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Importance: Mechanical power and driving pressure have known associations with survival for patients with acute respiratory distress syndrome., Objectives: To further understand the relative importance of mechanical power and driving pressure as clinical targets for ventilator management., Design: Secondary observational analysis of randomized clinical trial data., Setting and Participants: Patients with the acute respiratory distress syndrome from three Acute Respiratory Distress Syndrome Network trials., Main Outcomes and Measures: After adjusting for patient severity in a multivariate Cox proportional hazards model, we examined the relative association of driving pressure and mechanical power with hospital mortality. Among 2,410 patients, the relationship between driving pressure and mechanical power with mortality was modified by respiratory rate, positive end-expiratory pressure, and flow., Results: Among patients with low respiratory rate (< 26), only power was significantly associated with mortality (power [hazard ratio, 1.82; 95% CI, 1.41-2.35; p < 0.001] vs driving pressure [hazard ratio, 1.01; 95% CI, 0.84-1.21; p = 0.95]), while among patients with high respiratory rate, neither was associated with mortality. Both power and driving pressure were associated with mortality at high airway flow (power [hazard ratio, 1.28; 95% CI, 1.15-1.43; p < 0.001] vs driving pressure [hazard ratio, 1.15; 95% CI, 1.01-1.30; p = 0.041]) and neither at low flow. At low positive end-expiratory pressure, neither was associated with mortality, whereas at high positive end-expiratory pressure (≥ 10 cm H 2 O), only power was significantly associated with mortality (power [hazard ratio, 1.22; 95% CI, 1.09-1.37; p < 0.001] vs driving pressure [hazard ratio, 1.16; 95% CI, 0.99-1.35; p = 0.059])., Conclusions and Relevance: The relationship between mechanical power and driving pressure with mortality differed within severity subgroups defined by positive end-expiratory pressure, respiratory rate, and airway flow., Competing Interests: Dr. Tonna was supported by a career development award (K23HL141596) from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH). Dr. Tonna received speakers fees and travel compensation from LivaNova and Philips Healthcare, unrelated to this work. Dr. Peltan was supported by a career development award (K23GM129661) from the National Institute of General Medical Studies of the NIH. Dr. Peltan has received research funding from Janssen Pharmaceuticals; his institution has received funding to support work from Asahi Kasei Pharma and Regeneron. Dr. Brown is supported by grants from NIH/NHLBI: U01HL123018, R01HL144624. Dr. Brown’s institution has received funding to support his work from Faron Pharmaceuticals, Sedana Pharmaceuticals, and Janssen Pharmaceuticals. Dr. Brown receives royalties from Oxford University Press. Dr. Brown has been paid directly by Hamilton Ventilators to Chair a Data Safety Monitoring Board. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Inflammation and oxidative stress characterize sepsis and determine its severity. In this study, we investigated the relationship between albumin oxidation and sepsis severity in a selected cohort of patients from the Albumin Italian Outcome Study (ALBIOS). A retrospective analysis was conducted on the oxidation forms of human albumin [human mercapto-albumin (HMA), human non-mercapto-albumin form 1 (HNA1) and human non-mercapto-albumin form 2 (HNA2)] in 60 patients with severe sepsis or septic shock and 21 healthy controls. The sepsis patients were randomized (1:1) to treatment with 20% albumin and crystalloid solution or crystalloid solution alone. The albumin oxidation forms were measured at day 1 and day 7. To assess the albumin oxidation forms as a function of oxidative stress, the 60 sepsis patients, regardless of the treatment, were grouped based on baseline sequential organ failure assessment (SOFA) score as surrogate marker of oxidative stress. At day 1, septic patients had significantly lower levels of HMA and higher levels of HNA1 and HNA2 than healthy controls. HMA and HNA1 concentrations were similar in patients treated with albumin or crystalloids at day 1, while HNA2 concentration was significantly greater in albumin-treated patients ( p < 0.001). On day 7, HMA was significantly higher in albumin-treated patients, while HNA2 significantly increased only in the crystalloids-treated group, reaching values comparable with the albumin group. When pooling the septic patients regardless of treatment, albumin oxidation was similar across all SOFA groups at day 1, but at day 7 HMA was lower at higher SOFA scores. Mortality rate was independently associated with albumin oxidation levels measured at day 7 (HMA log-rank = 0.027 and HNA2 log-rank = 0.002), irrespective of treatment group. In adjusted regression analyses for 90-day mortality, this effect remained significant for HMA and HNA2. Our data suggest that the oxidation status of albumin is modified according to the time of exposure to oxidative stress (differences between day 1 and day 7). After 7 days of treatment, lower SOFA scores correlate with higher albumin antioxidant capacity. The trend toward a positive effect of albumin treatment, while not statistically significant, warrants further investigation., Competing Interests: MC, FM, and AP are full-time employees of Grifols, a manufacturer of plasma derivatives. Grifols had no access to clinical data from ALBIOS and did not perform statistical analyses of data, but only provided editorial support. Publication costs of this manuscript were sustained by Grifols. LG and PC received honoraria from Grifols., (Copyright © 2021 Bonifazi, Meessen, Pérez, Vasques, Busana, Vassalli, Novelli, Bernasconi, Signori, Masson, Romitti, Giosa, Macrì, Pasticci, Palumbo, Mota, Costa, Caironi, Latini, Quintel and Gattinoni.)

Purpose: High flow nasal cannula (HFNC) is commonly used post-extubation in intensive care (ICU). Patients' comfort during HFNC is affected by flow rate. The study aims to describe the relationship between pre-extubation inspiratory flow requirements and the post-extubation flow rates on HFNC that maximises patient's comfort., Methods: This was an observational, retrospective study conducted in a university-affiliated ICU. We included patients extubated following successful spontaneous breathing trial (SBT). During the SBT we recorded variables including inspiratory flow. Patients who passed the SBT were extubated onto HFNC. HFNC was titrated from 20 L/min and increased in steps of 10 L/min, up to 60 L/min. At each step, patient's level of comfort was assessed. Fraction of inspired oxygen was titrated to maintain oxygen saturation 92-97%., Results: Nineteen participants were enrolled in the study. There was a significant positive correlation between mean inspiratory flow pre-extubation and the flow setting on HFNC which achieved the best comfort post-extubation (r 2 0.88; p < 0.001). Overall, greatest comfort was observed for HFNC flows between 30 and 40 L/min but with individual variability., Conclusion: Measuring mean inspiratory flow during an SBT allows for individualised setting of HFNC flow rate immediately post-extubation and achieves the greatest comfort and interface tolerance., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: The variability of acute respiratory distress syndrome management may affect the referral practice to severe respiratory failure centres. We described the management of acute respiratory distress syndrome in our catchment area., Methods: An electronic survey was administered to 42 intensive care units in South-East England., Results: Response rate was 71.4%. High-flow nasal oxygen and non-invasive ventilation were used 'often' in moderate-acute respiratory distress syndrome by 46.7% and 60%. During invasive ventilation, 90% preferred pressure control, targeting tidal volumes of 6-8 ml/kg (53.3%) or 4-6 ml/kg (46.7%). Positive end-expiratory pressure was selected by positive end-expiratory pressure/inspiratory fraction of oxygen tables (50%) or decremental positive end-expiratory pressure trials (20%). Neuro-muscular blockers were widely used, although routinely by only 3.3%. High-frequency oscillatory ventilation (10%) and inhaled nitric oxide (13.3%) were rarely used. None used oesophageal manometry. Recruitment manoeuvres were used 'often' by 26.7%. Equipment (90%) and protocols (80%) for prone position were common, with sessions mostly lasting 12-18 h., Conclusions: Although variable, practice well reflected the available evidence. Proning was widely practiced with good availability of educational resources and protocolised care., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Intensive Care Society 2020.)

