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The respective effects of PEEP and pressure support delivered through the helmet interface in hypoxemic patients need to be better understood.To assess the respective effects of helmet pressure support (NIV) and continuous positive-airway pressure (CPAP) compared to high-flow nasal oxygen (HFNO) on effort to breathe, lung inflation and gas exchange in hypoxemic patients (PaO2/FiO2≤200).Fifteen patients underwent 1-hour phases (constant FiO2) of HFNO (60 L/min), helmet NIV (PEEP=14 cmH2O, pressure support=12 cmH2O) and CPAP (PEEP=14 cmH2O) in randomized sequence.Inspiratory esophageal (ΔPES) and transpulmonary pressure (ΔPL) swings were used as surrogates for inspiratory effort and lung distension, respectively. Tidal volume (VT) and end-expiratory lung volume were assessed with electrical impedance tomography.ΔPES was lower during NIV vs. CPAP and HFNO (5[3-9] cmH2O vs. 13[10-19] vs. 10[8-13], p=0.001 and p=0.01). ΔPL was not statistically different between treatments. PaO2/FiO2 ratio was significantly higher during NIV and CPAP vs. HFNO (166[136-215] and 175[158-281] vs. 120[107-149], p=0.002 and p=0.001). NIV and CPAP similarly increased VT vs. HFNO (mean change: 70%[95%CI: 17-122], p=0.02; 93% [95%CI: 30-155], p=0.002) and end-expiratory lung volume (mean change: 198%[95%CI: 67-330], p=0.001; 263%[95%CI: 121-407], p=0.001), mostly due to increased aeration/ventilation in dorsal lung regions. During HFNO, 14/15 patients had pendelluft involving10% of VT: pendelluft was mitigated by CPAP and further by NIV.Compared to HFNO, helmet NIV, but not CPAP, reduced ΔPES. CPAP and NIV similarly increased oxygenation, end-expiratory lung volume and VT, without affecting ΔPL. NIV, and to a lesser extent, CPAP, mitigated pendelluft. Clinical trial registration available at www.gov, ID: NCT04241861.

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.

Objective and design Our prospective study assesses the role of detailed lung ultrasound (LUS) features to discriminate the etiological diagnosis of acute lower respiratory tract infection (ALRTI) in children. Methodology We analyzed patients aged from 1 month to 17 years admitted between March 2018 and April 2020 who were hospitalized for ALRTI. For all patients, history, clinical parameters, microbiological data, and lung ultrasound data were collected. Patients were stratified into three main groups (“bacterial”, “viral”, “atypical”) according to the presumed microbial etiology and LUS findings evaluated according to the etiological group. Nasopharyngeal swabs were obtained from all patients. A qualitative diagnostic test developed by Nurex S.r.l. was used for identification of bacterial and fungal DNA in respiratory samples. The Seegene Allplex™ Respiratory assays were used for the molecular diagnosis of viral respiratory pathogens. In addition, bacterial culture of blood and respiratory samples were performed, when indicated. Results A total of 186 children with suspected ALRTI (44% female) with an average age of 6 were enrolled in the study. We found that some ultrasound findings as size, number and distribution of consolidations, the position and motion of air bronchograms, pleural effusions and distribution of vertical artifacts significantly differ (p Conclusion Our study provides a detailed analysis of LUS features able to predict the ALRTI ethology in children. These findings may help the physicians to better manage a child with ALRTI and to offer personalized approach, from diagnosis to treatment and follow-up.

In this paper we describe a new protocol—named RaFeVA (Rapid Femoral Vein Assessment)—for the systematic US assessment of the veins in the inguinal area and at mid-thigh, designed to evaluate patency and caliber of the common and superficial femoral veins and choose the best venipuncture site before insertion of a FICC.

