1
|
Gatti M, Cojutti PG, Bartoletti M, Tonetti T, Bianchini A, Ramirez S, Pizzilli G, Ambretti S, Giannella M, Mancini R, Siniscalchi A, Viale P, Pea F. Expert clinical pharmacological advice may make an antimicrobial TDM program for emerging candidates more clinically useful in tailoring therapy of critically ill patients. Crit Care 2022; 26:178. [PMID: 35701812 PMCID: PMC9199203 DOI: 10.1186/s13054-022-04050-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/02/2022] [Indexed: 12/13/2022] Open
Abstract
Background Therapeutic drug monitoring (TDM) may represent an invaluable tool for optimizing antimicrobial therapy in septic patients, but extensive use is burdened by barriers. The aim of this study was to assess the impact of a newly established expert clinical pharmacological advice (ECPA) program in improving the clinical usefulness of an already existing TDM program for emerging candidates in tailoring antimicrobial therapy among critically ill patients. Methods This retrospective observational study included an organizational phase (OP) and an assessment phase (AP). During the OP (January–June 2021), specific actions were organized by MD clinical pharmacologists together with bioanalytical experts, clinical engineers, and ICU clinicians. During the AP (July–December 2021), the impact of these actions in optimizing antimicrobial treatment of the critically ill patients was assessed. Four indicators of performance of the TDM-guided real-time ECPA program were identified [total TDM-guided ECPAs July–December 2021/total TDM results July–December 2020; total ECPA dosing adjustments/total delivered ECPAs both at first assessment and overall; and turnaround time (TAT) of ECPAs, defined as optimal (< 12 h), quasi-optimal (12–24 h), acceptable (24–48 h), suboptimal (> 48 h)]. Results The OP allowed to implement new organizational procedures, to create a dedicated pathway in the intranet system, to offer educational webinars on clinical pharmacology of antimicrobials, and to establish a multidisciplinary team at the morning bedside ICU meeting. In the AP, a total of 640 ECPAs were provided for optimizing 261 courses of antimicrobial therapy in 166 critically ill patients. ECPAs concerned mainly piperacillin–tazobactam (41.8%) and meropenem (24.9%), and also other antimicrobials had ≥ 10 ECPAs (ceftazidime, ciprofloxacin, fluconazole, ganciclovir, levofloxacin, and linezolid). Overall, the pre–post-increase in TDM activity was of 13.3-fold. TDM-guided dosing adjustments were recommended at first assessment in 61.7% of ECPAs (10.7% increases and 51.0% decreases), and overall in 45.0% of ECPAs (10.0% increases and 35.0% decreases). The overall median TAT was optimal (7.7 h) and that of each single agent was always optimal or quasi-optimal. Conclusions Multidisciplinary approach and timely expert interpretation of TDM results by MD Clinical Pharmacologists could represent cornerstones in improving the cost-effectiveness of an antimicrobial TDM program for emerging TDM candidates.
Collapse
Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.,Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pier Giorgio Cojutti
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Michele Bartoletti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.,Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Tommaso Tonetti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.,Anesthesia and Intensive Care Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Amedeo Bianchini
- Division of Anesthesiology, Department of Anesthesia and Intensive Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Giacinto Pizzilli
- Anesthesia and Intensive Care Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simone Ambretti
- Operative Unit of Microbiology, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.,Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Rita Mancini
- LUM Metropolitan Laboratory, AUSL Bologna, Bologna, Italy
| | - Antonio Siniscalchi
- Division of Anesthesiology, Department of Anesthesia and Intensive Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.,Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy. .,Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| |
Collapse
|
2
|
Ranieri VM, Tonetti T, Navalesi P, Nava S, Antonelli M, Pesenti A, Grasselli G, Grieco DL, Menga LS, Pisani L, Boscolo A, Sella N, Pasin L, Mega C, Pizzilli G, Dell’Olio A, Dongilli R, Rucci P, Slutsky AS. High-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19. Am J Respir Crit Care Med 2022; 205:431-439. [PMID: 34861135 PMCID: PMC8886947 DOI: 10.1164/rccm.202109-2163oc] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/03/2021] [Indexed: 11/16/2022] Open
Abstract
Rationale: The "Berlin definition" of acute respiratory distress syndrome (ARDS) does not allow inclusion of patients receiving high-flow nasal oxygen (HFNO). However, several articles have proposed that criteria for defining ARDS should be broadened to allow inclusion of patients receiving HFNO. Objectives: To compare the proportion of patients fulfilling ARDS criteria during HFNO and soon after intubation, and 28-day mortality between patients treated exclusively with HFNO and patients transitioned from HFNO to invasive mechanical ventilation (IMV). Methods: From previously published studies, we analyzed patients with coronavirus disease (COVID-19) who had PaO2/FiO2 of ⩽300 while treated with ⩾40 L/min HFNO, or noninvasive ventilation (NIV) with positive end-expiratory pressure of ⩾5 cm H2O (comparator). In patients transitioned from HFNO/NIV to invasive mechanical ventilation (IMV), we compared ARDS severity during HFNO/NIV and soon after IMV. We compared 28-day mortality in patients treated exclusively with HFNO/NIV versus patients transitioned to IMV. Measurements and Main Results: We analyzed 184 and 131 patients receiving HFNO or NIV, respectively. A total of 112 HFNO and 69 NIV patients transitioned to IMV. Of those, 104 (92.9%) patients on HFNO and 66 (95.7%) on NIV continued to have PaO2/FiO2 ⩽300 under IMV. Twenty-eight-day mortality in patients who remained on HFNO was 4.2% (3/72), whereas in patients transitioned from HFNO to IMV, it was 28.6% (32/112) (P < 0.001). Twenty-eight-day mortality in patients who remained on NIV was 1.6% (1/62), whereas in patients who transitioned from NIV to IMV, it was 44.9% (31/69) (P < 0.001). Overall mortality was 19.0% (35/184) and 24.4% (32/131) for HFNO and NIV, respectively (P = 0.2479). Conclusions: Broadening the ARDS definition to include patients on HFNO with PaO2/FiO2 ⩽300 may identify patients at earlier stages of disease but with lower mortality.