Extracorporeal life support (ECLS) for severe respiratory failure has seen an exponential growth in recent years. Extracorporeal membrane oxygenation (ECMO) and extracorporeal CO 2 removal (ECCO 2 R) represent two modalities that can provide full or partial support of the native lung function, when mechanical ventilation is either unable to achieve sufficient gas exchange to meet metabolic demands, or when its intensity is considered injurious. While the use of ECMO has defined indications in clinical practice, ECCO 2 R remains a promising technique, whose safety and efficacy are still being investigated. Understanding the physiological principles of gas exchange during respiratory ECLS and the interactions with native gas exchange and haemodynamics are essential for the safe applications of these techniques in clinical practice. In this review, we will present the physiological basis of gas exchange in ECMO and ECCO 2 R, and the implications of their interaction with native lung function. We will also discuss the rationale for their use in clinical practice, their current advances, and future directions.

Objectives: Changes in right ventricular size and function are frequently observed in patients with severe acute respiratory distress syndrome. The majority of patients who receive venovenous extracorporeal membrane oxygenation undergo chest CT and transthoracic echocardiography. The aims of this study were to compare the use of CT and transthoracic echocardiography to evaluate the right ventricular function and to determine the prevalence of acute cor pulmonale in this patient population., Design: Observational, retrospective, single-center, cohort study., Setting: Severe respiratory failure and extracorporeal membrane oxygenation center., Patients: About 107 patients with severe acute respiratory distress syndrome managed with venovenous extracorporeal membrane oxygenation., Interventions: Chest CT to evaluate right ventricular size and transthoracic echocardiography to evaluate right ventricular size and function., Measurements and Main Results: All 107 patients had a qualitative assessment of right ventricular size and function on transthoracic echocardiography. Quantitative measurements were available in 54 patients (50%) who underwent transthoracic echocardiography and in 107 of patients (100%) who received CT. Right ventricular dilatation was defined as a right ventricle end-diastolic diameter greater than left ventricular end-diastolic diameter upon visual assessment or an right ventricle end-diastolic diameter/left ventricular end-diastolic diameter and/or right ventricle cavity area/left ventricular cavity area of greater than 0.9. Right ventricle systolic function was visually estimated as being normal or impaired (visual right ventricular systolic impairment). The right ventricle was found to be dilated in 38/107 patients (36%) and in 58/107 patients (54%), using transthoracic echocardiography or CT right ventricle end-diastolic diameter/left ventricular end-diastolic diameter, respectively. When the CT right ventricle cavity/left ventricular cavity area criterion was used, the right ventricle was dilated in 19/107 patients (18%). About 33/107 patients (31%) exhibited visual right ventricular systolic impairment. Transthoracic echocardiography right ventricle end-diastolic diameter/left ventricular end-diastolic diameter showed good agreement with CT right ventricle cavity/left ventricular cavity area ( R 2 = 0.57; p < 0.01). A CT right ventricle cavity/left ventricular cavity area greater than 0.9 provided the optimal cutoff for acute cor pulmonale on transthoracic echocardiography with an AUC of 0.78. Acute cor pulmonale was defined by the presence of a right ventricle "D-shape" and quantitative right ventricle dilatation on transthoracic echocardiography or a right ventricle cavity/left ventricular cavity area greater than 0.9 on CT. A diagnosis of acute cor pulmonale was made in 9/54 (14% patients) on transthoracic echocardiography and in 19/107 (18%) on CT., Conclusions: Changes in right ventricular size and function are common in patients with severe acute respiratory distress syndrome requiring venovenous extracorporeal membrane oxygenation with up to 18% showing imaging evidence of acute cor pulmonale. A CT right ventricular cavity /left ventricular cavity area greater than 0.9 is indicative of impaired right ventricular systolic function., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Purpose of Review: Among noninvasive lung imaging techniques that can be employed at the bedside electrical impedance tomography (EIT) and lung ultrasound (LUS) can provide dynamic, repeatable data on the distribution regional lung ventilation and response to therapeutic manoeuvres.In this review, we will provide an overview on the rationale, basic functioning and most common applications of EIT and Point of Care Ultrasound (PoCUS, mainly but not limited to LUS) in the management of mechanically ventilated patients., Recent Findings: The use of EIT in clinical practice is supported by several studies demonstrating good correlation between impedance tomography data and other validated methods of assessing lung aeration during mechanical ventilation. Similarly, LUS also correlates with chest computed tomography in assessing lung aeration, its changes and several pathological conditions, with superiority over other techniques. Other PoCUS applications have shown to effectively complement the LUS ultrasound assessment of the mechanically ventilated patient., Summary: Bedside techniques - such as EIT and PoCUS - are becoming standards of the care for mechanically ventilated patients to monitor the changes in lung aeration, ventilation and perfusion in response to treatment and to assess weaning from mechanical ventilation., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Severe, acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a rapid deterioration of the respiratory symptoms of patients with COPD, requiring hospital admission and escalation of pharmacological and nonpharmacological care including the more severe cases of respiratory failure and admission to an intensive care unit (ICU). These events severely impact patients' quality of life and prognosis. This review will describe the nonantibiotic, pharmacological treatment options available for critically ill patients with AECOPD. The aim of treatment is to alleviate symptoms, improve patient's functional and respiratory status, reduce mortality, reduce the risk or the duration of invasive mechanical ventilation, and prevent reexacerbations. Inhaled bronchodilators (i.e., short-acting β2-agonists and anticholinergics) and systemic corticosteroids are the main drugs used in the treatment of AECOPD. These drugs are also used in the treatment of stable COPD and in the treatment of AECOPD patients in the non-ICU or community setting. Other drugs are essentially only used in the ICU setting such as inhaled anesthetic agents, ketamine, intravenous methylxanthines, and magnesium. Finally, recently developed drugs, such as the specific phosphodiesterase-4 inhibitors, may play a role in the prevention of relapsing AECOPD following a critical event than the treatment of the exacerbation itself. Although they significantly improve the survival of critically ill patients with AECOPD, none of available drugs, alone or combined, is able to significantly modify the prognosis of patients with COPD. This remains an open challenge for the current and future generations of researchers and clinicians., Competing Interests: None declared., (Thieme. All rights reserved.)

