135 results found
Lambden S, Leiper J, Gordon AC, 2016, Plasma Asymmetric Dimethylarginine (ADMA) Association with Risk of Death in Septic Shock - Subgroup Analysis of Patients from the VANISH Trial, American Thoracic Society International Conference, Publisher: American Thoracic Society, Pages: A2723-A2723
Lambden S, Leiper J, Gordon AC, 2016, The rs805305 SNP of Dimethylarginine Dimethylaminohydrolase 2(DDAH2) Is Associated with Reduced Duration of Shock, Improved Mortality and an Elevated Plasma ADMA:SDMA Ratio in Septic Shock - Subgroup Analysis of Patients from the VANISH Trial, American Thoracic Society International Conference, Publisher: American Thoracic Society, Pages: A7800-A7800
Nagendran M, Maruthappu M, Gordon AC, et al., 2016, Comparative safety and efficacy of vasopressors for mortality in septic shock: A network meta-analysis., J Intensive Care Soc, Vol: 17, Pages: 136-145, ISSN: 1751-1437
INTRODUCTION: Septic shock is a life-threatening condition requiring vasopressor agents to support the circulatory system. Several agents exist with choice typically guided by the specific clinical scenario. We used a network meta-analysis approach to rate the comparative efficacy and safety of vasopressors for mortality and arrhythmia incidence in septic shock patients. METHODS: We performed a comprehensive electronic database search including Medline, Embase, Science Citation Index Expanded and the Cochrane database. Randomised trials investigating vasopressor agents in septic shock patients and specifically assessing 28-day mortality or arrhythmia incidence were included. A Bayesian network meta-analysis was performed using Markov chain Monte Carlo methods. RESULTS: Thirteen trials of low to moderate risk of bias in which 3146 patients were randomised were included. There was no pairwise evidence to suggest one agent was superior over another for mortality. In the network meta-analysis, vasopressin was significantly superior to dopamine (OR 0.68 (95% CI 0.5 to 0.94)) for mortality. For arrhythmia incidence, standard pairwise meta-analyses confirmed that dopamine led to a higher incidence of arrhythmias than norepinephrine (OR 2.69 (95% CI 2.08 to 3.47)). In the network meta-analysis, there was no evidence of superiority of one agent over another. CONCLUSIONS: In this network meta-analysis, vasopressin was superior to dopamine for 28-day mortality in septic shock. Existing pairwise information supports the use of norepinephrine over dopamine. Our findings suggest that dopamine should be avoided in patients with septic shock and that other vasopressor agents should continue to be based on existing guidelines and clinical judgement of the specific presentation of the patient.
Gordon AC, Antcliffe D, 2016, Metabonomics and intensive care, Critical Care, Vol: 20, ISSN: 1364-8535
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency medicine 2016. Other selected articles can be found online at http://www.biomedcentral.com/collections/annualupdate2016. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
Antcliffe D, Gordon AC, 2016, Metabonomics and Intensive Care, Annual Update in Intensive Care and Emergency Medicine 2016, Editors: Vincent, Publisher: Springer, Pages: 353-364, ISBN: 978-3-319-27348-8
Cruickshank M, Henderson L, MacLennan G, et al., 2016, Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review, Health Technology Assessment, Vol: 20, Pages: 1-118, ISSN: 1366-5278
BACKGROUND:Care of critically ill patients in intensive care units (ICUs) often requires potentially invasive or uncomfortable procedures, such as mechanical ventilation (MV). Sedation can alleviate pain and discomfort, provide protection from stressful or harmful events, prevent anxiety and promote sleep. Various sedative agents are available for use in ICUs. In the UK, the most commonly used sedatives are propofol (Diprivan(¯), AstraZeneca), benzodiazepines [e.g. midazolam (Hypnovel(¯), Roche) and lorazepam (Ativan(¯), Pfizer)] and alpha-2 adrenergic receptor agonists [e.g. dexmedetomidine (Dexdor(¯), Orion Corporation) and clonidine (Catapres(¯), Boehringer Ingelheim)]. Sedative agents vary in onset/duration of effects and in their side effects. The pattern of sedation of alpha-2 agonists is quite different from that of other sedatives in that patients can be aroused readily and their cognitive performance on psychometric tests is usually preserved. Moreover, respiratory depression is less frequent after alpha-2 agonists than after other sedative agents. OBJECTIVES:To conduct a systematic review to evaluate the comparative effects of alpha-2 agonists (dexmedetomidine and clonidine) and propofol or benzodiazepines (midazolam and lorazepam) in mechanically ventilated adults admitted to ICUs. DATA SOURCES:We searched major electronic databases (e.g. MEDLINE without revisions, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE and Cochrane Central Register of Controlled Trials) from 1999 to 2014. METHODS:Evidence was considered from randomised controlled trials (RCTs) comparing dexmedetomidine with clonidine or dexmedetomidine or clonidine with propofol or benzodiazepines such as midazolam, lorazepam and diazepam (Diazemuls(¯), Actavis UK Limited). Primary outcomes included mortality, duration of MV, length of ICU stay and adverse events. One reviewer extracted data and assessed the risk of bias of included trials. A second rev
