Outcomes of severe aspergillosis in patients undergoing extracorporeal membrane oxygenation: A systematic review.

BACKGROUND: Invasive aspergillosis (IA) can lead to life-threatening respiratory failure necessitating extracorporeal membrane oxygenation (ECMO) support. However, data on ECMO experience in the management of IA patients are scarce. OBJECTIVES: The purpose of this systematic review was to evaluate the potential benefits and risks of ECMO as a supportive intervention for critically ill patients with IA. METHODS: We conducted a systematic review of the literature using the search terms ECMO, extracorporeal membrane oxygenation, Aspergillus and Aspergillosis in two databases (Medline and Scopus). Clinical data were extracted by two independent investigators. Clinical parameters, such as mode of ECMO support, duration of treatment and clinical outcomes, were assessed. RESULTS: Overall, 32 patients were included in the analysis. The age ranged from 5 to 69 years, 59% were male, and 38% were female. The majority of patients suffered from ARDS (82%). 82% received VV-ECMO, and 18% received VA-ECMO. Aspergillus fumigatus was the most frequent cause of IA, coinfections were frequently observed (51%). The overall mortality was 78%. Complications during ECMO support were observed in 21 of the 39 cases (53.8%). CONCLUSIONS: IA poses significant management challenges for critically ill ICU patients, even with ECMO support. Although ECMO appears to improve survival of patients at high risk of AI, potential risks such as bacterial superinfection and altered pharmacokinetics of antifungal drugs must be carefully considered.

Anisotropic Mechanical Response of Bovine Pericardium Membrane Through Bulge Test and In-Situ Confocal-Laser Scanning.

In this work, we present a new experimental setup for the assessment of the anisotropic properties of Bovine Pericardium (BP) membranes. The chemically fixed BP samples have been subjected to a bulge test with in situ confocal laser scanning at increasing applied pressure. The high resolution topography provided by the confocal laser scanning has allowed to obtain a quantitative measure of the bulge displacement; after polynomial fitting, principal curvatures have been obtained and a degree of anisotropy (DA) has been defined as the normalized difference between the maximum and minimum principal curvatures. The experiments performed on the BP membranes have allowed us to obtain pressure-displacement data which clearly exhibit distinct principal curvatures indicating an anisotropic response. A comparison with curvatures data obtained on isotropic Nitrile Buthadiene Rubber (NBR) samples has confirmed the effectiveness of the experimental setup for this specific purpose. Numerical simulations of the bulge tests have been performed with the purpose of identifying a range of constitutive parameters which well describes the obtained range of DA on the BP membranes. The DA values have been partially validated with biaxial tests available in literature and with suitably performed uni-axial tensile tests.

Pre-operative ultrasound prediction of difficult airway management in adult patients: A systematic review of clinical evidence.

BACKGROUND: Predicting a difficult airway, including difficult laryngoscopy, intubation or mask ventilation, is paramount in peri-operative management. As clinical predictors are only partially reliable, ultrasound-based measurements might be useful in evaluating anterior neck fat tissues depth. OBJECTIVES: The aim of this systematic review is to report clinical evidence on pre-operative ultrasound as a predictor of difficult laryngoscopy, difficult intubation or difficult mask ventilation. DESIGN: A systematic review of randomised controlled trials and observational studies. DATA SOURCES: The MEDLINE, EMBASE and Google Scholar databases were queried from inception until 28 February 2022. ELIGIBILITY CRITERIA: Studies involving adult patients who had undergone orotracheal intubation after evaluation with airways ultrasound were considered suitable. Exclusion criteria were a clinical history of difficult airways, cancer or trauma, pregnancy, supraglottic airway devices, video-laryngoscopy. Parameters were classified by reporting their accuracy in discriminating 'difficult' vs. 'not difficult' laryngoscopy, intubation or mask ventilation. RESULTS: Thirty-one observational studies were included and a total of 41 single parameters and 12 different combinations of clinical and ultrasound parameters were reported. The distance from skin to epiglottis midway with neutral position of head and neck, the distance from hyoid bone to skin surface with a neutral position of head and neck and the hyomental distance extended/neutral ratio are the most associated with difficult laryngoscopy or difficult intubation. A combination of clinical and ultrasound parameters (a modified Mallampati score, the distance from the skin to the epiglottis midway with neutral position of the head and neck, and the USED-MSH score) showed high accuracy. Only two studies reported the role of ultrasound in predicting difficult mask ventilation: the distance from hyoid bone to skin surface with neutral position of head and neck, the thickness of the base of the tongue with hyperextension of the head, and the hyomental distance with hyperextension of the head and active subluxation of the mandible are the parameters with the highest correlation. CONCLUSIONS: The use of ultrasound parameters might be useful in predicting difficult laryngoscopy or difficult intubation. Several ultrasound parameters and combinations have been associated with difficult laryngoscopy or difficult intubation prediction. The use of scores combining clinical predictors and ultrasound measures are very promising. Data on difficult mask ventilation are scarce and the role of ultrasound is still controversial. Future studies are needed. CLINICAL TRIAL REGISTRATION: CRD42021250574.

