Tracheostomy Practice in the Italian Intensive Care Units: A Point-Prevalence Survey

Ventilator-Induced Lung Injury: The Unseen Challenge in Acute Respiratory Distress Syndrome Management

Invasive mechanical ventilation is a cornerstone therapy for supporting patients with acute respiratory distress syndrome (ARDS) by relieving respiratory muscle strain and ensuring gas exchange. Despite its life-saving benefits, mechanical ventilation can induce ventilator-induced lung injury (VILI), a critical condition characterized by mechanisms such as barotrauma, volutrauma, atelectrauma, ergotrauma, and biotrauma. This review examines the pathophysiological mechanisms of VILI and their impact on lung function, particularly in patients with ARDS. It highlights the importance of lung-protective ventilation strategies, including low tidal volume and tailored positive end-expiratory pressure, which have been shown to improve outcomes in ARDS. The role of prone positioning in enhancing lung homogeneity and improving outcomes is also discussed. Furthermore, emerging concepts such as mechanical power and individual respiratory mechanics are explored as potential avenues for personalized ventilation strategies. Despite advancements, the optimal approach to mechanical ventilation remains a subject of ongoing research.

Diabetes Mellitus and Multidrug-Resistant Gram-Negative Bacterial Infections in Critically Ill COVID-19 Patients: A Retrospective Observational Study

Background: Diabetes mellitus (DM) is an independent risk factor for severe SARS-CoV-2 infection and is linked to higher incidences of infections and adverse outcomes in patients with DM. This study examines the association between DM and multidrug-resistant Gram-negative bacteria (MDR-GNB) in critically ill, intubated COVID-19 patients in the intensive care unit (ICU) and evaluates mortality rates and clinical factors contributing to unfavorable outcomes. Methods: This retrospective observational study included intubated COVID-19 patients diagnosed with secondary infections due to MDR-GNB. Patients were treated for acute respiratory distress syndrome (ARDS) in a tertiary care university hospital ICU between October 2020 and February 2022. Collected data included demographics, comorbidities, medication, and laboratory parameters including blood tests and culture samples. Results: Among 416 COVID-19 patients, 112 (26.9%) had T2DM. Cultures from lower respiratory tract specimens revealed a significantly higher likelihood of isolating Acinetobacter baumannii in patients with DM (OR: 2.18, 95% CI: 1.40-3.40, p < 0.001), and DM is an independent predictor of isolation Acinetobacter baumannii in bronchial secretions of COVID-19 intubated patients (OR: 2.046, 95% CI: 1.256-3.333. p < 0.004). DM was not significantly associated with differences in length of stay (LOS) until discharge or death (HR: 0.76, 95% CI: 0.51-1.12, p = 0.16; HR: 0.91, 95% CI: 0.70-1.19, p = 0.50) or 28-day ICU mortality (OR: 1.12, 95% CI: 0.52-2.41, p = 0.77). Age was linked to an increased 28-day mortality risk in patients with DM (OR: 1.10, 95% CI: 1.02-1.18, p = 0.011). Conclusions: In critically ill intubated COVID-19 patients, DM emerged as a significant and independent predictor for the isolation of Acinetobacter baumannii from bronchial secretions, highlighting a key link between DM and specific multidrug-resistant pathogens, even though no broader association with MDR-GNB-related secondary infections was observed.

Experiences and Educational Needs of Hospital Staff Providing Care to Tracheostomy-Dependent Pediatric Patients

OBJECTIVE

To assess the experience and educational needs of hospital staff who care for pediatric patients with tracheostomies.

STUDY DESIGN

Staff were surveyed and participated in semi-structured, facilitated focus groups regarding their experiences caring for children with tracheostomies and their educational needs. Survey data were analyzed using descriptive statistics and Kruskal-Wallis nonparametric tests. Focus groups were transcribed verbatim and coded for thematic analysis.

RESULTS

Pediatric advanced practice providers, nurses, physicians, and respiratory therapists (152/353, 43%) completed the survey. Within the last year, 76% of staff had worked with a tracheostomy-dependent child. However, up to 59% of staff had not performed at least one tracheostomy skill (e.g., tracheostomy site assessment, tube change, etc.). Staff reported the least confidence in changing tracheostomy tubes and using home ventilators and rated these skills as most important for additional education. Forty-three staff members participated in 1 of 10 focus groups. Three themes were identified: building staff competencies in tracheostomy care, promoting the caregiver development of tracheostomy skills, and building caregiver preparedness for home life. Staff emphasized the need for participating in emergency simulations and developing their skills to better prepare caregivers for home life. They indicated a need to streamline the discharge process, gain knowledge of community resources, and develop a standardized team to provide discharge teaching.

CONCLUSIONS

Hospital staff responsible for providing care to tracheostomy-dependent pediatric patients had limited opportunities to learn and maintain their skills. Survey and focus group findings can guide development of continuing education to optimize the care of tracheostomy-dependent children.

