Moribund Patients Research Articles

Azithromycin added to hydroxychloroquine for patients admitted to intensive care due to coronavirus disease 2019 (COVID-19)\u2014protocol of randomised controlled trial AZIQUINE-ICU

BackgroundNovel coronavirus SARS-CoV-2 is known to be susceptible in vitro to exposure to hydroxychloroquine and its effect has been found to be potentiated by azithromycin. We hypothesise that early administration of hydroxychloroquine alone or in combination with azithromycin can prevent respiratory deterioration in patients admitted to intensive care due to rapidly progressive COVID-19 infection.MethodsDesign: Prospective, multi-centre, double-blind, randomised, controlled trial (RCT). Participants: Adult (> 18 years) within 24 h of admission to the intensive care unit with proven or suspected COVID-19 infection, whether or not mechanically ventilated. Exclusion criteria include duration symptoms of febrile disease for ≥ 1 week, treatment limitations in place or moribund patients, allergy or intolerance of any study treatment, and pregnancy. Interventions: Patients will be randomised in 1:1:1 ratio to receive Hydroxychloroquine 800 mg orally in two doses followed by 400 mg daily in two doses and azithromycin 500 mg orally in one dose followed by 250 mg in one dose for a total of 5 days (HC-A group) or hydroxychloroquine + placebo (HC group) or placebo + placebo (C-group) in addition to the best standard of care, which may evolve during the trial period but will not differ between groups. Primary outcome is the composite percentage of patients alive and not on end-of-life pathway who are free of mechanical ventilation at day 14. Secondary outcomes: The percentage of patients who were prevented from needing intubation until day 14, ICU length of stay, and mortality (in hospital) at day 28 and 90.DiscussionAlthough both investigational drugs are often administered off label to patients with severe COVID-19, at present, there is no data from RCTs on their safety and efficacy. In vitro and observational trial suggests their potential to limit viral replication and the damage to lungs as the most common reason for ICU admission. Therefore, patients most likely to benefit from the treatment are those with severe but early disease. This trial is designed and powered to investigate whether the treatment in this cohort of patients leads to improved clinical patient-centred outcomes, such as mechanical ventilation-free survival.Trial registrationClinical trials.gov: NCT04339816 (Registered on 9 April 2020, amended on 22 June 2020); Eudra CT number: 2020-001456-18 (Registered on 29 March 2020).

Prevention of Panton-Valentine Toxin-Mediated Leucocyte Destruction Depending on the Ultra-Diluted Staphylococcinum Potency Gradient

Abstract Background Panton-Valentine toxin (PVT) is an important pathological marker of staphylococcal infection mediated by functional as well as morphological damage of the phagocytic cells. Human body being an ecological niche for the bacteria shows higher affinity toward staphylococcal infection. A steady escalation in mortality and morbidity associated with antibiotic resistance in gram-positive infections is an emerging threat all over the globe; thus, it is important to find out an alternative strategy that can diminish the virulence and pathogenicity of the bacteria. Staphylococcin is a colicin-type chemical secreted by Staphylococcus aureus helps to prevent growth of organisms other than its progenitor. In this study, we evaluated the efficacy of homoeopathic medicine Staphylococcinum against staphylococcal PVT at different potencies (6CH, 12CH, 30CH and 200CH). Materials and Methods Different potencies of Staphylococcinum were administered in a leucocyte buffy coat preparation infected with staphylococcal suspension (0.5 McFarland's standard) along with control with alcohol. They were kept in incubator for 2 hours and then centrifuged at 1200 rpm for 5 minutes. Smears prepared on slides with centrifuged deposits stained by Preston and Morrell's modified Gram's method of staining and evaluated under the microscope. Results It was observed that there was extensive destruction of leukocytes in control and 6CH potency, while the degree of destruction decreased markedly from 12CH to 200CH. At 200CH potency, leukocytes were almost normal, which clearly indicate the preventive action of Staphylococcinum against PVT. The mean percentages of intact leucocytes were 0.73, 0.93, 10.00, 27.67 and 65.00 in control, 6CH, 12CH, 30CH and 200CH potencies, respectively. Conclusion The finding may help in the use of this medicine in moribund patients in cases of disseminated S. aureus infection as there is no known side effect of the medicine. However, in vivo study is necessary before such use in those cases.

