How to insert a PICC: practical tips for the intensive care physician

Peripherally inserted central catheters (PICCs) are central vascular access devices inserted via deep veins of the arm, also useful in critical care settings. The purpose of this article is to offer to a critical care clinician with good skills in central venous catheterization, but who has limited experience on PICC catheters, the basic information on how the procedure is performed and how to minimize the risks of complications or failure of the maneuver. The main technical steps and the main precautions to be taken during PICC placement will be analyzed, with reference to the differences compared to central catheterization. Specifically, the pre-procedural phase and the intraprocedural main steps of the maneuver will be analyzed. A dedicated Vascular Access Team is considered useful and desirable by the current literature, but when the use of the PICC proves useful or even mandatory, the intensive care physician skilled in central venous catheters can transfer skills from central to peripheral catheterization

Venturi mask is the pioneer of High-Flow Oxygen Therapy Concepts

Oxygen therapy should be carefully considered and monitored because, as any other medications, it can cause harm to patients, if used inappropriately. This paper focus on the distinction between low-flow and high-flow oxygen therapy. A discussion about Venturi system for oxygen administration is carried on, given that some authors include it in the low-flow devices group despite its characteristics to deliver high flow therapy

Efectividad del 1-MCP sobre el centro de hongos fitopatogenos en postcosecha de manzana

Resumen (Spanish, English)45 p.Esta investigación tuvo la finalidad de probar la efectividad del inhibidor de la acción deetileno 1-metilciclopropeno (1-MCP) sobre el control de hongos fitopatógenos enpostcosecha de manzanas cv. Braeburn. Para esto, se realizaron ensayos durante latemporada 2002 en el Centro de Pomáceas de la Universidad de Talca. La fruta fueinoculada con micelio de los hongos Penicillium expansum y Botrytis cinerea y expuesta a los dostratamientos del ensayo: con y sin gasificación de 1-MCP (AgroFresh, 0,14%). La cantidadde fruta inoculada fue de 240, de las cuales 120 manzanas fueron inmediatamentealmacenadas a 0° C, y las restantes sometidas a gasificación por 24 horas con los 625 ppb de1-MCP. El periodo de almacenaje para ambos tratamientos fue de 90 días a 00 C y 95 HR,siguiendo un modelo de postcosecha comercial para la fruta, más 1 día a temperaturaambiente (22° C). Además, 40 frutos sin inocular y sin gasificar fueron almacenados como control negativo, para detectar posibles infecciones naturales dentro de las cámaras. Lasevaluaciones consistieron en mediciones de diámetro, peso y profundidad de pudrición enconjunto con mediciones de sólidos solubles, firmeza y color de fondo de las manzanas deambos tratamientos, además cada 30 dias de almacenaje, un total de 12 frutos portratamiento fueron evaluados. Por otra parte, 30 placas Petri con APD, fueron sembradas conconidias de B. cinerea y P. expansum a una concentración de 1,5 * 106 conidias por ml. Quinceplacas sembradas para cada hongo, fueron gasificadas con 625 ppb de 1-MCP (Agrofresh0,14 %). Finalmente, las placas sembradas con y sin gasificación fueron incubadas a 20 °C por 7 días. La fruta gasificada con 1-MCP mostró diámetro, peso y volumen de pudriciónsignificativamente menor (p < 0,01) que la fruta no gasificada, tanto para aquella evaluada cada30 días como para la que estuvo 90 días a 0° y 95 %HR más 1 día a temperatura ambiente.Sin embargo, los parámetros de calidad evaluados (SS,firmeza y color de fondo) nopresentaron diferencias significativas entre fruta gasificada con 1-MCP y fruta singasificar. El desarrollo de los hongos en las placas Petri bajo los tratamientos presentó elcrecimiento de éstos, descartándose el control directo del 1-MCP

Applicazione delle nuove linee guida AARC per l'aspirazione endotracheale : impatto sui parametri vitali in pazienti sottoposti a rivascolarizzazione miocardica (BPAC)

