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Background: Intraoperative arterial hypotension (IOH) leads to increased postoperative morbidity. Norepinephrine is often use to treat IOH. The question regarding the mode of administration in either a bolus or continuous infusion remains unanswered. The aim of the present study was to describe and compare the effects on macrocirculation and microcirculation of a bolus and a continuous infusion of norepinephrine to treat IOH. Methods: We conducted a prospective observational study with adult patients who underwent neurosurgery. Patients with invasive arterial blood pressure and cardiac output (CO) monitoring were screened for inclusion. All patients underwent microcirculation monitoring by video-capillaroscopy, laser doppler, near-infrared spectroscopy technology, and tissular CO2. In case of IOH, the patient could receive either a bolus of 10 µg or a continuous infusion of 200 µg/h of norepinephrine. Time analysis for comparison between bolus and continuous infusion were at peak of MAP. Results: Thirty-five patients were included, with 41 boluses and 33 continuous infusion. Bolus and continuous infusion induced an maximal increase in mean arterial pressure of +30[20-45] and +23[12-34] %, respectively (P=0,07). For macrocirculatory parameters, continuous infusion was associated with a smaller decrease in CO and stroke volume (pConclusions: These results on macro and microcirculation enlighten the potential benefits of a continuous infusion of norepinephrine rather than a bolus to treat anaesthesia-induced hypotension. Trial registration : (NOR-PHARM: 1-17-42 Clinical Trials: NCT03454204), 05/03/2018

Purpose: Intraoperative arterial hypotension (IOH) leads to increased postoperative morbidity and mortality. Norepinephrine is often use to treat IOH. However, the question regarding the mode of administration in either a bolus or continuous infusion (CI) remains unanswered. The aim of the present study was to describe and compare the effects on macrocirculation and microcirculation of a bolus and a CI of norepinephrine to treat IOH.Methods: We conducted a prospective observational study with adult patients who underwent neurosurgery. Patients with invasive arterial blood pressure and cardiac output (CO) monitoring were screened for inclusion. All patients underwent microcirculation monitoring by video capillaroscopy, laser doppler, near-infrared spectroscopy technology, and tissue CO2. In case of IOH, the patient could receive either a bolus of 10 µg or a CI of 200 µg/h of norepinephrine.Results: Thirty-six patients were included, with 41 boluses and 33 CI.Bolus and CI induced an increase in mean arterial pressure of +30[20-45] and +23[12-34] %, respectively (P=0,07). For macrocirculatory parameters, CI was associated with a smaller decrease in CO and stroke volume (pConclusions: These results on macro- and microcirculation could reveal the need for the preferential use of a continuous infusion of norepinephrine rather than a bolus to treat anaesthesia-induced hypotension.Trial registration : (NOR-PHARM: 1-17-42 Clinical Trials: NCT03454204).

Background Empirical antimicrobial therapy (EAT) is a challenge for community-acquired, hospital-acquired and ventilator-associated pneumonia, particularly in the context of the increasing occurrence of third-generation cephalosporin-resistant Enterobacterales (3GCR-E), including extended-spectrum beta-lactamase Enterobacterales (ESBL-E) and high-level expressed AmpC cephalosporinase-producing Enterobacterales (HLAC-E). To prevent the overuse of broad-spectrum antimicrobial therapies, such as carbapenems, we assessed the performance of screening for intestinal carriage of HLAC-E in addition to ESBL-E to predict 3GCR-E (ESBL-E and/or HLAC-E) presence or absence in respiratory samples in ICU, and to evaluate its potential impact on carbapenem prescription. Materials and methods This monocentric retrospective observational study was performed in a surgical ICU during a 4-year period (January 2013–December 2016). Patients were included if they had a positive culture on a respiratory sample and a previous intestinal carriage screening performed by rectal swabbing within 21 days. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and likelihood ratios were calculated for the screening for intestinal carriage of ESBL-E, HLAC-E and 3GCR-E (ESBL-E and/or HLAC-E) as predictor of their absence/presence in respiratory samples. Impact of HLAC-E and ESBL-E reporting on EAT was also studied. Results 765 respiratory samples, retrieved from 468 patients, were analyzed. ESBL-E prevalence was 23.8% in rectal swab and 4.4% in respiratory samples. HLAC-E prevalence was 9.0% in rectal swabs and 3.7% in respiratory samples. Overall, the 3GCR-E prevalence was 31.8% in rectal swabs and 7.7% in respiratory samples. NPVs were 98.8%, 98.0% and 96.6% for ESBL-E, HLAC-E and 3GCR-E, respectively. Over the study period, empirical antimicrobial therapy was initiated for 315 episodes of respiratory infections: 228/315 (72.4%) were associated with negative intestinal carriage screening for both HLAC-E and ESBL-E, of whom 28/228 (12.3%) were treated with carbapenems. Of 23/315 (7.3%) cases with screening for positive intestinal carriage with HLAC-E alone, 10/23 (43.5%) were treated with carbapenems. Conclusion Systematic screening and reporting of HLAC-E in addition to ESBL-E in intestinal carriage screening could help to predict the absence of 3GCR-E in respiratory samples of severe surgical ICU patients. This could improve the appropriateness of EAT in ICU patients with HAP and may prevent the overuse of carbapenems.

