Background: Sepsis is one of the major causes of in-hospital death, and is frequent in patients presenting to the emergency department (ED). Early identification of high-risk septic patients is ...critical. Machine learning (ML) techniques have been proposed for identification and prognostication of ED septic patients, but these models often lack pre-hospital data and lack validation against early sepsis identification scores (such as qSOFA) and scores for critically ill patients (SOFA, APACHE II). Methods We conducted an electronic health record (EHR) study to test whether interpretable and scalable ML models predict mortality in septic ED patients and compared their performance with clinical scores. Consecutive adult septic patients admitted to ED over 18 months were included. We built ML models, ranging from a simple-classifier model, to unbalanced and balanced logistic regression, and random forest, and compared their performance to qSOFA, SOFA, and APACHE II scores. Results: We included 425 sepsis patients after screening 38,500 EHR for sepsis criteria. Overall mortality was 15.2% and peaked in patients coming from retirement homes (38%). Random forest, like balanced (0.811) and unbalanced logistic regression (0.863), identified patients at risk of mortality (0.813). All ML models outperformed qSOFA, APACHE II, and SOFA scores. Age, mean arterial pressure, and serum sodium were major mortality predictors. Conclusions: We confirmed that random forest models outperform previous models, including qSOFA, SOFA, and APACHE II, in identifying septic patients at higher mortality risk, while maintaining good interpretability. Machine learning models may gain further adoption in the future with increasing diffusion and granularity of EHR data, yielding the advantage of increased scalability compared to standard statistical techniques.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
is zoonotic agent isolated from humans bitten by dogs or cats. Although rare, severe infection usually affects male patients over the age of 50, asplenic or immunocompromised. Diagnosis is often ...challenging, often missing a history of contact with dogs or pre-existing wounds. Mortality rate is extremely high, since infection can lead to fulminant sepsis. We report a case of a patient admitted to ED for septic shock of unknown origin. Severe sepsis developed since our patient was asplenic and possessed multiple comorbidities. Due to hypoxia and respiratory failure, the patient was promptly intubated and mechanically ventilated. Supportive treatment for hemodynamic shock was administered. Cultures were obtained in the ED and empiric antibiotic therapy with piperacillin/tazobactam was started, aiming at infection control. As for source identification, common infectious etiologies, SARS-CoV-2 swab, bronchoalveolar lavage and urine cultures were negative. Blood cultures proved Gram-negative rods after 12 h incubation and
was identified on day 4. During ICU stay, clinical conditions gradually improved, and source control proved to be effective. Culture samples collection and starting empiric antibiotic treatment are the essential points in ensuring patient survival, especially in sepsis or septic shock of unknown origin or uncommon etiology, as in our case. Why should an emergency physician be aware of this?
bacteremia is rare and difficult to diagnose. Although considering patient history in such cases is crucial, laboratory results are often delayed. Hence, the chance of survival is dependent on prompt culture samples collection and start of empiric antibiotic treatment, along with supportive treatment.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
For a long time, non-small cell lung cancer (NSCLC) arising less than 2 cm distal to the carina has been usually considered unresectable and incurable with a radical or extended resection because of ...surgical technical difficulty and airway management. Recently, the introduction of more advanced surgical techniques, often including the use of extracorporeal life support (ECLS), has allowed us to extend the limits of conventional surgery, increasing the rate of complete surgical resection. ECLS also overcomes the limitation of conventional ventilation during complex tracheo-bronchial reconstruction, avoiding the presence of disturbing lines or tubes that obstruct the operative field during a challenging surgery. In this article, we share our experience in performing right tracheal sleeve pneumonectomy with veno-venous extracorporeal membrane oxygenation (VV-ECMO) in three cases by anterior right thoracotomy, reporting our tips and tricks.
Acute kidney injury (AKI) is highly prevalent in critical COVID-19 patients. The diagnosis and staging of AKI are based on serum creatinine (sCr) and urinary output criteria, with limitations in the ...functional markers. New cell-cycle arrest biomarkers TIMP2*IGFBP7 have been proposed for early detection of AKI, but their role in critically ill COVID-19 patients is poorly understood.
