Monica Rocco

A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome

Objective: In randomized studies of heterogeneous patients with hypoxemic acute respiratory failure, noninvasive positive pressure ventilation (NPPV) was associated with a significant reduction in endotracheal intubation. The role of NPPV in patients with acute respiratory distress syndrome (ARDS) is still unclear. The objective was to investigate the application of NPPV as a first‐line intervention in patients with early ARDS, describing what happens in everyday clinical practice in centers having expertise with NPPV. Design: Prospective, multiple‐center cohort study. Setting: Three European intensive care units having expertise with NPPV. Patients: Between March 2002 and April 2004, 479 patients with ARDS were admitted to the intensive care units. Three hundred and thirty‐two ARDS patients were already intubated, so 147 were eligible for the study. Interventions: Application of NPPV. Measurements and Main Results: NPPV improved gas exchange and avoided intubation in 79 patients (54%). Avoidance of intubation was associated with less ventilator‐associated pneumonia (2% vs. 20%; p < .001) and a lower intensive care unit mortality rate (6% vs. 53%; p < .001). Intubation was more likely in patients who were older (p = .02), had a higher Simplified Acute Physiology Score (SAPS) II (p < .001), or needed a higher level of positive end‐expiratory pressure (p = .03) and pressure support ventilation (p = .02). Only SAPS II >34 and a Pao2/Fio2 ≤175 after 1 hr of NPPV were independently associated with NPPV failure and need for endotracheal intubation. Conclusions: In expert centers, NPPV applied as first‐line intervention in ARDS avoided intubation in 54% of treated patients. A SAPS II >34 and the inability to improve Pao2/Fio2 after 1 hr of NPPV were predictors of failure.

Noninvasive vs. conventional mechanical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial

Abstract Objective. We conducted a randomized prospective study comparing noninvasive positive pressure ventilation (NPPV) with conventional mechanical ventilation via endotracheal intubation (ETI) in a group of patients with chronic obstructive pulmonary disease who failed standard medical treatment in the emergency ward after initial improvement and met predetermined criteria for ventilatory support. Design and setting. Prospective randomized study in a university hospital 13-bed general ICU. Patients. Forty-nine patients were randomly assigned to receive NPPV (n=23) or conventional ventilation (n=26). Results. both NPPV and conventional ventilation significantly improved gas exchanges. The two groups had similar length of ICU stay, number of days on mechanical ventilation, overall complications, ICU mortality, and hospital mortality. In the NPPV group 11 (48%) patients avoided intubation, survived, and had a shorter duration of ICU stay than intubated patients. One year following hospital discharge the NPPV group had fewer patients readmitted to the hospital (65% vs. 100%) or requiring de novo permanent oxygen supplementation (0% vs. 36%). Conclusions. The use of NPPV in patients with chronic obstructive pulmonary disease and acute respiratory failure requiring ventilatory support after failure of medical treatment avoided ETI in 48% of the patients, had the same ICU mortality as conventional treatment and, at 1-year follow-up was associated with fewer patients readmitted to the hospital or requiring for long-term oxygen supplementation. An editorial regarding this article can be found in the same issue (http://dx.doi.org/10.1007/s00134-002-1503-3).

A Comparison of Noninvasive Positive-Pressure Ventilation and Conventional Mechanical Ventilation in Patients with Acute Respiratory Failure

BACKGROUND AND METHODS The role of noninvasive positive-pressure ventilation delivered through a face mask in patients with acute respiratory failure is uncertain. We conducted a prospective, randomized trial of noninvasive positive-pressure ventilation as compared with endotracheal intubation with conventional mechanical ventilation in 64 patients with hypoxemic acute respiratory failure who required mechanical ventilation. RESULTS Within the first hour of ventilation, 20 of 32 patients (62 percent) in the noninvasive-ventilation group and 15 of 32 (47 percent) in the conventional-ventilation group had an improved ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2:FiO2) (P=0.21). Ten patients in the noninvasive-ventilation group subsequently required endotracheal intubation. Seventeen patients in the conventional-ventilation group (53 percent) and 23 in the noninvasive-ventilation group (72 percent) survived their stay in the intensive care unit (odds ratio, 0.4; 95 percent confidence interval, 0.1 to 1.4; P=0.19); 16 patients in the conventional-ventilation group and 22 patients in the noninvasive-ventilation group were discharged from the hospital. More patients in the conventional-ventilation group had serious complications (66 percent vs. 38 percent, P=0.02) and had pneumonia or sinusitis related to the endotracheal tube (31 percent vs. 3 percent, P=0.003). Among the survivors, patients in the noninvasive-ventilation group had shorter periods of ventilation (P=0.006) and shorter stays in the intensive care unit (P=0.002). CONCLUSIONS In patients with acute respiratory failure, noninvasive ventilation was as effective as conventional ventilation in improving gas exchange and was associated with fewer serious complications and shorter stays in the intensive care unit.

