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Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients' lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries. info:eu-repo/semantics/publishedVersion

Background: Noninvasive ventilation (NIV) in COVID-19 patients outside of intensive care unit (ICU) settings was a feasible support during the pandemic outbreak. The aim of this study was to assess the effectiveness of an “on the job” NIV training program provided to 66 nurses working in 3 COVID-19 wards in an Italian university hospital. Methods: A quasi-experimental longitudinal before–after study was designed. The NIV Team education program, provided by expert ICU nurses, included: 3 h sessions of training on the job during work-shifts about the management of helmet-continuous positive airway pressure (CPAP) Venturi systems, and NIV with oronasal and full-face masks. An eleven-item “brief skills self-report tool” was administered before and after the program to explore the perception of NIV education program attendees about their level of skills. Results: In total, 59 nurses responded to the questionnaire. There was an improvement in the skill levels of the management of Helmet-CPAP (median before training 2, inter-quartile range (IQR) 0–6; median after training 8, IQR 3–9; p < 0.0001), and mask-NIV (median before training 2, IQR 0–6; median after training 8, IQR 3–9; p < 0.0001). Conclusions: Training on the job performed by expert ICU nurses can be a valuable and fast means to implement new Helmet-CPAP and mask-NIV skills outside of ICUs.

Background: The application of Continuous Positive Airway Pressure (CPAP) with a helmet is increasing around the world, both inside and outside of the intensive care unit. Current published literature focus's on indications, contraindications and efficiency of Helmet CPAP in differing clinical scenarios. Few reports, summarising the available knowledge concerning technical characteristics and nursing interventions to improve patient's comfort, are available. Aim: To identify the crucial technical aspects in managing patients undergoing Helmet-CPAP, and what nursing interventions may increase comfort. Methods: A narrative literature review of primary research published 2002 onwards. The search strategy comprised an electronic search of three bibliographic databases (Pubmed, Embase, CINAHL). Results: Twenty-three studies met the inclusion criteria and were included in the review. Research primarily originated from Italy. Nine key themes emerged from the review: gas flow management, noise reduction, impact of gas flow and HME filters on delivered FiO2, filtration of exhaled gas / environmental protection, PEEP monitoring, airway pressure monitoring, active humidification of gas flow, helmet fixation and tips to implement awake prone position during Helmet-CPAP. Conclusions: A Helmet-CPAP check-list has been made of nine key interventions based on the available evidence regarding system set up, monitoring and management. Implementation of this check-list may help nurses and physicians to increase the comfort of patients treated with Helmet CPAP and enhance their compliance with long-term treatment.

Background Appropriate levels and patterns of sound and light in an intensive care room help to maintain the patient's normal physiological functions. High sound levels can disrupt the patient's normal sleep architecture, cause hearing deficits, and induce the onset of delirium. Intensive care unit patients frequently report poor sleep, partly due to the environment. Objectives An observational pilot prospective study was designed to record sound pressure and light pollution levels in an Italian intensive care unit, without windows to provide natural light. Method Sound levels were measured in decibel A (dBA) every 10 seconds. Sound data were analyzed for sound peak, defined as the number of times sound levels exceeded 45, 50, 60, 65, 70, 75, 80, and 85 dBA. Light measures were taken every 10 seconds on a continuous basis. Light data were analyzed for light "peaks,"defined as the number of times light levels exceeded 100, 200, 300, 400, and 500 lux. Results The overall median sound level during the study period was equal to 54.60 (interquartile range [IQR], 51.70-57.70) dBA. The daytime median sound level was 56.00 (IQR, 53.00-59.50) dBA, and the nighttime median was 53.00 (IQR, 49.50-55.20) dBA (P

