CONTEXT Acute respiratory distress syndrome is characterised by activation of the inflammatory cascade. The only treatment that reduces the mortality rate associated with this syndrome is lung protective ventilation, which requires sedation of patients. Sedation in critical care units is usually induced intravenously, although there is reason to believe that inhaled anaesthetics are a suitable alternative. Sevoflurane has recently been shown to modulate the lung inflammatory response in a model of lung injury more favourably than propofol. OBJECTIVE The goal of this study was to confirm whether or not sevoflurane is more effective than propofol in ameliorating the inflammatory response in an animal model of acute respiratory distress syndrome. DESIGN A prospective, randomised, controlled study. SETTING Research foundation laboratory at the Hospital Clínico Universitario, Valencia, Spain. EXPERIMENTAL ANIMALS Sixteen Landrace/large white crossbred pigs weighing 30 to 45 kg. INTERVENTIONS Animals were allocated randomly to one of two groups: one sedated with intravenous propofol 5 to 7 mg kg⁻¹ h⁻¹ (group P) and the other with sevoflurane, administered using an AnaConDa device to obtain an end-tidal concentration of 1.5% (group S). Monitoring, lung protective ventilation and anaesthetic management were identical in both groups. MAIN OUTCOME MEASURES The PaO₂/FiO₂ ratio and cytokine concentrations in bronchoalveolar lavage specimens were determined at 10, 150 and 240 min after confirmation of acute respiratory distress syndrome (PaO₂/FiO₂ <26.7 kPa). RESULTS At 240 min, median and interquartile range (IQR) concentrations of cytokines in bronchial lavage specimens in group S were lower than those in group P [interleukin-1β (IL-1β) 53, IQR 16–140 vs. 311, IQR 183–637 pg ml⁻¹, P = 0.04; tumour necrosis factor-α 347, IQR 161–433 vs. 552, IQR 475–649 pg ml⁻¹, P = 0.04; and IL-6 101, IQR 76–282 vs. 580, IQR 369–701 pg ml⁻¹, P = 0.03]. The polymorphonuclear neutrophil count was also lower in group S (P = 0.007), which also had a higher PaO₂/FiO₂ ratio. TRIAL REGISTRATION GE-015/09. CONCLUSION In an animal model of acute respiratory distress syndrome, sevoflurane ameliorates the lung inflammatory response and improves oxygenation to a greater extent than propofol.

The purpose of the study was to assess blood flow in the upper limb arteries after prolonged catheterization with long radial artery catheters (LRC) which reach the subclavian artery compared to catheterization with standard short radial artery catheters (SRC) and a group of upper limb flow without any catheter placement (NOCATH), with both SRC and NOCATH as control groups. Prospective observational study with 20 patients admitted to ICU (40 upper limbs) with LRC and/or SRC inserted >48 h for hemodynamic monitoring. More than 45 days after catheter withdrawal, patients underwent a Doppler ultrasound study of both upper limbs. Arterial flows of arms with LRC (FlowLRC) were compared with arterial flows of arms with SRC (FlowSRC) and those without any catheter (FlowNOCATH). Flow in the ulnar, brachial, and subclavian arteries did not show any significant difference between the two types of catheters. The only significant difference was in the radial arteries, showing a lower mean flow in the arms with LRC than in the arms with SRC (2.2 vs. 8.5 cc/min; p = 0.041). Flow reduction in the radial artery (74%) in the arms with LRC compared to the SRC arms showed a tendency to increase ulnar flow as a compensatory mechanism. None of the patients with LRC included in our study had any ischemic events, in spite of observing complete flow occlusion in three radial arteries (18%) from the Doppler study. In this sample, the use of PiCCO long radial catheters reaching the subclavian artery did not produce chronic significant changes in brachial or subclavian flows. However, LRC produces a significant reduction in radial flow and a tendency to increase ulnar flow. When comparing these blood flow changes with those produced by SRC use, only the radial flow reduction was significantly lower, whereas the other arterial flow changes did not significantly differ.

