The addition of 1 sigh per minute during PSV in patients with early ARDS improved gas exchange and lung volume and decreased the respiratory drive.

Background Remdesivir has been associated with accelerated recovery of severe COVID-19. However, whether it is beneficial also in patients requiring mechanical ventilation is uncertain. Methods All consecutive ICU patients requiring mechanical ventilation due to COVID-19 were enrolled. Univariate and multivariable Cox models were used to explore the possible association between in-hospital death or hospital discharge, considered as competing-risk events, and baseline or treatment-related factors, including the use of remdesivir. The rate of extubation and the number of ventilator-free days were also calculated and compared between treatment groups. Results 113 patients requiring mechanical ventilation were observed for a median of 31 days of follow-up; 32% died, 69% were extubated and 66% were discharged alive from hospital. Among 33 treated with RDV, lower mortality (15.2% versus 38.8%), higher rates of extubation (88% versus 60%), ventilator-free days (in median, 11 [IQR 0-16] versus 5 [IQR 0-14.5]) and hospital discharge (85% versus 59%) were observed. Using multivariable analysis, RDV was significantly associated with hospital discharge (HR 2.25; 95%CI 1.27-3.97; P=0.005) and to a non-significantly lower mortality (HR 0.73; 95%CI 0.26-2.1; P=0.560). RDV was also independently associated with extubation (HR 2.10; 95%CI 1.19-3.73; P=0.011), considered as a competing risk to death in ICU, in an additional survival model. Conclusion In our cohort of mechanically ventilated patients, RDV was not associated with a significant reduction of mortality, but it was consistently associated with shorter duration of mechanical ventilation and higher probability of hospital discharge, independently of other risk factors.

Functional residual capacity is affected by PEEP. Ignoring this effect leads to relevant underestimation of alveolar recruitment as measure by pressure-volume curve displacement.

IntroductionSevere mixed β-blocker and calcium channel blocker intoxication presents a significant risk for patient mortality. Although treatment is well-established, it sporadically fails to support the patient through massive overdoses, thus requiring non-conventional treatments. We report the use of extra-corporeal life support in a patient with refractory hemodynamic impairment due to multi-drug intoxication. Although sometimes used in clinical practice, extra-corporeal membrane oxygenation for intoxications has rarely been reported.Case presentationA 36-year-old Caucasian man presented to our hospital with refractory hypotension, severe cardiac insufficiency and multi-organ failure due to mixed intoxication with atenolol, nifedipine, Lacidipine and sertraline. Together with standard treatment, we performed extra-corporeal membrane oxygenation to overcome refractory cardiogenic shock and lead the patient to achieve a full recovery.ConclusionStandard of care for β-blocker and calcium channel blocker intoxication is well-defined and condensed into protocols of treatment. Although aimed at clearing the noxious agents from the patient's system, standard measures may fail to provide adequate hemodynamic support to allow recovery. In selected cases, extra-corporeal membrane oxygenation could be considered a bridge to drug clearance while preventing multi-organ failure due to profound shock.

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Veno-arterial extracorporeal membrane oxygenation (ECMO) is a lifesaving treatment in patients with cardiogenic shock or cardiac arrest caused by massive pulmonary embolism. In these patients, positioning an inferior vena cava filter is often advisable, especially if deep venous thrombosis is not resolved at the time of the ECMO suspension. Moreover, in ECMO patients, a high incidence of deep venous thrombosis at the site of venous cannulation has been reported, and massive pulmonary embolism following ECMO decannulation has been described. Nonetheless, an inferior vena cava filter cannot be positioned as long as an ECMO cannula is inside the inferior vena cava. Thus, we developed a strategy to allow placement of an inferior vena cava filter through the internal jugular concurrently with the removal of the femoral venous ECMO cannula. In two women supported by veno-arterial ECMO for cardiac arrest secondary to pulmonary embolism, this novel approach allowed for safe ECMO decannulation.

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Studies on head injury-induced pituitary dysfunction are limited in number and conflicting results have been reported. To further clarify this issue, 29 consecutive patients (24 males), with severe (n = 21) or moderate (n = 8) head trauma, having a mean age of 37 ± 17 years were investigated in the immediate post-trauma period. All patients required mechanical ventilatory support for 8-55 days and were enrolled in the study within a few days before ICU discharge. Basal hormonal assessment included measurement of cortisol, corticotropin, free thyroxine (fT4), thyrotropin (TSH), testosterone (T) in men, estradiol (E2) in women, prolactin (PRL), and growth hormone (GH). Cortisol and GH levels were measured also after stimulation with 100 µg human corticotropin releasing hormone (hCRH) and 100 µg growth hormone releasing hormone (GHRH), respectively. Cortisol hyporesponsiveness was considered when peak cortisol concentration was less than 20 µg/dl following hCRH. TSH deficiency was diagnosed when a subnormal serum fT4 level was associated with a normal or low TSH. Hypogonadism was considered when T (males) or E2 (women) were below the local reference ranges, in the presence of normal PRL levels. Severe or partial GH deficiencies were defined as a peak GH below 3 µg/l or between 3 and 5 µg/l, respectively, after stimulation with GHRH. Twenty-one subnormal responses were found in 15 of the 29 patients (52%) tested; seven (24%) had hypogonadism, seven (24%) had cortisol hyporesponsiveness, five (17%) had hypothyroidism, and two patients (7%) had partial GH deficiency. These preliminary results suggest that a certain degree of hypopituitarism occurs in more than 50% of patients with moderate or severe head injury in the immediate post-trauma period, with cortisol hyporesponsiveness and hypogonadism being most common. Further studies are required to elucidate the pathogenesis of these abnormalities and to investigate whether they affect long-term morbidity. P2 Cortisol reserve in head trauma victims: evaluation with the low-dose (1 µ µg) corticotropin (ACTH) stimulation test