Davenport EE, Burnham KL, Radhakrishnan J, et al., 2016, Genomic landscape of the individual host response and outcomes in sepsis: a prospective cohort study, Lancet Respiratory Medicine, Vol: 4, Pages: 259-271, ISSN: 2213-2619
BackgroundEffective targeted therapy for sepsis requires an understanding of the heterogeneity in the individual host response to infection. We investigated this heterogeneity by defining interindividual variation in the transcriptome of patients with sepsis and related this to outcome and genetic diversity.MethodsWe assayed peripheral blood leucocyte global gene expression for a prospective discovery cohort of 265 adult patients admitted to UK intensive care units with sepsis due to community-acquired pneumonia and evidence of organ dysfunction. We then validated our findings in a replication cohort consisting of a further 106 patients. We mapped genomic determinants of variation in gene transcription between patients as expression quantitative trait loci (eQTL).FindingsWe discovered that following admission to intensive care, transcriptomic analysis of peripheral blood leucocytes defines two distinct sepsis response signatures (SRS1 and SRS2). The presence of SRS1 (detected in 108 [41%] patients in discovery cohort) identifies individuals with an immunosuppressed phenotype that included features of endotoxin tolerance, T-cell exhaustion, and downregulation of human leucocyte antigen (HLA) class II. SRS1 was associated with higher 14 day mortality than was SRS2 (discovery cohort hazard ratio (HR) 2·4, 95% CI 1·3–4·5, p=0·005; validation cohort HR 2·8, 95% CI 1·5–5·1, p=0·0007). We found that a predictive set of seven genes enabled the classification of patients as SRS1 or SRS2. We identified cis-acting and trans-acting eQTL for key immune and metabolic response genes and sepsis response networks. Sepsis eQTL were enriched in endotoxin-induced epigenetic marks and modulated the individual host response to sepsis, including effects specific to SRS group. We identified regulatory genetic variants involving key mediators of gene networks implicated in the hypoxic response and the switch to glycolysis t
Abdul-Aziz MH, Lipman J, Akova M, et al., 2015, Is prolonged infusion of piperacillin/tazobactam and meropenem in critically ill patients associated with improved pharmacokinetic/pharmacodynamic and patient outcomes? An observation from the Defining Antibiotic Levels in Intensive care unit patients (DALI) cohort., Journal of Antimicrobial Chemotherapy, Vol: 71, Pages: 196-207, ISSN: 0305-7453
OBJECTIVES: We utilized the database of the Defining Antibiotic Levels in Intensive care unit patients (DALI) study to statistically compare the pharmacokinetic/pharmacodynamic and clinical outcomes between prolonged-infusion and intermittent-bolus dosing of piperacillin/tazobactam and meropenem in critically ill patients using inclusion criteria similar to those used in previous prospective studies. METHODS: This was a post hoc analysis of a prospective, multicentre pharmacokinetic point-prevalence study (DALI), which recruited a large cohort of critically ill patients from 68 ICUs across 10 countries. RESULTS: Of the 211 patients receiving piperacillin/tazobactam and meropenem in the DALI study, 182 met inclusion criteria. Overall, 89.0% (162/182) of patients achieved the most conservative target of 50% fT>MIC (time over which unbound or free drug concentration remains above the MIC). Decreasing creatinine clearance and the use of prolonged infusion significantly increased the PTA for most pharmacokinetic/pharmacodynamic targets. In the subgroup of patients who had respiratory infection, patients receiving β-lactams via prolonged infusion demonstrated significantly better 30 day survival when compared with intermittent-bolus patients [86.2% (25/29) versus 56.7% (17/30); P = 0.012]. Additionally, in patients with a SOFA score of ≥9, administration by prolonged infusion compared with intermittent-bolus dosing demonstrated significantly better clinical cure [73.3% (11/15) versus 35.0% (7/20); P = 0.035] and survival rates [73.3% (11/15) versus 25.0% (5/20); P = 0.025]. CONCLUSIONS: Analysis of this large dataset has provided additional data on the niche benefits of administration of piperacillin/tazobactam and meropenem by prolonged infusion in critically ill patients, particularly for patients with respiratory infections.
