Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (CPR) restores perfusion and oxygenation in a patient who does not have spontaneous circulation. The evidence with regard to the effect of extracorporeal CPR on survival with a favorable neurologic outcome in refractory out-of-hospital cardiac arrest is inconclusive. METHODS: In this multicenter, randomized, controlled trial conducted in the Netherlands, we assigned patients with an out-of-hospital cardiac arrest to receive extracorporeal CPR or conventional CPR (standard advanced cardiac life support). Eligible patients were between 18 and 70 years of age, had received bystander CPR, had an initial ventricular arrhythmia, and did not have a return of spontaneous circulation within 15 minutes after CPR had been initiated. The primary outcome was survival with a favorable neurologic outcome, defined as a Cerebral Performance Category score of 1 or 2 (range, 1 to 5, with higher scores indicating more severe disability) at 30 days. Analyses were performed on an intention-to-treat basis. RESULTS: Of the 160 patients who underwent randomization, 70 were assigned to receive extracorporeal CPR and 64 to receive conventional CPR; 26 patients who did not meet the inclusion criteria at hospital admission were excluded. At 30 days, 14 patients (20%) in the extracorporeal-CPR group were alive with a favorable neurologic outcome, as compared with 10 patients (16%) in the conventional-CPR group (odds ratio, 1.4; 95% confidence interval, 0.5 to 3.5; P = 0.52). The number of serious adverse events per patient was similar in the two groups. CONCLUSIONS: In patients with refractory out-of-hospital cardiac arrest, extracorporeal CPR and conventional CPR had similar effects on survival with a favorable neurologic outcome. (Funded by the Netherlands Organization for Health Research and Development and Maquet Cardiopulmonary [Getinge]; INCEPTION ClinicalTrials.gov number, NCT03101787.).

The Impact of Thoracic Ultrasound on Clinical Management of Critically Ill Patients (UltraMan): An International Prospective Observational Study.

OBJECTIVES: To investigate the impact of thoracic ultrasound (TUS) examinations on clinical management in adult ICU patients. DESIGN: A prospective international observational study. SETTING: Four centers in The Netherlands and Italy. PATIENTS: Adult ICU patients (> 18 yr) that received a clinically indicated lung ultrasound examination. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinicians performing TUS completed a pre- and post-examination case report form. Patient characteristics, TUS, and resulting clinical effects were recorded. First, change of management, defined as a TUS-induced change in clinical impression leading to a change in treatment plan, was reported. Second, execution of intended management changes within 8 hours was verified. Third, change in fluid balance after 8 hours was calculated. A total of 725 TUS performed by 111 operators across 534 patients (mean age 63 ± 15.0, 70% male) were included. Almost half of TUS caused a change in clinical impression, which resulted in change of management in 39% of cases. The remainder of TUS confirmed the clinical impression, while a minority (4%) did not contribute. Eighty-nine percent of management changes indicated by TUS were executed within 8 hours. TUS examinations that led to a change in fluid management also led to distinct and appropriate changes in patient's fluid balance. CONCLUSIONS: In this international observational study in adult ICU patients, use of TUS had a major impact on clinical management. These results provide grounds for future randomized controlled trials to determine if TUS-induced changes in decision-making also lead to improved health outcomes.

Recovery of skeletal muscle strength and physical function in a patient with (post) COVID-19 requiring extra-corporeal membrane oxygenation.

BACKGROUND: The ongoing coronavirus-19 disease (COVID-19) has taught us that early mobilization is essential for functional recovery during and after prolonged intensive care unit (ICU) stay. This especially applies for patients receiving a challenging combination of prolonged invasive treatments such as mechanical ventilation (MV) and extra-corporeal membrane oxygenation (ECMO). This case report describes the recovery of skeletal muscle strength and physical function in a patient (post) COVID-19 during ICU stay. CASE DESCRIPTION: A 54 year old female patient was diagnosed with COVID-19 pneumonia, and ultimately needed ICU treatment with MV and ECMO for 69 days during which she received physiotherapy treatment. OUTCOMES: The patient recovered from intensive care acquired muscle weakness (ICUAW) at day 53, resulting in the ability to walk at day 62. She was discharged from the ICU after 69 days with the ability to walk 20 meters with support of one person and a mobility aid. No evident adverse events were noted during or after physiotherapy sessions. DISCUSSION: Early mobilization is feasible and safe in a patient (post) COVID-19 with prolonged ECMO treatment and facilitates functional recovery during ICU stay. This single case observation should be handled with caution and needs further validation.

Favourable outcome after prolonged veno-venous extracorporeal membrane oxygenation (V-V ECMO) support for Pneumocystis jirovecii pneumonia in a renal transplant recipient.

A 27-year-old man, with a history of renal transplantation, presented with acute kidney failure and Pneumocystis jirovecii pneumonia. The patient developed severe acute respiratory failure and required support by veno-venous extracorporeal membrane oxygenation for a total of 59 days. During this period, the patient had extremely low tidal volumes using a lung protective ventilation strategy and intermittent prone positioning was used to optimise oxygenation. There was full recovery of pulmonary and partial recovery of renal function.

