The correct identification of the appropriateness of fluid administration is important for the treatment of critically ill patients. Static and dynamic indices used to identify fluid responsiveness ...have been developed throughout the years, nonetheless fluid responsiveness does not indicate that fluid administration is appropriate, and indexes to evaluate appropriateness of fluid administration are lacking. The aim of this study was to evaluate if central venous pressure (CVP) anddynamic indices could correctly identify fluid appropriateness for critically ill patients.
Data from 31 ICU patients, for a total of 53 observations, was included in the analysis. Patients were divided into two cohorts based on the appropriateness of fluid administration. Fluid appropriateness was defined in presence of a low cardiac index (< 2.5 l/min/m2) without any sign of fluid overload, as assessed by global end-diastolic volume index, extravascular lung water index or pulmonary artery occlusion pressure.
For 10 patients, fluid administration was deemed appropriate, while for 21 patients it was deemed inappropriate. Central venous pressure was not different between the two cohorts (mean CVP 11 (4) mmHg in the fluid inappropriate group, 12 (4) mmHg in the fluid appropriate group, p 0.58). The same is true for pulse pressure variation (median PPV 5 2, 9 % in the fluid inappropriate group, 4 3, 13 % in the fluid appropriate group, p 0.57), for inferior vena cava distensibility (mean inferior vena cava distensibility 24 (14) % in the fluid inappropriate group, 22 (16) % in the fluid appropriate group, p 0.75) and for changes in end tidal carbon dioxide during a passive leg raising test (median d.ETCO2 1.5 0.0, 2.0% in the fluid inappropriate group, 1.0 0.0, 2.0 % in the fluid appropriate group, p 0.98). There was no association between static and dynamic indices and fluid appropriateness.
Central venous pressure, pulse pressure variation, changes in end tidal carbon dioxide during a passive leg raising test, inferior vena cava distensibility were not associated with fluid appropriateness in our cohorts.
Abstract
Background
The evaluation of patient effort is pivotal during pressure support ventilation, but a non-invasive, continuous, quantitative method to assess patient inspiratory effort is still ...lacking. We hypothesized that the concavity of the inspiratory flow-time waveform could be useful to estimate patient’s inspiratory effort. The purpose of this study was to assess whether the shape of the inspiratory flow, as quantified by a numeric indicator, could be associated with inspiratory effort during pressure support ventilation.
Methods
Twenty-four patients in pressure support ventilation were enrolled. A mathematical relationship describing the decay pattern of the inspiratory flow profile was developed. The parameter hypothesized to estimate effort was named
Flow Index
. Esophageal pressure, airway pressure, airflow, and volume waveforms were recorded at three support levels (maximum, minimum and baseline). The association between
Flow Index
and reference measures of patient effort (pressure time product and pressure generated by respiratory muscles) was evaluated using linear mixed effects models adjusted for tidal volume, respiratory rate and respiratory rate/tidal volume.
Results
Flow Index
was different at the three pressure support levels and all group comparisons were statistically significant. In all tested models,
Flow Index
was independently associated with patient effort (
p
< 0.001).
Flow Index
prediction of inspiratory effort agreed with esophageal pressure-based methods.
Conclusions
Flow Index
is associated with patient inspiratory effort during pressure support ventilation, and may provide potentially useful information for setting inspiratory support and monitoring patient-ventilator interactions.
Flow Index, a numerical expression of the shape of the inspiratory flow-time waveform recorded during pressure support ventilation, is associated with patient inspiratory effort. The aim of this ...study was to assess the accuracy of Flow Index in detecting high or low inspiratory effort during pressure support ventilation and to establish cutoff values for the Flow index to identify these conditions. The secondary aim was to compare the performance of Flow index,of breathing pattern parameters and of airway occlusion pressure (P
) in detecting high or low inspiratory effort during pressure support ventilation.
Data from 24 subjects was included in the analysis, accounting for a total of 702 breaths. Breaths with high inspiratory effort were defined by a pressure developed by inspiratory muscles (P
) greater than 10 cmH
O while breaths with low inspiratory effort were defined by a P
lower than 5 cmH
O. The areas under the receiver operating characteristic curves of Flow Index and respiratory rate, tidal volume,respiratory rate over tidal volume and P
were analyzed and compared to identify breaths with low or high inspiratory effort.
P
, P
, Pressure Time Product and Flow Index differed between breaths with high, low and intermediate inspiratory effort, while RR, RR/V
and V
/kg of IBW did not differ in a statistically significant way. A Flow index higher than 4.5 identified breaths with high inspiratory effort AUC 0.89 (CI 95% 0.85-0.93), a Flow Index lower than 2.6 identified breaths with low inspiratory effort AUC 0.80 (CI 95% 0.76-0.83).
Flow Index is accurate in detecting high and low spontaneous inspiratory effort during pressure support ventilation.
The comparison of respiratory system compliance (C
) between COVID and non-COVID ARDS patients has been the object of debate, but few studies have evaluated it when considering applied positive end ...expiratory pressure (PEEP), which is one of the known determinants of C
itself. The aim of this study was to compare C
taking into account the applied PEEP.
Two cohorts of patients were created: those with COVID-ARDS and those with non-COVID ARDS. In the whole sample the association between C
and type of ARDS at different PEEP levels was adjusted for anthropometric and clinical variables. As secondary analyses, patients were matched for predicted functional residual capacity and the same association was assessed. Moreover, the association between C
and type of ARDS was reassessed at predefined PEEP level of 0, 5, 10, and 15 cmH
O with a propensity score-weighted linear model.
