Comparison of four diagnostic criteria for invasive pulmonary aspergillosis-A diagnostic accuracy study in critically ill patients.

BACKGROUND: In the absence of lung biopsy, there are various algorithms for the diagnosis of invasive pulmonary aspergillosis (IPA) in critically ill patients that rely on clinical signs, underlying conditions, radiological features and mycology. The aim of the present study was to compare four diagnostic algorithms in their ability to differentiate between probable IPA (i.e., requiring treatment) and colonisation. METHODS: For this diagnostic accuracy study, we included a mixed ICU population with a positive Aspergillus culture from respiratory secretions and applied four different diagnostic algorithms to them. We compared agreement among the four algorithms. In a subgroup of patients with lung tissue histopathology available, we determined the sensitivity and specificity of the single algorithms. RESULTS: A total number of 684 critically ill patients (69% medical/31% surgical) were included between 2005 and 2020. Overall, 79% (n = 543) of patients fulfilled the criteria for probable IPA according to at least one diagnostic algorithm. Only 4% of patients (n = 29) fulfilled the criteria for probable IPA according to all four algorithms. Agreement among the four diagnostic criteria was low (Cohen's kappa 0.07-0.29). From 85 patients with histopathological examination of lung tissue, 40% (n = 34) had confirmed IPA. The new EORTC/MSGERC ICU working group criteria had high specificity (0.59 [0.41-0.75]) and sensitivity (0.73 [0.59-0.85]). CONCLUSIONS: In a cohort of mixed ICU patients, the agreement among four algorithms for the diagnosis of IPA was low. Although improved by the latest diagnostic criteria, the discrimination of invasive fungal infection from Aspergillus colonisation in critically ill patients remains challenging and requires further optimization.

Do we foresee new emerging drugs to treat malignant hyperthermia?

Malignant hyperthermia (MH) is a life-threatening genetic sensitivity of skeletal muscles to volatile anesthetics and depolarizing neuromuscular blocking drugs occurring during or after anesthesia. Mortality of MH has been significantly reduced by using the skeletal muscle relaxant dantrolene. However, pharmacological disadvantages are known. By approval of a nanocrystalline dantrolene sodium suspension (DSS), a new product enters the market. DSS is a promising substance, but clinical data are lacking up to now. Especially with regard to newer knowledge on MH and its associated clinical presentations, there might be an increasing interest on DSS.

The influence of prone positioning on the accuracy of calibrated and uncalibrated pulse contour-derived cardiac index measurements.

BACKGROUND: Patients with lung failure who undergo prone positioning often receive extended hemodynamic monitoring. We investigated the influence of modified prone positioning (135°) on the accuracy of pulse contour-derived calibrated cardiac index (CIPC) and uncalibrated cardiac index (CIVIG) in this patient population with transpulmonary thermodilution (TPTD) as reference technique. METHODS: We studied 16 critically ill and mechanically ventilated patients (11 men, 5 women, aged 20-71 years) with acute lung injury or acute respiratory distress syndrome. Patients were monitored by TPTD with an integrated calibrated pulse contour technique (PiCCO®) and by uncalibrated pulse contour analysis (FloTrac/Vigileo™). Before prone positioning, cardiac index (given in L·min(-1)·m(-2)) was measured by TPTD (CITPTD) and CIPC was calibrated. After positioning, CIPC and CIVIG were read from the monitor and CITPTD was measured. After 8 to 10 hours, prone positioning was completed and measurements were performed analogously. Bland-Altman analysis based on a random-effects model was used to calculate limits of agreement (LOA) and percentage errors. Polar plots were used for trend analysis. RESULTS: Supine CITPTD was 3.3 ± 0.9 (mean ± SD) and CIVIG was 3.1 ± 0.8. After proning, CIPC was 3.5 ± 0.8, CIVIG 3.3 ± 0.8, and CITPTD 3.6 ± 0.8. Before repositioning, CITPTD was 3.5 ± 0.7 and CIVIG 3.3 ± 1.0. After repositioning, CITPTD was 3.1 ± 0.7, CIPC 3.3 ± 0.7, and CIVIG 2.9 ± 0.6. Mean bias pooled for proning and repositioning was -0.1 (LOA -0.7 to 0.6) for CIPC (percentage error 19%) and 0.3 (LOA -1.3 to 1.9) for CIVIG (percentage error 48%). Changes in CI were too small for trending analysis. CONCLUSION: Although calibrated CI measurements are only marginally influenced by prone positioning, according to the criteria of Critchley and Critchley, uncalibrated CI values show a degree of error, too high to be considered clinically acceptable.

