Of the various muscles that make up the respiratory system, the diaphragm is the prima donna. In the past, only specialist research centers were able to estimate and challenge the effort of this ...muscle; this was achieved by measuring transdiaphragmatic pressure—an invasive technique involving a double-balloon probe inserted through the esophagus—or by measuring twitch pressure (ie, the pressure generated at the outside tip of the endotracheal tube). However, the prevalence of diaphragm dysfunction in critically ill patients requiring intubation can exceed 60% (at the time of hospital admission) and may rise to as high as 80% in patients requiring prolonged mechanical ventilation and experiencing difficult weaning.
Although still in its infancy, modern ultrasound (US) provides a fascinating way to study the diaphragm, permitting the assessment of its excursion, thickness, and thickening. Furthermore, US enables the course of diaphragmatic function to be followed on a day-to-day basis, from intensive care admission to discharge, and it can help us understand the different causes of underlying disease: trauma, infection (eg, sepsis-induced diaphragm dysfunction), cancer, weaning problems (eg, ventilation-induced diaphragm dysfunction), etc. Today, the assessment of diaphragm dysfunction with US provides an important first step toward improving the detection of diaphragm dysfunction and as a protective and supportive strategy for its management. The purposes of this review are as follows: (1) to explore which US method is best for evaluating diaphragm function in the intensive care unit and how and when it should be used, and (2) to discuss which diseases may involve the diaphragm, and what therapies should be used.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
3.
Levosimendan for Hemodynamic Support after Cardiac Surgery Landoni, Giovanni; Lomivorotov, Vladimir V; Alvaro, Gabriele ...
New England journal of medicine/The New England journal of medicine,
05/2017, Volume:
376, Issue:
21
Journal Article
Peer reviewed
Open access
In a randomized trial, 506 patients requiring perioperative hemodynamic support after cardiac surgery were assigned to receive levosimendan or placebo in addition to standard care. There was no ...significant between-group difference in 30-day mortality.
Every year, more than 1 million patients undergo cardiac surgery in the United States and Europe.
1
Acute perioperative left ventricular dysfunction is a major complication affecting up to 20% of such patients
2
,
3
and is associated with increased mortality.
4
Inotropic drugs (catecholamines and phosphodiesterase type 3 PDE-3 inhibitors) are the cornerstone of postoperative hemodynamic support.
3
,
5
However, no randomized, controlled trials have shown the superiority of any inotropic agent in terms of major clinical outcomes. Furthermore, meta-analyses and observational studies suggest that catecholamines and PDE-3 inhibitors may increase mortality.
6
,
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Levosimendan (Simdax, Orion) is an inotropic agent that has been . . .
In a randomized trial, 5400 patients scheduled to undergo CABG were assigned either to an anesthetic regimen that included a volatile anesthetic or to total intravenous anesthesia. At 1 year, there ...was no significant difference between the two groups in the number of deaths from any cause.
...it should be considered that the ISTH SSC on Fibrinolysis group has identified several technical pitfalls detected in current studies on D-dimer in COVID-19 cases. ...D-Dimer ...guided-anticoagulation management does not seem supported enough by evidence-based recommendations. Rights and permissions Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.
Coronavirus disease of 2019 (COVID-19) is a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has rapidly spread to a global pandemic in March ...2020. This emergency condition has been putting a severe strain on healthcare systems worldwide, and a prompt, dynamic response is instrumental in its management. While a definite diagnosis is based on microbiological evidence, the relationship between lung ultrasound (LU) and high-resolution computed tomography (HRCT) in the diagnosis and management of COVID-19 is less clear. Lung ultrasound is a point-of-care imaging tool that proved to be useful in the identification and severity assessment of different pulmonary conditions, particularly in the setting of emergency and critical care patients in intensive care units; HRCT of the thorax is regarded as the mainstay of imaging evaluation of lung disorders, enabling characterization and quantification of pulmonary involvement. Aims of this review are to describe LU and chest HRCT main imaging features of COVID-19 pneumonia, and to provide state-of-the-art insights regarding the integrated role of these techniques in the clinical decision-making process of patients affected by this infectious disease.
