Thoracic UltrasONOgraphy Reporting: The TUONO Consensus.

The widespread use of the lung ultrasound (LUS) has not been followed by the development of a comprehensive standardized tool for its reporting in the intensive care unit (ICU) which could be useful to promote consistency and reproducibility during clinical examination. This work aims to define the essential features to be included in a standardized reporting tool and provides a structured model form to fully express the diagnostic potential of LUS and facilitate intensivists in the use of a LUS in everyday clinical ICU examination. We conducted a modified Delphi process to build consensus on the items to be integrated in a standardized report form and on its structure. A committee of 19 critical care physicians from 19 participating ICUs in Italy was formed, including intensivists experienced in ultrasound from both teaching hospitals and referral hospitals, and internationally renowned experts on the LUS. The consensus for 31 statements out of 33 was reached at the third Delphi round. A structured model form was developed based on the approved statements. The development of a standardized model as a backbone to report a LUS may facilitate the guidelines' application in clinical practice and increase inter-operator agreement. Further studies are needed to evaluate the effects of standardized reports in critically ill patients.

COVID-19 Detection Using Photoplethysmography and Neural Networks.

The early identification of microvascular changes in patients with Coronavirus Disease 2019 (COVID-19) may offer an important clinical opportunity. This study aimed to define a method, based on deep learning approaches, for the identification of COVID-19 patients from the analysis of the raw PPG signal, acquired with a pulse oximeter. To develop the method, we acquired the PPG signal of 93 COVID-19 patients and 90 healthy control subjects using a finger pulse oximeter. To select the good quality portions of the signal, we developed a template-matching method that excludes samples corrupted by noise or motion artefacts. These samples were subsequently used to develop a custom convolutional neural network model. The model accepts PPG signal segments as input and performs a binary classification between COVID-19 and control samples. The proposed model showed good performance in identifying COVID-19 patients, achieving 83.86% accuracy and 84.30% sensitivity (hold-out validation) on test data. The obtained results indicate that photoplethysmography may be a useful tool for microcirculation assessment and early recognition of SARS-CoV-2-induced microvascular changes. In addition, such a noninvasive and low-cost method is well suited for the development of a user-friendly system, potentially applicable even in resource-limited healthcare settings.

Automatic COVID-19 severity assessment from HRV.

COVID-19 is known to be a cause of microvascular disease imputable to, for instance, the cytokine storm inflammatory response and the consequent blood coagulation. In this study, we propose a methodological approach for assessing the COVID-19 presence and severity based on Random Forest (RF) and Support Vector Machine (SVM) classifiers. Classifiers were applied to Heart Rate Variability (HRV) parameters extracted from photoplethysmographic (PPG) signals collected from healthy and COVID-19 affected subjects. The supervised classifiers were trained and tested on HRV parameters obtained from the PPG signals in a cohort of 50 healthy subjects and 93 COVID-19 affected subjects, divided into two groups, mild and moderate, based on the support of oxygen therapy and/or ventilation. The most informative feature set for every group's comparison was determined with the Least Absolute Shrinkage and Selection Operator (LASSO) technique. Both RF and SVM classifiers showed a high accuracy percentage during groups' comparisons. In particular, the RF classifier reached 94% of accuracy during the comparison between the healthy and minor severity COVID-19 group. Obtained results showed a strong capability of RF and SVM to discriminate between healthy subjects and COVID-19 patients and to differentiate the two different COVID-19 severity. The proposed method might be helpful for detecting, in a low-cost and fast fashion, the presence and severity of COVID-19 disease; moreover, these reasons make this method interesting as a starting point for future studies that aim to investigate its effectiveness as a possible screening method.

Thoracic UltrasONOgraphy Reporting: The TUONO Study.

