Level of Diffusion and Training of Lung Ultrasound during the COVID-19 Pandemic - A National Online Italian Survey (ITALUS) from the Lung Ultrasound Working Group of the Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI).

PURPOSE: The goal of this survey was to describe the use and diffusion of lung ultrasound (LUS), the level of training received before and during the COVID-19 pandemic, and the clinical impact LUS has had on COVID-19 cases in intensive care units (ICU) from February 2020 to May 2020. MATERIALS AND METHODS: The Italian Lung Ultrasound Survey (ITALUS) was a nationwide online survey proposed to Italian anesthesiologists and intensive care physicians carried out after the first wave of the COVID-19 pandemic. It consisted of 27 questions, both quantitative and qualitative. RESULTS: 807 responded to the survey. The median previous LUS experience was 3 years (IQR 1.0-6.0). 473 (60.9 %) reported having attended at least one training course on LUS before the COVID-19 pandemic. 519 (73.9 %) reported knowing how to use the LUS score. 404 (52 %) reported being able to use LUS without any supervision. 479 (68.2 %) said that LUS influenced their clinical decision-making, mostly with respect to patient monitoring. During the pandemic, the median of patients daily evaluated with LUS increased 3-fold (p < 0.001), daily use of general LUS increased from 10.4 % to 28.9 % (p < 0.001), and the daily use of LUS score in particular increased from 1.6 % to 9.0 % (p < 0.001). CONCLUSION: This survey showed that LUS was already extensively used during the first wave of the COVID-19 pandemic by anesthesiologists and intensive care physicians in Italy, and then its adoption increased further. Residency programs are already progressively implementing LUS teaching. However, 76.7 % of the sample did not undertake any LUS certification.

Early experience with remdesivir in SARS-CoV-2 pneumonia.

At present, there is no definitive antiviral treatment for coronavirus disease 2019 (COVID-19). We describe our early experience with remdesivir in four critically ill COVID-19 patients. Patients received a 200 mg loading dose, followed by 100 mg daily intravenously for up to 10 days. All patients had been previously treated with other antivirals before remdesivir initiation. One patient experienced a torsade de pointes requiring cardiac resuscitation and one died due to multiple organ failure. Three patients showed biochemical signs of liver injury. Lymphocyte count increased in all patients soon after remdesivir initiation. Nasal swab SARS-CoV-2 RNA became negative in three of four patients after 3 days of therapy. We observed an in vivo virological effect of remdesivir in four critically ill, COVID-19 patients, coupled with a significant burden of adverse events. Although limited by the low number of subjects studied, our preliminary experience may be relevant for clinicians treating COVID-19.

Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS.

AIM: To investigate the prevalence and prognostic impact of right heart failure and right ventricular-arterial uncoupling in Corona Virus Infectious Disease 2019 (COVID-19) complicated by an Acute Respiratory Distress Syndrome (ARDS). METHODS: Ninety-four consecutive patients (mean age 64 years) admitted for acute respiratory failure on COVID-19 were enrolled. Coupling of right ventricular function to the pulmonary circulation was evaluated by a comprehensive trans-thoracic echocardiography with focus on the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio RESULTS: The majority of patients needed ventilatory support, which was noninvasive in 22 and invasive in 37. There were 25 deaths, all in the invasively ventilated patients. Survivors were younger (62 ± 13 vs. 68 ± 12 years, p = 0.033), less often overweight or usual smokers, had lower NT-proBNP and interleukin-6, and higher arterial partial pressure of oxygen (PaO2)/fraction of inspired O2 (FIO2) ratio (270 ± 104 vs. 117 ± 57 mmHg, p < 0.001). In the non-survivors, PASP was increased (42 ± 12 vs. 30 ± 7 mmHg, p < 0.001), while TAPSE was decreased (19 ± 4 vs. 25 ± 4 mm, p < 0.001). Accordingly, the TAPSE/PASP ratio was lower than in the survivors (0.51 ± 0.22 vs. 0.89 ± 0.29 mm/mmHg, p < 0.001). At univariate/multivariable analysis, the TAPSE/PASP (HR: 0.026; 95%CI 0.01-0.579; p: 0.019) and PaO2/FIO2 (HR: 0.988; 95%CI 0.988-0.998; p: 0.018) ratios were the only independent predictors of mortality, with ROC-determined cutoff values of 159 mmHg and 0.635 mm/mmHg, respectively. CONCLUSIONS: COVID-19 ARDS is associated with clinically relevant uncoupling of right ventricular function from the pulmonary circulation; bedside echocardiography of TAPSE/PASP adds to the prognostic relevance of PaO2/FIO2 in ARDS on COVID-19.