In critical industrial monitoring and control applications, dependability evaluation will be usually required. For wireless sensor networks deployed in industrial plants, dependability evaluation can provide valuable information, enabling proper preventive or contingency measures to assure their correct and safe operation. However, when employing sensor nodes equipped with cameras, visual coverage failures may have a deep impact on the perceived quality of industrial applications, besides the already expected impacts of hardware and connectivity failures. This article proposes a comprehensive mathematical model for dependability evaluation centered on the concept of Quality of Monitoring (QoM), processing availability, reliability and effective coverage parameters in a combined way. Practical evaluation issues are discussed and simulation results are presented to demonstrate how the proposed model can be applied in wireless industrial sensor networks when assessing and enhancing their dependability.

Critically ill patients with coronavirus disease 2019 (COVID-19) present with hypoxaemia and are mechanically ventilated to support gas exchange. We performed a retrospective, observational study of blood gas analyses (n = 3518) obtained from patients with COVID-19 to investigate changes in haemoglobin oxygen (Hb-O 2 ) affinity. Calculated oxygen tension at half-saturation (p 50 ) was on average (±SD) 3·3 (3·13) mmHg lower than the normal p 50 value (23·4 vs. 26·7 mmHg; P < 0·0001). Compared to an unmatched historic control of patients with other causes of severe respiratory failure, patients with COVID-19 had a significantly higher Hb-O 2 affinity (mean [SD] p 50 23·4 [3·13] vs. 24·6 [5.4] mmHg; P < 0·0001). We hypothesise that, due to the long disease process, acclimatisation to hypoxaemia could play a role., (© 2020 British Society for Haematology and John Wiley & Sons Ltd.)

Node mobility in multi-hop communication environments is an important feature of Wireless Sensor Network (WSN)-based monitoring systems. It allows nodes to have freedom of movement, without being restricted to a single-hop communication range. In IEEE 802.15.4 WSNs, nodes are only able to transfer data messages after completing a connection with a coordinator through an association mechanism. Within this context, a handover procedure needs to be executed by a mobile node whenever there is a disconnection from a coordinator and the establishment of a connection to another one. Many applications, such as those found in health monitoring systems, strongly need support for node mobility without loss of data during the handover. However, it has been observed that the time required to execute the handover procedure is one of the main reasons why IEEE 802.15.4 cannot fully support mobility. This paper proposes an improvement to this procedure using a set of combined strategies, such as anticipation of both the handover mechanism and the scan phase enhancement. Simulations show that it is possible to reduce latency during the association and re-association processes, making it feasible to develop WSN-based distributed monitoring systems with mobile nodes and stringent time constraints.

The development of flexible and efficient communication mechanisms is of paramount importance within the context of the Internet of Things (IoT) paradigm. IoT has been used for industrial, commercial, and residential applications, and the IEEE 802.15.4/ZigBee standard is one of the most suitable protocols for this purpose. This protocol is now frequently used to implement large-scale Wireless Sensor Networks (WSNs). In industrial settings, it is becoming increasingly common to deploy cluster-tree WSNs, a complex IEEE 802.15.4/ZigBee-based peer-to-peer network topology, to monitor and control critical processes such as those related to oil or gas, mining, or certain specific chemicals. The remote monitoring of critical events for hazards or disaster detection in large areas is a challenging issue, since the occurrence of events in the monitored environment may severely stress the regular operation of the network. This paper proposes the Dynamic REconfiguration mechanism of cluster-Tree WSNs (DyRET), which is able to dynamically reconfigure large-scale IEEE 802.15.4 cluster-tree WSNs, and to assign communication resources to the overloaded branches of the tree based on the accumulated network load generated by each of the sensor nodes. A complete simulation assessment demonstrates the proposed mechanism's efficiency, and the results show that it can guarantee the required quality of service level for the dynamic reconfiguration of cluster-tree networks.

Objective: The criteria and process for liberation from extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome are not standardized. The predictive accuracy of the oxygen challenge test as a diagnostic test in determining weaning and decannulation from venovenous extracorporeal membrane oxygenation was tested., Design: A single-centre, retrospective, observational cohort study., Setting: Tertiary referral severe respiratory failure centre in a university hospital in the United Kingdom., Patients: 253 adults with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation., Intervention: None., Measurements and Main Results: Patients had median age: 43 years (interquartile range: 32-52) years, extracorporeal membrane oxygenation days: 9 (interquartile range: 6-14) and acute physiology and chronic health evaluation II score 17.5 (interquartile range: 15-20). Oxygen challenge test value (PaO 2-OCT ) with best prediction was 31 kPa (232 mmHg; sensitivity 0.74; specificity 0.70; area under curve 0.77 (confidence interval: 0.73-0.81)). PaO 2-OCT did not perform well as a prospective test to identify readiness to decannulation. Only 24 patients (10%) were decannulated 48 hours after their first positive oxygen challenge test (true positive) and 73.4% patients were false positives (positive oxygen challenge test but not decannulated). True positives had higher tidal volume (541 ± 218 vs 368 mL ± 210; p < 0.05) and minute ventilation (9.34 ± 5.36 vs 6.33 L/min ± 4.43; p < 0.05). Blood flow (3.17 ± 0.23 vs 3.53 L/min ± 0.56; p < 0.05), sweep gas flow (1.42 ±1.83 vs 3.74 L/min ± 2.43; p < 0.05) and extracorporeal membrane oxygenation minute volume at time of first positive oxygen challenge test was lower in true positives (1.66 ± 2.26 vs 4.82 ± 3.43 L/min). This was a strong predictor for decannulation within 48 hours (area under curve: 0.88, confidence interval: 0.88-0.89)., Conclusions: In severe acute respiratory distress syndrome requiring venovenous extracorporeal membrane oxygenation, the PaO 2-OCT is a poor predictor of readiness to decannulate from extracorporeal membrane oxygenation. Additional factors involved in the control of respiratory drive and carbon dioxide clearance, particularly native lung dead space and total minute ventilation, should be assessed.

This review focuses on the use of veno-venous extracorporeal membrane oxygenation for respiratory failure across all blood flow ranges. Starting with a short overview of historical development, aspects of the physiology of gas exchange (i.e., oxygenation and decarboxylation) during extracorporeal circulation are discussed. The mechanisms of phenomena such as recirculation and shunt playing an important role in daily clinical practice are explained.Treatment of refractory and symptomatic hypoxemic respiratory failure (e.g., acute respiratory distress syndrome [ARDS]) currently represents the main indication for high-flow veno-venous-extracorporeal membrane oxygenation. On the other hand, lower-flow extracorporeal carbon dioxide removal might potentially help to avoid or attenuate ventilator-induced lung injury by allowing reduction of the energy load (i.e., driving pressure, mechanical power) transmitted to the lungs during mechanical ventilation or spontaneous ventilation. In the latter context, extracorporeal carbon dioxide removal plays an emerging role in the treatment of chronic obstructive pulmonary disease patients during acute exacerbations. Both applications of extracorporeal lung support raise important ethical considerations, such as likelihood of ultimate futility and end-of-life decision-making. The review concludes with a brief overview of potential technical developments and persistent challenges.

