Emergently planned exclusive hub-and-spoke system in the epicenter of the first wave of COVID-19 pandemic in Italy: the experience of the largest COVID-19-free ICU hub for time-dependent diseases.

BACKGROUND: Lombardy was the epicenter in Italy of the first wave of COVID-19 pandemic. To face the contagion growth, from March 8 to May 8, 2020, a regional law redesigned the hub-and-spoke system for time-dependent diseases to better allocate resources for COVID-19 patients. METHODS: We report the reorganization of the major hospital in Lombardy during COVID-19 pandemic, including the rearrangement of its ICU beds to face COVID-19 pandemic and fulfill its role as extended hub for time-dependent diseases while preserving transplant activity. To highlight the impact of the emergently planned hub-and-spoke system, all patients admitted to a COVID-19-free ICU hub for trauma, neurosurgical emergencies and stroke during the two-month period were retrospectively collected and compared to 2019 cohort. Regional data on organ procurement was retrieved. Observed-to-expected (OE) in-ICU mortality ratios were computed to test the impact of the pandemic on patients affected by time-dependent diseases. RESULTS: Dynamic changes in ICU resource allocation occurred according to local COVID-19 epidemiology/trends of patients referred for time-dependent diseases. The absolute increase of admissions for trauma, neurosurgical emergencies and stroke was roughly two-fold. Patients referred to the hub were older and characterized by more severe conditions. An increase in crude mortality was observed, though OE ratios for in-ICU mortality were not statistically different when comparing 2020 vs. 2019. An increase in local organ procurement was observed, limiting the debacle of regional transplant activity. CONCLUSIONS: We described the effects of a regional emergently planned hub-and-spoke system for time-dependent diseases settled in the epicenter of COVID-19 pandemic in Italy.

Randomized, multicenter trial of lateral Trendelenburg versus semirecumbent body position for the prevention of ventilator-associated pneumonia.

PURPOSE: The lateral Trendelenburg position (LTP) may hinder the primary pathophysiologic mechanism of ventilator-associated pneumonia (VAP). We investigated whether placing patients in the LTP would reduce the incidence of VAP in comparison with the semirecumbent position (SRP). METHODS: This was a randomized, multicenter, controlled study in invasively ventilated critically ill patients. Two preplanned interim analyses were performed. Patients were randomized to be placed in the LTP or the SRP. The primary outcome, assessed by intention-to-treat analysis, was incidence of microbiologically confirmed VAP. Major secondary outcomes included mortality, duration of mechanical ventilation, and intensive care unit length of stay. RESULTS: At the second interim analysis, the trial was stopped because of low incidence of VAP, lack of benefit in secondary outcomes, and occurrence of adverse events. A total of 194 patients in the LTP group and 201 in the SRP group were included in the final intention-to-treat analysis. The incidence of microbiologically confirmed VAP was 0.5% (1/194) and 4.0% (8/201) in LTP and SRP patients, respectively (relative risk 0.13, 95% CI 0.02-1.03, p = 0.04). The 28-day mortality was 30.9% (60/194) and 26.4% (53/201) in LTP and SRP patients, respectively (relative risk 1.17, 95% CI 0.86-1.60, p = 0.32). Likewise, no differences were found in other secondary outcomes. Six serious adverse events were described in LTP patients (p = 0.01 vs. SRP). CONCLUSIONS: The LTP slightly decreased the incidence of microbiologically confirmed VAP. Nevertheless, given the early termination of the trial, the low incidence of VAP, and the adverse events associated with the LTP, the study failed to prove any significant benefit. Further clinical investigation is strongly warranted; however, at this time, the LTP cannot be recommended as a VAP preventive measure. CLINICALTRIALS. GOV IDENTIFIER: NCT01138540.

Índice de agua pulmonar extravascular y fracaso de la ventilación no invasiva. ¿Es la última frontera para una correcta decisión? / Extravascular lung water index as a predictive factor for non-invasive ventilation failure. The last chance to make the right decision?

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Chronic pain treatment and scrambler therapy: a multicenter retrospective analysis.

