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A 48-year-old woman presented to the emergency department with a one-week history of progressive dyspnea. During her hospitalization, the diagnosis of diffuse alveolar hemorrhage was made. She subsequently developed respiratory failure and acute right ventricular failure. Despite medical treatment, she continued to experience distributive shock due to a generalized inflammatory response. Circulatory support with ECMO was needed. We opted for triple cannulation to manage the multiorgan failure as a bridge to recovery. We describe our experience with an uncommon cannulation technique: veno-pulmonary-arterial cannulation, which enabled us to address cardiogenic shock, refractory hypoxemia, and distributive shock, leading to the successful recovery of the patient.

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Despite venovenous or venoarterial extracorporeal membrane oxygenation (ECMO) being increasingly used in patients with severe acute respiratory disease syndrome, severe cardiogenic shock, and refractory cardiac arrest, mortality rates still remain high mainly because of the severity of the underlying disease and the numerous complications associated with initiation of ECMO. Induced hypothermia might minimize several pathological pathways present in patients requiring ECMO; even though numerous studies conducted in the experimental setting have reported promising results, there are currently no recommendations suggesting the routine use of this therapy in patients requiring ECMO. In this review, we summarized the existing evidence on the use of induced hypothermia in patients requiring ECMO. Induced hypothermia was a feasible and relatively safe intervention in this setting; however, the effects on clinical outcomes remain uncertain. Whether controlled normothermia has an impact on these patients compared with no temperature control remains unknown. Further randomized controlled trials are required to better understand the role and impact of such therapy in patients requiring ECMO according to the underlying disease.

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Resumen abreviado: Se analizaron todas las radiografías de tórax con sospecha de afectación por COVID-19 durante la “primera ola”, aplicando el score ERVI al ingreso y correlacionando su evolución hacia fibrosis pulmonar documentada por TC, con el objetivo de identificar la relación entre ERVI grave y el desarrollo de fibrosis pulmonar.Objetivo: Analizamos todas las radiografías de tórax realizadas por el servicio de urgencias durante la primera ola de la COVID-19 con motivo de consulta “sospecha COVID-19”. Posteriormente, revisamos aplicando la escala ERVI y realizando un seguimiento de su evolución clínica y radiológica a los seis meses. Igualmente, todos aquellos pacientes positivos y que ingresaron en UCI fueron posteriormente revisados, realizando una TC de tórax de control. En el presente artículo nos centramos en intentar establecer una relación entre aquellas radiografías que presentaban un ERVI grave y el desarrollo de fibrosis pulmonar.Métodos: Identificamos un total de 653 radiografías de pacientes con clínica compatible y hallazgos sospechosos de infección por SARS-CoV-2. Del total, solo se realizaron TC de tórax a 83 pacientes, que son los que se han tenido en cuenta para este estudio, analizando la presencia de fibrosis pulmonar. Tras analizar la relación entre los valores del score ERVI y la presencia de fibrosis, en más de la mitad de los casos la fibrosis se desarrollaba en pacientes con ERVI grave al ingreso.Resultados: Existe una relación estadísticamente significativa con una p<0.005 entre la presencia de neumonía grave medida por la escala ERVI al ingreso y el posterior desarrollo de fibrosis pulmonar.Conclusiones: Consideramos sensata la recomendación de realizar seguimiento por TC a pacientes con enfermedad grave que pueda aportar datos para el diagnóstico de fibrosis pulmonar, especialmente a partir de tres semanas del inicio de los síntomas. (AU)

Short summary: All chest X-rays suspected of being affected by COVID-19 during the “first wave” were analyzed, applying the LVRI score at admission and correlating its evolution towards pulmonary fibrosis documented by CT, with the aim of identifying the relationship between severe ERVI and the development of pulmonary fibrosis.Objective: We analyzed all chest X-rays performed by the emergency department during the so-called first wave of COVID-19 with the reason for consultation "COVID-19 suspicion". Subsequently, these radiographs were reviewed, applying the ERVI scale and following their clinical and radiological evolution at six months. Similarly, all positive patients who were admitted to the ICU were subsequently reviewed and a control chest CT scan was performed. In the present article we focus on trying to establish a relationship between those radiographs showing severe ERVI and the development of pulmonary fibrosis.Methods: A total of 653 radiographs of patients with compatible symptoms and suspicious findings of SARS-CoV-2 infection have been identified. Of the total number of patients, chest CT scans were only performed in 83 patients, which are the ones taken into account for this study, analyzing the presence of pulmonary fibrosis. After analyzing the relationship between ERVI score values and the presence of fibrosis, in more than half of the cases patients with severe ERVI at admission developed pulmonary fibrosis.Results: We demonstrateda statistically significant association (p<0.005) between the presence of severe pneumonia measured by the ERVI scale on admission and the subsequent development of pulmonary fibrosis.Conclusions: We recommend CT follow-up of patients with severe disease that can provide data for the diagnosis of pulmonary fibrosis, especially if it is performed three weeks after the onset of symptoms. (AU)