Background Awake prone positioning research focuses primarily on improving oxygenation and reducing intubation and mortality rates. Secondary outcomes concerning patient safety have been poorly addressed. Objective To summarize current evidence on the frequency of adverse events during awake prone positioning and the effects on patients’ safety, comfort, and tolerance. Methods This scoping review used the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews. MEDLINE/PubMed and CINAHL databases were the primary sources for the systematic search. Results The review included 19 original studies involving 949 patients who underwent awake prone positioning. No major complications such as death, severe respiratory compromise, or hemodynamic disease were reported. Ten studies reported the following secondary adverse events related to awake prone positioning: skin breakdown (1%-6% of patients), pain (12%-42%), discomfort (35%-43%), vomiting (2%-7%), intolerance (3%-47%), and vascular catheter dislodgment (5%). The duration of awake prone positioning sessions varied widely (0.3-19 hours). Seven studies reported that nurses helped patients during prone positioning maneuvers, including monitoring and surveillance, and 3 studies reported patients placing themselves in the prone position. In 6 studies light or moderate sedation was employed in the procedures. Conclusions Awake prone positioning was not related to cardiorespiratory consequences but was associated with pain, intolerance, discomfort, and patients’ refusal. Patients should receive education regarding awake prone positioning to improve their acceptance. Health care professionals should optimize pain control, communication, patient comfort, patient adherence, and correct positioning.

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.

The incidence of COVID-19 gastrointestinal manifestations has been reported to range from 3% to 61%. There are limited data on the incidence rates and risk factors associated with gastrointestinal bleeding (GIB) in patients with COVID-19. A rapid review has been designed to investigate whether there is a relationship between COVID-19 and GIB in adult patients. PubMed, CINAHL, EMBASE, Cochrane Library, and Scopus databases have been analyzed. A total of 129 studies were found; 29 full texts were analyzed, and of these, 20 were found to be relevant to the topic. The key findings of the included studies present an overall GIB rate in COVID-19 patients ranging from 1.1% to 13%. The bleeding involves mucosal damage of the duodenum, stomach, colon, and rectum. The management of gastrointestinal bleeding could be conservative. The use of fecal diversion systems for the management of diarrhea in COVID-19 patients should be minimized and closely evaluated for the risk of rectal mucosal damages and erosions. It is recommended to provide an accurate nutritional assessment; an early setting up of enteral nutrition, if not contraindicated, can help protect the gut mucosa of patients and restore normal intestinal flora. Larger cohort studies are needed to increase the information about this topic.

Summary. Measuring the nursing workload in a medical-surgical high dependency unit through nursing activities score (NAS). a prospective observational study. Introduc-tion. Measuring the nursing staff workload allows adequate delivery of resources within the intensive care unit and high dependency unit to ensure an adequate nurse to patient ratio. Aim. Exploring the nursing workload in the me-dical-surgical high dependency unit (HDU) at Careggi Uni-versity Hospital (Florence, Italy). Methods. Monocentric prospective observational study. We enrolled patients admit-ted in HDU from 11 February to 13 March 2021. Nursing Activity Score (NAS) was measured every 24 hours. Results. Patients included in the study were 75. Three groups ba-sed on their admission diagnosis were identified (medical, surgical, trauma). The median NAS score was 59.7 (IQR: 53.7-68.2; range 34.7-119.7). Statistically significant dif-ferences were found between the median NAS values for the three admission diagnoses: 67.4 (IQR: 54.4-73.4) for medical patients, 60.2 (IQR: 54.4-63.3) for trauma patients and 59.1 (IQR: 55.1-64.7) for surgical patients. These results showed that the items of NAS that mostly affect workload are “monitoring”, “mobilization”, “patient hygiene”, and “ad-mission and discharge procedures”. Conclusions. This study confirms that the NAS scoree can be used in HDUs as well as in intensive care units. The ideal nurse-to-patient ratio was equal to 0.6.

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 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: 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.

Background and aim: Unplanned extubation (UE) in Intensive Care Units (ICU) is an indicator of quality and safety of care. UEs are classified in: accidental extubations, if involuntarily caused during nursing care or medical procedures; self-extubation, if determined by the patient him/herself. In scientific literature, the cumulative incidence of UEs varies from 0.3% to 35.8%. The aim of this study is to explore the incidence of UEs in an Italian university general ICU adopting a well-established protocol of tracheal tube nursing management and fixation. Methods: retrospective observational study. We enrolled all patients undergone to invasive mechanical ventilation from 1st January 2008 to 31st December 2016. Results: in the studied period 3422 patients underwent to endotracheal intubation. The UEs were 35: 33 self extubations (94%) and 2 accidental extubations (6%). The incidence of UEs calculated on 1497 patients intubated for more than 24 hours was 2.34%. Instead, it was 1.02%, if we consider the whole number of intubated patients. Only in 9 (26%) cases out of 35 UEs the patient was re-intubated. No deaths consequent to UE were recorded. Conclusions: The incidence of UEs in this study showed rates according to the minimal values reported in scientific literature. A standardized program of endotracheal tube management (based on an effective and comfortable fixing system) seems to be a safe and a valid foundation in order to maintain the UE episodes at minimum rates.

