A cannabinoid-intoxicated child treated with dexmedetomidine: a case report

In the last 20 years, the rate of exposure to marijuana has increased dramatically, even in the pediatric population. Effects of intoxication are variable, more severe neurological symptoms can be observed following ingestion, thus hospital or intensive care unit admission is often required. Usually cannabinoids intoxicated patients are treated with administration of benzodiazepines or opioids, accepting the related risk of intubation and mechanical ventilation. Dexmedetomidine is a highly selective \u3b12-adrenergic receptor agonist, with no effect on the respiratory drive and pattern and produces a good level of sedation, allowing to avoid the administration of other sedatives. To our knowledge, this is the first reported case of dexmedetomidine use to support a cannabis intoxicated patient

Influence of changes in ventricular systolic function and loading conditions on pulse contour analysis-derived femoral dP/dt max

Background: Femoral dP/dt (maximum rate of the arterial pressure increase during systole) measured by pulse contour analysis has been proposed as a surrogate of left ventricular (LV) dP/dt and as an estimator of LV systolic function. However, femoral dP/dt may be influenced by LV loading conditions. In this study, we evaluated the impact of variations of LV systolic function, preload and afterload on femoral dP/dt in critically ill patients with cardiovascular failure to ascertain its reliability as a marker of LV systolic function. Results: We performed a prospective observational study to evaluate changes in femoral dP/dt, thermodilution-derived variables (PiCCO2-Pulsion Medical Systems, Feldkirchen, Germany) and LV ejection fraction (LVEF) measured by transthoracic echocardiography during variations in dobutamine and norepinephrine doses and during volume expansion (VE) and passive leg raising (PLR). Correlations with arterial pulse and systolic pressure, effective arterial elastance, total arterial compliance and LVEF were also evaluated. In absolute values, femoral dP/dt deviated from baseline by 21% (201 ± 297 mmHg/s; p = 0.013) following variations in dobutamine dose (n = 17) and by 15% (177 ± 135 mmHg/s; p < 0.001) following norepinephrine dose changes (n = 29). Femoral dP/dt remained unchanged after VE and PLR (n = 24). Changes in femoral dP/dt were strongly correlated with changes in pulse pressure and systolic arterial pressure during dobutamine dose changes (R = 0.942 and 0.897, respectively), norepinephrine changes (R = 0.977 and 0.941, respectively) and VE or PLR (R = 0.924 and 0.897, respectively) (p < 0.05 in all cases). Changes in femoral dP/dt were correlated with changes in LVEF (R = 0.527) during dobutamine dose variations but also with effective arterial elastance and total arterial compliance in the norepinephrine group (R = 0.638 and R = − 0.689) (p < 0.05 in all cases). Conclusions: Pulse contour analysis-derived femoral dP/dt was not only influenced by LV systolic function but also and prominently by LV afterload and arterial waveform characteristics in patients with acute cardiovascular failure. These results suggest that femoral dP/dt calculated by pulse contour analysis is an unreliable estimate of LV systolic function during changes in LV afterload and arterial load by norepinephrine and directly linked to arterial waveform determinants

A physiologic comparison of proportional assist ventilation with load-adjustable gain factors (PAV+) versus pressure support ventilation (PSV).

PURPOSE: To compare patient-ventilator interaction during PSV and PAV+ in patients that are difficult to wean. METHODS: This was a physiologic study involving 11 patients. During three consecutive trials (PSV first trial--PSV1, followed by PAV+, followed by a second PSV trial--PSV2, with the same settings as PSV1) we evaluated mechanical and patient respiratory pattern; inspiratory effort from excursion Pdi (swing(Pdi)), and pressure-time products of the transdiaphragmatic (PTPdi) pressures. Inspiratory (delay(trinsp)) and expiratory (delay(trexp)) trigger delays, time of synchrony (time(syn)), and asynchrony index (AI) were assessed. RESULTS: Compared to PAV+, during PSV trials, the mechanical inspiratory time (Ti(flow)) was significantly longer than patient inspiratory time (Ti(pat)) (p < 0.05); Ti(pat) showed a prolongation between PSV1 and PAV+, significant comparing PAV+ and PSV2 (p < 0.05). PAV+ significantly reduced delay(trexp) (p < 0.001). The portion of tidal volume (VT) delivered in phase with Ti(pat) (VT(pat)/VT(mecc)) was significantly higher during PAV+ (p < 0.01). The time of synchrony was significantly longer during PAV+ than during PSV (p < 0.001). During PSV 5 patients out of 11 showed an AI greater than 10%, whereas the AI was nil during PAV+. CONCLUSION: PAV+ improves patient-ventilator interaction, significantly reducing the incidence of end-expiratory asynchrony and increasing the time of synchrony

Remifentanil effects on respiratory drive and timing during pressure support ventilation and neurally adjusted ventilatory assist

