Purpose To investigate whether (1 → 3)-β-d-Glucan (BDG)-guidance shortens time to antifungal therapy and thereby reduces mortality of sepsis patients with high risk of invasive Candida infection (ICI). Methods Multicenter, randomized, controlled trial carried out between September 2016 and September 2019 in 18 intensive care units enrolling adult sepsis patients at high risk for ICI. Patients in the control group received targeted antifungal therapy driven by culture results. In addition to targeted therapy, patients in the BDG group received antifungals if at least one of two consecutive BDG samples taken during the first two study days was ≥ 80 pg/mL. Empirical antifungal therapy was discouraged in both groups. The primary endpoint was 28-day-mortality. Results 339 patients were enrolled. ICI was diagnosed in 48 patients (14.2%) within the first 96 h after enrollment. In the BDG-group, 48.8% (84/172) patients received antifungals during the first 96 h after enrollment and 6% (10/167) patients in the control group. Death until day 28 occurred in 58 of 172 patients (33.7%) in the BDG group and 51 of 167 patients (30.5%) in the control group (relative risk 1.10; 95% confidence interval, 0.80–1.51; p = 0.53). Median time to antifungal therapy was 1.1 [interquartile range (IQR) 1.0–2.2] days in the BDG group and 4.4 (IQR 2.0–9.1, p < 0.01) days in the control group. Conclusions Serum BDG guided antifungal treatment did not improve 28-day mortality among sepsis patients with risk factors for but unexpected low rate of IC. This study cannot comment on the potential benefit of BDG-guidance in a more selected at-risk population.

Introduction: A reliable prediction of successful weaning from respiratory support may be crucial for the overall outcome of the critically ill patient. The electrical activity of the diaphragm (EAdi) allows one to monitor the patients’ respiratory drive and their ability to meet the increased respiratory demand. In this pilot study, we compared the EAdi with conventional parameters of weaning failure, such as the ratio of respiratory rate to tidal volume. Methods: We studied 18 mechanically ventilated patients considered difficult to wean. For a spontaneous breathing trial (SBT), the patients were disconnected from the ventilator and given oxygen through a T-piece. The SBT was evaluated by using standard criteria. Results: Twelve patients completed the SBT successfully, and six failed. The EAdi was significantly different in the two groups. We found an early increase in EAdi in the failing patients that was more pronounced than in any of the patients who successfully passed the SBT. Changes in EAdi predicted an SBT failure earlier than did conventional parameters. Conclusions: EAdi monitoring adds valuable information during weaning from the ventilator and may help to identify patients who are not ready for discontinuation of respiratory support.

(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute—refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative—advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ −2 points, PRESET score ≥ 6 points, and “do not attempt resuscitation” order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.

Zusammenfassung: Hintergrund: Sepsis ist eine akut lebensbedrohliche multiple Organdysfunktion, ausgelöst durch eine Infektion. Methodik: Bei der vorliegenden Leitlinie handelt es sich um ein Update der S3-Leitlinie „Sepsis – Prävention, Diagnose, Therapie und Nachsorge“ (AMWF-Register-Nr.: 079–001) der Deutschen Sepsis-Gesellschaft (DSG) vom 31.12.2018. Dabei wurde das Update der „Surviving sepsis campaign (SSC): international guidelines for management of sepsis and septic shock 2021“ vom 04.10.2021 als Referenzleitlinie zugrunde gelegt. Die DSG-Leitlinienkommission verglich jede Empfehlung zu den zugrunde liegenden PICO-Fragen der DSG-Leitlinie 2018 (Literaturrecherche bis 12/2018) mit denen der SSC-Leitlinie 2021 (Literaturrecherche bis 07/2019) und bewertete die in der Zwischenzeit neu verfügbare publizierte Datenlage (Literaturrecherche bis 12/2024) mittels systematischer Aktualisierungsrecherchen und Literaturbewertungen unter Befolgung des Regelwerkes des GRADE-Systems und der AWMF. Ergebnisse: Insgesamt wurden 88 PICO-Fragen u. a. zur Diagnose und Therapie der Infektion und des Organversagens adressiert. Davon wurden 2 als Statements, 29 als Expertenkonsens und 57 als evidenzbasierte Empfehlungen (26 mit starkem und 31 mit schwachem Empfehlungsgrad) konsentiert. Im Vergleich zur Vorgänger-Leitlinie 2018 wurden 43 Empfehlungen überprüft, aber beibehalten. 16 Empfehlungen wurden geändert, und 29 Empfehlungen wurden neu ausgesprochen. Schlussfolgerung: Angesichts fehlender Evidenz für zahlreiche Maßnahmen zur stationären Versorgung von Patienten mit Sepsis oder septischem Schock wurden alte und neue Wissenslücken offenbart. Bei den evidenzbasierten Empfehlungen war die zugrunde liegende Evidenzqualität nach GRADE nur bei 5 Empfehlungen hoch, bei 18 Empfehlungen moderat, bei 17 Empfehlungen niedrig und bei 16 sehr niedrig. Diese Evidenzlücken können nur durch zukünftige multizentrische, nichtkommerzielle klinische Prüfungen geschlossen werden. Das Update der S3-Leitlinie Sepsis beinhaltet einige Aktualisierungen zu Empfehlungen der Vorgängerleitlinie. Diese Aktualisierungen werden in einige der fall- und einrichtungsbezogenen QS-Indikatoren des QS-Verfahrens 2025 einfließen müssen. Beeinträchtigungen in der gesundheitsbezogenen Lebensqualität müssen bei Überlebenden mehr in den Fokus der ambulanten Versorgung gerückt werden.

BACKGROUND: During noninvasive ventilation (NIV) of COPD patients, delayed off-cycling of pressure support can cause patient ventilator mismatch and NIV failure. This systematic experimental study analyzes the effects of varying cycling criteria on patient-ventilator interaction. METHODS: A lung simulator with COPD settings was connected to an ICU ventilator via helmet or face mask. Cycling was varied between 10 and 70% of peak inspiratory flow at different breathing frequencies (15 and 30 breaths/min) and pressure support levels (5 and 15 cm H ₂ O) using the ventilator's invasive and NIV mode with and without an applied leakage. RESULTS: Low cycling criteria led to severe expiratory cycle latency. Augmenting off-cycling reduced expiratory cycle latency ( P < .001), decreased intrinsic PEEP, and avoided non-supported breaths. Setting cycling to 50% of peak inspiratory flow achieved best synchronization. Overall, using the helmet interface increased expiratory cycle latency in almost all settings ( P < .001). Augmenting cycling from 10 to 40% progressively decreased expiratory pressure load ( P < .001). NIV mode decreased expiratory cycle latency compared with the invasive mode ( P < .001). CONCLUSION: Augmenting the cycling criterion above the default setting (20–30% peak inspiratory flow) improved patient ventilator synchrony in a simulated COPD model. This suggests that an individual approach to cycling should be considered, since interface, level of pressure support, breathing frequency, and leakage influence patient-ventilator interaction and thus need to be considered.