Pediatric Emergency Front of the Neck Access: Assessing a New Learning Approach on an infant-sized rabbit model
Francis Ulmer (Zurich | CH)
Background: A pediatric “cannot intubate, cannot ventilate” situation is uncommon, but associated with poor outcome. Several airway algorithms suggest emergency tracheal access. Little evidence and agreement exists on how to perform emergency front of the neck access (eFONA) in children < 8 years. Seldinger techniques are inappropriate for this situation. Rapid sequence tracheotomy (RST) has been proposed instead. We investigated the learning curves, success- and injury rate of RST of clinicians performing simulated pediatric eFONA in a rabbit model.
Methods: Fifty physicians from 5 medical specialties (10 pediatric intensivists, 10 pediatric emergency physicians, 10 pediatric surgeons, 10 pediatric anesthesiologists, 10 emergency response physicians) performed 10 RST on rabbit cadavers each after watching an instructional video. We analyzed their learning curves relative to performance time and concurring injuries.
Results: With an overall success rate of 94%, RST performance time decreased from 107 sec (SD 45) to 55 sec (SD 17) over 10 attempts. The learning curve was steep between the first and the fourth attempt with an 11% decrease in performance time (95% CI: 9 - 13%, p < 0.001) per attempt and then flattened to a 4% (95% CI: 3 - 5%, p < 0.001) decrease per attempt between the fourth and the tenth attempt. Age, years of clinical experience and sex showed a significant effect on the learning curve, whereas medical specialty and adult eFONA experience did not. The 58% (95% CI: 44 - 72%) probability for severe injury during the first attempt decreased to 14% (95% CI: 8-20%) as of the second attempt. Male sex increased overall probability for minor injuries significantly (p < 0.001).
Conclusions: Irrespective of medical specialty pediatric clinicians acquired the eFONA technique within 4 attempts and were able to establish an airway in < 1 minute when performing RST on a pediatric airway simulator. Steady skill improvement was observed yielding a 94% tracheal tube placement success rate. Despite this apparent success, no reduction in minor injuries over the 10 attempts was observed. The complication rate (severe injuries and failure) remained high at around 20% following an initial precipitous decline after the first attempt. Injury rates and learning curve were not influenced the providers’ experience and medical specialty. Video-instruction followed by 10 RST attempts enables swift skill acquisition of this advanced invasive technique.
Impact of beta-glucan test on management of intensive care unit patients at risk of invasive candidiasis
Antonios Kritikos (Lausanne | CH)
Background: Invasive candidiasis (IC) is a life-threatening complication in intensive care unit (ICU) patients. 1,3-beta-D-glucan (BG) can be detected in serum during IC. Some studies support the use of BG for early IC diagnosis. However, the real utility of BG results on patients’ management is not well established. This prospective study aimed to assess the impact of BG results on therapeutic decisions.
Materials/methods: After introduction of the BG test (FungitellTM) in our institution, a screening of all BG test requests was performed over two periods of 6 months in ICU. During the second period, an intervention of infectious diseases specialists was performed (weekly evaluation and distribution of pocket cards with indications for testing and interventional algorithm). The performance of BG for the detection of IC was assessed, as well as the impact of BG results on antifungal drug prescriptions.
Results: A total of 82 patients had ≥1 BG test and 17(20%) of them had a diagnosis of IC. Sensitivity, specificity, positive and negative predictive values of one and two consecutive positive BG tests (≥80 pg/ml) were: 58%, 71%, 34%, 87%, and 61%, 69%, 42%, 83%, respectively. BG results influenced therapeutic decisions in 46/82 (56%) cases. Overall, it was estimated that BG had a positive impact in 31 (37%) cases (28 interruptions of empiric antifungal therapy with no subsequent IC and 3 preemptive antifungal treatments for subsequently confirmed IC) and could have served positively in 13 (16%) more cases. In 14 (17%) cases, antifungal therapy was started on the basis of a positive BG with no further evidence of IC. Major failure of the test (false negative results with real or potential therapeutic consequences) was noted in 3 (3.5%) cases. No differences were observed in terms of performance or impact of BG testing between the two periods.
Conclusions: BG testing was useful for guiding therapeutic decisions in ICU in about half of cases and was estimated to have a positive impact on antifungal prescription in 37% cases. However, efforts to optimize the use of the test on targeted high-risk patients and to propose an interventional algorithm had no significant impact.