BACKGROUND AND AIM: Scrambler Therapy is a novel neuromodulation that works by electrocutaneous stimulation in a non-invasive manner through C fibers surface receptors. It substitutes pain information with synthetic "non pain" information. The primary aim of this study was to analyze the efficacy and safety of Scrambler Therapy after ten sessions related to different usage conditions and different learning curves that occur in a multi-center study. METHODS: 201 patients have been treated with Scrambler Therapy. All the patients were suffering from chronic pain with a mean pain NRS of 7.41 (SD 2.06) before treatment. Main causes of chronic pain: post herpetic neuralgia 18.40 %, chronic low back pain (LBP) 37.31%, polyneuropathy 10.94%, and peripheral neuropathy 14.42 %. The remaining 18.93 % included chronic pain due to other causes. RESULTS: The difference between pre-treatment NRS 7.41 (SD 2.06) and post-treatment 1.60 (SD 2.22) was statistically significant (P< 0.0001). The mean number of sessions per patient was 10, but 39 had complete absence of pain sooner and used fewer sessions. Only 7 patients stopped treatment due to lack of results, and 2 for personal reasons not ascribable to the treatment. Stimulation pain score of 0 during treatment, and not just pain reduction, predicts long term effectiveness, so this must be pursued by optimizing electrode positioning and correct fine-tuning of stimulation intensity. CONCLUSION: Scrambler Therapy is an efficient and safe alternative for several different types of refractory chronic neuropathic pain, with a very rare possibility of adverse events.

Paravertebral block for patients older than 80 years in one day surgery elective mastectomy.

Paravertebral block (PVB) has been proposed as an alternative to General anaesthesia (GA) for breast surgery. It provides good operative anaesthesia, good pain control with little adverse effects. Six women older than 80 year were selected. All patients were post-operatively interviewed about the presence of pain, nausea and vomiting. All patients declared absence of pain and nausea and that they were satisfied with the procedure. The use of PVB allows elderly patients to undergo ambulatory surgery for the treatment of breast cancer with satisfaction. This technique allows a short recovery and adequate postoperative pain relief with reduced hospital costs.

Decompressive craniectomies, facts and fiction: a retrospective analysis of 526 cases.

BACKGROUND: The aim of this article was to review the clinical practice of "bone flap decompression" in Regional Neurosurgical Units with no particular protocol in use. METHODS: From January 2005 to December 2008, a retrospective and multicentre study was conducted on patients who were treated with decompressive craniectomy (DC) in seven departments of neurosurgery in Italy. This study included patients with traumatic brain injury, stroke, aneurysmal subarachnoid haemorrhage and cerebral arteriovenous malformations. Data were retrieved from individual medical records. RESULTS: We identified 526 patients with DC. Age was the most significant predictor factor of survival, together with pupil reactivity, time of decompression and size of the bone flap. The effect of age in predicting survival was so important that in patients over 65 years old we did not find any other significant factor related to survival. In younger patients, the survival rate was much better with a large bone flap (p = 0.01). Unfortunately, 57% of patients were decompressed with a bone flap of less than 12 cm in diameter. This was probably due to the association in 80% of cases between haematoma evacuation and decompression. CONCLUSIONS: The current practice in many centres is different from published papers. Decompression is common over the age of 65 years, is associated with haematoma evacuation and often the bone flaps are inadequate in terms of size.

Traumatic brain injury after frontal crashes: relationship with body mass index.

BACKGROUND: Previous studies had demonstrated that injury severity and risk of death after motor-vehicle crashes are related to human body characteristics. The purpose of this study was to clarify the relationship between body mass index (BMI) and head injury severity in front seat passengers after a frontal collision. METHODS: Data from all front seat occupants with at least one injury, older than 16 years old involved in a frontal collision from 1993 to 2005 were retrieved from the National Automotive Sampling System (NASS) database. Patient and collision characteristics were analyzed. Two cohorts were defined according to BMI < or > or =30 kg/m2. RESULTS: A total of 6,977 patients were included in this study, 5,918 (85%) had complete data on weight and height. Patient's mean age was 37 +/- 18 years old, the median ISS was 6, interquartile range (IQR) 15, and 61% were men. The mortality rate was positively associated to the crash delta velocity (DV) (p < 0.0001). The use of restraint system reduced the risk of death (p = 0.01). There was a significant increase in fatal outcome (p < 0.0001; RR 1.84 95% CI 1.61-2.1) and injury severity (ISS >25 p < 0.0001; RR 1.36 95% CI 1.19-1.54) in the obese cohort. Obese patients had higher chances of having a maximum head injury (Abbreviated Injury Score head = 6) than those not obese (p = 0.003; RR 1.97 95% CI 1.52-2.55). CONCLUSION: Obese passengers are more likely to suffer a more severe head trauma after a frontal collision. Further studies with computational models are needed to determine the precise role of BMI on brain injury-related biomechanical metrics.

