Expert perspectives on ECCO2R for acute hypoxemic respiratory failure: consensus of a 2022 European roundtable meeting.

BACKGROUND: By controlling hypercapnia, respiratory acidosis, and associated consequences, extracorporeal CO2 removal (ECCO2R) has the potential to facilitate ultra-protective lung ventilation (UPLV) strategies and to decrease injury from mechanical ventilation. We convened a meeting of European intensivists and nephrologists and used a modified Delphi process to provide updated insights into the role of ECCO2R in acute respiratory distress syndrome (ARDS) and to identify recommendations for a future randomized controlled trial. RESULTS: The group agreed that lung protective ventilation and UPLV should have distinct definitions, with UPLV primarily defined by a tidal volume (VT) of 4-6 mL/kg predicted body weight with a driving pressure (ΔP) ≤ 14-15 cmH2O. Fourteen (93%) participants agreed that ECCO2R would be needed in the majority of patients to implement UPLV. Furthermore, 10 participants (majority, 63%) would select patients with PaO2:FiO2 > 100 mmHg (> 13.3 kPa) and 14 (consensus, 88%) would select patients with a ventilatory ratio of > 2.5-3. A minimum CO2 removal rate of 80 mL/min delivered by continuous renal support machines was suggested (11/14 participants, 79%) for this objective, using a short, double-lumen catheter inserted into the right internal jugular vein as the preferred vascular access. Of the participants, 14/15 (93%, consensus) stated that a new randomized trial of ECCO2R is needed in patients with ARDS. A ΔP of ≥ 14-15 cmH2O was suggested by 12/14 participants (86%) as the primary inclusion criterion. CONCLUSIONS: ECCO2R may facilitate UPLV with lower volume and pressures provided by the ventilator, while controlling respiratory acidosis. Since recent European Society of Intensive Care Medicine guidelines on ARDS recommended against the use of ECCO2R for the treatment of ARDS outside of randomized controlled trials, new trials of ECCO2R are urgently needed, with a ΔP of ≥ 14-15 cmH2O suggested as the primary inclusion criterion.

Effect of prone positioning on end-expiratory lung volume, strain and oxygenation change over time in COVID-19 acute respiratory distress syndrome: A prospective physiological study.

Background: Prone position (PP) is a recommended intervention in severe classical acute respiratory distress syndrome (ARDS). Changes in lung resting volume, respiratory mechanics and gas exchange during a 16-h cycle of PP in COVID-19 ARDS has not been yet elucidated. Methods: Patients with severe COVID-19 ARDS were enrolled between May and September 2021 in a prospective cohort study in a University Teaching Hospital. Lung resting volume was quantitatively assessed by multiple breath nitrogen wash-in/wash-out technique to measure the end-expiratory lung volume (EELV). Timepoints included the following: Baseline, Supine Position (S1); start of PP (P0), and every 4-h (P4; P8; P12) until the end of PP (P16); and Supine Position (S2). Respiratory mechanics and gas exchange were assessed at each timepoint. Measurements and main results: 40 mechanically ventilated patients were included. EELV/predicted body weight (PBW) increased significantly over time. The highest increase was observed at P4. The highest absolute EELV/PBW values were observed at the end of the PP (P16 vs S1; median 33.5 ml/kg [InterQuartileRange, 28.2-38.7] vs 23.4 ml/kg [18.5-26.4], p < 0.001). Strain decreased immediately after PP and remained stable between P4 and P16. PaO2/FiO2 increased during PP reaching the highest level at P12 (P12 vs S1; 163 [138-217] vs 81 [65-97], p < 0.001). EELV/PBW, strain and PaO2/FiO2 decreased at S2 although EELV/PBW and PaO2/FiO2 were still significantly higher as compared to S1. Both absolute values over time and changes of strain and PaO2/FiO2 at P16 and S2 versus S1 were strongly associated with EELV/PBW levels. Conclusion: In severe COVID-19 ARDS, EELV steadily increased over a 16-h cycle of PP peaking at P16. Strain gradually decreased, and oxygenation improved over time. Changes in strain and oxygenation at the end of PP and back to SP were strongly associated with changes in EELV/PBW. Whether the change in EELV and oxygenation during PP may play a role on outcomes in COVID-ARDS deserves further investigation. Clinical trial registration: [www.ClinicalTrials.gov], identifier [NCT04818164].

Air leaks in COVID-19 pneumonia.

