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Montalto, Francesca, Ippolito, Mariachiara, Noto, Alberto, Madotto, Fabiana, Gelardi, Filippa, Savatteri, Paolino, Giarratano, Antonino, Cortegiani, Andrea, Brescia, Fabrizio, Fabiani, Fabio, Zanier, Chiara, Nadalini, Elisa, Gambaretti, Eros, Gabriele, Francesco, Astuto, Marinella, Murabito, Paolo, Sanfilippo, Filippo, Misseri, Giovanni, Moscarelli, Alessandra, Spadaro, Savino, Bussolati, Enrico, Squadrani, Eleonora, Villa, Gianluca, D’Errico, Raffaella, Cocci, Giulia, Lanini, Iacopo, Mirabella, Lucia, Morelli, Alessandra, Tullo, Livio, Caggianelli, Girolamo, Ball, Lorenzo, Iiriti, Margherita, Giordani, Francesca, Giardina, Massimiliano, Mazzeo, Anna Teresa, Grasselli, Giacomo, Cattaneo, Emanuele, Alongi, Salvatore, Marenghi, Cristina, Marmiere, Marilena, Rocchi, Margherita, Turi, Stefano, Landoni, Giovanni, Torrano, Vito, Tinti, Giulia, Giorgi, Antonio, Fumagalli, Roberto, Salvo, Francesco, Blangetti, Ilaria, Cascella, Marco, Forte, Cira Antonietta, Navalesi, Paolo, Montalbano, Marta, Chiarelli, Valentina, Bonanno, Giuseppe, Ferrara, Francesco Paolo, Pernice, Innocenza, Catalisano, Giulia, Marino, Claudia, Presti, Gabriele, Fricano, Dario Calogero, Fucà, Rosa, Palmeri di Villalba, Cesira, Strano, Maria Teresa, Caruso, Sabrina, Scafidi, Antonino, Mazzarese, Vincenzo, Augugliaro, Ettore, Terranova, Valeria, Forfori, Francesco, Corradi, Francesco, Taddei, Erika, Isirdi, Alessandro, Pratesi, Giorgia, Puccini, Francesca, Paternoster, Gianluca, Barile, Alessio, Tescione, Marco, Santacaterina, Irene, Siclari, Eliana Maria, Tripodi, Vincenzo Francesco, Vadalà, Mariacristina, Agrò, Felice Eugenio, Pascarella, Giuseppe, Piliego, Chiara, Aceto, Paola, De Pascale, Gennaro, Dottarelli, Alessandra, Romanò, Bruno, Russo, Andrea, Covotta, Marco, Giorgerini, Valeria, Sardellitti, Federica, Vitelli, Giulia Maria, Coluzzi, Flaminia, Bove, Tiziana, Vetrugno, Luigi.
Journal of Anesthesia, Analgesia and Critical Care ; 1(1):17-17, 2021.
Article in English | BioMed Central | ID: covidwho-1542137
Front Physiol ; 12: 728243, 2021.
Article in English | MEDLINE | ID: covidwho-1441134


Background: Different severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia phenotypes were described that match with different lung compliance and level of oxygenation, thus requiring a personalized ventilator setting. The burden of so many patients and the lack of intensive care unit (ICU) beds often force physicians to choose non-invasive ventilation (NIV) as the first approach, even if no consent has still been reached to discriminate whether it is safer to choose straightforward intubation, paralysis, and protective ventilation. Under such conditions, electrical impedance tomography (EIT), a non-invasive bedside tool to monitor lung ventilation and perfusion defects, could be useful to assess the response of patients to NIV and choose rapidly the right ventilatory strategy. Objective: The rationale behind this study is that derecruitment is a more efficient measure of positive end expiratory pressure (PEEP)-dependency of patients than recruitment. We hypothesized that patients who derecruit significantly when PEEP is reduced are the ones that do not need early intubation while small end-expiratory lung volume (ΔEELV) variations after a single step of PEEP de-escalation could be predictive of NIV failure. Materials and Methods: Consecutive patients admitted to ICU with confirmed SARS-CoV-2 pneumonia ventilated in NIV were enrolled. Exclusion criteria were former intubation or NIV lasting > 72 h. A trial of continuos positive airway pressure (CPAP) 12 was applied in every patient for at least 15 min, followed by the second period of CPAP 6, either in the supine or prone position. Besides standard monitoring, ventilation of patients was assessed by EIT, and end-expiratory lung impedance (ΔEELI) (%) was calculated as the difference in EELI between CPAP12 and CPAP6. Tidal volume (Vt), Ve, respiratory rate (RR), and FiO2 were recorded, and ABGs were measured. Data were analyzed offline using the dedicated software. The decision to intubate or continue NIV was in charge of treating physicians, independently from study results. Outcomes of patients in terms of intubation rate and ICU mortality were recorded. Results: We enrolled 10 male patients, with a mean age of 67 years. Six patients (60%) were successfully treated by NIV until ICU discharge (Group S), and four patients failed NIV and were intubated and switched to MV (Group F). All these patients died in ICU. During the supine CPAP decremental trial, all patients experienced an increase in RR and Ve. ΔEELI was < 40% in Group F and > 50% in Group S. In the prone trial, ΔEELI was > 50% in all patients, while RR decreased in Group S and remained unchanged in Group F. Conclusion: ΔEELI < 40% after a single PEEP de-escalation step in supine position seems to be a good predictor of poor recruitment and CPAP failure.

