These guidelines provide evidence-based recommendations for central venous cannulation in critically ill patients in the intensive care unit. The document was developed by the Working Group of the Polish Society of Anaesthesiology and Intensive Therapy (Polskie Towarzystwo Anestezjologii i Intensywnej Terapii - PTAiIT) based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, which encompasses systematic reviews of the literature, meta-analyses, and - in the absence of sufficient data - expert consensus. These guidelines aim to standardise the approach to central venous cannulation, increase the effectiveness of procedures, and minimise the risk of complications. The guidelines address pre-procedural ultrasound assessment, selection of the optimal vascular access site, comparison of ultrasound-guided versus landmark cannulation at different access sites, confirmation of catheter position after cannulation, and the role of positional manoeuvres.
Current scientific reports on pain pharmacotherapy focus on the side effects of opioid medications related to dysregulation of the oxidative-antioxidant balance and immunomodulation. Initial observations concerned the use of opioids in the treatment of acute postoperative and cancer pain. Little is known about oxidative stress modulation in multi-modal opioid-based analgesia for chronic non-cancer pain. The aim of this study was to describe oxidative stress using plasma total antioxidant capacity (TAC) and total oxidative capacity (TOC), to assess whether these metrics are dependent on pain intensity and the scheme of analgesia. The study group consisted of patients with chronic low back pain, who were divided under the following treatments: multi-modal opioid-based therapy (n = 42), monotherapy with opioids (n = 28), and the control group (n = 11). A significantly lower TAC was observed in the study group compared to the monotherapy and control groups (220 µmol/L vs. 295 µmol/L, p = 0.02 vs. 399 µmol/L, p = 0.01). TOC was significantly lower in the polytherapy group compared to the monotherapy group (594 µmol/L vs. 723 µmol/L, p = 0.0002). A significantly lower TAC was observed in the typical analgesia scheme compared to the adjuvant analgesia model (260 µmol/L vs. 339 µmol/L, p = 0.01). The TAC in the severe pain classification was significantly lower than in the moderate group (p = 0.03). Multi-modal therapy with opioids significantly reduced oxidative activity compared to monotherapy but did not improve antioxidant capacity. Opioid-based pain therapy combined with adjuvant analgesics produced better antioxidant properties, and the antioxidant capacity was lower in severe pain scores.
Although organ replacement therapy serves as a bridge to the recovery of vital organ function, it may lead to significant physiological and pharmacokinetic changes. To identify factors that may affect patient outcomes due to inadequate antimicrobial therapy, we aimed to evaluate the effectiveness of primary dosage determination of piperacillin (PIP) in the intensive care unit (ICU) setting, particularly in patients undergoing renal or lung replacement therapy. Between January 2020 and December 2021, we retrospectively analyzed all ICU patients with a confirmed SARS-CoV-2 infection who received piperacillin/tazobactam (PIP/TAZ) continuous infusion due to suspected secondary infection. The analysis included a comparison of serum PIP levels, demographic data, and laboratory findings among different patient groups. From 108 included patients, therapeutic drug monitoring (TDM) was performed at the initiation of antibiotic treatment in 91 (84.3%) cases. Of these patients, 15 received extracorporeal membrane oxygenation (ECMO), 12 underwent continuous renal replacement therapy (CRRT), and 43 received both procedures during their ICU stay. The median age was 58 years. The in-hospital mortality rate was significantly higher in patients receiving ECMO therapy (73.3% vs. 23.8%) and in those receiving both ECMO and CRRT (72.1% vs. 23.8%) compared to patients without organ replacement procedures. Dosing calculation adjusted to renal function was correctly performed according to the established standard operating procedure in 96.7% of cases. The PIP level after primary dosage, prior to further adjustments, was within the standard operating procedure-defined concentration range of 32-96 mg/L, encompassing the empirical target range and the higher exposure range relevant in specific clinical scenarios, in 59.0% [median target concentration: 44.0 mg/L] of patients without organ support, 58.3% of those on ECMO [median target concentration: 66.8 mg/L], 80.0% of those undergoing CRRT [median target concentration: 56.0 mg/L], and in 27.8% of the patients receiving both ECMO and CRRT [median target concentration: 116.0 mg/L]. In total, 17.6% of all patients did not reach the minimum PIP target level of 32 mg/L and 27.5% were above the maximum PIP target level of 96 mg/L. Binary regression analysis did not identify significant correlation between plasma bilirubin, plasma albumin, the capillary leak index (CLI) or anthropometric variables and achieving the target plasma concentration of PIP. In total, 45% of first-dose PIP concentrations in the analyzed critically ill patients were outside the recommended concentration corridor. While lowest concentrations of PIP levels were detected in critically ill patients without organ support therapy, levels above the therapeutic range were detected in patients treated with ECMO support. However, based on the data of this study, a predictor to prevent primary drug levels outside the therapeutic range was not identified. These findings underscore the critical role of TDM in daily clinical routine.
