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Background: Post-traumatic stress disorder (PTSD) and burnout are severe and frequent conditions among emergency healthcare workers exposed to repeated work-related traumatic experiences. The aim of the present study was to investigate PTSD, burnout and global functioning in a sample of emergency healthcare workers (HCWs) of a major university hospital in Italy, exploring possible correlations between the two constructs., Methods: The study sample included 137 medical and nursing Emergency Room and Intensive Care Unit staff members of a major University Hospital in Italy (Pisa), all assessed by means of the Trauma and Loss Spectrum - Self Report (TALS-SR), for post-traumatic stress spectrum, the Professional Quality of Life Scale - Revision IV (ProQOL R-IV), for burnout related to work activities, and the Work and Social Adjustment Scale (WSAS), for global functioning., Results: Forty-nine subjects reported a full (18, 14.3%) or partial (31, 24.6%) symptomatological DSM-5 PTSD. HCWs with PTSD reported significantly higher burnout scores and global functioning impairment compared to those without PTSD. Mean to good significant correlations emerged between the TALS-SR total and domains scores, the ProQOL subscales and the WSAS scores., Conclusions: This work, conducted before the COVID-19 pandemic, underlines a positive correlation between burnout and post-traumatic stress spectrum symptoms in emergency HCWs, showing the need for a deeper assessment of work-related post-traumatic stress symptoms in such population in order to improve the well-being and to prevent burnout.

Background: The aim of this study was to evaluate whether measurement of diaphragm thickness (DT) by ultrasonography may be a clinically useful noninvasive method for identifying patients at risk of adverse outcomes defined as need of invasive mechanical ventilation or death., Methods: We prospectively enrolled 77 patients with laboratory-confirmed COVID-19 infection admitted to our intermediate care unit in Pisa between March 5 and March 30, 2020, with follow-up until hospital discharge or death. Logistic regression was used identify variables potentially associated with adverse outcomes and those P<0.10 were entered into a multivariate logistic regression model. Cumulative probability for lack of adverse outcomes in patients with or without low baseline diaphragm muscle mass was calculated with the Kaplan-Meier product-limit estimator., Results: The main findings of this study are that: 1) patients who developed adverse outcomes had thinner diaphragm than those who did not (2.0 vs. 2.2 mm, P=0.001); and 2) DT and lymphocyte count were independent significant predictors of adverse outcomes, with end-expiratory DT being the strongest (ß=-708; OR=0.492; P=0.018)., Conclusions: Diaphragmatic ultrasound may be a valid tool to evaluate the risk of respiratory failure. Evaluating the need of mechanical ventilation treatment should be based not only on PaO2/FiO2, but on a more comprehensive assessment including DT because if the lungs become less compliant a thinner diaphragm, albeit free of intrinsic abnormality, may become exhausted, thus contributing to severe respiratory failure.

Background: The number of elderly patients undergoing major surgical interventions and then needing admission to intensive care unit (ICU) grows steadily. We investigated this issue in a cohort of 232,278 patients admitted in five years (2011-2015) to 163 Italian general ICUs., Methods: Surgical patients older than 75 registered in the GiViTI MargheritaPROSAFE project were analyzed. The impact on hospital mortality of important chronic conditions (severe COPD, NYHA class IV, dementia, end-stage renal disease, cirrhosis with portal hypertension) was investigated with two prognostic models developed yearly on patients staying in the ICU less or more than 24 hours., Results: 44,551 elderly patients (19.2%) underwent emergency (47.3%) or elective surgery (52.7%). At least one severe comorbidity was present in 14.6% of them, yielding a higher hospital mortality (32.4%, vs. 21.1% without severe comorbidity). In the models for patients staying in the ICU 24 hours or more, cirrhosis, NYHA class IV, and severe COPD were constant independent predictors of death (adjusted odds ratios [ORs] range 1.67-1.97, 1.54-1.91, and 1.34-1.50, respectively), while dementia was statistically significant in four out of five models (adjusted ORs 1.23-1.28). End-stage renal disease, instead, never resulted to be an independent prognostic factor. For patients staying in the ICU less than 24 hours, chronic comorbidities were only occasionally independent predictors of death., Conclusions: Our study confirms that elderly surgical patients represent a relevant part of all ICUs admissions. About one of seven bear at least one severe chronic comorbidity, that, excluding end-stage renal disease, are all strong independent predictors of hospital death.

