Lung sealant and morbidity after pleural decortication: a prospective randomized, blinded study

<p>Abstract</p> <p>Objectives</p> <p>Prolonged postoperative air leaks (AL) are a major cause of morbidity. Aim of this work was evaluating use of a Lung Sealant System (Pleuraseal™, Covidien, Mansfield, MA, U.S.A.) in pleural decortications for empyema thoracis.</p> <p>Methods</p> <p>From January 2008 to December 2008, 46 consecutive patients received pleural decortications for empyema thoracis. Post-procedural and malignancy-related empyemas were excluded. After hydro-pneumatic test and surgical correction of AL (until satisfaction), patients were assigned (23 per group) to Control or Sealant group. Control group underwent no additional interventions. In Sealant group, lung sealant was applied over AL areas. Following variables were measured daily: patients with AL; time to chest drainage (CD) removal; CD drainage volume at removal, postoperative length of hospital stay, postoperative C-reactive protein (CRP), and leukocyte counts. Personnel recording parameters were blinded to intervention. Two-tailed t-tests (normally distributed data) or Mann - Whitney U-test (not-normally distributed data) were used for evaluating significance of differences between group means or medians. Significance of any proportional differences in attributes were evaluated using Fisher's Exact Test. Statistical analysis was carried out using R-software (version 2.8.1).</p> <p>Results</p> <p>Groups were similar regarding demographic and baseline characteristics. No patients were withdrawn from study; no adverse effects were recorded. There were no significative differences on CRP and leukocyte levels between two groups. Compared with the Control group, in Sealant group significantly fewer patients had AL (30 versus 78%, <it>p = 0.012</it>), and drains were inserted for a shorter time (medians, 3 versus 5 days, <it>p = 0.05</it>). Postoperative hospitalization time was shorter in Sealant group than in control group, but difference was not significant (0.7 days, <it>p = 0.121</it>).</p> <p>Conclusions</p> <p>Pleuraseal™ Lung Sealant System significantly reduces AL following pleural decortications for empyema and, despite of not-increased infectious indexes, is suitable for routinely use, even in procedures with contaminated pleura.</p

Risk Management and Recommendations for the Prevention of Fatal Foreign Body Aspiration: Four Cases Aged 1.5 to 3 Years and Mini-Review of the Literature

(1) Background: Foreign body aspiration (FBA) is a significant public health concern among the pediatric population, and fatalities are dramatic for families. It typically involves organic foreign bodies (mainly food) aspirated by children under three years old, usually at home or school. This review aimed to focus on the preventive measures around four actual cases of fatal foreign body aspiration, emphasizing the correct execution of the Heimlich maneuver and cardiopulmonary resuscitation, supervised mealtimes, and high-risk foods. (2) Methods: Four fatal cases of foreign body aspiration in children are presented here. The children were in a free environment, such as school, home, and the countryside, and were in the presence of teachers, parents, and a grandmother who did not supervise the children adequately. A literature review was performed via the MEDLINE database using the key terms: "foreign body aspiration," "infant choking, 1.5 to 3 years," "food and foreign body aspiration," "common household," "prevention of foreign body aspiration," "guidelines," "recommendations," "training of caregivers (parents, educators)," "resuscitation," "Heimlich maneuver," and "disengagement of the upper airways." We focused on the prevention of foreign body aspiration. (3) Results: a complete postmortem examination was performed. In three cases, the foreign bodies were food (mozzarella cheese, pear, or raw bean), while in one case, the foreign body was a pebble. (4) Conclusions: This review aimed to discuss recent scientific literature and provide a perspective on the benefits of a dedicated approach to the management of fatal foreign body aspiration in children by caregivers who usually have no experience with the best ways of supervising children in a safe environment, especially regarding the correct execution of resuscitation maneuvers, such as the Heimlich maneuver. Recommendation updates could improve healthcare quality in a pediatric setting and reduce medico-legal implications

The Burden of Carbapenem-Resistant Acinetobacter baumannii in ICU COVID-19 Patients: A Regional Experience