Ultrasound for diagnostic and procedural purposes is becoming a standard in daily clinical practice including anaesthesiology and peri-operative medicine. The project of European Society of Anaesthesiology (ESA) Task Force for the development of clinical guidelines on the PERioperative uSE of Ultra-Sound (PERSEUS) project has focused on the use of ultrasound in two areas that account for the majority of procedures performed routinely in the operating room: vascular access and regional anaesthesia. Given the extensive literature available in these two areas, this paper will focus on the use of ultrasound-guidance for vascular access. A second part will be dedicated to peripheral nerve/neuraxial blocks. The Taskforce identified three main domains of application in ultrasound-guided vascular cannulation: adults, children and training. The literature search were performed by a professional librarian from the Cochrane Anaesthesia and Critical and Emergency Care Group in collaboration with the ESA Taskforce. The Grading of Recommendation Assessment (GRADE) system for assessing levels of evidence and grade of recommendations were used. For the use of ultrasound-guided cannulation of the internal jugular vein, femoral vein and arterial access, the level evidence was classified 1B. For other accesses, the evidence remains limited. For training in ultrasound guidance, there were no studies. The importance of proper training for achieving competency and full proficiency before performing any ultrasound-guided vascular procedure must be emphasised.

In recent years, lung ultrasound (LUS) has been increasingly used for the diagnosis of respiratory diseases in both adult and pediatric patients. However, asthma is a field in which the use of LUS is not yet well defined, or is in development. In the following case series, we describe clinical, laboratory, and radiological results, as well as detailed lung ultrasound findings of six children with asthma: some of them with acute asthma attack and with inadequately controlled allergic asthma or childhood asthma; others with acute asthma and allergic or infantile asthma adequately controlled by preventive therapy. Finally, we describe the clinical, laboratory, and imaging parameters of a child with severe allergic asthma in the absence of exacerbation. In these cases, albeit at different times, LUS played an important role in both the initial diagnostic process and follow-up. It also showed different ultrasound features depending on the severity of the individual asthma based on the type of asthmatic phenotype and control of it.

Background To produce statements based on the available evidence and an expert consensus (as members of the Lung Ultrasound Working Group of the Italian Society of Analgesia, Anesthesia, Resuscitation, and Intensive Care, SIAARTI) on the use of lung ultrasound for the management of patients with COVID-19 admitted to the intensive care unit. Methods A modified Delphi method was applied by a panel of anesthesiologists and intensive care physicians expert in the use of lung ultrasound in COVID-19 intensive critically ill patients to reach a consensus on ten clinical questions concerning the role of lung ultrasound in the following: COVID-19 diagnosis and monitoring (with and without invasive mechanical ventilation), positive end expiratory pressure titration, the use of prone position, the early diagnosis of pneumothorax- or ventilator-associated pneumonia, the process of weaning from invasive mechanical ventilation, and the need for radiologic chest imaging. Results A total of 20 statements were produced by the panel. Agreement was reached on 18 out of 20 statements (scoring 7–9; “appropriate”) in the first round of voting, while 2 statements required a second round for agreement to be reached. At the end of the two Delphi rounds, the median score for the 20 statements was 8.5 [IQR 8.9], and the agreement percentage was 100%. Conclusion The Lung Ultrasound Working Group of the Italian Society of Analgesia, Anesthesia, Resuscitation, and Intensive Care produced 20 consensus statements on the use of lung ultrasound in COVID-19 patients admitted to the ICU. This expert consensus strongly suggests integrating lung ultrasound findings in the clinical management of critically ill COVID-19 patients.

Central venous access devices are routinely used in clinical practice for administration of fluids and medications, for drawing blood samples and for hemodynamic monitoring. The adoption of ultrasound guided venipuncture has significantly reduced procedure-related complications, as documented by the recommendations of most recent guidelines. Ultrasound has also an important role also in other aspects of central venous catheterization, such as in the pre-procedural evaluation of the venous patrimony and in the detection of early and late non-infective complications. Recently, bedside ultrasound has been regarded as a promising tool also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in adult patients, and to suggest a structured standardized protocol for clinical practice.

