Tapered-cuff Endotracheal Tube Does Not Prevent Early Postoperative Pneumonia Compared with Spherical-cuff Endotracheal Tube after Major Vascular Surgery: A Randomized Controlled Trial.

BACKGROUND: Patients undergoing major vascular surgery often develop postoperative pneumonia that impacts their outcomes. Conflicting data exist concerning the potential benefit of tapered-shaped cuffs on tracheal sealing. The primary objective of this study was to assess the efficiency of a polyvinyl chloride tapered-cuff endotracheal tube at reducing the postoperative pneumonia rate after major vascular surgery. Secondary objectives were to determine its impact on microaspiration, ventilator-associated pneumonia rate, and inner cuff pressure. METHODS: This prospective randomized controlled study included 109 patients who were randomly assigned to receive either spherical- (standard cuff) or taper-shaped (tapered cuff) endotracheal tubes inserted after anesthesia induction and then admitted to the intensive care unit after major vascular surgery. Cuff pressure was continuously recorded over 5 h. Pepsin and α-amylase concentrations in tracheal aspirates were quantified on postoperative days 1 and 2. The primary outcome was the early postoperative pneumonia frequency. RESULTS: Comparing the tapered-cuff with standard-cuff group, respectively, postoperative pneumonia rates were comparable (42 vs. 44%, P = 0.87) and the percentage (interquartile range) of cuff-pressure time with overinflation was significantly higher (16.1% [1.5 to 50] vs. 0.6% [0 to 8.3], P = 0.01), with a 2.5-fold higher coefficient of variation (20.2 [10.6 to 29.4] vs. 7.6 [6.2 to 10.2], P < 0.001). Although microaspiration frequencies were high, they did not differ between groups. CONCLUSION: For major vascular surgery patients, polyvinyl chloride tapered-cuff endotracheal tubes with intermittent cuff-pressure control did not lower the early postoperative pneumonia frequency and did not prevent microaspiration.

Efficacy of high-dose nebulized colistin in ventilator-associated pneumonia caused by multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii.

BACKGROUND: Colistin often remains the only active agent against multidrug-resistant Gram-negative pathogens. The aim of the study was to assess efficacy of nebulized colistin for treating ventilator-associated pneumonia (VAP) caused by multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii. METHODS: One hundred and sixty-five patients with VAP caused by P. aeruginosa and A. baumannii were enrolled in a prospective, observational, and comparative study. The sensitive strain group included 122 patients with VAP caused by P. aeruginosa and A. baumannii susceptible to ß-lactams, aminoglycosides, or quinolones and treated with intravenous antibiotics for 14 days. The multidrug-resistant strain group included 43 patients with VAP caused by multidrug-resistant P. aeruginosa and A. baumannii and treated with nebulized colistin (5 million international units every 8 h) either in monotherapy (n=28) or combined to a 3-day intravenous aminoglycosides for 7-19 days. The primary endpoint was clinical cure rate. Aerosol was delivered using vibrating plate nebulizer. RESULTS: After treatment, clinical cure rate was 66% in sensitive strain group and 67% in multidrug-resistant strain group (difference -1%, lower limit of 95% CI for difference -12.6%). Mortality was not different between groups (23 vs. 16%). Among 16 patients with persisting or recurrent P. aeruginosa infection, colistin minimum inhibitory concentration increased in two patients. CONCLUSION: Nebulization of high-dose colistin was effective to treat VAP caused by multidrug-resistant P. aeruginosa or A. baumannii. Its therapeutic effect was noninferior to intravenous ß-lactams associated with aminoglycosides or quinolones for treating VAP caused by susceptible P. aeruginosa and A. baumannii.

Clostridium difficile bacteremia: Report of two cases in French hospitals and comprehensive review of the literature.

We report two cases of bacteremia due to Clostridium difficile from two French hospitals. The first patient with previously diagnosed rectal carcinoma underwent courses of chemotherapy, and antimicrobial treatment, and survived the C. difficile bacteremia. The second patient with colon perforation and newly diagnosed lung cancer underwent antimicrobial treatment in an ICU but died shortly after the episode of C. difficile bacteremia. A review of the literature allowed the identification of 137 cases of bacteremia between July 1962 and November 2016. Advanced age, gastro-intestinal disruption, severe underlying diseases and antimicrobial exposure were the major risk factors for C. difficile bacteremia. Antimicrobial therapy was primarily based on metronidazole and/or vancomycin. The crude mortality rate was 35% (21/60).

Aggressive management of nonocclusive ischemic colitis following aortic reconstruction.

HYPOTHESIS: Under standard conditions following aortic reconstruction, nonocclusive ischemic colitis (IC) type 1 (mucosal ischemia) and type 2 (mucosal and muscularis ischemia) can be managed nonoperatively, whereas type 3 (transmural ischemia) requires emergency surgery. Our objective was to standardize the surgical approach for IC complicating aortic reconstruction. DESIGN: Retrospective cohort study. SETTING: General surgery, vascular surgery, anesthesiology, and critical care units in a university-affiliated hospital. METHODS: From January 5, 1997, to December 15, 2003, 49 cases of IC complicating aortic reconstruction were diagnosed (rate, 2.7%). Nonoperative management was used for patients with type 1 or type 2 without multiple organ failure (MOF). All patients with type 3 or with type 2 with MOF underwent urgent resection of the ischemic colon without anastomosis. RESULTS: Immediate surgery was performed on 24 patients (49.0%). Nineteen (76.0%) of 25 patients without MOF and with transient endoscopic findings underwent secondary surgery for progression to final IC type 3 (16 patients) or to final IC type 2 with MOF (3 patients). Twenty-three (53.5%) of 43 patients died after colorectal resection (overall mortality, 46.9%). Factors causing significant risk of death were surgery, MOF, final IC type, and amount of perioperative transfusion. The mortality was 57.1% for final IC type 3, 37.5% for final IC type 2 with MOF, and 0% for final IC type 1 or type 2 without MOF. CONCLUSIONS: Selective management of postoperative IC, based on MOF and the degree of ischemia, is the suggested course of action. For patients with mild ischemia and MOF, an aggressive approach is recommended.