Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia: A Literature Review.

Hospital-acquired pneumonia (HAP) and its subtype, ventilator-associated pneumonia (VAP), remain two significant causes of morbidity and mortality worldwide, despite the better understanding of pathophysiological mechanisms, etiology, risk factors, preventive methods (bundle of care principles) and supportive care. Prior detection of the risk factors combined with a clear clinical judgement based on clinical scores and dosage of different inflammatory biomarkers (procalcitonin, soluble triggering receptor expressed on myelloid cells type 1, C-reactive protein, mid-regional pro-adrenomedullin, mid-regional pro-atrial natriuretic peptide) represent the cornerstones of a well-established management plan by improving patient's outcome. This review article provides an overview of the newly approved terminology considering nosocomial pneumonia, as well as the risk factors, biomarkers, diagnostic methods and new treatment options that can guide the management of this spectrum of infections.

Therapeutic Implications of Renin-Angiotensin System Modulators in Alzheimer's Dementia.

The Renin-Angiotensin System (RAS) has attracted considerable interest beyond its traditional cardiovascular role due to emerging data indicating its potential involvement in neurodegenerative diseases, including Alzheimer's dementia (AD). This review investigates the therapeutic implications of RAS modulators, specifically focusing on angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and renin inhibitors in AD. ACEIs, commonly used for hypertension, show promise in AD by reducing angiotensin (Ang) II levels. This reduction is significant as Ang II contributes to neuroinflammation, oxidative stress, and ß-amyloid (Aß) accumulation, all implicated in AD pathogenesis. ARBs, known for vasodilation, exhibit neuroprotection by blocking Ang II receptors, improving cerebral blood flow and cognitive decline in AD models. Renin inhibitors offer a novel approach by targeting the initial RAS step, displaying anti-inflammatory and antioxidant effects that mitigate AD degeneration. Preclinical studies demonstrate RAS regulation's favorable impact on neuroinflammation, neuronal damage, cognitive function, and Aß metabolism. Clinical trials on RAS modulators in AD are limited, but with promising results, ARBs being more effective that ACEIs in reducing cognitive decline. The varied roles of ACEIs, ARBs, and renin inhibitors in RAS modulation present a promising avenue for AD therapeutic intervention, requiring further research to potentially transform AD treatment strategies.

The Effects of Vitamin D Supplementation on Respiratory Infections in Children under 6 Years Old: A Systematic Review.

Childhood respiratory tract infections (RTIs) pose a significant health burden, especially in children under six years old. The main objective of this systematic review was to assess the effectiveness of vitamin D supplementation in the prevention of RTI in this population while also exploring potential effect modifiers such as age, baseline vitamin D status, and type of respiratory infection. A systematic review of the literature published up to February 2023 was conducted according to PRISMA guidelines, searching PubMed, Web of Science, Cochrane, and Scopus databases. Eight studies met the inclusion criteria, which investigated the association between vitamin D supplementation and respiratory infections in children between zero and five years old. The included studies were conducted between 2012 and 2021, encompassing a total of 2189 children from five randomized trials, two case-control studies, and one prospective cohort study. The relationship between vitamin D supplementation and the prevention of childhood RTI was not consistently observed across all included studies. Pooled results demonstrated varied effects of vitamin D supplementation on respiratory infection incidence, severity, and symptoms. Three studies reported statistically significant associations between low vitamin D levels and respiratory infections (OR = 4.90, OR = 6.97), while one study found that children who received vitamin D supplementation of 800 UI/day for 3 months during the cold season had fewer episodes of respiratory symptoms (RR = 0.55) and recovered more quickly from acute RTI. Lastly, according to one study, vitamin D intake < 80 IU/kg/day was significantly associated with the risk of acquiring pneumonia (OR 7.9) but not bronchiolitis. The remaining five studies found no statistically significant differences in infection rates or severity (p-value > 0.050). The available evidence on the effectiveness of vitamin D supplementation for preventing and treating respiratory infections in children under six years old is limited, with only a few favorable effects being reported. In some cases, a dose of 80 UI/kg/day was found to provide significant protection for acute respiratory infections, although in the major trials the only benefit was a quicker recovery and fewer respiratory symptoms, with no impact on incidence and severity of respiratory infections. Nevertheless, the study protocol, the supplementation dose, and duration of supplementation had significant variations between studies, leading to inconclusive findings.