The goal of this survey was to describe the use and diffusion of lung ultrasound (LUS), the level of training received before and during the COVID-19 pandemic, and the clinical impact LUS has had on COVID-19 cases in intensive care units (ICU) from February 2020 to May 2020. The Italian Lung Ultrasound Survey (ITALUS) was a nationwide online survey proposed to Italian anesthesiologists and intensive care physicians carried out after the first wave of the COVID-19 pandemic. It consisted of 27 questions, both quantitative and qualitative. 807 responded to the survey. The median previous LUS experience was 3 years (IQR 1.0-6.0). 473 (60.9 %) reported having attended at least one training course on LUS before the COVID-19 pandemic. 519 (73.9 %) reported knowing how to use the LUS score. 404 (52 %) reported being able to use LUS without any supervision. 479 (68.2 %) said that LUS influenced their clinical decision-making, mostly with respect to patient monitoring. During the pandemic, the median of patients daily evaluated with LUS increased 3-fold (p 0.001), daily use of general LUS increased from 10.4 % to 28.9 % (p 0.001), and the daily use of LUS score in particular increased from 1.6 % to 9.0 % (p 0.001). This survey showed that LUS was already extensively used during the first wave of the COVID-19 pandemic by anesthesiologists and intensive care physicians in Italy, and then its adoption increased further. Residency programs are already progressively implementing LUS teaching. However, 76.7 % of the sample did not undertake any LUS certification.ZIEL: Das Ziel dieser Umfrage war es, den Einsatz und die Verbreitung von Lungenultraschall (LUS), den Ausbildungstand vor und während der COVID-19-Pandemie sowie die klinische Bedeutung des LUS auf COVID-19-Fälle auf Intensivstationen (ICU) von Februar 2020 bis Mai 2020 zu beschreiben. Die „Italian Lung Ultrasound Survey“ (ITALUS) war eine landesweite Online-Umfrage, die italienischen Anästhesisten und Intensivmedizinern nach der ersten Welle der COVID-19-Pandemie unterbreitet wurde. Sie bestand aus 27 quantitativen und qualitativen Fragen. 807 Ärzte nahmen an der Umfrage teil. Die Vorerfahrung im LUS lag bei median 3 Jahren (IQR 1,0–6,0). 473 (60,9 %) gaben an, vor der COVID-19-Pandemie mindestens eine Schulung zu LUS besucht zu haben. 519 (73,9 %) gaben an, mit dem LUS-Score vertraut zu sein. 404 (52 %) gaben an, LUS ohne Aufsicht nutzen zu können. 479 (68,2 %) gaben an, dass LUS ihre klinische Entscheidungsfindung beeinflusst, vor allem in Bezug auf die Patientenüberwachung. Während der Pandemie stieg der Median der Patienten, die täglich mit LUS untersucht wurden, um das 3-Fache (p 0,001), der tägliche Einsatz des allgemeinen LUS erhöhte sich von 10,4 % auf 28,9 % (p 0,001), und insbesondere der tägliche Einsatz des LUS-Scores stieg von 1,6 % auf 9,0 % (p 0,001). Diese Umfrage zeigte, dass LUS bereits während der ersten Welle der COVID-19-Pandemie von Anästhesisten und Intensivmedizinern in Italien in großem Umfang eingesetzt wurde und dann weiter zugenommen hat. In der Facharztausbildung wird LUS bereits zunehmend eingeführt. Allerdings hatten in der Stichprobe 76,7 % keine LUS-Zertifizierung.

Background In critically ill patients continuous EEG (cEEG) is recommended in several conditions. Recently, a new wireless EEG headset (CerebAir®,Nihon-Kohden) is available. It has 8 electrodes, and its positioning seems to be easier than conventional systems. Aim of this study was to evaluate the feasibility of this device for cEEG monitoring, if positioned by ICU physician. Methods Neurological patients were divided in two groups according with the admission to Neuro-ICU (Study-group:20 patients) or General-ICU (Control-group:20 patients). In Study group, cEEG was recorded by CerebAir® assembled by an ICU physician, while in Control group a simplified 8-electrodes-EEG recording positioned by an EEG technician was performed. Results Time for electrodes applying was shorter in Study-group than in Control-group: 6.2 ± 1.1′ vs 10.4 ± 2.3′; p p > 0.05. In Study-group, cEEG was interrupted for risk of skin lesions in 4 cases after 52 ± 4 h. cEEG was obtained without EEG technician in all cases in Study-group; quality of EEG was similar. Conclusions Although several limitations should be considered, this simplified EEG system could be feasible even if EEG technician was not present. It was faster to position if compared with standard techniques, and can be used for continuous EEG monitoring. It could be very useful as part of diagnostic process in an emergency setting.

