rss_2.0The Journal of Critical Care Medicine FeedSciendo RSS Feed for The Journal of Critical Care Medicine Journal of Critical Care Medicine Feed Carboxyhaemoglobin an Effective Bedside Prognostic Tool for Sepsis and Septic Shock Patients?<abstract> <title style='display:none'>Abstract</title> <sec><title style='display:none'>Introduction</title> <p>Proper management of sepsis poses a challenge even today, with early diagnosis and targeted treatment being the most important steps. Easy, cost-effective bedside tools are needed in order to pinpoint towards the outcome of sepsis or septic shock.</p> </sec> <sec><title style='display:none'>Aim of study</title> <p>This study aims to find a correlation between Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) severity scores, the Neutrophil-Lymphocytes Ratio (NLR) and carboxyhaemoglobin (COHb) levels in septic or septic shock patients with the scope of establishing a bed side cost-effective prognostic tool.</p> </sec> <sec><title style='display:none'>Materials and methods</title> <p>A pilot, prospective, observational, and ongoing study was conducted on 61 patients admitted with sepsis or septic shock according to the SEPSIS 3 Consensus definition. We followed clinical and paraclinical parameters on day 1 (D1) and day 5 (D5) after meeting the inclusion criteria.</p> </sec> <sec><title style='display:none'>Results</title> <p>On D1 we found a statistically significant positive correlation between each severity score (p &lt;0.0001), r = 0.7287 for SOFA vs. APACHE II with CI: 0.5841–0.8285, r = 0.6862 for SOFA vs. SAPS II with CI: 0.5251–0.7998 and r = 0.8534 for APACHE II vs. SAPS II with CI: 0.7663 to 0.9097. On D5 we observed similar results: a significant positive correlation between each severity score (p &lt;0.0001), with r = 0.7877 for SOFA vs. APACHE II with CI: 0.6283 to 0.8836, r = 0.8210 for SOFA vs. SAPS II with CI: 0.6822 to 0.9027 and r = 0.8880 for APACHE II vs. SAPS II., CI: 0.7952 to 0.9401. Nil correlation was found between the severity scores, NLR and COHb on D1 and D5.</p> </sec> <sec><title style='display:none'>Conclusion</title> <p>Cost-effective bedside tools to pinpoint towards the outcome of sepsis are yet to be found, however the positive correlation between the severity scores point out to a combination of such tools for prognosis prediction of septic or septic shock patients.</p> </sec> </abstract>ARTICLEtrue of Non-Beneficial Interventions and their Impact on the Intensive Care Unit Costs<abstract> <title style='display:none'>Abstract</title> <sec><title style='display:none'>Introduction</title> <p>Using a plan to limit non-beneficial life support interventions has significantly reduced harm and loss of dignity for patients at the end of life. The association of these limitations with patients’ clinical characteristics and health care costs in the intensive care unit (ICU) needs further scientific evidence.</p> </sec> <sec><title style='display:none'>Aim of the study</title> <p>To explore decisions to limit non-beneficial life support interventions, their correlation with patients’ clinical data, and their effect on the cost of care in the ICU.</p> </sec> <sec><title style='display:none'>Material and Methods</title> <p>We included all patients admitted to the general ICU of a hospital in Greece in a two-year (2019–2021) prospective study. Data collection included patient demographic and clinical variables, data related to decisions to limit (withholding, withdrawing) non-beneficial interventions (NBIs), and economic data. Comparisons were made between patients with and without limitation decisions.</p> </sec> <sec><title style='display:none'>Results</title> <p>NBIs were limited in 164 of 454 patients (36.12%). Patients with limitation decisions were associated with older age (70y vs. 62y; p&lt;0,001), greater disease severity score (APACHE IV, 71 vs. 50; p&lt;0,001), longer length of stay (7d vs. 4.5d; p&lt;0,001), and worse prognosis of death (APACHE IV PDR, 48.9 vs. 17.35; p&lt;0,001). All cost categories and total cost per patient were also higher than the patient without limitation of NBIs (9247,79€ vs. 8029,46€, p&lt;0,004). The mean daily cost has not differed between the groups (831,24€ vs. 832,59€; p&lt;0,716). However, in the group of patients with limitations, all cost categories, including the average daily cost (767.31€ vs. 649.12€) after the limitation of NBIs, were reduced to a statistically significant degree (p&lt;0.001).