Collapse
Affiliation(s)
- V. Marco Ranieri
- Department of Medical and Surgical Sciences
- Anesthesia and Intensive Care Medicine and
| | - Tommaso Tonetti
- Department of Medical and Surgical Sciences
- Anesthesia and Intensive Care Medicine and
| | - Paolo Navalesi
- Department of Medicine, University of Padova
, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padova University Hospital, Padua, Italy
| | - Stefano Nava
- Department of Experimental, Diagnostic and Specialty Medicine
, and
- Pneumology and Respiratory Critical Care, Sant’Orsola Research Hospital IRCCS, Bologna, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
- Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation University of Milan
, Milan, Italy
- Anesthesia and Critical Care, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation University of Milan
, Milan, Italy
- Anesthesia and Critical Care, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
- Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca Salvatore Menga
- Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lara Pisani
- Department of Experimental, Diagnostic and Specialty Medicine
, and
- Pneumology and Respiratory Critical Care, Sant’Orsola Research Hospital IRCCS, Bologna, Italy
| | - Annalisa Boscolo
- Institute of Anesthesia and Intensive Care, Padova University Hospital, Padua, Italy
| | - Nicolò Sella
- Department of Medicine, University of Padova
, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padova University Hospital, Padua, Italy
| | - Laura Pasin
- Institute of Anesthesia and Intensive Care, Padova University Hospital, Padua, Italy
| | - Chiara Mega
- Department of Medical and Surgical Sciences
- Anesthesia and Intensive Care Medicine and
| | | | | | - Roberto Dongilli
- Division of Respiratory Diseases with Intermediate Respiratory Intensive Care Units, Central Hospital of Bolzano, Bolzano, Italy; and
| | - Paola Rucci
- Statistics and Epidemiology, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum–University of Bologna
, Bologna, Italy
| | - Arthur S. Slutsky
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| |
Collapse
|
3
|
Tonetti T, Grasselli G, Zanella A, Pizzilli G, Fumagalli R, Piva S, Lorini L, Iotti G, Foti G, Colombo S, Vivona L, Rossi S, Girardis M, Agnoletti V, Campagna A, Gordini G, Navalesi P, Boscolo A, Graziano A, Valeri I, Vianello A, Cereda D, Filippini C, Cecconi M, Locatelli F, Bartoletti M, Giannella M, Viale P, Antonelli M, Nava S, Pesenti A, Ranieri VM. Use of critical care resources during the first 2 weeks (February 24-March 8, 2020) of the Covid-19 outbreak in Italy. Ann Intensive Care 2020; 10:133. [PMID: 33044646 PMCID: PMC7549086 DOI: 10.1186/s13613-020-00750-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/23/2020] [Indexed: 01/08/2023] Open
Abstract
Background A Covid-19 outbreak developed in Lombardy, Veneto and Emilia-Romagna (Italy) at the end of February 2020. Fear of an imminent saturation of available ICU beds generated the notion that rationing of intensive care resources could have been necessary. Results In order to evaluate the impact of Covid-19 on the ICU capacity to manage critically ill patients, we performed a retrospective analysis of the first 2 weeks of the outbreak (February 24–March 8). Data were collected from regional registries and from a case report form sent to participating sites. ICU beds increased from 1545 to 1989 (28.7%), and patients receiving respiratory support outside the ICU increased from 4 (0.6%) to 260 (37.0%). Patients receiving respiratory support outside the ICU were significantly older [65 vs. 77 years], had more cerebrovascular (5.8 vs. 13.1%) and renal (5.3 vs. 10.0%) comorbidities and less obesity (31.4 vs. 15.5%) than patients admitted to the ICU. PaO2/FiO2 ratio, respiratory rate and arterial pH were higher [165 vs. 244; 20 vs. 24 breath/min; 7.40 vs. 7.46] and PaCO2 and base excess were lower [34 vs. 42 mmHg; 0.60 vs. 1.30] in patients receiving respiratory support outside the ICU than in patients admitted to the ICU, respectively. Conclusions Increase in ICU beds and use of out-of-ICU respiratory support allowed effective management of the first 14 days of the Covid-19 outbreak, avoiding resource rationing.