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

According to the current literature, Noninvasive Ventilation (NIV) is a well-recognized respiratory support technique for patients affected by Acute Respiratory Failure (ARF). As highlighted by recent meta-analysis, a tight adherence to protocols regarding patients' selection criteria, relative or absolute contraindications, plus highly skilled and experienced operators, can positively affect the NIV performance and mortality rates. Positive outcome from NIV respiratory support is dependent from: patient's clinical condition and education needs; confidence of the staff with NIV technology; choice and management of the most suitable interface available prevention of interface complications; nutritional assessment (artificial feeding if required) and conditioning of medical gas. Despite these issues, the air leakage represents the major threat during NIV support. Indeed, to obtain a positive outcome from this treatment, the 'NIV troubleshooting' management appears to be crucial. Common issues as air leakage, patient-ventilator asynchrony, interface related pressure ulcers, discomfort, and gastric distention should be promptly detected and solved. The analysis of these current issues reveals a lack of evidence based practice, resulting in bed-side clinical interventions based only on the expert consensus or local opinions. To improve this knowledge gap, more efforts are strongly recommended from medical and nursing research communities. Multicenter randomized controlled clinical trials are needed to achieve adequate knowledge to reach the best patient's outcome. Further information to identify new areas of nursing research on NIV, can be achieved from qualitative studies performed on patients and healthcare operators.

Enteral nutrition during prone positioning in mechanically ventilated patients. Introduction. The Enteral Nutrition (EN) tends to be stopped during prone positioning to prevent the risk of acid reflux and vomiting. Aims. To compare the gastric residual volume during continuous enteral nutrition in patients in prone and supine position. Methods. Observational restrospective study on Acute Respiratory Distress Syndrome patients, mechanically ventilated, with continuous enteral nutrition implemented according to the same protocol, in prone and supine position. Results. The 25 patients included had a mean age of 51.13±15.93 (range: 16-80) years. Gastic residual volume was checked on 656 occasions (408 in supine and 248 in prone position). Mean infusion rate was 63.3±18.5 ml/h: 62.1±18.9 ml/h in supine and 66.2±16.5 ml/h in prone position. The mean overall gastric residual volume was 24.4±54.2 ml: 20.6±18.9 ml in supime and 23.6±50.0 ml in prone posizion. In 4 occasions (2 in prone and 2 in supine position9, the gastric residual volume was > 300ml; EN was interrupted on 1 occasion with a gastric residual volume >500ml. Conclusions. No clinically relevant differences of gastric residual volume were observed in prone and supine position. A protocol for the management of gastric residual volume allows a safe and effective administration of EN also in patients positioned for several hours in prone position.

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.

Introduction. The incidence of catheter related Bloodstream infections (BSI) is high in intensive care units (ICU). Aim. To evaluate the BSI rate in a population of patients admitted to a General ICU before and after the implementation of the 2011 CDC guidelines. Methods. Retrospective observational study on patients admitted from January 2009 to December 2013. The infusion and monitoring lines were changed every 96 hours for the first 30 months, and every 7 days for the next 30. In all patients a closed infusion line with needlefree connectors pressure was used (Microclave). The following catheters were considered in the study: central venous catheter (CVC), arterial cannula (ART) and Swan Ganz catheter (SG). Results. During the period with change every 96 hours 15 BSI were observed over 13395 catheters/days (C/D), 1.12 per 1000 C/D, while when lines where changed every 7 days 11 BSI were observed over 13120 C/D, 0.83 per 1000 C/D. A statistically significant reduction of BSI was observed in SG catheters (4.17 vs. no BSI p = 0.02), while the CVCS (1.12 vs 1.45 - p = 0.37) and ART (0.35 vs 0.36 - p = 0.61) infection rates remained unchanged. Conclusions. The replacement of infusion lines every 7 days in our sample did not increase the BSI, helping to reduce the costs.

