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Purpose: High-flow nasal cannula (HFNC) oxygen therapy was noninferior to noninvasive ventilation (NIV) for preventing reintubation in a heterogeneous population at high-risk for extubation failure. However, outcomes might differ in certain subgroups of patients. Thus, we aimed to determine whether NIV with active humidification is superior to HFNC in preventing reintubation in patients with ≥ 4 risk factors (very high risk for extubation failure)., Methods: Randomized controlled trial in two intensive care units in Spain (June 2020‒June 2021). Patients ready for planned extubation with ≥ 4 of the following risk factors for reintubation were included: age > 65 years, Acute Physiology and Chronic Health Evaluation II score > 12 on extubation day, body mass index > 30, inadequate secretions management, difficult or prolonged weaning, ≥ 2 comorbidities, acute heart failure indicating mechanical ventilation, moderate-to-severe chronic obstructive pulmonary disease, airway patency problems, prolonged mechanical ventilation, or hypercapnia on finishing the spontaneous breathing trial. Patients were randomized to undergo NIV with active humidification or HFNC for 48 h after extubation. The primary outcome was reintubation rate within 7 days after extubation. Secondary outcomes included postextubation respiratory failure, respiratory infection, sepsis, multiorgan failure, length of stay, mortality, adverse events, and time to reintubation., Results: Of 182 patients (mean age, 60 [standard deviation (SD), 15] years; 117 [64%] men), 92 received NIV and 90 HFNC. Reintubation was required in 21 (23.3%) patients receiving NIV vs 35 (38.8%) of those receiving HFNC (difference -15.5%; 95% confidence interval (CI) -28.3 to -1%). Hospital length of stay was lower in those patients treated with NIV (20 [12‒36.7] days vs 26.5 [15‒45] days, difference 6.5 [95%CI 0.5-21.1]). No additional differences in the other secondary outcomes were observed., Conclusions: Among adult critically ill patients at very high-risk for extubation failure, NIV with active humidification was superior to HFNC for preventing reintubation., (© 2022. Springer-Verlag GmbH Germany, part of Springer Nature.)

This study aimed to assess the efficacy of ceftazidime/avibactam (C/A) in the treatment of infections due to Gram-negative bacteria (GNB) in critically ill patients. A multicentre, retrospective, observational study was conducted in critically ill patients receiving C/A for GNB infections. We evaluated demographic data, localisation and severity of infection, clinical and microbiological outcomes, and mortality. A total of 68 patients received C/A for serious GNB infections. The main infections were respiratory (33.8%), intra-abdominal (22.1%) and urinary tract infections (10.3%); bacteraemia was found in 22 cases (32.4%). Most infections were complicated by septic shock (58.8%) or sepsis (36.8%) and most of them required life-supporting therapies. Enterobacterales (79.4%) and Pseudomonas aeruginosa (19.1%) were the most frequently isolated bacteria; 84.2% of isolates were carbapenem-resistant. Thirty-four patients (50.0%) received C/A in combination with other antimicrobials. Fifty patients (73.5%) presented a favourable clinical response. Microbiological eradication was documented in 25 cases (36.8%). No significant differences were found in clinical response between patients treated with monotherapy or combined therapy (79.4% vs. 67.6%; P = 0.27). Overall intensive care unit (ICU) mortality was 41.2%. Univariate analysis showed that 30-day all-cause mortality was significantly (P < 0.05) associated with bacteraemia, previous corticosteroid use and the need of life-supporting therapies. C/A appears to be an effective therapy for severe infections due to GNB, including carbapenem-resistant isolates, in critically ill patients. C/A combination therapy was not associated with a higher clinical response. Mortality correlated significantly with the presence of bacteraemia, previous corticosteroid use and the need for life-supporting therapies., Competing Interests: Declaration of Competing Interests None declared., (Copyright © 2022 Elsevier Ltd and International Society of Antimicrobial Chemotherapy. All rights reserved.)

Background: This study aimed to assess the efficacy of ceftolozane-tazobactam (C/T) for treating infections due to Pseudomonas aeruginosa (P. aeruginosa) in critically ill patients., Patients and Methods: A multicenter, retrospective and observational study was conducted in critically ill patients receiving different C/T dosages and antibiotic combinations for P. aeruginosa infections. Demographic data, localisation and severity of infection, clinical and microbiological outcome, and mortality were evaluated., Results: Ninety-five patients received C/T for P. aeruginosa serious infections. The main infections were nosocomial pneumonia (56.2%), intra-abdominal infection (10.5%), tracheobronchitis (8.4%), and urinary tract infection (6.3%). Most infections were complicated with sepsis (49.5%) or septic shock (45.3%), and bacteraemia (10.5%). Forty-six episodes were treated with high-dose C/T (3 g every 8 hours) and 38 episodes were treated with standard dosage (1.5 g every 8 hours). Almost half (44.2%) of the patients were treated with C/T monotherapy, and the remaining group received combination therapy with other antibiotics. Sixty-eight (71.6%) patients presented a favourable clinical response. Microbiological eradication was documented in 42.1% (40/95) of the episodes. The global ICU mortality was 36.5%. Univariate analysis showed that 30-day mortality was significantly associated (P < 0.05) with Charlson Index at ICU admission and the need of life-supporting therapies., Conclusions: C/T appeared to be an effective therapy for severe infections due to P. aeruginosa in critically ill patients. Mortality was mainly related to the severity of the infection. No benefit was observed with high-dose C/T or combination therapy with other antibiotics., (Copyright © 2021. Published by Elsevier Ltd.)

