Lung ultrasound among Expert operator'S: ScOring and iNter-rater reliability analysis (LESSON study) a secondary COWS study analysis from ITALUS group.

BACKGROUND: Lung ultrasonography (LUS) is a non-invasive imaging method used to diagnose and monitor conditions such as pulmonary edema, pneumonia, and pneumothorax. It is precious where other imaging techniques like CT scan or chest X-rays are of limited access, especially in low- and middle-income countries with reduced resources. Furthermore, LUS reduces radiation exposure and its related blood cancer adverse events, which is particularly relevant in children and young subjects. The score obtained with LUS allows semi-quantification of regional loss of aeration, and it can provide a valuable and reliable assessment of the severity of most respiratory diseases. However, inter-observer reliability of the score has never been systematically assessed. This study aims to assess experienced LUS operators' agreement on a sample of video clips showing predefined findings. METHODS: Twenty-five anonymized video clips comprehensively depicting the different values of LUS score were shown to renowned LUS experts blinded to patients' clinical data and the study's aims using an online form. Clips were acquired from five different ultrasound machines. Fleiss-Cohen weighted kappa was used to evaluate experts' agreement. RESULTS: Over a period of 3 months, 20 experienced operators completed the assessment. Most worked in the ICU (10), ED (6), HDU (2), cardiology ward (1), or obstetric/gynecology department (1). The proportional LUS score mean was 15.3 (SD 1.6). Inter-rater agreement varied: 6 clips had full agreement, 3 had 19 out of 20 raters agreeing, and 3 had 18 agreeing, while the remaining 13 had 17 or fewer people agreeing on the assigned score. Scores 0 and score 3 were more reproducible than scores 1 and 2. Fleiss' Kappa for overall answers was 0.87 (95% CI 0.815-0.931, p < 0.001). CONCLUSIONS: The inter-rater agreement between experienced LUS operators is very high, although not perfect. The strong agreement and the small variance enable us to say that a 20% tolerance around a measured value of a LUS score is a reliable estimate of the patient's true LUS score, resulting in reduced variability in score interpretation and greater confidence in its clinical use.

Accuracy of Preoperative Lung Ultrasound Score for the prediction of Major Adverse Cardiac Events in elderly patients undergoing HIP Surgery under Spinal Anesthesia: the LUSHIP multicenter observational prospective study.

BACKGROUND AND OBJECTIVE: We hypothesize that lung ultrasound scores (LUS) can help stratify the cardiac risk of elderly patients undergoing orthopedic surgery for hip fracture, adding value to the Revised Cardiac Risk Index (RCRI), the American Society of Anesthesiologists Physical Status (ASA-PS) and the National Surgical Quality Improvement Program Myocardial infarction and Cardiac arrest (NSQIP-MICA). METHODS: Prospective, observational multicenter study of 11 Italian hospitals on patients aged >65 years with hip fractures needing urgent surgery. Subjects with major adverse cardiovascular events (MACE) in the previous 6 months or with ongoing acute heart failure were excluded. Trained anesthesiologists obtained preoperative LUS scores during preoperative evaluation. ROC curve analysis and comparison were used to evaluate test accuracy. RESULTS: A total of 877 patients were enrolled in the study period. 108 MACE events occurred in 98 patients, with an overall incidence of 11.2%. LUS score was higher in complicated than non-complicated patients, 11.6 ± 6.64 vs. 4.97 ± 4.90 (p < 0.001). Preoperative LUS score ≥8 showed both better AUC (0.78) and accuracy (0.76) in predicting MACE than the RCRI scores (p < 0.001), MICA scores (p = 0.001) and ASA classes (p < 0.001). LUS sensitivity was 0.71, specificity was 0.76, negative predictive value was 0.95. LUS score ≥8 showed an OR for MACE of 5.81[95% CI 3.55-9.69] at multivariate analysis. 91 patients (10.4%) experienced postoperative pneumonia showing a preoperative LUS score higher in the non-pneumonia group, p < 0.001. CONCLUSIONS: The preoperative LUS score, with its high negative predictive value, could improve patients' risk stratification when used alone or add further value to the RCRI score. REGISTRATION: Registered at clinicaltrials.gov as NCT04074876.

Association between preoperative evaluation with lung ultrasound and outcome in frail elderly patients undergoing orthopedic surgery for hip fractures: study protocol for an Italian multicenter observational prospective study (LUSHIP).

