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.

SummaryWe 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. Patients affected by the novel swine-origin influenza A ⁄ H1N1 virus can develop an acute alveolar interstitial syndrome. A recent survey of Spanish Intensive Care Units (ICUs) showed that patients requiring ICU admission had a young median age and a relatively high casemortality rate [1]. We present the case of a young healthy male who developed H1N1-induced Acute Respiratory Distress Syndrome (ARDS) and in whom management was guided by daily lung ultrasonography.A 39-year-old man was referred to the Emergency Room of a peripheral hospital with a fever (38.5°C), arthralgia and severe dyspnoea. Over the previous 4 days he had been complaining of mild fever, abdominal pain, nausea, and diarrhoea. He was a heavy cigarette smoker with no significant co-morbidities in his past medical history.At presentation in the Emergency Room the patient was disoriented. He had a systemic arterial pressure of 135 ⁄ 70 mmHg, a heart rate of 140 beats.min )1 , a respiratory rate of 35 breaths.min, and S p O 2 of 77% Arterial blood gas analysis demonstrated: pH 7.46; P a O 2 5.3 kPa with a F I O 2 0.3 (P a O 2 ⁄ F I O 2 ratio of 17.6 (140 if P a O 2 expressed in mmHg)); P a CO 2 4.6 kPa; base excess 1.5 mmol.l )1 and bicarbonate 25 mmol.l )1 . Computed tomography (CT) of the chest showed multiple, bilateral areas of increased lung density (Fig. 1). The patient was sedated, underwent tracheal intubation and his lungs were mechanically ventilated. After 2 h of mechanical ventilation with a F I O 2 of 1.0 and using high inspiratory pressure levels (plateau pressure 47 cmH 2 O, positive-end expiratory pressure (PEEP) 20 cmH 2 O), and with no response to recruitment manoeuvres, blood gas analysis showed a P a O 2 of 21 kPa (P a O 2 ⁄ F I O 2 ratio of 21 (160 if P a O 2 expressed in mmHg)). According to the local protocol for the management of patients with ARDS, the patient was subsequently transferred to our hospital which is the designated referral centre for extracorporeal membrane oxygenation. Following transfer and admission to our ICU, a pulmonary artery catheter was inserted; measurements showed a pulmonary artery wedge pressure of 14 mmHg, confirming the presence of ARDS. A protective lung

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.

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.

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.