Bickerstaff encephalitis in childhood: a review of 74 cases in the literature from 1951 to today

Bickerstaff brainstem encephalitis (BBE) is a rare autoimmune disease characterized by the subacute onset of bilateral external ophthalmoplegia, ataxia, and decreased level of consciousness. BBE is part of a group of rare autoimmune diseases in children that can affect the nervous system at any level. The onset of neurological deficits is often sudden and nonspecific. The diagnosis is based on clinical findings and abnormal findings on cerebrospinal fluid (CSF), electroencephalography (EEG), electromyography (EMG), and magnetic resonance imaging (MRI). BBE is associated with the presence of the antiganglioside antibody, anti-GQ1b and anti-GM1. Intravenous immunoglobulin (IVIg) and plasma exchange are often used as treatments for these patients. We conducted a review on clinical presentation, diagnosis, treatment and outcome of reported cases of BBE. 74 cases are reported in the literature from the first cases described in 1951 to today. The prevalence is unknown while the incidence is higher in males. In 50% of cases, BBE occurs following respiratory or gastrointestinal tract infections. The most frequent initial symptoms were consciousness disturbance, headache, vomiting, diplopia, gait disturbance, dysarthria and fever. During illness course, almost all the patients developed consciousness disturbance, external ophthalmoplegia, and ataxia. Lumbar puncture showed pleocytosis or cytoalbuminological dissociation. Abnormal EEG and MRI studies revealed abnormalities in most cases. Anti-GQ1b antibodies were detected in more than half of the patients; anti-GM1 antibodies were detected in almost 40% of patients. Treatment guidelines are missing. In our analysis, steroids and IVIg were administered alone or in combination; as last option, plasmapheresis was used. BBE has a good prognosis and recovery in childhood is faster than in adulthood; 70% of patients reported no sequelae in our analysis. Future studies need to investigate pathogenesis and possible triggers, and therapeutic possibilities.

Postoperative cognitive worsening in seniors with an age above life expectancy: a prospective longitudinal study

BACKGROUND

The growing number of elderly patients in hospitals is a challenge for healthcare systems. The main objective is to measure the postoperative change in the cognitive status at hospital discharge and one year after discharge in elderly patients undergoing planned or deferrable surgery.

METHODS

We planned a prospective longitudinal study, single-center study: secondary care level hospital, enrolment from September 2018 to May 2019. We enroll elderly patients, aged above life expectancy in Italy, who underwent planned or deferrable surgery (men over 80.5 years old, women over 85.0 years old). In six months, we enrolled 76 eligible patients. We collected the scores of the clinical impairment scales Charlson Index, Barthel Index, and Six-Item Cognitive Impairment Test (6CIT). The primary endpoint was the postoperative worsening of the cognitive status at one-year follow-up. Secondary endpoints aimed to describe postoperative disabilities and complications, to investigate possible risk factors for cognitive worsening, and to measure the role of anesthesia in cognitive changes.

RESULTS

We recorded an increased rate of pathological 6CIT values during the hospitalization period, rising from 39.47% to 55.26% (McNemar test, P=0.007), and this rate was still increased at 55.56% (P=0.021) one year after discharge. Anesthesia did not show any significant harmful effect on cognitive status. The preoperative hemoglobin value seems to be a risk factor for cognitive status and one-year mortality.

CONCLUSIONS

Elderly patients had a significantly worse 6CIT value after planned surgery, which may derive in part from age and in part from hospitalization. It is difficult to determine if general anesthesia alone has no harmful effects on cognitive performance in patients at discharge and one year later. Further data are necessary.

Serum LDH levels may predict poor neurological outcome after aneurysmal subarachnoid hemorrhage

INTRODUCTION

Serum lactate dehydrogenase (LDH) levels are often elevated in cardiovascular diseases. Their prognostic role after subarachnoid hemorrhage (SAH) remains poorly evaluated.

METHODS

This is a retrospective single-center study of patients with non-traumatic SAH admitted to the intensive care unit (ICU) of an University Hospital from 2007 to 2022. Exclusion criteria were pregnancy and incomplete medical records or follow-up data. Baseline information, clinical data, radiologic data, the occurrence of neurological complications as well as serum LDH levels during the first 14 days of ICU stay were collected. Unfavorable neurological outcome (UO) at 3 months was defined as a Glasgow Outcome Scale of 1-3.

RESULTS

Five hundred and forty-seven patients were included; median serum LDH values on admission and the highest LDH values during the ICU stay were 192 [160-230] IU/L and 263 [202-351] IU/L, respectively. The highest LDH value was recorded after a median of 4 [2-10] days after ICU admission. LDH levels on admission were significantly higher in patients with UO. When compared with patients with favorable outcome (FO), patients with UO had higher serum LDH values over time. In the multivariate logistic regression model, the highest LDH value over the ICU stay (OR 1.004 [95% CI 1.002 - 1.006]) was independently associated with the occurrence of UO; the area under the receiving operator (AUROC) curve for the highest LDH value over the ICU stay showed a moderate accuracy to predict UO (AUC 0.76 [95% CI 0.72-0.80]; p < 0.001), with an optimal threshold of > 272 IU/L (69% sensitivity and 74% specificity).