</p> </sec> <sec><title style='display:none'>Conclusions</title> <p>Limiting NBIs in the ICU reduces healthcare costs and may lead to better management of ICU resource use.</p> </sec> </abstract>ARTICLEtrue Psoas Area and Psoas Density Assessment in COVID-19 Patients Using CT Imaging – Could Muscle Mass Alteration During Intensive Care Hospitalization be Determined?<abstract> <title style='display:none'>Abstract</title> <sec><title style='display:none'>Background</title> <p>Since its debut, as reported by the first published studies, COVID-19 has been linked to life-threatening conditions that needed vital assistance and admission to the intensive care unit. Skeletal muscle is a core element in an organism’s health due to its ability to keep energy balance and homeostasis. Many patients with prolonged hospitalization are characterized by a greater probability prone to critical illness myopathy or intensive care unit-acquired weakness.</p> </sec> <sec><title style='display:none'>Objective</title> <p>The main aim of this study was to assess the skeletal muscle in a COVID-19 cohort of critically ill patients by measuring the psoas area and density.</p> </sec> <sec><title style='display:none'>Material and methods</title> <p>This is a retrospective study that included critically ill adult patients, COVID-19 positive, mechanically ventilated, with an ICU stay of over 24 hours, and who had 2 CT scans eligible for psoas muscle evaluation. In these patients, correlations between different severity scores and psoas CT scans were sought, along with correlations with the outcome of the patients.</p> </sec> <sec><title style='display:none'>Results</title> <p>Twenty-two patients met the inclusion criteria. No statistically significant differences were noticed regarding the psoas analysis by two blinded radiologists. Significant correlations were found between LOS in the hospital and in ICU with psoas area and Hounsfield Units for the first CT scan performed. With reference to AUC-ROC and outcome, it is underlined that AUC-ROC is close to 0.5 values, for both the psoas area and HU, indicating that the model had no class separation capacity.</p> </sec> <sec><title style='display:none'>Conclusion</title> <p>The study suggested that over a short period, the psoas muscle area, and the psoas HU decline, for both the left and the right sight, in adult COVID-19 patients in ICU conditions, yet not statistically significant. Although more than two-thirds of the patients had a negative outcome, it was not possible to demonstrate an association between the SARS-COV2 infection and psoas muscle impairment. These findings highlight the need for further larger investigations.</p> </sec> </abstract>ARTICLEtrue Prognostic Utility of Cytokines in Hospitalized COVID-19 Patients<abstract> <title style='display:none'>Abstract</title> <sec><title style='display:none'>Introduction</title> <p>The severity of COVID-19 relies on several factors, but the overproduction of pro-inflammatory cytokines remains a central mechanism. The aim of this study was to investigate the predictive utility of interleukin (IL)-6, IL-8, IL-10, IL-12, tumor necrosis factor alpha (TNF-α), and interferon gamma (IFN-γ) measurement in patients with COVID-19.</p> </sec> <sec><title style='display:none'>Material and Methods</title> <p>We prospectively enrolled 181 adult patients with COVID-19 admitted to the 1<sup>st</sup> Infectious Disease County Hospital Târgu Mureș from December 2020 to September 2021. Serum cytokine levels were measured and correlated with disease severity, need for oxygen therapy, intensive care unit (ICU) transfer, and outcome.</p> </sec> <sec><title style='display:none'>Results</title> <p>We found significantly higher serum levels of IL-6, IL-8, and IL-10 in patients with severe COVID-19 and in those with a fatal outcome. The logistic regression analysis showed a significant predictive value for IL-8 regarding disease severity, and for IL6 and IL-10 regarding ICU transfer and fatal outcome.</p> </sec> <sec><title style='display:none'>Conclusions</title> <p>Serum levels of IL-6, IL-8, and IL-10 were significantly increased in patients with COVID-19, but their predictive value regarding disease severity and the need for oxygen therapy was poor. We found IL-6 and IL-10 to have a good predictive performance regarding ICU transfer and fatal outcome.