Background: In patients with traumatic brain injury (TBI), ventilator-associated pneumonia (VAP) is considered a dangerous complication, prompting early aggressive antibiotic treatment and prophylaxis. While this approach increases the selection of multidrug-resistant bacteria (MDR), its clinical benefit has not been demonstrated., Methods: One-year incidence of VAP in severe TBI patients (ICU stay >48 hours, with either Glasgow Coma Scale ≤8 or receiving intracranial pressure monitoring, or having undergone emergency surgery) and the prevalence of MDR among those who eventually developed it, were compared in two Italian intensive care units (ICUs) adopting different antibiotic approaches. Antibiotic use was guideline-driven and aggressive in the Pisa-based unit (165 eligible patients), and very conservative and coupled with non-pharmacological prevention measures in Cesena (262 patients). Data were also compared with those of 208 Italian ICUs participating in the same infection surveillance program., Results: Patient case mix and general care were similar in the two units. Overall antibiotic pressure was higher in Pisa (58.9% vs. 26.1% of beds occupied by patients receiving antibiotics, P<0.0001), as was antibiotic prophylaxis in eligible patients (87.3% vs. 7.6%, P<0.0001; Italian ICUs, 69.2%) and empirical therapy in those who developed VAP (60.8% vs. 25.2%, P<0.0001; Italian ICUs, 51.6%). The incidence rate of VAP did not significantly differ (39.8 per 1000 days of mechanical ventilation in Pisa, 49.3 in Cesena, P=0.16), although it occurred earlier in Cesena (23.0% early VAP in Pisa vs. 61.2% in Cesena, P<0.0001). Mortality was higher in Pisa but Cesena transferred more patients to other hospitals, precluding comparison of the two rates. The prevalence of MDR was higher in Pisa (38.2% vs. 9.9%, P<0.0001; Italian ICUs, 30.2%)., Conclusions: Although not conclusive, these results call into question the prevalent aggressive use of antibiotics in TBI patients and urge the scientific community to produce better evidence for clinical recommendations.

Background: The aim of this study was to identify the risk factors for ventilator associated pneumonia (VAP) due to Klebsiella pneumoniae carbapenemase-producing K (KPC-Kp) development in ICU patients with documented rectal and tracheal colonization., Methods: We performed a retrospective, matched case-control study in a medical-surgical ICU (January 2011-December 2013) comparing 30 patients who developed KPC-Kp VAP during the ICU stay to 60 colonized patients not developing KPC-Kp VAP. Analysed risk factors included: age, sex, SAPS II and SOFA scores, comorbidities, type and length of antibiotic therapy, previous non KPC-Kp infections, time between admission to rectal and tracheal colonization., Results: Several risk factors were more frequent among patients who developed KPC-Kp pneumonia versus matched colonized controls: previous infection not related to KPC-Kp (P<0.001), duration of previous antibiotic therapy before (P<0.001) and after (P=0.002) KPC-Kp colonization. Amoxicillin/clavulanic acid prophylaxis was administered in 17% of VAP patients versus 73% of patients not developing VAP (P<0.001). Multivariate conditional logistic regression analysis identified several significant independent risk factors favoring KPC-Kp VAP in patients colonized at multiple sites: previous non KPC-Kp infections (OR: 2.046), duration of previous antibiotic therapy before (OR: 1.309) and after (OR: 1.122) KPC-Kp colonization; antibiotic therapy with amoxicillin/clavulanic acid prophylaxis (<48 hours) was associated with reduced risk of KPC-Kp VAP (OR: 0.987)., Conclusions: In rectal and tracheal KPC-Kp colonized patients, prolonged antibiotic therapy administered for non KPC-Kp infection predisposes patients to subsequent KPC-Kp VAP. Short prophylaxis of early pneumonia with amoxicillin/clavulanic acid, reducing the need for subsequent antibiotic use, may be associated with reduced risk for KPC-Kp VAP.

Aim: A continuous infection surveillance program was conducted by GiViTI throughout 2006 in Intensive Care Units (ICUs)., Methods: This was a prospective epidemiological study carried out in 125 Italian intensive care units. All patients have been included in the study. Aside from the detailed clinical information collected for all patients, in cases of infection upon ICU admission and for the first site-specific episode that occurred during the patient's stay, the following data were collected: severity upon admission, micro-organisms and their antibiotic resistance patterns, subsequent multiple episodes in the same site, origin of infections and maximum severity reached. The diagnostic criteria for all infections are explicitly stated., Results: A total of 34,472 patients entered the study. Infection upon admission was present in 12.6% of patients, with a high level of ICU and hospital mortality (29.4% and 38.7%, respectively). In 3148 patients one or more infections were reported as ICU-acquired with an overall incidence of 9.1% and an ICU and hospital mortality of 27.2% and 35.1%, respectively. Out of the device-related infections, ventilator-associated pneumonia was the most frequently diagnosed (8.9/1000 days on ventilator). Catheter-related blood stream infection was reported with a low incidence (1.9/1000 central venous catheter days). Nearly 20% of more than 5000 isolated microorganisms were classified as multi-drug resistant, with methicillin-resistant Staphylococcus aureus as the most frequently reported bug., Conclusions: The ad hoc expanded GiViTI software "Margherita2" allows continuous infection surveillance in Italian ICUs, annually providing an extensive and updated database. Interventions to improve infection prevention and patient safety should be tailored to accommodate these data.

