1
|
Florio G, Zanella A, Slobod D, Guzzardella A, Protti I, Carlesso E, Canakoglu A, Fumagalli J, Scaravilli V, Colombo SM, Caccioppola A, Brioni M, Pesenti AM, Grasselli G. Impact of Positive End-Expiratory Pressure and FiO 2 on Lung Mechanics and Intrapulmonary Shunt in Mechanically Ventilated Patients with ARDS Due to COVID-19 Pneumonia. J Intensive Care Med 2024; 39:420-428. [PMID: 37926984 DOI: 10.1177/08850666231210485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Purpose: This study aimed to investigate the effects of inspired oxygen fraction (FiO2) and positive end-expiratory pressure (PEEP) on gas exchange in mechanically ventilated patients with COVID-19. Methods: Two FiO2 (100%, 40%) were tested at 3 decreasing levels of PEEP (15, 10, and 5 cmH2O). At each FiO2 and PEEP, gas exchange, respiratory mechanics, hemodynamics, and the distribution of ventilation and perfusion were assessed with electrical impedance tomography. The impact of FiO2 on the intrapulmonary shunt (delta shunt) was analyzed as the difference between the calculated shunt at FiO2 100% (shunt) and venous admixture at FiO2 40% (venous admixture). Results: Fourteen patients were studied. Decreasing PEEP from 15 to 10 cmH2O did not change shunt (24 [21-28] vs 27 [24-29]%) or venous admixture (18 [15-26] vs 23 [18-34]%) while partial pressure of arterial oxygen (FiO2 100%) was higher at PEEP 15 (262 [198-338] vs 256 [147-315] mmHg; P < .05). Instead when PEEP was decreased from 10 to 5 cmH2O, shunt increased to 36 [30-39]% (P < .05) and venous admixture increased to 33 [30-43]% (P < .05) and partial pressure of arterial oxygen (100%) decreased to 109 [76-177] mmHg (P < .05). At PEEP 15, administration of 100% FiO2 resulted in a shunt greater than venous admixture at 40% FiO2, ((24 [21-28] vs 18 [15-26]%, P = .005), delta shunt 5.5% (2.3-8.8)). Compared to PEEP 10, PEEP of 5 and 15 cmH2O resulted in decreased global and pixel-level compliance. Cardiac output at FiO2 100% resulted higher at PEEP 5 (5.4 [4.4-6.5]) compared to PEEP 10 (4.8 [4.1-5.5], P < .05) and PEEP 15 cmH2O (4.7 [4.5-5.4], P < .05). Conclusion: In this study, PEEP of 15 cmH2O, despite resulting in the highest oxygenation, was associated with overdistension. PEEP of 5 cmH2O was associated with increased shunt and alveolar collapse. Administration of 100% FiO2 was associated with an increase in intrapulmonary shunt in the setting of high PEEP. Trial registration: NCT05132933.
Collapse
Affiliation(s)
- Gaetano Florio
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Ilaria Protti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Eleonora Carlesso
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Arif Canakoglu
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jacopo Fumagalli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sebastiano M Colombo
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessio Caccioppola
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Brioni
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio M Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
2
|
Fumagalli J, Punzi V, Scaravilli V, Passamonti SM, Morlacchi LC, Rossetti V, Maraschini A, Matinato C, Brivio M, Righi I, Blasi F, Bandera A, Rosso L, Panigada M, Zanella A, Grasselli G. Lung Donor Bronchoalveolar Lavage Positivity: Incidence, Risk Factors, and Lung Transplant Recipients' Outcome. J Heart Lung Transplant 2024:S1053-2498(24)01566-3. [PMID: 38677352 DOI: 10.1016/j.healun.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/05/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Inconsistent data exists regarding the risk factors for bronchoalveolar lavage (BAL) positivity in lung donors, the incidence of donor-derived infections (DDI), and the effect of BAL positivity on lung transplant (LuTx) recipients' outcome. METHODS A retrospective analysis was conducted on consecutive LuTx at a single center from January 2016 to December 2022. Donors' data, including characteristics, graft function and BAL samples were collected pre-procurement. Recipients underwent BAL before LuTx and about the 3rd, 7th and 14th day after LuTx. A DDI was defined as BAL positivity (bacterial growth ≥104 colony forming units) for identical bacterial species between donor and recipient. Recipients' pre-operative characteristics, intra-operative management, and post-operative outcomes were assessed. Two recipient cohorts were identified based on lung colonization status before undergoing LuTx. RESULTS Out of 188 LuTx procedures performed, 169 were analyzed. Thirty-six percent of donors' BAL tested positive. Donors' characteristics and graft function at procurement were not associated with BAL positivity. Fourteen DDI were detected accounting for 23% of recipients receiving a graft with a positive BAL. Only among uncolonized recipients, receiving a graft with positive BAL is associated with higher likelihood of requiring invasive ventilation at 72 hours after LuTx on higher positive end-expiratory pressure levels having lower PaO2/FiO2, prolonged duration of mechanical ventilation and longer ICU stay. No difference in hospital length of stay was observed. CONCLUSIONS Receiving a graft with a positive BAL, which is poorly predicted by donors' characteristics, carries the risk of developing a DDI and is associated to a worse early graft function among uncolonized recipients.
Collapse
Affiliation(s)
- Jacopo Fumagalli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Veronica Punzi
- Dipartimento of Anesthesia, Critical Care, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Biomedical, Surgical, and Dental Sciences, University of Milan, Milan, Italy
| | - Serena Maria Passamonti
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Letizia Corinna Morlacchi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda -Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Rossetti
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda -Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Maraschini
- Microbiology Laboratory, Clinical Laboratory, Fondazione IRCCS Ca' Granda -Ospedale Maggiore Policlinico, Milan, Italy
| | - Caterina Matinato
- Microbiology Laboratory, Clinical Laboratory, Fondazione IRCCS Ca' Granda -Ospedale Maggiore Policlinico, Milan, Italy
| | - Margherita Brivio
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Righi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda -Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Bandera
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Infectious Diseases Unit, Fondazione IRCCS Ca' Granda -Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Rosso
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Mauro Panigada
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
3
|
Guérin C, Li J, Grasselli G. Prone positioning. Intensive Care Med 2024:10.1007/s00134-024-07413-8. [PMID: 38656358 DOI: 10.1007/s00134-024-07413-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/24/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Claude Guérin
- Faculté de Médecine Lyon Est, Université Claude Bernard, Lyon, France
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| |
Collapse
|
4
|
De Falco S, Meli A, Caccioppola A, Grasselli G, Panigada M. Agreement between the thromboelastography reaction time parameter using fresh and citrated whole blood during extracorporeal membrane oxygenation with Teg®5000 and Teg®6s. Perfusion 2024; 39:77S-80S. [PMID: 38651576 DOI: 10.1177/02676591231223085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
PURPOSE We aimed at assessing the correlation between TEG reaction time (TEG-R) in citrated and fresh blood samples with TEG5000 and TEG 6S during heparin administration in patients with and without ECMO support. MATERIALS AND METHODS Paired TEG5000 (fresh and citrated whole blood, kaolin and kaolin-heparinase) and TEG6S (citrated whole blood) samples were obtained, together with standard coagulation laboratory tests. Bland-Altman analysis and Lin's concordance correlation coefficient were used to assess agreement. RESULTS Thirteen consecutive ECMO patients and eight consecutive non-ECMO patients were enrolled and TEG was performed for a total of 84 paired samples. ECMO patients received 19.2 (12.6-25.8) U/kg/h of heparin. Five of the non-ECMO patients did not receive heparin, two of them received a very low prophylactic dose (1.6 and 2.9 IU/kg/h, respectively), and one of them 13.1 U/kg/h of heparin. Using TEG®5000, TEG-R was 21.0 (-23.4; 65.5) min longer on fresh compared to citrated blood in patients receiving heparin while only 1.58 (-5.5; 8.7) min longer in patients not-receiving heparin. These differences were reverted by heparinase. CONCLUSIONS Using citrated-recalcified blood to perform TEG might lead to underestimation of the effect of heparin.
Collapse
Affiliation(s)
- Stefano De Falco
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Meli
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessio Caccioppola
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Mauro Panigada
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
5
|
Meani P, Veronese G, Todaro S, Marchese G, Mondellini GM, Protti I, de Arroyabe BML, Epis F, Pappalardo F, Pedrazzini G, Munch C, Margari V, Grazioli L, Lorini FL, Cattaneo S, Montisci A, Ballotta A, Raffa GM, Carboni P, Lucchelli M, Avalli L, Babuin L, Belliato M, Bertini P, Guarracino F, Paternoster G, Ajello V, Catena E, Scolletta S, Franchi F, Musazzi A, Pacini D, Sangalli F, Attisani M, Rinaldi M, Grasselli G, Mondino M, Ranucci M, Lorusso R. Evaluation of Left Ventricular Overload and Use of Unloading Techniques in Venoarterial Extracorporeal Life Support: A Nationwide Survey. ASAIO J 2024; 70:e57-e60. [PMID: 38039508 DOI: 10.1097/mat.0000000000002113] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023] Open
Affiliation(s)
- Paolo Meani
- From the Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Giacomo Veronese
- Department of Cardiac Anesthesia and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Cardiac Anesthesia and Intensive Care Unit, Milan, Italy
| | - Serena Todaro
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giuseppe Marchese
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giulio M Mondellini
- Division of Cardiovascular Medicine, Columbia University Irving Medical Center, New York City, New York
| | - Ilaria Protti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Blanca Martinez-Lopez de Arroyabe
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, University Hospital of Verona, Verona, Italy
| | - Francesco Epis
- Department of Anesthesia and Intensive Care, Struttura Complessa Anestesia e Rianimazione 2 Anestesia e Rianimazione Cardiotoracica, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, Cardiothoracic and Vascular Anesthesia and Intensive Care, Azienda Ospedaliera Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Giovanna Pedrazzini
- Department of Cardiac Anesthesia and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Cardiac Anesthesia and Intensive Care Unit, Milan, Italy
| | - Christopher Munch
- Department of Cardiac Anesthesia and Intensive Care Unit, Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ancona, Italy
| | - Vito Margari
- Division of Cardiac Surgery, Santa Maria Hospital, Gruppo Villa Maria Care & Research, Bari, Italy
| | - Lorenzo Grazioli
- Department of Anesthesia and Intensive Care, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Ferdinando Luca Lorini
- Department of Anesthesia and Intensive Care, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Sergio Cattaneo
- Division of Cardiothoracic Intensive Care, Cardiothoracic Department, Azienda Socio-Sanitaria Territoriale Spedali Civili, Brescia, Italy
| | - Andrea Montisci
- Division of Cardiothoracic Intensive Care, Cardiothoracic Department, Azienda Socio-Sanitaria Territoriale Spedali Civili, Brescia, Italy
| | - Andrea Ballotta
- Department of Cardiac Anesthesia and Intensive Care Unit, Cardiac Anaesthesia and Intensive Care Unit, Istituto di Ricovero e Cura a Carattere Scientifico Centro Cardiologico Monzino, Milano, Italy
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto mediterraneo per i trapianti e terapie ad alta specializzazione, Palermo, Italy
| | - Pietro Carboni
- Cardiovascular Department, Cardiac Intensive Care and Anesthesiology Unit, Manzoni Hospital, Lecco, Italy
| | - Matteo Lucchelli
- Department of Cardiac Anesthesia and Intensive Care Unit, Cardiac Anaesthesia and Intensive Care Unit, Azienda Socio-Sanitaria Territoriale Ovest Milanese, Legnano, Italy
| | - Leonello Avalli
- Department of Anesthesia and Intensive Care Unit, Unità operativa complessa Anestesia e Rianimazione, Ospedale San Gerardo, Azienda Socio-Sanitaria Territoriale Monza, Monza, Italy
| | - Luciano Babuin
- Department of Cardiac, Cardiologic Intensive Care Unit, Thoracic, Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Mirko Belliato
- Department of Anesthesia and Intensive Care, Struttura Complessa Anestesia e Rianimazione 2 Anestesia e Rianimazione Cardiotoracica, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Pietro Bertini
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Gianluca Paternoster
- Department of Anesthesia and Intensive Care Unit, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy
| | - Valentina Ajello
- Department of Cardiac Anesthesia, Tor Vergata University Hospital, Rome, Italy
| | - Emanuele Catena
- Department of Anesthesia and Intensive Care Unit, Unità operativa complessa Anestesia e Rianimazione, Ospedale Luigi Sacco, Milano, Italy
| | - Sabino Scolletta
- Department of Anesthesia and Intensive Care Unit, Anesthesia and Intensive Care Unit, University Hospital of Siena, University of Siena, Siena, Italy
| | - Federico Franchi
- Department of Anesthesia and Intensive Care Unit, Anesthesia and Intensive Care Unit, University Hospital of Siena, University of Siena, Siena, Italy
| | - Andrea Musazzi
- Department of Medicine, and Surgery, Unit of Cardiac Surgery, Azienda Socio-Sanitaria Territoriale dei Sette Laghi, University of Insubria, Varese, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fabio Sangalli
- Department of Anesthesia and Intensive Care, Anesthesia and Intensive Care, Azienda Socio-Sanitaria Territoriale Valtellina e Alto Lario, Sondrio, Italy
| | - Matteo Attisani
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
- Unità operativa semplice dipartimentale Cardiac Surgery, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Mauro Rinaldi
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Mondino
- Department of Cardiothoracic and Vascular Anesthesia and Cardiothoracic and Vascular Intensive Care Unit, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and ICU, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Roberto Lorusso
- From the Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| |
Collapse
|
6
|
Magliocca A, Castagna V, Fornari C, Zimei G, Merigo G, Penna A, Carlson J, Fumagalli F, Stirparo G, Migliari M, Coppo A, Sechi GM, Grasselli G, Hardig BM, Ristagno G. Transthoracic impedance variability to assess quality of chest compression in out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2024; 68:556-566. [PMID: 38221650 DOI: 10.1111/aas.14374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/20/2023] [Accepted: 12/21/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Chest compression is a lifesaving intervention in out-of-hospital cardiac arrest (OHCA), but the optimal metrics to assess its quality have yet to be identified. The objective of this study was to investigate whether a new parameter, that is, the variability of the chest compression-generated transthoracic impedance (TTI), namely ImpCC , which measures the consistency of the chest compression maneuver, relates to resuscitation outcome. METHODS This multicenter observational, retrospective study included OHCAs with shockable rhythm. ImpCC variability was evaluated with the power spectral density analysis of the TTI. Multivariate regression model was used to examine the impact of ImpCC variability on defibrillation success. Secondary outcome measures were return of spontaneous circulation and survival. RESULTS Among 835 treated OHCAs, 680 met inclusion criteria and 565 matched long-term outcomes. ImpCC was significantly higher in patients with unsuccessful defibrillation compared to those with successful defibrillation (p = .0002). Lower ImpCC variability was associated with successful defibrillation with an odds ratio (OR) of 0.993 (95% confidence interval [95% CI], 0.989-0.998, p = .003), while the standard chest compression fraction (CCF) was not associated (OR 1.008 [95 % CI, 0.992-1.026, p = .33]). Neither ImpCC nor CCF was associated with long-term outcomes. CONCLUSIONS In this population, consistency of chest compression maneuver, measured by variability in TTI, was an independent predictor of defibrillation outcome. ImpCC may be a useful novel metrics for improving quality of care in OHCA.
Collapse
Affiliation(s)
- Aurora Magliocca
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Valentina Castagna
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carla Fornari
- Research Centre on Public Health, University of Milano-Bicocca, Monza, Italy
| | - Gabriele Zimei
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Merigo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessio Penna
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jonas Carlson
- Clinical Sciences, Helsingborg, Medical Faculty, Lund University, Helsingborg, Sweden
| | - Francesca Fumagalli
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | | | - Anna Coppo
- Agenzia Regionale Emergenza Urgenza, Milan, Italy
| | | | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bjarne Madsen Hardig
- Clinical Sciences, Helsingborg, Medical Faculty, Lund University, Helsingborg, Sweden
| | - Giuseppe Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
7
|
Meli A, De Falco S, Novembrino C, Boscolo Anzoletti M, Arcadipane A, Panarello G, Occhipinti G, Grasselli G, Panigada M. The role of inflammation and antithrombin supplementation on thromboelastographic parameters during veno-venous ECMO for respiratory failure. Perfusion 2024; 39:66S-76S. [PMID: 38651578 DOI: 10.1177/02676591241237637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) may act as a driver or propagator of systemic inflammation. In turn, cytokine release can modify thromboelastographic (TEG) tests which are commonly used for anticoagulation monitoring. In this context, antithrombin (AT) supplementation might further modify TEG. METHODS This is a pre-specified sub-study of the "Randomized Controlled Trial of Antithrombin Supplementation During Extracorporeal Membrane Oxygenation" study (investigator-initiated, randomized, single-blind, two-arm trial) conducted in two Italian ECMO referral ICUs. Adult patients requiring vv-ECMO for respiratory failure and undergoing unfractioned heparin (UFH) administration were enrolled and randomized whether to receive AT supplementation. Plasma samples for cytokine assay (IL-8, IL-10, IL-6, IL-1β, TNF-α and Pro-ADM) and heparinase TEG were collected from every patient before ECMO start, 24 h and 72 h after ECMO start, before ECMO removal, and 7 days after ECMO removal or upon ICU discharge whichever happened first. AT concentration, coagulation and clinical data were collected before ECMO start and at pre-fixed time points. RESULTS Thirty-nine patients were enrolled (21 treatments, 18 controls). TEG-R had a weak-to-moderate positive correlation with IL-8, IL-6, IL-10 and TNF-α and a moderate positive correlation with Pro-ADM. TEG-ANG showed a weak negative correlation with IL-8, IL-6 and TNF-α, while TEG-MA negatively correlated with IL-8, TNF-α and Pro-ADM. AT supplementation seemed to modify the association between TEG-MA and IL-8, IL-10 and Pro-ADM; conversely, AT did not affect the relationship among TEG-R or TEG-ANG and the studied cytokines. CONCLUSIONS High concentrations of systemic cytokines correlated with longer reaction times and decreased angle and amplitude at TEG, suggesting that an increase in inflammation is related with hypocoagulability as revealed by thromboelastography.