CONCLUSIONS

The results in this study suggest that high serum LDH levels are associated with the occurrence of UO in SAH patients. As a readily and available biomarker, serum LDH levels should be evaluated to help with the prognostication of SAH patients.

Mechanical ventilation in patients with acute brain injury: a systematic review with meta-analysis

OBJECTIVE

To describe the potential effects of ventilatory strategies on the outcome of acute brain-injured patients undergoing invasive mechanical ventilation.

DESIGN

Systematic review with an individual data meta-analysis.

SETTING

Observational and interventional (before/after) studies published up to August 22nd, 2022, were considered for inclusion. We investigated the effects of low tidal volume Vt < 8 ml/Kg of IBW versus Vt >  = 8 ml/Kg of IBW, positive end-expiratory pressure (PEEP) < or >  = 5 cmH2O and protective ventilation (association of both) on relevant clinical outcomes.

POPULATION

Patients with acute brain injury (trauma or haemorrhagic stroke) with invasive mechanical ventilation for ≥ 24 h.

MAIN OUTCOME MEASURES

The primary outcome was mortality at 28 days or in-hospital mortality. Secondary outcomes were the incidence of acute respiratory distress syndrome (ARDS), the duration of mechanical ventilation and the partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio.

RESULTS

The meta-analysis included eight studies with a total of 5639 patients. There was no difference in mortality between low and high tidal volume [Odds Ratio, OR 0.88 (95%Confidence Interval, CI 0.74 to 1.05), p = 0.16, I2 = 20%], low and moderate to high PEEP [OR 0.8 (95% CI 0.59 to 1.07), p = 0.13, I2 = 80%] or protective and non-protective ventilation [OR 1.03 (95% CI 0.93 to 1.15), p = 0.6, I2 = 11]. Low tidal volume [OR 0.74 (95% CI 0.45 to 1.21, p = 0.23, I2 = 88%], moderate PEEP [OR 0.98 (95% CI 0.76 to 1.26), p = 0.9, I2 = 21%] or protective ventilation [OR 1.22 (95% CI 0.94 to 1.58), p = 0.13, I2 = 22%] did not affect the incidence of acute respiratory distress syndrome. Protective ventilation improved the PaO2/FiO2 ratio in the first five days of mechanical ventilation (p < 0.01).

CONCLUSIONS

Low tidal volume, moderate to high PEEP, or protective ventilation were not associated with mortality and lower incidence of ARDS in patients with acute brain injury undergoing invasive mechanical ventilation. However, protective ventilation improved oxygenation and could be safely considered in this setting. The exact role of ventilatory management on the outcome of patients with a severe brain injury needs to be more accurately delineated.

Occurrence of secondary insults during endovascular treatment of acute ischemic stroke and impact on outcome: the SIR-STROKE prospective observational study

BACKGROUND

Neurological outcome after endovascular treatment (EVT) of acute ischemic stroke (AIS) may depend on both patient-specific and procedural factors. We hypothesized that altered systemic homeostasis might be frequent and affect outcome in these patients. The aim of this study was to analyze secondary insults during EVT of AIS and its association with outcome and anesthesiologic regimen.

METHODS

This was a single-center prospective observational study on patients undergoing EVT for AIS under local anesthesia (LA), conscious sedation (CS), or general anesthesia (GA). Altered systemic parameters were recorded and quantified as secondary insults. The primary endpoint was to evaluate number, duration, and severity of secondary insults during EVT. Secondary endpoints were to analyze association of insults with modified Rankin Scale at 90 days and anesthesiologic regimen.

RESULTS AND CONCLUSIONS

One hundred twenty patients were enrolled. Overall, 78% of patients experienced at least one episode of hypotension, 21% hypertension, 54% hypoxemia, 16% bradycardia, and 13% tachycardia. In patients monitored with capnometry, 70% experienced hypocapnia and 21% hypercapnia. LA was selected in 24 patients, CS in 84, and GA in 12. Hypotension insult was more frequent during GA than LA and CS (p = 0.0307), but intraprocedural blood pressure variation was higher during CS (p = 0.0357). Hypoxemia was more frequent during CS (p = 0.0087). Proportion of hypotension duration was higher in unfavorable outcome but secondary insults did not remain in the final model of multivariable analysis. Secondary insults occurred frequently during EVT for AIS but the main predictors of outcome were age, NIHSS at admission, and prompt and successful recanalization.

Management of the Potential Lung Donor

The use of donor management protocols has significantly improved recovery rates; however, the inherent instability of lungs after death results in low utilization rates of potential donor lungs. Donor lungs are susceptible to direct trauma, aspiration, neurogenic edema, ventilator-associated barotrauma, and ventilator-associated pneumonia. After irreversible brain injury and determination of futility of care, the goal of medical management of the donor shifts to maintaining hemodynamic stability and maximizing the likelihood of successful organ recovery.

Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus

Purpose

To provide clinical practice recommendations and generate a research agenda on mechanical ventilation and respiratory support in patients with acute brain injury (ABI).

