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Patients with acute respiratory distress syndrome received conservative oxygen therapy or liberal oxygen therapy for 7 days. The trial was prematurely stopped because of futility and safety concerns. Mortality at day 28 was 34.3% in the conservative-oxygen group and 26.5% in the liberal-oxygen group. Five mesenteric ischemic events occurred, all in the conservative-oxygen group.

Background Extracorporeal carbon-dioxide removal (ECCO 2 R) might allow ultraprotective mechanical ventilation with lower tidal volume (VT) (< 6 ml/kg predicted body weight), plateau pressure (P plat ) (< 30 cmH 2 O), and driving pressure to limit ventilator-induced lung injury. This study was undertaken to assess the feasibility and safety of ECCO 2 R managed with a renal replacement therapy (RRT) platform to enable very low tidal volume ventilation of patients with mild-to-moderate acute respiratory distress syndrome (ARDS). Methods Twenty patients with mild ( n  = 8) or moderate ( n  = 12) ARDS were included. VT was gradually lowered from 6 to 5, 4.5, and 4 ml/kg, and PEEP adjusted to reach 23 ≤ P plat  ≤ 25 cmH 2 O. Standalone ECCO 2 R (no hemofilter associated with the RRT platform) was initiated when arterial PaCO 2 increased by > 20% from its initial value. Ventilation parameters (VT, respiratory rate, PEEP), respiratory system compliance, P plat and driving pressure, arterial blood gases, and ECCO 2 R-system operational characteristics were collected during at least 24 h of very low tidal volume ventilation. Complications, day-28 mortality, need for adjuvant therapies, and data on weaning off ECCO 2 R and mechanical ventilation were also recorded. Results While VT was reduced from 6 to 4 ml/kg and P plat kept < 25 cmH 2 O, PEEP was significantly increased from 13.4 ± 3.6 cmH 2 O at baseline to 15.0 ± 3.4 cmH 2 O, and the driving pressure was significantly reduced from 13.0 ± 4.8 to 7.9 ± 3.2 cmH 2 O (both p  < 0.05). The PaO 2 /FiO 2 ratio and respiratory-system compliance were not modified after VT reduction. Mild respiratory acidosis occurred, with mean PaCO 2 increasing from 43 ± 8 to 53 ± 9 mmHg and mean pH decreasing from 7.39 ± 0.1 to 7.32 ± 0.10 from baseline to 4 ml/kg VT, while the respiratory rate was not altered. Mean extracorporeal blood flow, sweep-gas flow, and CO 2 removal were 421 ± 40 ml/min, 10 ± 0.3 L/min, and 51 ± 26 ml/min, respectively. Mean treatment duration was 31 ± 22 h. Day-28 mortality was 15%. Conclusions A low-flow ECCO 2 R device managed with an RRT platform easily and safely enabled very low tidal volume ventilation with moderate increase in PaCO 2 in patients with mild-to-moderate ARDS. Trial registration ClinicalTrials.gov, NCT02606240. Registered on 17 November 2015.

According to this technique, the needle trajectory from the skin to the vessel corresponds to the hypotenuse of the triangle. [...]while controlling the long-axis plane by the previously described technique, the use of the short axis view during the vessel puncture allows checking structures lateral to the vessel, in particular arteries and nerves in the case of vein puncture. [...]the basis of Euclidean geometry might be an educational tool for the critical care physician teaching fellows for their first venous catheterizations, giving them a simple step by step procedure. 1.

