Predictors of successful extracorporeal membrane oxygenation (ECMO) weaning after assistance for refractory cardiogenic shock.

Purpose: Detailed extracorporeal membrane oxygenation (ECMO) weaning strategies and specific predictors of ECMO weaning success are lacking. This study evaluated a weaning strategy following support for refractory cardiogenic shock to identify clinical, hemodynamic, and Doppler echocardiography parameters associated with successful ECMO removal.

Methods: Hemodynamically stable patients underwent ECMO flow reduction trials to <1.

Biomarkers to optimize antibiotic therapy for pneumonia due to multidrug-resistant pathogens.

No currently available biomarker can be used as a diagnostic marker for ventilator-associated pneumonia due to multidrug-resistant pathogens. Procalcitonin can be used to customize the duration of antimicrobial treatment without excess morbidity and mortality: when its concentration is less than 0.5 ng/mL or has decreased by 80% or more compared with the peak concentration, antibiotics can be stopped.

Out-of-hospital extra-corporeal life support implantation during refractory cardiac arrest in a half-marathon runner.

For patients who present with an out-of-hospital refractory cardiac arrest, in-hospital extracorporeal life-support (ECLS) initiation represents an alternative therapy which allows significant survival. We describe here the first case of out-of-hospital ECLS implantation in a patient presenting with a refractory cardiac arrest during a road race. ECLS was initiated within the MICU ambulance 60 min after cardiac arrest and enabled restoration of cardiac output to 4.

Value of the serum procalcitonin level to guide antimicrobial therapy for patients with ventilator-associated pneumonia.

Procalcitonin's contribution to the diagnosis of nosocomial infection, particularly ventilator-associated pneumonia (VAP), is poor: its levels in patients with microbiologically documented VAP the day infection is diagnosed range from normal to extremely high. Moreover, the results of four studies showed that, despite relatively good specificity, this marker had low sensitivity for the diagnosis of VAP. However, because procalcitonin is well associated with outcome, its kinetics during antimicrobial therapy can be used to customize that treatment duration.

Predictive risk factors for primary graft failure requiring temporary extra-corporeal membrane oxygenation support after cardiac transplantation in adults.

Objective: Primary graft failure (PGF) is a major risk factor for death after heart transplantation. We investigated the predictive risk factors for severe PGF that require extra-corporeal membrane oxygenation (ECMO) circulatory support after cardiac transplantation.

Methods: Between January 2003 and December 2008, 402 adult patients underwent isolated cardiac transplantation at our institution.

Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial.

Background: Whether early percutaneous tracheotomy in patients who require prolonged mechanical ventilation can shorten mechanical ventilation duration and lower mortality remains controversial.

Objective: To compare the outcomes of severely ill patients who require prolonged mechanical ventilation randomly assigned to early percutaneous tracheotomy or prolonged intubation.

Design: Prospective, randomized, controlled, single-center trial (ClinicalTrials.

Pharmacokinetics and safety of panobacumab: specific adjunctive immunotherapy in critical patients with nosocomial Pseudomonas aeruginosa O11 pneumonia.

Objectives: Nosocomial Pseudomonas aeruginosa pneumonia remains a major concern in critically ill patients. We explored the potential impact of microorganism-targeted adjunctive immunotherapy in such patients.

Patients And Methods: This multicentre, open pilot Phase 2a clinical trial (NCT00851435) prospectively evaluated the safety, pharmacokinetics and potential efficacy of three doses of 1.

Pharmacokinetics and tolerability of amikacin administered as BAY41-6551 aerosol in mechanically ventilated patients with gram-negative pneumonia and acute renal failure.

Background: BAY41-6551, a drug-device combination in development for adjunctive treatment of Gram-negative pneumonia in intubated and mechanically ventilated patients, consists of amikacin formulated for inhalation coupled with the Pulmonary Drug Delivery System (PDDS) Clinical aerosol delivery platform. Given the predominantly renal clearance of aminoglycosides, understanding systemic amikacin exposure and safety during administration of BAY41-6551 to patients with acute renal failure (ARF) is clinically important.

Methods: Seven mechanically ventilated patients with Gram-negative pneumonia and ARF receiving continuous veno-venous hemodiafiltration (CVVHDF) were treated with multiple administrations of BAY41-6551 400 mg amikacin twice daily using the PDDS Clinical on-ventilator device [in addition to standard intravenous (i.

Outcomes, long-term quality of life, and psychologic assessment of fulminant myocarditis patients rescued by mechanical circulatory support.

Objective: Myocarditis is a rare disease that may progress rapidly to refractory cardiogenic shock and death. In such situations, emergent initiation of mechanical circulatory assistance is the only therapeutic option to rescue these dying patients. This study was designed to evaluate the outcomes, health-related quality of life and frequencies of anxiety, depression and posttraumatic stress disorder symptoms in fulminant myocarditis patients rescued by mechanical circulatory assistance, since these major components of outcome evaluation after serious illnesses have not yet been assessed in this setting.

Diagnostic techniques and procedures for establishing the microbial etiology of ventilator-associated pneumonia for clinical trials: the pros for quantitative cultures.

Use of only clinical criteria for enrolling patients in clinical trials leads to inclusion of many patients who have no pulmonary infection, which can make the evaluation of new treatment modalities difficult. Quantitative cultures of specimens obtained using bronchoscopic or nonbronchoscopic techniques, such as bronchoalveolar lavage and/or protected specimen brush, are much more specific and could improve identification of patients with ventilator-associated pneumonia. Microscopic examination of distal respiratory secretions with use of Gram staining permits randomizing only patients with a high probability of ventilator-associated pneumonia and, thus, avoids the potential bias that can result from secondary exclusions.