Collapse
Affiliation(s)
- Andrea Meli
- Department of Anesthesiology, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano De Falco
- Department of Anesthesiology, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Cristina Novembrino
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Boscolo Anzoletti
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, IRCCS, UPMC, ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC Palermo, Italy
| | - Giovanna Panarello
- Department of Anesthesia and Intensive Care, IRCCS, UPMC, ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC Palermo, Italy
| | - Giovanna Occhipinti
- Department of Anesthesia and Intensive Care, IRCCS, UPMC, ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC Palermo, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Mauro Panigada
- Department of Anesthesiology, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
8
|
Spinelli E, Giani M, Slobod D, Pavlovsky B, di Pierro M, Crotti S, Lissoni A, Foti G, Grasselli G, Mauri T. Physiologic Effects of ECMO in Patients with Severe Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024. [PMID: 38526489 DOI: 10.1164/rccm.202309-1688oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 03/22/2024] [Indexed: 03/26/2024] Open
Abstract
RATIONALE Blood flow rate affects mixed venous oxygenation (SvO2) during venovenous extracorporeal membrane oxygenation (ECMO), with possible effects on the pulmonary circulation and the right heart function. OBJECTIVES We aimed at describing the physiologic effects of different levels of SvO2 obtained by changing ECMO blood flow, in patients with severe ARDS receiving ECMO and controlled mechanical ventilation. METHODS Low (SvO2 target 70-75%), intermediate (SvO2 target 75-80%) and high (SvO2 target > 80%) ECMO blood flows were applied for 30 minutes in random order in 20 patients. Mechanical ventilation settings were left unchanged. The hemodynamic and pulmonary effects were assessed with pulmonary artery catheter and electrical impedance tomography (EIT). MEASUREMENTS AND MAIN RESULTS Cardiac output decreased from low to intermediate and to high blood flow/SvO2 (9.2 [6.2-10.9] vs 8.3 [5.9-9.8] vs 7.9 [6.5-9.1] L/min, p = 0.014), as well as mean pulmonary artery pressure (34 ± 6 vs 31 ± 6 vs 30 ± 5 mmHg, p < 0.001), and right ventricle stroke work index (14.2 ± 4.4 vs 12.2 ± 3.6 vs 11.4 ± 3.2 g*m/beat/m2, p = 0.002). Cardiac output was inversely correlated with mixed venous and arterial PO2 values (R2 = 0.257, p = 0.031 and R2 = 0.324, p = 0.05). Pulmonary artery pressure was correlated with decreasing mixed venous PO2 (R2 = 0.29, p <0.001) and with increasing cardiac output (R2 = 0.378 p < 0.007). Measures of ventilation/perfusion mismatch did not differ between the three steps. CONCLUSIONS In severe ARDS patients, increased ECMO blood flow rate resulting in higher SvO2 decreases pulmonary artery pressure, cardiac output, and right heart workload. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Collapse
Affiliation(s)
- Elena Spinelli
- Ospedale Maggiore Policlinico, 9339, Milano, Lombardia, Italy
| | - Marco Giani
- San Gerardo Hospital, 9265, Monza, Lombardia, Italy
| | | | - Bertrand Pavlovsky
- University Hospital Centre Angers, 26966, Angers, Pays de la Loire, France
| | | | - Stefania Crotti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 9339, Anesthesia, Intensive Care and Emergency, Milan, Lombardia, Italy
| | - Alfredo Lissoni
- La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, 9339, Department of Anesthesia, Critical Care and Emergency, Milano, Lombardia, Italy
| | - Giuseppe Foti
- San Gerardo Hospital, 9265, Department of Emergency and Intensive Care, Monza, Lombardia, Italy
| | - Giacomo Grasselli
- University of Milan, 9304, Department of Pathophysiology and Transplantation, Milano, Italy
| | - Tommaso Mauri
- Policlinico di Milano, 9339, Department of Anesthesia, Critical Care and Emergency, Milan, Lombardia, Italy;
| |
Collapse
|
9
|
Dondossola D, Lonati C, Pini A, Bignamini D, Zanella A, Lombardi R, Scaravilli V, La Mura V, Forzenigo L, Biondetti P, Grasselli G, Fracanzani A, Paleari C, Cespiati A, Todaro S, Cattaneo E, Di Feliciantonio M, Sigon G, Valsecchi C, Guzzardella A, Battistin M, Iuculano F. Portal hypertension-like pattern in coronavirus disease 2019 acute respiratory distress syndrome. J Crit Care 2024; 82:154759. [PMID: 38461659 DOI: 10.1016/j.jcrc.2024.154759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 01/12/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVES Although respiratory failure is the most common feature in coronavirus disease 2019 (COVID-19), abdominal organ involvement is likewise frequently observed. To investigate visceral and thoracic circulation and abdominal organ damage in COVID-19 patients. MATERIALS AND METHODS A monocentric observational study was carried on. In COVID-19 patients affected by acute respiratory distress syndrome (ARDS) (n = 31) or mild pneumonia (n = 60) thoracoabdominal circulation was evaluated using Doppler-ultrasound and computed tomography. The study also included non-COVID-19 patients affected by ARDS (n = 10) or portal hypertension (n = 10) for comparison of the main circulatory changes. RESULTS Patients affected by COVID-19 ARDS showed hyperdynamic visceral flow and increased portal velocity, hepatic artery resistance-index, and spleen diameter relative to those with mild-pneumonia (p = 0.001). Splanchnic circulatory parameters significantly correlated with the main respiratory indexes (p < 0.001) and pulmonary artery diameter (p = 0.02). The chest and abdominal vascular remodeling pattern of COVID-19 ARDS patients resembled the picture observed in the PH group, while differed from that of the non-COVID ARDS group. A more severe COVID-19 presentation was associated with worse liver dysfunction and enhanced inflammatory activation; these parameters both correlated with abdominal (p = 0.04) and chest imaging measures (p = 0.03). CONCLUSION In COVID-19 ARDS patients there are abdominal and lung vascular modifications that depict a portal hypertension-like pattern. The correlation between visceral vascular remodeling, pulmonary artery enlargement, and organ damage in these critically ill patients is consistent with a portal hyperlfow-like syndrome that could contribute to the peculiar characteristics of respiratory failure in these patients. CLINICAL RELEVANCE STATEMENT our data suggest that the severity of COVID-19 lung involvement is directly related to the development of a portal hyperflow-like syndrome. These observations should help in defining the need for a closer monitoring, but also to develop dedicated therapeutic strategies.
Collapse
Affiliation(s)
- Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi of Milan, 20019 Milan, Italy.
| | - Caterina Lonati
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Alessia Pini
- Department of Statistical Sciences, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Daniela Bignamini
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation, Università degli Studi of Milan, 20019 Milan, Italy; Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Rosa Lombardi
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Vittorio Scaravilli
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Vincenzo La Mura
- Internal Medicine, Hemostasis and Thrombosis Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy; Department of Biomedical Science for Health, Università degli Studi of Milan, 20019 Milan, Italy
| | - Laura Forzenigo
- Division of Radiology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Pierpaolo Biondetti
- Division of Radiology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, Università degli Studi of Milan, 20019 Milan, Italy; Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Anna Fracanzani
- Department of Pathophysiology and Transplantation, Università degli Studi of Milan, 20019 Milan, Italy; Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Chiara Paleari
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Annalisa Cespiati
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Serena Todaro
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Emanuele Cattaneo
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Marianna Di Feliciantonio
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Giordano Sigon
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Carlo Valsecchi
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Amedeo Guzzardella
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan 20019, Italy
| | - Michele Battistin
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| | - Federica Iuculano
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20019 Milan, Italy
| |
Collapse
|
10
|
Scaravilli V, Colombo SM, Fumagalli J, Mauri T, Zanella A, Rosso L, Grasselli G. Regional Ventilation-Perfusion Matching by Electrical Impedance Tomography After Single Lung Transplant. ASAIO J 2024; 70:e49-e52. [PMID: 37949061 PMCID: PMC10885861 DOI: 10.1097/mat.0000000000002055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
Single lung transplantation (LUTX) can be the last therapeutic option for a growing cohort of patients suffering from end-stage respiratory failure. Postoperative ventilatory management of single LUTX recipients is challenged by the coexistence of the diseased native lung and a healthy-but fragile-graft. In this case report, in a single LUTX recipient with idiopathic pulmonary fibrosis, regional ventilation ( ), perfusion ( ), and / matching and subsequent measurement of shunt fraction ( Qs / Qt ) and alveolar dead space ( Vd / Vt ) were obtained by integrating electrical impedance tomography (EIT) with volumetric capnography and pulmonary thermodilution technique. Although the preoperative pulmonary scintigraphy showed predominant right lung perfusion (79.8% vs. 20.2%), the EIT documented the postoperative re-establishment of between the lungs (demonstrating the adequate functioning of vascular anastomoses), the diversion of to the graft and similar global Qs / Qt (17%) and Vd / Vt (29%) between native and graft lung. Electrical impedance tomography mapping allowed regional Qs / Qt and Vd / Vt assessment: the native right lung had a completely deranged distribution of and ( Qs / Qt 25%, Vd / Vt 46%), whereas the graft showed normal coupling of and ( Qs / Qt 8%, Vd / Vt 12%). Electrical impedance tomography may allow noninvasive, repeatable, bedside assessments of the lung / coupling after single LUTX.
Collapse
Affiliation(s)
- Vittorio Scaravilli
- From the Department of Anesthesia Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Sebastiano Maria Colombo
- From the Department of Anesthesia Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jacopo Fumagalli
- From the Department of Anesthesia Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tommaso Mauri
- From the Department of Anesthesia Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alberto Zanella
- From the Department of Anesthesia Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lorenzo Rosso
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- From the Department of Anesthesia Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
11
|
Vivona L, Battistin M, Carlesso E, Florio G, Todaro S, Colombo SM, Zadek F, Grasselli G, Zanella A, Langer T. Hematocrit: The Neglected Variable of Extracorporeal CO 2 Removal. Am J Respir Crit Care Med 2024; 209:595-598. [PMID: 38033297 DOI: 10.1164/rccm.202309-1697le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/30/2023] [Indexed: 12/02/2023] Open
Affiliation(s)
| | - Michele Battistin
- Centro Ricerche Precliniche Sperimentale, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milano, Italia
| | - Eleonora Carlesso
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italia
| | - Gaetano Florio
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italia
| | - Serena Todaro
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italia
| | | | - Francesco Zadek
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; and
| | - Giacomo Grasselli
- Dipartimento Area Emergenza Urgenza and
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italia
| | - Alberto Zanella
- Dipartimento Area Emergenza Urgenza and
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italia
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; and
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| |
Collapse
|
12
|
Martucci G, Giani M, Schmidt M, Tanaka K, Tabatabai A, Tuzzolino F, Agerstrand C, Riera J, Ramanan R, Grasselli G, Ait Hssain A, Gannon WD, Buabbas S, Gorjup V, Trethowan B, Rizzo M, Fanelli V, Jeon K, De Pascale G, Combes A, Ranieri MV, Duburcq T, Foti G, Chico JI, Balik M, Broman LM, Schellongowski P, Buscher H, Lorusso R, Brodie D, Arcadipane A. Anticoagulation and Bleeding during Veno-Venous Extracorporeal Membrane Oxygenation: Insights from the PROTECMO Study. Am J Respir Crit Care Med 2024; 209:417-426. [PMID: 37943110 DOI: 10.1164/rccm.202305-0896oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 11/08/2023] [Indexed: 11/10/2023] Open
Abstract
Rationale: Definitive guidelines for anticoagulation management during veno-venous extracorporeal membrane oxygenation (VV ECMO) are lacking, whereas bleeding complications continue to pose major challenges. Objectives: To describe anticoagulation modalities and bleeding events in adults receiving VV ECMO. Methods: This was an international prospective observational study in 41 centers, from December 2018 to February 2021. Anticoagulation was recorded daily in terms of type, dosage, and monitoring strategy. Bleeding events were reported according to site, severity, and impact on mortality. Measurements and Main Results: The study cohort included 652 patients, and 8,471 days on ECMO were analyzed. Unfractionated heparin was the initial anticoagulant in 77% of patients, and the most frequently used anticoagulant during the ECMO course (6,221 d; 73%). Activated partial thromboplastin time (aPTT) was the most common test for monitoring coagulation (86% of days): the median value was 52 seconds (interquartile range, 39 to 61 s) but dropped by 5.3 seconds after the first bleeding event (95% confidence interval, -7.4 to -3.2; P < 0.01). Bleeding occurred on 1,202 days (16.5%). Overall, 342 patients (52.5%) experienced at least one bleeding event (one episode every 215 h on ECMO), of which 10 (1.6%) were fatal. In a multiple penalized Cox proportional hazard model, higher aPTT was a potentially modifiable risk factor for the first episode of bleeding (for 20-s increase; hazard ratio, 1.07). Conclusions: Anticoagulation during VV ECMO was a dynamic process, with frequent stopping in cases of bleeding and restart according to the clinical picture. Future studies might explore lower aPTT targets to reduce the risk of bleeding.
Collapse
Affiliation(s)
| | - Marco Giani
- Fondazione IRCCS San Gerardo dei Tintori, Università degli Studi di Milano Bicocca, Monza, Italy
| | - Matthieu Schmidt
- Sorbonne University, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Kenichi Tanaka
- The University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma
| | - Ali Tabatabai
- University of Maryland St. Joseph Medical Center, Towson, Maryland
| | - Fabio Tuzzolino
- Statistics and Data Management Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Cara Agerstrand
- Department of Medicine and Center for Acute Respiratory Failure, Irving Medical Center, Columbia University, New York, New York
| | - Jordi Riera
- Critical Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Shock Organ Dysfunction and Resuscitation (SODIR), Vall d'Hebron Institut de Recerca, Barcelona, Spain
- Centro de Investigacion en Red de Enfermedades Respiratorias (CIBERES) Instituto de Salud Carlos III, Barcelona, Spain
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care, and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Whitney D Gannon
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara Buabbas
- Kuwait Extracorporeal Life Support Program, Jaber Al-Ahmad Alsabah Hospital, Kuwait City, Kuwait
| | | | - Brian Trethowan
- Meijer Heart Center, Butterworth Hospital, Spectrum Health, Grand Rapids, Michigan
| | - Monica Rizzo
- Statistics and Data Management Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Vito Fanelli
- Department of Surgical Sciences and
- Department of Anesthesia, Critical Care, and Emergency, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Kyeongman Jeon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gennaro De Pascale
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alain Combes
- Sorbonne University, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Thibault Duburcq
- Centre Hospitalier Regional Universitaire (CHRU) Lille, Hôpital Roger Salengro, Lille, France
| | - Giuseppe Foti
- Fondazione IRCCS San Gerardo dei Tintori, Università degli Studi di Milano Bicocca, Monza, Italy
| | - Juan I Chico
- Critical Care Department, Alvaro Cunqueiro University Hospital, Vigo, Spain
| | - Martin Balik
- First Medical Faculty, General University Hospital, Prague, Czech Republic
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Center of Excellence in Medical Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Hergen Buscher
- St. Vincent's Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Maastricht University Medical Center, and
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands; and
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | |
Collapse
|
13
|
Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Eur Respir J 2024; 63:2300347. [PMID: 38387998 DOI: 10.1183/13993003.00347-2023] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.
Collapse
Affiliation(s)
- Alexandre Demoule
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Maxens Decavele
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behaviorial Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Anesthesia, Critical Care and Emergency, Milan, Italy
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
- L. Heunks and T. Similowski contributed equally to the manuscript
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, F-75013 Paris, France
- L. Heunks and T. Similowski contributed equally to the manuscript
| |
Collapse
|
14
|
Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Intensive Care Med 2024; 50:159-180. [PMID: 38388984 DOI: 10.1007/s00134-023-07246-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society (ERS) and the European Society of Intensive Care Medicine (ESICM). Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.
Collapse
Affiliation(s)
- Alexandre Demoule
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France.
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.
| | - Maxens Decavele
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behavioral Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
- Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| |
Collapse
|
15
|
Rudym D, Pham T, Rackley CR, Grasselli G, Schmidt M, Brodie D. Reply to: Candidacy for Extracorporeal Membrane Oxygenation Should Start with Ventilatory Support Optimization. Am J Respir Crit Care Med 2024; 209:229-230. [PMID: 37972376 PMCID: PMC10806422 DOI: 10.1164/rccm.202310-1783le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/15/2023] [Indexed: 11/19/2023] Open
Affiliation(s)
- Darya Rudym
- Department of Medicine, New York University Langone Health, New York, New York
| | - Tài Pham
- Service de Médecine Intensive–Réanimation, Assistance Publique–Hôpitaux de Paris, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche CARMAS, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, Université de Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm U1018, Equipe d’Epidémiologie Respiratoire Intégrative, Centre de Recherche en Epidémiologie et Santé des Populations, Villejuif, France
| | - Craig R. Rackley
- Department of Medicine, Duke University Health System, Durham, North Carolina
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30 RESPIRE, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive–Réanimation, Institut de Cardiologie, Assistance Publique–Hôpitaux de Paris, Hôpital Pitié–Salpêtrière, Paris, France; and
| | - Daniel Brodie
- Department of Medicine, School of Medicine, John Hopkins University, Baltimore, Maryland
| |
Collapse
|
16
|
Scaravilli V, Guzzardella A, Madotto F, Morlacchi LC, Bosone M, Bonetti C, Musso V, Rossetti V, Russo FM, Sorbo LD, Blasi F, Nosotti M, Zanella A, Grasselli G. Hemodynamic failure and graft dysfunction after lung transplant: A possible clinical continuum with immediate and long-term consequences. Clin Transplant 2023; 37:e15122. [PMID: 37694497 DOI: 10.1111/ctr.15122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION The postoperative hemodynamic management after lung transplant (LUTX) is guided by limited evidence. We aimed to describe and evaluate risk factors and outcomes of postoperative vasoactive support of LUTX recipients. METHODS In a single-center retrospective analysis of consecutive adult LUTX, two cohorts were identified: (1) patients needing prolonged vasoactive support (>12 h from ICU admission) (VASO+); (2) or not (VASO-). Postoperative hemodynamic characteristics were thoroughly analyzed. Risk factors and outcomes of VASO+ versus VASO- cohorts were assessed by multivariate logistic regression and propensity score matching. RESULTS One hundred and thirty-eight patients were included (86 (62%) VASO+ versus 52 (38%) VASO-). Vasopressors (epinephrine, norepinephrine, dopamine) were used in the first postoperative days (vasoactive inotropic score at 12 h: 6 [4-12]), while inodilators (dobutamine, levosimendan) later. Length of vasoactive support was 3 [2-4] days. Independent predictors of vasoactive use were: LUTX indication different from cystic fibrosis (p = .003), higher Oto score (p = .020), longer cold ischemia time (p = .031), but not preoperative cardiac catheterization. VASO+ patients showed concomitant hemodynamic and graft impairment, with longer mechanical ventilation (p = .010), higher primary graft dysfunction (PGD) grade at 72 h (PGD grade > 0 65% vs. 31%, p = .004, OR 4.2 [1.54-11.2]), longer ICU (p < .001) and hospital stay (p = .013). Levosimendan as a second-line inodilator appeared safe. CONCLUSIONS Vasoactive support is frequently necessary after LUTX, especially in recipients of grafts of lesser quality. Postoperative hemodynamic dysfunction requiring vasopressor support and graft dysfunction may represent a clinical continuum with immediate and long-term consequences. Further studies may elucidate if this represents a possible treatable condition.
Collapse
Affiliation(s)
- Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan(MI), Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Fabiana Madotto
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Letizia Corinna Morlacchi
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Marco Bosone
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Claudia Bonetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Valeria Musso
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Valeria Rossetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Filippo Maria Russo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Mario Nosotti
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Cardio-thoraco-vascular diseases, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| |
Collapse
|
17
|
Tonetti T, Zanella A, Pérez-Torres D, Grasselli G, Ranieri VM. Current knowledge gaps in extracorporeal respiratory support. Intensive Care Med Exp 2023; 11:77. [PMID: 37962702 PMCID: PMC10645840 DOI: 10.1186/s40635-023-00563-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 11/08/2023] [Indexed: 11/15/2023] Open
Abstract
Extracorporeal life support (ECLS) for acute respiratory failure encompasses veno-venous extracorporeal membrane oxygenation (V-V ECMO) and extracorporeal carbon dioxide removal (ECCO2R). V-V ECMO is primarily used to treat severe acute respiratory distress syndrome (ARDS), characterized by life-threatening hypoxemia or ventilatory insufficiency with conventional protective settings. It employs an artificial lung with high blood flows, and allows improvement in gas exchange, correction of hypoxemia, and reduction of the workload on the native lung. On the other hand, ECCO2R focuses on carbon dioxide removal and ventilatory load reduction ("ultra-protective ventilation") in moderate ARDS, or in avoiding pump failure in acute exacerbated chronic obstructive pulmonary disease. Clinical indications for V-V ECLS are tailored to individual patients, as there are no absolute contraindications. However, determining the ideal timing for initiating extracorporeal respiratory support remains uncertain. Current ECLS equipment faces issues like size and durability. Innovations include intravascular lung assist devices (ILADs) and pumpless devices, though they come with their own challenges. Efficient gas exchange relies on modern oxygenators using hollow fiber designs, but research is exploring microfluidic technology to improve oxygenator size, thrombogenicity, and blood flow capacity. Coagulation management during V-V ECLS is crucial due to common bleeding and thrombosis complications; indeed, anticoagulation strategies and monitoring systems require improvement, while surface coatings and new materials show promise. Moreover, pharmacokinetics during ECLS significantly impact antibiotic therapy, necessitating therapeutic drug monitoring for precise dosing. Managing native lung ventilation during V-V ECMO remains complex, requiring a careful balance between benefits and potential risks for spontaneously breathing patients. Moreover, weaning from V-V ECMO is recognized as an area of relevant uncertainty, requiring further research. In the last decade, the concept of Extracorporeal Organ Support (ECOS) for patients with multiple organ dysfunction has emerged, combining ECLS with other organ support therapies to provide a more holistic approach for critically ill patients. In this review, we aim at providing an in-depth overview of V-V ECMO and ECCO2R, addressing various aspects of their use, challenges, and potential future directions in research and development.
