Publications news

Setting positive end-expiratory pressure: using the pressure-volume curve

18

Dec 23

Have a look to this brand new review to improve your use of pressure-volume curves to set PEEP in ICU patients - on Current Opinion in Critical Care

In Pubmed https://pubmed.ncbi.nlm.nih.gov/38085871/

Setting positive end-expiratory pressure: using the pressure-volume curve

Francesco Mojoli^1 2, Marco Pozzi², Eric Arisi²

Abstract

Purpose of review: To discuss the role of pressure-volume curve (PV curve) in exploring elastic properties of the respiratory system and setting mechanical ventilator to reduce ventilator-induced lung injury. Recent findings: Nowadays, quasi-static PV curves and loops can be easily obtained and analyzed at the bedside without disconnection of the patient from the ventilator. It is shown that this tool can provide useful information to optimize ventilator setting. For example, PV curves can assess for patient's individual potential for lung recruitability and also evaluate the risk for lung injury of the ongoing mechanical ventilation setting. Summary: In conclusion, PV curve is an easily available bedside tool: its correct interpretation can be extremely valuable to enlighten potential for lung recruitability and select a high or low positive end-expiratory pressure (PEEP) strategy. Furthermore, recent studies have shown that PV curve can play a significant role in PEEP and driving pressure fine tuning: clinical studies are needed to prove whether this technique will improve outcome.

Multiorgan evaluation of perfusion and congestion using ultrasound in patients with shock

30

Sep 23

Eur Heart J Acute Cardiovasc Care. 2023 May 4;12(5):344-352. doi: 10.1093/ehjacc/zuad025. Guido Tavazzi, Rory Spiegel, Philippe Rola, Susanna Price, Francesco Corradi, Maxwell Hockstein

Abstract

There is increasing evidence on the role of ultrasound in the evaluation of multiorgan hypoperfusion and congestion in patients with cardiocirculatory shock both to identify the underlying pathophysiological mechanism and to drive and monitor the treatment. The cardiac and lung ultrasound is included as an integrated multiparametric approach to the very early phase of patients with haemodynamic instability/cardiogenic shock. Splanchnic ultrasound has been mainly applied in heart failure and predominant circulatory failure. Although poorly validated in the critically ill, many ultrasound parameters have a strong physiological background to support their use in the acute setting those that apply either for heart/lung and for splanchnic organ evaluation. This review summarizes the ultrasonographic parameters that have shown evidence in literature in the diagnostic/therapeutic pathway to define the congestion/perfusion profile of the organs that are involved in the pathophysiological cascade of cardiocirculatory shock.

How to unload the left ventricle during veno-arterial extracorporeal membrane oxygenation

20

Sep 23

Eur Heart J Cardiovasc Imaging. 2023 May 31;24(6):696-698. doi: 10.1093/ehjci/jead061. Free full text he re Guido Tavazzi, Carlos L Alviar, Costanza Natalia Julia Colombo, Valentino Dammassa, Susanna Price, Christophe Vandenbriele

The use of peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO) in patients with refractory cardiogenic shock (CS) has become increasingly common. Although bypassing and potentially supporting almost completely cardiac and respiratory function, this ECMO configuration leads to a rise in left ventricle (LV) afterload as a consequence of the increased retrograde pressure from the femoral/iliac artery to the ascending aorta. This may result in further worsening of ventricular function, from altering ventriculo/arterial coupling and from increasing left ventricular end-diastolic pressure (LVEDP) and left atrial pressure (LAP).

Recent studies have demonstrated that early LV unloading with additional percutaneous left ventricular assist devices (pLVAD) relieves ventricular distension and improves outcomes. However, the optimal unloading strategy (e.g. impella, intra-aortic balloon pump-IABP, transseptal cannulation) has not yet been defined.^3,4Additionally, the criteria for the indications, timing, and mode of LV unloading (pLVAD selection), are mostly based on pathophysiology and clinical experience, rather than on high-quality evidence-based from published data. No validated indices exist or cut-off values (e.g. chamber size quantification) as patients needed VA ECMO may have a wide range of underlying cardiac morpho-functional features (e.g. CS related to acute myocardial infarction in previously normal LV or related to acute decompensated heart failure with dilated cardiomyopathy).

We aim to describe a systematic ultrasound-guided approach, integrating imaging and pathophysiological information, to select the most appropriate unloading strategy in patients with CS undergoing peripheral VA ECMO. Only percutaneous approaches will be discussed.

