Erratic enteric absorption of dolutegravir in a critically ill patient

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Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial.

Importance: Daily spontaneous breathing trials (SBTs) are the best approach to determine whether patients are ready for disconnection from mechanical ventilation, but mode and duration of SBT remain controversial. Objective: To evaluate the effect of an SBT consisting of 30 minutes of pressure support ventilation (an approach that is less demanding for patients) vs an SBT consisting of 2 hours of T-piece ventilation (an approach that is more demanding for patients) on rates of successful extubation. Design, Setting, and Participants: Randomized clinical trial conducted from January 2016 to April 2017 among 1153 adults deemed ready for weaning after at least 24 hours of mechanical ventilation at 18 intensive care units in Spain. Follow-up ended in July 2017. Interventions: Patients were randomized to undergo a 2-hour T-piece SBT (n = 578) or a 30-minute SBT with 8-cm H2O pressure support ventilation (n = 557). Main Outcome and Measures: The primary outcome was successful extubation (remaining free of mechanical ventilation 72 hours after first SBT). Secondary outcomes were reintubation among patients extubated after SBT; intensive care unit and hospital lengths of stay; and hospital and 90-day mortality. Results: Among 1153 patients who were randomized (mean age, 62.2 [SD, 15.7] years; 428 [37.1%] women), 1018 (88.3%) completed the trial. Successful extubation occurred in 473 patients (82.3%) in the pressure support ventilation group and 428 patients (74.0%) in the T-piece group (difference, 8.2%; 95% CI, 3.4%-13.0%; P = .001). Among secondary outcomes, for the pressure support ventilation group vs the T-piece group, respectively, reintubation was 11.1% vs 11.9% (difference, -0.8%; 95% CI, -4.8% to 3.1%; P = .63), median intensive care unit length of stay was 9 days vs 10 days (mean difference, -0.3 days; 95% CI, -1.7 to 1.1 days; P = .69), median hospital length of stay was 24 days vs 24 days (mean difference, 1.3 days; 95% CI, -2.2 to 4.9 days; P = .45), hospital mortality was 10.4% vs 14.9% (difference, -4.4%; 95% CI, -8.3% to -0.6%; P = .02), and 90-day mortality was 13.2% vs 17.3% (difference, -4.1% [95% CI, -8.2% to 0.01%; P = .04]; hazard ratio, 0.74 [95% CI, 0.55-0.99]). Conclusions and Relevance: Among patients receiving mechanical ventilation, a spontaneous breathing trial consisting of 30 minutes of pressure support ventilation, compared with 2 hours of T-piece ventilation, led to significantly higher rates of successful extubation. These findings support the use of a shorter, less demanding ventilation strategy for spontaneous breathing trials. Trial Registration: ClinicalTrials.gov Identifier: NCT02620358.

Hypoxemic Patients With Bilateral Infiltrates Treated With High-Flow Nasal Cannula Present a Similar Pattern of Biomarkers of Inflammation and Injury to Acute Respiratory Distress Syndrome Patients.

OBJECTIVE: To examine whether patients with acute hypoxemia and bilateral opacities treated with high-flow nasal cannula and acute respiratory distress syndrome patients who were directly mechanically ventilated are similar in terms of lung epithelial, endothelial, and inflammatory biomarkers. DESIGN: Prospective, multicenter study. SETTING: ICUs at three university tertiary hospitals. PATIENTS: Intubated and nonintubated patients admitted to the ICU with acute hypoxemia (PaO2/FIO2 ≤ 300) and bilateral opacities. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Either high-flow nasal cannula or mechanical ventilation was initiated, at the discretion of the attending physician. We measured plasma biomarkers of lung epithelial injury (receptor for advanced glycation end products and surfactant protein D) and endothelial injury (angiopoietin-2) and inflammation (interleukin-6, interleukin-8, and interleukin-33 and soluble suppression of tumorigenicity-2) within 24 hours of acute respiratory distress syndrome onset. Propensity score matching was performed using six different variables (Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, PaO2/FIO2, origin of acute respiratory distress syndrome, steroids, renal failure and need for vasopressors). Nonhypoxemic mechanically ventilated critically ill patients and healthy volunteers served as controls. Of the 170 patients enrolled, 127 (74.7%) were intubated and 43 (25.3%) were treated with high-flow nasal cannula at acute respiratory distress syndrome onset. After propensity score matching (39 high-flow nasal cannula patients vs 39 mechanical ventilation patients), no significant differences were observed in receptor for advanced glycation end products, surfactant protein D, angiopoietin-2, interleukin-6, interleukin-8, interleukin-33, and soluble suppression of tumorigenicity-2 between matched patients who were treated with high-flow nasal cannula and those who were intubated at acute respiratory distress syndrome onset. After matching, no differences in mortality or length of stay were observed. All biomarkers (with the exception of interleukin-33) were higher in both groups of matched acute respiratory distress syndrome patients than in both control groups. CONCLUSIONS: Acute hypoxemic patients with bilateral infiltrates treated with high-flow nasal cannula presented a similar pattern of biomarkers of inflammation and injury to acute respiratory distress syndrome patients undergoing direct mechanical ventilation. The results suggest that these high-flow nasal cannula patients should be considered as acute respiratory distress syndrome patients.

