Thirty-Day Complications, Unplanned Hospital Encounters, and Mortality after Endosonography and/or Guided Bronchoscopy: A Prospective Study.

BACKGROUND AND OBJECTIVE: Limited data exist regarding the adverse events of advanced diagnostic bronchoscopy, with most of the available information derived from retrospective datasets that primarily focus on early complications. METHODS: We conducted a 15-month prospective cohort study among consecutive patients undergoing endosonography and/or guided bronchoscopy under general anesthesia. We evaluated the 30-day incidence of severe complications, any complication, unplanned hospital encounters, and deaths. Additionally, we analyzed the time of onset (immediate, within 1 h of the procedure; early, 1 h-24 h; late, 24 h-30 days) and identified risk factors associated with these events. RESULTS: Thirty-day data were available for 697 out of 701 (99.4%) enrolled patients, with 85.6% having suspected malignancy and multiple comorbidities (median Charlson Comorbidity Index (IQR): 4 (2-5)). Severe complications occurred in only 17 (2.4%) patients, but among them, 10 (58.8%) had unplanned hospital encounters and 2 (11.7%) died within 30 days. A significant proportion of procedure-related severe complications (8/17, 47.1%); unplanned hospital encounters (8/11, 72.7%); and the two deaths occurred days or weeks after the procedure. Low-dose attenuation in the biopsy site on computed tomography was independently associated with any complication (OR: 1.87; 95% CI 1.13-3.09); unplanned hospital encounters (OR: 2.17; 95% CI 1.10-4.30); and mortality (OR: 4.19; 95% CI 1.74-10.11). CONCLUSIONS: Severe complications arising from endosonography and guided bronchoscopy, although uncommon, have significant clinical consequences. A substantial proportion of adverse events occur days after the procedure, potentially going unnoticed and exerting a negative clinical impact if a proactive surveillance program is not implemented.

Introducing the CYSAS-S3 Dataset for Operationalizing a Mission-Oriented Cyber Situational Awareness.

The digital transformation of the defence sector is not exempt from innovative requirements and challenges, with the lack of availability of reliable, unbiased and consistent data for training automatisms (machine learning algorithms, decision-making, what-if recreation of operational conditions, support the human understanding of the hybrid operational picture, personnel training/education, etc.) being one of the most relevant gaps. In the context of cyber defence, the state-of-the-art provides a plethora of data network collections that tend to lack presenting the information of all communication layers (physical to application). They are synthetically generated in scenarios far from the singularities of cyber defence operations. None of these data network collections took into consideration usage profiles and specific environments directly related to acquiring a cyber situational awareness, typically missing the relationship between incidents registered at the hardware/software level and their impact on the military mission assets and objectives, which consequently bypasses the entire chain of dependencies between strategic, operational, tactical and technical domains. In order to contribute to the mitigation of these gaps, this paper introduces CYSAS-S3, a novel dataset designed and created as a result of a joint research action that explores the principal needs for datasets by cyber defence centres, resulting in the generation of a collection of samples that correlate the impact of selected Advanced Persistent Threats (APT) with each phase of their cyber kill chain, regarding mission-level operations and goals.

Hemodynamic response to positive end-expiratory pressure and prone position in COVID-19 ARDS.

BACKGROUND: Use of high positive end-expiratory pressure (PEEP) and prone positioning is common in patients with COVID-19-induced acute respiratory failure. Few data clarify the hemodynamic effects of these interventions in this specific condition. We performed a physiologic study to assess the hemodynamic effects of PEEP and prone position during COVID-19 respiratory failure. METHODS: Nine adult patients mechanically ventilated due to COVID-19 infection and fulfilling moderate-to-severe ARDS criteria were studied. Respiratory mechanics, gas exchange, cardiac output, oxygen consumption, systemic and pulmonary pressures were recorded through pulmonary arterial catheterization at PEEP of 15 and 5 cmH2O, and after prone positioning. Recruitability was assessed through the recruitment-to-inflation ratio. RESULTS: High PEEP improved PaO2/FiO2 ratio in all patients (p = 0.004), and significantly decreased pulmonary shunt fraction (p = 0.012), regardless of lung recruitability. PEEP-induced increases in PaO2/FiO2 changes were strictly correlated with shunt fraction reduction (rho=-0.82, p = 0.01). From low to high PEEP, cardiac output decreased by 18 % (p = 0.05) and central venous pressure increased by 17 % (p = 0.015). As compared to supine position with low PEEP, prone positioning significantly decreased pulmonary shunt fraction (p = 0.03), increased PaO2/FiO2 (p = 0.03) and mixed venous oxygen saturation (p = 0.016), without affecting cardiac output. PaO2/FiO2 was improved by prone position also when compared to high PEEP (p = 0.03). CONCLUSIONS: In patients with moderate-to-severe ARDS due to COVID-19, PEEP and prone position improve arterial oxygenation. Changes in cardiac output contribute to the effects of PEEP but not of prone position, which appears the most effective intervention to improve oxygenation with no hemodynamic side effects.