The Beginning of an ECLS Center: First Successful ECPR in an Emergency Department in Romania-Case-Based Review.

According to the latest international resuscitation guidelines, extracorporeal cardiopulmonary resuscitation (ECPR) involves the utilization of extracorporeal membrane oxygenation (ECMO) in specific patients experiencing cardiac arrest, and it can be considered in situations where standard cardiopulmonary resuscitation efforts fail if they have a potentially reversible underlying cause, among which we can also find hypothermia. In cases of cardiac arrest, both witnessed and unwitnessed, hypothermic patients have higher chances of survival and favorable neurological outcomes compared to normothermic patients. ECPR is a multifaceted procedure that requires a proficient team, specialized equipment, and comprehensive multidisciplinary support within a healthcare system. However, it also carries the risk of severe, life-threatening complications. With the increasing use of ECPR in recent years and the growing number of centers implementing this technique outside the intensive care units, significant uncertainties persist in both prehospital and emergency department (ED) settings. Proper organization is crucial for an ECPR program in emergency settings, especially given the challenges and complexities of these treatments, which were previously not commonly used in ED. Therefore, within a narrative review, we have incorporated the initial case of ECPR in an ED in Romania, featuring a successful resuscitation in the context of severe hypothermia (20 °C) and a favorable neurological outcome (CPC score of 1).

Mitochondrial Dysfunction, Oxidative Stress, and Therapeutic Strategies in Diabetes, Obesity, and Cardiovascular Disease.

Mitochondria are subcellular organelles involved in essential cellular functions, including cytosolic calcium regulation, cell apoptosis, and reactive oxygen species production. They are the site of important biochemical pathways, including the tricarboxylic acid cycle, parts of the ureagenesis cycle, or haem synthesis. Mitochondria are responsible for the majority of cellular ATP production through OXPHOS. Mitochondrial dysfunction has been associated with metabolic pathologies such as diabetes, obesity, hypertension, neurodegenerative diseases, cellular aging, and cancer. In this article, we describe the pathophysiological changes in, and mitochondrial role of, metabolic disorders (diabetes, obesity, and cardiovascular disease) and their correlation with oxidative stress. We highlight the genetic changes identified at the mtDNA level. Additionally, we selected several representative biomarkers involved in oxidative stress and summarize the progress of therapeutic strategies.

Does the Overall Survival of the Resectable Periampullary Carcinomas Correlate with High Expression of p53 and ki67?

Introduction: Periampullary carcinomas represent a group of tumors that develop in a complex area, implying different anatomical structures. The most common histological type of periampullary carcinomas is the adenocarcinoma. The pancreatic type of periampullary adenocarcinomas has the worst prognosis. Immunohistochemical markers, such as ki-67 and p53, can be used in predicting survival. Material and method: we selected the patients with periampullary adenocarcinomas, intestinal or biliopancreatic type, with resectable tumors, and we performed immunohistochemical stains for ki-67 and p53 markers. The overall survival was analyzed according to the expression of immunohistochemical markers, TNM staging, tumor grade and perineural invasion. Results: Sixty-seven patients were included in the study. The median overall survival for the whole cohort was 12 months, with a 2-year survival rate of 25%. High rate of tumor proliferation (ki67 more than 80%) was significantly associated with shorter overall survival (median survival 3 months compared with 17 months for the group with ki67 index less than 80%). A high expression of p53 protein has been associated with low overall survival. The low survival was associated with poorly differentiated tumor grade and lymph node status. Conclusion: Both immunohistochemical expression of ki67 and p53 can be used as prognostic and predictive factors for overall survival of patients with resectable periampullary adenocarcinomas.

The Role of Presepsin in Diagnosing Infections in Patients with Liver Cirrhosis and Overt Hepatic Encephalopathy.