Lung ultrasound and computed tomography to monitor COVID-19 pneumonia in critically ill patients: a two-center prospective cohort study.

BACKGROUND: Lung ultrasound can adequately monitor disease severity in pneumonia and acute respiratory distress syndrome. We hypothesize lung ultrasound can adequately monitor COVID-19 pneumonia in critically ill patients. METHODS: Adult patients with COVID-19 pneumonia admitted to the intensive care unit of two academic hospitals who underwent a 12-zone lung ultrasound and a chest CT examination were included. Baseline characteristics, and outcomes including composite endpoint death or ICU stay > 30 days were recorded. Lung ultrasound and CT images were quantified as a lung ultrasound score involvement index (LUSI) and CT severity involvement index (CTSI). Primary outcome was the correlation, agreement, and concordance between LUSI and CTSI. Secondary outcome was the association of LUSI and CTSI with the composite endpoints. RESULTS: We included 55 ultrasound examinations in 34 patients, which were 88% were male, with a mean age of 63 years and mean P/F ratio of 151. The correlation between LUSI and CTSI was strong (r = 0.795), with an overall 15% bias, and limits of agreement ranging - 40 to 9.7. Concordance between changes in sequentially measured LUSI and CTSI was 81%. In the univariate model, high involvement on LUSI and CTSI were associated with a composite endpoint. In the multivariate model, LUSI was the only remaining independent predictor. CONCLUSIONS: Lung ultrasound can be used as an alternative for chest CT in monitoring COVID-19 pneumonia in critically ill patients as it can quantify pulmonary involvement, register changes over the course of the disease, and predict death or ICU stay > 30 days. TRIAL REGISTRATION: NTR, NL8584. Registered 01 May 2020-retrospectively registered, https://www.trialregister.nl/trial/8584.

Lung ultrasound findings in patients with novel SARS-CoV-2.

BACKGROUND: Over 2 million people worldwide have been infected with severe acute respiratory distress syndrome-coronavirus-2 (SARS CoV-2). Lung ultrasound has been proposed to diagnose and monitor it, despite the fact that little is known about the ultrasound appearance due to the novelty of the illness. The aim of this manuscript is to characterise the lung ultrasonographic appearance of critically ill patients with SARS-CoV-2 pneumonia, with particular emphasis on its relationship with the time course of the illness and clinical parameters. METHODS: Adult patients from the intensive care unit of two academic hospitals who tested positive for SARS-CoV-2 were included. Images were analysed using internationally recognised techniques which included assessment of the pleura, number of B-lines, pathology in the PLAPS (posterolateral alveolar and/or pleural syndrome) point, bedside lung ultrasound in emergency profiles, and the lung ultrasound score. The primary outcomes were frequencies, percentages and differences in lung ultrasound findings overall and between short (≤14 days) and long (>14 days) durations of symptoms and their correlation with clinical parameters. RESULTS: In this pilot observational study, 61 patients were included with 76 examinations available for analysis. 26% of patients had no anterior lung abnormalities, while the most prevalent pathological ultrasound findings were thickening of the pleura (42%), ≥3 B-lines per view (38%) and presence of PLAPS (74%). Patients with "long" duration of symptoms presented more frequently with a thickened and irregular pleura (32 (21%) versus 11 (9%)), C-profile (18 (47%) versus 8 (25%)) and pleural effusion (14 (19%) versus 3 (5%)), compared to patients with short duration of symptoms. Lung ultrasound findings did not correlate with arterial oxygen tension/inspiratory oxygen fraction ratio, fluid balance or dynamic compliance. CONCLUSION: SARS-CoV-2 results in significant, but not specific, ultrasound changes, with decreased lung sliding, thickening of the pleura and a B-profile being the most commonly observed. With time, a thickened and irregular pleura, C-profile and pleural effusion become more common findings. When screening patients, a comprehensive ultrasound protocol might be necessary.

Percutaneous Decannulation of Femoral Venoarterial ECMO Cannulas Using MANTA Vascular Closure Device.

Extracorporeal membrane oxygenation (ECMO) has been increasingly used in the treatment of refractory cardiac arrest and postarrest cardiogenic shock. We propose a technique for percutaneous decannulation of femoral venoarterial ECMO cannulas by using the MANTA vascular closure device, designed to close large-bore arteriotomies. This technique significantly simplifies the decannulation and might diminish the potential complications caused by the standard surgical removal.

Aesthetic Plastic Surgery Checklist: A Safety Tool.

