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Introduction: In the literature, the change of a syringe pump is described as a dangerous situation, especially in the case of vasoactive drug administration. Methods: Different variables have been studied (central venous pressure, pump displacement in relation to the patient position, utilization of a stopcock, or a neutral displacement needle-free connector between the syringe and the infusion tubing) to understand their influence on medication administration in terms of backflow or bolus creation when changing the syringe. Results: We performed 576 measurements with different combinations. With respect to all the observations, in comparison with “time zero,” we found the following differences expressed in microliters: 0 (±1) at the plunger opening; 0 (±3) at the syringe extraction from the pump; 0 (±7) at the syringe disconnection from the infusion tubing; 0 (±11) at the syringe reconnection to the infusion tubing; 1 (±7) at the syringe insertion in the pump; 3 (±23) at the plunger closing; 8 (±33) at the stabilization at the maneuver end. Conclusion: The syringe change can be a very critical moment given different influencing variables. Syringe pump position, displaced higher than the patient level, always generates a medication bolus that is higher at the lowering of the central venous pressure value. The presence of a neutral displacement needle-free connector reduces the incidence of boluses. When the pump is placed at the patient level, the presence of neutral displacement needle-free connector reduces the establishment of boluses, even in a central venous pressure of −5 mmHg simulations.

Background Early application of prolonged prone positioning has been shown to improve patient survival in moderate to severe adult respiratory distress syndrome (ARDS) patients. Prone position is a key component of lung protective mechanical ventilation in association with low tidal volume and neuromuscular blocking agents in patients with severe ARDS. Pressure sores are the major prone position complication. The rate of complication is lowering with the increase in center expertise. Aims The aim of this study was to examine the onset of pressure sores and other complications caused by the use of prone position in patients having ARDS. Design This is a single-center, retrospective, observational study. Results One hundred seventy patients were enrolled, with a median age of 49 years (interquartile range [IQR], 38-63). Of all participants, 58% (n = 98) survived the intensive care unit recovery. The total prone position maneuvers were 526, with a median of 2 prone position sessions for each patient (IQR, 1-3). The median length of the prone position session was 9 hours (IQR, 7-12). Twenty-three patients developed pressure sores after prone position (14%). The anatomical positions of pressure sores were as follows: face/chin, 5% (n = 8); face/cheekbones, 6% (n = 11); thorax, 2% (n = 3); trochanter, 1% (n = 1); and other sites, 5% (n = 8). Complications were observed in 1% (n = 6) of all pronation maneuvers (vomit, 2%; respiratory device removal, 0.4%). No removal of intravascular catheter was observed. Conclusions The onset rate of complications given by the use of prone position in ARDS patients is similar to data reported by previous literature. The implementation of a dedicated protocol in specialized centers and the involvement of 5 trained and skilled professionals while moving the patient in the prone position are recommended to prevent the occurrence of similar adverse events.

Background Caring for patients with COVID-19 requires wearing a full set of personal protective equipment (PPE) to avoid contamination. Personal discomfort has been associated with use of PPE, and anecdotal reports describe pressure injuries related to wearing PPE. Objectives To investigate the occurrence of device-related pressure injuries due to wearing PPE among Italian nurses caring for patients with COVID-19 in critical care settings. Methods This descriptive study used an online survey investigating both the demographic characteristics of respondents and complications related to wearing PPE, including the development of pressure injuries. Results A total of 266 nurses throughout Italy completed the survey; 32% of respondents were men. Nurses’ median age was 36 years (range 22-59 years), and the median time spent working in their current clinical setting (an intensive care or high-dependency unit) was 3 years (range 0-32 years). Personal protective equipment was worn for a median duration of 5 hours (range 2-12 hours). While wearing PPE, 92.8% of nurses experienced pain and 77.1% developed device-related pressure injuries, mainly on the nose, ears, and forehead. Pain was more frequent among nurses with such injuries. Transparent dressings, emollient cream, and no dressing were associated with development of device-related pressure injury. Conclusions Pressure injuries related to PPE represent an important adverse effect for nurses caring for patients with COVID-19. This topic deserves study to determine adequate solutions for preventing and treating such injuries and their potential influence on nurses’ work tolerance.