Real-time ultrasound-guided laryngeal mask assisted percutaneous dilatational tracheostomy versus bronchoscopy-guided percutaneous dilatational tracheostomy in critically ill patients: a randomized controlled trial

BACKGROUND

Percutaneous dilatational tracheostomy (PDT) is a common procedure for mechanically ventilated patients in the intensive care unit (ICU). This study compared the real-time ultrasound-guided PDT using a laryngeal mask airway (LMA) with the standard bronchoscopy-guided PDT technique in ICU patients requiring elective tracheostomy.

METHODS

This randomized controlled study was conducted at Ain Shams University Hospital's Critical Care Department from December 4th, 2021, to December 3rd, 2022. The study population included 60 critically ill patients admitted to the ICU. Thirty patients were randomly assigned to the real-time ultrasound-guided LMA-assisted group, and 30 patients were randomly assigned to the bronchoscopy-guided technique. The primary study outcome was the procedure time, and the secondary outcomes included procedure-related complications rate and cost-effectiveness.

RESULTS

The real-time ultrasound-guided LMA-assisted group had significantly shorter procedure time (median 17 [IQR: 15-20] min vs. 35 [IQR: 28-39] min, p < 0.001) and lower equipment damage (0% vs. 20%, p = 0.024) during the procedure compared to the bronchoscopy-guided group. Additionally, the cost of tracheostomy was significantly lower in the real-time ultrasound-guided LMA-assisted group (median: 300 vs. 800 USD, p < 0.001). The real-time ultrasound-guided LMA group had a lower major complications rate than the bronchoscopy-guided group (36.7%) vs. 3.3%, p = 0.002).

CONCLUSIONS

The study demonstrated that real-time ultrasound-guided LMA-assisted PDT had shorter procedure time, reduced equipment damage, lower costs, and was associated with lower complications when compared to the bronchoscopy-guided technique. These findings suggest that ultrasound guidance can enhance the efficiency and cost-effectiveness of PDT procedures.

Telemedicine in Intensive Care Unit: Current Practice and Future Prospect

Telemedicine in the intensive care unit (tele-ICU) is an increasingly significant field that leverages advanced technology to provide remote critical care services for patients in the ICU. The primary goal of tele-ICU is to enhance access to expert intensive care specialists, improve clinical outcomes, and optimize the management of critical care capacity and resources. Numerous studies have demonstrated that telemedicine can improve the efficiency of resource utilization, foster adherence to clinical best practices, and directly enhance both the quality of care and patient outcomes in the ICU setting. Moreover, telemedicine facilitates greater access to critical care knowledge, strengthens collaboration between healthcare providers across different institutions, and supports the development of specialized training programs for critical care professionals. Currently, the most widely adopted tele-ICU model is the centralized hub-and-spoke model, where a central monitoring station oversees multiple ICUs at geographically distant locations. While this model has proven effective in many contexts, there remains significant potential for further advancements in tele-ICU practices. In this article, we propose two novel theoretical models of tele-ICU that aim to address current limitations, improve quality of care, optimize personnel deployment, and maximize resource utilization. These proposed models are intended to offer a more flexible, scalable, and efficient approach to delivering critical care in diverse healthcare settings, ultimately contributing to better patient outcomes and more sustainable healthcare practices.

Clinical Value of Tocilizumab in Reducing Mortality in Refractory Septic Shock in Children with Hematologic and Non-Hematologic Diseases

BACKGROUND

Pediatric sepsis remains the main cause of morbidity and mortality among children. Interleukin (IL)-6 is usually produced after infection, and elevated IL-6 levels may cause multisystemic damage. This study aimed to evaluate the effect of tocilizumab, an IL-6 receptor antibody, on children with septic shock.

METHODS

We conducted a retrospective cohort study of children diagnosed with septic shock and admitted to the pediatric intensive care unit (PICU) between 2018 and 2024. Tocilizumab was administered within 24 h to patients with high IL-6 levels who developed refractory septic shock. Outcomes, including 28-day mortality, morbidity, length of PICU stay, and shock duration, were analyzed between septic children with different etiologies and differed treatments.

RESULTS

Fifty-four children with refractory septic shock were included. Patients treated with tocilizumab (n = 21) showed improved outcomes compared to those without tocilizumab (n = 33), including shorter PICU stays and lower mortality rates (14.2% vs. 54.5%, p = 0.03). Subgroup analysis revealed that in the non-hematologic group, tocilizumab-treated patients had a 0% mortality rate compared to 50% in untreated patients (p = 0.006). In the hematologic group, tocilizumab-treated patients exhibited a 27.2% mortality rate compared to 61.5% in untreated patients (p = 0.09). Trends in IL-6 levels (D1 to D7) were significantly higher in non-survivors compared to survivors and in patients with hematological malignancies compared to those without. No adverse events, including secondary infections or long-term liver impairment, were observed.

CONCLUSIONS

Tocilizumab appears to mitigate systemic inflammation and improve outcomes in children with refractory septic shock and elevated IL-6 levels. Further prospective studies are warranted to confirm these findings and establish treatment guidelines.