Infections and sepsis represent severe liver cirrhosis (LC) complications and the precipitating factors of hepatic encephalopathy (HE). The early diagnosis and treatment of infections in patients with LC and HE can significantly increase their survival. Presepsin is a serum biomarker evaluated for the early diagnosis of infections and sepsis in the general and cirrhotic populations. This study aimed to evaluate the role of presepsin in the early diagnosis of infections in patients with LC and HE. This prospective observational study included all consecutive cirrhotic patients admitted to our tertiary university center with overt HE. The patients were follow-up until discharge. In this study, we included 365 patients with a median age of 59 years, of whom 61.9% were male. Infections were diagnosed in 134 patients (36.7%). The presepsin level was higher in patients with infections than those without infections (3167 vs. 500, p < 0.001). The ROC analysis results demonstrated that the best cut-off value for presepsin in infections detection was 980 pg/mL with a sensitivity of 80.17%, specificity of 82.5% (AUROC 0.869, CI 95%: 0.819−0.909, p < 0.001, Youden index J of 0.622), a positive predictive value of 40.63%, and a negative predictive value of 96.53%. In conclusion, in patients with LC and overt HE, presepsin levels >980 pg/mL could enhance the suspicion of bacterial infections. Presepsin may be an adequate non-invasive tool for the early diagnosis of infections in patients with LC and overt HE.

The Role of Presepsin and Procalcitonin in Early Diagnosis of Bacterial Infections in Cirrhotic Patients with Acute-on-Chronic Liver Failure.

Background and Objectives: Bacterial infections represent one of the most frequent precipitating events of acute-on-chronic liver failure (ACLF) in a patient with liver cirrhosis (LC). Early diagnosis and treatment could influence the ACLF reversal rate and decrease the mortality rate in these patients. The study aimed to evaluate the role of presepsin, C-reactive protein (CRP), and procalcitonin (PCT) in the early diagnosis of bacterial infections in patients with LC and ACLF, defined according to the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria. Material and Methods: We performed a prospective observational study including all consecutive cirrhotic patients with ACLF admitted to our tertiary university center. The patients were follow-up until discharge. All patients were screened for infection at admission, and we included patients with community-acquired or healthcare-associated bacterial infections. Results: In this study, we included 153 patients with a median age of 60 years, of whom 65.4% were male. Infections were diagnosed in 71 patients (46.4%). The presepsin, CRP, and PCT levels were higher in patients with infections than in those without infections (p < 0.001, p = 0.023, and p < 0.001, respectively). The ROC analysis results demonstrated that the best cut-offs values for infections diagnosis were for presepsin 2300 pg/mL (sensitivity of 81.7%, specificity of 92.7%, AUROC 0.959, p < 0.001), CRP 5.3 mg/dL (sensitivity of 54.9%, specificity of 69.6%, AUROC 0.648, p = 0.023), and PCT 0.9 ng/mL (sensitivity of 80.3%, specificity of 86.6%, AUROC 0.909, p < 0.001). Presepsin (OR 3.65, 95%CI 1.394−9.588, p = 0.008), PCT (OR 9.79, 95%CI 6.168−25.736, p < 0.001), and MELD score (OR 7.37, 95%CI 1.416−18.430, p = 0.018) were associated with bacterial infections in patients with ACLF. Conclusion: Presepsin level ≥2300 pg/mL and PCT level ≥0.9 ng/mL may be adequate non-invasive tools for the early diagnosis of infections in cirrhotics with ACLF.

Abdominopelvic Actinomycosis-The Diagnostic and Therapeutic Challenge of the Most Misdiagnosed Disease.

Abdominopelvic actinomycosis is a rare chronic or subacute bacterial infection caused by Actinomyces israelii, a Gram-positive anaerobic bacterium that normally colonizes the digestive and genital tracts, clinically presented as an inflammatory mass or abscess formation. METHODS: We reviewed the medical records of the patients from our clinic with abdominopelvic actinomycosis who underwent surgery between 2002 and 2022. In this period, 28 cases (9 men and 19 women) were treated. The mean age was 43.36 years and they were hospitalized for abdominopelvic tumors or inflammatory tumors in 15 cases and inflammatory disease in 13 cases. RESULTS: Causes of actinomycosis in the studied group were an intra-uterine contraceptive device in 17 cases, foreign bodies in 2 cases, diabetes in 4 cases, stenting of the bile duct in 1 case, and immunodepression. For 6 patients, we performed surgery by open approach and for 21 patients by a laparoscopic approach. For nine patients, abdominopelvic actinomycosis had been mimicking a colon malignancy (cecum and ascending colon, four cases; transverse colon, two cases; and on the greater omentum, three cases) and for six patients, a pelvic tumor (advanced ovarian cancer). After surgery the patients underwent specific treatment with antibiotics, with good results. In two cases we discovered and treated hepatic actinomycosis, one case by a laparoscopic approach and one case by a percutaneous approach. In our lot we noticed three recurrences that required reintervention in patients who had had short-term antibiotics due to non-compliance with treatment out of four such cases. CONCLUSIONS: For abdominopelvic malignancies, actinomycosis should be included in the differential diagnosis, as well as for inflammatory bowel diseases and bowel obstructions. We have a wide range of patients considering the rarity of this condition. Long-term antibiotics are necessary to prevent recurrence.

