Current knowledge gaps in extracorporeal respiratory support.

Extracorporeal life support (ECLS) for acute respiratory failure encompasses veno-venous extracorporeal membrane oxygenation (V-V ECMO) and extracorporeal carbon dioxide removal (ECCO2R). V-V ECMO is primarily used to treat severe acute respiratory distress syndrome (ARDS), characterized by life-threatening hypoxemia or ventilatory insufficiency with conventional protective settings. It employs an artificial lung with high blood flows, and allows improvement in gas exchange, correction of hypoxemia, and reduction of the workload on the native lung. On the other hand, ECCO2R focuses on carbon dioxide removal and ventilatory load reduction ("ultra-protective ventilation") in moderate ARDS, or in avoiding pump failure in acute exacerbated chronic obstructive pulmonary disease. Clinical indications for V-V ECLS are tailored to individual patients, as there are no absolute contraindications. However, determining the ideal timing for initiating extracorporeal respiratory support remains uncertain. Current ECLS equipment faces issues like size and durability. Innovations include intravascular lung assist devices (ILADs) and pumpless devices, though they come with their own challenges. Efficient gas exchange relies on modern oxygenators using hollow fiber designs, but research is exploring microfluidic technology to improve oxygenator size, thrombogenicity, and blood flow capacity. Coagulation management during V-V ECLS is crucial due to common bleeding and thrombosis complications; indeed, anticoagulation strategies and monitoring systems require improvement, while surface coatings and new materials show promise. Moreover, pharmacokinetics during ECLS significantly impact antibiotic therapy, necessitating therapeutic drug monitoring for precise dosing. Managing native lung ventilation during V-V ECMO remains complex, requiring a careful balance between benefits and potential risks for spontaneously breathing patients. Moreover, weaning from V-V ECMO is recognized as an area of relevant uncertainty, requiring further research. In the last decade, the concept of Extracorporeal Organ Support (ECOS) for patients with multiple organ dysfunction has emerged, combining ECLS with other organ support therapies to provide a more holistic approach for critically ill patients. In this review, we aim at providing an in-depth overview of V-V ECMO and ECCO2R, addressing various aspects of their use, challenges, and potential future directions in research and development.

Programa de optimización del uso de antimicrobianos en un Servicio de Medicina Intensiva: análisis retrospectivo observacional de los resultados 15 meses después de su implementación / Antimicrobial stewardship program in an Intensive Care Unit: A retrospective observational analysis of the results 15 months after its implementation

Objetivo. Determinar el grado de aceptación de un Pro grama de Optimización del Uso de Antimicrobianos (PROA) en un Servicio de Medicina Intensiva (SMI), y evaluar su efecto sobre el consumo de antibióticos, indicadores de calidad y re sultados clínicos. Pacientes y métodos. Descripción retrospectiva de las intervenciones propuestas por un PROA. Comparación de uso de antimicrobianos, indicadores de calidad y seguridad frente a un periodo sin PROA. Se realizó en un SMI polivalente de un Hospital Universitario mediano (600 camas). Se estudió a pacientes ingresados por cualquier causa en el SMI durante el periodo PROA en los que se hubiera obtenido una muestra di rigida al diagnóstico de una potencial infección, o se hubieran iniciado antimicrobianos. Se elaboraron recomendaciones no impositivas para mejorar la prescripción antimicrobiana (es tructura audit and feedback) y se procedió a su registro du rante periodo PROA (15 meses, octubre 2018–diciembre 2019). Comparación de indicadores en un periodo con PROA (abril– junio 2019) y sin PROA (abril–junio 2018). Resultados. Se emitieron 241 recomendaciones sobre 117 pacientes, el 67% de ellas de tipo desescalada terapéutica. La aceptación de las recomendaciones fue elevada (96.3%). En el periodo PROA se redujo el número medio de antibióticos por paciente (3.3±4.1 vs 2.4±1.7, p=0.04) y los días de tratamiento (155 DOT/100 PD vs 94 DOT/100 PD, p <0.01) (AU)