Airway ultrasound to detect subglottic secretion above endotracheal tube cuff

10

Sep 23

Ultrasound J. 2023 May 6;15(1):23. doi: 10.1186/s13089-023-00318-5. Osman Adi, Chan Pei Fong, Roslanuddin Mohd Sallehuddin, Azma Haryaty Ahmad, Kok Meng Sum, Zulrushdi Md Yusof, Gabriele Via, Guido Tavazzi ABSTRACT Background: Subglottic secretion had been proven as one of the causes of microaspiration and increased risk of ventilator-associated pneumonia (VAP). The role of ultrasound to detect subglottic secretion has not yet been established. Purpose: The purpose of this study is to determine the sensitivity and specificity of upper airway ultrasound (US) in the detection of subglottic secretions as compared to computed tomography (CT) scanning. Material and methods: A prospective observational study was carried out in adult trauma patients requiring mechanical ventilation and cervical CT scan. All patients had an endotracheal tube cuff-pressure maintained between 20 and 30 cm H2O. Airway US was performed at the bedside immediately before the patient was transferred to the CT scan suite. The sensitivity, specificity, and positive/negative predictive values (PPV, NPV) of the upper airway US detection of subglottic secretions were then calculated and compared with CT findings. Results: Fifty participants were consecutively included. Subglottic secretions were detected in 31 patients using upper airway US. The sensitivity and specificity of upper airway US in detecting subglottic secretion were 96.7% and 90%, respectively (PPV 93.5%, NPV 94.7%). 18 (58%) patients with subglottic secretions developed VAP during their ICU stay (p = 0.01). The area under the receiver operating curve (AUROC) was 0.977 (95% CI 0.936-1.00). Conclusions: Upper airway US is a useful tool for detecting subglottic secretions with high sensitivity and specificity. Clinical implications: This study shows: 1. Upper airway US may aid in detecting subglottic secretions, which are linked to VAP. 2. Detecting subglottic secretions at the bedside aids in determining the best frequency of subglottic aspiration to clean the subglottic trachea. 3. Upper airway US may also aid in detecting the correct ETT position. Trial registration Clinicaltrials.gov. Free full text here

Dynamic NLR and PLR in Predicting COVID-19 Severity: A Retrospective Cohort Study

30

Aug 23

Infectious Diseases and Therapy volume 12, pages 1625–1640 (2023) Erika Asperges, Giuseppe Albi, Valentina Zuccaro, Margherita Sambo, Teresa C. Pieri, Matteo Calia, Marta Colaneri, Laura Maiocchi, Federica Melazzini, Angioletta Lasagna, Andrea Peri, Francesco Mojoli, Paolo Sacchi & Raffaele Bruno

Abstract

Introduction

The hyperinflammation phase of severe SARS-CoV-2 is characterised by complete blood count alterations. In this context, the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) can be used as prognostic factors. We studied NLR and PLR trends at different timepoints and computed optimal cutoffs to predict four outcomes: use of continuous positive airways pressure (CPAP), intensive care unit (ICU) admission, invasive ventilation and death.

Methods

We retrospectively included all adult patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia admitted from 23 January 2020 to 18 May 2021. Analyses included non-parametric tests to study the ability of NLR and PLR to distinguish the patients’ outcomes at each timepoint. Receiver operating characteristic (ROC) curves were built for NLR and PLR at each timepoint (minus discharge) to identify cutoffs to distinguish severe and non-severe disease. Their statistical significance was assessed with the chi-square test. Collection of data under the SMACORE database was approved with protocol number 20200046877.

Results

We included 2169 patients. NLR and PLR were higher in severe coronavirus disease 2019 (COVID-19). Both ratios were able to distinguish the outcomes at each timepoint. For NLR, the areas under the receiver operating characteristic curve (AUROC) ranged between 0.59 and 0.81, and for PLR between 0.53 and 0.67. From each ROC curve we computed an optimal cutoff value.

Conclusion

NLR and PLR cutoffs are able to distinguish severity grades and mortality at different timepoints during the course of disease, and, as such, they allow a tailored approach. Future prospects include validating our cutoffs in a prospective cohort and comparing their performance against other COVID-19 scores.

