Inspiratory Effort and Respiratory Mechanics in Patients with Acute Exacerbation of Idiopathic Pulmonary fibrosis: A Preliminary Matched Control Study.

BACKGROUND: Patients with acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) may experience severe acute respiratory failure, even requiring ventilatory assistance. Physiological data on lung mechanics during these events are lacking. METHODS: Patients with AE-IPF admitted to Respiratory Intensive Care Unit to receive non-invasive ventilation (NIV) were retrospectively analyzed. Esophageal pressure swing (ΔPes) and respiratory mechanics before and after 2 hours of NIV were collected as primary outcome. The correlation between positive end-expiratory pressure (PEEP) levels and changes of in dynamic compliance (dynCRS) and PaO2/FiO2 ratio was assessed. Further, an exploratory comparison with a historical cohort of ARDS patients matched 1:1 by age, sequential organ failure assessment score, body mass index and PaO2/FiO2 level was performed. RESULTS: At baseline, AE-IPF patients presented a high respiratory drive activation with ΔPes = 27 (21-34) cmH2O, respiratory rate (RR) = 34 (30-39) bpm and minute ventilation (VE) = 21 (20-26) L/min. Two hours after NIV application, ΔPes, RR and VE values showed a significant reduction (16 [14-24] cmH2O, p<0.0001, 27 [25-30] bpm, p=0.001, and 18 [17-20] L/min, p=0.003, respectively) while no significant change was found in dynamic transpulmonary pressure, expiratory tidal volume (Vte), dynCRS and dynamic mechanical power. PEEP levels negatively correlated with PaO2/FiO2 ratio and dynCRS (r=-0.67, p=0.03 and r=-0.27, p=0.4, respectively). When compared to AE-IPF, ARDS patients presented lower baseline ΔPes, RR, VE and dynamic mechanical power. Differently from AE-IPF, in ARDS both Vte and dynCRS increased significantly following NIV (p=0.01 and p=0.004 respectively) with PEEP levels directly associated with PaO2/FiO2 ratio and dynCRS (r=0.24, p=0.5 and r=0.65, p=0.04, respectively). CONCLUSIONS: In this study, patients with AE-IPF showed a high inspiratory effort, whose intensity was reduced by NIV application without a significant improvement in respiratory mechanics. In an exploratory analysis, AE-IPF patients showed a different mechanical behavior under spontaneous unassisted and assisted breathing compared with ARDS patients of similar severity.

Association between respiratory distress time and invasive mechanical ventilation in COVID-19 patients: A multicentre regional cohort study.

AIM: To determine whether the duration of respiratory distress symptoms in severe COVID-19 pneumonia affects the need for invasive mechanical ventilation and clinical outcomes. MATERIALS AND METHODS: An observational multicentre cohort study of patients hospitalised in five COVID-19-designated ICUs of the University Hospitals of Emilia-Romagna Region. Patients included were adults with pneumonia due to SARS-CoV-2 with PaO2/FiO2 ratio <300 mmHg, respiratory distress symptoms, and need for mechanical ventilation (invasive or non-invasive). Exclusion criteria were an uncertain time of respiratory distress, end-of-life decision, and mechanical respiratory support before hospital admission. MEASUREMENTS AND MAIN RESULTS: We analysed 171 patients stratified into tertiles according to respiratory distress duration (distress time, DT) before application of mechanical ventilation support. The rate of patients requiring invasive mechanical ventilation was significantly different (p < 0.001) among the tertiles: 17/57 patients in the shortest duration, 29/57 in the intermediate duration, and 40/57 in the longest duration. The respiratory distress time significantly increased the risk of invasive ventilation in the univariate analysis (OR 5.5 [CI 2.48-12.35], p = 0.003). Multivariable regression analysis confirmed this association (OR 10.7 [CI 2.89-39.41], p < 0.001). Clinical outcomes (mortality and hospital stay) did not show significant differences between DT tertiles. DISCUSSION: Albeit preliminary and retrospective, our data raised the hypothesis that the duration of respiratory distress symptoms may play a role in COVID-19 patients' need for invasive mechanical ventilation. Furthermore, our observations suggested that specific strategies may be directed towards identifying and managing early symptoms of respiratory distress, regardless of the levels of hypoxemia and the severity of the dyspnoea itself.

Checklist for anesthesiological process: analysis of risks.