Nowadays, ultrasound-guidance is commonly used in regional anaesthesia (USGRA) and to locate the spinal anatomy in neuraxial analgesia. The aim of this second guideline on the PERi-operative uSE of UltraSound (PERSEUS-RA) is to provide evidence as to which areas of regional anaesthesia the use of ultrasound guidance should be considered a gold standard or beneficial to the patient. The PERSEUS Taskforce members were asked to define relevant outcomes and rank the relative importance of outcomes following the GRADE process. Whenever the literature was not able to provide enough evidence, we decided to use the RAND method with a modified Delphi process. Whenever compared with alternative techniques, the use of USGRA is considered well tolerated and effective for some nerve blocks but there are certain areas, such as truncal blocks, where a lack of robust data precludes useful comparison. The new frontiers for further research are represented by the application of USG during epidural analgesia or spinal anaesthesia as, in these cases, the evidence for the value of the use of ultrasound is limited to the preprocedure identification of the anatomy, providing the operator with a better idea of the depth and angle of the epidural or spinal space. USGRA can be considered an essential part of the curriculum of the anaesthesiologist with a defined training and certification path. Our recommendations will require considerable changes to some training programmes, and it will be necessary for these to be phased in before compliance becomes mandatory.

Objective and designOur prospective study is one of the largest prospective study assessing the role of detailed lung ultrasound features to discriminate the etiological diagnosis of Community acquired pneumonia (CAP) in children.MethodologyWe prospectively analysed patients aged from 1 month to 17 years admitted between March 2018 and April 2020 who were hospitalized for CAP. For all patients included in the study, history, clinical parameters, microbiological data, and lung ultrasound data were collected.Patients were stratified into three main groups (“bacterial”, “viral”, “atypical”) according to the presumed microbial aetiology and lung ultrasound findings evaluated according to the aetiological group.ResultsWe found that some ultrasound findings as size, number and distribution of consolidations, the position and motion of air bronchograms, pleural effusions and distribution of vertical artifacts significantly differ (p < 0.05) in children with bacterial, viral and atypical CAP. Conversely, clinical parameters and laboratory were not able to significantly distinguish between these groups. Chest x-ray, despite being still widely used, was the less useful tool in this discrimination.ConclusionOur study provides a detailed analysis of LUS features able to predict the etiology CAP in children. These findings may help the physicians to better manage a child with CAP and to offer personalized approach, from diagnosis to treatment and follow-up.

The 2020 COVID pandemic has forced everyone to update the usual medical procedures and adapt them to a new situation characterized by a high risk of contamination of the health operator. The placement of a venous access device is no exception. In the experience of the vascular access team of our hospital, hit by the COVID epidemic in March 2020, the safety of both the patient and the staff can be ensured by an insertion bundle of few smart strategies, which include choice of long dwelling peripheral catheters (midline catheters) rather than short venous cannulas; use of power injectable peripherally inserted central catheters in the COVID patients in intensive care unit requiring a central line; use of wireless probes—easy to carry, easy to clean—for ultrasound guided venipuncture; avoidance of x-rays, using alternative methods for tip location such as intracavitary electrocardiography or trans-thoracic echocardiography; strict adoption of the barrier precautions recommended by the international guidelines.