A Comparative Study of Different Techniques of Brachial Plexus Block in Upper Limb Surgery

Background: Different techniques of Brachial Plexus block in upper limb surgery depending on the site of operation the approach of the brachial plexus was chosen. For the operations around the shoulder joint interscalene approach was chosen; for the operations up to the shoulder either interscalene or supraclavicular or Infraclavicular routes were chosen and for the operations up to and around the elbow joint any one of the four approaches were tried. Objective of this study was to evaluate its clinical applications and practical utility in providing good analgesia for the upper extremity surgery in elective as well as emergency cases.Design: This was a hospital based retrospective study. Duration: One Year i.e. from June 2018 to June 2019. Participants: 80 patients.Subjects and Methods:The present study includes 80 blocks of brachial plexus by four different routes. 1. Supraclavicular approach – 20 cases. 2. Infraclavicular approach – 20 cases. 3. Axillary perivascular approach – 20 cases. 4. Interscalene – 20 cases. The cases were selected at random, who were subjected for various types of surgery of upper extremity both elective and emergency as in-patients.Results:In this series of 80 blocks, when the type of the surgery (emergency or elective) is considered, it has been that about one third of the patients underwent emergency surgery successfully with the brachial plexus block. In the remaining two-third of the patients, the surgery was planned procedure.Conclusion:Thus, our study reveals that the brachial plexus block can be equally safely employed for emergency surgery as for any elective procedure. Some-times the brachial plexus block can be the only choice with no alternatives affording a reasonable chance to a moribund patient to undergo emergency surgery. The dosage of the drug was modified according to the patient’s general condition.

Role of peritoneal drainage in moribund patients of perforation peritonitis

Background: Objective of the present study was to evaluate applicability of primary peritoneal drainage under local anesthesia in moribund patients as pre-laparotomy support when laparotomy under general anesthesia could not be done. Also to assess outcome in terms of survival, patients needing definitive surgery and complications associated with the procedure on immediate and follow up basis.Methods: We conducted this study in Teerthanker Mahaveer Medical College, Moradabad, UP, India from October 18 to October 2019. 71 patients were admitted as cases of perforation peritonitis in moribund condition, demographic data of all patients was noted, peritoneal drainage under local anesthesia in flanks was done and variable amount of fluid was drained in different patients, simple parameters were taken in to consideration in pre and post drainage phase. We also noted the complications after the definitive surgery.Results: Out of 71 patients, admitted in late and in very critical state, 61 patients improved after drainage and resuscitative procedures, although in ASA grade 3 and 4 they underwent surgical treatment and we were able to save their lives. 13 patients expired after definitive surgery inspite of best efforts.Conclusions: Peritoneal drainage under local anesthesia in late reporting and critical patients, not only improves general condition but makes patients better to undergo further surgery, and can prove to be life saver. It being a simple procedure can easily be done at even PHC level, before patient is referred or shifted to higher centre for further management.

Outcomes after neurosurgical operations in American Society of Anesthesiologists physical status (ASA) class 5 patients

IntroductionAn individual classified as American Society of Anesthesiologists (ASA) physical status 5 (ASA 5) is described as “a moribund patient who is not expected to survive without the operation.” We examined the outcomes of ASA 5 patients who underwent an index neurosurgical operation to characterize surgical results and to identify risk factors for adverse outcomes in this population. MethodsWe used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to identify 689 ASA 5 patients who underwent neurological surgery at any one of the 706 institutions participating in the NSQIP between 2006 and 2016. We used univariate logistic regression to identify baseline factors associated with adverse post-operative outcomes; all factors identified were incorporated into the final multivariate models. ResultsOf the entire study population of 689 patients, 90% (n = 620) had an emergency operation and 89% (n = 613) had a cranial procedure. At 30 days, 11% remained hospitalized, 5% had been readmitted to an acute care hospital, 16% required an additional, unplanned surgery, and 39% had expired. The most common post-operative complications were prolonged (>48 h) mechanical ventilation (57%), transfusion of blood or blood products (26%), and pneumonia (23%); for patients with these complications, the 30-day mortality rates were 61%, 33%, and 19%, respectively. The vast majority (81%) of those who survived to discharge required continued care at a location other than home.In multivariate models, a variety of medical, surgical and socioeconomic factors were identified that increased the risk of prolonged length of stay, peri- and post-operative transfusion of blood or blood products, unplanned return to the operating room, re-admission within 30 days, and continued care after discharge. ConclusionsWhile post-operative complications are common, >60% of ASA 5 patients who undergo neurosurgery survive and 20% are discharged home within 30 days. These novel findings may be useful to inform decision-making in critically-ill neurosurgical patients.

