Liberal transfusion strategy improves survival in perioperative but not in critically ill patients. A meta-analysis of randomised trials

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The Effect of Statins on Mortality in Septic Patients: a Meta-Analysis of Randomized Controlled Trials

OBJECTIVE: Statins are among the most prescribed drugs worldwide and their recently discovered anti-inflammatory effect seems to have an important role in inhibiting proinflammatory cytokine production, chemokines expression and counteracting the harmful effects of sepsis on the coagulation system. We decided to perform a meta-analysis of all randomized controlled trials ever published on statin therapy in septic patients to evaluate their effect on survival and length of hospital stay. DATA SOURCES AND STUDY SELECTION: Articles were assessed by four trained investigators, with divergences resolved by consensus. BioMedCentral, PubMed, Embase and the Cochrane Central Register of clinical trials were searched for pertinent studies. Inclusion criteria were random allocation to treatment and comparison of statins versus any comparator in septic patients. DATA EXTRACTION AND SYNTHESIS: Data from 650 patients in 5 randomized controlled studies were analyzed. No difference in mortality between patients receiving statins versus control (44/322 [14%] in the statins group vs 50/328 [15%] in the control arm, RR = 0.90 [95% CI 0.65 to 1.26], p = 0.6) was observed. No differences in hospital stay (p = 0.7) were found. CONCLUSIONS: Published data show that statin therapy has no effect on mortality in the overall population of adult septic patients. Scientific evidence on statins role in septic patients is still limited and larger randomized trials should be performed on this topic

Mechanical Ventilation. Total Eclipse of the Heart (Editorial)

Results from recent large randomized trials investigating the use of high PEEP in patients without ARDS all suggest that high levels may increase mortality due to hypotension and bradycardia. A careful assessment of cardiac function — with particular focus on the right ventricle — should be performed before planning our ventilation strategy in any setting, including COVID-19 and ARDS in general. Mechanical ventilation should be respectful in regards of heart function, and tolerant with moderate hypoxia and hypercapnia, noninvasive (whenever possible) and synchronized

An innovative technique to improve safety of volatile anesthetics suction from the cardiopulmonary bypass circuit

Context: Myocardial injury during cardiac surgery on cardiopulmonary bypass (CPB) is a major determinant of morbidity and mortality. Preclinical and clinical evidence of dose- and time-related cardioprotective effects of volatile anesthetic drugs exist and their use during the whole surgery duration could improve perioperative cardiac protection. Even if administering volatile agents during CPB are relatively easy, technical problems, such as waste gas scavenging, may prevent safe and manageable administration of halogenated vapors during CPB. Aims: The aim of this study is to improve the safe administration of volatile anesthesia during CPB. Settings and Design: Tertiary teaching hospital. Subjects and Methods: We describe an original device that collects and disposes of any volatile anesthetic vapors present in the exit stream of the oxygenator, hence preventing its dispersal into the operating theatre environment and adaptively regulates pressure of oxygenator chamber in the CPB circuit. Results: We have so far applied a prototype of this device in more than 1300 adult cardiac surgery patients who received volatile anesthetics during the CPB phase. Conclusions: Widespread implementation of scavenging system like the one we designed may facilitate the perfusionist and the anesthesiologist in delivering these cardioprotective drugs with beneficial impact on patients' outcome without compromising on safety

Volatile compared with total intravenous anaesthesia in patients undergoing high-risk cardiac surgery: a randomized multicentre study

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Analysis of influenza vaccination coverage among the elderly in Genoa (Italy) based on a deprivation index, 2009-2013

Introduction. The elderly suffer the most influenza-related complications, and 90%of deaths due to influenza occur in older subjects. Consequently, the elderly are among the main targets of influenza vaccination campaigns. The use of deprivation indexes can help to identify subgroups with lower vaccination uptake. This study analyzed influenza vaccination coverage in elderly persons living in Genoa (Italy) in relation to a local Index of Socio-Economic and Health Deprivation (SEHDI) in order to identify population subgroups needing specific intervention to improve vaccination coverage. Methods. The study targeted subjects aged 65 65 years living in Genoa in the period 2009-2013. Information on vaccination coverage was provided by general practitioners and Local Health Units. A combination of linear regression, factor analysis and cluster analysis was used to construct the SEHDI at Census Tract (CT) level, on the basis of data from the 2011 Italian census. Results. In 2011, people aged 65 65 years accounted for the 27.7%of the population of Genoa. Most elderly subjects were assigned to either the medium (45.3%) or medium-high (32%) deprivation groups, while the percentages in the extreme tails were low (3.6%high deprivation; 1.3%low deprivation). Significant, nonlinear (p < 0.05 NL) relationships were observed in both sexes with regard to mortality due to all respiratory diseases (RD) and chronic obstructive pulmonary disease (COPD), with the highest Standardized Mortality Ratio (SMR) values in women in the high deprivation group of women (1.81, p < 0.05 RD; 1.79, p < 0.05 COPD). The SMRs for influenza and pneumonia showed a positive linear trend in women (p < 0.05) with the highest value in the high deprivation group (1.97, p < 0.05), while in men the trend was NL (p < 0.05). A positive linear trend (p < 0.05) was found with regard to vaccination coverage, which grew weakly as deprivation increased, up to the medium-high deprived group (from 34.6%to 44.4%). However, the high deprivation group showed the lowest value (33.3%). Conclusions. The results revealed a relationship between deprivation and influenza vaccination coverage in the elderly. This finding should be taken into account in the organization of vaccination campaigns and should prompt differentiated intervention in each local area