Lung ultrasound has been suggested recently by the Chinese Critical Care Ultrasound Study Group and Italian Academy of Thoracic Ultrasound as an accurate tool to detect lung involvement in COVID-19. Although chest computed tomography (CT) represents the gold standard to assess lung involvement, with a specificity superior even to that of the nasopharyngeal swab for diagnosis, lung ultrasound examination can be a valid alternative to CT scan, with certain advantages, particularly for pregnant women. Ultrasound can be performed directly at the bed-side by a single operator, reducing the risk of spreading the disease among health professionals. Furthermore, it is a radiation-free exam, making it safer and easier to monitor those patients who require a series of exams. We report on four cases of pregnant women affected by COVID-19 who were monitored with lung ultrasound examination. All patients showed sonographic features indicative of COVID-19 pneumonia at admission: irregular pleural lines and vertical artifacts (B-lines) were observed in all four cases, and patchy areas of white lung were observed in two. Lung ultrasound was more sensitive than was chest X-ray in detecting COVID-19. In three patients, we observed almost complete resolution of lung pathology on ultrasound within 96 h of admission. Two pregnancies were ongoing at the time of writing, and two had undergone Cesarean delivery with no fetal complications. Reverse transcription polymerase chain reaction analysis of cord blood and newborn swabs was negative in both of these cases. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Introduction: The aim of this study was to evaluate the effectiveness and safety of a new three-component ‘bundle’ for insertion and management of centrally inserted central catheters (CICCs), designed to minimize catheter-related bloodstream infections (CRBSIs) in critically ill children. Methods: Our ‘bundle’ has three components: insertion, management, and education. Insertion and management recommendations include: skin antisepsis with 2% chlorhexidine; maximal barrier precautions; ultrasound-guided venipuncture; tunneling of the catheter when a long indwelling time is expected; glue on the exit site; sutureless securement; use of transparent dressing; chlorhexidine sponge dressing on the 7th day; neutral displacement needle-free connectors. All CICCs were inserted by appropriately trained physicians proficient in a standardized simulation training program. Results: We compared CRBSI rate per 1000 catheters-days of CICCs inserted before adoption of our new bundle with that of CICCs inserted after implementation of the bundle. CICCs inserted after adoption of the bundle remained in place for a mean of 2.2 days longer than those inserted before. We found a drop in CRBSI rate to 10%, from 15 per 1000 catheters-days to 1.5. Conclusions: Our data suggest that a bundle aimed at minimizing CR-BSI in critically ill children should incorporate four practices: (1) ultrasound guidance, which minimizes contamination by reducing the number of attempts and possible break-down of aseptic technique; (2) tunneling the catheter to obtain exit site in the infra-clavicular area with reduced bacterial colonization; (3) glue, which seals and protects the exit site; (4) simulation-based education of the staff.

Measuring and monitoring of intracranial pressure is considered standard of care in patients with suspected intracranial hypertension. Sonographic assessment of the optic nerve sheath diameter (ONSD) has been promising and potentially useful for noninvasive intracranial hypertension screening. ONSD measurements are easy to perform, repeatable at bedside, fast, low cost, and radiation-free. However, they are still burdened by inter-rater variability, lack of ultrasound (US) setting standardization (e.g., US frequency, focus depth, etc.), and possible artifacts. To overcome this problem, we propose the CLOSED protocol associated with equipment specifications, as a guide to minimize the occurrence of such artifacts enabling a more reliable and accurate measurement. We suggest that color Doppler could be used as a new standard evaluation for the ONSD.

Introduction:Ultrasound-guided cannulation of the axillary vein in the infraclavicular area has several potential advantages for both short-term and long-term venous access devices. Currently, there are two techniques to approach axillary vein for ultrasound-guided cannulation: out-of-plane puncture in the short-axis view and the in-plane puncture in the long-axis view. We propose a novel ultrasound-guided puncture technique of axillary vein for centrally inserted central catheter placement, which consists in the oblique-axis view of the axillary vein coupled with the in-plane puncture. The main objectives of this study were feasibility and safety of this approach. The primary endpoints were the success rate and early complications; the secondary endpoints were late complications.Methods:We analyzed data from a retrospective cohort of 80 ultrasound-guided cannulation of axillary vein performed with the oblique axis-in-plane technique in 80 cancer patients requiring a totally implantable central venous access, at CRO Aviano National Cancer Institute, during the period from January 2016 up to October 2017. We focused on the percentage of successful venous cannulation at the first attempt and on the cumulative incidence of early and late complications.Results:Axillary vein cannulation was successful at the first attempt in 77 out of 80 patients (96%). We had no significant complications during placement or in the first 48 h. The total number of catheter days was 27,432. The cumulative incidence of catheter-related bloodstream infection was of 0.036 per 1000 catheter days (only one case). We had no infection of the pocket of the reservoir, no symptomatic venous thrombosis, and no catheter migration.Conclusion:Our data show that the oblique axis-in-plane technique of the ultrasound approach to the axillary vein is feasible and safe.

