Evidence is not homogeneous on indicators able to monitor and assess qualityperformance for organ donation. This may be related to differences in healthcareorganizations among countries but also to the scarcity of dat...Evidence is not homogeneous on indicators able to monitor and assess qualityperformance for organ donation. This may be related to differences in healthcareorganizations among countries but also to the scarcity of data on this topic so far.In the present review, we assessed available evidence on quality metrics in solidorgan procurement in the United States and in Europe by means of a PubMedsearch. Evidence was summarized according to countries, considering that thedonation and transplantation systems differ from country to country. In UnitedStates, the assessment of these indicators is periodically performed by the nationalnetwork for organ sharing to evaluate the performance of each Organ ProcurementOrganization (OPO). Quality metrics consider several factors, in primispopulation characteristics (i.e. race/ethnicity, age, socio-economic status). That iswhy the assessment of each OPO performance relies on several quality metrics,not only one single indicator. In Europe, quality improvement programs representa structural element of organ and transplant system in several countries, but fewpapers have to date addressed the results obtained by a quality improvementprogram based on indicators. In Poland, the use of quality indicators and improvementprocedures were associated with better results in those hospitals whichimplemented these programs in respect to hospitals who did not. In TuscanyRegion (Italy) the implementation of a monitoring and reporting approach basedon indicators by the Regional Transplant Center was associated with an increasedin transplant and donation activity (especially in cDCD donors). According toavailable evidence, the development of a method for quality assessment andquality improvement has been recognized as pivotal for donation and transplantauthorities to identify key interventions either at national and/or hospital levels.展开更多
Donor management is the key in the complex donation process,since up to 20%of organs of brain death donors(DBD)are lost due to hemodynamic instability.This challenge is made more difficult due to the lack of strong re...Donor management is the key in the complex donation process,since up to 20%of organs of brain death donors(DBD)are lost due to hemodynamic instability.This challenge is made more difficult due to the lack of strong recommendations on therapies for hemodynamic management in DBDs and more importantly to the epidemiologic changes in these donors who are becoming older and with more comorbidities(marginal donors).In the present manuscript we aimed at summarizing the available evidence on therapeutic strategies for hemodynamic management(focusing on vasoactive drugs)and monitoring(therapeutic goals).Evidence on management in elderly DBDs is also summarized.Donor management continues critical care but with different and specific therapeutic goals since the number of donor goals met is related to the number of organs retrieved and transplanted.Careful monitoring of selected parameters(possibly including serial echocardiography)is the clinical tool able to guarantee the achievement and maintaining of therapeutic goals.Despide worldwide differences,norepinephrine is the vasoactive of choice in most countries but,whenever higher doses(>0.2 mcg/kg/min)are needed,a second vasoactive drug(vasopressin)is advisable.Hormonal therapy(desmopressin,corticosteroid and thyroid hormone)are suggested in all DBDs independently of hemodynamic instability.In the single patient,therapeutic regimen(imprimis vasoactive drugs)should be chosen also according to the potential organs retrievable(i.e.heart vs liver and kidneys).展开更多
BACKGROUND In brain death donors(BDDs),donor management is the key in the complex donation process.Donor management goals,which are standards of care or clinical parameters,have been considered an acceptable barometer...BACKGROUND In brain death donors(BDDs),donor management is the key in the complex donation process.Donor management goals,which are standards of care or clinical parameters,have been considered an acceptable barometer of successful donor management.AIM To test the hypothesis that aetiology of brain death could influence haemodynamic management in BDDs.METHODS Haemodynamic data(blood pressure,heart rate,central venous pressure,lactate,urine output,and vasoactive drugs)of BDDs were recorded on intensive care unit(ICU)admission and during the 6-h observation period(Time 1 at the beginning;Time 2 at the end).RESULTS The study population was divided into three groups according to the aetiology of brain death:Stroke(n=71),traumatic brain injury(n=48),and postanoxic encephalopathy(n=19).On ICU admission,BDDs with postanoxic encephalopathy showed the lowest values of systolic and diastolic blood pressure associated with higher values of heart rate and lactate and a higher need of norepinephrine and other vasoactive drugs.At the beginning of the 6-h period(Time 1),BDDs with postanoxic encephalopathy showed higher values of heart rate,lactate,and central venous pressure together with a higher need of other vasoactive drugs.CONCLUSION According to our data,haemodynamic management of BDDs is affected by the aetiology of brain death.BDDs with postanoxic encephalopathy have higher requirements for norepinephrine and other vasoactive drugs.展开更多