RIASSUNTOIntroduzione : La manovra di bronco aspirazione è una procedura che espone il paziente critico a modificazioni dei parametri vitali. Le nuove linee guida AARC hanno enfatizzato sia l'importanza dell'identificazione corretta del momento in cui eseguire la procedura, sia l'utilizzo routinario del sistema chiuso. Obiettivo : Applicare le nuove linee guida AARC utilizzando un rilevatore sonoro per l'identificazione della presenza di secrezioni (TBA care©) e l'aspirazione a circuito chiuso ed analizzare l'andamento dei parametri vitali in una popolazione di pazienti cardiochirurgici. Materiali e metrodi: Lo studio è di tipo osservazionale. Sono stati investigati 15 pazienti sottoposti a BPAC, ricoverati in terapia intensiva cardiochirurgia. Sono stati registrati in continuo i seguenti parametri vitali HR, PAS, PAS*HR, ST varie derivazioni, SpO2, PEEP, RRv, TVc in quattro finestre temporali, 5 minuti prima della manovra di Broncoaspirazione, al momento della manovra (momento 0), a 5 minuti dalla stessa e 10 minuti dopo. Risultati : I parametri vitali rimangono sostanzialmente stabili nei quattro step investigati, con minime variazioni (Variazione percentuale durante la manovra rispetto al basale : HR +2,93%, PAS + 5,66%, SpO2 – 0,13%) . Non si sono registrate modificazioni del tratto ST. Si registra un aumento dell'indice di lavoro cardiaco, che però rientra a 5 minuti dall'esecuzione della manovra. Non si sono verificate desaturazioni arteriose. Conclusioni : Le alterazioni dei parametri vitali osservate, seppur minime, suggeriscono di mantenere il massimo monitoraggio emodinamico e respiratorio. Nella popolazione osservata, l'utilizzo di tecnologie per la diagnosi associate al sistema chiuso di broncoaspirazione ha evitato l'insorgenza di complicanze legate alla manovra.Parole chiave: aspirazione endotracheale, identificazione delle secrezioni, sistema chiuso, ventilazione meccanica, gestione delle secrezioniABSTRACT Introduction: Endotracheal suctioning is a procedure that exposes the patient to critical changes in vital signs. New AARC guidelines have emphasized both the importance of correct identification when to perform the procedure, and the routine use of closed system. Objective: To implement the new guidelines AARC using a sound detector for identifying the presence of secretions (TBA care ©) , closed suctioning circuit and analyze the performance of vital signs in a population of cardiac patients. Methods : The study is observational. Were investigated 15 patients undergoing CABG, cardiac surgery ICU. Were continuously recorded the following vital signs HR, SBP, SBP * HR, ST various leads, SpO2, PEEP, RRV, TVC in four time windows, 5 minutes before the suctioning maneuver at the time of operation (time 0), 5 minutes from the same and 10 minutes later. Results: Vital signs remain stable in the four steps investigated, with minor variations (percent change from baseline during the maneuver: HR +2.93% 5.66% PAS +, SpO2 - 0.13%). There were no ST segment changes. There is an increase in the cardiac work, but within 5 minutes from the execution of the maneuver. There were no arterial desaturation. Conclusions: The observed changes in vital signs, albeit small, suggest to keep the maximum hemodynamic and respiratory monitoring. The use of technologies for the diagnosis associated with the closed system of broncoaspiration has prevented the onset of complications related to the maneuver.Keywords: endotracheal suctioning, secretion detector, closed system, mechanical ventilation, secretion managemen

Inciviltí sul luogo di lavoro, violenza orizzontale, bullismo e mobbing tra pari nella professione infermieristica: teorie e modelli di interpretazione dei fenomeni

