Major trauma critical pathway: preliminary results from the monitoring system in the regional network and in a hub center in Rome metropolitan area.

OBJECTIVE: The aim of this study is to collect the two years' data regarding the Integrated Trauma Management System (SIAT) by capturing the activity of its three Hubs in the Italian Lazio Region and test the performance of one of the Hubs' (Fondazione Policlinico Universitario A. Gemelli - IRCCS, FPG -IRCCS) Major Trauma Clinical Pathway's (MTCP) monitoring system, introducing the preliminary results through volume, process and outcome indicators. MATERIALS AND METHODS: A retrospective analysis on SIAT was conducted on years 2016 to 2018, by collecting outcome and timeliness indicators through the Lazio Informative System whereas the MTCP was monitored through set of indicators from the FPG - IRCCS Informative System belonging to randomly selected clinical records of the established period. RESULTS: Hubs managed 11.3% of the 998,240 patients admitted in SIAT. All patients eligible for MTCP were "Flagged", and 83% underwent a CT within 2 hours; intra-hospital mortality was 13% whereas readmission rates 16.9%. CONCLUSIONS: SIAT converges the most severe patients to its Hubs. The MTCP monitoring system was able to measure a total of 9 out of 13 indicators from the original panel. This research may serve as a departing point to conduct a pre-post analysis on the performance of the MTCP.

New insights into the infection of the American cockroach Periplaneta americana nymphs with Metarhizium anisopliae s.l. (Ascomycota: Hypocreales).

AIMS: To study the marked resistance of Periplaneta americana to entomopathogenic Metarhizium anisopliae. METHODS AND RESULTS: The low susceptibility of 4th instar nymphs applied topically with conidia seemed to be related to an active removal of conidia by the cockroach and to a disabled or retarded germination and subsequent development of conidia on the cuticle (up to 80% germination in the next 7 days after application). Inhibitions or delays of germination were related to the composition of the epicuticular fatty acids (30·1% w/w oleic, 28·3% w/w linoleic, 24·5% w/w palmitic and 11·7% w/w stearic acid) reported here. Propagules invading the nymphs through the cuticle took at least 3 days to reach the haemocoel, and no propagules were found after day 8 post-treatment. Strain IP 46 infected >50% of nymphs treated with doses ≥2 × 104  hyphal bodies (HB) nymph-1 and reduced the survival of nymphs ≤50%. Most nymphs (>70%) survived after injection of 6 × 103 and 2 × 103  HB nymph-1 . CONCLUSIONS: Findings emphasize a distinct resistance of nymphs of the American cockroach to infections by M. anisopliae. SIGNIFICANCE AND IMPACT OF THE STUDY: Our findings provide support for the development of biological control of this synanthropic cockroach pest.

Clinical and microbiological outcome in septic patients with extremely low 25-hydroxyvitamin D levels at initiation of critical care.

A relationship between vitamin D status and mortality in patients in intensive care units (ICU) has been documented. The present study aims to describe the clinical profile and sepsis-related outcome of critically ill septic patients with extremely low (<7 ng/mL) vitamin D levels at ICU admission. We conducted an observational study in the ICU of a teaching hospital including all patients admitted with severe sepsis/septic shock and undergoing 25-hydroxyvitamin D (25(OH)D) testing within the first 24 hours from admission. We studied 107 patients over 12 months. At ICU admission vitamin D deficiency (≤20 ng/mL) was observed in 93.5% of the patients: 57 (53.3%) showed levels <7 ng/mL. As primary outcome, sepsis-related mortality rate was higher in patients with vitamin D levels <7 ng/mL (50.9% versus 26%). Multivariate regression analysis showed that vitamin D concentration <7 ng/mL on ICU admission (p 0.01) and higher mean SAPS II (p <0.01) score were independent predictors of sepsis-related mortality. Patients with very low vitamin D levels suffered higher rate of microbiologically confirmed infections but a lower percentage of microbiological eradication with respect to patients whose values were >7 ng/mL (80.7% versus 58%, p 0.02; 35.3% versus 68%; p 0.03, respectively). Post hoc analysis showed that, in the extremely low vitamin D group, the 52 patients with pneumonia showed a longer duration of mechanical ventilation (9 days (3.75-12.5 days) versus 4 days (2-9 days), p 0.04) and the 66 with septic shock needed vasopressor support for a longer period of time (7 days (4-10 days) versus 4 days (2-7.25 days), p 0.02). Our results suggest that in critical septic patients extremely low vitamin D levels on admission may be a major determinant of clinical outcome. Benefits of vitamin D replacement therapy in this population should be elucidated.