Background: In the pediatric population, spontaneous intracerebral hemorrhage (sICH) is as common as ischemic stroke and accounts for significant mortality and morbidity. Differently from the ischemic stroke, there are few guidelines for directing management of sICH. This article aims to analyze both clinical outcomes and prognostic factors in order to produce tools for the design of prospective randomized studies addressed to implement treatment of pediatric sICH. Methods: Twelve-year retrospective review of a single-center consecutivesICH pediatric cases admitted to the pediatric intensive care unit (PICU). Selected end points were survival, PICU stay, and dichotomized Glasgow Outcome Score (GOS), with recovery and moderate disability (GOS 4-5) classified as favorable outcome and vegetative state or severe disability (GOS 2-3) classified as unfavorable. Results: Data of 107 children younger than 14 years admitted to our PICU due to sICH were analyzed. Overall PICU mortality was 24.2%. On multivariate analysis, the single factor markedly influencing survival was the presence of midline shift ( P = .002). In PICU survivors, there were 42 GOS 2-3 and 39 GOS 4-5. A low Glasgow Coma Scale (GCS) on PICU admission was predictive of severe neurological impairment in survivors ( P = .003). Intraventricular hemorrhage and infratentorial origin did not influence outcome in this series. Conclusion: The severity of presentation of sICH expressed by the midline shift and the GCS at PICU admission are significant prognostic factors for survival and neurological outcome. Some prognostic factors of the adult population have not been confirmed.

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.

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.

Introduction The central venous pressure (CVP) is the most commonly used static marker of preload for guiding fluid therapy in critically ill patients, though its usefulness remains controversial. Centrally inserted central catheters (CICCs) are the gold-standard devices for CVP monitoring but peripherally inserted central catheters (PICCs) may represent a valid alternative. We undertook a systematic review and meta-analysis with the aim to investigate whether the difference between PICC- and CICC-measured CVP is not significant. Methods We searched for clinical studies published in PubMed and EMBASE databases from inception until December 21st 2016. We included studies providing data on paired and simultaneous CVP measurement from PICCs and CICCs. We conducted two analyses on the values of CVP, the first one according to the total number of CVP assessments, the second one considering the number of patients recruited. Results Four studies matched the inclusion criteria, but only three of them provided data for the meta-analyses. Both analyses showed non-significant differences between PICC-measured and CICC-measured CVP: 1489 paired simultaneous CVP assessments (MD 0.16, 95%CI −0.14, 0.45, p = 0.30) on a total of 57 patients (MD 0.22, 95%CI −1.46, 1.91, p = 0.80). Both analyses showed no heterogeneity (I2 = 0%). Conclusions Available evidence supports that CVP monitoring with PICCs is accurate and reproduces similar values to those obtained from CICCs. The possibility to monitor CVP should not be used among clinical criteria for preferring a CICC over a PICC line.

Background The aim of this study is to examine the clinical data of children who underwent tracheostomy during their stay in Pediatric Intensive Care Unit (PICU), in order to describe the relationship between the timing of tracheostomy, the length of PICU stay and the occurrence of ventilator-associated pneumonia (VAP). Methods This is a retrospective cohort study that collects all patients undergoing tracheostomy during their PICU stay over a six-year period. Data collection included PICU length of stay, days of intubation, days of mechanical ventilation, primary indication for tracheostomy, information about VAP and decannulations. The early tracheostomy group was defined as patients who had ten or fewer days of continuous ventilation, whereas the late tracheostomy group had more than ten days of continuous ventilation. Results A significant decrease in the rate of VAP incidence was noticed in the early tracheostomy group vs. late group (P=0.004, OR=0.39, 95% CI: 0.18-0.85). No differences were observed about decannulation, need of long-term ventilation and death rate. Significant decreases of days of mechanical ventilation and PICU stay were found in subgroup of patients who underwent early tracheostomy and were decannulated within 18 months. Conclusions No standard timing for tracheostomy placement has been established in the pediatric population. Early tracheostomy can shorten the days of ventilation and hospitalization in PICU and reduce the incidence of VAP, but further studies are needed to identify patient categories in which it can be of benefit.

