Edi Prandi

Partial liberalization of visiting policies and ICU staff: a before-and-after study

PurposeTo investigate possible psychological distress among staff after partial liberalization of visiting policies in intensive care units (ICUs).MethodsWe surveyed eight Italian ICUs planning to increase daily visiting to at least 8xa0h. Participants completed the Maslach–Jackson Burnout Inventory and the State-Trait Anxiety Inventory before policy change (T0), after 6xa0months (T1) and 12xa0months (T2). At T0 and T2, their opinions on the new policy were solicited. Analyses were adjusted for main known confounders (age, gender, centre, educational and marital status, experience in ICU, baseline level of burnout or anxiety, and mortality rate).ResultsBaseline response rate was 89xa0% (230/258); 198 subjects (77xa0%) responded at T0 and T2, whereas 184 (71xa0%) participated in all three phases. High burnout levels were identified in 34.5xa0% of participants at T0 and 42.6xa0% at T2 (adjusted pxa0=xa00.001). All three phases showed a predominance of high burnout among nurses (adjusted pxa0=xa00.002). State and trait anxiety scores remained stable (adjusted pxa0=xa00.100 and 0.288, respectively). Most participants viewed the change positively at T0 (doctors 81.7xa0%; nurses 67.7xa0%) and T2 (doctors 87.0xa0%; nurses 62.7xa0%). At T2, 129 participants made comments (180 positive, 136 negative). Subjects with high burnout were more likely to comment negatively (pxa0=xa00.011).ConclusionsPartial liberalization of ICU visiting policies was associated over the course of a year with a small but significant increase in staff members’ burnout levels. Nonetheless, doctors and nurses viewed the policy positively, maintaining this opinion after 1xa0year. Negative views were strongly correlated with burnout.

Peribulbar anesthesia with either 0.75% ropivacaine or a 2% lidocaine and 0.5% bupivacaine mixture for vitreoretinal surgery: A double-blinded study

UNLABELLEDnNo study has evaluated the efficacy of ropivacaine in peribulbar block for ophthalmic surgery. The purpose of this prospective, randomized, double-blinded study was to compare ropivacaine and a lidocaine-bupivacaine mixture in peribulbar anesthesia. Sixty ASA physical status I or II patients scheduled for elective vitreoretinal surgery were randomized to receive a peribulbar block with 8 mL of either 0.75% ropivacaine (ropivacaine group, n = 30) or a 1:1 mixture of 2% plain lidocaine and 0.5% plain bupivacaine (lido-bupivacaine group, n = 30). Time required for onset of surgical anesthesia, quality of postoperative analgesia, incidence of side effects, and analgesic consumption were recorded. Surgical block was achieved after 8 +/- 5 min in the lido-bupivacaine group and after 10 +/- 5 min in the ropivacaine group (P = 0.23). A 3-mL supplemental injection 15 min after block placement was required in 6 patients in the lido-bupivacaine group (20%) and in 10 patients in the ropivacaine group (33%) due to inadequate motor block (P = 0.38). On Postoperative Day 1, 26 patients in the ropivacaine group (87%) reported no pain at the verbal rating score, compared with 18 patients in the lido-bupivacaine group (60%) (P = 0.005). We conclude that 0.75% ropivacaine may be a suitable choice when performing peribulbar anesthesia for vitreoretinal surgery.nnnIMPLICATIONSnQuick onset of block with prolonged postoperative analgesia is an important goal in regional anesthesia for ophthalmic surgery. Evaluating clinical properties of 0.75% ropivacaine and a 1:1 mixture of 2% lidocaine and 0.5% bupivacaine for peribulbar anesthesia, we demonstrated that ropivacaine has an onset similar to that of the lidocaine-bupivacaine mixture and provides a better quality of postoperative analgesia.

Respiratory failure in infants due to spinal muscular atrophy with respiratory distress type 1

BackgroundSpinal muscular atrophy with respiratory distress type 1 (SMARD1) is axa0rare autosomal recessive neuromuscular disease of unknown prevalence characterized by degeneration of anterior horn α-motoneurons and manifesting in the first 6u202fmonths of life as life-threatening irreversible diaphragmatic paralysis associated with progressive symmetrical muscular weakness (distal lower limbs mainly involved), muscle atrophy, and peripheral sensory neuropathy.SettingPediatric intensive care unit of tertiary care hospital.PatientsWe present two new cases of SMARD1 and report two new mutations in the gene IGHMBP2 which encodes immunoglobulinu202fμ-binding protein 2 on chromosome 11q13.ConclusionsSMARD1 is axa0poor-prognosis disease that should be considered when acute respiratory insufficiency, of suspected neuromuscular or unclear cause, develops during the first 6u202fmonths of life. Diaphragmatic paralysis, manifesting as dyspnea and paradoxical respiration, is the most prominent presenting sign and diaphragmatic motility should be investigated early by fluoroscopy or ultrasound. Electromyography and nerve conduction studies revealing peripheral motor and sensory neuropathy then suggest the diagnosis which should be confirmed by genetic analysis.