Collapse
Affiliation(s)
- Tommaso Tonetti
- Alma Mater Studiorum, Dipartimento Di Scienze Mediche E Chirurgiche, Anesthesia and Intensive Care Medicine, Università Di Bologna, Policlinico Di Sant'Orsola, Via Massarenti, 9 40138, Bologna, Italy.
| | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alberto Zanella
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacinto Pizzilli
- Alma Mater Studiorum, Dipartimento Di Scienze Mediche E Chirurgiche, Anesthesia and Intensive Care Medicine, Università Di Bologna, Policlinico Di Sant'Orsola, Via Massarenti, 9 40138, Bologna, Italy
| | - Roberto Fumagalli
- Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, University of Milano-Bicocca, Milan, Italy
| | - Simone Piva
- Anesthesia and Critical Care, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Luca Lorini
- Anesthesia and Critical Care, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giorgio Iotti
- Anesthesia and Critical Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Foti
- Anesthesia and Critical Care, ASST Ospedale San Gerardo Di Monza, University of Milano-Bicocca, Milan, Italy
| | - Sergio Colombo
- Anesthesia and Critical Care, IRCCS San Raffaele Scientific Institute, Università Vita-Salute San Raffaele, Milan, Italy
| | - Luigi Vivona
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Sandra Rossi
- Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Di Parma, Parma, Italy
| | - Massimo Girardis
- Anesthesia and Critical Care, Policlinico Di Modena, Università Di Modena E Reggio Emilia, Modena, Italy
| | - Vanni Agnoletti
- Anesthesia and Critical Care Ospedale "M. Bufalini", Cesena, Italy
| | - Anselmo Campagna
- Assessorato Cura Della Persona, Regione Emilia-Romagna, Salute e Walfare, Bologna, Italy
| | - Giovanni Gordini
- Anesthesia and Critical Care Ospedale, Ospedale Maggiore, Bologna, Italy
| | - Paolo Navalesi
- Anesthesia and Critical Care, Department of Medicine, DIMED - University of Padua, University Hospital of Padua, Padua, Italy
| | - Annalisa Boscolo
- Anesthesia and Critical Care, Department of Medicine, DIMED - University of Padua, University Hospital of Padua, Padua, Italy
| | - Alessandro Graziano
- Anesthesia and Critical Care, Department of Medicine, DIMED - University of Padua, University Hospital of Padua, Padua, Italy
| | - Ilaria Valeri
- Anesthesia and Critical Care, Department of Medicine, DIMED - University of Padua, University Hospital of Padua, Padua, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology Division University-City Hospital of Padua, Padua, Italy
| | - Danilo Cereda
- Direzione Generale Welfare, Lombardy Region, Milan, Italy
| | - Claudia Filippini
- Dipartimento Di Scienze Chirurgiche, Università Di Torino, Torino, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Humanitas University, Milan, Italy.,Department of Biomedical Sciences, Pieve Emanuele, Milan, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, Sapienza University of Rome, IRCCS Ospedale Pediatrico Bambino Gesù. President of the "Consiglio Superiore Di Sanità", Rome, Italy
| | - Michele Bartoletti
- Alma Mater Studiorum, Dipartimento Di Scienze Mediche E Chirurgiche, Infectious Diseases Unit, Università Di Bologna, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Maddalena Giannella
- Alma Mater Studiorum, Dipartimento Di Scienze Mediche E Chirurgiche, Infectious Diseases Unit, Università Di Bologna, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pierluigi Viale
- Alma Mater Studiorum, Dipartimento Di Scienze Mediche E Chirurgiche, Infectious Diseases Unit, Università Di Bologna, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Massimo Antonelli
- Dept. of Intensive Care Emergency Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Nava
- Department of Clinical, Integrated, and Experimental Medicine (DIMES), Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Bologna, Italy
| | - Antonio Pesenti
- Alma Mater Studiorum, Dipartimento Di Scienze Mediche E Chirurgiche, Anesthesia and Intensive Care Medicine, Università Di Bologna, Policlinico Di Sant'Orsola, Via Massarenti, 9 40138, Bologna, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - V Marco Ranieri
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | |
Collapse
|
4
|
Sakr Y, Giovini M, Leone M, Pizzilli G, Kortgen A, Bauer M, Tonetti T, Duclos G, Zieleskiewicz L, Buschbeck S, Ranieri VM, Antonucci E. The clinical spectrum of pulmonary thromboembolism in patients with coronavirus disease-2019 (COVID-19) pneumonia: A European case series. J Crit Care 2020; 61:39-44. [PMID: 33075608 PMCID: PMC7518181 DOI: 10.1016/j.jcrc.2020.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/22/2022]
Abstract
Purpose To describe the clinical characteristics and outcomes of coronavirus disease-2019 (COVID-19)-associated pulmonary thromboembolism (PTE). Materials and methods A case series of five patients, representing the clinical spectrum of COVID-19 associated PTE. Patients were admitted to four hospitals in Germany, Italy, and France. Infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was confirmed using a real-time reverse transcription polymerase chain reaction test. Results The onset of PTE varied from 2 to 4 weeks after the occurrence of the initial symptoms of SARS-CoV-2 infection and led to deterioration of the clinical picture in all cases. PTE was the primary reason for hospital admission after a 2-week period of self-isolation at home (1 patient) and hospital readmission after initial uncomplicated hospital discharge (2 patients). Three of the patients had no past history of clinically relevant risk factors for venous thromboembolism (VTE). Severe disease progression was associated with concomitant increases in IL-6, ferritin, and D-Dimer levels. The outcome from PTE was related to the extent of vascular involvement, and associated complications. Conclusion PTE is a potential life-threatening complication, which occurs frequently in patients with COVID-19. Intermediate therapeutic dose of anticoagulants and extend thromboprophylaxis are necessary after meticulous risk-benefit assessment. Pulnonary thromboembolism (PTE) is a frequent life-threatening complication in patients with COVID-19. The onset of PTE varies from 2 to 4 weeks after the occurrence of the initial symptoms. PTE may occur in patients without past history of risk factors for venous thromboembolism and in those receiving standard prophylactic anticoagulation. Intermediate therapeutic dose of anticoagulants and extend thromboprophylaxis are necessary in these patients after meticulous risk-benefit assessment.
