Invasive fungal infections are a growing problem in critically ill patients and are associated with increased morbidity and mortality. Most of them are due to Candida species, especially Candida albicans. Invasive candidiasis includes candidaemia, disseminated candidiasis with deep organ involvement and chronic disseminated candidiasis. During the last decades rare pathogenic fungi, such as Aspergillus species, Zygomycetes, Fusarium species and Scedosporium have also emerged. Timely diagnosis and proper treatment are of paramount importance for a favorable outcome. Besides blood cultures, several laboratory tests have been developed in the hope of facilitating an earlier detection of infection. The antifungal armamentarium has also been expanded allowing a treatment choice tailored to individual patients’ needs. The physician can choose among the old class of polyenes, the older and newer azoles and the echinocandins. Factors related to patient’s clinical situation and present co-morbidities, local epidemiology data and purpose of treatment (prophylactic, pre-emptive, empiric or definitive) should be taken into account for the appropriate choice of antifungal agent.

Peer reviewed article authored by (Flevari A, Theodorakopoulou M, Velegraki A, Armaganidis A, Dimopoulos G). Read article or submit your manuscript for publishing.

The aim of the study was to calculate the in vitro inspiratory resistance (R _ETT ) of adult endotracheal tubes (ETT), via the end-inspiratory occlusion method, and to apply this method in vivo in order to estimate R _ETT value in real time. By plotting R _ETT over inspiratory flow (V) and calculating Rohrer's coefficients of linear and nonlinear resistance, K ₁ and K ₂ respectively, we determined the resistive behaviour of each ETT. Peak and plateau pressures were recorded at both proximal and distal sites of the ETT after applying a three-second occlusion under constant flow. Distal pressure was obtained via an intraluminal catheter. R _ETT was calculated as (P _peak – P _plateau )/(V;), at both sites. R _ETT value resulted from the difference R _proximal - R _distal . Graph R _ETT over (V;) was plotted and Rohrer's constants were calculated by the method of least squares. For ETTs with inner diameter 9.0, 8.5, 8.0, 7.5, 7.0 and 6.5 mm, K ₂ was 2.42, 3.05, 4.65, 6.01, 9.17 and 12.80 cmH ₂ O/l/s, respectively. The intraluminal catheter increased R _ETT No.7.0 by an average of 49%. Finally, ten patients with partially obstructed ETTs were tested and K ₂ in vivo constants found to be higher than their corresponding in vitro values (P value 0.00012). Therefore, knowing the performing size of an ETT may help the clinicians identify ETT obstruction and deal with weaning problems.

Increased levels of cytokines or reactive oxygen species (ROS) in the bronchoalveolar lavage (BAL) fluid are associated with acute lung injury after ischemia/reperfusion. We investigated the correlation of these markers with the degree of lung injury in a rabbit model of hemorrhagic shock. Rabbits, maintained by mechanical ventilation, were left untreated (control) or subjected to hemorrhagic shock by withdrawing blood (n = 12 for each group). Shock animals were re-infused their shed blood for resuscitation. At the end of the experiment, BAL fluid was recovered, in which parameters of oxidative stress and cytokines were measured. Macrophages and malondialdehyde levels were increased (p = 0.043 and p = 0.003, respectively), and total antioxidant capacity (TAC) was decreased in the shock animals compared with control (p = 0.009). Production of ROS was significantly enhanced in shock animals compared with controls (p < 0.001). BAL fluid levels of tumor necrosis factor-alpha, interleukin (IL)-1beta and IL-6 were higher in shock rabbits by more than twofold (p < 0.001 for each). Shock animals also showed higher histopathological scores that represent severe tissue damage than controls (p = 0.022). Numbers of macrophages and levels of ROS and TAC were correlated with the degree of lung injury (p = 0.006, p = 0.02, and p = 0.04, respectively), but not cytokines. Therefore, resuscitation from hemorrhagic shock results in acute lung injury, with enhanced pulmonary oxidative and inflammatory responses. In conclusion, ROS in the BAL fluid are good markers that predict lung injury following hemorrhagic shock and resuscitation.

Hypoxemic reperfusion attenuates brain injury secondary to severe cerebral ischemia, myocardial, and intestinal injury occurring in intestinal postischemic shock, and offers hemodynamic stabilization and attenuation of inflammatory response when applied in the resuscitation from hemorrhagic shock. In this study, we sought to investigate the effect of hypoxemic resuscitation on pulmonary endothelium. Prospective, randomized, controlled animal study. Experimental laboratory of a university intensive care unit. Male New Zealand White rabbits weighting 3-3.5 kg. Hemorrhagic shock at mean arterial pressure of 40 mm Hg was induced by exsanguinations in anesthetized, mechanically ventilated animals for 60 minutes and thereafter rabbits were resuscitated by homologous blood and Ringer's lactate infusion under normoxemia (Normox-Res group, Pao2 = 95-105 mm Hg, n = 9) or hypoxemia (Hypox-Res group, Pao2 = 35-40 mm Hg, n = 7). Using indicator-dilution techniques we measured at baseline and post resuscitation pulmonary capillary endothelial angiotensin converting enzyme activity expressed as percentage of metabolism (%M) and hydrolysis (v) of the substrate H-benzoyl-Phe-Ala-Pro. Normox-Res rabbits exhibited decreased %M (p < 0.05) and v (p < 0.05) post resuscitation as compared with baseline, while no differences occurred in the Hypox-Res group. Myeloperoxidase was measured in lung tissue and was higher in Normox-Res than Hypox-Res animals (p < 0.01). Lung injury was estimated microscopically, whereas the expression of the intercellular adhesion molecule-1 and the vascular cell adhesion molecule-1 were assessed by immunohistochemistry on sections coming from the same tissue block. Compared with Normox-Res, Hypox-Res animals exhibited lower lung injury histopathological score (p < 0.01) and lung malondialdehyde concentration (p < 0.01), and lower intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 expressions in both the inflammatory cells (p < 0.01) and the blood vessels (p < 0.05). Normoxemic resuscitation of hemorrhagic shock is associated with pulmonary endothelial dysfunction and lung injury that may be attenuated by hypoxemic resuscitation.