Tra le interazioni relazionali negative tra infermieri ci sono le dinamiche relazionali laterali, cioè quelle che vengono esercitate tra pari, all'interno dei gruppi di lavoro. Alcuni autori hanno teorizzato la presenza di un continuum di comportamenti che vanno dall'inciviltí  sul posto di lavoro fino allo strutturarsi di violenze laterali, per finire al bullismo orizzontale. Per quanto diffusi e importanti siano questi fenomeni, ancora oggi le soluzioni di tipo reattivo e proattivo sono scarse, e scarsamente efficaci. I modelli e le interpretazioni che spiegano questi meccanismi di comportamento all'interno dei gruppi sono di tipo interpersonale, intrapersonale, evolutivo, e biologico. Questi ruotano intorno ad elementi centrali quali, le differenze di genere, la pressione del lavoro, le differenze di ruolo, lo stress, il conflitto generazionale, e non ultimo l'esercizio di controllo attraverso circuiti di potere. Esistono anche fascinazioni derivanti dagli studi antropologici, anche se ad oggi la teoria dei comportamenti del gruppo oppresso non è stata ancora del tutto sviluppata e nemmeno validata in ambito infermieristico Ciò nonostante, le variegate interpretazioni dei meccanismi che generano questa tipologia di fenomeni non sono mutuamente esclusive, e contribuiscono ad una visione sfaccettata del problema, che forse è l'elemento cardine su cui impostare una risposta in termini preventivi e reattivi. I modelli e le interpretazioni di queste modalití  di violenza sul posto di lavoro possono servire a costruire cornici concettuali all'interno delle quali sperimentare con opportuni studi di ricerca, gli interventi per abbattere la comparsa e la presenza dei fenomeni e le loro conseguenze.Parole Chiave: inciviltí , violenza laterale, mobbing, bullismo, nursingWorkplace incivility, horizontal violence, bullying and mobbing among peers in nursing. Theories and interpretation modelsAmong the negative interactions between nurses there are the lateral dynamics, exerted between peers, within the working groups. Some authors have theorized the presence of a continuum of behaviors ranging workplace incivility up to the lateral violence, and horizontal bullying. Although these phenomena are widespread and important, currently, reactive and proactive solutions are scarce, and barely effective. The models and interpretations that explain these mechanisms of behavior within groups are interpersonal, intrapersonal, evolutionary and biological. These revolve around central elements such as gender differences, work pressure, role differences, stress, generational conflict, and the need to exert control through circuits of power. There are also fascinations arising from anthropological studies, although to date the oppressed group behavior theory was not yet fully developed nor validated in the field of nursing. Nonetheless, the varied interpretations of the mechanisms that generate this type of phenomena are not mutually exclusive, and contribute to a multifaceted view of the problem, which is (perhaps) the key element on which to set preventive and reactive interventions. The models and interpretations of these forms of workplace violence can be used to construct conceptual frameworks to be used during the design of appropriate research studies that test interventions to reduce the rise and presence of these problems and their consequences. Parole Chiave: workplace incivility, lateral violence, mobbing, bullying, nursin

Long-term physical impairments in survivors of COVID-19-associated ARDS compared with classic ARDS: A two-center study

Purpose: This work aimed to compare physical impairment in survivors of classic ARDS compared with COVID-19-associated ARDS (CARDS) survivors. Material and methods: This is a prospective observational cohort study on 248 patients with CARDS and compared them with a historical cohort of 48 patients with classic ARDS. Physical performance was evaluated at 6 and 12 months after ICU discharge, using the Medical Research Council Scale (MRCss), 6-min walk test (6MWT), handgrip dynamometry (HGD), and fatigue severity score (FSS). We also assessed activities of daily living (ADLs) using the Barthel index. Results: At 6 months, patients with classic ARDS had lower HGD (estimated difference [ED]: 11.71 kg, p < 0.001; ED 31.9% of predicted value, p < 0.001), 6MWT distance (ED: 89.11 m, p < 0.001; ED 12.96% of predicted value, p = 0.032), and more frequent significant fatigue (OR 0.35, p = 0.046). At 12 months, patients with classic ARDS had lower HGD (ED: 9.08 kg, p = 0.0014; ED 25.9% of predicted value, p < 0.001) and no difference in terms of 6MWT and fatigue. At 12 months, patients with classic ARDS improved their MRCss (ED 2.50, p = 0.006) and HGD (ED: 4.13 kg, p = 0.002; ED 9.45% of predicted value, p = 0.005), while those with CARDS did not. Most patients in both groups regained independence in ADLs at 6 months. COVID-19 diagnosis was a significant independent predictor of better HGD (p < 0.0001) and 6MWT performance (p = 0.001), and lower prevalence of fatigue (p = 0.018). Conclusions: Both classic ARDS and CARDS survivors experienced long-term impairments in physical functioning, confirming that post-intensive care syndrome remains a major legacy of critical illness. Surprisingly, however, persisting disability was more common in survivors of classic ARDS than in CARDS survivors. In fact, muscle strength measured with HGD was reduced in survivors of classic ARDS compared to CARDS patients at both 6 and 12 months. The 6MWT was reduced and fatigue was more common in classic ARDS compared to CARDS at 6 months but differences were no longer significant at 12 months. Most patients in both groups regained independent function in ADLs at 6 months