End-of-life decisions may influence ICU mortality and hospital lengths of stay
Stephan von Düring (Genève | CH)
Context & Objectives
More than 70 % of ICU deaths occur after an End-Of-Life (EOL) decision consisting in withholding or withdrawing of life-sustaining therapy (LST). EOL decision-making varies greatly within Europe. Switzerland is separated into distinct cultural regions defined by languages related to the neighbouring countries. The three linguistic regions are the French (FR), the German (GR) and the Italian speaking region.
To determine the differences in EOL decisions between the FR and GR, and their influence on ICU and hospital length-of-stay (LOS) and mortality. As secondary objectives, we evaluated whether the type and timing of EOL decision had an influence on outcome issues.
Material & Methods
Patients admitted to ICU and who had treatment limitations over a 6 month period were included as part of the ETHICUS 2 study. Seven Swiss ICUs (3 in FR, 4 in GR) allowed us to compare two cultural regions. Patients were followed from admission until discharge from the ICU, death, or 2 months after the decision to limit the therapy.
During this study 1’115 patients were included across the 2 regions of Switzerland. ICU and hospital mortality differed significantly between FR and GR (33 vs 63 %, p < 0.0001, 48 vs 75 %, p < 0.0001 respectively), whereas mortality after ICU was similar in both groups. ICU LOS was similar in both groups. First EOL decision was made earlier in FR than in GR (0.79 ± 0.24 vs 1.92 ± 0.28 days, p < 0.01 respectively), whereas time to ICU discharge after first EOL limitation was similar in both groups. Time from first EOL decision to death was considerably longer in FR (10.6 ± 1.01 vs 2.27 ± 0.23, p < 0.0001 respectively). FR took decisions in multiple steps compared to GR (40 vs 24 %, p < 0.013), and GR withdrew LST as a single decision that impacted shortly on survival. Post-ICU LOS was longer in FR compared to GR (12.16 ± 0.76 vs 3.2 ± 0.34 days, p < 0.0001 respectively).
Mortality was significantly higher in GR. EOL decisions were made later in GR ICUs but with more withdrawals that were associated with more deaths. ICU LOS was similar in both regions but hospital LOS after ICU and total hospital LOS was significantly shorter in GR. Depending on the way EOL decision is made, the hospital LOS and the outcome may be impacted.
Variability among Modalities, Practices, Indications, Requests of Hematic products and blood Samplings in Swiss Intensive Care Units (Swiss VAMPIRES)
Marco Previsdomini (Bellinzona | CH)
Background and goals: Blood loss, anaemia and transfusion of blood products potentially damage critically ill patients and are associated with high costs. The aim of the present study is to gather information on the degree of implementation of Patient Blood Management (PBM) initiatives in Swiss hospitals, to study the processes related to iatrogenic anaemia and to assess the transfusion criteria applied in Swiss intensive care units (Swiss ICU).
Material and Methods: Anonymous online survey between October 16, 2018 and March 13, 2019 addressing all ordinary member physicians of the Swiss Society for Intensive Care Medicine (MD) and registered ICU nurses among all certified adult Swiss ICUs (invitation sent to the head nurses with a request to expand it to their co-workers). For both professional categories there was a specific questionnaire regarding the availability of initiatives, protocols, standard operating procedures and habits in their clinical practice around anaemia, blood sampling and transfusions.
Results: 115 MD and 624 nurses from regional, cantonal, university or private clinics in 29, 36, 20 and 15%, and 21, 30, 40 and 9%, respectively. The most noteworthy points for MD are: 1) PBM implementation as institutional initiative according to 42.5% with, in 78%, timely pre-operative detection and correction of anaemia as part of the program; 2) single blood unit transfusion policy as institutional guideline for 27%; 3) no need to justify the prescription of blood products to the managers of the hospital blood banks for 71%; 4) widespread availability of standard operating procedures about anaemia (75%); 5) use of restrictive transfusion thresholds in accordance with international guidelines ; 6) widespread absence of documentation of daily blood loss due to blood sampling. The most relevant information provided by nurses is: 1) at least 50% of respondents declare to sample between one and five blood tests per patient per eight-hour work-shift depending on clinical stability and therapies applied; 2) morning blood tests decided by the intensivist during the round in 47% with significant regional differences (p < 0.01); 3) autonomy regarding blood gas analysis for 49%.
