Implementing a bedside assessment of respiratory mechanics in patients with acute respiratory distress syndrome.

BACKGROUND: Despite their potential interest for clinical management, measurements of respiratory mechanics in patients with acute respiratory distress syndrome (ARDS) are seldom performed in routine practice. We introduced a systematic assessment of respiratory mechanics in our clinical practice. After the first year of clinical use, we retrospectively assessed whether these measurements had any influence on clinical management and physiological parameters associated with clinical outcomes by comparing their value before and after performing the test. METHODS: The respiratory mechanics assessment constituted a set of bedside measurements to determine passive lung and chest wall mechanics, response to positive end-expiratory pressure, and alveolar derecruitment. It was obtained early after ARDS diagnosis. The results were provided to the clinical team to be used at their own discretion. We compared ventilator settings and physiological variables before and after the test. The physiological endpoints were oxygenation index, dead space, and plateau and driving pressures. RESULTS: Sixty-one consecutive patients with ARDS were enrolled. Esophageal pressure was measured in 53 patients (86.9%). In 41 patients (67.2%), ventilator settings were changed after the measurements, often by reducing positive end-expiratory pressure or by switching pressure-targeted mode to volume-targeted mode. Following changes, the oxygenation index, airway plateau, and driving pressures were significantly improved, whereas the dead-space fraction remained unchanged. The oxygenation index continued to improve in the next 48 h. CONCLUSIONS: Implementing a systematic respiratory mechanics test leads to frequent individual adaptations of ventilator settings and allows improvement in oxygenation indexes and reduction of the risk of overdistention at the same time. TRIAL REGISTRATION: The present study involves data from our ongoing registry for respiratory mechanics (ClinicalTrials.gov identifier: NCT02623192 . Registered 30 July 2015).

Antibiotic treatment duration for bloodstream infections in critically ill patients: a national survey of Canadian infectious diseases and critical care specialists.

An optimum duration of antibiotic therapy would eradicate infection whilst minimising adverse drug reactions, resistance and costs. However, there is a paucity of evidence guiding the duration of therapy for bloodstream infections. Canadian infectious diseases (ID) and critical care specialists were surveyed regarding their recommended antibiotic treatment durations for five common bacteraemic syndromes. A descriptive analysis was performed to assess: (i) practice heterogeneity; (ii) equipoise for a trial of shorter versus longer therapy; and (iii) the influence of pathogen and host characteristics on recommendations. In total, 172 clinicians responded to the survey (60% ID, 39% critical care and 1% combined specialists). For each syndrome, the most common recommendation was 14 days, yet the majority of respondents recommended durations of ≤ 10 days. Median durations were similar for each syndrome: central vascular catheter-related bloodstream infection, 10 ± 3.6 days; bacteraemic pneumonia, 10 ± 2.8 days; bacteraemic urinary tract infection, 10 ± 3.8 days; bacteraemic intra-abdominal infection, 10 ± 4.1 days; and bacteraemic skin and soft-tissue infection, 14 ± 3.2 days. Respondents recommended the longest durations for Staphylococcus aureus and the shortest durations for coagulase-negative staphylococci. Most respondents would not modify duration based on host characteristics or measures of clinical response. ID physicians recommended longer durations than critical care physicians for all five syndromes, but the majority of both specialist groups would enrol patients in a trial of shorter (7 day) versus longer (14 day) antibiotic therapy. In conclusion, significant practice variation exists amongst clinicians' recommended durations of antibiotic treatment for bacteraemia. There is equipoise for a randomised trial comparing shorter versus longer courses of antibiotics for most bacteraemic syndromes and pathogens.