Tracheostomy must be individualized!

Tracheostomy is one of the most frequent procedures carried out in critically ill patients with major advantages compared to translaryngeal endotracheal intubation such as reduced laryngeal anatomical alterations, reduced inspiratory load, better patient's tolerance and nursing. Thus, tracheostomy can enhance patient's care in patients who need prolonged mechanical ventilation and/or control of airways. The right timing of tracheostomy remains controversial, however it appears that early tracheostomy in selected severe trauma, burn and neurological patients could be effective to reduce the duration of mechanical ventilation intensive care stay and costs. Percutaneous tracheostomy techniques are becoming the procedure of choice in the majority of the cases, since they are safe, easy and quick, and complications are minor. However, percutaneous tracheostomies should be always performed by experienced physicians to avoid unnecessary additional complications. It is not clear the superiority of one percutaneous technique compared to another, but experience of the operator and clinical individual anatomical, physiopathological characteristics of the patient should be always considered. We believe that the operator should have experience of at least one intrusive and one extrusive percutaneous technique. The general "optimal" tracheostomy technique and timing do not exist, but tracheostomy should be targeted on the patient's individual clinical characteristics

Early Outcomes of Out-of-Hospital Cardiac Arrest after Early Defibrillation: a 24 Months Retrospective Analysis

Introduction: Cardiovascular disease remains the most common cause of death in the United States and most other Western nations. Among these deaths, sudden, out-of-hospital cardiac arrest claims approximately 1000 lives each day in the United States alone. Most of these cardiac arrests are due to ventricular fibrillation. Though highly reversible with the rapid application of a defibrillator, ventricular fibrillation is otherwise fatal within minutes, even when cardiopulmonary resuscitation is provided immediately. The overall survival rate in the United States is estimated to be less than 5 percent. Recent developments in automated-external-defibrillator technology have provided a means of increasing the rate of prompt defibrillation after out-of-hospital cardiac arrest. After minimal training, nonmedical personnel (e.g., flight attendants and casino workers) are also able to use defibrillators in the workplace, with lifesaving effects. Nonetheless, such programs have involved designated personnel whose job description includes assisting persons who have had sudden cardiac arrest. Data are still lacking on the success of programs in which automated external defibrillators have been installed in public places to be used by persons who have no specific training or duty to act. Materials and Methods: All patients who had an out-of-hospital cardiac arrest between January 2003 and December 2004 and who received early defibrillation for ventricular fibrillation were included. We conducted a 24 months retrospective population-based analysis of the outcome in our population. Results: Over a 24 month period, 446 people had non–traumatic cardiac arrest, and in all of them it was observed to be ventricular fibrillation. In a very few cases, the defibrillator operators were good Samaritans, acting voluntarily. Eighty-nine patients (about 19%) with ventricular fibrillation were successfully resuscitated, including eighteen who regained consciousness before hospital admission. Conclusion: Automated external defibrillators deployed in readily accessible, well-marked areas, are really very effective in assisting patients with cardiac arrest. However, it's quite true that, in the cases of survivors, most of our users had good prior training in the use of these devices

Atrial Fibrillation and Pacing Algorithms

Pacing prevention algorithms have been introduced in order to maximize the benefits of atrial pacing in atrial fibrillation prevention. It has been demonstrated that algorithms actually keep overdrive atrial pacing, reduce atrial premature contractions, and prevent short-long atrial cycle phenomenon, with good patient tolerance. However, clinical studies showed inconsistent benefits on clinical endpoints such as atrial fibrillation burden. Factors which may be responsible for neutral results include an already high atrial pacing percentage in conventional DDDR, non-optimal atrial pacing site and deleterious effects of high percentages of apical ventricular pacing. Atrial antitachycardia pacing (ATP) therapies are effective in treating spontaneous atrial tachyarrhythmias, mainly when delivered early after arrhythmia onset and/or on slower tachycardias. Effective ATP therapies may reduce atrial fibrillation burden, but conflicting evidence does exist as regards this issue, probably because current clinical studies may be underpowered to detect such an efficacy. Wide application of atrial ATP may reduce the need for hospitalizations and electrical cardioversions and favorably impact on quality of life. Consistent monitoring of atrial and ventricular rhythm as well as that of ATP effectiveness may be extremely useful for optimizing device programming and pharmacological therapy

High flow biphasic positive airway pressure by helmet – effects on pressurization, tidal volume, carbon dioxide accumulation and noise exposure

Abstract INTRODUCTION: Non-invasive ventilation (NIV) with a helmet device is often associated with poor patient-ventilator synchrony and impaired carbon dioxide (CO2) removal, which might lead to failure. A possible solution is to use a high free flow system in combination with a time-cycled pressure valve placed into the expiratory circuit (HF-BiPAP). This system would be independent from triggering while providing a high flow to eliminate CO2. METHODS: Conventional pressure support ventilation (PSV) and time-cycled biphasic pressure controlled ventilation (BiVent) delivered by an Intensive Care Unit ventilator were compared to HF-BiPAP in an in vitro lung model study. Variables included delta pressures of 5 and 15 cmH2O, respiratory rates of 15 and 30 breaths/min, inspiratory efforts (respiratory drive) of 2.5 and 10 cmH2O) and different lung characteristics. Additionally, CO2 removal and noise exposure were measured. RESULTS: Pressurization during inspiration was more effective with pressure controlled modes compared to PSV (P < 0.001) at similar tidal volumes. During the expiratory phase, BiVent and HF-BiPAP led to an increase in pressure burden compared to PSV. This was especially true at higher upper pressures (P < 0.001). At high level of asynchrony both HF-BiPAP and BiVent were less effective. Only HF-BiPAP ventilation effectively removed CO2 (P < 0.001) during all settings. Noise exposure was higher during HF-BiPAP (P < 0.001). CONCLUSIONS: This study demonstrates that in a lung model, the efficiency of NIV by helmet can be improved by using HF-BiPAP. However, it imposes a higher pressure during the expiratory phase. CO2 was almost completely removed with HF-BiPAP during all settings

