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Introduction: Early coagulation support (ECS) includes prompt infusion of tranexamic acid, fibrinogen concentrate, and packed red blood cells for initial resuscitation of major trauma patients. The aim of this study was to determine the effects, in terms of blood product consumption, length of stay, and in-hospital mortality, of the ECS protocol, compared to the massive transfusion protocol (MTP) in the treatment of major trauma patients.Patients and Methods: A retrospective analysis was conducted using the registry data of two Italian trauma centres. Adult major trauma patients with, or at risk of, active bleeding who were managed according to the MTP during the years 2011-2012, or the ECS protocol during the years 2013-2014 and were considered at risk of multiple transfusions, were enrolled. The primary endpoint was to determine whether the ECS protocol reduces the use of blood products in the acute management of trauma patients. Secondary endpoints were the outcome measures of length of stay in ICU, length of stay in hospital, and mortality at 24-hours and 28-days after hospital admission.Results: Among the 518 major trauma patients admitted to the trauma centres during the study period, 235 patients (118 in the pre-ECS period and 117 in the ECS period) matched one of the inclusion criteria and were enrolled in the study. Compared with the pre-ECS period, the ECS period showed a reduction in the average consumption of packed red blood cells (-1.87 units, 95% confidence interval [CI], -2.40, -1.34), platelets (-1.28 units; 95% CI, -1.64, -0.91), and fresh frozen plasma (-1.69; 95% CI, -2.14, -1.25) in the first 24-hours. Furthermore, during the ECS period, we recorded a 10-day reduction in the hospital length of stay (-10 days, 95% CI, -11.6, -8.4) and a non-significant 28-day mortality increase.Conclusions: The ECS protocol was effective in reducing blood product consumption compared to the MTP and confirmed the importance of early fibrinogen administration as a strategy of rapid coagulation. This novel approach may be adopted in real-life management of major trauma patients. [ABSTRACT FROM AUTHOR]

Background: The 30‐day hospital re‐admission rate is a quality measure of hospital care to monitor the efficiency of the healthcare system. The hospital re‐admission of acute stroke (AS) patients is often associated with higher mortality rates, greater levels of disability and increased healthcare costs. The aim of our study was to identify predictors of unplanned 30‐day hospital re‐admissions after discharge of AS patients and define an early re‐admission risk score (RRS). Methods: This observational, retrospective study was performed on AS patients who were discharged between 2014 and 2019. Early re‐admission predictors were identified by machine learning models. The performances of these models were assessed by receiver operating characteristic curve analysis. Results: Of 7599 patients with AS, 3699 patients met the inclusion criteria, and 304 patients (8.22%) were re‐admitted within 30 days from discharge. After identifying the predictors of early re‐admission by logistic regression analysis, RRS was obtained and consisted of seven variables: hemoglobin level, atrial fibrillation, brain hemorrhage, discharge home, chronic obstructive pulmonary disease, one and more than one hospitalization in the previous year. The cohort of patients was then stratified into three risk categories: low (RRS = 0–1), medium (RRS = 2–3) and high (RRS >3) with re‐admission rates of 5%, 8% and 14%, respectively. Conclusions: The identification of risk factors for early re‐admission after AS and the elaboration of a score to stratify at discharge time the risk of re‐admission can provide a tool for clinicians to plan a personalized follow‐up and contain healthcare costs. [ABSTRACT FROM AUTHOR]

