Programme Hospitalier Recherche Clinique, Institut Pasteur, Inserm, French Public Health Agency.

Upper airway caliber was not significantly modified by HHFO₂, compared to standard oxygen therapy, but HHFO₂ significantly reduced discomfort in critically ill patients with respiratory failure. The system is usually preferred over standard oxygen therapy.

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BACKGROUND: A biofilm is found on the inner side of endotracheal tubes (ETT) in mechanically ventilated patients, but its features and role in pneumonia remain unclear. METHODS: This prospective, observational, monocentric study included critically ill ventilated subjects. Measurement of the ETT inner volume was first performed before extubation using the acoustic reflection method. After extubation, the biofilm was studied by means of optical and atomic force microscopy. Bacteriological analysis was then performed and compared with clinical documentation. RESULTS: Twenty-four subjects were included. Duration of intubation lasted from 2 to 79 d (mean ؎ SD: 11 ؎ 15 d). The mean percentage of ETT volume loss evaluated in situ (n ‫؍‬ 21) was 7.1% and was not linked with the duration of intubation. Analyses with atomic force microscopy (n ‫؍‬ 6) showed a full coverage of the inner part of the tube with biofilm, even after saline rinse. Its thickness ranged from 0.8 to 5 m. Bacteriological cultures of the biofilm (n ‫؍‬ 22) often showed the same bacteria as in tracheal secretions, especially for pathogenic organisms. Pseudomonas aeruginosa and Candida albicans were among the most frequent microorganisms. In subjects who had experienced a successfully treated episode of ventilator-associated pneumonia (n ‫؍‬ 5), the responsible bacteria were still present in the biofilm. CONCLUSIONS: ETT biofilm is always present in intubated patients whatever the duration of intubation and appears quickly after intubation. Even after soft rinse, a small but measurable part of biofilm remains always present, and seems strongly adherent to the ETT lumen. It contains potentially pathogenic bacteria for the lung.

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BackgroundAcute pancreatitis (AP) is associated with high morbidity and mortality in its most severe forms. Most patients with severe AP require intubation and invasive mechanical ventilation, frequently for more than 7 days, which is associated with the worst outcome. Recent increasing evidence from preclinical and clinical studies support the beneficial effects of epidural analgesia (EA) in AP, such as increased gut barrier function and splanchnic, pancreatic and renal perfusion, decreased liver damage and inflammatory response, and reduced mortality. Because recent studies suggest that EA might be a safe procedure in the critically ill, we sought to determine whether EA reduced AP-associated respiratory failure and other major clinical outcomes in patients with AP.Methods and analysisThe Epidural Analgesia for Pancreatitis (EPIPAN) trial is an investigator-initiated, prospective, multicentre, randomised controlled two-arm trial with assessor-blinded outcome assessment. The EPIPAN trial will randomise 148 patients with AP requiring admission to an intensive care unit (ICU) to receive EA (with patient-controlled epidural administration of ropivacaine and sufentanil) combined with standard care based on current recommendations on the treatment of AP (interventional group), or standard care alone (reference group). The primary outcome is the number of ventilator-free days at day 30. Secondary outcomes include main complications of AP (eg, organ failure and mortality, among others), levels of biological markers of systemic inflammation, epithelial lung injury, renal failure, and healthcare-associated costs.Ethics and disseminationThe study was approved by the appropriate ethics committee (CPP Sud-Est VI). Informed consent is required. If the combined application of EA and standard care proves superior to standard care alone in patients with AP in the ICU, the use of EA may become standard practice in experienced centres, thereby decreasing potential complications related to AP and its burden in critically ill patients. The results will be disseminated in a peer-reviewed journal.Trial registration numberNCT02126332.

Background Pneumonia is one of the major complications of drowning, but the optimal empirical antibiotic treatment is not clearly defined. Multidrug-resistant (MDR) bacteria and fungi have been identified in a recent series of freshwater drowning-associated pneumonia. However, microbial data in seawater drowning are scarce. The objective of the study is to describe the microorganisms isolated in early respiratory specimens obtained from seawater drowning-associated pneumonia and to provide their antibiotic susceptibility pattern.MethodsAll patients admitted for seawater drowning between 2003 and 2013 to two intensive care units, from the region in France with the highest drowning rate, were retrospectively included. Demographics, antimicrobial therapy and microbiological data from respiratory samples collected within the first 48 h after admittance were analyzed.ResultsSeventy-four drowned patients were included, of which 36 (49%) were diagnosed by the clinician as having early pneumonia. Concerning the overall population, the median simplified acute physiology score (version 2) was 45 (30–65), and the mortality was 26%. Twenty-four respiratory samples from different patients were obtained within the first 48 h. Sixteen were positive. The main microorganisms found were Enterobacteriaceae (Enterobacter spp., Klebsiella spp. and Escherichia coli) and Gram-positive aerobic cocci (Streptococcus pneumonia and Staphylococcus aureus) with a low rate of antimicrobial resistance. No MDR bacteria or fungi were identified. However, among the positive respiratory samples collected, 5/16 (31%) grew bacteria with natural resistance to amoxicillin–clavulanate, the first-line antibiotic commonly used in our cohort. Resistance was only found among Gram-negative bacteria and from respiratory samples of patients with a higher drowning grade at admission (p = 0.01).ConclusionsThis 10-year descriptive study, the largest cohort to date, provides early respiratory samples from seawater drowning patients. The microorganisms retrieved were either mostly part of the human oro-pharyngeal flora or Enterobacteriaceae and displayed low rates of antimicrobial resistance. Respiratory samples should nonetheless be collected at admittance to the ICU to avoid inappropriate treatment. Empiric use of cephalosporin could be restricted to severe patients or if Gram-negative bacilli are found after direct examination.

In obese patients, non-invasive evaluation of liver function with the indocyanine green clearance test correlated with histological features of NAFLD. This may detect non-invasively hepatopathy in obese population and could motive biopsy.