Simona Biondi

Ventilatory and ECMO treatment of H1N1-induced severe respiratory failure: results of an Italian referral ECMO center.

BackgroundSince the first outbreak of a respiratory illness caused by H1N1 virus in Mexico, several reports have described the need of intensive care or extracorporeal membrane oxygenation (ECMO) assistance in young and often healthy patients. Here we describe our experience in H1N1-induced ARDS using both ventilation strategy and ECMO assistance.MethodsFollowing Italian Ministry of Health instructions, an Emergency Service was established at the Careggi Teaching Hospital (Florence, Italy) for the novel pandemic influenza. From Sept 09 to Jan 10, all patients admitted to our Intensive Care Unit (ICU) of the Emergency Department with ARDS due to H1N1 infection were studied. All ECMO treatments were veno-venous. H1N1 infection was confirmed by PCR assayed on pharyngeal swab, subglottic aspiration and bronchoalveolar lavage. Lung pathology was evaluated daily by lung ultrasound (LUS) examination.ResultsA total of 12 patients were studied: 7 underwent ECMO treatment, and 5 responded to protective mechanical ventilation. Two patients had co-infection by Legionella Pneumophila. One woman was pregnant. In our series, PCR from bronchoalveolar lavage had a 100% sensitivity compared to 75% from pharyngeal swab samples. The routine use of LUS limited the number of chest X-ray examinations and decreased transportation to radiology for CT-scan, increasing patient safety and avoiding the transitory disconnection from ventilator. No major complications occurred during ECMO treatments. In three cases, bleeding from vascular access sites due to heparin infusion required blood transfusions. Overall mortality rate was 8.3%.ConclusionsIn our experience, early ECMO assistance resulted safe and feasible, considering the life threatening condition, in H1N1-induced ARDS. Lung ultrasound is an effective mean for daily assessment of ARDS patients.

Comparison between single-step and balloon dilatational tracheostomy in intensive care unit: a single-centre, randomized controlled study

BACKGROUND Balloon dilatational tracheostomy using the Ciaglia Blue Dolphin device has recently been introduced as a modification of the Ciaglia technique. The aim of this study was to compare the new Dolphin system with the single-step dilatational tracheostomy (Ciaglia Blue Rhino) in intensive care unit (ICU) patients. METHODS Consecutive patients admitted to the ICU of the Emergency Department (Careggi Teaching Hospital, Florence, Italy) from January 2009 to October 2009, aged >18 years and with an indication for percutaneous dilatational tracheostomy (PDT), were enrolled. Exclusion criteria were infection/injury/malignancy of the neck, thyroid gland hypertrophy, severe head injury with uncontrolled intracranial hypertension, and coagulopathy. Patients were randomly assigned to undergo PDT using either the Ciaglia Blue Rhino (n=35) or the Ciaglia Blue Dolphin technique (n=35). Groups were compared according to tracheal puncture, tracheal tube placement time, procedure-related complications, and bleeding. RESULTS Baseline clinical data were comparable between the two groups. Median procedure time was significantly shorter in the Rhino group compared with the Dolphin group (1.5 vs 4 min, P = 0.035). The presence of limited intra-tracheal bleeding at bronchoscopy examination after 6 h from PDT was more frequent in the Dolphin group than in the Rhino group patients (68.6% vs 34.3%, respectively, P = 0.008). No major bleeding occurred in either group. CONCLUSIONS PDT using the Ciaglia Blue Dolphin technique is a feasible and viable option in ICU patients, but the Rhino technique had a shorter execution time and seemed to be associated with fewer tracheal injuries.

The value of lung ultrasound monitoring in H1N1 acute respiratory distress syndrome

We present the case of a healthy young male who developed acute respiratory failure as a result of infection with influenza A/H1N1 of swine‐origin and in whom ventilatory support was optimised and recovery of lung function was monitored by the use of sequential chest ultrasound examinations. The potential pivotal role of bedside lung ultrasonography in H1N1‐induced respiratory failure is discussed.

Extracorporeal life support for management of refractory cardiac or respiratory failure: initial experience in a tertiary centre.

IntroductionExtracorporeal Life Support (ECLS) and extracorporeal membrane oxygenation (ECMO) have been indicated as treatment for acute respiratory and/or cardiac failure. Here we describe our first year experience of in-hospital ECLS activity, the operative algorithm and the protocol for centralization of adult patients from district hospitals.MethodsAt a tertiary referral trauma center (Careggi Teaching Hospital, Florence, Italy), an ECLS program was developed from 2008 by the Emergency Department and Heart and Vessel Department ICUs. The ECLS team consists of an intensivist, a cardiac surgeon, a cardiologist and a perfusionist, all trained in ECLS technique. ECMO support was applied in case of severe acute respiratory distress syndrome (ARDS) not responsive to conventional treatments. The use of veno-arterial (V-A) ECLS for cardiac support was reserved for cases of cardiac shock refractory to standard treatment and cardiac arrests not responding to conventional resuscitation.ResultsA total of 21 patients were treated with ECLS during the first year of activity. Among them, 13 received ECMO for ARDS (5 H1N1-virus related), with a 62% survival. In one case of post-traumatic ARDS, V-A ECLS support permitted multiple organ donation after cerebral death was confirmed. Patients treated with V-A ECLS due to cardiogenic shock (N = 4) had a survival rate of 50%. No patients on V-A ECLS support after cardiac arrest survived (N = 4).ConclusionsIn our centre, an ECLS Service was instituted over a relatively limited period of time. A strict collaboration between different specialists can be regarded as a key feature to efficiently implement the process.

