A rational empirical antimicrobial therapy for ventilator-associated pneumonia using limited-spectrum antibiotics is possible if local ecology and patient medical history and clinical status are considered. In addition, de-escalation is feasible in 42% of patients. This integrative approach may reduce the emergence of resistant bacteria, which in turns reduces the need for broad-spectrum antibiotics, breaking the vicious circle of antibiotic overuse.

Treating a positive urine culture in an asymptomatic patient with an indwelling urethral catheter does not reduce the occurrence of urosepsis in the medico-surgical ICU.

The goal of the study was to evaluate the effect of isoproterenol prescribed in goal-directed therapy for septic shock. Out of a cohort of 89 patients with septic shock, 14 patients treated with fluid and norepinephrine had inappropriate mixed venous oxygen saturation (SvO2<70%) not responding to correction of hypoxemia and anemia (>8 g.dL-1). Isoproterenol administration was started at a dose of 0.04 microg.kg-1.minute-1 with 0.025 microg.kg-1.minute-1 increments every 30 minutes until SvO2 was greater than 70%. Mean arterial pressure was maintained>or=65 mm.Hg by adjusting the norepinephrine infusion. Hemodynamic, oxygen, and renal variables were collected during a 12-h period. Patients with a known prior history of coronary disease were not eligible. Isoproterenol administration increased significantly SvO2 (62%+/-10% to 71%+/-9%), cardiac index (3.1+/-0.6 to 4.4+/-1.4 L.min-1.m-2), stroke index (27+/-3.4 to 38+/-6.1 mL.m-2), and left ventricular stroke work index (24+/-3.4 to 40+/-5.0 g.m-1.m-2). Heart rate rise did not reach a significant level. Arterial lactate concentration decreased significantly during the study period (5.7+/-2.8 to 3.4+/-1.6 mmol.L-1). No cardiac adverse events occurred with any electrocardiographic aspects of myocardial ischemia. This study suggests that isoproterenol is efficient to improve hemodynamics and oxygen variables in septic shock patients. There is a need for future investigations in larger groups of patients to determine whether isoproterenol can be an alternative to dobutamine.

The authors report a case of a craniocerebral penetrating injury caused by the shaft of a spear gun. The entry point of the spear was located in the mouth without an obvious exit point. The authors first note the presentation of the patient, whose airway was obstructed by the shaft, and then discuss the surgical procedure, which was focused on removing the shaft in an anterograde direction because of an articulated wishbone located at the tip of the shaft.