In a prospective, multicenter study of 342 blood samples from 187 patients with systemic inflammatory response syndrome, sepsis, or neutropenic fever, a new commercial PCR test (SepsiTest; Molzym) was evaluated for rapid diagnosis of bacteremia. The test comprises a universal PCR from the 16S rRNA gene, with subsequent identification of bacteria from positive samples by sequence analysis of amplicons. Compared to blood culture (BC), the diagnostic sensitivity and specificity of the PCR were 87.0 and 85.8%, respectively. Considering the 34 BC-positive patients, 28 were also PCR positive in at least one of the samples, resulting in a patient-related sensitivity of 82.4%. The concordance of PCR and BC for both positive and negative samples was (47 + 247)/342, i.e., 86.0%. In total, 31 patients were PCR/sequencing positive and BC negative, in whom the PCR result was judged as possible or probable to true bacteremia in 25. In conclusion, the PCR approach facilitates the detection of bacteremia in blood samples within a few hours. Despite the indispensability of BC diagnostics, the rapid detection of bacteria by SepsiTest appears to be a valuable tool, allowing earlier pathogen-adapted antimicrobial therapy in critically ill patients.

Introduction: Several single-center studies and meta-analyses have shown that perioperative goal-directed therapy may significantly improve outcomes in general surgical patients. We hypothesized that using a treatment algorithm based on pulse pressure variation, cardiac index trending by radial artery pulse contour analysis, and mean arterial pressure in a study group (SG), would result in reduced complications, reduced length of hospital stay and quicker return of bowel movement postoperatively in abdominal surgical patients, when compared to a control group (CG). Methods: 160 patients undergoing elective major abdominal surgery were randomized to the SG (79 patients) or to the CG (81 patients). In the SG hemodynamic therapy was guided by pulse pressure variation, cardiac index trending and mean arterial pressure. In the CG hemodynamic therapy was performed at the discretion of the treating anesthesiologist. Outcome data were recorded up to 28 days postoperatively. Results: The total number of complications was significantly lower in the SG (72 vs. 52 complications, p = 0.038). In particular, infection complications were significantly reduced (SG: 13 vs. CG: 26 complications, p = 0.023). There were no significant differences between the two groups for return of bowel movement (SG: 3 vs. CG: 2 days postoperatively, p = 0.316), duration of post anesthesia care unit stay (SG: 180 vs. CG: 180 minutes, p = 0.516) or length of hospital stay (SG: 11 vs. CG: 10 days, p = 0.929). Conclusions: This multi-center study demonstrates that hemodynamic goal-directed therapy using pulse pressure variation, cardiac index trending and mean arterial pressure as the key parameters leads to a decrease in postoperative complications in patients undergoing major abdominal surgery. Trial registration: ClinicalTrial.gov, NCT01401283.

Recently, continuous monitoring of cardiac output (CO) based on pulse contour analysis (Vigileo^®) has been introduced into practice. In this clinical study, we evaluated the accuracy of this system by comparing it with the transpulmonary thermodilution technique (TPID) in septic patients. We studied 24 mechanically ventilated patients with septic shock (16 male, 8 female, age 26–77 yr) receiving treatment with norepinephrine who for clinical indication underwent haemodynamic monitoring by the transpulmonary thermodilution technique using a PiCCO^®plus system (Pulsion Medical Systems, Munich, Germany). In parallel, arterial pulse contour was applied using the femoral arterial pressure curve (FloTrac^® pressure sensor, Vigileo^® monitor, Edwards Lifesciences, Irvine, USA). After baseline measurement, mean arterial pressure was elevated by increasing norepinephrine dosage, and CO was measured again before mean arterial pressure was reduced back to baseline levels. Fluid status and ventilator settings remained unchanged throughout. At each time point, CO by transpulmonary thermodilution was calculated from three central venous bolus injections of 15 ml of saline (<8°C). Linear regression and the Bland–Altman method were used for statistical analysis. Overall, CO was 6.7 (sd 1.8) (3.2–10.1) litre min⁻¹ for CO(TPID) and 6.2 (2.4) (3.0–17.6) litre min⁻¹ for CO(Vigileo^®). Linear regression revealed: CO(Vigileo^®) = 1.54 + 0.72 × CO(TPID) litre min⁻¹, r² = 0.26 (P < 0.0001). Mean bias between techniques [CO(TPID)–CO(Vigileo^®)] was 0.5 litre min⁻¹ (sd 2.3 litre min⁻¹). Correlation coefficients at the three time points were not significantly different from each other. Pulse contour analysis-derived CO (Vigileo^® system) underestimates CO(TPID) and is not as reliable as transpulmonary thermodilution in septic patients.

Dynamic variables, for example, systolic pressure variation (SPV), are superior to filling pressures for assessing fluid responsiveness. We analysed the effects of SPV-guided intraoperative fluid management on organ function and perfusion when compared with routine care. Eighty patients (44 female and 36 male) undergoing elective major abdominal surgery were randomly assigned to a control group [n=40, mean age 66 (sd 10), range 40–84 yr] or SPV group [n=40, age 61 (16), range 26–100 yr] in which intraoperative fluid management was guided by SPV (trigger: SPV>10%). Central venous O₂ saturation (ScvO₂), lactate and bilirubin, creatinine, indocyanine green plasma disappearance rate (ICG-PDR), and gastric mucosal CO₂ tension were measured after induction of anaesthesia, after 3, 6, 12, and 24 h. Patient characteristics, duration of surgery [5.8 (2.5) vs 5.4 (2.5) h], and infusion volumes (median 4865 vs 4330 ml) were comparable between the groups. At 3 and 6 h, SPV (P=0.04, P=0.01) and Δdown (P=0.005, P=0.01) were significantly higher in the control group. Oxygen transport and organ function were comparable: baseline and 24 h values for ICG-PDR: 28.5 (7.9) and 22.7 (7.8) vs 23.9 (6.9) and 26.1 (5.9)% min⁻¹, 77.7 (6.6) and 72.6 (5.5) vs 79.3 (7.1) and 72.8 (6.7)% for ScvO₂ and 1.0 (0.4) and 1.2 (0.6) vs 0.9 (0.2) and 1.3 (0.5) mmol litre⁻¹ for lactate. Length of mechanical ventilation, ICU stay, and mortality were comparable. In comparison with routine care, intraoperative SPV-guided treatment was associated with slightly increased fluid adminstration whereas organ perfusion and function was similar.