</p> </sec> </abstract>ARTICLEtrue of Biochemical Parameters as Predictors for Need of Invasive Ventilation in Severely Ill COVID-19 Patients<abstract> <title style='display:none'>Abstract</title> <sec><title style='display:none'>Background</title> <p>Though laboratory tests have been shown to predict mortality in COVID-19, there is still a dearth of information regarding the role of biochemical parameters in predicting the type of ventilatory support that these patients may require.</p> </sec> <sec><title style='display:none'>Methods</title> <p>The purpose of our retrospective observational study was to investigate the relationship between biochemical parameters and the type of ventilatory support needed for the intensive care of severely ill COVID-19 patients. We comprehensively recorded history, physical examination, vital signs from point-of-care testing (POCT) devices, clinical diagnosis, details of the ventilatory support required in intensive care and the results of the biochemical analysis at the time of admission. Appropriate statistical methods were used and P-values &lt; 0.05 were considered significant. Receiver operating characteristics (ROC) analysis was performed and Area Under the Curve (AUC) of 0.6 to 0.7, 0.7 to 0.8, 0.8 to 0.9, and &gt;0.9, respectively, were regarded as acceptable, fair, good, and exceptional for discrimination.</p> </sec> <sec><title style='display:none'>Results</title> <p>Statistically significant differences (p&lt;0.05) in Urea (p = 0.0351), Sodium (p = 0.0142), Indirect Bilirubin (p = 0.0251), Albumin (p = 0.0272), Aspartate Transaminase (AST) (p = 0.0060) and Procalcitonin (PCT) (p = 0.0420) were observed between the patients who were maintained on non-invasive ventilations as compared to those who required invasive ventilation. In patients who required invasive ventilation, the levels of Urea, Sodium, Indirect bilirubin, AST and PCT were higher while Albumin was lower. On ROC analysis, higher levels of Albumin was found to be acceptable indicator of maintenance on non-invasive ventilation while higher levels of Sodium and PCT were found to be fair predictor of requirement of invasive ventilation.</p> </sec> <sec><title style='display:none'>Conclusion</title> <p>Our study emphasizes the role of biochemical parameters in predicting the type of ventilatory support that is needed in order to properly manage severely ill COVID-19 patients.</p> </sec> </abstract>ARTICLEtrue Retrospective Cohort Study of Traumatic Brain Injury in Children: A Single-Institution Experience and Determinants of Neurologic Outcome<abstract> <title style='display:none'>Abstract</title> <sec><title style='display:none'>Introduction</title> <p>Traumatic brain injury (TBI) has become a significant cause of death and morbidity in childhood since the elucidation of infectious causes within the last century. Mortality rates in this population decreased over time due to developments in technology and effective treatment modalities.</p> </sec> <sec><title style='display:none'>Aim of the study</title> <p>This retrospective cohort study aimed to describe the volume, severity and mechanism of all hospital-admitted pediatric TBI patients at a university hospital over a 5-year period.</p> </sec> <sec><title style='display:none'>Material and Methods</title> <p>This was a single-center, retrospective cohort study including 90 pediatric patients with TBI admitted to a tertiary care PICU. The patients’ demographic data, injury mechanisms, disease and trauma severity scores, initiation of enteral nutrition and outcome measures such as hospital stay, PICU stay, duration of mechanical ventilation, mortality, and Glasgow Outcome Scale (GOS) were also recorded. Late enteral nutrition was defined as initiation of enteral feeding after 48 hours of hospitalization.</p> </sec> <sec><title style='display:none'>Results</title> <p>Of the 90 patients included in the cohort, 60% had mild TBI, 21.1% had moderate TBI and 18.9% had severe TBI. Their mean age was 69 months (3–210 months). TBI was isolated in 34 (37.8%) patients and observed as a part of multisystemic trauma in 56 (62.2%). The most commonly involved site in multisystemic injury was the thorax (33.3%). The length of hospitalization in the late enteral nutrition group was significantly higher than that in the early nutrition group, while the PICU stay was not significantly different between the two groups. The multiple logistic regression analysis found a significant relationship between GOS-3rd month and PIM3 score, the presence of diffuse axonal injury and the need for CPR in the first 24 h of hospitalization.