Kidney transplantation(KT)is the treatment of choice for patients with end-stage renal disease,providing a better survival rate and quality of life compared to dialysis.Despite the progress in the medical management o...Kidney transplantation(KT)is the treatment of choice for patients with end-stage renal disease,providing a better survival rate and quality of life compared to dialysis.Despite the progress in the medical management of KT patients,from a purely surgical standpoint,KT has resisted innovations during the last 50 years.Recently,robot-assisted KT(RAKT)has been proposed as an alternative approach to open surgery,especially due to its potential benefits for fragile and immunocompromised recipients.It was not until 2014 that the role of RAKT has found value thanks to the pioneering Vattikuti Urology Institute-Medanta collaboration that conceptualized and developed a new surgical technique for RAKT following the Idea,Development,Exploration,Assessment,Long-term follow-up recommendations for introducing surgical innovations into real-life practice.During the last years,mirroring the Vattikuti-Medanta technique,several centers developed RAKT program worldwide,providing strong evidence about the safety and the feasibility of this procedure.However,the majority of RAKT are still performed in the living donor setting,as an“eligible”procedure,while only a few centers have realized KT through a robotic approach in the challenging scenario of cadaver donation.In addition,despite the spread of minimally-invasive(predominantly robotic)surgery worldwide,many KTs are still performed in an open fashion.Regardless of the type of incision employed by surgeons,open KT may lead to nonnegligible risks of wound complications,especially among obese patients.Particularly,the assessment for KT should consider not only the added surgical technical challenges but also the higher risk of postoperative complications.In this context,robotic surgery could offer several benefits,including providing a better exposure of the surgical field and better instrument maneuverability,as well as the possibility to integrate other technological nuances,such as the use of intraoperative fluorescence vascular imaging with indocyanine green to assess the ureteral vascularization before the uretero-vesical anastomosis.Therefore,our review aims to report the more significant experiences regarding RAKT,focusing on the results and future perspectives.展开更多
BACKGROUND The prognostic role of right ventricle dilatation and dysfunction(RVDD)has not been elucidated in patients with coronavirus disease(COVID)-related respiratory failure refractory to standard treatment needin...BACKGROUND The prognostic role of right ventricle dilatation and dysfunction(RVDD)has not been elucidated in patients with coronavirus disease(COVID)-related respiratory failure refractory to standard treatment needing extracorporeal membrane oxygenation(ECMO)support.AIM To assess whether pre veno-venous(VV)ECMO RVDD were related to inintensive care unit(ICU)mortality.METHODS We enrolled 61 patients with COVID-related acute respiratory distress syndrome refractory to conventional treatment submitted to VV ECMO and consecutively admitted to our ICU(an ECMO referral center)from 31th March 2020 to 31th August 2021.An echocardiographic exam was performed immediately before VV ECMO implantation.RESULTS Males were prevalent(73.8%)and patients with a body mass index>30 kg/m^(2) were the majority(46/61,75%).The overall in-ICU mortality rate was 54.1%(33/61).RVDD was detectable in more than half of the population(34/61,55.7%)and associated with higher simplified organ functional assessment(SOFA)values(P=0.029)and a longer mechanical ventilation duration prior to ECMO support(P=0.046).Renal replacement therapy was more frequently needed in RVDD patients(P=0.002).A higher in-ICU mortality(P=0.024)was observed in RVDD patients.No echo variables were independent predictors of in-ICU death.CONCLUSION In patients with COVID-related respiratory failure on ECMO support,RVDD(dilatation and dysfunction)is a common finding and identifies a subset of patients characterized by a more severe disease(as indicated by higher SOFA values and need of renal replacement therapy)and by a higher in-ICU mortality.RVDD(also when considered separately)did not result independently associated with in-ICU mortality in these patients.展开更多
Intensive care in Africa is available only in teaching or referral hospitals. Here we report the experience of a multidisciplinary collaboration between physicians and nurses of the Emergency Department (First Aid and...Intensive care in Africa is available only in teaching or referral hospitals. Here we report the experience of a multidisciplinary collaboration between physicians and nurses of the Emergency Department (First Aid and Intensive Care Unit) of a tertiary referral hospital (Careggi Teaching Hospital, Florence, IT) and physicians and nurses of Orotta National referral Hospital in Asmara, Eritrea. The project was aimed at performing clinical assistance and training on the job to the local staff to improve the standard of care in the local Emergency Department. The duration of the project was initially planned to be 30 months, but unfortunately it was interrupted after 18 months because of lack of funds. The Italian staff was composed of two physicians and two nurses per period. To monitor local ICU activity, a retrospective survey of 36 months was performed. During the 36 months of data collection, 1169 patients were admitted to the ICU. Intra-ICU mortality rate resulted comparable before, during, and after Italian presence. On the contrary, the 28-day mortality resulted significantly lower bo th during and after the Italian stay. After project interruption, the Italian staff maintained contact with the Eritrean ICU personnel, who were invited to attend the Italian ICU for one month per year, and collected information about Orotta ICU activities.展开更多
We report an unexpected massive left pneumothorax at the end of a digestive upper endoscopy without evidences of perforation or airway over-pressure. The possible air passage through a diaphragmatic failing is discussed.
