Not only for caregivers: intranasal glucagon for severe hypoglycaemia in a simulation study.

AIMS: To evaluate: (i) the propensity of paediatrics and emergency medicine residents to select different therapeutic options and (ii) the speed and administration success in a high-fidelity simulation of severe hypoglycaemia in a child with type 1 diabetes (T1DM). METHODS: In this single-centre high-fidelity simulation study, 51 paediatrics or emergency medicine residents were exposed to a scenario of severe hypoglycaemia in a T1DM child attending an ambulatory setting, before and after a training on the preparation and administration of both injectable and IN glucagon. Time for drug delivery and its effectiveness were collected. RESULTS: Before training, 45.1% of participants chose to administer injectable glucagon, 43.1% intravenous glucose solution, 5.9% intranasal (IN) glucagon, and 5.9% took no action. Administration was successful in 74% of injectable glucagon, 33.3% intravenous glucose solution, and 22.7% IN glucagon. After training, 58.8% of participants chose IN and 41.2% injectable glucagon, with 100% of successful administrations for IN glucagon and 90.5% for injectable glucagon. Time to successful administration was shorter for IN than injectable glucagon (23 ± 10 vs. 38 ± 7 s, p < 0.0001). CONCLUSIONS: IN glucagon is an easy and effective option for severe hypoglycaemia treatment, with an almost zero possibility of failure provided that adequate training is imparted.

Predictors of intubation in COVID-19 patients treated with out-of-ICU continuous positive airway pressure.

BACKGROUND: As delayed intubation may worsen the outcome of coronavirus disease 2019 (COVID-19) patients treated with continuous positive airway pressure (CPAP), we sought to determine COVID-specific early predictors of CPAP failure. METHODS: In this observational retrospective multicentre study, we included all COVID-19 patients treated with out-of-ICU CPAP, candidates for intubation in case of CPAP failure. From these patients, we collected demographic and clinical data. RESULTS: A total of 397 COVID-19 patients were treated with CPAP for respiratory failure, with the therapeutic goal of providing intubation in case of CPAP failure. Univariable analysis showed that, age, lactate dehydrogenase (LDH) and white cell counts were all significantly lower in patients with successful CPAP treatment compared to those failing it and undergoing subsequent intubation. The percentage changes between baseline and CPAP application in the ratio of partial pressure arterial oxygen (PaO2) and fraction of inspired oxygen (FiO2), PaO2, respiratory rate and ROX index were higher in patients experiencing successful CPAP compared to those failing it. FiO2 and male gender were also significantly associated with intubation. Multivariable analysis adjusting for age, gender, Charlson comorbidity index, percentage change in PaO2/FiO2 or PaO2 and FiO2 separately, lactate, white blood cell count, LDH and C-reactive protein levels led to an area under the curve of 0.818 and confirmed that age, LDH and percentage increase in PaO2/FiO2 are predictors of intubation. CONCLUSIONS: In COVID-19 patients requiring CPAP, age, LDH and percentage change in PaO2/FiO2 after starting CPAP are predictors of intubation.

Intravenous infusion of magnesium sulfate and postoperative analgesia in total knee arthroplasty.

BACKGROUND: The effectiveness of combining magnesium (Mg) administration with both general and spinal anesthesia to reduce postoperative pain and analgesic consumption is still debated. We evaluated the effects of an intravenous (IV) infusion of Mg sulphate on analgesic consumption and postoperative pain score after total knee arthroplasty performed under spinal anesthesia. METHODS: We studied 40 patients who underwent spinal anesthesia with bupivacaine plus morphine. Patients were randomly assigned to two groups, each of 20 patients, who received either treatment (i.e., intravenous Mg sulphate 40 mg kg(-1) followed by an infusion of 10 mg kg(-1) h(-1)), or the same amounts of isotonic saline (controls). Irrespective of the group of randomization, all patients received postoperative paracetamol, ketorolac, and patient-controlled analgesia with morphine. RESULTS: The Mg postoperative blood level was 0.85 ± 0.02 mmol/L and 1.25 ± 0.11 mmol/L for C and Mg groups, respectively (P<0.001). Sensory level of the spinal block, height of spinal block, mean time to first pain and incidence of PONV were similar in the two groups. Morphine consumption did not show any statistically significant difference between the two groups. The pain score was not significantly different between the two groups. No severe adverse effects were recorded after Mg infusion. CONCLUSION: IV perioperative administration of Mg did not influence postoperative pain control and analgesic consumption after total knee arthroplasty. More studies should be performed with different intra and postoperative pain protocols to enhance the potential anti-nociceptive effect of Mg.