</p> </sec> <sec><title style='display:none'>Conclusion</title> <p>Although our study showed that delayed enteral nutrition did not affect neurologic outcome, it may lead to prolonged hospitalization and increased hospital costs. High PIM3 scores and diffuse axonal injury are both associated with worse neurologic outcomes.</p> </sec> </abstract>ARTICLEtrue Human Microbiome in Intensive Care - A Journey Forward? of Minitracheostomy After Extubation in Patients with Pneumonia at High Risk of Reintubation: A Case Series<abstract> <title style='display:none'>Abstract</title> <sec><title style='display:none'>Introduction</title> <p>Minitracheostomy involves the percutaneous insertion of a 4-mm-diameter cricothyroidotomy tube for tracheal suctioning to facilitate the clearance of airway secretions. The advantage of using the minitracheostomy is in the clearance of secretions, however data on their usefulness for respiratory failure after extubation is limited. Aim of the study: We aimed to assess the use of minitracheostomy for patients with challenging extubation caused by significant sputum.</p> </sec> <sec><title style='display:none'>Material and Methods</title> <p>We conducted a retrospective analysis of consecutive case series. We analyzed the data of 31 patients with pneumonia. After minitracheostomy, the primary endpoints of reintubation within 72 hours and clinical effects, including mortality, length of intensive care unit (ICU), or hospital stay, were assessed. The successful extubation group included patients who did not require reintubation within 72 hours. Conversely, the reintubation group consisted of patients mandating reestablishment of intubation within 72 hours.</p> </sec> <sec><title style='display:none'>Results</title> <p>Among those who underwent minitracheostomy after extubation, 22 (71%) underwent successful extubation and 9 underwent reintubation (reintubation rate: 29%). The in-hospital mortality rates after 30 days were 18.2% in the successful extubation group and 22.2% in the reintubation group. The ICU and hospital lengths of stay were 11 days (interquartile range: 8–14.3 days) and 23 days (interquartile range: 15.5–41 days), respectively, in the successful extubation group; they were 14 days (interquartile range: 11–18.5 days) and 30 days (interquartile range: 16–45.5 days), respectively, in the reintubation group.</p> </sec> <sec><title style='display:none'>Conclusions</title> <p>The prophylactic use of minitracheostomy may be an option as a means of reducing reintubation in patients with pneumonia who are at very high risk of reintubation.</p> </sec> </abstract>ARTICLEtrue Delirium Masking Acute Angle Closure Glaucoma<abstract> <title style='display:none'>Abstract</title> <sec><title style='display:none'>Introduction</title> <p>Acute angle closure glaucoma (AACG) is an ophthalmological emergency, and can lead to the devastating consequence of permanent vision loss if not detected and treated promptly. We present a case of an atypical presentation of unilateral AACG on post operative day (POD) 1, after a prolonged operation under general anaesthesia (GA).</p> </sec> <sec><title style='display:none'>Case presentation</title> <p>A 65-year-old female underwent a 16 hour long operation for breast cancer and developed an altered mental status with a left fixed dilated pupil on POD 1. She was intubated to secure her airway in view of a depressed consciousness level and admitted to the intensive care unit. Initial blood investigations and brain imaging were unremarkable. On subsequent review by the ophthalmologist, a raised intraocular pressure was noted and she was diagnosed with acute angle closure glaucoma. She was promptly started on intravenous acetazolamide and pressure-lowering ophthalmic drops. Her intraocular pressure normalized in the next 24 hours with improvement in her mental status to baseline.</p> </sec> <sec><title style='display:none'>Conclusion</title> <p>AACG needs to be consistently thought of as one of the top differentials in any post-operative patient with eye discomfort or abnormal ocular signs on examination. A referral to the ophthalmologist should be made promptly once AACG is suspected.