Conclusion: Based on our survey some principles of PBM have been introduced in Swiss hospitals and Swiss ICUs, but many other measures still need to be implemented. Blood is taken from patients several times a day and the decision to sample blood is often delegated to nurses.
Delirium In ICU Patients With Malignancy: Patient Characteristics and Resource Utilization
Mattia Sieber (Zurich | CH)
Background & Objectives: Knowledge on delirium in oncological intensive care unit (ICU) patients is scarce. The aim was to assess the frequency of delirium and its impact on resource utilizations in ICU patients with malignancy.
Material & Methods: This retrospective, single-center longitudinal cohort study included all patients with malignancy admitted to ICUs of a University Hospital during one year. Delirium was diagnosed by an Intensive Care Delirium Screening Checklist score ≥ 4. Group comparisons were made with Fisher’s exact and Mann-Whitney U tests. Multivariate analysis was performed with Cox regression with hazard ratios < 1 indicating longer length of stay (LOS), and multiple linear regression. Results are given as number (percentage) and median (interquartile range).
Results: Of the 488 ICU patients with malignancy, 176/488 (36%) developed delirium during their ICU stay. Delirium was particularly frequent in patients with hepatic (13/21 [62%]) and lung malignancies (29/65 [45%]) as well as lymphomas (7/15 [47%]). Delirious patients had higher age (66 [55-72] vs 61 [51-69] years, p = 0.001), Charlson Comorbidity Index (4 [2-8] vs. 4 [2-8]), p = 0.034) and SAPS II (41 [27-68] vs 24 [17-32], p < 0.001), and more often a sepsis (26/176 [15%] vs 6/312 [1.9%], p < 0.001) and a shock (30/176 [6.1%] vs 6/312 [1.9%], p < 0.001). Multivariate analysis showed that delirium was independently associated with longer LOS in ICU (HR [95% CI] 0.295 [0.234-0.371], p < 0.001) and hospital (HR [95% CI] 0.619 [0.500-0.765], p < 0.001), as well as higher ICU nursing workload measured with the Nine Equivalents of Nursing Manpower Use Score (B [95% CI] 1.917 [1.665-2.206], p < 0.001) and ICU (B [95% CI] 2.077 [1.811-2.382], p < 0.001) and total costs per case (B [95% CI] 1.442 [1.301-1.597], p < 0.001).
Conclusions: In oncological ICU patients, delirium was a frequent complication independently associated with high resource utilizations.
Accuracy of automated P0.1 measurements performed by ICU ventilators
Lise Piquilloud Imboden (Lausanne | CH)
Background: Occlusion pressure at 100 ms (P0.1), defined as the negative pressure measured during an occlusion 100 ms after breath initiation, is correlated with respiratory effort and respiratory drive intensity. Automated P0.1 measurement is available on modern ventilators but their reliability has not been studied. This bench study objective was to assess the accuracy of the different ventilator automated P0.1 measurements.
Material and methods: To simulate spontaneous ventilation, one chamber of a two-chamber Michigan test lung was connected to a driving ventilator set in volume controlled ventilation. The other chamber was connected to the tested ventilator by a double limb circuit (with active humidifier). Pressure and flow transducers were inserted between the test lung and the ventilator circuit for measurements. Five commercialized ventilators (Evita XL®, Dräger, Servo-U®, Getinge, PB 980®, Covidien, Engstrom Carestation®, GE and Elisa 800®, Lowenstein Medical) were tested in pressure support mode. Each ventilator was assessed for three levels of inspiratory effort (P0.1ref of 2.5, 5 and 10 cmH20). Automated P0.1 measurements displayed on the ventilator screen (P0.1vent) were recorded five times at each effort level. Impact of circuit length on P0.1 measurement accuracy was also assessed for tubes of 195, 360 and 690 cm.
