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Objectives: The primary objectives of this meta-analysis in critically ill adult patients admitted to the intensive care unit (ICU) were to analyse whether erythropoiesis-stimulating agents (ESAs) reduced the number of patients receiving red blood cell (RBC) transfusion and resulted in a change in haemoglobin (Hb) concentration. Our secondary objectives were adverse events and mortality., Background: Anaemia is common in ICU patients, and currently, the standard therapy is RBC transfusion, which is known to be associated with adverse events. ESA could potentially reduce the need for RBC transfusion., Methods: EMBASE, Cochrane and PubMed were searched up to January 2020., Results: A total of 1357 articles were identified, of which 18 articles met the inclusion criteria for the qualitative synthesis. Eight of these studies were used in the meta-analyses. Comparing ESA vs control group, there was a small reduction in the proportion of patients who received one or more RBC transfusions (relative risk [RR] 0.88; confidence interval [CI] 0.78-1.00, moderate certainty). The change in Hb concentration was trivial (mean difference -0.31 g/dL; CI -0.51 to -0.05, high certainty). The number of serious adverse events (RR 1.02; 0.90-1.15, low certainty) and the overall short-term mortality were similar (RR 0.80; CI 0.61-1.05, low certainty) between the groups., Conclusion: ESA resulted in a small reduction in the proportion of patients transfused and a trivial increase in haemoglobin concentration, both of questionable clinical relevance, without impacting adverse events or mortality. These results do not support the routine use of ESA to treat anaemia in critically ill adults., (© 2020 British Blood Transfusion Society.)

Background: The mean unbound vancomycin fraction and whether the unbound vancomycin level could be predicted from the total vancomycin level are still controversial, especially for patients in different groups, such as intensive care unit (ICU) versus non-ICU patients. Other relevant potential patient characteristics that may predict unbound vancomycin levels have yet to be clearly determined. Methods: We enrolled a relatively large study population and included widely comprehensive potential covariates to evaluate the unbound vancomycin fractions in a cohort of ICU (n=117 samples) and non-ICU patients (n=73 samples) by using a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. Results: The mean unbound vancomycin fraction was 45.80% ± 18.69% (median, 46.01%; range: 2.13– 99.45%) in the samples from the total population. No significant differences in the unbound vancomycin fraction were found between the ICU patients and the non-ICU patients (P=0.359). A significant correlation was established between the unbound and total vancomycin levels. The unbound vancomycin level can be predicted with the following equations: unbound vancomycin level=0.395×total vancomycin level+0.019×total bilirubin level+0.468 (R2=0.771) for the ICU patients and unbound vancomycin level=0.526×total vancomycin level-0.527 (R2=0.749) for the non-ICU patients. Overall, the observed-versus-predicted plots were acceptable. Conclusion: A significant correlation between the total and unbound vancomycin levels was found, and measurement of the unbound vancomycin level seems to have no added value over measurement of the total vancomycin level. The study developed parsimonious equations for predicting the unbound vancomycin level and provides a reference for clinicians to predict the unbound vancomycin level in adult populations. [ABSTRACT FROM AUTHOR]

Purpose: Our aim was to evaluate our institution's compliance with weight-based vancomycin dosing recommendations for pneumonia in critically ill injured patients and to assess the success rate in achieving therapeutic serum vancomycin levels. Additionally, we sought to assess the incidence of vancomycin-induced nephrotoxicity. Methods: All injured intensive care unit (ICU) patients receiving intravenous vancomycin between May 1, 2004 and July 31, 2010 were identified through our trauma database and pharmacy records. The initial weight-based dose was calculated and compared with vancomycin trough levels. Results: Thirty patients were identified who satisfied the inclusion/exclusion criteria. Only 12 patients (40%) received adequate weight-based dosing (weight-based, 30 mg/kg/day). Weight-based patients weighed significantly less than non-weight-based patients (62.7 vs. 84.2 kg, p = 0.0008). Weight-based patients were more likely to achieve therapeutic trough levels than non-weight-based patients (58 vs. 33%, p = 0.176). Of patients who achieved therapeutic trough levels, more weight-based patients achieved it at first trough than non-weight-based patients (33 vs. 5.6%, p = 0.046). Conclusions: When prescribing commonly used dosing regimens, appropriate weight-based administration of vancomycin occurred in only approximately one-third of patients. Those patients who did receive weight-based vancomycin dosing were more likely to achieve therapeutic levels, both initially (33 vs. 5.6%) and overall (58 vs. 33%). [ABSTRACT FROM AUTHOR]

