Double carbapenem as a rescue strategy for the treatment of severe carbapenemase-producing Klebsiella pneumoniae infections: a two-center, matched case-control study.

BACKGROUND: Recent reports have suggested the efficacy of a double carbapenem (DC) combination, including ertapenem, for the treatment of carbapenem-resistant Klebsiella pneumoniae (CR-Kp) infections. We aimed to evaluate the clinical impact of such a regimen in critically ill patients. METHODS: This case-control (1:2), observational, two-center study involved critically ill adults with a microbiologically documented CR-Kp invasive infection treated with the DC regimen matched with those receiving a standard treatment (ST) (i.e., colistin, tigecycline, or gentamicin). RESULTS: The primary end point was 28-day mortality. Secondary outcomes were clinical cure, microbiological eradication, duration of mechanical ventilation and of vasopressors, and 90-day mortality. Forty-eight patients treated with DC were matched with 96 controls. Occurrence of septic shock at infection and high procalcitonin levels were significantly more frequent in patients receiving DC treatment (p < 0.01). The 28-day mortality was significantly higher in patients receiving ST compared with the DC group (47.9% vs 29.2%, p = 0.04). Similarly, clinical cure and microbiological eradication were significantly higher when DC was used in patients infected with CR-Kp strains resistant to colistin (13/20 (65%) vs 10/32 (31.3%), p = 0.03 and 11/19 (57.9%) vs 7/27 (25.9%), p = 0.04, respectively). In the logistic regression and multivariate Cox-regression models, the DC regimen was associated with a reduction in 28-day mortality (OR 0.33, 95% CI 0.13-0.87 and OR 0.43, 95% CI 0.23-0.79, respectively). CONCLUSIONS: Improved 28-day mortality was associated with the DC regimen compared with ST for severe CR-Kp infections. A randomized trial is needed to confirm these observational results. TRIAL REGISTRATION: ClinicalTrials.gov NCT03094494 . Registered 28 March 2017.

ECMO Retrieval over the Mediterranean Sea: Extending Hospital Arms.

The retrieval and transport of patients from peripheral hospitals to high volume extracorporeal membrane oxygenation (ECMO) centers aims to reduce complications and improve survival. In Sicily (Italy), our institute houses a mobile ECMO team that serves a population of around 10 million people for a vast area in southern Italy and Malta. This observational, descriptive study includes all patients that required veno-venous (V-V) ECMO and transport by a mobile team between October 2009 and May 2020. Linear and multiple logistic regressions were applied to explore the risk factors for mortality in the ICU. Kaplan-Meier estimates were generated to predict the survival in patients transported by helicopter or ambulance, and the two cohorts were compared according to their baseline characteristics. Of 122 patients transported, 89 (73%) survived to ICU discharge (50 (41%) patients were transported by ambulance, and 72 (59%) were transported by helicopter). Independent predictive factors associated with mortality in a stepwise multiple regression model were prone positioning, acute kidney injury, and the number of days spent on mechanical ventilation (MV). Kaplan-Meier estimates for survival favored the helicopter cohort (79%) rather than the ambulance cohort (64%). Patients transported by helicopter had better pre-ECMO profiles, with shorter hospital and ICU stays, a shorter duration of MV use, and higher RESP scores, which indicate better survival probabilities. ECMO transport can be carried out safely over long distances; in rural areas with underdeveloped roads, transportation via helicopter or ambulance can extend the arm of the hospital to remote areas. Early ECMO initiation can be crucial in improving survival outcomes, and when transportation is the limiting factor to starting ECMO support, it should be attempted at the earliest logistical stage possible.

Impact of cannula design on packed red blood cell transfusions: technical advancement to improve outcomes in extracorporeal membrane oxygenation.

BACKGROUND: Technological improvement has contributed to making veno-venous extracorporeal membrane oxygenation (VV-ECMO) safer and easier, spreading its use in acute respiratory failure (ARF). METHODS: This is a retrospective observational study carried out in the ECMO center at IRCCS-ISMETT, a medical center focused on end-stage organ failure treatment in Italy. We investigated the effect of different cannula designs on the amount of blood product transfused. Eighty-nine consecutive patients affected with ARF on VV-ECMO from 2008 to 2016 were compared according to type of cannulation: older percutaneous cannula (Standard group, 52 patients) and HLS© BIOLINE-coated, but with shorter drainage cannula (BIOLINE group, 37 patients). RESULTS: The two study groups were comparable in terms of baseline characteristics [age, body mass index (BMI), Simplified Acute Physiology Score (SAPS-II), Sequential Organ Failure Assessment (SOFA), Predicting Death For Severe ARDS on VV-ECMO (PRESERVE) score] and ECMO management [median hematocrit (Htc), platelet nadir, antithrombin III (AT III), heparin, activated partial thromboplastin time (APTT)]. In the BIOLINE group, a lower amount of packed red blood cells (pRBC) was transfused considering both total number [4 units, interquartile range (IQR) 1-9 vs. 12 units, IQR 5.5-21; P<0.01] and mL of pRBC/day of ECMO support (91, IQR 21-158 vs. 193.5, IQR 140.5-254; P<0.01). In the BIOLINE group, a trend in reduction of ECMO days (P=0.05) and length of intensive care unit (ICU) stay was found (P=0.06), but no differences in rates of ECMO weaning and ICU discharge were evidenced. The BIOLINE group constituted a saving of €1,295.20 per patient/treatment, counting the costs for cannulation and pRBC administration. CONCLUSIONS: More biocompatible and shorter drainage cannula may represent one of the contributing factors to a reduction in transfusions and costs of VV-ECMO in the current ongoing technological improvement in ECMO.

