Diagnostic Accuracy of Procalcitonin in Bacterial Infections of the CNS: An Updated Systematic Review, Meta-Analysis, and Meta-Regression.

OBJECTIVES: To evaluate diagnostic accuracy of serum and cerebrospinal fluid (CSF) procalcitonin for diagnosing CNS bacterial infections. DATA SOURCES: We searched MEDLINE, Cochrane Central Register of Controlled Trials, and International Web of Science databases from January 1, 2016, to September 30, 2022. STUDY SELECTION: Randomized controlled trials and observational studies, either prospective or retrospective, focusing on procalcitonin as a biomarker for CNS infections. DATA EXTRACTION: We screened and extracted studies independently and in duplicate. We assessed risk of bias using the revised Quality Assessment for Studies of Diagnostic Accuracy tool. Data for diagnostic sensitivity and specificity were pooled using the bivariate or hierarchical model, as appropriate. DATA SYNTHESIS: Of 5,347 citations identified, 23 studies were included. Overall, CSF procalcitonin showed slightly higher pooled sensitivity, specificity, and positive likelihood ratio compared with serum procalcitonin. In adults, pooled sensitivity of CSF procalcitonin was 0.89 (95% CI, 0.71-0.96), specificity 0.81 (95% CI, 0.66-0.91); pooled sensitivity of serum procalcitonin was 0.82 (95% CI, 0.58-0.94), specificity 0.77 (95% CI, 0.60-0.89). In children, pooled sensitivity of CSF procalcitonin was 0.96 (95% CI, 0.88-0.99), specificity 0.91 (95% CI, 0.72-0.97); pooled sensitivity of serum procalcitonin was 0.90 (95% CI, 0.75-0.97), specificity 0.83 (95% CI, 0.67-0.92). In post-neurosurgical patients, pooled sensitivity of CSF procalcitonin was 0.82 (95% CI, 0.53-0.95), specificity 0.81 (95% CI, 0.63-0.91); pooled sensitivity of serum procalcitonin was 0.65 (95% CI, 0.33-0.88), specificity 0.61 (95% CI, 0.41-0.78). Logistic regression revealed between-study heterogeneity higher for serum than CSF procalcitonin. For the latter, threshold variability was found as source of heterogeneity. CONCLUSIONS: In children and critical post-neurosurgical patients, CSF procalcitonin gains superior sensitivity and specificity compared with serum procalcitonin. Overall, CSF procalcitonin appears to have a higher pooled positive likelihood ratio compared with serum procalcitonin.

Brain abscess caused by Actinomyces turicensis in a non-immunocompromised adult patient: a case report and systematic review of the literature.

BACKGROUND: Actinomyces turicensis is rarely responsible of clinically relevant infections in human. Infection is often misdiagnosed as malignancy, tuberculosis, or nocardiosis, therefore delaying the correct identification and treatment. Here we report a case of a 55-year-old immunocompetent adult with brain abscess caused by A. turicensis. A systematic review of A. turicensis infections was performed. METHODS: A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases MEDLINE, Embase, Web of Science, CINAHL, Clinicaltrials.gov and Canadian Agency for Drugs and Technology in Health (CADTH) were searched for all relevant literature. RESULTS: Search identified 47 eligible records, for a total of 67 patients. A. turicensis infection was most frequently reported in the anogenital area (n = 21), causing acute bacterial skin and skin structure infections (ABSSSI) including Fournier's gangrene (n = 12), pulmonary infections (n = 8), gynecological infections (n = 6), cervicofacial district infections (n = 5), intrabdominal or breast infections (n = 8), urinary tract infections (n = 3), vertebral column infections (n = 2) central nervous system infections (n = 2), endocarditis (n = 1). Infections were mostly presenting as abscesses (n = 36), with or without concomitant bacteremia (n = 7). Fever and local signs of inflammation were present in over 60% of the cases. Treatment usually involved surgical drainage followed by antibiotic therapy (n = 51). Antimicrobial treatments most frequently included amoxicillin (+clavulanate), ampicillin/sulbactam, metronidazole or cephalosporins. Eighty-nine percent of the patients underwent a full recovery. Two fatal cases were reported. CONCLUSIONS: To the best of our knowledge, we hereby present the first case of a brain abscess caused by A. turicensis and P. mirabilis. Brain involvement by A. turicensis is rare and may result from hematogenous spread or by dissemination of a contiguous infection. The infection might be difficult to diagnose and therefore treatment may be delayed. Nevertheless, the pathogen is often readily treatable. Diagnosis of actinomycosis is challenging and requires prompt microbiological identification. Surgical excision and drainage and antibiotic treatment usually allow for full recovery.