Role of cytology in differentiating anaplastic thyroid carcinoma with osteoclast like giant cells from giant cell variant of medullary thyroid carcinoma

Anaplastic thyroid carcinoma (ATC) is a highly aggressive tumor and constitutes 2%–5% of all thyroid carcinomas. The cytological diagnosis of osteoclast giant cell variant of ATC is extremely rare, and only a few cases have been described in literature. A 67 - year-old female underwent fine-needle aspiration cytology from the thyroid nodule. Smears revealed hypercellular aspirate comprising of clusters and singly scattered atypical cells with few interspersed multinucleated tumor cells. Cytomorphological differential diagnosis of giant cell/pleomorphic variant of medullary carcinoma and anaplastic carcinoma was offered. Histomorphological features on cell block assisted with immunohistochemistry confirmed the diagnosis of ATC with osteoclastic-like giant cells. Computed tomography-guided right lung lesion aspirate was reported as metastasis of high-grade poorly differentiated carcinoma. The patient was managed with cisplatin-based chemotherapy. This case highlights the importance of cytological diagnosis of ATC to guide the treatment modality of chemotherapy thus avoiding surgery, especially in old moribund patient with lung metastasis.

Intrasinus Thrombolysis for Cerebral Venous Sinus Thrombosis: Single-Center Experience.

Objective: The purpose of this research was to study the safety and efficacy of intrasinus thrombolysis in patients with cerebral venous sinus thrombosis unresponsive to conventional heparin therapy.Methods: A total of 156 CVST patients were treated using interventional thrombolysis in our center from January 2010 to June 2018. Clinical data, including duration of symptoms, indications and outcome of IST were retrieved, and outcomes were analyzed. DSA or MRV was used to assess the recanalization after thrombolysis. mRS was used to evaluate the outcome at admission, discharge, and follow-up.Results: 91.38% of patients obtained functional independence (mRS 0–2). The mRS score was 0–2 in 120 patients (76.92%, 120/156) at the time of discharge. Seven patients succumbed during hospitalization. MRV examination was performed in 149 patients, and the results showed that the venous sinus of 112 patients (75.17%) was completely recanalized, and it was partially recanalized in 28 patients (18.79%) and nine patients (6.04%) had no recanalization at the time of discharge. In total, 116 patients were followed up at least for 6 months, 89 patients (76.72%) were completely recanalized, 21 patients (18.1%) were partially recanalized, and six patients (5.17%) were not recanalized.Conclusion: IST may be more effective than systemic heparin anticoagulation in moribund and unresponsive patients despite the risk of hemorrhage. Large randomized controlled trials are required to further evaluate this issue.

Impact of death education courses on emergency nurses' perception of effective behavioral responses in dealing with sudden death in China: A quasi-experimental study

