Trauma-induced coagulopathy management

In the last years significant progress has been made in the understanding and treatment of hemorrhage caused by trauma which (along with the advances made in early resuscitation, and critical care) has led to a reduction of "late" deaths, meaning those due to trauma-induced organ failure/sepsis. Depending on the case, trauma is usually characterized by a variable equilibrium between hypo and hypercoagulation, with a majority of hypercoagulation cases. Trauma-induced coagulopathy (TIC), instead, is not only characterized by a coagulation disorder but also a state of inflammation which increases the need for transfusions, the risk of multiorgan failure and thromboembolic complications. In this clinical picture, hemostatic resuscitation, damage control resuscitation and homeostasis maintenance have been shown to reduce mortality. According to guidelines, the heart of TIC treatment is an early individualised goal-directed treatment relying on coagulation support and thromboprophylactic strategies (administration of tranexamic acid, fibrinogen concentrate and packed red blood cells), platelet function monitoring and viscoelastic Point-of-care testing. The implementation of the protocol suggested by the guidelines has allowed a more effective support of coagulopathy and has led to a reduction in hemoderivatives usage, hospitalization time and the death rate in severely injured trauma patients. The aforementioned improvements in TIC management were explicitly confirmed by a multicentric study in which the year the guidelines were implemented was compared with a prior year when no specific protocol was executed

Family-Centered Care to Improve Family Consent for Organ Donation

The need for organ donation has increased over time, but the shortage of available donors is the major limiting factor in transplantation. Organ donation refusal from relatives of potential donors with brain death significantly reduces organ availability. We report a brief analysis about family conflicts in decision-making and causes for refusing donation; moreover, we describe new family-centered strategies in the intensive care unit (ICU) and our systematic communication approach between medical staff and patients’ relatives. In 2016 we conducted a single-center, non-randomized, controlled and before and after study in our ICU, an 18-bed intensive care unit (ICU) of a university hospital. We compared the rate of consent for organ donation before and after the introduction of the new communication approach. The application of a new communication approach between medical staff and relatives of brain-dead patients was associated with a significant increase in the rate of consent to donation. The positive results of the 3-year period 2013–2015 have been confirmed in the 2-year period 2016–2017. Our results highlight the importance of empathy and counselor support of relatives in the ICU

Echography in brain imaging in intensive care unit: State of the art

Transcranial sonography (TCS) is an ultrasound-based imaging technique, which allows the identification of several structures within the brain parenchyma. In the past it has been applied for bedside assessment of different intracranial pathologies in children. Presently, TCS is also used on adult patients to diagnose intracranial space occupying lesions of various origins, intracranial hemorrhage, hydrocephalus, midline shift and neurodegenerative movement disorders, in both acute and chronic clinical settings. In comparison with conventional neuroimaging methods (such as computed tomography or magnetic resonance), TCS has the advantages of low costs, short investigation times, repeatability, and bedside availability. These noninvasive characteristics, together with the possibility of offering a continuous patient neuro-monitoring system, determine its applicability in the monitoring of multiple emergency and non-emergency settings. Currently, TCS is a still underestimated imaging modality that requires a wider diffusion and a qualified training process. In this review we focused on the main indications of TCS for the assessment of acute neurologic disorders in intensive care unit. KEYWORDS: Brain imaging; Brain sonography; Cerebral hemorrhage; Cerebral sonography; Hydrocephalus; Transcranial sonography; Ultrasounds PMID: 25276307 PMCID: PMC4176781 DOI: 10.4329/wjr.v6.i9.63

Lice, rodents, and many hopes: a rare disease in a young refugee

Borrelia recurrentis infection is a louse-borne disease and Leptospirosis is a rat-borne zoonosis, both endemic in areas characterized by a low hygiene condition. This is the first case of life-threatening Borrelia recurrentis and Leptospira species co-infectio

