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This multicenter randomized trial compared strategies of early and delayed renal-replacement therapy in patients with severe acute kidney injury. There was no significant difference in mortality, the primary outcome, between the study groups. Acute kidney injury is a common condition among patients in the intensive care unit 1 – 4 and is associated with high morbidity and mortality. 2 , 5 – 8 Renal-replacement therapy is the cornerstone of the management of severe acute kidney injury. Many studies have focused on methods of renal-replacement therapy, 5 , 6 , 8 , 9 but the issue of when to initiate the therapy in the absence of a potentially life-threatening complication directly related to renal failure remains a subject of debate. Indirect evidence has suggested that early renal-replacement therapy could confer a survival benefit. 10 – 12 However, two observational studies reported high survival rates among . . .

Background Consequences of hyperoxemia, such as acute lung injury, atelectasis, and reduced bacterial clearance, might promote ventilator-associated pneumonia (VAP). The aim of our study was to determine the relationship between hyperoxemia and VAP. Methods This retrospective observational study was performed in a 30-bed mixed ICU. All patients receiving invasive mechanical ventilation for more than 48 hours were eligible. VAP was defined using clinical, radiologic, and quantitative microbiological criteria. Hyperoxemia was defined as PaO 2  > 120 mmHg. All data, except those related to hyperoxemia, were prospectively collected. Risk factors for VAP were determined using univariate and multivariate analysis. Results VAP was diagnosed in 141 of the 503 enrolled patients (28 %). The incidence rate of VAP was 14.7 per 1000 ventilator days. Hyperoxemia at intensive care unit admission (67 % vs 53 %, OR = 1.8, 95 % CI (1.2, 29), p <0.05) and number of days spent with hyperoxemia were significantly more frequent in patients with VAP, compared with those with no VAP. Multivariate analysis identified number of days spent with hyperoxemia (OR = 1.1, 95 % CI (1.04, 1.2) per day, p  = 0.004), simplified acute physiology score (SAPS) II (OR = 1.01, 95 % CI (1.002, 1.024) per point, p  < 0 .05), red blood cell transfusion (OR = 1.8, 95 % CI (1.2, 2.7), p  = 0.01), and proton pomp inhibitor use (OR = 1.9, 95 % CI (1.03, 1.2), p  < 0.05) as independent risk factors for VAP. Other multiple regression models also identified hyperoxemia at ICU admission (OR = 1.89, 95 % CI (1.23, 2.89), p  = 0.004), and percentage of days with hyperoxemia (OR = 2.2, 95 % CI (1.08, 4.48), p  = 0.029) as independent risk factors for VAP. Conclusion Hyperoxemia is independently associated with VAP. Further studies are required to confirm our results.

The analgesia nociception index (ANI) assesses the relative parasympathetic tone as a surrogate for antinociception/nociception balance in sedated patients. The aim of this study is to determine the effectiveness of ANI in detecting pain in deeply sedated critically ill patients. This prospective observational study was performed in two medical ICUs. All patients receiving invasive mechanical ventilation and deep sedation were eligible. In all patients, heart rate and ANI were continuously recorded using the Physiodoloris® device during 5 minutes at rest (T1), during a painful stimulus (T2), and during 5 minutes after the end of the painful stimulus (T3). The chosen painful stimulus was patient turning for washstand. Pain was evaluated at T2, using the behavioral pain scale (BPS). The primary objective was to determine the effectiveness of ANI in detecting pain. Secondary objectives included the impact of norepinephrine on the effectiveness of ANI in detecting pain, and the correlation between ANI and BPS. Forty-one patients were included. ANI was significantly lower at T2 (Med (IQR) 69(55-78)) compared with T1 (85(67-96), p<0.0001), or T3 (81(63-89), p<0.0001). Similar results were found in the subgroups of patients with (n = 21) or without (n = 20) norepinephrine. ANI values were significantly higher in patients with norepinephrine compared with those without norepinephrine at T1, and T2. No significant correlation was found between ANI and BPS at T2. ANI is effective in detecting pain in deeply sedated critically ill patients, including those patients treated with norepinephrine. No significant correlation was found between ANI and BPS.