</p> </sec> </abstract>ARTICLEtrue A Possible Cause of Spontaneous Pneumoperitoneum<abstract> <title style='display:none'>Abstract</title> <sec><title style='display:none'>Introduction</title> <p>Pneumoperitoneum is the presence of air within the peritoneal cavity and is mostly caused by organ rupture. Spontaneous pneumoperitoneum accounts 5% to 15% of the cases and occurs in the absence of organ damage. The pulmonary origin of pneumoperitoneum is unusual, and probably associated with mechanical ventilation and alveolar leak. In patients with coronavirus disease 2019 (COVID-19) there are some reports of air leak, like pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema.</p> </sec> <sec><title style='display:none'>Case presentation</title> <p>We present the case of a 70-year-old man with COVID-19 pneumonia admitted to the Intensive Care Unit (ICU). Since admission he was on Non-Invasive Ventilation (NIV), without improvement, needing Invasive Mechanical Ventilation (IMV) due to severe respiratory failure. Five days after IMV despite protective lung ventilation, massive spontaneous subcutaneous emphysema, pneumomediastinum and pneumoperitoneum were diagnosed. Besides initial conservative management 12 hours later, the patient developed abdominal compartment syndrome requiring percutaneous needle decompression.</p> </sec> <sec><title style='display:none'>Conclusions</title> <p>Pneumoperitoneum can be considered a rare complication of COVID-19 pneumonia and its management, resulting not only from the viral pulmonary but also from secondary causes. Conservative management should be usually enough. However, in the presence of abdominal compartment syndrome prompt recognition and treatment are crucial and eventually lifesaving.</p> </sec> </abstract>ARTICLEtrue Injury in Critically Ill Patients with COVID-19 – From Pathophysiological Mechanisms to a Personalized Therapeutic Model<abstract> <title style='display:none'>Abstract</title> <p>Acute kidney injury is a common complication of COVID-19, frequently fuelled by a complex interplay of factors. These include tubular injury and three primary drivers of cardiocirculatory instability: heart-lung interaction abnormalities, myocardial damage, and disturbances in fluid balance. Further complicating this dynamic, renal vulnerability to a “second-hit” injury, like a SARS-CoV-2 infection, is heightened by advanced age, chronic kidney disease, cardiovascular diseases, and diabetes mellitus. Moreover, the influence of chronic treatment protocols, which may constrain the compensatory intrarenal hemodynamic mechanisms, warrants equal consideration. COVID-19-associated acute kidney injury not only escalates mortality rates but also significantly affects long-term kidney function recovery, particularly in severe instances. Thus, the imperative lies in developing and applying therapeutic strategies capable of warding off acute kidney injury and decelerating the transition into chronic kidney disease after an acute event. This narrative review aims to proffer a flexible diagnostic and therapeutic strategy that recognizes the multi-faceted nature of COVID-19-associated acute kidney injury in critically ill patients and underlines the crucial role of a tailored, overarching hemodynamic and respiratory framework in managing this complex clinical condition.</p> </abstract>ARTICLEtrue Therapy from Friend to Foe Factors for Weaning Failure in COVID-19 Patients<abstract> <title style='display:none'>Abstract</title> <sec><title style='display:none'>Background</title> <p>Data on risk factors associated with mechanical ventilation (MV) weaning failure among SARS-CoV2 ARDS patients is limited. We aimed to determine clinical characteristics associated with weaning outcome in SARS-CoV2 ARDS patients under MV.</p> </sec> <sec><title style='display:none'>Objectives</title> <p>To determine potential risk factors for weaning outcome in patients with SARS-CoV2 ARDS.</p> </sec> <sec><title style='display:none'>Methods</title> <p>A retrospective observational study was conducted in the ICUs of four Greek hospitals via review of the electronic medical record for the period 2020–2021. All consecutive adult patients were screened and were included if they fulfilled the following criteria: a) age equal or above 18 years, b) need for MV for more than 48 hours and c) diagnosis of ARDS due to SARS-CoV2 pneumonia or primary or secondary ARDS of other aetiologies. Patient demographic and clinical characteristics were recorded for the first 28 days following ICU admission. The primary outcome was weaning success defined as spontaneous ventilation for more than 48 hours.