Collapse
Affiliation(s)
- Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - David Pérez-Torres
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
| |
Collapse
|
18
|
Villar J, Szakmany T, Grasselli G, Camporota L. Redefining ARDS: a paradigm shift. Crit Care 2023; 27:416. [PMID: 37907946 PMCID: PMC10619227 DOI: 10.1186/s13054-023-04699-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 11/02/2023] Open
Abstract
Although the defining elements of "acute respiratory distress syndrome" (ARDS) have been known for over a century, the syndrome was first described in 1967. Since then, despite several revisions of its conceptual definition, it remains a matter of debate whether ARDS is a discrete nosological entity. After almost 60 years, it is appropriate to examine how critical care has modeled this fascinating syndrome and affected patient's outcome. Given that the diagnostic criteria of ARDS (e.g., increased pulmonary vascular permeability and diffuse alveolar damage) are difficult to ascertain in clinical practice, we believe that a step forward would be to standardize the assessment of pulmonary and extrapulmonary involvement in ARDS to ensure that each patient can receive the most appropriate and effective treatment. The selection of treatments based on arbitrary ranges of PaO2/FiO2 lacks sufficient sensitivity to individualize patient care.
Collapse
Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029, Madrid, Spain.
- Research Unit, Hospital Universitario Dr. Negrin, Barranco de La Ballena S/N, 4Th Floor-South Wing, 35019, Las Palmas de Gran Canaria, Spain.
- Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada.
| | - Tamas Szakmany
- Department of Intensive Care Medicine & Anesthesia, Aneurin Bevan University Health Board, Newport, NP20 2UB, Wales, UK
- Honorary Professor in Intensive Care, Cardiff University, Cardiff, CF14 4XW, Wales, UK
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| |
Collapse
|
19
|
Guarracino F, Cortegiani A, Antonelli M, Behr A, Biancofiore G, Del Gaudio A, Forfori F, Galdieri N, Grasselli G, Paternoster G, Rocco M, Romagnoli S, Sardo S, Treskatsch S, Tripodi VF, Tritapepe L. The role of beta-blocker drugs in critically ill patients: a SIAARTI expert consensus statement. J Anesth Analg Crit Care 2023; 3:41. [PMID: 37872608 PMCID: PMC10591347 DOI: 10.1186/s44158-023-00126-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/10/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND The role of β-blockers in the critically ill has been studied, and data on the protective effects of these drugs on critically ill patients have been repeatedly reported in the literature over the last two decades. However, consensus and guidelines by scientific societies on the use of β-blockers in critically ill patients are still lacking. The purpose of this document is to support the clinical decision-making process regarding the use of β-blockers in critically ill patients. The recipients of this document are physicians, nurses, healthcare personnel, and other professionals involved in the patient's care process. METHODS The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects underlying the use of β-blockers in critically ill adult patients. The methodology followed by the experts during this process was in line with principles of modified Delphi and RAND-UCLA methods. The experts developed statements and supportive rationales in the form of informative text. The overall list of statements was subjected to blind votes for consensus. RESULTS The literature search suggests that adrenergic stress and increased heart rate in critically ill patients are associated with organ dysfunction and increased mortality. Heart rate control thus seems to be critical in the management of the critically ill patient, requiring careful clinical evaluation aimed at both the differential diagnosis to treat secondary tachycardia and the treatment of rhythm disturbance. In addition, the use of β-blockers for the treatment of persistent tachycardia may be considered in patients with septic shock once hypovolemia has been ruled out. Intravenous application should be the preferred route of administration. CONCLUSION β-blockers protective effects in critically ill patients have been repeatedly reported in the literature. Their use in the acute treatment of increased heart rate requires understanding of the pathophysiology and careful differential diagnosis, as all causes of tachycardia should be ruled out and addressed first.
Collapse
Affiliation(s)
- Fabio Guarracino
- Cardiothoracic and Vascular Anesthesia and Intensive Care, Anesthesia and Resuscitation Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, 90127, Palermo, Italy.
| | - Massimo Antonelli
- Department of Emergency, Anesthesiological and Resuscitation Sciences, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Astrid Behr
- Operative Unit of Anesthesia and Resuscitation, Hospital of Camposampiero, Padua, Italy
| | - Giandomenico Biancofiore
- Anesthesia and Resuscitation Transplants, Department of Medical Pathology Surgical, Molecular and Critical Area, University of Pisa, Pisa, Italy
| | - Alfredo Del Gaudio
- Emergency Department, Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Francesco Forfori
- Anesthesia and Intensive Care, Anesthesia and Resuscitation Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Nicola Galdieri
- General Cardiac Surgery Unit, Critical Area Department, Ospedale Dei Colli, Naples, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Resuscitation and Emergency, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Medical-Surgical and Transplant Pathophysiology, University of Milan, Milan, Italy
| | | | - Monica Rocco
- Department of Surgical and Medical Science and Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Stefano Romagnoli
- Anesthesia and Intensive Care Section, Department of Health Sciences, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Salvatore Sardo
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Freie Universität and Humboldt-Universität Zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Vincenzo Francesco Tripodi
- Anesthesia and Intensive Care Unit, Department of Surgery, University Hospital "Gaetano Martino", Messina, Italy
| | - Luigi Tritapepe
- Anesthesia and Resuscitation Unit, San Camillo-Forlanini Hospital, Sapienza University, Rome, Italy
| |
Collapse
|
20
|
Abbruzzese C, Guzzardella A, Consonni D, Turconi G, Bonetti C, Brioni M, Panigada M, Grasselli G. Incidence of asymptomatic catheter-related thrombosis in intensive care unit patients: a prospective cohort study. Ann Intensive Care 2023; 13:106. [PMID: 37858003 PMCID: PMC10587047 DOI: 10.1186/s13613-023-01206-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Catheter-related thrombosis (CRT) incidence, rate, and risk factors vary in literature due to differences in populations, catheters, diagnostic methods, and statistical approaches. The aim of this single-center, prospective, observational study was to assess incidence, incidence rate (IR), cumulative incidence, and risk factors by means of IR ratio (IRR) of asymptomatic CRT in a non-oncologic Intensive Care Unit (ICU) population. CRT development was assessed daily by means of ultrasound screening. The proportions of patients and catheters developing CRT and CRT incidence rates, expressed as the number of events per catheter-days (cd), were calculated. Kalbfleisch and Prentice's method was used to estimate the cumulative incidence of CRTs. Univariate and multivariable Poisson regression models were fitted to calculate IRR in risk factors analysis. RESULTS Fifty (25%, 95% CI 19-31) out of 203 included patients, and 52 (14%, 95% CI 11-18) out of 375 catheters inserted developed CRT [IR 17.7 (13.5-23.2) CRTs/1000*cd], after 5 [3-10] days from insertion. Forty-six CRTs (88%) were partial thrombosis. All CRTs remained asymptomatic. Obesity and ECMO support were patient-related protective factors [IRR 0.24 (0.10-0.60), p = 0.002 and 0.05 (0.01-0.50), p = 0.011, respectively]. The internal jugular vein had higher CRT IR than other sites [20.1 vs. 5.9 CRTs/1000*cd, IRR 4.22 (1.22-14.63), p = 0.023]. Pulmonary artery catheter and left-side cannulation were catheter-related risk factors [IRR 4.24 (2.00-9.00), p < 0.001 vs. central venous catheters; IRR 2.69 (1.45-4.98), p = 0.002 vs. right cannulation, respectively]. No statistically significant effect of the number of simultaneously inserted catheters [IRR 1.11 (0.64-1.94), p = 0.708] and of the catheterization length [IRR 1.09 (0.97-1.22), p = 0.155] was detected. The ICU length of stay was longer in CRT patients (20 [15-31] vs. 6 [4-14] days, p < 0.001), while no difference in mortality was observed. CONCLUSIONS CRTs are frequent but rarely symptomatic. This study suggests that obesity and ECMO are protective factors, while pulmonary artery catheter, internal jugular vein and left-side positioning are risk factors for CRT.
Collapse
Affiliation(s)
- Chiara Abbruzzese
- Department of Anaesthesiology, Critical Care and Emergency, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza, 35, 20122, Milan, Italy.
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Gloria Turconi
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Claudia Bonetti
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Matteo Brioni
- Department of Anaesthesiology, Critical Care and Emergency, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Mauro Panigada
- Department of Anaesthesiology, Critical Care and Emergency, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Giacomo Grasselli
- Department of Anaesthesiology, Critical Care and Emergency, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza, 35, 20122, Milan, Italy
| |
Collapse
|
21
|
Tonelli R, Grasso S, Cortegiani A, Ball L, Castaniere I, Tabbì L, Fantini R, Andrisani D, Gozzi F, Moretti A, Bruzzi G, Manicardi L, Cerri S, Samarelli AV, Raineri G, Murgolo F, Carzoli A, Di Mussi R, Busani S, Rizzoni R, Grasselli G, Clini E, Marchioni A. Physiological effects of lung-protective ventilation in patients with lung fibrosis and usual interstitial pneumonia pattern versus primary ARDS: a matched-control study. Crit Care 2023; 27:398. [PMID: 37853480 PMCID: PMC10585808 DOI: 10.1186/s13054-023-04682-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/07/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Although patients with interstitial pneumonia pattern (ILD-UIP) and acute exacerbation (AE) leading to severe acute respiratory failure may require invasive mechanical ventilation (MV), physiological data on lung mechanics during MV are lacking. We aimed at describing the physiological effect of lung-protective ventilation in patients with AE-ILD-UIP compared with primary ARDS. METHODS Partitioned lung and chest wall mechanics were assessed in a series of AE-ILD-UIP patients matched 1:1 with primary ARDS as controls (based on BMI and PaO2/FiO2 ratio). Three PEEP levels (zero = ZEEP, 4-8 cmH2O = PEEPLOW, and titrated to achieve positive end-expiratory transpulmonary pressure PL,EE = PEEPTITRATED) were used for measurements. RESULTS Ten AE-ILD-UIP patients and 10 matched ARDS were included. In AE-ILD-UIP median PL,EE at ZEEP was - 4.3 [- 7.6- - 2.3] cmH2O and lung elastance (EL) 44 [40-51] cmH2O/L. At PEEPLOW, PL,EE remained negative and EL did not change (p = 0.995) versus ZEEP. At PEEPTITRATED, PL,EE increased to 0.8 [0.3-1.5] cmH2O and EL to 49 [43-59] (p = 0.004 and p < 0.001 compared to ZEEP and PEEPLOW, respectively). ΔPL decreased at PEEPLOW (p = 0.018) and increased at PEEPTITRATED (p = 0.003). In matched ARDS control PEEP titration to obtain a positive PL,EE did not result in significant changes in EL and ΔPL. CONCLUSIONS In mechanically ventilated AE-ILD-UIP patients, differently than in patients with primary ARDS, PEEP titrated to obtain a positive PL,EE significantly worsened lung mechanics.
Collapse
Affiliation(s)
- Roberto Tonelli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Salvatore Grasso
- Dipartimento di Medicina di Precisione e Rigenerativa e Area Ionica (DiMePre-J) Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Bari, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Ivana Castaniere
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Luca Tabbì
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Riccardo Fantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Dario Andrisani
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Filippo Gozzi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Antonio Moretti
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Giulia Bruzzi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Linda Manicardi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Stefania Cerri
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Anna Valeria Samarelli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Giulia Raineri
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Francesco Murgolo
- Dipartimento di Medicina di Precisione e Rigenerativa e Area Ionica (DiMePre-J) Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Bari, Italy
| | - Andrea Carzoli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Rossella Di Mussi
- Dipartimento di Medicina di Precisione e Rigenerativa e Area Ionica (DiMePre-J) Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Bari, Italy
| | | | - Raffaella Rizzoni
- Department of Engineering, University of Ferrara, Via Saragat 1, Ferrara, Italy
| | - Giacomo Grasselli
- Dipartimento di Anestesia, Rianimazione e Emergenza-Urgenza, Fondazione IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Enrico Clini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy.
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy.
- Laboratory of Experimental Pneumology, University Hospital of Modena, Policlinico, UNIMORE, Università degli Studi di Modena e Reggio Emilia, Modena, Italy.
| | - Alessandro Marchioni
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| |
Collapse
|
22
|
Cattaneo V, Caccioppola A, Colombo SM, Scaravilli V, Tubiolo D, Crotti S, Bosone M, Rafaniello Raviele P, Olmeda E, Menni F, Furlan F, Rossetti V, Damarco F, Panigada M, Grasselli G. Hyperammonemia Syndrome After Lung Transplantation: A Double-Hit Fatal Syndrome. A Case Report. Transplant Proc 2023; 55:1991-1994. [PMID: 37537075 DOI: 10.1016/j.transproceed.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 07/03/2023] [Indexed: 08/05/2023]
Abstract
Hyperammonemia after lung transplantation is a rare but potentially fatal condition. A 59-year-old male patient affected by pulmonary fibrosis underwent an uncomplicated bilateral lung transplant. Fourteen days after the procedure, the patient developed severe encephalopathy caused by elevated serum ammonia levels. Ureaplasma parvum and Mycoplasma hominis were found on bronchial aspirate and urinary samples as well as on pharyngeal and rectal swabs. Despite the initiation of multimodal therapy, brain damage due to hyperosmolarity was so extensive to evolve into brain death. The autopsy revealed glutamine synthetase hypo-expression in the hepatic tissue. The pathophysiology of hyperammonemia syndrome in lung transplant recipients remains unclear. Previous studies have described the presence of disorders of glutamine synthetase, while others considered the infection with urea-splitting microorganisms as a cause of hyperammonemia syndrome. Our report describes the case of a patient who developed hyperammonemia after a lung transplant in which both the aforementioned etiologies were documented. A high level of clinical suspicion for hyperammonemia syndrome should be maintained in lung transplant recipients. Timely recognition and treatment are critical to prevent the potentially dreadful evolution of this severe complication.
Collapse
Affiliation(s)
- Valentina Cattaneo
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alessio Caccioppola
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sebastiano Maria Colombo
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Daniela Tubiolo
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefania Crotti
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Bosone
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Paola Rafaniello Raviele
- Division of Pathology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Edoardo Olmeda
- Division of Pathology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Francesca Menni
- Regional Clinical Center for Expanded Newborn Screening, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Furlan
- Regional Clinical Center for Expanded Newborn Screening, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Rossetti
- Respiratory Unit and Adult Cystic Fibrosis Centre, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Damarco
- Thoracic Surgery and Lung Transplant Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mauro Panigada
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
23
|
Lombardi A, Renisi G, Dondossola D, Palomba E, Del Prete L, Viero G, Zefelippo A, Azzarà C, Maccaro A, Perali C, Alagna L, Franchi E, Muscatello A, Gori A, Grasselli G, Donato MF, Matinato C, Caccamo L, Antonelli B, Bandera A. Perfusion fluid-related infections in liver transplant recipients: A 5-year, single-center, retrospective study. Transpl Infect Dis 2023; 25:e14130. [PMID: 37605507 DOI: 10.1111/tid.14130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/16/2023] [Accepted: 08/10/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Perfusion fluid (PRF) is employed in liver transplantation (LTx) to maintain graft viability. Still, it represents a new potential way of infection transmission in LTx recipients (LTRs). Currently, no systematic research has investigated this topic. METHODS Five-year single-center retrospective study conducted on LTRs from January 2017 to December 2021. We analyzed the incidence of positive PRF culture (PRF+) and perfusion fluid-related infections (PRF-RI) and their associated factors. We also assessed 1-year mortality, both overall and infection-related. RESULTS Overall, 234 LTx were included. PRF+ were found in 31/234 (13.2%) LTx for a total of 37 isolates, with >1 isolate identified in 5 (2.1%) cases. High-risk microorganisms (Enterobacterales 13/37, Enterococcus spp. 4/37, S. aureus 3/37, P. aeruginosa 2/37) were isolated in 25/37 (67.6%) LTRs, the remaining being coagulase-negative staphylococci (12/37, 32.4%). Antimicrobial prophylaxis was administered to all LTRs, always active against the isolate even if suboptimal in 19 cases (61.3%). PRF-RI developed in 4/234 LTx (1.7%), and prophylaxis was considered suboptimal in 2/4 of them. The isolation of >1 microorganism in PRF culture was associated with an increased risk of developing PRF-RI (OR 37.5 [95%CI 2.6-548.4], p = .01). PRF-RI were associated with longer ICU stays (p = .005) and higher 1-year mortality, both overall and related to infections (p = .001). CONCLUSION Despite PRF+ being infrequent, only a minority of patients develops PRF-RI. Nonetheless, once occurred, PRF-RI seems to increase morbidity and mortality rates.
Collapse
Affiliation(s)
- Andrea Lombardi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giulia Renisi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Daniele Dondossola
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Emanuele Palomba
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Luca Del Prete
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Giulia Viero
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Arianna Zefelippo
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Cecilia Azzarà
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Angelo Maccaro
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Carolina Perali
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Laura Alagna
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Eloisa Franchi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Antonio Muscatello
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Andrea Gori
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anaesthesiology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Intensive Care and Emergency, Milan, Italy
| | - Maria Francesca Donato
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, A.M. & A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Caterina Matinato
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Medical Laboratory of Clinical Chemistry and Microbiology, Milan, Italy
| | - Lucio Caccamo
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Barbara Antonelli
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Alessandra Bandera
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
24
|
Mangioni D, Panigada M, Palomba E, Bobbio C, Chatenoud L, Alagna L, Fumagalli J, Gori A, Grancini A, Guzzardella A, Lombardi A, Matinato C, Meli A, Muscatello A, Porretti L, Tomasello M, Trombetta E, Valenti L, Bandera A, Grasselli G. Incidence, microbiological and immunological characteristics of ventilator-associated pneumonia assessed by bronchoalveolar lavage and endotracheal aspirate in a prospective cohort of COVID-19 patients: CoV-AP study. Crit Care 2023; 27:369. [PMID: 37749631 PMCID: PMC10521470 DOI: 10.1186/s13054-023-04658-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND No univocal recommendation exists for microbiological diagnosis of ventilator-associated pneumonia (VAP). Sampling of either proximal or distal respiratory tract likely impacts on the broad range of VAP incidence between cohorts. Immune biomarkers to rule-in/rule-out VAP diagnosis, although promising, have not yet been validated. COVID-19-induced ARDS made VAP recognition even more challenging, often leading to overdiagnosis and overtreatment. We evaluated the impact of different respiratory samples and laboratory techniques on VAP incidence and microbiological findings in COVID-19 patients. METHODS Prospective single-centre cohort study conducted among COVID-19 mechanically ventilated patients in Policlinico Hospital (Milan, Italy) from January 2021 to May 2022. Microbiological confirmation of suspected VAP (sVAP) was based on concomitant endotracheal aspirates (ETA) and bronchoalveolar lavage (BAL). Conventional and fast microbiology (FILMARRAY® Pneumonia Panel plus, BALFAPPP) as well as immunological markers (immune cells and inflammatory cytokines) was analysed. RESULTS Seventy-nine patients were included. Exposure to antibiotics and steroid therapy before ICU admission occurred in 51/79 (64.6%) and 60/79 (65.9%) patients, respectively. Median duration of MV at VAP suspicion was 6 (5-9) days. Incidence rate of microbiologically confirmed VAP was 33.1 (95% CI 22.1-44.0) and 20.1 (95% CI 12.5-27.7) according to ETA and BAL, respectively. Concordance between ETA and BAL was observed in 35/49 (71.4%) cases, concordance between BALFAPPP and BAL in 39/49 (79.6%) cases. With BAL as reference standard, ETA showed 88.9% (95% CI 70.8-97.7) sensitivity and 50.0% (95% CI 28.2-71.8) specificity (Cohen's Kappa 0.40, 95% CI 0.16-0.65). BALFAPPP showed 95.0% (95% CI 75.1-99.9) sensitivity and 69% (95% CI 49.2-84.7) specificity (Cohen's Kappa 0.60, 95% CI 0.39-0.81). BAL IL-1β differed significantly between VAP (135 (IQR 11-450) pg/ml) and no-VAP (10 (IQR 2.9-105) pg/ml) patients (P = 0.03). CONCLUSIONS In COVID-19 ICU patients, differences in microbial sampling at VAP suspicion could lead to high variability in VAP incidence and microbiological findings. Concordance between ETA and BAL was mainly limited by over 20% of ETA positive and BAL negative samples, while BALFAPPP showed high sensitivity but limited specificity when evaluating in-panel targets only. These factors should be considered when comparing results of cohorts with different sampling. BAL IL-1β showed potential in discriminating microbiologically confirmed VAP. CLINICAL TRIAL REGISTRATION NCT04766983, registered on February 23, 2021.