Lung ultrasound (LUS) is a validated technique for the prompt diagnosis and bedside monitoring of critically ill patients due to its availability, safety profile, and cost-effectiveness. The aim of this work is to detect similarities and differences among LUS reports performed in ICUs and to provide a common ground for an integrated report form. We collected all LUS reports during an index week in 21 ICUs from the GiViTI network. First, we considered signs, chest areas, and terminology reported. Then, we compared different report structures and categorized them as structured reports (SRs), provided with a predefined model form, and free unstructured text reports (FTRs) that had no predetermined structure. We analyzed 171 reports from 21 ICUs, and 59 reports from 5 ICUs were structured. All the reports presented a qualitative description that mainly focused on the presence of B-lines, consolidations, and pleural effusion. Zones were defined in 66 reports (39%). In SRs, a complete examination of all the regions was more frequently achieved (96% vs. 74%), and a higher impact on therapeutic strategies was observed (17% vs. 6%). LUS reports vary significantly among different centers. Adopting an integrated SR seems to promote a systematic approach in scanning and reporting, with a potential impact on LUS clinical applications.

Classifying sepsis from photoplethysmography.

Sepsis is a life-threatening organ dysfunction. It is caused by a dysregulated immune response to an infection and is one of the leading causes of death in the intensive care unit (ICU). Early detection and treatment of sepsis can increase the survival rate of patients. The use of devices such as the photoplethysmograph could allow the early evaluation in addition to continuous monitoring of septic patients. The aim of this study was to verify the possibility of detecting sepsis in patients from whom the photoplethysmographic signal was acquired via a pulse oximeter. In this work, we developed a deep learning-based model for sepsis identification. The model takes a single input, the photoplethysmographic signal acquired by pulse oximeter, and performs a binary classification between septic and nonseptic samples. To develop the method, we used MIMIC-III database, which contains data from ICU patients. Specifically, the selected dataset includes 85 septic subjects and 101 control subjects. The PPG signals acquired from these patients were segmented, processed and used as input for the developed model with the aim of identifying sepsis. The proposed method achieved an accuracy of 76.37% with a sensitivity of 70.95% and a specificity of 81.04% on the test set. As regards the ROC curve, the Area Under Curve reached a value of 0.842. The results of this study indicate how the plethysmographic signal can be used as a warning sign for the early detection of sepsis with the aim of reducing the time for diagnosis and therapeutic intervention. Furthermore, the proposed method is suitable for integration in continuous patient monitoring.

COVID-19 detection using a model of photoplethysmography (PPG) signals.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) targets several tissues of the human body; among these, a serious impact has been observed in the microvascular system. The aim of this study was to verify the presence of photoplethysmographic (PPG) signal modifications in patients affected by COVID-19 at different levels of severity. APPROACH: The photoplethysmographic signal was evaluated in 93 patients with COVID-19 of different severity (46: grade 1; 47: grade 2) and in 50 healthy control subjects. A pre-processing step removes the long-term trend and segments of each pulsation in the input signal. Each pulse is approximated with a model generated from a multi-exponential curve, and a Least Squares fitting algorithm determines the optimal model parameters. Using the parameters of the mathematical model, three different classifiers (Bayesian, SVM and KNN) were trained and tested to discriminate among healthy controls and patients with COVID, stratified according to the severity of the disease. Results are validated with the leave-one-subject-out validation method. MAIN RESULTS: Results indicate that the fitting procedure obtains a very high determination coefficient (above 99% in both controls and pathological subjects). The proposed Bayesian classifier obtains promising results, given the size of the dataset, and variable depending on the classification strategy. The optimal classification strategy corresponds to 79% of accuracy, with 90% of specificity and 67% of sensibility. SIGNIFICANCE: The proposed approach opens the possibility of introducing a low cost and non-invasive screening procedure for the fast detection of COVID-19 disease, as well as a promising monitoring tool for hospitalized patients, with the purpose of stratifying the severity of the disease.

Cardiovascular Dynamics in COVID-19: A Heart Rate Variability Investigation.