BackgroundNurses in emergency departments have to provide rescue care and life support for moribund patients, but also emotional support to patients' relatives. On the other hand, emergency nurses are also the most vulnerable to the sudden death of patients. Nurses working in the emergency department were invited to participate in a death education course. ObjectiveTo explore the impact of a death education course on the emergency nurses' perception of effective behavioral responses in dealing with sudden death. DesignA quasi-experimental study. SettingsA level A tertiary general hospital in China. ParticipantsA total number of 34 emergency nurses who met the inclusion criteria were randomly selected from the emergency department. MethodsParticipants received a death education course of 20 credit hours based on dealing with a sudden-death model. The general data questionnaire and the Chinese version of the list proposed by Fraser & Atkins were completed before the intervention and six weeks post-intervention. The scores of each item in the effective behavioral response to the sudden death questionnaire of the emergency nurses before and after the intervention were compared. ResultsAfter the intervention, the nurses considered that 10 items were relatively helpful (above 4 points) and 2 items relatively less helpful (<3 points). The post-intervention average scores of all items were higher than the pre-intervention ones, and there were significant differences in the scores of the 13 items pre- and post-intervention. ConclusionThe death education course enhanced emergency nurses' perceptions of effective behavioral responses in dealing with sudden death, which contributes to the improvement of the quality of their work.

Decision-making support in Intensive Care to facilitate organ donation : Position paper of the Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) in collaboration with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine (DGIIN)

Injuries, especially traumatic brain injury, or specific illnesses and their respective sequelae can result in the demise of the patients afflicted despite all efforts of modern intensive care medicine. If in principle organ donation is an option after apatient's death, intensive therapeutic measures are regularly required in order to maintain the homeostasis of the organs. These measures, however, cannot benefit the patient afflicted anymore-which in turn might lead to an ethical conflict between dignified palliative care for him/her and expanded intensive treatment to facilitate organ donation for others, especially if the patient has opted for the limitation of life-sustaining therapies in an advance directive. The Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) have convened several meetings and atelephone conference and have arrived at adecision-making aid as to the extent of treatment for potential organ donors. This instrument focusses first on the assessment of five individual dimensions regarding organ donation, namely the certitude of acomplete and irreversible loss of all brain function, the patient's wishes as to organ donation, his or her wishes as to limiting life-sustaining therapies, the intensity of expanded intensive treatment for organ protection and the odds of its successful attainment. Then, the combination of the individual assessments, as graphically shown in a{Netzdiagramm}, will allow for ajudgement as to whether acontinuation or possibly an expansion of intensive care measures is ethically justified, questionable or even inappropriate. The aid described can help mitigate ethical conflicts as to the extent of intensive care treatment for moribund patients, when organ donation is amedically sound option. NOTE: Gerald Neitzke und Annette Rogge contributed equally to this paper and should be considered co-first authors.

Trends and inpatient outcomes for palliative care services in major burn patients: A 10-year analysis of the nationwide inpatient sample

IntroductionDespite advances in critical care and the surgical management of major burns, highly moribund patients are unlikely to survive. Little is known regarding the utilization and effects of palliative care services in this population. MethodsAll major burn hospitalizations were identified within the Nationwide Inpatient Sample. Patients were characterized by burn, demographic, facility, and diseases factors. Palliative care services were identified with International Classification Disease 9th edition code V6.67. Temporal trends were assessed with Poisson modeling. Inpatient mortality and death without surgical intervention were assessed with logistic regression. Outcomes were stratified by modified Baux scores. Results7424 major burns were included; 1.9% received palliative care services. Patients receiving palliation had a mean age of 63.6 years (SD 19.6), mean total body surface area of 62.2% (SD 24.9%), and mean modified Baux score of 127.1 (SD 26.7). Adjusting for covariates, the incidence rate ratio was 1.42 over the 10-year period (95% CI, 1.31–1.54, p<0.001). Independent predictors of palliative consultations included older age, larger burns, deeper burns, and higher Elixhauser comorbidity score. Among patients with modified Baux scores between 100–153, those receiving palliative care services were significantly more likely to die without surgery, OR 3.24 (95% CI 1.13–10.39, p=0.029), with no significant difference in mortality, OR 11.72 (95% CI 0.87–22.57, p=0.051) Conclusion and relevancePalliative care services were increasingly used during the study period. Palliative care services in highly moribund burn patients do not impact survival and may decrease the likelihood of surgical intervention in select patients.

