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Pierluigi Fusco, Angela Iuorio, Mirco Della Valle, Fausto FerraroDipartimento Della Donna, Del Bambino, Della Chirurgia Generale e Specialistica, Università Degli Studi Della Campania Luigi Vanvitelli, Naples, IT 80138, ItalyAbstract: Since its introduction in 1985 with Ciaglia, percutaneous tracheostomy (PT) was contraindicated in emergency settings and obesity. However, several case series in the last 20 years have documented the use of PT in life-threatening airway emergencies. We present a case of severe acute airway obstruction in a 66-year-old woman successfully treated with a placement of an awake PT. The woman’s glottic obstruction was caused by a recurrent laryngeal neoplasia and revealed by nasoendoscopy. This acute condition required a serious effort from the patient to oxygenate and thereforeprevented orotracheal intubation as well as the use of any supraglottic device and/or sedation. Blood aspiration after a first attempt to make a quick access to the tracheal lumen with an emergency cricothyroidotomy, and difficulties in the exact identification of tumor infiltration, led us to perform an awake tracheostomy. Due to elevated risk of airway bleeding, we started with a surgical approach to better identify anatomical structures.After the correct inter-tracheal ring space identification, sudden worsening of clinical symptoms required that we complete the procedure quickly with the aid of a Ciaglia Blue Rhino™-Cook (CBR) tracheostomy kit. At the tracheostomy tube placement, the patient quickly resolved her dyspnea and physiological breathing was restored.Keywords: emergency, hypoxia, tracheostomy

PURPOSE: To evaluate (i) the appropriateness, safety, and patient outcomes after placement of the VenaTech LP caval filter and (ii) the success of filter insertion through various venous access routes. MATERIALS AND METHODS: An open multicenter prospective observational study was conducted in 12 European centers, including an initial part limited to four centers. Patients with common indications were eligible for inclusion after approval by an independent ethics committee. Over a 42-month period, 106 patients (46 men [43.4%], 60 women [56.6%]), 72.2 years +/- 13.3 of age (range, 37-97 y), with poor prognoses were included. Patients were examined 2-5 days after the procedure, then at 30 days +/- 5 and 90 days +/- 15 for clinical follow-up and filter assessment. Evaluation criteria were based on occurrence of pulmonary embolism (PE), adverse events, death, filter position, and caval patency. Data were available in 101 case report forms at days 2-5, in 75 at day 30 +/- 5, and in 60 at day 90 +/- 15. Two patients (1.9%) were lost to follow-up. RESULTS: The overall mortality rate was 20.8%. PE was present in 71 patients (67.0%). History of venous thromboembolic disease (VTED) was noted in 32 patients (30.2%), and recently diagnosed VTED was present in 101 patients (95.3%). Partial caval thrombosis was present before the procedure. Filter tilting of 10-45 degrees was seen in 3.9% of cases at days 2-5, 4.3% of cases at day 30 +/- 5, and 1.9% of cases at day 90 +/- 15. Follow-up evidenced neither clinical signs of PE nor significant device-related events. CONCLUSIONS: In a prospective patient cohort with a projected 3-month mortality rate of nearly 21.0% as a result of severe prognoses, the success of insertion via various venous access routes and the appropriateness and safety of the VenaTech LP caval filter were assessed. Findings at 90-day follow-up were free of symptomatic PE and device-related adverse effects

Background and Aim: percutaneous endoscopic gastrostomy (PEG) is an effective way of providing enteral feeding to patients with functionally normal gastrointestinal tract who cannot meet their nutritional needs because of inadequate oral intake. This retrospective study evaluated the clinical outcome of critically ill patients with high assistance level undergoing PEG in a general ICU over a 12 year period. Patients and Methods: we studied a cohort of 82 patients who underwent PEG over a 12-year period between 1 January 1999 and 31 December 2010. Patients were followed-up for 1 year after PEG placement. Results: There were no complications related either to the procedure or to the management of PEG, even in house nursing. In one patient, PEG with a collapsible bumper was successfully removed because the patient fully recovered from his neurological problem. Catheter substitution was necessary in three patients during the first year, because of stoma inflammation due to enteric reflux between the stoma and the catheter. One year after PEG, 66 patients were still alive while 16 patients died from the underlying disease during hospitalization. None of the patients with PEG had aspiration pneumonia. Conclusions: PEG, in expert hands, is a safe and effective procedure for enteral nutrition. Moreover, catheters should be chosen in relation to the duration of enteral feeding and as to whether the patient is likely to recover from his underlying disease.

