Thenar oxygen saturation (StO2) alterations during a spontaneous breathing trial predict extubation failure.

BACKGROUND: Weaning from mechanical ventilation (MV) is a cardiovascular stress test. Monitoring the regional oxygenation status has shown promising results in predicting the tolerance to spontaneously breathe in the process of weaning from MV. Our aim was to determine whether changes in skeletal muscle oxygen saturation (StO2) measured by near-infrared spectroscopy (NIRS) on the thenar eminence during a vascular occlusion test (VOT) can be used to predict extubation failure from mechanical ventilation. METHODS: We prospectively studied 206 adult patients with acute respiratory failure receiving MV for at least 48 h from a 30-bed mixed ICU, who were deemed ready to wean by their physicians. Patients underwent a 30-min spontaneous breathing trial (SBT), and were extubated according to the local protocol. Continuous StO2 was measured non-invasively on the thenar eminence. A VOT was performed prior to and at 30 min of the SBT (SBT30). The rate of StO2 deoxygenation (DeO2), StO2 reoxygenation (ReO2) rate and StO2 hyperemic response to ischemia (HAUC) were calculated. RESULTS: Thirty-six of the 206 patients (17%) failed their SBT. The remainder 170 patients (83%) were extubated. Twenty-three of these patients (13.5%) needed reinstitution of MV within 24 h. Reintubated patients displayed a lower HAUC at baseline, and higher relative changes in their StO2 deoxygenation rate between baseline and SBT30 (DeO2 Ratio). A logistic regression-derived StO2 score, combining baseline StO2, HAUC and DeO2 ratio, showed an AUC of 0.84 (95% CI 0.74-0.91) for prediction of extubation failure. CONCLUSIONS: Extubation failure was associated to baseline and dynamic StO2 alterations during the SBT. Monitoring StO2-derived parameters might be useful in predicting extubation outcome.

Effect of Postextubation High-Flow Nasal Oxygen With Noninvasive Ventilation vs High-Flow Nasal Oxygen Alone on Reintubation Among Patients at High Risk of Extubation Failure: A Randomized Clinical Trial.

Importance: High-flow nasal oxygen may prevent postextubation respiratory failure in the intensive care unit (ICU). The combination of high-flow nasal oxygen with noninvasive ventilation (NIV) may be an optimal strategy of ventilation to avoid reintubation. Objective: To determine whether high-flow nasal oxygen with prophylactic NIV applied immediately after extubation could reduce the rate of reintubation, compared with high-flow nasal oxygen alone, in patients at high risk of extubation failure in the ICU. Design, Setting, and Participants: Multicenter randomized clinical trial conducted from April 2017 to January 2018 among 641 patients at high risk of extubation failure (ie, older than 65 years or with an underlying cardiac or respiratory disease) at 30 ICUs in France; follow-up was until April 2018. Interventions: Patients were randomly assigned to high-flow nasal oxygen alone (n = 306) or high-flow nasal oxygen alternating with NIV (n = 342) immediately after extubation. Main Outcomes and Measures: The primary outcome was the proportion of patients reintubated at day 7; secondary outcomes included postextubation respiratory failure at day 7, reintubation rates up until ICU discharge, and ICU mortality. Results: Among 648 patients who were randomized (mean [SD] age, 70 [10] years; 219 women [34%]), 641 patients completed the trial. The reintubation rate at day 7 was 11.8% (95% CI, 8.4%-15.2%) (40/339) with high-flow nasal oxygen and NIV and 18.2% (95% CI, 13.9%-22.6%) (55/302) with high-flow nasal oxygen alone (difference, -6.4% [95% CI, -12.0% to -0.9%]; P = .02). Among the 11 prespecified secondary outcomes, 6 showed no significant difference. The proportion of patients with postextubation respiratory failure at day 7 (21% vs 29%; difference, -8.7% [95% CI, -15.2% to -1.8%]; P = .01) and reintubation rates up until ICU discharge (12% vs 20%, difference -7.4% [95% CI, -13.2% to -1.8%]; P = .009) were significantly lower with high-flow nasal oxygen and NIV than with high-flow nasal oxygen alone. ICU mortality rates were not significantly different: 6% with high-flow nasal oxygen and NIV and 9% with high-flow nasal oxygen alone (difference, -2.4% [95% CI, -6.7% to 1.7%]; P = .25). Conclusions and Relevance: In mechanically ventilated patients at high risk of extubation failure, the use of high-flow nasal oxygen with NIV immediately after extubation significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone. Trial Registration: ClinicalTrials.gov Identifier: NCT03121482.