Collapse
Affiliation(s)
- Davide Mangioni
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Mauro Panigada
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emanuele Palomba
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy.
| | - Chiara Bobbio
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Laura Alagna
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jacopo Fumagalli
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Anna Grancini
- Microbiology Laboratory, Clinical Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Lombardi
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Caterina Matinato
- Microbiology Laboratory, Clinical Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Meli
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Muscatello
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Porretti
- Flow Cytometry and Cell Sorting Laboratory, Clinical Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mara Tomasello
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Elena Trombetta
- Flow Cytometry and Cell Sorting Laboratory, Clinical Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Precision Medicine, Biological Resource Center Unit, Department of Transfusion Medicine, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Bandera
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
25
|
Rudym D, Pham T, Rackley CR, Grasselli G, Anderson M, Baldwin MR, Beitler J, Agerstrand C, Serra A, Winston LA, Bonadonna D, Yip N, Emerson LJ, Dzierba A, Sonett J, Abrams D, Ferguson ND, Bacchetta M, Schmidt M, Brodie D. Mortality in Patients with Obesity and Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation: The Multicenter ECMObesity Study. Am J Respir Crit Care Med 2023; 208:685-694. [PMID: 37638735 PMCID: PMC10515561 DOI: 10.1164/rccm.202212-2293oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 07/19/2023] [Indexed: 08/29/2023] Open
Abstract
Rationale: Patients with obesity are at increased risk for developing acute respiratory distress syndrome (ARDS). Some centers consider obesity a relative contraindication to receiving extracorporeal membrane oxygenation (ECMO) support, despite growing implementation of ECMO for ARDS in the general population. Objectives: To investigate the association between obesity and mortality in patients with ARDS receiving ECMO. Methods: In this large, international, multicenter, retrospective cohort study, we evaluated the association of obesity, defined as body mass index ⩾ 30 kg/m2, with ICU mortality in patients receiving ECMO for ARDS by performing adjusted multivariable logistic regression and propensity score matching. Measurements and Main Results: Of 790 patients with ARDS receiving ECMO in our study, 320 had obesity. Of those, 24.1% died in the ICU, compared with 35.3% of patients without obesity (P < 0.001). In adjusted models, obesity was associated with lower ICU mortality (odds ratio, 0.63 [95% confidence interval, 0.43-0.93]; P = 0.018). Examined as a continuous variable, higher body mass index was associated with decreased ICU mortality in multivariable regression (odds ratio, 0.97 [95% confidence interval, 0.95-1.00]; P = 0.023). In propensity score matching of 199 patients with obesity to 199 patients without, patients with obesity had a lower probability of ICU death than those without (22.6% vs. 35.2%; P = 0.007). Conclusions: Among patients receiving ECMO for ARDS, those with obesity had lower ICU mortality than patients without obesity in multivariable and propensity score matching analyses. Our findings support the notion that obesity should not be considered a general contraindication to ECMO.
Collapse
Affiliation(s)
- Darya Rudym
- Department of Medicine, New York University Langone Health, New York, New York
| | - Tài Pham
- Service de Médecine Intensive-Réanimation, Assistance Publique–Hôpitaux de Paris, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche CARMAS, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, Université de Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm U1018, Equipe d’Epidémiologie Respiratoire Intégrative, Centre d’Épidémiologie et de Santé des Populations, Villejuif, France
| | | | - Giacomo Grasselli
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italia
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Michaela Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew R. Baldwin
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jeremy Beitler
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure and
| | - Cara Agerstrand
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure and
| | - Alexis Serra
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Desiree Bonadonna
- Perfusion Services, Duke University Health System, Durham, North Carolina
| | - Natalie Yip
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure and
| | - Logan J. Emerson
- Duke Respiratory Care Services, Duke University Hospital, Durham, North Carolina
| | - Amy Dzierba
- Center for Acute Respiratory Failure and
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York
| | | | - Darryl Abrams
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure and
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine
- Department of Physiology, and
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Division of Respirology, University Health Network and Sinai Health, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt Medical Center East, Nashville, Tennessee
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30 RESPIRE, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique–Hôpitaux de Paris Hôpital Pitié–Salpêtrière, Paris, France; and
| | - Daniel Brodie
- Department of Medicine, School of Medicine, John Hopkins University, Baltimore, Maryland
| |
Collapse
|
26
|
Stucchi R, Ripoll-Gallardo A, Sechi GM, Weinstein ES, Villa GF, Frigerio C, Federighi F, Grasselli G, Zoli A, Bonora R, Fumagalli R. Severe Acute Respiratory Syndrome Coronavirus 2 and Medical Evacuation in Lombardy: Lessons Learned from an Unprecedented Pandemic. Disaster Med Public Health Prep 2023; 17:e480. [PMID: 37667885 DOI: 10.1017/dmp.2023.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerging infectious disease pandemic developed in Lombardy (northern Italy) during the last week of February 2020 with a progressive increase of patients presenting with serious clinical findings. Despite the efforts of the Central Italian Government, regional resources were rapidly at capacity. The solution was to plan the medical evacuation (MEDEVAC) of 119 critically ill patients (median age 61 years) to in-patient intensive care units in other Italian regions (77) and Germany (42). Once surviving patients were deemed suitable, the repatriation process concluded the assignment. The aim of this report is to underline the importance of a rapid organization and coordination process between different nodes of an effective national and international network during an emerging infectious disease outbreak and draw lessons learned from similar published reports.
Collapse
Affiliation(s)
- Riccardo Stucchi
- SSD AAT Milano, Agenzia Regionale Emergenza Urgenza (AREU), Dipartimento di Emergenza e Accettazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alba Ripoll-Gallardo
- SSD AAT Milano, Agenzia Regionale Emergenza Urgenza (AREU), Dipartimento di Emergenza e Accettazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- CRIMEDIM-Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
| | | | - Eric S Weinstein
- CRIMEDIM-Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
| | | | - Cristina Frigerio
- Dipartimento di Anestesia e Rianimazione, ASST Melegnano Martesana, Cernusco sul Naviglio, Italy
| | | | - Giacomo Grasselli
- Department of Anesthesia and Intensive Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy
| | - Alberto Zoli
- Agenzia Regionale Emergenza Urgenza (AREU), Milan, Italy
| | - Rodolfo Bonora
- Agenzia Regionale Emergenza Urgenza (AREU), Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Dipartimento di Anestesia e Rianimazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| |
Collapse
|
27
|
Russotto V, Lascarrou JB, Tassistro E, Parotto M, Antolini L, Bauer P, Szułdrzyński K, Camporota L, Putensen C, Pelosi P, Sorbello M, Higgs A, Greif R, Grasselli G, Valsecchi MG, Fumagalli R, Foti G, Caironi P, Bellani G, Laffey JG, Myatra SN. Efficacy and adverse events profile of videolaryngoscopy in critically ill patients: subanalysis of the INTUBE study. Br J Anaesth 2023; 131:607-616. [PMID: 37208282 DOI: 10.1016/j.bja.2023.04.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Tracheal intubation is a high-risk procedure in the critically ill, with increased intubation failure rates and a high risk of other adverse events. Videolaryngoscopy might improve intubation outcomes in this population, but evidence remains conflicting, and its impact on adverse event rates is debated. METHODS This is a subanalysis of a large international prospective cohort of critically ill patients (INTUBE Study) performed from 1 October 2018 to 31 July 2019 and involving 197 sites from 29 countries across five continents. Our primary aim was to determine the first-pass intubation success rates of videolaryngoscopy. Secondary aims were characterising (a) videolaryngoscopy use in the critically ill patient population and (b) the incidence of severe adverse effects compared with direct laryngoscopy. RESULTS Of 2916 patients, videolaryngoscopy was used in 500 patients (17.2%) and direct laryngoscopy in 2416 (82.8%). First-pass intubation success was higher with videolaryngoscopy compared with direct laryngoscopy (84% vs 79%, P=0.02). Patients undergoing videolaryngoscopy had a higher frequency of difficult airway predictors (60% vs 40%, P<0.001). In adjusted analyses, videolaryngoscopy increased the probability of first-pass intubation success, with an OR of 1.40 (95% confidence interval [CI] 1.05-1.87). Videolaryngoscopy was not significantly associated with risk of major adverse events (odds ratio 1.24, 95% CI 0.95-1.62) or cardiovascular events (odds ratio 0.78, 95% CI 0.60-1.02). CONCLUSIONS In critically ill patients, videolaryngoscopy was associated with higher first-pass intubation success rates, despite being used in a population at higher risk of difficult airway management. Videolaryngoscopy was not associated with overall risk of major adverse events. CLINICAL TRIAL REGISTRATION NCT03616054.
Collapse
Affiliation(s)
- Vincenzo Russotto
- Department of Anesthesia and Critical Care, University Hospital San Luigi Gonzaga, University of Turin, Italy
| | | | - Elena Tassistro
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 Center), University of Milano-Bicocca, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Matteo Parotto
- Department of Anesthesiology and Pain Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Laura Antolini
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 Center), University of Milano-Bicocca, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Konstanty Szułdrzyński
- Department of Anesthesiology and Intensive Care, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland; Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Luigi Camporota
- Health Centre for Human and Applied Physiological Sciences, Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Massimiliano Sorbello
- Anesthesia and Intensive Care, Policlinico Vittorio Emanuele San Marco University Hospital, Catania, Italy
| | - Andy Higgs
- Anaesthesia and Intensive Care Medicine, Warrington Teaching Hospitals NHS Foundation Trust, Warrington, UK
| | - Robert Greif
- Department of Anaesthesiology and Pain Therapy, Bern University Hospital, University of Bern, Bern, Switzerland; School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Giacomo Grasselli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria G Valsecchi
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 Center), University of Milano-Bicocca, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Anesthesiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Pietro Caironi
- Department of Anesthesia and Critical Care, University Hospital San Luigi Gonzaga, University of Turin, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - John G Laffey
- Regenerative Medicine Institute at CURAM Centre for Medical Devices, School of Medicine, University of Galway, Galway, Ireland; Anesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland.
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| |
Collapse
|
28
|
De Rosa S, Marengo M, Fiorentino M, Fanelli V, Brienza N, Fiaccadori E, Grasselli G, Morabito S, Pota V, Romagnoli S, Valente F, Cantaluppi V. Extracorporeal blood purification therapies for sepsis-associated acute kidney injury in critically ill patients: expert opinion from the SIAARTI-SIN joint commission. J Nephrol 2023; 36:1731-1742. [PMID: 37439963 PMCID: PMC10543830 DOI: 10.1007/s40620-023-01637-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 07/14/2023]
Abstract
Sepsis-Associated Acute Kidney Injury is a life-threatening condition leading to high morbidity and mortality in critically ill patients admitted to the intensive care unit. Over the past decades, several extracorporeal blood purification therapies have been developed for both sepsis and sepsis-associated acute kidney injury management. Despite the widespread use of extracorporeal blood purification therapies in clinical practice, it is still unclear when to start this kind of treatment and how to define its efficacy. Indeed, several questions on sepsis-associated acute kidney injury and extracorporeal blood purification therapy still remain unresolved, including the indications and timing of renal replacement therapy in patients with septic vs. non-septic acute kidney injury, the optimal dialysis dose for renal replacement therapy modalities in sepsis-associated acute kidney injury patients, and the rationale for using extracorporeal blood purification therapies in septic patients without acute kidney injury. Moreover, the development of novel extracorporeal blood purification therapies, including those based on the use of adsorption devices, raised the attention of the scientific community both on the clearance of specific mediators released by microorganisms and by injured cells and potentially involved in the pathogenic mechanisms of organ dysfunction including sepsis-associated acute kidney injury, and on antibiotic removal. Based on these considerations, the joint commission of the Italian Society of Anesthesiology and Critical Care (SIAARTI) and the Italian Society of Nephrology (SIN) herein addressed some of these issues, proposed some recommendations for clinical practice and developed a common framework for future clinical research in this field.
Collapse
Affiliation(s)
- Silvia De Rosa
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy.
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy.
| | - Marita Marengo
- Nephrology and Dialysis Unit, Department of Specialist Medicine, Azienda Sanitaria Locale (ASL) CN1, Cuneo, Italy
| | - Marco Fiorentino
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari, Bari, Italy
| | - Vito Fanelli
- Anesthesia, Critical Care and Emergency Unit, Department of Surgical Sciences, Città della Salute e della Scienza di Torino, University of Torino, Turin, Italy
| | - Nicola Brienza
- Unit of Anesthesia and Resuscitation, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Enrico Fiaccadori
- Dipartimento di Medicina e Chirurgia, UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Università di Parma, Parma, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Rome, Italy
| | - Vincenzo Pota
- Department of Women, Child, General and Specialty Surgery, L. Vanvitelli University of Campania, Naples, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, University of Firenze, Florence, Italy
| | - Fabrizio Valente
- Nephrology and Dialysis Unit, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine (DIMET), SCDU Nefrologia e Trapianto Renale, University of Piemonte Orientale (UPO), Azienda Ospedaliero-Universitaria Maggiore della Carità, via Solaroli 17, 28100, Novara, Italy.
| |
Collapse
|
29
|
Florio G, Valsecchi C, Vivona L, Battistin M, Colombo SM, Cattaneo E, Protti I, DI Feliciantonio M, Castelli G, Dondossola D, Biancolilli O, Carlin A, Gatti S, Pesenti AM, Zanella A, Grasselli G. Enhanced extracorporeal carbon dioxide removal by acidification and metabolic control. Minerva Anestesiol 2023; 89:773-782. [PMID: 36951601 DOI: 10.23736/s0375-9393.23.17142-2] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND Extracorporeal carbon dioxide removal (ECCO2R) promotes protective ventilation in patients with acute respiratory failure, but devices with high CO2 extraction capacity are required for clinically relevant impact. This study evaluates three novel low-flow techniques based on dialysate acidification, also combined with renal replacement therapy, and metabolic control. METHODS Eight swine were connected to a low-flow (350 mL/min) extracorporeal circuit including a dialyzer with a closed-loop dialysate circuit, and two membrane lungs on blood (MLb) and dialysate (MLd), respectively. The following 2-hour steps were performed: 1) MLb-start (MLb ventilated); 2) MLbd-start (MLb and MLd ventilated); 3) HLac (lactic acid infusion before MLd); 4) HCl-NaLac (hydrochloric acid infusion before MLd combined with renal replacement therapy and reinfusion of sodium lactate); 5) HCl-βHB-NaLac (hydrochloric acid infusion before MLd combined with renal replacement therapy and reinfusion of sodium lactate and sodium 3-hydroxybutyrate). Caloric and fluid inputs, temperature, blood glucose and arterial carbon dioxide pressure were kept constant. RESULTS The total MLs CO2 removal in HLac (130±25 mL/min), HCl-NaLac (130±21 mL/min) and HCl-βHB-NaLac (124±18 mL/min) were higher compared with MLbd-start (81±15 mL/min, P<0.05) and MLb-start (55±7 mL/min, P<0.05). Minute ventilation in HLac (4.3±0.9 L/min), HCl-NaLac (3.6±0.8 L/min) and HCl-βHB-NaLac (3.6±0.8 L/min) were lower compared to MLb-start (6.2±1.1 L/min, P<0.05) and MLbd-start (5.8±2.1 L/min, P<0.05). Arterial pH was 7.40±0.03 at MLb-start and decreased only during HCl-βHB-NaLac (7.35±0.03, P<0.05). No relevant changes in electrolyte concentrations, hemodynamics and significant adverse events were detected. CONCLUSIONS The three techniques achieved a significant extracorporeal CO2 removal allowing a relevant reduction in minute ventilation with a sufficient safety profile.
Collapse
Affiliation(s)
- Gaetano Florio
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Carlo Valsecchi
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Luigi Vivona
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Michele Battistin
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Sebastiano M Colombo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Emanuele Cattaneo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Protti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Gloria Castelli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Daniele Dondossola
- Liver Transplant and General Surgery Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Osvaldo Biancolilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Carlin
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Gatti
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio M Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy -
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
30
|
Mangioni D, Chatenoud L, Colombo J, Palomba E, Guerrero FA, Bolis M, Bottino N, Breda G, Chiaruttini MV, Fior G, Marotta M, Massobrio G, Matinato C, Muscatello A, Previtali P, Santambrogio S, Tardini F, Zuglian G, Grasselli G, Fumagalli R, Gori A, Stocchetti N, Monti G, Bandera A. Multidrug-Resistant Bacterial Colonization and Infections in Large Retrospective Cohort of Mechanically Ventilated COVID-19 Patients 1. Emerg Infect Dis 2023; 29:1598-1607. [PMID: 37486196 PMCID: PMC10370845 DOI: 10.3201/eid2908.230115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
Few data are available on incidence of multidrug-resistant organism (MDRO) colonization and infections in mechanically ventilated patients, particularly during the COVID-19 pandemic. We retrospectively evaluated all patients admitted to the COVID-19 intensive care unit (ICU) of Hub Hospital in Milan, Italy, during October 2020‒May 2021. Microbiologic surveillance was standardized with active screening at admission and weekly during ICU stay. Of 435 patients, 88 (20.2%) had MDROs isolated ≤48 h after admission. Of the remaining patients, MDRO colonization was diagnosed in 173 (51.2%), MDRO infections in 95 (28.1%), and non-MDRO infections in 212 (62.7%). Non-MDRO infections occurred earlier than MDRO infections (6 days vs. 10 days; p<0.001). Previous exposure to antimicrobial drugs within the ICU was higher in MDRO patients than in non-MDRO patients (116/197 [58.9%] vs. 18/140 [12.9%]; p<0.001). Our findings might serve as warnings for future respiratory viral pandemics and call for increased measures of antimicrobial stewardship and infection control.
