Publications by authors named "Alberto Lucchini"

71 Publications

Helmet and face mask for non-invasive respiratory support in patients with acute hypoxemic respiratory failure: A retrospective study.

J Crit Care 2021 May 29;65:56-61. Epub 2021 May 29.

Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, MB, Italy.; Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy. Electronic address:

Purpose: Non-invasive respiratory support could reduce the incidence of intubation in patients with Acute Hypoxemic Respiratory Failure (AHRF). The optimal interface or modality of non-invasive respiratory support is debated. We sought to evaluate the differences between patients who succeeded or failed non-invasive respiratory support, with a specific focus on the type of non-invasive respiratory support (i.e. helmet CPAP versus face mask NIV).

Materials And Methods: In a single-center observational retrospective study, we investigated baseline, clinical characteristics and AHRF management by non-invasive respiratory support between January 2015 to December 2016. Data on gas exchange and respiratory mechanics, non-invasive respiratory support duration, ICU length of stay and mortality were collected.

Results: 110 patients with AHRF were included of which 41 patients (37%) were intubated. The use of helmet CPAP (p = 0.016) and a lower fluid balance (p = 0.038) were independently associated with a decreased rate of intubation after adjustment for confounders. Face mask NIV patients trended to a higher respiratory frequency at 1 h after treatment [28 (22-36) versus 24 (18-29) hours, p = 0.067], and showed a longer ICU stay (p = 0.009) compared to patients treated with helmet CPAP.

Conclusions: Helmet CPAP and a lower fluid balance were independent predictors of a lower intubation rate in AHRF patients in ICU. Prospective studies aimed at identifying the optimal interface and modality of non-invasive respiratory support in AHRF patients are needed.
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http://dx.doi.org/10.1016/j.jcrc.2021.05.013DOI Listing
May 2021

Carboxyhemglobin and Drainage Pressure During Venovenous Extracorporeal Membrane Oxygenation.

ASAIO J 2021 06;67(6):e114-e115

Scuola di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy, Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy.

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http://dx.doi.org/10.1097/MAT.0000000000001394DOI Listing
June 2021

Use of Intensive Care Unit Diary as an Integrated Tool in an Italian General Intensive Care Unit: A Mixed-Methods Pilot Study.

Dimens Crit Care Nurs 2021 Jul-Aug 01;40(4):248-256

Purpose: The aim of this study was to investigate the implementation of an intensive care unit (ICU) diary in an Italian general ICU.

Methods: A mixed-methods pilot study was performed, enrolling all patients who received an ICU diary in an Italian ICU during the study period.

Results: Study results are presented in 2 sections: (1) diary evaluation and content themes and (2) follow-up program results. Sixty-six patients were assessed for eligibility. Diary administration was possible in 31 patients (47%). The overall diary entries, in 31 analyzed diaries, were 1331, with a median of 25 entries (interquartile range, 16-57 entries) for each diary. Participants' relatives and friends wrote a median of 1.2 (0.3-1.6), and nurses wrote 1.1 (0.8-1.2). Other ICU staff wrote a total of 24 entries (2%). Follow-up results revealed low incidence of delirium detected in only 1 patient at the 7-day visit (3%). The median value of PTSS-10 (Post Traumatic Stress Symptoms) score was 12 (3.5-12) at the 7-day visit, 6 (1.5-12) at 3 months' telephone interview, and 12 (1.5-17) at 6 months' visit.

Conclusions: To our knowledge, this is the first Italian report about the introduction of an ICU diary. The diaries were easily implemented in our clinical practice as a "low-cost" initiative. In our study, nurses and participants' relatives and friends wrote a similar number of entries in each analyzed diary. This project could be effective in reducing survivors' delirium and post-traumatic stress disorder and in implementing mutual understanding between clinical staff and relatives during ICU stay.
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http://dx.doi.org/10.1097/DCC.0000000000000480DOI Listing
May 2021

Pressure Injuries Due to Personal Protective Equipment in COVID-19 Critical Care Units.

Am J Crit Care 2021 07;30(4):287-293

Alberto Lucchini is a nurse coordinator in the general intensive care unit, ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.

Background: Caring for patients with COVID-19 requires wearing a full set of personal protective equipment (PPE) to avoid contamination. Personal discomfort has been associated with use of PPE, and anecdotal reports describe pressure injuries related to wearing PPE.

Objectives: To investigate the occurrence of device-related pressure injuries due to wearing PPE among Italian nurses caring for patients with COVID-19 in critical care settings.

Methods: This descriptive study used an online survey investigating both the demographic characteristics of respondents and complications related to wearing PPE, including the development of pressure injuries.

Results: A total of 266 nurses throughout Italy completed the survey; 32% of respondents were men. Nurses' median age was 36 years (range 22-59 years), and the median time spent working in their current clinical setting (an intensive care or high-dependency unit) was 3 years (range 0-32 years). Personal protective equipment was worn for a median duration of 5 hours (range 2-12 hours). While wearing PPE, 92.8% of nurses experienced pain and 77.1% developed device-related pressure injuries, mainly on the nose, ears, and forehead. Pain was more frequent among nurses with such injuries. Transparent dressings, emollient cream, and no dressing were associated with development of device-related pressure injury.