To facilitate the implementation of controlled donation after circulatory death(cDCD)programs even in hospitals not equipped with a local Extracorporeal Membrane Oxygenation(ECMO)team(Spokes),some countries and Italia...To facilitate the implementation of controlled donation after circulatory death(cDCD)programs even in hospitals not equipped with a local Extracorporeal Membrane Oxygenation(ECMO)team(Spokes),some countries and Italian Regions have launched a local cDCD network with a ECMO mobile team who move from Hub hospitals to Spokes for normothermic regional perfusion(NRP)implantation in the setting of a cDCD pathway.While ECMO teams have been clearly defined by the Extracorporeal Life Support Organization,regarding composition,responsibilities and training programs,no clear,widely accepted indications are to date available for NRP teams.Although existing NRP mobile networks were developed due to the urgent need to increase the number of cDCDs,there is now the necessity for transplantation medicine to identify the peculiarities and responsibility of a NRP team for all those centers launching a cDCD pathway.Thus,in the present manuscript we summarized the character-istics of an ECMO mobile team,highlighting similarities and differences with the NRP mobile team.We also assessed existing evidence on NRP teams with the goal of identifying the characteristic and essential features of an NRP mobile team for a cDCD program,especially for those centers who are starting the program.Differences were identified between the mobile ECMO team and NRP mobile team.The common essential feature for both mobile teams is high skills and experience to reduce complications and,in the case of cDCD,to reduce the total warm ischemic time.Dedicated training programs should be developed for the launch of de novo NRP teams.展开更多
文摘Evidence is not homogeneous on indicators able to monitor and assess qualityperformance for organ donation. This may be related to differences in healthcareorganizations among countries but also to the scarcity of data on this topic so far.In the present review, we assessed available evidence on quality metrics in solidorgan procurement in the United States and in Europe by means of a PubMedsearch. Evidence was summarized according to countries, considering that thedonation and transplantation systems differ from country to country. In UnitedStates, the assessment of these indicators is periodically performed by the nationalnetwork for organ sharing to evaluate the performance of each Organ ProcurementOrganization (OPO). Quality metrics consider several factors, in primispopulation characteristics (i.e. race/ethnicity, age, socio-economic status). That iswhy the assessment of each OPO performance relies on several quality metrics,not only one single indicator. In Europe, quality improvement programs representa structural element of organ and transplant system in several countries, but fewpapers have to date addressed the results obtained by a quality improvementprogram based on indicators. In Poland, the use of quality indicators and improvementprocedures were associated with better results in those hospitals whichimplemented these programs in respect to hospitals who did not. In TuscanyRegion (Italy) the implementation of a monitoring and reporting approach basedon indicators by the Regional Transplant Center was associated with an increasedin transplant and donation activity (especially in cDCD donors). According toavailable evidence, the development of a method for quality assessment andquality improvement has been recognized as pivotal for donation and transplantauthorities to identify key interventions either at national and/or hospital levels.