An easy access to α,β-unsaturated thioacylsilanes: a useful route to silylated 1,2-dithiins

Abstract Treatment of different silylated allenes with hexamethyldisilathiane (HMDST) in the presence of CoCl2·6H2O affords an easy and high yielding access to α,β-unsaturated thioacylsilanes, which undergo a self-dimerization reaction to afford polyfunctionalized 1,2-dithiins as the major products.

Late decompressive craniectomyafter traumatic brain injury: neurological outcome at 6 months after ICU discharge

IntroductionThe choice of optimal treatment in traumatic brain injured (TBI) patients is a challenge. The aim of this study was to verify the neurological outcome of severe TBI patients treated with decompressive craniectomy (early < 24 h, late > 24 h), compared to conservative treatment, in hospital and after 6-months.MethodsA total of 186 TBI patients admitted to the ICU of the Emergency Department of a tertiary referral center (Careggi Teaching Hospital, Florence, Italy) from 2005 through 2009 were retrospectively studied. Patients treated with decompressive craniectomy were divided into 2 groups: “early craniectomy group” (patients who underwent to craniectomy within the first 24 hours); and “late craniectomy group” (patients who underwent to craniectomy later than the first 24 hours). As a control group, patients whose intracranial hypertension was successfully controlled by medical treatment were included in the “no craniectomy group”.ResultsGroups included 41 patients who required early decompressive craniectomy, 21 patients treated with late craniectomy (7.7 days after trauma, on average), and 124 patients for whom intracranial hypertension was successfully controlled through conservative treatment. Groups were comparable in age and trauma/critical illness scores, except for a significantly higher Marshall score in early craniectomized patients. The Glasgow Outcome Scale was comparable between groups at ICU, at the time of hospital discharge and at 6 months.ConclusionsIn our sample, a late craniectomy in patients with refractory intracranial hypertension produced a comparable 6-months neurological outcome if compared to patients responder to standard treatment. This data must be reproduced and confirmed before considering as goal-treatment in refractory intracranial hypertension.

A General Access to 2-Silylthiazolidines and Their Reactions Under Fluoride Ion Conditions

Trimethylsilylthiazolidines were readily obtained through reaction of aminoethanethiol with (bromomethoxymethyl)trimethylsilane and efficiently N-functionalized with a variety of protecting groups. Such N-protected thiazolidines can then be satisfactorily reacted with several organic electrophiles under fluoride ion conditions, with a clean transfer of the thiazolidine moiety, to afford good yields of 2- functionalized heterocycles. The thiazolidine ring system derives special importance from the fact that it is an integral part of medicinally important compounds like the penicillins (1) and some antiradiation drugs (2). Substituted thiazolidine derivatives represent important key intermediates for the synthesis of pharmacologically active drugs (3). Recently a number of thiazolidines have been claimed to be retroviral protease inhibitors (3b,4) and have also been investigated as possible substitute for the carbohydrate moiety in the synthesis of new antiviral nucleosides (5). More recently they have also been shown as antitussive active molecules (6). Thiazolidines are also relevant in food chemistry, as far as they are incorporated in flavor enhancing additives (7), and their synthetic utility is shown by their use as blocking groups (8), and as intermediates in the synthesis of aldehydes (9) and aminoethane thiols (10). Despite the utility of the thiazolidine moiety, still very few methodologies for the functionalization of position 2 of the heterocyclic ring exist. Only two reports, in fact, to the

α,β-Unsaturated thioacylsilanes as efficient dienes in hetero Diels–Alder reactions

Abstract Reaction of several α,β-unsaturated thioacylsilanes with in situ generated thioaldehydes and thioacylsilanes affords under mild conditions a clean and regioselective access to 2-substituted 4-silyl-1,3-dithiacyclohex-4-ene derivatives, arising from an hetero-Diels–Alder reaction between two different thiocarbonyl compounds.

Cardiopulmonary resuscitation after traumatic cardiac arrest - there are survivors: registries must speak about it

We read with great interest the paper published on Critical Care by Graesner and collegues that strongly emphasizes the importance of encouraging attempts cardiopulmonary resuscitation (CPR) in cardiac arrest caused by severe trauma in contrast to trauma management programs. Despite the interesting contents, in our opinion the results presented by Graesner and colleagues suffer from the fact of being derived from the database designed for different purposes (Cardiac Arrest Registry and Trauma Registry).