A pilot study of a new test to predict extubation failure.

INTRODUCTION: To determine whether subjecting patients to 100 ml of additional dead space after a 120-minute weaning trial could predict readiness for extubation. METHODS: This was a prospective, non-randomised pilot study in an intensive care unit at a university hospital with 14 beds. It included all non-tracheostomised patients with improvement of the underlying cause of acute respiratory failure, and those with no need for vasoactive or sedative drugs were eligible. Patients fulfilling the Consensus Conference on Weaning extubation criteria after 120 minutes spontaneous breathing (n = 152) were included. To the endotracheal tube, 100 cc dead space was added for 30 minutes. Patients tolerating the test were extubated; those not tolerating it received six hours of supplementary ventilation before extubation. The measurements taken and main results were: arterial pressure, heart rate, respiratory rate, oxygen saturation, end-tidal carbon dioxide and signs of respiratory insufficiency were recorded every five minutes; and arterial blood gases were measured at the beginning and end of the test. Extubation failure was defined as the need for mechanical and non-invasive ventilation within 48 hours of extubation. RESULTS: Twenty-two patients (14.5%) experienced extubation failure. Only intercostal retraction was independently associated with extubation failure. The sensitivity (40.9%) and specificity (97.7%) yield a probability of extubation failure of 75.1% for patients not tolerating the test versus 9.3% for those tolerating it. CONCLUSIONS: Observing intercostal retraction after adding dead space may help detect susceptibility to extubation failure. The ideal amount of dead space remains to be determined. TRIAL REGISTRATION: Current Controlled Trials ISRCTN76206152.

Un caso de shoshin beriberi / No disponible

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Moisturizing body milk as a reservoir of Burkholderia cepacia: outbreak of nosocomial infection in a multidisciplinary intensive care unit.

BACKGROUND: An outbreak of severe nosocomial Burkholderia cepacia infections in patients admitted to intensive care unit (ICU), including investigation of the reservoir, is described. METHODS: Over a period of 18 days, isolates of Burkholderia cepacia were recovered from different biological samples from five patients who were admitted to a multidisciplinary 18-bed intensive care unit. Isolation of B. cepacia was associated with bacteraemia in three cases, lower respiratory tract infection in one and urinary tract infection in one. Contact isolation measures were instituted; new samples from the index patients and adjacent patients were collected; and samples of antiseptics, eau de Cologne and moisturizing body milk available in treatment carts at that time were collected and cultured. RESULTS: B. cepacia was isolated from three samples of the moisturizing body milk that had been applied to the patients. Three new hermetically closed units, from three different batches, were sent for culture; two of these were positive as well. All strains recovered from environmental and biological samples were identified as belonging to the same clone by pulsed-field gel electrophoresis. The cream was withdrawn from all hospitalization units and no new cases of B. cepacia infection developed. CONCLUSION: Moisturizing body milk is a potential source of infection. In severely ill patients, the presence of bacteria in cosmetic products, even within accepted limits, may lead to severe life-threatening infections.

[Intraabdominal hypertension and decompressive surgery. Clinical experience]. / Hipertensión abdominal y cirugía descompresiva. Experiencia clínica.