Methods

An international consensus panel was convened including 29 clinician-scientists in intensive care medicine with expertise in acute respiratory failure, neurointensive care, or both, and two non-voting methodologists. The panel was divided into seven subgroups, each addressing a predefined clinical practice domain relevant to patients admitted to the intensive care unit (ICU) with ABI, defined as acute traumatic brain or cerebrovascular injury. The panel conducted systematic searches and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to evaluate evidence and formulate questions. A modified Delphi process was implemented with four rounds of voting in which panellists were asked to respond to questions (rounds 1–3) and then recommendation statements (final round). Strong recommendation, weak recommendation, or no recommendation were defined when > 85%, 75–85%, and < 75% of panellists, respectively, agreed with a statement.

Results

The GRADE rating was low, very low, or absent across domains. The consensus produced 36 statements (19 strong recommendations, 6 weak recommendations, 11 no recommendation) regarding airway management, non-invasive respiratory support, strategies for mechanical ventilation, rescue interventions for respiratory failure, ventilator liberation, and tracheostomy in brain-injured patients. Several knowledge gaps were identified to inform future research efforts.

Conclusions

This consensus provides guidance for the care of patients admitted to the ICU with ABI. Evidence was generally insufficient or lacking, and research is needed to demonstrate the feasibility, safety, and efficacy of different management approaches.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-06283-0) contains supplementary material, which is available to authorized users.

Effects of liver ischemia-reperfusion injury on respiratory mechanics and driving pressure during orthotopic liver transplantation

BACKGROUND

During orthotopic liver transplantation (OLT), liver graft ischemia-reperfusion injury (IRI) triggers a cytokine-mediated systemic inflammatory response, which impairs graft function and disrupts distal organ homeostasis. The objective of this prospective, observational trial was to assess the effects of IRI on lung and chest wall mechanics in the intraoperative period of patients undergoing OLT.

METHODS

In 26 patients undergoing OLT, we measured elastance of the respiratory system (ERS), partitioned into lung (EL) and chest wall (ECW), hemodynamics, and fluid and blood product intake before laparotomy (T1), after portal/caval surgical clamp (T2), and immediately (T3) and, at 90 and 180 minutes post-reperfusion (T4 and T5, respectively). Interleukin-6 (IL-6), monocyte chemotactic protein-1 (MCP-1), IL-1β and tumor necrosis factor-α plasma concentrations were assessed at T1, T4 and T5.

RESULTS

EL significantly decreased from T1 to T2 (13.5±4.4 vs 9.7±4.8 cmH2O/L, P<0.05), remained stable at T3, while at T4 (12.3±4.4 cmH2O/L, P<0.05) was well above levels recorded at T2, reaching its highest value at T5 (15±3.9 cmH2O/L, P<0.05). Variations in ERS, EL, driving pressure (∆P) and trans-pulmonary pressure (∆PL) significantly correlated with changes in IL-6 and MCP-1 plasma concentrations, but not with changes in wedge pressure, fluid amounts, and red blood cells and platelets administered. No correlation was found between changes in cytokine concentrations and ECW.

CONCLUSIONS

We found that EL, ECW, ∆P and ∆PL underwent significant variations during the OLT procedure. Further, we documented a significant association between the respiratory mechanics changes and the inflammatory response following liver graft reperfusion.

How to optimize the lung donor

Over the last two decades, lung transplantation emerged as the standard of care for patients with advanced and terminal lung disease. Despite the increment in lung transplantation rates, in 2016 the overall mortality while on waiting list in Italy reached 10%, whereas only 39% of the wait-list patients were successfully transplanted. A number of approaches, including protective ventilatory strategy, accurate management of fluid balance, and administration of a hormonal resuscitation therapy, have been reported to improve lung donor performance before organ retrieval. These approaches, in conjunction with the use of ex-vivo lung perfusion technique contributed to expand the lung donor pool, without affecting the harvest of other organs and the outcomes of lung recipients. However, the efficacy of issues related to the ex-vivo lung perfusion technique, such as the optimal ventilation strategy, the ischemia-reperfusion induced lung injury management, the prophylaxis of germs transmission from donor to recipient and the application of targeted pharmacologic therapies to treat specific donor lung injuries are still to be explored. The main objective of the present review is to summarize the "state-of-art" strategies to optimize the donor lungs and to present the actual role of ex-vivo lung perfusion in the process of lung transplant. Moreover, different approaches about the technique reported in literature and several issues that are under investigation to treat specific donor lung injury will be discussed.

Blends of Aromatic Polysulphones and Alkene Terephthalate Polymers: Compatibilization with Polyhydroxyether of Bisphenol-A

An experimental study was carried out to examine the compatibilizing effect of phenoxy resin for blends of aromatic polysulphones and polyalkylene terephthalates. Dynamic mechanical spectra did not reveal relaxation peaks associated with the phenoxy phase, while the relaxation peaks associated with the glass transition temperatures of the polyester and polysulphone phases were closer to each other than for the corresponding individual polymers, confirming that the phenoxy was totally dissolved in the two main polymer phases.

