Iron metabolism and lymphocyte characterisation during Covid-19 infection in ICU patients: An observational cohort study

Background: Iron metabolism and immune response to SARS-CoV-2 have not been described yet in intensive care patients, although they are likely involved in Covid-19 pathogenesis. Methods: We performed an observational study during the peak of pandemic in our intensive care unit, dosing D-dimer, C-reactive protein, troponin T, lactate dehydrogenase, ferritin, serum iron, transferrin, transferrin saturation, transferrin soluble receptor, lymphocyte count and NK, CD3, CD4, CD8 and B subgroups of 31 patients during the first 2 weeks of their ICU stay. Correlation with mortality and severity at the time of admission was tested with the Spearman coefficient and Mann-Whitney test. Trends over time were tested with the Kruskal-Wallis analysis. Results: Lymphopenia is severe and constant, with a nadir on day 2 of ICU stay (median 0.555 109/L; interquartile range (IQR) 0.450 109/L); all lymphocytic subgroups are dramatically reduced in critically ill patients, while CD4/CD8 ratio remains normal. Neither ferritin nor lymphocyte count follows significant trends in ICU patients. Transferrin saturation is extremely reduced at ICU admission (median 9%; IQR 7%), then significantly increases at days 3 to 6 (median 33%, IQR 26.5%, p value 0.026). The same trend is observed with serum iron levels (median 25.5 μg/L, IQR 69 μg/L at admission; median 73 μg/L, IQR 56 μg/L on days 3 to 6) without reaching statistical significance. Hyperferritinemia is constant during intensive care stay: however, its dosage might be helpful in individuating patients developing haemophagocytic lymphohistiocytosis. D-dimer is elevated and progressively increases from admission (median 1319 μg/L; IQR 1285 μg/L) to days 3 to 6 (median 6820 μg/L; IQR 6619 μg/L), despite not reaching significant results. We describe trends of all the abovementioned parameters during ICU stay. Conclusions: The description of iron metabolism and lymphocyte count in Covid-19 patients admitted to the intensive care unit provided with this paper might allow a wider understanding of SARS-CoV-2 pathophysiology

Infection-Related Ventilator-Associated Complications in Critically Ill Patients with Trauma: A Retrospective Analysis

Background: Trauma is a leading cause of death and disability. Patients with trauma undergoing invasive mechanical ventilation (IMV) are at risk for ventilator-associated events (VAEs) potentially associated with a longer duration of IMV and increased stay in the intensive care unit (ICU). Methods: We conducted a retrospective cohort study aimed to evaluate the incidence of infection-related ventilator-associated complications (IVACs), possible ventilator-associated pneu- monia (PVAP), and their characteristics among patients experiencing severe trauma that required ICU admission and IMV for at least four days. We also determined pathogens implicated in PVAP episodes and characterized the use of antimicrobial therapy. Results: In total, 88 adult patients were included in the main analysis. In this study, we observed that 29.5% of patients developed a respiratory infection during ICU stay. Among them, five patients (19.2%) suffered from respiratory infections due to multi-drug resistant bacteria. Patients who developed IVAC/PVAP presented lower total GCS (median value, 7; (IQR, 9) vs. 12.5, (IQR, 8); p = 0.068) than those who did not develop IVAC/PVAP. Conclusions: We observed that less than one-third of trauma patients fulfilling criteria for ventilator associated events developed a respiratory infection during the ICU stay

Voice Improvement in Patients with Functional Dysphonia Treated with the Proprioceptive-Elastic (PROEL) Method

The objective of the study was to analyze the outcome of the proprioceptive-elastic (PROEL) voice therapy method in patients with functional dysphonia (FD). Fifty-two patients with FD were involved in the study; they were composed of three subgroups of patients with (1) FD without glottal insufficiency (n = 28), (2) FD and glottal insufficiency (n = 9), and (3) FD, glottal insufficiency, and vocal nodules (n = 15). A multidimensional assessment protocol including videolaryngostroboscopy; maximum phonation time; perceptual evaluation of dysphonia with the Grade, Instability, Roughness, Breathiness, Asthenia, and Strain (GIRBAS) scale; and 10-item version of the Voice Handicap Index was conducted before and after 15 sessions of voice therapy. All voice therapy sessions were conducted by the same speech-language pathologist. The comparison between voice assessment before and after voice therapy with the PROEL method in patients with FD, in all the three subgroups, revealed a statistically significant improvement in periodicity and the mucosal wave in the laryngostroboscopy, maximum phonation time, GIRBAS scale scores, and VHI-10.Voice of patients with FD improved after treatment with the PROEL method. Further studies are needed to analyze the efficacy of the PROEL method with randomized double-blind clinical trials using different methods for voice therapy. At present, the PROEL method represents an alternative tool for the speech pathologist to improve voice in patients with FD

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

Background: The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. Methods: Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. Results: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient’s directives, family feelings and representatives' desires, and all decisions should be shared. Conclusions: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes. Graphical abstract: (Figure presented.