We conducted an observational study to assess the performance of TIMP2*IGFBP7 for the detection of AKI in critical COVID-19 patients admitted to our intensive care unit (ICU). We sampled urinary TIMP2*IGFBP7 levels at ICU admission, 12 h, 24 h, and 48 h, and compared the results to the development of AKI, as well as baseline and laboratory data.
Forty-one patients were enrolled. The median age was 66 years 57-72 and most were males (85%). Thirteen patients (31.7%) developed no/mild stage AKI, 19 patients (46.3%) moderate AKI, and nine patients (22.0%) severe AKI. The ICU mortality was 29.3%. sCr levels in the Emergency Department or at ICU admission were not significantly different according to AKI stage. TIMP-2*IGFBP-7 urinary levels were elevated in severe AKI at 12 h after ICU admission, but not at ICU admission or 24 h or 48 h after ICU admission.
Urinary biomarkers TIMP-2*IGFBP-7 were generally increased in this population with a high prevalence of AKI, and were higher in patients with severe AKI measured at 12 h from ICU admission. Further studies are needed to evaluate the best timing of these biomarkers in this population.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
The region of Lombardy was the epicenter of the COVID-19 outbreak in Italy. Emergency Hospital 19 (EH19) was built in the Milan metropolitan area during the pandemic’s second wave as a facility of ...Humanitas Clinical and Research Center (HCRC). The present study aimed to assess whether the implementation of EH19 was effective in improving the quality of care of COVID-19 patients during the second wave compared with the first one. The demographics, mortality rate, and in-hospital length of stay (LOS) of two groups of patients were compared: the study group involved patients admitted at HCRC and managed in EH19 during the second pandemic wave, while the control group included patients managed exclusively at HCRC throughout the first wave. The study and control group included 903 (56.7%) and 690 (43.3%) patients, respectively. The study group was six years older on average and had more pre-existing comorbidities. EH19 was associated with a decrease in the intensive care unit admission rate (16.9% vs. 8.75%, p < 0.001), and an equal decrease in invasive oxygen therapy (3.8% vs. 0.23%, p < 0.001). Crude mortality was similar but overlap propensity score weighting revealed a trend toward a potential small decrease. The adjusted difference in LOS was not significant. The implementation of an additional COVID-19 hospital facility was effective in improving the overall quality of care of COVID-19 patients during the first wave of the pandemic when compared with the second. Further studies are necessary to validate the suggested approach.
COVID-19: dealing with ventilator shortage Santini, Alessandro; Messina, Antonio; Costantini, Elena ...
Current opinion in critical care,
12/2022, Volume:
28, Issue:
6
Journal Article
Open access
To describe different strategies adopted during coronavirus disease 2019 pandemic to cope with the shortage of mechanical ventilators.
Short-term interventions aimed to increase ventilator supply and ...decrease demand. They included: redistributing and centralizing patients, repurposing operating rooms into intensive care units (ICUs) and boosting ventilator production and using stocks and back-ups; support by the critical care outreach team to optimize treatment of patients in the ward and permit early discharge from the ICU, ethical allocation of mechanical ventilators to patients who could benefit more from intensive treatment and short term ICU trials for selected patients with uncertain prognosis, respectively. Long-term strategies included education and training of non-ICU physicians and nurses to the care of critically-ill patients and measures to decrease viral spread among the population and the progression from mild to severe disease.
The experience and evidence gained during the current pandemic is of paramount importance for physicians and law-makers to plan in advance an appropriate response to any future similar crisis. Intensive care unit, hospital, national and international policies can all be improved to build systems capable of treating an unexpectedly large number of patients, while keeping a high standard of safety.