Furosemide is the most common loop diuretic used worldwide. The off-label administration of furosemide bolus(es) for the prevention or to reverse acute kidney injury (AKI) is widespread but not ...supported by available evidence. We conducted a meta-analysis of randomized trials (RCTs) to investigate whether bolus furosemide to prevent or treat AKI is detrimental on patients' survival.
Electronic databases were searched through October 2017 for RCTs comparing bolus furosemide administration versus any comparator in patients with or at risk for AKI. The primary endpoint was all-cause longest follow-up mortality. Secondary endpoints included new or worsening AKI, receipt of renal replacement therapy, length of hospital stay, and peak serum creatinine after randomization.
A total of 28 studies randomizing 3,228 patients were included in the analysis. We found no difference in mortality between the two groups (143/892 16% in the furosemide group versus 141/881 16% in the control group; odds ratio OR, 0.84; 95% confidence interval CI, 0.63 to 1.13; p = 0.25). No significant differences in secondary outcomes were found. A significant improvement in survival was found in the subgroup of patients receiving furosemide bolus(es) as a preventive measure (43/613 7.0% versus 67/619 10.8%, OR 0.62; 95% CI, 0.41 to 0.94; p = 0.03).
Intermittent furosemide administration is not associated with an increased mortality in patients with or at risk for AKI, although it may reduce mortality when used as a preventive measure. Future high-quality RCTs are needed to define the role of loop diuretics in AKI prevention and management.
The study protocol was registered on PROSPERO database for systematic reviews (Registration no. CRD42017078607 - http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017078607).
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Purpose
To evaluate the daily values and trends over time of relevant clinical, ventilatory and laboratory parameters during the intensive care unit (ICU) stay and their association with outcome in ...critically ill patients with coronavirus disease 19 (COVID-19).
Methods
In this retrospective–prospective multicentric study, we enrolled COVID-19 patients admitted to Italian ICUs from February 22 to May 31, 2020. Clinical data were daily recorded. The time course of 18 clinical parameters was evaluated by a polynomial maximum likelihood multilevel linear regression model, while a full joint modeling was fit to study the association with ICU outcome.
Results
1260 consecutive critically ill patients with COVID-19 admitted in 24 ICUs were enrolled. 78% were male with a median age of 63 55–69 years. At ICU admission, the median ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO
2
/FiO
2
) was 122 89–175 mmHg. 79% of patients underwent invasive mechanical ventilation. The overall mortality was 34%. Both the daily values and trends of respiratory system compliance, PaO
2
/FiO
2
, driving pressure, arterial carbon dioxide partial pressure, creatinine, C-reactive protein, ferritin, neutrophil, neutrophil–lymphocyte ratio, and platelets were associated with survival, while for lactate, pH, bilirubin, lymphocyte, and urea only the daily values were associated with survival. The trends of PaO
2
/FiO
2
, respiratory system compliance, driving pressure, creatinine, ferritin, and C-reactive protein showed a higher association with survival compared to the daily values.
Conclusion
Daily values or trends over time of parameters associated with acute organ dysfunction, acid–base derangement, coagulation impairment, or systemic inflammation were associated with patient survival.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Lichter et al., on the other hand, in their study of critically ill COVID-19 patients report an optimal cutoff value of 18 on the 0–36 scale for predicting adverse outcome, with a reported ...sensitivity of 62% and a specificity of 75% 3, whereas Zhu et al. report a sensitivity of 81% and a specificity of 96% with a cutoff value of 7 4. 2 is difficult to compare with other studies in the literature for the following two reasons: first, they used a modified LUS scale (note a recent international expert consensus on the use of multi-organ point-of-care LU in COVID-19 adopts the scale range of 0–36 5 and does not consider the pleural line artifact); second, the patients in the study by Ji et al. appear less critically ill than those in other studies, as evidenced by the fact that 88% of patients had an average value of PaO2/FiO2 greater than 300 mmHg. Rights and permissions Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.
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