Italian Intersociety Recommendations on pain management in the emergency setting (SIAARTI, SIMEU, SIS 118, AISD, SIARED, SICUT, IRC).

BACKGRAUND: Pain is the primary reason for admission to the Emergency Department (ED). However, the management of pain in this setting is often inadequate because of opiophagia, fear of excessive sedation, and fear of compromising an adequate clinical assessment. METHODS: An intersociety consensus conference was held in 2010 on the assessment and treatment of pain in the emergency setting. This report is the Italian Intersociety recommendations on pain management in the emergency department setting. RESULTS: The list of level A recommendations includes: 1) use of IV acetaminophen for opioid sparing properties and reduction of opioid related adverse events; 2) ketamine-midazolam combination preferred over fentanyl-midazolam fentanyl-propofol in pediatric patients; 3) boluses of ketamine IV (particularly in the population under the age of 2 years and over the age of 13) can lead to impairment of the upper airways, including the onset of laryngospasm, requiring specific expertise and skills for administration; 4) the use of ketamine increases the potential risk of psychomotor agitation, which can happen in up to 30% of adult patients (this peculiar side effect can be significantly reduced by concomitant systemic use of benzodiazepines); 5) for shoulder dislocations and fractures of the upper limbs, the performance of brachial plexus block reduces the time spent in ED compared to sedation; 6) pain relief and the use of opioids in patients with acute abdominal pain do not increase the risk of error in the diagnostic and therapeutic pathway in adults; 7) in newborns, the administration of sucrose reduces behavioural responses to blood sampling from a heel puncture; 8) in newborns, breastfeeding or formula feeding during the procedure reduces the measures of distress; 9) in pediatric patients, non-pharmacological techniques such as distraction, hypnosis and cognitive-behavioural interventions reduce procedural pain caused by the use of needles; 10) in pediatric patients, preventive application of eutectic mixtures of prilocaine and lidocaine allows arterial and venous samples to be taken in optimum conditions; 11) in pediatric patients, the combination of hypnotics (midazolam) and N2O is effective for procedural pain, but may be accompanied by loss of consciousness. CONCLUSION: The diagnostic-therapeutic pathway of pain management in emergency should be implemented, through further interdisciplinary trials, in order to improve the EBM level of specific guidelines.

Osteopontin induces soluble urokinase-type plasminogen activator receptor production and release.

BACKGROUND: Osteopontin (OPN) and soluble urokinase plasminogen activator receptor (suPAR) have been proposed as markers of disease severity and risk-stratification in infection and inflammation. In breast cancer, OPN and the membrane bound form of urokinase plasminogen activator receptor (uPAR) are functionally related, as OPN-induced cell migration depends on uPAR triggering by urokinase plasminogen activator (uPA). The aim of this study was to prospectively evaluate the kinetic of OPN and suPAR blood levels in patients developing septic shock (SS) compared to those not developing SS, and to investigate the relationships between these two biomarkers in immune cells in vitro. METHODS: We measured the levels of OPN and suPAR for 15 days in forty-three patients, defined a priory as at risk to develop septic shock. Moreover, we investigated in vitro the effect of recombinant OPN on uPAR and suPAR expression in monocytes. RESULTS: We found that OPN and suPAR levels were directly correlated to each other both at intensive care unit admission and on the day patients met SIRS/sepsis or septic shock criteria. In patients developing septic shock, OPN increased prior to suPAR and was already detectable up to 4 days before the shock development. In vitro, OPN induced suPAR production in monocytes by increasing both uPAR gene expression, and suPAR release from the cell surface. CONCLUSION: These data suggest that OPN is partly responsible for the increased plasma levels of suPAR and might be a valuable tool to predict the occurrence of septic shock.

High-dose rocuronium for rapid-sequence induction and reversal with sugammadex in two myasthenic patients.