Пожилые люди и дети — не единственные жертвы обструкции дыхательных путей инородными предметами в Италии (Национальное исследование на основе анализа СМИ)

Choking is a relevant public health problem. Data in medical literature are scarce and fatal events are dramatically under-reported.The aim of this manuscript is to give a real estimation of this problem and to raise awareness about this topic.Materials and methods. All deaths caused by choking reported by Italian Mass Media over a two years period were collected. Suspected sudden infant death syndrome was an exclusion criteria.Results. 76 deaths due to foreign body airway obstruction were identified, 51% during 2018 and 49% in 2019, without identifiable time clusters. Choking affected every age, including pre-scholar children (25%), children 6 to 18 years old (3%), adults (38%), and elderly patients (34%). Witnessed cases were 61 (80%) but in almost half 26 cases (42%) the fatal event occurred before or without first aid maneuvers being performed.Conclusion. On the Italian territory, during a 2 years period, three cases per month of fatal choking due to foreign-body airway obstruction occurred, many of them in adult patients (38%). Italian people seem not to be educated to provide first aid in these settings.Асфиксия (удушье) является серьезной проблемой общественного здравоохранения. Данные медицинской литературы по этой проблеме скудны, а сообщения о смертельных исходах резко занижены.Цель публикации — оценить реальную частоту асфиксии и повысить осведомленность о ней.Материалы и методы. Собрали все случаи смерти от асфиксии, о которых итальянские СМИ сообщали в течение двух лет. Критерием исключения было подозрение на синдром внезапной детской смерти.Результаты. Выявили 76 смертей вследствие обструкции дыхательных путей инородным телом — 51% в 2018 году и 49% в 2019 году ото всех случаев асфиксии, без каких-либо определенных временных предпочтений по накоплению случаев в течение года. Асфиксию наблюдали среди лиц всех возрастов, включая детей дошкольного возраста (25%), детей от 6 до 18 лет (3%), взрослых (38%) и пожилых пациентов (34%). В присутствии свидетелей произошел 61 случай (80%), при этом почти в половине смертельных случаев (26, что составило 42%) смерть наступила до или без проведения мероприятий по оказанию первой помощи.Заключение. На территории Италии в течение двух лет ежемесячно происходило по три случая смертельной асфиксии вследствие обструкции дыхательных путей посторонними предметами, много случаев обнаружено в когорте пациентов зрелого возраста (38%). Такие данные СМИ свидетельствуют о том, что население Италии не обучено оказывать первую помощь, необходимую в таких случаях

Elderly and Children Are Not The Only Victims of Foreign Body Airway Obstruction in Italy (A National Media-Based Survey)

Choking is a relevant public health problem. Data in medical literature are scarce and fatal events are dramatically under-reported.The aim of this manuscript is to give a real estimation of this problem and to raise awareness about this topic.Materials and methods. All deaths caused by choking reported by Italian Mass Media over a two years period were collected. Suspected sudden infant death syndrome was an exclusion criteria.Results. 76 deaths due to foreign body airway obstruction were identified, 51% during 2018 and 49% in 2019, without identifiable time clusters. Choking affected every age, including pre-scholar children (25%), children 6 to 18 years old (3%), adults (38%), and elderly patients (34%). Witnessed cases were 61 (80%) but in almost half 26 cases (42%) the fatal event occurred before or without first aid maneuvers being performed.Conclusion. On the Italian territory, during a 2 years period, three cases per month of fatal choking due to foreign-body airway obstruction occurred, many of them in adult patients (38%). Italian people seem not to be educated to provide first aid in these settings

Inotropes and Vasopressors Use in Critical Care and Perioperative Medicine: Evidence-Based Approach (Review)

Inotropes and vasopressors are frequently required in critically ill patients and in patients undergoing major surgery. Several molecules are currently available, including catecholamines, phosphodiesterase-3 inhibitors, vasopressin and its analogues, and calcium sensitizers.We will review current evidence on inotropes use in perioperative and critically ill patients, with focus on most recent randomized controlled trials (RCTs).Despite being widely used in anesthesia and intensive care, evidences on safety and efficacy of inotropes are scarce. Data from observational studies suggest that inotropes administration may increase mortality in cardiac surgery, acute heart failure, and cardiogenic shock patients. However, randomized controlled trials did not confirm these findings in acute care settings.Epinephrine has been associated with increased mortality especially in cardiogenic shock, but randomized trials failed to show evidence of increased mortality associated with epinephrine use. Norepinephrine has been traditionally considered contraindicated in patients with ventricular dysfunction, but recent trials suggested hemodynamic effects similar to epinephrine in patients with cardiogenic shock. Dopamine has no additional advantages over norepinephrine and increases the risk of tachyarrhythmias and may increase mortality in cardiogenic shock. Phosphodiesterase-3 (PDE-3) inhibitors are equivalent to catecholamines in terms of major outcomes. Levosimendan is the most investigated inotrope of the last 30 years, but despite promising early studies, high-quality multicenter RCTs repeatedly failed to show any superiority over available agents. There is no highquality RCT clearly demonstrating superiority of one agent over another. In summary, current evidence suggest that the choice of inotrope is unlikely to affect outcome, as long as the target hemodynamic goals are achieved.Finally, in recent years, mechanical circulatory support (MCS) has become increasingly popular. Thanks to improvement in technology, the safety and biocompatibility of devices are constantly growing. MCS devices have theoretical advantages over inotropes, but their use is limited by costs, availability, and invasiveness.Conclusion. Future studies should investigate safety, efficacy, and cost-effectiveness of primary MCS versus primary inotropes in patients with acute cardiovascular failure