Background: Excessive tidal volume, respiratory rate, and positive end-expiratory pressure (PEEP) are all potential causes of ventilator-induced lung injury, and all contribute to a single variable: the mechanical power. The authors aimed to determine whether high tidal volume or high respiratory rate or high PEEP at iso-mechanical power produce similar or different ventilator-induced lung injury., Methods: Three ventilatory strategies-high tidal volume (twice baseline functional residual capacity), high respiratory rate (40 bpm), and high PEEP (25 cm H2O)-were each applied at two levels of mechanical power (15 and 30 J/min) for 48 h in six groups of seven healthy female piglets (weight: 24.2 ± 2.0 kg, mean ± SD)., Results: At iso-mechanical power, the high tidal volume groups immediately and sharply increased plateau, driving pressure, stress, and strain, which all further deteriorated with time. In high respiratory rate groups, they changed minimally at the beginning, but steadily increased during the 48 h. In contrast, after a sudden huge increase, they decreased with time in the high PEEP groups. End-experiment specific lung elastance was 6.5 ± 1.7 cm H2O in high tidal volume groups, 10.1 ± 3.9 cm H2O in high respiratory rate groups, and 4.5 ± 0.9 cm H2O in high PEEP groups. Functional residual capacity decreased and extravascular lung water increased similarly in these three categories. Lung weight, wet-to-dry ratio, and histologic scores were similar, regardless of ventilatory strategies and power levels. However, the alveolar edema score was higher in the low power groups. High PEEP had the greatest impact on hemodynamics, leading to increased need for fluids. Adverse events (early mortality and pneumothorax) also occurred more frequently in the high PEEP groups., Conclusions: Different ventilatory strategies, delivered at iso-power, led to similar anatomical lung injury. The different systemic consequences of high PEEP underline that ventilator-induced lung injury must be evaluated in the context of the whole body.

The development of efficient sensing technologies and the maturation of the Internet of Things (IoT) paradigm and related protocols have considerably fostered the expansion of sensor-based monitoring applications. A great number of those applications has been developed to monitor a set of information for better perception of the environment, with some of them being dedicated to identifying emergency situations. Current IoT-based emergency systems have limitations when considering the broader scope of smart cities, exploiting one or just a few monitoring variables or even allocating high computational burden to regular sensor nodes. In this context, we propose a distributed multi-tier emergency alerting system built around a number of sensor-based event detection units, providing real-time georeferenced information about the occurrence of critical events, while taking as input a configurable number of different scalar sensors and GPS data. The proposed system could then be used to detect and to deliver emergency alarms, which are computed based on the detected events, the previously known risk level of the affected areas and temporal information. Doing so, modularized and flexible perceptions of critical events are provided, according to the particularities of each considered smart city scenario. Besides implementing the proposed system in open-source electronic platforms, we also created a real-time visualization application to dynamically display emergency alarms on a map, demonstrating a feasible and useful application of the system as a supporting service. Therefore, this innovative approach and its corresponding physical implementation can bring valuable results for smart cities, potentially supporting the development of adaptive IoT-based emergency-aware applications.

Among recent lung imaging techniques and devices, electrical impedance tomography (EIT) can provide dynamic information on the distribution regional lung ventilation. EIT images possess a high temporal and functional resolution allowing the visualization of dynamic physiological and pathological changes on a breath-by-breath basis. EIT detects changes in electric impedance (i.e., changes in gas/fluid ratio) and describes them in real time, both visually through images and waveforms, and numerically, allowing the clinician to monitor disease evolution and response to treatment. The use of EIT in clinical practice is supported by several studies demonstrating a good correlation between impedance tomography data and other validated methods of measuring lung volume. In this review, we will provide an overview on the rationale, basic functioning and most common applications of EIT in the management of mechanically ventilated patients.

Objectives: Quantification of potential for lung recruitment may guide the ventilatory strategy in acute respiratory distress syndrome. However, there are no quantitative data on recruitability in patients with severe acute respiratory distress syndrome who require extracorporeal membrane oxygenation. We sought to quantify potential for lung recruitment and its relationship with outcomes in this cohort of patients., Design: A single-center, retrospective, observational cohort study., Setting: Tertiary referral severe respiratory failure center in a university hospital in the United Kingdom., Patients: Forty-seven adults with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation., Intervention: None., Measurements and Main Results: In patients with severe acute respiratory distress syndrome-mainly of pulmonary origin (86%)-the potential for lung recruitment and the weight of nonaerated, poorly aerated, normally aerated, and hyperaerated lung tissue were assessed at low (5 cmH2O) and high (45 cmH2O) airway pressures. Patients were categorized as high or low potential for lung recruitment based on the median potential for lung recruitment value of the study population. The median potential for lung recruitment was 24.3% (interquartile range = 11.4-37%) ranging from -2% to 76.3% of the total lung weight. Patients with potential for lung recruitment above the median had significantly shorter extracorporeal membrane oxygenation duration (8 vs 13 d; p = 0.013) and shorter ICU stay (15 vs 22 d; p = 0.028), but mortality was not statistically different (24% vs 46%; p = 0.159)., Conclusions: We observed significant variability in potential for lung recruitment in patients with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation. Patients with high potential for lung recruitment had a shorter ICU stay and shorter extracorporeal membrane oxygenation duration.

Rationale: Hyperlactatemia in sepsis may derive from a prevalent impairment of oxygen supply/demand and/or oxygen use. Discriminating between these two mechanisms may be relevant for the early fluid resuscitation strategy. Objectives: To understand the relationship among central venous oxygen saturation (Scv O 2 ), lactate, and base excess to better determine the origin of lactate. Methods: This was a post hoc analysis of baseline variables of 1,741 patients with sepsis enrolled in the multicenter trial ALBIOS (Albumin Italian Outcome Sepsis). Variables were analyzed as a function of sextiles of lactate concentration and sextiles of Scv O 2 . We defined the "alactic base excess," as the sum of lactate and standard base excess. Measurements and Main Results: Organ dysfunction severity scores, physiologic variables of hepatic, metabolic, cardiac, and renal function, and 90-day mortality were measured. Scv O 2 was lower than 70% only in 35% of patients. Mortality, organ dysfunction scores, and lactate were highest in the first and sixth sextiles of Scv O 2 . Although lactate level related strongly to mortality, it was associated with acidemia only when kidney function was impaired (creatinine >2 mg/dl), as rapidly detected by a negative alactic base excess. In contrast, positive values of alactic base excess were associated with a relative reduction of fluid balance. Conclusions: Hyperlactatemia is powerfully correlated with severity of sepsis and, in established sepsis, is caused more frequently by impaired tissue oxygen use, rather than by impaired oxygen transport. Concomitant acidemia was only observed in the presence of renal dysfunction, as rapidly detected by alactic base excess. The current strategy of fluid resuscitation could be modified according to the origin of excess lactate.