The anesthetic management of patients affected by myasthenia gravis is usually challenging in elective surgery and even more so in emergency procedures. The difficulties involved are several-fold, ranging from the choice of an appropriate muscle relaxant (i.e. one that enables safe and rapid airway management) to neuromuscular monitoring and normal muscular recovery. Additionally, optimizing patient conditions - either pharmacologically or with plasmapheresis - before intervention is well beyond the realm of possibility. We discuss the anesthetic management of two myasthenic patients undergoing emergency surgery (for sigmoid perforation and upper gastrointestinal bleeding respectively). In both cases, we opted for rapid-sequence induction with high-dose rocuronium to prevent inhalation of gastric contents. We also report on the implication of neuromuscular monitoring. We found that the rocuronium-sugammadex combination was a useful and effective option in the emergency setting.

Non-invasive ventilation after surgery in amyotrophic lateral sclerosis.

BACKGROUND: Surgery in patients affected by amyotrophic lateral sclerosis (ALS) presents a particular anesthetic challenge because of the risk of post-operative pulmonary complications. AIMS OF THE STUDY: We report on the use of non-invasive ventilation (NIV) to prevent post-operative pulmonary complications (PPCs) in nine patients affected by ALS enrolled in a phase-1 clinical trial with stem cell transplantation. METHODS: All patients were treated with autologous mesenchymal stem cells implanted into the spinal cord with a surgical procedure. Anesthesia was induced with propofol and maintained with remifentanil and sevoflurane. No muscle relaxant was used. After awakening and regain of spontaneous breathing, patients were tracheally extubated. Non-invasive ventilation through nasal mask was delivered and non-invasive positive pressure ventilation and continuous positive pressure ventilation were started. RESULTS: The average time on NIV after surgery was 3 h and 12 min. All patients regained stable spontaneous breathing after NIV discontinuation and had no episodes of respiratory failure until the following day. CONCLUSIONS: Our case series suggest that the use of NIV after surgery can be a safe strategy to prevent PPCs in patients affected by ALS. The perioperative procedure we chose for these patients appeared safe even in patients with advanced functional stage of the disease.

Impacto de la formación en gestión médica de desastres: resultados de un estudio piloto utilizando una nueva herramienta para la simulación in vivo / Impact of training in medical disaster management: a pilot study using a new tool for live simulation

OBJETIVOS: Probar la nueva aplicación de simulación de desastres (ASD) y evaluar su utilización durante el mismo tipo de ejercicio a gran escala, reproducido en dos ocasiones diferentes. MÉTODOS: Los jugadores (los médicos) fueron clasificados como entrenados (E) y no entrenados (NE), en base a su formación previa en medicina de desastres. La ASD es una herramienta informática basada en la web, diseñada para permitir una evaluación objetiva, sistemática, y cuantitativa del desempeño sanitario en diferentes entornos dinámicos, tales como ejercicios de atención a accidentes con múltiples víctimas. La hipótesis es que el sistema permite detectar diferencias entre los dos grupos durante la gestión de estos eventos.Hemos simulado el colapso de una estructura, el techo en una habitación llena de gente. El uso de la ASD, por vía electrónica recoge los datos relativos a los momentos clave prehospitalarios y hospitalarios, y a la precisión de triaje, del puesto de mando y control y del pretratamiento en el hospital. RESULTADOS: No hubo problemas durante su uso en las dos simulaciones. Los E fueron más rápidos que los NE en el envío de las víctimas desde la escena hasta el hospital [67,5 (50,0-111,0) frente a 145,0 (110,0-150,0) min, p < 0,001]. También trataron y dieron de alta a más pacientes desde las urgencias hospitalarias (32/38 vs 14/31, p < 0,001) y dieron un mejor rendimiento en la evaluación del puesto mando (31/44 vs 17/44 en E vs NE, respectivamente, p < 0,05). No se encontraron diferencias en cuanto a triaje prehospitalario y precisión del tratamiento. CONCLUSIÓN: El uso de la ASD en dos escenarios comparables permitió identificar diferencias en la respuesta ante un incidente con múltiples víctimas llevada a cabo por el personal E en comparación con el NE. Estos resultados pueden reflejar algunos de los objetivos específicos de la educación la medicina de catástrofes cuando se orienta a la gestión organizativa de las crisis en lugar del manejo clínico de las lesiones