Objective To determinate the accuracy and safety of implantation of the PORT-A-CATH®Fluoro Free®with CATH-FINDER® systemaidto determinate cathetertip position. Study Design The studyincluded32patients (15 males, 17 females) aged 51± 25 (mean ± s.d.) with malignantdiseaseneedinglong termintravenoustherapy. The CATH-FINDER® electroniccathetersensingdevicewasutilized to localize and position the central venous catheter tip.All patients underwent to post-operative chest x-ray and to a 2-weeks follow-up, to evaluate early complications. Results For the 32 portimplanted the operative time was 33,78± 5,39 minutes (mean ±s.d.). Allcathetertipswerepositionedaccurately(in the lower part of the superior vena cava) with CATH-FINDER® system, asconfirmed by chestradiography, performed 2 hours post implantation, and no patient required fluoroscopy. 20 ports(62,5%) wereplaced via the right subclavianvein, 5 (15,62%) via the leftsubclavianvein, 5 (15,62%) via the right innerjugularvein and 2 (6,25%) via the leftinnerjugularvein. No intraoperative or postoperative early complication wasdeveloped (suchasthrombophlebitis, hematoma, obstruction, pneumothorax,dislodgement or malposition of the central venous catheter). Discussion Implantation of the PORT-A-CATH® with the CATH-FINDER® system was performed easily, accurately and safely. The CATH-FINDER® system appears as an effective alternative to fluoroscopy peroperatively for accurate placement of catheter tip in the lower part of superior vena cava, by using the 3rd rib parasternally as external landmark. This determines a lower radiation exposure to staff and patients, and a significant reduction in cost placement.

Aim. Noninvasive positive-pressure ventilation (NIV) is a safe method of improving gas exchange in patients with several types of acute respiratory failure,1 but its application in hypoxemic ALI/ARDS is controversial.2 We report two cases of conscious and collaborative patients with moderate ARDS (3) successfully treated with a helmet-NIV in our ICU. Case report 1. A 17 years-old woman underwent, in one month, four abdominal surgeries, until final total colectomy for Hirschprung disease, complicated by intra-abdominal sepsis. After the last surgery, in fourth day, she developed tachycardia, dyspnea, respiratory rate (RR)=45 breaths/min and bilateral opacities on chest X-ray, so she was admitted to our ICU. Arterial blood gases revealed hypoxemia (PaO2/FiO2=184) and hypocapnia (pCO2=24 mmHg). Hemodynamic was stable with no left ventricular failure (APACHE II score 14). During the first 24 hrs, we used hel- met-NIV (BIPAP: PEEP=5 cmH2O; “delta”ASB=4 cmH2O; FiO2=0.5) until oxygenation improved and RR decreased (PaO2/FiO2=300, RR=30 breaths/min). On the seventh day opacities at the chest X-ray disappeared and the patient was discharged in spontaneous breathing with PaO2/FiO2=500. Case report 2. A 26 years-old woman suffering from anorexia nervosa, BMI=10.93 and immunocompromised, was admit- ted in ICU for hypoglycemic coma. After resolution, she remained at our unit for vital signs monitoring and forced parenteral nutrition. In 13th day, acutely, hyperthermia without leukocytosis, dyspnea (SpO2=92%, RR=42 breaths/min, PaO2/FiO2=124, pCO2=36 mmHg), tachycar-  dia, and bilateral infiltrates on chest X-ray, with stable hemodynamics, appeared (APACHE II score 19). We placed helmet-NIV (BIPAP: PEEP=7 cmH2O, “delta”ASB=9 cmH2O; FiO2=0.5). In the first 36 hrs there was a rapid increase in oxygenation (SpO2=100%, PaO2/FiO2=246, RR=26 breaths/min), but the patient had poor compliance, so we performed small cycles of NIV lasting 2-4 hrs, interrupted by Venturi mask O2-therapy, applying Helmet when desatura- tion occurred. Only in the seventh day there was a sensible improvement of oxygenation (PaO2/FiO2=430) and weaning was carried out until the restoration of physiological breathing and negativity of chest X-ray on the 11th day. Conclusions. The conventional treatment of ALI/ARDS includes endotracheal intubation that is performed when ARDS deteriorate despite aggressive medical management.1 NIV is not generally advisable, but recent studies 2 conside- red it as an alternative treatment in several categories such as hemodynamically stable 4 and immunocompromised patients in which early NIV should decrease the risk of infections, pneumonia and death, linked to the endotracheal tube. Our two cases, despite the mild ARDS, were young patients with low APACHE II. However, the safety issues and the potential damage linked to a NIV failure with an inappropriate delay of intubation are not to be underestimated, that’s why NIV requires a close monitoring in ICU by a skilled staff. References 1. Antonelli M, Conti G, Rocco M et al. A comparison of noninvasive positive- pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998;339:429-35. 2. Nava S, Schreiber A, Domenighetti G. Non invasive ventilation for patients with acute lung injury or acute respiratory distress syndrome Respir Care. 2011; 56:1583-8. 3. Hecker M, Seeger W, Mayer K. The Berlin Definition: novel criteria and classifi- cation of ARDS. Med Klin Intensivmed Notfmed. 2012;107:488-90. 4. Rocker GM, Mackenzie MG, Williams B, Logan PM. Noninvasive pressure sup- port ventilation: successful outcome in patients with acute lung injury/ARDS. Chest 1999;115:173-7.