Background: Positive end-expiratory pressure is usually considered protective against ventilation-induced lung injury by reducing atelectrauma and improving lung homogeneity. However, positive end-expiratory pressure, together with tidal volume, gas flow, and respiratory rate, contributes to the mechanical power required to ventilate the lung. This study aimed at investigating the effects of increasing mechanical power by selectively modifying its positive end-expiratory pressure component., Methods: Thirty-six healthy piglets (23.3 ± 2.3 kg) were ventilated prone for 50 h at 30 breaths/min and with a tidal volume equal to functional residual capacity. Positive end-expiratory pressure levels (0, 4, 7, 11, 14, and 18 cm H2O) were applied to six groups of six animals. Respiratory, gas exchange, and hemodynamic variables were recorded every 6 h. Lung weight and wet-to-dry ratio were measured, and histologic samples were collected., Results: Lung mechanical power was similar at 0 (8.8 ± 3.8 J/min), 4 (8.9 ± 4.4 J/min), and 7 (9.6 ± 4.3 J/min) cm H2O positive end-expiratory pressure, and it linearly increased thereafter from 15.5 ± 3.6 J/min (positive end-expiratory pressure, 11 cm H2O) to 18.7 ± 6 J/min (positive end-expiratory pressure, 14 cm H2O) and 22 ± 6.1 J/min (positive end-expiratory pressure, 18 cm H2O). Lung elastances, vascular congestion, atelectasis, inflammation, and septal rupture decreased from zero end-expiratory pressure to 4 to 7 cm H2O (P < 0.0001) and increased progressively at higher positive end-expiratory pressure. At these higher positive end-expiratory pressure levels, striking hemodynamic impairment and death manifested (mortality 0% at positive end-expiratory pressure 0 to 11 cm H2O, 33% at 14 cm H2O, and 50% at 18 cm H2O positive end-expiratory pressure). From zero end-expiratory pressure to 18 cm H2O, mean pulmonary arterial pressure (from 19.7 ± 5.3 to 32.2 ± 9.2 mmHg), fluid administration (from 537 ± 403 to 2043 ± 930 ml), and noradrenaline infusion (0.04 ± 0.09 to 0.34 ± 0.31 μg · kg(-1) · min(-1)) progressively increased (P < 0.0001). Lung weight and lung wet-to-dry ratios were not significantly different across the groups. The lung mechanical power level that best discriminated between more versus less severe damage was 13 ± 1 J/min., Conclusions: Less than 7 cm H2O positive end-expiratory pressure reduced atelectrauma encountered at zero end-expiratory pressure. Above a defined power threshold, sustained positive end-expiratory pressure contributed to potentially lethal lung damage and hemodynamic impairment.

Objectives: Minimally invasive extracorporeal CO2 removal is an accepted supportive treatment in chronic obstructive pulmonary disease patients. Conversely, the potential of such technique in treating acute respiratory distress syndrome patients remains to be investigated. The aim of this study was: 1) to quantify membrane lung CO2 removal (VCO2ML) under different conditions and 2) to quantify the natural lung CO2 removal (VCO2NL) and to what extent mechanical ventilation can be reduced while maintaining total expired CO2 (VCO2tot = VCO2ML + VCO2NL) and arterial PCO2 constant., Design: Experimental animal study., Setting: Department of Experimental Animal Medicine, University of Göttingen, Germany., Subjects: Eight healthy pigs (57.7 ± 5 kg)., Interventions: The animals were sedated, ventilated, and connected to the artificial lung system (surface 1.8 m, polymethylpentene membrane, filling volume 125 mL) through a 13F catheter. VCO2ML was measured under different combinations of inflow PCO2 (38.9 ± 3.3, 65 ± 5.7, and 89.9 ± 12.9 mm Hg), extracorporeal blood flow (100, 200, 300, and 400 mL/min), and gas flow (4, 6, and 12 L/min). At each setting, we measured VCO2ML, VCO2NL, lung mechanics, and blood gases., Measurements and Main Results: VCO2ML increased linearly with extracorporeal blood flow and inflow PCO2 but was not affected by gas flow. The outflow PCO2 was similar regardless of inflow PCO2 and extracorporeal blood flow, suggesting that VCO2ML was maximally exploited in each experimental condition. Mechanical ventilation could be reduced by up to 80-90% while maintaining a constant PaCO2., Conclusions: Minimally invasive extracorporeal CO2 removal removes a relevant amount of CO2 thus allowing mechanical ventilation to be significantly reduced depending on extracorporeal blood flow and inflow PCO2. Extracorporeal CO2 removal may provide the physiologic prerequisites for controlling ventilator-induced lung injury.

Background: The transversalis fascia plane and the quadratus lomborum blocks target the branches of T12-L1 nerves and provide analgesia in patients undergoing surgery involving the corresponding dermatomes. The transversalis fascia is believed to contribute to determine the spread of local anesthetic in such blocks. Nonetheless, the anatomy of this fascia and its possible role in these blocks still have to be precisely defined., Methods: We conducted a series of 10 dissections and full-thickness specimens were obtained from one side for the microscopic analysis., Results: Macroscopic study showed failed to identify a distinguishable fascial structure between the fascia of the transversus abdominis muscle and the peritoneum. Microscopic examination showed the presence of a further fascial layer (0.1-0.2 mm), ascribable to transversalis fascia. Transversalis fascia and transversus abdominis epimysium posteriorly diverge: transversus epimysium goes posteriorly to quadratus lomborum to joint the oblique internal aponeurosis, while transversalis fascia continues in front to quadratus lomborum. So, a little fascial triangle (2-3 mm) is formed on the lateral border of quadratus lomborum, defined by transversalis fascia and transversus abdominis. Inside this triangle, T12 and L1 nerves are present., Conclusions: Considering the thinness of the transversalis fascia and the small size of the triangular space that contains the target nerves, this is most likely a virtual, ideal rather than realistic injection site. Accordingly, it is probable that the local anesthetic is injected in the much wider retroperitoneal space and reaches the nerves by spreading backwards through the thin transversalis fascia.

Wireless Sensor Networks (WSN) are enabler technologies for the implementation of the Internet of Things (IoT) concept. WSNs provide an adequate infrastructure for the last-link communication with smart objects. Nevertheless, the wireless communication medium being inherently unreliable, there is the need to increase its communication reliability. Techniques based on the use of cooperative communication concepts are one of the ways to achieve this target. Within cooperative communication techniques, nodes selected as relays transmit not only their own data, but also cooperate by retransmitting data from other nodes. A fundamental step to improve the communication reliability of WSNs is related to the use of efficient relay selection techniques. This paper proposes a relay selection technique based on multiple criteria to select the smallest number of relay nodes and, at the same time, to ensure an adequate operation of the network. Additionally, two relay updating schemes are also investigated, defining periodic and adaptive updating policies. The simulation results show that both proposed schemes, named Periodic Relay Selection and Adaptive Relay Selection, significantly improve the communication reliability of the network, when compared to other state-of-the-art relay selection schemes.