OBJECTIVES: The aim of this study was to test a new disaster simulation suite (DSS). We aimed to evaluating its application during the same type of full-scale exercise on 2 different occasions. Our hypothesis was that the system would allow us to detect differences between trained and nontrained physicians during event management. METHODS: We simulated the collapse of a ceiling structure in a crowded room. Using the DSS, we lectronically collected data relative to prehospital and hospital times, triage accuracy, command-and-control and prehospital treatment accuracy. RESULTS: Players (physicians) were classed as trained or nonrained based on their background in disaster medicine training. No usability problems arose during either simulation. Trained physicians were faster than nontrained physicians in dispatching the victims from scene to hospital [median (interquartile range) times, 67.5 (50.0-111.0) vs 145.0 (110.0-150.0) min, P<0.001]; trained treated and discharged more patients in the emergency department (32/38 vs 14/31, P<0.001) and performed better on command-and-control items (31/44 vs 17/44 for trained and nontrained players respectively, P<0.05). No differences were found as regards triage or prehospital treatment accuracy. CONCLUSION: Using the DSS in 2 comparable scenarios allowed us to identify differences in mass casualty responses trained and nontrained physicians. These results may reflect of the some specific objectives of disaster medicine training oriented to the organizational management of health crises rather than to the clinical management of injuries

Electromagnetic navigation bronchoscopy and rapid on site evaluation added to fluoroscopy-guided assisted bronchoscopy and rapid on site evaluation: improved yield in pulmonary nodules.

AIM: Electromagnetic navigation bronchoscopy (ENB) was reported to increase diagnostic yield in pulmonary nodules (PNs). The aim of this study was to assess if rapid on site evaluation (ROSE) associated with ENB could improve diagnostic accuracy in PNs after non-diagnostic fluoroscopy-guided bronchoscopy added to ROSE. METHODS: Forty patients with PNs suspected for lung cancer underwent to ENB + ROSE after non-diagnostic Fluoroscopy-guided Bronchoscopy + ROSE. Each lesion was studied with reference to size, location, presence of bronchus sign on CT. All lesions were sampled by needle and brush; if negative, by forceps and bronchoalveolar lavage. All patients were followed-up until achievement of definitive diagnosis. RESULTS: Twenty-nine out of 41 lesions (70.7%) had a definitive diagnosis. ENB sensitivity for malignancy was 76.5%, with higher rate in presence of bronchus sign on CT (86.2%) and in case of lesions located in the upper and middle lobes (87.5%). CONCLUSION: ENB is a useful tool in the evaluation of PNs. High diagnostic accuracy may be related to sampling (transbronchial needle aspiration), ROSE, location and presence of bronchus sign.

Hemodynamic changes associated with spinal and general anesthesia for hip fracture surgery in severe ASA III elderly population: a pilot trial.

BACKGROUND: Patients affected by hip fracture (HF) have high risk of perioperative complications. Despite regional anesthesia is widely used, hypotension is common and increases the risk of myocardial ischemia. The aim of this work was to study hemodynamic changes following spinal (SA) and general (GA) anesthesia in this selected population of patients. METHODS: Twenty patients over 70 years, ASA III, scheduled for HF repair were randomized to receive SA or general anesthesia GA. Hemodynamic responses to SA and GA were analyzed trough LiDCO™plus monitor (LiDCO Ltd., Cambridge, UK). RESULTS: SA provided a more stable hemodynamic profile. SA group received less interventions to keep mean arterial pressure (MAP) within limits. GA group had intraoperative cardiac index (CI), stroke volume index (SVI) and MAP significantly lower than baseline. Despite both groups experienced hypotension after the induction, MAP reduction in SA group was primarily due to systemic vascular resistance index (SVRI) decline, whereas hypotension in GA group was primarily due to a reduction in SVI and CI. The coefficient of variation (CV) was significantly higher in GA group for CI, SVI, MAP and heart rate (HR) within one hour analysis comparing to SA group. SA group had an higher CV for SVRI. CONCLUSION: SA in the elderly population with hip fracture provides a more stable hemodynamic profile requiring less intervention to keep MAP close to baseline value. Hypotension was common in SA and GA after induction and within intraoperative period. A larger randomized clinical study should be performed to confirm these preliminary data.

S(+)-ketamine for control of perioperative pain and prevention of post thoracotomy pain syndrome: a randomized, double-blind study.