Underinflation of the tracheal cuff frequently occurs in critically ill patients and represents a risk factor for microaspiration of contaminated oropharyngeal secretions and gastric contents that plays a major role in the pathogenesis of ventilator-associated pneumonia (VAP). To determine the impact of continuous control of tracheal cuff pressure (P(cuff)) on microaspiration of gastric contents. Prospective randomized controlled trial performed in a single medical intensive care unit. A total of 122 patients expected to receive mechanical ventilation for at least 48 hours through a tracheal tube were randomized to receive continuous control of P(cuff) using a pneumatic device (intervention group, n = 61) or routine care of P(cuff) (control group, n = 61). The primary outcome was microaspiration of gastric contents as defined by the presence of pepsin at a significant level in tracheal secretions collected during the 48 hours after randomization. Secondary outcomes included incidence of VAP, tracheobronchial bacterial concentration, and tracheal ischemic lesions. The pneumatic device was efficient in controlling P(cuff). Pepsin was measured in 1,205 tracheal aspirates. Percentage of patients with abundant microaspiration (18 vs. 46%; P = 0.002; OR [95% confidence interval], 0.25 [0.11-0.59]), bacterial concentration in tracheal aspirates (mean ± SD 1.6 ± 2.4 vs. 3.1 ± 3.7 log(10) cfu/ml, P = 0.014), and VAP rate (9.8 vs. 26.2%; P = 0.032; 0.30 [0.11-0.84]) were significantly lower in the intervention group compared with the control group. However, no significant difference was found in tracheal ischemia score between the two groups. Continuous control of P(cuff) is associated with significantly decreased microaspiration of gastric contents in critically ill patients.

Background Community-acquired bacterial meningitis (CABM) is associated with high mortality and persistent disability. We aimed to assess changing trends in the initial management of patients requiring Intensive Care Unit (ICU) admission for CABM and their possible consequences on outcome over a period of fifteen years. Methods We performed a retrospective observational study in two french ICUs, including all patients with proven or probable CABM. Three periods were defined: period 1 (2005–2009), period 2 (2010–2014) and period 3 (2015–2019). The criteria studied were: the time from hospital admission (HA) to lumbar puncture (LP), the time from HA to the delivery of antibiotics, the time from HA to ICU admission, the head CT scan-LP sequence and the administration of dexamethasone. Recommendations from the French Infectious Diseases Society (FIDS) were used to assess the relevance of the head CT scan-LP sequence. The outcome was analyzed using in-ICU mortality and the Glasgow Outcome Scale (GOS) at three months. Results A total of 166 patients were included (51 patients during period 1, 61 during period 2 and 54 during period 3). The mean age was 57.2 ± 19.9 yrs and the mean Glasgow Coma Scale score on ICU admission was 10.5 ± 3.4. CABM was proven in 146 patients. The median time from HA to LP and antibiotics was respectively 4 h [IQR 2-7.5] and 4.5 h [IQR 1.75-8] with no significant difference between the three periods. Only 30 (22.2%) patients received appropriate antibiotics within 1 h following HA. ICU admissions were faster during period 3 with a median time of 3 h [IQR 0-8.5]. Dexamethasone was delivered more often during period 3 (80% of patients). The ICU mortality rate was 18.1% and remained unchanged over the three periods. A severe disability at three months was significantly lower during the third period with respectively, a GOS score 2–3 for 5 patients in period 1, 6 in period 2 and none in period 3. Conclusion The time for the delivery of appropriate antibiotics remains too high in our patients. Neurologic sequelae at three months have decreased without a significant change in in-ICU mortality. Clinical trial number Not applicable.

Purpose The aim of this study was to determine the impact of a biomarker-based strategy on early discontinuation of empirical antifungal treatment. Methods Prospective randomized controlled single-center unblinded study, performed in a mixed ICU. A total of 110 patients were randomly assigned to a strategy in which empirical antifungal treatment duration was determined by (1,3)-β- d -glucan, mannan, and anti-mannan serum assays, performed on day 0 and day 4; or to a routine care strategy, based on international guidelines, which recommend 14 days of treatment. In the biomarker group, early stop recommendation was determined using an algorithm based on the results of biomarkers. The primary outcome was the percentage of survivors discontinuing empirical antifungal treatment early, defined as a discontinuation strictly before day 7. Results A total of 109 patients were analyzed (one patient withdraw consent). Empirical antifungal treatment was discontinued early in 29 out of 54 patients in the biomarker strategy group, compared with one patient out of 55 in the routine strategy group [54% vs 2%, p  < 0.001, OR (95% CI) 62.6 (8.1–486)]. Total duration of antifungal treatment was significantly shorter in the biomarker strategy compared with routine strategy [median (IQR) 6 (4–13) vs 13 (12–14) days, p  < 0.0001). No significant difference was found in the percentage of patients with subsequent proven invasive Candida infection, mechanical ventilation-free days, length of ICU stay, cost, and ICU mortality between the two study groups. Conclusions The use of a biomarker-based strategy increased the percentage of early discontinuation of empirical antifungal treatment among critically ill patients with suspected invasive Candida infection. These results confirm previous findings suggesting that early discontinuation of empirical antifungal treatment had no negative impact on outcome. However, further studies are needed to confirm the safety of this strategy. This trial was registered at ClinicalTrials.gov, NCT02154178.