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International audience; Introduction: To examine the effects of positive end-expiratory pressure (PEEP) on intra-abdominal pressure (IAP) in patients with acute lung injury (ALI).Methods: Thirty sedated and mechanically ventilated patients with ALI or acute respiratory distress syndrome (ARDS) admitted to a sixteen-bed surgical medical ICU were included. All patients were studied with sequentially increasing PEEP (0, 6 and 12 cmH2O) during a PEEP-trial.Results: Age was 55 ± 17 years, weight was 70 ± 17 kg, SAPS II was 44 ± 14 and PaO2/FIO2 was 192 ± 53 mmHg. The IAP was 12 ± 5 mmHg at PEEP 0 (zero end-expiratory pressure, ZEEP), 13 ± 5 mmHg at PEEP 6 and 15 ± 6 mmHg at PEEP 12 (P < 0.05 vs ZEEP). In the patients with intra-abdominal hypertension defined as IAP ≥ 12 mmHg (n = 15), IAP significantly increased from 15 ± 3 mmHg at ZEEP to 20 ± 3 mmHg at PEEP 12 (P < 0.01). Whereas in the patients with IAP < 12 mmHg (n = 15), IAP did not significantly change from ZEEP to PEEP 12(8 ± 2 vs 10 ± 3 mmHg). In the 13 patients in whom cardiac output was measured, increase in PEEP from 0 to 12 cmH2O did not significantly change cardiac output, nor in the 8 out of 15 patients of the high-IAP group. The observed effects were similar in both ALI (n = 17) and ARDS (n = 13) patients.Conclusions: PEEP is a contributing factor that impacts IAP values. It seems necessary to take into account the level of PEEP whilst interpreting IAP values in patients under mechanical ventilation.

Prescription of antifungal treatments (AFT) in ICUs in case of suspected or confirmed invasive candidiasis (SIC or CIC) has been challenged by different guidelines. The study aimed to describe the epidemiology of the invasive candidiasis (IC), analyze the criteria for the AFT initiation, the AFT type, and its changes during patient follow-up.

We report the case of a 35-y-old HIV-infected female, who presented fulminant varicella hepatitis and recovered under medical treatment. Varicella zoster virus is an uncommon cause of acute liver disease which occurs mainly in immunocompromized patients. Acyclovir is the cornerstone of the treatment.

Objective: To measure the impact of implementation of the systematic evaluation of pain and agitation by nurses using the Behavioral Pain Scale (BPS), the Numerical Rating Scale (NRS) for pain, and the Richmond Agitation Sedation Scale (RASS) associated with medical staff education in analgesia and sedation management in intensive care unit (ICU) patients. Design: Two-phase, prospective, controlled study. Setting: Twelve-bed medical-surgical ICU in a university hospital. Patients: Consecutive patients staying >24 hrs in ICU. Interventions: BPS, NRS, and RASS were measured twice daily, at rest, by independent observers during 21 wks (control group) and after 4 wks of training, by nurses during 29 wks (intervention group). In the intervention group, the treating physician was alerted in case of pain defined by BPS > 5o r NRS>3 or in case of agitation defined by RASS >1. Measurements and Main Results: A total of 230 patients were included (control group, n 100; intervention group, n 130). Baseline characteristics were not significantly different. The incidence of pain and agitation decreased significantly in the intervention group: 63% vs. 42% (p .002) and 29% vs. 12% (p .002), respectively. Rate of severe pain and agitation events defined by NRS >6 and RASS >2, respectively, also decreased significantly. There were significantly more therapeutic changes in the intervention group in the way of an escalation but also in the way of a de-escalation for analgesic and psychoactive drugs. Compared with the control group, there was a marked decrease in the duration of mechanical ventilation (120 [interquartile range 48‐312] vs. 65 (24‐192) hrs, p .01) and nosocomial infections rate (17% vs. 8%, p < .05) in the intervention group. There was no significant difference in median length of stay (9 [4, 15] vs. 7 [4, 13] days) and mortality in ICU (12 vs. 15%). Conclusions: Systematic evaluation of pain and agitation, and analgesics and sedatives need was associated with a decrease in incidence of pain and agitation, duration of mechanical ventilation and nosocomial infections. (Crit Care Med 2006; 34:1691‐1699)