Background The properties of semi-elemental enteral nutrition might theoretically improve gastrointestinal tolerance in brain-injured patients, known to suffer gastroparesis. The purpose of this study was to compare the efficacy and tolerance of a semi-elemental versus a polymeric formula for enteral nutrition (EN) in brain-injured critically ill patients. Methods Prospective, randomized study including brain-injured adult patients [Glasgow Coma Scale (GCS) ≤ 8] with an expected duration of mechanical ventilation > 48 h. Intervention: an enteral semi-elemental (SE group) or polymeric (P group) formula. EN was started within 36 h after admission to the intensive care unit and was delivered according to a standardized nurse-driven protocol. The primary endpoint was the percentage of patients who received both 60% of the daily energy goal at 3 days and 100% of the daily energy goal at 5 days after inclusion. Tolerance of EN was assessed by the rate of gastroparesis, vomiting and diarrhea. Results Respectively, 100 and 95 patients were analyzed in the SE and P groups: Age (57[44–65] versus 55[40–65] years) and GCS (6[3–7] versus 5[3–7]) did not differ between groups. The percentage of patients achieving the primary endpoint was similar (46% and 48%, respectively; relative risk (RR) [95% confidence interval (CI)] = 1.05 (0.78–1.42); p  = 0.73). The mean daily energy intake was, respectively, 20.2 ± 6.3 versus 21.0 ± 6.5 kcal/kg/day ( p  = 0.42). Protein intakes were 1.3 ± 0.4 versus 1.1 ± 0.3 g/kg/day ( p  < 0.0001). Respectively, 18% versus 12% patients presented gastroparesis ( p  = 0.21), and 16% versus 8% patients suffered from diarrhea ( p  = 0.11). No patient presented vomiting in either group. Conclusion Semi-elemental compared to polymeric formula did not improve daily energy intake or gastrointestinal tolerance of enteral nutrition. Trial registration EudraCT/ID-RCB 2012-A00078-35 (registered January 17, 2012).

During refractory cardiogenic shock and cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to restore a circulatory output. However, it also impacts significantly arterial oxygenation. Recent guidelines of the Extracorporeal Life Support Organization (ELSO) recommend targeting postoxygenator partial pressure of oxygen (P POST O 2 ) around 150 mmHg. In this narrative review, we intend to summarize the rationale and evidence for this P POST O 2 target recommendation. Because this is the most used configuration, we focus on peripheral VA-ECMO. To date, clinicians do not know how to set the sweep gas oxygen fraction (F S O 2 ). Because of the oxygenator’s performance, arterial hyperoxemia is common during VA-ECMO support. Interpretation of oxygenation is complex in this setting because of the dual circulation phenomenon, depending on both the native cardiac output and the VA-ECMO blood flow. Such dual circulation results in dual oxygenation, with heterogeneous oxygen partial pressure (PO 2 ) along the aorta, and heterogeneous oxygenation between organs, depending on the mixing zone location. Data regarding oxygenation during VA-ECMO are scarce, but several observational studies have reported an association between hyperoxemia and mortality, especially after refractory cardiac arrest. While hyperoxemia should be avoided, there are also more and more studies in non-ECMO patients suggesting the harm of a too restrictive oxygenation strategy. Finally, setting F S O 2 to target strict normoxemia is challenging because continuous monitoring of postoxygenator oxygen saturation is not widely available. The threshold of P POST O 2 around 150 mmHg is supported by limited evidence but aims at respecting a safe margin, avoiding both hypoxemia and severe hyperoxemia.

Background With recent advances in technology, patients with acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) could benefit from extracorporeal CO 2 removal (ECCO 2 R). However, current evidence in these indications is limited. A European ECCO 2 R Expert Round Table Meeting was convened to further explore the potential for this treatment approach. Methods A modified Delphi-based method was used to collate European experts’ views to better understand how ECCO 2 R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of consensus. Results Fourteen participants were selected based on known clinical expertise in critical care and in providing respiratory support with ECCO 2 R or extracorporeal membrane oxygenation. ARDS was considered the primary indication for ECCO 2 R therapy ( n  = 7), while 3 participants considered ae-COPD the primary indication. The group agreed that the primary treatment goal of ECCO 2 R therapy in patients with ARDS was to apply ultra-protective lung ventilation via managing CO 2 levels. Driving pressure (≥ 14 cmH 2 O) followed by plateau pressure ( P plat ; ≥ 25 cmH 2 O) was considered the most important criteria for ECCO 2 R initiation. Key treatment targets for patients with ARDS undergoing ECCO 2 R included pH (> 7.30), respiratory rate (< 25 or < 20 breaths/min), driving pressure (< 14 cmH 2 O) and P plat (< 25 cmH 2 O). In ae-COPD, there was consensus that, in patients at risk of non-invasive ventilation (NIV) failure, no decrease in PaCO 2 and no decrease in respiratory rate were key criteria for initiating ECCO 2 R therapy. Key treatment targets in ae-COPD were patient comfort, pH (> 7.30–7.35), respiratory rate (< 20–25 breaths/min), decrease of PaCO 2 (by 10–20%), weaning from NIV, decrease in HCO 3 − and maintaining haemodynamic stability. Consensus was reached on weaning protocols for both indications. Anticoagulation with intravenous unfractionated heparin was the strategy preferred by the group. Conclusions Insights from this group of experienced physicians suggest that ECCO 2 R therapy may be an effective supportive treatment for adults with ARDS or ae-COPD. Further evidence from randomised clinical trials and/or high-quality prospective studies is needed to better guide decision making.