Noninvasive Continuous Positive Airway Pressure in Acute Respiratory Failure: Helmet Versus Facial Mask

OBJECTIVE: Noninvasive continuous positive airway pressure (nCPAP) is applied through different interfaces to treat mild acute respiratory failure (ARF) in infants. Recently a new pediatric helmet was introduced in clinical practice to deliver nCPAP. The objective of this study was to compare the feasibility of the delivery of nCPAP by the pediatric helmet with delivery by a conventional facial mask in infants with ARF. PATIENTS AND METHODS: We conducted a single-center physiologic, randomized, controlled study with a crossover design on 20 consecutive infants with ARF. All patients received nCPAP by helmet and facial mask in random order for 90 minutes. In infants in both trials, nCPAP treatment was preceded by periods of unassisted spontaneous breathing through a Venturi mask. The primary end point was the feasibility of nCPAP administered with the 2 interfaces (helmet and facial mask). Feasibility was evaluated by the number of trial failures defined as the occurrence of 1 of the following: intolerance to the interface; persistent air leak; gas-exchange derangement; or major adverse events. nCPAP application time, number of patients who required sedation, and the type of complications with each interface were also recorded. The secondary end point was gas-exchange improvement. RESULTS: Feasibility of nCPAP delivery was enhanced by the helmet compared with the mask, as indicated by a lower number of trial failures (P < .001), less patient intolerance (P < .001), longer application time (P < .001), and reduced need for patient sedation (P < .001). For both delivery methods, no major patient complications occurred. CONCLUSIONS: The results of this current study revealed that the helmet is a feasible alternative to the facial mask for delivery of nCPAP to infants with mild ARF.

Ventilator-associated pneumonia in an Italian pediatric intensive care unit: a prospective study.

BackgroundThis study was undertaken to determine the prevalence, risk factors and outcomes associated with ventilator-associated pneumonia (VAP) in a European pediatric intensive care unit (PICU).MethodsA total of 451 children who had been mechanically ventilated in the PICU for ≥48 hours during a 3-year period were enrolled in this prospective study.ResultsIn comparison with children without VAP, 30 children (6.6%) who developed VAP had a longer PICU stay (P=0.0001) and hospital stay (P=0.0001), and a higher mortality rate (P=0.04). Logistic regression analysis showed that the need for re-intubation (P=0.0001), the presence of tracheostomy (P=0.04), and enteral feeding (P=0.02) were independent risk factors for VAP.ConclusionsA relevant proportion of intubated children develop VAP, which is closely related to invasive procedures. As VAP is associated with increased medical costs and death, multicenter studies are urgently needed to improve the therapeutic approach to VAP and VAP prevention.

Assessment of respiratory system viscoelasticity in spontaneously breathing rabbits

Airflow, volume (V), inspiratory time (TI), tracheal pressure (Ptr), abdomen (Dab) and rib cage diameters (Drc), peak diaphragm (Adi) and parasternal muscle activity (Aic) were measured in thirteen anaesthetized and vagotomized rabbits and in six vagotomized rabbits with cordotomy at T1 during unimpeded inspirations followed by rapid end-inspiratory airway occlusion, relaxation against closed airways, and inspiratory effort. To modify the inspiratory flow pattern, such sequences were performed at different volume, levels of chemical drive, and body temperatures (BT). Under all conditions, Adi, Aic, TI, Drc and Dab at iso-volume were the same for unimpeded and occluded inspirations; end-inspiratory Ptr was lower for occluded than for unimpeded inspirations, the difference (Pdiff) being larger the lower the volume at which occlusions were performed and the higher the chemical drive and BT. After paralysis, the viscoelastic constants of the respiratory system, modelled as a Kelvin body, were assessed according to the rapid airway occlusion method and used together with the inspiratory flow waveform to predict the end-inspiratory viscoelastic pressure (Pvisc) of unimpeded inspirations. Since the slope of the Pdiff vs. Pvisc relationship never differed from unity, Pdiff under the specified conditions should represent the effective Pvisc of unimpeded inspirations.