COVID-19 is known to be a cause of microvascular disease due, for example, to the cytokine storm inflammatory response and the result of blood coagulation. This study reports an investigation on Heart Rate Variability (HRV) extracted from photoplethysmography (PPG) signals measured from healthy subjects and COVID-19 affected patients. We aimed to determine a statistical difference between HRV parameters among subjects' groups. Specifically, statistical analysis through Mann-Whitney U Test (MWUT) was applied to compare 42 dif-ferent parameters extracted from PPG signals of 143 subjects: 50 healthy subjects (i.e. group 0) and 93 affected from COVID-19 patients stratified through increasing COVID severity index (i.e. groups 1 and 2). Results showed significant statistical differences between groups in several HRV parameters. In particular, Multiscale Entropy (MSE) analysis provided the master key in patient stratification assessment. In fact, MSE11, MSE12, MSE15, MSE16, MSE17, MSE18, MSE19 and MSE20 keep statistical significant difference during all the comparisons between healthy subjects and patients from all the pathological groups. Our preliminary results suggest that it could be possible to distinguish between healthy and COVID-19 affected subjects based on cardiovascular dynamics. This study opens to future evaluations in using machine learning models for automatic decision-makers to distinguish between healthy and COVID-19 subjects, as well as within COVID-19 severity levels. Clinical Relevance - This establishes the possibility to distin-guish healthy subjects from COVID-19 affected patients basing on HRV parameters monitored non invasively by PPG.

Prognostic role of Interleukin-6/lymphocytes ratio in SARS-CoV2 related pneumonia.

INTRODUCTION AND AIM: Interleukin-6 to lymphocyte (IL-6/Lym) ratio has been identified as a potential prognostic tool in patients with SARS-CoV2 related pneumonia. The aim of our study was to compare the prognostic power of IL-6/Lym ratio with other biomarkers in patients initially admitted in a non intensive unit and suffering for respiratory failure associated with SARS-CoV2 related pneumonia. MATERIALS AND METHODS: IL-6/Lym ratio, IL-6, D-Dimer, D-Dimer/fibrinogen ratio, fibrinogen, C-reactive protein (CRP), lymphocytes count and neutrophil/lymphocyte (N/L) ratio collected at hospital admission were tested as prognosticators of negative outcome, defined as combined endpoint in-hospital mortality and/or Intensive Care Unit (ICU) admission requiring oro-tracheal intubation (OTI). RESULTS: Study population encompassed two hundreds and twenty-three patients (46% females) with mean age ± DS 69.4 ± 13.3 years. Eighty-nine patients (39.9%) suffered for severe respiratory failure and required non invasive ventilation, helmets and/or high flow nasal cannula. Fourty-one patients (18.3%) died during hospital stay and/or required OTI. In these patients mean values of IL-6/Lym ratio, IL-6, CRP and N/L were significantly higher and lymphocytes count was significantly lower compared with patients discharged alive and/or not requiring OTI, while no difference was found in mean values of D-Dimer, D-Dimer/Fibrinogen ratio and fibrinogen. AUC (0.797, 95% CI: 0.738-0.848) of IL-6/Lym ratio was the highest compared with those of all the other analyzed biomarkers and the difference was significant with the exception of IL-6. At multivariate logistic regression IL-6/Lym ratio > 66.5 resulted the only independent biomarker associated with mortality and/or OTI (OR 5.65; 95% 1.63-19.54). CONCLUSION: IL-6/Lym ratio seems to be an optimal prognosticator in SARS-CoV2 related pneumonia. Its routinary use in COVID-19 patients could be warranted.

Prognostic determinants in patients with non traumatic intracerebral hemorrhage: a real life report.