Results: Analysis of airway pressure-time and flow-time curves showed that all the tested ventilators except the Servo-U® ventilator performed an occlusion of at least 100 ms to measure P0.1. Overall, variations of P0.1vent correlated well with variations of P0.1ref. P0.1Vent underestimated P0.1ref for absolute values except for the Löwenstein® ventilator at P0.1ref 2.5 cmH2O and for the Servo-u® ventilator at P0.1ref 10 cmH2O. Correlation between P0.1vent and P0.1ref assessed with the Bland-Altman method gave a mean bias of 1.3 cmH20 (limits of agreement: 1 and -3.7 cmH20). The circuit’s length affected P0.1 measurements’ values. A longer tube was associated with lower measured P0.1 values.
Conclusion: P0.1vent relative changes are well correlated to P0.1ref changes in all the tested ventilators. Accuracy of absolute values of P0.1vent varies according to the ventilator model. Overall, P0.1vent underestimates P0.1ref. The length of the circuit partially explains P0.1vent underestimation. Our results suggest that unique P0.1 threshold values could be of limited interest to help in decision making in clinical practice.
Voriconazole and liposomal Amphotericin B adsorption by the Cytosorb-Adsorber: Pharmacokinetic modelling of a case
Pedro David Wendel Garcia (Zürich | CH)
Cytokine Adsorption as offered by the Cytosorb device (Cytosorbents Inc.) is an adjunctive treatment in septic shock thought to counteract the overshooting of cytokines involved in the cytokine storm. However, little is known about the adsorption of antifungals and certain antibiotics, an expensive and indispensable cornerstone of sepsis therapy, by the Cytosorb device.
We present the case of a 53 year old patient suffering an ARDS on grounds of an Influenza A infection complicated by invasive pulmonary aspergillosis and septic shock.
In light of the severity of the pulmonary aspergillosis a dual antifungal therapy with 2 x 200mg/d Voriconazole (Vfend) and 400mg/d liposomal Amphotericin B (Ambisome), with a rate of 200mg/h, was established. Additionally and due to the septic shock with elevated Interleukin-6 levels and high vasopressor reqirements, a Cytosorb therapy was initiated. The Cytosorb device was connected in series to a CRRT device. The filtration rate was 120ml/min and CRRT as well as Cytosorb filter were exchanged every 24 hours for three days.
Voriconazole and Ambisome treatment were started 9 and 3 days prior to initiation of Cytosorb treatment, and the patient was already on hemodiafiltration for 20 hours.
Plasma levels of Voriconazole and Ambisome were measured before initiation of the Cytosorb therapy and every 24 hours from that time point on for 3 days. A pharmacokinetic model, one- and two-compartmental respectively, for both Voriconazole and Ambisome was generated using the R library RxODE  and literature on the pharmacokinetic characteristics of both antifungals [2-5]. The Cytosorb influence on the antifungals was modeled in the case of Voriconazole by an exponential and in the case of Ambisome by a sigmoid elimination model fitting the measured antifungal levels.
The effect of the Cytosorb on antifungal levels in blood, calculated as the proportion of antifungal concentration with adsorber to the modeled concentration without adsorber after 3 days of Cytosorb therapy, was 51.6% for Ambisome and 36.7% for Voriconazole. At a modeled steady state, the proportions were 73.8% for Ambisome and 36.7% for Voriconazole.
The use of the Cytosorb device may lead to adsorption of fundamental therapeutic elements as Voriconazole and Amphotericin B, decreasing systemic concentrations of the delivered substances, as well as maximally achievable steady state concentrations.
Nasal high flow oxygen used between NIV treatments in hypercapnic respiratory failure (COPD exacerbation) can be associated with decrease in respiratory rate, PaCO2 and minute ventilation
Lise Piquilloud Imboden (Lausanne | CH)
In stable COPD (chronic obstructive pulmonary diasese) patients, nasal high flow oxygen (NHF) use can be associated with reduction in respiratory rate (RR) and minute ventilation (MV). In these patients, PaCO2 remains stable or decreases under NHF 1, 2. This suggests a possible dead space reduction related to a washout effect of NHF. The aim of this study was to assess the physiological effects of NHF in hypercapnic patients with acute COPD exacerbation.
Crossover study in hypercapnic patients suffering from acute COPD exacerbation and treated with intermittent non-invasive ventilation (NIV). NHF or standard oxygenotherapy (STAND O2) were randomly administered during 1 hour between NIV treatments. RR, tidal volumes (VT) and MV variations were recorded during the last 10 minutes of each study period using respiratory inductive plethysmography. Blood gas analysis was performed at the end of each period. Corrected MV (corMV = MV x PaCO2/40) was computed for each period. Visual analogic dyspnea score (VAS) was assessed by the patient after 30 and 60 minutes. VAS values were averaged for each period. Results are given as median [IQR]. Wilcoxon tests were used to compare data between STAND O2 and NHF.
