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Vito Defilippis,1 Davide D’Antini,2 Gilda Cinnella,2 Michele Dambrosio,2 Fernando Schiraldi,3 Vito Procacci1 1Emergency Department, Riuniti Hospital, 2Department of Anaesthesiology and Intensive Care, University of Foggia, Foggia, 3Emergency Department, San Paolo Hospital, Naples, Italy Background: Patients with severe hypercapnia represent a particularly serious condition in an emergency department (ED), requiring immediate attention. Noninvasive ventilation (NIV) is an integral part of the treatment for acute respiratory failure. The present study aimed to validate the measurement of end-tidal CO2 (EtCO2) as a noninvasive technique to evaluate the effectiveness of NIV in acute hypercapnic respiratory failure. Methods: Twenty consecutive patients admitted to the ED with severe dyspnea were enrolled in the study. NIV by means of bilevel positive airway pressure, was applied to the patients simultaneously with standard medical therapy and continued for 12 hours; the arterial blood gases and side-stream nasal/oral EtCO2 were measured at subsequent times: T0 (admission to the ED), T1h (after 1 hour), T6h (after 6 hours), and T12h (after 12 hours) during NIV treatment. Results: The arterial CO2 partial pressure (PaCO2)–EtCO2 gradient decreased progressively, reaching at T6h and T12h values lower than baseline (P < 0.001), while arterial pH increased during the observation period (P < 0.001). A positive correlation was found between EtCO2 and PaCO2 values (r = 0.89, P < 0.001) at the end of the observation period. Conclusion: In our hypercapnic patients, the effectiveness of the NIV was evidenced by the progressive reduction of the PaCO2–EtCO2 gradient. The measurement of the CO2 gradient could be a reliable method in monitoring the effectiveness of NIV in acute hypercapnic respiratory failure in the ED. Keywords: arterial end-tidal CO2 gradient, noninvasive ventilation, bilevel positive airway pressure, acute respiratory failure

Aims: The role of dynamic changes in lactate concentrations on prognosis in acute heart failure has been poorly investigated. The aim of this study was to explore the predictive value of 24 h time-weighted lactate (LAC TW ) in patients with acute heart failure., Methods and Results: Ninety-six consecutive acute heart failure patients presenting to the Emergency Department of San Paolo Hospital, Naples, Italy, were prospectively enrolled. Arterial blood lactate was measured at admission and during the following 24 h at random time intervals. LAC TW was obtained by the sum of the average lactate values among consecutive time points multiplied by the intervals between consecutive time points and dividing the sum by the total time (24 h). The outcome was a composite of need of admission to the intensive care unit, hospitalization duration >7 days, or intra-hospital death. Admission lactate, maximum measured lactate, and LAC TW were collected. Univariate and multivariate Cox regression analysis was applied to determine the hazard ratio (HR) of developing the outcome. Forty-three patients experienced the pre-specified outcome. In sex-adjusted and age-adjusted multivariable analysis, LAC TW predicted the outcome occurrence (HR: 1.51, 95% confidence interval: 1.24, 1.84, P < 0.001). Risk stratification analysis based on LAC TW tertiles demonstrated a gradual increase in risk of developing the outcome (HR: 17.32, 95% confidence interval: 2.30, 130.23, P = 0.006) for the highest LAC TW tertile., Conclusions: In acute heart failure patients, 24 h LAC TW had a significant independent predictive value for adverse intra-hospital outcome. LAC TW could be a useful index at identifying high-risk patients who may require a more aggressive treatment during hospitalization., (©2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Objective: In physiological conditions, arterial blood lactate concentration is equal to or lower than central venous blood lactate concentration. A reversal in this rate (i.e., higher lactate concentration in central venous blood), which could reflect a derangement in the mitochondrial metabolism of lung cells induced by inflammation, has been previously reported in patients with ARDS but has been never explored in COVID-19 patients. The aim of this study was to explore if the COVID-19-induced lung cell damage was mirrored by an arterial lactatemia higher than the central venous one; then if the administration of anti-inflammatory therapy (i.e., canakinumab 300 mg subcutaneous) could normalize such abnormal lactate a-cv difference., Methods: A prospective cohort study was conducted, started on March 25, 2020, for a duration of 10 days, enrolling 21 patients affected by severe COVID-19 pneumonia undergoing mechanical ventilation consecutively admitted to the ICU of the Rimini Hospital, Italy. Arterial and central venous blood samples were contemporarily collected to calculate the difference between arterial and central venous lactate (Delta a-cv lactate) concentrations within 24 h from tracheal intubation ( T 0 ) and 24 hours after canakinumab administration ( T 1 )., Results: At T 0 , 19 of 21 (90.5%) patients showed a pathologic Delta a-cv lactate (median 0.15 mmol/L; IQR 0.07-0.25). In the 13 patients undergoing canakinumab administration, at T 1 , Delta a-cv lactate decreased in 92.3% of cases, the decrease being statistically significant ( T 0 : median 0.24, IQR 0.09-0.31 mmol/L; T 1 : median -0.01, IQR -0.08-0.04 mmol/L; p =0.002)., Conclusion: A reversed Delta a-cv lactate might be interpreted as one of the effects of COVID-19-related cytokine storm, which could reflect a derangement in the mitochondrial metabolism of lung cells induced by severe inflammation or other uncoupling mediators. In addition, Delta a-cv lactate decrease might also reflect the anti-inflammatory activity of canakinumab. Our preliminary findings need to be confirmed by larger outcome studies., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Giuseppe Nardi et al.)

