Impact of protein intake on weaning from mechanical ventilation in ICU patients

Background: In pazienti ventilati meccanicamente, la nutrizione enterale, iniziata entro 24-48 ore dal ricovero in terapia intensiva, ha dimostrato ridurre le complicanze infettive e la durata dell’ospedalizzazione. A causa dell’insufficienza respiratoria associata, il 30% dei pazienti ricoverati nelle terapie intensive richiede ventilazione meccanica. Lo svezzamento ritardato dalla ventilazione meccanica aumenta i costi, i rischi di polmoniti nosocomiali, comorbidità cardiache associate e morte. Uno svezzamento precoce dalla ventilazione spesso implica reintubazione e complicanze associate allo svezzamento prolungato. La gestione della nutrizione rappresenta una sfida per l’intensivista. La malnutrizione causa la diffusione di patologie associate alla disfunzione d’organo, difficoltà di guarigione, riduce l’efficacia del sistema immunitario e si associa ad uno scarso successo di svezzamento dalla ventilazione. La quantità di tessuto muscolare distrutto e la perdita di peso sono inversamente correlati con la sopravvivenza a lungo termine dei pazienti critici. In questa tesi sarà discusso il ruolo del supporto nutrizionale in un setting di malati critici, in associazione allo svezzamento dalla ventilazione meccanica. Obiettivi: 1. Valutazione dello stato nutrizionale (parametri clinici e antropometrici); 2. Differenza di outcome misurato come durata dello svezzamento dalla ventilazione, eventi avversi e uso delle risorse (durata dell’ospedalizzazione e costi per la terapia intensiva). Materiali e metodi: Sono stati arruolati pazienti > 18 anni, ricoverati tra novembre 2016 e novembre 2018. Sono stati raccolti dati antropometrici, dati relativi allo stato nutrizionale come BMI e peso, tipo di nutrizione somministrata (enterale o parenterale), livelli di albumina, proteine totali, parametri clinici come il P/F. Risultati: Sono stati analizzati 30 pazienti (12 femmine). La durata media di ogni degenza è stata 25.6 ± 14.7 giorni. L’84% di pazienti è stato nutrito per via enterale. Non ci sono state alterazioni statisticamente significative nei livelli di albumina e proteine totali durante l’intera degenza in terapia intensiva. Diverse miscele nutrizionali influenzano le risposte cliniche (migliori P/F tra i pazienti alimentati con queste ultime). Le calorie stimate e somministrate sono state adeguate alla fase ventilatoria associata. Il supporto nutrizionale era appropriato, dal momento che BMI e peso sono rimasti invariati nel confronto tra inizio e fine degenza in terapia intensiva. Conclusioni: Applicando una strategia di supporto nutrizionale adeguato alla nostra terapia intensiva non si aumentano i giorni di ospedalizzazione, riducendo l’incidenza di condizioni associate ad uno svezzamento dalla ventilazione difficile o prolungato e le complicanze associate ad esso.Background: In mechanically ventilated ICU patients enteral nutrition started 24 to 48 hours of ICU admission, shown to reduce infectious complications and duration of hospitalization. Due to acute respiratory failure 30% of patients admitted to ICUs require mechanical ventilation. Delayed weaning increases costs, risks of nosocomial pneumonia, cardiac-associated morbidity, and death. Early weaning often results in reintubation, and associated complications due to prolonged ventilation. Nutritional management poses a vital challenge to the intensivist in the ICU. Malnutrition causes widespread organ dysfunction, associated with poor healing, reduce immune competence & poor weaning from ventilator (decreasing the diaphragmatic contractility and depressing the hypoxic drive & ventilatory drive to CO2). The extent of muscle wasting and weight loss in the ICU is inversely correlated with long-term survival of the patients. In this thesis will be discussed the role of the nutritional support in the critical care setting when associated to weaning from mechanical ventilation. Objectives: 1. Assessment of Clinical And Anthropometric nutritional status. 2. Differences in outcomes measuring weaning duration, harm (adverse events) and resource use (ICU and hospital length of stay, cost). Material and methods: Patients >18 y-o, admitted to the ICU from November 2016 to November 2018 were enrolled. Anthropometrics, nutritional status such as BMI and weight, nutritional support such as enteral or parenteral nutrition, albumin and total proteins levels, clinical parametrs such as P/F were recorded for the entire ICU stay. Results: 30 consecutive patients (12 female) were enrolled. The average duration of each admission to the ICU was 24.58 ± 14.7 days. The 84% of patients was enterally fed. Albumine and total proteins were not significantly different throughtout the ICU stay. Different enteral nutrition mixtures influence clinical response (better P/F). Calories estimated and provided were adequate to the ventilatory phase associate. The nutritional support was adequate, since BMI and weight were the same at admission and discharge from the ICU. Conclusions: through an optimal planning of the nutritional supply, in our ICU days of hospitalization were not increased, avoiding the incidence of difficult or prolonged weaning conditions and the consequences associated with it