Twelve patients were included and data could be recorded in 10 patients (8 Males/2 females, 63 [60-78] years old, SAPS II 30 [24-38]. Median PaCO2 at inclusion was 58 [54-66] mmHg. Respiratory rate was lower (22 [20-23] vs 25 [23-27] breath/minute, p = 0.049) during NHF than during STAND O2. PaCO2 was also lower during NHF (48.7 [46.4 - 58.1] vs 50.7 [48.4 - 57.5] mmHg, p = 0.0488). PaCO2 decreased during NHF in 9/10 patients. MV decreased in the majority of the patients. Corrected MV decreased in 9/10 patients. The percentages of variation of VT, MV and corMV were respectively, + 2.9 [-18.6 – 9.7] % (p=1.0), -16.2 [-30.9 - 0.4] % (p 0.049) and -18.7 [-48.5 - -1.66] %(p 0.02). Dyspnea score were the same between the 2 modalities.
In case of acute COPD exacerbation, using NHF between NIV treatments was associated with PaCO2 and RR decrease in the majority of patients. MV concomitantly decreased or was nearly stable suggesting a deadspace volume reduction related to a washout effect of NHF. Corrected MV decreased in all the patients except one. These results suggest that NHF could be used to deliver oxygen between NIV treatments to COPD patients suffering from acute exacerbation and could contribute reducing PaCO2.
Ethische Fallbesprechungen auf der Intensivstation – Erfahrungen aus der regelmässigen Durchführung während 8 Jahren
Barbara Meyer-Zehnder (Basel | CH)
Komplexe Patientensituationen benötigen nicht ausschliesslich medizinisches und pflegerisches Wissen und Entscheidungen, sondern es stellen sich auch vielfältige ethische Fragen. Seit mehreren Jahren werden auf der ehemaligen Operativen Intensivstation des Universitätsspitals Basel (OIB) regelmässig ethische Fallbesprechungen (eFB) nach der Methode METAP durchgeführt [1,2]. Die Indikation für eine eFB ist in den allermeisten Fällen eine Überprüfung der aktuellen Behandlungsstrategie und des Patientenwillens bei längerer intensivmedizinischer Behandlung.
Die Studie untersucht, welche Ergebnisse die eFB erbrachten, und wieviele der besprochenen Patienten auf der OIB, resp. im Spital verstarben oder austreten, resp. verlegt werden konnten.
Für die eFB ist ein Zeitfenster im Wochenprogramm reserviert. Im Voraus wird festgelegt, wer jeweils verantwortlich ist für die Organisation (Einladung der Beteiligten), inhaltliche Vorbereitung, Moderation und Dokumentation der eFB.
Alle eFB, die zwischen dem 1.1.2011 und dem 31.12.2018 stattfanden, wurden nach einem Kategoriensystems ausgewertet.
Im Untersuchungszeitraum fanden 268 eFB bei 240 Patienten statt. Zwei Drittel der Patienten (159) waren Männer. Das Durchschnittalter betrug 69.3 (34-91) Jahre, der durchschnittliche SAPS-II Wert 58.21 (15-105) Punkte. Eine Fallbesprechung dauerte im Durchschnitt 40 Minuten und es nahmen rund 7 Personen daran teil.
Die 268 eFB ergaben folgende Ergebnisse: 46 mal (17.2%) aktuelle Therapie weiter, Komplikationen werden behandelt; 68 mal (25.4%) aktuelle Therapie weiter, der Patientenwille muss weiter ermittelt werden; 55 mal (20.4%) aktuelle Therapie weiter, Komplikationen werden erst nach Evaluation behandelt; 77 mal (28.7%) aktuelle Therapie weiter mit Einschränkungen (z.B. DNR); 15 mal (5.6%) Umstellung auf palliative, resp. End-of-Life Therapie. 7 Protokolle konnten nicht eindeutig zugeordnet werden.
