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Acute cerebral complications (ACC) of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are associated with poor long-term neurologic outcome. We described the role of rSO2 monitoring in detecting ACC and desaturations and their relationship with poor outcome when employing VA-ECMO. Retrospective analysis of patients monitored by cerebral frontal near-infrared spectroscopy (NIRS) (CAS Medical Systems Inc., Branford, CT, USA) during VA-ECMO (November 2008–December 2015). ACC was defined as the presence of stroke and/or brain death, while cerebral desaturation as cortical oxygen tissue saturation (rSO2)

Introduction: Despite the development of new molecules with anti-Gram positive bacteria activity, vancomycin is still the treatment of choice in septic critically ill patients. Because sepsis can alter drug pharmacokinetics, the development of an administration strategy able to promptly provide adequate antimicrobial concentrations is crucial.Hypothesis: The aim of this study was to prospectively validate a new regimen of vancomycin given by continuous infusion (CI)1 in septic patients.Methods: We prospectively included septic patients admitted to a mixed ICU from January 2011 to May 2012, treated with a new regimen of CI vancomycin, including a loading dose (LD) of 35 mg/kg of body weight given as a 4-hr infusion, followed by a daily CI dose adapted on creatinine clearance (CrCL), estimated by the Cockroft-Gault formula. We excluded patients treated by extracorporeal replacement therapies or less than 18 years of age. Serum vancomycin levels were measured at the end of LD, 12, 24 (n=107) and 48 hours (n=56) after the start of therapy. Dose adjustment was decided on drug concentrations at 24 and/or 48 hours. Adequate vancomycin concentrations were considered between 20 and 30 [micro]g/ml.Results: A total of 107 patients were included (77 male, age: 59 [48-71] years; weight: 75 [65-85] kgs; medical admission 69 (64%). Median APACHE II score on admission was 19 [14-23]. Mechanical ventilation was used in 58 (54%) patients and septic shock was present in 54 (53%). Overall ICU mortality was 22%. Median loading and daily doses were 2650 [2288 +/- 2295] mg and 2112 [1500-2838] mg/day, respectively. Vancomycin concentrations were 44 [37-49] [micro]g/mL at the end of LD and then 25 [21-32], 22 [19-28] and 26 [22-29] [micro]g/mL at 12, 24 and 48 hrs, respectively. Insufficient drug concentrations were found in 17 (16%), 29 (27%) and 4 (7%) patients at 12, 24 and 48 hrs, respectively and excessive levels (>30[micro]g/mL) were found in 30 (28%), 19 (17%) and 5 (9%).Conclusions: Higher than recommended regimen of vancomycin is needed to avoid insufficient drug concentrations levels in septic patients within the first 48 hours of therapy.

Introduction: Antibiotics are often administered in patients treated by extracorporeal membrane oxygenation (ECMO) but pharmacokinetics (PKs) of antibiotics during ECMO have not been well defined.Hypothesis: To evaluate vancomycin concentrations in critically ill patients treated with ECMO.Methods: We reviewed all patients who received a continuous infusion (CI) of vancomycin when on ECMO support from January 2011 to May 2012. Vancomycin was given as a 35 mg/kg loading dose in 4-hr, and the infusion doses were adapted to creatinine clearance, CrCL). Drug concentrations were measured at 4 (T1), 12 (T2) and in the first 24 hours (T3) after the onset of therapy. Using a database reporting all patients having this vancomycin regimen, ECMO patients were matched (1:1) with non-ECMO patients according to four criteria: 1) renal function (i.e. same CrCL or both on continuous renal replacement therapy, CRRT); 2) total body weight; 3) Sequential Organ Failure Assessment (SOFA) score; 4) age. Vancomycin concentrations between 20 and 30 [micro]g/ml were considered as adequate.Results: We compared 11 patients treated with ECMO and 11 well matched controls. Mean vancomycin loading (2500 [1610-2975] mg vs. 2450 [1645-3500] mg) and daily doses (1125 [750-3000] vs. 1200 [750-2500] mg) were similar in the two groups. Drug concentrations in ECMO and non-ECMO patients were: 51 [28-71] mcg/mL vs. 45 [37-71] mcg/mL on T1; 23 [16-38] vs. 29 [21-35] mcg/mL on T2; 20 [12-36] vs. 23 [17-28] mcg/mL on T3 (ANOVA, p=0.53). The number of patients with insufficient drug concentrations in ECMO group was 2 on T2 and 4 on T3 when compared to 0 and 1, respectively, in the control group.Conclusions: Vancomycin concentrations in the early phase of therapy were quite similar in patients treated or not with ECMO. Nevertheless, more patients in the ECMO group tended to have insufficient drug concentrations, so that vancomycin doses should be probably increased somewhay in these patients.

