Francesco Marrazzo

Objective: To describe the health-care resources implemented during the Italian Formula 1 Grand Prix (F1GP) and to calculate the patient presentation rate (PPR) based on both real data and a prediction model. Methods: Observational and descriptive study conducted from September 9 to September 11, 2022, during the Italian F1GP hosted in Monza (Italy). Maurer’s formula was applied to decide the number and type of health resources to be allocated. Patient presentation rate (PPR) was computed based on real data (PPR_real) and based on the Arbon formula (PPR_est). Results: Of 336,000 attendees, n = 263 requested medical assistance with most of them receiving treatment at the advanced medical post, and n = 16 needing transport to the hospital. The PPR_real was 51 for Friday, 78 for Saturday, 134 for Sunday, and 263 when considering the whole event as a single event. The PPR_est resulted in 85 for Friday, 93 for Saturday, 97 for Sunday, and 221 for the total population. Conclusions: A careful organization of health-care resources could mitigate the impact of the Italian F1GP on local hospital facilities. The Arbon formula is an acceptable model to predict and estimate the number of patients requesting medical assistance, but further investigation needs to be conducted to implement the model and tailor it to broader categories of MGE.

Background: Changing trunk inclination affects lung function in patients with ARDS. However, its impacts on PEEP titration remain unknown. The primary aim of this study was to assess, in mechanically ventilated patients with COVID-19 ARDS, the effects of trunk inclination on PEEP titration. The secondary aim was to compare respiratory mechanics and gas exchange in the semi-recumbent (40° head-of-the-bed) and supine-flat (0°) positions following PEEP titration. Methods: Twelve patients were positioned both at 40° and 0° trunk inclination (randomized order). The PEEP associated with the best compromise between overdistension and collapse guided by Electrical Impedance Tomography (PEEP_EIT) was set. After 30 min of controlled mechanical ventilation, data regarding respiratory mechanics, gas exchange, and EIT parameters were collected. The same procedure was repeated for the other trunk inclination. Results: PEEP_EIT was lower in the semi-recumbent than in the supine-flat position (8 ± 2 vs. 13 ± 2 cmH₂O, p < 0.001). A semi-recumbent position with optimized PEEP resulted in higher PaO₂:FiO₂ (141 ± 46 vs. 196 ± 99, p = 0.02) and a lower global inhomogeneity index (46 ± 10 vs. 53 ± 11, p = 0.008). After 30 min of observation, a loss of aeration (measured by EIT) was observed only in the supine-flat position (−153 ± 162 vs. 27 ± 203 mL, p = 0.007). Conclusions: A semi-recumbent position is associated with lower PEEP_EIT and results in better oxygenation, less derecruitment, and more homogenous ventilation compared to the supine-flat position.

Background: Perchloroethylene is a colorless, strong-smelling substance commonly used for dry cleaning. Liver and kidney toxicities and carcinogenicity are well-known occupational hazards caused by chronic perchloroethylene exposure. Acute intoxication by ingestion of nondiluted perchloroethylene is rare in the adult population owing to its strong smell and taste. Very few data are available to physicians managing patients in this situation. Case presentation: An 89-year-old Caucasian woman accidentally drank perchloroethylene while visiting her laundry, leading to a coma within a few minutes. The poison control center provided little information about perchloroethylene toxicity after ingestion, including an estimated long biological half-life (144 hour) and detrimental effects to liver and kidneys. A long intensive care unit stay was thus expected, potentially leading to several complications. After intubation, transitory hypoxemia appeared and rapidly resolved, while mild hemodynamic instability was managed with fluid resuscitation and anti-arrhythmic drugs. Twelve hours after perchloroethylene ingestion, the patient suddenly woke up and self-extubated. Less than 24 hours after ingestion, she was discharged from the intensive care unit, and 4 days later she was discharged home. Conclusion: The patient drank perchloroethylene from a bottle, which prevented her from smelling it, and owing to its taste, only a small sip was likely drunk. However, a much larger intake was presumed, given her rapid and profound central nervous system depression. This case was challenging owing to the paucity of information available regarding acute perchloroethylene ingestion and the duration and magnitude of its effect. The present report will hopefully be of support for clinicians managing patients with this rare acute intoxication.

