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Background Transport of critically ill patients for diagnostic or therapeutic procedures is at risk of complications. Adverse events during transport are common and may have significant consequences for the patient. The objective of the study was to collect prospectively adverse events that occurred during intrahospital transports of critically ill patients and to determine their risk factors. Methods This prospective, observational study of intrahospital transport of consecutively admitted patients with mechanical ventilation was conducted in a 38-bed intensive care unit in a university hospital from May 2009 to March 2010. Results Of 262 transports observed (184 patients), 120 (45.8%) were associated with adverse events. Risk factors were ventilation with positive end-expiratory pressure >6 cmH2O, sedation before transport, and fluid loading for intrahospital transports. Within these intrahospital transports with adverse events, 68 (26% of all intrahospital transports) were associated with an adverse event affecting the patient. Identified risk factors were: positive end-expiratory pressure >6 cmH2O, and treatment modification before transport. In 44 cases (16.8% of all intrahospital transports), adverse event was considered serious for the patient. In our study, adverse events did not statistically increase ventilator-associated pneumonia, time spent on mechanical ventilation, or length of stay in the intensive care unit. Conclusions This study confirms that the intrahospital transports of critically ill patients leads to a significant number of adverse events. Although in our study adverse events have not had major consequences on the patient stay, efforts should be made to decrease their incidence.

Community-acquired pneumonia (CAP) is the most common cause for severe sepsis and the leading cause of death from infection in the United States. Despite important advances in the field of pathogenesis and treatment of severe CAP, the mortality rate related to severe CAP has changed little in the pa

To determine incidence, risk factors and outcome of tracheal ischemic lesions related to intubation. Planned post hoc analysis using patients from a previous randomized controlled study. Fiberoptic tracheoscopy was performed during the 24 h following extubation. In patients with >2 ischemic lesions, ulcer or tracheal rupture, fiberoptic tracheoscopy was repeated 2 weeks after the last extubation. Tracheal ischemic lesions were predefined based on a quantitative score. Ninety-six adult patients were included in this study. Eighty (83 %) patients had at least one tracheal ischemic lesion. Thirty-seven (38 %) patients had a tracheal ischemia score > median score (5; IQ 1, 7). The most common tracheal ischemic lesion was ischemia (68 %), followed by hyperemia (54 %), ulcer (10 %), and tracheal rupture (1 %). Univariate analysis identified duration of neuromuscular-blocking agent use, overinflation of tracheal cuff (>30 cmH2O), percentage of P cuff determination >30 cmH2O, duration of assist-control ventilation, and plateau pressure as risk factors for having a tracheal ischemia score >5. Duration of assist-control mechanical ventilation was the only factor independently associated with tracheal ischemia score >5 [OR (95 % CI) 1.10 per hour (1.02–1.20)]. A fiberoptic tracheoscopy was performed 2 weeks after extubation in 22 patients. This examination was normal in all patients, except the one with tracheal rupture who had marked improvement. Tracheal ischemic lesions are common in intubated, critically ill patients. Duration of assist-control mechanical ventilation through a tracheal tube is the only independent risk factor. These lesions healed in the majority of patients 2 weeks after extubation.

Underinflation of the tracheal cuff frequently occurs in critically ill patients and represents a risk factor for microaspiration of contaminated oropharyngeal secretions and gastric contents that plays a major role in the pathogenesis of ventilator-associated pneumonia (VAP).To determine the impact of continuous control of tracheal cuff pressure (P(cuff)) on microaspiration of gastric contents.Prospective randomized controlled trial performed in a single medical intensive care unit. A total of 122 patients expected to receive mechanical ventilation for at least 48 hours through a tracheal tube were randomized to receive continuous control of P(cuff) using a pneumatic device (intervention group, n = 61) or routine care of P(cuff) (control group, n = 61).The primary outcome was microaspiration of gastric contents as defined by the presence of pepsin at a significant level in tracheal secretions collected during the 48 hours after randomization. Secondary outcomes included incidence of VAP, tracheobronchial bacterial concentration, and tracheal ischemic lesions. The pneumatic device was efficient in controlling P(cuff). Pepsin was measured in 1,205 tracheal aspirates. Percentage of patients with abundant microaspiration (18 vs. 46%; P = 0.002; OR [95% confidence interval], 0.25 [0.11-0.59]), bacterial concentration in tracheal aspirates (mean ± SD 1.6 ± 2.4 vs. 3.1 ± 3.7 log(10) cfu/ml, P = 0.014), and VAP rate (9.8 vs. 26.2%; P = 0.032; 0.30 [0.11-0.84]) were significantly lower in the intervention group compared with the control group. However, no significant difference was found in tracheal ischemia score between the two groups.Continuous control of P(cuff) is associated with significantly decreased microaspiration of gastric contents in critically ill patients.