INTRODUCTION: Increased intraabdominal pressure (IAP) is associated with higher complication and mortality rates. Decompressive surgery is the most effective treatment for abdominal hypertension in trauma and septic patients with IAP. OBJECTIVE: To establish the association between IAP, complications, and mortality and to evaluate morbidity and mortality after decompressive surgery. MATERIAL AND METHOD: We performed a prospective, analytical, longitudinal study designed in 2 phases. In the first phase, 17 patients (mean age = 66 years, range: 39-78) admitted to the intensive care unit who underwent abdominal surgery were studied. In the second phase, 47 patients (mean age = 65 years, range: 48-78) underwent decompressive surgery, 6 for abdominal trauma and 41 for postoperative peritonitis. In both phases, all patients were fitted with urinary, arterial, and pulmonary artery catheters. The following variables were recorded: hemodynamic, respiratory and renal parameters; IAP, APACHE II, complications, and mortality. RESULTS: Patients with complications had significantly higher mean IAP (12.3 mm Hg; 95% CI, 10.7-13.9) than those without complications (7.9 mm Hg; 95% CI, 4.7-11.1) (p = 0.004). Patients that survived had a significantly lower mean IAP (8.7 mm Hg; 95% CI, 5.9-11.5) than those that died (12.4 mm Hg; 95% CI, 10.2-14.7) (p = 0.03). In patients who underwent decompressive surgery, a significant difference was found between APACHE II predicted mortality (40.4%) and observed mortality (25.5%) (p = 0.02). One patient with decompressive surgery developed an intestinal fistula. CONCLUSIONS: Controlling IAP, prophylaxis against abdominal hypertension, recognizing abdominal hypertension and decompressive surgery are new parameters and new concepts to be considered in the treatment of critical surgical patients.

Hipertensión abdominal y cirugía descompresiva. Experiencia clínica / Intraabdominal hypertension and decompressive surgery. Clinical experience

Introducción. El aumento de la presión intraabdominal (PIA) se relaciona con un mayor número de complicaciones y mortalidad. La cirugía descompresiva es el mejor método para el tratamiento de los pacientes traumáticos y sépticos afectos de hipertensión abdominal. Objetivo. Establecer la relación entre PIA, complicaciones y mortalidad. Evaluar la morbilidad y la mortalidad tras cirugía descompresiva. Material y método. Estudio prospectivo, longitudinal y analítico diseñado en dos fases: 17 pacientes ingresados en la unidad de cuidados intensivos e intervenidos de cirugía abdominal. Edad, 66 (39-78) años. Colocación de sonda vesical, catéter arterial y catéter de arteria pulmonar. Registro de parámetros hemodinámicos, respiratorios y renales. Registro de la presión intraabdominal y del APACHE-II, complicaciones y mortalidad. Segunda fase: 47 pacientes sometidos a cirugía descompresiva, 6 por trauma abdominal y 41 por peritonitis postoperatorias. Edad, 65 (48-78) años. Idéntica metodología. Resultados. La PIA media de los pacientes complicados fue significativamente mayor que la de los que no presentaron complicaciones, 12,3 mmHg (intervalo de confianza [IC] del 95%, 10,7-13,9) y 7,9 mmHg (IC del 95%, 4,7-11,1; p = 0,004). PIA media de los pacientes que sobrevivieron, 8,7 mmHg (IC del 95%, 5,9- 11,5) y 12,4 mmHg de los que fallecieron (IC del 95%, 10,2-14,7; p = 0,03). La diferencia entre la mortalidad esperada por el APACHE-II de los pacientes sometidos a cirugía descompresiva (40,4%) y la observada (25,5%) es significativa (p = 0,02). Una fístula intestinal en los pacientes con cirugía descompresiva. Conclusiones. Controlar la presión intraabdominal, reconocerla, su profilaxis y la cirugía descompresiva constituyen nuevos parámetros y nuevos conceptos que tener en cuenta en el tratamiento de los pacientes quirúrgicos críticos (AU)

Introduction. Increased intraabdominal pressure (IAP) is associated with higher complication and mortality rates. Decompressive surgery is the most effective treatment for abdominal hypertension in trauma and septic patients with IAP. Objective. To establish the association between IAP, complications, and mortality and to evaluate morbidity and mortality after decompressive surgery. Material and method. We performed a prospective, analytical, longitudinal study designed in 2 phases. In the first phase, 17 patients (mean age = 66 years, range: 39-78) admitted to the intensive care unit who underwent abdominal surgery were studied. In the second phase, 47 patients (mean age = 65 years, range: 48-78) underwent decompressive surgery, 6 for abdominal trauma and 41 for postoperative peritonitis. In both phases, all patients were fitted with urinary, arterial, and pulmonary artery catheters. The following variables were recorded: hemodynamic, respiratory and renal parameters; IAP, APACHE II, complications, and mortality. Results. Patients with complications had significantly higher mean IAP (12.3 mm Hg; 95% CI, 10.7- 13.9) than those without complications (7.9 mm Hg; 95% CI, 4.7-11.1) (p = 0.004). Patients that survived had a significantly lower mean IAP (8.7 mm Hg; 95% CI, 5.9-11.5) than those that (..) (AU)