Whereas the blends containing the butylene terephthalate polymers (homopolymer and block copolymer) exhibited a co-continuous two-phase morphology even at high concentrations of polysulphone, those based on polyethylene terephthalate revealed the presence of discrete particles. These two types of morphologies gave rise to large differences in mechanical properties and solvent resistance. The best properties were obtained with the systems characterized by a co-continuous two-phase morphology. Moreover, the systems based on bisphenol A polysulphones showed superior properties to the corresponding systems containing polyethersulphones.

Optimization of Morphology of Polyimide–Silica Hybrids in the Production of Matrices for Carbon Fibre Composites

Hybrids of polyimide and silica have been produced from solutions via the sol–gel process. Compatibilization of the organic phase, originating from a polyamic acid and the inorganic phase, based on alkoxysilane solutions of tetraethoxysilane (TEOS), was achieved through the use of an epoxy-functional trialkoxysilane coupling agent, γ-glycidyloxypropyltrimethoxysilane (GOTMS). The use of GOTMS brings about the intimate inter-dispersion of the two phases, which results in the formation of nano-sized co-continuous domains. The materials were evaluated by a variety of techniques, including differential scanning calorimetry, thermogravimetric analysis, electron microscopy and dynamic mechanical tests. The gelation characteristics of the precursor solutions, the mechanical and thermal properties of the resulting hybrids as matrices for carbon fibre composites were used as parameters to assess the compatibilization efficiency. The results show notable improvements in the thermal stability and mechanical properties of hybrids over those of the base polymer. Above the optimum concentration of the coupling agent, however, properties were found to deteriorate owing to a diluting effect by the aliphatic component in its structure, as well as to the reduction in the degree of imidization of the polymeric component.

Effects of dexmedetomidine and propofol on patient-ventilator interaction in difficult-to-wean, mechanically ventilated patients: a prospective, open-label, randomised, multicentre study

Background

Dexmedetomidine can be used for sedation of mechanically ventilated patients and has minor respiratory effects. The aim of this study was to compare the incidence of patient-ventilator dyssynchronies during sedation with dexmedetomidine or propofol.

Methods

We conducted a multicentre, prospective, open-label, randomised clinical trial, comparing dexmedetomidine with standard propofol sedation at three intensive care units of university hospitals in Italy. Twenty difficult-to-wean patients for whom the first weaning trial had failed and who were on pressure support ventilation were randomised to receive sedation with either dexmedetomidine or propofol at a similar level of sedation (Richmond Agitation-Sedation Scale [RASS] score +1 to −2). The asynchrony index (AI) was calculated using tracings of airflow, airway pressure and electrical activity of the diaphragm sampled at 0, 0.5, 1, 2, 6, 12, 18 and 24 h.

Results

The mean AI was lower with dexmedetomidine than with propofol from 2 h onwards, although the two groups significantly differed only at 12 h (2.68 % vs 9.10 %, p < 0.05). No further difference was observed at 18 and 24 h.

Conclusions

When sedation with propofol and dexmedetomidine was compared at similar RASS scores of patients in whom first weaning trial had failed, the AI was lower with dexmedetomidine than with propofol, and this difference was statistically significant at 12 h. These results suggest that sedation with dexmedetomidine may offer some advantages in terms of patient-ventilator synchrony.

Multivariate projection method to investigate inflammation associated with secondary insults and outcome after human traumatic brain injury: a pilot study

Background

Neuroinflammation has been proposed as a possible mechanism of brain damage after traumatic brain injury (TBI), but no consensus has been reached on the most relevant molecules. Furthermore, secondary insults occurring after TBI contribute to worsen neurological outcome in addition to the primary injury. We hypothesized that after TBI, a specific pattern of cytokines is related to secondary insults and outcome.

Methods

A prospective observational clinical study was performed. Secondary insults by computerized multimodality monitoring system and systemic value of different cytokines were collected and analysed in the first week after intensive care unit admission. Neurological outcome was assessed at 6 months (GOSe). Multivariate projection technique was applied to analyse major sources of variation and collinearity within the cytokines dataset without a priori selecting potential relevant molecules.

Results

Twenty-nine severe traumatic brain injury patients undergoing intracranial pressure monitoring were studied. In this pilot study, we demonstrated that after TBI, patients who suffered of prolonged and severe secondary brain damage are characterised by a specific pattern of cytokines. Patients evolving to brain death exhibited higher levels of inflammatory mediators compared to both patients with favorable and unfavorable neurological outcome at 6 months. Raised ICP and low cerebral perfusion pressure occurred in 21 % of good monitoring time. Furthermore, the principal components selected by multivariate projection technique were powerful predictors of neurological outcome.

Conclusions

The multivariate projection method represents a valuable methodology to study neuroinflammation pattern occurring after secondary brain damage in severe TBI patients, overcoming multiple putative interactions between mediators and avoiding any subjective selection of relevant molecules.