Correction to: Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus.

The article Perioperative Management of Elderly patients (PriME).

Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus.

BACKGROUND: Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue. AIMS: To develop evidence-based recommendations for the integrated care of geriatric surgical patients. METHODS: A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria. RESULTS: A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items). CONCLUSIONS: These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient's conditions.

Accuracy and trending ability of hemoglobin measurement by the Pulse CO-Oximeter during vascular surgery.

Real time information of Hb concentration can guide a tailored patient blood management. The study investigates the accuracy, precision and trending ability of the Pulse CO-Oximeter (SpHb) and blood gas analyzer in measuring the Hb concentration, compared to hematological analysis, in surgery at high risk of hemorrhage. We performed an observational study, involving 48 patients undergoing abdominal aortic open surgery. The primary endpoints of the study were to compare the accuracy in measuring the Hb concentration using non-invasive method (Masimo rainbow SET® Radical 7 Pulse CO-Oximetry™) compared to the values provided by invasive conventional blood gas analyzer and hematological analysis. The secondary endpoint was to compare the differences between the baseline and the final value of the Hb after surgery (Δ-values), as well as the trending ability. Bias (precision) for the SpHb was 1.63 g/dL (± 0.05) with 95% limits of agreement between 0.85 and + 2.4 g/dL, while for the blood gas analyzer was 0.69 g/dL (± 0.04) with 95% limits of agreement between 0.07 and 1.3 g/dL. Δ-values values were not statistically different from the reference values of ΔHb obtained with the hematological analysis. Trending ability was good for both Pulse CO-Oximeter and blood gas analysis. Our results have shown that the SpHb is not precise enough to replace an invasive approach, but the trending ability of SpHb is accurate and may provide important information on the changes in hemoglobin concentration to guide blood management.

Opioid-induced bowel dysfunction: suggestions from a multidisciplinary expert Board.

Constipation, one of the adverse effects of opioid therapy with a major impact on quality of life, is still an unmet need for cancer patients, particularly those with an advanced and progressive disease, and for non-cancer patients chronically treated with opioids. The awareness of this condition is poor among healthcare providers, despite the recent publication of guidelines and consensus conferences. An early multidisciplinary approach of opioid-induced bowel dysfunction (OIBD), based on available therapies of proven effectiveness, could support clinicians in managing this condition, thus increasing patients' adherence to pain therapy. Several Italian experts involved in the management of patients suffering from pain (anaesthesia pain therapy, oncology, haematology, palliative care, gastroenterology) joined in a Board in order to draw up an expert opinion on OIBD. The most frequent and still unsolved issues in this field were examined, including a more comprehensive definition of OIBD, the benefits of early intervention to prevent its occurrence and the most appropriate use of peripherally acting mu-opioid receptor antagonists (PAMORAs). The use of the recently introduced PAMORA naloxegol was analysed, in light of the current literature. The Board proposed a solution for each open issue in the form of recommendations, integrated with the contribution of representatives from different disciplines and often accompanied by procedural algorithms immediately usable and applicable in daily clinical practice. Safety and quality of life of the patient suffering from pain and from the adverse effects of pain therapies have been the mainstays of this expert opinion, in cooperation with general practitioners and caregivers.

Assessing the correct inflation of the endotracheal tube cuff: a larger pilot balloon increases the sensitivity of the 'finger-pressure' technique, but it remains poorly reliable in clinical practice.