In prehospital emergency medicine, opioids are usually used to treat acute traumatic pain. A common side effect of opioids is nausea. To prevent this, the prophylactic administration of 5-HT3 antagonists such as ondansetron has become established in clinical practice, even though there is currently no evidence to support its use. Aromatherapy is also used as an alternative non-pharmacological method for the treatment of nausea. We therefore investigated whether the prophylactic administration of ondansetron or prophylactic aromatherapy after opioid administration is beneficial to the patient. Patients over the age of 16 who received opioid therapy due to acute traumatic pain by the crews of a total of six HEMS bases between February 2024 and April 2025 were prospectively included. Nausea prophylaxis after opioid-based pain therapy was performed according to a fixed rotating 7-day schedule: no nausea prophylaxis, medication-based nausea prophylaxis with ondansetron 4 mg intravenously, and aromatherapy-based nausea prophylaxis by inhalation of isopropanol. A nausea score was evaluated at the time of opioid administration and upon handover at the destination hospital, using a numeric rating scale (NRS) between 0 (no nausea) and 10 (maximum nausea). Primary endpoint was the change in NRS between the time before opioid administration and the time of patient handover at the emergency department. Secondary endpoints were incidence of moderate and severe nausea (defined as an NRS > 3), the incidence of vomiting during prehospital patient care and need of rescue medication (ondansetron for therapeutic use). A total of 205 patients were included in the analysis. Eighty-six in the "no prophylaxis" group, 64 in the ondansetron group, and 55 in the aromatherapy group. We found a median change in NRS of 0 (interquartile range 0-0) points across all groups. An increase in NRS was observed in 15% of patients in the no prophylaxis group, 14% in the ondansetron group, and 15% in the aromatherapy group. An NRS > 3 was observed in 14% of patients in the no prophylaxis group and in 11% of patients in both the ondansetron and aromatherapy groups. Vomiting occurred in 4% of patients in the no prophylaxis group, 2% in the ondansetron group, and in none of the aromatherapy group. Therapeutic administration of ondansetron was necessary in 4 patients in the "no prophylaxis" group and in one patient in the aromatherapy group. None of the patients experienced any improvement in nausea as a result, three of these patients from the "no prophylaxis" group vomited after ondansetron administration. Neither the prophylactic administration of ondansetron nor aromatherapy seem to be beneficial for the prevention of opioid-induced nausea in unselected patients in the setting of prehospital emergency medicine. Larger randomized controlled trials are needed to clarify whether certain subgroups may benefit. Not applicable.
Background/Objectives: Intracranial hypotension is a rare and underdiagnosed serious condition characterized by low cerebrospinal fluid (CSF) pressure, often resulting from trauma to the dura mater. While manual therapy is increasingly used for musculoskeletal complaints, it is not without risk and may, in rare cases, result in complications such as dural tears. Although these complications are rare, they require early recognition and appropriate treatment to prevent further morbidity. This case report aims to highlight a rare presentation of multilevel dural defects in temporal association with manual therapy and to demonstrate the efficacy of epidural blood patch (EBP) treatment. Case Presentation: We report a case of a 46-year-old woman without chronic illness who developed worsening orthostatic headaches, weakness, and vomiting after multiple manual therapy sessions. Only after 6 months did the patient undergo magnetic resonance imaging (MRI), which revealed intracranial hypotension due to dural damage in the spinal dura mater at C6-T1 and T8-T10, brain sagging, and an increased risk of subdural hematoma. After excluding other causes of dural defects, EBP was performed under CT guidance at C6-C7 and T8-T9, which resulted in symptom regression. Follow-up MRI was recommended for the patient. Conclusions: This case highlights a rare but clinically significant occurrence of multilevel dural defects and intracranial hypotension in temporal association with manual therapy. This emphasizes the critical role of timely diagnosis using MRI and the clinical effectiveness of EBP as a minimally invasive procedure.