BMJ Open ; 11(2): e036616, 2021 02 11.
Article in English | MEDLINE | ID: covidwho-1228874


INTRODUCTION: In patients with septic shock, low levels of circulating immunoglobulins are common and their kinetics appear to be related to clinical outcome. The pivotal role of immunoglobulins in the host immune response to infection suggests that additional therapy with polyclonal intravenous immunoglobulins may be a promising option in patients with septic shock. Immunoglobulin preparations enriched with the IgM component have largely been used in sepsis, mostly at standard dosages (250 mg/kg per day), regardless of clinical severity and without any dose adjustment based on immunoglobulin serum titres or other biomarkers. We hypothesised that a personalised dose of IgM enriched preparation based on patient IgM titres and aimed to achieve a specific threshold of IgM titre is more effective in decreasing mortality than a standard dose. METHODS AND ANALYSIS: The study is designed as a multicentre, interventional, randomised, single-blinded, prospective, investigator sponsored, two-armed study. Patients with septic shock and IgM titres <60 mg/dL will be randomly assigned to an IgM titre-based treatment or a standard treatment group in a ratio of 1:1. The study will involve 12 Italian intensive care units and 356 patients will be enrolled. Patients assigned to the IgM titre-based treatment will receive a personalised daily dose based on an IgM serum titre aimed at achieving serum titres above 100 mg/dL up to discontinuation of vasoactive drugs or day 7 after enrolment. Patients assigned to the IgM standard treatment group will receive IgM enriched preparation daily for three consecutive days at the standard dose of 250 mg/kg. The primary endpoint will be all-cause mortality at 28 days. ETHICS AND DISSEMINATION: The study protocol was approved by the ethics committees of the coordinating centre (Comitato Etico dell'Area Vasta Emilia Nord) and collaborating centres. The results of the trial will be published within 12 months from the end of the study and the steering committee has the right to present them at public symposia and conferences. TRIAL REGISTRATION DETAILS: The trial protocol and information documents have received a favourable opinion from the Area Vasta Emilia Nord Ethical Committee on 12 September 2019. The trial protocol has been registered on EudraCT (2018-001613-33) on 18 April 2018 and on (NCT04182737) on 2 December 2019.

COVID-19 , Shock, Septic , Humans , Immunization, Passive , Immunoglobulin M , Prospective Studies , SARS-CoV-2 , Shock, Septic/drug therapy , Treatment Outcome
BMC Anesthesiol ; 21(1): 9, 2021 01 08.
Article in English | MEDLINE | ID: covidwho-1015835


BACKGROUND: Pneumonia induced by 2019 Coronavirus (COVID-19) is characterized by hypoxemic respiratory failure that may present with a broad spectrum of clinical phenotypes. At the beginning, patients may have normal lung compliance and be responsive to noninvasive ventilatory support, such as CPAP. However, the transition to more severe respiratory failure - Severe Acute Respiratory Syndrome (SARS-CoV-2), necessitating invasive ventilation is often abrupt and characterized by a severe V/Q mismatch that require cycles of prone positioning. The aim of this case is to report the effect on gas exchange, respiratory mechanics and hemodynamics of tripod (or orthopneic sitting position) used as an alternative to prone position in a patient with mild SARS-CoV-2 pneumonia ventilated with helmet CPAP. CASE PRESENTATION: A 77-year-old awake and collaborating male patient with mild SARS-CoV-2 pneumonia and ventilated with Helmet CPAP, showed sudden worsening of gas exchange without dyspnea. After an unsuccessful attempt of prone positioning, we alternated three-hours cycles of semi-recumbent and tripod position, still keeping him in CPAP. Arterial blood gases (PaO2/FiO2, PaO2, SaO2, PaCO2 and A/a gradient), respiratory (VE, VT, RR) and hemodynamic parameters (HR, MAP) were collected in the supine and tripod position. Cycles of tripod position were continued for 3 days. The patient had a clinically important improvement in arterial blood gases and respiratory parameters, with stable hemodynamic and was successfully weaned and discharged to ward 10 days after pneumonia onset. CONCLUSIONS: Tripod position during Helmet CPAP can be applied safely in patients with mild SARS-CoV-2 pneumonia, with improvement of oxygenation and V/Q matching, thus reducing the need for intubation.

COVID-19/diagnostic imaging , COVID-19/therapy , Continuous Positive Airway Pressure/methods , Patient Positioning/methods , Respiratory Mechanics/physiology , SARS-CoV-2 , Aged , COVID-19/physiopathology , Humans , Male , Treatment Outcome