Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Apr 2011
ReviewNew challenges in the diagnosis, management, and prevention of central venous catheter-related infections.
Catheters are the leading source of bloodstream infections in critically ill patients. Because the clinical signs of infection are nonspecific, such infections are overly suspected, which results in unnecessary removal of catheters. A conservative approach might be attempted in mild infections, whereas catheters should always be removed in cases of severe sepsis or septic shock. ⋯ Antiseptic dressings and, to a lesser extent, antimicrobial-coated catheters, might be added to the prevention strategies if the level of infections remains high despite implementation of a prevention program. In the case of CR-BSI in intensive care units (ICUs), the catheter should be removed. In the case of persistence of fever or positive blood cultures after 3 days, inadequate antibiotic therapy, endocarditis, or thrombophlebitis should be ruled out.
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Semin Respir Crit Care Med · Apr 2011
ReviewSelective decontamination of the digestive tract (SDD): is the game worth the candle?
Selective decontamination of the digestive tract (SDD) is an infection prevention strategy in intensive care unit (ICU) patients by topical administration of antibiotics to the mouth and stomach to eradicate potentially pathogenic bacteria and yeast that may cause infections. It also includes a short course of intravenous antibiotics to treat incubating infections at the time of ICU admission. Several randomized, controlled studies, all performed in ICUs with low rates of antibiotic resistance, have shown that SDD prevents ventilator-associated pneumonia and improves survival. ⋯ In areas with low prevalence of MRSA and VRE, SDD should be considered the standard of care in ICUs. In countries where colonization with MRSA and VRE is frequent, resistance may increase, and SDD should be considered experimental therapy. Future research should focus on the effects of SDD compared with SOD on resistance and on SDD-like strategies in areas where MRSA and VRE are endemic.
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Semin Respir Crit Care Med · Apr 2011
ReviewExtracorporeal membrane oxygenation for 2009 influenza A (H1N1)-associated acute respiratory distress syndrome.
The 2009 novel swine-origin influenza A (H1N1) virus was identified in April 2009 in Mexico, and the World Health Organization declared the first phase 6 global influenza pandemic of the century on June 11, 2009. The pandemic spread worldwide in just a few weeks. Most patients diagnosed with H1N1-2009 virus had a self-limited respiratory illness. ⋯ Despite attempts to optimize ventilator settings, some patients developed refractory hypoxemia or hypercapnia and received extracorporeal membrane oxygenation (ECMO) as a rescue therapy. In most of these cases, patients were retrieved from outside major cities and safely transported under ECMO to experienced tertiary centers through semiformal referral networks. However, whether the 25 to 50% mortality observed in the reported ECMO series was affected by the recourse to this technique could not be established.