The importance of lung recruitability: A novel ultrasound pattern to guide lung recruitment in neonates.

BACKGROUND: Lung Ultrasound (LUS)-guided Lung Recruitment Maneuver (LRM) has been shown to possibly reduce ventilator-induced lung injury in preterm infants. However, to avoid potential hemodynamic and pulmonary side effects, the indication to perform the maneuver needs to be supported by early signs of lung recruitability. Recently, a new LUS pattern (S-pattern), obtained during the reopening of collapsed parenchyma, has been described. This study aims to evaluate if this novel LUS pattern is associated with a higher clinical impact of the LUS-guided LRMs. METHODS: All the LUS-guided rescue LRMs performed on infants with oxygen saturation/fraction of inspired oxygen (S/F) ratio below 200, were included in this cohort study. The primary outcome was to determine if the presence of the S-pattern is associated with the success of LUS-guided recruitment, in terms of the difference between the final and initial S/F ratio (Delta S/F). RESULTS: We reported twenty-two LUS-guided recruitments, performed in nine patients with a median gestational age of 34 weeks, interquartile range (IQR) 28-35 weeks. The S-pattern could be obtained in 14 recruitments (64%) and appeared early during the procedure, after a median of 2 cmH2O (IQR 1-3) pressure increase. The presence of the S-pattern was significantly associated with the effectiveness of the maneuver as opposed to the cases in which the S-pattern could not be obtained (Delta S/F 110 +/- 47 vs 44 +/- 39, p = 0.01). CONCLUSIONS: Our results suggest that the presence of the S-pattern may be an early sign of lung recruitability, predicting LUS-guided recruitment appropriateness and efficacy.

Thoracic ultrasonography: a narrative review.

This narrative review focuses on thoracic ultrasonography (lung and pleural) with the aim of outlining its utility for the critical care clinician. The article summarizes the applications of thoracic ultrasonography for the evaluation and management of pneumothorax, pleural effusion, acute dyspnea, pulmonary edema, pulmonary embolism, pneumonia, interstitial processes, and the patient on mechanical ventilatory support. Mastery of lung and pleural ultrasonography allows the intensivist to rapidly diagnose and guide the management of a wide variety of disease processes that are common features of critical illness. Its ease of use, rapidity, repeatability, and reliability make thoracic ultrasonography the "go to" modality for imaging the lung and pleura in an efficient, cost effective, and safe manner, such that it can largely replace chest imaging in critical care practice. It is best used in conjunction with other components of critical care ultrasonography to yield a comprehensive evaluation of the critically ill patient at point of care.

Diffusion and practice of ultrasound in emergency medicine departments in Italy.

INTRODUCTION: This paper reports data from a cognitive survey on the diffusion, practice and organization of ultrasound (US) in emergency medicine departments (EMDs) in Italy. The study was carried out by the Emergency Medicine Section of the Italian Society for Ultrasound in Medicine and Biology (SIUMB) in collaboration with the Italian Society for Emergency Medicine and Urgent Care (SIMEU). METHODS: We created a questionnaire with 10 items, relating to 4 thematic areas. The questionnaires were administered from September 2007 to February 2008, by email, telephone or regular mail. In August 2008 the data were subjected to nonparametric statistical analysis (Spearman's Rho and Pearson's chi-square - software SPSS). RESULTS: We analyzed 170 questionnaires from the EMDs of all Italian regions. A US scanner is present in 64.7% of the ERs, emergency US (E-US) is practiced only in 47.6% of the ERs, and only in 24% of these more than 60% of the ER team members have training in US. The diffusion of US in other operative units of the EMDs ranges from 8.2% to 26.5%. DISCUSSION: The presence of a US scanner in the ER is essential for the practice and training and is correlated with the level of the EMD. The use of US appears to be less common in less equipped hospitals, regardless of the size of the ER and the availability of radiological services. Wider diffusion of US and greater integration with other services for the installment of the required equipment is to be hoped for.

Ultrasound diagnosis of pneumonia in children.