Patients with moderate head injury: a prospective multicenter study of 315 patients.

OBJECTIVE: To analyze the risk factors of worst outcome associated with moderate head injury. METHODS: Data on patients with moderate head injury were collected prospectively in 11 Italian neurosurgical units over a period of 18 months. Patients older than 18 years with blunt head injury and at least one Glasgow Coma Scale (GCS) score between 9 and 13 were enrolled. The outcome was determined at 6 months using the Glasgow Outcome Scale. RESULTS: We analyzed 315 patients. Initial computed tomographic scans showed a diffuse injury type I or II in 63%, a mass lesion in 35%, and traumatic subarachnoid hemorrhage in 42% of the patients. The risk of progression toward a mass lesion was 23% when the admission computed tomographic scan showed diffuse injury type I or II. An emergency craniotomy was performed in 22% of the patients, delayed surgery was performed in 14%, and both were performed in 25%. A favorable outcome was obtained in 74% of the patients. When the GCS score was 9 or 10, the predictor of worst outcome was a motor GCS score of 4 or lower (odds ratio [OR], 8.08; 95% confidence interval [CI], 1.22-67.35; P = 0.008), but when the GCS score was 11 to 13, the factors associated with worst outcome were neuroworsening (OR, 3.43; 95% CI, 1.45-8.17; P = 0.002), seizures (OR, 7.94; 95% CI, 1.18-64.48; P = 0.02), and medical complications (OR, 4.24; 95% CI, 1.74-10.33; P = 0.0006). CONCLUSION: There is a high percentage of surgery and worsening on computed tomographic scans in patients with moderate head injury. Neuroworsening, seizures, and medical complications as outcome predictors were more strongly associated with a GCS score of 11 to 13, whereas a low motor GCS score was more outcome-related in patients with GCS scores of 9 and 10.

Xenon-CT and transcranial Doppler in poor-grade or complicated aneurysmatic subarachnoid hemorrhage patients undergoing aggressive management of intracranial hypertension.

OBJECTIVE: To evaluate whether elevated flow velocimetry values are associated with critically reduced cerebral blood flow values in deeply sedated patients with acute aneurysmatic subarachnoid hemorrhage and in whom the detection of clinical vasospasm is not feasible. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Neurosurgical and trauma patients in an intensive care unit in a regional hospital. PATIENTS AND PARTICIPANTS: Twenty-nine patients in the acute phase following subarachnoid hemorrhage who were sedated and ventilated for elevated intracranial pressure, transcranial Doppler vasospasm, or respiratory failure and were studied with at least a coupled xenon-CT/transcranial Doppler study. MEASUREMENTS AND RESULTS: Combined measurement and comparison of cerebral blood flow by means of xenon-CT and of mean velocity by means of transcranial Doppler in middle cerebral artery territories. The case mix studied was consistent with patients' predominantly poor grade and with a complicated course. The results suggest that in sedated patients flow velocity and measured cortical mixed cerebral blood flow are not correlated, and, more specifically, that flow velocities values above 120 or 160 cm/s and Lindegaard index above 3 are not associated with an ischemic regional cerebral blood flow. Conversely, as many as 55% of the xenon-CT studies were associated with hyperemia. CONCLUSIONS: In patients with elevated intracranial pressure, mean middle cerebral artery flow velocity or Lindegaard Index does not help to detect critical cerebral blood flow nor elevated cerebral blood flow.