BACKGROUND: Post-thoracotomy pain syndrome (PTPS) often complicates the long term outcome of patients; its appearance has been related to perioperative acute pain. The main goal of this study was to evaluate a possible role of S(+)-ketamine in the prevention of PTPS up to 6 months and secondarily its efficacy in the control of perioperative pain when added to thoracic epidural analgesia (TEA) and adjuvants. METHODS: Sixty-six patients underwent thoracotomy under general anesthesia. A thoracic epidural catheter was placed for levobupivacaine and sufentanil administration. Thirty-three patients received an i.v. infusion of S(+)-ketamine (Group S(+)K) for 60 hours and 33 patients received i.v. placebo (Group PLAC). Pain was evaluated by Numeric Rating Scale (NRS) during the whole study. All patients had supplementary doses of analgesics, as needed, to have NRS targeted to a value of ≤3 in the 1st and <3 in the following days. Neuropathic Pain Symptom Inventory (NPSI) was evaluated at 1, 3 and 6 months. RESULTS: All patients had NRS ≤3 in the early postoperative period and NPSI was less or equal to 1 in the follow-up control for each group with no significant difference at three (P=0.67, OR 0.8 [IC95% 0.3-2.2]) and at six months (P=0.23, OR 1.9 [0.7-5.4]). Incidence of moderate PTPS was 24.6% at 3 and 21.1% at six months while severe PTPS was 6.6% at 3 and 1.8% at six months. No difference was detected in NRS and NPSI at 3 and 6 months between groups. CONCLUSION: S(+)-ketamine had no effects in respect to placebo in the prevention of PTPS at 3 and 6 months but had a significant role in maintaining a NRS≤3 in the early postoperative period. A tight control of perioperative pain seems to be associated with a low incidence of moderate and severe PTPS.

NAVA ventilation.

Neurally adjusted ventilatory assist (NAVA) is a form of partial ventilatory support wherein the machine applies positive pressure to the airway opening throughout each inspiration. In contrast to all other modes of ventilation, which adopt conventional pneumatic signals (flow, volume, and airway pressure) to drive and control the ventilator operation, NAVA utilizes the electrical activity of the diaphragm, which is the best available signal to estimate the respiratory drive and to trigger on and cycle off the delivery of the mechanical assistance and regulate its amount and intra-breath profile. With NAVA, therefore, the patient retains full control of the breathing pattern. Following the first description of NAVA ten years ago, various studies have been performed on this mode of ventilation, either in animal models, healthy subjects, or in adult and pediatric critically ill patients. These investigations indicate that this novel mode is efficient in unloading the respiratory muscles and maintaining adequate gas exchange while improving the patient-ventilator interaction. This review article aims to summarize the results of the studies published to date on this topic.

Thoracic epidural analgesia in post-thoracotomy patients: comparison of three different concentrations of levobupivacaine and sufentanil.

BACKGROUND: Relative effects of dosage, volume and concentration of local anaesthetics used for postoperative thoracic epidural analgesia are still under debate. In this randomized, prospective, double-blinded study, we evaluated the incidence of side-effects such as changes in arterial pressure, postoperative nausea, vomiting, and pruritus in patients admitted for thoracic surgery during continuous thoracic epidural infusion using levobupivacaine and sufentanil mixture in three different volumes. METHODS: We studied 150 patients who underwent thoracotomy with a thoracic epidural catheter placed between T4 and T7. The patients were randomized into three groups which received 10 mg h(-1) of levobupivacaine at three different concentrations (0.5%, 0.25%, and 0.15%), in combination with sufentanil at 2.6 microg h(-1). Haemodynamic effects, pruritus, nausea, vomiting, sensory and motor block, pain score, additional analgesic requirement, sedation, and patient satisfaction were registered immediately after the surgical operation and on the first, second, and third postoperative days. RESULTS: We did not detect any differences in the incidence of side-effects such as changes in arterial pressure, and also postoperative nausea, vomiting, and pruritus. The three groups were also similar with regard to patient characteristics, sensory and motor block, pain score, analgesic rescue dose, sedation, and patient satisfaction. CONCLUSIONS: The same dose of a mixture of levobupivacaine and sufentanil administered in three different volumes and concentrations during continuous thoracic epidural infusion for thoracotomy provided an equal incidence of adverse haemodynamic effects, nausea, vomiting, or pruritus.