PURPOSE: This study was done to compare the diagnostic accuracy of ultrasound and chest X-ray (CXR) in children with suspected pneumonia. MATERIALS AND METHODS: Seventy-nine children aged from 6 months to 16 years with clinical signs suggestive of pneumonia underwent lung ultrasound and CXR. RESULTS: Lung ultrasound was positive for the diagnosis of pneumonia in 60 patients, whereas CXR was positive in 53. In four patients with negative CXR and positive ultrasound findings, pneumonia was confirmed by chest computed tomography (CT) (performed for recurrent pneumonia in the same location). In the other three patients with negative CXR and positive ultrasound findings, the clinical course was consistent with pneumonia. CONCLUSIONS: Lung ultrasound is a simple and reliable tool that can be used by the clinician in the case of suspected pneumonia. It is as reliable as CXR, can be easily repeated at the patient's bedside and carries no risk of irradiation.

[Paradoxical embolism: a case]. / Embolia paradossa: un caso.

We report a case of pulmonary embolism complicated by paradoxical embolism (which is rarely diagnosed in life). Foramen ovale patency is a relatively common condition and this, together with the presence of pulmonary embolism, increases the probability of paradoxical embolism.

[Is serotonin implicated in the pathogenesis of the alcohol abstinence syndrome?]. / E la serotonina implicata nella patogenesi della sindrome da astinenza alcoolica?

5-Hydroxyindoleacetic acid (5-HIAA), the main metabolite of 5-hydroxytryptamine or serotonin, excreted in the urine over a 24 hour period was systematically measured in 35 patients with alcohol withdrawal syndrome (AWS). The level of excreted urinary 5-HIAA ac. was high in only a few patients. The pathogenic mechanisms involved are discussed and though the role of serotonin in the pathogenesis of AWS seems of secondary importance, some 5-hydroxytryptamine methyl analogues may have a major role in the pathogenesis of hallucinations caused by alcohol withdrawal.

[Pituitary prolactin reserve in acute exacerbation of chronic respiratory insufficiency]. / La riserva prolattinica ipofisaria nell'insufficienza respiratoria cronica riacutizzata.

The level of pituitary prolactin reserve (PPR) was studied in 56 patients with chronic respiratory failure (CRF) in the acute stage after injections of metoclopramide and Thyrotropin Releasing Hormone (TRH). PPR was low in 90% of the subjects in both groups so that the pathogenic mechanism is more likely to be hypophyseal than hypothalamic and due to the reduced synthesis of PRL by the pituitary gland as a result of inadequate ATP synthesis and/or functional alterations to the receptors or pituitary cells following hypoxaemia and hypercapnia.

[Hypopotassemia during delirium tremens. Pathogenesis and clinical significance]. / Ipopotassiemia in corso di delirium tremens. Patogenesi e significato clinico.

The authors have investigated the changes of kalemia and kaluria levels in 40 patients suffering from delirium tremens, and have observed during the acute stage of the illness, a swift fall of kalemia level without an increase of the kaluric excretion. The kalemic values quickly rise up again at the end of the delirium.. The authors think that an adrenergic mechanism is responsible for this quick and transient hypokalemia. The significance of this adrenergic mechanism in the alcohol withdrawal syndrome is at present widely proved.

[Dupuytren's disease in clinical practice]. / La malattia di Dupuytren nella pratica clinica.

The Authors have investigated the incidence of Dupuytren's disease in the field of internal medicine, they have observed a rather high rate in the old people, especially between 60 and 80 years, and point out the significance of metabolic and genetic factors in the pathogenesis and the development of the disease.

[The thyroid hormones in alcoholic liver cirrhosis. Clinical and prognostic aspects]. / Gli ormoni tiroidei nelle cirrosi epatiche alcooliche. Aspetti clinici e prognostici.

The Authors confirm the clinical and prognostic importance of the measurement of circulating thyroid hormones - especially of Triiodothyronine (T3) - in evaluating the decompensated phases of alcoholic liver cirrhosis. The assay was performed in 90 patients affected by liver cirrhosis and was compared with the clinical manifestations and other laboratory test: only prothrombin time was showed to be as useful as T3 concentration in following the clinical course of cirrhosis. Low levels of tetraiodothyronine (T4) - if one can rule out the presence of hypothyroidism - are evidence for a bad impending prognosis.