Intensive Care Therapy Research Articles

Indirect Calorimetry Reveals That Better Monitoring of Nutrition Therapy in Pediatric Intensive Care Is Needed

Monitoring nutrition therapy is essential in the care of critically ill children, but the risk of nutrition failure seems to remain. The aims of the present study were to examine the prevalence of underfeeding, adequate feeding, and overfeeding in mechanically ventilated children and to identify barriers to the delivery of nutrition support. Children aged 0-14 years who fulfilled the criteria for indirect calorimetry were enrolled in this prospective, observational study and were studied for up to 5 consecutive days. Actual energy intake was recorded and compared with the required energy intake (measured energy expenditure plus 10%); energy intake was classified as underfeeding (<90% of required energy intake), adequate feeding (90%-110%), or overfeeding (>110%). The reasons for interruptions to enteral and parenteral nutrition were recorded. In total, 104 calorimetric measurements for 140 total days were recorded for 30 mechanically ventilated children. Underfeeding, adequate feeding, and overfeeding occurred on 21.2%, 18.3%, and 60.5% of the 104 measurement days, respectively. There was considerable variability in the measured energy expenditure between children (median, 37.2 kcal/kg/d; range, 16.81-66.38 kcal/kg/d), but the variation within each child was small. Respiratory quotient had low sensitivity of 21% and 27% for detecting underfeeding and overfeeding, respectively. Fasting for procedures was the most frequent barrier that led to interrupted nutrition support. The high percentage of children (~61%) who were overfed emphasizes the need to measure energy needs by using indirect calorimetry.

Treatment Of Infection-Associated Purpura Fulminans With Protein C Zymogen Is Associated With a High Survival Rate

Purpura fulminans (PF) is rapidly progressing, life-threatening disorder, characterized by skin lesions with a typical morphology, disseminated intravascular coagulopathy, multiple organ failure, septic shock, most often, but not exclusively caused by infections (meningococci, pneumococci, and others). It is associated with a breakdown of the protein C system, an important regulator of blood coagulation, leading to consumption coagulopathy, intravascular fibrin deposition, downregulated fibrinolysis, disturbance of microcirculation and finally death from multiple organ failure. Mortality of severe sepsis with coagulopathy is as high as 80-100%, and persistent disabilities (i.e. amputations) are frequent in survivors. Several case series including more than 340 patients, suggest that substitution of protein C zymogen can impressively improve coagulopathy, reduce amputation rate and improve survival compared to historical controls in PF associated with sepsis in neonates, children and adults, encouraging some centers to incorporate it in their local guidelines for treatment of purpura fulminans.We report a series of 9 consecutive patients with purpura fulminans, treated with a plasma-derived protein C zymogen concentrate (Ceprotin®, Baxter, Vienna, Austria) for acute onset PF in 3 Vienna hospitals, in which the treatment guidelines included protein C replacement. Median age was 29 years (range 2 months to 73 years), 5 male, 4 female, 5 adult, 4 pediatric patients were treated, respectively. Six patients had meningococcal sepsis, 2 had overwhelming post-splenectomy infections, and 1 had heat-shock induced coagulopathy. All patients presented with typical skin lesions and acute critical illness and were admitted to intensive care units. Coagulopathy was present in 100%, severe vasopressor-dependent sepsis in 100%, acute renal failure in 89%, respiratory failure in 89%. Median SAPS II score in the adults was 78 (range 45-97), predicting a mortality of 78.3% (range 31-88.5%). All pediatric patients had a Glasgow Meningococcal Septicemia prognostic score >8, indicating a fatal outcome. Renal replacement therapy was necessary in 56%, mechanical ventilation in 89%. Initial protein C levels were markedly decreased in the 8 patients with infections.Standardized sepsis therapy was applied according to the surviving sepsis guidelines. Protein C was given as an initial bolus infusion (100 U/kg) followed by a continuous infusion with 10 U/kg/h, adjusted to obtain plasma protein C activity levels of 1.0 U/mL. In addition, platelet, red blood cell, fibrinogen and antithrombin concentrates were given as needed.In one patient (PF caused by heat shock) protein C infusion was stopped after 2 days, and he died after 10 days from refractory multiple organ failure. All other patients (with infection-induced PF) survived. Coagulopathy resolved within a few days, and all patients could successfully be weaned from intensive care therapy. Organ function was completely restored without residual dysfunction. One patient needed amputation of both forefeet and nose reconstruction, 6 patients had, in part extended, scar formation at the skin. Median follow up was 8 months (range 2-20). At that time all patients were fully active without apparent limitations.In conclusion, standardized, full-code sepsis therapy, together with protein C substitution, resulted in very high survival rate of patients with infection-induced PF (as compared to predicted mortality) and a low rate of disabilities in this otherwise deleterious disease. As Ceprotin® is approved only for congenital protein C deficiency, controlled clinical studies are urgently needed to gain more scientific evidence for this potentially life-saving, but still off-label therapy in patients with PF. Disclosures:Knoebl:Novo Nordisk: Consultancy, Honoraria; Baxter: Consultancy, Honoraria. Off Label Use: plasma derived protein C concentrate (Ceprotin(R)) for acquired protein C deficiency in purpura fulminans.

