To develop management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along 5 levels to create recommendation grades from A–E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management. Participants included 44 critical care and infectious disease experts representing 11 international organizations. A total of 46 recommendations plus pediatric management considerations. Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that will hopefully translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually, and even more rapidly when some important new knowledge becomes available.

/pdf/surviving-sepsis-campaign-guidelines-for-management-of-2my3xcb472.pdf

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV). In contrast to infections of more frequently involved organs (e.g., urinary tract and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. The predominant organisms responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae, but etiologic agents widely differ according to the population of patients in an intensive care unit, duration of hospital stay, and prior antimicrobial therapy. Because appropriate antimicrobial treatment of patients with VAP significantly improves outcome, more rapid identification of infected patients and accurate selection of antimicrobial agents represent important clinical goals. Our personal bias is that using bronchoscopic techniques to obtain protected brush and bronchoalveolar lavage specimens from the affected area in the lung permits physicians to devise a therapeutic strategy that is superior to one based only on clinical evaluation. When fiberoptic bronchoscopy is not available to physicians treating patients clinically suspected of having VAP, we recommend using either a simplified nonbronchoscopic diagnostic procedure or following a strategy in which decisions regarding antibiotic therapy are based on a clinical score constructed from seven variables. Selection of the initial antimicrobial therapy should be based on predominant flora responsible for VAP at each institution, clinical setting, information provided by direct examination of pulmonary secretions, and intrinsic antibacterial activities of antimicrobial agents and their pharmacokinetic characteristics. Further trials will be needed to clarify the optimal duration of treatment and the circumstances in which monotherapy can be safely used.

Ventilator-associated pneumonia.

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice—Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Sixth Special Issue

Background: Understanding the risk factors for ventilator-associated pneumonia can help to assess prognosis and devise and test preventive strategies Objective: To examine the baseline and time-de

Incidence of and Risk Factors for Ventilator-Associated Pneumonia in Critically Ill Patients

http://wickup.weebly.com/uploads/1/0/3/6/10368008/critical_care_1_ali_and_ards_lancet_2007.pdf

Acute lung injury and the acute respiratory distress syndrome: a clinical review

The purpose of this study was to characterize changes in oxygenation, expressed as Pa02/F'02, when patients with ,severe acute respiratory failure (Pa02/FI02 < 150), unrelated to left ventricular failure to atelectasis, were turned to and from a supine to prone position at 1- and 4-h intervals. Ventilator settings were unchanged. Thirty-two consecutive patients were studied 1 h before, 1 and 4 h during and 1 h after placing in a prone position with Pa02/F102 of 103 ± 28, 158 ± 62, 159 ± 59, and 128 ± 52, respectively (ANOVA, p < 0.001). After 1 h in a prone position, improvement of Pa02/Flo2 by 20 mm Hg or more was considered a positive response. Seven patients studied had no response (22%), hereafter referred to as nonresponders, and 25 had a positive response (78%), hereafter referred to as responders. Among the seven nonresponders, two did not tolerate the prone position and were returned supine before the end of the 4-h trial. With the remaining five, Pa02/F102 evolution was 83 ± 29, 77 ± 19, 83 ± 33, and 81 ± 47, respectively. For two of the 25 responders, measurements are missing after returning to the supine position. In 10 of the 23 responders (43%) who completed the 4 h prone trial, the Pa02/F102 returned to its starting value when patients were repositioned supine: 117 ± 24, 164 ± 44, 156 ± 55, and 110 ± 34, respectively (ANOVA, p < 0.01). In 13 of the 23 (57%) improvement persisted: 105 ± 27, 187 ± 58, 189 ± 49, and 157 ± 49, respectively (ANOVA, p < 0.001). Repeated improvements after turning to a prone position were frequently observed. Side effects in the 32 patients after a total of 294 periods in a prone position included minor skin injury and edema, two instances of apical atelectasis, one catheter removal, one catheter compression, one extubation, and one transient supraventricular tachycardia. C"atte G, Sab J-M, DuBois J-M, Sirodot M, Gaussor­ gues P, Robert D. Prone position in mechanically ventilated patients with severe acute respira­ tory failure. AM J RESPIR CRIT CARl MED 1997;155:47)-478. The purpose of this study was to determine the effect of the prone position in a large consecutive series of 32 patients presenting severe acute respiratory failure characterized by Pa02/PI02~ 150 and to determine the persistence and recurrence of any positive effect. Patients with acute respiratory failure characterized by rapid impairment of oxygenation unrelated to left ventricular failure or atelectasis require mechanical ventilation with high lev­ els of the fractional concentration of inspired oxygen (PIo2) and positive end-expiratory pressure (PEEP) to maintain adequate oxygenation. These ventilator settings may themselves be toxic and dangerous; therefore, any intervention that allows reduction of the PIo2 and/or PEEP may be beneficial. Previous studies have demonstrated that patients with adult respiratory distress syn­ drome (ARDS) have lung condensations that are preferentially located in the dorsal regions (1). Several smaller studies have reported in selected cases that turning patients with ARDS to a prone position might substantially improve oxygenation (2-6). Our results show that use of the prone position is frequently help­ ful in clinical practice.