Collapse
|
31
|
Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 97.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
Collapse
Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| |
Collapse
|
32
|
Panigada M, Meli A, Forastieri Molinari A, Grazioli L, Giani M, Ceriani D, Bianchi C, Passarelli MT, Consonni D, Grasselli G. Agreement Between Viscoelastic Coagulation Monitor (VCM), TEG 5000, and Coagulation Tests in Critically Ill Patients: A Multicenter Study. ASAIO J 2023; 69:e230-e239. [PMID: 37019087 DOI: 10.1097/mat.0000000000001932] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
The performance of viscoelastic coagulation monitor (VCM) compared with TEG 5000 (TEG) is unknown. In this multicenter study, the authors evaluated the agreement among VCM/TEG parameters and their relationship with standard coagulation tests in critically ill patients. Viscoelastic coagulation monitor, TEG, and laboratory samples were analyzed simultaneously. Viscoelastic coagulation monitor/TEG agreement was computed by Bland and Altman's plots, association with laboratory parameters was studied with Spearman's correlation coefficient and random-intercept linear models. One-hundred and twenty-seven patients enrolled, 320 paired observations: 210 (65.6%) under unfractioned heparin (UFH), 94 (29.4%) under low molecular weight heparin (LMWH), 16 (5.0%) no heparin. Under UFH prolonged clot formation times and reduced the amplitude of viscoelastic tracings on both devices, especially on TEG. The type of heparin affected the agreement between VCM/TEG homolog parameters. Reaction time (TEG-R) resulted 23.1 min longer than the homolog clotting time (VCM-CT) under UFH; maximum amplitude (TEG-MA) resulted 29.5 mm higher than maximum clot firmness (VCM-MCF) under LMWH. Weak correlation was observed between VCM-CT/TEG-R and activated partial thromboplastin time (aPTT)/anti-Xa; no correlation was found between VCM-alpha/TEG-angle and fibrinogen concentration. Viscoelastic coagulation monitor-MCF showed strong (LWMH) to moderate (UFH) correlation with platelet count, while TEG-MA only showed lower correlation. Viscoelastic coagulation monitor and TEG are differently affected by heparin. The platelet count is well represented by VCM-MCF even during UFH administration.
Collapse
Affiliation(s)
- Mauro Panigada
- From the Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Meli
- From the Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Lorenzo Grazioli
- Department of Anesthesia and Intensive Care, ASST Papa Giovanni, Bergamo, Italy
| | - Marco Giani
- Department of Emergency and Intensive Care, ASST Monza, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Daniele Ceriani
- Department of Anesthesia and Intensive Care, A. Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Cecilia Bianchi
- Department of Anesthesia and Intensive Care, ASST Papa Giovanni, Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Maria Teresa Passarelli
- Department of Emergency and Intensive Care, ASST Monza, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- From the Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
33
|
Ghosn L, Assi R, Evrenoglou T, Buckley BS, Henschke N, Probyn K, Riveros C, Davidson M, Graña C, Bonnet H, Jarde A, Ávila C, Nejstgaard CH, Menon S, Ferrand G, Kapp P, Breuer C, Schmucker C, Sguassero Y, Nguyen TV, Devane D, Meerpohl JJ, Rada G, Hróbjartsson A, Grasselli G, Tovey D, Ravaud P, Chaimani A, Boutron I. Interleukin-6 blocking agents for treating COVID-19: a living systematic review. Cochrane Database Syst Rev 2023; 6:CD013881. [PMID: 37260086 PMCID: PMC10237088 DOI: 10.1002/14651858.cd013881.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND It has been reported that people with COVID-19 and pre-existing autoantibodies against type I interferons are likely to develop an inflammatory cytokine storm responsible for severe respiratory symptoms. Since interleukin 6 (IL-6) is one of the cytokines released during this inflammatory process, IL-6 blocking agents have been used for treating people with severe COVID-19. OBJECTIVES To update the evidence on the effectiveness and safety of IL-6 blocking agents compared to standard care alone or to a placebo for people with COVID-19. SEARCH METHODS We searched the World Health Organization (WHO) International Clinical Trials Registry Platform, the Living OVerview of Evidence (L·OVE) platform, and the Cochrane COVID-19 Study Register to identify studies on 7 June 2022. SELECTION CRITERIA We included randomized controlled trials (RCTs) evaluating IL-6 blocking agents compared to standard care alone or to placebo for people with COVID-19, regardless of disease severity. DATA COLLECTION AND ANALYSIS Pairs of researchers independently conducted study selection, extracted data and assessed risk of bias. We assessed the certainty of evidence using the GRADE approach for all critical and important outcomes. In this update we amended our protocol to update the methods used for grading evidence by establishing minimal important differences for the critical outcomes. MAIN RESULTS This update includes 22 additional trials, for a total of 32 trials including 12,160 randomized participants all hospitalized for COVID-19 disease. We identified a further 17 registered RCTs evaluating IL-6 blocking agents without results available as of 7 June 2022. The mean age range varied from 56 to 75 years; 66.2% (8051/12,160) of enrolled participants were men. One-third (11/32) of included trials were placebo-controlled. Twenty-two were published in peer-reviewed journals, three were reported as preprints, two trials had results posted only on registries, and results from five trials were retrieved from another meta-analysis. Eight were funded by pharmaceutical companies. Twenty-six included studies were multicenter trials; four were multinational and 22 took place in single countries. Recruitment of participants occurred between February 2020 and June 2021, with a mean enrollment duration of 21 weeks (range 1 to 54 weeks). Nineteen trials (60%) had a follow-up of 60 days or more. Disease severity ranged from mild to critical disease. The proportion of participants who were intubated at study inclusion also varied from 5% to 95%. Only six trials reported vaccination status; there were no vaccinated participants included in these trials, and 17 trials were conducted before vaccination was rolled out. We assessed a total of six treatments, each compared to placebo or standard care. Twenty trials assessed tocilizumab, nine assessed sarilumab, and two assessed clazakizumab. Only one trial was included for each of the other IL-6 blocking agents (siltuximab, olokizumab, and levilimab). Two trials assessed more than one treatment. Efficacy and safety of tocilizumab and sarilumab compared to standard care or placebo for treating COVID-19 At day (D) 28, tocilizumab and sarilumab probably result in little or no increase in clinical improvement (tocilizumab: risk ratio (RR) 1.05, 95% confidence interval (CI) 1.00 to 1.11; 15 RCTs, 6116 participants; moderate-certainty evidence; sarilumab: RR 0.99, 95% CI 0.94 to 1.05; 7 RCTs, 2425 participants; moderate-certainty evidence). For clinical improvement at ≥ D60, the certainty of evidence is very low for both tocilizumab (RR 1.10, 95% CI 0.81 to 1.48; 1 RCT, 97 participants; very low-certainty evidence) and sarilumab (RR 1.22, 95% CI 0.91 to 1.63; 2 RCTs, 239 participants; very low-certainty evidence). The effect of tocilizumab on the proportion of participants with a WHO Clinical Progression Score (WHO-CPS) of level 7 or above remains uncertain at D28 (RR 0.90, 95% CI 0.72 to 1.12; 13 RCTs, 2117 participants; low-certainty evidence) and that for sarilumab very uncertain (RR 1.10, 95% CI 0.90 to 1.33; 5 RCTs, 886 participants; very low-certainty evidence). Tocilizumab reduces all cause-mortality at D28 compared to standard care/placebo (RR 0.88, 95% CI 0.81 to 0.94; 18 RCTs, 7428 participants; high-certainty evidence). The evidence about the effect of sarilumab on this outcome is very uncertain (RR 1.06, 95% CI 0.86 to 1.30; 9 RCTs, 3305 participants; very low-certainty evidence). The evidence is uncertain for all cause-mortality at ≥ D60 for tocilizumab (RR 0.91, 95% CI 0.80 to 1.04; 9 RCTs, 2775 participants; low-certainty evidence) and very uncertain for sarilumab (RR 0.95, 95% CI 0.84 to 1.07; 6 RCTs, 3379 participants; very low-certainty evidence). Tocilizumab probably results in little to no difference in the risk of adverse events (RR 1.03, 95% CI 0.95 to 1.12; 9 RCTs, 1811 participants; moderate-certainty evidence). The evidence about adverse events for sarilumab is uncertain (RR 1.12, 95% CI 0.97 to 1.28; 4 RCT, 860 participants; low-certainty evidence). The evidence about serious adverse events is very uncertain for tocilizumab (RR 0.93, 95% CI 0.81 to 1.07; 16 RCTs; 2974 participants; very low-certainty evidence) and uncertain for sarilumab (RR 1.09, 95% CI 0.97 to 1.21; 6 RCTs; 2936 participants; low-certainty evidence). Efficacy and safety of clazakizumab, olokizumab, siltuximab and levilimab compared to standard care or placebo for treating COVID-19 The evidence about the effects of clazakizumab, olokizumab, siltuximab, and levilimab comes from only one or two studies for each blocking agent, and is uncertain or very uncertain. AUTHORS' CONCLUSIONS In hospitalized people with COVID-19, results show a beneficial effect of tocilizumab on all-cause mortality in the short term and probably little or no difference in the risk of adverse events compared to standard care alone or placebo. Nevertheless, both tocilizumab and sarilumab probably result in little or no increase in clinical improvement at D28. Evidence for an effect of sarilumab and the other IL-6 blocking agents on critical outcomes is uncertain or very uncertain. Most of the trials included in our review were done before the waves of different variants of concern and before vaccination was rolled out on a large scale. An additional 17 RCTs of IL-6 blocking agents are currently registered with no results yet reported. The number of pending studies and the number of participants planned is low. Consequently, we will not publish further updates of this review.
Collapse
Affiliation(s)
- Lina Ghosn
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Rouba Assi
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Theodoros Evrenoglou
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | | | | | | | - Carolina Riveros
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Mauricia Davidson
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Carolina Graña
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Hillary Bonnet
- Cochrane France, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Alexander Jarde
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | | | - Camilla Hansen Nejstgaard
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | | | | | - Philipp Kapp
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Breuer
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | | | | | - Declan Devane
- Evidence Synthesis Ireland, Galway, Ireland
- Cochrane Ireland and HRB-Trials Methodology Research Network, Galway, Ireland
- University of Galway, Galway, Ireland
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Gabriel Rada
- Epistemonikos Foundation, Santiago, Chile
- UC Evidence Center, Cochrane Chile Associated Center, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Philippe Ravaud
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Anna Chaimani
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Isabelle Boutron
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| |
Collapse
|
34
|
Galazzi A, Bruno M, Binda F, Caddeo G, Chierichetti M, Roselli P, Grasselli G, Laquintana D. Thematic analysis of intensive care unit diaries kept by staff: insights for caring. Intensive Crit Care Nurs 2023; 76:103392. [PMID: 36731262 PMCID: PMC9870754 DOI: 10.1016/j.iccn.2023.103392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/07/2023] [Accepted: 01/16/2023] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To explore recurrent themes in diaries kept by intensive care unit (ICU) staff during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN Qualitative study. SETTING Two ICUs in a tertiary level hospital (Milan, Italy) from January to December 2021. METHODS ICU staff members wrote a digital diary while caring for adult patients hospitalized in the intensive care unit for >48 hours. A thematic analysis was performed. FINDINGS Diary entries described what happened and expressed emotions. Thematic analysis of 518 entries gleaned from 48 diaries identified four themes (plus ten subthemes): Presenting (Places and people; Diary project), Intensive Care Unit Stay (Clinical events; What the patient does; Patient support), Outside the Hospital (Family and topical events; The weather), Feelings and Thoughts (Encouragement and wishes; Farewell; Considerations). CONCLUSION The themes were similar to published findings. They offer insight into care in an intensive care unit during a pandemic, with scarce resources and no family visitors permitted, reflecting on the patient as a person and on daily care. The staff wrote farewell entries to dying patients even though no one would read them. IMPLICATIONS FOR CLINICAL PRACTICE The implementation of digital diaries kept by intensive care unit staff is feasible even during the COVID-19 pandemic. Diaries kept by staff can provide a tool to humanize critical care. Staff can improve their work by reflecting on diary records.
Collapse
Affiliation(s)
- Alessandro Galazzi
- Department of Healthcare Professions, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Bruno
- Department of Healthcare Professions, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Filippo Binda
- Department of Healthcare Professions, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Corresponding author at: Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35 – 20122 Milan, Italy
| | - Giorgia Caddeo
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Monica Chierichetti
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Roselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Dario Laquintana
- Department of Healthcare Professions, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
35
|
Fanning JP, Weaver N, Fanning RB, Griffee MJ, Cho SM, Panigada M, Obonyo NG, Zaaqoq AM, Rando H, Chia YW, Fan BE, Sela D, Chiumello D, Coppola S, Labib A, Whitman GJR, Arora RC, Kim BS, Motos A, Torres A, Barbé F, Grasselli G, Zanella A, Etchill E, Usman AA, Feth M, White NM, Suen JY, Li Bassi G, Peek GJ, Fraser JF, Dalton H. Hemorrhage, Disseminated Intravascular Coagulopathy, and Thrombosis Complications Among Critically Ill Patients with COVID-19: An International COVID-19 Critical Care Consortium Study. Crit Care Med 2023; 51:619-631. [PMID: 36867727 PMCID: PMC10089926 DOI: 10.1097/ccm.0000000000005798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
OBJECTIVES To determine the prevalence and outcomes associated with hemorrhage, disseminated intravascular coagulopathy, and thrombosis (HECTOR) complications in ICU patients with COVID-19. DESIGN Prospective, observational study. SETTING Two hundred twenty-nine ICUs across 32 countries. PATIENTS Adult patients (≥ 16 yr) admitted to participating ICUs for severe COVID-19 from January 1, 2020, to December 31, 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS HECTOR complications occurred in 1,732 of 11,969 study eligible patients (14%). Acute thrombosis occurred in 1,249 patients (10%), including 712 (57%) with pulmonary embolism, 413 (33%) with myocardial ischemia, 93 (7.4%) with deep vein thrombosis, and 49 (3.9%) with ischemic strokes. Hemorrhagic complications were reported in 579 patients (4.8%), including 276 (48%) with gastrointestinal hemorrhage, 83 (14%) with hemorrhagic stroke, 77 (13%) with pulmonary hemorrhage, and 68 (12%) with hemorrhage associated with extracorporeal membrane oxygenation (ECMO) cannula site. Disseminated intravascular coagulation occurred in 11 patients (0.09%). Univariate analysis showed that diabetes, cardiac and kidney diseases, and ECMO use were risk factors for HECTOR. Among survivors, ICU stay was longer (median days 19 vs 12; p < 0.001) for patients with versus without HECTOR, but the hazard of ICU mortality was similar (hazard ratio [HR] 1.01; 95% CI 0.92-1.12; p = 0.784) overall, although this hazard was identified when non-ECMO patients were considered (HR 1.13; 95% CI 1.02-1.25; p = 0.015). Hemorrhagic complications were associated with an increased hazard of ICU mortality compared to patients without HECTOR complications (HR 1.26; 95% CI 1.09-1.45; p = 0.002), whereas thrombosis complications were associated with reduced hazard (HR 0.88; 95% CI 0.79-0.99, p = 0.03). CONCLUSIONS HECTOR events are frequent complications of severe COVID-19 in ICU patients. Patients receiving ECMO are at particular risk of hemorrhagic complications. Hemorrhagic, but not thrombotic complications, are associated with increased ICU mortality.