Indications and outcomes in children receiving renal replacement therapy in pediatric intensive care

PurposeWe aimed to describe patient characteristics, indications for renal replacement therapy (RRT), and outcomes in children requiring RRT. We hypothesized that fluid overload, not classic blood chemistry indications, would be the most frequent reason for RRT initiation. Materials and MethodsA retrospective cohort study of all patients receiving RRT at a single-center quaternary pediatric intensive care unit between January 2004 and December 2008 was conducted. ResultsNinety children received RRT. The median age was 7 months (interquartile range, 1-83). Forty-six percent of patients received peritoneal dialysis, and 54% received continuous renal replacement therapy. The median (interquartile range) PRISM-III score was 14 (8-19). Fifty-seven percent had congenital heart disease, and 32% were on extracorporeal life support. The most common clinical condition associated with acute kidney injury was hemodynamic instability (57%; 95% confidence interval [CI], 46-67), followed by multiorgan dysfunction syndrome (17%; 95% CI, 10-26). The most common indication for RRT initiation was fluid overload (77%; 95% CI, 66-86). Seventy-three percent (95% CI, 62-82) of patients survived to hospital discharge. ConclusionsHemodynamic instability and multiorgan dysfunction syndrome are the most common clinical conditions associated with acute kidney injury in our population. In the population studied, the mortality was lower than previously reported in children and much lower than in the adult population.

Terminalidade humana na UTI: reflexões sobre a formação profissional e ética diante da finitude

In an intensive care unit environment (ICU), healthcare professionals live in straight contact with critically ill patients and their relatives, also continuously dealing with the presence of biotechnological support to vital organs, possibilities of life maintenance, and coping with death. Given this reality, deep emotional tensions arise from expectations and frustrations stemming from the daily fight against the supposed enemy – human finitude. However, throughout the process of qualification of the different intensive care therapy professionals, the absence of any approach from various disciplines to discuss cognitive and affective aspects related to the process of death is evidenced. Even if the reflection about the factors involved in the best preparation to cope with death is encouraged by many authors, it is undeniable that health training institutions still struggle to take over an educational commitment with this subject. Such reality evidences the lack of appropriate repertoire to deal with decisions inherent to the performance of healthcare professionals: the determination of who lies on a bed, of those who live or die corresponds to ethical dilemmas to be addressed. That entails a multidisciplinary discussion, both in health training institutions and in healthcare work environments - which explains the growing presence of psychology and mental healthcare professionals in ICUs - making room for talking about death with healthcare team members who often deal with feelings of loss, pain, and failure, but also with patients and their relatives. In this scenario, it is possible to realize the importance, complexity and specificity of situations experienced by healthcare professionals and patients within an ICU context. The systematization of discussions related to death can be an effective alternative to articulate hands-on experiences with personal and professional perspectives from physicians, nurses, physiotherapists, among others, who witness or will witness the complex death of human beings.