Although agitation is thought to be common in the ICU, it has been poorly studied. We evaluated the incidence, risks factors, and outcomes of agitation in ICU.Prospective observational study.None.All consecutive ICU admissions over an 8-month period were analyzed.Two hundred eleven patients were admitted a total of 216 times during the period of the study. Twenty-nine patients were excluded from the study because their pathology findings did not allow an evaluation of their level of consciousness; 182 patients were actually enrolled. Agitation developed in 95 of 182 patients (52%). Agitation began 4.4 +/- 5.6 days (+/- SD) after admission to the ICU and lasted 3.9 +/- 4.1 days. Patients with agitation had a higher Simplified Acute Physiology Score II on ICU admission than those who did not have agitation (40 +/- 16 vs 33 +/- 13, p0.01). By stepwise logistic regression, the independent risks factors for development of agitation included psychoactive drug use at the time of ICU admission (odds ratio, 5.63; 95% confidence interval [CI], 1.32 to 23.70), history of alcohol abuse (odds ratio, 3.32; 95% CI, 1.12 to 10.00), dysnatremia (odds ratio, 4.95; 95% CI, 1.95 to 12.54), fever (odds ratio, 4.52; 95% CI, 1.80 to 11.49), use of sedatives in the ICU (odds ratio, 4.03; 95% CI, 1.62 to 10.40), and sepsis (odds ratio, 2.61; 95% CI, 1.03 to 6.58). Agitation was associated with a prolonged ICU stay (16 +/- 19 days vs 6 +/- 6 days, p = 0.0001), nosocomial infections (34% vs 7%, p0.0001), unplanned extubations (17% vs 2%, p = 0.003), and unplanned central venous catheter removal (16% vs 1%, p = 0.001), but not with mortality (12% in the agitation group vs 8% in patients without agitation).Agitation is a common event in a mixed medical-surgical ICU. It is associated with adverse outcomes including prolonged stay, nosocomial infections, and unplanned extubations. A better knowledge of incidence and risk factors should facilitate identification of patients at risk and decrease the incidence of agitation.

To determine the prevalence, associated findings, and consequences of cytomegalovirus (CMV) antigenemia in critically ill patients.A retrospective, case-control clinical study.A 12-bed university hospital medical-surgical ICU.Two hundred thirty-seven patients with fever for72 h, without proven evidence of bacteriologic and/or fungal origin, and whose pp65 antigenemia assays were studied. Patients with HIV infection and transplant recipients were excluded.None.CMV antigenemia was diagnosed within 20 +/- 12 days (mean +/- SD) after ICU admission in 17% patients in whom the pathology was suspected. The 40 patients in the CMV group were matched with 40 other patients in the control group. CMV infection was linked to renal failure (58% vs 33%, respectively; p = 0.02) and steroid use (55% vs 33%, respectively; p = 0.04). Patients with CMV had a significantly longer stay in the ICU (41 +/- 28 days vs 31 +/- 22 days, respectively; p = 0.04), a longer duration of mechanical ventilation (35 +/- 27 days vs 24 +/- 20 days, respectively; p = 0.03), a higher rate of nosocomial infection (75% vs 50%, respectively; p = 0.04), and a higher mortality (50% vs 28%, p = 0.02).CMV antigenemia is not an uncommon diagnosis in critically ill ICU patients with unexplained prolonged fever after 10 days of hospitalization, regardless of their immune system status. Although associated with a higher morbidity and mortality, the clinical significance of CMV is unknown. Further prospective studies should evaluate the impact on ICU outcome and whether CMV is truly a pathogen or simply another indicator of immunosuppression.