Collapse
Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Natasha Weaver
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Robert B Fanning
- Northern Hospital, Northern Health, Melbourne, VIC, Australia
- Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Matthew J Griffee
- Department of Anesthesiology and Perioperative Medicine, Sections of Critical Care and Perioperative Echocardiography, University of Utah, Salt Lake City, UT
- Department of Anesthesiology, Anesthesiology Service, Veteran Affairs Medical Center, Salt Lake City, UT
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Neuroscience Critical Care, Department of Neurology and Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Mauro Panigada
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, Department of Anesthesia, Intensive Care and Emergency. Milano, Lombardia, Italy
| | - Nchafatso G Obonyo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Initiative to Develop African Research Leaders (IDeAL)/KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Wellcome Trust Centre for Global Health Research, Imperial College London, London, United Kingdom
| | - Akram M Zaaqoq
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC
- Department of Medicine, Georgetown University, Washington, DC
| | - Hannah Rando
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Yew Woon Chia
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bingwen Eugene Fan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Haematology, Tan Tock Seng Hospital, Singapore
- Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore
| | - Declan Sela
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Davide Chiumello
- Department of Anesthesia and Intensive Care, Aziende Socio Sanitarie Territoriali (ASST) Santi Paolo e Carlo, San Paolo University Hospital of Milan, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, Aziende Socio Sanitarie Territoriali (ASST) Santi Paolo e Carlo, San Paolo University Hospital of Milan, Milan, Italy
| | - Ahmed Labib
- Medical Intensive Care Unit, Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Bo S Kim
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anna Motos
- Harrington Heart and Vascular Institute, University Hospitals - Cleveland Medical Center, Cleveland, OH
- Division of Cardiac Surgery, Department of Surgery, Case Western Reserve University, Cleveland, OH
| | - Antoni Torres
- Harrington Heart and Vascular Institute, University Hospitals - Cleveland Medical Center, Cleveland, OH
- Division of Cardiac Surgery, Department of Surgery, Case Western Reserve University, Cleveland, OH
- Centro de Investigación Biomedica En Red - Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Ferran Barbé
- Harrington Heart and Vascular Institute, University Hospitals - Cleveland Medical Center, Cleveland, OH
- Servei de Pneumologia, Hospital Clinic, University of Barcelona, Spain
| | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, Department of Anesthesia, Intensive Care and Emergency. Milano, Lombardia, Italy
- Institució Catalana de Recerca i Estudis Avançats, Spain
| | - Alberto Zanella
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, Department of Anesthesia, Intensive Care and Emergency. Milano, Lombardia, Italy
- Institució Catalana de Recerca i Estudis Avançats, Spain
| | - Eric Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Asad Ali Usman
- Translational Research in Respiratory Medicine, Respiratory Department, Hospital Universitari Aranu de Vilanova and Santa Maria, IRBLleida, Leida, Spain
| | - Maximilian Feth
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Nicole M White
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology, Critical Care, Emergency and Pain Medicine, Military Medical Center Ulm, Ulm, Germany
| | - Giles J Peek
- Department of Anesthesiology, Critical Care, Emergency and Pain Medicine, Military Medical Center Ulm, Ulm, Germany
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
- Queensland University of Technology, Brisbane, QLD, Australia
| | - Heidi Dalton
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
- Congenital Heart Centre, University of Florida, Gainesville, FL
| |
Collapse
|
36
|
Meli A, Grasselli G, Panigada M. Hemoglobin Concentration and Viscoelastic Tests: Remember to Consider Fibrinogen and Platelets. Crit Care Med 2023; 51:e122-e123. [PMID: 37052444 DOI: 10.1097/ccm.0000000000005799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Affiliation(s)
- Andrea Meli
- Department of Anesthesia and Intensive Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia and Intensive Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Mauro Panigada
- Department of Anesthesia and Intensive Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
37
|
Pham T, Heunks L, Bellani G, Madotto F, Aragao I, Beduneau G, Goligher EC, Grasselli G, Laake JH, Mancebo J, Peñuelas O, Piquilloud L, Pesenti A, Wunsch H, van Haren F, Brochard L, Laffey JG, Acharya SP, Amin P, Arabi Y, Aragao I, Bauer P, Beduneau G, Beitler J, Berkius J, Bugedo G, Camporota L, Cerny V, Cho YJ, Clarkson K, Estenssoro E, Goligher E, Grasselli G, Gritsan A, Hashemian SM, Hermans G, Heunks LM, Jovanovic B, Kurahashi K, Laake JH, Matamis D, Moerer O, Molnar Z, Ozyilmaz E, Panka B, Papali A, Peñuelas Ó, Perbet S, Piquilloud L, Qiu H, Razek AA, Rittayamai N, Roldan R, Serpa Neto A, Szuldrzynski K, Talmor D, Tomescu D, Van Haren F, Villagomez A, Zeggwagh AA, Abe T, Aboshady A, Acampo-de Jong M, Acharya S, Adderley J, Adiguzel N, Agrawal VK, Aguilar G, Aguirre G, Aguirre-Bermeo H, Ahlström B, Akbas T, Akker M, Al Sadeh G, Alamri S, Algaba A, Ali M, Aliberti A, Allegue JM, Alvarez D, Amador J, Andersen FH, Ansari S, Apichatbutr Y, Apostolopoulou O, Arabi Y, Arellano D, Arica M, Arikan H, Arinaga K, Arnal JM, Asano K, Asín-Corrochano M, Avalos Cabrera JM, Avila Fuentes S, Aydemir S, Aygencel G, Azevedo L, Bacakoglu F, Badie J, Baedorf Kassis E, Bai G, Balaraj G, Ballico B, Banner-Goodspeed V, Banwarie P, Barbieri R, Baronia A, Barrett J, Barrot L, Barrueco-Francioni JE, Barry J, Bauer P, Bawangade H, Beavis S, Beck E, Beehre N, Belenguer Muncharaz A, Bellani G, Belliato M, Bellissima A, Beltramelli R, Ben Souissi A, Benitez-Cano A, Benlamin M, Benslama A, Bento L, Benvenuti D, Berkius J, Bernabe L, Bersten A, Berta G, Bertini P, Bertram-Ralph E, Besbes M, Bettini LR, Beuret P, Bewley J, Bezzi M, Bhakhtiani L, Bhandary R, Bhowmick K, Bihari S, Bissett B, Blythe D, Bocher S, Boedjawan N, Bojanowski CM, Boni E, Boraso S, Borelli M, Borello S, Borislavova M, Bosma KJ, Bottiroli M, Boyd O, Bozbay S, Briva A, Brochard L, Bruel C, Bruni A, Buehner U, Bugedo G, Bulpa P, Burt K, Buscot M, Buttera S, Cabrera J, Caccese R, Caironi P, Canchos Gutierrez I, Canedo N, Cani A, Cappellini I, Carazo J, Cardonnet LP, Carpio D, Carriedo D, Carrillo R, Carvalho J, Caser E, Castelli A, Castillo Quintero M, Castro H, Catorze N, Cengiz M, Cereijo E, Ceunen H, Chaintoutis C, Chang Y, Chaparro G, Chapman C, Chau S, Chavez CE, Chelazzi C, Chelly J, Chemouni F, Chen K, Chena A, Chiarandini P, Chilton P, Chiumello D, Cho YJ, Chou-Lie Y, Chudeau N, Cinel I, Cinnella G, Clark M, Clark T, Clarkson K, Clementi S, Coaguila L, Codecido AJ, Collins A, Colombo R, Conde J, Consales G, Cook T, Coppadoro A, Cornejo R, Cortegiani A, Coxo C, Cracchiolo AN, Crespo Ramirez M, Crova P, Cruz J, Cubattoli L, Çukurova Z, Curto F, Czempik P, D'Andrea R, da Silva Ramos F, Dangers L, Danguy des Déserts M, Danin PE, Dantas F, Daubin C, Dawei W, de Haro C, de Jesus Montelongo F, De Mendoza D, de Pablo R, De Pascale G, De Rosa S, Decavèle M, Declercq PL, Deicas A, del Carmen Campos Moreno M, Dellamonica J, Delmas B, Demirkiran O, Demirkiran H, Dendane T, di Mussi R, Diakaki C, Diaz A, Diaz W, Dikmen Y, Dimoula A, Doble P, Doha N, Domingos G, Dres M, Dries D, Duggal A, Duke G, Dunts P, Dybwik K, Dykyy M, Eckert P, Efe S, Elatrous S, Elay G, Elmaryul AS, Elsaadany M, Elsayed H, Elsayed S, Emery M, Ena S, Eng K, Englert JA, Erdogan E, Ergin Ozcan P, Eroglu E, Escobar M, Esen F, Esen Tekeli A, Esquivel A, Esquivel Gallegos H, Ezzouine H, Facchini A, Faheem M, Fanelli V, Farina MF, Fartoukh M, Fehrle L, Feng F, Feng Y, Fernandez I, Fernandez B, Fernandez-Rodriguez ML, Ferrando C, Ferreira da Silva MJ, Ferreruela M, Ferrier J, Flamm Zamorano MJ, Flood L, Floris L, Fluckiger M, Forteza C, Fortunato A, Frans E, Frattari A, Fredes S, Frenzel T, Fumagalli R, Furche MA, Fusari M, Fysh E, Galeas-Lopez JL, Galerneau LM, Garcia A, Garcia MF, Garcia E, Garcia Olivares P, Garlicki J, Garnero A, Garofalo E, Gautam P, Gazenkampf A, Gelinotte S, Gelormini D, Ghrenassia E, Giacomucci A, Giannoni R, Gigante A, Glober N, Gnesin P, Gollo Y, Gomaa D, Gomero Paredes R, Gomes R, Gomez RA, Gomez O, Gomez A, Gondim L, Gonzalez M, Gonzalez I, Gonzalez-Castro A, Gordillo Romero O, Gordo F, Gouin P, Graf Santos J, Grainne R, Grando M, Granov Grabovica S, Grasselli G, Grasso S, Grasso R, Grimmer L, Grissom C, Gritsan A, Gu Q, Guan XD, Guarracino F, Guasch N, Guatteri L, Gueret R, Guérin C, Guerot E, Guitard PG, Gül F, Gumus A, Gurjar M, Gutierrez P, Hachimi A, Hadzibegovic A, Hagan S, Hammel C, Han Song J, Hanlon G, Hashemian SM, Heines S, Henriksson J, Herbrecht JE, Heredia Orbegoso GO, Hermans G, Hermon A, Hernandez R, Hernandez C, Herrera L, Herrera-Gutierrez M, Heunks L, Hidalgo J, Hill D, Holmquist D, Homez M, Hongtao X, Hormis A, Horner D, Hornos MC, Hou M, House S, Housni B, Hugill K, Humphreys S, Humbert L, Hunter S, Hwa Young L, Iezzi N, Ilutovich S, Inal V, Innes R, Ioannides P, Iotti GA, Ippolito M, Irie H, Iriyama H, Itagaki T, Izura J, Izza S, Jabeen R, Jamaati H, Jamadarkhana S, Jamoussi A, Jankowski M, Jaramillo LA, Jeon K, Jeong Lee S, Jeswani D, Jha S, Jiang L, Jing C, Jochmans S, Johnstad BA, Jongmin L, Joret A, Jovanovic B, Junhasavasdikul D, Jurado MT, Kam E, Kamohara H, Kane C, Kara I, Karakurt S, Karnjanarachata C, Kataoka J, Katayama S, Kaushik S, Kelebek Girgin N, Kerr K, Kerslake I, Khairnar P, Khalid A, Khan A, Khanna AK, Khorasanee R, Kienhorst D, Kirakli C, Knafelj R, Kol MK, Kongpolprom N, Kopitko C, Korkmaz Ekren P, Kubisz-Pudelko A, Kulcsar Z, Kumasawa J, Kurahashi K, Kuriyama A, Kutchak F, Laake JH, Labarca E, Labat F, Laborda C, Laca Barrera MA, Lagache L, Landaverde Lopez A, Lanspa M, Lascari V, Le Meur M, Lee SH, Lee YJ, Lee J, Lee WY, Lee J, Legernaes T, Leiner T, Lemiale V, Leonor T, Lepper PM, Li D, Li H, Li O, Lima AR, Lind D, Litton E, Liu N, Liu L, Liu J, Llitjos JF, Llorente B, Lopez R, Lopez CE, Lopez Nava C, Lovazzano P, Lu M, Lucchese F, Lugano M, Lugo Goytia G, Luo H, Lynch C, Macheda S, Madrigal Robles VH, Maggiore SM, Magret Iglesias M, Malaga P, Mallapura Maheswarappa H, Malpartida G, Malyarchikov A, Mansson H, Manzano A, Marey I, Marin N, Marin MDC, Markman E, Martin F, Martin A, Martin Dal Gesso C, Martinez F, Martínez-Fidalgo C, Martin-Loeches I, Mas A, Masaaki S, Maseda E, Massa E, Mattsson A, Maugeri J, McCredie V, McCullough J, McGuinness S, McKown A, Medve L, Mei C, Mellado Artigas R, Mendes V, Mervat MKE, Michaux I, Mikhaeil M, Milagros O, Milet I, Millan MT, Minwei Z, Mirabella L, Mishra S, Mistraletti G, Mochizuki K, Moerer O, Moghal A, Mojoli F, Molin A, Molnar Z, Montiel R, Montini L, Monza G, Mora Aznar M, Morakul S, Morales M, Moreno Torres D, Morocho Tutillo DR, Motherway C, Mouhssine D, Mouloudi E, Muñoz T, Munoz de Cabo C, Mustafa M, Muthuchellappan R, Muthukrishnan M, Muttini S, Nagata I, Nahar D, Nakanishi M, Nakayama I, Namendys-Silva SA, Nanchal R, Nandakumar S, Nasi A, Nasir K, Navalesi P, Naz Aslam T, Nga Phan T, Nichol A, Niiyama S, Nikolakopoulou S, Nikolic E, Nitta K, Noc M, Nonas S, Nseir S, Nur Soyturk A, Obata Y, Oeckler R, Oguchi M, Ohshimo S, Oikonomou M, Ojados A, Oliveira MT, Oliveira Filho W, Oliveri C, Olmos A, Omura K, Orlandi MC, Orsenigo F, Ortiz-Ruiz De Gordoa L, Ota K, Ovalle Olmos R, Öveges N, Oziemski P, Ozkan Kuscu O, Özyilmaz E, Pachas Alvarado F, Pagella G, Palaniswamy V, Palazon Sanchez EL, Palmese S, Pan G, Pan W, Panka B, Papanikolaou M, Papavasilopoulou T, Parekh A, Parke R, Parrilla FJ, Parrilla D, Pasha T, Pasin L, Patão L, Patel M, Patel G, Pati BK, Patil J, Pattnaik S, Paul D, Pavesi M, Pavlotsky VA, Paz G, Paz E, Pecci E, Pellegrini C, Peña Padilla AG, Perchiazzi G, Pereira T, Pereira V, Perez M, Perez Calvo C, Perez Cheng M, Perez Maita R, Pérez-Araos R, Perez-Teran P, Perez-Torres D, Perkins G, Persona P, Petnak T, Petrova M, Pham T, Philippart F, Picetti E, Pierucci E, Piervincenzi E, Pinciroli R, Pintado MC, Piquilloud L, Piraino T, Piras S, Piras C, Pirompanich P, Pisani L, Platas E, Plotnikow G, Porras W, Porta V, Portilla M, Portugal J, Povoa P, Prat G, Pratto R, Preda G, Prieto I, Prol-Silva E, Pugh R, Qi Y, Qian C, Qin T, Qiu H, Qu H, Quintana T, Quispe Sierra R, Quispe Soto R, Rabbani R, Rabee M, Rabie A, Rahe Pereira MA, Rai A, Raj Ashok S, Rajab M, Ramdhani N, Ramey E, Ranieri M, Rathod D, Ray B, Redwanul Huq SM, Regli A, Reina R, Resano Sarmiento N, Reynaud F, Rialp G, Ricart P, Rice T, Richardson A, Rieder M, Rinket M, Rios F, Rios F, Risso Vazquez A, Rittayamai N, Riva I, Rivette M, Roca O, Roche-Campo F, Rodriguez C, Rodriguez G, Rodriguez Gonzalez D, Rodriguez Tucto XY, Rogers A, Romano ME, Rørtveit L, Rose A, Roux D, Rouze A, Rubatto Birri PN, Ruilan W, Ruiz Robledo A, Ruiz-Aguilar AL, Sadahiro T, Saez I, Sagardia J, Saha R, Saha R, Saiphoklang N, Saito S, Salem M, Sales G, Salgado P, Samavedam S, Sami Mebazaa M, Samuelsson L, San Juan Roman N, Sanchez P, Sanchez-Ballesteros J, Sandoval Y, Sani E, Santos M, Santos C, Sanui M, Saravanabavan L, Sari S, Sarkany A, Sauneuf B, Savioli M, Sazak H, Scano R, Schneider F, Schortgen F, Schultz MJ, Schwarz GL, Seçkin Yücesoy F, Seely A, Seiler F, Seker Tekdos Y, Seok Chan K, Serano L, Serednicki W, Serpa Neto A, Setten M, Shah A, Shah B, Shang Y, Shanmugasundaram P, Shapovalov K, Shebl E, Shiga T, Shime N, Shin P, Short J, Shuhua C, Siddiqui S, Silesky Jimenez JI, Silva D, Silva Sales B, Simons K, Sjøbø BÅ, Slessor D, Smiechowicz J, Smischney N, Smith P, Smith T, Smith M, Snape S, Snyman L, Soetens F, Sook Hong K, Sosa Medellin MÁ, Soto G, Souloy X, Sousa E, Sovatzis S, Sozutek D, Spadaro S, Spagnoli M, Spångfors M, Spittle N, Spivey M, Stapleton A, Stefanovic B, Stephenson L, Stevenson E, Strand K, Strano MT, Straus S, Sun C, Sun R, Sundaram V, SunPark T, Surlemont E, Sutherasan Y, Szabo Z, Szuldrzynski K, Tainter C, Takaba A, Tallott M, Tamasato T, Tang Z, Tangsujaritvijit V, Taniguchi L, Taniguchi D, Tarantino F, Teerapuncharoen K, Temprano S, Terragni P, Terzi N, Thakur A, Theerawit P, Thille AW, Thomas M, Thungtitigul P, Thyrault M, Tilouch N, Timenetsky K, Tirapu J, Todeschini M, Tomas R, Tomaszewski C, Tonetti T, Tonnelier A, Trinder J, Trongtrakul K, Truwit J, Tsuei B, Tulaimat A, Turan S, Turkoglu M, Tyagi S, Ubeda A, Vagginelli F, Valenti MF, Vallverdu I, Van Axel A, van den Hul I, van der Hoeven H, Van Der Meer N, Van Haren F, Vanhoof M, Vargas-Ordoñez M, Vaschetto R, Vascotto E, Vatsik M, Vaz A, Vazquez-Sanchez A, Ventura S, Vermeijden JW, Vidal A, Vieira J, Vilela Costa Pinto B, Villagomez A, Villagra A, Villegas Succar C, Vinorum OG, Vitale G, Vj R, Vochin A, Voiriot G, Volta CA, von Seth M, Wajdi M, Walsh D, Wang S, Wardi G, Ween-Velken NC, Wei BL, Weller D, Welsh D, Welters I, Wert M, Whiteley S, Wilby E, Williams E, Williams K, Wilson A, Wojtas J, Won Huh J, Wrathall D, Wright C, Wu JF, Xi G, Xing ZJ, Xu H, Yamamoto K, Yan J, Yáñez J, Yang X, Yates E, Yazicioglu Mocin O, Ye Z, Yildirim F, Yoshida N, Yoshido HHL, Young Lee B, Yu R, Yu G, Yu T, Yuan B, Yuangtrakul N, Yumoto T, Yun X, Zakalik G, Zaki A, Zalba-Etayo B, Zambon M, Zang B, Zani G, Zarka J, Zerbi SM, Zerman A, Zetterquist H, Zhang J, Zhang H, Zhang W, Zhang G, Zhang W, Zhao H, Zheng J, Zhu B, Zumaran R. Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study. Lancet Respir Med 2023; 11:465-476. [PMID: 36693401 DOI: 10.1016/s2213-2600(22)00449-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. METHODS WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. FINDINGS Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. INTERPRETATION In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. FUNDING European Society of Intensive Care Medicine, European Respiratory Society.
Collapse
Affiliation(s)
- Tài Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche CARMAS, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France; Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, 94807, Villejuif, France
| | - Leo Heunks
- Department of Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Fabiana Madotto
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Aragao
- Department of Intensive Care Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Gaëtan Beduneau
- Normandie University, UNIROUEN, UR 3830, CHU Rouen, Department of Medical Intensive Care, F-76000 Rouen, France
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, Division of Respirology, Toronto General Hospital Research Institute University Health Network, Toronto, Canada
| | - Giacomo Grasselli
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Jon Henrik Laake
- Department of Anaesthesiology and Department of Research and Development, Division of Critical Care and Emergencies, Oslo University Hospital, Oslo, Norway
| | - Jordi Mancebo
- Department of Intensive Care Medicine, Hospital Universitari Sant Pau, Barcelona, Spain
| | - Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red, CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Antonio Pesenti
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Frank van Haren
- College of Health and Medicine, Australian National University, Canberra, ACT, Australia; Intensive Care Unit, St George Hospital, Sydney, NSW, Australia
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, Clinical Sciences Institute, Galway University Hospitals, Galway, Ireland; School of Medicine, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Slobod D, Spinelli E, Crotti S, Lissoni A, Galazzi A, Grasselli G, Mauri T. Effects of an asymmetrical high flow nasal cannula interface in hypoxemic patients. Crit Care 2023; 27:145. [PMID: 37072854 PMCID: PMC10111067 DOI: 10.1186/s13054-023-04441-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/12/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Optimal noninvasive respiratory support for patients with hypoxemic respiratory failure should minimize work of breathing without increasing the transpulmonary pressure. Recently, an asymmetrical high flow nasal cannula (HFNC) interface (Duet, Fisher & Paykel Healthcare Ltd), in which the caliber of each nasal prong is different, was approved for clinical use. This system might reduce work of breathing by lowering minute ventilation and improving respiratory mechanics. METHODS We enrolled 10 patients ≥ 18 years of age who were admitted to the Ospedale Maggiore Policlinico ICU in Milan, Italy, and had a PaO2/FiO2 < 300 mmHg during HFNC support with a conventional cannula. We investigated whether the asymmetrical interface, compared to a conventional high flow nasal cannula, reduces minute ventilation and work of breathing. Each patient underwent support with the asymmetrical interface and the conventional interface, applied in a randomized sequence. Each interface was provided at a flow rate of 40 l/min followed by 60 l/min. Patients were continuously monitored with esophageal manometry and electrical impedance tomography. RESULTS Application of the asymmetrical interface resulted in a -13.5 [-19.4 to (-4.5)] % change in minute ventilation at a flow rate of 40 l/min, p = 0.006 and a -19.6 [-28.0 to (-7.5)] % change at 60 l/min, p = 0.002, that occurred despite no change in PaCO2 (35 [33-42] versus 35 [33-43] mmHg at 40 l/min and 35 [32-41] versus 36 [32-43] mmHg at 60 l/min). Correspondingly, the asymmetrical interface lowered the inspiratory esophageal pressure-time product from 163 [118-210] to 140 [84-159] (cmH2O*s)/min at a flow rate of 40 l/min, p = 0.02 and from 142 [123-178] to 117 [90-137] (cmH2O*s)/min at a flow rate of 60 l/min, p = 0.04. The asymmetrical cannula did not have any impact on oxygenation, the dorsal fraction of ventilation, dynamic lung compliance, or end-expiratory lung impedance, suggesting no major effect on PEEP, lung mechanics, or alveolar recruitment. CONCLUSIONS An asymmetrical HFNC interface reduces minute ventilation and work of breathing in patients with mild-to-moderate hypoxemic respiratory failure supported with a conventional interface. This appears to be primarily driven by increased ventilatory efficiency due to enhanced CO2 clearance from the upper airway.