Herrmann IK, Bertazzo S, O'Callaghan D, et al., 2015, Differentiating sepsis from non-infectious systemic inflammation based on microvesicle-bacteria aggregation, Nanoscale, Vol: 7, Pages: 13511-13520, ISSN: 2040-3364
Sepsis is a severe medical condition and a leading cause of hospital mortality. Prompt diagnosis and early treatment has a significant, positive impact on patient outcome. However, sepsis is not always easy to diagnose, especially in critically ill patients. Here, we present a conceptionally new approach for the rapid diagnostic differentiation of sepsis from non-septic intensive care unit patients. Using advanced microscopy and spectroscopy techniques, we measure infection-specific changes in the activity of nano-sized cell-derived microvesicles to bind bacteria. We report on the use of a point-of-care-compatible microfluidic chip to measure microvesicle-bacteria aggregation and demonstrate rapid (≤1.5 hour) and reliable diagnostic differentiation of bacterial infection from non-infectious inflammation in a double-blind pilot study. Our study demonstrates the potential of microvesicle activities for sepsis diagnosis and introduces microvesicle-bacteria aggregation as a potentially useful parameter for making early clinical management decisions.
O'Callaghan DJ, O'Dea KP, Scott AJ, et al., 2015, Monocyte Tumor Necrosis Factor-α-Converting Enzyme Catalytic Activity and Substrate Shedding in Sepsis and Noninfectious Systemic Inflammation., Critical Care Medicine, Vol: 43, Pages: 1375-1385, ISSN: 1530-0293
OBJECTIVES: To determine the effect of severe sepsis on monocyte tumor necrosis factor-α-converting enzyme baseline and inducible activity profiles. DESIGN: Observational clinical study. SETTING: Mixed surgical/medical teaching hospital ICU. PATIENTS: Sixteen patients with severe sepsis, 15 healthy volunteers, and eight critically ill patients with noninfectious systemic inflammatory response syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Monocyte expression of human leukocyte antigen-D-related peptide, sol-tumor necrosis factor production, tumor necrosis factor-α-converting enzyme expression and catalytic activity, tumor necrosis factor receptor 1 and 2 expression, and shedding at 48-hour intervals from day 0 to day 4, as well as p38-mitogen activated protein kinase expression. Compared with healthy volunteers, both sepsis and systemic inflammatory response syndrome patients' monocytes expressed reduced levels of human leukocyte antigen-D-related peptide and released less sol-tumor necrosis factor on in vitro lipopolysaccharide stimulation, consistent with the term monocyte deactivation. However, patients with sepsis had substantially elevated levels of basal tumor necrosis factor-α-converting enzyme activity that were refractory to lipopolysaccharide stimulation and this was accompanied by similar changes in p38-mitogen activated protein kinase signaling. In patients with systemic inflammatory response syndrome, monocyte basal tumor necrosis factor-α-converting enzyme, and its induction by lipopolysaccharide, appeared similar to healthy controls. Changes in basal tumor necrosis factor-α-converting enzyme activity at day 0 for sepsis patients correlated with Acute Physiology and Chronic Health Evaluation II score and the attenuated tumor necrosis factor-α-converting enzyme response to lipopolysaccharide was associated with increased mortality. Similar changes in monocyte tumor necrosis factor-α-converting enz
Mills TC, Chapman S, Hutton P, et al., 2015, Variants in the mannose-binding lectin gene MBL2 do not associate with sepsis susceptibility or survival in a large European cohort, Clinical Infectious Diseases, Vol: 61, Pages: 695-703, ISSN: 1537-6591
BACKGROUND: Sepsis is an increasingly common condition, which continues to be associated with unacceptably high mortality. A large number of association studies have investigated susceptibility to, or mortality from sepsis for variants in the functionally important immune-related gene MBL2. These studies have largely been underpowered and contradictory. METHODS: We genotyped and analysed four important MBL2 SNPs (rs5030737, rs1800450, rs1800451 and rs7096206) in 1839 European community-acquired pneumonia (CAP) and peritonitis sepsis cases, and 477 controls from the UK. We analysed the following predefined subgroups and outcomes: 28-day and 6 month mortality from sepsis due to CAP or peritonitis combined, 28-day mortality from CAP sepsis, peritonitis sepsis, pneumococcal sepsis or sepsis in younger patients, and susceptibility to CAP sepsis or pneumococcal sepsis in the UK. RESULTS: There were no significant associations (all p-values were greater than 0.05 after correction for multiple testing) between MBL2 genotypes and any of our predefined analyses. CONCLUSIONS: In this large, well-defined cohort of immune competent adult patients, no associations between MBL2 genotype and sepsis susceptibility or outcome were identified.
