Executive Summary Introduction Methodology Used to Prepare the Guideline Epidemiology Incidence Etiology Major Epidemiologic Points Pathogenesis Major Points for Pathogenesis Modifiable Risk Factors Intubation and Mechanical Ventilation Aspiration, Body Position, and Enteral Feeding Modulation of Colonization: Oral Antiseptics and Antibiotics Stress Bleeding Prophylaxis, Transfusion, and Glucose Control Major Points and Recommendations for Modifiable Risk Factors Diagnostic Testing Major Points and Recommendations for Diagnosis Diagnostic Strategies and Approaches Clinical Strategy Bacteriologic Strategy Recommended Diagnostic Strategy Major Points and Recommendations for Comparing Diagnostic Strategies Antibiotic Treatment of Hospital-acquired Pneumonia General Approach Initial Empiric Antibiotic Therapy Appropriate Antibiotic Selection and Adequate Dosing Local Instillation and Aerosolized Antibiotics Combination versus Monotherapy Duration of Therapy Major Points and Recommendations for Optimal Antibiotic Therapy Specific Antibiotic Regimens Antibiotic Heterogeneity and Antibiotic Cycling Response to Therapy Modification of Empiric Antibiotic Regimens Defining the Normal Pattern of Resolution Reasons for Deterioration or Nonresolution Evaluation of the Nonresponding Patient Major Points and Recommendations for Assessing Response to Therapy Suggested Performance Indicators

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia the official statement of the American Thoracic Society and the Infectious Disease Society of America (特集 救急診療ガイドライン) -- (海外のガイドライン)

BACKGROUND: Although obstetric morbidity and mortality have decreased recently, rates are still high enough to constitute a significant health problem. With the COVID-19 pandemic, many obstetric patients have required treatment in intensive care units (ICU). OBJECTIVES: Evaluate critical obstetric patients who were treated in an ICU for COVID-19 and followed up for 90 days. DESIGN: Medical record review SETTING: Intensıve care unit PATİENTS AND METHODS: Obstetric patients admitted to the ICU between 15 March 2020 and 15 March 2022 and followed up for at least 90 days were evaluated retrospectively. Patients with and without COVID-19 were compared by gestational week, indications, comorbidities, length of stay in the hospital and ICU, requirement for mechanical ventilation, blood transfusion, renal replacement therapy (RRT), plasmapheresis, ICU scores, and mortality. MAIN OUTCOME MEASURES: Clinical outcomes and mortality. SAMPLE SIZE AND CHARACTERISTICS: 102 patients with a mean (SD) maternal age of 29.1 (6.3) years, and median (IQR) length of gestation of 35.0 (7.8) weeks. RESULTS: About 30% (n=31) of the patients were positive for COVID-19. Most (87.2%) were cesarean deliveries; 4.9% vaginal (8.7% did not deliver). COVID-19, eclampsia/preeclampsia, and postpartum hemorrhage were the most common ICU indications. While the 28-day mortality was 19.3% (n=6) in the COVID-19 group, it was 1.4% (n=1) in the non-COVID-19 group (P<.001). The gestational period was significantly shorter in the COVID-19 group (P=.01) while the duration of stay in ICU (P<.001) and mechanical ventilation (P=.03), lactate (P=.002), blood transfusions (P=.001), plasmapheresis requirements (P=.02), and 28-day mortality were significantly higher (P<.001). APACHE-2 scores (P=.007), duration of stay in ICU (P<.001) and mechanical ventilation (P<.001), RRT (P=.007), and plasmapheresis requirements (P=.005) were significantly higher in patients who died than in those who were discharged. CONCLUSION: The most common indication for ICU admission was COVID-19. The APACHE-2 scoring was helpful in predicting mortality. We think multicenter studies with larger sample sizes are needed for COVID-19 obstetric patients. In addition to greater mortality and morbidity, the infection may affect newborn outcomes by causing premature birth. LIMITATIONS: Retrospectıve, single-center, small population size. CONFLICT OF INTEREST: None.