BACKGROUND: Hip fracture is one of the most common orthopedic causes of hospital admission in frail elderly patients. Hip fracture fixation in this class of patients is considered a high-risk procedure. Preoperative physical examination, plasma natriuretic peptide levels (BNP, Pro-BNP), and cardiovascular scoring systems (ASA-PS, RCRI, NSQIP-MICA) have all been demonstrated to underestimate the risk of postoperative complications. We designed a prospective multicenter observational study to assess whether preoperative lung ultrasound examination can predict better postoperative events thanks to the additional information they provide in the form of "indirect" and "direct" cardiac and pulmonary lung ultrasound signs. METHODS: LUSHIP is an Italian multicenter prospective observational study. Patients will be recruited on a nation-wide scale in the 12 participating centers. Patients aged > 65 years undergoing spinal anesthesia for hip fracture fixation will be enrolled. A lung ultrasound score (LUS) will be generated based on the examination of six areas of each lung and ascribing to each area one of the four recognized aeration patterns-each of which is assigned a subscore of 0, 1, 2, or 3. Thus, the total score will have the potential to range from a minimum of 0 to a maximum of 36. The association between 30-day postoperative complications of cardiac and/or pulmonary origin and the overall mortality will be studied. Considering the fact that cardiac complications in patients undergoing hip surgery occur in approx. 30% of cases, to achieve 80% statistical power, we will need a sample size of 877 patients considering a relative risk of 1.5. CONCLUSIONS: Lung ultrasound (LU), as a tool within the anesthesiologist's armamentarium, is becoming increasingly widespread, and its use in the preoperative setting is also starting to become more common. Should the study demonstrate the ability of LU to predict postoperative cardiac and pulmonary complications in hip fracture patients, a randomized clinical trial will be designed with the scope of improving patient outcome. Trial registration ClinicalTrials.gov, NCT04074876. Registered on August 30, 2019.

Incidence and outcome of in-hospital cardiac arrest in Italy: a multicentre observational study in the Piedmont Region.

AIMS: to report the incidence, characteristics, and outcome of in-hospital cardiac arrest (IHCA) in a large Italian region. SETTING: all hospitals participating in the IHCA Registry Initiative of Piedmont. METHODS: observational cohort study in adult (>18year old) inpatients resuscitated from IHCA during three consecutive years (2012-2014). The main outcome measures were IHCA incidence and survival to hospital discharge. RESULTS: A total of1539 arrests in adult inpatients were recorded in the study period, yielding an overall incidence of 1.51 arrests/1000 admissions. The incidence was highest at day 1 after hospital admission and in the morning hours, with a peak at 9.00 a.m. Median age was 77 (interquartile range 68-83) years. The presenting rhythm was ventricular fibrillation/pulseless ventricular tachycardia in 291/1539 (18.9%) cases. A total of 549/1539 (35.7%) patients achieved recovery of spontaneous circulation (ROSC) and 228/1539(14.8%) survived hospital discharge, with 207 (90.8%) of the latter having good neurological outcome (Cerebral Performance Categories [CPC] 1 or 2).After adjustment for major confounders, a pre-arrest CPC=1, a cardiac cause of arrest, a shockable presenting rhythm, and a shorter duration of resuscitation were independently associated with a higher likelihood of survival to discharge. CONCLUSIONS: in this Italian registry the incidence of IHCA and its circadian distribution were comparable to those in the NCAA registry in the UK. Patients were older and had a lower ROSC rate than these observed in other large IHCA registries, but post-ROSC survival rate and factors affecting survival to discharge were similar.

Factors affecting attitudes and barriers to a medical emergency team among nurses and medical doctors: a multi-centre survey.

AIM: To identify factors underlying attitudes towards the medical emergency team (MET) and barriers to its utilisation among ward nurses and physicians. METHODS: Multicentre survey using an anonymous questionnaire in hospitals with a fully operational MET system in the Piedmont Region, Italy. Response to questions was scored on a 5-point Likert-type agreement scale. Dichotomised results were included in a logistic regression model. RESULTS: Among 2279 staff members who were contacted, 1812 (79.6%) completed the survey. The vast majority of respondents valued the MET. Working in a surgical vs. medical ward and having participated in either the MET educational programme (METal course) or MET interventions were associated with better acceptance of the MET system. Reluctance by nurses to call the covering doctor first instead of the MET for deteriorating patients (62%) was significantly less likely in those working in surgical vs. medical wards or having a higher seniority or a METal certification (OR 0.51 [0.4-0.65], 0.69 [0.47-0.99], and 0.6 [0.46-0.79], respectively). Reluctance to call the MET in a patient fulfilling calling criteria (21%), was less likely to occur in medical doctors vs. nurses and in surgical vs. medical ward staff, and it was unaffected by the METal certification. CONCLUSIONS: The MET was well accepted in participating hospitals. Nurse referral to the covering physician was the major barrier to MET activation. Medical status, working in surgical vs. medical wards, seniority and participation in the METal educational programme were associated with lower likelihood of showing barriers to MET activation.