Introduction: Postoperative acute kidney injury (AKI) is a common complication in cardiac surgery. Levels of intravascular haemolysis are strongly associated with postoperative AKI and with prolonged (>90 min) use of cardiopulmonary bypass (CPB). Ferrous plasma haemoglobin released into the circulation acts as a scavenger of nitric oxide (NO) produced by endothelial cells. Consequently, the vascular bioavailability of NO is reduced, leading to vasoconstriction and impaired renal function. In patients with cardiovascular risk factors, the endothelium is dysfunctional and cannot replenish the NO deficit. A previous clinical study in young cardiac surgical patients with rheumatic fever, without evidence of endothelial dysfunction, showed that supplementation of NO gas decreases AKI by converting ferrous plasma haemoglobin to ferric methaemoglobin, thus preserving vascular NO. In this current trial, we hypothesised that 24 hours administration of NO gas will reduce AKI following CPB in patients with endothelial dysfunction.Methods: This is a single-centre, randomised (1:1) controlled, parallel-arm superiority trial that includes patients with endothelial dysfunction, stable kidney function and who are undergoing cardiac surgery procedures with an expected CPB duration >90 min. After randomisation, 80 parts per million (ppm) NO (intervention group) or 80 ppm nitrogen (N₂, control group) are added to the gas mixture. Test gases (N₂or NO) are delivered during CPB and for 24 hours after surgery. The primary study outcome is the occurrence of AKI among study groups. Key secondary outcomes include AKI severity, occurrence of renal replacement therapy, major adverse kidney events at 6 weeks after surgery and mortality. We are recruiting 250 patients, allowing detection of a 35% AKI relative risk reduction, assuming a two-sided error of 0.05.Ethics and dissemination: The Partners Human Research Committee approved this trial. Recruitment began in February 2017. Dissemination plans include presentations at scientific conferences, scientific publications and advertising flyers and posters at Massachusetts General Hospital.Trial registration number: NCT02836899.

Editor’s Perspective: What We Already Know about This Topic: Obesity increases the propensity to atelectasis in acute respiratory distress syndrome, but the optimal approach to reversing this atelectasis is uncertain What This Article Tells Us That Is New: A clinical crossover study comparing three approaches to titrate positive end-expiratory pressure (PEEP; according to a fixed table, according to end-expiratory esophageal pressure, and targeting the best compliance during a decremental PEEP trial) found that a recruitment maneuver followed by decremental PEEP minimized atelectasis and overdistension, and best restored compliance and oxygenation without causing hemodynamic impairment Background: Obese patients are characterized by normal chest-wall elastance and high pleural pressure and have been excluded from trials assessing best strategies to set positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS). The authors hypothesized that severely obese patients with ARDS present with a high degree of lung collapse, reversible by titrated PEEP preceded by a lung recruitment maneuver. Methods: Severely obese ARDS patients were enrolled in a physiologic crossover study evaluating the effects of three PEEP titration strategies applied in the following order: (1) PEEP_ARDSNET: the low PEEP/Fio ₂ ARDSnet table; (2) PEEP_INCREMENTAL: PEEP levels set to determine a positive end-expiratory transpulmonary pressure; and (3) PEEP_DECREMENTAL: PEEP levels set to determine the lowest respiratory system elastance during a decremental PEEP trial following a recruitment maneuver on respiratory mechanics, regional lung collapse, and overdistension according to electrical impedance tomography and gas exchange. Results: Fourteen patients underwent the study procedures. At PEEP_ARDSNET (13 ± 1 cm H₂O) end-expiratory transpulmonary pressure was negative (−5 ± 5 cm H₂O), lung elastance was 27 ± 12 cm H₂O/L, and PaO₂/Fio ₂ was 194 ± 111 mmHg. Compared to PEEP_ARDSNET, at PEEP_INCREMENTAL level (22 ± 3 cm H₂O) lung volume increased (977 ± 708 ml), lung elastance decreased (23 ± 7 cm H₂O/l), lung collapse decreased (18 ± 10%), and ventilation homogeneity increased thus rising oxygenation (251 ± 105 mmHg), despite higher overdistension levels (16 ± 12%), all values P < 0.05 versus PEEP_ARDSnet. Setting PEEP according to a PEEP_DECREMENTAL trial after a recruitment maneuver (21 ± 4 cm H₂O, P = 0.99 vs. PEEP_INCREMENTAL) further lowered lung elastance (19 ± 6 cm H₂O/l) and increased oxygenation (329 ± 82 mmHg) while reducing lung collapse (9 ± 2%) and overdistension (11 ± 2%), all values P < 0.05 versus PEEP_ARDSnet and PEEP_INCREMENTAL. All patients were maintained on titrated PEEP levels up to 24 h without hemodynamic or ventilation related complications. Conclusions: Among the PEEP titration strategies tested, setting PEEP according to a PEEP_DECREMENTAL trial preceded by a recruitment maneuver obtained the best lung function by decreasing lung overdistension and collapse, restoring lung elastance, and oxygenation suggesting lung tissue recruitment.