Open Access full text here

Multimodality imaging in cardiogenic shock: state-of-the art

20

Aug 23

Curr Opin Crit Care. 2023 Aug 1;29(4):381-391. doi: 10.1097/MCC.0000000000001068. Epub 2023 Jun 22. From Pubmed Guido Tavazzi, Francesco Corradi, Christophe Vandenbriele, Carlos L Alviar

Abstract

Purpose of review: There is emerging evidence on the role of the multimodality imaging in the setting of cardiogenic shock. The utility of different imaging modalities, along with their pitfalls and limitations, and their integration in a multiparametric approach are discussed in the current review. Recent findings: The evaluation of congestion and perfusion in patients with shock has allowed a better understanding of the underlying physiopathological mechanisms. Integration of echocardiography, using more physiological parameters, with lung ultrasound, as well as the Doppler evaluation of abdominal blood flow dynamics, has led to a better stratification in patinas with hemodynamic instability. Summary: Although validation of the integrated approaches and single parameters are needed, the physiopathological-driven approach using ultrasound in patients with cardiogenic shock on top of the clinical and biochemical evaluation, may aid to a quicker and more detailed evaluation of patient's phenotype.

Perioperative Renal Ultrasonography of Arterio-to-Venous Coupling Predicts Postoperative Complications after Major Laparoscopic Urologic Surgery

10

Aug 23

J. Clin. Med. 2023, 12(15), 5013; FREE FULL TEXT https://doi.org/10.3390/jcm12155013 Claudia Brusasco, Guido Tavazzi, Giada Cucciolini, Pierpaolo Di Nicolò, Adrian Wong, Antonia Di Domenico, Federico Germinale, Federico Dotta, Marco Micali, Federico Coccolini, Gregorio Santori, Federico Dazzi, Carlo Introini and Francesco Corradi

Abstract

Point-of-care ultrasonography (POCUS) with concomitant venous and arterial Doppler assessment enables clinicians to assess organ-specific blood supply. To date, no studies have investigated the usefulness of including a comprehensive perioperative POCUS assessment of patients undergoing major laparoscopic surgery. The primary aim of the present study was to evaluate whether the combined venous and arterial renal flow evaluation, measured at different time points of perioperative period, may represent a clinically useful non-invasive method to predict postoperative acute kidney injury (AKI) after major laparoscopic urologic surgery. The secondary outcome was represented by the development of any postoperative complication at day 7. We included 173 patients, subsequently divided for analysis depending on whether they did (n = 55) or did not (n = 118) develop postoperative AKI or any complications within the first 7 days. The main results of the present study were that: (1) the combination of arterial hypoperfusion and moderate-to-severe venous congestion inferred by POCUS were associated with worst outcomes (respectively, HR: 2.993, 95% CI: 1.522–5.884 and HR: 8.124, 95% CI: 3.542–18, p < 0.001); (2) high intra-operative abdominal pressure represents the only independent determinant of postoperative severe venous congestion (OR: 1.354, 95% CI: 1.017–1.804, p = 0.038); (3) the overall number of complications relies on the balance between arterial inflow and venous outflow in order to ensure the adequacy of peripheral perfusion; and (4) the overall reliability of splanchnic perfusion assessment by Doppler is high with a strong inter-rater reliability (ICC: 0.844, 95% CI: 0.792–0.844). The concomitant assessment of arterial and venous Doppler patterns predicts postoperative complications after major laparoscopic urologic surgery and may be considered a useful ultrasonographic biomarker to stratify vulnerable patients at risk for development of postoperative complications.

Inferior Vena Cava Ultrasonography for Volume Status Evaluation: An Intriguing Promise Never Fulfilled

6

Aug 23

J Clin Med. 2023 Mar; 12(6): 2217. Published online 2023 Mar 13. doi: 10.3390/jcm12062217 Free full text here Pierpaolo Di Nicolò, Guido Tavazzi, Luca Nannoni, Francesco Corradi

Abstract

The correct determination of volume status is a fundamental component of clinical evaluation as both hypovolaemia (with hypoperfusion) and hypervolaemia (with fluid overload) increase morbidity and mortality in critically ill patients. As inferior vena cava (IVC) accounts for two-thirds of systemic venous return, it has been proposed as a marker of volaemic status by indirect assessment of central venous pressure or fluid responsiveness. Although ultrasonographic evaluation of IVC is relatively easy to perform, correct interpretation of the results may not be that simple and multiple pitfalls hamper its wider application in the clinical setting. In the present review, the basic elements of the pathophysiology of IVC behaviour, potential applications and limitations of its evaluation are discussed.