External ventricular drainage (EVD)-associated ventriculitis is a serious complication in neurocritical care. Diagnostic uncertainty and heterogeneous infection prevention and control (IPC) practices may contribute to variable ventriculitis rates and potentially avoidable antibiotic exposure. We evaluated the impact of implementing an interdisciplinary standard operating procedure (SOP) on ventriculitis incidence and antimicrobial stewardship (ABS)-related outcomes. We conducted a retrospective single-centre pre-post study in one intensive care unit (ICU) at Charité-Universitätsmedizin Berlin (2019-2023). Adult patients with EVDs were assigned to a pre-SOP cohort (Group 1) or a post-SOP cohort (Group 2). The SOP comprised standardized IPC protocols, an algorithm-based diagnostic workup and evidence-based anti-infective strategies. The primary endpoint was study-defined EVD-associated ventriculitis, adjudicated retrospectively using uniform criteria. Secondary endpoints included empirical antibiotic initiation, duration of therapy, antibiotic consumption, ICU length of stay (LOS), mortality, and SOP adherence. Cerebrospinal fluid (CSF) parameters and clinical signs were summarized descriptively. A total of 166 patients were included (pre-SOP, Group 1: n = 50; post-SOP, Group 2: n = 116). The study-defined ventriculitis rate decreased from 22% [95% CI 0.13-0.35] to 9.5% [95% CI 0.05-0.16] with an unadjusted OR 0.37 [95% CI 0.13-1.04]; p = 0.053, attenuated with an adjusted OR of 0.50 [95% CI 0.19-1.35]; p = 0.169. Incidence density declined from 21.1 to 12.0 per 1000 EVD days. Empirical antibiotic use fell from 28.0% [95% CI 17.5-41.7] to 12.9% [95% CI 8.0-20.2], corresponding to an unadjusted OR of 0.38 [95% CI 0.17-0.87] and median therapy duration decreased from 16 [95% CI 13.5-18.5] to 10 days [95% CI 6.5-13.5]. ICU LOS shortened by 4 days, while ICU mortality remained unchanged (26% vs. 27%). An interdisciplinary SOP was associated with reduced empirical antibiotic exposure and shorter treatment duration without affecting ICU mortality. The SOP appeared to improve diagnostic consistency and standardization of the workup rather than diagnostic test performance. The study is registered in the German Clinical Trial Register (DRKS ID: 00036075) in February 2025.
Early mobilisation in the intensive care unit (ICU) is associated with improved patient outcomes. The Intensive Care Unit Mobility Scale (IMS) is established for rapid bedside assessment of patient mobilisation, but its predictive validity and interrater reliability have not been evaluated in German-speaking ICUs. In a prospective, single-centre observational study, the German translation of the IMS was validated in a 21-bed anaesthesiology-led ICU. The IMS was assessed by nurses, physical therapists, residents and attending physicians, three times daily. Clinical endpoints included ICU and hospital length of stay (LOS), 90-day mortality, and functional outcomes at discharge (grip strength, Medical Research Council Sum Score (MRC-SS)). Interrater reliability (IRR) was calculated for the German IMS. A total of 100 patients were included. Higher mean IMS during ICU stay independently predicted shorter hospital LOS (Incidence Rate Ratio: 0.90, 95% CI (0.82, 0.95); p = 0.004) and lower 90-day mortality (Odds Ratio: 0.47; 95% CI (0.30, 0.74); p = 0.002). Higher discharge IMS correlated with improved functional outcomes (grip strength, MRC-SS), lower risk of ICU-acquired weakness (ICUAW), and reduced 90-day mortality. IRR was excellent, exceeding 0.95 across all professional categories. The German IMS demonstrates robust predictive validity and exceptional interrater reliability in a multiprofessional ICU setting. Both sustained mobilisation throughout the ICU stay and higher mobilisation at discharge are associated with shorter hospital stays, reduced mortality, and better functional recovery. These findings support routine integration of the IMS into ICU practice to guide targeted mobilisation strategies and improve patient outcomes.