The link between anesthesiology and neurology: a mindful cooperation to improve brain protection

Preventing neurological injury is mandatory during the perioperative period of any kind of surgery and in the care of critically ill patients in the intensive care unit. During daily practice, both anesthesiologists and neurologists focus on brain protection as an integral part of systemic homeostasis maintenance. This article highlights the intriguing overlap between anesthesiology and neurology in clinical practice along with its potential implications for outcome. Moreover, it focuses on the importance of the complementary expertise of both specialists in maintaining cerebral homeostasis, with the aim of improving outcome. A review of available evidence on anesthesiology and neurology interplay in clinical practice along with its potential implications for outcome has been conducted. Clinical vigilance and the use of shared monitoring and diagnostic technology could allow early recognition and treatment of cerebral dysfunction occurring in the perioperative period or in the critical care setting, thus reducing morbidity and mortality. In order to improve patient safety and outcome, neurologists and anesthesiologists should more closely and successfully collaborate, using shared monitoring tools and integrating traditional areas of expertise. Daily activity, education, research and training programs in anesthesia and neurology could benefit from a stronger relationship with each other.

Heart rate reduction with esmolol is associated with improved arterial elastance in patients with septic shock: a prospective observational study

PURPOSE

Ventricular-arterial (V-A) decoupling decreases myocardial efficiency and is exacerbated by tachycardia that increases static arterial elastance (Ea). We thus investigated the effects of heart rate (HR) reduction on Ea in septic shock patients using the beta-blocker esmolol. We hypothesized that esmolol improves Ea by positively affecting the tone of arterial vessels and their responsiveness to HR-related changes in stroke volume (SV).

METHODS

After at least 24 h of hemodynamic optimization, 45 septic shock patients, with an HR ≥95 bpm and requiring norepinephrine to maintain mean arterial pressure (MAP) ≥65 mmHg, received a titrated esmolol infusion to maintain HR between 80 and 94 bpm. Ea was calculated as MAP/SV. All measurements, including data from right heart catheterization, echocardiography, arterial waveform analysis, and norepinephrine requirements, were obtained at baseline and at 4 h after commencing esmolol.

RESULTS

Esmolol reduced HR in all patients and this was associated with a decrease in Ea (2.19 ± 0.77 vs. 1.72 ± 0.52 mmHg l(-1)), arterial dP/dt max (1.08 ± 0.32 vs. 0.89 ± 0.29 mmHg ms(-1)), and a parallel increase in SV (48 ± 14 vs. 59 ± 18 ml), all p < 0.05. Cardiac output and ejection fraction remained unchanged, whereas norepinephrine requirements were reduced (0.7 ± 0.7 to 0.58 ± 0.5 µg kg(-1) min(-1), p < 0.05).

CONCLUSIONS

HR reduction with esmolol effectively improved Ea while allowing adequate systemic perfusion in patients with severe septic shock who remained tachycardic despite standard volume resuscitation. As Ea is a major determinant of V-A coupling, its reduction may contribute to improving cardiovascular efficiency in septic shock.

A new training approach in endoscopic percutaneous tracheostomy using a simulation model based on biological tissue

BACKGROUND

Ciaglia et al. originally proposed the percutaneous tracheostomy in 1985 as an alternative to the surgical approach. Several variants have been developed in the years with a convincing evidence that, compared to surgical tracheostomy, the percutaneous approach is more cost-effective without compromising safety. However the procedure is not immune from complications and requires procedural skills and adequate level of expertise with a steep learning curve. In this contest, to optimize safety and efficacy of percutaneous tracheostomy in different clinical scenarios, physicians should be familiar with the different available percutaneous techniques. Traditionally, the training has been performed using manikins or animal models. However, by definition the manikin is not able to replicate the complex anatomy and does not provide a realist model for learning.

METHODS

A sheep model was implemented and was tested in a simulation-based course for percutaneous dilational tracheostomy and cricothyrotomy organized by the Department of Surgical Sciences of University of Turin at the Special Educational Section of the Veterinary Sciences Department (University of Turin).

RESULTS

From September 2012 to December 2014, 2 sessions of the training course were performed. Thirty-two anesthesiologists (16 men and 16 women, mean (SD) age 40.4 (SD 8.6) attended the course. A quality assessment of the course was then collected by participants.

CONCLUSIONS

The biological model we implemented proved to be adequate and effective. Future studies are required to compare its efficacy with previously proposed training methods.

Dynamic airway pressure-time curve profile (Stress Index): a systematic review

The assessment of respiratory mechanics at the bedside is necessary in order to identify the most protective ventilatory strategy. Indeed in the last 20 years, adverse effects of positive ventilation to the lung structures have led to a reappraisal of the objectives of mechanical ventilation. The ventilator setting requires repeated readjustment over the period of mechanical ventilation dependency and careful respiratory monitoring to minimize the risks, preventing further injury and permitting the lung and airways healing. Among the different methods that have been proposed and validated, the analysis of dynamic P-t curve (named Stress Index, SI) represents an adequate tool available at the bedside, repeatable and, therefore, able to identify the amount of overdistension occurring in the daily clinical practice, when modifying positive end-expiratory pressure. In this review we will analyze the evidence that supports respiratory mechanics assessment at the bedside and the application of the dynamic P/t curve profile (SI) to optimize protective ventilation in patients with acute respiratory failure.

A cross-sectional nationwide survey on esophageal atresia and tracheoesophageal fistula

BACKGROUND

Our study aims at disclosing epidemiology and most relevant clinical features of esophageal atresia (EA) pointing to a model of multicentre collaboration.