The mental health toll of COVID-19: significant increase in admissions to ICU for voluntary self-inflicted injuries after the beginning of the pandemic

31

Jul 23

Int J Ment Health Syst. 2023 Jul 15;17(1):22. doi: 10.1186/s13033-023-00590-x. Silvia Mongodi, Giulia Salve, Marta Ravasi, Damiano Rizzi, Matteo Mangiagalli, Valeria Musella, Catherine Klersy, Luca Ansaloni, Francesco Mojoli

Abstract

Background: COVID-19 outbreak deeply impacted on mental health, with high rate of psychological distress in healthcare professionals, patients and general population. Current literature on trauma showed no increase in ICU admissions for deliberate self-inflicted injuries in the first weeks after the beginning of COVID-19. Objectives: We tested the hypothesis that self-inflicted injuries/harms of any method requiring ICU admission increased in the year following COVID-19 outbreak. Methods: Retrospective cohort single-center study comparing admissions to ICU the year before and the year after the pandemic start. All patients admitted to polyvalent ICUs-Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy from February 21st, 2019 to February 21st, 2020 (pre-COVID) and from February 22nd, 2020 to February 22nd, 2021 (post-COVID) were enrolled. Results: We enrolled 1038 pre-COVID and 854 post-COVID patients. In post-COVID, the incidence of self-inflicted injuries was 32/854 (3.8% [2.5-5.1]), higher than in pre-COVID (23/1038, 2.2%-p = 0.0014-relative increase 72.7%). The increase was more relevant when excluding COVID-19 patients (suicide attempts 32/697 (4.6% [3.0-6.2])-relative increase 109.1%; p < 0.0001). Both in pre-COVID and post-COVID, the most frequent harm mean was poisoning [15 (65.2%) vs. 25 (78.1%), p = 0.182] and the analysed population was younger than general ICU population (p = 0.0015 and < 0.0001, respectively). The distribution of admissions for self-inflicted injuries was homogeneous in pre-COVID along the year. In post-COVID, no admissions were registered during the lockdown; an increase was observed in summer with pandemic curve at minimal levels. Conclusions: An increase in ICU admissions for self-inflicted injuries/harms was observed in the year following COVID-19 outbreak.

Free full text here

Tidal lung hysteresis to interpret PEEP-induced changes in compliance in ARDS patients

15

Jun 23

Lung hysteresis in a decremental PEEP trial helps identifying tidal recruitment and optimise the setting of PEEP in a personalised mechanical ventilation.

Full test on Critical Care here

Abstract

Background

In ARDS, the PEEP level associated with the best respiratory system compliance is often selected; however, intra-tidal recruitment can increase compliance, falsely suggesting improvement in baseline mechanics. Tidal lung hysteresis increases with intra-tidal recruitment and can help interpreting changes in compliance. This study aims to assess tidal recruitment in ARDS patients and to test a combined approach, based on tidal hysteresis and compliance, to interpret decremental PEEP trials.

Methods

A decremental PEEP trial was performed in 38 COVID-19 moderate to severe ARDS patients. At each step, we performed a low-flow inflation-deflation manoeuvre between PEEP and a constant plateau pressure, to measure tidal hysteresis and compliance.

Results

According to changes of tidal hysteresis, three typical patterns were observed: 10 (26%) patients showed consistently high tidal-recruitment, 12 (32%) consistently low tidal-recruitment and 16 (42%) displayed a biphasic pattern moving from low to high tidal-recruitment below a certain PEEP. Compliance increased after 82% of PEEP step decreases and this was associated to a large increase of tidal hysteresis in 44% of cases. Agreement between best compliance and combined approaches was accordingly poor (K = 0.024). The combined approach suggested to increase PEEP in high tidal-recruiters, mainly to keep PEEP constant in biphasic pattern and to decrease PEEP in low tidal-recruiters. PEEP based on the combined approach was associated with lower tidal hysteresis (92.7 ± 20.9 vs. 204.7 ± 110.0 mL; p < 0.001) and lower dissipated energy per breath (0.1 ± 0.1 vs. 0.4 ± 0.2 J; p < 0.001) compared to the best compliance approach. Tidal hysteresis ≥ 100 mL was highly predictive of tidal recruitment at next PEEP step reduction (AUC 0.97; p < 0.001).

Conclusions

Assessment of tidal hysteresis improves the interpretation of decremental PEEP trials and may help limiting tidal recruitment and energy dissipated into the respiratory system during mechanical ventilation of ARDS patients.

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