Combined lung and brain ultrasonography for an individualized “brain-protective ventilation strategy” in neurocritical care patients with challenging ventilation needs

When intracranial hypertension and severe lung damage coexist in the same clinical scenario, their management poses a difficult challenge, especially as concerns mechanical ventilation management. The needs of combined lung and brain protection from secondary damage may conflict, as ventilation strategies commonly used in patients with ARDS are potentially associated with an increased risk of intracranial hypertension. In particular, the use of positive end-expiratory pressure, recruitment maneuvers, prone positioning, and protective lung ventilation can have undesirable effects on cerebral physiology: they may positively or negatively affect intracranial pressure, based on the final repercussions on PaO2and cerebral perfusion pressure (through changes in cardiac output, mean arterial pressure, venous return, PaO2and PaCO2), also according to the baseline conditions of cerebral autoregulation. Lung ultrasound (LUS) and brain ultrasound (BUS, as a combination of optic nerve sheath diameter assessment and cerebrovascular Doppler ultrasound) have independently proven their potential in respectively monitoring lung aeration and brain physiology at the bedside. In this narrative review, we describe how the combined use of LUS and BUS on neurocritical patients with demanding mechanical ventilation needs can contribute to ventilation management, with the aim of a tailored “brain-protective ventilation strategy.

Splenic Doppler Resistive Index Variation Mirrors Cardiac Responsiveness and Systemic Hemodynamics upon Fluid Challenge Resuscitation in Postoperative Mechanically Ventilated Patients

Objective. To test if splenic Doppler resistive index (SDRI) allows noninvasive monitoring of changes in stroke volume and regional splanchnic perfusion in response to fluid challenge. Design and Setting. Prospective observational study in cardiac intensive care unit. Patients. Fifty-three patients requiring mechanical ventilation and fluid challenge for hemodynamic optimization after cardiac surgery. Interventions. SDRI values were obtained before and after volume loading with 500 mL of normal saline over 20 min and compared with changes in systemic hemodynamics, determined invasively by pulmonary artery catheter, and arterial lactate concentration as expression of splanchnic perfusion. Changes in stroke volume >10% were considered representative of fluid responsiveness. Results. A <4% SDRI reduction excluded fluid responsiveness, with 100% sensitivity and 100% negative predictive value. A >9% SDRI reduction was a marker of fluid responsiveness with 100% specificity and 100% positive predictive value. A >4% SDRI reduction was always associated with an improvement of splanchnic perfusion mirrored by an increase in lactate clearance and a reduction in systemic vascular resistance, regardless of fluid responsiveness. Conclusions. This study shows that SDRI variations after fluid administration is an effective noninvasive tool to monitor systemic hemodynamics and splanchnic perfusion upon volume administration, irrespective of fluid responsiveness in mechanically ventilated patients after cardiac surgery

Outcome assessment of the VADO approach in psychiatric rehabilitation: a partially randomised multicentric trial

BACKGROUND: Recent studies on representative samples of psychiatric services have shown that low proportions of cases received effective rehabilitation interventions. The following are likely to be the most important causes: the scarcity of mental health workers trained in social and work skills strategies and the absence of a structured framework to formulate rehabilitation practices. The aim of this study was to assess if a specific structured planning and evaluation manual, called VADO (Valutazione delle Abilità e Definizione degli Obiettivi – in english: Skills Assessment and Definition of Goals), is more effective than routine interventions in reducing disability in patients with schizophrenia. METHOD: Each of 10 mental health services were invited to recruit 10 patients with a schizophrenic disorder. Altogether 98 patients were recruited. Of these, 62 patients were randomly allocated to the intervention/experimental or a control group. The remaining group of 36 patients was not randomised and it was considered as a parallel effectiveness study. Assessment measures at the beginning of the study and at the one-year follow-up included the FPS scale of social functioning and the BPRS 4.0. Between group (VADO vs. Routine) and time effects were examined with ANOVA, Chi-square or Fisher exact. Clinical "improvement" was defined as an increase of at least ten points on the FPS or a decrease of at least 20% on BPRS scores. RESULTS: 31 of the 62 randomized patients received the experimental interventions, while 31 followed the routine ones. At follow-up, the experimental group showed statistically and clinically greater improvements in psychopathology and social functioning. Better outcomes of both social functioning and symptom severity were observed in non randomised patients (parallel effectiveness study). CONCLUSION: The results suggest that setting personalised and measurable objectives, as recommended by the manual, can improve the outcome of rehabilitation of severe mental disorders. Better outcomes in the parallel effectiveness study could be attributed to the greater confidence and enthusiasm of staff in centres where the VADO approach originated

Acute respiratory distress syndrome in traumatic brain injury: How do we manage it?

Traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide. TBI patients frequently suffer from lung complications and acute respiratory distress syndrome (ARDS), which is associated with poor clinical outcomes. Moreover, the association between TBI and ARDS in trauma patients is well recognized. Mechanical ventilation of patients with a concomitance of acute brain injury and lung injury can present significant challenges. Frequently, guidelines recommending management strategies for patients with traumatic brain injuries come into conflict with what is now considered best ventilator practice. In this review, we will explore the strategies of the best practice in the ventilatory management of patients with ARDS and TBI, concentrating on those areas in which a conflict exists. We will discuss the use of ventilator strategies such as protective ventilation, high positive end expiratory pressure (PEEP), prone position, recruitment maneuvers (RMs), as well as techniques which at present are used for 'rescue' in ARDS (including extracorporeal membrane oxygenation) in patients with TBI. Furthermore, general principles of fluid, haemodynamic and hemoglobin management will be discussed. Currently, there are inadequate data addressing the safety or efficacy of ventilator strategies used in ARDS in adult patients with TBI. At present, choice of ventilator rescue strategies is best decided on a case-by-case basis in conjunction with local expertise

Optic nerve sheath diameter measured sonographically as non-invasive estimator of intracranial pressure: a systematic review and meta-analysis

Purpose: Although invasive intracranial devices (IIDs) are the gold standard for intracranial pressure (ICP) measurement, ultrasonography of the optic nerve sheath diameter (ONSD) has been suggested as a potential non-invasive ICP estimator. We performed a meta-analysis to evaluate the diagnostic accuracy of sonographic ONSD measurement for assessment of intracranial hypertension (IH) in adult patients. Methods: We searched on electronic databases (MEDLINE/PubMed\uae, Scopus\uae, Web of Science\uae, ScienceDirect\uae, Cochrane Library\uae) until 31 May 2018 for comparative studies that evaluated the efficacy of sonographic ONSD vs. ICP measurement with IID. Data were extracted independently by two authors. We used the QUADAS-2 tool for assessing the risk of bias (RB) of each study. A diagnostic meta-analysis following the bivariate approach and random-effects model was performed. Results: Seven prospective studies (320 patients) were evaluated for IH detection (assumed with ICP > 20 mmHg or > 25 cmH2O). The accuracy of included studies ranged from 0.811 (95% CI 0.678\u20120.847) to 0.954 (95% CI 0.853\u20120.983). Three studies were at high RB. No significant heterogeneity was found for the diagnostic odds ratio (DOR), positive likelihood ratio (PLR) and negative likelihood ratio (NLR), with I2< 50% for each parameter. The pooled DOR, PLR and NLR were 67.5 (95% CI 29\u2012135), 5.35 (95% CI 3.76\u20127.53) and 0.088 (95% CI 0.046\u20120.152), respectively. The area under the hierarchical summary receiver-operating characteristic curve (AUHSROC) was 0.938. In the subset of five studies (275 patients) with IH defined for ICP > 20 mmHg, the pooled DOR, PLR and NLR were 68.10 (95% CI 26.8\u2012144), 5.18 (95% CI 3.59\u20127.37) and 0.087 (95% CI 0.041\u20120.158), respectively, while the AUHSROC was 0.932. Conclusions: Although the wide 95% CI in our pooled DOR suggests caution, ultrasonographic ONSD may be a potentially useful approach for assessing IH when IIDs are not indicated or available (CRD42018089137, PROSPERO)

Head to toe ultrasound: a narrative review of experts’ recommendations of methodological approaches

Critical care ultrasonography (US) is widely used by intensivists managing critically ill patients to accurately and rapidly assess different clinical scenarios, which include pneumothorax, pleural effusion, pulmonary edema, hydronephrosis, hemoperitoneum, and deep vein thrombosis. Basic and advanced critical care ultrasonographic skills are routinely used to supplement physical examination of critically ill patients, to determine the etiology of critical illness and to guide subsequent therapy. European guidelines now recommend the use of US for a number of practical procedures commonly performed in critical care. Full training and competence acquisition are essential before significant therapeutic decisions are made based on the US assessment. However, there are no universally accepted learning pathways and methodological standards for the acquisition of these skills. Therefore, in this review, we aim to provide a methodological approach of the head to toe ultrasonographic evaluation of critically ill patients considering different districts and clinical applications

Long-term cardiac sequelae in patients referred into a diagnostic post-COVID-19 pathway: the Different Impacts on the Right and Left Ventricles