METHODS

A detailed questionnaire was sent to all Italian Units of pediatric surgery in order to collect data of patients born with EA between January and December 2012. The results were crosschecked by matching date and place of birth of the patients with those of diagnosis-related group provided by the Italian Ministry of Health (MOH).

RESULTS

A total of 146 questionnaires were returned plus a further 32 patients reported in the MOH database. Basing on a total of 178 patients with EA born in Italy in 2012, the incidence of EA was calculated in 3.33 per 10,000 live births. Antenatal diagnosis was suspected in 29.5% patients. 55.5% showed associated anomalies. The most common type of EA was Gross type C (89%). Postoperative complications occurred in 37% of type C EA and 100% of type A EA. A 9.5% mortality rate was reported.

CONCLUSIONS

This is the first Italian cross-sectional nationwide survey on EA. We can now develop shared guidelines and provide more reliable prognostic expectations for our patients.

Extracorporeal Co2 removal in hypercapnic patients at risk of noninvasive ventilation failure: a matched cohort study with historical control

OBJECTIVES

To assess efficacy and safety of noninvasive ventilation-plus-extracorporeal Co2 removal in comparison to noninvasive ventilation-only to prevent endotracheal intubation patients with acute hypercapnic respiratory failure at risk of failing noninvasive ventilation.

DESIGN

Matched cohort study with historical control.

SETTING

Two academic Italian ICUs.

PATIENTS

Patients treated with noninvasive ventilation for acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease (May 2011 to November 2013).

INTERVENTIONS

Extracorporeal CO2 removal was added to noninvasive ventilation when noninvasive ventilation was at risk of failure (arterial pH ≤ 7.30 with arterial PCO2 > 20% of baseline, and respiratory rate ≥ 30 breaths/min or use of accessory muscles/paradoxical abdominal movements). The noninvasive ventilation-only group was created applying the genetic matching technique (GenMatch) on a dataset including patients enrolled in two previous studies. Exclusion criteria for both groups were mean arterial pressure less than 60 mm Hg, contraindications to anticoagulation, body weight greater than 120 kg, contraindication to continuation of active treatment, and failure to obtain consent.

MEASUREMENTS AND MAIN RESULTS

Primary endpoint was the cumulative prevalence of endotracheal intubation. Twenty-five patients were included in the noninvasive ventilation-plus-extracorporeal CO2 removal group. The GenMatch identified 21 patients for the noninvasive ventilation-only group. Risk of being intubated was three times higher in patients treated with noninvasive ventilation-only than in patients treated with noninvasive ventilation-plus-extracorporeal CO2 removal (hazard ratio, 0.27; 95% CI, 0.07-0.98; p = 0.047). Intubation rate in noninvasive ventilation-plus-extracorporeal CO2 removal was 12% (95% CI, 2.5-31.2) and in noninvasive ventilation-only was 33% (95% CI, 14.6-57.0), but the difference was not statistically different (p = 0.1495). Thirteen patients (52%) experienced adverse events related to extracorporeal CO2 removal. Bleeding episodes were observed in three patients, and one patient experienced vein perforation. Malfunctioning of the system caused all other adverse events.

CONCLUSIONS

These data provide the rationale for future randomized clinical trials that are required to validate extracorporeal CO2 removal in patients with hypercapnic respiratory failure and respiratory acidosis nonresponsive to noninvasive ventilation.

Cerebrospinal fluid from patients with subarachnoid haemorrhage and vasospasm enhances endothelin contraction in rat cerebral arteries

INTRODUCTION

Previous studies have suggested that cerebrospinal fluid from patients with subarachnoid hemorrhage (SAH) leads to pronounced vasoconstriction in isolated arteries. We hypothesized that only cerebrospinal fluid from SAH patients with vasospasm would produce an enhanced contractile response to endothelin-1 in rat cerebral arteries, involving both endothelin ETA and ETB receptors.

METHODS

Intact rat basilar arteries were incubated for 24 hours with cerebrospinal fluid from 1) SAH patients with vasospasm, 2) SAH patients without vasospasm, and 3) control patients. Arterial segments with and without endothelium were mounted in myographs and concentration-response curves for endothelin-1 were constructed in the absence and presence of selective and combined ETA and ETB receptor antagonists. Endothelin concentrations in culture medium and receptor expression were measured.

RESULTS

Compared to the other groups, the following was observed in arteries exposed to cerebrospinal fluid from patients with vasospasm: 1) larger contractions at lower endothelin concentrations (p<0.05); 2) the increased endothelin contraction was absent in arteries without endothelium; 3) higher levels of endothelin secretion in the culture medium (p<0.05); 4) there was expression of ETA receptors and new expression of ETB receptors was apparent; 5) reduction in the enhanced response to endothelin after ETB blockade in the low range and after ETA blockade in the high range of endothelin concentrations; 6) after combined ETA and ETB blockade a complete inhibition of endothelin contraction was observed.

CONCLUSIONS

Our experimental findings showed that in intact rat basilar arteries exposed to cerebrospinal fluid from patients with vasospasm endothelin contraction was enhanced in an endothelium-dependent manner and was blocked by combined ETA and ETB receptor antagonism. Therefore we suggest that combined blockade of both receptors may play a role in counteracting vasospasm in patients with SAH.