Wireless sensor networks have been considered as an effective solution to a wide range of applications due to their prominent characteristics concerning information retrieving and distributed processing. When visual information can be also retrieved by sensor nodes, applications acquire a more comprehensive perception of monitored environments, fostering the creation of wireless visual sensor networks. As such networks are being more often considered for critical monitoring and control applications, usually related to catastrophic situation prevention, security enhancement and crises management, fault tolerance becomes a major expected service for visual sensor networks. A way to address this issue is to evaluate the system dependability through quantitative attributes (e.g., reliability and availability), which require a proper modeling strategy to describe the system behavior. That way, in this paper, we propose a methodology to model and evaluate the dependability of wireless visual sensor networks using Fault Tree Analysis and Markov Chains. The proposed modeling strategy considers hardware, battery, link and coverage failures, besides considering routing protocols on the network communication behavior. The methodology is automated by a framework developed and integrated with the SHARPE (Symbolic Hierarchical Automated Reliability and Performance Evaluator) tool. The achieved results show that this methodology is useful to compare different network implementations and the corresponding dependability, enabling the uncovering of potentially weak points in the network behavior.

Objective: The aim of this study was to pool data on the proportion and prognostic impact of sources of bleeding in patients requiring re-exploration after adult cardiac surgery., Design: Systematic review of the literature and meta-analysis., Setting: Multistitutional study., Measurements and Main Results: A literature review was performed to identify studies published since 1990 evaluating the outcome after reoperation for bleeding or tamponade after adult cardiac surgery. Eighteen studies including 5,1497 patients fulfilled the selection criteria. Reoperation for bleeding/tamponade was performed in 2,455 patients (4.6%; 95% confidence interval [CI] 3.9%-5.2%, I 2 92%). These had a significantly higher risk of in-hospital/30-day mortality compared with patients not reoperated for bleeding (pooled rates: 9.3% v 2.3%; risk ratio 3.30; 95% CI 2.52-4.32; I 2 47%; 8 studies; 25,463 patients). Surgical sites of bleeding were identified in 65.7% of cases (95% CI 58.3%-73.2%; I 2 94%), cardiac site bleeding in 40.9% of cases (95% CI 29.7%-52.0%; I 2 94%), and mediastinal/sternum site bleeding in 27.0% of cases (95% CI 16.8%-37.3%; I 2 94%). The main sites of bleeding were the body of the graft (20.2%), the sternum (17.0%), vascular sutures (12.5%), the internal mammary artery harvest site (13.0%), and anastomoses (9.9%). In metaregression, surgical site bleeding was associated with a lower risk of in-hospital/30-day mortality compared with diffuse bleeding (p = 0.003)., Conclusions: Surgical site bleeding is identified in two-thirds of patients undergoing re-exploration after adult cardiac surgery. Meticulous surgical technique and systematic intraoperative checking of potential surgical sites of bleeding at the time of the original cardiac surgery may reduce the risk of such a severe complication., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Extracorporeal gas exchange is increasingly used for various indications. Among these are refractory acute respiratory failure, including the acute respiratory distress syndrome (ARDS), and the avoidance of ventilator-induced lung injury (VILI) by enabling lung-protective ventilation. Additionally, extracorporeal gas exchange allows the treatment of hypercapnic respiratory failure while helping to unload the respiratory muscles and avoid intubation and invasive ventilation, as well as facilitating weaning from the ventilator. These indications are based on a reasonable physiologic rationale but must be weighed against the costs and complications associated with the technique. This article summarizes current evidence and indications for extracorporeal gas exchange., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Ventilator-induced lung injury develops from interactions between the lung parenchyma and applied mechanical power. In acute respiratory distress syndrome, the lung is smaller size with an inhomogeneous structure. The same mechanical force applied on a reduced parenchyma would produce volutrauma; the concentration of mechanical forces at inhomogeneous interfaces produces atelectrauma. Higher positive end-expiratory pressures favor volutrauma and reduce atelectrauma; lower values do the opposite. Volutrauma and atelectrauma harms and benefits, however, seem to be equivalent at 5 to 15 cm H 2 O. At values greater than 15 cm H 2 O, the risk of damage outweighs the benefits of major atelectrauma prevention., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Rationale: The ratio of Pa O 2 to Fi O 2 (P/F) defines acute respiratory distress syndrome (ARDS) severity and suggests appropriate therapies., Objectives: We investigated 1) whether a 150-mm-Hg P/F threshold within the range of moderate ARDS (100-200 mm Hg) would define two subgroups that were more homogeneous; and 2) which criteria led the clinicians to apply extracorporeal membrane oxygenation (ECMO) in severe ARDS., Methods: At the 150-mm-Hg P/F threshold, moderate patients were split into mild-moderate (n = 50) and moderate-severe (n = 55) groups. Patients with severe ARDS (Fi O 2 not available in three patients) were split into higher (n = 63) and lower (n = 18) Fi O 2 groups at an 80% Fi O 2 threshold., Measurements and Main Results: Compared with mild-moderate ARDS, patients with moderate-severe ARDS had higher peak pressures, Pa CO 2 , and pH. They also had heavier lungs, greater inhomogeneity, more noninflated tissue, and greater lung recruitability. Within 84 patients with severe ARDS (P/F < 100 mm Hg), 75% belonged to the higher Fi O 2 subgroup. They differed from the patients with severe ARDS with lower Fi O 2 only in Pa CO 2 and lung weight. Forty-one of 46 patients treated with ECMO belonged to the higher Fi O 2 group. Within this group, the patients receiving ECMO had higher Pa CO 2 than the 22 non-ECMO patients. The inhomogeneity ratio, total lung weight, and noninflated tissue were also significantly higher., Conclusions: Using the 150-mm-Hg P/F threshold gave a more homogeneous distribution of patients with ARDS across the severity subgroups and identified two populations that differed in their anatomical and physiological characteristics. The patients treated with ECMO belonged to the severe ARDS group, and almost 90% of them belonged to the higher Fi O 2 subgroup.

Background: Severe hypoperfusion can cause lung damage. We studied the effects of regional perfusion block in normal lungs and in the lungs that had been conditioned by lavage with 500 ml saline and high V T (20 ml kg -1 ) ventilation., Methods: Nineteen pigs (61.2 ± 2.5 kg) were randomized to five groups: controls (n = 3), the right lower lobe block alone (n = 3), lavage and high V T (n = 4), lung lavage, and high V T plus perfusion block of the right (n = 5) or left (n = 4) lower lobe. Gas exchange, respiratory mechanics, and hemodynamics were measured hourly. After an 8-h observation period, CT scans were obtained at 0 and 15 cmH 2 O airway pressure., Results: Perfusion block did not damage healthy lungs. In conditioned lungs, the left perfusion block caused more edema in the contralateral lung (777 ± 62 g right lung vs 484 ± 204 g left; p < 0.05) than the right perfusion block did (581 ± 103 g right lung vs 484 ± 204 g left; p n.s.). The gas/tissue ratio, however, was similar (0.5 ± 0.3 and 0.8 ± 0.5; p n.s.). The lobes with perfusion block were not affected (gas/tissue ratio right 1.6 ± 0.9; left 1.7 ± 0.5, respectively). Pulmonary artery pressure, PaO 2 /FiO 2 , dead space, and lung mechanics were more markedly affected in animals with left perfusion block, while the gas/tissue ratios were similar in the non-occluded lobes., Conclusions: The right and left perfusion blocks caused the same "intensity" of edema in conditioned lungs. The total amount of edema in the two lungs differed because of differences in lung size. If capillary permeability is altered, increased blood flow may induce or increase edema.