To determine the impact of aerosolized bronchodilators on ventilator-associated pneumonia.Prospective cohort study.A 30-bed medical and surgical intensive care unit.All intubated patients requiring mechanical ventilation for48 hrs were eligible during a 13-month period. Nebulized β2-agonists were administered at the intensive care unit physician's discretion. Ventilator-associated pneumonia definition included clinical and quantitative microbiological criteria. Only first ventilator-associated pneumonia episodes were analyzed. Risk factors for ventilator-associated pneumonia were determined using univariate and multivariate analyses. The influence of inhaled β2-agonists on ventilator-associated pneumonia occurrence was also adjusted for confounding factors using Cox's proportional-hazards model.Ventilator-associated pneumonia was diagnosed in 137 (31%) of the 439 enrolled patients. Ventilator-associated pneumonia was early-onset in 14 (10%) patients. The incidence rate of ventilator-associated pneumonia was 20 per 1,000 ventilator days. Ventilator-associated pneumonia was polymicrobial in 16 (11%) patients, and related to multidrug-resistant bacteria in 42 (28%) patients. Most cases of ventilator-associated pneumonia were caused by Gram-negative bacteria. Inhaled β2-agonists were significantly more frequently used in patients with ventilator-associated pneumonia compared with those without ventilator-associated pneumonia (49% vs. 34%, odds ratio [95% confidence interval] = 1.9 [1.2-2.8], p = .003). Multivariate analysis identified aerosolized β2-agonists (odds ratio [95% confidence interval] = 1.7 [1.1-2.6], p = .012), Simplified Acute Physiology Score II at intensive care unit admission (odds ratio [95% confidence interval] = 1.01 [1.001-1.02] per point, p = .031), and red blood cell transfusion (odds ratio [95% confidence interval] = 2 [1.3-3.1], p = .001) as independent risk factors for ventilator-associated pneumonia. Cox's proportional-hazards model also identified inhaled β2-agonists as a risk factor for ventilator-associated pneumonia (odds ratio [95% confidence interval] = 1.52 [1.06-2.19], p = .021).Use of aerosolized bronchodilators in intensive care unit mechanically ventilated patients is an independent risk factor for ventilator-associated pneumonia.

Microaspiration of contaminated oropharyngeal secretions and gastric contents frequently occurs in intubated critically ill patients, and plays a major role in the pathogenesis of ventilator-associated pneumonia. Risk factors for microaspiration include impossible closure of vocal cords, longitudinal folds in high-volume low-pressure polyvinyl chloride cuffs, and underinflation of tracheal cuff. Zero positive end expiratory pressure, low peak inspiratory pressure, tracheal suctioning, nasogastric tube and enteral nutrition increase the risk for microaspiration. Other patient related factors include supine position, coma, sedation, and hyperglycemia. Technetium 99 labelled enteral feeding is probably the most accurate marker of microaspiration in critically ill patients. However, use of this radioactive marker is restricted to nuclear medicine departments. Blue methylene is a reliable qualitative marker of microaspiration. However, fiberoptic bronchoscopy is required to diagnose microaspiration of blue dye in ICU patients. Quantitative pepsin measurement in tracheal aspirates is accurate in diagnosing microaspiration of gastric contents in critically ill patients. In addition, this marker is easy to use in routine practice. However, pepsin should be detected rapidly after aspiration. In vitro, and clinical studies suggested that semirecumbent position, polyurethane cuffs, positive end expiratory pressure, low-volume low-pressure cuff, and continuous control of cuff pressure were efficient in reducing microaspiration in ICU patients. Other preventive measures such as subglottic aspiration, tapered shape cuff, guayule latex cuff, lateral horizontal patient position, gastrostomy tube, and postpyloric feeding require further investingation.

To determine the impact of polyurethane (PU) on variations in cuff pressure (P cuff) in intubated critically ill patients. Prospective observational before-after study performed in a ten-bed ICU. Cuff pressure was continuously recorded for 24 h in 76 intubated patients, including 26 with polyvinyl chloride (PVC), 22 with cylindrical polyurethane (CPU), and 28 with tapered polyurethane (TPU)-cuffed tracheal tubes. P cuff was manually adjusted every 8 h by nurses and was maintained around 25 cmH2O. Time spent with cuff underinflation and overinflation was continuously measured. In addition, pepsin, a proxy for microaspiration of gastric contents, was quantitatively measured in tracheal secretions at the end of recording period. A total of 1,824 h of continuous recording of cuff pressure was analyzed. Patient characteristics were similar in the three groups. No significant difference was found in percentage of time spent with underinflation (mean ± SD, 26 ± 22, 28 ± 12, 30 ± 13% in PVC, CPU, and TPU groups, respectively) and overinflation [median (IQR), 7 (2–14), 6 (3–14), 11% (5–20)] among the three groups. However, a significant difference was found in the coefficient of variation of P cuff (mean ± SD, 82 ± 48, 92 ± 47, 135 ± 67, p = 0.002). While the coefficient of P cuff variation was significantly (p