We assessed the effects of varying doses of remifentanil on respiratory drive and timing in patients receiving Pressure Support Ventilation (PSV) and Neurally Adjusted Ventilatory Assist (NAVA). Four incrementing remifentanil doses were randomly administered to thirteen intubated patients (0.03, 0.05, 0.08, and 0.1\u3bcg\ub7Kg 121\ub7min 121) during both PSV and NAVA. We measured the patient's (Ti/Ttotneu) and ventilator (Ti/Ttotmec) duty cycle, the Electrical Activity of the Diaphragm (EAdi), the inspiratory (Delaytrinsp) and expiratory (Delaytrexp) trigger delays and the Asynchrony Index (AI). Increasing doses of remifentanil did not modify EAdi, regardless the ventilatory mode. In comparison to baseline, remifentanil infusion >0.05\u3bcg/Kg 121/min 121produced a significant reduction of Ti/Ttotneuand Ti/Ttotmecby prolonging the expiratory time. Delaytrinspand Delaytrexpwere significantly shorter in NAVA, respect to PSV. AI was not influenced by the different doses of remifentanil, but it was significantly lower during NAVA, compared to PSV. In conclusion remifentanil did not affect the respiratory drive, but only respiratory timing, without differences between modes

Characteristics and outcomes of patients undergoing anesthesia while SARS-CoV-2 infected or suspected: a multicenter register of consecutive patients

International audienceBackground There are limited data to detail the perioperative anesthetic management and the incidence of postoperative respiratory complications among patients requiring an anesthetic procedure while being SARS-CoV-2 positive or suspected.Methods An observational multicenter cohort study was performed including consecutive patients who were SARS-CoV-2 confirmed or suspected and who underwent scheduled and emergency anesthesia between March 17 and May 26, 2020.Results A total of 187 patients underwent anesthesia with SARS-CoV-2 confirmed or suspected, with ultimately 135 (72.2%) patients positive and 52 (27.8%) negative. The median SOFA score was 2 [0; 5], and the median ARISCAT score was 49 [36; 67]. The major respiratory complications rate was 48.7% ( n = 91) with 40.4% ( n = 21) and 51.9% ( n = 70) in the SARS-CoV-2–negative and –positive groups, respectively ( p = 0.21). Among both positive and negative groups, patients with a high ARISCAT risk score (> 44) had a higher risk of presenting major respiratory complications ( p < 0.01 and p = 0.1, respectively).Discussion When comparing SARS-COV-2–positive and –negative patients, no significant difference was found regarding the rate of postoperative complications, while baseline characteristics strongly impact these outcomes. This finding suggests that patients should be scheduled for anesthetic procedures based on their overall risk of postoperative complication, and not just based on their SARS-CoV-2 status

MOESM1 of The passive leg raising test to guide fluid removal in critically ill patients

Additional file 1:  Tables SDC1, SDC2 and SDC3

A laser-produced plasma X-ray source for contact microscopy

A promising field of application of the X-ray radiation generated by intense laser-matter interaction is the contact-microscopy of biological samples. In order to optimize the yield on the desired spectral window, it is fundamental to have an accurate characterization of this emitted radiation. To this purpose, an experimental campaign is underway with the three-nanosecond phosphate Nd:glass laser at the ABC laboratory in ENEA. The plasma was generated by irradiating solid targets with energy up to 30 J, and intensity on target up to 1014 Wcm−2. A transmission grating provided low-resolution spectra of a wide spectral range (2–50 Å). This covered also the so-called "water window" region, namely the spectral region between Oxygen and Carbon K-absorption edges (23 to 44 Å) where the absorption of carbon is ten times that of oxygen, and for this reason is of high interest for the contact-microscopy application. The X-ray yield in this spectral region was also monitored by a PIN diode filtered with 0.5 μm vanadium foil and coupled with a grazing-incidence copper mirror. A spherically-bent mica crystal was used to obtain high resolution spectra of the region going from 5.1 to 5.8 Å. This narrow spectral range was analyzed for determining the temperature of the produced plasma through the identification of different lines and of their intensity

A bench study of 2 ventilator circuits during helmet noninvasive ventilation

OBJECTIVE: To compare helmet noninvasive ventilation (NIV), in terms of patient-ventilator interaction and performance, using 2 different circuits for connection: a double tube circuit (with one inspiratory and one expiratory line) and a standard circuit (a Y-piece connected only to one side of the helmet, closing the other side). METHODS: A manikin, connected to a test lung set at 2 breathing frequencies (20 and 30 breaths/min), was ventilated in pressure support ventilation (PSV) mode with 2 different settings, randomly applied, of the ratio of pressurization time to expiratory trigger time (T(press)/T(exp-trigger)) 50%/25%, default setting, and T(press)/T(exp-trigger) 80%/60%, fast setting, through a helmet. The helmet was connected to the ventilator randomly with the double and the standard circuit. We measured inspiratory trigger delay (T(insp-delay)), expiratory trigger delay (T(exp-delay)), T(press)), time of synchrony (T(synch)), trigger pressure drop, inspiratory pressure-time product (PTP), PTP at 300 ms and 500 ms, and PTP at 500 ms expressed as percentage of an ideal PTP500 (PTP500 index). RESULTS: At both breathing frequencies and ventilator settings, helmet NIV with the double tube circuit showed better patient-ventilator interaction, with shorter T(insp-delay), T(exp-delay), and T(press); longer T(synch); and higher PTP300, PTP500, and PTP500 index (all P < .01). CONCLUSIONS: The double tube circuit had significantly better patient-ventilator interaction and a lower rate of wasted effort at 30 breaths/min