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Objective: guidelines recommend first-line systemic antifungal therapy (SAT) with echinocandins in invasive candidiasis (IC), especially in critically ill patients. This study aimed at assessing the impact of echinocandins compared to azoles as initial SAT on the 28-day prognosis in adult ICU patients.Methods: From the prospective multicenter AmarCAND2 cohort (835 patients), we selected those with documented IC and treated with echinocandins (ECH) or azoles (AZO). The average causal effect of echinocandins on 28-day mortality was assessed using an inverse probability of treatment weight (IPTW) estimator.Results: 397 patients were selected, treated with echinocandins (242 patients, 61%) or azoles (155 patients, 39%); septic shock: 179 patients (45%). The median SAPSII was higher in the ECH group (48 [35; 62] vs. 43 [31; 58], p = 0.01). Crude mortality was 34% (ECH group) vs. 25% (AZO group). After adjustment on baseline confounders, no significant association emerged between initial SAT with echinocandins and 28-day mortality (HR: 0.95; 95% CI: [0.60; 1.49]; p = 0.82). However, echinocandin tended to benefit patients with septic shock (HR: 0.46 [0.19; 1.07]; p = 0.07).Conclusion: Patients who received echinocandins were more severely ill. Echinocandin use was associated with a non-significant 7% decrease of 28-day mortality and a trend to a beneficial effect for patient with septic shock. [ABSTRACT FROM AUTHOR]

Background: Intubation procedure in obese patients is a challenging issue both in the intensive care unit (ICU) and in the operating theatre (OT). The objectives of the study were (i) to compare the incidence of difficult intubation and (ii) its related complications in obese patients admitted to ICU and OT.Methods: We conducted a multicentre prospective observational cohort study in ICU and OT in obese (BMI≥30 kg m(-2)) patients. The primary endpoint was the incidence of difficult intubation. Secondary endpoints were the risk factors for difficult intubation, the use of difficult airway management techniques, and severe life-threatening complications related to intubation (death, cardiac arrest, severe hypoxaemia, severe cardiovascular collapse).Results: In cohorts of 1400 and 11 035 consecutive patients intubated in ICU and in the OT, 282 (20%) and 2103 (19%) were obese. In obese patients, the incidence of difficult intubation was twice more frequent in ICU than in the OT (16.3% vs 8.2%, P<0.01). In both cohorts, risk factors for difficult intubation were Mallampati score III/IV, obstructive sleep apnoea syndrome, and reduced mobility of cervical spine, while limited mouth opening, severe hypoxaemia, and coma appeared only in ICU. Specific difficult airway management techniques were used in 66 (36%) cases of difficult intubation in obese patients in the OT and in 10 (22%) cases in ICU (P=0.04). Severe life-threatening complications were significantly more frequent in ICU than in the OT (41.1% vs 1.9%, relative risk 21.6, 95% confidence interval 15.4-30.3, P<0.01).Conclusions: In obese patients, the incidence of difficult intubation was twice more frequent in ICU than in the OT and severe life-threatening complications related to intubation occurred 20-fold more often in ICU.Clinical Trial Registration: Current controlled trials. Identifier: NCT01532063. [ABSTRACT FROM AUTHOR]

Abstract: Background: The aim of this study was to report current anaesthetic management brain-dead organ donors and to assess its impact on delayed kidney graft function (DGF). Methods: To achieve this retrospective multicenter study, brain-dead patient records were analysed for the years 2005 to 2007. Expanded donor criteria, length of stay in ICU, duration of brain death, respect of recommended cold ischemia time, preoperative and intraoperative management, type of anaesthesia, hemodynamic and respiratory parameters during organ retrieval, and impact of anaesthesia on DGF were analysed. Results: One hundred and forty-nine out of 165 files were available. Sixty-two percent of donors received anaesthetic drugs. There were no differences in demographic characteristics between the anaesthesia group (group A) and the no-anaesthesia group (group NA). In group NA, the mean arterial pressure (MAP)>65mmHg was more frequent (53% vs. 29%, P <0.01), but did not differ for maximal MAP. In group A, maximal heart rate was higher (120 vs. 105b/min, P =0.02) and donors received significantly more colloids (P <0.01). Independent risk factors of DGF included absence of hydroxyethyl starch infusion during the preoperative period and mechanical ventilation without PEEP. Conclusion: During organ retrieval, 62% of organ donors received anaesthetic drugs. Use of anaesthesia lead to lower MAP requiring more fluid challenge with colloids but did not influence the DGF. [Copyright &y& Elsevier]

