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Background: Alternative noninvasive methods capable of excluding intracranial hypertension through use of transcranial Doppler (ICPtcd) in situations where invasive methods cannot be used or are not available would be useful during the management of acutely brain-injured patients. The objective of this study was to determine whether ICPtcd can be considered a reliable screening test compared to the reference standard method, invasive ICP monitoring (ICPi), in excluding the presence of intracranial hypertension. Methods: This was a prospective, international, multicenter, unblinded, diagnostic accuracy study comparing the index test (ICPtcd) with a reference standard (ICPi), defined as the best available method for establishing the presence or absence of the condition of interest (i.e., intracranial hypertension). Acute brain-injured patients pertaining to one of four categories: traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) or ischemic stroke (IS) requiring ICPi monitoring, were enrolled in 16 international intensive care units. ICPi measurements (reference test) were compared to simultaneous ICPtcd measurements (index test) at three different timepoints: before, immediately after and 2 to 3 h following ICPi catheter insertion. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated at three different ICPi thresholds (> 20, > 22 and > 25 mmHg) to assess ICPtcd as a bedside real-practice screening method. A receiver operating characteristic (ROC) curve analysis with the area under the curve (AUC) was used to evaluate the discriminative accuracy and predictive capability of ICPtcd. Results: Two hundred and sixty-two patients were recruited for final analysis. Intracranial hypertension (> 22 mmHg) occurred in 87 patients (33.2%). The total number of paired comparisons between ICPtcd and ICPi was 687. The NPV was elevated (ICP > 20 mmHg = 91.3%, > 22 mmHg = 95.6%, >

BACKGROUND: The aim of this study is to determine relationships between lung aeration assessed by lung ultrasound (WS) with non-invasive ventilation (NIMV) outcome, intensive care unit (ICU) admission and mechanical ventilation (MV) needs in COVID-19 respiratory failure.METHODS: A cohort of adult patients with COVID-19 respiratory failure underwent LUS during initial assessment. A simplified LUS protocol consisting in scanning six areas, three for each side. was adopted. A score from 0 to 3 was assigned to each area. Comprehensive LUS score (LUSsc) was calculated as the sum of the score in all areas. LUSsc, the amount of involved sonographic lung areas (LUSq), the number of lung quadrants radiographically infiltrated and the degree of oxygenation impairment at admission (SpO(2)/FiO(2) ratio) were compared to NIMV Outcome, MV needs and ICU admission.RESULTS: Among 85 patients prospectively included in the analysis, 49 of 61 needed MV. LUSsc and LUSq were higher in patients who required MV (median 12 [IQR 8-14] and median 6 [IQR 4-6], respectively) than in those who did not (6 [IQR 2-9] and 3 [IQR 1-5], respectively), both P<0.001. NIMV trial failed in 26 patients out 36. LUSsc and LUSq were significantly higher in patients who failed NIMV than in those who did not. From ROC analysis, LUSsc >= 12 and LUSq >= 5 gave the best cut-off values for NIMV failure prediction (AUC=0.95, 95% CI 0.83-0.99 and AUC=0.81, 95% CI 0.65-0.91, respectively).CONCLUSIONS: Our data suggest LUS as a possible tool for identifying patients who are likely to require MV and ICU admission or to fail a NIMV trial.

Central venous access devices are often needed in neonates admitted to Neonatal Intensive Care Unit. The location of the tip of the central catheter is usually assessed by post-procedural X-ray. However, this strategy is inaccurate and time consuming. Recent guidelines strongly recommend intra-procedural methods of tip location, to increase the cost-effectiveness of the maneuver and to shorten the time between device placement and utilization. In this regard, real-time ultrasound represents the most promising tool for tip navigation and location in neonates. The aim of this paper is (a) to review all the evidence available about ultrasound-based tip navigation and tip location of central catheters in the neonatal population (b) to propose a novel protocol for tip navigation and location (Neo-ECHOTIP) based on such evidence.

Introduction: The intracavitary electrocardiographic method is recommended for assessing the location of the tip of central venous catheter when there is an identifiable P wave. Previous reports suggested that intracavitary electrocardiographic method might also be applied to patients with atrial fibrillation, considering the so-called f waves as a surrogate of the P wave. Methods: We studied 18 atrial fibrillation patients requiring simultaneously a central venous catheter and a trans-esophageal echocardiography. An intracavitary electrocardiographic trace was recorded with the catheter tip in three different positions defined by trans-esophageal echocardiography imaging: in the superior vena cava, 2 cm above the cavo-atrial junction; at the cavo-atrial junction; and in the right atrium, 2 cm below the cavo-atrial junction. Three different criteria of measurement of the f wave pattern in the TQ tract were used: the mean height of f waves (method A); the height of the highest f wave (method B); the difference between the highest positive peak and the lowest negative peak (method C). Results: There were no complications. With the tip placed at the cavo-atrial junction, the mean value of the f waves was significantly higher than in the other two positions. All three methods were effective in discriminating the tip position at the cavo-atrial junction, though method B proved to be the most accurate. Conclusion: A modified intracavitary electrocardiographic technique can be safely used for detecting the location of the tip of central venous catheters in atrial fibrillation patients: the highest activity of the f waves is an accurate indicator of the location of the tip at the cavo-atrial junction.

Background: Recent meta-analyses failed to support the reliability of ultrasound assessment of the inferior vena cava (IVC) to predict fluid responsiveness. However, the techniques utilized were heterogeneous. We hypothesized that the variability of the elliptic section and caliber of the IVC along its course may influence ultrasound evaluation. Therefore, we investigated IVC size and shape at four levels, before and after a fluid challenge. Methods: Twenty mechanically-ventilated adult patients who received a fluid challenge after cardiac surgery were enrolled. They were regarded as responders if the cardiac index increased more than 15%. Before and after the fluid challenge, IVC anteroposterior (AP) and lateral (LA) diameters, the flat ratio, and the distensibility index were assessed by ultrasound just above the iliac veins, at the confluence of the renal veins, before the confluence of the hepatic veins (where blood flow velocity was also measured), and after it. Results: At all levels, IVC section was elliptical, so that IVC diameters varied between a minimum and a maximum according to the measurement angle. Such interval increased in correspondence of the renal veins, where IVC section was more eccentric. The distensibility index was higher when assessed on AP diameters. After the fluid challenge, non-responders showed a diffuse increase of AP diameters, whereas responders showed an increase of blood velocity before the confluence of the hepatic veins. Conclusions: The elliptic section should be considered when assessing IVC size. AP diameters are shorter and more affected by the respiratory cycle. After a fluid challenge, an increase of blood velocity associated with unchanged AP diameters may suggest fluid responsiveness.

Clinical Outcomes and Prognostic Factors for Spontaneous Intracerebral Hemorrhage in Pediatric ICU: A 12-Year Experience

Targeting zero catheter-related bloodstream infections in pediatric intensive care unit: a retrospective matched case-control study