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First-line symptomatic treatment of acute respiratory failure (ARF) usually requires standard oxygen therapy, of which the limits have nonetheless led to the development of heated and humidified high-flow nasal oxygen therapy (HFNO). HFNO enables the delivery, through simple nasal cannula, of up to 100% of well-heated and humidified fraction of inspired oxygen (FiO

High flow oxygen via nasal cannula (HFO

Background: Little is known about cannula-related infection (CRI) in patients supported by extracorporeal membrane oxygenation (ECMO). The aim of this study was to assess the incidence, the risk factors, prognosis, and microbiological characteristics of CRI in patients supported by ECMO. Methods: This retrospective cohort study was conducted in one intensive care unit of French university hospital, between 2010 January and 2016 December, in Reunion Island. Results: Among 220 consecutive patients with peripheral ECMO, 39 (17.7%) developed CRI. The incidence of CRI was 17.2 per 1000 ECMO-days. The main isolated microorganisms were Enterobacteriaceae (38%), Staphylococcus spp. (28.2%) (8.5% were methicillin-sensitive Staphylococcus aureus and 19.7% were coagulase-negative staphylococci) and Pseudomonas aeruginosa (18.3%). Bacteremia was present in 23 cases (59.7%). In multivariate analysis, the risk factors for CRI were longer ECMO duration (P=0.006) and higher Simplified Acute Physiology score 2 (P=0.004). Forty-one percent of patients with CRI needed surgical management of the infected site. Cannula-related infection was not associated with higher in-hospital mortality (P = 0.73), but it was associated with a longer stay in ICU (P < 0.0001) and a longer stay in hospital (P = 0.002). Conclusion: CRI is frequent in patients with ECMO and associated with a longer stay in hospital. Risk factors for CRI were longer ECMO duration and higher Simplified Acute Physiology score 2. Concomitant bacteremia was frequent (59.7%) and CRI should be strongly investigated in cases of positive blood culture., Introduction : il existe encore des lacunes de connaissance à propos des infections de canule (IDC) chez les patients assistés par membrane d’oxygénation extracorporelle (extracoporeal membrane oxygenation, ECMO). L’objectif de cette étude était de déterminer l’incidence, les facteurs de risque, le pronostic et les caractéristiques microbiologiques des IDC chez les patients assistés par ECMO. Méthodes : cette étude rétrospective a été réalisée dans la réanimation polyvalente du centre hospitalo-universitaire de Saint-Denis de la Réunion, chez tous les patients, ayant bénéficié d’une ECMO périphérique entre janvier 2010 et décembre 2016 consécutivement. Résultats : Sur 220 patients consécutifs assistés par ECMO périphérique, 39 (17 ,7%) ont développé une IDC. L’incidence de l’IDC était de 17,2 pour 1000 jours d’ECMO. Les principaux germes isolés étaient les Enterobacteriaceae (38%), les Staphylococcus spp. (28,2%) (8,5% de Staphylococcus aureus sensibles à la méticilline, et 19,7% de Staphylococcus coagulase-negative), et les Pseudomonas aeruginosa (18,3%). Une bactériémie était présente dans 23 cas (59,7%). En analyse multivariée, les facteurs de risques étaient une durée prolongée de l’assistance par ECMO (p=0,0006) et un Index de Gravité Simplifié II (IGS2) élevé (p=0,004). 41% des patients présentant une IDC ont bénéficié d’un lavage et parage chirurgical du site infecté. L’IDC n’était pas associée à une mortalité plus élevée (p=0,73), mais à une durée de séjour en réanimation plus élevée (p

Objective To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications. Options The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems. Outcomes Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy. Evidence English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations and Summary Statement 1.Left upper quadrant (LUQ, Palmer's) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus (II-2 A). Other sites of insertion, such as transuterine Veress CO 2 insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option (I-A). 2.The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels (II-1 A). 3.The Veress intraperitoneal (VIP-pressure ->10 mm Hg) is a reliable indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO 2 source to the Veress needle on entry (II-1 A). 4.Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury (II-2 B). 5.The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45° in non-obese women to 90° in obese women (II-2 B). 6.The volume of CO 2 inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO 2 volume (II-1 A). 7.In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women (II-1 A). 8.The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available (II-2 C). 9.Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique (II-2). 10.Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique (I). 11.Shielded trocars may be used in an effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access (II-B). 12.Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars (I-A). 13.The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury (2 B).