367 patients were included in the study, 276 patients with COVID-ARDS and 91 with non-COVID ARDS. The association between C
and type of ARDS was not significant in both the complete cohorts (p = 0.17) and in the matched cohorts (p = 0.92). This was true also for the propensity score weighted association at PEEP 5, 10 and 15 cmH
O, while it was statistically significant at PEEP 0 (with a median difference of 3 ml/cmH
O, which in our opinion is not clinically significant).
The compliance of the respiratory system is similar between COVID ARDS and non-COVID ARDS when calculated at the same PEEP level and while taking into account patients' anthropometric characteristics.
Thyroid and breast nodules (BNs) are common, their prevalence varying based mainly on the population (including age, residence in area of different iodine availability) studied and methods used. The ...coincidence of thyroid and breast diseases remains controversial and the majority of the studies evaluate the association between breast cancer and thyroid disorders. Here we describe our experience of such association in a non-oncological series.
Between the years 2000 and 2005, 3,372 patients from outpatient clinics were referred for thyroid ultrasonography (US) at our University Hospital; concurrent breast US in the 1,896 women revealed the presence of BNs in 127. The 127 women were divided into two groups, based on the cystic or solid nature of the BN(s).
In 84/127 (66.1%) the single or multiple BN was/were cystic (group 1), while in the remaining 43 (33.9%) the single or multiple BN was/were solid group 2; 19/43 had one thyroid nodule (TN) and the remaining 24/43 had ≥2 TNs. When BN were cystic the coexisting TN(s) was/were more likely to be concordant in localization (i.e., right/right or left/left localization) whereas, when the BN were solid, the coexisting thyroid nodule/nodules was/were more likely to be discordant. In women with cystic BNs (CBNs), TNs were more frequently multiple (64% of cases), whereas in cases with solid BNs (SBNs), the frequency of single and multiple TNs was approximately the same. In patients with TNs/CBNs, TNs tend to be subcentimetric and localized in the inferior pole of either thyroid lobe. In patients with TNs/SBNs, TNs tend to be larger and localized in the middle of either thyroid lobe.
In women with BNs associated with TNs, there are interesting differences concerning TNs when patients are stratified based on the cystic or solid nature of the BN.
OBJECTIVES:Early tracheotomy, defined as a procedure performed within 10 days from intubation, is associated with more ventilator free days, shorter ICU stay, and lower mortality than late ...tracheotomy. During the coronavirus disease 2019 pandemic, it was especially important to save operating room resources and to have a shorter ICU stay for patients, when ICUs had insufficient beds. In this context of limited resources, early percutaneous tracheostomy could be an effective way to manage mechanically ventilated patients. Nevertheless, current recommendations suggest delaying or avoiding the tracheotomy in coronavirus disease 2019 patients. Aim of the study was to analyze the hospital mortality of coronavirus disease 2019 patients who had received early percutaneous tracheostomy and factors associated with removal of tracheostomy cannula at ICU discharge.
DESIGN:Cohort study.
SETTING:Coronavirus disease 2019 ICU.
PATIENTS:Adult patients with coronavirus disease 2019 3 days after ICU admission.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:Three days after ICU admission, 164 patients were present in ICU and included in the analysis. One-hundred and twenty-one patients (74%) were tracheostomized, whereas the other 43 (26%) were managed with translaryngeal intubation only. In multivariable analysis, early percutaneous tracheostomy was associated with lower hospital mortality. Sixty-six of tracheostomized patients (55%) were discharged alive from the hospital. Age and male sex were the only characteristics that were independently associated with mortality in the tracheostomized patients (45.5% and 62.8% in tracheostomized and nontracheostomized patients, respectively; p = 0.009). Tracheostomy tube was removed in 47 of the tracheostomized patients (71%). The only variable independently associated with weaning from tracheostomy at ICU discharge was a faster start of spontaneous breathing after tracheotomy was performed.
CONCLUSIONS:Early percutaneous tracheostomy was safe and effective in coronavirus disease 2019 patients, giving a good chance of survival and of weaning from tracheostomy cannula at ICU discharge.
OBJECTIVE
An increased frequency of papillary thyroid carcinoma (PTC) has been reported in the literature, including studies based on fine-needle aspiration cytology (FNAC).
DESIGN
To substantiate ...our own ascertainment of such an increase, we retrieved all the diagnoses of ultrasound-guided FNAC which was performed on 11,389 patients referred for cytological evaluation of a single or dominant thyroid nodule from 1988 to 2010. FNAC yielded 11,258 adequate specimens.
RESULTS
The number of patients with PTC was 200 (age 10–83 yrs) and increased significantly from 1988 to 2010 (r= 0.916,
P<0.001
). Expressing data as percent of FNAC in any given year, PTC and colloid goiter increased, while adenomatous goiter, follicular lesions and anaplastic or medullary thyroid cancer decreased. PTC accounted for 0% of all FNAC diagnoses in 1988 but for 2% in 2010, with a peak of 2.6% in 2006. Of interest, chronic lymphocytic thyroiditis (CLT) also increased, preceding the increase of PTC by 5–6 years.
CONCLUSION
We conclude that in the regions on either side of the Strait of Messina (Italy), PTC has become progressively more frequent during the 23-year period between 1988 and 2010 and that this increase lagged behind the increase of CLT.
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