Point-of-care ultrasound for non-vascular invasive procedures in critically ill neonates and children: current status and future perspectives.

Point-of-care ultrasound (POCUS) has been established as an essential bedside tool for real-time image guidance of invasive procedures in critically ill neonates and children. While procedural guidance using POCUS has become the standard of care across many adult medicine subspecialties, its use has more recently gained popularity in neonatal and pediatric medicine due in part to improvement in technology and integration of POCUS into physician training programs. With increasing use, emerging data have supported its adoption and shown improvement in pediatric outcomes. Procedures that have traditionally relied on physical landmarks, such as thoracentesis and lumbar puncture, can now be performed under direct visualization using POCUS, increasing success, and reducing complications in our most vulnerable patients. In this review, we describe a global and comprehensive use of POCUS to assist all steps of different non-vascular invasive procedures and the evidence base to support such approach. CONCLUSION: There has been a recent growth of supportive evidence for using point-of-care ultrasound to guide neonatal and pediatric percutaneous procedural interventions. A global and comprehensive approach for the use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures. WHAT IS KNOWN: • Point-of-care ultrasound has been established as a powerful tool providing for real-time image guidance of invasive procedures in critically ill neonates and children and allowing to increase both safety and success. WHAT IS NEW: • A global and comprehensive use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures: from diagnosis to semi-quantitative assessment, and from real-time puncture to follow-up.

Point-of-care brain ultrasound and transcranial doppler or color-coded doppler in critically ill neonates and children.

Point-of-care brain ultrasound and transcranial doppler or color-coded doppler is being increasingly used as an essential diagnostic and monitoring tool at the bedside of critically ill neonates and children. Brain ultrasound has already established as a cornerstone of daily practice in the management of the critically ill newborn for diagnosis and follow-up of the most common brain diseases, considering the easiness to insonate the brain through transfontanellar window. In critically ill children, doppler based techniques are used to assess cerebral hemodynamics in acute brain injury and recommended for screening patients suffering from sickle cell disease at risk for stroke. However, more evidence is needed regarding the accuracy of doppler based techniques for non-invasive estimation of cerebral perfusion pressure and intracranial pressure, as well as regarding the accuracy of brain ultrasound for diagnosis and monitoring of acute brain parenchyma alterations in children. This review is aimed at providing a comprehensive overview for clinicians of the technical, anatomical, and physiological basics for brain ultrasonography and transcranial doppler or color-coded doppler, and of the current status and future perspectives of their clinical applications in critically ill neonates and children. CONCLUSION: In critically ill neonates, brain ultrasound for diagnosis and follow-up of the most common cerebral pathologies of the neonatal period may be considered the standard of care. Data are needed about the possible role of doppler techniques for the assessment of cerebral perfusion and vasoreactivity of the critically ill neonate with open fontanelles. In pediatric critical care, doppler based techniques should be routinely adopted to assess and monitor cerebral hemodynamics. New technologies and more evidence are needed to improve the accuracy of brain ultrasound for the assessment of brain parenchyma of critically ill children with fibrous fontanelles. WHAT IS KNOWN: • In critically ill neonates, brain ultrasound for early diagnosis and follow-up of the most common cerebral and neurovascular pathologies of the neonatal period is a cornerstone of daily practice. In critically ill children, doppler-based techniques are more routinely used to assess cerebral hemodynamics and autoregulation after acute brain injury and to screen patients at risk for vasospasm or stroke (e.g., sickle cell diseases, right-to-left shunts). WHAT IS NEW: • In critically ill neonates, research is currently focusing on the use of novel high frequency probes, even higher than 10 MHz, especially for extremely preterm babies. Furthermore, data are needed about the role of doppler based techniques for the assessment of cerebral perfusion and vasoreactivity of the critically ill neonate with open fontanelles, also integrated with a non-invasive assessment of brain oxygenation. In pediatric critical care, new technologies should be developed to improve the accuracy of brain ultrasound for the assessment of brain parenchyma of critically ill children with fibrous fontanelles. Furthermore, large multicenter studies are needed to clarify role and accuracy of doppler-based techniques to assess cerebral perfusion pressure and its changes after treatment interventions.

