Bronchopleural fistulae and pulmonary ossification in posttraumatic acute respiratory distress syndrome: Successful treatment with extracorporeal support

We report a case of severe posttraumatic acute respiratory distress syndrome (ARDS) complicated by bronchopleural fistulae (BPF). The stiff ARDS lung and huge air leaks from BPF resulted in the failure of different protective mechanical ventilation strategies to provide viable gas exchange. Lung rest, achieved by extracorporeal carbon dioxide removal (ECCO2R), allowed weaning from mechanical ventilation, closure of BPF, and resumption of spontaneous breathing. Copyright \uc2\ua9 American Society of Artificial Internal Organs

Extracorporeal membrane oxygenation for interhospital transfer of severe acute respiratory distress syndrome patients: A 5-year experience

Purpose: Transfer of severely hypoxic patients is a high-risk procedure. Extracorporeal Membrane Oxygenation (ECMO) allows safe transport of these patients to tertiary care institutions. Our ECMO transportation program was instituted in 2004; here we report results after 5 years of activity. Methods: This is a clinical observational study. Criteria for ECMO center activation were: potentially reversibile respiratory failure, PaO2<50 mmHg with FiO2>0.6 for >12 hours, PEEP >5 cmH20, Lung Injury Score (LIS) \ue2\u89\ua53 or respiratory acidosis with pH<7.2, no intracranial bleeding, and no absolute contraindication to anticoagulation. If eligible, a skilled crew applied ECMO at the referral hospital. Transportation was performed with a specially equipped ambulance. Results: Sixteen patients were possible candidates for ECMO transfer. Two patients were excluded while 14 (mean\uc2\ub1SD, age 35.4\uc2\ub118.6, SOFA 8.4\uc2\ub13.7, Oxygenation Index 43.7\uc2\ub113.4) were transported to our institution (distance covered 102\uc2\ub1114 km, global duration of transport 589\uc2\ub1186 minutes). Two patients improved after iNO-trial and were transferred and subsequently managed without ECMO. The remaining 12 patients were transferred on veno-venous ECMO with extracorporeal blood flow 2.7\uc2\ub11 L\uc2\ub7min-1, gas flow 3.8\uc2\ub11.8 L\uc2\ub7min-1, and FiO21. Data were recorded 30 minutes before and 60 minutes after initiation of ECMO. ECMO improved PCO2(75\uc2\ub123 vs. 53\uc2\ub19 mmHg, p<0.01) thus improving pH (7.28\uc2\ub10.13 vs. 7.39\uc2\ub10.05, p<0.01) and allowing a reduction in respiratory rate (35\uc2\ub114 vs. 10\uc2\ub14 breaths/min, p<0.01), minute ventilation (10.1\uc2\ub13.8 vs. 3.7\uc2\ub11.7 L\uc2\ub7min-1, p<0.01), and mean airway pressure (26\uc2\ub16.5 vs. 22\uc2\ub15 cmH2O, p<0.01). No major clinical or technical complications were observed. Conclusions: ECMO effectively enabled high-risk ground transfer of severely hypoxic patients. \uc2\ua9 2011 Wichtig Editore

Respiratory pattern during neurally adjusted ventilatory assist in acute respiratory failure patients

Purpose: To investigate the effect of a wide range of assistance levels during neurally adjusted ventilatory assist (NAVA) and pressure support ventilation (PSV) on respiratory pattern, breathing variability, and incidence of tidal volumes (VT) above 8 and 10 ml/kg in acute respiratory failure patients. Methods: Eight increasing NAVA levels (0.5, 1, 1.5, 2, 2.5, 3, 4, and 5 cmH2O/\uce\ubcV) and four increasing pressure support (PSV) levels (4, 8, 12, and 16 cmH2O) were applied to obtain 10 min of stable recordings in 15 patients. Results: One out of 15 patients did not sustain the NAVA levels of 3, 4, and 5 cmH2O/\uce\ubcV and was excluded. The 5 cmH2O/\uce\ubcV NAVA level was not tolerated by three patients and it was excluded. Increasing NAVA levels were associated with decreased diaphragm electrical activity (EAdi), and, at variance with PSV, with small changes in VT, no changes in respiratory rate (RR), and increases in VTand EAdi variability. At high NAVA levels, an increase in VTvariability was associated with increased incidence of VTabove 8 and 10 ml/kg and an uncomfortable respiratory pattern in some patients. Conclusions: Increasing NAVA levels were associated with no effect on RR, small increase in VT, and increase in VTand EAdi variability. Effective decrease in EAdi occurred at NAVA levels below 2-2.5 cmH2O/\uce\ubcV, while preserving respiratory variability and low risks of VTabove 8 or 10 ml/kg. \uc2\ua9 2011 jointly held by Springer and ESICM