Background: Long-term outcomes of patients treated with helmet noninvasive ventilation (NIV) are unknown: safety concerns regarding the risk of patient self-inflicted lung injury and delayed intubation exist when NIV is applied in hypoxemic patients. We assessed the 6-month outcome of patients who received helmet NIV or high-flow nasal oxygen for COVID-19 hypoxemic respiratory failure. Methods: In this prespecified analysis of a randomized trial of helmet NIV versus high-flow nasal oxygen (HENIVOT), clinical status, physical performance (6-min-walking-test and 30-s chair stand test), respiratory function and quality of life (EuroQoL five dimensions five levels questionnaire, EuroQoL VAS, SF36 and Post-Traumatic Stress Disorder Checklist for the DSM) were evaluated 6 months after the enrollment. Results: Among 80 patients who were alive, 71 (89%) completed the follow-up: 35 had received helmet NIV, 36 high-flow oxygen. There was no inter-group difference in any item concerning vital signs (N = 4), physical performance (N = 18), respiratory function (N = 27), quality of life (N = 21) and laboratory tests (N = 15). Arthralgia was significantly lower in the helmet group (16% vs. 55%, p = 0.002). Fifty-two percent of patients in helmet group vs. 63% of patients in high-flow group had diffusing capacity of the lungs for carbon monoxide < 80% of predicted (p = 0.44); 13% vs. 22% had forced vital capacity < 80% of predicted (p = 0.51). Both groups reported similar degree of pain (p = 0.81) and anxiety (p = 0.81) at the EQ-5D-5L test; the EQ-VAS score was similar in the two groups (p = 0.27). Compared to patients who successfully avoided invasive mechanical ventilation (54/71, 76%), intubated patients (17/71, 24%) had significantly worse pulmonary function (median diffusing capacity of the lungs for carbon monoxide 66% [Interquartile range: 47–77] of predicted vs. 80% [71–88], p = 0.005) and decreased quality of life (EQ-VAS: 70 [53–70] vs. 80 [70–83], p = 0.01). Conclusions: In patients with COVID-19 hypoxemic respiratory failure, treatment with helmet NIV or high-flow oxygen yielded similar quality of life and functional outcome at 6 months. The need for invasive mechanical ventilation was associated with worse outcomes. These data indicate that helmet NIV, as applied in the HENIVOT trial, can be safely used in hypoxemic patients. Trial registration Registered on clinicaltrials.gov NCT04502576 on August 6, 2020 [ABSTRACT FROM AUTHOR]

The article discusses a study which compared the usefulness of transcranial echography compared with computed tomography (CT) scan in patients with decompressive craniectomy. It concluded that echocardiography tomography may be a valid option to assess the size of acute hemorrhagic lesions, to measure midline structures and the width of lateral ventricles, and to visualize the tip of the ventricular catheter.

Importance: High-flow nasal oxygen is recommended as initial treatment for acute hypoxemic respiratory failure and is widely applied in patients with COVID-19.Objective: To assess whether helmet noninvasive ventilation can increase the days free of respiratory support in patients with COVID-19 compared with high-flow nasal oxygen alone.Design, Setting, and Participants: Multicenter randomized clinical trial in 4 intensive care units (ICUs) in Italy between October and December 2020, end of follow-up February 11, 2021, including 109 patients with COVID-19 and moderate to severe hypoxemic respiratory failure (ratio of partial pressure of arterial oxygen to fraction of inspired oxygen ≤200).Interventions: Participants were randomly assigned to receive continuous treatment with helmet noninvasive ventilation (positive end-expiratory pressure, 10-12 cm H2O; pressure support, 10-12 cm H2O) for at least 48 hours eventually followed by high-flow nasal oxygen (n = 54) or high-flow oxygen alone (60 L/min) (n = 55).Main Outcomes and Measures: The primary outcome was the number of days free of respiratory support within 28 days after enrollment. Secondary outcomes included the proportion of patients who required endotracheal intubation within 28 days from study enrollment, the number of days free of invasive mechanical ventilation at day 28, the number of days free of invasive mechanical ventilation at day 60, in-ICU mortality, in-hospital mortality, 28-day mortality, 60-day mortality, ICU length of stay, and hospital length of stay.Results: Among 110 patients who were randomized, 109 (99%) completed the trial (median age, 65 years [interquartile range {IQR}, 55-70]; 21 women [19%]). The median days free of respiratory support within 28 days after randomization were 20 (IQR, 0-25) in the helmet group and 18 (IQR, 0-22) in the high-flow nasal oxygen group, a difference that was not statistically significant (mean difference, 2 days [95% CI, -2 to 6]; P = .26). Of 9 prespecified secondary outcomes reported, 7 showed no significant difference. The rate of endotracheal intubation was significantly lower in the helmet group than in the high-flow nasal oxygen group (30% vs 51%; difference, -21% [95% CI, -38% to -3%]; P = .03). The median number of days free of invasive mechanical ventilation within 28 days was significantly higher in the helmet group than in the high-flow nasal oxygen group (28 [IQR, 13-28] vs 25 [IQR 4-28]; mean difference, 3 days [95% CI, 0-7]; P = .04). The rate of in-hospital mortality was 24% in the helmet group and 25% in the high-flow nasal oxygen group (absolute difference, -1% [95% CI, -17% to 15%]; P > .99).Conclusions and Relevance: Among patients with COVID-19 and moderate to severe hypoxemia, treatment with helmet noninvasive ventilation, compared with high-flow nasal oxygen, resulted in no significant difference in the number of days free of respiratory support within 28 days. Further research is warranted to determine effects on other outcomes, including the need for endotracheal intubation.Trial Registration: ClinicalTrials.gov Identifier: NCT04502576. [ABSTRACT FROM AUTHOR]