Background and aim: Nontraumatic intracerebral hemorrhage (ICH) remains a devastating disease for high in-hospital and long-term mortality and residual neurological disability. The aim of our study was to analyze the prognostic factors in patients managed for ICH in the real-life clinical practice.Materials and Methods: We retrospectively analyzed clinical and neuro-radiological data of consecutive patients admitted to our Hospital for ICH along 1 year. In-hospital mortality and 90-day modified Rankin scale (mRS) ≥4 were the study outcomes. Moreover, we compared patients admitted in Intensive Care Unit (ICU) with patients admitted in Stroke Unit (SU).Results: Ninety-eight patients with mean age ± SD 78 ± 12 years were enrolled. In-hospital and 90-day mortality were 36.7% and 41.8%, respectively. Patients who died had a significantly higher percentage of ICH volume >30 mL, irregular shape, lobar location, intraventricular hemorrhage (IVH), midline shift, hydrocephalus, hematoma enlargement, Glasgow Coma Scale (GCS) ≤9 at hospital admission, early neurological worsening (ENW), higher Hemphill ICH score, and underwent oro-tracheal intubation more frequently compared with patients who survived. Patients admitted to ICU were younger and significantly more critical compared with those who were admitted to SU. In-hospital mortality in patients admitted to ICU was 52.6% compared with 25% in patients admitted to SU (p < 0.01). Median mRS score at hospital discharge was 4 (IQR 3-5) and at 90 days was 4 (IQR 3-4). ENW, hematoma enlargement, Hemphill ICH score ≥3 and midline shift >10 mm were found independent risk factors for in-hospital mortality, while age was found as independent risk factor for 90-day mRS ≥4).Conclusion: In real life, prognosis of ICH is associated with clinical and radiological determinants. In our study ENW, hematoma enlargement, Hemphill ICH score ≥3 and midline shift >10 mm were associated with short-term mortality risk, while age with 90-day mRS ≥4.

Adoption and application in Italy of the principal guidelines and international recommendations on venous access.

Vascular access is the commonest invasive procedure in secondary care. Vascular access is understood as being access to the bloodstream of acute and chronic patients for diagnostic and therapeutic purposes such as blood sampling, vessel pressure monitoring, fluid infusions (blood transfusions, parenteral nutrition), pharmacological treatments (e.g. antibiotic therapies, chemotherapy, analgesic therapies) or apheresis/dialysis through catheters that may remain in the vessels for weeks or months. There is a wide variety of options available for venous access. Device selection for venous access must be adapted to the patient's needs, and to the type, duration and frequency of the infusion. The scenario is rapidly evolving and hence treatments such as cancer chemotherapy, total parenteral nutrition, long-term parenteral antimicrobial therapies are increasing not only in hospitalized patients, but also in contexts other than traditional ones, such as local care, in response to needs related to healthcare expenditure or patients' needs. This paper originates from the idea of a multidisciplinary group of experts to analyze the main, most recent international guidelines and recommendations on vascular access and to evaluate its implementation in Italy. It often happens that documents acquired in different contexts, however extraordinarily effective and exhaustive, are difficult to apply in contexts where the healthcare organization, professional resources, communication dynamics and regulations are different. The consequence is a progressive departure from international standards and evidence-based medicine, which is particularly burdensome in sectors (such as vascular access and devices used for access) where technological innovation requires constant updating, alignment and method sharing. The work motivation of this group of authors, which sees its final finding in the welfare standards and criteria of appropriateness contained in this document, lies in the particular ongoing and future Italian epidemiological scenario and in the assessments of health economics that demand conscious and appropriate decisions in the interest of the citizen and the healthcare system. The vascular access field is undergoing a veritable revolution; once upon a time the leading lights were those who possessed the best technical skills, the best manual skills, whereas nowadays vascular access decisions are strategic decisions involving specially trained health professionals, able to assess complex interactions and work in teams. There is a strong cultural need, not only with regard to technical aspects, but also for the execution of procedures in daily clinical practice that comply with the recommendations set out in the guidelines published and elaborated by public and private bodies and institutions, as well as by scientific societies and recognized technical and scientific associations. This document is not a manual on vascular access for consultation by all those who intend to go deeper into operating aspects (selection of the device, implantation and management), but a reflection on the most recent pointers in the field of vascular access within Italy's complex healthcare situation.

Experimental measurement of forces during percutaneous dilatational tracheostomy.