Vasoactive Drugs and Hemodynamic Monitoring in Pediatric Cardiac Intensive Care: An Italian Survey

BACKGROUND: Little is known about practitioner preference, the availability of technology, and variability in practice with respect to hemodynamic monitoring and vasoactive drug use after congenital heart surgery. The aim of this study was to characterize current hospital practices related to the management of low cardiac output syndrome (LCOS) across Italy. METHODS: We issued a 22-item questionnaire to 14 Italian hospitals performing pediatric cardiac surgery. RESULTS: Electrocardiogram, invasive blood pressure, central venous pressure, pulse oximetry, diuresis, body temperature, arterial lactate, and blood gas analysis were identified as routine in hemodynamic monitoring. With regard to advanced hemodynamic monitoring, pulmonary arterial catheter and transpulmonary thermodilution were available in 43% of the centers, uncalibrated pulse contour methods in 29% of the centers, and transesophageal/transthoracic echocardiograms in all of the centers. Dopamine added to milrinone was the most frequent drug regimen for LCOS prevention after cardiopulmonary bypass. Overall, 86% of centers used milrinone alone as the initial treatment for LCOS with elevated systemic vascular resistances and levosimendan, the second preferred choice. In cases of LCOS with low vascular resistance, epinephrine was the first choice (10 centers), dopamine was the second choice (4 centers), followed by vasopressin and norepinephrine (3 centers). For treatment of LCOS with elevated pulmonary resistances, milrinone was the first choice (eight centers), followed by inhaled nitric oxide (five centers). CONCLUSIONS: The survey shows that advanced hemodynamic monitoring is rarely performed. The most commonly used vasoactive drugs are milrinone, levosimendan, dopamine, epinephrine, vasopressin, and norepinephrine. Guidelines on the topic are warranted

L'Attore tragico. Studi in onore di Fernando Balestra.

La pubblicazione intende conservare memoria scritta delle conversazioni svolte in Universit\ue0 Cattolica del S.C. di Milano il 25 febbraio 2015 in una giornata di studio dedicata a Fernando Balestra (25 febbraio 1952-2 giugno 2016), in cui \ue8 avvenuto un fruttuoso confronto e dibattito tra le tante persone che negli anni \u2013 sui fronti di attivit\ue0 diverse - lo hanno incontrato e frequentato condividendo progetti aventi al centro il grande valore del teatro e in particolare del teatro classico. Il volume \ue8 diviso in due sezioni: la prima contiene le testimonianze di chi ha condiviso i progetti di ricerche attorno alla \u201cterza via del teatro\u201d, rappresentata dalla messinscena di testi classici nelle scuole e nelle universit\ue0, la seconda propone invece i contributi di studiosi (G. Ieran\uf2, E. Matelli, M. Treu, A. Rodighiero, G. Zanetto) e di artisti (A. Calenda, E. Isgr\uf2, L. Piazza, C. Poggioni) sulla professionalit\ue0 dell\u2019attore tragico di et\ue0 classica e contemporanea

Enhanced liver fibrosis test as a reliable tool for assessing fibrosis in nonalcoholic fatty liver disease in a clinical setting

Background: Liver fibrosis is the main determinant and predictor of the clinical course of nonalcoholic fatty liver disease (NAFLD). To date, a liver biopsy is still considered the gold standard for staging fibrosis. The aim of this study was to investigate the diagnostic accuracy of the commercial enhanced liver fibrosis (ELF) test manufacturer\ue2\u80\u99s cutoff value (\ue2\u89\ua59.8) in identifying severe fibrosis for adult patients with histologically confirmed NAFLD. Methods: We tested the ELF test in a clinical practice, prospective cohort of 82 consecutive patients who consecutively underwent percutaneous liver biopsy. Results: All stages of liver fibrosis were represented in our cohort, and severe fibrosis was present in 15 of 82 patients (18.3%). The stage of fibrosis was significantly associated with ELF score (Spearman\ue2\u80\u99s rho = 0.483, p<0.001). The commercial ELF test manufacturer\ue2\u80\u99s cutoff identified severe fibrosis with good sensitivity (86.7%; 95% confidence interval [95% CI], 0.69-1.04) and high specificity (92.5%; 95% CI, 0.86-0.99), with a positive predictive value of 72% and negative predictive value of 97%. Conclusions: Our data could support the use of the ELF test in clinical practice

Parental presence in Italian pediatric intensive care units: a reappraisal of current visiting policies

Parental presence in Italian pediatric intensive care units: a reappraisal of current visiting policie