Critically ill children receiving continuous renal replacement therapy may experience sub-therapeutic concentrations for antimicrobials leading to treatment failure and antimicrobial resistant pathogens. The objective of this study was to determine whether antimicrobial concentrations are reduced by a paediatric continuous renal replacement therapy (CRRT). An ex vivo closed continuous veno-venous haemodiafiltration was simulated for a 3 kg infant to assess antimicrobial clearance across three ultrafiltration rates (zero, low and high flux). Slow continuous ultrafiltration was used to assess antimicrobial adsorption and recovery over 240 minutes. Controls were included to account for spontaneous drug degradation. This study was conducted in a university research laboratory with no participants. Antimicrobial concentrations were measured using a validated HPLC-MS/MS method. The antimicrobial filter clearance during high-flux filtration was significantly increased for fluconazole, piperacillin, tazobactam, vancomycin and voriconazole (P < 0.05). The antimicrobial recovery [mean (%)] at 240 minutes in the CRRT model was significantly different from baseline (time zero) for ampicillin 49%, fluconazole 76%, gentamicin (0%) meropenem 51%, piperacillin 54%, vancomycin 31% and voriconazole 47% (P < 0.05). A significant relationship was demonstrated between antimicrobial recovery and molecular charge (R2 = 0.58 P < 0.001) in the CRRT model; no relationships were reported for lipophilicity or protein binding. The concentrations were reduced in >70% of the study antimicrobials in the ex vivo paediatric CRRT model, as a result of an increase in filter clearance during high-flux filtration or from drug-circuit adsorption. These findings suggests that antimicrobial dosing in critically ill children receiving CRRT requires assessment to determine whether antimicrobial concentrations are therapeutic.
Carbapenems, often regarded as the last line of defense in treatment of urinary tract infections and urosepsis caused by Escherichia coli, are under pressure from emerging resistance. Thus, it is necessary to investigate carbapenem-sparing agents to mitigate the dissemination of carbapenem resistance. In this study, we aimed to evaluate the efficacy of ceftazidime/avibactam plus amikacin combination therapy against two ceftazidime/avibactam-resistant E. coli clinical isolates harboring IMP-4 carbapenemase (CTAP #226 and CTAP #233). To achieve this, we used a hollow fiber infection model (HFIM) with clinically relevant regimens of amikacin (15 mg/kg q24h) and ceftazidime/avibactam (2 g ceftazidime/0.5 g avibactam q8h), which were administered to the HFIM either alone or in combination over a 7-day treatment course. Initial inoculum was ~1 × 107 CFU/mL. Both amikacin and ceftazidime/avibactam monotherapies resulted in bacterial killing (~4 log10 and ~3 log10, respectively) within the first 8 h; however, regrowth surpassing the baseline was observed over the following 7 days. Conversely, combination therapy resulted in bacterial killing to <the limit of quantification (102 CFU/mL) within the first 48 h, which was sustained for the entirety of the experiment. This study showed that the combination of amikacin and ceftazidime/avibactam was superior to both monotherapies and therefore presents a promising carbapenem-sparing option for the treatment of ceftazidime/avibactam-resistant E. coli. Further clinical studies are required to assess the suitability for use in vivo.