Development of a device to measure MCC-IMS peaks of pure analytes (IMS-BOX)

Ion mobility spectrometry coupled with multi-capillary columns (MCC-IMS) is a highly sensitive instrument to analyse air samples and gaseous elements therein (ppmv pptv-range). The MCC-IMS is characterized by its ability to pre-separate specimens. It provides an additional dimension (drift-time) to the retention time of the pre-separation column and has the advantage of analysing especially humid air without a filter system or further devices like membranes. Therefore, the MCC-IMS can be used as diagnostic instrument for diseases like asthma [14], sarcoidosis [20], lung cancer [21] or ammonia during haemo-dialysis [13]. Breath analysis can also be used for drug or disease monitoring. For example, Propofol, a hypnotic used for maintaining general anaesthesia, can be measured in exhaled breath [3, 10, 15, 16] or acetone, a VOC from fatty acid metabolisation [9]. The MCC-IMS is a relatively new device and comprehensive databases with clearly identified compounds, like those defined for gas chromatography/mass spectrometry, are lacking so far. Air or breath analysis with MCC-IMS measures many compounds in the chromatogram, which cannot be identified yet in many cases. Especially in case of drug monitoring via exhaled breath it is obligatory to know the exact position of the compound in the chromatogram before breath analysis. Otherwise peak assignment of a breath sample remains uncertain. Actually, in such cases the retention time and the drift time or the 1/K0-value will be added to the Peak name or number. Generally, the role of sample collection is crucial [8]. One way of peak assignment with the MCC-IMS is the analysis of the highly pure substance of interest (e.g. of a certain drug) prior to further experiments, in case they are known or expected. Different sampling introduction systems were compared by L. Arce et al. including permeation tubes, sample containers, headspace sampling with a syringe, ceramic evaporators, membrane inlets, solid-phase microextraction, stir-bar sorptive extraction, thermal desorber units, multi capillary columns, fluid chromatography and electrospray ionization with respect to the analytes, different ionisationosurces like UV, corona discharge, s-radiation and electro-spray. In addition, the limits of detection are considered [1]. Especially permeation tubes goes back to the 1970s [6, 7, 12, 18]. The elimination of room air pollution is sometimes critical, because it contains a large amount of different volatile organic compounds (VOCs) also in trace concentrations to be considered as potential contaminations. If compounds of room air and the pure substance have a similar retention time or inversed reduced ion mobility, a clear assignment of its position in the MCC-IMS chromatogram is difficult. Commercial available systems like HovaCAL® (IAS GmbH, Frankfurt, Germany) [19] developed to realise multi-compound calibration down to the pptV range including relative humidity values up to 100 % for identification of analytes are highly expensive. Therefore, for laboratory use, an exponential dilution unit was developed by Sieleman using a glas flask directly, containing a volume of about This work is dedicated to our friend and colleague Rouven Hellbruck. Rouven deceased on January 4th 2013. S. Kreuer (*) : R. Hellbruck : T. Fink :N. Heim : T. Volk :A. Wolf Department of Anaesthesiology, Intensive Care and Pain Therapy at Saarland University Medical Center, Building 57, 66421 Homburg, Germany e-mail: Sascha.Kreuer@uniklinikum-saarland.de

Ruptured middle cerebellar peduncle AVM presenting with a coma treated to complete recovery with endovascular and intensive care therapy: Discussion of management

Ruptured middle cerebellar peduncle AVM presenting with a coma treated to complete recovery with endovascular and intensive care therapy: Discussion of management

Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in critically ill paediatric patients.