Severe Acute Respiratory Failure due to Inhalation of Baby Powder and Successfully Treated with Venous-Venous Extracorporeal Membrane Oxygenation.

Accidental inhalation of powder is a potential problem for infants. The clinical effects of inhaling powder depend on the powder contents, degree of aspiration, and the child's underlying systemic response. We present a case of accidental inhalation of rice starch powder in a 17-month-old girl, which led to severe acute respiratory distress syndrome responsive to conventional treatment, ultimately requiring venous-venous extracorporeal membrane oxygenation.

Respiratory mechanics in COPD patients who failed non-invasive ventilation: role of intrinsic PEEP.

Non-invasive positive pressure ventilation (NPPV) is the first choice to treat exacerbations in COPD patients. NPPV can fail owing to different causes related to gas exchange impairment (RF group) or intolerance (INT group). To assess if the respiratory mechanical properties and the ratio between the dynamic and static intrinsic positive end-expiratory pressure (PEEP(i),dyn/PEEP(i),stat), reflecting lung mechanical inequalities, were different between groups, 29 COPD patients who failed NPPV (15 RF and 14 INT) were studied, early after the application of invasive ventilation. Blood gas analysis, clinical status, and mechanical properties were measured. pH was higher in INT patients before intubation (p<0.001). PEEP(i),dyn/PEEP(i),stat was found higher in INT group with (p=0.021) and without PEEP (ZEEP, p<0.01). PEEP(i),dyn/PEEP(i),stat was exponentially associated with the duration of NPPV in INT group (p=0.011). INT and RF patients had similar impairment of respiratory system resistance and elastance.

Extracorporeal membrane oxygenator rescue and airborne transportation of patients with influenza A (H1N1) acute respiratory distress syndrome in a Mediterranean underserved area.

Adult respiratory distress syndrome (ARDS) secondary to H1N1 viral infection has been a worldwide medical and organizational challenge. We report our experience with extracorporeal membrane oxygenator (ECMO) rescue and transportation of patients with H1N1 ARDS within an insular and rural Mediterranean area of seven million inhabitants. A 24/7 on-call ECMO team was organized including one anesthesiologist, one cardiac surgeon, and one perfusionist. To limit missions' time to and from peripheral hospitals, airborne transportation with helicopter was the first choice. From November 2009 to January 2010, we performed 10 missions. Eight patients (80%) were placed on ECMO and transferred either on helicopter (70%) or with standard ambulance (10%). Average mission duration was nine hours (6-16 h). No complications secondary to the transportation means or to the ECMO were reported. Delivery of advanced medical technology can be achieved even in remote and underserved areas presenting geographical barriers. A multidisciplinary mobile ECMO team coordinated with adequate means of transportation could be routinely employed to rescue patients affected with other forms of severe acute hemodynamic and/or respiratory impairment.

Intrapulmonary percussive ventilation improves the outcome of patients with acute exacerbation of chronic obstructive pulmonary disease using a helmet.

OBJECTIVE: To evaluate the effect of intrapulmonary percussive ventilation (IPV) by mouthpiece during noninvasive positive-pressure ventilation with helmet in patients with exacerbation of chronic obstructive pulmonary disease (COPD). DESIGN: Randomized clinical trial. SETTING: General intensive care unit, university hospital. PATIENTS: Forty patients with exacerbation of COPD ventilated with noninvasive positive-pressure ventilation by helmet were randomized to two different mucus clearance strategies: IPV (IPV group) vs. respiratory physiotherapy (Phys group). As historical control group, 40 patients receiving noninvasive positive pressure and ventilated by face mask treated with respiratory physiotherapy were studied. INTERVENTIONS: Two daily sessions of IPV (IPV group) or conventional respiratory physiotherapy (Phys group). MEASUREMENTS AND MAIN RESULTS: Physiologic variables were measured at entry in the intensive care unit, before and after the first session of IPV, and at discharge from the intensive care unit. Outcome variables (need for intubation, ventilatory assistance, length of intensive care unit stay, and complications) were also measured. All physiologic variables improved after IPV. At discharge from the intensive care unit, Paco2 was lower in the IPV group compared with the Phys and control groups (mean +/- sd, 58 +/- 5.4 vs. 64 +/- 5.2 mm Hg, 67.4 +/- 4.2 mm Hg, p < .01). Pao2/Fio2 was higher in IPV (274 +/- 15) than the other groups (Phys, 218 +/- 34; control, 237 +/- 20; p < .01). In the IPV group, time of noninvasive ventilation (hrs) (median, 25th-75th percentile: 61, 60-71) and length of stay in the intensive care unit (days) (7, 6-8) were lower than other groups (Phys, 89, 82-96; control, 87, 75-91; p < .01; and Phys, 9, 8-9; control, 10, 9-11; p < .01). CONCLUSIONS: IPV treatment was feasible for all patients. Noninvasive positive-pressure ventilation by helmet associated with IPV reduces the duration of ventilatory treatment and intensive care unit stay and improves gas exchange at discharge from intensive care unit in patients with severe exacerbation of COPD.