Aim: The aim of this study was to assess the noisiness levels produced by different gas source systems, breathing circuits setup, and gas flow rates during continuous positive airway pressure (CPAP) delivered through helmet. Methods: This was a crossover design study. Ten healthy subjects received helmet CPAP at 5 cm H2O in random order with different gas flow rates (60 and 80 L/min), 3 diverse gas source systems (A: Venturi system, B: oxygen and air flowmeters, C: electronic Venturi system), and 3 different breathing circuit configurations. During every step of this study, a heat and moisture exchanger (HME) was placed on the helmet inlet gas port to measure the effects on noise production. Noise intensity level was recorded through a sound-level meter. Participants scored their noisiness perception on a visual analog scale. Results: The noise level inside the helmet ranged between 76 ± 4 and 117 ± 1 Decibel A. The gas source and the gas flow rate always affected the noise level inside and outside the helmet (P < .001). The different "breathing circuit setup" did not change the noise levels inside the helmet (P = .244), but affected the noise level outside, especially when a Venturi system was used (P < .001). An HME filter placed at the junction between the inspiratory limb of the breathing circuit and the helmet significantly decreased the noise intensity inside the helmet (mean dBA without HME, 99.56 ± 13.30 vs 92.26 ± 10.72 with HME; P < .001) and outside (mean dBA without HME, 68.16 ± 12.05 vs 64.97 ± 12.17 with HME; P < .001). The perception of noise inside the helmet was lower when an HME filter was placed on the inspiratory inlet gas port (median, 6 [interquartile range, 4-7] vs 7 [5-8]; P < .001). Conclusions: When helmet CPAP is delivered through gas flow rates up to 50 L/min, an HME placed on the helmet inlet gas port should be used to reduce noise inside the helmet and to improve patients' comfort.

Background: Lateral violence and bullying affect nurses’ professional and health status. Worldwide prevalence ranges from 1% to 87%. Aim: To investigate prevalence and risk factors of lateral violence and bullying among Italian nurse peers in different work settings, inside and outside hospitals. Methods: Web survey using the 17-item “Negative Interactions Among Nurses Questionnaire.” Emails were sent to 5,009 nurses in three Tuscan public health care institutions. Results: Response rate was 18.6% (n=930). Twenty-six respondents were removed as they reported working with no peer colleagues. Negative interactions were experienced by 35.8% (n=324), 42.3% of whom (n=137) were bullied. Psycho-physical consequences of negative interactions were reported by 59% (n=191). Victims who thought of leaving nursing were 21.9% (n=71). Conclusions: Lateral violence and bullying among nurses are consistently present in all studied settings. Implications for Nursing Management: Nurse managers could play a crucial role in preventing negative interactions among nurses. Strategies could include continuing education programs to promote awareness of this problem; implementation of an anonymous reporting system for bullying; introduction of occupational psychologists in wards with larger numbers of reported negative interactions and bullying; and increasing changes in staff composition within shifts.

Background: Prolonged application time of helmet continuous positive airway pressure (CPAP) leads to better outcomes, but its timing can be influenced by the patient's tolerance. Aims and objectives: To investigate patients' pain and tolerance experience related to different options of helmet fixing system: ‘armpits strap’ versus ‘counterweights system’. Design: This was a non–randomized crossover study performed in a 10-bed intensive care unit and referral extra corporeal membrane oxigenation (ECMO) centre of an Italian university hospital. Results: Twenty patients were enrolled. For helmet-CPAP cycles performed with the armpit straps option, the mean pain numerical rate on a 0–10 scale was: 0·5 ± 1·4 at T0 (baseline), 1·5 ± 2·0 at T1 (after 1 h) and 2·6 ± 2·5 at T2 (end of cycle) (p = 0·023). The same analysis was performed for the counterweights fixing option. The mean score was 0·3 ± 0·6 at T0, 0·3 ± 0·2 at T1 and 0·5 ± 0·7 at T2 (p = 0·069). The mean duration for CPAP cycles performed with armpits strap and counterweights system was 3·0 ± 1·0 and 3·9 ± 2·3 h, respectively (p < 0·001). The mean section of the Basilic vein that was investigated before wearing the helmet was equal to 0·23 ± 0·20 cm2. After 1 h of therapy with the counterweight option and armpit straps, the mean increase of the vein's section was 0·27 ± 0·21(p = 0·099) and 0·30 ± 0·25, respectively (p = 0·080). Conclusions: The fixing system options in use to anchor the helmet during CPAP could worsen the pain experience level and cause device-related pressure ulcers. When compared with the armpit straps option, the counterweights system appears to be a suitable approach to minimize the risks of pressure sores and pain during the treatment. Relevance to practice: The helmet CPAP is a reliable therapy to manage acute respiratory failure. Major improvements regarding pulmonary alveolar recruitment and oxygen levels are strictly related to a prolonged time of helmet CPAP cycles. Using a counterweight fixing system, where the armpits straps are not necessary, could be helpful in reducing patients' pain experience.