Objective. We aim to evaluate the adherence rate to an Antimicrobial Stewardship Program (ASP) in an Intensive Care Unit (ICU), and to assess its effect on the use of antibiotics, quality indicators and clinical outcomes. Patients and methods. Retrospective description of the interventions proposed by the ASP. We compared antimi crobial use, quality and safety indicators in an ASP versus a non-ASP period. The study was performed in a polyvalent ICU of a medium-size University Hospital (600 beds). We studied patients admitted to the ICU for any cause during the ASP pe riod, provided that a microbiological sample aiming to diag nose a potential infection has been drawn, or antibiotics have been started. We elaborated and registered of non-mandatory recommendations to improve antimicrobial prescription (audit and feedback structure) and its registry during the ASP peri od (15 months, October 2018-December 2019). We compared indicators in a period with ASP (April-June 2019) and without ASP (April-June 2018). Results. We issued 241 recommendations on 117 pa tients, 67% of them classified as de-escalation type. The rate of adherence to the recommendations was high (96.3%). In the ASP period, the mean number of antibiotics per patient (3.3±4.1 vs 2.4±1.7, p=0.04) and the days of treatment (155 DOT/100 PD vs 94 DOT/100 PD, p <0.01) (AU)

Nosocomial Pneumonia in the Era of Multidrug-Resistance: Updates in Diagnosis and Management.

Nosocomial pneumonia (NP), including hospital-acquired pneumonia in non-intubated patients and ventilator-associated pneumonia, is one of the most frequent hospital-acquired infections, especially in the intensive care unit. NP has a significant impact on morbidity, mortality and health care costs, especially when the implicated pathogens are multidrug-resistant ones. This narrative review aims to critically review what is new in the field of NP, specifically, diagnosis and antibiotic treatment. Regarding novel imaging modalities, the current role of lung ultrasound and low radiation computed tomography are discussed, while regarding etiological diagnosis, recent developments in rapid microbiological confirmation, such as syndromic rapid multiplex Polymerase Chain Reaction panels are presented and compared with conventional cultures. Additionally, the volatile compounds/electronic nose, a promising diagnostic tool for the future is briefly presented. With respect to NP management, antibiotics approved for the indication of NP during the last decade are discussed, namely, ceftobiprole medocaril, telavancin, ceftolozane/tazobactam, ceftazidime/avibactam, and meropenem/vaborbactam.

Ecografía en el manejo del paciente crítico con infección por SARS-CoV-2 (COVID-19): aplicaciones clínicas en Medicina Intensiva-una revisión narrativa / Ultrasound in the Management of the Critically Ill Patient with SARS-CoV-2 Infection (COVID-19): clinical applications in Intensive Care Medicine -a narrative review

La infección por SARS-CoV-2 (COVID-19) se caracteriza por producir en las formas graves, un cuadro de insuficiencia respiratoria que puede evolucionar hacia neumonía y síndrome de distrés respiratorio agudo (SDRA), presentar complicaciones como fenómenos trombóticos y disfunción cardiaca, lo que motiva el ingreso en la Unidad de Cuidados Intensivos (UCI).La ecografía, convertida en una herramienta de uso habitual en la UCI, puede ser muy útil durante la pandemia COVID-19 ya que la información obtenida por el clínico puede ser interpretada e integrada en la valoración global durante la exploración del paciente. Este documento describe algunas de sus aplicaciones con el objetivo de proporcionar una guía a los médicos responsables adaptado al paciente crítico con COVID-19. Alguna de sus aplicaciones desde el ingreso en la UCI incluyen confirmar la correcta posición del tubo endotraqueal, facilitar la inserción segura de las vías, e identificar complicaciones y fenómenos trombóticos. Además, la ecografía pleuropulmonar puede ser una alternativa diagnóstica válida que permite evaluar el grado de afectación pulmonar, mediante el análisis de patrones ecográficos específicos, identificación del derrame pleural y del barotrauma. La ecocardiografía proporciona información acerca de la afectación cardíaca, detección del cor pulmonaley estados de shock

The clinical picture of SARS-CoV-2 infection (COVID-19) is characterized in its more severe form, by an acute respiratory failure which can worsen to pneumonia and acute respiratory distress syndrome (ARDS), and get complicated with thrombotic events and heart dysfunction. Therefore, admission to the Intensive Care Unit (ICU) is common.Ultrasound, which has become an everyday tool in the ICU, can be very useful during COVID-19 pandemic, since it provides the clinician with information which can be interpreted and integrated within a global assessment during the physical examination A description of some of the potential applications of ultrasound is depicted in this document, in order to supply the physicians taking care of these patients with a adapted guide to the intensive care setting.Some of its applications since ICU admission include verification of the correct position of the endotracheal tube, contribution to safe cannulation of lines, and identification of complications and thrombotic events. Furthermore, pleural and lung ultrasound can be an alternative diagnostic test to assess the degree of involvement of the lung parenchyma by means of the evaluation of specific ultrasound patterns, identification of pleural effusions and barotrauma. Echocardiography provides information of heart involvement, detects cor pulmonaleand shock states