</p> </sec> <sec><title style='display:none'>Results</title> <p>A hundred and fifty eight patients were included; 96 SARS-CoV2 ARDS patients. SOFA score, Chronic Obstructive Pulmonary Disease (COPD) and shock were independently associated with the weaning outcome OR(95% CI), 0.86 (0.73–0.99), 0.27 (0.08–0.89) and 0.30 (0.14–0.61), respectively]. When we analysed data from SARS-CoV2 ARDS patients separately, COPD [0.18 (0.03–0.96)] and shock [0.33(0.12 – 0.86)] were independently associated with the weaning outcome.</p> </sec> <sec><title style='display:none'>Conclusions</title> <p>The presence of COPD and shock are potential risk factors for adverse weaning outcome in SARS-CoV2 ARDS patients.</p> </sec> </abstract>ARTICLEtrue Gender Gap in Aortic Dissection: A Prospective Analysis of Risk and Outcomes<abstract> <title style='display:none'>Abstract</title> <p>Aortic dissection (AD) is a severe cardiovascular condition that could have negative consequences. Our study employed a prospective design and examined preoperative, perioperative, and postoperative data to evaluate the effects of gender on various medical conditions. We looked at how gender affected the results of aortic dissection (AD). In contrast to female patients who had more systemic hypertension (p=0.031), male patients had higher rates of hemopericardium (p=0.003), pulmonary hypertension (p=0.039), and hemopericardium (p=0.003). Dobutamine administration during surgery significantly raised the mortality risk (p=0.015). There were noticeably more women patients (p=0.01) in the 71 to 80 age group. Significant differences in age (p=0.004), eGFR at admission (p=0.009), and eGFR at discharge (p=0.006) were seen, however, there was no association between gender and mortality. In conclusion, our findings highlight that gender may no longer be such an important aspect of aortic dissection disease as we previously thought, and this information could have an important contribution for surgeons as well as for anesthesiologists involved in the management of acute aortic dissection.</p> </abstract>ARTICLEtrue of Intubation with McGrath Videolaryngoscope and Incidence of Adverse Events During Tracheal Intubation in COVID-19 Patients: A Prospective Observational Study<abstract> <title style='display:none'>Abstract</title> <sec><title style='display:none'>Background</title> <p>Tracheal intubation in critically ill patients remains high-risk despite advances in equipment, technique, and clinical guidelines. Many patients with COVID-19 were in respiratory distress and required intubation that is considered an aerosol-generating procedure (AGP). The transition to videolaryngoscopy as a routine first line option throughout anesthetic and ICU practice has been reported. We evaluated the ease of intubation, success rate, use of accessory maneuvers and adverse outcomes during and 24 hours after intubation with the McGrath videolaryngoscope.</p> </sec> <sec><title style='display:none'>Methods</title> <p>This was a prospective, observational single center study conducted at non-operating room locations that included all adults (&gt;18 years old) with suspected or confirmed COVID-19 infection and were intubated by McGrath videolaryngoscope. The anesthesiologist performed tracheal intubation were requested to fill online data collection form. A co-investigator was responsible to coordinate daily with assigned consultants for COVID intubation and follow up of patients at 24 hours after intubation.</p> </sec> <sec><title style='display:none'>Results</title> <p>A total of 105 patients were included in our study. Patients were predominantly male (n=78; 74.3%), their COVID status was either confirmed (n=97, 92.4%) or suspected (n=8, 7.6%). Most were intubated in the COVID ward (n=59, 56.2%) or COVID ICU (n=23, 21.9%). The overall success rate of intubation with McGrath in the first attempt was 82.9%. The glottic view was either full (n=85, 80.95%), partial (n=16, 15.24%) or none (n=4, 3.81%). During intubation, hypoxemia occurred in 18.1% and hypotension in 16.2% patients. Within 24 hours of intubation, pneumothorax occurred in 1.9%, cardiac arrest and return of spontaneous circulation in 6.7% and mortality in 13.3% of patients.