This prospective, multicenter, epidemiological study was carried out in 99 Italian ICUs, distributed throughout the country, from April 1993 to March 1994. In the study, we applied the new ACCP/SCCM classification system for sepsis (SIRS, sepsis, severe sepsis and septic shock) and determined the prevalence, incidence, evolution and outcome of these categories in critically ill patients. The preliminary analysis of 1101 patients showed that on admission SIRS accounted for about half of the diagnoses (52%) with sepsis, severe sepsis and septic shock accounting for 4.5%, 2.1% and 3% of patients, respectively. Patients with severe sepsis or septic shock more frequently had high SAPS scores than patients without sepsis. Mortality rates were similar in patients with SIRS (26.5%) and without SIRS or infection (24%), but rose to 36% in patients with sepsis, to 52% in those with severe sepsis and to 81.8% in those with septic shock. Sepsis, severe sepsis and septic shock were more common in patients with medical diagnoses, and neither severe sepsis nor septic shock was observed in trauma patients. With respect to evolution, the incidence of septic shock was progressively higher in patients admitted with more severe "sepsis-related" diagnoses, while only a trivial difference in rates of incidence was observed between SIRS patients and those admitted without SIRS or any septic disorder (nil). The breakdown of the various ACCP/SCCM "sepsis-related" diagnoses at any time during the study was: SIRS in 58% of the population, sepsis in 16.3%, severe sepsis in 5.5% and septic shock in 6.1%. It seems reasonable to expect from the final evaluation of our study answers to the questions raised by the ACCP/SCCM Consensus Conference about the correlations between "sepsis-related" diagnosis, severity score, organ dysfunction score and outcome.

Aim. MELAS (mitochondrial myopathy, encephalopathy, lac- tic acidosis, and stroke-like episodes) syndrome is a maternal- ly inherited multisystem disease caused by mutations of the mitochondrial DNA. Clinical features are: encephalopathy manifesting as dementia and seizures, stroke-like episodes at young age (usually 0.90 was 280 sec.) allowed to reduce the risk of resi- dual muscle weakness and adverse respiratory events in postoperative period5. References 1. Sproule DM, Kaufmann P. Mitochondrial encephalopathy, lactic acidosis, and strokelike episodes. basic concepts, clinical phenotype, and therapeutic manage- ment of MELAS syndrome. Ann NY Acad Sci 2008;1142:133-58. 2. Fricker RM, et al. Positive malignant hyperthermia susceptibility in vitro test in a patient with mitochondrial myopathy and myoadenylate deaminase deficiency. Anesthesiology 2002;97:1635-7. 3. Aouad MT, et al. Resistance to cisatracurium in a patient with MELAS syndro- me. Paediatr Anaesth 2005;15:1124-7. 4. Vasile B, et al. “e pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. Intensive Care Med 2003; 29: 1417-25. 5. Grattan-Smith PJ, et al. Acute respiratory failure precipitated by general ane- sthesia in Leigh’s syndrome. J Child Neurol 1990; 5:137-41.

