs in patients admitted to intensive care units (ICUs) reaches 35%–50%. The emergence and dif…

Untargeted Antifungal Treatment Strategies for Invasive Candidiasis in Non-neutropenic Critically Ill Patients: Current Evidence and Insights

Purpose of Review: The purpose of this study was to provide an overview and insights on important new concepts on untargeted antifungal treatment strategies, namely prophylaxis pre-emptive and empiric treatments for the management of invasive candidiasis (IC) in non-neutropenic critically ill patients. Recent Findings: Recently, clinical practice guidelines provided recommendation for the management of IC. However, results from recent trials and systematic reviews questioned the effect of untargeted antifungal treatment strategies, especially in terms of survival benefits in non-neutropenic patients, even with septic shock. Summary: Widespread use of untargeted antifungal treatment strategi…

Simulation-based education for cardiopulmonary resuscitation and airway management protocols: a brief report of a systematic review and meta-analysis.

We aimed to summarize the efficacy of simulation-based education in cardiopulmonary resuscitation and airway management [1].

Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries

Importance: Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events. Objective: To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients. Design, Setting, and Participants: The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs…

Should Reinke edema be considered a contributing factor to post-extubation failure?

We read with interest the recently published review in Critical Care about post-extubation laryngeal edema and stridor by Pluijms et al. [1]. The review considers in detail the risk factors for post-extubation respiratory failure and describes a post-extubation algorithm for its prevention and reduction. We recently published a case report describing the occurrence of post-extubation stridor leading to post-extubation respiratory failure in a woman with a previously undiagnosed Reinke edema (RE) [2]. RE is a progressive laryngeal soft-tissue swelling. The condition typically manifests in female gender as hoarseness and as a gradually deepening voice in patients with a history of smoking, vo…

Rapid detection of carbapenem resistance: Targeting a zero level of inadequate empiric antibiotic exposure

Resistance to carbapenems is an increasingly encountered phenomenon in the ICU, complicating empiric and targeted antimicrobial therapy. Infections due to carbapenem-resistant microorganisms are characterized by high morbidity and mortality [1, 2]. Recently, there has been an increasing interest in rapid detection techniques, based on real time on-demand easy-to-use PCR, to detect genes responsible for carbapenem resistance. One of these techniques is the Cepheid Xpert Carba-R assay, which is able to detect and differentiate five of the most frequent genes associated with non-susceptibility to carbapenems in Gram-negative bacteria (bla KPC, bla VIM, bla OXA-48, bla IMP-1, bla NDM). The diag…

Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (V(T)). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients. OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference. DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries. MAIN OUTCOME MEASURES: Women and men were compared with respect to use o…

Respiratory support techniques to avoid desaturation in critically ill patients requiring endotracheal intubation: A systematic review and meta-analysis

Abstract Purpose To evaluate which respiratory support method for critically ill patients undergoing endotracheal intubation (ETI) is associated with less desaturation. Methods We searched PubMed, Cochrane Library, Scopus and CINAHL databases. We included randomized (RCT) and non-randomized (non-RCT) studies investigating any method of respiratory support before/during ETI compared to a reference control. Results Apneic oxygenation (ApOx) was the most commonly investigated respiratory support technique for critically ill patients undergoing intubation (4 RCTs, 358 patients). Three of these studies investigated high-flow nasal cannula (HFNC) for ApOx while standard nasal cannula was used in …

Indication and Timing

Tracheostomy is performed in patients requiring prolonged mechanical ventilation aiming at avoiding the potential detrimental effect of a sustained translaryngeal intubation (e.g. laryngeal oedema, mucosal ulcerations). Potential benefits of tracheostomy in critically ill patients are improved comfort and reduced need for sedation, easier clearance of secretions and oral hygiene, and a possible faster weaning from mechanical ventilation. Controversy exists over optimal timing (early, tracheostomy placement compared with later time points) in patients with respiratory failure. Among the published randomised controlled trials, two large studies did not report a significant advantage of an ear…