Surgical repair of left ventricular free-wall rupture complicating acute myocardial infarction: a single-center 30 years of experience

Background: Left ventricular free-wall rupture (LVFWR) is a catastrophic complication of acute myocardial infarction (AMI). Historically, cardiac surgery is considered the treatment of choice. However, because of the rarity of this entity, little is known regarding the efficacy and safety of surgical treatment for post-infarction LVFWR. The aim of this study was to report a single-center experience in this field over a period of 30 years. Methods: Patients who developed LVFWR following AMI and underwent surgical repair at our Institution from January 1990 to December 2019 were considered. The primary end-point was in-hospital morality rate; secondary outcomes were long-term survival and postoperative complications. Multivariate analysis was carried out by constructing a logistic regression model to identify risk factors for early mortality. Results: A total of 35 patients were enrolled in this study. The mean age was 68.9 years; 65.7% were male. The oozing type of LVFWR was encountered in 29 individuals, and the blowout type in 6 subjects. Sutured repair was used in 77.1% of patients, and sutureless repair in the remaining cases. The in-hospital mortality rate was 28.6%. Low cardiac output syndrome was the main cause of postoperative death. Multivariable analysis identified age &gt;75 years at operation, preoperative cardiac arrest, concurrent ventricular septal rupture (VSR) as independent predictors of in-hospital death. Follow-up was complete in 100% of patients who survived surgery (mean follow-up: 9.3 ± 7.8 years); among the survivors, 16 patients died during the follow-up with a 3-year and 12-year overall survival rate of 82.5% and 55.2%, respectively. Conclusions: Surgical treatment of LVFWR following AMI is possible with acceptable in-hospital mortality and excellent long-term results. Advanced age, concurrent VSR and cardiac arrest at presentation are independent risk factors of poor early outcome

Rationale and study design of PROVHILO - a worldwide multicenter randomized controlled trial on protective ventilation during general anesthesia for open abdominal surgery

<p>Abstract</p> <p>Background</p> <p>Post-operative pulmonary complications add to the morbidity and mortality of surgical patients, in particular after general anesthesia >2 hours for abdominal surgery. Whether a protective mechanical ventilation strategy with higher levels of positive end-expiratory pressure (PEEP) and repeated recruitment maneuvers; the "open lung strategy", protects against post-operative pulmonary complications is uncertain. The present study aims at comparing a protective mechanical ventilation strategy with a conventional mechanical ventilation strategy during general anesthesia for abdominal non-laparoscopic surgery.</p> <p>Methods</p> <p>The PROtective Ventilation using HIgh versus LOw positive end-expiratory pressure ("PROVHILO") trial is a worldwide investigator-initiated multicenter randomized controlled two-arm study. Nine hundred patients scheduled for non-laparoscopic abdominal surgery at high or intermediate risk for post-operative pulmonary complications are randomized to mechanical ventilation with the level of PEEP at 12 cmH₂O with recruitment maneuvers (the lung-protective strategy) or mechanical ventilation with the level of PEEP at maximum 2 cmH₂O without recruitment maneuvers (the conventional strategy). The primary endpoint is any post-operative pulmonary complication.</p> <p>Discussion</p> <p>The PROVHILO trial is the first randomized controlled trial powered to investigate whether an open lung mechanical ventilation strategy in short-term mechanical ventilation prevents against postoperative pulmonary complications.</p> <p>Trial registration</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/ISRCTN70332574">ISRCTN70332574</a></p

Lung parenchyma modifications after mechanical ventilation and fluid load

Mechanical ventilation with or without positive pressure in the airways (PEEP) and with or without mild fluid load can cause some modification on the morphology of the lung matrix in the ventral and dorsal lung regions of supine healthy rats. To evaluate the differences between dorsal and ventral areas of the lungs after different strategies of ventilation we subdivided rats in two sets of animals, one without any intravenous infusion, the other one with intravenous infusion of phosphate buffered saline (PBS) maintained during all the mechanical ventilation. Each set was further subdivided in groups which underwent different ventilation strategies, vary- ing the end-expiratory pressure (0 or 5 mmH2O) and the spontaneous/mechanical breathing. At the morphological analysis no signs of parenchyma injury were collected in all the groups of either sets, although were evident differences in alveolar septa thick- ness: in all the not-infused groups submitted to mechanical ventilation was observed a thinning of the alveolar septa combined with a enlargement of the perivascular fluid cuffs both in ventral and dorsal regions. The infused specimens demonstrate a more congested parenchyma with irregular development of perivascular fluid cuffs around lung microvessels. In all groups, the maintaining of the PEEP during the mechanical ventilation induced significative corner and alveolar septa thinning respect to the controls, more accentuate in the ventral regions. In infused groups, we observed general alveolar septa and corner thickening, with reduction of the differ- ences between dorsal and ventral regions. Mechanical ventilation and fluid load may cause injuries to the lung parenchyma, mainly in the ventral region, injuries that seems to be reduced using a positive pres- sure on the airways, as the PEEP, which seemed to be protective for the extracellular matrix of the lung during the mechanical ventilation. The authors gratefully acknowledge the “Centro Grandi Attrezzature per la Ricer- ca Biomedica” of Insubria University for instruments availability