To compare two evaluation pain scale the Behavioral Pain Scale (BPS) e Critical Care Pain Observation Tool (CPOT) in Intensive Care Unit in the Azienda Ospedaliera di Monza, and their correlation. To evaluate if consciousness level (evaluate through a third scale the Ritchmond Agitation Sedation Scale - RASS) influence the use of the pain scales.1083 data were collected from May 2012 and November 2012. The sample was made up by 36 patients, of these 20 men and 16 women, average age of 62,94±13,21 and hospital stay on average of 17±12 days.BPS median is 3 (Q1: 3 - Q3:3 - range 3-12), CPOT median is (Q1-Quartile 25%: 0 - Q3- Quartile 75% : 1, range 0-8), RASS median is-1 (Q1: -4, Q3: 0 - range 0/- 5). Corellational coefficient is 0.784. There is a overall difficulty on use BPS and CPOT expecially with individuals with RASS -1.Results of this study suggest the need to carry out further research, expanding the validation of the pain scales for patients not able to speach to unexplored patients.Confrontare le due scale di valutazione del dolore utilizzate in Terapia Intensiva generale dell’Azienda Ospedaliera di Monza, Behavioral Pain Scale (BPS) e Critical Care Pain Observation Tool (CPOT) e la loro correlazione. Verificare se la rilevazione delle scale sia influenzata dal livello di coscienza valutato per mezzo di una terza scala (Ritchmond Agitation Sedation Scale - RASS).Sono state raccolte ed analizzate 1083 rilevazioni nel periodo Maggio 2012 / Novembre 2012. Le valutazioni sono relative ad un campione di 36 pazienti, 20 uomini e 16 donne, con un’età media di anni 62,94±13,21 e una degenza media di 17±12 giorni.La mediana della scala BPS è stata pari a 3 (Q1: 3 – Q3:3 – range 3-12), la mediana della scala CPOT è stata pari a 0 (Q1-Quartile 25% : 0 – Q3- Quartile 75% : 1, range 0- 8), e la mediana della scala RASS è risultata essere -1 (Q1: -4, Q3: 0 – range 0/-5). Il coef- ficiente di correlazione era di 0.784. Si segnala la difficoltà nell’utilizzo delle suddette scale soprattutto nelle persone con RASS -1.I risultati di questo studio suggeriscono la necessità di implementare ulteriormente la ricerca, ampliando la validazione delle scale di valutazione del dolore per pazienti non in grado di verbalizzare a popolazioni di pazienti finora inesplorate.

Invasive and non invasive ventilation: impact on nursing workload. Introduction. Non invasive ventilation (NIV) is increasingly used in intensive and non intensive wards. Objective. To detect the impact of ventilation modes on nursing workload. Methods. Retrospective observational study of 200 patients admitted to a general Intensive Care Unit (ICU). Nursing Activities Score (NAS) was used to measure the nursing workload. Patients enrolled were treated with the following ventilation modes: oxygen therapy without positive end-expiratory pressure (PEEP), helmet Continuous Positive Airway Pressure (CPAP), controlled mechanical ventilation, Invasive pressure support ventilation (I-PSV). Results. The overall mean NAS score of patients was 74.3% (SD ±8.88 - range 39/143) corresponding to an ideal nurse/patient ratio of 0.7 and varied with the different ventilation modes. In the days in oxygen therapy, the average NAS was 64.5% (±11.9), with helmet CPAP 69.7% (±12.7), with controlled mechanical ventilation 86.1% (SD ±15.1) and with invasive assisted ventilation 76.4% (±11.4) [p=0.0001]. In patients with helmet CPAP the NAS increased of 14% when FiO2 >0.6 and PEEP >10 compared to oxygen therapy. The average NAS score of the 15 patients (7.5%) with mask-PSV was 80.2% (±12:5). Conclusions. Overall, the nursing workload of patient with helmet CPAP was lower than with invasive ventilation. In Helmet CPAP, with FiO2 >0.6 and PEEP level >10 cmH2O and mask-PSV, the nursing workload is similar to that of patients with invasive ventilation. NAS scores in patients with Invasive ventilation in the controlled mode is higher than with assisted mode