Abstract: Objective: To define the causes of mortality of patients who died within the first three months after a liver transplantation. Type of study: Retrospective, observational, and single centre study. Patients and methods: Between March 1989 and July 2010, all patients who died within three months after a liver transplantation were included. Demographic characteristics, preoperative and peroperative data, donor characteristics, postoperative complications and causes of mortality were collected. Results: Among the 788 performed liver transplantations, 76 patients died in intensive care unit (11%). The main indications of liver transplantation were alcoholic cirrhosis (30%), hepatitis C (28%), hepatocarcinoma (15%), primitive or secondary biliary cirrhosis (10%). Fifty percent of the patients were categorized as Child C. The main causes of death were non-function or dysfunction with retransplantation contra-indication graft (18%), sepsis (18%), neurological complications (12%), hemorrhagic shock (13%), (9%), multiorgan failures (5%), cardiac complications (6%). Conclusion: In this study, the main causes of mortality were infectious, neurological and hemorrhagic. These results emphasize the necessity for better control of sepsis, haemorrhage and immunosupressors. [Copyright &y& Elsevier]

Abstract: Objectives: To describe the demographic characteristics, incidence of extra-abdominal hospital-acquired infections and outcome of patients admitted to intensive care unit (ICU) with severe acute pancreatitis. Study design: A retrospective, observational multiple center (65 centers) analysis of prospectively acquired data. Patients and methods: During 2 years, all consecutive admitted patients to ICU for severe acute pancreatitis in the centers participating in the nosocomial infections surveillance network CClin Sud-Est were included. Patients whose ICU stay was less than 48hours were not included. Demographic characteristics, extra-abdominal hospital-acquired infections and clinical course were described. Results: During the study period, 510 patients were included which represented 2 % of patients with a length of stay longer than 48hours in the 65 participating ICUs. The global attack rate of extra-abdominal hospital-acquired infections (pneumonia, bacteremia, urinary tract or central venous catheter infection) was 23 % in overall patients and it was 33 % in the 294 mechanically ventilated patients. ICU mortality was 20 % in overall patients and it was 34 % in mechanically ventilated patients. Conclusion: Severe acute pancreatitis represents 2 % of ICU stay longer than 48hours. Its clinical course is frequently complicated by hospital-acquired infections and is associated with an high ICU mortality rate. This epidemiological observational study may be used for calculating sample size for future multicenter interventional therapeutic studies. [Copyright &y& Elsevier]

Abstract: Objective: The authors had for objective to assess systemic antifungal treatment for candidemia in non-neutropenic patients, in intensive care units (ICU), and compare the results with French 2004 recommendations. Study design: A retrospective multicenter study (nine ICU in two teaching hospitals) was made. Patients and method: Thirty-eight non-neutropenic patients with at least one positive blood culture for Candida who had received systemic antifungal treatment were included between May 2004 and September 2007. Results: Thirty-nine cases of candidemia were analyzed. The median age was 54.5 (21–80), the median SAPS II score at admission was 44 (20–79), the median duration of stay in ICU was 22.5days (2–82), and the death rate was 45%. Candida albicans was identified in 69% of the cases. Eight percent of Candida sp. isolates were resistant or susceptible dose-dependent (S-DD) to fluconazole. Before identification, fluconazole, caspofungin, voriconazole, and amphotericin B were used in 74%, 15%, 5%, and 5% of cases respectively. After identification and antifungal susceptibility determination, fluconazole was used in 68% of cases, caspofungin in 24% of cases, any formulation of amphotericin B in 6% of cases, voriconazole in 3% of cases. The French recommendations were applied in 71% of cases before identification and in 68% of cases after identification and antifungal susceptibility determination. Conclusion: The main causes of non-compliance to recommendations were the use of fluconazole in patients previously exposed to azole agents, the use of caspofungin in hemodynamically unstable patients, and the absence of therapeutic desescalade. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To report our experience of tigecycline use in a medical and surgical intensive care unit. To describe its prescription, microbiology findings, tolerance and efficacy. Study design: Prospective, observational, single center study. Patients and methods: All consecutive patients treated with tigecycline were included. Demography, indication of treatment, bacteriology before, during and in the month after treatment and ICU mortality were collected. The main endpoints were clinical and microbiological efficacy and tolerance. Results: Twenty-four patients were included. In half of the cases, tigecycline was prescribed in monotherapy for a complicated intra-abdominal infection. Overall tolerance of tigecycline was good. Clinical and microbiological cure was obtained in six cases, not obtained in nine, indeterminate in six cases and not evaluable in the three cases of prophylaxis. During the treatment, four bacteria commonly sensitives were shown to be resistant to tigecycline. Conclusion: Our pilot study on 24 patients suggests that tigecycline is well tolerated in critically ill patients. Clinical cure in severe infections was compromised in nine patients essentially because of resistant pathogens suggesting its prescription on antibiogram. However, the impact of association or the increasing doses in severe critically ill patients should be evaluated. [Copyright &y& Elsevier]