Chest pain caused by tracheostomy tube malposition: the importance of choosing the right tube.

We describe a case of chest pain caused by tracheostomy tube malposition in a 65-year old woman with chronic respiratory failure due to chronic obstructive pulmonary disease. This report highlights the importance of the correct choice of tracheostomy tube devices for mechanically ventilated and/or spontaneously breathing patients.

Diurnal and nocturnal shifts do not influence non-invasive ventilation outcome.

AIM: The aim of this study was to assess if diurnal or nocturnal shifts were independent risk factors for non-invasive ventilation (NIV) failure. METHODS: This was an observational study carried out on 18 patients of the general Intensive Care Unit in Rome. A total number of 189 consecutive patients needing mechanical ventilation for respiratory failure were prospectively enrolled: 82 were treated with NIV as a first line intervention. Of the 107 patients who were initially intubated, 59 patients were extubated; once extubation failed they were treated with NIV. NIV failure was assessed during both the day (between 7 am and 10 pm) and night shifts (between 10 pm and 7 am). RESULTS: Of the 141 total patients who received NIV, 51 experienced failure during the day shifts and 18 during the night shifts. No difference in the median day and night shift TISS-28 values were observed in any patients who failed NIV during both day and night shifts. Causes of NIV failure were similar during both diurnal and nocturnal shifts. The inability to correct gas exchanges was the main reason for failure. CONCLUSION: In a center with NIV expertise, notwithstanding nurse understaffing, diurnal and nocturnal shifts did not affect the rate of NIV failure.

Hypoalbuminaemia does not impair Diprifusor performance during sedation with propofol.

BACKGROUND: About 98% of plasma propofol is bound to albumin. We investigated if severe hypoalbuminaemia may affect the accuracy of a target-controlled infusion (TCI) device, the Diprifusor, during sedation in critically ill patients. METHODS: Ten critically ill hypoalbuminaemic patients (<24 g litre(-1)) and 10 critically ill normoalbuminaemic patients (>32 g litre(-1)) were included in this study. They underwent sedation with propofol, aimed at a Ramsey sedation score of 4-5. The Diprifusor was used to achieve target propofol plasma concentrations that ranged between 0.6 and 1.5 mg litre(-1). Propofol concentration was measured by high-performance liquid chromatography 5 min, 15 min, 30 min, 1 h, 2 h, 4 h, 6 h and 8 h after starting TCI. The accuracy of TCI was evaluated by calculating performance errors [PE=100x(measured concentration-predicted concentration)/predicted concentration], absolute and relative individual median performance errors (MDAPE and MDPE) and divergence (the slope of individual regression lines between PEs and time). RESULTS: PEs [median (range)] were -7 (-65, 79) in hypoalbuminaemic patients and -2 (-53, 188) in normoalbuminaemic patients; absolute PEs were 21 (1, 79) and 22 (0, 188). No significant difference was observed between the two groups. MDPE, MDAPE and divergence values were also similar. In most patients the accuracy of TCI increased with time because higher PE values were observed during the first 30 min. CONCLUSIONS: Hypoalbuminaemia does not affect the accuracy of Diprifusor during sedation with propofol in critically ill patients.

New advances in the use of noninvasive ventilation for acute hypoxaemic respiratory failure.

Noninvasive ventilation (NIV) includes various techniques for augmenting alveolar ventilation without an endotracheal airway. The theoretical advantages of this approach include avoiding the complications associated with endotracheal intubation, improving patient comfort, preserving airway defence mechanisms, speech and swallowing. The successful application of NIV in hypoxaemic acute respiratory failure (ARF) of varied etiologies has been extensively described but success rate is strictly dependent on ARF etiology and until today the application of NIV strategies in the setting of hypoxaemic ARF is controversial. Larger, controlled studies are required to clarify the role of NIV in the setting of hypoxaemic ARF. The correct choice of the patient ventilator interface is a crucial issue in noninvasive ventilation. The study of new interfaces could improve tolerability reducing the noninvasive ventilation failure rate.