Surgical Critical Care and Emergency Surgery. Группа авторов

N, et al. Effect of early vasopressin vs norepinephrine on kidney failure in patients with septic shock: the VANISH randomized clinical trial. JAMA ‐ J Am Med Assoc. 2016; 316(5):509–518. doi:10.1001/jama.2016.10485Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. 2008; 358(9):877–887. doi:10.1056/nejmoa067373Demiselle J, Fage N, Radermacher P, Asfar P . Vasopressin and its analogues in shock states: a review. Ann Intensive Care. 2020; 10(1):9. doi:10.1186/s13613‐020‐0628‐2

      10 A 68‐year‐old woman with diabetes, coronary artery disease, and peripheral vascular disease presents to the hospital 21 days after an emergent fem‐femoral bypass. She is febrile and tachycardic with a white count of 16 × 103/microL. Her right groin incision is open with visible pus, and the area over the graft is erythematous and tender. A CTA shows increased soft tissue inflammation around the graft. What is the next best step?Obtain an ultrasound to assess blood flow velocities.Start intravenous ceftriaxone and flagyl.Start oral cephalexin.Explant the graft and replace with autologous vein.Start intravenous vancomycin and piperacillin‐ tazobactam.This patient has a graft infection. Gram‐positive bacteria are the most causative organisms. Typically, the rate of vascular graft infection is 1.5–2.5%, but the infection rate of grafts in the groin can be as high as 6%. Not only does this patient have grafts in the bilateral groins, but her diabetes and the urgent nature of her initial procedure also increases her risk of graft infection.While Staphylococcus aureus is the most common cause of vascular graft infection, there has been a documented rise of MRSA isolates from infected grafts as well as Pseudomonas aeruginosa, which is about 10% of graft infections. Because of this, a patient with a vascular graft infection should initially receive broad‐spectrum antibiotic coverage extended to cover Pseudomonas and MRSA. Of the choices, only choice E (vancomycin and piperacillin‐tazobactam) provides appropriate antibiotic coverage for this patient.Ceftriaxone, metronidazole, and cephalexin do not cover MRSA. While obtaining an ultrasound can help assess blood flow, a CTA is 85–100% sensitive and 85–94% specific for graft infection and can be obtained quickly. There are some scenarios of surgical site infection after a vascular graft in which antibiotics, debridement, and wound care can be used to preserve an infected graft, and the graft will first need to be surgically explored before the decision for preservation or explant is made. If the decision is made to preserve the graft, a prolonged course of antibiotics will be required.Answer: ESpelman D . Overview of infected (mycotic) arterial aneurysm ‐ UpToDate. UpToDate. https://www.uptodate.com/contents/overview‐of‐infected‐mycotic‐arterial‐aneurysm?search=infected vascular graft&source=search_result&selectedTitle=1~20&usage_type=default&display_rank=1#H1118621. Published July 2019. (accessed 3 December 2020).Chakfé N, Diener H, Lejay A, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2020 clinical practice guidelines on the management of vascular graft and endograft infections. Eur J Vasc Endovasc Surg. 2020; 59(3):339–384. doi:10.1016/j.ejvs.2019.10.016Kilic A, Arnaoutakis DJ, Reifsnyder T, et al. Management of infected vascular grafts. Vasc Med (United Kingdom). 2016; 21(1):53–60. doi:10.1177/1358863X15612574Wilson WR, Bower TC, Creager MA, et al. American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Surgery and Anesthesia; Council on Peripheral Vascular Disease; and Stroke Council. Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement from the American Heart Association. Circulation. 2016; 134(20): e412–e460. doi: 10.1161/CIR.0000000000000457. Epub 2016 Oct 13. PMID: 27737955.

      11 A 53‐year‐old man is in the ICU after a severe MVC. He has been on the ventilator for six days due to respiratory failure and lung contusion. He is noted to have increased inspiratory pressures, worsening hypoxemia, and purulent secretions. He has a white count of 16 × 103/microL and a progressive infiltrate on his chest x‐ray. What is the appropriate duration of antibiotics to treat his ventilator‐associated pneumonia?3 days5 days7 days10 days14 daysMultiple studies have shown that short‐course antibiotic regimens (7–8 days) increased the antibiotic‐free days; when compared to longer duration of antibiotics (10–15 days), there was also no difference in mortality, duration of mechanical ventilation, or length of ICU stay. In turn, reducing antibiotic exposure reduces side effects, antibiotic resistance, and costs.In patients with VAP, it is recommended that coverage includes S. aureus, P. aeruginosa, and gram‐negative bacilli. Empiric treatment of MRSA and Pseudomonas should be employed if the patient has recent risk factors for drug‐resistant infection including prior IV antibiotics use within 90 days, current septic shock, ARDS preceding the VAP, more than 5 hospital days preceding VAP diagnosis, and acute renal replacement therapy prior to the VAP onset. If the patient received IV antibiotics within the past 90 days, it is recommend that they be prescribed two agents that cover Pseudomonas in addition to an agent that covers MRSA.Answer: CZilahi G, McMahon MA, Povoa P, et al. Duration of antibiotic therapy in the intensive care unit. J Thorac Dis. 2016; 8(12):3774–3780. doi:10.21037/jtd.2016.12.89Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital‐acquired and ventilator‐associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; 63(5):e61–e111. doi:10.1093/cid/ciw353Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital‐acquired pneumonia and ventilator‐associated pneumonia. Eur Respir J. 2017; 50(3). doi:10.1183/13993003.00582‐2017

      12 An 83‐year‐old man with COPD, diabetes, and renal failure underwent resection of necrotic bowel from a closed‐loop small bowel obstruction. He remains mechanically ventilated. On post‐operative day six, he developed a fever to 102°F and a leukocytosis. A new right lobe infiltrate is seen on chest x‐ray, and he is diagnosed with ventilator‐associated pneumonia. Culture results are positive for Acinetobacter. What is the appropriate treatment?Piperacillin‐tazobactam and gentamicinVancomycinColistinMeropenemCiprofloxacinAcinetobacter is a gram‐negative bacilli that is a common cause of late‐onset VAP. Acinetobacter species are sensitive to carbapenems, ampicillin‐sulbactam, and colistin. Carbapenems and ampicillin‐sulbactam are preferred to colistin due to the risk of nephrotoxicity with colistin. Vancomycin is ineffective. Historically, ciprofloxacin has been effective in treating Acinetobacter, but the rate of ciprofloxacin‐resistant Acinetobacter infections has been reported as high as 67% in recent years and is thus no longer considered an effective empiric treatment. Gentamicin is a viable treatment option for an Acinetobacter infection; however, the addition of piperacillin‐tazobactam in choice A is unnecessary to treat this infection.Answer: DKalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital‐acquired and ventilator‐associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; 63(5):e61–e111. doi:10.1093/cid/ciw353Wood GC, Hanes SO, Croce MA, et al. Comparison of ampicillin‐sulbactam and imipenem‐cilastatin for the treatment of Acinetobacter ventilator‐associated pneumonia. Clin Infect Dis. 2002; 34(11):1425–1430. doi:10.1086/340055

      13 A 35‐year‐old man suffers a 50% total body surface area third‐degree burns after a house fire and has been in the burn ICU for the past 28 days. He has undergone multiple surgeries for his wounds and has been treated for a ventilator‐associated pneumonia and a central line infection. Overnight, he develops a fever to 103°F and increased tachycardia and hypotension.