ROCURONIO/SUGAMMADEX VS ROCURONIO/ NEOSTIGMINA NELLA CHIRURGIA BARIATRICA PER BYPASS

Obiettivo. La chirurgia bariatrica è caratterizzata da un incre- mento di morbidità e mortalità post operatoria tre volte maggiore dei pazienti normopeso, in assenza di altri fattori di rischio. La decurarizzazione efficace, riduce il rischio di cura- rizzazione residua post operatoria, e le complicanze ad essa associate 1. Obiettivo del nostro studio è di valutare l’efficacia in termini di recupero dell’attività neuromuscolare all’accele- romiografia e in termini di ripresa clinicamente obiettivabile della Neostigmina vs Sugammadex. Materiali e metodi. Abbiamo arruolato 40 pazienti sottoposti a chirurgia bariatrica per bypass, suddivisi in due gruppi di età >18 anni, BMI >30 kg/m2, classe …

Use of Cepheid Xpert Carba-R® for rapid detection of carbapenemase-producing bacteria in critically ill, abdominal surgical patients: first report of an observational study

Introduction Xpert Carba-R® (Cepheid®, USA) is a PCR-based assay for rapid (<1 hour) detection of bacteria carrying carbapenem-resistance genes (KPC, NDM, VIM, OXA-48, IMP-1). The aim of the study is to compare PCR with microbiological cultures in critically ill, abdominal surgical patients. Methods We performed an observational study at University Hospital 'P. Giaccone' Palermo. We enrolled abdominal surgical patients admitted to the ICU with suspected abdominal sepsis or developing sepsis during the ICU stay. We obtained two rectal swab specimens and two drainage samples to perform PCR assay and classic culture tests. We used Cohen's K to test concordance of results. We considered conc…

Adenosine triphosphate bioluminescence in intensive care units: Be careful with its use

LETTER TO EDITOR

Should we administer antifungal drugs before the diagnosis of invasive fungal infection in non-neutropenic critically ill patients?

No-touch methods of terminal cleaning in the intensive care unit: results from the first large randomized trial with patient-centred outcomes

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Medical simulation for ICU staff: does it influence safety of care?

Dear Editor, We read with great interest the article by Garrouste-Orgeas et al. entitled ‘‘Understanding medical errors and adverse events in ICU patients’’ [1]. In particular, two sentences caught our attention: ‘‘medical errors are the consequence of multiple actions of a whole chain of organizational and humans interaction...’’ and ‘‘leadership, trust, respect, open communication, non-punitive actions and coordination of behavior are essential for a multidisciplinary ICU team to provide safe care’’. In a teamworking setting like the ICU, shared knowledge and non-technical skills are pivotal to deliver a high quality of care and to reduce medical errors. Medical simulation has been demons…

What is the risk of acquiring bacteria from prior intensive care unit bed occupants?

Effect of High-Fidelity Simulation on Medical Students' Knowledge about Advanced Life Support: A Randomized Study

High-fidelity simulation (HFS) is a learning method which has proven effective in medical education for technical and non-technical skills. However, its effectiveness for knowledge acquisition is less validated. We performed a randomized study with the primary aim of investigating whether HFS, in association with frontal lessons, would improve knowledge about advanced life support (ALS), in comparison to frontal lessons only among medical students. The secondary aims were to evaluate the effect of HFS on knowledge acquisition of different sections of ALS and personal knowledge perception. Participants answered a pre-test questionnaire consisting of a subjective (evaluating personal percepti…

Lessons from uncertainty on antifungal treatment in ICU

We read with great interest the Editorial from Moghnieh et al. on the EMPIRICUS trial and antifungal use in intensive care unit (ICU) (1). Authors described nicely the trial and some background evidence on untargeted antifungal treatment in non-neutropenic critically ill patients in ICU (2,3). However, we believe that some points may be further clarified. First, it may be useful to cite the study from Knitsch et al. among those evaluating empiric antifungal treatment in ICU (4). Knitsch et al. enrolled 252 critically ill patients with localized/generalized intra-abdominal infection either of community or of nosocomial origin requiring emergency surgery.

The paradox of the evidence about invasive fungal infections prevention

Invasive fungal infections (IFIs) are characterized by high morbidity and mortality in non-neutropenic critically ill patients. Attributable mortality due to Candida spp. infections ranges from about 42 to 63 % [1, 2]. Data from large observational and retrospective studies show an association between early antifungal treatment and improved survival [3, 4]. Updated clinical practice guidelines for the management of candidiasis have been recently published [5]. In 2006, Playford et al. published a Cochrane systematic review investigating the use of antifungal agents for prevention of IFIs in non-neutropenic critically ill patients [6]. In that review, the outcome of proven IFI was defined as…

Bacterial contamination of inanimate surfaces and equipment in the intensive care unit.