The pilot balloon palpation (or 'finger-pressure') method is still widely used to assess the endotracheal tube cuff inflation, despite consistent evidence of its poor sensitivity in recognizing cuff overinflation. It was recently speculated that this may be related to the lower wall tension (due to the smaller radius) of the pilot balloon as compared with the cuff, according to Laplace's law. To verify this hypothesis and, secondarily, to assess whether the use of a 'large' pilot balloon (identical to the cuff) increases the reliability of this technique, 62 anesthetists (41 experienced anesthesiologists and 21 residents) were asked to estimate the pressure of a cuff inflated to 88 mmHg into a simulated trachea by feeling both a usual and a modified 'large' pilot balloon. A similar test was repeated at 40 mmHg. After palpation of the usual pilot balloon, only 35% of participants (49% of experienced anesthesiologists and 10% of residents) recognized considerable overinflation (88 mmHg), as compared with 87% of participants (95% of experienced anesthesiologists and 71% of residents) after palpation of the 'large' pilot balloon. Moreover, 89% of participants (85% of experienced anesthesiologists and 95% of residents) believed that pressure was higher in the 'large' balloon than in the normal one. However, only 32% of participants (51% of experienced anesthesiologists and none of residents) recognized slight overinflation (40 mmHg) after feeling the 'large' balloon. The pilot balloon size affects the sensitivity of the 'finger-pressure' technique, but it remains poorly reliable with a larger pilot balloon.

A high PCT level correlates with disease severity in Plasmodium falciparum malaria in children.

Most clinicians in developed countries have limited experience in making clinical assessments of malaria disease severity and/or monitoring high-level parasitemia in febrile patients with imported malaria. Hyperparasitemia is a risk factor for severe P. falciparum malaria, and procalcitonin (PCT) has recently been related to the severity of malaria. In developed countries, where not all hospital have skilled personnel to count parasitemia, a rapid test might be useful for the prompt diagnosis of malaria but unfortunately these tests are not able to count the number of parasites. In this context, PCT might have a prognostic value for the assessment of severe malaria, especially in children with cerebral malaria. We describe two children with severe cerebral malaria, who were directly admitted to the ICU with a high level of PCT and extremely high (>25%) parasitemia. Our conclusion is that PCT may also be a measure of severity of P. falciparum malaria in children.

A randomized controlled trial of levosimendan to reduce mortality in high-risk cardiac surgery patients (CHEETAH): Rationale and design.

OBJECTIVE: Patients undergoing cardiac surgery are at risk of perioperative low cardiac output syndrome due to postoperative myocardial dysfunction. Myocardial dysfunction in patients undergoing cardiac surgery is a potential indication for the use of levosimendan, a calcium sensitizer with 3 beneficial cardiovascular effects (inotropic, vasodilatory, and anti-inflammatory), which appears effective in improving clinically relevant outcomes. DESIGN: Double-blind, placebo-controlled, multicenter randomized trial. SETTING: Tertiary care hospitals. INTERVENTIONS: Cardiac surgery patients (n = 1,000) with postoperative myocardial dysfunction (defined as patients with intraaortic balloon pump and/or high-dose standard inotropic support) will be randomized to receive a continuous infusion of either levosimendan (0.05-0.2 µg/[kg min]) or placebo for 24-48 hours. MEASUREMENTS AND MAIN RESULTS: The primary end point will be 30-day mortality. Secondary end points will be mortality at 1 year, time on mechanical ventilation, acute kidney injury, decision to stop the study drug due to adverse events or to start open-label levosimendan, and length of intensive care unit and hospital stay. We will test the hypothesis that levosimendan reduces 30-day mortality in cardiac surgery patients with postoperative myocardial dysfunction. CONCLUSIONS: This trial is planned to determine whether levosimendan could improve survival in patients with postoperative low cardiac output syndrome. The results of this double-blind, placebo-controlled randomized trial may provide important insights into the management of low cardiac output in cardiac surgery.

Tracheostomy procedures in the intensive care unit: an international survey.

INTRODUCTION: Percutaneous dilatational tracheostomy (PDT) is one of the most frequent procedures performed in the intensive care unit (ICU). PDT may add potential benefit to clinical management of critically ill patients. Despite this, no clinical guidelines are available. We sought to characterize current practice in this international survey. METHODS: An international survey, endorsed and peer reviewed by European Society of Intensive Care Medicine (ESICM), was carried out from May to October 2013. The questionnaire was accessible from the ESICM website in the 'survey of the month' section. RESULTS: 429 physicians from 59 countries responded to this survey. Single step dilatational tracheostomy was the most used PDT in ICU. Almost 75% of PDT's were performed by intensive care physicians. The main indication for PDT was prolonged mechanical ventilation. Tracheostomies were most frequently performed between 7-15 days after ICU admission. Volume control mechanical ventilation, and a combination of sedation, analgesia, neuromuscular blocking agents and fiberoptic bronchoscopy were used. Surgical tracheostomy was mainly performed in ICU by ENT specialists, and was generally chosen when for patients at increased risk for difficult PDT insertion. Bleeding controlled by compression and stoma infection/inflammation were the most common intra-procedural and late complications, respectively. Informed consent for PDT was obtained in only 60% of cases. CONCLUSIONS: This first international picture of current practices in regard to tracheostomy insertion demonstrates considerable geographic variation in practice, suggesting a need for greater standardization of approaches to tracheostomy insertion.