Conclusions: Pressure injuries related to PPE represent an important adverse effect for nurses caring for patients with COVID-19. This topic deserves study to determine adequate solutions for preventing and treating such injuries and their potential influence on nurses' work tolerance.
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http://dx.doi.org/10.4037/ajcc2021178DOI Listing
July 2021

Retrospective survey from vascular access team Lombardy net in COVID-19 era.

J Vasc Access 2021 Feb 23:1129729821997252. Epub 2021 Feb 23.

Emergency Department ASST Lodi, Lodi, Italy.

Background: Venous Access Devices (VADs) are the most used devices in COVID-19 patients.

Objective: Identify VADs implanted, catheter related thrombosis (CRT), catheter-related bloodstream infection (CRBSI), and accidental remove of VADs in both COVID-19 positive and COVID-19 free patients. Successive analysis was conducted comparing COVID-19 positive patients with COVID-19 free with inverse probability propensity score weights using simple regression to account for these two confounders (peripheral tip as central/peripheral and hospitalization as no/yes).

Methods: This multicenter, retrospective cohort study collected data from seven hospitals in Lombardy during the pandemic period from February 21st to May 31st 2020.

Results: A total of 2206 VADs were evaluated, 1107 (50.2%) of which were inserted in COVID-19 patients. In COVID-19 cohort the first choice was Long Peripheral Cannula in 388 patients (35.1%) followed by Midline Catheter in 385 (34.8%). The number of "central tip" VADs inserted in COVID-free inpatients and COVID-19 positive were similar (307 vs 334). We recorded 42 (1.9%) CRT; 32 (79.2%) were observed in COVID-19 patients. A total of 19 CRBSI were diagnosed; 15 (78.95%) were observed in COVID-19. Accidental removals were the more represented complication with 123 cases, 85 (69.1%) of them were in COVID-19. COVID-19 significantly predicted occurrence of CRT (OR = 2.00(1.85-5.03);  < 0.001), CRSB (OR = 3.82(1.82-8.97);  < 0.001), and Accidental Removal (OR = 2.39(1.80-3.20);  < 0.001) in our propensity score weighted models.

Conclusions: CRT, CRBSI, and accidental removal are significantly more frequent in COVID-19 patients. Accidental removals are the principal complication, for this reason, the use of subcutaneously anchored securement is recommended for a shorter period than usual.
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http://dx.doi.org/10.1177/1129729821997252DOI Listing
February 2021

Volatile Sedation for Acute Respiratory Distress Syndrome Patients on Venovenous Extracorporeal Membrane Oxygenation and Ultraprotective Ventilation.

Crit Care Explor 2021 Jan 8;3(1):e0310. Epub 2021 Jan 8.

Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy.

Patients on extracorporeal support for severe acute respiratory distress syndrome may require a prolonged period of deep sedation. In these patients, volatile sedation may represent a valid alternative to IV drugs. The aim of our study was to describe the feasibility of volatile sedation in a large cohort of acute respiratory distress syndrome patients undergoing venovenous extracorporeal membrane oxygenation and ultraprotective ventilation.

Design: Retrospective monocentric study.

Setting: Adult ICU, ASST Monza, Italy.

Patients: Adult patients who underwent volatile sedation with isoflurane during venovenous extracorporeal membrane oxygenation between 2009 and 2019.

Interventions: Isoflurane was delivered via the AnaConDa system. The sedation level, hemodynamics, and laboratory tests were compared between the volatile sedation phase and the IV sedation phases before and after the isoflurane sedation period.

Measurements And Main Results: About 74 patients (50 yr [43-56 yr]) were included. Median duration of venovenous extracorporeal membrane oxygenation support was 22 days (14-51 d). Volatile sedation started on day 3 (2-6) of extracorporeal membrane oxygenation support, and its median duration was 7 days (4-13 d), ranging from 1 to 38 days. A total of 970 venovenous extracorporeal membrane oxygenation days were analyzed. During the volatile phase, the sedation level was slightly deeper (bispectral index 39 ± 6) compared with the IV phase before and after isoflurane (42 ± 8 and 43 ± 9, respectively, < 0.001). Requirements of fentanyl and remifentanyl were reduced during the volatile phase. Minor differences in hemodynamics were observed during volatile sedation: mean arterial pressure was lower (75 ± 13 vs 79 ± 14 and 80 ± 15; < 0.001), whereas cardiac output was higher (8.5 ± 1.9 vs 7.9 ± 1.8 and 8.0 ± 1.8; = 0.003). Aspartate aminotransferase levels were lower during the volatile sedation phases ( < 0.001), whereas alanine aminotransferase, triglycerides, and creatine phosphokinase were more altered during the IV sedation phase before isoflurane ( < 0.001).

Conclusions: Volatile sedation represents an alternative to IV agents to achieve long-term deep sedation in critically ill patients on extracorporeal membrane oxygenation undergoing ultraprotective ventilation.
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http://dx.doi.org/10.1097/CCE.0000000000000310DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803679PMC
January 2021

Effect of central venous pressure on back-flow and bolus events during vasopressor syringe changeover. Comment on Br J Anaesth 2020; 125: 622-628.