Aims: To identify the most accurate early warning score (EWS) for predicting an adverse outcome in COVID-19 patients admitted to the emergency department (ED).Methods: In adult consecutive patients admitted (March 1-April 15, 2020) to the ED of a major referral centre for COVID-19, we retrospectively calculated NEWS, NEWS2, NEWS-C, MEWS, qSOFA, and REMS from physiological variables measured on arrival. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and the area under the receiver operating characteristic (AUROC) curve of each EWS for predicting admission to the intensive care unit (ICU) and death at 48 h and 7 days were calculated.Results: We included 334 patients (119 [35.6%] females, median age 66 [54-78] years). At 7 days, the rates of ICU admission and death were 56/334 (17%) and 26/334 (7.8%), respectively. NEWS was the most accurate predictor of ICU admission within 7 days (AUROC 0.783 [95% CI, 0.735-0.826]; sensitivity 71.4 [57.8-82.7]%; NPV 93.1 [89.8-95.3]%), while REMS was the most accurate predictor of death within 7 days (AUROC 0.823 [0.778-0.863]; sensitivity 96.1 [80.4-99.9]%; NPV 99.4[96.2-99.9]%). Similar results were observed for ICU admission and death at 48 h. NEWS and REMS were as accurate as the triage system used in our ED. MEWS and qSOFA had the lowest overall accuracy for both outcomes.Conclusion: In our single-centre cohort of COVID-19 patients, NEWS and REMS measured on ED arrival were the most sensitive predictors of 7-day ICU admission or death. EWS could be useful to identify patients with low risk of clinical deterioration. [ABSTRACT FROM AUTHOR]

• In moderate-to-severe COVID-19-induced ARDS, PEEP and prone position improve oxygenation by reducing pulmonary shunt fraction. • The effect of PEEP on these parameters is not only dependent on alveolar recruitment, but also caused by significant reduction in cardiac output. • Changes in cardiac output contribute to the effects of PEEP but not of prone position, which is the most effective intervention to improve oxygenation with no hemodynamic side effects. • In COVID-19 patients, hemodynamic response to ventilatory interventions follows classical ARDS physiology. Use of high positive end-expiratory pressure (PEEP) and prone positioning is common in patients with COVID-19-induced acute respiratory failure. Few data clarify the hemodynamic effects of these interventions in this specific condition. We performed a physiologic study to assess the hemodynamic effects of PEEP and prone position during COVID-19 respiratory failure. Nine adult patients mechanically ventilated due to COVID-19 infection and fulfilling moderate-to-severe ARDS criteria were studied. Respiratory mechanics, gas exchange, cardiac output, oxygen consumption, systemic and pulmonary pressures were recorded through pulmonary arterial catheterization at PEEP of 15 and 5 cmH 2 O, and after prone positioning. Recruitability was assessed through the recruitment-to-inflation ratio. High PEEP improved PaO 2 /FiO 2 ratio in all patients (p = 0.004), and significantly decreased pulmonary shunt fraction (p = 0.012), regardless of lung recruitability. PEEP-induced increases in PaO2/FiO2 changes were strictly correlated with shunt fraction reduction (rho=-0.82, p = 0.01). From low to high PEEP, cardiac output decreased by 18 % (p = 0.05) and central venous pressure increased by 17 % (p = 0.015). As compared to supine position with low PEEP, prone positioning significantly decreased pulmonary shunt fraction (p = 0.03), increased PaO 2 /FiO 2 (p = 0.03) and mixed venous oxygen saturation (p = 0.016), without affecting cardiac output. PaO 2 /FiO 2 was improved by prone position also when compared to high PEEP (p = 0.03). In patients with moderate-to-severe ARDS due to COVID-19, PEEP and prone position improve arterial oxygenation. Changes in cardiac output contribute to the effects of PEEP but not of prone position, which appears the most effective intervention to improve oxygenation with no hemodynamic side effects. [ABSTRACT FROM AUTHOR]