Effect of different pressure-targeted modes of ventilation on transpulmonary pressure and inspiratory effort

Spontaneous breathing during mechanical ventilation improves gas exchange and might prevent ventilator- induced diaphragm dysfunction. In pressure-targeted modes, transpulmonary pressure (PL) is the sum of pres- sure generated by the ventilator and muscular pressure. When inspiratory effort increases, PL and tidal volume (VT) increase, potentially resulting in lung injury. This effect depends on the degree of inspiratory synchroniza- tion (i-sync); pressure-targeted modes can be classified into fully, partially, and non i-sync modes. A bench study [1] demonstrated that non-i-sync mode resulted in lower PL and VT than other modes, protecting the lungs from injury. We undertook to assess the effect of varying synchronization during pressure-targeted venti- lation in critically ill patients

Direct Anterior versus Lateral Approach for Femoral Neck Fracture: Role in COVID-19 Disease

Background: During the COVID-19 emergency, the incidence of fragility fractures in elderly patients remained unchanged. The management of these patients requires a multidisciplinary approach. The study aimed to assess the best surgical approach to treat COVID-19 patients with femoral neck fracture undergoing hemiarthroplasty (HA), comparing direct lateral (DL) versus direct anterior approach (DAA). Methods: A single-center, observational retrospective study including 50 patients affected by COVID-19 infection (30 males, 20 females) who underwent HA between April 2020 to April 2021 was performed. The patients were allocated into two groups according to the surgical approach used: lateral approach and anterior approach. For each patient, the data were recorded: age, sex, BMI, comorbidity, oxygen saturation (SpO2), fraction of the inspired oxygen (FiO2), type of ventilation invasive or non-invasive, HHb, P/F ratio (PaO2/FiO2), hemoglobin level the day of surgery and 1 day post operative, surgical time, Nottingham Hip Fractures Score (NHFS) and American Society of Anesthesiologists Score (ASA). The patients were observed from one hour before surgery until 48 h post-surgery of follow-up. The patients were stratified into five groups according to Alhazzani scores. A non-COVID-19 group of patients, as the control, was finally introduced. Results: A lateral position led to a better level of oxygenation (p < 0.01), compared to the supine anterior approach. We observed a better post-operative P/F ratio and a reduced need for invasive ventilation in patients lying in the lateral position. A statistically significant reduction in the surgical time emerged in patients treated with DAA (p < 0.01). Patients within the DAA group had a significantly lower blood loss compared to direct lateral approach. Conclusions: DL approach with lateral decubitus seems to preserved respiratory function in HA surgery. Thus, the lateral position may be associated with beneficial effects on gas exchange

Impact of CT Scan Phenotypes in Clinical Manifestations, Management and Outcomes of Hospitalised Patients with COVID-19

COVID-19 is such a heterogeneous disease that a one-size-fits-all approach is not recommended, so the management of patients has been based on their clinical and laboratory characteristics. We therefore investigated possible homogeneous groups presenting similar features of lung involvement based on chest CT and laboratory results. We designed a study to identify a possible correlation between CT scan phenotypes, laboratory exams, and clinical outcomes. We retrospectively analysed 120 adult patients with COVID-19 5who underwent chest CT scan during hospitalisation, between March and December 2020 at our COVID-19 Hospital in two different wards: Respiratory Intensive Care Unit (RICU) and Intensive Care Unit (ICU). The analysis of CT scans resulted in the identification of three radiological phenotypes by two blinded pulmonologists (Cohen's κ = 0.9 for Phenotype 1, 0.9 for Phenotype 2 and 0.89 for Phenotype 3), in accordance with what previously described by Robba et al. “Phenotype 1” (PH1) is characterised by modest interstitial oedema with presentation on chest CT of diffuse ground glass opacities (GGO). “Phenotype 2” (PH2) shows predominant consolidation at lung lobes. “Phenotype 3” (PH3) shows a typical CT pattern of moderate-to-severe ARDS, with alveolar oedema. Based on our results, we could hypothesise that phenotype 2 shows a different trend from all the others and would seem to be more related to a coagulopathy, although we cannot exclude the hypothesis that one phenotype evolves from the other. Further studies might focus on the predictive role of D-dimer, and its cut-offs, in delineating the PH2 patients, that could require an early CT scan to avoid excessive pressure support and finally prevent VILI. To further understand the exact basis of the different CT scan phenotype, a longer longitudinal analysis of clinical and laboratory features (e.g., timing of weaning, pressures and FiO2 delivered) in each phenotype and a comparison among them is needed