Necrotizing Fasciitis and Methicillin Resistant Staphylococcus Aureus

Necrotizing fasciitis (NF) is an aggressive and life-threatening infection of skin and soft tissue characterized by widespread fascial necrosis which leads to morbidity and mortality if left untreated. There is difficulty in managing this condition because there is a combination of difficulty in diagnosis, and also of early as well as late management. It can be caused by either a single organism or more frequently by a variety of microbes - both aerobic and anaerobic. Necrotizing fasciitis seems to have preponderance in males, perhaps due to increased incidence of trauma in males. Staphylococcus aureus is the most prevalent pathogen in hospitals and communities and MRSA has become a common isolate associated with skin and soft tissue infections over the past few years, monomicrobial MRSA necrotizing fasciitis has been reported only in a few studies. Early surgical intervention, early diagnosis and aggressive treatment should be done. Material and Methods: All patients were diagnosed as NF on surgical report. Surgical exploration is undertaken after resuscitation. Penicillin along with, an amino glycoside and clindamycin or metronidazole is administered preoperatively in moribund patients. Cefoxitin or imipenem or meropenem is used in more limited infections. Fair amount of desloughing is done without anesthesia. Overlying fat as patchy greenish-black liquefaction necrotic tissues are excised primarily, and specimen sent for culture in microbiology department. Cultures were processed the susceptibility of S. aureus isolates to antimicrobials was done. Results: A total of 200 hospitalized patients those who were surgically treated for NF were included in the study. Of the 200 patients 42 patients were culture positive for MRSA. In our study mean age was 56± 11.21 of which 124 (62%) were male , mean hospitalization days were 16.5± 6.2. patients with underlying diabetes mellitus were 66 (33%) and hypertension were 74(37%). In MRSA group (n=42) mean age was 53 ± 9.22. Male were 36 (73.81%) , mean hospitalization days were 17.6 ± 6.2. patients with underlying diabetes mellitus were 21 (50%) and hypertension were 19(45.24%).42 (21%) were MRSA, 31 (15.5%) were MSSA, 21 (10.5%) were coagulase negative staphylococcus, 4(2%) were Streptococcus group A, 11 (5.5%) were Streptococcus species, 6 (3%) were Bacillus species, 24 (12 %) were Escherichia coli, 19 (9.5%) were Acinetobacter species, 3 (1.5%) were Candida albicans and in 30 (15%) no growth was observed in culture. Discussion and Conclusion: Some experts recommend use of broad-spectrum empirical antimicrobial therapy for suspected cases of necrotizing fasciitis and therapy directed against MRSA is not a standard practice. For treatment selection of appropriate antimicrobial agents for any suspected necrotizing fasciitis must take into account the nature of patient's exposure and local epidemiologic data but no reliable epidemiological or clinical risk factors with MRSA from those infected with MSSA or non-S. aureus are available. In our study mean age of patients diagnosed NF was 53 ± 9.22. While male were 36 (73.81%). In study by Cheng NC et al. the median age was 62 years (range, 12-81 years) There was male predominance in NF by MRSA in our study . In our study lesions on extremities had better prognosis similar results were shown in other study. Necrotizing fasciitis caused by MRSA is a challenge to the treating surgeon. Prompt diagnosis and surgical management with empiric MRSA cover in areas where community acquired MRSA (CA-MRSA) is endemic. Lesions of extremities have better prognosis where MRSA infection is becoming endemic and empirical treatment of suspected necrotizing fasciitis or pneumonia should include active MRSA cover.

Abstract 673: Preoperative radiation therapy in advanced carcinoma colon with post-colostomy intestinal obstruction: The first report