Racemic ketamine in adult head injury patients: use in endotracheal suctioning

INTRODUCTION: Endotracheal suctioning (ETS) is essential for patient care in an ICU but may represent a cause of cerebral secondary injury. Ketamine has been historically contraindicated for its use in head injury patients, since an increase of intracranial pressure (ICP) was reported; nevertheless, its use was recently suggested in neurosurgical patients. In this prospective observational study we investigated the effect of ETS on ICP, cerebral perfusion pressure (CPP), jugular oxygen saturation (SjO2) and cerebral blood flow velocity (mVMCA) before and after the administration of ketamine. METHODS: In the control phase, ETS was performed on patients sedated with propofol and remifentanil in continuous infusion. If a cough was present, patients were assigned to the intervention phase, and 100 \u3b3/kg/min of racemic ketamine for 10 minutes was added before ETS. RESULTS: In the control group ETS stimulated the cough reflex, with a median cough score of 2 (interquartile range (IQR) 1 to 2). Furthermore, it caused an increase in mean arterial pressure (MAP) (from 89.0\u2009\ub1\u200911.6 to 96.4\u2009\ub1\u200913.1 mmHg; P <0.001), ICP (from 11.0\u2009\ub1\u20096.7 to 18.5\u2009\ub1\u20098.9 mmHg; P <0.001), SjO2 (from 82.3\u2009\ub1\u20097.5 to 89.1\u2009\ub1\u20095.4; P\u2009=\u20090.01) and mVMCA (from 76.8\u2009\ub1\u200920.4 to 90.2\u2009\ub1\u200930.2 cm/sec; P\u2009=\u20090.04). CPP did not vary with ETS. In the intervention group, no significant variation of MAP, CPP, mVMCA, and SjO2 were observed in any step; after ETS, ICP increased if compared with baseline (15.1\u2009\ub1\u20099.4 vs. 11.0\u2009\ub1\u20096.4 mmHg; P <0.05). Cough score was significantly reduced in comparison with controls (P <0.0001). CONCLUSIONS: Ketamine did not induce any significant variation in cerebral and systemic parameters. After ETS, it maintained cerebral hemodynamics without changes in CPP, mVMCA and SjO2, and prevented cough reflex. Nevertheless, ketamine was not completely effective when used to control ICP increase after administration of 100 \u3b3/kg/min for 10 minutes

How to communicate with families living in complete isolation

The global emergency caused by the SARS-CoV-2 pandemic has suddenly changed how we communicate with families in all the CoViD19 care settings, on account of the need to maintain complete social isolation. Far-reaching mental suffering manifests itself in widespread anxiety. Health workers are isolated from their families, and must manage the consequences of this isolation just like the patients under their care. Patients and their families perceive not only the clinical results but also the personal attitudes, closeness and psychological support from the care teams. This perception of genuine participation by the health worker in the course of the treatment is especially important when a patient dies, and may influence the whole process of grief

Good neurological recovery after cardiopulmonary resuscitation and thrombolysis in two old patients with pulmonary embolism

The use of thrombolysis as an emergency treatment for cardiac arrest (CA) due to massive pulmonary embolism (MPE) has been described. However, there are no reports of successful treatment of MPE-associated CA in patients over 77 years of age. We report two cases of successful cardiopulmonary resuscitation for an MPE-associated CA in two very old women (87 and 86 years of age). In both cases, typical signs of MPE were documented using emergency echocardiography, which showed an acute right ventricle enlargement and a paradoxical movement of the interventricular septum. Emergency thrombolysis was administered during resuscitation, which lasted 45 and 21 min, respectively. Despite old age and prolonged resuscitation efforts, both patients had good neurological recovery and one of them was alive and neurologically intact 1 year later. Thrombolysis is a potentially useful therapy in MPE-associated CA. A good neurological outcome can be obtained even in very old patients and after prolonged resuscitation

Linear and Nonlinear Heart Rate Variability Indexes in Clinical Practice

Biological organisms have intrinsic control systems that act in response to internal and external stimuli maintaining homeostasis. Human heart rate is not regular and varies in time and such variability, also known as heart rate variability (HRV), is not random. HRV depends upon organism&apos;s physiologic and/or pathologic state. Physicians are always interested in predicting patient&apos;s risk of developing major and life-threatening complications. Understanding biological signals behavior helps to characterize patient&apos;s state and might represent a step toward a better care. The main advantage of signals such as HRV indexes is that it can be calculated in real time in noninvasive manner, while all current biomarkers used in clinical practice are discrete and imply blood sample analysis. In this paper HRV linear and nonlinear indexes are reviewed and data from real patients are provided to show how these indexes might be used in clinical practice