BACKGROUND: Several methods are reported in the literature to analyze medically undesirable events during hospital care. Each method has several limitations, so no one has been defined as the standard tool to be able to detect failure during a medical process. The aim of this study was to compare an anesthesiological perioperative checklist with traditional Regional Incident Reporting (RIR) form in detecting and describing failures. METHODS: We analyzed RIR number of reports, seriousness and contributing factors. We also analyzed anesthesiological checklist data for: number of reports, seriousness of incident, contributing factors and distribution in macro-phases. RESULTS: We screened 2681 patients who underwent gynecological and obstetrical surgeries. RIR showed only the most harmful events in 0.4% of surgeries. Conversely, we recorded 135 failures with anesthesiological checklists (3.3%), of which 123 (91.1%) were solved. Categories of incident in checklists were: failures for medical device/equipment (N.=30, 22.2%), for treatment/procedures (N.=25, 18.5%), for clinical assessment (N.=22, 16.2%), for consent/communication (N.=19, 14%), for medication (N.=16, 11.8%) and for documentation (N.=8, 5.9%). Ninety-four failures (69.6%) resulted in no harm for the patient, 41 (30.3%) in reversible damage and there were no cases of permanent damage/death. Contributing factors in checklists were mainly related to team (43.7%), task factors (28.1%) and work environment (22.2%). Failures detected in macro-phases were related to: clinical assessment (31.8%), presurgical re-assessment (23.7%), preparation for anesthesia (30.3%), anesthesia conduction (8.8%) and awakening (5.1%). CONCLUSION: An anesthesiological checklist compared with traditional RIR provided a more sensible and complete framework for incident analysis during the perioperative period in patients undergoing gynecological and obstetrical surgeries.

Acute renal failure and renal replacement therapy in the postoperative period of orthotopic liver transplant patients versus nonelective abdominal surgery patients.

Acute renal failure (ARF) often complicates the postoperative period of patients undergoing orthotopic liver transplantation (OLT); it is habitually associated with high mortality rates. Similarly, patients undergoing major nonelective abdominal surgery are prone to ARF because of their frequent preexistent morbidities, abdominal sepsis, and needed for extended surgical procedures. The aim of this study was to evaluate the incidence of ARF and use of renal replacement therapy (RRT) among OLT versus nonelective abdominal surgery patients and associations with clinical outcomes. We studied all the patients admitted to a surgical intensive care unit (ICU) from January 2008 to December 2009 after OLT or nonelective abdominal surgery. The inclusion criteria were an ICU stay of at least 48 hours and without prior end-stage renal failure. OLT patients (n=84) were younger and less severly ill than surgery patients (n=60). ARF occurrence was lower among the OLT (29%) than the surgery group (47%) requiring RRT in 71% and 53% of patients due to ARF, respectively. The ICU mortality of ARF patients in both groups (29% OLT and 51% surgery) were greater than among subjects without ARF (2% and 6%). The occurrence of ARF is common among these two patient groups, and associated with increased risk of death among in surgery (+45%) versus in OLT (+27%) patients.

Liver transplantation in patients aged 65 and over: a case-control study.

INTRODUCTION: The average age of patients undergoing liver transplantation (LT) is consistently increasing. The aim of this case-control study is to evaluate survival and outcome of patients ≥65 yr compared to younger patients undergoing LT. MATERIALS AND METHODS: From 10/00 to 4/08 we performed 330 primary LT, 31 (9.4%) of these were in patients aged 65-70. Following a case-control approach, we compared these patients with 31 patients aged between 41 and 64 yr and matched according to sex, LT indication, viral status, cadaveric/living donor, LT timing, and Model for End-Stage Liver Disease (MELD) score. RESULTS: There were no statistically significant differences in demographic and surgical donor characteristics. The mean MELD score was under 18 in both groups. Post-LT complications occurred with a similar incidence in the two groups. one-, three-, and five-yr survival was 83.9%, 80.6%, and 80.6%, respectively, for the elderly group, and 80.6%, 73.8%, and 73.8%, respectively, for the young group (p = 0.61). DISCUSSION: Patients aged between 65 and 70 with low MELD score who undergo LT have the same short- and middle-term survival expectancy, morbidity, and outcome quality as younger patients with the same indication and same pre-LT pathology severity, whatever they might be. Thus, chronological age alone should not deter LT workup in patients >65 and <70.

Perioperative red blood cell transfusion and outcome in stable patients after elective major vascular surgery.