Mechanical ventilation is a critical component of paediatric intensive care therapy. It is indicated when the patient's spontaneous ventilation is inadequate to sustain life. Weaning is the gradual reduction of ventilatory support and the transfer of respiratory control back to the patient. Weaning may represent a large proportion of the ventilatory period. Prolonged ventilationis associated with significant morbidity, hospital cost, psychosocial and physical risks to the child and even death. Timely and effective weaning may reduce the duration of mechanical ventilation and may reduce the morbidity and mortality associated with prolonged ventilation. However, no consensus has been reached on criteria that can be used to identify when patients are ready to wean or the best way to achieve it. To assess the effects of weaning by protocol on invasively ventilated critically ill children. To compare the total duration of invasive mechanical ventilation of critically ill children who are weaned using protocols versus those weaned through usual (non-protocolized) practice. To ascertain any differences between protocolized weaning and usual care in terms of mortality, adverse events, intensive care unit length of stay and quality of life. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, Issue 10, 2012), MEDLINE (1966 to October 2012), EMBASE (1988 to October 2012), CINAHL (1982 to October 2012), ISI Web of Science and LILACS. We identified unpublished data in the Web of Science (1990 to October 2012), ISI Conference Proceedings (1990 to October 2012) and Cambridge Scientific Abstracts (earliest to October 2012). We contacted first authors of studies included in the review to obtain further information on unpublished studies or work in progress. We searched reference lists of all identified studies and review papers for further relevant studies. We applied no language or publication restrictions. We included randomized controlled trials comparing protocolized weaning (professional-led or computer-driven) versus non-protocolized weaning practice conducted in children older than 28 days and younger than 18 years. Two review authors independently scanned titles and abstracts identified by electronic searching. Three review authors retrieved and evaluated full-text versions of potentially relevant studies, independently extracted data and assessed risk of bias. We included three trials at low risk of bias with 321 children in the analysis. Protocolized weaning significantly reduced total ventilation time in the largest trial (260 children) by a mean of 32 hours (95% confidence interval (CI) 8 to 56; P = 0.01). Two other trials (30 and 31 children, respectively) reported non-significant reductions with a mean difference of -88 hours (95% CI -228 to 52; P = 0.2) and -24 hours (95% CI -10 to 58; P = 0.06). Protocolized weaning significantly reduced weaning time in these two smaller trials for a mean reduction of 106 hours (95% CI 28 to 184; P = 0.007) and 21 hours (95% CI 9 to 32; P < 0.001). These studies reported no significant effects for duration of mechanical ventilation before weaning, paediatric intensive care unit (PICU) and hospital length of stay, PICU mortality or adverse events. Limited evidence suggests that weaning protocols reduce the duration of mechanical ventilation, but evidence is inadequate to show whether the achievement of shorter ventilation by protocolized weaning causes children benefit or harm.

Current Oxygenation Practice in Ventilated Patients—An Observational Cohort Study

Oxygen therapy is a mainstay of critical care medicine, yet its optimal therapeutic use has not been systematically evaluated. A detailed understanding of current practice in oxygen therapy in intensive care is required to enable future interventional studies. We aimed to describe current oxygenation practice in patients requiring ≥48 hours of mechanical ventilation (MV) at an academic tertiary referral centre. We collected longitudinal arterial blood gas and hourly oxygenation data from intensive care unit charts in a consecutive cohort of 40 trauma, 41 medical and 20 surgical patients for their first seven MV days, analysed data for 14,063 MV hours, and derived time-weighted averages (TWA) of variables for each 24-hour interval on MV for all patients.The TWA-FiO2 was 0.42 (95% CI 0.41 to 0.44) and TWA-SpO2 was 97.1% (95% CI 96.8 to 97.4) for the first seven MV days. TWA-PaO2 was >80 mmHg on 80% of MV days. TWA-FiO2 of ≥0.35 was used to achieve TWA-SpO2 >95% on 61% of MV days. Of 58 MV days with TWA-FiO2 ≥0.60, TWA-SpO2 ≥96% occurred on 28 (48%) days. Mean SpO2 and PaO2 in patients with severe acute lung injury (ALI) scores were higher than recommended targets. Wide variability in the mean SpO2 and PaO2 was observed in patients with comparable ALI scores. Inspired oxygen therapy in these MV patients was 'liberal', with PaO2 and SpO2 values generally above 80 mmHg and 96% respectively. An interventional study comparing current practice to more conservative targets (PaO2≍60 to 65 mmHg and/or SpO2≍90 to 92%) appears possible.