How temperate trees respond to drier summers strongly depends on the drought susceptibility and the starch reserve of the very‐fine roots (<0.5 mm in diameter). We performed morphological, ...physiological, chemical, and proteomic analyses on very‐fine roots of Fagus sylvatica seedlings grown under moderate‐ and severe drought conditions. Moreover, to reveal the role of the starch reserves, a girdling approach was adopted to interrupt the flux of photosynthates toward the downstream sinks. Results show a seasonal sigmoidal growth pattern without evident mortality under moderate drought. After the severe‐drought period, intact plants showed lower starch concentration and higher growth than those subjected to moderate drought, highlighting that very‐fine roots rely on their starch reserves to resume growth. This behavior caused them to die with the onset of autumn, which was not observed under moderate drought. These findings indicated that extreme dry soil conditions are needed for significant root death in beech seedlings and that mortality mechanisms are defined within individual compartments. The girdling treatment showed that the physiological responses of very‐fine roots to severe drought stress are critically related to the altered load or the reduced transport velocity of the phloem and that the changes in starch allocation critically alter the distribution of biomass. Proteomic evidence revealed that the phloem flux‐dependent response was characterized by the decrease of carbon enzymes and the establishment of mechanisms to avoid the reduction of the osmotic potential. The response independent from the aboveground mainly involved the alteration of primary metabolic processes and cell wall‐related enzymes.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Modern supportive therapy of ARDS generally consists of endotracheal intubation and mechanical ventilation with supplemental oxygen and Positive End Expiratory Pressure (PEEP), along with muscle ...paralysis, prone positioning, and ExtraCorporeal Membrane Oxygenation (ECMO) for the most severe cases 5,6. Inhaled nitric oxide (iNO) can be considered as rescue therapy for hypoxemia due to its potent vasodilator effect on the pulmonary circulation 7. Herein we describe the response to iNO in a small group of mechanically ventilated patients with severe COVID admitted to our Intensive Care Unit.2 Methods As part of our routine clinical practice for ARDS, we administered a 30-min test dose of 20 ppm to ten adults with COVID-19 treated with invasive mechanical ventilation and with a partial pressure of arterial oxygen (PaO2) to the fraction of inspired oxygen ratio (FiO2) around or below 100 mmHg.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). Aim of this study is to investigate the use and effect of ...prone position in this population during the first 2020 pandemic wave.
Retrospective, multicentre, national cohort study conducted between February 24 and June 14, 2020, in 24 Italian Intensive Care Units (ICU) on adult patients needing invasive mechanical ventilation for respiratory failure caused by COVID-19. Clinical data were collected on the day of ICU admission. Information regarding the use of prone position was collected daily. Follow-up for patient outcomes was performed on July 15, 2020. The respiratory effects of the first prone position were studied in a subset of 78 patients. Patients were classified as Oxygen Responders if the PaO
/FiO
ratio increased ≥ 20 mmHg during prone position and as Carbon Dioxide Responders if the ventilatory ratio was reduced during prone position.
Of 1057 included patients, mild, moderate and severe ARDS was present in 15, 50 and 35% of patients, respectively, and had a resulting mortality of 25, 33 and 41%. Prone position was applied in 61% of the patients. Patients placed prone had a more severe disease and died significantly more (45% vs. 33%, p < 0.001). Overall, prone position induced a significant increase in PaO
/FiO
ratio, while no change in respiratory system compliance or ventilatory ratio was observed. Seventy-eight % of the subset of 78 patients were Oxygen Responders. Non-Responders had a more severe respiratory failure and died more often in the ICU (65% vs. 38%, p = 0.047). Forty-seven % of patients were defined as Carbon Dioxide Responders. These patients were older and had more comorbidities; however, no difference in terms of ICU mortality was observed (51% vs. 37%, p = 0.189 for Carbon Dioxide Responders and Non-Responders, respectively).
During the COVID-19 pandemic, prone position has been widely adopted to treat mechanically ventilated patients with respiratory failure. The majority of patients improved their oxygenation during prone position, most likely due to a better ventilation perfusion matching.
clinicaltrials.gov number: NCT04388670.
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