Pressure ulcers after prone positioning in patients undergoing extracorporeal membrane oxygenation: A cross-sectional study.

BACKGROUND: The combination of prone positioning and extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome (ARDS) is recognized as safe but its use has been limited due to potential complications. AIM: To report the prevalence of pressure ulcers and other complications due to prone positioning in adult patients receiving veno-venous ECMO. STUDY DESIGN: This cross-sectional study was conducted in a tertiary level intensive care unit (ICU) in Milan (Italy), between January 2015 and December 2019. The study population was critically ill adult patients undergoing veno-venous ECMO. Statistical association between pressure ulcers and the type of body positioning (prone versus supine) was explored fitting a logistic model. RESULTS: In the study period, 114 patients were treated with veno-venous ECMO and 62 (54.4%) patients were placed prone for a total of 130 prone position cycles. ECMO cannulation was performed via femoro-femoral configuration in the majority of patients (82.4%, 94/114). Pressure ulcers developed in 57.0% of patients (95%CI: 44.0%-72.6%), most often arising on the face and the chin (37.1%, 23/62), particularly in those placed prone. The main reason of prone positioning interruption was the decrease of ECMO blood flow (8.1%, 5/62). The fitted model showed no association between body position during ECMO and occurrence of pressure ulcers (OR 1.3, 95%CI: 0.5-3.6, p = .532). CONCLUSIONS: Facial pressure ulcers were the most frequent complications of prone positioning. Nurses should plan and implement evidence-based care to prevent such pressure injuries in patients undergoing ECMO. RELEVANCE TO CLINICAL PRACTICE: The combination of prone positioning and ECMO shows few life-threating complications. This manoeuvre during ECMO is feasible and safe when performed by experienced ICU staff.

Thematic analysis of intensive care unit diaries kept by staff: insights for caring.

OBJECTIVE: To explore recurrent themes in diaries kept by intensive care unit (ICU) staff during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: Qualitative study. SETTING: Two ICUs in a tertiary level hospital (Milan, Italy) from January to December 2021. METHODS: ICU staff members wrote a digital diary while caring for adult patients hospitalized in the intensive care unit for >48 hours. A thematic analysis was performed. FINDINGS: Diary entries described what happened and expressed emotions. Thematic analysis of 518 entries gleaned from 48 diaries identified four themes (plus ten subthemes): Presenting (Places and people; Diary project), Intensive Care Unit Stay (Clinical events; What the patient does; Patient support), Outside the Hospital (Family and topical events; The weather), Feelings and Thoughts (Encouragement and wishes; Farewell; Considerations). CONCLUSION: The themes were similar to published findings. They offer insight into care in an intensive care unit during a pandemic, with scarce resources and no family visitors permitted, reflecting on the patient as a person and on daily care. The staff wrote farewell entries to dying patients even though no one would read them. IMPLICATIONS FOR CLINICAL PRACTICE: The implementation of digital diaries kept by intensive care unit staff is feasible even during the COVID-19 pandemic. Diaries kept by staff can provide a tool to humanize critical care. Staff can improve their work by reflecting on diary records.

Accidental removal of devices in intensive care unit: An eight-year observational study.

BACKGROUND: In the intensive care unit, invasive devices can be accidentally removed by the patient or by the operators, increasing workload, staff stress level and hospitalisation costs. OBJECTIVE: to know the incidence of accidental removal of devices in critical patients, to identify their cause, when they occur and if they are repositioned. METHODS: Retrospective observational study carried out in an academic, tertiary-level critical care department composed of three intensive care units. All adult patients recovered between 2011 and 2018 were enrolled. We calculated rates per 1000 device-years. RESULTS: In the study period 10514 patients (194372 device-days) were admitted to the intensive care units and the number of reported accidental removal of devices was 451, corresponding to a rate of 2.3 episodes per 1000 device-days (95% confidence interval: 2.1-2-5). The overall rates of accidental removals were as follows: gastric tubes 10.2 (n = 270), intracranial devices 3.9 (n = 9), endotracheal tubes 2.4 (n = 27), central venous catheters and arterial catheters 1.5 (n = 92), peripheral intravenous catheters 1.2 (n = 25), surgical drains 0.5 (n = 15), urinary catheters 0.4 (n = 11), Extra Corporeal Membrane Oxygenation cannulas 0.4 (n = 1), tracheostomy cannulas 0.1 (n = 1). CONCLUSION: Compared to the literature, this study shows fewer incidents of accidental removal of devices. The number of accidental removals could be an indicator of the quality and safety of the care.

Ablation treatment of primary and secondary liver tumors under contrast-enhanced ultrasound guidance in field practice of interventional ultrasound centers. A multicenter study.

