IntroductionSuccinylcholine and rocuronium are widely used to facilitate rapid sequence induction (RSI) intubation in intensive care. Concerns relate to the side effects of succinylcholine and to slower onset and inferior intubation conditions associated with rocuronium. So far, succinylcholine and rocuronium have not been compared in an adequately powered randomized trial in intensive care. Accordingly, the aim of the present study was to compare the incidence of hypoxemia after rocuronium or succinylcholine in critically ill patients requiring an emergent RSI.MethodsThis was a prospective randomized controlled single-blind trial conducted from 2006 to 2010 at the University Hospital of Basel. Participants were 401 critically ill patients requiring emergent RSI. Patients were randomized to receive 1 mg/kg succinylcholine or 0.6 mg/kg rocuronium for neuromuscular blockade. The primary outcome was the incidence of oxygen desaturations defined as a decrease in oxygen saturation ≥ 5%, assessed by continuous pulse oxymetry, at any time between the start of the induction sequence and two minutes after the completion of the intubation. A severe oxygen desaturation was defined as a decrease in oxygen saturation ≥ 5% leading to a saturation value of ≤ 80%.ResultsThere was no difference between succinylcholine and rocuronium regarding oxygen desaturations (succinylcholine 73/196; rocuronium 66/195; P = 0.67); severe oxygen desaturations (succinylcholine 20/196; rocuronium 20/195; P = 1.0); and extent of oxygen desaturations (succinylcholine -14 ± 12%; rocuronium -16 ± 13%; P = 0.77). The duration of the intubation sequence was shorter after succinycholine than after rocuronium (81 ± 38 sec versus 95 ± 48 sec; P = 0.002). Intubation conditions (succinylcholine 8.3 ± 0.8; rocuronium 8.2 ± 0.9; P = 0.7) and failed first intubation attempts (succinylcholine 32/200; rocuronium 36/201; P = 1.0) did not differ between the groups.ConclusionsIn critically ill patients undergoing emergent RSI, incidence and severity of oxygen desaturations, the quality of intubation conditions, and incidence of failed intubation attempts did not differ between succinylcholine and rocuronium.Trial RegistrationClinicalTrials.gov, number NCT00355368.

BackgroundSince the Influenza A pandemic in 1819, the association between the influenza virus and Streptococcus pneumoniae has been well described in literature. While a leading role has been so far attributed solely to Influenza A as the primary infective pathogen, Influenza B is generally considered to be less pathogenic with little impact on morbidity and mortality of otherwise healthy adults. This report documents the severe synergistic pathogenesis of Influenza B infection and bacterial pneumonia in previously healthy persons not belonging to a special risk population and outlines therapeutic options in this clinical setting.Case PresentationDuring the seasonal influenza epidemic 2007/2008, three previously healthy women presented to our hospital with influenza-like symptoms and rapid clinical deterioration. Subsequent septic shock due to severe bilateral pneumonia necessitated intensive resuscitative measures including the use of an interventional lung assist device. Microbiological analysis identified severe dual infections of Influenza B with Streptococcus pyogenes in two cases and Streptococcus pneumoniae in one case. The patients presented with no evidence of underlying disease or other known risk factors for dual infection such as age (< one year, > 65 years), pregnancy or comorbidity.ConclusionsInfluenza B infection can pose a risk for severe secondary infection in previously healthy persons. As patients admitted to hospital due to severe pneumonia are rarely tested for Influenza B, the incidence of admission due to this virus might be greatly underestimated, therefore, a more aggressive search for influenza virus and empirical treatment might be warranted. While the use of an interventional lung assist device offers a potential treatment strategy for refractory respiratory acidosis in addition to protective lung ventilation, the combined empiric use of a neuraminidase-inhibitor and antibiotics in septic patients with pulmonary manifestations during an epidemic season should be considered.

SummarySpinal anaesthesia for Caesarean section has gained widespread acceptance. We assessed the impact of spinal anaesthesia and body mass index (BMI) on spirometric performance. In this prospective study, we consecutively assessed 71 consenting parturients receiving spinal anaesthesia with hyperbaric bupivacaine and fentanyl for elective Caesarean section. We performed spirometry during the antepartum visit (baseline), immediately after spinal anaesthesia, 10-20 min, 1 h, 2 h after the operation, and after mobilisation (3 h). Baseline values were within normal ranges. There was a significant decrease in all spirometric parameters after effective spinal anaesthesia that persisted throughout the study period. The decrease in respiratory function was significantly greater in obese (BMI > 30 kg.m )2 ) than in normal-weight parturients (BMI < 25 kg.m )2 ), e.g. median (IQR) vital capacity directly after spinal anaesthesia; )24 ()16 to )31)% vs. )11 ()6 to )16)%, p < 0.001 and recovery was significantly slower. We conclude that both spinal anaesthesia and obesity significantly impair respiratory function in parturients.

Three cases are reported of spondylodiscitis caused by coagulase-negative staphylococci in patients without osteosynthetic material. All three patients had bacteraemia associated with an infected intravascular device left in place. On the basis of this observation, it is concluded that such devices should be removed promptly in cases of prolonged or relapsing bacteraemia. Furthermore, spondylodiscitis should be suspected in patients with back pain after bacteraemia caused by coagulase-negative staphylococci.