Ultrasound-assessed lung aeration correlates with respiratory system compliance in adults and neonates with acute hypoxemic restrictive respiratory failure: an observational prospective study.

BACKGROUND: Lung ultrasound allows lung aeration to be assessed through dedicated lung ultrasound scores (LUS). Despite LUS have been validated using several techniques, scanty data exist about the relationships between LUS and compliance of the respiratory system (Crs) in restrictive respiratory failure. Aim of this study was to investigate the relationship between LUS and Crs in neonates and adults affected by acute hypoxemic restrictive respiratory failure, as well as the effect of patients' age on this relationship. METHODS: Observational, cross-sectional, international, patho-physiology, bi-center study recruiting invasively ventilated, adults and neonates with acute respiratory distress syndrome (ARDS), neonatal ARDS (NARDS) or respiratory distress syndrome (RDS) due to primary surfactant deficiency. Subjects without lung disease (NLD) and ventilated for extra-pulmonary conditions were recruited as controls. LUS, Crs and resistances (Rrs) of the respiratory system were measured within 1 h from each other. RESULTS: Forty adults and fifty-six neonates were recruited. LUS was higher in ARDS, NARDS and RDS and lower in control subjects (overall p < 0.001), while Crs was lower in ARDS, NARDS and RDS and higher in control subjects (overall p < 0.001), without differences between adults and neonates. LUS and Crs were correlated in adults [r = - 0.86 (95% CI - 0.93; - 0.76), p < 0.001] and neonates [r = - 0.76 (95% CI - 0.85; - 0.62), p < 0.001]. Correlations remained significant among subgroups with different causes of respiratory failure; LUS and Rrs were not correlated. Multivariate analyses confirmed the association between LUS and Crs both in adults [B = - 2.8 (95% CI - 4.9; - 0.6), p = 0.012] and neonates [B = - 0.045 (95% CI - 0.07; - 0.02), p = 0.001]. CONCLUSIONS: Lung aeration and compliance of the respiratory system are significantly and inversely correlated irrespective of patients' age. A restrictive respiratory failure has the same ultrasound appearance and mechanical characteristics in adults and neonates.

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.

Continuous EEG monitoring by a new simplified wireless headset in intensive care unit.

BACKGROUND: In critically ill patients continuous EEG (cEEG) is recommended in several conditions. Recently, a new wireless EEG headset (CerebAir®,Nihon-Kohden) is available. It has 8 electrodes, and its positioning seems to be easier than conventional systems. Aim of this study was to evaluate the feasibility of this device for cEEG monitoring, if positioned by ICU physician. METHODS: Neurological patients were divided in two groups according with the admission to Neuro-ICU (Study-group:20 patients) or General-ICU (Control-group:20 patients). In Study group, cEEG was recorded by CerebAir® assembled by an ICU physician, while in Control group a simplified 8-electrodes-EEG recording positioned by an EEG technician was performed. RESULTS: Time for electrodes applying was shorter in Study-group than in Control-group: 6.2 ± 1.1' vs 10.4 ± 2.3'; p < 0.0001. Thirty five interventions were necessary to correct artifacts in Study-group and 11 in Control-group. EEG abnormalities with or without epileptic meaning were respectively 7(35%) and 7(35%) in Study-group, and 5(25%) and 9(45%) in Control-group;p > 0.05. In Study-group, cEEG was interrupted for risk of skin lesions in 4 cases after 52 ± 4 h. cEEG was obtained without EEG technician in all cases in Study-group; quality of EEG was similar. CONCLUSIONS: Although several limitations should be considered, this simplified EEG system could be feasible even if EEG technician was not present. It was faster to position if compared with standard techniques, and can be used for continuous EEG monitoring. It could be very useful as part of diagnostic process in an emergency setting.

A Proposal for a New Protocol for Sonographic Assessment of the Optic Nerve Sheath Diameter: The CLOSED Protocol.

Measuring and monitoring of intracranial pressure is considered standard of care in patients with suspected intracranial hypertension. Sonographic assessment of the optic nerve sheath diameter (ONSD) has been promising and potentially useful for noninvasive intracranial hypertension screening. ONSD measurements are easy to perform, repeatable at bedside, fast, low cost, and radiation-free. However, they are still burdened by inter-rater variability, lack of ultrasound (US) setting standardization (e.g., US frequency, focus depth, etc.), and possible artifacts. To overcome this problem, we propose the CLOSED protocol associated with equipment specifications, as a guide to minimize the occurrence of such artifacts enabling a more reliable and accurate measurement. We suggest that color Doppler could be used as a new standard evaluation for the ONSD.