Background:Patients with acute pancreatitis (AP) who require mechanical ventilation have high morbidity and mortality rates. Noninvasive positive pressure ventilation (NPPV) delivered through a mask has become increasingly popular for the treatment of acute respiratory failure (ARF) and may limit some mechanical ventilation complications. Objectives: The purpose of this retrospective, observational study was to evaluate our clinical experience with the use of NPPV in AP patients with ARF. Methods: From 1997 to 2003, we documented clinical data, gas exchange and outcome of the 62 AP patients admitted to our intensive care unit. Patients who benefited from NPPV (success) were compared with those who failed (intubated). Results:Twenty-nine patients were intubated at admission and 5 did not develop ARF. Of the 28 patients treated with NPPV, 15 were not intubated (54%). Both groups had a similar PaO2/FiO2 ratio (142 ± 21 vs. 133 ± 20; p = 0.127) and severity of illness (Ranson and Balthazar scores). Presence of atelectasis, bilateral alveolar infiltrates and abdominal distension were associated with failure of NPPV. Oxygenation improved and respiratory rate decreased significantly only in the success group. Additionally, the length of stay at the intensive care unit was significantly lower in the success group. Conclusion: NPPV is feasible and safe to treat ARF in selected patients with AP who require ventilatory support.

Objective. To compare the short-term effects of a heat and moisture exchanger (HME) and a heated humidifier (HH) during non-invasive ventilation (NIV). Design. Prospective, clinical investigation. Setting. Intensive care unit of a university hospital. Patients. Twenty-four patients with acute respiratory failure (ARF). Intervention. Each patient was studied with a HME and a HH in a random order during two consecutive 20min periods of NIV. Measurements and results. Respiratory rate (RR), expiratory tidal volume (VTe) and expiratory minute ventilation (VE) were measured during the last 5 min of each period and blood gases were measured. Mean pressure support and positive end-expiratory pressure levels were, respectively, 15±4 and 6±2 cmH2O. VE was significantly greater with HME than with HH (14.8±4.8 vs 13.2±4.3 l/min; p

Background/Aims: Bacterial infections, specially Staphylococcus aureus (S. aureus) septicemia, remain a leading cause of death following liver transplantation. It has been demonstrated that nasal carriage of S. aureus is associated with invasive infections in patients undergoing hemodialysis and could be decreased by use of antibiotic nasal ointment. However, in cirrhotic patients, the frequency of nasal carriage is unknown. The aims of this study were to determine the prevalence of S. aureus nasal carriage in cirrhotic patients and to assess nosocomial contamination. Methods: One hundred and four patients were included in a prospective study, 52 cirrhotic and 52 control (hospitalized patients without cirrhosis or disease which might increase the rate of nasal carriage of S. aureus ). On admission and after a few days of hospitalization, nasal specimens from each anterior naris were obtained for culture. S. aureus was identified by the gram strain, positive catalase and coagulase reactions; antibiotic susceptibility was determined using a disk-diffusion test. Results: Both groups were similar with regard to age and sex. The prevalence of nasal colonization on hospital admission was 56% in cirrhotic patients and 13% in control patients ( p =0.001). After an average of 4 days, 42% of cirrhotics and 8% of control patients were colonized ( p =0.001), without any nosocomial contamination. Three strains out of 29 were oxacillin-resistant in cirrhotic patients, and none in controls ( p >0.05). There was no statistical difference in carriage rate according to sex, age, cause of cirrhosis and Child-Pugh score. Previous hospitalization (OR, 6.3; 95% CI, 2.3 to 19.9; p =0.0006) and cirrhosis (OR, 4.4; 95% CI, 1.5 to 13.4; p =0.0048) were independent predictors of colonization. Conclusion: Cirrhotic patients had a higher S. aureus nasal carriage rate than control subjects. Previous hospitalization and cirrhosis diagnosis were correlated to nasal colonization. Further studies are necessary to determine if nasal decontamination could reduce S. aureus infections after liver transplantation.