Accuracy of computer simulation to predict patient flow during mass-casualty incidents.

INTRODUCTION: Although most hospitals have an emergency department disaster plan, most never have been implemented in a true disaster or been tested objectively. Computer simulation may be a useful tool to predict emergency department patient flow during a disaster. PURPOSE: The aim of this study was to compare the accuracy of a computer simulation in predicting emergency department patient flow during a mass-casualty incident with that of a real-time, virtual, live exercise. METHODS: History, physical examination findings, and laboratory results for 136 simulated patients were extracted from the disastermed.ca patient database as used as input into a computer simulation designed to represent the emergency department at the University of Alberta Hospital. The computer simulation was developed using a commercially available simulation software platform (2005, SimProcess, CACI Products, San Diego CA). Patient flow parameters were compared to a previous virtual, live exercise using the same data set. RESULTS: Although results between the computer simulation and the live exercise appear similar, they differ statistically with respect to many patient benchmarks. There was a marked difference between the triage codes assigned during the live exercise and those from the patient database; however, this alone did not account for the differences between the patient groups. It is likely that novel approaches to patient care developed by the live exercise group, which are difficult to model by computer software, contributed to differences between the groups. Computer simulation was useful, however, in predicting how small changes to emergency department structure, such as adding staff or patient care areas, can influence patient flow. CONCLUSIONS: Computer simulation is helpful in defining the effects of changes to a hospital disaster plan. However, it cannot fully replace participant exercises. Rather, computer simulation and live exercises are complementary, and both may be useful for disaster plan evaluation.

Simulation of a hospital disaster plan: a virtual, live exercise.

INTRODUCTION: Currently, there is no widely available method to evaluate an emergency department disaster plan. Creation of a standardized patient database and the use of a virtual, live exercise may lead to a standardized and reproducible method that can be used to evaluate a disaster plan. PURPOSE: A virtual, live exercise was designed with the primary objective of evaluating a hospital's emergency department disaster plan. Education and training of participants was a secondary goal. METHODS: A database (disastermed.ca) of histories, physical examination findings, and laboratory results for 136 simulated patients was created using information derived from actual patient encounters. The patient database was used to perform a virtual, live exercise using a training version of the emergency department's information system software. RESULTS: Several solutions to increase patient flow were demonstrated during the exercise. Conducting the exercise helped identify several faults in the hospital disaster plan, including outlining the important rate-limiting step. In addition, a significant degree of under-triage was demonstrated. Estimates of multiple markers of patient flow were identified and compared to Canadian guidelines. Most participants reported that the exercise was a valuable learning experience. CONCLUSIONS: A virtual, live exercise using the disastermed.ca patient database was an inexpensive method to evaluate the emergency department disaster plan. This included discovery of new approaches to managing patients, delineating the rate-limiting steps, and evaluating triage accuracy. Use of the patient timestamps has potential as a standardized international benchmark of hospital disaster plan efficacy. Participant satisfaction was high.

Prognosis of isolated acute post-traumatic subdural haematoma.

AIM: Acute subdural haematoma (ASDH) is seldom an isolated lesion and it is difficult to understand the mechanisms which determine the poor prognosis associated to this occurrence. Aim of this study was estimating the outcome of patients with ASDH without any companion lesions by analysing the haematoma volume, its thickness and midline shift. METHODS: Twenty-eight severely head injured patients (Glasgow Coma Scale, GCS =/<8) with isolated unilateral ASDH admitted in intensive care unit (ICU) were retrospectively studied. The haematoma thickness, the midline shift, the ASDH volume were obtained from the first emergency computerized tomography (CT) scan and analysed by a computer assisted programme (Osiris). Patients' outcome was scored according to the Glasgow Outcome Scale (GOS) 6 months after the event. According to their GOS the patients were further divided in 2 groups (favourable outcome: GOS 4-5, poor outcome: GOS 1-2-3). RESULTS: Midline shift ranged from 0 to 19.2 mm; we found a larger midline shift in those patients who died and in patients with severe disability or vegetative state 6 months after the trauma. CONCLUSION: The presence and size of midline shift was a more important determinant of outcome than ASDH volume or its thickness.