European Society of Anaesthesiology guidelines on peri-operative use of ultrasound-guided for vascular access (PERSEUS vascular access).

: Ultrasound for diagnostic and procedural purposes is becoming a standard in daily clinical practice including anaesthesiology and peri-operative medicine. The project of European Society of Anaesthesiology (ESA) Task Force for the development of clinical guidelines on the PERioperative uSE of Ultra-Sound (PERSEUS) project has focused on the use of ultrasound in two areas that account for the majority of procedures performed routinely in the operating room: vascular access and regional anaesthesia. Given the extensive literature available in these two areas, this paper will focus on the use of ultrasound-guidance for vascular access. A second part will be dedicated to peripheral nerve/neuraxial blocks. The Taskforce identified three main domains of application in ultrasound-guided vascular cannulation: adults, children and training. The literature search were performed by a professional librarian from the Cochrane Anaesthesia and Critical and Emergency Care Group in collaboration with the ESA Taskforce. The Grading of Recommendation Assessment (GRADE) system for assessing levels of evidence and grade of recommendations were used. For the use of ultrasound-guided cannulation of the internal jugular vein, femoral vein and arterial access, the level evidence was classified 1B. For other accesses, the evidence remains limited. For training in ultrasound guidance, there were no studies. The importance of proper training for achieving competency and full proficiency before performing any ultrasound-guided vascular procedure must be emphasised.

Influence of intercostal muscles contraction on sonographic evaluation of lung sliding: a physiological study on healthy subjects.

OBJECTIVES: To investigate the following: (a) effects of intercostal muscle contraction on sonographic assessment of lung sliding and (b) inter-rater and intra-observer agreement on sonographic detection of lung sliding and lung pulse. METHODS: We used Valsalva and Muller maneuvers as experimental models in which closed glottis and clipped nose prevent air from entering the lungs, despite sustained intercostal muscles contraction. Twenty-one healthy volunteers underwent bilateral lung ultrasound during tidal breathing, apnea, hyperventilation, and Muller and Valsalva maneuvers. The same expert recorded 420 B-mode clips and 420 M-mode images, independently evaluated for the presence or absence of lung sliding and lung pulse by three raters unaware of the respiratory activity corresponding to each imaging. RESULTS: During Muller and Valsalva maneuvers, lung sliding was certainly recognized in up to 73.0% and up to 68.7% of imaging, respectively, with a slight to fair inter-rater agreement for Muller maneuver and slight to moderate for Valsalva. Lung sliding was unrecognized in up to 42.0% of tidal breathing imaging, and up to 12.5% of hyperventilation imaging, with a slight to fair inter-rater agreement for both. During apnea, interpretation errors for sliding were irrelevant and inter-rater agreement moderate to perfect. Even if intra-observer agreement varied among raters and throughout respiratory patterns, we found it to be higher than inter-rater reliability. CONCLUSIONS: Intercostal muscles contraction produces sonographic artifacts that may simulate lung sliding. Clinical studies are needed to confirm this hypothesis. We found slight to moderate inter-rater agreement and globally moderate to almost perfect intra-observer agreement for lung sliding and lung pulse. TRIAL REGISTRATION: ClinicalTrials.gov registration number. NCT02386696.

Lung ultrasound and supine chest X-ray use in modern adult intensive care: mapping 30 years of advancement (1993-2023).

In critically ill patients with acute respiratory failure, thoracic images are essential for evaluating the nature, extent and progression of the disease, and for clinical management decisions. For this purpose, computed tomography (CT) is the gold standard. However, transporting patients to the radiology suite and exposure to ionized radiation limit its use. Furthermore, a CT scan is a static diagnostic exam for the thorax, not allowing, for example, appreciation of "lung sliding". Its use is also unsuitable when it is necessary to adapt or decide to modify mechanical ventilation parameters at the bedside in real-time. Therefore, chest X-ray and lung ultrasound are today's contenders for shared second place on the podium to acquire a thoracic image, with their specific strengths and limitations. Finally, electrical impedance tomography (EIT) could soon have a role, however, its assessment is outside the scope of this review. Thus, we aim to carry out the following points: (1) analyze the advancement in knowledge of lung ultrasound use and the related main protocols adopted in intensive care units (ICUs) over the latest 30 years, reporting the principal publications along the way, (2) discuss how and when lung ultrasound should be used in a modern ICU and (3) illustrate the possible future development of LUS.