The aim of the present study was to evaluate the benefit of monitoring serum piperacillin concentrations in critically ill patients. This was an 11-month, prospective, observational study in a 30-bed Intensive Care Unit in a teaching hospital, involving 24 critically ill patients with evidence of bacterial sepsis. All patients received a 66 mg/kg intravenous bolus of piperacillin in combination with tazobactam (ratio 1:0.125) followed by continuous infusion of 200mg/kg/24h. The dosage was adjusted when the serum piperacillin concentration either fell below 4x the drug's minimum inhibitory concentration (MIC) for the causative agent or exceeded the toxic threshold of 150 mg/L. With the initial regimen, serum piperacillin concentrations were within the therapeutic target range in only 50.0% of patients (n=12). This proportion increased to 75.0% (18 patients) (P=0.006) following dosage adjustment. For patients with low initial serum piperacillin concentrations (n=8), the percentage of time during which the concentration remained above 4x MIC (%T>4x MIC) was 7.1+/-5.9% before dosage adjustment and 27.3+/-8.6% afterwards. In conclusion, in critically ill patients, monitoring and adjustment of serum piperacillin levels is required to prevent overdosing and might also help to correct underdosing, an important cause of antibiotic therapy failure.

Florence Ader1, Anne-Lise Bienvenu2, Blandine Rammaert3, Saad Nseir41Service des Maladies Infectieuses et Tropicales; 2Service de Parasitologie et Mycologie Médicale, Université Claude Bernard Lyon 1, Hospices Civils de Lyon, Hôpital de La Croixrousse, Lyon, France; 3Service des Maladies Infectieuses et Tropicales, Université Paris Descartes, Hôpital Necker Enfants Malades, Centre d’infectiologieNecker-Pasteur, Paris, France; 4Service de Réanimation Médicale, Hôpital A. Calmette, Centre Hospitalier Régional Universitaire, Lille, FranceAbstract: Invasive pulmonary aspergillosis (IPA) is an important cause of mortality in patients with hematologic malignancies. The reported incidence of IPA in the context of chronic obstructive pulmonary disease (COPD) seems to increase. Approximately 1%–2% of overall fatal cases of IPA occur in COPD patients. The combination of factors such as lung immune imbalance, long-term corticosteroid use, increasing rate of bacterial exacerbations over time, and malnutrition are responsible for the emergence of IPA in these patients. The diagnosis of IPA is difficult to establish, which explains the delay in implementing accurate antifungal therapy and the high mortality rate. Persistent pneumonia nonresponsive to appropriate antibiotic treatment raises the concern of an invasive fungal infection. Definite diagnosis is obtained from tissue biopsy evidencing Aspergillus spp. on microscopic examination or in culture. Culture and microscopy of respiratory tract samples have a sensitivity and specificity of around 50%. Other diagnostic tools can be useful in documenting IPA: computed tomography (CT) scan, nonculture-based tests in serum and/or in bronchoalveolar lavage such as antibody/antigen tests for Aspergillus spp. More recent tools such as polymerase chain reaction or [1→3]-β-D-glucan have predictive values that need to be further investigated in COPD patients. Antifungal monotherapy using azole voriconazole is recommended as a first-line treatment of IPA. This review assesses the use of voriconazole in COPD patients. Keywords: chronic obstructive pulmonary disease, corticosteroid, Aspergillus, invasive pulmonary aspergillosis, voriconazole

Objectives: Metformin-associated lactic acidosis is a rare and serious complication of biguanide treatment. It usually occurs when a precipitating disease induces an acute renal failure and an incidental overdose. Voluntary intoxication is rare. Bicarbonate hemodialysis (HD) is recommended to decrease metformin levels and correct acidosis but its optimal duration has not been determined. This study was designed to document the characteristics and prognostic factors of intentional and incidental metformin overdose and to determine the optimal duration of HD. Design: Ten years retrospective analysis of patients admitted in intensive care unit for metformin-associated lactic acidosis. Setting: Two intensive care units (50 beds) in a university hospital. Measurements and Main Results: Clinical and biological characteristics, organ failures, and sequential metformin levels during HD were recorded. Forty-two patients were included (13 voluntary intoxications and 29 incidental overdoses); 74% of patients were in acute renal failure and needed HD. No death was observed in intentional overdose patients compared with 48.3% mortality in incidental overdose patients. The factors significantly associated with mortality were logistic organ dysfunction system score, pH, plasma lactate, and prothrombin activity. By multivariate analysis, a prothrombin activity

An endotracheal cuff pressure of 20-30 cmH(2)O is recommended. Underinflation and overinflation are associated with complications such as aspiration and tracheal wall damage. The aim of this study was to identify prevalence of, and risk factors for, endotracheal cuff underinflation and overinflation.Prospective observational cohort study. All critically ill patients intubated with a high-volume lowpressure endotracheal tube were eligible. After manual adjustment of cuff pressure at 25 cmH(2)O, continuous recording of cuff pressure and airway pressure was performed for 8 h. Underinflation and overinflation of the endotracheal cuff were defined as cuff pressure less than 20 cmH(2)O and more than 30 cmH(2)O, respectively. In all patients, the time spent with normal cuff pressure or with underinflation or overinflation of the endotracheal cuff was measured. Univariate and multivariate analyses were used to determine risk factors for cuff underinflation and overinflation.Eight hundred and eight hours of cuff pressure recordings were analysed in 101 patients. Eighteen per cent of study patients spent 100% of recording time with normal (20-30 cmH(2)O) cuff pressure. Fifty-four per cent of study patients developed cuff underinflation, 73% developed cuff overinflation, and 44% developed both. Thirty- three per cent of study patients developed underinflation or overinflation for more than 30 min. Absence of sedation [odds ratio (95% confidence interval)=2.51 (1-6), P=0.03] and duration of prior intubation [1.16 (1.04-1.29), P0.01] were independently associated with cuff underinflation. No risk factor for overinflation could be determined. The percentage of time spent with underinflation significantly (P0.01) increased during the recording period.Variations in endotracheal cuff pressure are common in ICU patients. Duration of prior intubation and absence of sedation are independently associated with increased risk for cuff underinflation.