Ultrasound-Guided Regional Anesthesia Using a Mixture of Dexamethasone, Dexmedetomidine, and 0.2% Levobupivacaine for Bilateral Breast Cancer Surgery Under a Spontaneous Breathing Opioid-Free Anesthesia: A Case Report.

Breast cancer is unfortunately the most common cancer in women, although survival rates have greatly increased in recent years. Breast surgery can be very aggressive and therefore highly painful, leading to high rates of acute postsurgical pain and chronic pain. In addition to general anesthesia (GA), ultrasound-guided regional anesthesia (RA) is sometimes performed to help reduce acute postoperative pain and consumption of opioids. Although effective, the main limitation of fascial plane blocks is that they require high volumes of local anesthetics, carrying the risk of local anesthetic systemic toxicity. In this article, we present the case of a 41-year-old woman, who refused GA and was successfully operated on for bilateral breast cancer, under a spontaneous breathing opioid-free sedation and ultrasound-guided RA, based on only 0.2% levobupivacaine with the addition of dexamethasone and dexmedetomidine as adjuvants. Despite this, postoperative analgesia lasted for more than 48 hours, and the patient did not require additional analgesia or opioids.

Pharmacokinetic parameters of CAZ-AVI in the normal lung and in models of pneumonia: lessons for treatment optimization in critical care.

The spread of multidrug-resistant Gram-negative bacterial infections is a significant issue for worldwide public health. Gram-negative organisms regularly develop resistance to antibiotics, especially to ß-lactam antimicrobials, which can drastically restrict the number of therapies. A third-generation cephalosporin and the non-ß-lactam ß-lactamase inhibitor avibactam, which exhibits broad-spectrum ß-lactamase inhibition in vitro, are combined to form ceftazidime-avibactam (CAZ-AVI). In this narrative review, we summarize data on pharmacokinetic (PK) parameters for CAZ-AVI in both animal and human models of pneumonia, as well as in healthy individuals. We assessed current literature performing an extensive search of the literature, using as search words 'CAZ-AVI', 'pharmacokinetics', 'pneumonia', 'lung', and 'epithelial lining fluid'. Overall, lung exposure studies of CAZ-AVI revealed that the epithelial lining fluid penetration ranges between 30% and 35% of plasma concentration. Despite the fair lung penetration of CAZ-AVI, this antimicrobial agent has a pivotal role in managing patients with multi-drug resistant Gram-negative pneumonia, however further studies are needed to better assess its PK profile.

Colistin and rifampicin compared with colistin alone for the treatment of serious infections due to extensively drug-resistant Acinetobacter baumannii: a multicenter, randomized clinical trial.

BACKGROUND: Extensively drug-resistant (XDR) Acinetobacter baumannii may cause serious infections in critically ill patients. Colistin often remains the only therapeutic option. Addition of rifampicin to colistin may be synergistic in vitro. In this study, we assessed whether the combination of colistin and rifampicin reduced the mortality of XDR A. baumannii infections compared to colistin alone. METHODS: This multicenter, parallel, randomized, open-label clinical trial enrolled 210 patients with life-threatening infections due to XDR A. baumannii from intensive care units of 5 tertiary care hospitals. Patients were randomly allocated (1:1) to either colistin alone, 2 MU every 8 hours intravenously, or colistin (as above), plus rifampicin 600 mg every 12 hours intravenously. The primary end point was overall 30-day mortality. Secondary end points were infection-related death, microbiologic eradication, and hospitalization length. RESULTS: Death within 30 days from randomization occurred in 90 (43%) subjects, without difference between treatment arms (P = .95). This was confirmed by multivariable analysis (odds ratio, 0.88 [95% confidence interval, .46-1.69], P = .71). A significant increase of microbiologic eradication rate was observed in the colistin plus rifampicin arm (P = .034). No difference was observed for infection-related death and length of hospitalization. CONCLUSIONS: In serious XDR A. baumannii infections, 30-day mortality is not reduced by addition of rifampicin to colistin. These results indicate that, at present, rifampicin should not be routinely combined with colistin in clinical practice. The increased rate of A. baumannii eradication with combination treatment could still imply a clinical benefit. CLINICAL TRIALS REGISTRATION: NCT01577862.