Br J Anaesth 2020 12 25;125(6):e463-e464. Epub 2020 Sep 25.

Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy.

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http://dx.doi.org/10.1016/j.bja.2020.09.005DOI Listing
December 2020

Prone Positioning during Venovenous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome. A Multicenter Cohort Study and Propensity-matched Analysis.

Ann Am Thorac Soc 2021 03;18(3):495-501

Dipartimento di Anestesia, Terapia Intensive, e Emergenza, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.

Prone positioning reduces mortality in patients with severe acute respiratory distress syndrome (ARDS). To date, no evidence supports the use of prone positioning (PP) during venovenous extracorporeal oxygenation (ECMO). The aim of the study was to assess the feasibility, safety, and effect on oxygenation and lung mechanics of PP during ECMO. As a secondary exploratory aim, we assessed the association between PP and hospital mortality. We performed a multicenter retrospective cohort study in six Italian ECMO centers, including patients managed with PP during ECMO support (prone group; four centers) and patients managed in the supine position (control group; two centers). Physiological variables were analyzed at four time points (supine before PP, start of PP, end of PP, and supine after PP). The association between PP and hospital mortality was assessed by multivariate analysis and propensity score-matching. A total of 240 patients were included, with 107 in the prone group and 133 in the supine group. The median duration of the 326 pronation cycles was 15 (12-18) hours. Minor reversible complications were reported in 6% of PP maneuvers. PP improved oxygenation and reduced intrapulmonary shunt. Unadjusted hospital mortality was lower in the prone group (34 vs. 50%;  = 0.017). After adjusting for covariates, PP remained significantly associated with a reduction of hospital mortality (odds ratio, 0.50; 95% confidence interval, 0.29-0.87). Sixty-six propensity score-matched patients were identified in each group. In this matched sample, patients who underwent pronation had higher ECMO duration (16 vs. 10 d;  = 0.0344) but lower hospital mortality (30% vs. 53%;  = 0.0241). PP during ECMO improved oxygenation and was associated with a reduction of hospital mortality.
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http://dx.doi.org/10.1513/AnnalsATS.202006-625OCDOI Listing
March 2021

Nursing workload in the COVID-19 era.

Intensive Crit Care Nurs 2020 12 11;61:102929. Epub 2020 Aug 11.

Medical & Surgical Intensive Care Unit, Careggi University Hospital, Florence, Italy.

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http://dx.doi.org/10.1016/j.iccn.2020.102929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418697PMC
December 2020

COVID-19 in Critical Care Units: Rethinking the Humanization of Nursing Care.

Dimens Crit Care Nurs 2020 Sep/Oct;39(5):239-241

Pasquale Iozzo, MSN, RN, is nurse manager at the Anesthesia and Intensive Care Department, "Paolo Giaccone" University Hospital, Palermo, Italy. Laura Rasero, MSN, RN, is nursing associate professor at the Health Science Department, University of Florence, Italy. Alberto Lucchini, RN, is nurse coordinator at the General Intensive Care Unit, Ospedale San Gerardo, Monza, Italy.

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http://dx.doi.org/10.1097/DCC.0000000000000438DOI Listing
August 2020

Procedures to minimize viral diffusion in the intensive care unit during the COVID-19 pandemic.

Intensive Crit Care Nurs 2020 10 26;60:102894. Epub 2020 May 26.

Emergency Department - ASST Monza - San Gerardo Hospital, University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy.

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http://dx.doi.org/10.1016/j.iccn.2020.102894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247976PMC
October 2020

New Issues in Nursing Management During the COVID-19 Pandemic in Italy.

Am J Crit Care 2020 07;29(4):e92-e93

Alberto Lucchini is a nurse coordinator in the general intensive care unit, Ospedale San Gerardo, Monza, Italy.

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http://dx.doi.org/10.4037/ajcc2020937DOI Listing
July 2020

Noise Level and Comfort in Healthy Subjects Undergoing High-Flow Helmet Continuous Positive Airway Pressure.

Dimens Crit Care Nurs 2020 Jul/Aug;39(4):194-202

Alberto Lucchini, RN, General Intensive Care Unit, Emergency Department, ASST Monza, San Gerardo Hospital, Monza; and University of Milano-Bicocca, Milan, Italy. He is the coordinator of the master's degree program in intensive and critical care nursing at Milano-Bicocca University, Italy. His main publications concern the nursing workload in intensive care, nursing care of ECMO patients, invasive and non-invasive mechanical ventilation, endotracheal suctioning. Stefano Bambi, PhD, MSN, RN, Medical and Surgical Intensive Care Unit, Careggi University Hospital, Florence, Italy. He is a staff nurse and professor in charge at Florence University and Milano-Bicocca University. His main publications concern the, invasive and non-invasive mechanical ventilation, nursing in critical care settings. Silvia Gurini, RN, Emergency Department, ASST Valtellina ed Alto Lario, Italy. Enrico di Francesco, RN, Cardiosurgical Intensive Care Unit, S. Antonio Hospital, Padova, Italy. Luigino Pace, RN, General Intensive Care Unit, APSS-Santa Maria del Carmine Hospital, Rovereto, Italy. Roberto Rona, MD, General Intensive Care Unit, Emergency Department, ASST Monza, San Gerardo Hospital, Monza; and University of Milano-Bicocca, Milan, Italy. Roberto Fumagalli, MD, is a professor in the University of Milan-Bicocca located in Milan, Italy. He is also the director of the Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda Hospital of Milan, Italy. Giuseppe Foti, MD, General Intensive Care Unit, Emergency Department, ASST Monza, San Gerardo Hospital, Monza; and University of Milano-Bicocca, Milan. Stefano Elli, RN, General Intensive Care Unit, Emergency Department, ASST Monza, San Gerardo Hospital, Monza; and University of Milano-Bicocca, Milan.