Collapse
Affiliation(s)
- Yasser Sakr
- Dept. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
| | - Manuela Giovini
- Intermediate Care Unit, Emergency Department, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Marc Leone
- Service d'Anesthésie et de Réanimation, Aix Marseille Université, Assistance Publique Hôpitaux Universitaires de Marseille, Hôpital Nord, Marseille, France
| | - Giacinto Pizzilli
- Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Alma Mater Studiorum - Università di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | - Andreas Kortgen
- Dept. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Michael Bauer
- Dept. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Tommaso Tonetti
- Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Alma Mater Studiorum - Università di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | - Gary Duclos
- Service d'Anesthésie et de Réanimation, Aix Marseille Université, Assistance Publique Hôpitaux Universitaires de Marseille, Hôpital Nord, Marseille, France
| | - Laurent Zieleskiewicz
- Service d'Anesthésie et de Réanimation, Aix Marseille Université, Assistance Publique Hôpitaux Universitaires de Marseille, Hôpital Nord, Marseille, France
| | - Samuel Buschbeck
- Dept. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - V Marco Ranieri
- Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Alma Mater Studiorum - Università di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | - Elio Antonucci
- Intermediate Care Unit, Emergency Department, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| |
Collapse
|
5
|
Sakr Y, Giovini M, Leone M, Pizzilli G, Kortgen A, Bauer M, Tonetti T, Duclos G, Zieleskiewicz L, Buschbeck S, Ranieri VM, Antonucci E. Pulmonary embolism in patients with coronavirus disease-2019 (COVID-19) pneumonia: a narrative review. Ann Intensive Care 2020; 10:124. [PMID: 32953201 PMCID: PMC7492788 DOI: 10.1186/s13613-020-00741-0] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 09/06/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Preliminary reports have described significant procoagulant events in patients with coronavirus disease-2019 (COVID-19), including life-threatening pulmonary embolism (PE). MAIN TEXT We review the current data on the epidemiology, the possible underlying pathophysiologic mechanisms, and the therapeutic implications of PE in relation to COVID-19. The incidence of PE is reported to be around 2.6-8.9% of COVID-19 in hospitalized patients and up to one-third of those requiring intensive care unit (ICU) admission, despite standard prophylactic anticoagulation. This may be explained by direct and indirect pathologic consequences of COVID-19, complement activation, cytokine release, endothelial dysfunction, and interactions between different types of blood cells. CONCLUSION Thromboprophylaxis should be started in all patients with suspected or confirmed COVID-19 admitted to the hospital. The use of an intermediate therapeutic dose of low molecular weight (LMWH) or unfractionated heparin can be considered on an individual basis in patients with multiple risk factors for venous thromboembolism, including critically ill patients admitted to the ICU. Decisions about extending prophylaxis with LMWH after hospital discharge should be made after balancing the reduced risk of venous thromboembolism (VTE) with the risk of increased bleeding events and should be continued for 7-14 days after hospital discharge or in the pre-hospital phase in case of pre-existing or persisting VTE risk factors. Therapeutic anticoagulation is the cornerstone in the management of patients with PE. Selection of an appropriate agent and correct dosing requires consideration of underlying comorbidities.