The adverse effects of mechanical ventilation in acute respiratory distress syndrome (ARDS) arise from two main causes: unphysiological increases of transpulmonary pressure and unphysiological increases/decreases of pleural pressure during positive or negative pressure ventilation. The transpulmonary pressure-related side effects primarily account for ventilator-induced lung injury (VILI) while the pleural pressure-related side effects primarily account for hemodynamic alterations. The changes of transpulmonary pressure and pleural pressure resulting from a given applied driving pressure depend on the relative elastances of the lung and chest wall. The term 'volutrauma' should refer to excessive strain, while 'barotrauma' should refer to excessive stress. Strains exceeding 1.5, corresponding to a stress above ~20 cmH 2 O in humans, are severely damaging in experimental animals. Apart from high tidal volumes and high transpulmonary pressures, the respiratory rate and inspiratory flow may also play roles in the genesis of VILI. We do not know which fraction of mortality is attributable to VILI with ventilation comparable to that reported in recent clinical practice surveys (tidal volume ~7.5 ml/kg, positive end-expiratory pressure (PEEP) ~8 cmH 2 O, rate ~20 bpm, associated mortality ~35%). Therefore, a more complete and individually personalized understanding of ARDS lung mechanics and its interaction with the ventilator is needed to improve future care. Knowledge of functional lung size would allow the quantitative estimation of strain. The determination of lung inhomogeneity/stress raisers would help assess local stresses; the measurement of lung recruitability would guide PEEP selection to optimize lung size and homogeneity. Finding a safety threshold for mechanical power, normalized to functional lung volume and tissue heterogeneity, may help precisely define the safety limits of ventilating the individual in question. When a mechanical ventilation set cannot be found to avoid an excessive risk of VILI, alternative methods (such as the artificial lung) should be considered.

Several factors have been recognized as possible triggers of ventilator-induced lung injury (VILI). The first is pressure (thus the 'barotrauma'), then the volume (hence the 'volutrauma'), finally the cyclic opening-closing of the lung units ('atelectrauma'). Less attention has been paid to the respiratory rate and the flow, although both theoretical considerations and experimental evidence attribute them a significant role in the generation of VILI. The initial injury to the lung parenchyma is necessarily mechanical and it could manifest as an unphysiological distortion of the extracellular matrix and/or as micro-fractures in the hyaluronan, likely the most fragile polymer embedded in the matrix. The order of magnitude of the energy required to break a molecular bond between the hyaluronan and the associated protein is 1.12×10 -16 Joules (J), 70-90% higher than the average energy delivered by a single breath of 1L assuming a lung elastance of 10 cmH 2 O/L (0.5 J). With a normal statistical distribution of the bond strength some polymers will be exposed each cycle to an energy large enough to rupture. Both the extracellular matrix distortion and the polymer fractures lead to inflammatory increase of capillary permeability with edema if a pulmonary blood flow is sufficient. The mediation analysis of higher vs. lower tidal volume and PEEP studies suggests that the driving pressure, more than tidal volume, is the best predictor of VILI, as inferred by increased mortality. This is not surprising, as both tidal volume and respiratory system elastance (resulting in driving pressure) may independently contribute to the mortality. For the same elastance driving pressure is a predictor similar to plateau pressure or tidal volume. Driving pressure is one of the components of the mechanical power, which also includes respiratory rate, flow and PEEP. Finding the threshold for mechanical power would greatly simplify assessment and prevention of VILI., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

The positive end-expiratory pressure (PEEP), since its introduction in the treatment of acute respiratory failure, up to the 1980s was uniquely aimed to provide a viable oxygenation. Since the first application, a large debate about the criteria for selecting the PEEP levels arose within the scientific community. Lung mechanics, oxygen transport, venous admixture thresholds were all proposed, leading to PEEP recommendations from 5 up to 25 cmH 2 O. Throughout this period, the main concern was the hemodynamics. This paradigm changed during the 1980s after the wide acceptance of atelectrauma as one of the leading causes of ventilator induced lung injury. Accordingly, the PEEP aim shifted from oxygenation to lung protection. In this framework, the prevention of lung opening and closing became an almost unquestioned dogma. Consequently, as PEEP keeps open the pulmonary units opened during the previous inspiratory phase, new methods were designed to identify the 'optimal' PEEP during the expiratory phase. The open lung approach requires that every collapsed unit potentially openable is opened and maintained open. The methods to assess the recruitment are based on imaging (computed tomography, electric impedance tomography, ultrasound) or mechanically-driven gas exchange modifications. All the latest assume that whatever change in respiratory system compliance is due to changes in lung compliance, which in turn is uniquely function of the recruitment. Comparative studies, however, showed that the only possible approach to measure the amount of collapsed tissue regaining inflation is the CT scan. In fact, all the other methods estimate as recruitment the gas entry in pulmonary units already open at lower PEEP, but increasing their compliance at higher PEEP. Since higher PEEP is usually more indicated (also for oxygenation) when the recruitability is higher, as occurs with increasing severity, a meaningful PEEP selection requires the assessment of recruitment. The Berlin definition may help in this assessment., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

The IEEE 802.15.4/ZigBee cluster-tree topology is a suitable technology to deploy wide-scale Wireless Sensor Networks (WSNs). These networks are usually designed to support convergecast traffic, where all communication paths go through the PAN (Personal Area Network) coordinator. Nevertheless, peer-to-peer communication relationships may be also required for different types of WSN applications. That is the typical case of sensor and actuator networks, where local control loops must be closed using a reduced number of communication hops. The use of communication schemes optimised just for the support of convergecast traffic may result in higher network congestion and in a potentially higher number of communication hops. Within this context, this paper proposes an Alternative-Route Definition (ARounD) communication scheme for WSNs. The underlying idea of ARounD is to setup alternative communication paths between specific source and destination nodes, avoiding congested cluster-tree paths. These alternative paths consider shorter inter-cluster paths, using a set of intermediate nodes to relay messages during their inactive periods in the cluster-tree network. Simulation results show that the ARounD communication scheme can significantly decrease the end-to-end communication delay, when compared to the use of standard cluster-tree communication schemes. Moreover, the ARounD communication scheme is able to reduce the network congestion around the PAN coordinator, enabling the reduction of the number of message drops due to queue overflows in the cluster-tree network.

This retrospective, observational study compared the impact of a point-of-care rotational thromboelastometry (ROTEM ® ) method versus conventional bleeding management in terms of postoperative (24-h) blood loss, intraoperative and postoperative (24-h) transfusion requirement and length of stay in the postoperative intensive care unit (ICU) in patients undergoing cardiac surgery. Forty consecutive patients undergoing cardiac surgery under ROTEM ® -guided hemostatic management were enrolled; the control population included 40 selected patients undergoing similar interventions without ROTEM ® monitoring. Significantly more patients in the thromboelastometry group versus the control group received fibrinogen (45 vs 10 %; p < 0.0001), while fewer received a transfusion (40 vs 72.5 %; p < 0.0033). Compared with control group patients, those in the thromboelastometry group had less postoperative bleeding (285 vs 393 mL; p < 0.0001), a shorter time from cardiopulmonary bypass discontinuation to skin suture (79.3 vs 92.6 min; p = 0.0043) and a shorter stay in the ICU (43.7 vs 52.5 h; p = 0.0002). In our preliminary experience, ROTEM ® -guided bleeding management was superior to conventional management of bleeding in patients undergoing complex cardiac surgery with cardiopulmonary bypass in terms of reduced postoperative blood loss, transfusion requirement, and length of ICU stay.