Aim: The aim of this study was to investigate the hypothesis that periodical sampling of the tracheo-bronchial tree in the absence of clinical suspicion of pneumonia is useful to identify bacteria responsible for subsequent late ventilator associated pneumonia (VAP). This was a retrospective observational human study carried out in two medical-surgical intensive care units of two different hospitals. From January 1999 to December 2000, 559 patients, who received invasive respiratory support for more than 48 hours, were screened., Methods: Tracheal aspiration (TA) was performed once or twice weekly in all mechanically ventilated patients. The microbiological findings from TA surveillance cultures done in the eight days before suspicion of VAP were compared to those isolated from the positive diagnostic samples done for late onset VAP (after more than four days of mechanical ventilation). The sensitivity, specificity, and positive/negative predictive values of the ability of the surveillance sample to anticipate the VAP pathogen were calculated., Results: Among the microorganisms isolated from TA, 68% were retrieved from diagnostic samples. All VAP pathogens previously isolated were from 43% of the TA samples. If TA was collected 2-4 days before the clinical diagnosis of VAP, pathogens were detected in 58% of samples. In contrast, only 27% were collected more than four days earlier (P<0.05). The positive predictive values for Pseudomonas aeruginosa and methicillin resistant Staphylococcus aureus from routine TA samples were 92% and 90%, respectively. The negative predictive values for Pseudomonas aeruginosa and methicillin resistant Staphylococcus aureus from routine TA samples were 75% and 89%, respectively., Conclusions: TA cultures in ventilated patients may help to predict pathogens. Early detection may lead to earlier treatment in long term ventilated patients when VAP is suspected.

Aim: The aim of this paper was to study in intensive care unit (ICU) the impact of variable ''professional role'' and ''gender'' on the defence mechanisms, on the troubles of mood and on the markers of the burnout syndrome, and to study the correlation between specific defence mechanisms or specific troubles of mood and the onset of burnout syndrome., Methods: An observational study by administration of psychometric tests was carried out. Twenty-five nurses and 25 doctors working in two differents ICU of the Azienda Ospedaliera-Universitaria Pisana were enrolled. Three psychometric tests concerning the defence mechanisms (Defense Mechanism Inventory), the troubles of mood (Profile of Moods States) and the burnout syndrome (Maslach Burnout Inventory) were administered and the three tests were analysed to study the features of each person enrolled., Results: The study shows the presence within doctors of two dimensions of burnout syndrome (emotional exhaustion in women and depersonalization in men) much greater than nurses. The doctors show the presence of defence mechanism as overturning, aggressiveness and rationalization, and troubles of mood as depression-despondency and aggressiveness-anger. Compared to men, women show turning to one self as defence mechanisms, whereas the men show aggressiveness-anger as trouble of mood. The women doctors show depression-disheartement as trouble of mood, the men doctors show tension-anxiety. We showed a correlation between tiredness-indolence, depression-disheartement and onset of emotional exhaustion, as a correlation between aggressiveness, aggressiveness-anger in man and oncet of depersonalization. Finally we correlated the absence of tension-anxiety as trouble of mood and overturning as defence mechanism with a good personal accomplishment at work., Conclusion: The burnout syndrome is present in health-care workers in ICU and it is significantly affected by operating role and gender. We must be aware of this phenomenon in order to study it and to reduce it.