Other therapeutic modalities and practices: implications for clinical trials of hospital-acquired or ventilator-associated pneumonia.

Direct delivery of antimicrobial agents to the site of infection via aerosolization may represent a valid option in patients with ventilator-associated pneumonia (VAP). Although promising and supported by the results of several recent investigations, antibiotic aerosolization to treat VAP has not yet entered the armamentarium for daily practice. Its potential efficacy should be first evaluated as an adjunctive therapy in a superiority trial in which all participants receive a standard-of-care intravenous regimen and then are randomized to receive additional antibiotics by aerosol or a placebo (eg, combination therapy trials).

Controversies in ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is the most frequent intensive care unit (ICU)-acquired infection among patients receiving mechanical ventilation. Consensus, however, on the most appropriate diagnostic strategy for patients clinically suspected of having developed VAP has yet to be reached. Concern about the inaccuracy of clinical approaches to VAP recognition and potential for excessive use of antibiotics in the ICU had led numerous investigators to postulate that quantitative cultures of specimens obtained with bronchoscopic or nonbronchoscopic techniques, such as bronchoalveolar lavage (BAL) and/or protected specimen brush (PSB), could improve identification of patients with true VAP and facilitate decisions whether to treat.

Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial.

Background: Reduced duration of antibiotic treatment might contain the emergence of multidrug-resistant bacteria in intensive care units. We aimed to establish the effectiveness of an algorithm based on the biomarker procalcitonin to reduce antibiotic exposure in this setting.

Methods: In this multicentre, prospective, parallel-group, open-label trial, we used an independent, computer-generated randomisation sequence to randomly assign patients in a 1:1 ratio to procalcitonin (n=311 patients) or control (n=319) groups; investigators were masked to assignment before, but not after, randomisation.

Pharmacokinetics and lung delivery of PDDS-aerosolized amikacin (NKTR-061) in intubated and mechanically ventilated patients with nosocomial pneumonia.

Introduction: Aminoglycosides aerosolization might achieve better diffusion into the alveolar compartment than intravenous use. The objective of this multicenter study was to evaluate aerosol-delivered amikacin penetration into the alveolar epithelial lining fluid (ELF) using a new vibrating mesh nebulizer (Pulmonary Drug Delivery System (PDDS), Nektar Therapeutics), which delivers high doses to the lungs.

Methods: Nebulized amikacin (400 mg bid) was delivered to the lungs of 28 mechanically ventilated patients with Gram-negative VAP for 7-14 days, adjunctive to intravenous therapy.

Prolonged mechanical ventilation after cardiac surgery: outcome and predictors.

Objective: Prolonged mechanical ventilation after cardiac surgery is a serious complication that warrants search for new treatment strategies. Our objective was to identify patients still requiring mechanical ventilation 3 days after the operation and those successfully weaned by day 10 to avoid needless and potentially hazardous interventions, such as tracheostomy.

Methods: All consecutive patients still mechanically ventilated on day 3 after cardiac surgery were included in a prospective observational cohort.

Extra-corporeal membrane oxygenation temporary support for early graft failure after cardiac transplantation.

Objective: Early graft failure (EGF) is a major risk for death after heart transplantation. We studied the impact of an extra-corporeal membrane oxygenation (ECMO) temporary support on the operative mortality and the mean-term survival after EGF.

Materials And Methods: Between January 2000 and December 2006, 394 patients underwent orthotopic heart transplantation at our institution.

Gender impact on the outcomes of critically ill patients with nosocomial infections.

Objectives: : To investigate gender impact on the outcomes of severe nosocomial infections (pneumonia, bacteremia, catheter-related bloodstream infections, poststernotomy mediastinitis, urinary infections) occurring in a large cohort of patients hospitalized in a medical-surgical intensive care unit. Highly controversial data exist regarding gender-related differences in outcomes of severe nosocomial infections, reflecting potential confounders related to case-mixes or heterogeneity of populations evaluated.

Design: : Retrospective study of patients admitted to our intensive care unit.

Aerosolized antibiotics to treat ventilator-associated pneumonia.

Purpose Of Review: This review summarizes the recent data on antibiotic aerosolization to treat ventilator-associated pneumonia.

Recent Findings: Most studies on antibiotic aerosolization have been case reports or descriptive studies. The results of a recent randomized, placebo-controlled trial indicated that adjunctive use of nebulized antibiotic with intravenous antibiotics to treat purulent tracheobronchitis was associated with a better outcome than placebo aerosolization.

Viral infections in the ICU.

Purpose Of Review: The present study reviews the precise role of viruses as causes of pneumonia in mechanically ventilated patients.

Recent Findings: In patients requiring mechanical ventilation, Herpesviridae, mostly herpes simplex virus and cytomegalovirus, are commonly recovered from the respiratory tract. However, viral detection does not necessarily mean viral disease, and the exact role of viruses recovered in the respiratory tract is still being debated.

Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock.

Objective: To assess the outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation (ECMO) for refractory cardiogenic shock.

Design, Setting, And Patients: Refractory cardiogenic shock is almost always lethal without emergency circulatory support, e.g.

Usefulness of procalcitonin for the diagnosis of ventilator-associated pneumonia.

Objective: To assess the predictive capacity for the diagnosis of ventilator-associated pneumonia (VAP) of serum procalcitonin levels before and on the day it is suspected.

Design And Setting: Single-center observational study in the intensive care unit of a teaching hospital.

Patients And Participants: Consecutive patients whose serum procalcitonin levels were available on the day that VAP was clinically suspected (day 1) and at some time within the preceding 5 days ("before").