Collapse
Affiliation(s)
- Yasser Sakr
- Dept. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07743 Jena, Germany
| | - Manuela Giovini
- Intermediate Care Unit, Emergency Department, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Marc Leone
- Service d’Anesthésie et de Réanimation, Aix Marseille Université, Assistance Publique Hôpitaux Universitaires de Marseille, Hôpital Nord, Marseille, France
| | - Giacinto Pizzilli
- Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Alma Mater Studiorum, Università di Bologna, Policlinico di Sant’Orsola, Bologna, Italy
| | - Andreas Kortgen
- Dept. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07743 Jena, Germany
| | - Michael Bauer
- Dept. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07743 Jena, Germany
| | - Tommaso Tonetti
- Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Alma Mater Studiorum, Università di Bologna, Policlinico di Sant’Orsola, Bologna, Italy
| | - Gary Duclos
- Service d’Anesthésie et de Réanimation, Aix Marseille Université, Assistance Publique Hôpitaux Universitaires de Marseille, Hôpital Nord, Marseille, France
| | - Laurent Zieleskiewicz
- Service d’Anesthésie et de Réanimation, Aix Marseille Université, Assistance Publique Hôpitaux Universitaires de Marseille, Hôpital Nord, Marseille, France
| | - Samuel Buschbeck
- Dept. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07743 Jena, Germany
| | - V. Marco Ranieri
- Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Alma Mater Studiorum, Università di Bologna, Policlinico di Sant’Orsola, Bologna, Italy
| | - Elio Antonucci
- Intermediate Care Unit, Emergency Department, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| |
Collapse
|
6
|
Grasselli G, Tonetti T, Protti A, Langer T, Girardis M, Bellani G, Laffey J, Carrafiello G, Carsana L, Rizzuto C, Zanella A, Scaravilli V, Pizzilli G, Grieco DL, Di Meglio L, de Pascale G, Lanza E, Monteduro F, Zompatori M, Filippini C, Locatelli F, Cecconi M, Fumagalli R, Nava S, Vincent JL, Antonelli M, Slutsky AS, Pesenti A, Ranieri VM. Pathophysiology of COVID-19-associated acute respiratory distress syndrome: a multicentre prospective observational study. Lancet Respir Med 2020; 8:1201-1208. [PMID: 32861276 PMCID: PMC7834127 DOI: 10.1016/s2213-2600(20)30370-2] [Citation(s) in RCA: 437] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/23/2020] [Accepted: 08/07/2020] [Indexed: 02/07/2023]
Abstract
Background Patients with COVID-19 can develop acute respiratory distress syndrome (ARDS), which is associated with high mortality. The aim of this study was to examine the functional and morphological features of COVID-19-associated ARDS and to compare these with the characteristics of ARDS unrelated to COVID-19. Methods This prospective observational study was done at seven hospitals in Italy. We enrolled consecutive, mechanically ventilated patients with laboratory-confirmed COVID-19 and who met Berlin criteria for ARDS, who were admitted to the intensive care unit (ICU) between March 9 and March 22, 2020. All patients were sedated, paralysed, and ventilated in volume-control mode with standard ICU ventilators. Static respiratory system compliance, the ratio of partial pressure of arterial oxygen to fractional concentration of oxygen in inspired air, ventilatory ratio (a surrogate of dead space), and D-dimer concentrations were measured within 24 h of ICU admission. Lung CT scans and CT angiograms were done when clinically indicated. A dataset for ARDS unrelated to COVID-19 was created from previous ARDS studies. Survival to day 28 was assessed. Findings Between March 9 and March 22, 2020, 301 patients with COVID-19 met the Berlin criteria for ARDS at participating hospitals. Median static compliance was 41 mL/cm H2O (33–52), which was 28% higher than in the cohort of patients with ARDS unrelated to COVID-19 (32 mL/cm H2O [25–43]; p<0·0001). 17 (6%) of 297 patients with COVID-19-associated ARDS had compliances greater than the 95th percentile of the classical ARDS cohort. Total lung weight did not differ between the two cohorts. CT pulmonary angiograms (obtained in 23 [8%] patients with COVID-19-related ARDS) showed that 15 (94%) of 16 patients with D-dimer concentrations greater than the median had bilateral areas of hypoperfusion, consistent with thromboembolic disease. Patients with D-dimer concentrations equal to or less than the median had ventilatory ratios lower than those of patients with D-dimer concentrations greater than the median (1·66 [1·32–1·95] vs 1·90 [1·50–2·33]; p=0·0001). Patients with static compliance equal to or less than the median and D-dimer concentrations greater than the median had markedly increased 28-day mortality compared with other patient subgroups (40 [56%] of 71 with high D-dimers and low compliance vs 18 [27%] of 67 with low D-dimers and high compliance, 13 [22%] of 60 with low D-dimers and low compliance, and 22 [35%] of 63 with high D-dimers and high compliance, all p=0·0001). Interpretation Patients with COVID-19-associated ARDS have a form of injury that, in many aspects, is similar to that of those with ARDS unrelated to COVID-19. Notably, patients with COVID-19-related ARDS who have a reduction in respiratory system compliance together with increased D-dimer concentrations have high mortality rates. Funding None.
Collapse
Affiliation(s)
- Giacomo Grasselli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tommaso Tonetti
- Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Alessandro Protti
- Humanitas Clinical and Research Center-IRCCS, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Dipartimento di Anestesia e Rianimazione, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care, University Hospital of Modena, Modena, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Anesthesia and Intensive Care Medicine, ASST Monza-Ospedale San Gerardo, Monza, Italy
| | - John Laffey
- Regenerative Medicine Institute at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland; Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Gianpaolo Carrafiello
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Dipartimento di Scienze della Salute, University of Milan, Milan, Italy
| | - Luca Carsana
- Department of Anatomy and Histopathology, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Chiara Rizzuto
- Department of Anesthesia and Intensive Care Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Polo Universitario, University of Milan, Milan, Italy
| | - Alberto Zanella
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Vittorio Scaravilli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giacinto Pizzilli
- Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Letizia Di Meglio
- Dipartimento di Scienze della Salute, University of Milan, Milan, Italy
| | - Gennaro de Pascale
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Ezio Lanza
- Humanitas Clinical and Research Center-IRCCS, Milan, Italy
| | - Francesco Monteduro
- Dipartimento di Radiologia, Policlinico di Sant'Orsola, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Maurizio Zompatori
- Dipartimento di Radiologia, Policlinico di Sant'Orsola, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Claudia Filippini
- Dipartimento di Scienze Chirurgiche, Università di Torino, Torino, Italy
| | - Franco Locatelli
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, IRCCS Bambino Gesù Children Hospital, Rome, Italy
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center-IRCCS, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Dipartimento di Anestesia e Rianimazione, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Nava
- Department of Clinical, Integrated and Experimental Medicine, Respiratory and Critical Care Unit, S Orsola-Malpighi Hospital, Alma Mater University, Bologna, Italy
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
| | - Antonio Pesenti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - V Marco Ranieri
- Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Alma Mater Studiorum-Università di Bologna, Bologna, Italy.
