INTRODUCTION:Surgical site infections (SSIs) are a leading cause of healthcare-associated infections, particularly in abdominal surgery. In patients allergic to beta-lactams, gentamicin is often used for surgical antibiotic prophylaxis (SAP), but its efficacy is questioned due to limited tissue-level pharmacokinetic/pharmacodynamic (PK/PD) data. MATERIALS AND METHODS:We conducted a monocentric prospective study involving eight adult patients undergoing major abdominal surgery who received gentamicin (5 mg/kg IV) for SAP. Subcutaneous unbound gentamicin concentrations were measured using microdialysis over 6 h. Plasma and tissue PKs were analysed using nonlinear mixed-effects modelling. Monte Carlo simulations assessed the probability of target attainment (PTA) for Cmax/MIC >8 at doses of 5 and 8 mg/kg, using EUCAST MIC distributions for Escherichia coli and Staphylococcus aureus. RESULTS:A total of 246 samples were collected (100 plasma and 146 microdialysate). Subcutaneous gentamicin concentrations were lower than plasma concentrations throughout the 0-6 h interval. Mean Cmax values were 43.7 ± 4.5 mg/L in plasma and 17.8 ± 11.5 mg/L in subcutaneous tissue. Given the lack of defined tissue PK/PD targets in surgical prophylaxis, a plasma-based Cmax/MIC > 8 target was used for PTA simulations. At 5 mg/kg, PTA was suboptimal for MIC ≥1 mg/L in subcutaneous tissue. Simulations showed that increasing the dose to 8 mg/kg improved the cumulative fraction of response against E. coli and S. aureus from 70% and 79% to 80% and 87%, respectively. DISCUSSION:This study highlights insufficient subcutaneous gentamicin exposure with standard SAP dosing. An 8 mg/kg dose improved tissue PK/PD target attainment, supporting updated dosing recommendations for beta-lactam-allergic patients. Further research is needed to validate safety and efficacy in broader populations.
Prehospital airway and ventilatory management is a frequent, high-stakes and technically demanding component of emergency care. Environmental constraints, limited resources, and variable provider experience make it particularly challenging, and prehospital care systems differ substantially across countries, from paramedic-based to physician-led models, contributing to heterogeneity in clinical practices and patient outcomes. In this narrative review, we discuss evidence-based best practice, including indications, timing, physiological optimization, procedural conduct, and post-intubation management of prehospital tracheal intubation or non-invasive ventilation and high-flow nasal oxygen. Tracheal intubation remains the definitive airway management strategy when performed for appropriate indications by adequately trained providers. Indications span major trauma, traumatic brain injury, out-of-hospital cardiac arrest, and comatose patients, though its role in comatose poisoned patients is increasingly questioned. Physiology optimization before intubation is a critical and frequently underappreciated determinant of outcome, encompassing preoxygenation with non-invasive positive pressure ventilation, bag-valve-mask ventilation between induction and laryngoscopy, and careful sedative selection to limit peri-intubation hemodynamic compromise. When intubation fails, a structured escalation strategy including videolaryngoscopy, supraglottic airway devices, and emergency front-of-neck access must be rehearsed and immediately available. In out-of-hospital cardiac arrest, supraglottic airways represent a valid primary alternative with equivalent neurological survival and faster placement. Non-invasive ventilation (primarily CPAP and BiPAP) has a well-established role in acute cardiogenic pulmonary edema and COPD exacerbations, reducing intubation rates and mortality. High-flow nasal oxygen is an emerging modality with strong in-hospital evidence, but prehospital data remain extremely limited and logistical constraints restrict its routine use. Non-invasive support must never delay intubation when clinical deterioration demands it. Specific contexts require tailored adaptations: altitude physiology in helicopter transport, obesity-specific positioning, cervical spine precautions in neurological injury, comfort-focused strategies in palliative patients, and proactive stabilization before prolonged transport. Evidence gaps remain, particularly regarding prehospital high-flow nasal oxygen.
The beneficial effects of prophylactic noninvasive ventilation (NIV) after extubation in patients without hypercapnia are uncertain. Our objective was to assess the effects of prophylactic NIV on reintubation among patients without hypercapnia at the time of extubation. Post hoc analysis of two multicenter clinical trials including high-risk patients (i.e., patients older than 65 years or with underlying cardiac/respiratory disease). Our analysis focused on the 829 patients without hypercapnia (PaCO2 ≤ 45 mmHg), the day of extubation who received NIV alternating high-flow nasal cannula (HFNC) oxygen or HFNC alone after extubation. The primary outcome was the proportion of patients who required reintubation within seven days following extubation. We used G-computation to robustly estimate the marginal causal effect of treatment on the risk of reintubation. After extubation, 540 patients (65