Morphology and one immunohistochemical marker are enough for diagnosis of primary thyroid angiosarcoma.

Primary thyroid angiosarcoma is a very rare and extremely aggressive mesenchymal malignant neoplasm showing morphological and immunophenotypic evidence of endothelial cell differentiation. Early diagnosis of this tumor along with radical thyroidectomy followed by postoperative radiotherapy and chemotherapy are essential for adequate management of the patient. Currently available data on diagnosis and treatment options of this neoplasm are limited because it is a rare disease in endocrine organs. Raising awareness regarding its diagnosis can help to optimize the treatment and to improve the survival of the patient. We present the case of a 72-year-old female patient with multiple comorbidities who addressed to the hospital with obstructive respiratory symptoms: dyspnea, wheezing and hoarseness. The investigations, both clinical and paraclinical, identified a local invasive cervical mass located mainly in the left thyroid lobe, whose immunohistochemical examination confirmed primary thyroid angiosarcoma. Although this type of neoplasm is described mainly in the Alpine regions, it can appear in lower altitude regions and this tumor needs to be differentiated from a high-grade neoplasm (anaplastic thyroid carcinoma).

Lung Ultrasound-Guided Fluid Management versus Standard Care in Surgical ICU Patients: A Randomised Controlled Trial.

The value of lung ultrasound (LU) in assessing extravascular lung water (EVLW) was demonstrated by comparing LU with gold-standard methods for EVLW assessment. However, few studies have analysed the value of B-Line score (BLS) in guiding fluid management during critical illness. The purpose of this trial was to evaluate if a BLS-guided fluid management strategy could improve fluid balance and short-term mortality in surgical intensive care unit (ICU) patients. We conducted a randomised, controlled trial within the ICUs of two university hospitals. Critically ill patients were randomised upon ICU admission in a 1:1 ratio to BLS-guided fluid management (active group) or standard care (control group). In the active group, BLS was monitored daily until ICU discharge or day 28 (whichever came first). On the basis of BLS, different targets for daily fluid balance were set with the aim of avoiding or correcting moderate/severe EVLW increase. The primary outcome was 28-day mortality. Over 24 months, 166 ICU patients were enrolled in the trial and included in the final analysis. Trial results showed that daily BLS monitoring did not lead to a different cumulative fluid balance in surgical ICU patients as compared to standard care. Consecutively, no difference in 28-day mortality between groups was found (10.5% vs. 15.6%, p = 0.34). However, at least 400 patients would have been necessary for conclusive results.

Proposal of a Preoperative CT-Based Score to Predict the Risk of Clinically Relevant Pancreatic Fistula after Cephalic Pancreatoduodenectomy.