Aim: Infection surveillance and control in ICU is believed to be a means to improve the quality of assistance. The importance of this activity is supported by both epidemiological (rate and severity of infection in ICU) and economic (efficiency, cost-benefit and cost-effectiveness analysis) evaluations. Many authors thinks that infection surveillance and control should be performed with a routine tool in order to obtain remarkable data without too much time loss, and used by many ICUs, in order to compare the data., Methods: A prospective observational study in 71 Italian ICUs participating in GiViTi. All patients admitted in each ICU during 6 month (except those discharged alive within 48 hours from admission) were enrolled and surveyed. Demographic and clinical data, data relating to nosocomial and at admission infections, risk factors, responsible micro-organisms, antibiotics use and outcome were collected., Results: A total of 5814 patients (98% of eligible patients) were surveyed. The overall incidence of infected patients was 43%. The incidence of patients with nosocomial infection was 18% (1062 patients). Pneumonia, bacteraemia and urinary tract were the main sites. The major isolated micro-organism responsible of infection were staphylococcus (29.7%) and pseudomonas (16.2). Only 17% of all patients was not treated with antibiotics, and 72% of patients without infection was treated with antibiotics., Conclusion: These preliminary data confirm the importance of infection in ICU and the need of continuous surveillance. We propose a tool that can be useful for continuous and multicentric infection surveillance in ICU.

Data concerning antibiotic therapy in italian ICUs are presented. These data were not directly measured: they have been derived from a previous study on costs of intensive care treatments. 78% of 1065 patients received antibiotic therapy. Empirical therapy was started in 82% of septic patients. 93% of septic patients had at least one antibiogram. In 96% of cases, 2 or more antibiotics were given. 85% of surgical non septic patients received antibiotic prophylaxis for an average of 3.6 days, with a 3rd generation cephalosporin in the majority of cases. 60% of medical non septic patients received antibiotic prophylaxis for an average of 6.2 days, mostly with a 3rd generation cephalosporin. These data raise doubts about the proper use of prophylaxis. These data can be considered a useful starting point for the development of a program of surveillance of infections in Italian ICUs.

The authors report the accidental insertion of a nose-gastric tube inside the brain-pan of a patient affected by a cranic-facial trauma. The wrong tubes positioning was performed at the Emergency Department of the authors' hospital; it was discovered a few minutes later when a cranic CT scan had been performed. In the meantime an important neurologic syndrome developed. The poor objective evidence of the injury, which, even though causing not very evident physical damage to the patient's face, produced a communication between the patient's nose-pharynx and brain-pan, made the case worth reporting. The aim of this report is to remember and to stress how in every case of craniofacial injury, although if of poor evidence, the insertion of a naso-gastric tube is exposed to its dislocation to the brain-pan. The tube positioning must then be performed only after a cranic CT scan showed no disruption of the anatomic structures dividing the nose-pharynx by the brain-pan. The simple skull X-ray is not sufficient.

The diagnostic potential of Transesophageal Echocardiography (TEE) is well established in patients with suspicion for some life-threatening diseases as cardiogenic cerebral embolization, aortic dissection, intracardiac or thoracic masses, acute valvular dysfunction or sepsis of undetermined origin, which represent a relevant part in the activity of Intensive Care Units (ICU). Thus, an increasing role of TEE may be foreseen in this arena, also due to some of the known odds of ultrasound techniques compared to other imaging tools like CT scan or MRI (lower cost and beside availability). The aim of the present paper is to briefly review the main indications for TEE in ICU, and to report on some illustrative cases from our experience of I year in this field. Twenty-eight seriously-ill patients referred to our ICU between December 1991 and December 1992 were investigated for 1 of the following diagnostic problems: a) chest trauma with suspicion for aortic dissection and/or mediastinal bleeding; b) sepsis of undetermined origin; c) cerebral transient ischemic attack or stroke; d) assessment of cardiac function in potential heart donors. TEE was performed by means of commercially available instruments (either Hp Sonos 1500 or Esaote Sim 7000 Color Flow Mapping), with conventional monoplane probe or so-called wide-angle, "panoramic" probe, respectively. In most of the patients studied, TEE provided either unique or complementary, diagnostically useful, information. By panoramic approach, which yields imaging field up to 270 degrees, a comprehensive visualization of the heart, aorta and mediastinal structures was possible.(ABSTRACT TRUNCATED AT 250 WORDS)

In an overall of the value of an antibiotic it is important to take into account the onset of bacterial resistance in addition to its immediate clinical effects since the former can render an otherwise efficacious antibiotic obsolete within a short space of time. We studied two groups of intubated patients with pneumonia infections during two different periods in 1990: January-June and October-December; each patient was treated with pefloxacin 400 mg twice a day i.v. for 6 days on the basis of an antibiogram carried out on tracheobronchial secretion; at the end of that period patients were clinically evaluated and a second bacteriological test was performed. It was found that the percentage of pefloxacin-resistant bacterial strains did not increase significantly after this antibiotic had been used for a year for pneumonia infections (from 27.5% to 33%). The appearance of bacterial resistance at the six-day treatment cycle was similar in both groups (19% and 22%). Of all the bacterial strains, Pseudomonas aeruginosa showed the greatest tendency to become resistant.