文摘Donor management is the key in the complex donation process,since up to 20%of organs of brain death donors(DBD)are lost due to hemodynamic instability.This challenge is made more difficult due to the lack of strong recommendations on therapies for hemodynamic management in DBDs and more importantly to the epidemiologic changes in these donors who are becoming older and with more comorbidities(marginal donors).In the present manuscript we aimed at summarizing the available evidence on therapeutic strategies for hemodynamic management(focusing on vasoactive drugs)and monitoring(therapeutic goals).Evidence on management in elderly DBDs is also summarized.Donor management continues critical care but with different and specific therapeutic goals since the number of donor goals met is related to the number of organs retrieved and transplanted.Careful monitoring of selected parameters(possibly including serial echocardiography)is the clinical tool able to guarantee the achievement and maintaining of therapeutic goals.Despide worldwide differences,norepinephrine is the vasoactive of choice in most countries but,whenever higher doses(>0.2 mcg/kg/min)are needed,a second vasoactive drug(vasopressin)is advisable.Hormonal therapy(desmopressin,corticosteroid and thyroid hormone)are suggested in all DBDs independently of hemodynamic instability.In the single patient,therapeutic regimen(imprimis vasoactive drugs)should be chosen also according to the potential organs retrievable(i.e.heart vs liver and kidneys).
文摘BACKGROUND In brain death donors(BDDs),donor management is the key in the complex donation process.Donor management goals,which are standards of care or clinical parameters,have been considered an acceptable barometer of successful donor management.AIM To test the hypothesis that aetiology of brain death could influence haemodynamic management in BDDs.METHODS Haemodynamic data(blood pressure,heart rate,central venous pressure,lactate,urine output,and vasoactive drugs)of BDDs were recorded on intensive care unit(ICU)admission and during the 6-h observation period(Time 1 at the beginning;Time 2 at the end).RESULTS The study population was divided into three groups according to the aetiology of brain death:Stroke(n=71),traumatic brain injury(n=48),and postanoxic encephalopathy(n=19).On ICU admission,BDDs with postanoxic encephalopathy showed the lowest values of systolic and diastolic blood pressure associated with higher values of heart rate and lactate and a higher need of norepinephrine and other vasoactive drugs.At the beginning of the 6-h period(Time 1),BDDs with postanoxic encephalopathy showed higher values of heart rate,lactate,and central venous pressure together with a higher need of other vasoactive drugs.CONCLUSION According to our data,haemodynamic management of BDDs is affected by the aetiology of brain death.BDDs with postanoxic encephalopathy have higher requirements for norepinephrine and other vasoactive drugs.
文摘Kidney transplantation(KT)is the treatment of choice for patients with end-stage renal disease,providing a better survival rate and quality of life compared to dialysis.Despite the progress in the medical management of KT patients,from a purely surgical standpoint,KT has resisted innovations during the last 50 years.Recently,robot-assisted KT(RAKT)has been proposed as an alternative approach to open surgery,especially due to its potential benefits for fragile and immunocompromised recipients.It was not until 2014 that the role of RAKT has found value thanks to the pioneering Vattikuti Urology Institute-Medanta collaboration that conceptualized and developed a new surgical technique for RAKT following the Idea,Development,Exploration,Assessment,Long-term follow-up recommendations for introducing surgical innovations into real-life practice.During the last years,mirroring the Vattikuti-Medanta technique,several centers developed RAKT program worldwide,providing strong evidence about the safety and the feasibility of this procedure.However,the majority of RAKT are still performed in the living donor setting,as an“eligible”procedure,while only a few centers have realized KT through a robotic approach in the challenging scenario of cadaver donation.In addition,despite the spread of minimally-invasive(predominantly robotic)surgery worldwide,many KTs are still performed in an open fashion.Regardless of the type of incision employed by surgeons,open KT may lead to nonnegligible risks of wound complications,especially among obese patients.Particularly,the assessment for KT should consider not only the added surgical technical challenges but also the higher risk of postoperative complications.In this context,robotic surgery could offer several benefits,including providing a better exposure of the surgical field and better instrument maneuverability,as well as the possibility to integrate other technological nuances,such as the use of intraoperative fluorescence vascular imaging with indocyanine green to assess the ureteral vascularization before the uretero-vesical anastomosis.Therefore,our review aims to report the more significant experiences regarding RAKT,focusing on the results and future perspectives.