Coated medical devices have been shown to reduce catheter-related infections. We coated endotracheal tubes (ETT) with silver sulfadiazine (SSD), and tested them in a clinical study to assess the feasibility, safety, and efficacy of preventing bacterial colonization. A prospective, randomized clinical trial, phase I–II. Academic intensive care unit (ICU). Forty-six adult patients expected to need 12–24 h of intubation were randomized into two groups. Patients were randomized to be intubated with a standard non-coated ETT (St-ETT, n = 23; control group), or with a SSD-coated ETT (SSD-ETT, n = 23). Coating with SSD prevented bacterial colonization of the ETT (frequency of colonization: SSD-ETT 0/23, St-ETT 8/23; p < 0.01). No organized bacterial biofilm could be identified on the lumen of any ETT; however, SSD was associated with a thinner mucus layer (in the SSD-ETT secretion deposits ranged from 0 to 200 μm; in the St-ETT deposits ranged between 50 and 700 μm). No difference was observed between the two groups in the tracheobronchial brush samples (frequency of colonization: SSD-ETT 0/23, St-ETT 2/23; p = 0.48). No adverse reactions were observed with the implementation of the novel device. SSD-ETT can be safely used in preventing bacterial colonization and narrowing of the ETT in patients intubated for up to 24 h (mean intubation time 16 h). [ABSTRACT FROM AUTHOR]

Antimicrobials are among the most important and commonly prescribed drugs in the management of critically ill patients. Selecting the appropriate antimicrobial at the commencement of therapy, both in terms of spectrum of activity and dose and frequency of administration according to concentration or time dependency, is mandatory in this setting. Despite appropriate standard dosage regimens, failure of the antimicrobial treatment may occur because of the inability of the antimicrobial to achieve adequate concentrations at the infection site through alterations in its pharmacokinetics due to underlying pathophysiological conditions. According to the intrinsic chemicophysical properties of antimicrobials, hydrophilic antimicrobials (β-lactams, aminoglycosides, glycopeptides) have to be considered at much higher risk of inter- and intraindividual pharmacokinetic variations than lipophilic antimicrobials (macrolides, fluoroquinolones, tetracyclines, chloramphenicol, rifampicin [rifampin]) in critically ill patients, with significant frequent fluctuations of plasma concentrations that may require significant dosage adjustments. For example, underexposure may occur because of increased volume of distribution (as a result of oedema in sepsis and trauma, pleural effusion, ascites, mediastinitis, fluid therapy or indwelling post-surgical drainage) and/or enhanced renal clearance (as a result of burns, drug abuse, hyperdynamic conditions during sepsis, acute leukaemia or use of haemodynamically active drugs). On the other hand, overexposure may occur because of a drop in renal clearance caused by renal impairment. Care with all these factors whenever choosing an antimicrobial may substantially improve the outcome of antimicrobial therapy in critically ill patients. However, since these situations may often coexist in the same patient and pharmacokinetic variability may be unpredictable, the antimicrobial policy may further benefit from real-time application of therapeutic drug monitoring, since this practice, by tailoring exposure to the individual patient, may consequently be helpful both in improving the outcome of antimicrobial therapy and in containing the spread of resistance in the hospital setting. [ABSTRACT FROM AUTHOR]

Rapidly, establishing a difficult intravenous access in a dangerously agitated patient is a real challenge. Intranasal midazolam has been shown to be effective and safe for rapidly sedating patients before anesthesia, for procedural sedation and for control of seizure. Here, we report a patient in intensive care unit who was on mechanical ventilation and on inotropic support for management of septic shock and who turned out extremely agitated after accidental catheter removal. Intravenous access was successfully established following sedation with intranasal midazolam, using ultrasound guidance. [ABSTRACT FROM AUTHOR]