The measurement of mechanical effects associated with the dilatation phase of a percutaneous dilatational tracheostomy is of primary importance to identify the causes of major complications associated with this procedure, such as tracheal cartilage subluxation or fracture and bleeding. Such information can be very useful also for the design of better instruments and procedures. The aim of this study was to present a methodology to evaluate mechanical effects of the dilatation phase of a percutaneous dilatational tracheostomy on the tracheal rings and adjacent anatomical structures. Forces and moments were measured through a dilator instrumented with strain gauges. Two surgeons, with different levels of expertise, performed the percutaneous dilatational tracheostomy on a lifelike reproduction of an adult head, specifically designed for training professionals. The modified dilator was effective in measuring forces involved in the percutaneous dilatational tracheostomy without affecting the ability of the operator to perform the procedure. The main contribution to the insertion of the dilator was given by the axial force, defined as the force acting on the handle, compressing it (mean and peak force: 48.8 and 88.2 N for Surgeon 1, 31.3 and 82.8 N for Surgeon 2, respectively). The proposed method was effective in measuring differences between procedures performed by surgeons with different amounts of experience in terms of duration, forces applied and repeatability. In addition, it may have applications for use as a feedback for incorrect positioning or excessively variable pressure during the training of surgeons for the execution of percutaneous dilatational tracheostomy.

Current adoption of lung ultrasound in Intensive Care Units: an Italian multi-center survey.

BACKGROUND: Lung ultrasound (LUS) is a useful tool for assessing lung status in critically ill patients, but is not widely applied in intensive care units (ICUs). The aim of this study was to investigate the use of LUS in Italian ICUs. METHODS: A questionnaire was distributed to 116 ICU representatives belonging to the Italian GiViTI network, participating in a national project on continuous quality of care assessment. The answers to the questionnaire were analyzed with the data collected in the course of said project. RESULTS: 87 ICUs took part in the study. LUS was performed in 94.3% of them, generally by an internal intensivist. The mean number of tests per bed per week was 0.97 (SD, 1.0). A standardized reporting format was present in only 11% of ICUs. LUS was generally used to investigate known or suspected diseases and as a screening tool in only 10%. The number of testes per bed per week was inversely correlated to the number of beds per physician (P<0.001) and to the provider performing the LUS (P<0.001), but not to other structural, organizational or performance data. CONCLUSIONS: LUS is performed in the majority of ICUs and is generally used to investigate known or suspected diseases. Frequency of use appears to be low and related to selected organizational factors. There is generally no standardized format for reporting LUS findings.

Advanced accident research system based on a medical and engineering data in the metropolitan area of Florence.

BACKGROUND: In the metropolitan area of Florence, 62% of major traumas involve powered two wheeler rider and pillion passengers, 10% cyclists, and 7% pedestrians. The urban and extra-urban areas are the most dangerous for the vulnerable road user. In-depth investigations are needed for assessing detailed information on road accidents. This type of study has been very limited in time frame in Italy, and completely absent in the Tuscan region.Consequently a study called "In-depth Study of road Accident in FlorencE" (In-SAFE) has been initiated. METHODS: A network between the Department of Mechanics and Industrial Technologies (University of Florence) and the Intensive Care Unit of the Emergency Department (Careggi Teaching Hospital, Florence) was created with the aim of collecting information about the road accidents. The data collected includes: on-scene data, data coming from examination of the vehicles, kinematics and dynamic crash data, injuries, treatment, and injury mechanisms. Each injury is codified thorough the AIS score, localized by a three-dimensional human body model based on computer tomography slices, and the main scores are calculated. We then associate each injury with its cause and crash technical parameters. Finally, all the information is collected in the In-SAFE database. RESULTS: Patient mean age at the time of the accident was 34.6 years, and 80% were males. The ISS mean is 24.2 (SD 8.7) and the NISS mean is 33.6 (SD 10.5). The main road accident configurations are the "car-to-PTW" (25%) and "pedestrian run over" (17,9%). For the former, the main collision configuration is "head-on crash" (57%). Cyclists and PTW riders-and-pillions-passengers suffer serious injuries (AIS3+) mainly to the head and the thorax. The head (56.4%) and the lower extremities (12.7%) are the most frequently injured pedestrian body regions. CONCLUSIONS: The aim of the project is to create an in-depth road accident study with special focus on the correlation between technical parameters and injuries. An in-depth investigation team was setup and is currently active in the metropolitan area of Florence.Twenty-eight serious road accidents involving twenty-nine ICU patients are studied. PTW users, cyclist and pedestrians are the most frequently involved in metropolitan accidents.

