The Burden of Carbapenem-Resistant Acinetobacter baumannii in ICU COVID-19 Patients: A Regional Experience.

Since the beginning of the COVID-19 pandemic, the impact of superinfections in intensive care units (ICUs) has progressively increased, especially carbapenem-resistant Acinetobacter baumannii (CR-Ab). This observational, multicenter, retrospective study was designed to investigate the characteristics of COVID-19 ICU patients developing CR-Ab colonization/infection during an ICU stay and evaluate mortality risk factors in a regional ICU network. A total of 913 COVID-19 patients were admitted to the participating ICUs; 19% became positive for CR-Ab, either colonization or infection (n = 176). The ICU mortality rate in CR-Ab patients was 64.7%. On average, patients developed colonization or infection within 10 ± 8.4 days from ICU admission. Scores of SAPS II and SOFA were significantly higher in the deceased patients (43.8 ± 13.5, p = 0.006 and 9.5 ± 3.6, p < 0.001, respectively). The mortality rate was significantly higher in patients with extracorporeal membrane oxygenation (12; 7%, p = 0.03), septic shock (61; 35%, p < 0.001), and in elders (66 ± 10, p < 0.001). Among the 176 patients, 129 (73%) had invasive infection with CR-Ab: 105 (60.7%) Ventilator-Associated Pneumonia (VAP), and 46 (26.6%) Bloodstream Infections (BSIs). In 22 cases (6.5%), VAP was associated with concomitant BSI. Colonization was reported in 165 patients (93.7%). Mortality was significantly higher in patients with VAP (p = 0.009). Colonized patients who did not develop invasive infections had a higher survival rate (p < 0.001). Being colonized by CR-Ab was associated with a higher risk of developing invasive infections (p < 0.001). In a multivariate analysis, risk factors significantly associated with mortality were age (OR = 1.070; 95% CI (1.028−1.115) p = 0.001) and CR-Ab colonization (OR = 5.463 IC95% 1.572−18.988, p = 0.008). Constant infection-control measures are necessary to stop the spread of A. baumannii in the hospital environment, especially at this time of the SARS-CoV-2 pandemic, with active surveillance cultures and the efficient performance of a multidisciplinary team.

Risk Management and Recommendations for the Prevention of Fatal Foreign Body Aspiration: Four Cases Aged 1.5 to 3 Years and Mini-Review of the Literature.

(1) Background: Foreign body aspiration (FBA) is a significant public health concern among the pediatric population, and fatalities are dramatic for families. It typically involves organic foreign bodies (mainly food) aspirated by children under three years old, usually at home or school. This review aimed to focus on the preventive measures around four actual cases of fatal foreign body aspiration, emphasizing the correct execution of the Heimlich maneuver and cardiopulmonary resuscitation, supervised mealtimes, and high-risk foods. (2) Methods: Four fatal cases of foreign body aspiration in children are presented here. The children were in a free environment, such as school, home, and the countryside, and were in the presence of teachers, parents, and a grandmother who did not supervise the children adequately. A literature review was performed via the MEDLINE database using the key terms: "foreign body aspiration," "infant choking, 1.5 to 3 years," "food and foreign body aspiration," "common household," "prevention of foreign body aspiration," "guidelines," "recommendations," "training of caregivers (parents, educators)," "resuscitation," "Heimlich maneuver," and "disengagement of the upper airways." We focused on the prevention of foreign body aspiration. (3) Results: a complete postmortem examination was performed. In three cases, the foreign bodies were food (mozzarella cheese, pear, or raw bean), while in one case, the foreign body was a pebble. (4) Conclusions: This review aimed to discuss recent scientific literature and provide a perspective on the benefits of a dedicated approach to the management of fatal foreign body aspiration in children by caregivers who usually have no experience with the best ways of supervising children in a safe environment, especially regarding the correct execution of resuscitation maneuvers, such as the Heimlich maneuver. Recommendation updates could improve healthcare quality in a pediatric setting and reduce medico-legal implications.

Pilot prospective open, single-arm multicentre study on off-label use of tocilizumab in patients with severe COVID-19.