The present retrospective study was aimed at characterizing the clinical impact of contrast-enhanced ultrasound (CEUS) as a guidance technique for ablation of primary and secondary liver tumors at six interventional ultrasound centers. 148 patients (103M/45F, median age 74 yrs.) with 151 liver target lesions (median size 15 mm, 86.7% Hepatocellular Carcinomas) in whom CEUS guidance was used for Percutaneous Ethanol Injection (35.2%), Radiofrequency (46.3%) and Microwave (18.5%) were selected during the period 2008-2016. CEUS-guided ablations represented 7.3% (range 2.5%-13.8%) of 2015 ablative sessions performed at the participating centers. Indications to CEUS-guided ablation were: improvement of conspicuity of the target (28.5%), a target lesion undetectable on B-mode ultrasound (29.8%), detection of viable areas in nodules with either incomplete ablation or local tumor progression (41.7%). Overall, complete radiological ablation was obtained in 113/151 tumors (74.8%), with heat-based techniques (RF and MW) achieving higher rate of successful ablation (86.7%) than PEI (51%). Neither deaths nor major complications occurred after ablations. CEUS guidance demonstrates improved visibility and effectiveness in aiding ablation procedures that are otherwise technically difficult using only B-Mode US guidance.

Biopsy of Liver Target Lesions under Contrast-Enhanced Ultrasound Guidance - A Multi-Center Study.

PURPOSE: To retrospectively characterize the prevalence and impact of contrast-enhanced ultrasound (CEUS) as a guidance technique for the biopsy of liver target lesions (LTLs) at six interventional ultrasound centers. MATERIALS AND METHODS: The six participating centers retrospectively selected all patients in whom biopsy needles were positioned in LTLs during CEUS. The prevalence of CEUS-guided biopsies at each center between 2005 and 2016, contrast agent consumption, procedure indications, diagnostic yield and complications were assessed. Informed consent was obtained for all patients. RESULTS: CEUS-guided biopsy of LTLs was carried out in 103 patients (68 M/35 F, median age: 69 yrs) with 103 liver target lesions (median size: 20 mm) using cutting needles (18 - 20 g) in 94 cases (91.2 %). CEUS-guided biopsy represented 2.6 % (range: 0.8 - 7.7 %) of 3818 biopsies on LTLs carried out at the participating centers. Indications to CEUS-guided biopsy were: a target lesion not visible on non-enhanced US (27.2 %), improvement of conspicuity of the target (33 %), choice of non-necrotic area inside the target (39.8 %). 26 patients (25.2 %) had a previously non-diagnostic cyto-histological exam. The diagnostic accuracy of the technique was 99 %. No major complications followed infusion of contrast agent or biopsy performance. CONCLUSION: The indications for CEUS-guided biopsy for LTLs are limited, but CEUS can be useful in challenging clinical scenarios, e. g. poorly visualized or invisible lesions or sampling of non-necrotic areas in the target lesions. There is also a potential advantage in using CEUS to guide repeat biopsies after unsuccessful sampling performed using the standard ultrasound technique.

Single hepatocellular carcinoma smaller than 2 cm: are ethanol injection and radiofrequency ablation equally effective?

BACKGROUND/AIM: The impact of radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI) on survival in patients with small hepatocellular carcinoma (HCC) is unclear. We compared their efficacy in cirrhotics with single HCC ≤2 cm. PATIENTS AND METHODS: Two hundred forty-four cirrhotics with single HCC ≤2 cm treated with PEI (108 cases) or RFA (136 cases) were enrolled in the study. Eighty-one patients in each group were selected for propensity score matching analysis. RESULTS: The five-year survival was not significantly different (64.7% in PEI and 72.9% in RFA group) but the 5-year recurrence (73.3% in PEI and 49% in RFA group, p=0.023) and local tumor progression (49% in PEI and 30.1% in RFA group, p=0.018) were higher in the PEI group. CONCLUSION: PEI and RFA are equally effective in treating HCCs smaller than 2 cm in terms of 5-year survival, despite higher cumulative and local recurrence rates, in patients treated with PEI.

Long-term effectiveness of radiofrequency ablation for solitary small hepatocellular carcinoma: a retrospective analysis of 363 patients.

BACKGROUND: Radiofrequency Ablation is the most widely performed percutaneous treatment for Hepatocellular Carcinoma. This multicentre study was aimed at assessing the complication, overall survival and disease-free survival rates in cirrhotic patients with single Hepatocellular Carcinoma nodule ≤3 cm undergoing Radiofrequency Ablation. METHODS: Data of 365 patients (59% males; mean age 67 ± 8 years), Child-Pugh A/B, with single Hepatocellular Carcinoma nodule ≤3 cm (tumours >2-3 cm = 127/236), showing complete necrosis after Radiofrequency Ablation between 1998 and 2010 in 7 Italian Centers were retrospectively reviewed. Complication, overall survival and disease-free survival rates were analyzed as main clinical end-points. RESULTS: Major complications were observed in 8 patients (2.2%) and minor complications in 23 patients (6.3%). The 3-, and 5-year overall survival rates were 80% and 64%. One hundred and seven patients (29.5%) died, being 41 deaths (38.3%) Hepatocellular Carcinoma-related. At multivariate analysis only age (p = 0.04; OR 2.29), ascites (p < 0.001; OR 3.74) and Child-Pugh class ≥B8 (p = 0.003; OR 2.42) were confirmed as independent predictors for overall survival. The disease-free survival rates at 3- and 5-year were 50%, and 41.8%. CONCLUSIONS: Radiofrequency Ablation is an effective and safe tool for the treatment of single Hepatocellular Carcinoma ≤3 cm providing excellent 5-year overall survival and disease-free survival rates. Patient's age and liver status appeared as main determinants of outcome.