Evaluation of critically ill obstetric patients treated in an intensive care unit during the COVID-19 pandemic

Introduction
Peripartum cardiomyopathy (PPCM) is a rare but potentially fatal disease defined by heart failure towards the end of pregnancy or in the months following delivery. We aim to raise awareness of the condition and give the clinician an overview of current knowledge on the mechanisms of pathophysiology, diagnostics and clinical management.

Material and methods
Systematic literature searches were performed in PubMed and Embase up to June 2016. Cohorts of more than 20 women with PPCM conducted after 2000 were selected to report contemporary outcomes and prognostic data. Guidelines and reviews that provided comprehensive overviews were included, too.

Results
New research on the pathophysiological mechanisms of PPCM points towards a two-hit multifactorial cause involving genetic factors and an antiangiogenic hormonal environment of late gestation with high levels of prolactin and sFlt-1. The prevalence of concomitant preeclampsia is high (often 30–45%) and symptoms can be similar, posing diagnostic difficulties. Most women (71–98%) present postpartum. Echocardiography is essential for diagnosis, and cardiac magnetic resonance imaging may provide new insights to pathophysiology and prognosis. Management is multidisciplinary and involves advanced heart failure therapy. Treatment, timing and mode of delivery in pregnant women depend on disease severity. The risk of relapse in subsequent pregnancies is >20%, and women are often advised against a new pregnancy.

Conclusions
PPCM has a huge impact on cardiovascular health and reproductive life perspective. New insights into genetics, molecular pathophysiological mechanisms and clinical studies have resulted in potential disease-specific therapies, but many questions remain unanswered.

Peripartum Cardiomyopathy: A Systematic Literature Review

espanolEl higado graso agudo del embarazo es una de las alteraciones hepaticas con mayor mortalidad (cerca del 18 %) presentes en la gestacion, aunque es una patologia poco frecuente: 1 de cada 7000 a 16.000 embarazos presenta muchas complicaciones y requiere un manejo inmediato para evitar la muerte de la gestante o del feto; sin embargo esta patologia se puede enmascarar con la preeclampsia, que es otra patologia hepatica de mayor frecuencia, lo cual retrasa el manejo y aumenta el numero de complicaciones. El objetivo de este articulo es realizar una busqueda bibliografica acerca del higado graso agudo del embarazo e identificar los factores similares entre esta patologia y la preeclampsia severa para lograr hacer un diagnostico y manejo oportunos. Para ello se realizo una busqueda sistematica en las bases de datos, PubMed, Science Direct, Medline, Embase, en junio de 2017; ademas, se seleccionaron articulos originales, reportes de casos y articulos de revision, publicados en los ultimos diez anos. portuguesO figado gorduroso agudo da gestacao e uma das alteracoes hepaticas com mais mortalidade (cerca de 18 %) presentes na gravidez, embora seja uma patologia pouco frequente: 1 de cada 7.000 a 16.000 gestacoes apresenta muitas complicacoes e requer uma acao imediata para evitar a morte da gestante ou do feto. Contudo, essa patologia pode ser camuflada com a pre-eclâmpsia, que e outra patologia hepatica de maior frequencia, o que atrasa seu tratamento e aumenta o numero de complicacoes. Nesse sentido, o objetivo deste estudo e realizar uma busca bibliografica sobre o figado gorduroso agudo da gestacao e identificar os fatores semelhantes entre ele e a pre-eclâmpsia grave para poder fazer um diagnostico e tratamento oportunos. Para isso, foi realizada uma busca sistematica nas bases de dados, PubMed, Science Direct, Medline, Embase, em junho de 2017, das quais foram selecionados artigos originais, relatos de caso e artigos de revisao, publicados nos ultimos dez anos. EnglishAcute fatty liver of pregnancy (AFLP) is one of the liver disorders with the highest mortality rate (about 18 %) during pregnancy, although it is rare: 1 in 7,000 to 16,000 pregnancies has many complications and requires immediate treatment to avoid the death of the pregnant woman or the fetus. However, this pathology can be masked by preeclampsia, which is another more frequent liver disease. This delays treatment and increases the number of complications. The aim of this article is to conduct a bibliographic search about AFLP and identify similar factors between this pathology and severe preeclampsia to make a diagnosis and provide treatment in a timely manner. For this, a systematic search was carried out in databases (PubMed, Science Direct, Medline, Embase) in June 2017. In addition, original articles, case reports, and review articles published in the last ten years were selected.

