ABSTRACT
Background: ECMO is an extracorporeal circulation used as a short-term life-saving support in patients with refractory cardiac and respiratory failure. Fluid overload (FO) in patient with this support, sometimes due to the onset of AKI, is associated with an increased morbidity and mortality rate and with prolonged duration of mechanical ventilation and ECMO. It also alters the volume of distribution of most drugs and can even mask the presence of AKI. Mantaining a negative fluid balance is an essential goal to improve gas exchanges in patients with respiratory failure who have undergone ECMO support. So, fluid overload removal has a significant prognostic value. Diuretic therapy, at the maximal dosage, can be insufficient to reach a negative water balance and it can also lead to metabolic disorders. Initiating RRT may help to obtain this goal. Method(s): A 32-years-old man, without any comorbidity, was admitted to the intensive care unite (ICU) with severe acute respiratory distress syndrome (ARDS) due to SARS Cov-2 infection and refractory hypoxemia. After intubation and mechanical ventilation, he was treated with VV-ECMO. In order to maintain a negative fluid balance, diuretic therapy at maximum dosage was started. Despite this therapy, the patient continued to show fluid overload clinical and its radiological signs, with a little improvement in gas exchanges. For that reason and in order to avoid metabolic alterations due to the diuretic therapy, it was decided to start CVVHF treatment. Thus, the patient was submitted to 3 sessions of CVVHF with a total ultrafiltration of 12 liters. He never lost spontaneous diuresis (his hourly dieresis was about of 150 ml). Diuretic therapy was restarted at the end of the CRRT sessions. Result(s): There was an improvement in patient's gas exchanges already during the first treatment which led to the stop of ECMO after 14 days. FGF (fresh gas flow) had been progressively decreased to the oxygenator. At the same time, lung ventilation has been increased to maintain an adequate CO2 clearance. The patient remained stable at a FGF of 0 L/min for a period of 24 hours;thus only mechanical ventilation was kept. A negative fluid balance has led to a significant patient's clinical conditions improvement to permit VV-ECMO weaning. Conclusion(s): Fluid overload removal is an essential goal to improve gas exchanges and, consequently, outcomes in patients treated with ECMO and its duration can both improve. This goal requires continuous renal replacement therapy (CRRT) because of patient's hemodynamic instability. However, the approach combining CRRT and ECMO is facilitated by several ways to link the different circuits without the necessity of positioning a bilumen CVC and, also, by using the same anticoagulation regimen.
ABSTRACT
In a context where digital giants are increasingly influencing the actions decided by public policies, smart data platforms are a tool for collecting a great deal of information on the territory and a means of producing effective public policies to meet contemporary challenges, improve the quality of the city, and create new services. Within the framework of the Smarter Together project, the cities of Lyon (France), Munich (Germany), and Vienna (Austria) have integrated this tool into their city’s metabolism and use it at different scales. Nevertheless, the principle remains the same: the collection (or even dissemination) of internal and external data to the administration will enable the communities, companies, not-for-profit organizations, and civic administrations to “measure” the city and identify areas for improvement in the territory. Furthermore, through open data logics, public authorities can encourage external partners to become actors in territorial action by using findings from the data to produce services that will contribute to the development of the territory and increase the quality of the city and its infrastructure. Nevertheless, based on data that is relatively complex to extract and process, public data platforms raise many legal, technical, economic, and social issues. The cities either avoided collecting personal data or when dealing with sensitive data, use anonymized aggregated data. Cocreation activities with municipal, commercial, civil society stakeholders, and citizens adopted the strategies and tools of the intelligent data platforms to develop new urban mobility and government informational services for both citizens and public authorities. The data platforms are evolving for transparent alignment with 2030 climate-neutrality objectives while municipalities strive for greater agility to respond to disruptive events like the COVID-19 pandemic. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.
ABSTRACT
Global health emergencies such as Covid-19 have highlighted the importance of access to nature and open spaces in our cities for social, physical, and mental health. However, there continues to be a disconnect between our need for nature and our daily lived experience. Recent research indicates that our connectedness and relationship with nature, and in particular biophilic design, may be key for improving both health and quality of life. Rather than relying on abstract universal ideas of “nature”, using evidence-based biophilic design and policy at a building, neighborhood, and city scale, to link our daily lives with biodiversity, may encourage sense of place and make environmental action more meaningful. Then, improving our natural capital in the urban built environment might help address the current climate and disease crisis, as well as improving our physical and mental health. Drawing from emerging research and innovative practice, the paper describes key research and design paradigms that influence the way we understand the benefits of nature for different environments, including the workplace, neighborhood, and city, and explains where biophilic design theory sits in this field. Examples from recent research carried out in London and Chicago are provided, aiming at demonstrating what kind of research can be functional to what context, followed by a detailed analysis of its application supporting both human and ecological health. The study concludes indicating key policy and design lessons learned around regenerative design and biophilia as well as new directions for action, particularly with regard to climate change, sense of place, and well-being. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.