Factors influencing liberation from mechanical ventilation in coronavirus disease 2019: multicenter observational study in fifteen Italian ICUs

Background: A large proportion of patients with coronavirus disease 2019 (COVID-19) develop severe respiratory failure requiring admission to the intensive care unit (ICU) and about 80% of them need mechanical ventilation (MV). These patients show great complexity due to multiple organ involvement and a dynamic evolution over time; moreover, few information is available about the risk factors that may contribute to increase the time course of mechanical ventilation. The primary objective of this study is to investigate the risk factors associated with the inability to liberate COVID-19 patients from mechanical ventilation. Due to the complex evolution of the disease, we analyzed both pulmonary variables and occurrence of non-pulmonary complications during mechanical ventilation. The secondary objective of this study was the evaluation of risk factors for ICU mortality. Methods: This multicenter prospective observational study enrolled 391 patients from fifteen COVID-19 dedicated Italian ICUs which underwent invasive mechanical ventilation for COVID-19 pneumonia. Clinical and laboratory data, ventilator parameters, occurrence of organ dysfunction, and outcome were recorded. The primary outcome measure was 28 days ventilator-free days and the liberation from MV at 28 days was studied by performing a competing risks regression model on data, according to the method of Fine and Gray; the event death was considered as a competing risk. Results: Liberation from mechanical ventilation was achieved in 53.2% of the patients (208/391). Competing risks analysis, considering death as a competing event, demonstrated a decreased sub-hazard ratio for liberation from mechanical ventilation (MV) with increasing age and SOFA score at ICU admission, low values of PaO2/FiO2 ratio during the first 5 days of MV, respiratory system compliance (CRS) lower than 40 mL/cmH2O during the first 5 days of MV, need for renal replacement therapy (RRT), late-onset ventilator-associated pneumonia (VAP), and cardiovascular complications. ICU mortality during the observation period was 36.1% (141/391). Similar results were obtained by the multivariate logistic regression analysis using mortality as a dependent variable. Conclusions: Age, SOFA score at ICU admission, CRS, PaO2/FiO2, renal and cardiovascular complications, and late-onset VAP were all independent risk factors for prolonged mechanical ventilation in patients with COVID-19. Trial registration: NCT04411459

Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study

none95noBackground: Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (< median PaO2/FiO2 variation) based on the PaO2/FiO2 percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO2/FiO2 response after the first pronation cycle was associated to liberation from mechanical ventilation. Results: The median PaO2/FiO2 variation after the first PP cycle was 49 [19–100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO2/FiO2 before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP. Conclusions: Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically ill COVID-19 patients.noneScaramuzzo G.; Gamberini L.; Tonetti T.; Zani G.; Ottaviani I.; Mazzoli C.A.; Capozzi C.; Giampalma E.; Bacchi Reggiani M.L.; Bertellini E.; Castelli A.; Cavalli I.; Colombo D.; Crimaldi F.; Damiani F.; Fusari M.; Gamberini E.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Nardi G.; Papa R.; Potalivo A.; Russo E.; Taddei S.; Consales G.; Cappellini I.; Ranieri V.M.; Volta C.A.; Guerin C.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Barbalace C.; Citino M.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Matteo F.; Marchio A.; Bacchilega I.; Bernabe L.; Guarino S.; Mosconi E.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Pagni A.; Pompa Cleta P.; Cavagnino M.; Malfatto A.; Adduci A.; Pareschi S.; Melegari G.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Becherucci F.; Parise M.; Masoni F.; Imbriani M.; Orlandi P.; Monetti F.; Dalpiaz G.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Bartolucci M.Scaramuzzo G.; Gamberini L.; Tonetti T.; Zani G.; Ottaviani I.; Mazzoli C.A.; Capozzi C.; Giampalma E.; Bacchi Reggiani M.L.; Bertellini E.; Castelli A.; Cavalli I.; Colombo D.; Crimaldi F.; Damiani F.; Fusari M.; Gamberini E.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Nardi G.; Papa R.; Potalivo A.; Russo E.; Taddei S.; Consales G.; Cappellini I.; Ranieri V.M.; Volta C.A.; Guerin C.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Barbalace C.; Citino M.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Matteo F.; Marchio A.; Bacchilega I.; Bernabe L.; Guarino S.; Mosconi E.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Pagni A.; Pompa Cleta P.; Cavagnino M.; Malfatto A.; Adduci A.; Pareschi S.; Melegari G.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Becherucci F.; Parise M.; Masoni F.; Imbriani M.; Orlandi P.; Monetti F.; Dalpiaz G.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Bartolucci M