Incoherence between Systemic Hemodynamic and Microcirculatory Response to Fluid Challenge in Critically Ill Patients.

BACKGROUND: The aim of the study was to assess the coherence between systemic hemodynamic and microcirculatory response to a fluid challenge (FC) in critically ill patients. METHODS: We prospectively collected data in patients requiring a FC whilst cardiac index (CI) and microcirculation were monitored. The sublingual microcirculation was assessed using the incident dark field (IDF) CytoCam device (Braedius Medical, Huizen, The Netherlands). The proportion of small perfused vessels (PPV) was calculated. Fluid responders were defined by at least a 10% increase in CI during FC. Responders according to changes in microcirculation were defined by at least 10% increase in PPV at the end of FC. Cohen's kappa coefficient was measured to assess the agreement to categorize patients as "responders" to FC according to CI and PPV. RESULTS: A total of 41 FC were performed in 38 patients, after a median time of 1 (0-1) days after ICU admission. Most of the fluid challenges (39/41, 95%) were performed using crystalloids and the median total amount of fluid was 500 (500-500) mL. The main reasons for fluid challenge were oliguria (n = 22) and hypotension (n = 10). After FC, CI significantly increased in 24 (58%) cases; a total of 19 (46%) FCs resulted in an increase in PPV. Both CI and PPV increased in 13 responders and neither in 11; the coefficient of agreement was only 0.21. We found no correlation between absolute changes in CI and PPV after fluid challenge. CONCLUSIONS: The results of this heterogenous population of critically ill patients suggest incoherence in fluid responsiveness between systemic and microvascular hemodynamics; larger cohort prospective studies with adequate a priori sample size calculations are needed to confirm these findings.

Relationship between Microcirculatory Perfusion and Arterial Elastance: A Pilot Study.

BACKGROUND: Arterial elastance (Ea) represents the total afterload imposed on the left ventricle, and it is largely influenced by systemic vascular resistance (SVR). Although one can expect that Ea is influenced by peripheral endothelial function, no data are available to support it in patients. The aim of this study was to investigate the relationship between Ea, SVR, and microvascular perfusion in critically ill patients undergoing the fluid challenge (FC). METHODS: A prospective study in patients receiving a fluid challenge. A pulse wave analysis system (MostCare, Vygon, France) was used to estimate Ea and an incident dark field (IDF) handheld device (Braedius Medical BV, The Netherlands) to evaluate the sublingual microcirculation. Microvascular perfusion was assessed using the proportion of small-perfused vessels (PPV). Relative changes in each variable were calculated before and after FC; fluid responsiveness was defined as an increase in the cardiac index by at least 10% from baseline. RESULTS: We studied 20 patients requiring a fluid challenge (n=10 for hypotension; n=5 for oliguria; n=3 for lactate values greater than 2 mmol/l; n=2 for tachycardia), including 12 fluid responders. There was a strong correlation between Ea and SVR (r 2 = 0.75; p < 0.001) and only a weak correlation between Ea and PPV at baseline (r 2 = 0.22; p=0.04). Ea decreased from 1.4 [1.2-1.6] to 1.2 [1.1-1.4] mmHg/mL (p=0.01), SVR from 1207 [1006-1373] to 1073 [997-1202] dyn ∗ s/cm5 (p=0.06), and PPV from 56 [51-64] % to 59 [47-73] % (p=0.25) after fluid challenge. Changes in Ea were significantly correlated with changes in SVR, but not with changes in PPV. CONCLUSIONS: The correlation between Ea and indexes of microvascular perfusion in the sublingual region is weak. The impact of microcirculatory perfusion on the arterial load is probably limited.

Non-invasive ventilation in cardiogenic pulmonary edema.

Cardiogenic pulmonary edema (CPE) is among the most common causes of acute respiratory failure (ARF) in the acute care setting and often requires ventilatory assistance. In patients with ARF due to CPE, use of non-invasive positive airway pressure can decrease the systemic venous return and the left ventricular (LV) afterload, thus reducing LV filling pressure and limiting pulmonary edema. In these patients, either non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP) can improve vital signs and physiological parameters, decreasing the need for endotracheal intubation (ETI) and hospital mortality when compared to conventional oxygen therapy. Results on the use of NIV or CPAP in patients with CPE prior to hospitalization are not homogeneous among studies, hampering any conclusive recommendation regarding their role in the pre-hospital setting.

Capnography during cardiac arrest.