Parental presence in Italian pediatric intensive care units: a reappraisal of current visiting policies

Dear Editor, In 2007 a national survey found a clear tendency in Italian pediatric intensive care units (PICUs) to apply restrictive visiting policies and to limit parental presence at the bedside [1]. In order to update our picture on current parental presence and visiting polices in Italian PICUs and assess the possible impact of the recent position statement on this topic by the Italian National Committee for Bioethics (INCB) [2], we carried out a fresh nationwide survey. A questionnaire was sent to all 30 Italian PICUs. Response rate was 100%. Median daily visiting time was 8 h for parents and 2 h for other visitors. Only 23% of PICUs had a 24-h visiting policy; 59% of units did not allow the constant presence of a parent even during the day. Just 7% of units permitted parental presence during invasive procedures and cardiopulmonary resuscitation; for ordinary nursing procedures it was allowed in 70% of them. Moreover, parental presence at the patient’s bedside during doctors’ visits, attendance at clinical rounds, and nurses’ handovers (allowed in 33, 14, and 7% of units, respectively) represented more the exception than the rule. Children can visit in only 37% of PICUs. A gowning procedure was still compulsory for visitors in most (70%) units. Units with a lower nurse/patient ratio and cardiac surgery units had more restricted visiting hours for parents. Daily meetings of doctors with parents were held systematically in almost all PICUs (97%) and were mainly conducted by the physician on duty (79%) and/ or unit head (21%). Nearly half the units revised their visiting policy in the last 5 years and in 43% of PICUs a process of revision of the ward’s visiting policies was underway. The snapshot that this study provides has both good and bad news. On the one hand, despite authoritative recommendations [2] Italian PICUs today still have essentially restrictive visiting policies. On the other hand, many units have moved on and currently have on the whole more “liberal” policies than those of 9 years ago (Table 1) and those of Italian adult ICUs [3]. Although organizational factors may play a part (e.g., understaffing of nurses), we believe that the concept of the family-centered ICU [4, 5] has yet to make a breakthrough. Moreover, the INCB recommendations have yet to be fully taken in. On the subject of visiting policies in PICUs there are no national surveys from other countries and the recent literature offers no substantial data for comparison purposes. We can conjecture that, in contrast to the findings in Italy, in most European and North American countries parental presence and a 24-h visiting policy are now widely established and are no longer a question for debate.

Il coinvolgimento dei genitori nelle cure di fine vita: studio qualitativo in una Terapia Intensiva Pediatrica

Introduzione. Recentemente la letteratura ha iniziato ad occuparsi del tema del coinvolgimento dei pazienti nelle cure attraverso il concetto di patient engagement. Il costrutto di engagement e stato fin’ora studiato in relazione al paziente ma mancano contributi volti a studiare il processo di engagement dei caregivers. Il fine vita pediatrico e un ambito in cui il coinvolgimento dei genitori e stato invocato sotto diversi aspetti, eppure poco si sa dell’esperienza di engagement dei genitori nel processo di cura. All’interno di un piu ampio studio sulla qualita delle cure di fine vita in Terapia Intensiva Pediatrica (TIP), il presente lavoro ha avuto l’obiettivo di esplorare l’esperienza di engagement dei genitori. Metodi. Lo studio si e svolto presso la TIP dell’Ospedale Policlinico di Milano. Con i genitori dei bambini deceduti tra il 2007-2010 sono state effettuate delle interviste semi-strutturate riguardanti l’esperienza delle cure di fine vita. I passaggi delle interviste riguardanti l’esperienza di engagement sono state analizzate tramite analisi del contenuto. Risultati. Sono state condotte 8 interviste con 12 genitori. L’engagement dei genitori si articola su tre dimensioni: 1) informativa (sapere); 2) decisionale (decidere); 3) relazionale (esserci). Queste dimensioni possono variare come essere compresenti in gradazioni diverse durante il ricovero del figlio. Conclusioni. Dai risultati emerge un concetto multidimensionale di engagement. In questo ambito clinico sembra che l’engagement dei genitori nelle cure mediche si fondi sul ruolo genitoriale e ne costituisca una declinazione. L’engagement verso i clinici e la TIP sembra continuare anche dopo la morte del figlio durante il processo del lutto.