Aim: The aim of this study was to assess the noisiness levels produced by different gas source systems, breathing circuits setup, and gas flow rates during continuous positive airway pressure (CPAP) delivered through helmet.

Methods: This was a crossover design study. Ten healthy subjects received helmet CPAP at 5 cm H2O in random order with different gas flow rates (60 and 80 L/min), 3 diverse gas source systems (A: Venturi system, B: oxygen and air flowmeters, C: electronic Venturi system), and 3 different breathing circuit configurations. During every step of this study, a heat and moisture exchanger (HME) was placed on the helmet inlet gas port to measure the effects on noise production. Noise intensity level was recorded through a sound-level meter. Participants scored their noisiness perception on a visual analog scale.

Results: The noise level inside the helmet ranged between 76 ± 4 and 117 ± 1 Decibel A. The gas source and the gas flow rate always affected the noise level inside and outside the helmet (P < .001). The different "breathing circuit setup" did not change the noise levels inside the helmet (P = .244), but affected the noise level outside, especially when a Venturi system was used (P < .001). An HME filter placed at the junction between the inspiratory limb of the breathing circuit and the helmet significantly decreased the noise intensity inside the helmet (mean dBA without HME, 99.56 ± 13.30 vs 92.26 ± 10.72 with HME; P < .001) and outside (mean dBA without HME, 68.16 ± 12.05 vs 64.97 ± 12.17 with HME; P < .001). The perception of noise inside the helmet was lower when an HME filter was placed on the inspiratory inlet gas port (median, 6 [interquartile range, 4-7] vs 7 [5-8]; P < .001).

Conclusions: When helmet CPAP is delivered through gas flow rates up to 50 L/min, an HME placed on the helmet inlet gas port should be used to reduce noise inside the helmet and to improve patients' comfort.
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http://dx.doi.org/10.1097/DCC.0000000000000430DOI Listing
March 2021

[Continuous bedside pressure mapping in a general intensive care unit: a prospective observational study].

Assist Inferm Ric 2020 Jan-Mar;39(1):5-12

. Continuous bedside pressure mapping in a general intensive care unit: a prospective observational study.

Introduction: A continuous bedside pressure mapping device (PMD) can provide real-time feedback of ideal body position to allow off-loading of high-pressure areas to prevent pressure ulcers development.

Objective: To describe the implementation of a PMD to measure tissue interface pressure (PIT) in Intensive Care (ICU) patients.

Methods: Prospective observational study in ICU critically ill mechanically ventilated adults, in an Italian University Hospital. Subjects were enrolled in the first 24 hours after ICU admission. A pressure mapping system (M.A.P. System TM) was used and 3 measurements of PIT with patient in supine position, every 6 hours after admission, were performed. The following anti-decubitus surfaces were used: Duo2® - Hill-Rom, Proficare®, Nimbus 3® or Therakair Visio® - Arjohuntleigh, Getinge Group.

Results: 27 patients (8 females) were enrolled; average Body Mass Index 27±6 (range: 16-43); 4 patients (14%) were diabetic. The average pressure of the 1215 areas analyzed was 26.7±19.6 mmHg (range: 3-78); the region with the highest contact pressure was the dorsal region (average: 48.7±12.5 mmHg), followed by the occipital (44.7±19.6 mmHg), and sacrum (44.7±10.7 mmHg). The three anti-decubitus surfaces showed different performances in the distribution of PITs, with statistically significant differences for the following factors: body weight (p = 0.017), patient height (p = 0.034), with increased pressures in taller patients, and higher BMI (p <0.0001).

Conclusions: Mean values of PIT were above critical levels, especially in the dorsal, occipital and sacrum region.
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http://dx.doi.org/10.1702/3371.33471DOI Listing
April 2021

Nursing Activities Score is increased in COVID-19 patients.

Intensive Crit Care Nurs 2020 08 23;59:102876. Epub 2020 Apr 23.

Emergency Department, ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy.

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http://dx.doi.org/10.1016/j.iccn.2020.102876DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177066PMC
August 2020

The "helmet bundle" in COVID-19 patients undergoing non invasive ventilation.

Intensive Crit Care Nurs 2020 06 2;58:102859. Epub 2020 Apr 2.

Emergency Department, ASST Monza - San Gerardo Hospital, Via Pergolesi 33, Monza (MB), Italy; University of Milano-Bicocca, Italy.

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http://dx.doi.org/10.1016/j.iccn.2020.102859DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270556PMC
June 2020

Reliability of cutaneous landmarks for the catheter length assessment during peripherally inserted central catheter insertion: A retrospective observational study.