INTRODUCTION During anesthesia, decreases in mean arterial pressure (MAP) are common but the impact on possible cerebral hypoperfusion remains a matter of debate. We evaluated cerebral perfusion in patients with or without cardiovascular comorbidities (Hi-risk vs Lo-risk) during induction of general anesthesia and during hypotensive episodes. METHODS Patients scheduled for neuroradiology procedure using standardized target-controlled Propofol-Remifentanil infusion were prospectively included. Monitoring included Transcranial Doppler (TCD) measuring mean blood velocity of the middle cerebral artery (Vm), Bispectral Index with burst suppression ratio (SR) and cerebral Near-Infrared Spectroscopy (NIRS). Hypotensive episodes were treated with a 10 µg bolus of Norepinephrine. RESULTS Eighty-one patients were included, 37 Hi-risk and 44 Lo-risk. During induction of anesthesia, MAP and Vm decreased in all patients, with greater changes observed in Hi-risk patients compared to Lo-risk patients (-34 [38-29]% vs -17 [25-8]%, P

Empirical antimicrobial therapy (EAT) is a challenge for community-acquired, hospital-acquired and ventilator-associated pneumonia, particularly in the context of the increasing occurrence of third-generation cephalosporin-resistant Enterobacterales (3GCR-E), including extended-spectrum beta-lactamase Enterobacterales (ESBL-E) and high-level expressed AmpC cephalosporinase-producing Enterobacterales (HLAC-E). To prevent the overuse of broad-spectrum antimicrobial therapies, such as carbapenems, we assessed the performance of screening for intestinal carriage of HLAC-E in addition to ESBL-E to predict 3GCR-E (ESBL-E and/or HLAC-E) presence or absence in respiratory samples in ICU, and to evaluate its potential impact on carbapenem prescription.This monocentric retrospective observational study was performed in a surgical ICU during a 4-year period (January 2013-December 2016). Patients were included if they had a positive culture on a respiratory sample and a previous intestinal carriage screening performed by rectal swabbing within 21 days. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and likelihood ratios were calculated for the screening for intestinal carriage of ESBL-E, HLAC-E and 3GCR-E (ESBL-E and/or HLAC-E) as predictor of their absence/presence in respiratory samples. Impact of HLAC-E and ESBL-E reporting on EAT was also studied.765 respiratory samples, retrieved from 468 patients, were analyzed. ESBL-E prevalence was 23.8% in rectal swab and 4.4% in respiratory samples. HLAC-E prevalence was 9.0% in rectal swabs and 3.7% in respiratory samples. Overall, the 3GCR-E prevalence was 31.8% in rectal swabs and 7.7% in respiratory samples. NPVs were 98.8%, 98.0% and 96.6% for ESBL-E, HLAC-E and 3GCR-E, respectively. Over the study period, empirical antimicrobial therapy was initiated for 315 episodes of respiratory infections: 228/315 (72.4%) were associated with negative intestinal carriage screening for both HLAC-E and ESBL-E, of whom 28/228 (12.3%) were treated with carbapenems. Of 23/315 (7.3%) cases with screening for positive intestinal carriage with HLAC-E alone, 10/23 (43.5%) were treated with carbapenems.Systematic screening and reporting of HLAC-E in addition to ESBL-E in intestinal carriage screening could help to predict the absence of 3GCR-E in respiratory samples of severe surgical ICU patients. This could improve the appropriateness of EAT in ICU patients with HAP and may prevent the overuse of carbapenems.

Additional file 1. Supplementary table 1a. Prevalence of extended-spectrum beta-lactamase producing Enterobacterales (ESBL-E) in intestinal carriage screening and respiratory samples paired by patients. Supplementary table 1b. Prevalence of Enterobacterales producing AmpC cephalosporinase (HLAC-E) in intestinal respiratory samples paired by patients. Supplementary table 1b. Prevalence of Enterobacterales producing AmpC cephalosporinase (HLAC-E) in intestinal cephalosporins (3GCR-E) in intestinal carriage screening and respiratory samples paired by patients.