Abstract: We investigated the haemodynamic response to the mental stress induced by being evaluated as a team leader in simulated advanced life support (ALS) scenarios. Methods:: Healthcare providers participating as candidates to ALS courses were monitored while acting as team leaders in a cardiac arrest testing scenario (CASTest). Heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured before, during and after the CASTest. The correlation between the haemodynamic responses and sex, age, body mass index (BMI) and marks on course multiple choice questions (MCQs) were studied using multiple linear regression. Results:: Eighty-eight subjects (46 women, 42 men, mean age 34.9±6.8 years) were enrolled. Mean HR, SBP and DBP increased significantly during the CASTest and reached a peak after a phase of the scenario which included an unsuccessful defibrillation. Ten minutes after the CASTest, HR, SBP and DBP were still significantly higher than their respective baseline values. A significant positive correlation was found between the DBP and SBP response during the scenario and the BMI, and between the DBP response and the candidates’ age. The haemodynamic stress response was neither correlated with the candidates’ marks in the course MCQ nor with their instructor potential (IP). Conclusion:: During the testing scenario the ALS candidates showed a significant haemodynamic response to mental stress, which depended mainly on their age and BMI rather than on their knowledge and skills. [Copyright &y& Elsevier]

Objective: To compare the outcomes and the short- and long-term complications of percutaneous translaryngeal tracheostomy (TLT) and surgical tracheostomy (ST).Design: Prospective, randomized clinical trial with 1-yr double-blind follow-up.Setting: A general intensive care unit of a university hospital.Patients: A total of 139 consecutive critically ill patients who required a tracheostomy between February 2001 and June 2002 were randomly assigned to receive either ST or TLT.Results: TLTs were performed more rapidly than STs (17 +/- 10 mins vs. 22 +/- 6 mins, p = .003). Early complications were rare in both groups. Major postoperative bleeding was less frequent with TLT (0 [0%] vs. 6 [8%], p = .03). Only one case of bleeding (in the ST group) required blood transfusion. Immediately after tracheostomy, six TLT patients (9%) and six patients (8%) in the ST group (p = .56) developed culture-confirmed bacteremia with microbes previously isolated from the pharynx or trachea. Group rates for stomal infections and pneumonia after tracheostomy were similar. At 1-yr follow-up, the overall survival rate was 27%, and 14 patients (45% of survivors) still had open tracheostomies. Both groups rated their quality of life as moderately to severely compromised, and the deterioration was strictly related to the presence of tracheostomy. One TLT and two ST survivors (p = .53) had clinical signs of tracheal stenosis, and bronchoscopy revealed narrowing of >50%.Conclusions: Compared with ST, the main advantages of TLT are that it is more rapid and associated with less postoperative bleeding. Infectious complications, particularly postoperative bacteremia, and long-term effects (physical and emotional) are similar with the two procedures. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness of traditional and online teaching methods for educating anesthesiology residents in the principles and practice of difficult airway management.Design: Prospective, randomized, controlled trial.Setting: University hospital.Participants: Two randomly selected groups, each containing 28 physicians enrolled from among residents in Anesthesiology and Intensive Care Medicine in Italy.Interventions: Residents in Group 1 took a traditional 5-h course on the principles and practice of airway management, which included lectures, slide projection, and dummy demonstrations. The same material was presented to Group 2 in an exclusively online format, which could be individually accessed for a period of 36 h. In the online course, student-instructor interaction was provided through threaded discussion forums during three 30-min real-time question-and-answer sessions.Measurements and Results: Differences in baseline and post-course scores on written tests and practical skills tests were measured. Knowledge gains in Group 2 were slightly, but not significantly, greater compared with Group 1 both in written (P=0.228) and practical skills (P=0.376) tests. Semi-quantitative ratings of learner satisfaction were significantly higher in the online group (P=0.014). Almost all online students (93%) were logged in for at least 45 of the 90 min of real-time question-and-answer sessions. The four instructors spent an average of 144+/-10 min preparing answers and interacting with online students.Conclusions: Online teaching formats may be a valid alternative for teaching residents the principles and practice of difficult airway management. Interaction with instructors seems to be an important element, but it may require substantial time commitments by instructors. [ABSTRACT FROM AUTHOR]