Treatment of early phase severe acute pancreatitis in intensive care units: a retrospective multicenter study

Objective To analyse the experience and treatment of early phase severe acute pancreatitis (SAP) in intensive care units (ICU).Methods A multicenter retrospective study was done on patients with SAP treated in three major teaching hospitals (Beijing Hospital,Peking University First Hospital and Peking University Shenzhen Hospital) in China from Jan.2001 to Dec.2011.Results There were 188 patients who were enrolled in the study,including 121 males and 67 females.The age ranged from 19 to 104 (51.0±18.2) years.The mean APACHE Ⅱ score was (22.2±4.6).84.0％ of patients survived,the mortality was 10.1％ in the early phase and 5.9％ in the late phase.The most common systemic complications were acute renal injury (46.3 ％),acute respiratory distress syndrome (35.6％),and septic shock (17.6％).The local complication rate was 47.3％,which included acute peripancreatic fluid collections (32.8％),acute necrotic collection and walled-off necrosis (48.4 ％) and pseudocyst (18.8 ％).The conservative treatments included intensive care,fluid resuscitation,mechanical ventilation,continuous renal replacement therapy,antibiotics,glucose control,inhibition of pancreatic enzyme activity and secretion,and nutritional support.Surgical intervention included endoscopic retrospective cholangio-pancreatography and endoscopic sphincterectomy,B ultrasound or CT guided puncture and drainage,and surgical drainage and debridement of necrosis.Conclusions The early phase of SAP was characterized by systemic inflammatory response syndrome and multiple organ dysfunction syndrome which accounted for the first peak in mortality.Intensive care therapy and multi disciplinary comprehensive combined strategy were very important for these patients with systemic and local complications.ICU treatment in the early phase was preferred for patients with SAP. Key words: Pancreatitis, acute necrotizing; Intensive care therapy; Retrospective studies

A case of Plasmodium vivax malaria with respiratory failure

Acute renal failure disseminated intravascular coagulastion, acute respiratory distress syndrome (ARDS), hyposglycemia, coma or epileptic seizures are manifestations of severe Plasmodium (P.) falciparum malaria. P. vivax malaria is rarely associated with severe complications. We report a case of 30-year-old male refugee coming from Pakistan, has been found in hospital garden as unsconscious. After therapy of pneumonia requiring intensive care unit and intensive supportive care, the patient left invasive mechanical ventilation (IMV). Because of continsued fever and chills attacks focused on malaria diagnosis, Plasmodium vivax malaria detected on thick peripheral blood smear. After intensive supportive care and specific anti-plasmodial therapy, the patient recovered and was discharged from hospital. The use of IMV vivax-malaria related ARDS was associated with a good outcome. J Clin Exp Invest 2013; 4 (2): 226-228 Key words: ARDS, Plasmodium vivax, pneumonia, resspiratory failure

An Evaluation to Assess the Knowledge regarding Palliative Care in Neonatal Nursing among Staff Nurses Working in Selected Hospitals at Bangalore

The neonatal unit frequently occupied by newborns that are marginally viable or critically unwell and could be considered as terminally ill. It is a busy, highly technical environment with advanced life saving medical equipments, at its disposal. The technology has had a profound effect on neonatal nursing practice. The escalation of technology and medical advances has been followed by an increase in later disabilities. Many devices have altered from being one of the supporting clinical practices to that of being an essential requirement in treatment delivery. Even after the use of all settings. Some newborns will die in the NICU. The mortality and morbidity rate is still high. This has given rise to many ethical issues including withdrawal of intensive care therapies. The conceptual framework for the study is based on Health Belief Model. Health Beliefs are person’s knowledge, ideas and attitude, about health and illness. In this study various literature was reviewed which includes, the research design selected for the study was Descriptive research design. The dependent variable and independent variable were selected for the research. DOI: http://dx.doi.org/10.11591/ijphs.v2i2.2779