Prone position in mechanically ventilated patients with severe acute respiratory failure.

Nosocomial maxillary sinusitis during mechanical ventilation may cause life-threatening complications in ICU patients. The aim of this prospective study was to compare the incidence of maxillary sinusitis according to the route of intubation. 111 consecutive adult patients (mean age: 53, mean SAPS: 12) were randomly assigned to receive either orotracheal (n=53) or nasotracheal (n=58) intubation. All had a nasogastric feeding tube. Patients with head trauma or mechanical ventilation for less than 48h were excluded. Sinusitis diagnosis was made by radiography (waters' view) at the bedside. The two groups were similar in age, SAPS, duration of ventilation. Maxillary sinusitis occurred in 1/53 (1.8%) of the orotracheal group (on the nasogastric tube side), and in 25/58 (43.1%) of the nasotracheal group (7 on the nasogastric tube side, 11 on the endotracheal tube side, 7 bilateral;p<0.001). Nine of the 26 cases of sinusitis were initially treated by sinus drainage because of signs of infection (3 failures) and the 17 others were treated by tube removal. This procedure proved successful in 12 out of 17 cases but secondary drainage was performed in 5 cases (1 failure). Incidents related to the route for long-term intubation were significantly (p<0.001) more frequent in the orotracheal group (8/53 vs 2/58), however no patient died because of them. In this study, long-term orotracheal intubation reduced significantly the incidence of maxillary sinusitis in comparison with nasotracheal intubation.

Nosocomial maxillary sinusitis during mechanical ventilation : a prospective comparison of orotracheal versus the nasotracheal route for intubation

Efficacité de la décontamination digestive sur la survenue des bactériémies nosocomiales chez les patients sous ventilation mécanique et recevant des bêtamimétiques

Long-term parenteral nutrition hepatic-related impairment is commonly reported and diversely explained. However, with a low cyclic caloric intake (100% to 130% of basal metabolism calculated with the Harris-Benedict formula) consisting of two-thirds glucose, one-third lipid, and 0.20 to 0.25 g of nitrogen per kilogram per day, these complications were infrequent in a clinical practice of home long-term parenteral nutrition. Retrospectively, it was noticed that the switch from Intralipid 20% to Ivelip 20% at the same amount was followed within 2 months by four cases of jaundice in a population of four home long-term parenteral nutrition patients with short bowel disease. Hepatic disturbances were characterized by cytolysis and cholestasis and were reversible after switching from Ivelip 20% back to Intralipid 20%. Neither viral, nor biliary, nor septic etiologies were detected. The exact pathological mechanism remains unknown. The basal composition of both lipid emulsions seems to be identical: soy oil emulsion emulsified by egg phospholipids. However, some differences exist such as the size of particles, the presence of sodium oleate in Ivelip 20%, and the purification process of lecithin. These may explain the difference in hepatic tolerance during long-term parenteral nutrition.

Hepatic Cytolytic and Cholestatic Changes Related to a Change of Lipid Emulsions in Four Long-Term Parenteral Nutrition Patients With Short Bowel

La ventilation par masque facial dans le traitement des poussees d'insuffisance respiratoire chronique est utilisable de longue date mais elle ne connait un developpement que recemment depuis 1987

Ventilation mécanique au masque dans les poussées d'insuffisance respiratoire chronique

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