Background and Objectives: Postoperative pancreatic fistula after cephalic pancreatoduodenectomy (CPD) is still the leading cause of postoperative morbidity, entailing long hospital stay and costs or even death. The aim of this study was to propose the use of morphologic parameters based on a preoperative multisequence computer tomography (CT) scan in predicting the clinically relevant postoperative pancreatic fistula (CRPF) and a risk score based on a multiple regression analysis. Materials and Methods: For 78 consecutive patients with CPD, we measured the following parameters on the preoperative CT scans: the density of the pancreas on the unenhanced, arterial, portal and delayed phases; the unenhanced density of the liver; the caliber of the main pancreatic duct (MPD); the preoperatively estimated pancreatic remnant volume (ERPV) and the total pancreatic volume. We assessed the correlation of the parameters with the clinically relevant pancreatic fistula using a univariate analysis and formulated a score using the strongest correlated parameters; the validity of the score was appreciated using logistic regression models and an ROC analysis. Results: When comparing the CRPF group (28.2%) to the non-CRPF group, we found significant differences of the values of unenhanced pancreatic density (UPD) (44.09 ± 6.8 HU vs. 50.4 ± 6.31 HU, p = 0.008), delayed density of the pancreas (48.67 ± 18.05 HU vs. 61.28 ± 16.55, p = 0.045), unenhanced density of the liver (UDL) (44.09 ± 6.8 HU vs. 50.54 ± 6.31 HU, p = 0.008), MPD (0.93 ± 0.35 mm vs. 3.14 ± 2.95 mm, p = 0.02) and ERPV (46.37 ± 10.39 cm3 vs. 34.87 ± 12.35 cm3, p = 0.01). Based on the odds ratio from the multiple regression analysis and after calculating the optimum cut-off values of the variables, we proposed two scores that both used the MPD and the ERPV and differing in the third variable, either including the UPD or the UDL, producing values for the area under the receiver operating characteristic curve (AUC) of 0.846 (95% CI 0.694-0.941) and 0.774 (95% CI 0.599-0.850), respectively. Conclusions: A preoperative CT scan can be a useful tool in predicting the risk of clinically relevant pancreatic fistula.

Medical Staff Training - Quality Initiative to Reduce Errors in the Pre-Preanalytical Phase.

BACKGROUND: Numerous studies indicate that most error sources in hemostasis laboratories occur during the pre preanalytical phase through biological product sampling. OBJECTIVES: The purpose of this study was documentation, monitoring, and reduction of preanalytical errors through operator training. METHODS: For a period of 4 months in the "St. SpiridonË® Hospital from Iasi, 978 specimens were identified with non-conformities, due to the following causes: insufficiently-collected, hemolyzed- and coagulated samples. Data collection was conducted in two stages: before and after training of medical staff in clinical departments, upon improving the coagulation specimen sampling practices. RESULTS: The study pointed out that subsequent to training, a reduction of the coagulated samples has been registered as follows: in medical departments from 33.33% to 16.78%, in surgery from 27.20% to 17.02%, ICU (intensive care units) from 10.63% to 8.74%, and slightly in EU (emergency) from 10.63% to 8.74%. Moreover, we noticed that the incidence of hemolyzed samples increased in clinical sections, as follows: EU from 4.50% to 14.89%, medical departments from 3.42% to 9.21%, surgery from 1.44% to 6.38%, and 4.50% to 14.89% for ICU. The insufficiently sampled volume persisted during the study in almost all sections: surgery from 1.80% to 4.96%, medical from 2.52% to 4.96%, EU from 1.80% to 3.78% with a slight decrease in ICU from 1.26% to 1.18%. CONCLUSIONS: Nurses traditionally represent the core of quality medical services. Peer education is effective and implementation and compliance of sample collection procedure rules ultimately providing patient safety.

Outcome Predictive Value of Serum Ferritin in ICU Patients with Long ICU Stay.

Background and Objectives: The simplified interpretation of serum ferritin levels, according to which low ferritin levels indicate iron deficiency and high levels indicate hemochromatosis is obsolete, as in the presence of inflammation serum ferritin levels, no longer correlate with iron stores. However, further data are needed to interpret serum ferritin levels correctly in patients with ongoing inflammation. Our study aimed to assess serum iron and ferritin dynamics in patients with long ICU stay and the possible correlations with organ dysfunction progression and outcome. Materials and Methods: We conducted a prospective study in a university hospital intensive care unit (ICU) over six months. All patients with an ICU length-of-stay of more than seven days were enrolled. Collected data included: demographics, Sequential Organ Failure Assessment (SOFA) score, admission, weekly serum iron and ferritin levels, ICU length-of-stay and outcome. Interactions between organ dysfunction progression and serum iron and ferritin levels changes were investigated. Outcome predictive value of serum ferritin was assessed. Results: Seventy-two patients with a mean ICU length-of-stay of 15 (4.4) days were enrolled in the study. The average age of patients was 62 (16.8) years. There were no significant differences between survivors (39 patients, 54%) and nonsurvivors (33 patients, 46%) regarding demographics, serum iron and ferritin levels and SOFA score on ICU admission. Over time, serum iron levels remained normal or low, while serum ferritin levels statedly increased in all patients. Serum ferritin increase was higher in nonsurvivors than survivors. There was a significant positive correlation between SOFA score and serum ferritin (r = 0.7, 95%CI for r = 0.64 to 0.76, p < 0.01). The predictive outcome accuracy of serum ferritin was similar to the SOFA score. Conclusions: In patients with prolonged ICU stay, serum ferritin dynamics reflects organ dysfunction progression and parallels SOFA score in terms of outcome predictive accuracy.