103 der besprochenen Patienten (42.9%) verstarben auf der Intensivstation, 23 (9.6%) nach Verlegung auf die Abteilung. 5 Patienten (2.1%) wurden in ein Hospiz verlegt, 48 (20.0%) in ein anderes Spital. 59 (24.6%) konnten in eine rehabilitative Einrichtung austreten, 2 nach Hause.
Ethische Fallbesprechungen werden auf einer Intensivstation regelmässig durchgeführt, wenn die Rahmenbedingungen gegeben sind. In mehr als der Hälfte der eFB wurden Patienten besprochen, die im Verlauf des Spitalaufenthaltes verstarben.
Establishing a procedure for organ donation after cardiac death in the ICU
Samir Hafdi (1708 Fribourg | CH)
The swiss law on transplantation enables organ donation after cardiac death (DCD) following therapeutic withdrawal in the ICU. Having successfully implemented DCD-protocols in the transplant centers, the PLDO network decided to extend this approach, starting with Fribourg hospital. On the basis of SWISSPOD data 2017 for the 19-bed ICU, the annual number of potential DCD-donors was estimated at 6.
All senior ICU physicians and nurses accepted the project. Strong support was obtained from the college of chief physicians, the directory board, the administrative council and the Department of Health of Fribourg. The protocol already applied in the transplant centers was adapted to local requirements by an interdisciplinary and interprofessional group including all main actors of the hospital and the network. After validation by senior staffs of the ICU, operating theater, anesthesia and PLDO network, the procedure was presented to the involved teams during two exchange conferences. Two full-scale simulations were held, with the participation of all teams including transplant surgeons. Essential information obtained during these sessions contributed to refine the final procedure. Further small-group simulations were held in the ICU. After official announcement, the program started in October 2018, with systematic screening for DCD-eligibility for lung, kidney, pancreas and liver donation after each decision of therapeutic withdrawal.
Between the first 6 months, we identified 6 potential donors. Family consent for DCD was obtained for 3: their mean age was 68 (64-72 years), reason for therapeutic withdrawal was respiratory failure for 2 patients and neurological failure for 1. The mean duration of hypoperfusion (first drop of MAP < 50 mmHg till circulatory arrest) was 13 min (10-18 min), mean time from circulatory arrest till beginning of cold perfusion was 13 min (13-14 min), total warm ischemia time was 26 min (24-31 min). All 6 organs allocated could be explanted: kidneys + liver; kidneys; liver. At three months’ follow-up, all patients are doing well.
Establishment of a DCD-program is feasible in a non-transplant center, with achievement of acceptable warm ischemia time and organ quality. The key to success is a strong support by all involved parties and a multidisciplinary, interprofessional approach. Personal engagement and support by the network are fundamental, as dedicated resources for transplant activity are limited.
Esophageal pressure measurement can help managing ventilation during venovenous ECMO : a case report
Davy Cabrio (Lausanne | CH)
BACKGROUND : Optimal ventilator settings during venovenous extra-corporeal membrane oxygenation (ECMO) remain controversial. Ultra-protective tidal volumes (VT < 4 mL/kg predicted body weight - PBW) and plateau pressure (Pplat) < 25-30 cmH2O are common targets . Driving pressure (ΔP = Pplat - total PEEP) should also be kept < 14 cmH2O [2,3]. Esophageal pressure (Pes, pleural pressure surrogate) measurement can be used to further optimize ventilation targeting transpulmonary pressure (PL) at end-inspiration < 18 cmH2O (lung stress) and PL at end-expiration > 0 cmH2O (alveolar collapse prevention).
CASE REPORT : A 32-years old patient with pneumococcal pneumonia and severe acute respiratory distress syndrome (ARDS) was started on ECMO due to refractory hypoxemia and very low compliance (Pplat > 45 cmH2O with VT < 4 mL/kg PBW).
At day 1 of ECMO, ventilator settings were: volume assist control (VAC), VT 100 mL (1.4 mL/kg PBW), PEEP 5 cmH2O. Pplat was 30 cmH2O and respiratory system compliance (Crs) was 4 mL/cmH2O.
On day 3, an esophageal probe was inserted. VAC settings were unchanged. Pplat = 20.9 cmH2O, no intrinsic PEEP, ΔP = 15.6 cmH2O, end-inspiratory PL = 20.6 cmH2O. Due to high ΔP and PL, ventilator was set to BIPAP mode (bi-level positive airway pressure, high pressure 15 cmH2O for 0.8s, low pressure 5 cmH2O for 1.6s), resulting in average VT of 64 mL.