INTRODUCTION: About one in ten patients experiences iatrogenic events, and more than half of these occur in the perioperative environment. The objective of this study was to develop a complete and functional checklist for aesthetic plastic surgery and test it in patients who would undergo elective plastic surgeries. METHODS: Patient data were collected from a general hospital and the particular clinic between October 2013 and October 2015, through history, physical examination, diagnosis, laboratory tests, pre-, during, and postoperatively, and complications. An expanded safety checklist was developed and optimized for aesthetic plastic surgery based on the model presented by the WHO in 2009 with reference to the information related to the prevention of more frequent complications in this specialty. RESULTS: The tool was applied to 486 patients, of whom 430 (88 %) were women and 56 (12 %) were men. The most frequently performed procedure was liposuction with 30 % of cases, and the most widely used type of anesthesia (39 %) was local anesthesia + sedation. The greater adherence of professionals to the checklist was the group of residents (98 %). The observed complications were seromas (7 %), other complications unrelated to the wound (3 %), and hematoma (0.2 %) in only one patient who underwent facelift. CONCLUSION: The use of the checklist in addition to allowing data collection and the identification of potential risks promoted favorable changes in the attitudes of some professionals and generated interest in patient safety and teamwork. LEVEL OF EVIDENCE IV: This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Flap and abdominal wall washing and debridement using dressings to prevent seromas and hematomas in abdominoplasty / Lavagem e desbridamento do retalho e da parede abdominal com compressas como prevenção de seromas e hematomas em abdominoplastia

Seroma formation remains a common complication of abdominoplasty. The use of drain, flap fixation points, and fibrin glue has been described to reduce the incidence of seroma formation. The authors present herein an easyto- reproduce technique to decrease the risk of bleeding and eliminate the devitalized tissue caused by the detachment. The proposed strategy consists of washing and debridement, which was conducted with mechanical friction using moist flap and abdominal wall dressings.

A formação de seroma após uma abdominoplastia continua sendo uma complicação frequente. O uso de dreno, os pontos de fixação do retalho e o uso da cola de fibrina foram descritos com a finalidade de diminuir a sua incidência. Os autores apresentam uma técnica de fácil reprodução para reduzir o risco de sangramento, bem como para eliminar o tecido desvitalizado decorrente do descolamento. A tática proposta constitui-se de lavagem e desbridamento por meio da fricção mecânica com compressas umedecidas do retalho e da parede abdominal.

Caracterização e fatores de risco para óbito até o dia +100 pós transplante autólogo de células tronco hematopoéticas

Transplante autólogo de células progenitoras hematopoéticas (TaCPH) é parte importante no tratamento de várias doenças onco-hematológicas, mas a despeito de melhorias no tratamento de suporte, a mortalidade relacionada a esse procedimento ainda é uma limitação ao seu sucesso. Neste estudo, identificamos fatores associados ao óbito até o dia +100 em pacientes submetidos a TaCPH de uma única instituição. Pacientes que evoluíram para óbito até o D+ 100 foram comparados com pacientes vivos quanto às características clinicas e terapêuticas das fases de mobilização, condicionamento e fase precoce pós-transplante. Entre 1994 e 2002 foram realizados 169 TaCPH. As principais doenças de base foram mieloma múltiplo (39%), doença de Hodgkin (28%) e linfoma não-Hodgkin (22,5%). Óbito ocorreu em 12 casos (7%). Performance status baixo (p=0,01), uso de corticosteróides (p=0,005), protocolo de condicionamento CBVP Vancouver (0,03), complicações gastrintestinais (p=0,002), pulmonares (p<0,001) ou renais (p<0,001), duração de febre (p=0,02), e número de concentrados de hemácias (p=0,009) e de plaquetas (p=0,002) transfundidas foram associadas a óbito em análise univariada. Em análise multivariada os fatores prognósticos identificados foram complicações pulmonares e renais (razão de chance rOR] 16; IC [intervalo de confiança] 95% 1,6-153 e OR 12; IC 95% 1,04-144, respectivamente)., e performance status baixo (OR 1,07; IC 95% 1,003-1,075).A identificação de fatores prognósticos pode ajudar no desenvolvimento de estratégias para reduzir a TRM

Autologous hematopoietic stem celI transplantation (ASCT) is an important therapeutic modality for various hematologic malignancies, but transplant-related mortality still remains one of the major drawbacks for its success. In this study, we identified factors associated with mortality until day + 100 in ASCT recipients. We reviewed the medical records of alI HSCT recipients from a single institution between 1994 and 2002. Patients who died were compared with those who survived regarding baseline characteristics, treatment and complications during the early post-transplant period. The under1ying diseases among 169 HSCT recipients were multiple mye10ma (39%), Hodgkin's disease (28%) and non-Hodgkin's lymphoma (22.5%). Twelve patients (7%) died. Univariate predictors of death were poor performance status (p=0.01), use of corticosteroids (p=0.005), conditioning regimen with CBVP Vancouver (0.03), gastrointestinal (p=0.002), lung (p<0.001) or renal complications (p<0.001), longer duration of fever (p=0.02), and number of red blood celIs (p=0.009) and platelet transfusions (p=0.002). By multivariate analysis, lung complications (odds ratio [aR] 16,95% CI [confidence interval] 1.6 - 153), renal complications (aR 12,95% CI 1.04144) and poor performance status (aR 1.07, 95% CI 1.003 - 1.075) were associated with increased death rate. The identification of prognostic factors may help in defining strategies aimed at reducing the mortality associated with ASCT