Intensive care unit (ICU)-acquired infections are a challenging health problem worldwide, especially when caused by multidrug-resistant (MDR) pathogens. In ICUs, inanimate surfaces and equipment (e.g., bedrails, stethoscopes, medical charts, ultrasound machine) may be contaminated by bacteria, including MDR isolates. Cross-transmission of microorganisms from inanimate surfaces may have a significant role for ICU-acquired colonization and infections. Contamination may result from healthcare workers' hands or by direct patient shedding of bacteria which are able to survive up to several months on dry surfaces. A higher environmental contamination has been reported around infected patients tha…

Update on perioperative management of the child with asthma

Asthma represents the leading cause of morbidity from a chronic disease among children. Dealing with this disease during the perioperative period of pediatric surgical procedures is, therefore, quite common for the anesthesiologist and other professionalities involved. Preoperative assessment has a key role in detecting children at increased risk of perioperative respiratory complications. For children without an optimal control of symptoms or with a recent respiratory tract infection elective surgery should be postponed, if possible, after the optimization of therapy. According to clinical setting, loco-regional anesthesia represents the desirable option since it allows to avoid airway ins…

A perioperative uncontrollable bleeding in an elderly patient with acquired hemophilia A: a case report

Key Clinical Message Acquired hemophilia A should be taken into account in the differential diagnosis of perioperative bleeding in patients without any apparent reason for activated partial thromboplastin time prolongation.

Antifungal Stewardship in Light of the Updated Evidence on Untargeted Antifungal Treatment in Critically Ill Patients

Epidemiological characteristics, practice of ventilation, and clinical outcome in patients at risk of acute respiratory distress syndrome in intensive care units from 16 countries (PRoVENT): an international, multicentre, prospective study

Background Scant information exists about the epidemiological characteristics and outcome of patients in the intensive care unit (ICU) at risk of acute respiratory distress syndrome (ARDS) and how ventilation is managed in these individuals. We aimed to establish the epidemiological characteristics of patients at risk of ARDS, describe ventilation management in this population, and assess outcomes compared with people at no risk of ARDS. Methods PRoVENT (PRactice of VENTilation in critically ill patients without ARDS at onset of ventilation) is an international, multicentre, prospective study undertaken at 119 ICUs in 16 countries worldwide. All patients aged 18 years or older who were rece…

Use of a real-Time training software (Laerdal QCPR®) compared to instructor-based feedback for high-quality chest compressions acquisition in secondary school students: A randomized trial

High-quality chest compressions are pivotal to improve survival from cardiac arrest. Basic life support training of school students is an international priority. The aim of this trial was to assess the effectiveness of a real-time training software (Laerdal QCPR®) compared to a standard instructor-based feedback for chest compressions acquisition in secondary school students. After an interactive frontal lesson about basic life support and high quality chest compressions, 144 students were randomized to two types of chest compressions training: 1) using Laerdal QCPR® (QCPR group– 72 students) for real-time feedback during chest compressions with the guide of an instructor who considered sof…

Antifungal agents for preventing fungal infections in non-neutropenic critically ill patients

Background Invasive fungal infections are important causes of morbidity and mortality among critically ill patients. Early institution of antifungal therapy is pivotal for mortality reduction. Starting a targeted antifungal therapy after culture positivity and fungi identification requires a long time. Therefore, alternative strategies (globally defined as 'untargeted antifungal treatments') for antifungal therapy institution in patients without proven microbiological evidence of fungal infections have been discussed by international guidelines. This review was originally published in 2006 and updated in 2016. This updated review provides additional evidence for the clinician dealing with s…

Additional file 1: of Is it time to consider visual feedback systems the gold standard for chest compression skill acquisition?

Shows the graphic interface of the Laerdal QCPRÂŽ feedback system. Screenshot representing how Laerdal QCPRÂŽ provides real-time visual feedback during training. In this case, compressions are too shallow, 40Â mm for the last one, with incomplete chest recoil (another yellow arrow suggests you should allow complete chest recoil), and the compression rate is too low, 84 compressions/minute (a continuous yellow line shows that the compressions are not in the correct range). The system recognizes as correct parameters those recommended by international guidelines. (TIFF 123 kb)