Extracorporeal life support in patients with severe trauma: an advanced treatment strategy for refractory clinical settings.

OBJECTIVES: Major trauma is a leading cause of death, particularly among young patients. New strategies in management are needed to improve poor outcomes in cases of severe trauma. Extracorporeal life support (ECLS) has proven to be effective in acute cardiopulmonary failure of different causes, even when conventional therapies fail. We report our initial experience with ECLS as a rescue therapy in severely polytraumatized patients in a refractory clinical setting. This study identifies the pre-ECLS characteristics of patients to predict the appropriateness of ECLS treatment. METHODS: From December 2008 to May 2012, 375 patients with polytrauma were treated in the Careggi Teaching Hospital, a tertiary-level referral trauma center. Our ECLS team was alerted on 30 patients and applied ECLS in 18 adult patients with trauma. We adopted venoarterial ECLS in 14 patients with cardiopulmonary failure with refractory shock and venovenous ECLS in 4 patients with isolated refractory acute respiratory failure. RESULTS: ECLS was initiated at a mean of 359.176 ± 216.606 (145-950) minutes from trauma. In 4 patients, the ECLS treatment failed because of an incapability to maintain adequate ECLS flow and perfusion. In 14 patients, efficiently supported by ECLS, the cardiac index, mean arterial pressure, blood lactate concentration, arterial oxygen tension, arterial carbon dioxide tension, and pH showed significant improvement, with normal values reached at 3.5 ± 1.5 hours. CONCLUSIONS: From our data, ECLS seems to be a valuable option to resuscitate patients with severe trauma when conventional therapies are insufficient. ECLS is safe, feasible, and effective in providing hemodynamic support and blood gas exchange.

Vacuum-assisted closure for managing neck abscesses involving the mediastinum.

A 57-year-old immunocompetent male patient with a deep neck abscess involving the mediastinum was referred to us following unsuccessful treatment at his local hospital with medical therapy and ultrasound-guided aspiration. After initial evaluation and resuscitation, a contrast-enhanced computed tomography (CT) scan was performed, and the patient was transferred for surgical drainage. A vacuum-assisted closure (VAC) device was used as a surgical drain to help prevent reaccumulation of the purulent collections. A repeat CT scan on day 3 confirmed the absence of residual pus in the mediastinum and in the neck spaces, and the VAC device was removed. Perfect healing of the deep tissues with successful mediastinal toilette was observed. The patient resumed oral meals on postoperative day 10, and 2 days later he was discharged. A 1-month follow-up CT again demonstrated the complete healing and absence of the neck abscess. This case illustrates the possibility of avoiding more extensive and life-threatening procedures, such as open thoracotomy, in the treatment of neck abscesses extending into the mediastinum, and highlights the utility of VAC in the management of deep neck abscesses.

Feasibility of inter-hospital transportation using extra-corporeal membrane oxygenation (ECMO) support of patients affected by severe swine-flu(H1N1)-related ARDS.

BACKGROUND: To describe the organization of an ECMO-centre from triage by telephone to the phase of inter-hospital transportation with ECMO of patients affected by H1N1-induced ARDS, describing techniques and equipment used. METHODS: From September 2009 to January 2010, 18 patients with H1N1-induced ARDS were referred to our ECMO-centre from other hospitals. Six patients had contraindications to treatment with ECMO and remained in the local hospital. Twelve patients were transported to our centre and were included in this study. Four patients were transported on ECMO (Group A) and eight on conventional ventilation (Group B). The groups were compared on the basis of adverse events during transport, clinical characteristics and outcome. RESULTS: The PaO2/FiO2 ratio was lower in the patients of Group A (46.8 vs 89.7 [median]) despite the PEEP values being higher (15.0 vs 8.5 [median]). The Murray score was higher in Group A (3.50 vs 2.75 [median]). During the transfer there were no significant complications noted in Group A, whereas two patients in Group B were reported with hypoxia (SpO2 < 90%). One patient in Group A died. All the other patients of the two groups have been discharged from hospital. CONCLUSIONS: The creation of an ECMO team, with various experts in the treatment of ARDS, assured a safe transfer of patients with severe hypoxia, over long distances, when in other cases they wouldn't have been be transportable.