Collapse
Affiliation(s)
- Douglas Slobod
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Critical Care Medicine, McGill University, Montreal, Canada
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Stefania Crotti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Alfredo Lissoni
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Alessandro Galazzi
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| |
Collapse
|
39
|
Spinelli E, Pesenti A, Slobod D, Fornari C, Fumagalli R, Grasselli G, Volta CA, Foti G, Navalesi P, Knafelj R, Pelosi P, Mancebo J, Brochard L, Mauri T. Clinical risk factors for increased respiratory drive in intubated hypoxemic patients. Crit Care 2023; 27:138. [PMID: 37041553 PMCID: PMC10088111 DOI: 10.1186/s13054-023-04402-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 03/14/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND There is very limited evidence identifying factors that increase respiratory drive in hypoxemic intubated patients. Most physiological determinants of respiratory drive cannot be directly assessed at the bedside (e.g., neural inputs from chemo- or mechano-receptors), but clinical risk factors commonly measured in intubated patients could be correlated with increased drive. We aimed to identify clinical risk factors independently associated with increased respiratory drive in intubated hypoxemic patients. METHODS We analyzed the physiological dataset from a multicenter trial on intubated hypoxemic patients on pressure support (PS). Patients with simultaneous assessment of the inspiratory drop in airway pressure at 0.1-s during an occlusion (P0.1) and risk factors for increased respiratory drive on day 1 were included. We evaluated the independent correlation of the following clinical risk factors for increased drive with P0.1: severity of lung injury (unilateral vs. bilateral pulmonary infiltrates, PaO2/FiO2, ventilatory ratio); arterial blood gases (PaO2, PaCO2 and pHa); sedation (RASS score and drug type); SOFA score; arterial lactate; ventilation settings (PEEP, level of PS, addition of sigh breaths). RESULTS Two-hundred seventeen patients were included. Clinical risk factors independently correlated with higher P0.1 were bilateral infiltrates (increase ratio [IR] 1.233, 95%CI 1.047-1.451, p = 0.012); lower PaO2/FiO2 (IR 0.998, 95%CI 0.997-0.999, p = 0.004); higher ventilatory ratio (IR 1.538, 95%CI 1.267-1.867, p < 0.001); lower pHa (IR 0.104, 95%CI 0.024-0.464, p = 0.003). Higher PEEP was correlated with lower P0.1 (IR 0.951, 95%CI 0.921-0.982, p = 0.002), while sedation depth and drugs were not associated with P0.1. CONCLUSIONS Independent clinical risk factors for higher respiratory drive in intubated hypoxemic patients include the extent of lung edema and of ventilation-perfusion mismatch, lower pHa, and lower PEEP, while sedation strategy does not affect drive. These data underline the multifactorial nature of increased respiratory drive.
Collapse
Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Douglas Slobod
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Critical Care Medicine, McGill University, Montreal, QC, Canada
| | - Carla Fornari
- Research Centre On Public Health, University of Milano - Bicocca, Monza, Italy
| | - Roberto Fumagalli
- Anesthesia and Critical Care Service 1, Niguarda Hospital, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Carlo Alberto Volta
- Morphology, Surgery and Experimental Medicine, Anesthesia and Intensive Care Unit, University of Ferrara, Ferrara, Italy
| | - Giuseppe Foti
- Anesthesia and Critical Care, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Department of Medicine - DIMED, Padua University Hospital, University of Padua, Padua, Italy
| | - Rihard Knafelj
- Center for Internal Intensive Medicine (MICU), University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Jordi Mancebo
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| |
Collapse
|
40
|
Colombo SM, Scaravilli V, Castagna L, Zanella A, Brioni M, Abbruzzese C, Grasselli G. Neural pressure support ventilation as a novel strategy to improve patient-ventilator synchrony in adult respiratory distress syndrome. Br J Anaesth 2023; 130:e430-e432. [PMID: 36725377 DOI: 10.1016/j.bja.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/01/2023] [Accepted: 01/01/2023] [Indexed: 02/01/2023] Open
Affiliation(s)
- Sebastiano M Colombo
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vittorio Scaravilli
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
| | - Luigi Castagna
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Matteo Brioni
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Abbruzzese
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
41
|
Fumagalli J, Rosso L, Cattaneo M, Romeo G, Scaravilli V, Righi I, Damarco F, Mangioni D, Gori F, Bandera A, Rossetti V, Morlacchi L, Nosotti M, Zanella A, Grasselli G. Multiorgan Donor Bronchoalveolar Lavage Positivity: Incidence, Risk Factors, and Lung Transplant Recipients’ Outcome. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
|
42
|
Pistolesi V, Morabito S, Pota V, Valente F, Di Mario F, Fiaccadori E, Grasselli G, Brienza N, Cantaluppi V, De Rosa S, Fanelli V, Fiorentino M, Marengo M, Romagnoli S. Regional citrate anticoagulation (RCA) in critically ill patients undergoing renal replacement therapy (RRT): expert opinion from the SIAARTI-SIN joint commission. J Anesth Analg Crit Care 2023; 3:7. [PMID: 37386664 DOI: 10.1186/s44158-023-00091-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/15/2023] [Indexed: 07/01/2023]
Abstract
Renal replacement therapies (RRT) are essential to support critically ill patients with severe acute kidney injury (AKI), providing control of solutes, fluid balance and acid-base status. To maintain the patency of the extracorporeal circuit, minimizing downtime periods and blood losses due to filter clotting, an effective anticoagulation strategy is required.Regional citrate anticoagulation (RCA) has been introduced in clinical practice for continuous RRT (CRRT) in the early 1990s and has had a progressively wider acceptance in parallel to the development of simplified systems and safe protocols. Main guidelines on AKI support the use of RCA as the first line anticoagulation strategy during CRRT in patients without contraindications to citrate and regardless of the patient's bleeding risk.Experts from the SIAARTI-SIN joint commission have prepared this position statement which discusses the use of RCA in different RRT modalities also in combination with other extracorporeal organ support systems. Furthermore, advise is provided on potential limitations to the use of RCA in high-risk patients with particular attention to the need for a rigorous monitoring in complex clinical settings. Finally, the main findings about the prospective of optimization of RRT solutions aimed at preventing electrolyte derangements during RCA are discussed in detail.
Collapse
Affiliation(s)
- Valentina Pistolesi
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy.
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy
| | - Vincenzo Pota
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Fabrizio Valente
- Nephrology and Dialysis Unit, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Nicola Brienza
- Department of Interdisciplinary Medicine, ICU Section, University of Bari "Aldo Moro", Bari, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine (DIMET), University of Piemonte Orientale (UPO), AOU "Maggiore Della Carità", Novara, Italy
| | - Silvia De Rosa
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Vito Fanelli
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Marco Fiorentino
- Nephrology Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Bari, Italy
| | - Marita Marengo
- Department of Medical Specialist, Nephrology and Dialysis Unit, ASL CN1, Cuneo, Italy
| | - Stefano Romagnoli
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
| |
Collapse
|
43
|
Mangioni D, Fox V, Chatenoud L, Bolis M, Bottino N, Cariani L, Gentiloni Silverj F, Matinato C, Monti G, Muscatello A, Teri A, Terranova L, Piatti A, Gori A, Grasselli G, Stocchetti N, Alteri C, Bandera A. Genomic Characterization of Carbapenem-Resistant Acinetobacter baumannii (CRAB) in Mechanically Ventilated COVID-19 Patients and Impact of Infection Control Measures on Reducing CRAB Circulation during the Second Wave of the SARS-CoV-2 Pandemic in Milan, Italy. Microbiol Spectr 2023; 11:e0020923. [PMID: 36976013 PMCID: PMC10100775 DOI: 10.1128/spectrum.00209-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/06/2023] [Indexed: 03/29/2023] Open
Abstract
COVID-19 has significantly affected hospital infection prevention and control (IPC) practices, especially in intensive care units (ICUs). This frequently caused dissemination of multidrug-resistant organisms (MDROs), including carbapenem-resistant Acinetobacter baumannii (CRAB). Here, we report the management of a CRAB outbreak in a large ICU COVID-19 hub Hospital in Italy, together with retrospective genotypic analysis by whole-genome sequencing (WGS). Bacterial strains obtained from severe COVID-19 mechanically ventilated patients diagnosed with CRAB infection or colonization between October 2020 and May 2021 were analyzed by WGS to assess antimicrobial resistance and virulence genes, along with mobile genetic elements. Phylogenetic analysis in combination with epidemiological data was used to identify putative transmission chains. CRAB infections and colonization were diagnosed in 14/40 (35%) and 26/40 (65%) cases, respectively, with isolation within 48 h from admission in 7 cases (17.5%). All CRAB strains belonged to Pasteur sequence type 2 (ST2) and 5 different Oxford STs and presented blaOXA-23 gene-carrying Tn2006 transposons. Phylogenetic analysis revealed the existence of four transmission chains inside and among ICUs, circulating mainly between November and January 2021. A tailored IPC strategy was composed of a 5-point bundle, including ICU modules' temporary conversion to CRAB-ICUs and dynamic reopening, with limited impact on ICU admission rate. After its implementation, no CRAB transmission chains were detected. Our study underlies the potentiality of integrating classical epidemiological studies with genomic investigation to identify transmission routes during outbreaks, which could represent a valuable tool to ensure IPC strategies and prevent the spread of MDROs. IMPORTANCE Infection prevention and control (IPC) practices are of paramount importance for preventing the spread of multidrug-resistant organisms (MDROs) in hospitals, especially in the intensive care unit (ICU). Whole-genome sequencing (WGS) is seen as a promising tool for IPC, but its employment is currently still limited. COVID-19 pandemics have posed dramatic challenges in IPC practices, causing worldwide several outbreaks of MDROs, including carbapenem-resistant Acinetobacter baumannii (CRAB). We present the management of a CRAB outbreak in a large ICU COVID-19 hub hospital in Italy using a tailored IPC strategy that allowed us to contain CRAB transmission while preventing ICU closure during a critical pandemic period. The analysis of clinical and epidemiological data coupled with retrospective genotypic analysis by WGS identified different putative transmission chains and confirmed the effectiveness of the IPC strategy implemented. This could be a promising approach for future IPC strategies.
Collapse
Affiliation(s)
- Davide Mangioni
- Infectious Diseases Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Valeria Fox
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | | | - Matteo Bolis
- Infectious Diseases Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Nicola Bottino
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Lisa Cariani
- Microbiology Laboratory, Clinical Laboratory, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | | | - Caterina Matinato
- Microbiology Laboratory, Clinical Laboratory, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Gianpaola Monti
- Department of Anesthesia and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Muscatello
- Infectious Diseases Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Antonio Teri
- Microbiology Laboratory, Clinical Laboratory, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Leonardo Terranova
- Department of Internal Medicine, Respiratory Unit and Adult Cystic Fibrosis Center, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Piatti
- Medical Direction, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Claudia Alteri
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alessandra Bandera
- Infectious Diseases Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| |
Collapse
|
44
|
Catalisano G, Ippolito M, Blanda A, Meessen J, Giarratano A, Todesco N, Bonato V, Restuccia F, Montomoli J, Fiore G, Grasselli G, Caironi P, Latini R, Cortegiani A. Effects of hyperoxemia in patients with sepsis - A post-hoc analysis of a multicentre randomized clinical trial. Pulmonology 2023:S2531-0437(23)00042-9. [PMID: 36907813 DOI: 10.1016/j.pulmoe.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Administration of supplemental oxygen is a life-saving treatment in critically ill patients. Still, optimal dosing remains unclear during sepsis. The aim of this post-hoc analysis was to assess the association between hyperoxemia and 90-day mortality in a large cohort of septic patients. METHODS This is a post-hoc analysis of the Albumin Italian Outcome Sepsis (ALBIOS) randomized controlled trial (RCT). Patients with sepsis who survived the first 48 h since randomization were included and stratified into two groups according to their average PaO2 levels during the first 48 h (PaO2 0-48 h). The cut-off value was established at 100 mmHg (average PaO2 0-48 h >100 mmHg: hyperoxemia group; PaO2 0-48h≤100: normoxemia group). The primary outcome was 90-day mortality. RESULTS 1632 patients were included in this analysis (661 patients in the hyperoxemia group, 971 patients in the normoxemia group). Concerning the primary outcome, 344 (35.4%) patients in the hyperoxemia group vs. 236 (35.7%) in the normoxemia group had died within 90 days from randomization (p = 0.909). No association was found after adjusting for confounders (HR 0.87; CI [95%] 0.736-1.028, p = 0.102) or after excluding patients with hypoxemia at enrollment, patients with lung infection or including post-surgical patients only. Conversely, we found an association between lower risk of 90-day mortality and hyperoxemia in the subgroup including patients who had the lung as primary site of infection (HR 0.72; CI [95%] 0.565-0.918). Mortality at 28 days, ICU mortality, incidence of acute kidney injury, use of renal replacement therapy, days to suspension of vasopressor or inotropic agents, and resolution of primary and secondary infections did not differ significantly. Duration of mechanical ventilation and length of stay in ICU were significantly longer in patients with hyperoxemia. CONCLUSIONS In a post-hoc analysis of a RCT enrolling septic patients, hyperoxemia as average PaO2>100 mmHg during the first 48 h was not associated with patients' survival.
Collapse
Affiliation(s)
- G Catalisano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy
| | - M Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Department of Anaesthesia, Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, Italy
| | - A Blanda
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri - IRCCS, Italy
| | - J Meessen
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri - IRCCS, Italy
| | - A Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Department of Anaesthesia, Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, Italy
| | - N Todesco
- Servizio di Anestesia, Rianimazione e Terapie Intensive, Azienda Sanitaria Friuli Occidentale, P.O. Santa Maria degli Angeli, Pordenone, Italy
| | - V Bonato
- S.C. Anestesia e Rianimazione, Ospedale SS. Arrigo e Biagio, Alessandria, Italy
| | - F Restuccia
- Department of Anesthesiology and Critical Care Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - J Montomoli
- Department of Anesthesia and Intensive Care, Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - G Fiore
- S.C. Anestesia e Rianimazione Moncalieri-Carmagnola (TO), Dipartimento Area Chirurgica, ASLTO5, Italy
| | - G Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - P Caironi
- Department of Anaesthesia and Critical Care, AOU S. Luigi Gonzaga, Department of Oncology, University of Turin, Italy
| | - R Latini
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri - IRCCS, Italy
| | - A Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Department of Anaesthesia, Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, Italy.
| |
Collapse
|
45
|
Madotto F, Guzzardella A, Scaravilli V, Grasselli G. "Reply on: statistics on steroids-how recognizing competing risks gets us closer to the truth about COVID-19-associated VAP". Crit Care 2023; 27:100. [PMID: 36894967 PMCID: PMC9997426 DOI: 10.1186/s13054-023-04351-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/07/2023] [Indexed: 03/11/2023] Open
Affiliation(s)
- Fabiana Madotto
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Vittorio Scaravilli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy. .,Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
| | - Giacomo Grasselli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
46
|
Piralla A, Mojoli F, Pellegrinelli L, Ceriotti F, Valzano A, Grasselli G, Gismondo MR, Micheli V, Castelli A, Farina C, Arosio M, Lorini FL, Fanti D, Busni A, Laratta M, Maggi F, Novazzi F, Cabrini L, Callegaro AP, Keim R, Remuzzi G, Cavallero A, Malandrin SMI, Rona R, Giardina F, Ferrari G, Zavaglio F, D'angelo P, Galli C, Bubba L, Binda S, Oggioni M, Uceda Renteria SC, Bono P, Baj A, Ferrante FD, Guarneri D, Tonelli M, Napolitano G, Nava A, Romeo L, Nicolini E, Valaperta R, Varisano L, Mele C, Liguori L, Raggi M, Mongodi S, Pagani M, Severgnini P, Gasberti D, Bonanomi E, Gritti P, Marrazzo F, Giovannini I, Sacchi N, Sagliocco O, Cereda D, Buoro S, Baldanti F, Pariani E. Impact of SARS-CoV-2 Omicron and Delta variants in patients requiring intensive care unit (ICU) admission for COVID-19, Northern Italy, December 2021 to January 2022. Respir Med Res 2023; 83:100990. [PMID: 36871459 PMCID: PMC9984278 DOI: 10.1016/j.resmer.2023.100990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 03/06/2023]
Abstract
This multicenter observational study included 171 COVID-19 adult patients hospitalized in the ICUs of nine hospitals in Lombardy (Northern Italy) from December, 1st 2021, to February, 9th 2022. During the study period, the Delta/Omicron variant ratio of cases decreased with a delay of two weeks in ICU patients compared to that in the community; a higher proportion of COVID-19 unvaccinated patients was infected by Delta than by Omicron whereas a higher rate of COVID-19 boosted patients was Omicron-infected. A higher number of comorbidities and a higher comorbidity score in ICU critically COVID-19 inpatients was positively associated with the Omicron infection as well in vaccinated individuals. Although people infected by Omicron have a lower risk of severe disease than those infected by Delta variant, the outcome, including the risk of ICU admission and the need for mechanical ventilation due to infection by Omicron versus Delta, remains uncertain. The continuous monitoring of the circulating SARS-CoV-2 variants remains a milestone to counteract this pandemic.