O'Callaghan DJ, Gordon AC, 2015, What's new in vasopressin?, Intensive Care Medicine, Vol: 41, Pages: 2177-2179, ISSN: 1432-1238
Tridente A, Clarke GM, Walden A, et al., 2015, Association between trends in clinical variables and outcome in intensive care patients with faecal peritonitis: analysis of the GenOSept cohort., Critical Care, Vol: 19, ISSN: 1364-8535
INTRODUCTION: Patients admitted to intensive care following surgery for faecal peritonitis present particular challenges in terms of clinical management and risk assessment. Collaborating surgical and intensive care teams need shared perspectives on prognosis. We aimed to determine the relationship between dynamic assessment of trends in selected variables and outcomes. METHODS: We analysed trends in physiological and laboratory variables during the first week of ICU stay in 977 patients from 102 centres across 16 European countries. The primary outcome was 6-month mortality. Secondary end-points were ICU, hospital and 28 day mortality. For each trend, Cox proportional hazards (PH) regression analyses, adjusted for age and gender, were performed for each endpoint. Trends remaining significant after Bonferroni correction for multiple testing were entered into a multivariate Cox PH model to determine independent associations with mortality. RESULTS: Trends over the first 7 days ICU stay independently associated with 6 month mortality were worsening thrombocytopaenia (mortality HR = 1.02, 95% CI 1.01-1.03, p < 0.001) and renal function (total daily urine output HR = 1.02, 95%CI 1.01-1.03, p < 0.001; renal SOFA sub-score HR = 0.87, 95%CI 0.75-0.99, p = 0.047), maximum bilirubin level (HR = 0.99, 95%CI 0.99-0.99, p = 0.02) and GCS SOFA sub-score (HR = 0.81, 95%CI 0.68-0.98, p = 0.028). Changes in renal function (total daily urine output and renal component of the SOFA score), GCS component of the SOFA score, total SOFA and worsening thrombocytopaenia were also independently associated with secondary outcomes (ICU, hospital and 28 day mortality). We detected the same pattern when analysing trends on days 2, 3 and 5. Dynamic trends in all other measured laboratory and physiological variables and in radiologica
Gordon A, 2015, Disease Management - Sepsis, Guidelines for the Provision of Intensive Care Services, Pages: 67-70
Gordon AC, 2015, Evidence about inotropes: when is enough, enough?, Intensive Care Medicine, Vol: 41, Pages: 695-697, ISSN: 1432-1238
Rautanen A, Mills TC, Gordon AC, et al., 2015, Genome-wide association study of survival from sepsis due to pneumonia: an observational cohort study, LANCET RESPIRATORY MEDICINE, Vol: 3, Pages: 53-60, ISSN: 2213-2600
Antcliffe D, Wolfer A, O'Dea KP, et al., 2015, Profiling Of Eicosanoids And Cytokines As An Aid To Diagnosing Pneumonia On Intensive Care, International Conference of the American-Thoracic-Society (ATS), Publisher: AMER THORACIC SOC, ISSN: 1073-449X