</p> </sec> <sec><title style='display:none'>Conclusion</title> <p>These results illustrate the ease and utility of the McGrath videolaryngoscope for tracheal intubation in COVID-19 patients. Its disposable blade is of significant value in protectin during tracheal intubation.</p> </sec> </abstract>ARTICLEtrue and Early Vasopressors in the Management of Septic Shock: Do We Have the Right Answers Yet?<abstract> <title style='display:none'>Abstract</title> <p>Septic shock is a common condition associated with hypotension and organ dysfunction. It is associated with high mortality rates of up to 60% despite the best recommended resuscitation strategies in international guidelines. Patients with septic shock generally have a Mean Arterial Pressure below 65 mmHg and hypotension is the most important determinant of mortality among this group of patients. The extent and duration of hypotension are important. The two initial options that we have are 1) administration of intravenous (IV) fluids and 2) vasopressors, The current recommendation of the Surviving Sepsis Campaign guidelines to administer 30 ml/kg fluid cannot be applied to all patients. Complications of fluid over-resuscitation further delay organ recovery, prolong ICU and hospital length of stay, and increase mortality. The only reason for administering intravenous fluids in a patient with circulatory shock is to increase the mean systemic filling pressure in a patient who is volume-responsive, such that cardiac output also increases. The use of vasopressors seems to be a more appropriate strategy, the very early administration of vasopressors, preferably during the first hour after diagnosis of septic shock, may have a multimodal action and potential advantages, leading to lower morbidity and mortality in the management of septic patients. Vasopressor therapy should be initiated as soon as possible in patients with septic shock.</p> </abstract>ARTICLEtrue Intelligence: The Next Blockbuster Drug in Critical Care? Plus Intravenous Polymyxin B Versus Colistin in the Treatment of Pandrug-Resistant Klebsiella Pneumonia-mediated Ventilator-Associated Pneumonia: A Retrospective Cohort Study in Bangladesh<abstract> <title style='display:none'>ABSTRACT</title> <sec> <title style='display:none'>Background</title> <p>Pandrug-resistant Klebsiella pneumoniae ventilator associated pneumonia (VAP) is associated with high rate of mortality in intensive care unit (ICU) and has been recognized as a difficult-to-treat infection worldwide. Polymyxin B or colistin-based combination therapies are frequently used worldwide though microbial eradication rate is not promising.</p> </sec> <sec> <title style='display:none'>Aim</title> <p>The aim of this study is to compare the clinical outcome of intravenous with aerosolized polymyxin B versus colistin in the treatment of pandrug-resistant K. pneumoniae VAP.</p> </sec> <sec> <title style='display:none'>Methods</title> <p>This retrospective cohort study was conducted on 222 mechanically ventilated patients admitted from May 11, 2019 to October 19, 2020. K. pneumoniae isolates were resistant to all available antibiotics, including polymyxins in culture sensitivity tests. As treatment, polymyxin B and colistin was administered in intravenous and aerosolized form concurrently twice daily in 106 patients and 116 patients in PMB and CLN group, respectively for 14 days. Survival rate, safety, and clinical outcomes were compared among the groups. The Cox proportional-hazard model was performed to calculate hazard ratio (HR) with 95% confidence intervals (CI).</p> </sec> <sec> <title style='display:none'>Results</title> <p>Patients in PMB group showed more microbial eradication than the patients CLN group [68.1% (n=116)/83% (n=106), respectively; P &lt;0.05). The median day of intubation and ICU stay in PMB group was shorter than that in CLN group [10 (IQR: 9-12.25) vs. 14 (IQR: 11-19), P &lt;0.05; 12 (IQR: 10-14) vs. 15 (IQR: 9-18.5), P=0.072, respectively] with reduced 60-day all-cause mortality rate [15% (n=106) vs. 21.55% (n=116)]. Polymyxin B improved survival compared to colistin (multivariate HR: 0.662; 95% CI=0.359-1.222, P=0.195).</p> </sec> <sec> <title style='display:none'>Conclusions</title> <p>Concurrent administration of intravenous and aerosolized polymyxin B in patients with pandrug-resistant K. pneumoniae-associated VAP revealed better microbial eradication, reduced the length of intubation and ICU stay, and improved survival rate compared to colistin.