Критерии назначения системной антимикотической терапии в хирургическом отделении реанимации и интенсивной терапии (обзор литературы)

This review focuses on the practical aspects of prevention and treatment of fungal infections in surgical patients. It covers epidemiology and risk factors for invasive candidiasis, updates on the etiological structure of fungal infections in patients in critical conditions, and provides the information on drug sensitivity of Candida species. The authors discuss the limitations of cultural and non-cultural diagnostic methods used in invasive candidiasis, emphasizing the importance of analyzing the existing risk factors in combination with a comprehensive assessment of clinical and laboratory data for timely initiation of adequate antifungal therapy. The review provides a brief description of currently available antimicotics, including polyenes, triazoles, and echinocandins. It also describes the benefits of anidulafungin, which does not interact with other drugs and has no negative effect on the liver and kidney. The article also covers indications for antifungal agents in surgical intensive care units in accordance with international and Russian guidelines. A cohort of patients with abdominal diseases requiring preventive and empirical treatment with antimicotics is described. In additions to that, the manuscript contains a rationale for the use of echinocandins in targeted therapy of invasive candidiasis.Данный обзор посвящен практическим аспектам антифунгальной профилактики и терапии у хирургических пациентов. Подробно рассматриваются эпидемиология и факторы риска развития инвазивного кандидоза, приведены актуальные данные по этиологической структуре грибковых инфекций у пациентов в критических состояниях, отражены сведения по чувствительности грибов рода Candida к антимикотикам. Авторы обзора отмечают ограничения культуральных и некультуральных методов диагностики инвазивного кандидоза, подчеркивая важность анализа имеющихся у пациента факторов риска в сочетании с комплексной оценкой клинических и лабораторных данных для своевременного назначения адекватного антифунгального лечения. В обзоре дана краткая характеристика доступных в настоящее время антимикотиков: полиенов, триазолов и эхинокандинов, приведены доказательные данные о преимуществах анидулафунгина, не имеющего лекарственных взаимодействий и не оказывающего отрицательного влияния на функции печени и почек. В соответствии с современными международными и отечественными рекомендациями рассмотрены показания для назначения противогрибковых препаратов в отделениях реанимации хирургического профиля. Охарактеризована когорта пациентов с заболеваниями органов брюшной полости, нуждающихся в профилактическом и эмпирическом назначении антимикотиков, обоснована необходимость применения эхинокандинов для целенаправленной терапии инвазивного кандидоза

Септический шок у взрослых: клинические рекомендации Общероссийской общественной организации «Федерация анестезиологов и реаниматологов»

В статье представлены основные положения клинических рекомендаций по септическому шоку у взрослых, утвержденных Общероссийской общественной организацией «Федерация анестезиологов и реаниматологов» в 2023 г. Актуальность проблемы связана со значительной распространенностью и высокими показателями летальности при септическом шоке. Рекомендации включают вопросы этиологии, патогенеза, клинической картины, методов лабораторной и инструментальной диагностики септического шока. Представлена стартовая интенсивная терапия септического шока, включая подходы по назначению вазопрессорных и инотропных препаратов, рекомендации по выбору антибактериальных препаратов, особенности инфузионной и адъювантной терапии, в том числе при рефрактерном к терапии септическом шоке. Обсуждены вопросы хирургического лечения очага инфекции. Представлены критерии качества оказания медицинской помощи взрослым пациентам с септическим шоком и алгоритмы действий врача при диагностике и интенсивной терапии пациентов с септическим шоком

The clinical relevance of oliguria in the critically ill patient : Analysis of a large observational database

Funding Information: Marc Leone reports receiving consulting fees from Amomed and Aguettant; lecture fees from MSD, Pfizer, Octapharma, 3 M, Aspen, Orion; travel support from LFB; and grant support from PHRC IR and his institution. JLV is the Editor-in-Chief of Critical Care. The other authors declare that they have no relevant financial interests. Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Urine output is widely used as one of the criteria for the diagnosis and staging of acute renal failure, but few studies have specifically assessed the role of oliguria as a marker of acute renal failure or outcomes in general intensive care unit (ICU) patients. Using a large multinational database, we therefore evaluated the occurrence of oliguria (defined as a urine output 16 years) patients in the ICON audit who had a urine output measurement on the day of admission were included. To investigate the association between oliguria and mortality, we used a multilevel analysis. Results: Of the 8292 patients included, 2050 (24.7%) were oliguric during the first 24 h of admission. Patients with oliguria on admission who had at least one additional 24-h urine output recorded during their ICU stay (n = 1349) were divided into three groups: transient - oliguria resolved within 48 h after the admission day (n = 390 [28.9%]), prolonged - oliguria resolved > 48 h after the admission day (n = 141 [10.5%]), and permanent - oliguria persisting for the whole ICU stay or again present at the end of the ICU stay (n = 818 [60.6%]). ICU and hospital mortality rates were higher in patients with oliguria than in those without, except for patients with transient oliguria who had significantly lower mortality rates than non-oliguric patients. In multilevel analysis, the need for RRT was associated with a significantly higher risk of death (OR = 1.51 [95% CI 1.19-1.91], p = 0.001), but the presence of oliguria on admission was not (OR = 1.14 [95% CI 0.97-1.34], p = 0.103). Conclusions: Oliguria is common in ICU patients and may have a relatively benign nature if only transient. The duration of oliguria and need for RRT are associated with worse outcome.publishersversionPeer reviewe