OBJECTIVES: Definitive evidence that red blood cell transfusion improves outcome after vascular surgery is lacking. The aims of the study were to determine, among stable consecutive patients who underwent elective major vascular surgery, (1) the association between postoperative transfusion and 30-day death, myocardial infarction, and both, and (2) and if this association differs according to the presence of postoperative anaemia (haemoglobin value less than 9.0 g/dL within 7 days after surgery). METHODS: A retrospective observational study was conducted on 359 patients prospectively screened according to the ACC/AHA guidelines for preoperative risk in non-cardiac surgery. Main outcome was 30-day death; secondary outcomes 30-day myocardial infarction, and composite of 30-day myocardial infarction or death. RESULTS: Of the patients included, 95 (26.5%) received at least one unit of red blood cells. Patients who received transfusion had a significantly increased hazard of 30-day death (hazard ratio [HR] 11.72, 95% confidence interval [CI] 3.92-35.10; p<0.0001), myocardial infarction (HR 3.3, 95% CI 1.7-6.1; p=0.0003), and both (HR 4.0 95% CI 2.2-7.3; p<0.0001). Such associations held even after adjusting for baseline characteristics, surgical risk, bleeding, and propensity to receive transfusion. There was a significant interaction between transfusion and postoperative anaemia (p=0.012). In patients without anaemia, transfusion was associated with higher risk of 30-day death (HR 19.20, 95% CI 3.99-92.45; p=0.007), myocardial infarction (HR 5.05, 95% CI 2.23-11.44; p=0.0001), and both. Conversely, in patients with anaemia this association was not significant. CONCLUSIONS: In patients who underwent elective major vascular surgery, perioperative transfusion was associated with a significantly increased risk of 30-day events which was more attributable to patients with lesser degree of anaemia. Our data caution against the use of liberal transfusion in stable vascular surgery patients.

Recombinant activated factor VII in critical bleeding after orthotopic liver transplantation.

Critical bleeding throughout the intraoperative phase of orthotopic liver transplantation (OLT) strongly increases patient mortality and intensive care unit (ICU) stay. The aim of this study was to report our experience on the use of recombinant activated factor VII (rFVIIa) in postoperative critical bleeding after OLT. In 7 patients with persistent severe bleeding after application of a standard transfusion protocol, we administered a 90 microg/kg bolus of rFVIIa and if necessary eventually repeated it after 3 hours. We recorded the blood loss and the need for transfusions before and after the rFVIIa therapy. Blood losses and need for platelets significantly decreased after rFVIIa administration; a nonsignificant decrease in red blood cells and fresh frozen plasma transfusions also occurred. In 6 patients treatment with rFVIIa was effective; only 1 patient died because of hemorrhagic shock and no thromboses were detected among the treated patients. Awaiting stronger evidence from randomized controlled trials, we suggest that in some challenging cases of massive bleeding rFVIIa should be considered a useful option to control bleeding.

Strategies to control massive abdominal bleeding.

Abdominal trauma is divided into blunt and penetrating causes. Massive intraabdominal hemorrhage after injury represents the most dangerous precipitating factor that can affect survival if not promptly managed. The first target to achieve management of bleeding patients is control of the source, and then adequate resuscitation and optimization of hemostasis. New procoagulant drugs as recombinant activated factor VII (rFVIIa) seem to play an interesting role in bleeding control after trauma. Our experience with rFVIIa in six patients who were refractory to standard treatments demonstrated a good survival rate after massive abdominal bleeding. Regardless of new drugs and new technologies, a multidisciplinary approach is the cornerstone of the primary care of the these patients.

Peri-operative respiratory failure in a cirrhotic patient: a misleading diagnosis.

Patients with chronic liver disease may present with different degrees of respiratory dysfunction whose differential diagnosis is important before elective surgery. We report the case of a misleading diagnosis of peri-operative respiratory failure in a cirrhotic patient who underwent mastectomy. Intra-operative respiratory failure was ascribed by the anaesthetic team to pulmonary embolism and after the operation this diagnosis was still suspected. Despite postoperative heparin treatment, pulmonary gas exchange remained severely impaired. On the hypothesis of a right to left shunt, we performed transoesophageal echocardiography with a bubble test and confirmed hepatopulmonary syndrome. We administered anticoagulant therapy to the patient following surgery, increasing the risk of haemorrhage. We also continued orotracheal intubation and mechanical ventilation longer than was needed. Respiratory symptoms in a patient with liver disease should not be underestimated and up to 20% of these patients may have hepatopulmonary syndrome.

Living donor liver transplantation and management of portal venous pressure.

