Minerva anestesiologica
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Minerva anestesiologica · Sep 2011
Invasive and non-invasive long-term mechanical ventilation in Italian children.
To date, few studies have been published regarding the number of children in Italy who require long-term mechanical ventilation (LTV) and their underlying diagnoses, ventilatory needs and hospital discharge rate. ⋯ Managing pediatric home LTV requires tremendous effort on the part of the patient's family and places a significant strain on community financial resources. In particular, neurological patients require more health care than patients in other categories. To further improve the quality of care for these patients, it is essential to establish a dedicated national database.
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Minerva anestesiologica · Sep 2011
Review Meta AnalysisSteroids in severe pneumonia: a literature review.
Despite more than sixty years of scientific medical research, severe pneumonia, either community-acquired or nosocomial, remains a leading cause of death regardless of the patients' immunity state. The clinical introduction of new and more potent antibiotic molecules and the continuous development of efficient respiratory assistance devices may not be able to radically improve the clinical outcome of pneumonia. Adjunctive therapies based on the physiopathological mechanisms of lung damage in severe pneumonia have been strongly advocated, and corticosteroids, which present many properties that theoretically interfere with these pathways, have been widely used, with conflicting results. ⋯ In severe pneumonia, preclinical data, including cytokine level detection and animal studies, have shown encouraging results, although the clinical data is controversial. Moreover, large randomized controlled trials have not been conducted to determine steroid side effects and the risk of immunosuppression-induced superinfections. The benefits of steroid use in patients with severe pneumonia have not been proven by current literature, but ongoing investigations of anti-inflammatory molecules probably represent the key point of severe infection management in the near future.
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Minerva anestesiologica · Sep 2011
ReviewAre guidelines for non-invasive ventilation during weaning still valid?
Noninvasive ventilation (NIV) has gained increasing acceptance over the years to reduce endotracheal intubation, pneumonia and to prevent or treat respiratory failure in patients with different diagnoses. The international consensus conference, and the British society guidelines on NIV ventilation have analyzed its use during the weaning phase concluding that there were still conflicting results of its use. However, recent clinical trials have shown clear clinical benefits on the use of NIV in several patient populations during the weaning period. ⋯ The latest published randomized trials on the application of NIV for acute respiratory failure following extubation failed to demonstrate any favorable outcome. Even so, the use of NIV during the process of weaning in patients experiencing multiple weaning failure or as a preventive therapy in patients at higher risk of respiratory deterioration showed improved clinical outcomes only in chronic obstructive pulmonary disease and in particular in hypercapnic patients. Reduced invasive mechanical ventilation, tracheostomy and lower mortality rate at 90 days were the major advantages.
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Minerva anestesiologica · Sep 2011
ReviewEnd of life care in Italian intensive care units: where are we now?
Most patients in the ICU are unable to make decisions for themselves at the end of life (EOL), and the responsibility for these decisions falls to the medical staff and patients' relatives. Therefore, clinicians must frequently communicate with patients' relatives to understand the patients' values and preferences as they perform medical decision making. The family's role in this process varies: the entire burden of decision making could rest with the family, or family members could be informed of the decisions without admission into the decision-making process. ⋯ In this latter scenario, the effectiveness of the discussions that take place between clinicians and family members becomes a crucial marker of high-quality intensive care. In this review, we provide an overview of the current literature concerning the state of EOL care in European and Italian ICUs and then summarize several European and American recommendations for improving EOL care in the ICU. Finally, we examine the opportunity to use shared decision making to improve EOL care in the ICU through interdisciplinary communication, open and realistic discussion of prognosis with families, and an approach respecting different cultural perspectives.