Acute Care Medicine Surgery and Anesthesia

Retroversion bronchoscopy: an innovative approach to percutaneous dilatational tracheostomy and more

Giovanni Scognamiglio — 2024-09-10

Tracheostomy is one of the most performed procedures in intensive care unit. Dilatational techniques, such as those described by Ciaglia, Griggs, or Fantoni, are currently the best choices as they can be easily performed at the bedside. Like any other intervention, early and late complications can occur even if the procedure appears to be performed without any issues. Although using a bronchoscope can make tracheostomy easier and safer, its routine utilization remains controversial. We describe a new method to further reduce the incidence of some complications: retroversion bronchoscopy. This new approach is not difficult to master and may be useful in other intensive care unit scenarios as well.

Which neurocritical care skills support daily work in general critically ill patients?

Raffaele Aspide — 2024-05-06

Intensive Care Medicine is a relatively new discipline that now deals with increasingly complex patients. Aside from the various specificities of the Intensive Care Unit, there are transversal skills that can aid in the care of critically ill patients. Some neurocritical care tools, in particular, deserve adequate dissemination because they have the potential to be useful for a variety of purposes. This manuscript discusses specific indications for electroencephalographic monitoring systems, the use of ultrasonography to measure the diameter of the optic nerve, and, finally, the use of transcranial Doppler. The last two are for the diagnosis or suspicion of intracranial hypertension. Multidisciplinarity and the culture of “patient-centered approach to care” are non-technical skills that are indispensable for quality personalized medicine.

Potential of the Bayesian approach in critical care

Claudia Cerantola — 2024-03-21

Bayesian statistics are becoming increasingly popular in medical data analysis and decision-making. Because of the difficulties that RCTs face in critical care, these methods may be particularly useful. We explain the fundamental concepts and examine recent relevant literature in the field.

Enhancing psychological support and communication in intensive care unit data transmission

Giacomo Fiacco — 2024-08-19

Dear Editor,

We have read with great attention and interest the article "Clinical data transmission in intensive care unit: what have we learned from COVID-19?"1 by Pota et al. We believe that the authors have addressed a very important clinical and ethical aspect regarding the transmission of clinical data. The pandemic has taught us that unforeseen emergent events are still possible and that the global healthcare and economic systems may not be adequately prepared to respond. We agree that, to date, there is no precise regulation on the transmission of patient-related clinical data to families. This includes challenges such as identifying the appropriate recipient, the lack of qualified personnel for medical communication, and the use of uncertified channels that neglect data protection regulations. Additionally, we wish to draw attention to another crucial aspect: psychological support. Healthcare personnel often find themselves communicating severe clinical evaluations and sometimes unfavorable treatment outcomes. Some of the main challenges faced daily by operators in intensive care contexts involve continuous exposure to severe physical and psychological suffering, navigating uncertainty and unpredictability, and balancing the needs of the patient with those of their family. The complexity of current technological aspects introduces new challenges in this scenario.2 The lack of in-person communication could weaken the trust and empathy that should exist between healthcare personnel and the family. [...]

Awake intubation in a patient with morbid obesity in the emergency department: our experience

Gianmaria Chicone — 2024-07-04

Awake intubation is considered the standard of care for the management of the anticipated difficult airway. For its pharmacological properties, remifentanil is ideal for managing difficult endotracheal insertions. This process is augmented by the use of transtracheal injection of lidocaine as it disperses evenly around the area and facilitates the action of remifentanil further. A 48-year-old male patient, weight 200 kg, 184cm tall (BMI>40) came into the emergency room for severe hypercapnic hypoxic respiratory failure. Awake fiberoptic intubation was the option to secure the airway. Successful airway management is critical to the practice of emergency medicine. All anesthesiologists should be familiar with the airway management of obese patients.

COVID-19 in pregnant women: description of a possible case of COVID-19-linked HELLP-like syndrome

Fara Russo — 2024-03-25

New evidence suggests that Sars-CoV2 infection during pregnancy may result in complications such as hypertension, nephropathy, thrombocytopenia, and liver damage. A pre-eclampsia-like syndrome has also been proposed in pregnant women with severe SARS-CoV-2 infection, which meets the pre-eclampsia criteria but resolves without delivery, with improvement in respiratory symptoms. 31-year-old, second pregnancy, in Emergency Room for PROM (premature rupture of membranes), has Sars-CoV2 infection and has not been vaccinated. Normal examinations and mild hypertension were present upon admission, but no treatment was administered. Vaginal Leukocytic Delivery 12 hours after admission, newborn Apgar score 9/10, weight 3.250 kg. At 20 hours after delivery, epigastric pain VAS 8-9 for 20 minutes, systolic/diastolic hypertension peak, increase in transaminases, LDH, ALP, Bilirubin, Dimer, platelet and fibrinogen drop. Neurological and respiratory objectivity were negative, and renal indices were within normal limits, so nifedipine 30mgx2/day + methyldopa 500 mgx2/day was started. Abdominal ultrasound revealed a thin perihepatic fluid stratum. A prophilaxis of dexamethasone 12mg twice a day and magnesium sulfate was introduced. At 32 hours after delivery, the laboratory detected an increase in transaminases, LDH, and worsening of thrombocytopenia. The patient is always eupnoic, and the diuresis is adequate. Blood tests improved gradually after 56 hours postpartum. Methyldopa and steroids are escalating. On day 7, discharge with normalized platelet and bilirubin counts and a decreasing trend in transaminases, LDH, and PAL. At the one-week follow-up, liver enzymes and coagulation were completely normal, and blood pressure was well controlled with methyldopa. We conclude that the simultaneous presence of the two diseases could have had a synergistic or opportunistic effect, resulting in severe clinical manifestations via interaction with the Renin-Angiotensin-Aldosterone system.

Loxosceles rufescens: single-institutional epidemiology, diagnosis and treatment

Francesco Coletta — 2024-01-22

Loxosceles rufescens, also known as “violin spider” due to its characteristic appearance, is a medium-sized spider species that can potentially pose a threat to humans. For this study, patients who presented to our hospital’s Poison Control Center between January 1, 2022, and December 31, 2022, and met the following inclusion criteria were included: Suspicion of a violin spider bite, as evaluated by our center. Our protocol involves an initial local treatment, which includes local washing with copious water and disinfection, along with the application of chlorotetracycline hydrochloride. Systemic therapy utilizes Amoxicillin and Clavulanic Acid as the first-line medication. The primary endpoints of this study are the timing and effectiveness of the treatment for cutaneous lesions. Demographic and anamnestic information regarding age, gender, and timelines was summarized using descriptive methods. Our study’s results indicate that erythema and pain are the most frequent symptoms. Loxoscelism is highly concentrated in the Western hemisphere and is considered the only proven arachnological cause of dermo-necrosis. In recent years, there has been an increase in diagnoses.