OBJECTIVES: No agent has yet been proven to be effective for the treatment of patients with severe COVID-19. METHODS: We conducted a pilot prospective open, single-arm multicentre study on off-label use of tocilizumab (TCZ) involving 63 hospitalised adult patients (56 males, age 62.6±12.5) with severe COVID-19. Clinical and laboratory parameters were prospectively collected at baseline, day 1, 2, 7 and 14. No moderate-to-severe adverse events attributable to TCZ were recorded. RESULTS: We observed a significant improvement in the levels of ferritin, C-reactive protein, D-dimer. The ratio of the partial pressure of oxygen (Pa02) to the fraction of inspired oxygen (Fi02) improved (mean±SD Pa02/Fi02 at admission: 152±53; at day 7: 283.73±115.9, at day 14: 302.2±126, p<0.05). The overall mortality was 11%; D-dimer level at baseline, but not IL-6 levels were predictors of mortality. TCZ administration within 6 days from admission in the hospital was associated with an increased likelihood of survival (HR 2.2 95%CI 1.3-6.7, p<0.05). CONCLUSIONS: In hospitalised adult patients with severe COVID-19, TCZ could be a safe option. An improvement in respiratory and laboratory parameters was observed. Future controlled trials in patients with severe illness are urgently needed to confirm the definite benefit with IL-6 target therapy.

Tracheobronchopathia osteochondroplastica in recurrent retrosternal goiter. Surgical management.

Tracheobronchopathia osteochondroplastica (TPO) is a rare pathology characterized by a progressive segmentary stenosis of the respiratory tract due to proliferation of osteocartilagineous nodules in the lumen of the distal part of the trachea and large bronchial trunks. Prognosis is usually benign, but some cases with an acute progression and a lethal outcome have been described. Clinical presentation is non specific, the chest x-ray is generally normal and there are not typical radiological signs of suspicion: diagnosis of TPO is usually incidental. We report a case of TPO associated with a retrosternal recurrent goiter. The CT scan conducted to evaluate the extension and the vascular relationships showed the characteristic lesions of the TPO with a segmental stenosis of the trachea greater than 70%. A bronchofiberoscopy confirmed the suspect of TPO. To date, the clinical studies carried out do not show a certain etiology, but all agree that chronic damage or chronic inflammations could be the cause of the onset of structural anomalies of the respiratory tract In literature, there is only a report which describes an association between TPO and thyroid pathology. It is obscure whatever these disease could be etiologically or fortuitously associated but a relationship cannot be completely excluded. Surgeons, anesthetists and radiologists which deal with thyroid pathology must recognize the disease, especially in the presence of bulky retrosternal goiters, to make a correct diagnosis and provide adequate perioperative management. KEY WORDS: Mediastinal goiter, Osteocartilagineous Nodules, Tracheal Stenosis, Total Thyroidectomy, Tracheobronchopathia Osteochondroplastica.

Combination of conventional blood cultures and the SeptiFast molecular test in patients with suspected sepsis for the identification of bloodstream pathogens.

We evaluated performances of the molecular test SeptiFast (SF) for the detection of agents of bloodstream infection (BSI) in patients with suspected sepsis, the majority of them under antibiotic treatment and at high prevalence of HIV-1 infection (10.5%). Matched SF and blood culture (BC) samples (n=1186) from 1024 patients were studied. Two hundred fifty-one episodes of BSI out of 1144 were identified with the combined methods (22%). SF identified more episodes of BSI than BC: 206 versus 176 (χ(2)=7.008, P=0.0081) and a significantly higher number of Gram-negative bacteria than BC (77 versus 53, χ(2)=9.12; P=0.0025), as well as of polymicrobial infections (χ(2)=4.50, P=0.0339). In conclusion, SF combined with BC improved the diagnosis of sepsis, especially in immunocompromised patients.

Deep impact of ultrasound in the intensive care unit: the "ICU-sound" protocol.