Invasive candidiasis (IC) is a frequent and life-threatening infection in critically ill patients. The aim of this study was to evaluate the epidemiology of IC and the antifungal susceptibility of etiological agents in patients admitted to our surgical intensive care unit (SICU) in Spain. We designed a prospective, observational, single center, population-based study in a SICU. We included all consecutive adult patients (≥18 years old) who had documented IC, either on admission or during their stay, between January 2012 and December 2013. There were a total of 22 episodes of IC in the 1149 patients admitted during the 24-month study. The overall IC incidence was 19.1 cases per 1000 admissions. Thirteen cases of IC (59.1 %) were intra-abdominal candidiasis (IAC) and 9 (40.9 %) were candidemias. All cases of IAC were patients with secondary peritonitis and severe sepsis or septic shock. The overall crude mortality rate was 13.6 %; while, it was 33 % in patients with candidemia. All patients with IAC survived, including one patient with concomitant candidemia. The most common species causing IC was Candida albicans (13; 59.1 %) followed by Candida parapsilosis (5; 22.7 %), and Candida glabrata (2; 9.1 %). There was also one case each (4.5 %) of Candida krusei and Candida tropicalis. Thus, the ratio of non-C. albicans (9) to C. albicans (13) was 1:1.4. There was resistance to fluconazole and itraconazole in 13.6 % of cases. Resistance to other antifungals was uncommon. Candida parapsilosis was the second most common species after C. albicans, indicating the high prevalence of non-C. albicans species in the SICU. Resistance to azoles, particularly fluconazole, should be considered when starting an empirical treatment. Although IAC is a very frequent form of IC in critically ill surgical patients, prompt antifungal therapy and adequate source control appears to lead to a good outcome. However, our results are closely related to our ICU and any generalization must be taken with caution. Therefore, further investigations are needed.

Anidulafungin is indicated as a first-line treatment for invasive candidiasis in critically ill patients. In the intensive care unit, sepsis is the main cause of acute renal failure, and treatment with continuous renal replacement therapy (CRRT) has increased in recent years. Antimicrobial pharmacokinetics is affected by CRRT, but few studies have addressed the optimal dosage for anidulafungin during CRRT. We included 12 critically ill patients who received continuous venovenous haemodiafiltration to treat acute renal failure. Anidulafungin was infused on 3 consecutive days, starting with a loading dose (200 mg) on Day 1, and doses of 100 mg on Days 2 and 3. Blood and ultradiafiltrate samples were collected on Day 3 (during steady-state) before, and at regular intervals after, the infusion had started. Anidulafungin concentrations were determined with HPLC. On Day 3, peak plasma concentrations with the 100 mg dose were 6.2 ± 1.7 mg/L and 7.1 ± 1.9 mg/L in the arterial and venous samples, respectively. The mean, pre-filter trough concentration was 3.0 ± 0.6 mg/L. The mean AUC_0–24 values for plasma anidulafungin were 93.9 ± 19.4 and 104.1 ± 20.3mg·h/L in the arterial and venous samples, respectively. There was no adsorption to synthetic surfaces, and the anidulafungin concentration in the ultradiafiltrate was below the limit of detection. The influence of CRRT on anidulafungin elimination appeared to be negligible. Therefore, we recommend no adjustments to the anidulafungin dose for patients receiving CRRT.

Infections due to Klebsiella pneumoniae have been increasing in intensive care units (ICUs) in the last decade. Such infections pose a serious problem, especially when antimicrobial resistance is present. We created a task force of experts, including specialists in intensive care medicine, anaesthesia, microbiology and infectious diseases, selected on the basis of their varied experience in the field of nosocomial infections, who conducted a comprehensive review of the recently published literature on the management of carbapenemase-producing Enterobacterales (CPE) infections in the intensive care setting from 2012 to 2022 to summarize the best available treatment. The group established priorities regarding management, based on both the risk of developing infections caused by K. pneumoniae and the risk of poor outcome. Moreover, we reviewed and updated the most important clinical entities and the new antibiotic treatments recently developed. After analysis of the priorities outlined, this group of experts established a series of recommendations and designed a management algorithm.