Wilkinson KM, Krige A, Brearley SG, et al., 2014, Thoracic Epidural analgesia versus Rectus Sheath Catheters for open midline incisions in major abdominal surgery within an enhanced recovery programme (TERSC): study protocol for a randomised controlled trial., Trials, Vol: 15, Pages: 400-400
Antcliffe D, Jimenez B, Veselkov K, et al., 2014, DIAGNOSING PNEUMONIA ON THE INTENSIVE CARE UNIT WITH SERUM H-1 NMR SPECTROSCOPY, 27th Annual Congress of the European-Society-of-Intensive-Care-Medicine (ESICM), Publisher: SPRINGER, Pages: S237-S238, ISSN: 0342-4642
Hatcher J, Myers A, Donaldson H, et al., 2014, Comment on: Effects of selective digestive decontamination (SDD) on the gut resistome., Journal of Antimicrobial Chemotherapy, Pages: dku288-dku288
Orme RMLE, Perkins GD, McAuley DF, et al., 2014, An efficacy and mechanism evaluation study of Levosimendan for the Prevention of Acute oRgan Dysfunction in Sepsis (LeoPARDS): protocol for a randomized controlled trial, Trials, Vol: 15, Pages: 1-10
Roberts JA, Paul SK, Akova M, et al., 2014, DALI: Defining Antibiotic Levels in Intensive Care Unit Patients: Are Current beta-Lactam Antibiotic Doses Sufficient for Critically Ill Patients?, CLINICAL INFECTIOUS DISEASES, Vol: 58, Pages: 1072-1083, ISSN: 1058-4838
Walden AP, Clarke GM, McKechnie S, et al., 2014, Patients with community acquired pneumonia admitted to European Intensive Care Units: an epidemiological survey of the GenOSept cohort, Critical Care, Vol: 18
IntroductionCommunity acquired pneumonia (CAP) is the most common infectious reason for admission to the Intensive Care Unit (ICU). The GenOSept study was designed to determine genetic influences on sepsis outcome. Phenotypic data was recorded using a robust clinical database allowing a contemporary analysis of the clinical characteristics, microbiology, outcomes and independent risk factors in patients with severe CAP admitted to ICUs across Europe.MethodsKaplan-Meier analysis was used to determine mortality rates. A Cox Proportional Hazards (PH) model was used to identify variables independently associated with 28-day and six-month mortality.ResultsData from 1166 patients admitted to 102 centres across 17 countries was extracted. Median age was 64 years, 62% were male. Mortality rate at 28 days was 17%, rising to 27% at six months. Streptococcus pneumoniae was the commonest organism isolated (28% of cases) with no organism identified in 36%. Independent risk factors associated with an increased risk of death at six months included APACHE II score (hazard ratio, HR, 1.03; confidence interval, CI, 1.01-1.05), bilateral pulmonary infiltrates (HR1.44; CI 1.11-1.87) and ventilator support (HR 3.04; CI 1.64-5.62). Haematocrit, pH and urine volume on day one were all associated with a worse outcome.ConclusionsThe mortality rate in patients with severe CAP admitted to European ICUs was 27% at six months. Streptococcus pneumoniae was the commonest organism isolated. In many cases the infecting organism was not identified. Ventilator support, the presence of diffuse pulmonary infiltrates, lower haematocrit, urine volume and pH on admission were independent predictors of a worse outcome.