Health-related quality of life profiles, trajectories, persistent symptoms and pulmonary function one year after ICU discharge in invasively ventilated COVID-19 patients, a prospective follow-up study

none112siBackground: Health-related quality of life (HRQoL) impairment is often reported among COVID-19 ICU survivors, and little is known about their long-term outcomes. We evaluated the HRQoL trajectories between 3 months and 1 year after ICU discharge, the factors influencing these trajectories and the presence of clusters of HRQoL profiles in a population of COVID-19 patients who underwent invasive mechanical ventilation (IMV). Moreover, pathophysiological correlations of residual dyspnea were tested. Methods: We followed up 178 survivors from 16 Italian ICUs up to one year after ICU discharge. HRQoL was investigated through the 15D instrument. Available pulmonary function tests (PFTs) and chest CT scans at 1 year were also collected. A linear mixed-effects model was adopted to identify factors associated with different HRQoL trajectories and a two-step cluster analysis was performed to identify HRQoL clusters. Results: We found that HRQoL increased during the study period, especially for the significant increase of the physical dimensions, while the mental dimensions and dyspnea remained substantially unchanged. Four main 15D profiles were identified: full recovery (47.2%), bad recovery (5.1%) and two partial recovery clusters with mostly physical (9.6%) or mental (38.2%) dimensions affected. Gender, duration of IMV and number of comorbidities significantly influenced HRQoL trajectories. Persistent dyspnea was reported in 58.4% of patients, and weakly, but significantly, correlated with both DLCO and length of IMV. Conclusions: HRQoL impairment is frequent 1 year after ICU discharge, and the lowest recovery is found in the mental dimensions. Persistent dyspnea is often reported and weakly correlated with PFTs alterations. Trial registration: NCT04411459.mixedGamberini L.; Mazzoli C.A.; Prediletto I.; Sintonen H.; Scaramuzzo G.; Allegri D.; Colombo D.; Tonetti T.; Zani G.; Capozzi C.; Dalpiaz G.; Agnoletti V.; Cappellini I.; Melegari G.; Damiani F.; Fusari M.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Papa R.; Potalivo A.; Montomoli J.; Taddei S.; Mazzolini M.; Ferravante A.F.; Nicali R.; Ranieri V.M.; Russo E.; Volta C.A.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Orlando S.; Fecarotti D.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Cavalli I.; Castelli A.; Marchio A.; Bacchilega I.; Bernabe L.; Facondini F.; Morini L.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Venni A.; Pagni A.; Cleta P.P.; Cavagnino M.; Guzzo A.; Malfatto A.; Adduci A.; Pareschi S.; Bertellini E.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Ottaviani I.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Tutino L.; Senzi A.; Consales G.; Becherucci F.; Imbriani M.; Orlandi P.; Candini S.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Giampalma E.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Monari M.; Valli M.; Daniele F.; Ferioli M.; Nava S.; Lazzari Agli L.A.; Valentini I.; Bernardi E.; Balbi B.; Contoli M.; Padovani M.; Oldani S.; Ravaglia C.; Goti P.Gamberini L.; Mazzoli C.A.; Prediletto I.; Sintonen H.; Scaramuzzo G.; Allegri D.; Colombo D.; Tonetti T.; Zani G.; Capozzi C.; Dalpiaz G.; Agnoletti V.; Cappellini I.; Melegari G.; Damiani F.; Fusari M.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Papa R.; Potalivo A.; Montomoli J.; Taddei S.; Mazzolini M.; Ferravante A.F.; Nicali R.; Ranieri V.M.; Russo E.; Volta C.A.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Orlando S.; Fecarotti D.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Cavalli I.; Castelli A.; Marchio A.; Bacchilega I.; Bernabe L.; Facondini F.; Morini L.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Venni A.; Pagni A.; Cleta P.P.; Cavagnino M.; Guzzo A.; Malfatto A.; Adduci A.; Pareschi S.; Bertellini E.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Ottaviani I.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Tutino L.; Senzi A.; Consales G.; Becherucci F.; Imbriani M.; Orlandi P.; Candini S.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Giampalma E.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Monari M.; Valli M.; Daniele F.; Ferioli M.; Nava S.; Lazzari Agli L.A.; Valentini I.; Bernardi E.; Balbi B.; Contoli M.; Padovani M.; Oldani S.; Ravaglia C.; Goti P