Which clinical and sonographic parameters may be useful to discriminate NASH from steatosis?

BACKGROUND: The natural history of nonalcoholic steatohepatitis (NASH) includes the passage through steatosis. GOAL: To retrospectively evaluate the usefulness of sonographic parameters compared to histological diagnosis when differentiating steatosis from NASH. STUDY: This retrospective study reviewed records of patients with steatosis from databases of our Departments, selecting only those who had been diagnosed by sonography and liver biopsy [64 males (63.82%); 30 females (36.18%)]. RESULTS: Attenuation of the echo amplitude (P<0.05; odds ratio (OR): 3.43; confidence interval (CI): 1.02-11.57), focal fat sparing (P<0.05; OR: 3; CI: 1.02-11.88) and splenic diameter (P<0.05; OR: 1.66; CI: 1.04-3.26) were independent predictors of NASH. A significantly higher association of attenuation of the echo amplitude, enlarged splenic diameter, and presence of focal fat sparing was observed in NASH patients (P<0.01). CONCLUSIONS: It is very difficult to build a predictive system to distinguish NASH from steatosis based on sonographic scores. However, it is already possible to differentiate NASH from steatosis by combining 3 simple sonographic parameters: attenuation of the echo amplitude, enlarged splenic diameter, and presence of focal fat sparing.

Referrals for bowel ultrasound in clinical practice: a survey in 12 nationwide centres in Italy.

BACKGROUND: The value of ultrasound (US) in assessing gastrointestinal diseases is well documented, but its demand in clinical practice is unknown. This survey evaluated the demand for bowel US in Italy. METHODS: Twelve sonographers of the Gastroenterology Section of the Italian Society of Ultrasound participated in a 1-month survey; they compiled a questionnaire assessing total number of patients referred for abdominal US and for gastrointestinal tract US, type of referring physician, indications and results of examinations. RESULTS: The survey included 2424 examinations, 586 of which (24%) investigated the gastrointestinal tract: 280 for signs or symptoms and 268 for follow-up of pre-existing gastrointestinal diseases. Referring physicians were mainly gastroenterologists (78%) and general practitioners (13%). Organic lesions were found or suspected in 292 examinations. CONCLUSIONS: Bowel US is used in Italy in routine practice, mainly by gastroenterologists and general practitioners, both for follow-up of pre-existing diseases and for gastrointestinal complaints.

Liver schistosomiasis: an unexpected finding in hepatitis B virus-related chronic hepatitis.

CASE REPORT: We report the unusual case of an African patient who underwent a liver biopsy for a chronic HBV-related hepatitis, whose histological sample also unexpectedly revealed elements diagnostic for schistosomiasis. The patient was only mildly symptomatic for the Schistosoma infestation; stool examination confirmed the presence of parasitic eggs. Hepatitis B virus (HBV)-schistosomiasis co-infection is particularly rare in Western countries. Only the identification of some pathological elements atypical for HBV infection by means of step sections in the liver biopsy sample allowed us to disclose the unsuspected diagnosis. CONCLUSIONS: Since migratory flows have increased, the number of foreign people being referred to our hospitals has increased. Patients coming from areas endemic for infectious diseases that are absent in Western countries must be carefully evaluated, taking into account possible unexpected co-infections, including in the setting of pathological studies of liver biopsies.

Fine needle biopsy of focal liver lesions: the hepatologist's point of view.

Guided biopsy of hepatocellular carcinoma has been recently discussed again due to the progress of imaging techniques and the risk of malignant seeding after the procedure. Ultrasound is probably still the most accurate imaging modality for early detection of nodules arising on cirrhosis, even when compared with more advanced imaging techniques. It can be easily employed in the surveillance of high-risk cirrhotic patients. Ultrasound-guided biopsy has very high sensitivity and almost absolute specificity, which allows the appropriate treatment to start after a positive diagnosis. It also allows correct diagnosis of lymphomatous nodules, the incidence of which is increased in hepatitis C virus-related cirrhosis. The risk of seeding appears limited according to the currently available epidemiological data; this should be considered against the risk of false-positive diagnosis of malignancy based on imaging studies alone. Ultrasound-guided biopsy is a valuable tool also for the diagnosis of small nodules (less than 10 mm in diameter). The best accuracy in the sampling of hepatocellular carcinoma nodules is obtained by combining smear cytology and microhistology. This can be achieved by a single biopsy with a fine cutting needle that furnishes pathologic material suitable for both examinations, reducing risks and costs.