Abstract: Objectives: To compare the clinical outcomes and the causative pathogens of early-onset and late-onset ventilator-associated pneumonia (VAP) diagnosed by bronchoalveolar lavage (BAL). Study design: Prospective, observational, epidemiological study. Patients and methods: During a 7-years period, all first episodes of VAP were prospectively included. Diagnosis was confirmed by a BAL with a threshold of 104 cfu/ml. Late-onset pneumonia was defined if occurred after the seventh day after mechanical ventilation. Results: One hundred and thirteen VAP were studied. Fifty were early-onsets and 63 late-onsets. Thirty-four per cent of early-onset VAP and 73% of late-onset VAP were due to potential multiresistants pathogens. Pseudomonas aeruginosa was the most commonly isolated bacteria both in early-onset and late-onset VAP (16 and 39% respectively). Morbidity and mortality (29 vs 29%, ns) were not statically different between the two groups (early-onset and late-onset VAP). Conclusion: In our study, both early-onset and late-onset VAP were mainly caused by potentially multiresistants bacteria, most commonly Gram negative bacilli. Even for early VAP, clinicians should be aware about all risk factors for potentially multiresistants pathogens and not only the delay of onset of the VAP episode. [Copyright &y& Elsevier]

Introduction Durant la deuxième phase d’anesthésie, en chirurgie éveillée pour prise en charge des gliomes situés dans les zones fonctionnelles du cerveau, l’intubation (IOT) par laryngoscopie traditionnelle directe est impossible en raison du positionnement du patient (décubitus latéral, tête fixée dans la têtière de Mayfield, sous les champs, face à l’anesthésiste) [1] . L’utilisation d’un masque laryngé ne garantit pas la protection totale des voies aériennes lors d’une anesthésie profonde pour chirurgie intracrânienne. L’objectif de cette étude était d’évaluer la faisabilité de l’IOT à l’aide d’un vidéolaryngoscope dans cette posture stéréotypée. Matériel et méthodes Étude prospective, observationnelle et monocentrique incluant des patients majeurs ayant bénéficié de l’exérèse d’un gliome en condition éveillée. Critères d’exclusion : reflux œsophagien patent et IMC > 40. La deuxième anesthésie générale était d’emblée profonde, associant rémifentanil et propofol en mode AIVOC, sans recours à un curare. L’oxygénation et la ventilation étaient assurées par un masque facial en pression contrôlée. L’IOT était effectuée indifféremment par un IADE, un interne ou un senior à l’aide d’un vidéolaryngoscope avec écran séparé (Glidescope ® ). Facilité de ventilation, nombre de tentatives d’IOT, durée totale de la procédure (première introduction de la lame à première expiration), première PetC02 et complications étaient colligées. Les résultats sont exprimés en moyenne ± écart type (ET) ( Tableau 1 , Fig. 1 ) Résultats Deux cent trente-trois patients consécutifs ont été inclus de septembre 2010 à février 2014 dont 53,6 % d’hommes, d’âge moyen 40 ans (± 11), IMC 24,5 (± 3,7), et ASA 2 dans 79,9 % des cas. La ventilation du patient a été facile dans 97 % des cas. L’intubation a été réussie dès le premier essai dans 51 % des cas. Pour les 15 IOT impossibles (6,4 %) le recours au masque laryngé a toujours été efficace. À noter : un cas de régurgitation sans inhalation, ainsi qu’un gonflement cérébral brutal sans conséquence chirurgicale. Discussion Dans ce contexte d’intubation difficile prévue due à la posture chirurgicale, le Glidescope ® paraît être un outil efficace et fiable pour l’IOT. La durée de notre procédure apparaît réduite comparée à d’autres techniques dans des conditions chirurgicales similaires (fibroscopie à travers un Fastrach ® ou Igel) [2] . De plus, les échecs d’IOT, tous survenus chez des patients sans critère clinique d’intubation difficile semblent en rapport avec une mauvaise installation de la tête ou un déplacement secondaire du patient. [ABSTRACT FROM AUTHOR]