Reducing mortality in acute kidney injury patients: systematic review and international web-based survey.

OBJECTIVE: To identify all interventions that increase or reduce mortality in patients with acute kidney injury (AKI) and to establish the agreement between stated beliefs and actual practice in this setting. DESIGN AND SETTING: Systematic literature review and international web-based survey. PARTICIPANTS: More than 300 physicians from 62 countries. INTERVENTIONS: Several databases, including MEDLINE/PubMed, were searched with no time limits (updated February 14, 2012) to identify all the drugs/techniques/strategies that fulfilled all the following criteria: (a) published in a peer-reviewed journal, (b) dealing with critically ill adult patients with or at risk for acute kidney injury, and (c) reporting a statistically significant reduction or increase in mortality. MEASUREMENTS AND MAIN RESULTS: Of the 18 identified interventions, 15 reduced mortality and 3 increased mortality. Perioperative hemodynamic optimization, albumin in cirrhotic patients, terlipressin for hepatorenal syndrome type 1, human immunoglobulin, peri-angiography hemofiltration, fenoldopam, plasma exchange in multiple-myeloma-associated AKI, increased intensity of renal replacement therapy (RRT), CVVH in severely burned patients, vasopressin in septic shock, furosemide by continuous infusion, citrate in continuous RRT, N-acetylcysteine, continuous and early RRT might reduce mortality in critically ill patients with or at risk for AKI; positive fluid balance, hydroxyethyl starch and loop diuretics might increase mortality in critically ill patients with or at risk for AKI. Web-based opinion differed from consensus opinion for 30% of interventions and self-reported practice for 3 interventions. CONCLUSION: The authors identified all interventions with at least 1 study suggesting a significant effect on mortality in patients with or at risk of AKI and found that there is discordance between participant stated beliefs and actual practice regarding these topics.

The postoperative analgesic efficacy of preperitoneal continuous wound infusion compared to epidural continuous infusion with local anesthetics after colorectal cancer surgery: a randomized controlled multicenter study.

BACKGROUND: Open colorectal cancer (CRC) surgery induces severe and prolonged postoperative pain. The optimal method of postoperative analgesia in CRC surgery has not been established. We evaluated the efficacy of preperitoneal continuous wound infusion (CWI) of ropivacaine for postoperative analgesia after open CRC surgery in a multicenter randomized controlled trial. METHODS: Candidates for open CRC surgery randomly received preperitoneal CWI analgesia or continuous epidural infusion (CEI) analgesia with ropivacaine 0.2% 10 mL/h for 48 hours after surgery. Fifty-three patients were allocated to each group. All patients received patient-controlled IV morphine analgesia. RESULTS: Over the 72-hour period after the end of surgery, CWI analgesia was not inferior to CEI analgesia. The difference of the mean visual analog scale score between CEI and CWI patients was 1.89 (97.5% confidence interval = -0.42, 4.19) at rest and 2.76 (97.5% confidence interval = -2.28, 7.80) after coughing. Secondary end points, morphine consumption and rescue analgesia, did not differ between groups. Time to first flatus was 3.06 ± 0.77 days in the CWI group and 3.61 ± 1.41 days in the CEI group (P = 0.002). Time to first stool was shorter in the CWI than the CEI group (4.49 ± 0.99 vs 5.29 ± 1.62 days; P = 0.001). Mean time to hospital discharge was shorter in the CWI group than in the CEI group (7.4 ± 0.41 and 8.0 ± 0.38 days, respectively). More patients in the CWI group reported excellent quality of postoperative pain control (45.3% vs 7.6%). Quality of night sleep was better with CWI analgesia, particularly at the postoperative 72-hour evaluation (P = 0.009). Postoperative nausea and vomiting was significantly less frequent with CWI analgesia at 24 hours (P = 0.02), 48 hours (P = 0.01), and 72 hours (P = 0.007) after surgery evaluations. CONCLUSIONS: Preperitoneal CWI analgesia with ropivacaine 0.2% continuous infusion at 10 mL/h during 48 hours after open CRC surgery provided effective postoperative pain relief not inferior to CEI analgesia.