Randomized, multicenter trial of lateral Trendelenburg versus semirecumbent body position for the prevention of ventilator-associated pneumonia.

PURPOSE: The lateral Trendelenburg position (LTP) may hinder the primary pathophysiologic mechanism of ventilator-associated pneumonia (VAP). We investigated whether placing patients in the LTP would reduce the incidence of VAP in comparison with the semirecumbent position (SRP). METHODS: This was a randomized, multicenter, controlled study in invasively ventilated critically ill patients. Two preplanned interim analyses were performed. Patients were randomized to be placed in the LTP or the SRP. The primary outcome, assessed by intention-to-treat analysis, was incidence of microbiologically confirmed VAP. Major secondary outcomes included mortality, duration of mechanical ventilation, and intensive care unit length of stay. RESULTS: At the second interim analysis, the trial was stopped because of low incidence of VAP, lack of benefit in secondary outcomes, and occurrence of adverse events. A total of 194 patients in the LTP group and 201 in the SRP group were included in the final intention-to-treat analysis. The incidence of microbiologically confirmed VAP was 0.5% (1/194) and 4.0% (8/201) in LTP and SRP patients, respectively (relative risk 0.13, 95% CI 0.02-1.03, p = 0.04). The 28-day mortality was 30.9% (60/194) and 26.4% (53/201) in LTP and SRP patients, respectively (relative risk 1.17, 95% CI 0.86-1.60, p = 0.32). Likewise, no differences were found in other secondary outcomes. Six serious adverse events were described in LTP patients (p = 0.01 vs. SRP). CONCLUSIONS: The LTP slightly decreased the incidence of microbiologically confirmed VAP. Nevertheless, given the early termination of the trial, the low incidence of VAP, and the adverse events associated with the LTP, the study failed to prove any significant benefit. Further clinical investigation is strongly warranted; however, at this time, the LTP cannot be recommended as a VAP preventive measure. CLINICALTRIALS. GOV IDENTIFIER: NCT01138540.

Circulating Biologically Active Adrenomedullin (bio-ADM) Predicts Hemodynamic Support Requirement and Mortality During Sepsis.

BACKGROUND: The biological role of adrenomedullin (ADM), a hormone involved in hemodynamic homeostasis, is controversial in sepsis because administration of either the peptide or an antibody against it may be beneficial. METHODS: Plasma biologically active ADM (bio-ADM) was assessed on days 1, 2, and 7 after randomization of 956 patients with sepsis or septic shock to albumin or crystalloids for fluid resuscitation in the multicenter Albumin Italian Outcome Sepsis trial. We tested the association of bio-ADM and its time-dependent variation with fluid therapy, vasopressor administration, organ failures, and mortality. RESULTS: Plasma bio-ADM on day 1 (median [Q1-Q3], 110 [59-198] pg/mL) was higher in patients with septic shock, associated with 90-day mortality, multiple organ failures and the average extent of hemodynamic support therapy (fluids and vasopressors), and serum lactate time course over the first week. Moreover, it predicted incident cardiovascular dysfunction in patients without shock at enrollment (OR [95% CI], 1.9 [1.4-2.5]; P < .0001, for an increase of 1 interquartile range of bio-ADM concentration). bio-ADM trajectory during the first week of treatment clearly predicted 90-day mortality after adjustment for clinically relevant covariates (hazard ratio [95% CI], 1.3 [1.2-1.4]; P < .0001), and its reduction below 110 pg/mL at day 7 was associated with a marked reduction in 90-day mortality. Changes over the first 7 days of bio-ADM concentrations were not dependent on albumin treatment. CONCLUSIONS: In patients with sepsis, the circulating, biologically active form of ADM may help individualizing hemodynamic support therapy, while avoiding harmful effects. Its possible pathophysiologic role makes bio-ADM a potential candidate for future targeted therapies. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00707122.

How formative courses about damage control surgery and non-operative management improved outcome and survival in unstable politrauma patients in a Mountain Trauma Center.