BACKGROUND: Ultrasound can influence the diagnosis and impact the treatment plan in critical patients. The aim of this study was to determine whether, without encountering major environment- or patient-related limitations, ultrasound examination under a critical care ultrasonography protocol can be performed to detect occult anomalies, to prompt urgent changes in therapy or induce further testing or interventions, and to confirm or modify diagnosis. METHODS: One hundred and twenty-five consecutive patients admitted to a general intensive care unit were assessed under a critical care ultrasonography protocol, and the data were analyzed prospectively. Systematic ultrasound examination of the optic nerve, thorax, heart, abdomen, and venous system was performed at the bedside. RESULTS: Environmental conditions hampered the examination slightly in 101/125 patients (80.8%), moderately in 20/125 patients (16%), and strongly in 4/125 patients (3.2%). Ultrasonographic findings modified the admitting diagnosis in 32/125 patients (25.6%), confirmed it in 73/125 patients (58.4%), were not effective in confirming or modifying it in 17/125 patients (13.6%), and missed it in 3/125 patients (2.4%). Ultrasonographic findings prompted further testing in 23/125 patients (18.4%), led to changes in medical therapy in 22/125 patients (17.6%), and to invasive procedures in 27/125 patients (21.6%). CONCLUSIONS: In this series of patients consecutively admitted to an intensive care unit, ultrasound examination revealed a high prevalence of unsuspected clinical abnormalities, with the highest number of new ultrasound abnormalities detected in patients with septic shock. As part of rapid global assessment of the patient on admission, our ultrasound protocol holds potential for improving healthcare quality.

Patient to nurse ratio and risk of ventilator-associated pneumonia in critically ill patients.

OBJECTIVE: To determine how the patient to nurse ratio affects risk for ventilator-associated pneumonia. METHODS: Data from an earlier study in 27 intensive care units in 9 European countries were examined in a secondary analysis. The initial cohort included 2585 consecutive patients who had mechanical ventilation (1) after admission for treatment of pneumonia or (2) for more than 48 hours irrespective of the diagnosis at admission. In units with variable staffing levels, the highest patient to nurse ratio in a 24-hour period was considered. Patients from 6 units that did not provide data on nurse staffing levels were excluded from the analysis. RESULTS: Ventilator-associated pneumonia developed in 393 of the 1658 patients (23.7%) in the secondary cohort. In units with patient to nurse ratios of 1 to 1, 2 to 1, 2.5 to 1, and 3 to 1, rates were 9.3%, 25.7%, 18.7%, and 24.2%, respectively (P = .003). Rates were significantly lower (P = .002) in units with a ratio of 1 to 1 (9.3%) than in units with a ratio of more than 1 patient to 1 nurse (24.4%). After adjustments for confounding covariates, ratios of more than 1 patient to 1 nurse were no longer associated with increased risk for ventilator-associated pneumonia. CONCLUSIONS: A patient to nurse ratio of 1 to 1 appears to be associated with a lower risk for ventilator-associated pneumonia, but after adjustments for confounding covariates, the difference is not significant.

Lung sealant and morbidity after pleural decortication: a prospective randomized, blinded study.

OBJECTIVES: Prolonged postoperative air leaks (AL) are a major cause of morbidity. Aim of this work was evaluating use of a Lung Sealant System (Pleuraseal, Covidien, Mansfield, MA, U.S.A.) in pleural decortications for empyema thoracis. METHODS: From January 2008 to December 2008, 46 consecutive patients received pleural decortications for empyema thoracis. Post-procedural and malignancy-related empyemas were excluded. After hydro-pneumatic test and surgical correction of AL (until satisfaction), patients were assigned (23 per group) to Control or Sealant group. Control group underwent no additional interventions. In Sealant group, lung sealant was applied over AL areas. Following variables were measured daily: patients with AL; time to chest drainage (CD) removal; CD drainage volume at removal, postoperative length of hospital stay, postoperative C-reactive protein (CRP), and leukocyte counts. Personnel recording parameters were blinded to intervention. Two-tailed t-tests (normally distributed data) or Mann - Whitney U-test (not-normally distributed data) were used for evaluating significance of differences between group means or medians. Significance of any proportional differences in attributes were evaluated using Fisher's Exact Test. Statistical analysis was carried out using R-software (version 2.8.1). RESULTS: Groups were similar regarding demographic and baseline characteristics. No patients were withdrawn from study; no adverse effects were recorded. There were no significative differences on CRP and leukocyte levels between two groups. Compared with the Control group, in Sealant group significantly fewer patients had AL (30 versus 78%, p = 0.012), and drains were inserted for a shorter time (medians, 3 versus 5 days, p = 0.05). Postoperative hospitalization time was shorter in Sealant group than in control group, but difference was not significant (0.7 days, p = 0.121). CONCLUSIONS: Pleuraseal Lung Sealant System significantly reduces AL following pleural decortications for empyema and, despite of not-increased infectious indexes, is suitable for routinely use, even in procedures with contaminated pleura.