Estudio experimental de un colector con acumulación integrada de dos tanques con superficies reflectantes y cubierta de policarbonato

El objetivo de este trabajo es analizar experimentalmente el comportamiento de un colector con acumulación integrada de dos tanques horizontales, superficies reflectantes y cubierta de policarbonato, a fin de determinar la capacidad del mismo para proveer agua caliente. A un prototipo construido en la Universidad Nacional de Río Cuarto se le midieron temperaturas a la entrada, a la salida y en lugares intermedios, a la vez que se analizaron la radiación solar incidente y la temperatura ambiente durante varios días. Los resultados se presentan en diagramas que muestran la evolución de las temperaturas en función del tiempo y se realiza un cálculo estimativo de la cantidad de agua caliente que podría proveer el sistema. Se llega a la conclusión de que el sistema posee una buena capacidad de captación y almacenamiento de energía y que sería capaz de proveer una fracción solar aceptable en un servicio de tipo residencial.The goal of this work is to analyse by means of experiments the behaviour of an integral collector storage system composed by two horizontal tanks, reflective surfaces and a polycarbonate cover, in order to determine the ability of this system to provide hot water. Inlet, outlet, and intermediate temperatures were measured to a prototype built in the National University of Rio Cuarto, and in the same time the ambient temperature and global horizontal solar radiation were recorded, during a series of days. The results are presented in diagrams, which show the evolution of the temperatures and radiation as a function of time and an estimative calculation is performed in order to check the quantity of hot water the system can provide. The conclusion is that the system has a good absorption and storage energy capacity and it would be able to provide an acceptable solar fraction in a residential service.Asociación Argentina de Energías Renovables y Medio Ambiente (ASADES

Estudio experimental de un colector con acumulación integrada de dos tanques con superficies reflectantes y cubierta de policarbonato

El objetivo de este trabajo es analizar experimentalmente el comportamiento de un colector con acumulación integrada de dos tanques horizontales, superficies reflectantes y cubierta de policarbonato, a fin de determinar la capacidad del mismo para proveer agua caliente. A un prototipo construido en la Universidad Nacional de Río Cuarto se le midieron temperaturas a la entrada, a la salida y en lugares intermedios, a la vez que se analizaron la radiación solar incidente y la temperatura ambiente durante varios días. Los resultados se presentan en diagramas que muestran la evolución de las temperaturas en función del tiempo y se realiza un cálculo estimativo de la cantidad de agua caliente que podría proveer el sistema. Se llega a la conclusión de que el sistema posee una buena capacidad de captación y almacenamiento de energía y que sería capaz de proveer una fracción solar aceptable en un servicio de tipo residencial.The goal of this work is to analyse by means of experiments the behaviour of an integral collector storage system composed by two horizontal tanks, reflective surfaces and a polycarbonate cover, in order to determine the ability of this system to provide hot water. Inlet, outlet, and intermediate temperatures were measured to a prototype built in the National University of Rio Cuarto, and in the same time the ambient temperature and global horizontal solar radiation were recorded, during a series of days. The results are presented in diagrams, which show the evolution of the temperatures and radiation as a function of time and an estimative calculation is performed in order to check the quantity of hot water the system can provide. The conclusion is that the system has a good absorption and storage energy capacity and it would be able to provide an acceptable solar fraction in a residential service.Asociación Argentina de Energías Renovables y Medio Ambiente (ASADES