Small-for-size syndrome occurs in the presence of a reduced mass of liver that is insufficient to maintain normal liver function. It has been speculated that this dysfunction is principally associated with graft exposure to excessive portal perfusion. The aim of these cases was to evaluate the efficacy of octreotide, a splanchnic vasoconstrictor, and esmolol, a selective beta-blocker, to modify the portal perfusion in the postoperative phase after left living related liver transplantation (LRLT). Four patients who underwent left LRLT with graft-to-recipient weight ratios of 0.60 +/- 0.24 were studied with a catheter placed in a jejunal vein. We observed high basal values of hepatic venous pressure gradient (HVPG) and portal vein flow (PVF). Octreotide infusion decreased HVPG, an effect that was more pronounced when it was combined with esmolol. The administration of both drugs was also associated with an improvement in portal vein oxygen saturation. Despite variation in PVF, the plasma disappearance rate of indocyanin green did not change during the infusion of the two drugs. In conclusion, octreotide and esmolol infusion allowed a manipulation of portal vein pressure that should be measured in left LRLT using a small-for-size graft.

Pathophysiology of bleeding in surgery.

Bleeding is a major surgical complication. Although mortality rates of 0.1% are observed for surgical procedures, it may be 5% to 8% for elective vascular surgery, and increase to 20% in the presence of severe bleeding. In major surgery for liver diseases, as well as in cardiac surgery, excessive blood loss is associated with increased mortality, morbidity, and intensive care stay. Approximately 75% to 90% of intraoperative and early postoperative bleeding is due to technical factors. However, in some cases either acquired or congenital coagulopathies may favor, if not directly cause, surgical hemorrhage. Uncontrolled bleeding leads to a combination of hemodilution, hypothermia, consumption of clotting factors, and acidosis, which in turn worsen the clotting process, further exacerbating the problem in a vicious bloody circle. At present, the standard treatment for surgical bleeding is the rapid control of the source of bleeding by either surgical or radiological techniques. Blood-derived products as well as hemostatic agents, such as aprotinin, tranexamic acid, and DDAVP, are widely used to improve hemostatic balance in bleeding patients. Recombinant activated factor VII (rFVIIa) has been reported to be effective for the treatment of surgical or traumatic massive bleeding unresponsive to conventional therapy. Although most reports are anecdotal, and therefore exposed to a "positive" selection bias, the number of cases is impressive, strongly suggesting that in such patients rFVIIa may afford a hemostatic advantage beyond that of conventional replacement therapy.

Intra-abdominal hypertension in nonelective surgery: a preliminary report.

Intra-abdominal hypertension (IAH) is recognized to be associated with adverse outcomes in critically ill patients. Etiologic factors for IAH can be divided into three categories: medical, posttraumatic, and surgical/postoperative. No studies have been performed on patients who underwent nonelective surgery, so our aim was to determine prospectively the incidence of IAH among these patients during their intensive care stay to correlate intra-abdominal pressure (IAP) and other parameters. Abdominal pressure was recorded twice daily with the standard method. The study group enrolled 22 patients who underwent an abdominal operation that met urgency criteria and with a postoperative intensive care unit (ICU) stay of at least 48 hours. Several serum and clinical parameters were studied for the first 5 postoperative days as well as during ICU and hospital stay as well as monitored hospital mortality. Our results demonstrated that mortality was definitely higher among patients who developed IAH compared with non-IAH patients. Our results highlighted that a strong correlation existed between increasing values of IAP and worsening serum creatinine and PaO2/FiO2 quotient among patients who underwent nonelective surgery.

Thymoglobulin-induced severe cardiovascular reaction and acute renal failure in a patient scheduled for orthotopic liver transplantation.

Antithymocyte globulin (ATG) has been shown to be effective as a pretreatment immunosuppressive agent in liver transplantation because of the ability to wean tacrolimus monotherapy after 4 months in pretreated recipients. However, the use of ATG can be complicated by serious side effects. Reported side effects include severe cardiopulmonary reactions, adult respiratory distress syndrome and hematological disorders. We report a case of a patient with a medical history of cirrhosis scheduled for orthotopic liver transplantation that, during the operation, showed swelling, hyperthermia, tachycardia and hypotension after the administration of ATG. Acute renal failure (ARF) was another serious side effect that our patient developed during ICU stay; we ascribed the occurrence of ARF to the serum sickness disease triggered by the ATG administration. Only one case has been reported of ARF after ATG-therapy before our experience. Therefore, severe hyperthermia and signs of cardiovascular dysfunction early after the beginning of ATG administration should be carefully evaluated and may need to consider the immediate ATG therapy withdrawal to prevent ARF.