International audience; Objective To analyse the incidence and the impact on outcome of right ventricular failure (RVF) in patients with acute respiratory distress syndrome (ARDS). Patients and methods A total of 145 ARDS patients included in the previously published French Pulmonary Artery Catheter (PAC) study were randomly assigned to receive a PAC. All patients were ventilated according to a strategy aimed at limiting plateau pressure. The RVF was defined by the concomitant presence of: (1) a mean pulmonary artery pressure (MPAP) > 25 mmHg, (2) a central venous pressure (CVP) higher than pulmonary artery occlusion pressure (PAOP) and (3) a stroke volume index < 30 mL m−2. Results Right ventricular failure was present in 9.6% of patients. Mortality was 68% at day-90 with no difference between patients with RVF (RVF+) and without RVF (71 vs. 67%, respectively). SAPS II, PaO2/FiO2 and PaCO2 were similar in both groups. Tidal volume and I/E ratio were significantly higher in RVF+ (9.7 ± 2.8 vs. 8.6 ± 1.8 ml m−2 and 0.7 ± 0.5 vs. 0.5 ± 0.2). Plateau pressure tended to be higher in RVF+ (28 ± 6 vs. 25 ± 6 cmH2O, NS). In multivariate analysis, PaO2/FiO2, mean arterial pressure, arterial pH, SvO2, MPAP and presence of CVP > PAOP, but not RVF, were independently associated with day-90 mortality. Conclusion In this group of patients investigated early in the course of ARDS and ventilated according to a strategy aimed at limiting plateau pressure, the presence of RVF was about 10%. Unlike MPAP and the presence of CVP > PAOP, RVF at this early stage did not appear as an independent factor of mortality.

Introduction Recent animal studies demonstrated immunosuppressive effects of opioid withdrawal resulting in a higher risk of infection. The aim of this study was to determine the impact of remifentanil discontinuation on intensive care unit (ICU)-acquired infection. Methods This was a prospective observational cohort study performed in a 30-bed medical and surgical university ICU, during a one-year period. All patients hospitalised in the ICU for more than 48 hours were eligible. Sedation was based on a written protocol including remifentanil with or without midazolam. Ramsay score was used to evaluate consciousness. The bedside nurse adjusted sedative infusion to obtain the target Ramsay score. Univariate and multivariate analyses were performed to determine risk factors for ICU-acquired infection. Results Five hundred and eighty-seven consecutive patients were included in the study. A microbiologically confirmed ICU-acquired infection was diagnosed in 233 (39%) patients. Incidence rate of ICU-acquired infection was 38 per 1000 ICU-days. Ventilator-associated pneumonia was the most frequently diagnosed ICU-acquired infection (23% of study patients). Pseudomonas aeruginosa was the most frequently isolated microorganism (30%). Multivariate analysis identified remifentanil discontinuation (odds ratio (OR) = 2.53, 95% confidence interval (CI) = 1.28 to 4.99, P = 0.007), simplified acute physiology score II at ICU admission (1.01 per point, 95% CI = 1 to 1.03, P = 0.011), mechanical ventilation (4.49, 95% CI = 1.52 to 13.2, P = 0.006), tracheostomy (2.25, 95% CI = 1.13 to 4.48, P = 0.021), central venous catheter (2.9, 95% CI = 1.08 to 7.74, P = 0.033) and length of hospital stay (1.05 per day, 95% CI = 1.03 to 1.08, P < 0.001) as independent risk factors for ICU-acquired infection. Conclusions Remifentanil discontinuation is independently associated with ICU-acquired infection.