Diagnosis of carotid arterial injury in major trauma using a modification of Memphis criteria.

BACKGROUND: Incidence of Blunt Cerebrovascular Injuries (BCVI) after head injury has been reported as 0.5-1% of all admissions for blunt trauma, with a high stroke and mortality rate. The purpose of this study is to evaluate if a modification of Memphis criteria could improve the rate of BCVI diagnosis. METHODS: Trauma patients consecutively admitted to Intensive Care Unit (ICU) from Jan 2008 to Oct 2009 were considered for the study. Memphis criteria comprehend: basilar skull fracture with involvement of the carotid canal, cervical spine fracture, neurological exam not explained by brain imaging, Horner's syndrome, LeFort II-III fractures, and neck soft tissue injury. As single criteria modification, we included all patients with petrous bone fracture, even without carotid canal involvement. In all patients at risk of BCVI, 64-slice angio-CT-scans was performed. RESULTS: During the study period, 266 patients were admitted to the ICU for blunt major trauma. Among them, 162 presented traumatic brain injury or cervical spine fracture. In accordance with the proposed modified-Memphis criteria, 53 patients showed risk factors for BCVI compared to 45 using the original Memphis criteria. Among the 53 patients, 6 resulted as having carotid lesions (2.2% of all blunt major traumas; one patient more than when using Memphis criteria). Anticoagulant therapy with low molecular weight heparin was administered in all patients. No stroke or hemorrhagic complications occurred. Clinical examination at 6-months showed no central neurological deficit. CONCLUSION: A modification of a single criteria of Memphis screening protocol might permit the identification of a higher percentage of BCVI. Limited by sample size, this study needs to be validated.

Implantation of 3951 long-term central venous catheters: performances, risk analysis, and patient comfort after ultrasound-guidance introduction.

BACKGROUND: Despite evidence demonstrating improved safety with ultrasound-guided placement of central venous catheters (CVC) in comparison with the use of anatomical landmarks, ultrasound guidance is still not routinely used by all physicians when obtaining central venous access. METHODS: We report data pertaining to the placement of long-term CVCs in a 7-year period before and after ultrasound guidance was introduced. We included 3951 procedures (total of 1,642,402 catheter days) in our study: 1584 using the anatomical landmark method (landmark group, January 2000 to May 2003), and 2367 with ultrasound guidance (ultrasound group, June 2003 to May 2007). All procedures were performed by the same team of intensivists. Comparison criteria included procedural data, complications, patient's comfort, and perceptions. Variables were analyzed with Student's t test and χ(2) test. Multivariate analysis was performed according to the Cox proportional hazards regression model. RESULTS: Using ultrasound guidance, we noted a significant reduction in procedure time in both port (mean difference 4.9 ± 0.4 minutes, confidence interval [CI] 4.1 to 5.7) and tunneled catheter (mean difference 2.4 ± 0.8 minutes, CI 0.9 to 3.8) placement. The landmark method was associated with an increased risk of overall perioperative complications (4.5, CI 3.6 to 5.6). Among disease entities, acute leukemia patients had a significantly higher risk of CVC-related infections (2.6, CI 2.1 to 3.8). On the basis of questionnaires submitted to patients from both groups, ultrasound guidance was associated with improved patient comfort and satisfaction. CONCLUSIONS: Ultrasound guidance reduces complications and improves patient comfort. Further studies are needed to define whether acute leukemia patients should be considered a separate category with regard to the higher incidence of infections.