Intermittent subglottic secretion drainage and ventilator-associated pneumonia: a multicenter trial.

RATIONALE: Ventilator-associated pneumonia (VAP) causes substantial morbidity and mortality. The influence of subglottic secretion drainage (SSD) in preventing VAP remains controversial. OBJECTIVES: To determine whether SSD reduces the overall incidence of microbiologically confirmed VAP. METHODS: Randomized controlled clinical trial conducted at four French centers. A total of 333 adult patients intubated with a tracheal tube allowing drainage of subglottic secretions and expected to require mechanical ventilation for ≥48 hours was included. Patients were randomly assigned to undergo intermittent SSD (n = 169) or not (n = 164). MEASUREMENTS AND MAIN RESULTS: Primary outcome was the overall incidence of VAP based on quantitative culture of distal pulmonary samplings performed after each clinical suspicion. Other outcomes included incidence of early- and late-onset VAP, duration of mechanical ventilation, and hospital mortality. Microbiologically confirmed VAP occurred in 67 patients, 25 of 169 (14.8%) in the SSD group and 42 of 164 (25.6%) in the control group (P = 0.02), yielding a relative risk reduction of 42.2% (95% confidential interval, 10.4-63.1%). Using the Day 5 threshold, the beneficial effect of SSD in reducing VAP was observed in both early-onset VAP (2 of 169 [1.2%] patients undergoing SSD vs. 10 of 164 [6.1%] control patients; P = 0.02) and late-onset VAP (23 of 126 [18.6%] patients undergoing SSD vs. 32 of 97 [33.0%] control patients; P = 0.01). VAP was clinically suspected at least once in 51 of 169 (30.2%) patients undergoing SSD and 60 of 164 (36.6%) control patients (P = 0.25). No significant between-group differences were observed in duration of mechanical ventilation and hospital mortality. CONCLUSIONS: Subglottic secretion drainage during mechanical ventilation results in a significant reduction in VAP, including late-onset VAP. Clinical trial registered with www.clinicaltrials.gov (NCT00219661).

Frequency and clinical impact of preserved bispectral index activity during deep sedation in mechanically ventilated ICU patients.

OBJECTIVE: Despite an overall correlation between the bispectral index of the EEG (BIS) and clinical sedation assessment, unexpectedly high BIS values can be observed at deep sedation levels. We assessed the frequency, interindividual variability and clinical impact of high BIS values during clinically deep sedation. DESIGN AND SETTING: Prospective observational study in two university-affiliated intensive care units. PATIENTS: Sixty-two mechanically ventilated patients requiring intravenous sedation and analgesia for >or=24 h. MEASUREMENTS AND MAIN RESULTS: Paired measurements of BIS and sedation measured on the adaptation to intensive care environment (ATICE) score were obtained every 3 h until awakening. A paired measurement with BIS >60 at deep sedation (ATICE Awakeness

Failure to achieve glycemic control despite intensive insulin therapy in a medical ICU: incidence and influence on ICU mortality.

OBJECTIVE: Intensive insulin therapy reduces mortality in subgroups of intensive care unit (ICU) patients, and awareness of the importance of blood glucose level (BGL) control has increased among ICU physicians and nurses. The impact of insulin treatment strategies on mortality may be influenced by their efficacy in achieving the target BGL range. We assessed the efficacy of an insulin treatment strategy in maintaining BGL within the target range, and we compared ICU mortality in patients who did and did not reach the BGL target. DESIGN: Prospective cohort study. SETTING: 12-bed medical ICU in a tertiary teaching hospital. PATIENTS AND PARTICIPANTS: Adults consecutively admitted over a 9-month period to an ICU where standard care included an insulin treatment strategy aimed at maintaining BGL7 mmol/l after initial hyperglycemia correction) occurred in 32 patients (31.1%) and was associated with a significant increase in ICU mortality (56.2 vs. 23.3% in patients with successful BGL control). In the multivariate analysis, failure to control BGL independently predicted death in the ICU (OR 5.9, 2.1-16.6, p<0.001). CONCLUSIONS: Failure to control BGL despite intensive insulin therapy was common and independently associated with ICU mortality. Failure to control BGL may considerably affect the overall impact of insulin treatment strategies on mortality.