High estradiol and low testosterone levels are associated with critical illness in male but not in female COVID-19 patients: a retrospective cohort study.

Male sex was repeatedly identified as a risk factor for death and intensive care admission. However, it is yet unclear whether sex hormones are associated with disease severity in COVID-19 patients. In this study, we analysed sex hormone levels (estradiol and testosterone) of male and female COVID-19 patients (n = 50) admitted to an intensive care unit (ICU) in comparison to control non-COVID-19 patients at the ICU (n = 42), non-COVID-19 patients with the most prevalent comorbidity (coronary heart diseases) present within the COVID-19 cohort (n = 39) and healthy individuals (n = 50). We detected significantly elevated estradiol levels in critically ill male COVID-19 patients compared to all control cohorts. Testosterone levels were significantly reduced in critically ill male COVID-19 patients compared to control cohorts. No statistically significant differences in sex hormone levels were detected in critically ill female COVID-19 patients, albeit similar trends towards elevated estradiol levels were observed. Linear regression analysis revealed that among a broad range of cytokines and chemokines analysed, IFN-γ levels are positively associated with estradiol levels in male and female COVID-19 patients. Furthermore, male COVID-19 patients with elevated estradiol levels were more likely to receive ECMO treatment. Thus, we herein identified that disturbance of sex hormone metabolism might present a hallmark in critically ill male COVID-19 patients.

Computed tomography for the identification of a potential infectious source in critically ill surgical patients.

INTRODUCTION: Computed tomography (CT) seems already to have an important role to identify an infectious source in the management of patients with sepsis. However, our daily clinical behavior in ordering CT imaging was never scrutinized. METHODS: We conducted a retrospective single-center analysis of CT and its therapeutic consequences in an operative intensive care unit in a tertiary care hospital in Germany. All CTs of the abdomen and/or thorax between 1st January and 31st December 2012 were included. One hundred forty-four CT studies were enrolled: 60.4% visceral, 6.9% vascular, 17.4% thoracic, and 14.6% trauma surgical cases and in 0.7% other disciplines. RESULTS: In 76 CT studies (52.8%), a source of infection was found and was associated with a change in treatment in 65 (85.5%) cases. In contrast, in patients without identification of an infectious source in the CT imaging, treatment was changed after CT imaging in 11 (16.2%) cases. Computed tomography provided positive findings predominantly in the organ or the region of the surgical field. CONCLUSIONS: Computed tomographic imaging detected an infectious source in more than 50% of cases. Our data suggest that CT should be recommended to identify a source of infection in critically ill patients. Furthermore, prospective studies are needed to investigate the potential impact of CT imaging on outcome and to define criteria when to perform a CT imaging study.

The effectiveness of an intensive care quick reference checklist manual--a randomized simulation-based trial.

PURPOSE: We aimed to test the effectiveness of checklists for emergency procedures on medical staff performance in intensive care crises. MATERIALS AND METHODS: This is a prospective single-center randomized trial in a high-fidelity simulation center modeling an intensive care unit (ICU) in a tertiary care hospital in Germany. Teams consisted of 1 ICU resident and 2 ICU nurses (in total, n = 48). All completed 4 crisis scenarios, in which they were randomized to use checklists or to perform without any aid. In 2 of the scenarios, checklists could be used immediately (type 1 scenarios); and for the remaining, some further steps, for example, confirming diagnosis, were required first (type 2 scenarios). Outcome measurements were number of predefined items and time to completion of more than 50% and more than 75% of steps, respectively. RESULTS: When using checklists, participants initiated items faster and more completely according to appropriate treatment guidelines (9 vs 7 items with and without checklists, P < .05). Benefit of checklists was better in type 2 scenarios than in type 1 scenarios (2 vs 1 additional item, P < .05). In type 2 scenarios, time to complete 50% and 75% of items was faster with the use of checklists (P < .005). CONCLUSIONS: Use of checklists in ICU crises has a benefit on the completion of critical treatment steps. Within the type 2 scenarios, items were fulfilled faster with checklists. The implementation of checklists for intensive care crises is a promising approach that may improve patients' care.