SummaryIntroduction Performed for many years in clinical settings, pleural and lung ultrasound (PLUS) has emerged to be an invaluable tool to diagnose underlying conditions of respiratory failure, to monitor disease progression and to ensure appropriate therapeutic intervention. PLUS basically relies on the analysis of two prevalent ultrasound artefacts: A-lines and B-lines. A-lines are hyperechoic reverberation artefacts of the pleural line. A-lines combined with lung sliding show that lungs are well aerated. B-lines are vertical hyperechoic reverberation artefacts arising from pleural line extending to the bottom of the screen. The prevalence of B-lines indicates a pathologic parenchyma. Since PLUS is readily available, easily affordable, and biologically non-invasive, it is especially suitable for bedside clinical care in critically ill and unstable adult patients. Several authors have recently proposed PLUS for application in critically ill neonates and children. We report a case in which PLUS was used to clinically monitor a complex lung lesion during treatment of a child with congenital heart disease suffering from severe lung injury. Case Description A 1-year-old male with hypoplastic left heart syndrome underwent bidirectional Glenn procedure and systemic-to-left pulmonary artery shunt for heart palliation. After surgery, he developed a severe acute respiratory distress syndrome (ARDS) and extra-corporeal membrane oxygenation (ECMO) treatment was started. PLUS was performed daily to monitor the disease's progression and response to treatment during lung rest. As B-lines were decreasing and A-lines were becoming visible, we were able to monitor the improving aeration of the injured lung. The ultrasound showed high consistency with traditional imaging. Discussion Due to its non-ionizing nature, low cost, easy availability, easy repeatability and real-time results, PLUS is a feasible and beneficial bedside imaging technique for critically ill and unstable adult and pediatric patients. A reliable monitoring of ongoing treatments is certainly helpful to provide appropriate intervention, correctly schedule chest X-ray and CT-scan, and optimize ECMO weaning. The present case suggests that PLUS may be a successful and useful tool for monitoring lung diseases in children with CHD with severe post-operative complex lung injury. Pediatr Pulmonol. 2014; 49:n–n. © 2014 Wiley Periodicals, Inc.

We report the case of a 12-day-old newborn affected by coarctation of the aorta and intraventricular defect who underwent coarctectomy and pulmonary artery banding. On post-operative day 7, the patient suffered from pulseless electric activity due to tension pneumothorax. Point-of-care ultrasound was performed during cardiopulmonary resuscitation in an attempt to diagnose pneumothorax. The diagnosis was made without delaying or interrupting chest compressions, and the pneumothorax was promptly treated.

Purpose Placement of central venous catheters by the infraclavicular route can be achieved by ultrasound-guided puncture of the axillary vein. However, in some cases, the axillary vein may be difficult to puncture because it is too deep or too small or because it is collapsing significantly during breathing. The objective of this observational study was to determine the effect of 90° abduction of the arm associated with forward position of the shoulder on axillary vein diameters. Material and methods In a group of 30 healthy volunteers and in a group of 40 patients during spontaneous breathing, we used ultrasound to examine the axillary vein, visualizing it in short axis, with the arm at 0° and at 90° abduction, pushing the shoulder forward. Results The axillary vein was easily identified in 100% of subjects, with relevant variability in terms of depth from the skin, diameter, and tendency to collapse during inspiration. Significant increase of axillary vein diameters was found after 90° abduction in 52 of the 70 cases studied. Conclusion These findings suggest that a 90° abduction of the arm, particularly if associated with a forward position of the shoulder, facilitates the visualization of the axillary vein, making its ultrasound-guided venipuncture easier.