028 OUT OF HOSPITAL CARDIAC ARREST: THE RESULTS OF THE HEART ATTACK TEAM IN THE FIRST YEAR

<h3>Introduction</h3> Historically patients who presented following an Out of Hospital Cardiac Arrest (OHCA) of presumed cardiac origin had dismal survival data with concerns that survivors would have poor neurological outcomes. In recent years there has been increased focus on prehospital care and coordinated care once patients arrive in hospital, including urgent percutaneous coronary intervention (PCI) and targeted temperature management (TTM). In our unit we have a multi-disciplinary heart attack team (HAT) in place that specialises in treating this challenging patient population by delivering the patients directly to our cardiac catheter laboratories and then to intensive care where they have TTM in addition to standard intensive care. <h3>Methods</h3> This is a retrospective observational study looking at the outcome of consecutive OHCA patients who were managed by the HAT and presented to our institution over a period of 1 year. The HAT was formally introduced in July 2011. We focused on survival, neurological status on hospital discharge using the cerebral performance scores (CPC), length of stay (LOS) in cardiothoracic ITU (CTITU) and in hospital and activity in the coronary catheter lab notably door to balloon times (DBT) for PCI. Data were derived from hospital notes, electronic records and ambulance sheets. <h3>Results</h3> A total of 53 patients presented directly to our institution following an OHCA of presumed cardiac origin. The mean age was 61 years (SD 14 years) with 75.5% male. 36 patients (67.9%) survived to hospital discharge with a mean age 59 years (SD 15 years) and 73% male. 30 patients had ST elevation or LBBB on their presenting ECG. 30 patients (83.3%) were discharged with no significant neurological impairment, CPC 1 and 2. 6 patients were discharged with neurological impairment, CPC3; there were no patients in CPC4. The median LOS on CTITU was 4 days (IQR 6.5 days) and for the survivors the median LOS was 5 days (IQR 7.4 days). The hospital LOS for all patients was 11 days (IQR 13.4 days) with the median LOS in hospital for survivors 16 days (IQR 13.5 days). 49 patients (92.5%) had urgent angiography with 29 patients proceeding to successful PCI (59.2%) and 5 patients (10.2%) referred for CABG with three vessel disease. The median DBT for these patients was 49 min (IQR 31 min), with the survivors having a median DBT 46 min (IQR 30 min). 7 patients (19.4%) were discharged from hospital with an ICD. <h3>Conclusions</h3> The survival of OHCA patients presenting to our cardiac unit compares favourably with published data. We believe these outcomes are a result of our successful heart attack team which enables us to deliver high rate of urgent coronary intervention and aggressive intensive care therapy including targeted temperature management.

How can we prevent postoperative pulmonary complications?

aDepartment of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr, Dresden, Germany bDepartment of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy Correspondence to Paolo Pelosi, MD, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16132 Genoa, Italy. E-mail: [email protected]

Fat Embolism Syndrome: Our Experience

Fat embolism syndrome is a serious consequence of fat emboli producing a distinct pattern of clinical symptoms and signs. It is most commonly associated with fractures of long bones and the pelvis. Patients usually present with signs and symptoms of multiorgan dysfunction, particularly involving the triad of lungs, brain, and skin. A combination of clinical criteria and MRI brain will enable early and accurate diagnosis of FES. Prevention, early diagnosis, and adequate symptomatic treatment are the mainstay of management. We present a case who became drowsy, after a few hours of a traumatic fracture and developed pulmonary insufficiency, cutaneous petechiae. MRI findings were consistent with cerebral fat embolism. Treatment included intensive care, artificial respiration, and symptomatic therapy. The patient had recovered completely. DOI: http://dx.doi.org/10.3329/bccj.v1i1.14370 Bangladesh Crit Care J March 2013; 1: 49-52

Comparative Analysis of von Willebrand Disease in Patients with Mechanical Circulatory Pulsatile and Non-Pulsatile Support

Purpose Aquired von Willebrand (vW) disease is induced by continuous flow ventricular assist devices (VAD) in patients under mechanical circulatory support (MCS). However, the influence of different MCS on the degradation of high molecular weight vW aggregates is less investigated. In addition the influence of intensive care therapy on vW-multimere analysis before MCS is not known. Methods and Materials We analysed the vW-antigene (vWA), ristocetin-(RCA) and collagen binding activity (CBA) and the vW multimers in patients supported by different MCS-systems: Thoratec biventricular VAD (THOB, n=30), Syncardia total artificial heart (TAH, n=40); LVADs: Thoratec (THOL, n=39), Novacor (NOV, n=37), Heartmate II (HM2, n=40) and Heartware (HW, n=38). vW-factor was analysed before and about 14 days after implantation. The data were compared to healthy blood donor controls (BDC). Results vWA, RCA and CBA was highly increased at the time of MCS-system implantation. Pulsatile LVADs and TAH had no influence on vWA, RCA and CBA during the observation period. BVAD-patients revealed significant reduction of CBA during MCS (p=0.0001). In contrast support with the axial flow HM2 was associated with reduced CBA (p Conclusions vW disease is prevalent in terminal heart failiure patients before MCS-system implantation. Continuous flow systems seem to have an increased effect on vW-factor activity compared to pulsatile devices. Centrifugal pumps may exert increased shear stress on blood components compared to other systems.