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In critically ill patients with acute respiratory distress syndrome (ARDS) coronavirus disease 2019 (COVID-19), a high incidence of thromboembolic and hemorrhagic events is reported. COVID-19 may lead to impairment of the coagulation cascade, with an imbalance in platelet function and the regulatory mechanisms of coagulation and fibrinolysis. Clinical manifestations vary from a rise in laboratory markers and subclinical microthrombi to thromboembolic events, bleeding, and disseminated intravascular coagulation. After an inflammatory trigger, the mechanism for activation of the coagulation cascade in COVID-19 is the tissue factor pathway, which causes endotoxin and tumor necrosis factor-mediated production of interleukins and platelet activation. The consequent massive infiltration of activated platelets may be responsible for inflammatory infiltrates in the endothelial space, as well as thrombocytopenia. The variety of clinical presentations of the coagulopathy confronts the clinician with the difficult questions of whether and how to provide optimal supportive care. In addition to coagulation tests, advanced laboratory tests such as protein C, protein S, antithrombin, tissue factor pathway inhibitors, D-dimers, activated factor Xa, and quantification of specific coagulation factors can be useful, as can thromboelastography or thromboelastometry. Treatment should be tailored, focusing on the estimated risk of bleeding and thrombosis. The aim of this review is to explore the pathophysiology and clinical evidence of coagulation disorders in severe ARDS-related COVID-19 patients.

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Acute respiratory failure secondary to COVID-19 pneumonia may require a variety of non-pharmacological strategies in addition to oxygen therapy to avoid endotracheal intubation. The response to all these strategies, which include high nasal flow, continuous positive pressure, non-invasive ventilation, or even prone positioning in awake patients, can be highly variable depending on the predominant phenotypic involvement. Deciding when to replace conventional oxygen therapy with non-invasive respiratory support, which to choose, the role of combined methods, definitions, and attitudes toward treatment failure, and improved case improvement procedures are directly relevant clinical questions for the daily care of critically ill COVID-19 patients. The experience accumulated after more than a year of the pandemic should lead to developing recommendations that give answers to all these questions.

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We report the current situation regarding the COVID-19 pandemic with particular regard to seafarers and with the indications drawn up by the Centro Internazionale Radio Medico (C.I.R.M.) in this regard.

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Little is still known about the clinical features associated with the occurrence of acute respiratory distress syndrome (ARDS) in hospitalized patients with Coronavirus disease 2019 (COVID-19). The aim of the present study was to describe the prevalence of pre-admission antithrombotic therapies in patients with COVID-19 and to investigate the potential association between antithrombotic therapy and ARDS, as disease clinical presentation, or in-hospital mortality. We enrolled 192 consecutive patients with laboratory-confirmed COVID-19 admitted to emergency department of five Italian hospitals. The study population was divided in two groups according to the evidence of ARDS at chest computed tomography at admission. Propensity score weighting adjusted regression analysis was performed to assess the risk ARDS at admission, and death during hospitalization, in patients treated or not with antiplatelet and anticoagulant agents. ARDS was reported in 73 cases (38 %), who showed more likely hypertension compared to those without ARDS (57.8 % vs 49.6 %; P = 0.005). Thirty-five patients (18.5 %) died during the hospitalization. Not survived COVID-19 patients showed a statistically significant increased age (77 ± 8.31 vs 65.57 ± 8.31; P = 0.001), hypertension (77.1 % vs 53.5 %; P = 0.018) and coronary artery disease prevalence (28.6 % vs 10.2 %; P = 0.009). Both unadjusted and adjusted regression analyses showed no difference in the risk of ARDS at admission, or death during hospitalization, between patients treated or not with antiplatelets or anticoagulants. Pre-admission antithrombotic therapy, both antiplatelet and anticoagulant, does not seem to show a protective effect in severe forms of COVID-19 with ARDS at presentation and rapidly evolving toward death.

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Patients undergoing emergency surgery may present with the acute respiratory distress syndrome (ARDS) or develop this syndrome postoperatively. The incidence of ARDS in the postoperative period is relatively low, but the impact of ARDS on patient outcomes and healthcare costs is relevant Aakre et.al (Mayo Clin Proc 89:181-9, 2014).The development of ARDS as a postoperative pulmonary complication (PPC) is associated with prolonged hospitalisation, longer duration of mechanical ventilation, increased intensive care unit length of stay and high morbidity and mortality Ball et.al (Curr Opin Crit Care 22:379-85, 2016). In order to mitigate the risk of ARDS after surgery, the anaesthetic management and protective mechanical ventilation strategies play an important role. In particular, a careful integration of general anaesthesia with neuraxial or locoregional techniques might promote faster recovery and reduce opioid consumption. In addition, the use of low tidal volume, minimising plateau pressure and titrating a low-moderate PEEP level based on the patient's need can improve outcome and reduce intraoperative adverse events. Moreover, perioperative management of ARDS patients includes specific anaesthesia and ventilator settings, hemodynamic monitoring, moderately restrictive fluid administration and pain control.The aim of this review is to provide an overview and evidence- and opinion-based recommendations concerning the management of patients at risk of and with ARDS who undergo emergency surgical procedures.

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After risk assessment, veno-venous extracorporeal membrane oxygenation (ECMO) has been achieved in a superobese adult patient as a bridge to recovery of respiratory failure, despite the weight-related difficulties. Early v-v ECMO implantation could be considered to support and to conduct weaning both from sedation and from invasive mechanical ventilation, with the goal to perform physiokinesitherapy during awake ECMO.

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