| | | |
Collapse
|
7
|
Bartoletti M, Pascale R, Cricca M, Rinaldi M, Maccaro A, Bussini L, Fornaro G, Tonetti T, Pizzilli G, Francalanci E, Giuntoli L, Rubin A, Moroni A, Ambretti S, Trapani F, Vatamanu O, Ranieri VM, Castelli A, Baiocchi M, Lewis R, Giannella M, Viale P. Epidemiology of invasive pulmonary aspergillosis among COVID-19 intubated patients: a prospective study. Clin Infect Dis 2020; 73:e3606-e3614. [PMID: 32719848 PMCID: PMC7454393 DOI: 10.1093/cid/ciaa1065] [Citation(s) in RCA: 283] [Impact Index Per Article: 70.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/22/2020] [Indexed: 01/17/2023] Open
Abstract
Background In this study we evaluated the incidence of invasive pulmonary aspergillosis among intubated patients with critical coronavirus disease 2019 (COVID-19) and evaluated different case definitions of invasive aspergillosis. Methods Prospective, multicentre study on adult patients with microbiologically confirmed COVID-19 receiving mechanical ventilation. All included participants underwent screening protocol for invasive pulmonary aspergillosis with bronchoalveolar lavage galactomannan and cultures performed on admission at 7 days and in case of clinical deterioration. Cases were classified as coronavirus associated pulmonary aspergillosis (CAPA) according to previous consensus definitions. The new definition was compared with putative invasive pulmonary aspergillosis (PIPA). Results A total of 108 patients were enrolled. Probable CAPA was diagnosed in 30 (27.7%) of patients after a median of 4 (2-8) days from intensive care unit (ICU) admission. Kaplan-Meier curves showed a significant higher 30-day mortality rate from ICU admission among patients with either CAPA (44% vs 19%, p= 0.002) or PIPA (74% vs 26%, p<0.001) when compared with patients not fulfilling criteria for aspergillosis. The association between CAPA [OR 3.53 (95%CI 1.29-9.67), P=0.014] or PIPA [OR 11.60 (95%CI 3.24-41.29) p<0.001] with 30-day mortality from ICU admission was confirmed even after adjustment for confounders with a logistic regression model. Among patients with CAPA receiving voriconazole treatment (13 patients, 43%) A trend toward lower mortality (46% vs 59% p=0.30) and reduction of galactomannan index in consecutive samples was observed. Conclusion We found a high incidence of CAPA among critically ill COVID-19 patients and that its occurrence seems to change the natural history of disease
Collapse
Affiliation(s)
- Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Renato Pascale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Monica Cricca
- Operative unit of Microbiology, University of Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Matteo Rinaldi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Angelo Maccaro
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Linda Bussini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Giacomo Fornaro
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Tommaso Tonetti
- Intensive Care Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Giacinto Pizzilli
- Intensive Care Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Eugenia Francalanci
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | | | - Arianna Rubin
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Alessandra Moroni
- Operative unit of Microbiology, University of Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Simone Ambretti
- Operative unit of Microbiology, University of Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Filippo Trapani
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Oana Vatamanu
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Vito Marco Ranieri
- Intensive Care Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Andrea Castelli
- Cardio-Thoracic Anesthesiology Unit, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Massimo Baiocchi
- Cardio-Thoracic Anesthesiology Unit, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Russell Lewis
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | | |
Collapse
|
8
|
Tonetti T, Zanella A, Pizzilli G, Irvin Babcock C, Venturi S, Nava S, Pesenti A, Ranieri VM. One ventilator for two patients: feasibility and considerations of a last resort solution in case of equipment shortage. Thorax 2020; 75:517-519. [PMID: 32327566 PMCID: PMC7211107 DOI: 10.1136/thoraxjnl-2020-214895] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), Anesthesia and Intensive Care Medicine, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Emilia-Romagna, Italy
| | - Alberto Zanella
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Lombardia, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Milano, Italy
| | - Giacinto Pizzilli
- Anesthesia and Intensive Care Medicine, Sant'Orsola Malpighi Hospital, Bologna, Italy
| | - Charlene Irvin Babcock
- Department of Emergency Medicine, Ascension St John Hospital and Medical Center, Detroit, Michigan, USA
| | - Sergio Venturi
- Covid-19 Commissioner, Emilia-Romagna Region, Bologna, Emilia-Romagna, Italy
| | - Stefano Nava
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Antonio Pesenti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Lombardia, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Milano, Italy
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Anesthesia and Intensive Care Medicine, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Emilia-Romagna, Italy
| |
Collapse
|
9
|
Santonastaso DP, De Chiara A, Pizzilli G, Musetti G, Agnoletti V. Ultrasound-guided erector spinae plane block for breast reconstruction surgery with latissimus dorsi muscle flap. Minerva Anestesiol 2019; 85:443-444. [DOI: 10.23736/s0375-9393.18.13206-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
10
|