The novel coronavirus infection 2019 (COVID-19), which was first identified in Wuhan, China in December 2019 and caused a pandemic, is mostly survived with mild symptoms, while invasive and non-invasive mechanical ventilation support is required in some patients. Pneumothorax, pneumomediastinum, and subcutaneous emphysema may develop in COVID-19 patients. In this study, cases of pneumothorax, pneumomediastinum, and subcutaneous emphysema in patients who were followed in the intensive care unit with the diagnosis of COVID-19 were evaluated. In conclusion, although rare, these complications can be fatal and increase the severity of the disease, which already has a high mortality rate in the intensive care unit. Early detection and management of these complications can reduce morbidity and mortality.

Incidence, Risk Factors, and Prognosis of Bloodstream Infections in COVID-19 Patients in Intensive Care: A Single-Center Observational Study.

BACKGROUND: Critically ill COVID-19 patients are prone to bloodstream infections (BSIs). AIM: To evaluate the incidence, risk factors, and prognosis of BSIs developing in COVID-19 patients in the intensive care unit (ICU). METHODS: Patients staying at least 48 h in ICU from 22 March 2020 to 25 May 2021 were included. Demographic, clinical, and laboratory data were analyzed. RESULTS: The median age of the sample (n = 470) was 66 years (IQR 56.0-76.0), and 64% were male. The three most common comorbidities were hypertension (49.8%), diabetes mellitus (32.8%), and coronary artery disease (25.7%). Further, 252 BSI episodes developed in 179 patients, and the BSI incidence rate was 50.2 (95% CI 44.3-56.7) per 1000 patient-days. The source of BSI is central venous catheter in 42.5% and lower respiratory tract in 38.9% of the episodes. Acinetobacter baumannii (40%) and carbapenem-resistant Klebsiella pneumoniae (21%) were the most common pathogens. CRP levels were lower in patients receiving tocilizumab. Multivariable analysis revealed that continuous renal replacement therapy, extracorporeal membrane oxygenation, and treatment with a combination of methylprednisolone and tocilizumab were independent risk factors for BSI. The estimated cumulative risk of developing first BSI episode was 50% after 6 days and 100% after 25 days. Of the 179 patients, 149 (83.2%) died, and a statistically significant difference (p < 0.001) was found in the survival distribution in favor of the group without BSI. CONCLUSION: BSI is a common complication in COVID-19 patients followed in the ICU, and it can lead to mortality. Failure in infection control measures, intensive immunosuppressive treatments, and invasive interventions are among the main factors leading to BSIs.

Religious and Cultural Aspects of Organ Donation in the Turkish Population.

OBJECTIVE: Organ donation is becoming more important with increasing organ transplantation possibilities. We aimed to determine the knowledge, sociocultural view, and influences of religious belief regarding opinions on organ donation. MATERIAL AND METHOD: This study was based on a self-administered survey questionnaire distributed via the Internet. The study sample was sent to Internet communication groups. RESULTS: Three hundred and seventeen participants completed the survey: 39.4% of respondents said that they would definitely donate their organs; 6.9% would only give via live donation; 51.4% were undetermined; and 2.2% absolutely refused to donate. Muslim respondents favored organ donation (36.5%) and linked it to religious reasons (6.3%). Only 4 (1.3%) of the 6 (1.9%) Muslim respondents who said they would definitely not donate did so because they felt that organ donation was religiously inappropriate. Of 22 Muslim participants (7.3%), 5 (1.6%) attributed the idea of living donation to religious reasons and 11 (3.6%) did not have enough information. The atheist respondents believed that the reason for organ donation was to do someone else a favor (88.8%). The deist and agnostic believers also ascribed to this view. In order to evaluate the effects of cultural causes, we examined regional responses and found that 85 of the 196 participants in the Marmara Region would definitely donate organs, 18 would do so only for live donations, and 5 would definitely not donate. CONCLUSION: Religious and cultural factors affect people's decision to donate their organs. In the survey we conducted on Turkish responders, we saw that religious causes are particularly effective in organ donation.

Development and internal validation of the multivariable CIPHER (Collaborative Integrated Pregnancy High-dependency Estimate of Risk) clinical risk prediction model.