Brain-heart crosstalk: the many faces of stress-related cardiomyopathy syndromes in anaesthesia and intensive care

Neurogenic stress cardiomyopathy (NSC) is a well-known syndrome complicating the early phase after an acute brain injury, potentially affecting outcomes. This article is a review of recent data on the putative role of localization and lateralization of brain lesions in NSC, cardiac innervation abnormalities, and new polymorphisms and other genetic causes of the sympathetic nervous system over-activity. Concerns regarding the management of stress-related cardiomyopathy syndromes during the perioperative period are also discussed. Future clinical research should explore whether specific factors explain different patient susceptibilities to the disease and should be directed towards early identification and stratification of patients at risk, so that such patients can be more carefully monitored and appropriately managed in critical care and during the perioperative period.

Epidemiology and outcome of sepsis syndromes in Italian ICUs: a muticentre, observational cohort study in the region of Piedmont

BACKGROUND

Sepsis is an important cause of mortality and morbidity in the intensive care unit (ICU). We performed a study to describe the epidemiology of sepsis syndromes in patients admitted to ICUs of the Piedmont region.

METHODS

In this prospective, multicentre, observational study, all 3902 patients admitted to a network of 24 ICUs from 17 hospitals during a 180 day period (April 3-September 29, 2006) were included. Patients were followed from the first day of admission until death or ICU discharge.

RESULTS

The incidence of sepsis during the ICU stay was 11.4% (N.=446), corresponding to an incidence of 25 cases/100,000 inhabitants/year; 141 (31.6%) patients had only sepsis, 160 patients had severe sepsis (35.9%) and 145 patients (32.5%) had septic shock In 227 patients (50.9%), sepsis was observed within 48 hours after admission to the ICU, and 219 patients (49.1%) developed ICU-acquired sepsis. The main sources of infection were the lungs, abdomen, and urinary tract. ICU mortality was higher (41.3 vs. 17.3%, P<0.0001) and the median ICU length of stay longer (15 vs. 2 days, P<0.0001) in patients with sepsis than in those without sepsis. The mortality rate increased with the severity of sepsis. ICU-acquired sepsis was associated with higher ICU mortality rates than sepsis occurring within 48 hours of ICU admission (49.8 vs. 33.0%, P<0.0001).

CONCLUSION

Sepsis is a common occurrence in critically ill patients. Our data underscore the regional variability in the epidemiology and outcome of sepsis syndromes and may be useful to guide appropriate resource allocation.

Orientation Evolution in Convergent-Divergent Dies

Solid-state extrusion experiments were carried out through constant area convergent-divergent dies using two crystalline polymers, i.e. ultra high molecular weight polyethylene (UHMWPE) and polytetrafluorethylene (PTFE), with the aim of producing extrudates exhibiting biaxial orientation. The evolution of orientation was examined along the extrusion axis by measuring the off-plane birefringence values at various distances from the entry on specimens removed from the dies. Simple analytical expressions relating orientation factor to draw ratio in the three mutually perpendicular directions were derived for crystalline polymers. These generalised relationships were found applicable for all types of deformations, i.e. monoaxial, biaxial and pure shear. On the basis of the data obtained and the predictions from the theoretical analysis, the deformations taking place in dies with small converging angles, known as fish-tail dies, were found to be close to a state of pure shear deformations, while dies with high converging angles initially, then changing to high divergencies in the second section, known as dual-taper dies, were found to give rise to a state of unbalanced biaxial deformations.

Donation after cardiac death: is a "paradigm shift" feasible in Italy?

Donation after cardiac death (DCD) is one of the growing strategies to overcome the problem of organ shortage. Cardiac death is defined as "irreversible cessation of circulatory and respiratory function"; the time interval to define irreversibility of cardiac death, the peculiarity of consent, and the framework of end-of-life decision making are the most compelling ethical issues which have been raised with DCD. National protocols that balance medical, ethical, and social issues are mandatory to guide transplant care professionals. In Italy, the 20 min cardiac arrest demonstrated by continuous electrocardiography recording is the time interval necessary for death diagnosis based on cardiopulmonary criteria. This time negatively affects donation after cardiac death because warm ischemic time (WIT) - the most important predictor of grafts' poor outcome - is prolonged. However, this time seems to be prudential to define the irreversibility of death and to respect the "dead donor rule", as established by the National Committee of Bioethics. National reference protocols regulating DCD practice are therefore a compelling issue.

The influence of gender on the epidemiology of and outcome from severe sepsis

INTRODUCTION

The impact of gender on outcome in critically ill patients is unclear. We investigated the influence of gender on the epidemiology of severe sepsis and associated morbidity and mortality in a large cohort of ICU patients in the region of Piedmont in Italy.

METHODS

This was a post-hoc analysis of data from a prospective, multicenter, observational study in which all patients admitted to one of 24 participating medical and/or surgical ICUs between 3 April 2006 and 29 September 2006 were included.