Colloids Use in Asian ICU Patients: Do not Mix Oranges with Apples. Consider the Proven Concerns on Hydroxyethyl Starch Use in ICU Patients.

How to cite this article: Giordano G, Purgatori A, Bilotta F. Colloids Use in Asian ICU Patients: Do not Mix Oranges with Apples. Consider the Proven Concerns on Hydroxyethyl Starch Use in ICU Patients. Indian J Crit Care Med 2021;25(5):595-596.

Diagnostic Role of Multi-Detector Computed Tomography in Acute Mesenteric Ischemia.

Mesenteric ischemia diagnosis is challenging, with an overall mortality of up to 50% of cases despite advances in treatment. The main problem that affects the outcome is delayed diagnosis because of non-specific clinical presentation. Multi-Detector CT Angiography (MDCTA) is the first-line investigation for the suspected diagnosis of vascular abdominal pathologies and the diagnostic test of choice in suspected mesenteric bowel ischemia. MDCTA can accurately detect the presence of arterial and venous thrombosis, determine the extent and the gastrointestinal tract involved, and provide detailed information determining the subtype and the stage progression of the diseases, helping clinicians and surgeons with appropriate management. CT (Computed Tomography) can differentiate forms that are still susceptible to pharmacological or interventional treatment (NOM = non-operative management) from advanced disease with transmural necrosis in which a surgical approach is required. Knowledge of CT imaging patterns and corresponding vascular pathways is mandatory in emergency settings to reach a prompt and accurate diagnosis. The aims of this paper are 1. to provide technical information about the optimal CTA (CT Angiography) protocol; 2. to explain the CTA arterial and venous supply to the gastrointestinal tract and the relevant ischemic pattern; and 3. to describe vascular, bowel, and extraintestinal CT findings for the diagnosis of acute mesenteric ischemia.

Predictors of Mortality and Orotracheal Intubation in Patients with Pulmonary Barotrauma Due to COVID-19: An Italian Multicenter Observational Study during Two Years of the Pandemic.

Introduction: Coronavirus disease 2019 (COVID-19) is a significant and novel cause of acute respiratory distress syndrome (ARDS). During the COVID-19 pandemic, there has been an increase in the incidence of cases involving pneumothorax and pneumomediastinum. However, the risk factors associated with poor outcomes in these patients remain unclear. Methods: This observational study collected clinical and imaging data from COVID-19 patients with PTX and/or PNM across five tertiary hospitals in central Italy between 1 March 2020 and 1 March 2022. This study also calculated the incidence of PTX and PNM and utilized multivariable regression analysis and Kaplan-Meier curve analysis to identify predictor factors for 28-day mortality and 3-day orotracheal intubation after PTX/PNM. This study also considered the impact of the three main variants of concern (VoCs) (alfa, delta, and omicron) circulating during the study period. Results: During the study period, a total of 11,938 patients with COVID-19 were admitted. This study found several factors independently associated with a higher risk of death in COVID-19 patients within 28 days of pulmonary barotrauma. These factors included a SOFA score ≥ 4 (OR 3.22, p = 0.013), vasopressor/inotropic therapy (OR 11.8, p < 0.001), hypercapnia (OR 2.72, p = 0.021), PaO2/FiO2 ratio < 150 mmHg (OR 10.9, p < 0.001), and cardiovascular diseases (OR 7.9, p < 0.001). This study also found that a SOFA score ≥ 4 (OR 3.10, p = 0.015), PCO2 > 45 mmHg (OR 6.0, p = 0.003), and P/F ratio < 150 mmHg (OR 2.9, p < 0.042) were factors independently associated with a higher risk of orotracheal intubation (OTI) within 3 days from PTX/PNM in patients with non-invasive mechanical ventilation. SARS-CoV-2 VoCs were not associated with 28-day mortality or the risk of OTI. The estimated cumulative probability of OTI in patients after pneumothorax was 44.0% on the first day, 67.8% on the second day, and 68.9% on the third day, according to univariable survival analysis. In patients who had pneumomediastinum only, the estimated cumulative probability of OTI was 37.5%, 46.7%, and 57.7% on the first, second, and third days, respectively. The overall incidence of PTX/PNM among hospitalized COVID-19 patients was 1.42%, which increased up to 4.1% in patients receiving invasive mechanical ventilation. Conclusions: This study suggests that a high SOFA score (≥4), the need for vasopressor/inotropic therapy, hypercapnia, and PaO2/FiO2 ratio < 150 mmHg in COVID-19 patients with pulmonary barotrauma are associated with higher rates of intubation, ICU admission, and mortality. Identifying these risk factors early on can help healthcare providers anticipate and manage these patients more effectively and provide timely interventions with appropriate intensive care, ultimately improving their outcomes.