Aim. Tracheostomy is a technique for airway management commonly used in critically ill patients. The development of various percutaneous tracheostomy (PT) techniques has faci- litated the performance of this procedure by reducing the time of the procedure and improving the utilization of resour- ces1. The experience of the operator and clinical individual characteristics of the patient should be discriminative factors to choose the appropriated technique2. An optimal TS techni- que does not exist, but several reports indicate Ciaglia Blue Rhino kit used for obese patients in ICU. We report a PDT placement in an obese critically ill patient using the new Uni- percTM kit, it’s designed for difficult neck. Case report. A 65 yars old patient, BMI: 44 kg/m2, admitted in post operative ICU for lobectomy because of Pulmonary Cancer. He showed an important obstructive and restrictive Pulmonary Disease, mechanically ventilated by endotracheal tube. He was scheduled for video-assisted TS because of the weaning fail. Ultra sound study of the neck documented a measure of the tracheal-cutaneous tract was over 7 cm. So UnipercTM TS was chosen; it was performed in total intrave- nous anaesthesia (TIVA) as already described3. The neck was positioned in hyperextension. Antiseptic solution was applied to the operative site. An incision of approximately 8 mm on the skin overlying the site for tracheal puncture was made. With ultrasonography (US) guide the puncture site was loca- ted between the first and second tracheal ring. Following puncture with an extra long 14-G needle, the guidewire was introduced and the dilation process was performed with the UnipercTM single stage dilator. The dilator was advanced over the guidewire into the trachea up to the marking of 38 F external diameters. Once maximum dilation was achieved with the corresponding devicès mark visualized into the tra-cheal lumen by bronchoscopy, the UniPercTM Adjustable Flange Extended-Length Tracheostomy Tube was placed (Fig. 1). Discussion. Obesity has been considered a relative contrain- dication to the performance of PT because it can make diffi- cult to properly identify anatomical landmarks of the neck. Various authors have proposed the use of US guide as a com- plementary tool to avoid potential complications4. We chose a Uniperc kit with a dilator longer than the other PT devices because of pre-tracheal soft tissue (over 70 mm). This charac- teristic of UnipercTM dilator combined with US and endo- scopy allowed a successfully positioning of TS. Conclusions. Uniperc technique seem to be a safe procedure and suited to clinical characteristics of the obese pts. Howe- ver it would be appropriate to validate this experience with a statistically significant number of pts. References 1. Bardell T, Drover JW. Recent developments in percutaneous tracheostomy: improving techniques and expanding roles. Curr Opin Crit Care 2005;11:326- 32. 2. Pelosi P et al. Tracheostomy must be individualized! Crit Care 2004;8:322-4 3. Ferraro F et al. Assessment of ventilation during the performance of elective endoscopic-guided percutaneous tracheostomy: clinical evolution of a new method. Chest 2004;126:159-64. 4. Kollig E et al. Ultrasound and bronchoscopic controlled percutaneous tracheo- stomy on trauma UCI. Injury 2000;31:663-8.