Most patients who had COVID-19 are still symptomatic after many months post infection, but the long-term outcomes are not yet well-defined. The aim of our prospective/retrospective study was to define the cardiac sequelae of COVID-19 infection. This monocentric cohort study included 160 consecutive patients who had been discharged from the ward or from the outpatient clinic after a diagnosis of COVID-19 and subsequently referred for a follow up visit. Clinical features data about the acute phase along with information about the follow up visit, including ECG and Echocardiographic parameters, were recorded. At an average follow-upfollow up of 5 months, echocardiography showed morpho-functional changes characteristics of both right (RV) and left (LV) ventricles, such as RV dilation, increased pressure in the pulmonary circulation, and biy-ventricular systolic-diastolic dysfunction. When examined using multivariate analysis, independent of age, sex, and co-morbidities, RV and LV changes were significantly associated with chest High Resolution computed tomography score and hemodynamic Instability (HI) and with C-reactive protein, respectively. Our results suggest that COVID-19 may impact RV and LV differently. Notably, the extent of the pneumonia and HI may affect RV, whereas the inflammatory status may influence LV. A long-term follow-up is warranted to refine and customize the most appropriate therapeutic strategies

Vegetal Fiber Additives in Mortars: Experimental Characterization of Thermal and Acoustic Properties

This paper investigates the influence of adding vegetal fibers on thermal and acoustic performance based on natural hydraulic lime. Mortar samples with 10% weight of vegetal fibers were fabricated adding water to obtain easily workable mortars with good consistency; their performance was compared to mortar samples without vegetal fibers. The fibers were of different types (rice husk, spelt bran, and Khorasan (turanicum) wheat chaff) and size (as-found and ground form). Thermal performance was measured with the Small Hot Box experimental apparatus. Thermal conductivity was reduced in the 1−11% range (with Khorasan wheat chaff and rice husk); no significant reduction was found with spelled bran in the mixture. When ground, fibers were characterized by both good thermal and acoustic absorption performance; a reduction of 6−22% in thermal conductivity λ was achieved with spelled bran (λ = 0.64 W/mK) and rice husks (λ = 0.53 W/mK), whereas the Khorasan wheat chaff had the highest sound absorption average index (0.38). However, the addition of fibers reduced sound insulation properties due to their low weight densities. This reduction was limited for rice husks (transmission loss value was only 2 dB lower than the reference)

Glacial, \ufb02uvioglacial and \ufb02uvial sedimentary discharge in the northwestern coastal sectorof the Ross Sea continental margin since upper Miocene to LGM

The Borchgrevink Coast stretches from the Coulman Island northward to the Cape Adare for at least 200 km, bordering the western side of the northern Drygalski Trough. The early phase of the acquisition objectives of the PNRAProjectGlevors(GlacialEvolutioninthenorthwesternRossSea,offshoreNorthVictoriaLand,Antarctica) was accomplished in the north western coastal sector of the Ross Sea continental margin along the Borchgrevink Coast, from Coulman Island to Cape Hallett. Single channel seismic and sub bottom pro\ufb01les, swath bathymetry and gravity cores were collected during the Austral summer of 2016/2017, by the scienti\ufb01c research vessel OGS/Explora. The studied area along this segment of the Borchgrevink Coast documents, by the analysis and the interpretation of available geophysical, geological and oceanographic data, the paleo ice discharge and ice \ufb02owing patterns of the inferred Mariner-Borchgrevink and Tucker coastal glaciers, since at least the Upper Miocene until the Holocene Time. The repeated and possibly asynchronous oscillations of these valley glaciers from the North Victoria Land coast, at least about tens km offshore, and their interaction with fast \ufb02owing ice streams from the south are recorded. In particular, the analysis of the architecture and of the geometrical relationship of the interpreted seismic facies and units allows to infer past glacial and interglacial environments. Modelling of paleo environments and related climate condition is achieved despite the age constrain uncertainty of local seismic stratigraphy and of biostrathigraphic correlations to coeval sediment section in southern Ross Sea inner-shelf sector (McMurdo Sound), and besides the acoustic facies ambiguity due to not enough data resolution. The interpreted shallower and Holocene-Present glacial related features are simple or composite ice-marginal landforms, with overstepping smaller recessional deposits on top or behind. They testify the coastal glaciers grounded events and the ice retreat modality during the pre-LGM and the LGM. We infer that northern coastal glaciers, from the Tucker glacier northward, about 72\u25e6 latitude, did not advance or reach the northwestern Ross Sea shelf edge at the LGM, but possibly before. The grounding line of NVL coastal glaciers would correlate with the pre-LGM grounding lineament reconstructed for the major ice-streams \ufb02owing from the south. More ancient and buried wedge, underlying the main composite Grounding Zone Wedge (GZW) system raises the issue if it was possible the formation and the preservation as a pinning point, of a previously developed GZW or of the upper part of a \ufb02uvioglacial delta in late Miocene or Pliocene time. Moreover, further offshore from the coast, the evidence, of an ancient buried glacial/\ufb02uvioglacial or \ufb02uvial delta, embedded within the glaciomarine clinoforms of the Trough Mouth Fans (TMFs) deposits \ufb01lling the Northern Drygalski Trough, suggest climate change and an inferred preceding coastal open-sea condition