</p> </sec> </abstract>ARTICLEtrue Prone Decubitus Positioning in COVID-19 Patients: A Systematic Review and MetaAnalysis<abstract> <title style='display:none'>ABSTRACT</title> <p>To date, recommendations for the implementation of awake prone positioning in patients with hypoxia secondary to SARSCoV2 infection have been extrapolated from prior studies on respiratory distress. Thus, we carried out a systematic review and metaanalysis to evaluate the benefits of pronation on the oxygenation, need for endotracheal intubation (ETI), and mortality of this group of patients. We carried out a systematic search in the PubMed and Embase databases between June 2020 and November 2021. A randomeffects metaanalysis was performed to evaluate the impact of pronation on the ETI and mortality rates. A total of 213 articles were identified, 15 of which were finally included in this review. A significant decrease in the mortality rate was observed in the group of pronated patients (relative risk [RR] = 0.69; 95% confidence interval [CI]: 0.480.99; p = 0.044), but no significant effect was observed on the need for ETI (RR = 0.79; 95% CI: 0.631.00; p = 0.051). However, a subgroup analysis of randomized clinical trials (RCTs) did reveal a significant decrease in the need for this intervention (RR = 0.83; 95% CI: 0.710.97). Prone positioning was found to significantly reduce mortality, also diminishing the need for ETI, although this effect was statistically significant only in the subgroup analysis of RCTs. Patients’ response to awake prone positioning could be greater when this procedure is implemented early and in combination with noninvasive mechanical ventilation (NIMV) or highflow nasal cannula (HFNC) therapy.</p> </abstract>ARTICLEtrue Injury Risk in Traumatic Brain Injury Managed With Optimal Cerebral Perfusion Pressure Guided-Therapy<abstract> <title style='display:none'>ABSTRACT</title> <sec> <title style='display:none'>Introduction</title> <p>Management of traumatic brain injury (TBI) has to counterbalance prevention of secondary brain injury without systemic complications, namely lung injury. The potential risk of developing acute respiratory distress syndrome (ARDS) leads to therapeutic decisions such as fluid balance restriction, high PEEP and other lung protective measures, that may conflict with neurologic outcome. In fact, low cerebral perfusion pressure (CPP) may induce secondary ischemic injury and mortality, but disproportionate high CPP may also increase morbidity and worse lung compliance and hypoxia with the risk of developing ARDS and fatal outcome. The evaluation of cerebral autoregulation at bedside and individualized (optimal CPP) CPPopt-guided therapy, may not only be a relevant measure to protect the brain, but also a safe measure to avoid systemic complications.</p> </sec> <sec> <title style='display:none'>Aim of the study</title> <p>We aimed to study the safety of CPPopt-guided-therapy and the risk of secondary lung injury association with bad outcome.</p> </sec> <sec> <title style='display:none'>Methods and results</title> <p>Single-center retrospective analysis of 92 severe TBI patients admitted to the Neurocritical Care Unit managed with CPPopt-guided-therapy by PRx (pressure reactivity index). During the first 10 days, we collected data from blood gas, ventilation and brain variables. Evolution along time was analyzed using linear mixed-effects regression models. 86% were male with mean age 53±21 years. 49% presented multiple trauma and 21% thoracic trauma. At hospital admission, median GCS was 7 and after 3-months GOS was 3. Monitoring data was CPP 86±7mmHg, CPP-CPPopt -2.8±10.2mmHg and PRx 0.03±0.19. The average PFratio (PaO<sub>2</sub>/FiO<sub>2</sub>) was 305±88 and driving pressure 15.9±3.5cmH<sub>2</sub>O. PFratio exhibited a significant quadratic dependence across time and PRx and driving pressure presented significant negative association with PFRatio. CPP and CPPopt did not present significant effect on PFratio (p=0.533; p=0.556). A significant positive association between outcome and the difference CPP-CPPopt was found.</p> </sec> <sec> <title style='display:none'>Conclusion</title> <p>Management of TBI using CPPopt-guided-therapy was associated with better outcome and seems to be safe regarding the development of secondary lung injury.</p> </sec> </abstract>ARTICLEtrue