A series of 186 patients with blunt chest trauma was studied with transthoracic ultrasonography to diagnose pneumothorax and to evaluate its size and location. The results were compared with bedside chest radiography and spiral CT scan. The prevalence of pneumothorax on CT scan was 56/186 (30.1%). Pneumothorax was proven on radiography in 30/56 cases without false positive results: "radiographic deep sulcus sign" was evident in 3/29 cases, 26/29 cases being occult. The ultrasound study demonstrated the presence of pneumothorax in 55/56 patients: one occult pneumothorax was missed and no false positive results were observed. The CT scan differed of +/-2.3 cm (range 1-5 cm) from the US study in evaluating size and location of pneumothorax. In conclusion, ultrasound study may detect occult pneumothorax undiagnosed by standard plain radiography. It reflects accurately the extent of pneumothorax if compared with CT scan, outlining the "ultrasonographic deep sulcus sign" on anterior chest wall.

Neurally adjusted ventilatory assist (NAVA) is a new ventilator modality with an innovative synchronization technique. Our aim is to verify if NAVA is feasible and safe in terms of physiological and clinical variables in infants recovering from severe acute respiratory distress syndrome (ARDS).This is a pilot nested study to help future trial design.The study was performed in third-level academic pediatric intensive care units.Infants affected by severe ARDS requiring high-frequency ventilation and weaned with NAVA during 2010 were included. Controls (2:1 ratio) were ARDS infants weaned with pressure support ventilation (PSV) during 2008-2009 matched for age, gas exchange impairment, and weight.The main outcome measures were the physiological and ventilator parameters and the duration of ventilator support in PSV or NAVA.Ten infants treated with NAVA and 20 with PSV were studied. Heart rate (P.001) and mean arterial pressure (P.001) increased less during NAVA than during PSV. Similarly, Pao2/Fio2 ratio decreased less in NAVA than in PSV (P.001). Neurally adjusted ventilatory assist also resulted in lower Paco2 (P.001) and peak pressure (P = .001), as well as higher minute ventilation (P = .013). COMFORT score (P = .004) and duration of support were lower in NAVA than in PSV (P = .011).Neurally adjusted ventilatory assist is safe and suitable in infants recovering from severe ARDS. It could provide better results than PSV and is worth to be investigated in a multicenter randomized trial.

In patients affected by intra-abdominal hypertension, bladder or gastric pressure measurement may be usefully integrated by ultrasounds in order to detect early hemodynamic impairment. The purpose of this study was to search for changes in abdominal vein size and flow induced by intra-abdominal hypertension.Physiologic study.Postoperative intensive care unit of a university hospital.Sixteen healthy volunteers.Four echographic assessments of vessel sizes and blood velocities were randomly performed in the following settings: 1) baseline, 2) intra-abdominal hypertension simulated by a tight pelvic stabilizer around the waist, 3) noninvasive ventilation with a facial mask, and 4) intra-abdominal hypertension plus noninvasive ventilation.The model of intra-abdominal hypertension was validated in eight subjects by measuring gastric pressure. During intra-abdominal hypertension, 1) the inferior vena cava was compressed (significant decrease of both anteroposterior and lateral diameters) and deformed (decreased anteroposterior/lateral diameter ratio), and deformation, but not compression, was attenuated by noninvasive ventilation associated with intra-abdominal hypertension; 2) the portal vein was also compressed (decreased diameter); and 3) blood velocities did not change significantly in the inferior vena cava, portal vein, right suprahepatic vein, or right external iliac vein. In the receiver operating characteristic curve analysis, an inferior vena cava section area (normalized for body surface) of lower than 1 cm²/m² discriminated between intra-abdominal hypertension presence and absence with a sensitivity of 65.6% and a specificity of 87.5% (p = .0001). Noninvasive ventilation alone did not significantly affect vein sizes and velocities. The resistive index, calculated by pulse wave Doppler signal from segmental branches of the right renal artery, increased slightly, but significantly, during intra-abdominal hypertension alone, suggesting an increase of intrarenal pressure.Simulated intra-abdominal hypertension was associated with decreased inferior vena cava section area and increased resistive index in renal arteries. Further studies are now needed to investigate whether these changes may be of value to integrate bladder or gastric pressure measurement in clinical practice.