Noninvasive positive pressure ventilation using a helmet in patients with acute exacerbation of chronic obstructive pulmonary disease : a feasibility study

BackgroundNoninvasive positive pressure ventilation (NPPV) with a facemask (FM) is effective in patients with acute exacerbation of their chronic obstructive pulmonary disease. Whether it is feasible to treat these patients with NPPV delivered by a helmet is not known. MethodsOver a 4-month period, the authors studied 33 chronic obstructive pulmonary disease patients with acute exacerbation who were admitted to four intensive care units and treated with helmet NPPV. The patients were compared with 33 historical controls treated with FM NPPV, matched for simplified acute physiologic score (SAPS II), age, Paco2, pH, and Pao2:fractional inspired oxygen tension. The primary endpoints were the feasibility of the technique, improvement of gas exchange, and need for intubation. ResultsThe baseline characteristics of the two groups were similar. Ten patients in the helmet group and 14 in the FM group (P = 0.22) were intubated. In the helmet group, no patients were unable to tolerate NPPV, whereas five patients required intubation in the FM group (P = 0.047). After 1 h of treatment, both groups had a significant reduction of Paco2 with improvement of pH; Paco2 decreased less in the helmet group (P = 0.01). On discontinuing support, Paco2 was higher (P = 0.002) and pH lower (P = 0.02) in the helmet group than in the control group. One patient in the helmet group, and 12 in the FM group, developed complications related to NPPV (P < 0.001). Length of intensive care unit stay, intensive care unit, and hospital mortality were similar in both groups. ConclusionsHelmet NPPV is feasible and can be used to treat chronic obstructive pulmonary disease patients with acute exacerbation, but it does not improve carbon dioxide elimination as efficiently as does FM NPPV.

Cytoreductive surgery (peritonectomy procedures) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of diffuse peritoneal carcinomatosis from ovarian cancer

Because of scarce data from larger series and nonhomogeneous selection criteria, further information is needed on peritonectomy with hyperthermic intraperitoneal chemotherapy (HIPEC) in managing patients with ovarian peritoneal carcinomatosis.

Effects of levosimendan on right ventricular afterload in patients with acute respiratory distress syndrome: a pilot study.

Objective:Acute respiratory distress syndrome (ARDS) is frequently associated with increased pulmonary vascular resistance and thus with systolic load of the right ventricle. We hypothesized that levosimendan, a new calcium sensitizer with potential pulmonary vasodilator properties, improves hemodynamics by unloading the right ventricle in patients with ARDS. Design:Prospective, randomized, placebo-controlled, pilot study. Setting:Twenty-two-bed multidisciplinary intensive care unit of a university hospital. Patients:Thirty-five patients with ARDS in association with septic shock. Interventions:Patients were randomly allocated to receive a 24-hr infusion of either levosimendan 0.2 &mgr;g/kg/min (n = 18) or placebo (n = 17). Data from right heart catheterization, cardiac magnetic resonance, arterial and mixed venous oxygen tensions and saturations, and carbon dioxide tensions were obtained before and 24 hrs after drug infusion. Measurements and Main Results:At a mean arterial pressure between 70 and 80 mm Hg (sustained with norepinephrine infusion), levosimendan increased cardiac index (from 3.8 ± 1.1 to 4.2 ± 1.0 L/min/m2) and decreased mean pulmonary artery pressure (from 29 ± 3 to 25 ± 3 mm Hg) and pulmonary vascular resistance index (from 290 ± 77 to 213 ± 50 dynes/s/cm5/m2; each p < .05). Levosimendan also decreased right ventricular end-systolic volume and increased right ventricular ejection fraction (p < .05). In addition, levosimendan increased mixed venous oxygen saturation (from 63 ± 8 to 70 ± 8%; p < .01). Conclusions:This study provides evidence that levosimendan improves right ventricular performance through pulmonary vasodilator effects in septic patients with ARDS. A large multiple-center trial is needed to investigate whether levosimendan is able to improve the overall prognosis of patients with sepsis and ARDS.

Fluid balance and urine volume are independent predictors of mortality in acute kidney injury

IntroductionIn ICUs, both fluid overload and oliguria are common complications associated with increased mortality among critically ill patients, particularly in acute kidney injury (AKI). Although fluid overload is an expected complication of oliguria, it remains unclear whether their effects on mortality are independent of each other. The aim of this study is to evaluate the impact of both fluid balance and urine volume on outcomes and determine whether they behave as independent predictors of mortality in adult ICU patients with AKI.MethodsWe performed a secondary analysis of data from a multicenter, prospective cohort study in 10 Italian ICUs. AKI was defined by renal sequential organ failure assessment (SOFA) score (creatinine >3.5 mg/dL or urine output (UO) <500 mL/d). Oliguria was defined as a UO <500 mL/d. Mean fluid balance (MFB) and mean urine volume (MUV) were calculated as the arithmetic mean of all daily values. Use of diuretics was noted daily. To assess the impact of MFB and MUV on mortality of AKI patients, multivariate analysis was performed by Cox regression.ResultsOf the 601 included patients, 132 had AKI during their ICU stay and the mortality in this group was 50%. Non-surviving AKI patients had higher MFB (1.31 ± 1.24 versus 0.17 ± 0.72 L/day; P <0.001) and lower MUV (1.28 ± 0.90 versus 2.35 ± 0.98 L/day; P <0.001) as compared to survivors. In the multivariate analysis, MFB (adjusted hazard ratio (HR) 1.67 per L/day, 95%CI 1.33 to 2.09; <0.001) and MUV (adjusted HR 0.47 per L/day, 95%CI 0.33 to 0.67; <0.001) remained independent risk factors for 28-day mortality after adjustment for age, gender, diabetes, hypertension, diuretic use, non-renal SOFA and sepsis. Diuretic use was associated with better survival in this population (adjusted HR 0.25, 95%CI 0.12 to 0.52; <0.001).ConclusionsIn this multicenter ICU study, a higher fluid balance and a lower urine volume were both important factors associated with 28-day mortality of AKI patients.