Blood culture differential time to positivity enables safe catheter retention in suspected catheter-related bloodstream infection: a randomized controlled trial

OBJECTIVE: To evaluate the clinical usefulness and safety of the differential-time-to-positivity (DTP) method for managing the suspicion of catheter-related bloodstream infection (CR-BSI) in comparison with a standard method that includes catheter removal in critically ill patients. METHODS-DESIGN: A prospective randomized study was carried out. Setting: A 16-bed clinical-surgical ICU (July 2007-February 2009). Interventions: Patients were randomly assigned to one of two groups at the time CR-BSI was suspected. In the standard group, a standard strategy requiring catheter withdrawal was used to confirm or rule out CR-BSI. In the DTP group, DTP without catheter withdrawal was used to confirm or rule out CR-BSI. Measurements: clinical and microbiological data, CR-BSI rates, unnecessary catheter removals, and complications due to new puncture or to delays in catheter removal. RESULTS: Twenty-six patients were analyzed in each group. In the standard group, 6 of 37 suspected episodes of CR-BSI were confirmed and 5 colonizations were diagnosed. In the DTP group, 5 of 26 suspected episodes of CR-BSI were confirmed and four colonizations were diagnosed. In the standard group, all catheters (58/58, 100%) were removed at the time CR-BSA was suspected, whereas in the DTP group, only 13 catheters (13/41, 32%) were removed at diagnosis, and 10 due to persistent septic signs (10/41, 24%). In cases of confirmed CR-BSI, there were no differences between the two groups in the evolution of inflammatory parameters during the 48hours following the suspicion of CR-BSI. CONCLUSIONS: In critically ill patients with suspected CR-BSI, the DTP method makes it possible to keep the central venous catheter in place safely

OBJETIVO: Evaluar la utilidad clínica y la seguridad de la diferencia del tiempo de positivización (DTP) de hemocultivos en el manejo de la sospecha de bacteriemia asociada a catéter (BAC) comparándola con un método estándar que incluye la retirada de catéter en los pacientes de cuidados intensivos. MÉTODOS-DISEÑO: Estudio prospectivo aleatorizado. ÁMBITO: UCI médico-quirúrgica de 16 camas (julio de 2007-febrero de 2009). Intervención: aleatorización en 2 ramas de los pacientes en el momento de la sospecha de BAC. GRUPO ESTÁNDAR: estrategia clásica que requiere la retirada de catéter para descartar o confirmar la BAC; grupo DTP: método DTP sin retirada de catéter que confirma o descarta la BAC. Variables: datos clínicos y microbiológicos, tasas de BAC, recambios innecesarios de catéteres, complicaciones debidas al recambio de catéter o al retraso en el recambio de catéter. RESULTADOS: Veintiséis pacientes fueron estudiados en cada grupo. En el grupo estándar 6 de los 37 episodios de sospecha de BAC fueron confirmados y 5 colonizaciones de catéter fueron diagnosticadas. En el grupo DTP 5 de los 26 episodios de BAC fueron confirmados y 4 colonizaciones diagnosticadas. En el grupo estándar todos los catéteres (58/58, 100%) se retiraron en el momento de la sospecha de BAC, mientras que en el grupo DTP solo 13 catéteres (13/41, 32%) se retiraron en el momento del diagnóstico y 10 por persistencia de signos inflamatorios (10/41, 24%). En los casos de BAC confirmada no se encontraron diferencias en la evolución de los parámetros inflamatorios en las 48 h que siguieron la sospecha de BAC. CONCLUSIONES: En los pacientes críticos con sospecha de BAC el método DTP permite mantener los catéteres venosos centrales de forma segura

Blood culture differential time to positivity enables safe catheter retention in suspected catheter-related bloodstream infection: a randomized controlled trial.