Laparoscopic Approach of Primary Hydatid Cyst of the Pancreas - Case Report and Literature Review.

The pancreatic localization of the hydatid cyst is exceptional, even in countries where hydatid disease is considered endemic. We describe a female patient, 63 years old, with hydatid cyst of the pancreas. The diagnosis was difficult because the presentation was that of an epigastric cyst of unknown origin, with no suggestive radiological and ultrasonography features. We performed a laparoscopic exploration of abdominal cavity which revealed a retrogastric cystic mass developed from the pancreatic body. The surgical treatment consisted in puncture, evacuation of proligera, lavage with hypertonic serum, partial excision of the pericyst and drainage of the cavity. The postoperative course was uneventfull and the patient was released after 5 days. The follow-up at 6, 12 and 24 month did not show relapse. Through this observation and a review of the literature, we discuss the diagnostic and therapeutic difficulties of this rare localization of the hydatid cyst. Hydatid cyst is a rare cause of a cystic lesion of the pancreas, especially in endemic areas. Surgery still remains the most effective treatment option. Laparoscopic approach is feasible and secure but requires a trained team with experience in minimally invasive surgery.

Possible Involvement of Vitamin C in Periodontal Disease-Diabetes Mellitus Association.

Ascorbic acid (vitamin C) is an important water-soluble vitamin found in many fruits and vegetables. It has well-documented beneficial effects on the human body and is used as a supplement, alone or in combination with other vitamins and minerals. Over recent years, research has focused on possible new therapeutic actions in chronic conditions including periodontal disease (PD). We conducted a systematic review on clinical trials from four databases (PubMed, Clinical Trials, Cochrane, Web of Science) which measured plasmatic/salivary levels of ascorbic acid in PD-diabetes mellitus (DM) association. Six studies were included in our review, three of them analyzing patients with different grades of PD and DM who received vitamin C as a treatment (500 mg vitamin C/day for 2 months and 450 mg/day for 2 weeks) or as part of their alimentation (guava fruits), in combination with standard therapies and procedures. Decreased levels of vitamin C were observed in PD patients with DM but data about efficacy of vitamin C administration are inconclusive. Given the important bidirectional relationship between PD and DM, there is a strong need for more research to assess the positive effects of ascorbic acid supplementation in individuals suffering from both diseases and also its proper regimen for these patients.

Bio-electrical impedance analysis for perioperative fluid evaluation in open major abdominal surgery.

Water retention and intercompartmental redistribution occur frequently in association with adverse postoperative outcomes, yet the available strategies for non-invasive assessment are limited. One such approach for evaluating body water composition in various circumstances is bio-electrical impedance analysis (BIA). This study aims to appraise the usefulness of the Body Composition Monitor (BCM, Fresenius Medical Care, Germany) in assessing body fluid composition and intercompartmental shifts before and after open major abdominal surgery. This prospective, clinician blinded observational study enrolled all the patients scheduled consecutively for elective major open abdominal surgery during a 1-year period starting from January 1st, 2016. BIA parameters-total body water (TBW), extracellular water (ECW), intracellular water (ICW), absolute fluid overload (AFO), and relative fluid overload (RFO) were measured before and after surgery. The results were compared with fluid balance and outcome parameters such as organ dysfunction, ICU-and hospital length of stay (-LOS). The study population included 71 patients aged 60.2 ± 12 of whom 60.6% men and with a BMI of 26.3 ± 5.1 kg/m2. Postoperative acute kidney injury, respiratory dysfunction, and infections occurred in 14.0%, 19.7% and 28.1% of cases, respectively. The median LOS in ICU was 20 h and the hospital-LOS was 10 days. Positive intraoperative fluid balance (2.4 ± 1.0 L) resulted in a significant increase of TBW (1.4 ± 2.4 L) and of ECW (1.4 ± 1.2 L). Intraoperative fluid balance significantly correlated with TBW change (r = 0.23, p = 0.04) and with AFO change (r = 0.31, p < 0.01). A significant correlation was found between pre- and postoperative AFO and RFO on one hand, and ICU-LOS on the other. BIA may be a useful tool for the perioperative assessment of volume status.