Coccolini F, Pizzilli G, Corbella D, Sartelli M, Agnoletti V, Agostini V, Baiocchi GL, Ansaloni L, Catena F. Pre-hospital plasma in haemorrhagic shock management: current opinion and meta-analysis of randomized trials. World J Emerg Surg 2019; 14:6. [PMID: 30815028 PMCID: PMC6377767 DOI: 10.1186/s13017-019-0226-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/07/2019] [Indexed: 01/12/2023] Open
Abstract
Background Trauma-induced coagulopathy is one of the most difficult issues to manage in severely injured patients. The plasma efficacy in treating haemorrhagic-shocked patients is well known. The debated issue is the timing at which it should be administered. Few evidences exist regarding the effects on mortality consequent to the use of plasma alone given in pre-hospital setting. Recently, two randomized trials reported interesting and discordant results. The present paper aims to analyse data from those two randomized trials in order to obtain more univocal results. Methods A systematic review with meta-analysis of randomized controlled trials (RCTs) of pre-hospital plasma vs. usual care in patients with haemorrhagic shock. Results Two high-quality RCTs have been included with 626 patients (295 in plasma and 331 in usual care arm). Twenty-four-hour mortality seems to be reduced in pre-hospital plasma group (RR = 0.69; 95% CI = 0.48–0.99). Pre-hospital plasma has no significant effect on 1-month mortality (RR = 0.86; 95% CI = 0.68–1.11) as on acute lung injury and on multi-organ failure rates (OR = 1.03; 95% CI = 0.71–1.50, and OR = 1.30; 95% CI = 0.92–1.86, respectively). Conclusions Pre-hospital plasma infusion seems to reduce 24-h mortality in haemorrhagic shock patients. It does not seem to influence 1-month mortality, acute lung injury and multi-organ failure rates. Level of evidence: Level I Study type: Systematic review with Meta-analysis
Collapse
Affiliation(s)
- Federico Coccolini
- 1General, Emergency and Trauma Surgery, Bufalini Hospital, Viale Ghirotti 268, 47521 Cesena, Italy
| | | | - Davide Corbella
- 3ICU department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | | | - Vanessa Agostini
- 5Transfusional and Immunohaematological disorders department, Bufalini hospital, Cesena, Italy
| | - Gian Luca Baiocchi
- 6Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Luca Ansaloni
- 1General, Emergency and Trauma Surgery, Bufalini Hospital, Viale Ghirotti 268, 47521 Cesena, Italy
| | - Fausto Catena
- 7Emergency surgery department, Parma University Hospital, Parma, Italy
| |
Collapse
|
11
|
Monti G, Bottiroli M, Pizzilli G, Minnini M, Terzi V, Vecchi I, Gesu G, Brioschi P, Vesconi S, Casella G. Endotoxin activity level and septic shock: a possible role for specific anti-endotoxin therapy? Contrib Nephrol 2010; 167:102-110. [PMID: 20519904 DOI: 10.1159/000315924] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Endotoxin activity (EA) plays an essential role in sepsis syndrome pathogenesis. There has been considerable interest in measuring and removing EA to predict and improve the morbidity and mortality of patients with sepsis. We performed a prospective study to assess the prevalence of EA in critically ill patients and its association with organ dysfunction and outcome, as well as in septic shock. EA (EAA(TM)) was measured within 24 h from onset of refractory septic shock in an intensive care unit. Our study demonstrated that EA level is independent from the type or the source of infection, but reflects the severity of illness in critically ill septic shock patients. Extracorporeal EA removal (PMX-HP) was assessed following our ICU clinical practice. PMX-HP seems to have better outcome, but further studies are required to verify this hypothesis.
Collapse
|
12
|
Monti G, Pizzilli G, Cecconi M, Rhodes A, Vesconi S, Brioschi P, Pulici M, Casella G. Bioreactance versus PICCOTD/PC in critically ill septic shock patients. Crit Care 2010. [PMCID: PMC2934106 DOI: 10.1186/cc8331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
13
|
Chiara O, Cimbanassi S, Andreani S, Sammartano F, Pizzilli G, Girotti P, Mariani A, Bassi G, Baticci F, Fontana A, Mariani M, Massi M, Pozzi C, Ardizzone MVR, Sansonna F, Vesconi S, Pugliese R. [The model of the Niguarda Hospital Trauma Team in Milan]. Chir Ital 2008; 60:627-640. [PMID: 19062485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The aim of this work was to describe the model and clinical results obtained by the Niguarda Trauma Team referral center for major trauma, in Milan. The Trauma Team is organized as a trauma service, where general surgeons, anesthesiologists, orthopedic surgeons and neurosurgeons work on a 24 hour rotation. When not in duty in the rotations, specialists work in their specific elective activities. The director of the Trauma Team has the responsibility for discussion and application of protocols, clinical assistance, quality assessment and training. The results of 1334 consecutive cases of major trauma during a 51 month period were reviewed using the trauma registry. 39% overtriage, which increased over the years, and 1.12% undertriage were recorded. Mortality of patients with injury severity scores > 15 was 21%, with a progressive decrease over the years. Blunt trauma accounted for 91.75% and were road-related in most cases. Skeletal injuries were the most frequent findings, but brain and thoraco-abdominal injuries were associated with a higher risk of death. 1476 surgical procedures (16.93% general surgery and 111 interventional angiographic studies) were performed. Quality assessment revealed a significant decrease in preventable deaths within the first 72 hours, after excluding patients admitted in extremis. The results presented in this study demonstrate the possibility of realising a model of organized trauma care in an emergency department in Italy, with patient outcomes comparable to those obtained in Trauma Center in other countries.