Introduction Ventilator-associated tracheobronchitis (VAT) is associated with increased duration of mechanical ventilation. We hypothesized that, in patients with VAT, antibiotic treatment would be associated with reduced duration of mechanical ventilation. Methods We conducted a prospective, randomized, controlled, unblinded, multicenter study. Patients were randomly assigned (1:1) to receive or not receive intravenous antibiotics for 8 days. Patients with ventilator-associated pneumonia (VAP) prior to VAT and those with severe immunosuppression were not eligible. The trial was stopped early because a planned interim analysis found a significant difference in intensive care unit (ICU) mortality. Results Fifty-eight patients were randomly assigned. Patient characteristics were similar in the antibiotic (n = 22) and no antibiotic (n = 36) groups. Pseudomonas aeruginosa was identified in 32% of VAT episodes. Although no difference was found in mechanical ventilation duration and length of ICU stay, mechanical ventilation-free days were significantly higher (median [interquartile range], 12 [8 to 24] versus 2 [0 to 6] days, P < 0.001) in the antibiotic group than in the no antibiotic group. In addition, subsequent VAP (13% versus 47%, P = 0.011, odds ratio [OR] 0.17, 95% confidence interval [CI] 0.04 to 0.70) and ICU mortality (18% versus 47%, P = 0.047, OR 0.24, 95% CI 0.07 to 0.88) rates were significantly lower in the antibiotic group than in the no antibiotic group. Similar results were found after exclusion of patients with do-not-resuscitate orders and those randomly assigned to the no antibiotic group but who received antibiotics for infections other than VAT or subsequent VAP. Conclusion In patients with VAT, antimicrobial treatment is associated with a greater number of days free of mechanical ventilation and lower rates of VAP and ICU mortality. However, antibiotic treatment has no significant impact on total duration of mechanical ventilation. Trial registration ClinicalTrials.gov, number NCT00122057.

Background: Strategies aiming at reducing antibiotic use are required in the intensive care unit (ICU). Although antibiotic treatment is recommended in patients with severe exacerbation of chronic obstructive pulmonary disease (COPD), a bacterial etiology is found in only a half of these patients. Objectives: The aim of this study was to determine factors predicting bacterial isolation in severe acute exacerbations of COPD. Methods: All patients with severe acute exacerbation of COPD requiring intubation and mechanical ventilation were included in this prospective observational cohort study. At ICU admission, information on endotracheal aspirate purulence and hyperthermia was collected. In all patients, Gram stain and quantitative endotracheal aspirate culture (positive at 106 cfu/ml) were performed. In addition, leukocyte count, C-reactive protein and procalcitonin (PCT) levels were measured. Results: Ninety-eight severe acute exacerbations of COPD requiring intubation and mechanical ventilation were studied. Forty-nine bacteria were isolated at significant threshold in 40 exacerbations. Streptococcus pneumoniae (16%), methicillin-sensitive Staphylococcus aureus (16%) and Hemophilus influenzae (14%) were the most frequently isolated bacteria. PCT >0.5 ng/ml and positive Gram stain of endotracheal aspirate were independently associated with bacterial isolation in severe acute exacerbation of COPD. Positive Gram stain and PCT >0.5 ng/ml had a negative predictive value >95%. Similar results were found after excluding patients with prior antibiotic treatment. Conclusion: Positive Gram stain of endotracheal aspirate and PCT >0.5 ng/ml are independently associated with bacterial isolation in severe acute exacerbation of COPD. These results could be helpful for future interventional studies aiming at reducing antibiotic use in these patients.

The aim of the present study was to determine the relationship between tracheotomy and ventilator-associated pneumonia (VAP). The study used a retrospective case-control study design based on prospective data. All nontrauma immunocompetent patients, intubated and ventilated for >7 days, were eligible for inclusion in the study. A diagnosis of VAP was based on clinical, radiographical and microbiological criteria. Four matching criteria were used, including duration of mechanical ventilation (MV). The indication and timing of tracheotomy were at the discretion of attending physicians. Univariate and multivariate analyses were performed to determine risk factors for VAP in cases (patients with tracheotomy) and controls (patients without tracheotomy). In total, 1,402 patients were eligible for inclusion. Surgical tracheotomy was performed in 226 (16%) patients and matching was successful for 177 (78%). The rate of VAP (22 versus 14 VAP episodes.1,000 MV-days(-1)) was significantly higher in controls than in cases. The rate of VAP after tracheotomy in cases, or after the corresponding day of MV in controls, was also significantly higher in control than in case patients (9.2 versus 4.8 VAP episodes.1,000 MV-days(-1)). In multivariate analysis, neurological failure (odds ratio (95% confidence interval) 2.7 (1.3-5)), antibiotic treatment (2.1 (1.1-3.2)) and tracheotomy (0.18 (0.1-0.3)) were associated with VAP. In summary, the present study demonstrates that tracheotomy is independently associated with decreased risk for ventilator-associated pneumonia.