J Vasc Access 2020 Nov 31;21(6):917-922. Epub 2020 Mar 31.

Emergency Department and Intensive Care, University of Milano-Bicocca, A.S.S.T. Monza, San Gerardo Hospital, Monza, MB, Italy.

Introduction: Peripherally inserted central catheters are very common devices for short, medium and long-term therapies. Their performance is strictly dependent on the correct tip location, at the junction between the upper caval vein and the right atrium. It is very important to obtain an estimated measure of the catheter, in order to reach the cavo-atrial junction and optimize the catheter length. Estimated measures are often obtained using cutaneous landmarks.

Objective: Evaluate the reliability of cutaneous landmark-based length estimation during catheter insertion. Identify any patient's related factors that may affect cutaneous landmarks reliability.

Methods: We used two distinct techniques and collected data about cutaneous landmark-based length estimation, electrocardiographic guided intravascular length, age, weight and height. We studied the reliability of possible correcting factors, balancing the error average by regression models, and we found and tested two different models of prediction.

Results: A total number of 519 patients were studied. The average bias, between the two studied length assessment by cutaneous landmarks and electrocardiographic guided catheter length, were 3.77 ± 2.44 cm and 3.28 ± 2.57 cm, respectively. The analysed prediction models (deviance explained 43.5%, Akaike information criterion = 1313.67% and 43.4%, Akaike information criterion = 1313.92), fitted on the validation set, showed a root mean square error of 3.07 and 3.06.

Conclusion: Landmark-based length estimation for preventive catheter length assessment seems to be unreliable, when associated with post-procedural tip location. They are useful for distal trimming catheters to optimize the 'out of skin' portion when associated with electrocardiographic tip location. Models identified for balancing bias are probably not useful.
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http://dx.doi.org/10.1177/1129729820911225DOI Listing
November 2020

Changing the syringe pump: A challenging procedure in critically ill patients.

J Vasc Access 2020 Nov 4;21(6):868-874. Epub 2020 Mar 4.

General Intensive Care Unit, Emergency Department - ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.

Introduction: In the literature, the change of a syringe pump is described as a dangerous situation, especially in the case of vasoactive drug administration.

Methods: Different variables have been studied (central venous pressure, pump displacement in relation to the patient position, utilization of a stopcock, or a neutral displacement needle-free connector between the syringe and the infusion tubing) to understand their influence on medication administration in terms of backflow or bolus creation when changing the syringe.

Results: We performed 576 measurements with different combinations. With respect to all the observations, in comparison with "time zero," we found the following differences expressed in microliters: 0 (±1) at the plunger opening; 0 (±3) at the syringe extraction from the pump; 0 (±7) at the syringe disconnection from the infusion tubing; 0 (±11) at the syringe reconnection to the infusion tubing; 1 (±7) at the syringe insertion in the pump; 3 (±23) at the plunger closing; 8 (±33) at the stabilization at the maneuver end.

Conclusion: The syringe change can be a very critical moment given different influencing variables. Syringe pump position, displaced higher than the patient level, always generates a medication bolus that is higher at the lowering of the central venous pressure value. The presence of a neutral displacement needle-free connector reduces the incidence of boluses. When the pump is placed at the patient level, the presence of neutral displacement needle-free connector reduces the establishment of boluses, even in a central venous pressure of -5 mmHg simulations.
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http://dx.doi.org/10.1177/1129729820909024DOI Listing
November 2020

Ultrasound-guided tip location of midline catheters.

J Vasc Access 2020 Sep 28;21(5):764-768. Epub 2020 Feb 28.

General Intensive Care Unit, Emergency Department, University of Milan-Bicocca, ASST Monza, San Gerardo Hospital, Monza, Italy.

Introduction: Midline catheters are widely used in clinical practice. Proper placement of midline catheter tip is usually assessed only by aspirating blood and flushing with normal saline without resistance.

Purpose: To describe the ultrasound-guided tip location for midline catheters and its feasibility and to compare incidence of catheter-related venous thrombosis associated with or without ultrasound tip localization.

Methods: The ultrasound-guided tip location is described step by step. Feasibility of the technique and incidence of catheter-related venous thrombosis were measured (study group) and compared with two historical groups: study group, 20-cm midline catheters inserted with ultrasound-guided tip location; group 1, 25-cm midline catheters inserted without ultrasound-guided tip location and group 2, 20-cm midline catheters inserted without ultrasound-guided tip location.

Results: In the study group, ultrasound-guided tip location was easily feasible in 98.9% of patients. Incidence of catheter-related venous thrombosis was 2.42% in control group 1, 9% in control group 2 and 2.62% in the study group.

Discussion: In the study group and control group 1, the tip was placed in the axillary vein, about 3 cm distal to the clavicle and in the subclavian vein. In control group 2, the tip was probably located at the transition between the axillary and the subclavian vein. It is possible that such position may have been associated with an increased incidence of catheter-related venous thrombosis.