Lung Ultrasound Guided Fluid Management Protocol for the Critically Ill Patient: study protocol for a multi-centre randomized controlled trial.

BACKGROUND: In routine intensive care unit (ICU) practice, fluids are often administered without a safety limit, which may lead to fluid overload and decreased survival. Recently, B-lines score (BLS) has been validated as a lung ultrasound (LUS) quantification of pulmonary congestion. This suggests that LUS may provide a safety threshold to conduct fluid therapy and to avoid overhydration. However, there is no randomized study to test the utility of LUS in guiding fluid management in ICU patients by using a pre-specified BLS cut-off value as a threshold for fluid removal. METHODS: LUS Guided Fluid Management Protocol for the Critically Ill Patient is a prospective, multi-centre, randomized controlled trial. Five hundred ICU patients will be randomly assigned in a 1:1 ratio, to protocolized LUS-based fluid management or usual care. The trial intervention will start on ICU admission and will consist in daily assessment of BLS and triggered evacuation of excessive fluids with loop diuretics (Furosemide) when BLS ≥ 15. If rebalancing volume status with diuretics fails, forced evacuation by ultrafiltration will be used. The main endpoint is death from all causes at 28 days from randomization. The secondary outcomes are presence and time-course evolution of organ dysfunctions, ICU- and hospital length of stay, all-cause mortality at 90 days, and health economics data. DISCUSSION: If study results will show that LUS guided fluid management protocol improves outcome in ICU patients, it will be the base for other studies to refine this protocol or track those categories of critically ill patients to whom it may bring maximum benefits. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03393065 . Registered on 8 January 2018.

A Rare Colonization in Peritoneum After Blunt Abdominal Trauma: S. putrefaciens and S. cerevisiae

BACKGROUND: Shewanella spp. are gram-negative bacteria, saprophytes, and rarely pathogenic. Saccharomyces cerevisiae is the well-known yeast used for fermentation in industry and molecular biology for research. In humans, it is a very rare pathogen which colonizes the digestive tract, and its utility has been linked to the treatment and prevention of diarrhea associated with Clostridium difficile. CASE REPORT: A 27-year-old male, victim of aggressive, blunt trauma with a 4-day history of symptoms was admitted to our surgery unit. Abdominal sonography revealed peritoneal fluid in all spaces with fibrin. We performed laparotomy and observed perforations on the ileum and general peritonitis with pus. Following surgery, patient was admitted to the intensive care unit with septic shock. The antibiogram from the peritoneal liquid revealed S. putrefaciens and S. cerevisiae. CONCLUSION: Although very rare, S. putrefaciens and S. cerevisiae may colonize in the peritoneum after blunt abdominal trauma.

B-lines score on lung ultrasound as a direct measure of respiratory dysfunction in ICU patients with acute kidney injury.

PURPOSE: Fluid overload is frequently found in critically ill patients with acute kidney injury (AKI) and is associated with adverse outcomes. Lung ultrasonography (LUS) and bioimpedance spectroscopy (BIS) are potentially useful tools for the noninvasive volume assessment. We evaluated the utility of these measures, alone or in combination, in estimating the PaO2/FiO2 ratio in critical patients with AKI. METHODS: In a prospective pilot observational study we included 45 patients who presented on admission or developed at any time during intensive care unit stay AKI defined according to KDIGO criteria. Patients were studied at baseline and after 48 h with LUS, BIS and arterial blood gas. RESULTS: In the univariable analysis, the PaO2/FiO2 ratio was negatively correlated with the B-lines score, and this association was maintained even after adjustments. A cutoff value of 17 for the B-lines score has a sensibility of 76% and a specificity of 65% in identifying patients with PaO2/FiO2 < 300. CONCLUSION: LUS can be used for functional lung evaluation and identification of patients with increase pulmonary water content and decrease PaO2/FiO2 ratio.