Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis.

Background: Optimal timing for the start of vasopressors (VP) in septic shock has not been widely studied since it is assumed that fluids must be administered in advance. We sought to evaluate whether a very early start of VP, even without completing the initial fluid loading, might impact clinical outcomes in septic shock.

Methods: A total of 337 patients with sepsis requiring VP support for at least 6 h were initially selected from a prospectively collected database in a 90-bed mixed-ICU during a 24-month period.

Correction to: Recruiting the microcirculation in septic shock.

After publication of the original article [1], we were notified that an author's name has been incorrectly spelled. Author's first name is Hafid and the family name is Ait-Oufella (with a hyphen between Ait and Oufella). The original article has been corrected.

Estimation of central arterial pressure from the radial artery in patients undergoing invasive neuroradiological procedures.

Backgrounds: Central arterial pressure can be derived from analysis of the peripheral artery waveform. The aim of this study was to compare central arterial pressures measured from an intra-aortic catheter with peripheral radial arterial pressures and with central arterial pressures estimated from the peripheral pressure wave using a pressure recording analytical method (PRAM).

Methods: We studied 21 patients undergoing digital subtraction cerebral angiography under local or general anesthesia and equipped with a radial arterial catheter.

Accurate prediction of glaucoma from colour fundus images with a convolutional neural network that relies on active and transfer learning.

Purpose: To assess the use of deep learning (DL) for computer-assisted glaucoma identification, and the impact of training using images selected by an active learning strategy, which minimizes labelling cost. Additionally, this study focuses on the explainability of the glaucoma classifier.

Methods: This original investigation pooled 8433 retrospectively collected and anonymized colour optic disc-centred fundus images, in order to develop a deep learning-based classifier for glaucoma diagnosis.

Thinking forward: promising but unproven ideas for future intensive care.

Progress toward determining the true worth of ongoing practices or value of recent innovations can be glacially slow when we insist on following the conventional stepwise scientific pathway. Moreover, a widely accepted but flawed conceptual paradigm often proves difficult to challenge, modify or reject. Yet, most experienced clinicians, educators and clinical scientists privately entertain untested ideas about how care could or should be improved, even if the supporting evidence base is currently thin or non-existent.

Minimizing catecholamines and optimizing perfusion.

Catecholamines are used to increase cardiac output and blood pressure, aiming ultimately at restoring/improving tissue perfusion. While intuitive in its concept, this approach nevertheless implies to be effective that regional organ perfusion would increase in parallel to cardiac output or perfusion pressure and that the catecholamine does not have negative effects on the microcirculation. Inotropic agents may be considered in some conditions, but it requires prior optimization of cardiac preload.

Is microcirculatory assessment ready for regular use in clinical practice?

Purpose Of Review: The present review discusses the current role of microcirculatory assessment in the hemodynamic monitoring of critically ill patients.

Recent Findings: Videomicroscopic techniques have demonstrated that microvascular perfusion is altered in critically ill patients, and especially in sepsis. These alterations are associated with organ dysfunction and poor outcome.

Challenges in the management of septic shock: a narrative review.

While guidelines provide important information on how to approach a patient in septic shock, "many challenges remain" for the management of these patients. In this narrative review, the panel discusses the challenges in identifying the right hemodynamic target, optimization of fluid therapy, selection of vasopressor agents, identification of patients who may benefit from inotropic agents or on the contrary beta-blockade, and use of steroids. The place for microcirculation-targeted therapy is debated as well as the use of alternative techniques (blood purification) and therapies (vitamin C).

Current use of vasopressors in septic shock.

Background: Vasopressors are commonly applied to restore and maintain blood pressure in patients with sepsis. We aimed to evaluate the current practice and therapeutic goals regarding vasopressor use in septic shock as a basis for future studies and to provide some recommendations on their use.

Methods: From November 2016 to April 2017, an anonymous web-based survey on the use of vasoactive drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM).

Sigh maneuver to enhance assessment of fluid responsiveness during pressure support ventilation.

Background: Assessment of fluid responsiveness is problematic in intensive care unit (ICU) patients, in particular for those undergoing modes of partial support, such as pressure support ventilation (PSV). We propose a new test, based on application of a ventilator-generated sigh, to predict fluid responsiveness in ICU patients undergoing PSV.

Methods: This was a prospective bi-centric interventional study conducted in two general ICUs.

Correction to: Fluid administration for acute circulatory dysfunction using basic monitoring: narrative review and expert panel recommendations from an ESICM task force.

The original article can be found online.

Fluid administration for acute circulatory dysfunction using basic monitoring: narrative review and expert panel recommendations from an ESICM task force.

An international team of experts in the field of fluid resuscitation was invited by the ESICM to form a task force to systematically review the evidence concerning fluid administration using basic monitoring. The work included a particular emphasis on pre-ICU hospital settings and resource-limited settings. The work focused on four main questions: (1) What is the role of clinical assessment to guide fluid resuscitation in shock? (2) What basic monitoring is required to perform and interpret a fluid challenge? (3) What defines a fluid challenge in terms of fluid type, ranges of volume, and rate of administration? (4) What are the safety endpoints during a fluid challenge? The expert panel found insufficient evidence to provide recommendations according to the GRADE system, and was only able to make recommendations for basic interventions, based on the available evidence and expert opinion.

Roux-en-Y gastric bypass, sleeve gastrectomy, or one anastomosis gastric bypass as rescue therapy after failed adjustable gastric banding: a multicenter comparative study.

Background: To date, laparoscopic adjustable gastric banding remains the third most commonly performed surgical procedure for weight loss. Some patients fail to get acceptable outcomes and undergo revisional surgery at rates ranging from 7% to 60%. Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), and sleeve gastrectomy (SG) are among the most common salvage options for failed laparoscopic adjustable gastric banding.

Surviving sepsis campaign: research priorities for sepsis and septic shock.

Objective: To identify research priorities in the management, epidemiology, outcome and underlying causes of sepsis and septic shock.

Design: A consensus committee of 16 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine was convened at the annual meetings of both societies. Subgroups had teleconference and electronic-based discussion.

Days alive and free as an alternative to a mortality outcome in pivotal vasopressor and septic shock trials.

Purpose: RCTs in septic shock negative for mortality may show organ dysfunction benefits. We hypothesized that RCTs in septic shock show significant differences between treatment groups in organ support despite no mortality differences.

Methods: RCTs of epinephrine vs.

Surviving Sepsis Campaign: Research Priorities for Sepsis and Septic Shock.

Objective: To identify research priorities in the management, epidemiology, outcome and underlying causes of sepsis and septic shock.

Design: A consensus committee of 16 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine was convened at the annual meetings of both societies. Subgroups had teleconference and electronic-based discussion.

A global perspective on vasoactive agents in shock.

Purpose: We set out to summarize the current knowledge on vasoactive drugs and their use in the management of shock to inform physicians' practices.

Methods: This is a narrative review by a multidisciplinary, multinational-from six continents-panel of experts including physicians, a pharmacist, trialists, and scientists.

Results And Conclusions: Vasoactive drugs are an essential part of shock management.

Alternatives to the Swan-Ganz catheter.

While the pulmonary artery catheter (PAC) is still interesting in specific situations, there are many alternatives. A group of experts from different backgrounds discusses their respective interests and limitations of the various techniques and related measured variables. The goal of this review is to highlight the conditions in which the alternative devices will suffice and when they will not or when these alternative techniques can provide information not available with PAC.