[Cardiac arrest management in outpatient clinics: integration between hospital emergency care and the 118 emergency system in the model of Turin ASL 3]. / La gestione dell'arresto cardiocircolatorio negli ambulatori extraospedalieri delle aziende sanitarie locali: l'integrazione tra i servizi di emergenza ospedalieri e il 118 nel modello dell'ASL 3 di torino.

The incidence of sudden cardiac death ranges from 0.4 to 1.28 every 1000 inhabitants per year. Sudden cardiac death is responsible for about 10% of all deaths in Italy in 2000. It is unpredictable and is related to malignant ventricular arrhythmias that may be interrupted in more than 70% of cases. Survival rates generally do not exceed 5% in out-of-hospital cardiac arrest, but, as previously reported, early defibrillation may increase survival rate by 3 times. The Italian law of April 3, 2001, and its recent amendments authorized healthcare providers and trained lay rescuers to use automated external defibrillators either for in-hospital or out-of-hospital settings. We planned a program for early defibrillation in ASL 3 in four outpatient clinics where a transit of 300,000 patients was expected in 2004. Defibrillators were placed in wall-mounted boxes. Opening of these boxes enable an automatic calling to the 118 emergency service that is able to dispatch an advanced cardiac life support team to the pertinent outpatient clinic. The system of wall-mounted boxes automatically communicates by modem with a programmable rate, the state of repair and efficiency of the single boxes, in order to simplify the control of the whole system of defibrillators. This plan of Turin ASL 3 is innovative in the metropolitan area and emphasizes the central role of the 118 emergency system in the management of out-of-hospital cardiac arrest, even in hospital settings such as outpatient clinics with a high number of old users at higher risk of cardiac events. This plan with the availability of automatic calling of the 118 emergency service will be proposed to remaining local hospital utilities for their outpatient settings as well as to other public utilities such as general stores, drugstores, airports where a significant transit mat be expected. The plan will include a specific training for the use of automated external defibrillators by first responders.

[Does reluctance to perform mouth-to-mouth ventilation exist among emergency healthcare providers as first responders?]. / Esiste la riluttanza a praticare la rianimazione con ventilazione bocca a bocca senza mezzi di barriera tra gli operatori sanitari intervenuti come first responders?

BACKGROUND: Only 30% of survivors from out-of-hospital cardiac arrest receive basic life support (BLS) before the arrival of emergency personnel. This is also due to reluctance to perform BLS, especially mouth-to-mouth ventilation without barrier devices in victims who are unknown to the rescuer (either layperson or healthcare provider). METHODS: To evaluate the incidence of reluctance to perform mouth-to-mouth ventilation without barrier devices and its consequences in a simulated BLS scenario proposed by a questionnaire to healthcare providers of critical area in a public general hospital. RESULTS: Answers were collected from 128 of 165 (77.5%) interviewed healthcare providers. Physicians were 46 of 128 (35.9%), professional nurses were 78 of 128 (60.9%) and 4 of 128 (3.2%) were other health workers devoted to patient assistance. Seventy-five of 128 (58.6 %) were reluctant to perform mouth-to-mouth ventilation without barrier devices; 68 of 75 (90.6%) would perform BLS only by chest compression. Compared with non-reluctant providers, they would have been available to perform assisted ventilation by non-validated alternative methods (54.2 vs 18.8% respectively, p < 0.001). Seven of 75 (9.6%, no physician among them) would perform no BLS at all. The most significant predictors of reluctance were age < 40 years (p = 0.07) and previous attendance of BLS-BLSD courses (p = 0.07). CONCLUSIONS: Reluctance to perform mouth-to-mouth ventilation without barrier devices is frequent and may reduce the number of potential BLS providers. Because of the concern about disease transmission between victim and rescuer, rescuers with a duty to respond such as healthcare providers should follow precautions including the use of barrier device also outside their workplace. When barrier devices are unavailable first responders should consider chest compression alone instead of not performing any BLS maneuvers. BLS training should help give a greater emphasis on this topics.