[Arousal disorders]. / Troubles graves de la vigilance.

Altered states of consciousness are a common reason for visits to the emergency room and admission to intensive care unit. Management of unconscious patient can be difficult because the potential causes of an altered mental status are considerable and the time for diagnosis and effective intervention is short. First, the patient must airway, breathing, and circulation protected. It is important to obtain carefully taken history from eyewitnesses and to perform a general complete examination particularly neurologic focusing on pupillary responses, eye movements, and motor responses. Technical investigations like CT-scan and laboratory tests should make part of a careful diagnostic plan. The prognosis for recovery depends greatly on the underlying etiology as well as its optimal treatment, which seeks to preserve neurologic function and maximize the potential for recovery by reversing the primary cause of brain injury, if known, and preventing secondary brain injury from anoxia, ischemia, hypoglycemia, cerebral edema, and electrolyte disturbances.

Early embolization and vasopressor administration for management of life-threatening hemorrhage from pelvic fracture.

BACKGROUND: In this retrospective study, we reviewed our protocol for management of hemodynamically unstable patients with pelvic injury. METHODS: We managed the patients with the same predetermined plan including controlled hemodynamic resuscitation with early use of vasopressors and pelvic angiography as a first-line treatment. RESULTS: Of 311 patients with pelvic fracture, 32 hemodynamically unstable patients (10.3%) underwent pelvic angiography, which was followed by embolization in 25 cases. Angiography was successful for 24 patients (96%) and extrapelvic bleeding was diagnosed in 5 patients (15%). Three of six laparotomies performed before angiography were nontherapeutic. One of seven laparotomies performed after angiography was negative. CONCLUSION: A protocol for management of patients with pelvic injury and hemodynamic instability that is associated with controlled resuscitation including vasopressor and early pelvic angioembolization is effective for treating pelvic hemorrhage and diagnosing extrapelvic hemorrhage. Further studies are needed to confirm the respective place of angiographic and surgical control of bleeding.

Sedation algorithm in critically ill patients without acute brain injury.

OBJECTIVE: To determine whether use of a sedation algorithm to promote a high level of tolerance to the intensive care environment and preserve consciousness affected time to arousal and duration of mechanical ventilation in patients without acute brain injury. DESIGN: Two-phase, prospective, controlled study. SETTING: University-affiliated medical intensive care unit. PATIENTS: : Patients without acute brain injury requiring mechanical ventilation for at least 24 hrs. INTERVENTIONS: During the control phase, sedatives and analgesics were adjusted according to the physician's decision. During the algorithm phase, sedatives and analgesics were adjusted according to an algorithm developed by a multidisciplinary team including nurses and physicians. The algorithm was based on regular assessments of consciousness and tolerance to the intensive care unit environment using the Adaptation to Intensive Care Environment instrument and was designed to achieve tolerance and maintain a high level of consciousness. Standard practices, including weaning from the ventilator, were the same during both study phases. MEASUREMENTS AND MAIN RESULTS: A total of 102 patients were enrolled (control group, n = 54; algorithm group, n = 48). Median duration of mechanical ventilation was significantly shorter in the algorithm group (4.4 days [interquartile range, 2.1-9.8]) compared with the control group (10.3 days [3.5-17.2], p = .014), representing a 57.3% reduction. In Cox multivariate analysis, the risk of remaining on mechanical ventilation was 0.48 times (95% confidence interval, 0.29-0.78) lower for algorithm patients compared with controls. The median time to arousal was also significantly shorter in patients in the algorithm group (2 days [2-5]) compared with the control group (4 days [2-9], p = .006). CONCLUSIONS: The use of a sedation algorithm to promote tolerance to the intensive care environment and preserve consciousness in patients without acute brain injury resulted in a marked decrease in the duration of mechanical ventilation. This reduction was at least partly attributable to a shorter time to arousal after initiation of mechanical ventilation.