Three-dimensional critical care transesophageal echocardiography: A bedside tool in the diagnosis and management of shock.

Critical care echocardiography has become fundamental in diagnosis, management, and monitoring of patients in shock. Transesophageal echocardiography has gained importance, particularly in critically ill patients under mechanical ventilation. We describe echocardiographic findings concerning a patient admitted with confusion, pulmonary edema, hypotension, and systolic murmur at apex.

COVID-19 pandemic: overview of protective-ventilation strategy in ARDS patients.

Objectives: In the context of COVID-19 pandemic, the aim of this manuscript is to provide a standard of care of patients with ARDS for non-emergency medicine trained physicians who are not customary with mechanical ventilation.Methods: We conducted a systematic review of the literature to investigate the best practice recommendations regarding the mechanical ventilation of patients with ARDS.Conclusion: We summarized the principal strategies for lung-protective ventilation of patients with ARDS. This focus is particularly addressed to physicians who are not experienced in the invasive respiratory management of ARDS patients. Nevertheless, it remains fundamental to acknowledge that new insights concerning this quickly spreading illness become available on a regular base.

Leptospirosis-induced purpura: An atypical manifestation of Weil's disease.

Purpura is a rare but documented presenting feature of severe leptospirosis. We describe a case of Weil's disease characterized by predominating coagulopathy and hepato-nephritis. We illustrate dynamic changes in cutaneous lesions.

Endomyocardial and pericardial aspergillosis in critically ill patients.

Invasive aspergillosis(IA) is a potentially lethal complication of Aspergillus infection affecting mainly immunocompromised hosts; however, during the last two decades its incidence was increasingly observed in critically ill immunocompetent patients. The objective of this study is to describe the clinical characteristics of histologically proven endomyocardial and pericardial invasion, in the context of IA, in critically ill patients. Eight critically ill patients with histopathological confirmation of endomyocardial/pericardial aspergillosis were evaluated. Risk factors, clinical and laboratory characteristics, treatment, histopathological characteristics and mortality were recorded. Signs and symptoms of cardiac dysfunction were not observed in any of the patients. Therapy was administered to six of them shortly after the first positive culture. The observed histopathological lesions included haemorrhagic lesions, small vessels with central thrombosis and surrounding consolidated tissue with necrosis. Voriconazole, caspofungin, lipid amphotericin B and itraconazole were the used antifungals. The mortality rate was high (87.5%). Endomyocardial and pericardial aspergillosis are devastating complications of invasive aspergillosis. Clinical suspicion is low making the diagnosis difficult, therefore histopathological examination of tissues are required. The mortality is high.

Patterns of antimicrobial therapy in severe nosocomial infections: empiric choices, proportion of appropriate therapy, and adaptation rates--a multicentre, observational survey in critically ill patients.

This prospective, observational multicentre (n=24) study investigated relationships between antimicrobial choices and rates of empiric appropriate or adequate therapy, and subsequent adaptation of therapy in 171 ICU patients with severe nosocomial infections. Appropriate antibiotic therapy was defined as in vitro susceptibility of the causative pathogen and clinical response to the agent administered. In non-microbiologically documented infections, therapy was considered adequate in the case of favourable clinical response <5 days. Patients had pneumonia (n=127; 66 ventilator-associated), intra-abdominal infection (n=23), and bloodstream infection (n=21). Predominant pathogens were Pseudomonas aeruginosa (n=29) Escherichia coli (n=26), Staphylococcus aureus (n=22), and Enterobacter aerogenes (n=21). In 49.6% of infections multidrug-resistant (MDR) bacteria were involved, mostly extended-spectrum beta-lactamase (EBSL)-producing Enterobacteriaceae and MDR non-fermenting Gram-negative bacteria. Prior antibiotic exposure and hospitalisation in a general ward prior to ICU admission were risk factors for MDR. Empiric therapy was appropriate/adequate in 63.7% of cases. Empiric schemes were classified according to coverage of (i) ESBL-producing Enterobacteriaceae and non-fermenting Gram-negative bacteria ("meropenem-based"), (ii) non-fermenting Gram-negative bacteria (schemes with an antipseudomonal agent), and (iii) first-line agents not covering ESBL-Enterobacteriaceae nor non-fermenting Gram-negative bacteria. Meropenem-based schemes allowed for significantly higher rates of appropriate/adequate therapy (p<0.001). This benefit remained when only patients without risk factors for MDR were considered (p=0.021). In 106 patients (61%) empiric therapy was modified: in 60 cases following initial inappropriate/inadequate therapy, in 46 patients in order to refine empiric therapy. In this study reflecting real-life practice, first-line use of meropenem provided significantly higher rates of the appropriate/adequate therapy, irrespective of presence of risk factors for MDR.