Little is known about patients with sickle cell disease (SCD) who require intensive care unit (ICU) admission. The goals of this study were to assess outcomes in patients admitted to the ICU for acute complications of SCD and to identify factors associated with adverse outcomes. This multicenter retrospective study included consecutive adults with SCD admitted to one of 17 participating ICUs. An adverse outcome was defined as death or a need for life-sustaining therapies (non-invasive or invasive ventilation, vasoactive drugs, renal replacement therapy, and/or extracorporeal membrane oxygenation). Factors associated with adverse outcomes were identified by mixed multivariable logistic regression. We included 488 patients admitted in 2015–2017. The main reasons for ICU admission were acute chest syndrome (47.5%) and severely painful vaso-occlusive event (21.3%). Sixteen (3.3%) patients died in the ICU, mainly of multi-organ failure following a painful vaso-occlusive event or sepsis. An adverse outcome occurred in 81 (16.6%; 95% confidence interval [95% CI], 13.3%–19.9%) patients. Independent factors associated with adverse outcomes were low mean arterial blood pressure (adjusted odds ratio [aOR], 0.98; 95% CI 0.95–0.99; p  = 0.027), faster respiratory rate (aOR, 1.09; 95% CI 1.05–1.14; p  < 0.0001), higher haemoglobin level (aOR, 1.22; 95% CI 1.01–1.48; p  = 0.038), impaired creatinine clearance at ICU admission (aOR, 0.98; 95% CI 0.97–0.98; p  < 0.0001), and red blood cell exchange before ICU admission (aOR, 5.16; 95% CI 1.16–22.94; p  = 0.031). Patients with SCD have a substantial risk of adverse outcomes if they require ICU admission. Early ICU admission should be encouraged in patients who develop abnormal physiological parameters.

The optimal treatment duration for ventilator-associated pneumonia is based on one study dealing with late-onset of the condition. Shortening the length of antibiotic treatment remains a major prevention factor for the emergence of multiresistant bacteria. To demonstrate that 2 different antibiotic treatment durations (8 versus 15 days) are equivalent in terms of clinical cure for early-onset ventilator-associated pneumonia. Randomized, prospective, open, multicenter trial carried out from 1998 to 2002. The primary endpoint was the clinical cure rate at day 21. The mortality rate was evaluated on days 21 and 90. 225 patients were included in 13 centers. 191 (84.9%) patients were cured: 92 out of 109 (84.4%) in the 15 day cohort and 99 out of 116 (85.3%) in the 8 day cohort (difference = 0.9%, odds ratio = 0.929). 95% two-sided confidence intervals for difference and odds ratio were [-8.4% to 10.3%] and [0.448 to 1.928] respectively. Taking into account the limits of equivalence (10% for difference and 2.25 for odds ratio), the objective of demonstrative equivalence between the 2 treatment durations was fulfilled. Although the rate of secondary infection was greater in the 8 day than the 15 day cohort, the number of days of antibiotic treatment remained lower in the 8 day cohort. There was no difference in mortality rate between the 2 groups on days 21 and 90. Our results suggest that an 8-day course of antibiotic therapy is safe for early-onset ventilator-associated pneumonia in intubated patients. ClinicalTrials.gov NCT01559753.