Background: Dyspnea is one of the most frequent complaints in the Emergency Department. Thoracic ultrasound should help to differentiate cardiogenic from non-cardiogenic causes of dyspnea. We evaluated whether the diagnostic accuracy can be improved by adding a point-of-care-ultrasonography (POC-US) to routine exams and if an early use of this technique produces any advantage., Methods: One hundred sixty-eight patients were enrolled and randomized in two groups: Group 1 received an immediate POC-US in addition to routine laboratory and instrumental tests; group 2 received an ultrasound scan within 1 h from the admission to the Emergency Department. The concordance between initial and final diagnosis and the percentage of wrong diagnosis in the two groups were evaluated. Mortality, days of hospitalization in Emergency Medicine department and transfers to other wards were compared. Sensitivity and specificity of the routine protocol and the one including ultrasonography for the diagnosis of the causes of dyspnea were also analyzed., Results: Eighty-eight patients were randomized in group 1 and 80 in group 2. The concordance rate between initial and final diagnoses was significantly different (0.94 in group 1 vs. 0.22 in group 2, p < 0.005). The percentage of wrong initial diagnosis was 5% in group 1 and 50% in group 2 (p < 0.0001)., Conclusions: Adding POC-US to routine exams improves the diagnostic accuracy of dyspnea and reduces errors in the Emergency Department.

Critical care patients are submitted to multiple derangements of vital parameters. Even in patients with a normally performing heart, its electrical activity can be strongly influenced by dyselectrolytemias, acid-base imbalance and aggressive drug therapy. In this paper, the basic principles of the electrophysiologic properties of the heart are reviewed, and the impact of dyselectrolytemias on heart excitability are underlined. Some clinically relevant aspects are described in greater depth, with respect to life-threatening arrhythmias.

Objective. To evaluate 2-hour lactate clearance as a prognostic marker in acute cardiorespiratory insufficiency. Design. Prospective observational study. Setting. Emergency Department (ED) and 16-bed medical High Dependency Unit (HDU). Methods and Main Results. 95 consecutive admissions from the ED for acute cardiorespiratory insufficiency were prospectively enrolled. Arterial lactate concentration was assessed at ED arrival and 1, 2, 6, and 24 hours later. The predictive value of 2-hour lactate clearance was evaluated for negative outcomes defined as hospital mortality or need for endotracheal intubation versus positive outcomes defined as discharge or transfer to a general medical ward. Logistic regression and ROC curves found 2-hour lactate clearance >15% was a strong predictor of negative outcome (P < .0001) with a sensitivity of 86% (95%CI = 67%-95%) and a specificity of 91% (95%CI = 82%-96%), Positive predictive value was 80% (95%CI = 61%-92%), and negative predictive value was 92% (95%CI = 84%-98%). Conclusions. Systematic monitoring of lactate clearance at 2 hours can be used in to identify patients at high risk of negative outcome and perhaps to tailor more aggressive therapy. Equally important is that a 2-hour lactate clearance >15% is highly predictive of positive outcome and may reassure clinicians that the therapeutic approach is appropriate.