Arterial cannulation for arterial line placement is a common procedure in critically ill patients. The radial artery is usually cannulated for this purpose, but in excessive vaso-constriction or shock, this approach may be inaccessible. In such cases, the femoral artery is frequently selected for the placement of an arterial catheter. Given this, the low number of clinical trials conducted in intensive care concerning femoral artery cannulation is surprising. The femoral approach is particularly useful in patients who require hemodynamic monitoring using transpulmonary thermodilution and fluid responsiveness tests. Arterial catheters inserted through the femoral artery are considered more durable than those placed in the radial artery. In addition, arterial pressure has higher values when measured in the femoral artery than in the radial artery. This narrative review presents current evidence on percutaneous cannulation of the common femoral artery for arterial pressure measurement in critically ill patients. The cannulation techniques are described with their limitations and contraindications. In addition, practical tips that may be useful in daily practice, and some potential pitfalls, are also presented.
Regional citrate anticoagulation (RCA) is recommended by guidelines over systemic heparinization for continuous renal replacement therapy (CRRT). However, its use in patients with impaired citrate metabolism poses specific challenges and standardized guidance for managing RCA-related metabolic complications remains lacking. A modified Delphi study was conducted according to a predefined protocol and reported in adherence with the CREDES (Conducting and REporting of DElphi Studies) checklist. The international expert panel comprised 29 clinicians and researchers from Europe, United States and Canada, with recognized expertise in RCA for CRRT in critically ill patients. Three iterative survey rounds were conducted to obtain agreement with proposed statements. Twenty-three experts completed all Delphi rounds, achieving consensus on twenty-two statements. RCA was considered feasible in patients with liver dysfunction, severe shock, or hyperlactatemia, with close monitoring and citrate dosing adjustment. Citrate accumulation can be prevented and managed using a stepwise approach, focused on reducing citrate delivery and discontinuing RCA in cases of overt accumulation. Metabolic alkalosis and electrolyte disturbances were identified as relevant but manageable complications, underscoring the need for individualizing CRRT settings. These consensus statements support the use of RCA during CRRT in critically ill patients with impaired citrate metabolism and provide practical guidance for monitoring and management of metabolic complications. However they reflect expert opinion, especially for questions with limited data and low-level evidence.
Outpatient parenteral antimicrobial therapy (OPAT) is practised worldwide due to the benefits it provides to patients and healthcare systems. However, its full potential remains unrealized due to different implementation challenges. This study aims to identify barriers and facilitators that influence the routine implementation of current practices in the OPAT programme. An international, multi-centre electronic survey was conducted among healthcare facilities providing OPAT services in Australia, Malaysia, the UK, Spain, Turkey and Middle East countries. The survey instrument was developed based on the Consolidated Framework for Implementation Research and guideline recommendations for OPAT. Statistical analyses were performed using SPSS version 30. The survey received responses from 150 healthcare facilities across 10 countries offering OPAT services. The majority (11 879.7%) of healthcare facilities implement OPAT through a formal structure. The majority (92.2%) had a designated team lead. Most facilities (12 685.7%) reported the implementation of antimicrobial toxicity monitoring. Only 58 facilities (39.5%) reported implementation of regular audits of their OPAT programmes. The most reported barriers to OPAT implementation included wide geographic distribution of patients (50.7%), lack of financial support (42.7%) and the dosing frequency of antimicrobials (40.6%). Facilitators to OPAT implementation include hospital bed savings, clinical safety and efficacy, cost-effectiveness and patient satisfaction. The majority of healthcare facilities implement OPAT through a formal structure. However, several challenges continue to hinder its routine implementation. Ongoing efforts to address implementation barriers are crucial for strengthening existing services and supporting the expansion of new services.