/pdf/que-hay-en-comun-entre-el-higado-graso-agudo-del-embarazo-y-3faj5fdrg9.pdf

¿Qué hay en común entre el hígado graso agudo del embarazo y la preeclampsia?: Subdiagnóstico clínico de alta mortalidad

Septic abortion represents the main causes of abortion-induced maternal death. Hysterectomy may represent a beneficial therapeutic solution for septic abortion, nevertheless with irreversible effects on a woman's reproductive condition. The study analyzes the anatomopathological damage found in ninety-one patients hospitalized for septic abortion. The patients were admitted to the "Dr. D. Popescu" Clinical Hospital, Timisoara, between 1980-1989 and 1999-2008; hysterectomy was performed in all the cases to eliminate uterine sepsis responsible for the emerging complications.

Utero-adnexal damage in septic abortion. Histopathological study on 91 cases.

Pregnant and postpartum patients represent a challenge to critical care physicians, as two patients in one have to be cared for and because specific obstetric disorders, not universally covered in formal critical care training, need to be managed. Pregnancy also alters physiologic norms, so that the critical care physician may either fail to recognize a value as abnormal in pregnancy or mistakenly identify as abnormal a value within the normal range for a pregnant woman. In this article, we will review the most frequent obstetric causes of admission of pregnant/postpartum patients to the intensive care unit (hypertensive disease of pregnancy, obstetric hemorrhage, and obstetric sepsis) along with their diagnostic criteria, clinical presentation, and recommended treatment. We will also cover some specific, although less frequent, obstetric disorders, such as acute fatty liver of pregnancy, peripartum cardiomyopathy, and amniotic fluid embolism. Our primary aim is to improve quality of care for these types of patients.

Obstetric Disorders in the ICU.

Objective: To describe the clinical characteristics of patients with AHRF (without ARDS) hospitalized in the ICU who require IMV. To evaluate the association between mortality and different variables. Design: Inception cohort. Scope: This study was conducted in two Argentine ICUs from the private health sector between 07/01/2013 and 12/31/2014. Patients: From a consecutive sample of 2526 patients, 229 individuals aged 18 and upwards were included in the study; they were admitted to the ICU requiring IMV for over 24 hours and developed AHRF (without ARDS). Primary endpoints: Demographic variables and variables associated with the number of days with IMV and at the ICU were documented, as well as the initial setting of the respirator, monitoring variables and evolution at discharge. Likewise, the number and type of complications developed during the period of IMV were documented. Results: 70.7% of admissions were for medical reasons. SAPS II score was 42. The period of IMV and at the ICU was higher in patients with delirium (p<0.0001 in both). In the logistic regression model adjusted by the severity of hypoxemia, age (OR 1.02; 95% CI 1.002-1.04: p = 0.033) and shock (OR 2.37; 95% CI 1.12-5: p = 0.023) acted as independent predictors of mortality. Conclusions: In this group of patients who required IMV for over 24 hours and who developed AHRF (without ARDS) there was a demographic distribution similar to that described in other reports. Mortality was not associated with the severity of hypoxemia, whereas shock and age were independent predictors of mortality.

/pdf/mechanical-ventilation-in-patients-with-acute-hypoxemic-54g0376pm5.pdf

Mechanical ventilation in patients with acute hypoxemic respiratory failure

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Obstetric Disorders in the ICU.

Mechanical ventilation in patients with acute hypoxemic respiratory failure