Collapse
Affiliation(s)
- Antonio Piralla
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Francesco Mojoli
- Anaesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Laura Pellegrinelli
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Ferruccio Ceriotti
- Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonia Valzano
- Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Rita Gismondo
- Laboratory of Clinical Microbiology, Virology and Bioemergencies, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Valeria Micheli
- Laboratory of Clinical Microbiology, Virology and Bioemergencies, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Antonio Castelli
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Claudio Farina
- Microbiology and Virology Laboratory, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | - Marco Arosio
- Microbiology and Virology Laboratory, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | | | - Diana Fanti
- Laboratory of Clinical Microbiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Busni
- Laboratory of Clinical Microbiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Laratta
- Department of Anesthesia and Intensive Care Ospedale Niguarda, Università degli studi Milano Bicocca, Milan, Italy
| | - Fabrizio Maggi
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Federica Novazzi
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Luca Cabrini
- Intensive Care and Anesthesia Unit, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | | | | | | | | | | | - Roberto Rona
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Federica Giardina
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Guglielmo Ferrari
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federica Zavaglio
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Piera D'angelo
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Cristina Galli
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Laura Bubba
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Sandro Binda
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Massimo Oggioni
- Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Patrizia Bono
- Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andreina Baj
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Davide Guarneri
- Microbiology and Virology Laboratory, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | - Marco Tonelli
- Microbiology and Virology Laboratory, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | - Gavino Napolitano
- Microbiology and Virology Laboratory, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | - Alice Nava
- Laboratory of Clinical Microbiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Lorenzo Romeo
- Residency in Microbiology and Virology, Università degli Studi di Milano, Milan
| | - Elena Nicolini
- Residency in Microbiology and Virology, Università degli Studi di Milano, Milan
| | | | | | - Caterina Mele
- Laboratory of Immunology and Genetics of Rare Diseases, Istituto di Ricerche Farmacologiche Mario Negri IRCCS
| | - Lucia Liguori
- Laboratory of Immunology and Genetics of Rare Diseases, Istituto di Ricerche Farmacologiche Mario Negri IRCCS
| | - Monica Raggi
- Microbiology Laboratory San Gerardo Hospital, Monza, Italy
| | - Silvia Mongodi
- Anaesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Michele Pagani
- Anaesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paolo Severgnini
- Department of Biotechnology and Life, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Dario Gasberti
- Intensive Care and Anesthesia Unit, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Ezio Bonanomi
- Department of Emergency and ICU, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | - Paolo Gritti
- Department of Emergency and ICU, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | - Francesco Marrazzo
- Department of Anesthesia and Intensive Care Ospedale Niguarda, Università degli studi Milano Bicocca, Milan, Italy
| | - Ilaria Giovannini
- Department of Anesthesia and Intensive Care Ospedale Niguarda, Università degli studi Milano Bicocca, Milan, Italy
| | | | | | - Danilo Cereda
- Direzione Generale Welfare, Regione Lombardia, Milan, Italy
| | - Sabrina Buoro
- Direzione Generale Welfare, Regione Lombardia, Milan, Italy
| | - Fausto Baldanti
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Elena Pariani
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| |
Collapse
|
47
|
Martucci G, Schmidt M, Agerstrand C, Tabatabai A, Tuzzolino F, Giani M, Ramanan R, Grasselli G, Schellongowski P, Riera J, Hssain AA, Duburcq T, Gorjup V, De Pascale G, Buabbas S, Gannon WD, Jeon K, Trethowan B, Fanelli V, Chico JI, Balik M, Broman LM, Pesenti A, Combes A, Ranieri MV, Foti G, Buscher H, Tanaka K, Lorusso R, Arcadipane A, Brodie D, Arcadipane A, Pesenti A, Grasselli G, Brioni M, De Pascale G, Montini L, Giani M, Foti G, Bosa L, Curcio P, Fanelli V, Garofalo E, Martin-Villen L, Garcìa-Álvarez R, Lopez Sanchez M, Principe N, Chica Saez V, Chico JI, Gomez V, Colomina-Climent J, Riera J, Pacheco AF, Gorjup V, Goutay J, Thibault D, Szułdrzyński K, Eller P, Lobmeyr E, Schellongowski P, Schmidt M, Combes A, Lorusso R, Mariani S, Ranieri MV, Suk P, Maly M, Balik M, Forestier J, Broman LM, Rizzo M, Tuzzolino F, Tanaka K, Holsworth T, Trethowan B, Serra A, Agerstrand C, Brodie D, Cavayas YA, Tabatabai A, Menaker J, Galvagno S, Gannon WD, Rice TW, Grandin WE, Nunez J, Cheplic C, Ramanan R, Rivosecchi R, Cho YJ, Buabbas S, Jeon K, Kwan MC, Sallam H, Villanueva JA, Aliudin J, Ait Hssain A, Hoshino K, Hara Y, Ramanathan K, Maclaren G, Buscher H. Transfusion practice in patients receiving VV ECMO (PROTECMO): a prospective, multicentre, observational study. Lancet Respir Med 2023; 11:245-255. [PMID: 36240836 DOI: 10.1016/s2213-2600(22)00353-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND In patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) packed red blood cell (PRBC) transfusion thresholds are usually higher than in other patients who are critically ill. Available guidelines suggest a restrictive approach, but do not provide specific recommendations on the topic. The main aim of this study was, in a short timeframe, to describe the actual values of haemoglobin and the rate and the thresholds for transfusion of PRBC during VV ECMO. METHODS PROTECMO was a multicentre, prospective, cohort study done in 41 ECMO centres in Europe, North America, Asia, and Australia. Consecutive adult patients with acute respiratory distress syndrome (ARDS) who were receiving VV ECMO were eligible for inclusion. Patients younger than 18 years, those who were not able to provide informed consent when required, and patients with an ECMO stay of less than 24 h were excluded. Our main aim was to monitor the daily haemoglobin concentration and the value at the point of PRBC transfusion, as well as the rate of transfusions. The practice in different centres was stratified by continent location and case volume per year. Adjusted estimates were calculated using marginal structural models with inverse probability weighting, accounting for baseline and time varying confounding. FINDINGS Between Dec 1, 2018, and Feb 22, 2021, 604 patients were enrolled (431 [71%] men, 173 [29%] women; mean age 50 years [SD 13·6]; and mean haemoglobin concentration at cannulation 10·9 g/dL [2·4]). Over 7944 ECMO days, mean haemoglobin concentration was 9·1 g/dL (1·2), with lower concentrations in North America and high-volume centres. PRBC were transfused on 2432 (31%) of days on ECMO, and 504 (83%) patients received at least one PRBC unit. Overall, mean pretransfusion haemoglobin concentration was 8·1 g/dL (1·1), but varied according to the clinical rationale for transfusion. In a time-dependent Cox model, haemoglobin concentration of less than 7 g/dL was consistently associated with higher risk of death in the intensive care unit compared with other higher haemoglobin concentrations (hazard ratio [HR] 2·99 [95% CI 1·95-4·60]); PRBC transfusion was associated with lower risk of death only when transfused when haemoglobin concentration was less than 7 g/dL (HR 0·15 [0·03-0·74]), although no significant effect in reducing mortality was reported for transfusions for other haemoglobin classes (7·0-7·9 g/dL, 8·0-9·9 g/dL, or higher than 10 g/dL). INTERPRETATION During VV ECMO, there was no universally accepted threshold for transfusion, but PRBC transfusion was invariably associated with lower mortality only when done with haemoglobin concentration of less than 7 g/dL. FUNDING Extracorporeal Life Support Organization.
Collapse
Affiliation(s)
- Gennaro Martucci
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy.
| | - Matthieu Schmidt
- INSERM 1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris France; Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Cara Agerstrand
- Department of Medicine and Center for Acute Respiratory Failure, Irving Medical Center, Columbia University, New York, NY, USA
| | - Ali Tabatabai
- School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Fabio Tuzzolino
- Statistics and Data Management Services, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Marco Giani
- Ospedale San Gerardo, Università degli Studi Di Milano-Bicocca, Monza, Italy
| | - Raj Ramanan
- Department of Critical Care, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Center of Excellence in Medical Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Jordi Riera
- Critical Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Shock Organ Dysfunction and Resuscitation, Vall d'Hebron Institut de Recerca, Barcelona, Spain; Centro de Investigacion en Red de Enfermedades Respiratorias Instituto de Salud Carlos III, Barcelona, Spain
| | | | - Thibault Duburcq
- Centre Hospitalier Regional Universitaire Lille, Hôpital Roger Salengro, Lille, France
| | | | - Gennaro De Pascale
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sarah Buabbas
- Kuwait Extracorporeal Life Support Program, Jaber Al-Ahmad Alsabah Hospital, Kuwait City, Kuwait
| | - Whitney D Gannon
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kyeongman Jeon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Brian Trethowan
- Meijer Heart Center Butterworth Hospital, Spectrum Health, Grand Rapids, MI, USA
| | - Vito Fanelli
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Juan I Chico
- Critical Care Department, Alvaro Cunqueiro University Hospital, Vigo, Spain
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, 1st Medical Faculty, General University Hospital, Prague, Czech Republic
| | - Lars M Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Antonio Pesenti
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Alain Combes
- INSERM 1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris France; Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Giuseppe Foti
- Ospedale San Gerardo, Università degli Studi Di Milano-Bicocca, Monza, Italy
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Kenichi Tanaka
- The University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Daniel Brodie
- Department of Medicine and Center for Acute Respiratory Failure, Irving Medical Center, Columbia University, New York, NY, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Palleschi A, Zanella A, Citerio G, Musso V, Rosso L, Tosi D, Fumagalli J, Bonitta G, Benazzi E, Lopez G, Rossetti V, Morlacchi LC, Uslenghi C, Cardillo M, Blasi F, Grasselli G, Valenza F, Nosotti M. Lung Transplantation From Controlled and Uncontrolled Donation After Circulatory Death (DCD) Donors With Long Ischemic Times Managed by Simple Normothermic Ventilation and Ex-Vivo Lung Perfusion Assessment. Transpl Int 2023; 36:10690. [PMID: 36846600 PMCID: PMC9945516 DOI: 10.3389/ti.2023.10690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 01/26/2023] [Indexed: 02/11/2023]
Abstract
Donation after cardiac death (DCD) donors are still subject of studies. In this prospective cohort trial, we compared outcomes after lung transplantation (LT) of subjects receiving lungs from DCD donors with those of subjects receiving lungs from donation after brain death (DBD) donors (ClinicalTrial.gov: NCT02061462). Lungs from DCD donors were preserved in-vivo through normothermic ventilation, as per our protocol. We enrolled candidates for bilateral LT ≥14 years. Candidates for multi-organ or re-LT, donors aged ≥65 years, DCD category I or IV donors were excluded. We recorded clinical data on donors and recipients. Primary endpoint was 30-day mortality. Secondary endpoints were: duration of mechanical ventilation (MV), intensive care unit (ICU) length of stay, severe primary graft dysfunction (PGD3) and chronic lung allograft dysfunction (CLAD). 121 patients (110 DBD Group, 11 DCD Group) were enrolled. 30-day mortality and CLAD prevalence were nil in the DCD Group. DCD Group patients required longer MV (DCD Group: 2 days, DBD Group: 1 day, p = 0.011). ICU length of stay and PGD3 rate were higher in DCD Group but did not significantly differ. LT with DCD grafts procured with our protocols appears safe, despite prolonged ischemia times.
Collapse
Affiliation(s)
- Alessandro Palleschi
- University of Milan, Milan, Italy
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- University of Milan, Milan, Italy
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine, University of Milano - Bicocca, Milano, Italy
- Neurointensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Valeria Musso
- University of Milan, Milan, Italy
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Rosso
- University of Milan, Milan, Italy
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Tosi
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Jacopo Fumagalli
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Elena Benazzi
- Coordinamento Trapianti North Italy Transplantation Program (NITp), Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluca Lopez
- Pathology Unit, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Rossetti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Letizia Corinna Morlacchi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Clarissa Uslenghi
- University of Milan, Milan, Italy
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Francesco Blasi
- University of Milan, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- University of Milan, Milan, Italy
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Franco Valenza
- University of Milan, Milan, Italy
- Department of Anaesthesia and Critical Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Mario Nosotti
- University of Milan, Milan, Italy
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
49
|
Schmidt M, Hajage D, Landoll M, Pequignot B, Langouet E, Amalric M, Mekontso-Dessap A, Chiscano-Camon L, Surman K, Finnerty D, Santa-Teresa P, Arcadipane A, Millán P, Roncon-Albuquerque R, Blandino-Ortiz A, Blanco-Schweizer P, Ricart P, Gimeno-Costa R, Albacete CL, Fortuna P, Schellongowski P, Dauwe D, Winiszewski H, Kimmoun A, Levy B, Hermans G, Grasselli G, Lebreton G, Guervilly C, Martucci G, Karagiannidis C, Riera J, Combes A. Comparative outcomes of extracorporeal membrane oxygenation for COVID-19 delivered in experienced European centres during successive SARS-CoV-2 variant outbreaks (ECMO-SURGES): an international, multicentre, retrospective cohort study. Lancet Respir Med 2023; 11:163-175. [PMID: 36640786 PMCID: PMC9889098 DOI: 10.1016/s2213-2600(22)00438-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/21/2022] [Accepted: 10/27/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND To inform future research and practice, we aimed to investigate the outcomes of patients who received extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) due to different variants of SARS-CoV-2. METHODS This retrospective study included consecutive adult patients with laboratory-confirmed SARS-CoV-2 infection who received ECMO for ARDS in 21 experienced ECMO centres in eight European countries (Austria, Belgium, England, France, Germany, Italy, Portugal, and Spain) between Jan 1, 2020, and Sept 30, 2021. We collected data on patient characteristics, clinical status, and management before and after the initiation of ECMO. Participants were grouped according to SARS-CoV-2 variant (wild type, alpha, delta, or other) and period of the pandemic (first [Jan 1-June 30] and second [July 1-Dec 31] semesters of 2020, and first [Jan 1-June 30] and second [July 1-Sept 30] semesters of 2021). Descriptive statistics and Kaplan-Meier survival curves were used to analyse evolving characteristics, management, and patient outcomes over the first 2 years of the pandemic, and independent risk factors of mortality were determined using multivariable Cox regression models. The primary outcome was mortality 90 days after the initiation of ECMO, with follow-up to Dec 30, 2021. FINDINGS ECMO was initiated in 1345 patients. Patient characteristics and management were similar for the groups of patients infected with different variants, except that those with the delta variant had a younger median age and less hypertension and diabetes. 90-day mortality was 42% (569 of 1345 patients died) overall, and 43% (297/686) in patients infected with wild-type SARS-CoV-2, 39% (152/391) in those with the alpha variant, 40% (78/195) in those with the delta variant, and 58% (42/73) in patients infected with other variants (mainly beta and gamma). Mortality was 10% higher (50%) in the second semester of 2020, when the wild-type variant was still prevailing, than in other semesters (40%). Independent predictors of mortality were age, immunocompromised status, a longer time from intensive care unit admission to intubation, need for renal replacement therapy, and higher Sequential Organ Failure Assessment haemodynamic component score, partial pressure of arterial carbon dioxide, and lactate concentration before ECMO. After adjusting for these variables, mortality was significantly higher with the delta variant than with the other variants, the wild-type strain being the reference. INTERPRETATION Although crude mortality did not differ between variants, adjusted risk of death was highest for patients treated with ECMO infected with the delta variant of SARS-CoV-2. The higher virulence and poorer outcomes associated with the delta strain might relate to higher viral load and increased inflammatory response syndrome in infected patients, reinforcing the need for a higher rate of vaccination in the population and updated selection criteria for ECMO, should a new and highly virulent strain of SARS-CoV-2 emerge in the future. Mortality was noticeably lower than in other large, multicentre series of patients who received ECMO for COVID-19, highlighting the need to concentrate resources at experienced centres. FUNDING None.
Collapse
Affiliation(s)
- Matthieu Schmidt
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP Sorbonne Université Hôpital Pitié–Salpêtrière, Paris, France
| | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Micha Landoll
- ARDS and ECMO Centre Cologne-Merheim, Witten/Herdecke University, Cologne, Germany,Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Benjamin Pequignot
- Université de Lorraine, CHRU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, Service de Médecine Intensive-Réanimation, U1116, FCRIN-INICRCT, Nancy, France
| | - Elise Langouet
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP Sorbonne Université Hôpital Pitié–Salpêtrière, Paris, France
| | - Matthieu Amalric
- Service de Médecine Intensive Réanimation, CHU Hôpital Nord, AP-HM, Marseille, France
| | - Armand Mekontso-Dessap
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri-Mondor, AP-HP, Créteil, France
| | - Luis Chiscano-Camon
- Department of Intensive Care, Hospital Universitari Vall d'Hebron, Barcelona, Spain,SODIR, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Katy Surman
- Intensive Care, Division of Surgery, Transplant and Anaesthetics, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Dylan Finnerty
- Intensive Care, Division of Surgery, Transplant and Anaesthetics, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Patricia Santa-Teresa
- Department of Intensive Care, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapia ad alta specializzazione), Palermo, Italy
| | - Pablo Millán
- Department of Intensive Care, Hospital Universitario La Paz, Madrid, Spain
| | | | - Aaron Blandino-Ortiz
- Department of Intensive Care, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | | | - Pilar Ricart
- Department of Intensive Care Hospital Universitari Germans Trias i Pujol, Badalona – Barcelona, Spain
| | - Ricardo Gimeno-Costa
- Department of Intensive Care, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Carlos Luis Albacete
- Department of Intensive Care, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Philip Fortuna
- Medical Emergency Unit, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Centre, Centre of Excellence in Medical Intensive Care (CEMIC), Medical University of Vienna, Vienna, Austria
| | - Dieter Dauwe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Hadrien Winiszewski
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France,Research Unit EA 3920, University of Franche-Comté, Besançon, France
| | - Antoine Kimmoun
- Université de Lorraine, CHRU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, Service de Médecine Intensive-Réanimation, U1116, FCRIN-INICRCT, Nancy, France
| | - Bruno Levy
- Université de Lorraine, CHRU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, Service de Médecine Intensive-Réanimation, U1116, FCRIN-INICRCT, Nancy, France
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium,Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Belgium
| | - Giacomo Grasselli
- Dipartimento di Anestesia, Rianimazione ed Emergenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy,Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, University of Milan, Milan, Italy
| | - Guillaume Lebreton
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France,Service de Chirurgie Cardiaque, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié–Salpêtrière, Paris, France
| | - Christophe Guervilly
- Service de Médecine Intensive Réanimation, CHU Hôpital Nord, AP-HM, Marseille, France,CEReSS - Centre for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapia ad alta specializzazione), Palermo, Italy
| | - Christian Karagiannidis
- ARDS and ECMO Centre Cologne-Merheim, Witten/Herdecke University, Cologne, Germany,Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Jordi Riera
- SODIR, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Alain Combes
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France; Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France.
| | | |
Collapse
|
50
|
Giani M, Rezoagli E, Guervilly C, Rilinger J, Duburcq T, Petit M, Textoris L, Garcia B, Wengenmayer T, Bellani G, Grasselli G, Pesenti A, Combes A, Foti G, Schmidt M. Timing of Prone Positioning During Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. Crit Care Med 2023; 51:25-35. [PMID: 36519981 DOI: 10.1097/ccm.0000000000005705] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To assess the association of timing to prone positioning (PP) during venovenous extracorporeal membrane oxygenation (V-V ECMO) with the probability of being discharged alive from the ICU at 90 days (primary endpoint) and the improvement of the respiratory system compliance (Cpl,rs). DESIGN Pooled individual data analysis from five original observational cohort studies. SETTING European extracorporeal membrane oxygenation (ECMO) centers. PATIENTS Acute respiratory distress syndrome (ARDS) patients who underwent PP during ECMO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Time to PP during V-V ECMO was explored both as a continuous and a categorical variable with Cox proportional hazard models. Three hundred patients were included in the analysis. The longer the time to PP during V-V ECMO, the lower the adjusted probability of alive ICU discharge (adjusted hazard ratio [HR] 0.90 for each day increase; 95% CI, 0.87-0.93). Two hundred twenty-three and 77 patients were included in the early PP (≤ 5 d) and late PP (> 5 d) groups, respectively. The cumulative 90-day probability of being discharged alive from the ICU was 61% in the early PP group vs 36% in the late PP group (log-rank test, p <0.001). This benefit was maintained after adjustment for confounders (adjusted HR, 2.52; 95% CI, 1.66-3.81; p <0.001). In the early PP group, PP was associated with a significant improvement of Cpl,rs (4 ± 9 mL/cm H2O vs 0 ± 12 in the late PP group, p=0.038). CONCLUSIONS In a large cohort of ARDS patients on ECMO, early PP during ECMO was associated with a higher probability of being discharged alive from the ICU at 90 days and a greater improvement of Cpl,rs.
Collapse
Affiliation(s)
- Marco Giani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, ASST Monza, Monza, Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, ASST Monza, Monza, Italy
| | - Christophe Guervilly
- Medical Intensive Care Unit North Hospital, Department of Anaesthesiology and Critical Care, APHM, Marseille, France
- CER- eSS, Center for Studies and Research On Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Jonathan Rilinger
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Thibault Duburcq
- Service de Médecine Intensive-Réanimation, Department of Anaesthesiology and Critical Care, CHU Lille, F-59000 Lille, France
| | - Matthieu Petit
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne Université Hôpital Pitié- Salpêtrière, Paris, France
| | - Laura Textoris
- Medical Intensive Care Unit North Hospital, Department of Anaesthesiology and Critical Care, APHM, Marseille, France
| | - Bruno Garcia
- Service de Médecine Intensive-Réanimation, Department of Anaesthesiology and Critical Care, CHU Lille, F-59000 Lille, France
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, ASST Monza, Monza, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne Université Hôpital Pitié- Salpêtrière, Paris, France
- INSERM, UMRS 1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, ASST Monza, Monza, Italy
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne Université Hôpital Pitié- Salpêtrière, Paris, France
- INSERM, UMRS 1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| |
Collapse
|