BACKGROUND: Intensive care unit (ICU) outcome prediction models, such as Acute Physiology And Chronic Health Evaluation (APACHE), were designed in general critical care populations and their use in obstetric populations is contentious. The aim of the CIPHER (Collaborative Integrated Pregnancy High-dependency Estimate of Risk) study was to develop and internally validate a multivariable prognostic model calibrated specifically for pregnant or recently delivered women admitted for critical care. METHODS: A retrospective observational cohort was created for this study from 13 tertiary facilities across five high-income and six low- or middle-income countries. Women admitted to an ICU for more than 24 h during pregnancy or less than 6 weeks post-partum from 2000 to 2012 were included in the cohort. A composite primary outcome was defined as maternal death or need for organ support for more than 7 days or acute life-saving intervention. Model development involved selection of candidate predictor variables based on prior evidence of effect, availability across study sites, and use of LASSO (Least Absolute Shrinkage and Selection Operator) model building after multiple imputation using chained equations to address missing data for variable selection. The final model was estimated using multivariable logistic regression. Internal validation was completed using bootstrapping to correct for optimism in model performance measures of discrimination and calibration. RESULTS: Overall, 127 out of 769 (16.5%) women experienced an adverse outcome. Predictors included in the final CIPHER model were maternal age, surgery in the preceding 24 h, systolic blood pressure, Glasgow Coma Scale score, serum sodium, serum potassium, activated partial thromboplastin time, arterial blood gas (ABG) pH, serum creatinine, and serum bilirubin. After internal validation, the model maintained excellent discrimination (area under the curve of the receiver operating characteristic (AUROC) 0.82, 95% confidence interval (CI) 0.81 to 0.84) and good calibration (slope of 0.92, 95% CI 0.91 to 0.92 and intercept of -0.11, 95% CI -0.13 to -0.08). CONCLUSIONS: The CIPHER model has the potential to be a pragmatic risk prediction tool. CIPHER can identify critically ill pregnant women at highest risk for adverse outcomes, inform counseling of patients about risk, and facilitate bench-marking of outcomes between centers by adjusting for baseline risk.

Rare case of bilateral incarcerated obturator hernia: a case report.

Here, we report the case of an 84-year-old woman with acute mechanical intestinal obstruction (AMIO) who was admitted to our Emergency Department. Computed tomography (CT) scan revealed an incarcerated bilateral obturator hernia, and the defect was resolved using transabdominal preperitoneal (TAPP) technique with polypropylene mesh. The patient was administered an oral regimen two days after the operation. The patient stayed in the intensive care unit for 4 days and was uneventfully discharged on the 9th postoperative day. Follow-up was scheduled at the 6th month, during which no adverse events were detected and the patient did not report any complaints. Obturator hernia is among the differential diagnoses of intestinal obstruction requiring early diagnosis and prompt surgical intervention. Laparoscopic approach is less invasive compared with open surgery, and it can be attempted in cases presenting with no sign of ischemia or peritonitis. TAPP technique should be preferred since it allows the control of all intraabdominal pathologies and the viability of the intestines.

The effects of pneumothorax on the respiratory mechanics during laparoscopic surgery.

Pneumothorax is rare but can be a severe complication of laparoscopic surgery. Diagnosis of pneumothorax in laparoscopy includes the sudden increase in end-tidal carbon dioxide (EtCO(2)) with a decrease in compliance and an abnormal increase in airway pressure. By these case reports, we recommend the simultaneous monitoring of airway pressures, dynamic compliance, and particularly, EtCO(2) for an immediate diagnosis and prompt treatment of pneumothorax.

Effects of sevoflurane, propofol and position changes on respiratory mechanics.

This study was designed to investigate the effects of propofol, sevoflurane and position changes on respiratory mechanics. Forty patients scheduled for thyroid surgery were divided randomly into two groups; those receiving sevoflurane (group S) (n=20), and those receiving TIVA propofol (group P) (n=22). Dynamic compliance (Cdyn), peak inspiratory pressure (PIP), and respiratory resistance (Rr) values were recorded with a VenTrak respiratory monitor (Novometrix Inc. USA) at three time instances. The first measurement was done immediately after the beginning of ventilation and before the inhalation agent was initiated (Induction). Second measurement was done after 5 minutes of thyroid position (Thyroid) (ventilation with 1 MAC sevoflurane concentration or propofol infusion at the rate of 6 mg/kg/h). The third measurement was performed 5 minutes after end of surgery in the supine position (Supine) Blood gases were measured at the three time instances. Respiratory mechanics did not change in the P group (51 +/- 13, 46 +/- 11, 48 +/- 10 mL/cmH2O) at Induction, Thyroid and Supine positions). In the S group, dynamic compliance measurements showed changes statistically significant in the supine position (52 +/- 6 mL/cmH2O)) when compared to Induction (47 +/- 9 mL/cmH2O) and Thyroid position (47 +/- 6 mL/cmH2O) measurements (p<0.05). When the groups were compared with each other, there was no significant difference whatsoever at all periods (p>0.05). His concluded that sevoflurane, propofol and position changes exhibit similar effects on respiratory mechanics and blood gases at described dose and concentration.

Chediak-Higashi syndrome in the intensive care unit.

Chediak-Higashi Syndrome is a rare autosomal recessive disease characterized by recurrent infections, giant cytoplasmic granules and oculocutaneous albinism. We describe the clinical and laboratory findings of a patient with Chediak-Higashi syndrome who was diagnosed and treated in the intensive care unit because of bleeding tendency after surgery.