Prophylactic fenoldopam for renal protection in sepsis: a randomized, double-blind, placebo-controlled pilot trial.

Objective:Acute renal failure is common in septic patients. Fenoldopam, a dopamine-1 receptor agonist, increases renal blood flow and may, therefore, reduce the risk of acute renal failure in such patients. Accordingly, we sought to determine the safety and efficacy of fenoldopam for the prevention of acute renal failure in septic patients. Design:Prospective, double-blind, placebo-controlled trial. Setting:Three multidisciplinary intensive care units at a university hospital. Patients:Three hundred septic patients with baseline serum creatinine concentrations <150 &mgr;mol/L. Interventions:We randomized patients to a continuous infusion of either fenoldopam (n = 150) at 0.09 &mgr;g·kg−1·min−1 or placebo (n = 150) while in the intensive care unit. The primary outcome measure was the incidence of acute renal failure, defined as a serum creatinine concentration increase to >150 &mgr;mol/L, during study drug infusion. Measurements and main results:The incidence of acute renal failure was significantly lower in the fenoldopam group compared with the control group (29 vs. 51 patients; p = .006). The odds ratio of developing acute renal failure for patients treated with fenoldopam was estimated to be 0.47 (p = .005). The difference in the incidence of severe acute renal failure (creatinine >300 &mgr;mol/L), however, failed to achieve statistical significance (10 vs. 21; p = .056). The length of intensive care unit stay in surviving patients was significantly lower in the fenoldopam group compared with the control group (10.64 ± 9.3 vs. 13.4 ± 14.0; p < .001). There were no complications of fenoldopam infusion. A direct effect of treatment on the probability of death, beyond its effect on acute renal failure, was not significant (odds ratio = 0.68, p = .1). Conclusions:Compared with placebo, low-dose fenoldopam resulted in a smaller increase in serum creatinine in septic patients. The clinical significance of this finding is uncertain. A large multiple-center trial is now needed to confirm these findings.

Functional and ultrastructural evidence of myocardial stunning after acute carbon monoxide poisoning

OBJECTIVE To study human myocardial ultrastructural changes after carbon monoxide (CO) poisoning inducing reversible cardiac failure. DESIGN CASE REPORT clinical, functional and morphologic findings. SETTINGS Public university-affiliated hospital and electron microscopy laboratory. PATIENT A 25-yr-old woman with functional evidence of cardiac failure after acute CO poisoning. INTERVENTIONS Hyperbaric and intensive care treatment over 10 days. Scintigraphic and cardiac angiography with endomyocardial biopsy. MEASUREMENTS AND MAIN RESULTS Scintigraphy with 99mTc hexakis 2-methoxy-2-isobutyl isonitrile (sestaMIBI) showed an uptake defect in the left anterior descending artery territory. The cardiac angiography demonstrated a slight hypokinesis of the superior two thirds of the anterior wall and of the septal region with completely normal coronary angiograms. Electron microscopy of left ventricular biopsies showed slight ultrastructural changes in the myocytes. In addition, large glycogen deposits were mostly associated with swollen mitochondria. The patient was discharged in good clinical condition on day 10. CONCLUSIONS Presence of glycogen deposits associated with abnormal mitochondria may be signs of the incapability of myocardial cells in utilizing energy substrata. In the presence of normal myocardial perfusion, our findings are consistent with the presence of a stunned myocardium-like syndrome. Early recognition and treatment of this clinical syndrome allow the prevention of myocardial infarction.

Diagnostic accuracy of bedside ultrasonography in the ICU: Feasibility of detecting pulmonary effusion and lung contusion in patients on respiratory support after severe blunt thoracic trauma

Background: Blunt thoracic trauma is a major concern in critically ill patients. Repeated lung diagnostic evaluations are needed in order to follow up the clinical situation and the results of the therapeutic strategies. The aim of this prospective clinical study was to evaluate the possible role of lung ultrasound (LU) compared with bedside radiography (CXR) and computed tomography (CT) used as the gold standard in the evaluation of trauma patients admitted to the intensive care unit with acute respiratory failure.