BACKGROUND The purpose of this study was to investigate changes in breathing pattern, neuromuscular drive (P 0.1 ), and activity of the sternocleidomastoid muscles (SCM) during a gradual reduction in pressure support ventilation (PSV) in patients being weaned off controlled mechanical ventilation. METHODS Eight non-COPD patients recovering from acute respiratory failure were included in this prospective interventional study. All patients were unable to tolerate discontinuation from mechanical ventilation. Each patient was evaluated during a period of spontaneous breathing and during PSV. Four successive levels of PSV were assessed in the following order: 20 cm H 2 O (PS20), 15 cm H 2 O (PS15), 10 cm H 2 O (PS10), and 5 cm H 2 O (PS5). RESULTS When pressure support was reduced from PS20 to PS10 the respiratory rate (f) and the rapid shallow breathing index (f/Vt) significantly increased and tidal volume (Vt) significantly decreased. These parameters did not vary when pressure support was reduced from PS10 to PS5. Conversely, P 0.1 varied negligibly between PS20 and PS15 but increased significantly at low PSV levels. P 0.1 values were always greater than 2.9 cm H 2 O (4.1 (1.1) cm H 2 O) when SCM activity was present. When contraction of the SCM muscles reappeared the P 0.1 was the only parameter that changed significantly. CONCLUSIONS In postoperative septic patients the value of P 0.1 seems to be more useful than breathing pattern parameters for setting the optimal level of pressure assistance during PSV.

Objective: To compare the influence of gastric and postpyloric enteral feeding on the gastric tonometric Pco 2 gap (tonometric Pco 2 - Paco 2 ). Design: A prospective, clinical trial. Setting: Two intensive care units in a university hospital. Patients: Twenty patients undergoing mechanical ventilation and enteral feeding without catecholamines, sepsis, or sign of hypoxia. Interventions: Patients were randomized to receive feeding through the tonometer (gastric group), or through a postpyloric tube (postpyloric group). Measurements and Main Results: The patients received tube feeding at a rate of 50 mL/hr during 4 hrs. Baseline measurements included: mean arterial pressure, heart rate, tonometric parameters, arterial gases, and arterial lactate concentration. Except for lactate concentration, these measurements were repeated after 1 and 4 hrs of enteral feeding and 2 hrs after stopping enteral feeding. During the study, arterial pH and Paco 2 did not change. During enteral feeding, the Pco 2 gap increased in the gastric group from a mean of 7 ± 5 to 17 ± 14 (so) torr (0.9 ± 0.7 to 2.3 ± 1.9 kPa) (p

Background/Aims: Acute rejection is still a major problem after liver transplantation. Ursodeoxycholic acid has beneficial effects in cholestasis by reducing the expression of major histocompatibility complex antigens. Methods: We have performed a double-blind randomised study comparing ursodeoxycholic acid with placebo for the prevention of acute cellular rejection after liver transplantation. Twenty-six patients received ursodeoxycholic acid 600 mg per day and 24 patients received placebo for 2 months. Results: Neither rejection incidence nor rejection severity was significantly different in the two group ( p >0.90). Conclusions: We conclude that adjuvant ursodeoxycholic acid administration does not prevent rejection after liver transplantation.

We report the case of a patient who developed jaundice, encephalopathy, a marked increase in serum aminotransferase activity and a decrease in prothrombin and proaccelerin levels, after 6 weeks' treatment with carbimazole and propranolol for hyperthyroidism. The patient ultimately underwent orthotopic liver transplantation. This case strongly suggests that carbimazole may occasionally induce fulminant hepatitis and that careful monitoring of liver enzymes may be useful during the treatment of hyperthyroidism with this drug.

International audience; Systemic Antifungal therapy (SAT) of invasive candidiasis (IC) needs to be started immediately upon clinical suspicion. Controversies exist then about potential harms from antifungal de-escalation (DE).(1) in cases of documented IC, early DE to fluconazole is recommended by US guidelines but discouraged in EU guidelines. in non-documented IC, no data are available to guide SAT DE. These questions are key issues however as the relationship between antifungal use and Candida antifungal resistance has been repeatedly demonstrated.