Lung anatomy, energy load, and ventilator-induced lung injury

High tidal volume can cause ventilator-induced lung injury (VILI), but positive end-expiratory pressure (PEEP) is thought to be protective. We aimed to find the volumetric VILI threshold and see whether PEEP is protective per se or indirectly

Extracorporeal Chloride Removal by Electrodialysis (CRe-ED): A Novel Approach to Correct Acidemia

RATIONALE: Acidemia is a severe condition among critically ill patients. Despite lack of evidence, sodium bicarbonate is frequently used to correct pH. However, its administration is burdened by several side effects. We hypothesized that the reduction of plasma chloride concentration could be an alternative strategy to correct acidemia. OBJECTIVES: To evaluate feasibility, safety, and effectiveness of a novel strategy to correct acidemia through Extracorporeal Chloride Removal by Electrodialysis (CRe-ED). METHODS: Ten swine (6 treatments, 4 controls) were sedated, mechanically ventilated and connected to an electrodialysis extracorporeal device capable of removing selectively chloride. In random order, an arterial pH of 7.15 was induced either through reduction of ventilation (respiratory acidosis) or through lactic acid infusion (metabolic acidosis). Acidosis was subsequently sustained for 12-14 hours. In treatment pigs, soon after reaching target acidemia, electrodialysis was started in order to restore pH. MEASUREMENTS AND MAIN RESULTS: During respiratory acidosis, electrodialysis reduced plasma chloride concentration by 26\ub15 mEq/L within 6 hours (final pH=7.36\ub10.04). Control animals exhibited incomplete and slower compensatory response to respiratory acidosis (final pH=7.29\ub10.03, p<0.001). During metabolic acidosis, electrodialysis reduced plasma chloride concentration by 15\ub13 mEq/L within 4 hours (final pH=7.34\ub10.07). No effective compensatory response occurred in controls (final pH=7.11\ub10.08; p<0.001). No complications occurred. CONCLUSIONS: We described the first in-vivo application of an extracorporeal system targeted to correct severe acidemia by lowering plasma chloride concentration. The CRe-ED proved to be feasible, safe, and effective. Further studies are warranted to assess its performance in presence of impaired respiratory and renal functions

Patients with an Open Abdomen in Asian, American and European Continents: A Comparative Analysis from the International Register of Open Abdomen (IROA)

Background: International register of open abdomen (IROA) enrolls patients from several centers in American, European, and Asiatic continent. The aim of our study is to compare the characteristics, management and clinical outcome of adult patients treated with OA in the three continents. Material and methods: A prospective analysis of adult patients enrolled in the international register of open abdomen (IROA). Trial registration: NCT02382770. Results: 1183 patients were enrolled from American, European and Asiatic Continent. Median age was 63 years (IQR 49–74) and was higher in the European continent (65 years, p < 0.001); 57% were male. The main indication for OA was peritonitis (50.6%) followed by trauma (15.4%) and vascular emergency (13.5%) with differences among the continents (p < 0.001). Commercial NPWT was preferred in America and Europe (77.4% and 52.3% of cases) while Barker vacuum pack (48.2%) was the preferred temporary abdominal closure technique in Asia (p < 0.001). Definitive abdominal closure was achieved in 82.3% of cases in America (fascial closure in 90.2% of cases) and in 56.4% of cases in Asia (p < 0.001). Prosthesis were mostly used in Europe (17.3%, p < 0.001). The overall entero-atmospheric fistula rate 2.5%. Median open abdomen duration was 4 days (IQR 2–7). The overall intensive care unit and hospital length-of-stay were, respectively, 8 and 11 days (no differences between continents). The overall morbidity and mortality rates for America, Europe, and Asia were, respectively, 75.8%, 75.3%, 91.8% (p = 0.001) and 31.9%, 51.6%, 56.9% (p < 0.001). Conclusion: There is no uniformity in OA management in the different continents. Heterogeneous adherence to international guidelines application is evident. Different temporary abdominal closure techniques in relation to indications led to different outcomes across the continents. Adherence to guidelines, combined with more consistent data, will ultimately allow to improving knowledge and outcome