Abstract Introduction We report the use of preoperative radiotherapy in a moribund patient with advanced carcinoma colon with complete intestinal obstruction who had undergone colostomy for a previous episode of intestinal obstruction. Methods Fifty-five-year-old man presented in Dec 2016 with acute intestinal obstruction with pain in abdomen and vomiting for 3 months. On exploratory laparotomy, a 12x15 cm hard mass in splenic flexure of colon was found involving root of mesentery, superior mesenteric vein and third part of duodenum and abutting tail of pancreas. Finding it unresectable, loop transverse colostomy was performed. He was started on Capecitabine. In Mar 2017, he presented to us in emaciated condition weighing 28 kilograms with acute intestinal obstruction with a large abdominal mass. He was started on nasogastric aspiration with total parenteral nutrition. Imaging revealed a 14x19 cm large abdominal mass involving pancreas, duodenum, spleen and transverse colon with dilated stomach. In view of poor general condition and advanced disease, the prognosis was discussed with the family and the idea of radiotherapy to relieve intestinal obstruction was discussed with family. After taking the consent, he was started on radiation therapy with 1.8 Gy per fraction after three-dimensional conformal radiation planning to spare maximum bowel. After 11 fractions, the patient started passing stools through the stoma. He was gradually started on enteral nutrition and was discharged to continue radiation therapy on outpatient basis. After 15 fractions, planning PET-CT scan was taken for adaptive therapy to make changes as per the reducing tumor size. He was also started on capecitabine as he was taking orally well. He completed 45 Gy in 25 fractions over 5 weeks. One month after completion of radiation therapy, he was found to be doing well and was planned for definitive surgery. Six weeks after the radiation therapy completion, extended left hemicolectomy with distal pancreatico-splenectomy and colostomy closure was performed. Histopathology showed residual viable poorly differentiated adenocarcinoma invading full thickness of colonic wall into pericolic soft tissues with a discontinuous microscopic nodular tumor deposit in pericolic soft tissue with all margins and nodes negative. Postoperatively, he developed biliary leak which healed with conservative management. Six weeks after the surgery, he recovered completely and was started on adjuvant Capecitabine. Five months after the surgery, he is doing well and is on oral Capecitabine. Conclusion To our knowledge, this is the first reported case of preoperative radiation therapy in advanced carcinoma colon and also in the setting of intestinal obstruction. Radiotherapy should be further tested in setting of malignant intestinal obstruction due to unresectable carcinoma colon and may spare patients with ileo/colostomy. Citation Format: Amit Jain, Elumalai L, Punam Goswami. Preoperative radiation therapy in advanced carcinoma colon with post-colostomy intestinal obstruction: The first report [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 673.

Reconstruction using the tensor fasciae latae muscle flap

The tensor fasciae latae (TFL) muscle flap can be used for reconstruction of decubital ulcers in the trochanteric or ischial region. Deep decubital ulcers in the gluteal or ischial area after debridement and exhaustion of conservative measures. Moribund or palliative patients who do not benefit from defect coverage and are likely to suffer alife-threatening complication. Noncompliant patients who cannot follow the postoperative recommendations or protocols in regard to positioning or recurrence prevention. The presence of extensive scars after previous operations in the donor area or irradiation of the donor area can lead to flap necrosis. The TFL flap is commonly used as aregional transposition flap. Rare cases of afree TFL flap have been described. Following surgery the patient needs to be positioned on the side or prone to prevent recurrence. Drains should be left for 5-7days. Antibiotics are only needed in the case of persistent florid infection. The TFL muscle flap is known to be areliable flap for the coverage of ulcers in the ischial and trochanteric region following radical debridement. This flap can also be transferred with its sensitive nerve supply resulting in areduced chance of arecurring ulcer.

Procalcitonin-guided antibiotic therapy in patients with fever in a general emergency department population: a multicentre non-inferiority randomized clinical trial (HiTEMP study)