AIM: Aim of this study is to analyze how the starting of Course of Trauma in our hospital improved survival and organization in management of polytraumatized patients. MATERIAL OF STUDY: We analysed all major trauma patients (Injury Severity Score (Injury Severity Score (ISS)> 15) treated at Emergency Department of the Santa Chiara Hospital between January 2011 and December 2014. The training courses (TC) were named "management of polytrauma" (MP) and "clinical cases discussion" (CCD), and started in November 2013. We divided the patients between two groups: before November 2013 (pre-TC group) and after November 2013 (post-TC group). RESULTS: MTG's courses (EMC accredited), CCD and MP courses started in November 2013. The target of these courses was the multidisciplinary management of polytrauma patient; the courses were addressed to general surgeons, anaesthesiologists, radiologists, orthopaedics and emergency physicians. Respectively 110 and 78 doctors were formed in CCD's and MP's courses. Patients directly transported to our trauma centre rose from 67.5% to 83% (p<0,005), and E-FAST grew from 15.6% in the pre-TC group to 51.3% in the post-TC group. Time of access in operatory theatre decreased from 62 to 44 minutes. Early Mortality (within 48 hours from the hospital arrival) was 9% in the pre-TC group and 4.5% in the post-tc group (p<0.005). DISCUSSION: Be needed to complete our goal. Further analysis and possible comparison with other trauma centers be needed to complete our goal CONCLUSIONS: Our results show that in our experience the multidisciplinary approach to polytrauma patients increased early survival and improved outcome with an evidence of worker's satisfaction. However, the best practice would ask to start with the approval of procedures and guidelines by the hospital governance, followed by clinical practice changes, in order to create a dedicated emergency and trauma surgery group. KEY WORD: Damage Control Surgery, Non Operative Management, Trauma Course, Trauma Team, Trauma Center.

[High altitude pulmonary edema: the importance of early diagnosis]. / Edema polmonare da alta quota: l'importanza di una diagnosi precoce.

In high altitude setting is present a syndrome linked to hypoxia, exercise and low temperatures, causing multiple organ damage, which may also lead to death. The main clinical pictures are represented by acute mountain sickness, high altitude pulmonary edema (HAPE), high altitude cerebral edema. A clinical case with the main determinants of HAPE, during a trek in the Himalayas valley is described.

Frequent subclinical high-altitude pulmonary edema detected by chest sonography as ultrasound lung comets in recreational climbers.

OBJECTIVE: The ultrasound lung comets detected by chest sonography are a simple, noninvasive, semiquantitative sign of increased extravascular lung water. The aim of this study was to evaluate, by chest sonography, the incidence of interstitial pulmonary edema in recreational high-altitude climbers. DESIGN: Observational study. SUBJECTS: Eighteen healthy subjects (mean age 45 +/- 10 yrs, ten males) participating in a high-altitude trek in Nepal. INTERVENTIONS: Chest and cardiac sonography at sea level and at different altitudes during ascent. Ultrasound lung comets were evaluated on anterior chest at 28 predefined scanning sites. MEASUREMENTS AND MAIN RESULTS: At individual patient analysis, ultrasound lung comets during ascent appeared in 15 of 18 subjects (83%) at 3440 m above sea level and in 18 of 18 subjects (100%) at 4790 m above sea level in the presence of normal left and right ventricular function and pulmonary artery systolic pressure rise (sea level = 24 +/- 5 mm Hg vs. peak ascent = 42 +/- 11 mm Hg, p < .001). Ultrasound lung comets were absent at baseline (day 2, altitude 1350 m, 1.06 +/- 1.3), increased progressively during the ascent (day 14, altitude 5130 m: 16.5 +/- 8; p < .001 vs. previous steps), and decreased at descent (day 20, altitude 1355 m: 2.9 +/- 1.7; p = nonsignificant vs. baseline). An ultrasound lung comet score showed a negative correlation with O(2) saturation (R = -.7; p < .0001). CONCLUSIONS: In recreational climbers, chest sonography revealed a high prevalence of clinically silent interstitial pulmonary edema mirrored by decreased O(2) saturation, whereas no statistically significant relationship with pulmonary artery systolic pressure was observed during ascent.

The clinical experience with levosimendan in anesthesiology and in the intensive care unit.

In the present review striking data showing that intensive care unit patients with acute heart failure and high-risk surgical patients may markedly benefit from the use of levosimendan are presented. Indeed, levosimendan is an effective new agent that acts via two complementary mechanisms. It enhances cardiac contractility by improving the response of the myofilaments to intracellular calcium, and it reduces the cardiac workload by opening the adenosine triphosphate-dependent potassium channels for the dilation of blood vessels. Because the therapeutic levels of levosimendan do not increase the intracellular calcium concentrations, levosimendan is less likely than traditional inotropes (beta-agonist inotropes or phosphodiesterase inhibitors) to elicit arrhythmias or impair diastolic relaxation. In fact, the results of recent clinical studies indicate that levosimendan offers significant hemodynamic and survival benefits when given to patients who are hospitalized for acute heart failure. Indeed, in the near future, it is likely that levosimendan may also prove effective for the treatment of patients with diastolic heart failure or for those with a low cardiac output following coronary artery bypass grafting. In addition, levosimendan has the potential of supporting the cardiac function during the initiation of beta-blocker therapy, for weaning patients from cardiopulmonary bypass, for individuals with valvular abnormalities and for those with myocarditis. Preliminary results also suggest that levosimendan may be beneficial for the treatment of patients with right ventricular heart failure. Although the use of levosimendan has been fully validated for the most common causes of acute heart failure, additional clinical trials are needed to safety broaden its therapeutic indications.