RESUMEN
BACKGROUND: Extracorporeal carbon dioxide removal (ECCO2R) is a promising technique for the management of acute respiratory failure, but with a limited level of evidence to support its use outside clinical trials and/or data collection initiatives. We report a collaborative initiative in a large metropolis. METHODS: To assess on a structural basis the rate of utilization as well as efficacy and safety parameters of 2 ECCO2R devices in 10 intensive care units (ICU) during a 2-year period. RESULTS: Seventy patients were recruited in 10 voluntary and specifically trained centers. The median utilization rate was 0.19 patient/month/center (min 0.04; max 1.20). ECCO2R was started under invasive mechanical ventilation (IMV) in 59 patients and non-invasive ventilation in 11 patients. The Hemolung Respiratory Assist System (Alung) was used in 53 patients and the iLA Activve iLA kit (Xenios Novalung) in 17 patients. Main indications were ultraprotective ventilation for ARDS patients (n = 24), shortening the duration of IMV in COPD patients (n = 21), preventing intubation in COPD patients (n = 9), and controlling hypercapnia and dynamic hyperinflation in mechanically ventilated patients with severe acute asthma (n = 6). A reduction in median V T was observed in ARDS patients from 5.9 to 4.1 ml/kg (p <0.001). A reduction in PaCO2 values was observed in AE-COPD patients from 67.5 to 51 mmHg (p< 0.001). Median duration of ECCO2R was 5 days (IQR 3-8). Reasons for ECCO2R discontinuation were improvement (n = 33), ECCO2R-related complications (n = 18), limitation of life-sustaining therapies or measures decision (n = 10), and death (n = 9). Main adverse events were hemolysis (n = 21), bleeding (n = 17), and lung membrane clotting (n = 11), with different profiles between the devices. Thirty-five deaths occurred during the ICU stay, 3 of which being ECCO2R-related. CONCLUSIONS: Based on a registry, we report a low rate of ECCO2R device utilization, mainly in severe COPD and ARDS patients. Physiological efficacy was confirmed in these two populations. We confirmed safety concerns such as hemolysis, bleeding, and thrombosis, with different profiles between the devices. Such results could help to design future studies aiming to enhance safety, to demonstrate a still-lacking strong clinical benefit of ECCO2R, and to guide the choice between different devices. TRIAL REGISTRATION: ClinicalTrials.gov: Identifier: NCT02965079 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT02965079.
RESUMEN
In head and neck cancer surgery antibiotic prophylaxis is effective in reducing the incidence of surgical site infections (SSI). However, controversies between antibiotic prophylaxis and curative antibiotic therapy exist, particularly when complex and decaying surgeries are performed in risky underlying conditions, with a risk of persisting salivary effusion in the postoperative period, or in the case of reconstruction with myo-cutaneous flaps. We have performed a systematic review of the literature according to PRISMA recommendations to answer the following questions: indications for antibiotic prophylaxis and curative antibiotic therapy, optimal duration, and choice of antibiotics for prophylaxis in head and neck cancer surgery. Literature analysis allows to conclude that patients undergoing Altemeier classes 2 and 3 surgical procedures should receive perioperative antibiotic prophylaxis restricted to the first 24 postoperative hours. No benefit has been shown with its extension beyond these 24 hours. The most adapted combinations of antibiotics in this setting are "amoxicillin+clavulanic acid" and "clindamycin+gentamicin". However, the level of evidence regarding the most decaying surgeries with high risk of SSI is low, making it necessary to perform new high-powered randomized trials in these patients. Eventually, it should be noted that antibiotic prophylaxis should be an integral part of SSI preventive measures, including application of hygiene measures, and postoperative monitoring of SSI clinical signs.