The usefulness of trans-splenic retrocardiac imaging in prone positioned critically ill patients.

In the last few years prone positioning has been used increasingly in the treatment of patients with acute respiratory distress syndrome and this maneuver is now considered a simple and safe method to improve oxygenation. Hemodynamic monitoring by echocardiography may be required but prone positioning imposes certain challenges limiting standard examination. The article describes the application of the "trans-splenic retrocardiac view," a little-known echographic window for obtaining Doppler parameters from the back in prone-positioned patients.

Neonatal Early Onset Sepsis (EOS) Calculator plus Universal Serial Physical Examination (SPE): A Prospective Two-Step Implementation of a Neonatal EOS Prevention Protocol for Reduction of Sepsis Workup and Antibiotic Treatment.

Current neonatal early-onset sepsis (EOS) guidelines lack consensus. Recent studies suggest three different options for EOS risk assessment among infants born ≥35 wks gestational age (GA), leading to different behaviors in the sepsis workup and antibiotic administration. A broad disparity in clinical practice is found in Neonatal Units, with a large number of non-infected newborns evaluated and treated for EOS. Broad spectrum antibiotics in early life may induce different short- and long-term adverse effects, longer hospitalization, and early mother-child separation. In this single-center prospective study, a total of 3002 neonates born in three periods between 2016 and 2020 were studied, and three different workup algorithms were compared: the first one was based on the categorical risk assessment; the second one was based on a Serial Physical Examination (SPE) strategy for infants with EOS risk factors; the third one associated an informatic tool (Neonatal EOS calculator) with a universal extension of the SPE strategy. The main objective of this study was to reduce the number of neonatal sepsis workups and the rate of antibiotic administration and favor rooming-in and mother−infant bonding without increasing the risk of sepsis and mortality. The combined strategy of universal SPE with the EOS Calculator showed a significant reduction of laboratory tests (from 33% to 6.6%; p < 0.01) and antibiotic treatments (from 8.5% to 1.4%; p < 0.01) in term and near-term newborns. EOS and mortality did not change significantly during the study period.

Incidence, clinical characteristics and outcome of barotrauma in critically ill patients with COVID-19: a systematic review and meta-analysis.

INTRODUCTION: Barotrauma is rare in patients with acute respiratory distress syndrome undergoing mechanical ventilation. Its incidence seems increased among critically ill COVID-19 patients. We performed a systematic review and meta-analysis to investigate the incidence, risk factors and clinical outcomes of barotrauma among critically ill COVID-19 patients. EVIDENCE ACQUISITION: PubMed was searched from March 1st, 2020 to August 31st, 2021; case series and retrospective cohort studies concerning barotrauma in adult critically ill COVID-19 patients, either hospitalized in the Intensive Care Unit (ICU) or invasively ventilated were included. Primary outcome was the incidence of barotrauma in COVID-19 versus non-COVID-19 patients. Secondary outcomes were clinical characteristics, ventilator parameters, mortality and length of stay between patients with and without barotrauma. EVIDENCE SYNTHESIS: We identified 21 studies (six case series, 15 retrospective cohorts). The overall incidence of barotrauma was 11 [95% CI: 8-14]% in critically ill COVID-19 patients, vs. 2 [1-3]% in non-COVID-19, P<0.001; the incidence in mechanically ventilated patients was 14 [11-17]% vs. 4 [2-5]% non-COVID-19 patients, P<0.001. There were no differences in demographic, clinical, ventilatory parameters between patients who did and did not develop barotrauma, while, on average, protective ventilation criteria were always respected. Among COVID-19 patients, those with barotrauma had a higher mortality (60 [55-66] vs. 48 [42-54]%, P<0.001) and a longer ICU length of stay (20 [14-26] vs. 13 [10,5-16] days, P=0.03). CONCLUSIONS: Barotrauma is a frequent complication in critically ill COVID-19 patients and is associated with a poor prognosis. Since lung protective ventilation was delivered, the ventilatory management might not be the sole factor in the development of barotrauma.

Qualitative and quantitative muscle ultrasound changes in patients with COVID-19-related ARDS.

OBJECTIVES: Severe forms of the novel coronavirus-19 (COVID-19) are associated with systemic inflammation and hypercatabolism. The aims of this study were to compare the time course of the size and quality of both rectus femoris and diaphragm muscles between critically ill, COVID-19 survivors and non-survivors and to explore the correlation between the change in muscles size and quality with the amount of nutritional support delivered and the cumulative fluid balance. METHODS: This was a prospective observational study in the general intensive care unit (ICU) of a tertiary care hospital for COVID-19. The right rectus femoris cross-sectional area and the right diaphragm thickness, as well as their echo densities were assessed within 24 h from ICU admission and on day 7. We recorded anthropometric and biochemical data, respiratory mechanics and gas exchange, daily fluid balance, and the number of calories and proteins administered. RESULTS: Twenty-eight patients were analyzed (65 ± 10 y of age; 80% men, body mass index 30 ± 7.8 kg/m2). Rectus femoris and diaphragm sizes were significantly reduced at day 7 (median = -26.1 [interquartile ratio [IQR], = -37.8 to -15.2] and -29.2% [-37.8% to -19.6%], respectively) and this reduction was significantly higher in non-survivors. Both rectus femoris and diaphragm echo density were significantly increased at day 7, with a significantly higher increase in non-survivors. The change in both rectus femoris and diaphragm size at day 7 was related to the cumulative protein deficit (R = 0.664, P < 0.001 and R = 0.640, P < 0.001, respectively), whereas the change in rectus femoris and diaphragm echo density was related to the cumulative fluid balance (R = 0.734, P < 0.001 and R = 0.646, P < 0.001, respectively). CONCLUSIONS: Early changes in muscle size and quality seem related to the outcome of critically ill COVID-19 patients, and to be influenced by nutritional and fluid management strategies.