Successful resuscitation from cardiac arrest depends on provision of adequate blood flow to vital organs generated by cardiopulmonary resuscitation (CPR). Measurement of end-tidal expiratory pressure of carbon dioxide (ETCO2) using capnography provides a noninvasive estimate of cardiac output and organ perfusion during cardiac arrest and can therefore be used to monitor the quality of CPR and predict return of spontaneous circulation (ROSC). In clinical observational studies, mean ETCO2 levels in patients with ROSC are higher than those in patients with no ROSC. In prolonged out of hospital cardiac arrest, ETCO2 levels <10 mmHg are consistently associated with a poor outcome, while levels above this threshold have been suggested as a criterion for considering patients for rescue extracorporeal resuscitation. An abrupt rise of ETCO2 during CPR suggests that ROSC has occurred. Finally, detection of CO2 in exhaled air following intubation is the most specific criterion for confirming endotracheal tube placement during CPR. The aetiology of cardiac arrest, variations in ventilation patterns during CPR, and the effects of drugs such as adrenaline or sodium bicarbonate administered as a bolus may significantly affect ETCO2 levels and its clinical significance. While identifying ETCO2 as a useful monitoring tool during resuscitation, current guidelines for advanced life support recommend against using ETCO2 values in isolation for decision making in cardiac arrestmanagement.

The potential role of auditory evoked potentials to assess prognosis in comatose survivors from cardiac arrest.

AIM: Few data are available on the use of brainstem auditory evoked potentials (BAEPs) in combination with other electrophysiological tools to assess prognosis of comatose survivors from cardiac arrest (CA). METHODS: Retrospective analysis of data from all adult patients (>18years of age) admitted to our Dept of Intensive Care after CA over a 6-year period who were comatose (Glasgow Coma Scale <9) on admission, had been treated with targeted temperature management and had BAEP testing. We collected variables related to CA, as well as electroencephalography (EEG) findings, N20 somatosensory evoked potentials, and the presence of I, III and/or V waves on BAEP testing. Outcome was assessed at 3 months using the Cerebral Performance Categories (3-5=poor outcome). RESULTS: We studied 65 patients; 48 (74%) had a poor neurological outcome. BAEP assessment was performed day 3 [3,4] after the CA. At least one of the three waves was absent bilaterally in 34 patients (52%); of these patients, 29 (85%) had a poor neurological outcome (sensitivity 60%, specificity 71%, positive predictive value [PPV] 85% and negative predictive value [NPV] 39%). Three patients (5%) had bilateral absence of all three waves, all of whom had a poor neurological outcome. CONCLUSIONS: In this series of patients after CA, at least one of the BAEP waves was absent bilaterally in half the survivors; however, their use for prediction of poor neurological outcome remains limited.

Accuracy of plethysmographic indices as predictors of fluid responsiveness in mechanically ventilated adults: a systematic review and meta-analysis.

PURPOSE: To systematically review the accuracy of the variation in pulse oxymetry plethysmographic waveform amplitude (∆POP) and the Pleth Variability Index (PVI) as predictors of fluid responsiveness in mechanically ventilated adults. METHODS: MEDLINE, Scopus and the Cochrane Database of Systematic Reviews were screened for clinical studies in which the accuracy of ∆POP/PVI in predicting the hemodynamic response to a subsequent fluid bolus had been investigated. Random-effects meta-analysis was used to summarize the results. Data were stratified according to the amount of fluid bolus (large vs. small) and to the study index (∆POP vs. PVI). RESULTS: Ten studies in 233 patients were included in this meta-analysis. All patients were in normal sinus rhythm. The pooled area under the receiver operating characteristic curve (AUC) for identification of fluid responders was 0.85 [95 % confidence interval (CI) 0.79-0.92]. Pooled sensitivity and specificity were 0.80 (95 % CI 0.74-0.85) and 0.76 (0.68-0.82), respectively. No heterogeneity was found within studies with the same amount of fluid bolus, nor between studies on ∆POP and those on PVI. The AUC was significantly larger in studies with a large bolus amount than in those with a small bolus [0.92 (95 % CI 0.87-0.96) vs. 0.70 (0.62-0.79); p < 0.0001]. Sensitivity and specificity were also higher in studies with a large bolus [0.84 (95 % CI 0.77-0.90) vs. 0.72 (0.60-0.82) (small bolus), p = 0.08 and 0.86 (95 % CI 0.75-0.93) vs. 0.68 (0.56-0.77) (small bolus), p = 0.02], respectively. CONCLUSIONS: Based on our meta-analysis, we conclude that ∆POP and PVI are equally effective for predicting fluid responsiveness in ventilated adult patients in sinus rhythm. Prediction is more accurate when a large fluid bolus is administered.

Assessment and prediction of whole-body vibration exposure in transport truck drivers.

The European Directive 2002/44/EC on the minimum Health and Safety prescriptions regarding the exposure of workers to vibrations, was implemented in Italy through the Legislative Decree 187/2005, recently amended by the Legislative Decree 81/2008. The Decrees contain legal obligations and minimum requirements for the evaluation by direct measurement, which is the reference method, although not always appropriate or necessary, and by means of vibration data banks or information provided by equipment manufacturers. The values assessed must be representative of the actual working environment: in order to adapt assessed values to real working conditions it may be useful to adopt some statistical models. Statistically significant relationships were observed by means of a multiple linear regression on a limited set of measures on different models of trucks, in different operating conditions and settings: the relative influence of predictor variables was then assessed. Finally a short digression about the evolution of the suspension fitting has been made in order to briefly describe the historical context of WBV exposure level reduction and the state of the art of industrial vehicle comfort improvement technologies.