ObjectivesOveruse of broad-spectrum antibiotics in emergency departments (EDs) results in antibiotic resistance. We determined whether procalcitonin (PCT) -guided therapy can be used to reduce antibiotic regimens in EDs by investigating efficacy, safety and accuracy. MethodsThis was a non-inferiority multicentre randomized clinical trial, performed in two Dutch hospitals. Adult patients with fever ≥38.2°C (100.8°F) in triage were randomized between standard diagnostic workup (control group) and PCT-guided therapy, defined as standard workup with the addition of one single PCT measurement. The treatment algorithm encouraged withholding antibiotic regimens with PCT <0.5 μg/L, and starting antibiotic regimens at PCT ≥0.5 μg/L. Exclusion criteria were immunocompromised conditions, pregnancy, moribund patients, patients <72 h after surgery or requiring primary surgical intervention. Primary outcomes were efficacy, defined as number of prescribed antibiotic regimens; safety, defined as combined safety end point consisting of 30 days mortality, intensive-care unit admission, ED return visit within 2 weeks; accuracy, defined as sensitivity, specificity and area-under-the-curve (AUC) of PCT for bacterial infections. Non-inferiority margin for safety outcome was 7.5%. ResultsBetween August 2014 and January 2017, 551 individuals were included. In the PCT-guided group (n = 275) 200 (73%) patients were prescribed antibiotic regimens, in the control group (n = 276) 212 (77%) patients were prescribed antibiotics (p 0.28). There was no significant difference in combined safety end point between the PCT-guided group, 29 (11%), and control group, 46 (16%) (p 0.16), with a non-inferiority margin of 0.46% (n = 526). AUC for confirmed bacterial infections for PCT was 0.681 (95% CI 0.633–0.730), and for CRP was 0.619 (95% CI 0.569–0.669). ConclusionsPCT-guided therapy was non-inferior in terms of safety, but did not reduce prescription of antibiotic regimens in an ED population with fever. In this heterogeneous population, the accuracy of PCT in diagnosing bacterial infections was poor. Trial Registration in Netherlands trial registerhttp://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4949.

Flap coverage using the posterior gluteal thigh flap

Defect coverage of the sacral, trochanteric or ischial region with durable tissue (gluteal thigh flap). Decubital ulcers of the sacral, trochanteric or ischial region after exhaustion of conservative measures. Moribund or palliative patients who do not benefit from defect coverage and are likely to suffer alife-threatening complication. Noncompliant patients, who cannot follow the postoperative recommendations or protocols in regard to positioning or recurrence prevention. The presence of extensive scars after previous operations in the donor area or irradiation of the donor area can lead to flap necrosis. The posterior gluteal thigh flap can either be used as afasciocutaneous flap or in combination with the gluteus muscle as myofasciocutaneous flap. Further microsurgical transfers have been described. Following surgery the patient needs to be positioned on the side or prone to prevent recurrence. Drains should be left for 5-7days. Antibiotics are only needed in the case of persistent florid infection. The posterior gluteal thigh flap is awell-known, reliable and versatile option for coverage of decubital ulcers in the sacral and ischial region with low recurrence rates described in the literature.

Defektdeckung durch Gluteuslappen

Gluteal skin, fasciocutaneous and myocutaneous flaps can be used to cover decubitus ulcers in the sacral and ischiocrural area. Decubitus ulcers in the sacral or ischial area that do not heal after exhausted conservative therapy. Moribund patients who are very likely to suffer a life-threatening complication. Non-cooperative patients who cannot follow the postoperative recommendations. The presence of extensive scars after previous operations in the donor area or irradiation of the donor area which may compromise the flap perfusion. A distinction is made between local skin flaps, perforator-based fasciocutaneous flaps and the myocutaneous gluteus maximus flap. By partial or complete elevation of the gluteus maximus muscle based on the superior and inferior gluteal vessels, this flap is useful for larger and deep defects in the sacral and ischial region. For more superficial defects, fasciocutaneous perforator flaps might be used. Smaller ulcers can be treated with local skin flaps. The donor site should be closed primarily. Consistent, postoperative relief by prone and lateral positioning of the patient, avoiding new decubitus ulcers. Drainage for at least 5-7 days. Antibiotic therapy is indicated only with appropriate detection of pathogens and in case of persistent infection. With distinct anatomical and improved technical knowledge, the use of fasciocutaneous and myocutaneous flaps in the gluteal region is now an established procedure and can be used for reliable coverage of sacral and ischiocrural decubitus ulcers.

Heparin-free extracorporeal membrane oxygenation in a patient with severe pulmonary contusions and bronchial disruption.

Pulmonary contusion complicated with endobronchial hemorrhage is potentially life-threatening, particularly in patients with tracheobronchial tree disruption and severe airway bleeding after blunt trauma, and pose a high mortality risk. In such cases, extracorporeal membrane oxygenation (ECMO) can be used as a salvage treatment modality. However, the use of ECMO for moribund trauma patients with respiratory failure may be limited for several reasons, such as intractable bleeding. In this case report, we describe a patient with severe bilateral pulmonary contusions with tracheobronchial tree disruption that was successfully treated using heparin-free venovenous ECMO.