Introduction The aim of this study was to determine incidence, risk factors, and impact on outcome of intensive care unit (ICU)-acquired Stenotrophomonas maltophilia. Methods This prospective observational case-control study, which was a part of a cohort study, was conducted in a 30-bed ICU during a three year period. All immunocompetent patients hospitalised >48 hours were eligible. Patients with non-fermenting Gram-negative bacilli (NF-GNB) at ICU admission were excluded. Patients without ICU-acquired S. maltophilia who developed an ICU-acquired NF-GNB other than S. maltophilia were also excluded. Screening (tracheal aspirate and skin, anal, and nasal swabs) for NF-GNB was performed in all patients at ICU admission and weekly. Univariate and multivariate analyses were performed to determine risk factors for ICU-acquired S. maltophilia and for ICU mortality. Results Thirty-eight (2%) patients developed an S. maltophilia ICU-acquired colonisation and/or infection and were all successfully matched with 76 controls. Chronic obstructive pulmonary disease (COPD) and duration of antibiotic treatment (odds ratio [OR] [95% confidence interval (CI)] = 9.4 [3 to 29], p < 0.001, and 1.4 [1 to 2.3], p = 0.001, respectively) were independently associated with ICU-acquired S. maltophilia. Mortality rate (60% versus 40%, OR [95% CI] = 1.3 [1 to 1.7, p = 0.037]), duration of mechanical ventilation (23 ± 16 versus 7 ± 11 days, p < 0.001), and duration of ICU stay (29 ± 21 versus 15 ± 17 days, p < 0.001) were significantly higher in cases than in controls. In addition, ICU-acquired infection related to S. maltophilia was independently associated with ICU mortality (OR [95% CI] = 2.8 [1 to 7.7], p = 0.044). Conclusion COPD and duration of antibiotic treatment are independent risk factors for ICU-acquired S. maltophilia. ICU-acquired S. maltophilia is associated with increased morbidity and mortality rates. ICU-acquired infection related to S. maltophilia is an independent risk factor for ICU mortality.

To investigate whether the respiratory changes in arterial pulse (DeltaPP) and in systolic pressure (DeltaSP) could predict fluid responsiveness in spontaneously breathing (SB) patients. Because changes in intrathoracic pressure during spontaneous breathing (SB) might be insufficient to modify loading conditions of the ventricles, performances of indicators were also assessed during a forced respiratory maneuver.Prospective interventional study.A 34-bed university hospital medico-surgical ICU.Thirty-two SB patients with clinical signs of hemodynamic instability.A 500-ml volume expansion (VE).Cardiac index, assessed using transthoracic echocardiography, increased by at least 15% after VE in 19 patients (responders). At baseline, only dynamic indicators were higher in responders than in nonresponders (13+/-5% vs. 7+/-3%, p=0.003 for DeltaPP and 10+/-4% vs. 6+/-2%, p=0.002 for DeltaSP). Moreover, they significantly decreased after VE (11+/-5% to 6+/-4%, p0.001 for DeltaPP and 8+/-4% to 6+/-3%, p0.001 for DeltaSP). DeltaPP and DeltaSP areas under the ROC curve were high (0.81+/-0.08 and 0.82+/-0.08; p=0.888, respectively). A DeltaPPor=12% predicted fluid responsiveness with high specificity (92%) but poor sensitivity (63%). The forced respiratory maneuver reproducing a dyspneic state decreased the predictive power.Due to their lack of sensitivity and their dependence to respiratory status, DeltaPP and DeltaSP are clearly less reliable to predict fluid responsiveness during SB than in mechanically ventilated patients. However, when their baseline value is high without acute right ventricular dysfunction in a participating patient, a positive response to fluid is likely.

A 74-yr-old diabetic woman developed necrotizing fasciitis of the right upper limb after axillary brachial plexus block for carpal tunnel decompression. Clinical signs included oedema, diffuse swelling and bullae; rapidly followed by toxic shock syndrome and multiorgan failure. The patient died 48 h after hospital admission, despite broad-spectrum antibiotics, surgical treatment and supportive measures for the management of shock and multiorgan failure. Cultures yielded group A Streptococcus. Delay in antibiotic and surgical treatment probably affected the outcome. Early diagnosis and treatment are essential to improve the outcome of streptococcal necrotizing fasciitis.

Determine the risk factors and germs responsible for early-onset (E) and late-onset (L) nosocomial broncho-pulmonary infections (NBPI), in order to improve preventive strategies and the choice of initial antibiotherapy.An observational prospective study conducted in an intensive care unit of 30 beds, from March 1993 to September 1999. The patients presenting with an ENBPI and those with an LNBPI were compared with patients without NBPI using univariate and then multivariate analysis.517 (14%) of early-onset NBPI were diagnosed, but the majority of NBPI were late-onset (87%). Multiresistant bacteria predominated. The similarity in the germs responsible for the early and late onset forms of NBPI was probably related to the large number of patients transferred from other departments (82%) and having already received antibiotics before their admission to the intensive care unit (49%). Multivariate analysis identified anti-ulcer and long term corticosteroid treatments as common risk factors for early and late onset forms of NBPI, digestive failure, tracheotomy and kidney failure as risk factors for ENBPI and the number of antibiotics used in intensive care and the duration of mechanical ventilation as factors of risk for LNBPI.The limited use of antibiotics and anti-ulcer agents could improve the prevention of early and late onset forms of NBPI. The distinction in intensive care between the two forms of NBPI must be emphasized by the notion of prior hospitalization.

