The consequences of the COVID-19 pandemic in nurses in the pre-hospital emergency syste

Introduction The COVID-19 pandemic has highlighted the crucial role of nurses and their commitment to their work in facing the situation. Italy has seen a substantial increase in the number of requests for respiratory assistance, and nurses employed on emergency vehicles have been overwhelmed by the situation, with psychological and physical repercussions such as depression and Post Traumatic Stress Disease (PTSD). The study aims to assess the impact of the pandemic on nurses in the Local Emergency System (SET). Method Depression and PTSD via “Screening Questionnaire for Disaster Mental Health”. The questionnaire was distributed among Italian SET nurses with non-probability sampling between 1 December 2020 and 31 January 2021. Results A total of 441 Italian nurses participated in the study, with an average age of 43.28 years (SD ± 9.38) and average working experience in EMS of 11.68 years (SD ± 7.98). 6.12% of the participants worked in an Operations Centre (CO), 72.34% worked in local emergency services and 21.54% worked in both settings. 17.01% of the sample were at high risk for PTSD and 15.65% for depression.

INTERVENTIONAL PULMONARY ASSISTANCE (iLA) AS A BRIDGE TO LUNG TRANSPLANTATION

INTRODUCTION According to the “International Society for Heart and Lung Transplantation” (ISHLT), between 1 and 4% of patients awaiting a lung transplant will need some type of respiratory assistance as a bridge to transplantation. The objective of this study is to analyze the results of patients assisted with the iLA “Interventional Lung Assist” system (Novalung®). MATERIAL AND METHODS The iLA respiratory assistance system (Novalung®) has been used in 12 patients as a bridge to lung transplantation (three chronic obstructive pulmonary disease, five obliterative bronchiolitis, two pulmonary fibrosis, one chest trauma, one pulmonary leiomyomatosis). The gasometric parameters that indicated the assistance were: PaO2: 76.1 ± 29; PaCO2: 110.6 ± 49; pH: 7.12 ± 0.1. The patients were anticoagulated with intravenous sodium heparin (aPTT 160-180 seconds). RESULTS Six hours after the start of respiratory assistance, the gasometric parameters were: PaO2: 89 ± 17 (p > 0.05); PaCO2: 54.6 ± 5 (p < 0.05); pH 7.34 ± 0.1 (p < 0.05). The mean time of attendance was 16.8 ± 8 (4-28) days. Of the total number of patients attended: one died during the care and the remaining 11 were transplanted, of which 8 survived the lung transplant. CONCLUSIONS Respiratory assistance using iLA (Novalung®) has proven to be an effective method as a bridge to lung transplantation. It allows to improve lung function and avoid mechanical ventilation. It is indicated in patients with nonpermissive hypercapnia to avoid mechanical ventilation. In mechanically ventilated patients, iLA assistance improves ventilator tidal volume, FiO2 and PEEP.

RESULTS OF LUNG TRANSPLANTATION ASSISTED WITH EXTRACORPOREAL MEMBRANE OXYGENATOR (ECMO)

INTRODUCTION According to the registry of the “International Society for Heart and Lung Transplantation” (ISHLT), 32% of lung transplants (Tx P) will require respiratory assistance in the perioperative period. The aim of the study is to compare the results of the Tx P that required ECMO, versus those that did not require respiratory assistance. MATERIAL AND METHODS Between January 2015 and December 31th 2018, 184 lung transplants were performed in the organ transplant unit. In 119 (64.7%) of the transplants, they did not need respiratory assistance and in 65 (35.3%) they required ECMO either intraoperatively and/or postoperatively. The indications for lung transplantation were: interstitial fibrosis 77 (41.8%), pulmonary emphysema 64 (34.7%), cystic fibrosis 28 (15.3%), others 15 (8.2%). RESULTS Patients with Mean Pulmonary Pressure (MPP) greater than 54 mmHg required assistance with ECMO during transplantation (p < 0.03). 83% of transplanted patients remained in NYHA grade I and grade II. Hospital mortality was 21/184 (11.4%); ECMO mortality 14/67 (20.9%) vs NO-ECMO mortality 6/117 (5.1%), significantly higher (p < 0.005 OR = 4.98). Survival and quality of life at 5 years were similar in both groups (p = 0.09). CONCLUSIONS ECMO has proven to be safe and effective in Tx P. Patients with PMP> 54 mmHg required ECMO (p < 0.03). After the hospital postoperative period, the quality of life and survival at five years were similar in both groups.

Association between Urinary Metabolites and the Exposure of Intensive Care Newborns to Plasticizers of Medical Devices Used for Their Care Management

Care management of newborns in the neonatal intensive care unit (NICU) requires numerous PVC (PolyVinyl Chloride) medical devices (MD) containing plasticizers that can migrate and contaminate the patient. We measured the magnitude of neonates’ exposure to plasticizers (di-ethylhexylphthalate (DEHP) and alternatives) in relation to urinary concentrations of their metabolites. Plasticizers’ exposure was evaluated (1) by calculating the amounts of plasticizers prone to be released from each MD used for care management, and (2) by measuring the patients’ urinary levels of each plasticizers’ metabolites. 104 neonates were enrolled. They were exposed to di-isononylphthalate (DINP), especially via transfusion and infusion MD, and to DEHP via ECMO (Extra Corporeal Membrane Oxygenation) and respiratory assistance MD. Mean exposure doses exceeded the derived no-effect level of DINP and DEHP by a 10-fold and a 1000-fold factor. No PVC MD were plasticized with di-isononylcyclohexane-1,2-dicarboxylate (DINCH). High urinary concentrations of DEHP metabolites were directly correlated with DEHP exposure through ECMO MD. Urinary concentrations of DINP metabolites in transfused patients were also high. DINCH metabolites were found in urine, suggesting another route of exposure. Neonates in NICU are considerably exposed to plasticizers, with magnitudes varying with the type of MD used. The high exposure to DEHP and DINP leads to a risk of their metabolites’ toxicity.