Since the beginning of the COVID-19 pandemic, the impact of superinfections in intensive care units (ICUs) has progressively increased, especially carbapenem-resistant Acinetobacter baumannii (CR-Ab). This observational, multicenter, retrospective study was designed to investigate the characteristics of COVID-19 ICU patients developing CR-Ab colonization/infection during an ICU stay and evaluate mortality risk factors in a regional ICU network. A total of 913 COVID-19 patients were admitted to the participating ICUs; 19% became positive for CR-Ab, either colonization or infection (n = 176). The ICU mortality rate in CR-Ab patients was 64.7%. On average, patients developed colonization or infection within 10 &plusmn; 8.4 days from ICU admission. Scores of SAPS II and SOFA were significantly higher in the deceased patients (43.8 &plusmn; 13.5, p = 0.006 and 9.5 &plusmn; 3.6, p &lt; 0.001, respectively). The mortality rate was significantly higher in patients with extracorporeal membrane oxygenation (12; 7%, p = 0.03), septic shock (61; 35%, p &lt; 0.001), and in elders (66 &plusmn; 10, p &lt; 0.001). Among the 176 patients, 129 (73%) had invasive infection with CR-Ab: 105 (60.7%) Ventilator-Associated Pneumonia (VAP), and 46 (26.6%) Bloodstream Infections (BSIs). In 22 cases (6.5%), VAP was associated with concomitant BSI. Colonization was reported in 165 patients (93.7%). Mortality was significantly higher in patients with VAP (p = 0.009). Colonized patients who did not develop invasive infections had a higher survival rate (p &lt; 0.001). Being colonized by CR-Ab was associated with a higher risk of developing invasive infections (p &lt; 0.001). In a multivariate analysis, risk factors significantly associated with mortality were age (OR = 1.070; 95% CI (1.028&ndash;1.115) p = 0.001) and CR-Ab colonization (OR = 5.463 IC95% 1.572&ndash;18.988, p = 0.008). Constant infection-control measures are necessary to stop the spread of A. baumannii in the hospital environment, especially at this time of the SARS-CoV-2 pandemic, with active surveillance cultures and the efficient performance of a multidisciplinary team

Tocilizumab for patients with COVID-19 pneumonia. The single-arm TOCIVID-19 prospective trial

BackgroundTocilizumab blocks pro-inflammatory activity of interleukin-6 (IL-6), involved in pathogenesis of pneumonia the most frequent cause of death in COVID-19 patients.MethodsA multicenter, single-arm, hypothesis-driven trial was planned, according to a phase 2 design, to study the effect of tocilizumab on lethality rates at 14 and 30 days (co-primary endpoints, a priori expected rates being 20 and 35%, respectively). A further prospective cohort of patients, consecutively enrolled after the first cohort was accomplished, was used as a secondary validation dataset. The two cohorts were evaluated jointly in an exploratory multivariable logistic regression model to assess prognostic variables on survival.ResultsIn the primary intention-to-treat (ITT) phase 2 population, 180/301 (59.8%) subjects received tocilizumab, and 67 deaths were observed overall. Lethality rates were equal to 18.4% (97.5% CI: 13.6-24.0, P=0.52) and 22.4% (97.5% CI: 17.2-28.3, P&lt;0.001) at 14 and 30 days, respectively. Lethality rates were lower in the validation dataset, that included 920 patients. No signal of specific drug toxicity was reported. In the exploratory multivariable logistic regression analysis, older age and lower PaO2/FiO2 ratio negatively affected survival, while the concurrent use of steroids was associated with greater survival. A statistically significant interaction was found between tocilizumab and respiratory support, suggesting that tocilizumab might be more effective in patients not requiring mechanical respiratory support at baseline.ConclusionsTocilizumab reduced lethality rate at 30 days compared with null hypothesis, without significant toxicity. Possibly, this effect could be limited to patients not requiring mechanical respiratory support at baseline.Registration EudraCT (2020-001110-38); clinicaltrials.gov (NCT04317092)