26-year-old man was referred to our intensive care unit shortly after having ingested a massive amount of a caustic agent (200 mL of potassium hydroxide) with suicidal intent. He had epigastric tenderness, severe oropharyngeal burns, and respiratory distress. In view of the severity of the injury, esophageal endoscopy could not be performed. Examination with a fiberoptic bronchoscope revealed extensive necrosis of the posterior wall of the tracheobronchial tree from the proximal trachea to the distal ends of both main bronchi. The patient was started on a regimen of intravenous broad-spectrum antibiotics (piperacillin/tazobactam and amikacin). A decision was made to perform emergency surgery, which began 9 hours after the ingestion. Exploratory laparotomy was performed initially. Severe injuries to the gastrointestinal tract necessitated extensive resection of necrotic organs. A total gastrectomy, cephalic duodenopancreatectomy extending to 30 cm of the jejunum, and a cholecystectomy were performed. Biliodigestive and pancreaticodigestive anastomoses were created. A feeding jejunostomy tube was also placed. Cervical esophagostomy was then performed over a large rubber tube. The patient was reintubated with a long left-sided endobronchial tube over a flexible bronchoscope. A right thoracotomy was performed and severe mediastinitis was evident. Necrosis involved all layers of the esophagus including the periesophageal tissues. Gentle dissection was used to remove the esophagus, with care taken to preserve the tracheobronchial tree. After pleural and mediastinal irrigation, the posterior tracheal membrane appeared grayish, but without visible perforation. So that further deterioration and complications could be avoided, the posterior aspects of the trachea and main bronchi were patched with the right lung (Figure 1, A).

Introduction Several aspects of ventilator-associated tracheobronchitis (VAT)—including diagnostic criteria, overlap with ventilator-associated pneumonia (VAP), and appropriate treatment regimens—remain poorly defined. The objectives of this study were to survey reported practices in the clinical and microbiological diagnosis of VAT and to evaluate perceptions of the impact of VAT on patient outcomes. Methods We developed a questionnaire consisting of (a) characteristics of the respondent, the ICU, and hospital; (b) current clinical and microbiological diagnostic approach; (c) empirical antibiotic therapy; and (d) the perception of physicians regarding the clinical impact of VAT and its implications. Results A total of 288 ICUs from 16 different countries answered the survey: 147 (51%) from the Latin American (LA) group and 141 (49%) from Spain, Portugal, and France (SPF group). The majority of respondents (n = 228; 79.2%) reported making the diagnosis of VAT based on clinical and microbiological criteria, and 40 (13.9%) by clinical criteria alone. Approximately half (50.3%) of the respondents agreed that patients should receive antibiotics for the treatment of VAT. Out of all respondents, 269 (93.4%) assume that a VAT episode increases ICU length of stay, and this perception is greater in the LA group (97.3%) than in the SPF group (89.4%, P

We would like to thank P. Frost and M.P. Wise for their comments, and wish to respond to some of the points they raised. Dental plaque, the oropharyngeal cavity and the stomach are potential reservoirs for microorganisms in critically ill patients. Aspiration of contaminated oropharyngeal and gastric secretions is common in intensive care unit (ICU) patients requiring mechanical ventilation through an endotracheal tube or a tracheotomy cannula 1. The most important mechanism of ventilator-associated pneumonia (VAP) is gross or micro-aspiration of oropharyngeal microorganisms into the distal bronchi, followed by bacterial proliferation and parenchymal invasion, leading to bronchopneumonia …

Zolfaghari and Wyncoll [1] propose that it may now be against good medical practice to continue to use a 'standard cuffed tube' given the weight of evidence supporting the use of newer tube designs to prevent ventilator-associated pneumonia (VAP). There is strong evidence supporting the use of subglottic aspiration to prevent VAP [2]. However, other new tracheal tubes, such as polyurethane cuffed, silver-coated, or low-volume low-pressure tubes, could not be recommended to prevent VAP in routine practice. Although recent studies found polyurethane-cuffed tracheal tubes to be associated with significantly reduced VAP rate, major limitations of these studies preclude definitive conclusions; these limitations include the use of subglottic aspiration [3], before/after study design [4], and clinical criteria to define pneumonia [4,5]. One large multicenter study found the use of silver-coated tracheal tubes to be associated with significant reduction in VAP rate [6]. However, limitations of this study should be taken into account, such as the significant difference in the proportion of patients with chronic obstructive pulmonary disease between the two groups, and the small rate of late-onset VAP. Low-volume, low-pressure tracheal tubes were found to be associated with significantly reduced leakage of blue dye in a randomized controlled study performed in a single ICU [7]. Similarly, some in vitro studies suggested beneficial effects of conical shaped and guayule latex double-layered cuffs [8]. However, to date no randomized controlled study has evaluated the effect of these tubes on VAP prevention [9]. Therefore, further well designed studies are required before recommending the use of new tracheal tubes in every critically ill patient requiring mechanical ventilation for longer than 24 hours.