A worldwide perspective of sepsis epidemiology and survival according to age: Observational data from the ICON audit

Purpose: To investigate age-related differences in outcomes of critically ill patients with sepsis around the world. Methods: We performed a secondary analysis of data from the prospective ICON audit, in which all adult ( >16 years ) patients admitted to participating ICUs between May 8 and 18, 2012, were included, except admissions for routine postoperative observation. For this sub-analysis, the 10,012 patients with completed age data were included. They were divided into five age groups - <= 50, 51-60, 61-70, 71-80, >80 years. Sepsis was defined as infection plus at least one organ failure. Results: A total of 2963 patients had sepsis, with similar proportions across the age groups (<= 50 = 25.2%: 51-60 = 30.3%; 61-70 = 32.8%; 71-80 = 30.7%; >80 = 30.9%). Hospital mortality increased with age and in patients >80 years was almost twice that of patients <= 50 years (493% vs 25.2%, p < .05). The maximum rate of increase in mortality was about 0.75% per year, occurring between the ages of 71 and 77 years. In multilevel analysis, age > 70 years was independently associated with increased risk of dying. Conclusions: The odds for death in ICU patients with sepsis increased with age with the maximal rate of increase occurring between the ages of 71 and 77 years. (C) 2019 Elsevier Inc. All rights reserved

Assessment of the worldwide burden of critical illness: The Intensive Care Over Nations (ICON) audit

Background Global epidemiological data regarding outcomes for patients in intensive care units (ICUs) are scarce, but are important in understanding the worldwide burden of critical illness. We, therefore, did an international audit of ICU patients worldwide and assessed variations between hospitals and countries in terms of ICU mortality.Methods 730 participating centres in 84 countries prospectively collected data on all adult (>16 years) patients admitted to their ICU between May 8 and May 18, 2012, except those admitted for fewer than 24 h for routine postoperative monitoring. Participation was voluntary. Data were collected daily for a maximum of 28 days in the ICU and patients were followed up for outcome data until death or hospital discharge. In-hospital death was analysed using multilevel logistic regression with three levels: patient, hospital, and country.Findings 10 069 patients were included from ICUs in Europe (5445 patients; 54.1%), Asia (1928; 19.2%), the Americas (1723; 17.1%), Oceania (439; 4.4%), the Middle East (393; 3.9%), and Africa (141; 1.4%). Overall, 2973 patients (29.5%) had sepsis on admission or during the ICU stay. ICU mortality rates were 16.2% (95% CI 15.5-16.9) across the whole population and 25.8% (24.2-27.4) in patients with sepsis. Hospital mortality rates were 22.4% (21.6-23.2) in the whole population and 35.3% (33.5-37.1) in patients with sepsis. Using a multilevel analysis, the unconditional model suggested significant between-country variations (var=0.19, p=0.002) and between-hospital variations (var=0.43, p<0.0001) in the individual risk of in-hospital death. There was a stepwise increase in the adjusted risk of in-hospital death according to decrease in global national income.Interpretation This large database highlights that sepsis remains a major health problem worldwide, associated with high mortality rates in all countries. Our findings also show a significant association between the risk of death and the global national income and suggest that ICU organisation has an important effect on risk of death

Higher Fluid Balance Increases the Risk of Death from Sepsis: Results from a Large International Audit∗

Objectives: Excessive fluid therapy in patients with sepsis may be associated with risks that outweigh any benefit. We investigated the possible influence of early fluid balance on outcome in a large international database of ICU patients with sepsis. Design: Observational cohort study. Setting: Seven hundred and thirty ICUs in 84 countries. Patients: All adult patients admitted between May 8 and May 18, 2012, except admissions for routine postoperative surveillance. For this analysis, we included only the 1,808 patients with an admission diagnosis of sepsis. Patients were stratified according to quartiles of cumulative fluid balance 24 hours and 3 days after ICU admission. Measurements and Main Results: ICU and hospital mortality rates were 27.6% and 37.3%, respectively. The cumulative fluid balance increased from 1,217 mL (-90 to 2,783 mL) in the first 24 hours after ICU admission to 1,794 mL (-951 to 5,108 mL) on day 3 and decreased thereafter. The cumulative fluid intake was similar in survivors and nonsurvivors, but fluid balance was less positive in survivors because of higher fluid output in these patients. Fluid balances became negative after the third ICU day in survivors but remained positive in nonsurvivors. After adjustment for possible confounders in multivariable analysis, the 24-hour cumulative fluid balance was not associated with an increased hazard of 28-day in-hospital death. However, there was a stepwise increase in the hazard of death with higher quartiles of 3-day cumulative fluid balance in the whole population and after stratification according to the presence of septic shock. Conclusions: In this large cohort of patients with sepsis, higher cumulative fluid balance at day 3 but not in the first 24 hours after ICU admission was independently associated with an increase in the hazard of death