COVID-19 cognitive deficits after respiratory assistance in the subacute phase: A COVID-rehabilitation unit experience

Introduction COVID-19 complications can include neurological, psychiatric, psychological, and psychosocial impairments. Little is known on the consequences of SARS-COV-2 on cognitive functions of patients in the sub-acute phase of the disease. We aimed to investigate the impact of COVID-19 on cognitive functions of patients admitted to the COVID-19 Rehabilitation Unit of the San Raffaele Hospital (Milan, Italy). Material and methods 87 patients admitted to the COVID-19 Rehabilitation Unit from March 27th to June 20th 2020 were included. Patients underwent Mini Mental State Evaluation (MMSE), Montreal Cognitive Assessment (MoCA), Hamilton Rating Scale for Depression, and Functional Independence Measure (FIM). Data were divided in 4 groups according to the respiratory assistance in the acute phase: Group1 (orotracheal intubation), Group2 (non-invasive ventilation using Biphasic Positive Airway Pressure), Group3 (Venturi Masks), Group4 (no oxygen therapy). Follow-ups were performed at one month after home-discharge. Results Out of the 87 patients (62 Male, mean age 67.23 ± 12.89 years), 80% had neuropsychological deficits (MoCA and MMSE) and 40% showed mild-to-moderate depression. Group1 had higher scores than Group3 for visuospatial/executive functions (p = 0.016), naming (p = 0.024), short- and long-term memory (p = 0.010, p = 0.005), abstraction (p = 0.024), and orientation (p = 0.034). Group1 was younger than Groups2 and 3. Cognitive impairments correlated with patients’ age. Only 18 patients presented with anosmia. Their data did not differ from the other patients. FIM (<100) did not differ between groups. Patients partly recovered at one-month follow-up and 43% showed signs of post-traumatic stress disorder. Conclusion Patients with severe functional impairments had important cognitive and emotional deficits which might have been influenced by the choice of ventilatory therapy, but mostly appeared to be related to aging, independently of FIM scores. These findings should be integrated for correct neuropsychiatric assistance of COVID-19 patients in the subacute phase of the disease, and show the need for long-term psychological support and treatment of post-COVID-19 patients.

Management of COVID-19 Patient in Cardiac Surgery with Cardiopulmonary Bypass.

Introduction; The diagnosis of COVID-19 is quite challenging due to the inconsistent correlation between laboratory findings, radiological imaging, and the clinical picture and contact history of the patient. The patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) face double risk because CBP triggers an intense inflammatory response and the leading cause of mortality in COVID-19 patients is “cytokine storm”. In our institution 15 confirmed cases operated on with open-heart surgery. 9 cases isolated CABG, 4 cases valvular combined with CABG, and 1 valvular disease. Materials and method; All patients undergoing elective or urgent cardiac surgery at “Mother Theresa” ’s Hospital from 11 March to 30 November 2020 were included in this study. Patients diagnosed with COVID-19 infection via positive throat swab taken due to clinical suspicion postoperatively were reviewed. Patients characteristics, type of intervention, date of COVID-19 diagnosis. Results: 9 patients (72%) normal recovery, no respiratory failure, only 3-5 days of fever (max 39,4). 3 of them a moderate respiratory failure. 3 patients with severe respiratory failure. Only 3 deaths (26,6%). Recommendation: It's important to a preoperative screening for COVID-19 patients. The outcome of cardiac surgical patients who contracted COVID-19 infection perioperatively is extremely poor. Aggressive respiratory assistance (early intubation), high doses of corticosteroids, and anticoagulation, better results.

Mask Ventilation, Direct Laryngoscopy, and Supraglottic Airway Placement Procedures

The basic skills required for competence in pediatric airway management include mask ventilation, supraglottic airway placement, direct laryngoscopy, and intubation. Although techniques used for children are similar to those used for adults, there are some nuances that pertain only to the pediatric patient. This chapter describes and illustrates these basic airway management procedures for pediatric patients. Bag mask ventilation is used extensively in the operating room, emergency department, and intensive care unit. Effective bag mask ventilation can save a child’s life in emergent situations.1 Respiratory assistance is provided to the patient through a mask on the patient’s face, held in a specialized way to maximize airway patency (described later), that is attached to a device capable of delivering positive pressure manually or automatically. Oxygenation is achieved by compressing air/oxygen through the delivery device into the lungs, and ventilation is ensured by maintaining airway patency as the patient exhales with chest wall recoil. Intubation is indicated in any patient who is unable to maintain adequate spontaneous respiration or who is at risk for aspiration. Examples are patients in respiratory arrest, those in cardiac arrest, or sometimes those experiencing neurologic issues such as seizures. Patients undergoing surgical procedures will often require intubation because of the apnea and risk for aspiration caused by the anesthetics and the surgical procedure itself.