Introduction: Sedative and analgesic medications are routinely used in mechanically ventilated patients. The aim of this review is to discus epidemiologic data that suggest a relationship between infection and sedation, to review available data for the potential causes and pathophysiology of this relationship, and to identify potential preventive measures. Methods: Data for this review were identified through searches of PubMed, and from bibliographies of relevant articles. Results: Several epidemiologic studies suggested a link between sedation and ICU-acquired infection. Prolongation of exposure to risk factors for infection, microaspiration, gastrointestinal motility disturbances, microcirculatory effects are main mechanisms by which sedation may favour infection in critically ill patients. Furthermore, experimental evidence coming from studies both in humans and animals suggest that sedatives and analgesics present immunomodulatory properties that might alter the immunologic response to exogenous stimuli. Clinical studies comparing different sedative agents do not provide evidence to recommend the use of a particular agent to reduce ICU-acquired infection rate. However, sedation strategies aiming to reduce the duration of mechanical ventilation, such as daily interruption of sedatives or nursing-implementing sedation protocol, should be promoted. In addition, the use of short acting opioids, propofol, and dexmedetomidine is associated with shorter duration of mechanical ventilation and ICU stay, and might be helpful in reducing ICU-acquired infection rates. Conclusions: Prolongation of exposure to risk factors for infection, microaspiration, gastrointestinal motility disturbances, microcirculatory effects, and immunomodulatory effects are main mechanisms by which sedation may favour infection in critically ill patients. Future studies should compare the effect of different sedative agents, and the impact of progressive opioid discontinuation compared with abrupt discontinuation on ICU-acquired infection rates.

The aim of this study was to determine incidence, risk factors, and impact on outcome of intensive care unit (ICU)-acquired Stenotrophomonas maltophilia. This prospective observational case-control study, which was a part of a cohort study, was conducted in a 30-bed ICU during a three year period. All immunocompetent patients hospitalised >48 hours were eligible. Patients with non-fermenting Gram-negative bacilli (NF-GNB) at ICU admission were excluded. Patients without ICU-acquired S. maltophilia who developed an ICU-acquired NF-GNB other than S. maltophilia were also excluded. Screening (tracheal aspirate and skin, anal, and nasal swabs) for NF-GNB was performed in all patients at ICU admission and weekly. Univariate and multivariate analyses were performed to determine risk factors for ICU-acquired S. maltophilia and for ICU mortality. Thirty-eight (2%) patients developed an S. maltophilia ICU-acquired colonisation and/or infection and were all successfully matched with 76 controls. Chronic obstructive pulmonary disease (COPD) and duration of antibiotic treatment (odds ratio [OR] [95% confidence interval (CI)] = 9.4 [3 to 29], p < 0.001, and 1.4 [1 to 2.3], p = 0.001, respectively) were independently associated with ICU-acquired S. maltophilia. Mortality rate (60% versus 40%, OR [95% CI] = 1.3 [1 to 1.7, p = 0.037]), duration of mechanical ventilation (23 ± 16 versus 7 ± 11 days, p < 0.001), and duration of ICU stay (29 ± 21 versus 15 ± 17 days, p < 0.001) were significantly higher in cases than in controls. In addition, ICU-acquired infection related to S. maltophilia was independently associated with ICU mortality (OR [95% CI] = 2.8 [1 to 7.7], p = 0.044). COPD and duration of antibiotic treatment are independent risk factors for ICU-acquired S. maltophilia. ICU-acquired S. maltophilia is associated with increased morbidity and mortality rates. ICU-acquired infection related to S. maltophilia is an independent risk factor for ICU mortality.

Our objective was to determine the effect of ventilator-associated tracheobronchitis (VAT) on outcome in patients without chronic respiratory failure. This was a retrospective observational matched study, conducted in a 30-bed intensive care unit (ICU). All immunocompetent, nontrauma, ventilated patients without chronic respiratory failure admitted over a 6.5-year period were included. Data were collected prospectively. Patients with nosocomial pneumonia, either before or after VAT, were excluded. Only first episodes of VAT occurring more than 48 hours after initiation of mechanical ventilation were studied. Six criteria were used to match cases with controls, including duration of mechanical ventilation before VAT. Cases were compared with controls using McNemar's test and Wilcoxon signed-rank test for qualitative and quantitative variables, respectively. Variables associated with a duration of mechanical ventilation longer than median were identified using univariate and multivariate analyses. Using the six criteria, it was possible to match 55 (87%) of the VAT patients (cases) with non-VAT patients (controls). Pseudomonas aeruginosa was the most frequently isolated bacteria (34%). Although mortality rates were similar between cases and controls (29% versus 36%; P = 0.29), the median duration of mechanical ventilation (17 days [range 3–95 days] versus 8 [3–61 days]; P < 0.001) and ICU stay (24 days [range 5–95 days] versus 12 [4–74] days; P < 0.001) were longer in cases than in controls. Renal failure (odds ratio [OR] = 4.9, 95% confidence interval [CI] = 1.6–14.6; P = 0.004), tracheostomy (OR = 4, 95% CI = 1.1–14.5; P = 0.032), and VAT (OR = 3.5, 95% CI = 1.5–8.3; P = 0.004) were independently associated with duration of mechanical ventilation longer than median. VAT is associated with longer durations of mechanical ventilation and ICU stay in patients not suffering from chronic respiratory failure.

We investigated whether the respiratory changes in arterial pulse pressure (ΔPP), an accurate indicator during mechanical ventilation (MV), and in arterial systolic pressure (ΔPS), easy to calculate, could predict fluid responsiveness in spontaneously breathing patients. The respiratory changes in intrathoracic pressure during spontaneous breathing, reversed compared with MV, could be insufficient to modify loading conditions of ventricles. We thus also tested those indicators during a forced respiratory cycle.