文摘BACKGROUND The prognostic role of right ventricle dilatation and dysfunction(RVDD)has not been elucidated in patients with coronavirus disease(COVID)-related respiratory failure refractory to standard treatment needing extracorporeal membrane oxygenation(ECMO)support.AIM To assess whether pre veno-venous(VV)ECMO RVDD were related to inintensive care unit(ICU)mortality.METHODS We enrolled 61 patients with COVID-related acute respiratory distress syndrome refractory to conventional treatment submitted to VV ECMO and consecutively admitted to our ICU(an ECMO referral center)from 31th March 2020 to 31th August 2021.An echocardiographic exam was performed immediately before VV ECMO implantation.RESULTS Males were prevalent(73.8%)and patients with a body mass index>30 kg/m^(2) were the majority(46/61,75%).The overall in-ICU mortality rate was 54.1%(33/61).RVDD was detectable in more than half of the population(34/61,55.7%)and associated with higher simplified organ functional assessment(SOFA)values(P=0.029)and a longer mechanical ventilation duration prior to ECMO support(P=0.046).Renal replacement therapy was more frequently needed in RVDD patients(P=0.002).A higher in-ICU mortality(P=0.024)was observed in RVDD patients.No echo variables were independent predictors of in-ICU death.CONCLUSION In patients with COVID-related respiratory failure on ECMO support,RVDD(dilatation and dysfunction)is a common finding and identifies a subset of patients characterized by a more severe disease(as indicated by higher SOFA values and need of renal replacement therapy)and by a higher in-ICU mortality.RVDD(also when considered separately)did not result independently associated with in-ICU mortality in these patients.
文摘Intensive care in Africa is available only in teaching or referral hospitals. Here we report the experience of a multidisciplinary collaboration between physicians and nurses of the Emergency Department (First Aid and Intensive Care Unit) of a tertiary referral hospital (Careggi Teaching Hospital, Florence, IT) and physicians and nurses of Orotta National referral Hospital in Asmara, Eritrea. The project was aimed at performing clinical assistance and training on the job to the local staff to improve the standard of care in the local Emergency Department. The duration of the project was initially planned to be 30 months, but unfortunately it was interrupted after 18 months because of lack of funds. The Italian staff was composed of two physicians and two nurses per period. To monitor local ICU activity, a retrospective survey of 36 months was performed. During the 36 months of data collection, 1169 patients were admitted to the ICU. Intra-ICU mortality rate resulted comparable before, during, and after Italian presence. On the contrary, the 28-day mortality resulted significantly lower bo th during and after the Italian stay. After project interruption, the Italian staff maintained contact with the Eritrean ICU personnel, who were invited to attend the Italian ICU for one month per year, and collected information about Orotta ICU activities.
文摘We report an unexpected massive left pneumothorax at the end of a digestive upper endoscopy without evidences of perforation or airway over-pressure. The possible air passage through a diaphragmatic failing is discussed.
文摘To facilitate the implementation of controlled donation after circulatory death(cDCD)programs even in hospitals not equipped with a local Extracorporeal Membrane Oxygenation(ECMO)team(Spokes),some countries and Italian Regions have launched a local cDCD network with a ECMO mobile team who move from Hub hospitals to Spokes for normothermic regional perfusion(NRP)implantation in the setting of a cDCD pathway.While ECMO teams have been clearly defined by the Extracorporeal Life Support Organization,regarding composition,responsibilities and training programs,no clear,widely accepted indications are to date available for NRP teams.Although existing NRP mobile networks were developed due to the urgent need to increase the number of cDCDs,there is now the necessity for transplantation medicine to identify the peculiarities and responsibility of a NRP team for all those centers launching a cDCD pathway.Thus,in the present manuscript we summarized the character-istics of an ECMO mobile team,highlighting similarities and differences with the NRP mobile team.We also assessed existing evidence on NRP teams with the goal of identifying the characteristic and essential features of an NRP mobile team for a cDCD program,especially for those centers who are starting the program.Differences were identified between the mobile ECMO team and NRP mobile team.The common essential feature for both mobile teams is high skills and experience to reduce complications and,in the case of cDCD,to reduce the total warm ischemic time.Dedicated training programs should be developed for the launch of de novo NRP teams.