Objective: To conduct a blinded evaluation of the predictors of weaning from mechanical ventilation.Design: A prospective clinical study.Setting: A 23-bed general intensive care unit.Patients: Ninety-three non-selected patients, ventilated for more than 48 h.Methods: The study had two steps: at first, patients' data were used to select the cut-off value for weaning predictors (the minimal false classification). The cut-off value for each index was prospectively assessed in a group of 52 patients. The predictive performance of these indexes was evaluated by calculating the area under the receiver operating characteristic curve. In the prospective-validation set we used Bayes' theorem to assess the probability of each test in predicting weaning. The physicians making decisions about the weaning process were always unaware of the predictive values. Weaning was considered successful if spontaneous breathing was sustained for more than 48 h after extubation.Measurements and Results: During the first 2 min after discontinuation of mechanical ventilation the following tests were performed: vital capacity, tidal volume, airway occlusion pressure (P(0.1)), minute ventilation, respiratory rate, maximal inspiratory pressure (MIP), respiratory frequency to tidal volume (f/V(T)), P(0.1)/MIP and P(0.1) x f/V(T). The areas under the curve showed that the tests had not the ability to distinguish between successful and unsuccessful weaning.Conclusion: Our results show that all the evaluated indexes are poor predictors of weaning outcome in a general intensive care unit population. [ABSTRACT FROM AUTHOR]

Families of ICU patients have a pressing need for information: they find themselves suddenly in a complex technical environment often because of a life-threatening illness of a loved one. Some evidence suggests that specific communication tools (like websites or brochures) could improve the experience of ICU families. Randomized, multicenter, stepped wedge trial for large-scale assessment of the effectiveness of a multitasking intervention to improve communication with families of critically ill patients. Main outcome: correct understanding of the prognosis. Secondary outcomes: correct understanding of medical treatments, prevalence of anxiety, depression and post-traumatic stress symptoms in the first ICU week. Prevalence of PTSD 6 months from ICU discharge. Empathy and burnout among ICU staff. Prevalence of refusals for tissues/organ donation, and medical claims. 2100 ICU relatives of critically ill patients. The intervention employs specific tools especially designed to raise the correctness of information and to improve the quality of communication: a website presenting the ICU world and justifying the relatives' emotions, with a webpage specifically dedicated to each participating ICU; a standard brochure; eight posters for the families' waiting room and a signboard for the ICU door. The study plans to assess these materials in up to 300 Italian ICUs that will participate, according to a five waves program, each one with randomized starting order. This way the effect of the intervention will be evaluated simultaneously. This is an educational study , aiming to spread good medical practices, while also verifying their real effectiveness in a large number of ICUs. Trial registration number: NCT03438175. [ABSTRACT FROM AUTHOR]