Aim. Post-intubation tracheal rupture is a rare but life-threa- tening complication. It can appear as a linear lesion in the membranous wall of the trachea. Subcutaneous emphysema, pneumothorax, pneumomediastinum and respiratory distress, it usually appears during surgery or in the immediate post- operative period. Diagnostic suspicion is essential, with sub- sequent confirmation by fibrobronchoscopy. Case reports. We report two cases, with similar lesions; the one recovered eventfully after conservative management, and the other received an invasive treatment. These are two tra- cheal rupture after unespected difficult endotracheal intuba- tion in elective surgery. Both cases were transferred to our ICU after the event, and surgery was delayed. Case 1. A 77 years-old woman was scheduled for Miles’abdo- minal perineal amputation. Successful orotracheal intubation was reached at the third attempt by an armed tube with sty- let. Following the intubation subcutaneous emphysema, and oxygen desaturation occurred and caused the admission in ICU. A computer tomography scan visualized a tracheal lesion, pneumothorax and pneumomediastinum. The pneu- mothorax was drained by a Trocar, but the patient needed mechanical ventilation, anymore. In fifth day fibrobronchopy revealed the longitudinal, subglottic, tracheal rupture, and surgical therapy was proposed. Instead, another computer tomography suggested a conservative management, since the full-thickness lesion was no longer visible. So, in tenth day, according to hemogasanalysis (P/F >300) and clinical signs, we performed a safe extubation. When fibrobronchoscopy showed a lesion's improvement, the abdominal surgery was performed successufully in combined spinal epidural anae- sthesia and sedation with spontaneous breath through laryn- geal mask. Case 2. A 56 year-old woman was scheduled for a colecistec- tomy. Successful orotracheal intubation was reached at the third attempt. Subcutaneous emphysema appeared, than a safe estubation failed because of tirage and oxygen desatura- tion caused by glottis oedema. In ICU a fibrobronchoscopy showed a subglottic longitudinal tracheal rupture (lenght: 3 cm) (Fig. 1). We performed a Fantoni’s pecutaneous tracheo- sthomy with not cuffed cannula. This approach allowed the spontaneous breathing, overcoming the glottis obstruction, and it avoided the stress linked to long time mechanical venti- lation. Sudden the patient was orally feed and was able to speak through a phonetic valve. She was transferred in surgi- cal unit, and the tracheostomy cannula was removed in sixth day, when glottis oedema was resolved. Discussion. Prognosis of tracheal ruptures depends both on the underlying disease, general condition of the patient, and on the rapidity of diagnosis and treatment. Traditionally, early surgical repair has been the mainstay of treatment.1 However, some authors opt to conservative treatment in patients with small ruptures, less than 2 cm, and in selected patients with minimal, non-progressive symptoms and with no air leakage on spontaneous breathing. The reported lesions were similar, but needed different treatment. The first case received a con- servative treatment, but the respiratory distress exposed patient to the risks of prolonged mechanical ventilation. In the second case, despite the invasiveness of the tracheostomy and the lesion length(>2 cm), a spontaneous healing of the lesion was possible removing the stress induced by mechani- cal ventilation. References 1. Pinegger S et al. Delayed iatrogenic tracheal post-intubation rupture: A short review of the aetiopathology and treatment. Rev Esp Anestesiol Reanim 2012 May 31.

Controversy continues regarding whether the presence of meticillin resistance increases mortality risk in Staphylococcus aureus infections. In this study, we assessed the role of meticillin resistance in survival of patients with S. aureus infection included in the EPIC II point-prevalence study of infection in critically ill patients performed on 8 May 2007. Demographic, physiological, bacteriological and therapeutic data were collected for 13 796 adult patients in 1265 participating Intensive Care Units (ICUs) from 75 countries on the study day. ICU and hospital outcomes were recorded. Characteristics of patients with meticillin-sensitive S. aureus (MSSA) and meticillin-resistant S. aureus (MRSA) infections were compared. Co-morbidities, age, Simplified Acute Physiology Score (SAPS) II, site of infection, geographical region and MRSA/MSSA were entered into a multivariate model, and adjusted odds ratios (ORs) [95% confidence interval (CI)] for ICU and hospital mortality rates were calculated. On the study day, 7087 (51%) of the 13 796 patients were classified as infected. There were 494 patients with MRSA infections and 505 patients with MSSA infections. There were no significant differences between the two groups in use of mechanical ventilation or haemofiltration/haemodialysis. Cancer and chronic renal failure were more prevalent in MRSA than in MSSA patients. ICU mortality rates were 29.1% and 20.5%, respectively (P andlt; 0.01) and corresponding hospital mortality rates were 36.4% and 27.0% (P andlt; 0.01). Multivariate analysis of hospital mortality for MRSA infection showed an adjusted OR of 1.46 (95% CI 1.03-2.06) (P = 0.03). In ICU patients, MRSA infection is therefore independently associated with an almost 50% higher likelihood of hospital death compared with MSSA infection. Original Publication:Håkan Hanberger, Sten Walther, Marc Leone, Philip S Barie, Jordi Rello, Jeffrey Lipman, John C Marshall, Antonio Anzueto, Yasser Sakr, Peter Pickkers, Peter Felleiter, Milo Engoren and Jean-Louis Vincent, Increased mortality associated with meticillin-resistant Staphylococcus aureus (MRSA) infection in the Intensive Care Unit: results from the EPIC II study, 2011, International Journal of Antimicrobial Agents, (38), 4, 331-335.http://dx.doi.org/10.1016/j.ijantimicag.2011.05.013Copyright: Elsevierhttp://www.elsevier.com/