Bioimpedance-assessed muscle wasting and its relation to nutritional intake during the first week of ICU: a pre-planned secondary analysis of Nutriti Study.

BACKGROUND: Muscle mass evaluation in ICU is crucial since its loss is related with long term complications, including physical impairment. However, quantifying muscle wasting with available bedside tools (ultrasound and bioimpedance analysis) must be more primarily understood. Bioimpedance analysis (BIA) provides estimates of muscle mass and phase angle (PA). The primary aim of this study was to evaluate muscle mass changes with bioimpedance analysis during the first 7 days after ICU admission. Secondary aims searched for correlations between muscular loss and caloric and protein debt. METHODS: Patients with an expected ICU-stay ≥ 72 h and the need for artificial nutritional support were evaluated for study inclusion. BIA evaluation of muscle mass and phase angle were performed at ICU admission and after 7 days. Considering the difference between ideal caloric and protein targets, with adequate nutritional macronutrients delivered, we calculated the caloric and protein debt. We analyzed the potential correlation between caloric and protein debt and changes in muscle mass and phase angle. RESULTS: 72 patients from September 1st to October 30th, 2019 and from August 1st to October 30th, 2021 were included in the final statistical analysis. Median age was 68 [59-77] years, mainly men (72%) admitted due to respiratory failure (25%), and requiring invasive mechanical ventilation for 7 [4-10] days. Median ICU stay was 8 [6-12] days. Bioimpedance data at ICU admission and after 7 days showed that MM and PA resulted significantly reduced after 7 days of critically illness, 34.3 kg vs 30.6 kg (p < 0.0001) and 4.90° vs 4.35° (p = 0.0004) respectively. Mean muscle loss was 3.84 ± 6.7 kg, accounting for 8.4% [1-14] MM reduction. Correlation between caloric debt (r = 0.14, p = 0.13) and protein debt (r = 0.18, p = 0.13) with change in MM was absent. Similarly, no correlation was found between caloric debt (r = -0.057, p = 0.631) and protein debt (r = -0.095, p = 0.424) with changes in PA. CONCLUSIONS: bioimpedance analysis demonstrated that muscle mass and phase angle were significantly lower after 7 days in ICU. The total amount of calories and proteins does not correlate with changes in muscle mass and phase angle.

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.

Complications associated with the use of peripherally inserted central catheters and midline catheters in COVID-19 patients: An observational prospective study.

BACKGROUND: Among the many interesting aspects of clinical care during the SARS-CoV-2 pandemic, vascular access still deserves some attention. Peripherally inserted central catheters (PICCs) and midline catheters (MCs) are venous access devices inserted by ultrasound-guided puncture of veins of the arm, which have been associated with the possibility of minimizing infectious complications in different populations of patients. We have investigated their performance in SARS-CoV-2 patients. METHODS: As the incidence of catheter-related bloodstream infections (CRBSI) in patients hospitalized for COVID-19 is still unclear, we have designed a single-center, prospective observational study enrolling all patients with established diagnosis of SARS-CoV-2 infection who were admitted to our hospital in the period between October 2020 and April 2021 and who required either a PICC or a MC. RESULTS: We recruited 227 patients. The cumulative incidence of CRBSI was 4.35% (10 cases), that is, 3.5 episodes/1,000 catheter days. Four CRBSI occurred in patients with PICCs (4.5/1,000 catheter days) and 6 in those with MCs (3.2/1,000 catheter days). CONCLUSIONS: Our data suggest that COVID-19 patients may have a more pronounced tendency for the development of catheter-related infections compared to other populations of patients.

Magnetic Resonance-Based Assessment of Optic Nerve Sheath Diameter: A Prospective Observational Cohort Study on Inter- and Intra-Rater Agreement.

