Intracranial hypertension (IH) is a clinical condition commonly encountered in the intensive care unit, which requires immediate treatment. The maintenance of normal intracranial pressure (ICP) and cerebral perfusion pressure in order to prevent secondary brain injury (SBI) is the central focus of management. SBI can be detected through clinical examination and invasive and non-invasive ICP monitoring. Progress in monitoring and understanding the pathophysiological mechanisms of IH allows the implementation of targeted interventions in order to improve the outcome of these patients. Initially, general prophylactic measures such as patient's head elevation, fever control, adequate analgesia and sedation depth should be applied immediately to all patients with suspected IH. Based on specific indications and conditions, surgical resection of mass lesions and cerebrospinal fluid drainage should be considered as an initial treatment for lowering ICP. Hyperosmolar therapy (mannitol or hypertonic saline) represents the cornerstone of medical treatment of acute IH while hyperventilation should be limited to emergency management of life-threatening raised ICP. Therapeutic hypothermia could have a possible benefit on outcome. To control elevated ICP refractory to maximum standard medical and surgical treatment, at first, high-dose barbiturate administration and then decompressive craniectomy as a last step are recommended with unclear and probable benefit on outcomes, respectively. The therapeutic strategy should be based on a staircase approach and be individualized for each patient. Since most therapeutic interventions have an uncertain effect on neurological outcome and mortality, future research should focus on both studying the long-term benefits of current strategies and developing new ones.

Backgroundland-White-Garland syndrome (anomalous origin of the left coronary artery from the pulmonary artery) is a rare disease which may result in myocardial infarction, congestive heart failure and sometimes death during the early infantile period. Case presentation: A succesfully treated case of a 45-year-old mother of 2 children with Bland-White-Garland syndrome and concomitant severe mitral regurgitation is presented. Subsequent therapy consisted of ligation of the anomalous origin of the left coronary artery, anastomosis of the left internal mammary artery to the left anterior descending branch and mitral valve replacement. Continuous blood flow from the left coronary artery ostium during extracorporeal circulation and aorta clamping suggested systemic collateral supply. Conclusions: Recognition and diagnosis of Bland-White-Garland syndrome is important due to its potentially life-threatening complications.

Purpose In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials. Methods We carried out a prospective international cohort study of adult patients (≥ 18 years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021. Results 2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp . (20.3%), Escherichia coli (15.8%), and Pseudomonas spp . (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) was present in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24 h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alive from hospital by day-28. Conclusions HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06944-2.

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This work aims at the better comprehension of epidemiology of ICU infections, using a classification based on the carrier state of the patient. This classification distinguishes the infections in primary endogenous (PE), secondary endogenous (SE) and exogenous (EX) infections. The material used was derived from ICU patients who were admitted to the ICU without being transferred from another ward of the same hospital or another hospital. Culture swabs were obtained from the pharynx and perineum of the patients at ICU admission and from then onwards every 3 days during their hospitalization. At the same time, cultures of clinical samples were carried out, on suspicion of infection. Ninety-six ICU patients were studied. In 31 of these, a total of 78 infections were developed. According to the proposed classification, 26 of the infections were PE (rate 33.3%), 34 SE (rate 43.6%) and 18 EX (rate 23.1%). Using the carrier state criterion, there were 11 fewer infections characterized as nosocomial (rate 14.1%), contrary to the 48-hour criterion. Based on this new taxonomy ofinfections, we are able to know in advance the source of the causative microorganisms and reduce the prevalence of ICU infections, by applying appropriate prevention and treatment strategies.Infections occurring in the hospital environment are one of the major factors affecting the duration of hospitalization of patients and outcome of their treatment. The hospital-acquired (nosocomial) infections constitute one of the major issues which trouble global health (1). They affect two million patients (5% of hospitalized patients) in the U.S.A., leading to 77,000 deaths and costs of 4.5 billion dollars each year (2).This problem becomes more intense, especially in the ICUs. In a French survey in 1996 involving 58% of total hospital beds nationwide, a total rate of 6.7% of nosocomial infections was found, whereas in ICUs this rate rose up to 22% (3). Other studies report rates of nosocomial infections which vary from 13% to 42% (4-7). This high prevalence of infections occurring in the ICUs is related to the special conditions in these hospital sections and to the high-risk factors for infections in ICUs, such as the use of intravenous catheters, urinary catheters,

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