RESULTS

Of the 3,902 patients included in the study, 63.5% were male. Female patients were significantly older than male patients (66±16 years vs. 63±16 years, P<0.001). Female patients were less likely to have severe sepsis and septic shock on admission to the ICU and to develop these syndromes during the ICU stay. ICU mortality was similar in men and women in the whole cohort (20.1% vs. 19.8%, P=0.834), but in patients with severe sepsis was significantly greater in women than in men (63.5% vs. 46.4%, P=0.007). In multivariate logistic regression analysis with ICU outcome as the dependent variable, female gender was independently associated with a higher risk of ICU death in patients with severe sepsis (odds ratio=2.33, 95% confidence interval=1.23 to 4.39, P=0.009) but not in the whole cohort (odds ratio=1.07, 95% confidence interval=0.87 to 1.34).

CONCLUSION

In this large regional Italian cohort of ICU patients, there were more male than female admissions. The prevalence of severe sepsis was lower in women than in men, but female gender was independently associated with a higher risk of death in the ICU for patients with severe sepsis.

Brain-lung crosstalk in critical care: how protective mechanical ventilation can affect the brain homeostasis

The maintenance of brain homeostasis against multiple internal and external challenges occurring during the acute phase of acute brain injury may be influenced by critical care management, especially in its respiratory, hemodynamic and metabolic components. The occurrence of acute lung injury represents the most frequent extracranial complication after brain injury and deserves special attention in daily practice as optimal ventilatory strategy for patients with acute brain and lung injury are potentially in conflict. Protecting the lung while protecting the brain is thus a new target in the modern neurointensive care. This article discusses the essentials of brain-lung crosstalk and focuses on how mechanical ventilation may exert an active role in the process of maintaining or treatening brain homeostasis after acute brain injury, highlighting the following points: 1) the role of inflammation as common pathomechanism of both acute lung and brain injury; 2) the recognition of ventilatory induced lung injury as determinant of systemic inflammation affecting distal organs, included the brain; 3) the possible implication of protective mechanical ventilation strategy on the patient with an acute brain injury as an undiscovered area of research in both experimental and clinical settings.

Being overweight or obese is associated with decreased mortality in critically ill patients: a retrospective analysis of a large regional Italian multicenter cohort

PURPOSE

To describe the epidemiology of obesity in a large cohort of intensive care unit (ICU) patients and study its impact on outcomes.

METHODS

All 3902 patients admitted to one of 24 ICUs in the Piedmont region of Italy from April 3 to September 29, 2006, were included in this retrospective analysis of data from a prospective, multicenter study.

RESULTS

Mean body mass index (BMI) was 26.0 ± 5.4 kg/m(2): 32.8% of patients had a normal BMI, 2.6% were underweight, 45.1% overweight, 16.5% obese, and 2.9% morbidly obese. ICU mortality was significantly (P < .05) lower in overweight (18.8%) and obese (17.5%) patients than in those of normal BMI (22%). In multivariate logistic regression analysis, being overweight (OR = 0.73; 95%CI: 0.58-0.91, P = .007) or obese (OR = 0.62; 95%CI: 50.45-0.85, P = .003) was associated with a reduced risk of ICU death. Being morbidly obese was independently associated with an increased risk of death in elective surgery patients whereas being underweight was independently associated with an increased risk of death in patients admitted for short-term monitoring and after elective surgery.

CONCLUSIONS

In this cohort, overweight and obese patients had a reduced risk of ICU death. Being underweight or morbidly obese was associated with an increased risk of death in some subgroups of patients.

ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure

PURPOSE

To assess whether partitioning the elastance of the respiratory system (E (RS)) between lung (E (L)) and chest wall (E (CW)) elastance in order to target values of end-inspiratory transpulmonary pressure (PPLAT(L)) close to its upper physiological limit (25 cmH(2)O) may optimize oxygenation allowing conventional treatment in patients with influenza A (H1N1)-associated ARDS referred for extracorporeal membrane oxygenation (ECMO).

METHODS

Prospective data collection of patients with influenza A (H1N1)-associated ARDS referred for ECMO (October 2009-January 2010). Esophageal pressure was used to (a) partition respiratory mechanics between lung and chest wall, (b) titrate positive end-expiratory pressure (PEEP) to target the upper physiological limit of PPLAT(L) (25 cmH(2)O).

RESULTS

Fourteen patients were referred for ECMO. In seven patients PPLAT(L) was 27.2 ± 1.2 cmH(2)O; all these patients underwent ECMO. In the other seven patients, PPLAT(L) was 16.6 ± 2.9 cmH(2)O. Raising PEEP (from 17.9 ± 1.2 to 22.3 ± 1.4 cmH(2)O, P = 0.0001) to approach the upper physiological limit of transpulmonary pressure (PPLAT(L) = 25.3 ± 1.7 cm H(2)O) improved oxygenation index (from 37.4 ± 3.7 to 16.5 ± 1.4, P = 0.0001) allowing patients to be treated with conventional ventilation.

CONCLUSIONS

Abnormalities of chest wall mechanics may be present in some patients with influenza A (H1N1)-associated ARDS. These abnormalities may not be inferred from measurements of end-inspiratory plateau pressure of the respiratory system (PPLAT(RS)). In these patients, titrating PEEP to PPLAT(RS) may overestimate the incidence of hypoxemia refractory to conventional ventilation leading to inappropriate use of ECMO.