Introduction: Early prognostication of neurological outcome after cardiopulmonary resuscitation (CPR) is extremely important as it can help to reassess therapeutic intensity or select high-risk patients for specific interventionsHypothesis: Age and biological variables obtained from initial simple blood tests could predict poor neurological outcome (PNO) after CPRMethods: Data from all patients admitted after CPR (in and out-of-hospital) from January 2008 to December 2011 in a mixed 35-bed ICU were assessed. Therapeutic hypothermia was used in all patients. We identified those who had a complete blood gas/electrolyte panel within the first hour after ICU admission. PNO was defined as a cerebral performance category (CPC) score of 4-5 at hospital discharge. We calculated areas under the receiver operating characteristic curve (AUROC) for each variable and derived the score from those having the highest AUROCs. We identified the best cut-off point (the best combination of sensitivity and specificity) which was used as a dichotomic value (0 or 1), with 1 representing PNO. We constructed 20 different models with combinations of the variables to identify the best model according to the highest AUROC. All analyses were performed with SPSS 19.0Results: A total of 127 patients (mean age 61 years, male gender 76%) were included in the analysis; 69% had out-of-hospital CPR and 57% had shockable rhythms. Overall mortality was 58%. Individual AUROCs (CI 95%) used in the model were: Hemoglobin (Hb) 0.65 (0.55-0.74), blood glucose (Gly) 0.63 (0.53-0.73), lactate (Lac) 0.62 (0.52-0.72), total CO2 (TCO2) 0.59 (0.49-0.69), and age 0.62 (0.52-0.71). The model with the best AUROC (0.772 (0.69-0.85)) included Hb 180 mg/dl, Lac > 2 mEq/L, TCO2

Introduction: The aim of this study was to describe the population pharmacokinetics of vancomycin in critically ill patients treated with and without extracorporeal membrane oxygenation (ECMO).Methods: We retrospectively reviewed data from critically ill patients treated with ECMO and matched controls who received a continuous infusion of vancomycin (35 mg/kg loading dose over 4 hours followed by a daily infusion adapted to creatinine clearance, CrCl)). The pharmacokinetics of vancomycin were described using non-linear mixed effects modeling.Results: We compared 11 patients treated with ECMO with 11 well-matched controls. Drug dosing was similar between groups. The median interquartile range (IQR) vancomycin concentrations in ECMO and non-ECMO patients were 51 (28 to 71) versus 45 (37 to 71) mg/L at 4 hours; 23 (16 to 38) versus 29 (21 to 35) mg/L at 12 hours; 20 (12 to 36) versus 23 (17-28) mg/L at 24 hours (ANOVA, P =0.53). Median (ranges) volume of distribution (Vd) was 99.3 (49.1 to 212.3) and 92.3 (22.4 to 149.4) L in ECMO and non-ECMO patients, respectively, and clearance 2.4 (1.7 to 4.9) versus 2.3 (1.8 to 3.6) L/h (not significant). Insufficient drug concentrations (that is drug levels 2 of 0.67; P, SCOPUS: ar.j, info:eu-repo/semantics/published