OBJECTIVE: To evaluate the clinical usefulness and safety of the differential-time-to-positivity (DTP) method for managing the suspicion of catheter-related bloodstream infection (CR-BSI) in comparison with a standard method that includes catheter removal in critically ill patients. METHODS-DESIGN: A prospective randomized study was carried out. SETTING: A 16-bed clinical-surgical ICU (July 2007-February 2009). INTERVENTIONS: Patients were randomly assigned to one of two groups at the time CR-BSI was suspected. In the standard group, a standard strategy requiring catheter withdrawal was used to confirm or rule out CR-BSI. In the DTP group, DTP without catheter withdrawal was used to confirm or rule out CR-BSI. MEASUREMENTS: clinical and microbiological data, CR-BSI rates, unnecessary catheter removals, and complications due to new puncture or to delays in catheter removal. RESULTS: Twenty-six patients were analyzed in each group. In the standard group, 6 of 37 suspected episodes of CR-BSI were confirmed and 5 colonizations were diagnosed. In the DTP group, 5 of 26 suspected episodes of CR-BSI were confirmed and four colonizations were diagnosed. In the standard group, all catheters (58/58, 100%) were removed at the time CR-BSA was suspected, whereas in the DTP group, only 13 catheters (13/41, 32%) were removed at diagnosis, and 10 due to persistent septic signs (10/41, 24%). In cases of confirmed CR-BSI, there were no differences between the two groups in the evolution of inflammatory parameters during the 48hours following the suspicion of CR-BSI. CONCLUSIONS: In critically ill patients with suspected CR-BSI, the DTP method makes it possible to keep the central venous catheter in place safely.

Thenar oxygen saturation and invasive oxygen delivery measurements in critically ill patients in early septic shock.

This prospective study was aimed to test the hypothesis that tissue hemoglobin oxygen saturation (StO2) measured noninvasively using near-infrared spectroscopy is a reliable indicator of global oxygen delivery (DO2) measured invasively using a pulmonary artery catheter (PAC) in patients with septic shock. The study setting was a 26-bed medical-surgical intensive care unit at a university hospital. Subjects were adult patients in septic shock who required PAC hemodynamic monitoring for resuscitation. Interventions included transient ischemic challenge on the forearm. After blood pressure normalization, hemodynamic and oximetric PAC variables and, simultaneously, steady-state StO2 and its changes from ischemic challenge (deoxygenation and reoxygenation rates) were measured. Fifteen patients were studied. All the patients had a mean arterial pressure above 65 mmHg. The DO2 index (iDO2) range in the studied population was 215 to 674 mL O2/min per m. The mean mixed venous oxygen saturation value was 61% ± 10%, mean cardiac index was 3.4 ± 0.9 L/min per m, and blood lactate level was 4.6 ± 2.7 mmol/L. Steady-state StO2 significantly correlated with iDO2, arterial and venous O2 content, and O2 extraction ratio. A StO2 cutoff value of 75% predicted iDO2 below 450, with a sensitivity of 0.9 and a specificity of 0.9. In patients in septic shock and normalized MAP, low StO2 reflects extremely low iDO2. Steady-state StO2 does not correlate with moderately low iDO2, indicating poor sensitivity of StO2 to rule out hypoperfusion.

Treatment strategies for central venous catheter infections.

Intravascular catheters are essential in most hospital units. These devices are the most common source of nosocomial bloodstream infections. Catheter-related bloodstream infections (CR-BSI) are associated with increased morbidity and mortality, prolonged hospitalization, and increased costs. CR-BSI can be diagnosed by different bacteriologic techniques, some of which can be performed in situ without withdrawing the device. Prevention strategies should aim to avoid extra- and endoluminal contamination. The management of CR-BSI includes catheter withdrawal and an appropriate antibiotic, which depends on the patient's clinical situation and on etiologic factors. Glycopeptide antibiotics are widely used for empirical treatment because of the high prevalence of staphylococcal infections. Antibiotic therapy should be reassessed when culture and sensitivity results are known.