Driving pressure during routine ventilation in the ICU: Is the ICU-team as driven as they should be?

PURPOSE: To evaluate the effect of structured staff training on the respiratory support provided. MATERIALS AND METHODS: Staff training with emphasis on the applied DP in mechanical ventilation was provided during one year. After completion of staff training, the effect was prospectively evaluated in patients who were continuously mechanically ventilated in a controlled mode for at least 6 h starting from admission. Pressure difference (Pdiff = Ppeak - PEEPtot) in the baseline period, as a derivative of the driving pressure, was compared with two evaluation periods from 0 to 6 months and 6-12 months (i.e. follow-up) after completion of the training. RESULTS: At analysis 248 patients met the inclusion criteria. In the baseline period Pdiff was not lung protective (> 15 cm H2O) in 39% of cases. In the first follow-up period this decreased to 25% of cases and further dropped to 17% in the second follow-up period. This was a relative decrease of 56% compared to the training period. At the end of evaluation the proportion of patients with a safe Pdiff had gradually increased from 58% during training to 82% (χ2 = p 0.005). CONCLUSIONS: These results suggest that ICU staff training could lead to more adequate respiratory support provided during controlled mechanical ventilation.

Phosphodiesterase 3 inhibitors do not influence lactate kinetics and clinical outcomes in patients with septic shock: A multicentre cohort study.

PURPOSE: We investigated the association between the administration of phosphodiesterase 3 inhibitors (PDE3i) and lactate kinetics, resolution of organ failure, ICU and hospital length of stay (LOS) and hospital mortality in a retrospective cohort of patients with septic shock and persistently elevated lactate concentrations. MATERIAL AND METHODS: Patients with septic shock and two arterial lactate concentrations ≥4 mmol/L with at least 4 h between measurements were eligible. Clinical data of the first four days of admission were collected in an online database. For each patient, the area between the actual lactate concentrations and 2.2 mmol/L (AUClact2.2), was calculated for three days. RESULTS: Data on 229 patients from 10 hospitals were collected, of whom 123 received PDE3i (54%). First, a linear multivariate model was developed to predict AUClact2.2 (R2 = 0.57). Adding PDE3i as a cofactor did not affect R2. Second, 60 patients receiving PDE3i at any time between days 0 and 2 were compared to 60 propensity matched no-PDE3i patients. Third, 30 patients who received PDE3i from ICU admission to day 3 were compared to 30 propensity-matched no-PDE3i patients. These analyses showed no differences in AUClact2.2, SOFA scores, ICU or hospital LOS or hospital mortality between treatment groups. CONCLUSIONS: No association was found between the administration of PDE3i and lactate kinetics, resolution of organ failure, ICU or hospital LOS or hospital mortality.

Incidence, risk factors and pre-emptive screening for COVID-19 associated pulmonary aspergillosis in an era of immunomodulant therapy.

PURPOSE: COVID-19 associated pulmonary aspergillosis (CAPA) is associated with increased morbidity and mortality in ICU patients. We investigated the incidence of, risk factors for and potential benefit of a pre-emptive screening strategy for CAPA in ICUs in the Netherlands/Belgium during immunosuppressive COVID-19 treatment. MATERIALS AND METHODS: A retrospective, observational, multicentre study was performed from September 2020-April 2021 including patients admitted to the ICU who had undergone diagnostics for CAPA. Patients were classified based on 2020 ECMM/ISHAM consensus criteria. RESULTS: CAPA was diagnosed in 295/1977 (14.9%) patients. Corticosteroids were administered to 97.1% of patients and interleukin-6 inhibitors (anti-IL-6) to 23.5%. EORTC/MSGERC host factors or treatment with anti-IL-6 with or without corticosteroids were not risk factors for CAPA. Ninety-day mortality was 65.3% (145/222) in patients with CAPA compared to 53.7% (176/328) without CAPA (p = 0.008). Median time from ICU admission to CAPA diagnosis was 12 days. Pre-emptive screening for CAPA was not associated with earlier diagnosis or reduced mortality compared to a reactive diagnostic strategy. CONCLUSIONS: CAPA is an indicator of a protracted course of a COVID-19 infection. No benefit of pre-emptive screening was observed, but prospective studies comparing pre-defined strategies would be required to confirm this observation.

[Influenza-associated acute necrotizing encephalitis: unknown makes undertreated?] / Influenza-geassocieerde acute necrotiserende encefalitis.

BACKGROUND: Influenza-associated acute necrotizing encephalitis (ANE) is a very rare, but severe complication from influenza infection. CASE DESCRIPTION: We present a 48 year old male who presented with fever, malaise, confusion and altered mental status (E4M5V2) and influenza A infection. He quickly develops convulsions after which he is intubated and admitted to the Intensive Care Unit following which he remains comatose (E1M1V1). The diagnosis of influenza associated acute necrotizing encephalitis is made based on his neurological symptoms, generalized slowing on electro-encephalogram, classic bilateral findings on MRI in the thalamus and basal ganglia and proven influenza infection in the cerebrospinal fluid. CONCLUSION: Acute necrotising encephalitis is a severe complication from a common infection. It is advised to consider early MRI imaging in patients with influenza and fitting neurological symptoms and to consider treatment with corticosteroids.

The 2021 Dutch Working Party on Antibiotic Policy (SWAB) guidelines for empirical antibacterial therapy of sepsis in adults.

BACKGROUND: The Dutch Working Party on Antibiotic Policy (SWAB) in collaboration with relevant professional societies, has updated their evidence-based guidelines on empiric antibacterial therapy of sepsis in adults. METHODS: Our multidisciplinary guideline committee generated ten population, intervention, comparison, and outcome (PICO) questions relevant for adult patients with sepsis. For each question, a literature search was performed to obtain the best available evidence and assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The quality of evidence for clinically relevant outcomes was graded from high to very low. In structured consensus meetings, the committee formulated recommendations as strong or weak. When evidence could not be obtained, recommendations were provided based on expert opinion and experience (good practice statements). RESULTS: Fifty-five recommendations on the antibacterial therapy of sepsis were generated. Recommendations on empiric antibacterial therapy choices were differentiated for sepsis according to the source of infection, the potential causative pathogen and its resistance pattern. One important revision was the distinction between low, increased and high risk of infection with Enterobacterales resistant to third generation cephalosporins (3GRC-E) to guide the choice of empirical therapy. Other new topics included empirical antibacterial therapy in patients with a reported penicillin allergy and the role of pharmacokinetics and pharmacodynamics to guide dosing in sepsis. We also established recommendations on timing and duration of antibacterial treatment. CONCLUSIONS: Our multidisciplinary committee formulated evidence-based recommendations for the empiric antibacterial therapy of adults with sepsis in The Netherlands.

Tailored modulation of the inflammatory balance in COVID-19 patients admitted to the ICU?-a viewpoint.

A growing consensus seems to be emerging that dexamethasone is a crucial component in the treatment of COVID-19-associated oxygen-dependent respiratory failure. Although dexamethasone has an undeniably beneficial effect on the inflammatory response in a subgroup of patients, the potential negative effects of corticosteroids must also be considered. In view of these negative effects, we argue that a one-size-fits-all dexamethasone approach may be potentially harmful in specific subsets of patients with COVID-19-associated ARDS. We propose a different individually tailored treatment strategy based on the patient's inflammatory response.