Material and Technology: Back to the Future for the Choice of Interface for Non-Invasive Ventilation - A Concise Review.

Non-invasive ventilation (NIV) has dramatically changed the treatment of both acute and chronic respiratory failure in the last 2 decades. The success of NIV is correlated to the application of the "best ingredients" of a patient's "tailored recipe," including the appropriate choice of the selected candidate, the ventilator setting, the interface, the expertise of the team, and the education of the caregiver. The choice of the interface is crucial for the success of NIV. Type (oral, nasal, nasal pillows, oronasal, hybrid mask, helmet), size, design, material and headgears may affect the patient's comfort with respect to many aspects, such as air leaks, claustrophobia, skin erythema, eye irritation, skin breakdown, and facial deformity in children. Companies are paying great attention to mask development, in terms of shape, materials, comfort, and leak reduction. Although the continuous development of new products has increased the availability of interfaces and the chance to meet different requirements, in patients necessitating several daily hours of NIV, both in acute and in chronic home setting, the rotational use of different interfaces may remain an excellent strategy to decrease the risk of skin breakdown and to improve patient's tolerance. The aim of the present review was to give the readers a background on mask technology and materials in order to enhance their "knowledge" in making the right choice for the interface to apply during NIV in the different clinical scenarios.

Medical masks and Respirators for the Protection of Healthcare Workers from SARS-CoV-2 and other viruses.

The use of medical masks and respirators as personal protective equipment is pivotal to reducing the level of biological hazard to which healthcare workers are exposed during the outbreak of highly diffusible pathogens, such as the recent novel coronavirus SARS-CoV-2. Unfortunately, during this pandemic, supplies are rapidly running out worldwide, with potential consequences for the rate of occupational infections. Also, knowledge about specific characteristics of respirators is of utmost importance to select the proper type according to the clinical setting. A wide variety of literature is available on the topic, but mostly based on Influenza viruses infection models. Clinical evidence on the use of respirators is poor and interest in the topic has not been constant over time. A better understanding of SARS-CoV-2 transmission is needed, together with high-quality clinical data on the use of respirators or alternative devices. Moreover, healthcare workers, regardless of their level of experience, should receive specific training. This review aims to summarize the available evidence on the use of medical masks and respirators in the context of viral infections, especially the current coronavirus disease 2019 (COVID-19).

Fake news and patient-family-physician interaction in critical care: concepts, beliefs and potential countermeasures.

Fake news has been defined as fabricated information mimicking media content in form but not in organizational process or intent. Science and medicine are deeply affected by this increasing phenomenon. Critical care represents a hot spot for fake news due to the high risk of conflictive communication, the rapid turnaround of clinical news and high prevalence of unpleasant information. Communication with patients' relatives is one of the hardest aspects. The relationship between physicians and families is pivotal to improve relatives' comfort, and reduce anxiety and pain. Fake news may undermine this relationship, posing an alternative truth between the critical care physician and relatives, which must be countered without worsening their suffering. The aim of this review is to provide intensivists an overview of concepts, characteristics and risk to better understand the fake news phenomenon and counter its potentially devastating effects.

Regional anticoagulation with heparin of an extracorporeal CO2 removal circuit: a case report.

BACKGROUND: Extracorporeal carbon dioxide removal is an increasingly used respiratory support technique. As is true of all extracorporeal techniques, extracorporeal carbon dioxide removal needs proper anticoagulation. We report a case of a patient at risk of bleeding complications who was treated with extracorporeal carbon dioxide removal and anticoagulated with a regional technique. CASE PRESENTATION: A 56-year-old Caucasian man with a history of chronic obstructive pulmonary disease exacerbation required extracorporeal carbon dioxide removal for severe hypercapnia and acidosis despite mechanical ventilation. The extracorporeal circuit was anticoagulated using a regional heparin technique to limit the patient's risk of bleeding due to a low platelet count. The patient underwent 96 h of effective extracorporeal carbon dioxide removal without any adverse events. He was successfully weaned from extracorporeal carbon dioxide removal. During the treatment, no bleeding complications or unexpected circuit clotting was observed. CONCLUSIONS: The use of regional heparin anticoagulation technique seems to be feasible and safe during extracorporeal carbon dioxide removal.