Background: Fiberoptic bronchoscopy (FOB) is a procedure routinely performed in clinical practice for both diagnostic and therapeutic purposes. FOB frequently impairs respiratory function, which may exacerbate respiratory failure. Currently, conventional oxygen therapy (COT) is the most commonly used form of respiratory support; however, non-invasive ventilation (NIV) and high-flow nasal cannula (HFNC) are being used increasingly. The optimal settings and indications for NIV and HFNC in patients with respiratory acidosis undergoing FOB have not yet been determined. Methods: This is a prospective, multicenter, randomized controlled trial including two parallel study populations defined by the indication for bronchoscopy and the type of respiratory acidosis. Therapeutic FOB (Study 1): Patients with decompensated type 2 respiratory failure (pH < 7.35 and PaCO2 > 45 mmHg) will be randomized to receive one of four methods of respiratory support during bronchoscopy: COT, NIV, HFNC, or invasive mechanical ventilation (IMV) (n = 315). Diagnostic FOB (Study 2): Patients with chronic respiratory acidosis (pH ≥ 7.35, PaCO2 > 45 mmHg, and/or HCO3- > 27 mmol/L) will be randomized to receive COT, NIV, or HFNC during bronchoscopy (n = 210). Before FOB, patients in both groups will undergo arterial blood gas (ABG) analysis. During FOB, vital signs will be continuously monitored, including SpO2, FiO2, TcCO2, ECG, and heart rate. After FOB, ABG analysis will be repeated, and study endpoints and complications, if any, will be recorded. The planned study period is from April 2026 to April 2029. Results: Based on the study results, we aim to evaluate the effectiveness and safety of different respiratory support strategies during flexible bronchoscopy, with the primary objective of comparing the rate of treatment failure among COT, HFNC, NIV, and IMV. Treatment failure is defined as the need for endotracheal intubation, premature termination of the procedure, or escalation of respiratory support. Additionally, we aim to identify the optimal NIV and HFNC settings, as well as complication rates in both study groups. Conclusions: The results of this study will help define the role of optimal respiratory support in patients with respiratory acidosis undergoing FOB, potentially leading to a shorter time from admission to diagnosis, better tolerance of the procedure, and faster recovery afterward.
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Appropriate antibiotic (AB) therapy remains a challenge in intensive care units (ICUs). Guidelines recommend against using procalcitonin (PCT) to guide the initiation of AB therapy, although with low certainty and a very low level of evidence. Recent studies suggest that changes in PCT levels may be more accurate than a single measurement; however, this has never been tested in a randomised trial. In this multicentre, randomised controlled trial (RCT), we aim to compare the efficacy and safety of two different PCT protocols for initiating AB therapy. Hemodynamically stable, critically ill adult patients with suspected new-onset infection at admission or during ICU stay will be randomised in a 1:1 ratio. In the treatment arm (Kinetics Group, KG), initiation of AB treatment is strongly recommended if PCT ≥0.5 ng/mL and increases by more than 100% compared with the previous day. In the control arm (Absolute Group, AG), the initiation of AB treatment is strongly recommended if PCT ≥0.5 ng/mL. The primary outcome will be the rate of unnecessary AB therapy: 72 hours after recruitment, an independent intensivist, microbiologist and infectologist will determine whether the therapy was necessary, using all relevant clinical, microbiological and radiographic results. If no consensus is reached, a decision will be made by secret vote. We plan to enrol 250 participants in the study, with 80% statistical power and a 5% alpha level. Ethics approval was obtained from the National Centre for Public Health and Pharmacy (BM/20019/2025). We plan to present our results at relevant national and international conferences and meetings and to submit them for publication in a peer-reviewed journal. Moreover, we plan to disseminate the results to important stakeholders in the Hungarian healthcare system. This is the first version of the trial protocol, prepared in accordance with the SPIRIT 2025 guideline (version 1.0, dated 30 September 2025). The trial has been registered on ClinicalTrials.gov (NCT07211620).