Gordon AC, Mason AJ, Perkins GD, et al., 2014, The interaction of vasopressin and corticosteroids in septic shock: A pilot randomized controlled trial, Critical Care Medicine, Vol: 42, Pages: 1325-1333, ISSN: 0090-3493
OBJECTIVES: Vasopressin and corticosteroids are both commonly used adjunctive therapies in septic shock. Retrospective analyses have suggested that there may be an interaction between these drugs, with higher circulating vasopressin levels and improved outcomes in patients treated with both vasopressin and corticosteroids. We aimed to test for an interaction between vasopressin and corticosteroids in septic shock. DESIGN: Prospective open-label randomized controlled pilot trial. SETTING: Four adult ICUs in London teaching hospitals. PATIENTS: Sixty-one adult patients who had septic shock. INTERVENTIONS: Initial vasopressin IV infusion titrated up to 0.06 U/min and then IV hydrocortisone (50 mg 6 hourly) or placebo. Plasma vasopressin levels were measured at 6-12 and 24-36 hours after hydrocortisone/placebo administration. MEASUREMENTS AND MAIN RESULTS: Thirty-one patients were allocated to vasopressin + hydrocortisone and 30 patients to vasopressin + placebo. The hydrocortisone group required a shorter duration of vasopressin therapy (3.1 d; 95% CI, 1.1-5.1; shorter in hydrocortisone group) and required a lower total dose of vasopressin (ratio, 0.47; 95% CI, 0.32-0.71) compared with the placebo group. Plasma vasopressin levels were not higher in the hydrocortisone group compared with the placebo group (64 pmol/L difference at 6- to 12-hour time point; 95% CI, -32 to 160 pmol/L). Early vasopressin use was well tolerated with only one serious adverse event possibly related to study drug administration reported. There were no differences in mortality rates (23% 28-day mortality in both groups) or organ failure assessments between the two treatment groups. CONCLUSIONS: Hydrocortisone spared vasopressin requirements, reduced duration, and reduced dose, when used together in the treatment of septic shock, but it did not alter plasma vasopressin levels. Further trials are needed to assess the clinical effectiveness of vasopressin as the initial vasopressor therapy with or
Tridente A, Clarke GM, Walden A, et al., 2014, Patients with faecal peritonitis admitted to European intensive care units: an epidemiological survey of the GenOSept cohort, INTENSIVE CARE MEDICINE, Vol: 40, Pages: 202-210, ISSN: 0342-4642
Gordon AC, Myburgh JA, 2014, Vasodilators and antihypertensives, Oh's Intensive Care Manual, Editors: Bersten, Soni, Pages: 923-934, ISBN: 9780702047626
Dunning JW, Merson L, Rohde GGU, et al., 2014, Open source clinical science for emerging infections, The Lancet Infectious Diseases, Vol: 14, Pages: 8-9, ISSN: 1473-3099
Gordon AC, Mason AJ, Perkins GD, et al., 2014, Protocol for a randomised controlled trial of VAsopressin versus Noradrenaline as Initial therapy in Septic sHock (VANISH), BMJ Open, Vol: 4
Introduction Vasopressin is an alternative vasopressor in the management of septic shock. It spares catecholamine use but whether it improves outcome remains uncertain. Current evidence suggests that it may be most effective if used early and possibly in conjunction with corticosteroids. This trial will compare vasopressin to noradrenaline as initial vasopressor in the management of adult septic shock and investigate whether there is an interaction of vasopressin with corticosteroids.Methods and analysis This is a multicentre, factorial (2×2), randomised, double-blind, placebo-controlled trial. 412 patients will be recruited from multiple UK intensive care units and randomised to receive vasopressin (0–0.06 U/min) or noradrenaline (0–12 µg/min) as a continuous intravenous infusion as initial vasopressor therapy. If maximum infusion rates of this first study drug are reached, the patient will be treated with either hydrocortisone (initially 50 mg intravenous bolus six-hourly) or placebo, before additional open-label catecholamine vasopressors are prescribed. The primary outcome of the trial will be the difference in renal failure-free days between treatment groups. Secondary outcomes include need for renal replacement therapy, survival rates, other organ failures and resource utilisation.Ethics and dissemination The trial protocol and information sheets have received a favourable opinion from the Oxford A Research Ethics Committee (12/SC/0014). There is an independent Data Monitoring and Ethics Committee and independent membership of the Trial Steering Committee including patient and public involvement. The trial results will be published in peer-reviewed journals and presented at national and international scientific meetings.Trial registration number: ISRCTN 20769191 and EudraCT 2011-005363-24.
Gordon AC, Russell JA, 2013, Vasopressin Guidelines in Surviving Sepsis Campaign: 2012, CRITICAL CARE MEDICINE, Vol: 41, Pages: E482-E483, ISSN: 0090-3493
Antcliffe DB, Veselkov K, Pearce JTM, et al., 2013, TRAJECTORY ANALYSIS OF CLINICAL VARIABLES TO IMPROVE DIAGNOSIS OF VENTILATOR ASSOCIATED PNEUMONIA IN PATIENTS Wan BRAIN INJURY, ESICM 26th Annual Congress, Publisher: SPRINGER, Pages: S312-S313, ISSN: 0342-4642
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