Conclusion: The ideal position of the tip of a midline catheter might be inside the axillary vein, about 3 cm distal to the axillary-subclavian transition or inside the subclavian vein. Ultrasound-guided tip location is safe, inexpensive, easy and potentially useful during midline catheters insertion.
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http://dx.doi.org/10.1177/1129729820907250DOI Listing
September 2020

Prone Position in Acute Respiratory Distress Syndrome Patients: A Retrospective Analysis of Complications.

Dimens Crit Care Nurs 2020 Jan/Feb;39(1):39-46

Alberto Lucchini, RN, is head nurse at the General Intensive Care Unit, ASST Monza, San Gerardo Hospital, Italy. He is the coordinator of the master's degree program in intensive and critical care nursing at Milano-Bicocca University, Italy. Stefano Bambi, PhD, MSc, RN, CCN, is a staff nurse at the Medical & Surgical Intensive Care Unit, Careggi Teaching Hospital, Florence, Italy. He was formerly a lecturer in emergency and critical care nursing at University of Florence (Italy). Elisa Mattiussi, MSc, RN, CCN, is a professor-in-charge at School of Nursing, Department of Medical and Biological Sciences, Udine University, Italy. Stefano Elli, RN, is currently employed at the General Intensive Care Unit, Emergency Department, San Gerardo Hospital, and University of Milan-Bicocca, Italy. Laura Villa, RN, CCN, is a staff nurse at General Intensive Care Unit, ASST Monza, San Gerardo Hospital. Herman Bondi, RN, CCN, is a staff nurse at General Intensive Care Unit, ASST Monza, San Gerardo Hospital. Roberto Rona, MD, is director of general intensive care unit, ASST Monza, San Gerardo Hospital. Roberto Fumagalli, MD, is director and a full professor at Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda Hospital, University of Milan-Bicocca, Milan, Italy. Giuseppe Foti, MD, is director and an associate professor at the Emergency Department, ASST Monza, San Gerardo Hospital.

Background: Early application of prolonged prone positioning has been shown to improve patient survival in moderate to severe adult respiratory distress syndrome (ARDS) patients. Prone position is a key component of lung protective mechanical ventilation in association with low tidal volume and neuromuscular blocking agents in patients with severe ARDS. Pressure sores are the major prone position complication. The rate of complication is lowering with the increase in center expertise.

Aims: The aim of this study was to examine the onset of pressure sores and other complications caused by the use of prone position in patients having ARDS.

Design: This is a single-center, retrospective, observational study.

Results: One hundred seventy patients were enrolled, with a median age of 49 years (interquartile range [IQR], 38-63). Of all participants, 58% (n = 98) survived the intensive care unit recovery. The total prone position maneuvers were 526, with a median of 2 prone position sessions for each patient (IQR, 1-3). The median length of the prone position session was 9 hours (IQR, 7-12). Twenty-three patients developed pressure sores after prone position (14%). The anatomical positions of pressure sores were as follows: face/chin, 5% (n = 8); face/cheekbones, 6% (n = 11); thorax, 2% (n = 3); trochanter, 1% (n = 1); and other sites, 5% (n = 8). Complications were observed in 1% (n = 6) of all pronation maneuvers (vomit, 2%; respiratory device removal, 0.4%). No removal of intravascular catheter was observed.

Conclusions: The onset rate of complications given by the use of prone position in ARDS patients is similar to data reported by previous literature. The implementation of a dedicated protocol in specialized centers and the involvement of 5 trained and skilled professionals while moving the patient in the prone position are recommended to prevent the occurrence of similar adverse events.
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http://dx.doi.org/10.1097/DCC.0000000000000393DOI Listing
August 2020

Water content of delivered gases during Helmet Continuous Positive Airway Pressure in healthy subjects.

Acta Biomed 2019 11 11;90(11-S):65-71. Epub 2019 Nov 11.

ASST Monza, Ospedale San Gerardo - università degli Studi di Milano-Bicocca.

Introduction: During Continuous Positive Pressure Ventilation delivered through helmet, the patient inhales high flows of gas without adequate conditioning. However, the need to humidify the inspired gas during Helmet-CPAP, has not been sufficiently explored.

Methods: Experimental design study. Six healthy individuals underwent High Flow Helmet CPAP with different gas flows (60 and 80 L/min) and FiO2 (0.35, 0.5, 0.7 and 1) generated by a Venturi system, with and without active humidification. The active humidifier setting was 26 ° at the humidification chamber and 28 ° at the helmet gas inlet. At each setting, measurements about temperature and relative humidity inside helmet were taken. Comfort level at each setting was evaluated using a visual analog scale rated from 0 to 10.

Results: Without heated humidification, the mean value of absolute humidity in the eight combinations investigated was 5.9±2.1 mg H2O/L, with a mean  temperature of 25.8±0.9°. With heated  humidification mean absolute humidity was 15.0±3.5 mg H2O/L with mean temperature of 29.0±0.1°. The median comfort scale value was 6 (IQR: 5.25-6.75) during the phase without humidification vs 8 (7.25-8.0 - P<0.01) when active humidification was applied.