BACKGROUND: The measurement of optic nerve sheath diameter (ONSD) as a non-invasive method of estimating intracranial pressure has been widely reported in the literature. However, few studies have evaluated the accuracy of magnetic resonance imaging (MRI) in assessing ONSD measurements, although it is considered a very reliable method, it is not easily repeatable, expensive and is not readily available bedside. Herein, an assessment of the intra- and inter-rater reliability of ONSD assessment using MRI was conducted. METHODS: A consecutive, prospective cohort of patients with suspected idiopathic normal-pressure hydrocephalus was analyzed. ONSD MRI measurements of the transverse and sagittal diameters at a distance of 3 mm behind the papilla were evaluated twice each by two expert neuroradiologists. The correlations between MRI examiners were calculated using the concordance correlation coefficient (CCC). RESULTS: Fifty patients were included in the study. ONSD MRI average measurements were substantially higher than clinically expected (>5 mm). Considering intra-rater concordance, only one of the two neuroradiologists achieved an excellent score at CCC. Only a moderate inter-observer CCC for MRI assessment was found at all diameters. CONCLUSIONS: The use of a widespread MRI sequence (3D T1) to measure ONSD is not an accurate method since it may overestimate measurements and is dependent upon an operator.

ECHOTIP: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in adult patients.

Central venous access devices are routinely used in clinical practice for administration of fluids and medications, for drawing blood samples and for hemodynamic monitoring. The adoption of ultrasound guided venipuncture has significantly reduced procedure-related complications, as documented by the recommendations of most recent guidelines. Ultrasound has also an important role also in other aspects of central venous catheterization, such as in the pre-procedural evaluation of the venous patrimony and in the detection of early and late non-infective complications. Recently, bedside ultrasound has been regarded as a promising tool also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in adult patients, and to suggest a structured standardized protocol for clinical practice.

ECHOTIP-Ped: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in pediatric patients.

Central venous access devices are routinely used in pediatric care for administration of fluids and medications and for drawing blood samples. The adoption of ultrasound guided venipuncture, the availability of bedside ultrasound devices and the use of intraprocedural methods for tip location have been shown to reduce procedure-related complications, as documented by the recommendations of most recent guidelines. In pediatric patients, bedside ultrasound is a promising tool not only for optimizing the choice of the vein and guiding the venipuncture, but also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in pediatric patients, and to suggest a structured protocol for clinical practice.

The CLOSED protocol to assess optic nerve sheath diameter using color-Doppler: a comparison study in a cohort of idiopathic normal pressure hydrocephalus patients.

BACKGROUND: Sonographic assessment of the optic nerve sheath diameter represents a promising non-invasive technique for estimation of the intracranial pressure. A wide inter-observer variability, along with a lack of a standardized protocol for the optic nerve sheath diameter measurements, could lead to over- or under-estimation. The present study was aimed at evaluating feasibility of color-Doppler for better delineating optic nerve sheath borders, comparing it to B-mode imaging, using the magnetic resonance measurements as a comparison. METHODS: Optic nerve sheath diameters were evaluated using magnetic resonance by an expert radiologist in a cohort of patients with suspected idiopathic normal pressure hydrocephalus. Magnetic resonance findings were evaluated twice. In the first half of this cohort, optic nerve sheath diameters were measured using B-mode only, in the second half applying color-Doppler. Measurements obtained using these two techniques were compared to magnetic resonance imaging measurements. The Bland-Altman analysis and concordance correlation coefficient were computed to quantify the strength of agreement between the two magnetic resonance assessments. Box plots and average (± SD) were used to compare assessments by sonographic and magnetic resonance methods. RESULTS: Fifty patients were included. MRI assessment showed a moderate concordance correlation coefficient. Optic nerve sheath diameters measured applying color-Doppler were lower (p < 0.001) and less scattered compared to B-mode assessment, which approached more to magnetic resonance measurements. CONCLUSIONS: In this cohort of patients, magnetic resonance showed high intra-rater variability in optic nerve sheath diameter assessments. Optic nerve sheath diameter assessments using color-Doppler yielded lower and less scattered diameters compared to B-mode only.

Utility and Limits of Lung Ultrasound in Childhood Pulmonary Tuberculosis: Lessons from a Case Series and Literature Review.

Childhood pulmonary tuberculosis (PTB) diagnosis is often a challenge that requires a combination of history, clinical, radiological, immunological and microbiological findings. Radiological diagnosis is based today on the use of chest X-ray and chest CT that, in addition to being radio-invasive tools for children, are often not available in countries with low-resources. A non-invasive, easily usable and reproducible, low-cost diagnostic tool as LUS would therefore be useful to use to support the diagnosis of childhood PTB. Data on the use of LUS for the diagnosis and follow-up of childhood PTB are limited and in some respects contradictory. To help better define the potential role of LUS we have described the pros and cons of lung ultrasound method through a brief review of the studies in the literature and reporting some case series in which we describe clinical, laboratory, radiological results as well as detailed lung ultrasound findings of four children/adolescents with PTB.