Time course of risk factors associated with mortality of 1260 critically ill patients with COVID-19 admitted to 24 Italian intensive care units

Purpose: To evaluate the daily values and trends over time of relevant clinical, ventilatory and laboratory parameters during the intensive care unit (ICU) stay and their association with outcome in critically ill patients with coronavirus disease 19 (COVID-19). Methods: In this retrospective–prospective multicentric study, we enrolled COVID-19 patients admitted to Italian ICUs from February 22 to May 31, 2020. Clinical data were daily recorded. The time course of 18 clinical parameters was evaluated by a polynomial maximum likelihood multilevel linear regression model, while a full joint modeling was fit to study the association with ICU outcome. Results: 1260 consecutive critically ill patients with COVID-19 admitted in 24 ICUs were enrolled. 78% were male with a median age of 63 [55–69] years. At ICU admission, the median ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) was 122 [89–175] mmHg. 79% of patients underwent invasive mechanical ventilation. The overall mortality was 34%. Both the daily values and trends of respiratory system compliance, PaO2/FiO2, driving pressure, arterial carbon dioxide partial pressure, creatinine, C-reactive protein, ferritin, neutrophil, neutrophil–lymphocyte ratio, and platelets were associated with survival, while for lactate, pH, bilirubin, lymphocyte, and urea only the daily values were associated with survival. The trends of PaO2/FiO2, respiratory system compliance, driving pressure, creatinine, ferritin, and C-reactive protein showed a higher association with survival compared to the daily values. Conclusion: Daily values or trends over time of parameters associated with acute organ dysfunction, acid–base derangement, coagulation impairment, or systemic inflammation were associated with patient survival

Association of kidney disease measures with risk of renal function worsening in patients with type 1 diabetes

Background: Albuminuria has been classically considered a marker of kidney damage progression in diabetic patients and it is routinely assessed to monitor kidney function. However, the role of a mild GFR reduction on the development of stage 653 CKD has been less explored in type 1 diabetes mellitus (T1DM) patients. Aim of the present study was to evaluate the prognostic role of kidney disease measures, namely albuminuria and reduced GFR, on the development of stage 653 CKD in a large cohort of patients affected by T1DM. Methods: A total of 4284 patients affected by T1DM followed-up at 76 diabetes centers participating to the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD) initiative constitutes the study population. Urinary albumin excretion (ACR) and estimated GFR (eGFR) were retrieved and analyzed. The incidence of stage 653 CKD (eGFR < 60 mL/min/1.73 m2) or eGFR reduction > 30% from baseline was evaluated. Results: The mean estimated GFR was 98 \ub1 17 mL/min/1.73m2 and the proportion of patients with albuminuria was 15.3% (n = 654) at baseline. About 8% (n = 337) of patients developed one of the two renal endpoints during the 4-year follow-up period. Age, albuminuria (micro or macro) and baseline eGFR < 90 ml/min/m2 were independent risk factors for stage 653 CKD and renal function worsening. When compared to patients with eGFR > 90 ml/min/1.73m2 and normoalbuminuria, those with albuminuria at baseline had a 1.69 greater risk of reaching stage 3 CKD, while patients with mild eGFR reduction (i.e. eGFR between 90 and 60 mL/min/1.73 m2) show a 3.81 greater risk that rose to 8.24 for those patients with albuminuria and mild eGFR reduction at baseline. Conclusions: Albuminuria and eGFR reduction represent independent risk factors for incident stage 653 CKD in T1DM patients. The simultaneous occurrence of reduced eGFR and albuminuria have a synergistic effect on renal function worsening