Conclusions: In healthy subjects undergoing High Flow Helmet CPAP, heated humidifiers with heated wires tubes are necessary to avoid the under-humidification inside the helmet. To obtain patient's comfort and airways mucosal humidification during continuous Helmet CPAP, the most desirable conditions are reached by heated humidifiers with a humidifying chamber temperature settled between 26-28°C.
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http://dx.doi.org/10.23750/abm.v90i11-S.8820DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7233631PMC
November 2019

Pressure-flow relationship of cannulae for extracorporeal membrane oxygenation.

Perfusion 2020 04 13;35(3):271-272. Epub 2019 Aug 13.

Dipartimento di Emergenza-Urgenza, ASST Monza, Monza, Italy.

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http://dx.doi.org/10.1177/0267659119867182DOI Listing
April 2020

The evaluation of nursing workload within an Italian ECMO Centre: A retrospective observational study.

Intensive Crit Care Nurs 2019 Dec 7;55:102749. Epub 2019 Aug 7.

General Intensive Care Unit, Emergency Department - ASST Monza - San Gerardo Hospital, University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy.

Introduction: The Nursing Activities Score (NAS) measures the amount of nursing time required for each patient and it has been widely used across Europe since its first validation in 2003.

Objective: To determine the nursing workload within an Extracorporeal Membrane Oxygenation (ECMO) Centre using a dedicated scoring tool.

Methods: Retrospective observational study. Data from NAS were collected for seventy-two consecutive months from January 2010.

Results: A total amount of 2606 patients were enrolled. Their median NAS recorded at Intensive Care Unit's admission was 69.8 (IQR: 56.2-82.9), whilst the daily average NAS was 68.1 (IQR: 58.3-76.7). ECMO patients enrolled were 95 (4%), with 3141 ECMO days. The median NAS of the ECMO patients versus patients without ECMO support was 87.0 (IQR: 82-96) and 67.2 (IQR: 58-78) respectively (p < 0.0001). The number of daily ECMO treatments showed a slight correlation with the average daily NAS (r = 0.176-p < 0.0001).

Conclusions: Our findings suggest that in ECMO patients a nurse-to-patient ratio equal to 1:1, should be guaranteed in accordance to the national health regulations and organizations. The results of this study reinforce the current recommendation about the implementation of referral ECMO centres, in order to centralise patients, provide a dedicated clinical-technical support and also guarantee an adequate number of ECMO nurses supported by an accurate nurse management.
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http://dx.doi.org/10.1016/j.iccn.2019.07.008DOI Listing
December 2019

Noninvasive ventilation: education and training. A narrative analysis and an international consensus document.

Adv Respir Med 2019 4;87(1):36-45. Epub 2019 Mar 4.

Respiratory Unit, AO Ospedali dei Colli Naples PO, Monaldi, Italy.

Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients' lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries.
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http://dx.doi.org/10.5603/ARM.a2019.0006DOI Listing
February 2020

[Incidence and risk factors associated with the development of pressure ulcers in an Italian general intensive care unit].

Assist Inferm Ric 2018 Oct-Dec;37(4):181-188

. Incidence and risk factors associated with the development of pressure ulcers in an Italian general intensive care unit.

Introduction: Pressure ulcers (PU) represent one of the most frequent adverse event in intensive care units (ICU). Critical patients are at higher risk of developing a PU, with an incidence between 3.3-39.3%.

Aim: To assess the incidence and risk factors for developing PUs in a general ICU of an Italian University hospital.

Methods: Retrospective observational study on a sample of 122 patients admitted to a general intensive care unit, from January to December 2015, with a length of ICU stay > 5 days. PUs were stadied according to the National Pressure Ulcer Advisory Panel.

Results: One hundred and twenty two patients were enrolled. The incidence of PUs was 33%, and the incidence rate was 23 PUs for 1.000 days of ICU stay; 29% of PUs were of stage I, 56% of stage II, 8% stage III and 6% stage IV. PUs mainly affected the sacrum (21%) with a very low incidence in the heels (1.6%). Despite several factors were associated to the development of PUs (being female, Sequential Organ Failure Assessment, length of stay, mechanical ventilation > 72 hours, administration of dobutamine, Admission pO 2/FiO2 ratio, mean Braden during ICU stay and admission diagnosis) only ICU lenght of day remained statistically significant.

Conclusions: The incidence of PUs is comparable to other recent studies. Many factors are potentially involved in the onset of PUs. Identifying these factors can help nurses to plan interventions to prevent their development.
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http://dx.doi.org/10.1702/3080.30722DOI Listing
August 2019

Unplanned extubations in general intensive care unit: A nine-year retrospective analysis.

Acta Biomed 2018 12 7;89(7-S):25-31. Epub 2018 Dec 7.

ASST Monza, Ospedale San Gerardo - università degli Studi di Milano-Bicocca.

Background And Aim: Unplanned extubation (UE) in Intensive Care Units (ICU) is an indicator of quality and safety of care. UEs are classified in: accidental extubations, if involuntarily caused during nursing care or medical procedures; self-extubation, if determined by the patient him/herself.  In scientific literature, the cumulative incidence of UEs varies from 0.3% to 35.8%. The aim of this study is to explore the incidence of UEs in an Italian university general ICU adopting a well-established protocol of tracheal tube nursing management and fixation.

Methods: retrospective observational study. We enrolled all patients undergone to invasive mechanical ventilation from 1st January 2008 to 31st December 2016.