Precision and Bias of Target-Controlled Prolonged Propofol Infusion for General Anesthesia and Sedation in Neurosurgical Patients.

The aim of this study was to determine the relationship, precision, and bias of a propofol target-controlled infusion (TCI) system during prolonged infusion in neurosurgical patients. We retrospectively included patients undergoing general anesthesia for elective neurosurgical removal of brain tumors and postoperative sedation in the intensive care unit over a period of 3 months. TCI of propofol (Diprifusor - Marsh model) and remifentanil were used for general anesthesia and sedation. We compared propofol blood concentration (Cmeas ) measured by liquid chromatography-mass spectroscopy with predicted concentrations (Cpred ) by the TCI system at 40 minutes (T0), 2 hours (T1), and 4 hours (T2) and every 8 hours after starting the drug infusion and at the time of emergence from sedation. Ninety-four paired determinations of Cmeas and Cpred from 15 adult ASA I patients (8 men and 7 women 54.9 ± 13 years old; BMI, 24 ± 3.2 kg/m2 ) were analyzed. Mean duration of drug administration was 31 ± 6 hours. The coefficient of determination (R2 ) of the linear regression model for the relationship of Cmeas and Cpred was 0.43. At the time of emergence, Cmeas was 0.5 ± 0.18 µg/mL. The bias of the TCI system (median performance error) was -34.7%, and the precision (median absolute performance error) was 36%. Wobble and divergence were 0.3% and 12.3%, respectively. This study found bias of the system out of the range of tolerability and showed a high tendency toward overestimation. These findings may lead to undersedation when propofol TCI is used for prolonged infusion.

Two episodes of Taravana syndrome in a breath-hold diver with hyperhomocysteinemia.

Taravana syndrome is a rare dysbaric disease characterized by neurologic signs and symptoms. Differently from others decompression illness, it has unspecified pathophysiology and unclear predisposing factors. Our cases suggest that thrombophilic state due to hyperhomocysteinemia could increase the risk to develop Taravana syndrome.

Procalcitonin for the diagnosis of invasive candidiasis: what is the evidence?

Procalcitonin is a widely used marker for the evaluation of infection and sepsis and to guide antibiotic therapy. During the last decade, several studies evaluated its role and diagnostic performance as a surrogate marker for the identification of Candida spp. in suspected invasive candidiasis. A low serum level and a favorable negative predictive value are the main findings for procalcitonin in this setting. The aim of this report is to provide an updated brief summary of the evidence supporting the use of PCT for the management of invasive candidiasis.

Efficacy and Safety of Using High-Flow Nasal Oxygenation in Patients Undergoing Rapid Sequence Intubation.

OBJECTIVE: To assess the efficacy and safety of high-flow nasal oxygen (HFNO) therapy in patients undergoing rapid sequence intubation (RSI) for emergency abdominal surgery. METHODS: HFNO of 60 L.min-1 at an inspiratory oxygen fraction of 1 was delivered 4 min before laryngoscopy and maintained until the patient was intubated, and correct intubation was verified by the appearance of the end-tidal CO2 (EtCO2) waveform. Transcutaneous oxygenation (SpO2), heart rate and non-invasive mean arterial pressure were monitored at baseline (T0), after 4 min on HFNO (T1) and at the time of laryngoscopy (T2) and endotracheal intubation (ETI) (T3). An SpO2 of <3% from baseline was recorded at any sampled time. The value of EtCO2 at T3 was registered after two mechanical breaths. The apnoea time was defined as the time from the end of propofol injection to ETI. RSI was performed with propofol, fentanyl and rocuronium. RESULTS: Forty-five patients were enrolled. SpO2 levels showed a statistically significant increase at T1, T2 and T3 compared with those at T0 (p<0.05); median SpO2% (interquartile range) was 97% (range, 96%-99%) at T0, 99% (range, 99%-100%) at T1, 99% (range, 99%-100%) at T2 and 99% (range, 99%-100%) at T3. Minimal SpO2 was 96%; no patient showed an SpO2 of <3% from baseline; mean EtCO2 at the time of ETI was 36±4 mmHg. Maximum apnoea time was 12 min. CONCLUSION: HFNO is an effective and safe technique for pre-oxygenation in patients undergoing rapid sequence induction of general anaesthesia for emergency surgery.