INTRODUCTION Oral care, using either a mouth rinse, gel, toothbrush, or combination of them, together with aspiration of secretions, may reduce the risk of ventilator-acquired pneumonia in intubated patents. Oral care procedure in patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) may cause bleeding due to the systemic anticoagulation required. PURPOSE The aim of this study was to investigate the rate of bleeding episodes during oral care in patients supported by VV-ECMO. METHODS A retrospective observational study was performed. All patients admitted to an Italian ECMO center during 2014 were included in the study. RESULTS Data from 14 patients were analyzed. The median intensive care unit length of stay was 39.0 days (interquartile range, 27.3-83.3 days), and median days on VV-ECMO was 19.5 (10.3-46.0). There were 440 ECMO days, with 1320 oral care maneuvers. In 7 patients, bleeding episodes occurred: 2 with orotracheal intubation and 5 initially managed with orotracheal intubation, thereafter via Translaryngeal tracheostomy tube (according to Fantoni's technique). In 61 oral care procedures (4.6%), bleeding was detected during or after the maneuver, whereas the total numbers of days with at least 1 bleeding episode were 35 (8%).The presence or absence of bleeding during ECMO days was statistically significant for international normalized ratio (1.01 [0.95-1.11] vs 1.13 [1.03-1.25], P < .0001), platelets (163 000 [93 500-229 000] vs 61 000 [91 00-100 000], P < .0001), and mouth care score (6 [5-7] vs 8 [7-9], P < .001). CONCLUSION Oral care can cause bleeding in patients on VV-ECMO. Implementation of protocols for daily oral care in patients on ECMO may reduce risks. As recommended by the literature, this category of patients should be treated in selected centers distinguished by a regular volume of ECMO activity and the presence of dedicated ECMO specialist nurses.

To the Editor: We read with interest the paper by Kogo et al.[1][1] In our opinion, the delivery of enteral nutrition during noninvasive ventilation (NIV) represents one of the main topics related to this type of respiratory support, and the authors have well addressed this issue in their

Introduction: Tracheal suctioning is recalled by mechanically ventilated patients as the most painful procedure during their stay in the intensive care unit. Aim: The aim of this study was to evaluate whether the implementation of American Association of Respiratory Care suction guidelines positively affects the levels of patients' pain. Materials and Methods: This is a prospective observational study on adult patients admitted to 2 general intensive care units. Pain levels in sedated mechanically ventilated patients were recorded before, during, and after tracheal suctioning, using the Critical Care Pain Observation Tool (CPOT). Results: Forty-seven patients were enrolled, with a mean age of 61.72 (T18.46) years. Median CPOT value was 0 (quartile 1 [Q1] [25%], 0; quartile 3 [Q3] [75%], 0; min, 0; max, 2) during the procedure. The Critical Care Pain Observation Tool reached a median value of 3, while 5 minutes after suctioning. Postprocedural CPOT median score was 0 (Q1 [25%], 0; Q3 [75%], 0; min, 0; max, 2). The median number of passes during suctioning was 1 (Q1, 1; Q3, 2). The sizes of suction catheters used in the recorded procedures were as follows: 12F in 27 cases (57%), 14F in 18 cases (38%), and 10F in 2 cases (5%). The median size of the endotracheal tube was 7.5 mm (Q1, 7.5; Q3, 8). The correct ratio between endotracheal tube diameter and suction catheter was used in 24 procedures (51%). Conclusions: Despite the low number of patients, this study showed that the implementation of the American Association of Respiratory Care 2010 endotracheal suctioning guidelines into practice helps to reduce procedural-induced pain. Therefore, training and continuing education are important for clinical staff performing tracheal suctioning.