Energy consumption is a major issue in Wireless Sensor Networks (WSNs), as nodes are powered by chemical batteries with an upper bounded lifetime. Estimating the lifetime of batteries is a difficult task, as it depends on several factors, such as operating temperatures and discharge rates. Analytical battery models can be used for estimating both the battery lifetime and the voltage behavior over time. Still, available models usually do not consider the impact of operating temperatures on the battery behavior. The target of this work is to extend the widely-used Kinetic Battery Model (KiBaM) to include the effect of temperature on the battery behavior. The proposed Temperature-Dependent KiBaM (T-KiBaM) is able to handle operating temperatures, providing better estimates for the battery lifetime and voltage behavior. The performed experimental validation shows that T-KiBaM achieves an average accuracy error smaller than 0.33%, when estimating the lifetime of Ni-MH batteries for different temperature conditions. In addition, T-KiBaM significantly improves the original KiBaM voltage model. The proposed model can be easily adapted to handle other battery technologies, enabling the consideration of different WSN deployments.

The use ofWireless Sensor Network (WSN) technologies is an attractive option to support wide-scale monitoring applications, such as the ones that can be found in precision agriculture, environmental monitoring and industrial automation. The IEEE 802.15.4/ZigBee cluster-tree topology is a suitable topology to build wide-scale WSNs. Despite some of its known advantages, including timing synchronisation and duty-cycle operation, cluster-tree networks may suffer from severe network congestion problems due to the convergecast pattern of its communication traffic. Therefore, the careful adjustment of transmission opportunities (superframe durations) allocated to the cluster-heads is an important research issue. This paper proposes a set of proportional Superframe Duration Allocation (SDA) schemes, based on well-defined protocol and timing models, and on the message load imposed by child nodes (Load-SDA scheme), or by number of descendant nodes (Nodes-SDA scheme) of each cluster-head. The underlying reasoning is to adequately allocate transmission opportunities (superframe durations) and parametrize buffer sizes, in order to improve the network throughput and avoid typical problems, such as: network congestion, high end-to-end communication delays and discarded messages due to buffer overflows. Simulation assessments show how proposed allocation schemes may clearly improve the operation of wide-scale cluster-tree networks.

Traditional coagulative parameters are of limited use in identifying perioperative coagulopathy occurring in patients undergoing major elective orthopedic surgery (MEOS). The aim of our study was to evaluate the coagulation changes in patients undergoing MEOS and to facilitate an early detection of perioperative coagulopathy in patients experiencing major intraoperative bleeding. We enrolled 40 consecutive patients (M/F 10/30, age range 34-90 years) who underwent MEOS at the Orthopedic Unit of the Padua University Hospital, Italy, between January 2014 and January 2015. Blood samples were obtained at the following time points: T0-pre: 30 min before surgery; T0-post: 30 min after the end of the procedure; T1: morning of the first postoperative day; T2: 7 ± 2 days after surgery. Patients who experienced an intraoperative blood loss ≥250 mL/h were considered as cases. Routine coagulative parameters, thromboelastometry and thrombin generation (TG) profiles were evaluated. At baseline, a significantly lower platelet count and FIBTEM MCF/AUC were observed in patents with excessive bleeding (p < 0.05 and 0.02/0.01, respectively). At T0-post and T1 intervals, cases showed hypocoagulation characterized by a significantly low platelet count (p = 0.001), prolonged CFT INTEM/EXTEM, reduction of alpha-angle and MaxV INTEM/EXTEM, MCF and AUC INTEM/EXTEM/FIBTEM (p < 0.05 in all comparisons). The only TG parameter standing out between study groups was time to peak at T0-pre. A low platelet count and fibrinogen activity were associated with significant intraoperative bleeding in patients undergoing MEOS. Thromboelastometry performed by ROTEM(®) identifies patients with coagulopathy.

Background: The objective was to evaluate the early outcome after adult cardiac surgery in Jehovah's Witnesses (JWs) compared with controls not refusing blood transfusions., Study Design and Methods: A literature review was performed through PubMed, Scopus, and Google Scholar to identify any comparative study evaluating the outcome of JWs and patients not refusing blood transfusion after adult cardiac surgery., Results: Six studies comparing the outcome of 564 JWs and 903 controls fulfilled the inclusion criteria of this study. All series included a matched control cohort. Baseline characteristics of these two cohorts were similar, but JWs had higher hemoglobin (Hb) levels as reported in three studies. Pooled analysis of postoperative outcomes showed that JWs had higher postoperative levels of Hb (data from four studies: mean, 11.5 g/L vs. 9.8 g/L; p < 0.001) and significantly less postoperative blood loss (mean, 402 mL vs. 826 mL; p < 0.001) compared to controls. JWs and controls had similar early outcome. However, JWs had a nonsignificant trend toward decreased early mortality (2.6% vs. 3.6%; p = 0.318), reoperation for bleeding (3.2% vs. 4.7%; p = 0.070), atrial fibrillation (9.9% vs. 14.3%; p = 0.056), stroke (2.2% vs. 3.1%; p = 0.439), myocardial infarction (0.4% vs. 1.4%; p = 0.203), and length of stay in the intensive care unit (1.5 days vs. 2.0 days; p = 0.081)., Conclusion: JWs undergoing adult cardiac surgery have a nonsignificant trend toward better early outcome than controls receiving or not blood transfusions. The suboptimal quality of available studies prevents conclusive results on the possible benefits of a transfusion-free strategy in patients not refusing blood transfusion., (© 2016 AABB.)

Dairy cattle farming is of great economic and social importance in all Brazilian's regions. Parasites can reduce milk productivity, especially the tick Rhipicephalus (Boophilus) microplus. This study consisted of a questionnaire answered by 40 milk producers in the northwestern region of the State of São Paulo. The aim was to ascertain how these producers controlled ticks and other parasites. Very many of them knew nothing about the biological cycle of the cattle tick or about strategic control or acaricide efficacy tests. The majority (87.5%) controlled ticks at a high frequency, without technical criteria and care to apply the acaricide. Spraying was the most used mode of acaricide application (95%) and endectocides were used by 45%. Cattle tick fever was the harm most associated with ticks (87.5%) followed closely by screwworm (77.5%). However, 65% were satisfied with their tick control. About the control of others parasites, all dewormed at least twice a year their animals; 65% were controlling horn fly; 40% had problems with screwworm. The interviewers had in general good level of education and the farms generally exhibited a high degree of technology for milk production on pasture because half of them received technical assistance frequently.