Antibiotic therapies are the main treatment for bacterial infections, but growing antibiotic resistance is a major global health threat, severely impacting patients with sepsis. Rapid selection of the most effective antibiotic therapy is critical for survival and for preventing further resistance. Physicians must consider numerous factors for proper empiric treatment selection. A clinical decision support system (CDSS) aims to support physicians in this process, facilitating rapid and targeted therapy. The purpose of this work is to explore the extent to which the realization of a CDSS is possible based on the data available to us and to document insights gained during the development of a foundational model designed to assist physicians in determining empiric treatment options for patients with sepsis. In this regard, rather than aiming to develop a CDSS for clinical application, we highlight the importance of close interprofessional collaboration between scientists from various disciplines and analyze the effects of data quality and quantity on the performance of our statistical models. Empirical scientists conducted interviews with medical practitioners to acquire the medical knowledge required to develop sound statistical models. We developed and applied 2-step cross-sectional, as well as time-series classification models, to carefully preprocessed data of patients with sepsis admitted to the intensive care unit of a German hospital. We identified several factors as crucial information for valid decisions on empiric therapy for treating patients with sepsis. These include the patients' core data, especially the infection focus. To prevent further resistance, individual risk factors such as travel history and professional background should be considered. The evaluation of a therapy's effectiveness is mainly based on the patient's general condition and blood values such as procalcitonin and interleukin 6. One key factor in the acceptance of a CDSS is the explainability of the results produced by the applied methods. Our models demonstrated mainly weak predictive ability for all considered empiric antibiotic therapies. However, they are not yet suitable for use in clinical practice, especially as they are based on prescribing habits rather than on optimal treatment decisions. This work highlights the importance of interprofessional collaboration between medical experts and model developers, ensuring that data quality and clinical relevance are central to the process. It emphasizes the urgent need for high-quality, comprehensive data to overcome challenges such as data discontinuity and improve model performance, particularly through enhanced digitization in health care. This feasibility study will facilitate future efforts to develop a CDSS for treating patients with sepsis and to translate it into clinical use.
Discomfort of noninvasive respiratory supports remain controversial. In the present study, the discomfort of high flow nasal cannula oxygen, noninvasive ventilation, and conventional oxygen therapy were evaluated in the post-extubation period. Noninvasive ventilation alternating with high flow nasal cannula oxygen or conventional oxygen therapy were implemented for 48 h following extubation in patients free of chronic obstructive pulmonary disease. Using a 10-cm visual analog scale, the discomfort of the interface (oxygen mask, nasal prongs or facial mask), was self-evaluated by 264 patients after extubation whereas the discomfort of the respiratory support (conventional oxygen therapy or high flow nasal cannula oxygen alternating with noninvasive ventilation) was evaluated by the nurses in 306 patients. Evaluations were performed in patients at high (n = 127) and low (n = 179) risk of postextubation respiratory failure, 6, 24 and 48 h after extubation. Facial mask was the source of a significant and persisting self-evaluated discomfort. Nasal prongs and oxygen mask were less uncomfortable, with a progressive reduction of the discomfort with time. High flow nasal cannula oxygen alternating with noninvasive ventilation caused a significant and persisting nurse-reported discomfort. Conventional oxygen therapy was significantly less uncomfortable, and the degree of discomfort was not different in patients at high and low risk of extubation failure. Noninvasive ventilation was associated with a significant and persisting discomfort whereas high flow nasal cannula oxygen-induced discomfort remained limited. After 48 h, discomfort resulting from high flow nasal cannula oxygen and conventional oxygen therapy was similar and negligible.
Hyperinflammation syndrome is a life-threatening condition of heterogeneous etiology. Common manifestations include fever, organomegaly, leukopenia or leukocytosis and malaise. We would like to present a rare case of hyperinflammatory syndrome of unknown origin complicated by shock, severe coagulopathy, spontaneous splenic rupture, and intracranial hemorrhage. A 24-year-old man with no past medical history was admitted to intensive care unit presenting with hemodynamic instability, severe acidosis, splenomegaly, bi-cytopenia, with significantly elevated inflammatory markers. Broad spectrum microbiology, hematology and genetic tests were performed to identify a trigger. Due to presence of both sepsis and hemophagocytic lymphohistiocytosis features (HLH), sepsis-HLH overlap syndrome was suspected. Aggressive treatment (broad-spectrum antibiotics, immunomodulation therapy, therapeutic plasma exchange and renal replacement therapy) was instantly initiated. Despite that, shock and profound disseminated intravascular coagulopathy exacerbated. Unexpected splenic rupture and intracranial hemorrhage required urgent surgical intervention, along with amputation of distal foot phalanges due to severe ischemia. Treatment in the intensive care unit lasted 40 days. One year after a discharge from ICU, patient still required neurological rehabilitation and orthopedic treatment. We do hope that this case will make clinicians more aware of HLH and sepsis-HLH overlap syndrome. Further research is required to improve treatment of severe hyperinflammation.