Objectives: To determine whether the alveolar-arterial oxygen gradient (Grad[A-a]O₂) helps confirm the influence of PEEP on PaFi (PaO₂/FiO₂)., Design: Observational study; we used linear regression to perform a multivariate study to improve the PaFi formula by taking PEEP into account., Setting: Tertiary hospital., Patients: We included all patients who were admitted to the intensive care unit, regardless of pulmonary damage., Variables: We recorded personal history, clinical judgment, intensive care data, severity scores on the first day and progression. Two calculated variables: PaFi and Grad(A-a)O₂., Results: A total of 956 patients were included: 63.9% men; median age 68 years. On the first day, 31.8% did not have mechanical ventilation (MV), 13.1% had non-invasive MV and 55.1% had invasive MV. PaFi values: 32.9% 0-200, 32.2% 201-300, and 34.8% >300. PEEP values: 0-5 69.8%, 6-10 27.5% and >10 2.6%. We observed a correlation (Pearson) between Grad(A-a)O₂ and PaFi of -0.84 (p<0.001). On performing multiple regression (dependent variable: Grad[A-a]O₂), the following variables were included in the model: PaFi, PEEP, APACHE IV and SOFA; coefficient of determination (R²) of 0.62 without PEEP and 0.72 with PEEP. We changed the PaFi formula, referring to it as PaFip (PaFi plus PEEP): Ln (PaFi/[PEEP+12]). Correlation index between PaFip and Grad(A-a)O₂: -0.9 (p<0.001). We performed linear regression (dependent variable: Grad[A-a]O₂) and used PaFip instead of PaFi. Only PaFi remained in the model, and was discretely complemented by APACHE IV; R²=0.8., Conclusions: By adding PEEP to the PaFi model (PaFip), we clearly improve the latter, as reflected by a better goodness of fit., (Copyright © 2011 Elsevier España, S.L. and SEMICYUC. All rights reserved.)

Objective: To evaluate the frequency of severe thrombocytopenia (STCP) (≤ 50,000/μl) in the first 24 hours in patients with multiple organ dysfunction syndrome, and the factors that influence its occurrence., Design: A retrospective, observational study. AREA: Medical-surgical intensive care unit (ICU). Tertiary hospital., Patients: Those with failure of at least two organs, according to SOFA criteria, with the exclusion of neurological and traumatologic critical cases., Variables: Medical history, regular medication, baseline functional status, demographic variables, severity scores in ICU, multiple-organ failure data, course in ICU and main hospital data., Results: A total of 587 patients were included; 6.3% (37 patients) presented with STCP during the first day of admission; 64.6% were men; SOFA 8 (5-10); APACHE II 18 (13-24); APACHE IV 59 (46-73); 32.5% were surgical patients. A total of 79.9% subsequently needed mechanical ventilation, and 71.4% required vasoactive drugs. Overall stay in ICU: 4 (2-10) days, main hospital stay 18 (9-35) days. A total of 29.2% died in the ICU; 11.7% developed STCP during admission to the ICU. Multivariate analysis found the main determining factors in the occurrence of thrombocytopenia on admission to be: history of hospitalization in the last year, albumin and bilirubin levels, and sepsis., Conclusion: The prevalence of STCP among critical patients was 6.3%. Its occurrence was associated with albumin and bilirubin levels, sepsis, and with patient admittance in the last year., (Copyright © 2011 Elsevier España, S.L. and SEMICYUC. All rights reserved.)

Objective: To analyze the efficacy of nebulized colistin in the microbiological eradication and clinical improvement of patients with pulmonary infection by multi-resistant Acinetobacter baumannii (MAB)., Design: A retrospective study., Setting: Intensive Care Unit of a Tertiary hospital., Patients: Hospitalized patients on invasive mechanical ventilation with positive MAB cultures of the airway., Interventions: All received treatment with colistin (CL). Nosocomial pneumonia (NP) or Tracheobronchitis (TB) was determined according to routine criteria and colonization (CO) was determined in the case of a positive culture in the absence of infection criteria. Three groups of patients were defined: those treated with nebulized CL, those treated with IV CL and those treated with IV CL plus nebulized CL., Main Measurements: Baseline characteristics. Microbiological eradication and clinical recovery were evaluated according to routine criteria., Results: 83 patients were studied, 54 of whom were treated, with the following diagnoses: 15 (27.8%) with NP, 16 (29.6%) with TB and 23 patients (42.6%) with CO. Nebulized CL was used in 36 patients (66.7%): 66.7% of which for CO, 33.3% in treatment for TB and in no case of NP. In 61.1% of the patients, IV CL was used: 22.2% of which for CO, 38.9% for TB and 38.9% in NP. The combination of IV CL and nebulized CL was used in 15 patients (27.8%): 5 patients (33.3%) CO, 2 patients (13.3%) TB and 8 patients (53.3%) NP. Microbiological eradication was achieved in 32 patients (59.3%), with the following distribution: 8 (47.1%) with IV CL, 15 (83.3%) with nebulized CL and 9 patients (69.2%) with a combination of IV CL and nebulized CL. Clinical recovery was achieved in 42 patients (77.8%): 12 (80%) with IV CL, 18 (94.7%) with nebulized CL and 12 (85.7%) with a combination of nebulized and IV CL. These differences were not significant. In the group of patients with infection due to TB and NP (31 patients, 57.4%), microbiological eradication was achieved in 5 patients (100%) treated with nebulized CL and in 6 of the 9 patients (42.9%) treated with IV CL, the difference being significant (P<.05). Clinical recovery in this group was 100% (6 patients) treated with nebulized CL and 75% (9 of the 12 patients) in the IV CL group. This difference was not significant., Conclusions: Our study suggests that treatment with colistin in patients with pulmonary infection with multi-resistant Acinetobacter baumannii could be more efficient if it were to be administrated solely nebulized or in combination with IV colistin rather than administered solely intravenously., (Copyright © 2010 Elsevier España, S.L. y SEMICYUC. All rights reserved.)