Results: in the studied period 3422 patients underwent to endotracheal intubation. The UEs were 35: 33 self extubations (94%) and 2 accidental extubations (6%). The incidence of UEs calculated on 1497 patients intubated for more than 24 hours was 2.34%. Instead, it was 1.02%, if we consider the whole number of intubated patients. Only in 9 (26%) cases out of 35 UEs the patient was re-intubated. No deaths consequent to UE were recorded.

Conclusions: The incidence of UEs in this study showed rates according to the minimal values reported in scientific literature. A standardized program of endotracheal tube management (based on an effective and comfortable fixing system) seems to be a safe and a valid foundation in order to maintain the UE episodes at minimum rates.
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http://dx.doi.org/10.23750/abm.v89i7-S.7815DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502139PMC
December 2018

Negative interactions among nurses: An explorative study on lateral violence and bullying in nursing work settings.

J Nurs Manag 2019 May 21;27(4):749-757. Epub 2019 Jan 21.

Department of Health Sciences, University of Florence, Florence, Italy.

Background: Lateral violence and bullying affect nurses' professional and health status. Worldwide prevalence ranges from 1% to 87%.

Aim: To investigate prevalence and risk factors of lateral violence and bullying among Italian nurse peers in different work settings, inside and outside hospitals.

Methods: Web survey using the 17-item "Negative Interactions Among Nurses Questionnaire." Emails were sent to 5,009 nurses in three Tuscan public health care institutions.

Results: Response rate was 18.6% (n = 930). Twenty-six respondents were removed as they reported working with no peer colleagues. Negative interactions were experienced by 35.8% (n = 324), 42.3% of whom (n = 137) were bullied. Psycho-physical consequences of negative interactions were reported by 59% (n = 191). Victims who thought of leaving nursing were 21.9% (n = 71).

Conclusions: Lateral violence and bullying among nurses are consistently present in all studied settings.

Implications For Nursing Management: Nurse managers could play a crucial role in preventing negative interactions among nurses. Strategies could include continuing education programs to promote awareness of this problem; implementation of an anonymous reporting system for bullying; introduction of occupational psychologists in wards with larger numbers of reported negative interactions and bullying; and increasing changes in staff composition within shifts.
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http://dx.doi.org/10.1111/jonm.12738DOI Listing
May 2019

The burden of not-weighted factors in nursing workload: Can Nursing Activities Score be more suitable than TISS 28 and NEMS?

Intensive Crit Care Nurs 2019 04 22;51:82-83. Epub 2018 Nov 22.

Neurosurgical ICU, Careggi University Hospital, Florence, Italy.

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http://dx.doi.org/10.1016/j.iccn.2018.11.002DOI Listing
April 2019

How different helmet fixing options could affect patients' pain experience during helmet-continuous positive airway pressure.

Nurs Crit Care 2019 11 20;24(6):369-374. Epub 2018 Nov 20.

General Intensive Care Unit, Emergency Department, ASST Monza - San Gerardo Hospital, University of Milano-Bicocca, Monza, MB, Italy.

Background: Prolonged application time of helmet continuous positive airway pressure (CPAP) leads to better outcomes, but its timing can be influenced by the patient's tolerance.

Aims And Objectives: To investigate patients' pain and tolerance experience related to different options of helmet fixing system: 'armpits strap' versus 'counterweights system'.

Design: This was a non-randomized crossover study performed in a 10-bed intensive care unit and referral extra corporeal membrane oxigenation (ECMO) centre of an Italian university hospital.

Results: Twenty patients were enrolled. For helmet-CPAP cycles performed with the armpit straps option, the mean pain numerical rate on a 0-10 scale was: 0·5 ± 1·4 at T (baseline) 1·5 ± 2·0 at T (after 1 h) and 2·6 ± 2·5 at T (end of cycle) (p = 0·023). The same analysis was performed for the counterweights fixing option. The mean score was 0·3 ± 0·6 at T , 0·3 ± 0·2 at T and 0·5 ± 0·7 at T (p = 0·069). The mean duration for CPAP cycles performed with armpits strap and counterweights system was 3·0 ± 1·0 and 3·9 ± 2·3 h, respectively (p < 0·001). The mean section of the Basilic vein that was investigated before wearing the helmet was equal to 0·23 ± 0·20 cm . After 1 h of therapy with the counterweight option and armpit straps, the mean increase of the vein's section was 0·27 ± 0·21(p = 0·099) and 0·30 ± 0·25, respectively (p = 0·080).

Conclusions: The fixing system options in use to anchor the helmet during CPAP could worsen the pain experience level and cause device-related pressure ulcers. When compared with the armpit straps option, the counterweights system appears to be a suitable approach to minimize the risks of pressure sores and pain during the treatment.

Relevance To Practice: The helmet CPAP is a reliable therapy to manage acute respiratory failure. Major improvements regarding pulmonary alveolar recruitment and oxygen levels are strictly related to a prolonged time of helmet CPAP cycles. Using a counterweight fixing system, where the armpits straps are not necessary, could be helpful in reducing patients' pain experience.
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http://dx.doi.org/10.1111/nicc.12399DOI Listing
November 2019
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