Collapse
Affiliation(s)
- Osvaldo Chiara
- Dipartimento DEA-EAS, Ospedale Niguarda Ca' Granda, Milano
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Chiara O, Cimbanassi S, Andreani S, Girotti P, Pizzilli G, Vesconi S. Niguarda Trauma Team: outcome of three years of activity. Minerva Anestesiol 2008; 74:11-15. [PMID: 18216763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND The aim of this study was to prove the existence of a direct relationship between the comprehensive strategy of trauma management and an enhancement in outcome. Tests were carried out on the impact of the Niguarda Trauma Team System on mortality rates due to severe trauma. METHODS The epidemiological data was retrospectively reviewed along with, the severity scores: Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Revised Trauma Score (RTS), Probability of survival (Ps) and the outcome of severe trauma admitted to Niguarda hospital between October 2002 and September 2005. All data were collected from the Trauma Registry of the Niguarda Hospital. Two subsequent periods of 20 and 16 months were compared. RESULTS Nine hundred forty-two severe traumas (94.05% blunt trauma) were recorded with an overtriage rate of 36.09%. Most patients were admitted for bone and muscular injuries (52.22%). Excluding the patients who were overtriaged, there were 129 patients who died. Comparing the two periods, the Authors observed a significant reduction in mortality from 22.56% to 19.75%, mainly related to a decrease in early mortality due to hemodynamic instability. Central nervous system injury was the main cause of death (65%). Average hospital stay significantly decreased from 17.01+/-12.07 days to 14.97+/-10.34 days. CONCLUSION Introducing a comprehensive strategy of severe trauma management, the Niguarda Trauma Team System had a significant impact on mortality rates and hospital stay.
Collapse
Affiliation(s)
- O Chiara
- DEA-EAS Department, SSD Trauma Team, Niguarda Ca' Granda Hospital, Milan, Italy.
| | | | | | | | | | | |
Collapse
|
15
|
Chiara O, Cimbanassi S, Castelli F, Spagnolo R, Girotti P, Pizzilli G, Pitidis A, Andreani S, Pugliese R, Capitani D. Protocol-driven approach of bleeding abdominal and pelvic trauma. World J Emerg Surg 2006; 1:17. [PMID: 16780596 PMCID: PMC1540410 DOI: 10.1186/1749-7922-1-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2006] [Accepted: 06/17/2006] [Indexed: 12/03/2022] Open
Affiliation(s)
- Osvaldo Chiara
- Dipartimento di Emergenza Accettazione – Trauma Team Ospedale Niguarda Ca'Granda Milano, Scuola di Specializzazione in Chirurgia Generale, Universita' degli Studi di Milano, Italy
| | - Stefania Cimbanassi
- Dipartimento di Emergenza Accettazione – Trauma Team Ospedale Niguarda Ca'Granda Milano, Scuola di Specializzazione in Chirurgia Generale, Universita' degli Studi di Milano, Italy
| | - Fabio Castelli
- Divisione di Orto-Traumatologia, Ospedale Niguarda Ca'Granda Milano, Scuola di Specializzazione in Ortopedia, Universita' degli Studi di Milano, Italy
| | - Rosario Spagnolo
- Divisione di Orto-Traumatologia, Ospedale Niguarda Ca'Granda Milano, Scuola di Specializzazione in Ortopedia, Universita' degli Studi di Milano, Italy
| | - Paolo Girotti
- Dipartimento di Emergenza Accettazione – Trauma Team Ospedale Niguarda Ca'Granda Milano, Scuola di Specializzazione in Chirurgia Generale, Universita' degli Studi di Milano, Italy
| | - Giacinto Pizzilli
- Dipartimento di Emergenza Accettazione – Trauma Team Ospedale Niguarda Ca'Granda Milano, Scuola di Specializzazione in Chirurgia Generale, Universita' degli Studi di Milano, Italy
| | - Alessio Pitidis
- Istituto Superiore di Sanita' del Ministero della Salute, Roma, Italy
| | - Sara Andreani
- Dipartimento di Emergenza Accettazione – Trauma Team Ospedale Niguarda Ca'Granda Milano, Scuola di Specializzazione in Chirurgia Generale, Universita' degli Studi di Milano, Italy
| | - Raffaele Pugliese
- Divisione di Chirurgia Generale e Videolaparoscopica Scuola di Specializzazione in Chirurgia Generale, Universita' degli Studi di Milano, Italy
| | - Dario Capitani
- Divisione di Orto-Traumatologia, Ospedale Niguarda Ca'Granda Milano, Scuola di Specializzazione in Ortopedia, Universita' degli Studi di Milano, Italy
| |
Collapse
|