How intensive care nurses perceive good death

ABSTRACTThis study was to determine the attitude of nurses regarding the concept of a good death and terminal phase was conducted to determine the effect on patient care. This is a descriptive and analytical study. The study was conducted with 102 nurses who worked at an intensive care unit and were willing to participate to the study. The mean Good Death Scale total score was 56.75 ± 8.90 and the Frommelt Scale score was 95.10 ± 8.53. In conclusion, our study results suggest that the attitudes of the nurses during care to moribund patients are moderate and, when appropriate care is given, they perceive the death as a positive experience.

High-flow nasal oxygen vs. standard oxygen therapy in immunocompromised patients with acute respiratory failure: study protocol for a randomized controlled trial

BackgroundAcute respiratory failure (ARF) is the leading reason for intensive care unit (ICU) admission in immunocompromised patients. High-flow nasal oxygen (HFNO) therapy is an alternative to standard oxygen. By providing warmed and humidified gas, HFNO allows the delivery of higher flow rates via nasal cannula devices, with FiO2 values of nearly 100%. Benefits include alleviation of dyspnea and discomfort, decreased respiratory distress and decreased mortality in unselected patients with acute hypoxemic respiratory failure. However, in preliminary reports, HFNO benefits are controversial in immunocompromised patients in whom it has never been properly evaluated.Methods/designThis is a multicenter, open-label, randomized controlled superiority trial in 30 intensive care units, part of the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique (GRRR-OH). Inclusion criteria will be: (1) adults, (2) known immunosuppression, (3) ARF, (4) oxygen therapy ≥ 6 L/min, (5) written informed consent from patient or proxy. Exclusion criteria will be: (1) imminent death (moribund patient), (2) no informed consent, (3) hypercapnia (PaCO2 ≥ 50 mmHg), (4) isolated cardiogenic pulmonary edema, (5) pregnancy or breastfeeding, (6) anatomical factors precluding insertion of a nasal cannula, (7) no coverage by the French statutory healthcare insurance system, and (8) post-surgical setting from day 1 to day 6 (patients with ARF occurring after day 6 of surgery can be included).The primary outcome measure is day-28 mortality. Secondary outcomes are intubation rate, comfort, dyspnea, respiratory rate, oxygenation, ICU length of stay, and ICU-acquired infections.Based on an expected 30% mortality rate in the standard oxygen group, and 20% in the HFNO group, error rate set at 5%, and a statistical power at 90%, 389 patients are required in each treatment group (778 patients overall). Recruitment period is estimated at 30 months, with 28 days of additional follow-up for the last included patient.DiscussionThe HIGH study will be the largest multicenter, randomized controlled trial seeking to demonstrate that survival benefits from HFNO reported in unselected patients also apply to a large immunocompromised population.Trial registrationClinicalTrials.gov, ID: NCT02739451. Registered on 15 April 2016.

Pediatric Mass Casualty Incident: A Real Crisis Mandating Inter-Disciplinary Coordination, Considering Ethical Issues

Interdisciplinary coordination of the director of crisis committee with emergency and other department's staff, financial support team, public relations, rehabilitation team,and police are required to successfully manage mass casualty incidents (MCIs). Prevention, staff training, equipment availability, clear-cut responsibilities and predicting all requirements are crucial aspects to be prepared (1). The task force for Mass Critical Care published guidance for adult MCI in 2008; For children, 17 experts of the Oak Ridge Institute for Science and Education developed recommendations for pediatric MCI (2). Certain guidelines have been suggested by the Centers for Disease Control and Prevention (CDC) and subsequently published in Pediatric Critical Care Medicine as a supplement as well as the more recent supplement in CHEST that updates the previous works (3, 4). Although the literature has provided sufficient evidence managing the situation, some major difficulties still exist in the stage of response to the crisis. Lack of equipment especially in international crises may lead to neglect moribund patients. This problem is more prominent for pediatric patients (5, 6). Personnel shortage mandates to accept the less-qualified staff contribution for pediatric care