Therapy with autologous adipose-derived regenerative cells for the care of chronic ulcer of lower limbs in patients with peripheral arterial disease.

BACKGROUND: An ulcer is a trophic lesion with loss of tissue that often has a multifactorial genesis. It typically diverges from the physiologic processes of regeneration because it rarely tends to heal spontaneously. In this study, we used purified adipose-derived stem and regenerative cells (ADRCs) extracted from autologous fat, for the care of chronic ulcers of the lower limbs of arteriopathic patients. The primary objective of this study was complete re-epithelization of chronic ulcers; the secondary objective was a decrease in diameter and depth. METHODS: From January 2010 to January 2012, 20 patients with peripheral arterial disease, with an ankle-brachial index between 0.30-0.40, in the age range 60-70 y (14 men and six women), with chronic ulcers of the lower limb, were involved in the study. Only 10 arteriopathic patients (seven men and three women) with chronic ulcers of the lower limb were surgically treated. Using the Celution system, we isolated a solution of ADRCs in about 150 min. The isolated cells were injected through a 10-mL syringe into the edges of the ulcer, taking care to spread it in all directions. Using a small amount of Celution extract, we performed cell characterization by flow cytometry analysis and cell viability assay. RESULTS: We monitored patients treated with ADRC or untreated at 4, 10, 20, 60, and 90 d. In all cases treated with ADRC, we found a reduction in both diameter and depth of the ulcer, which led to a decrease in pain associated with the ulcer process. In six of 10 cases there was complete healing of the ulcer. Characterization of the cells by FACS clearly showed that the ADRC cells contained adipose-derived stem cells. Viability assays demonstrated that partial or total closure of the ulcer was attributable exclusively to ADRC cells present in the Celution extract, and not to growth factors extracted during the process of purification of the Celution and injected together with the cells. CONCLUSIONS: For the first time, the Celution method has been applied for the care of chronic ulcers in the lower extremity of patients with peripheral arterial disease. Our results demonstrate that the technique is feasible for autologous cell application and is not associated with adverse events. Moreover, the transplantation of autologous stem cells extracted with Celution may represent a valuable method for the treatment of chronic ulcers in lower limbs of arteriopathic patients.

In vitro analysis of peri-articular soft tissues passive constraining effect on hip kinematics and joint stability.

PURPOSE: Aim of the study is to assess the contribution of peri-articular soft tissues to hip joint kinematics and their influence on hip stability. METHODS: Four hemi-corpse specimens (3 males, average age 72 years) were studied using a custom navigation system. Hip kinematics (femoral head motion relative to the acetabulum and joint range of motion) were evaluated with the hip manually positioned in 36 different positions with (I) soft tissues intact, (II) after removal of the skin and muscles and (III) after partial capsulectomy. Each position was repeated 3 times in each state. RESULTS: Excellent interclass correlation for each test was determined (ICC range, 0.84-0.96). Femoral head anatomical centre displacement relative to the acetabulum occurred in all 3 planes, even with all the soft tissue intact (average, 3.3 ± 2.8 mm lateral translation; 1.4 ± 1.8 mm posterior translation and 0.3 ± 1.5 mm distally). These translations increased as more soft tissue was removed, except medial-lateral displacement, with an average 4.6 ± 2.9 mm lateral translation, 0.7 ± 1.3 mm posterior translation and 1.5 ± 1.9 mm distal translation when partial capsulectomy was performed. Range of motion increased in all 3 planes with increasing removal of the soft tissues. CONCLUSIONS: This study showed that femoral head anatomical centre displacement within the acetabulum occurs and increases with increasing removal of peri-articular soft tissues, confirming their influence on hip stability. Hip kinematics was also influenced by peri-articular soft tissues; specifically range of motion increases with increasing removal of those tissues. From clinicians' point of view, they have therefore to consider the influence of their surgeries on peri-articular soft tissues, since excessive translations may promote hip arthritis.

Special Issue "Clinical Consequences of COVID-19": Taking a Look at Complexity.

The consequences of SARS-CoV-2 infection are far from being fully understood or accounted for [...].