On day 9, Pes was used to optimize PEEP setting. Increase in PEEP from 5 to 13 cmH2O was needed to have end-expiratory PL > 0 . Crs improved immediately afterwards from 6.1 to 10.3 mL/cmH2O.
On subsequent days, patient’s status progressively improved with Crs at 29 mL/cmH2O on day 13. ECMO was weaned on day 14 and pressure support ventilation (PSV) was started (pressure support 10 cmH2O, PEEP 12 cmH2O). At this point, end-inspiratory PL was 10.9 cmH2O (safe). No asynchronies were observed.
On day 21, patient was eupneic with low pressure support. Maximal Pes swings were 6 cmH2O (indirect information on inspiratory effort intensity). Patient was extubated after successful spontaneous breathing T-tube trial and transferred to the ward 2 days later.
CONCLUSION : Pes monitoring can be useful in ECMO patients along the entire course of illness. It allows detecting injurious ventilation despite theoretical ultra-protective ventilation settings and adapting ventilation accordingly. It also helps optimizing PEEP titration and detecting risk of patient-self inflicted lung injury  during weaning.
Mortalität von Patientinnen und Patienten 5 Jahre nach einer verlängerten Behandlung auf einer chirurgischen Intensivstation
Barbara Meyer-Zehnder (Basel | CH)
Hintergrund und Ziele:
Eine Langzeitbehandlung auf einer Intensivstation bedeutet für Patientinnen und Patienten und deren Angehörige eine grosse physische, psychische und soziale Belastung. Aber auch das Behandlungsteam kann an seine Grenzen stossen, und die Kosten einer langen Intensivtherapie sind beträchtlich.
Die Studie untersucht, wie gross die Mortalität von Patienten ist, die länger als 7 Tage ununterbrochen auf der ehemaligen Operativen Intensivbehandlung des Universitätsspitals Basel (OIB) behandelt wurden und wie sich die Überlebenden gegenüber den Verstorbenen bezüglich verschiedener Parameter unterscheiden. Es gibt in der Schweiz nur wenige Untersuchungen zu dieser Fragestellung.
Material und Methoden:
Es handelt sich um eine retrospektive Auswertung von bereits vorliegenden Patientendaten und die Überprüfung, ob die untersuchten Patienten noch während des Spitalaufenthalts oder zu einem späteren Zeitpunkt verstorben sind (Stichtag 31. Juli 2017). Eingeschlossen wurden alle Patientinnen und Patienten, die zwischen dem 1. Januar 2011 und dem 31. Dezember 2012 während mindestens 7 Tagen ununterbrochen auf der OIB behandelt wurden.
Im Untersuchungszeitraum wurden 250 Patienten mindestens 7 Tage auf der OIB behandelt. 3 Patienten konnten nicht nachverfolgt werden. Das Durchschnittalter betrug 62.59 Jahre und rund zwei Drittel der Patienten waren Männer. 52 (21.1%) Patienten verstarben auf der OIB, 25 (10.1%) nach Verlegung auf die Abteilung. 71 Patienten verstarben im weiteren Verlauf. Bis zum Stichtag überlebten 99 Patienten (40.08%). Insgesamt verstarben 108 (43.72%) Patienten innerhalb eines Jahres nach Beginn der Intensivbehandlung. Diese Patienten waren im Durchschnitt älter (69.05 vs. 57.58 Jahre), hatten einen höheren Charlson Comorbidity Index (2.31 vs. 1.22), einen längeren OIB-Aufenthalt (18.98 vs. 14.43 Tg.) und einen höheren SAPS-II (52.17 vs. 45.64). Sie entwickelten häufiger eine Pneumonie (50.9% vs. 29.5%), einen septischen Schock (51.9% vs. 20.1%), eine akute Niereninsuffizienz (38.0% vs. 23.7%) oder eine Critical Illness Polyneuropathie (16.7% vs. 2.9%).
Patienten, die im Untersuchungszeitraum länger als 7 Tage intensivmedizinisch behandelt werden mussten, haben eine hohe Langzeitmortalität.