Efficiency of substitutive renal therapy in the complex intensive care of multiple organ failure in patients with polytrauma

This study was to evaluate the efficiency of the early start of intermittent substitutive renal therapy in patients with polytrauma complicated by multiple organ failure syndrome.

Severe trauma of the chest wall: surgical rib stabilisation versus non-operative treatment.

Serial rib fractures and flail chest injury can be treated by positive-pressure ventilation. Operative techniques reduce intensive care unit (ICU) stay, overall costs, mortality and morbidity, as well as pain. The aim of this study was to evaluate the benefit of surgical rib stabilisation in comparison to non-operative treatment in patients with severe trauma of the chest wall. From 2006 to 2011, the data of 44 patients with flail chest and serial rib fractures were collected retrospectively. A surgical group and an intensive care group with only intensive care therapy were formed. Rib and sternal fractures, flail chest, injury severity, thoracic injuries, mechanical ventilation, time in the ICU, overall hospital stay and mortality were evaluated. No postoperative surgical complications had been observed. The time under mechanical ventilation in the surgical group was 10.6±10.2days, whereas in the non-surgical group, it was 13.7±13.7days. Mechanical ventilation time after surgery was 6.9±6.5days. Time in the ICU for the surgical group was 16.4±13.6days, compared to the non-surgical group with 20.1±16.2days. Postoperative time in the ICU was 11.7±10.3days. The mortality in the surgical group was 10% and in the non-surgical group it was 17%. Operative rib stabilisation with plates is a safe therapy option for severe trauma of the chest wall. Provided that the duration of preoperative mechanical ventilation and time spent in the ICU is minimised due to early operation, our data suggest that the stabilisation of serial rib fractures and flail chest may lead to a reduced time of mechanical ventilation, time in the ICU and mortality.

Editorial introductions

Editorial introductions

Parenteral diclofenac infusion significantly decreases brain-tissue oxygen tension in patients with poor-grade aneurysmal subarachnoid hemorrhage

IntroductionDiclofenac, a nonsteroidal antiinflammatory drug, is commonly used as antipyretic therapy in intensive care. The purpose of this study was to investigate the effects of parenteral diclofenac infusion on brain homeostasis, including brain-tissue oxygen tension (PbtO2) and brain metabolism after aneurysmal subarachnoid hemorrhage (aSAH).MethodsWe conducted a prospective, observational study with retrospective analysis of 21 consecutive aSAH patients with multimodal neuromonitoring. Cerebral perfusion pressure (CPP), mean arterial pressure (MAP), intracranial pressure (ICP), body temperature, and PbtO2 were analyzed after parenteral diclofenac infusion administered over a 34-minute period (20 to 45 IQR). Data are given as mean ± standard error of mean and median with interquartile range (IQR), as appropriate. Time-series data were analyzed by using a general linear model extended by generalized estimation equations (GEEs).ResultsOne-hundred twenty-three interventions were analyzed. Body temperature decreased from 38.3°C ± 0.05°C by 0.8°C ± 0.06°C (P < 0.001). A 10% decrease in MAP and CPP (P < 0.001) necessitated an increase of vasopressors in 26% (n = 32), colloids in 33% (n = 41), and crystalloids in 5% (n = 7) of interventions. PbtO2 decreased by 13% from a baseline value of 28.1 ± 2.2 mm Hg, resulting in brain-tissue hypoxia (PbtO2 <20 mm Hg) in 38% (n = 8) of patients and 35% (n = 43) of interventions. PbtO2 <30 mm Hg before intervention was associated with brain-tissue hypoxia after parenteral diclofenac infusion (likelihood ratio, 40; AUC, 93%; 95% confidence interval (CI), 87% to 99%; P < 0.001). Cerebral metabolism showed no significant changes after parenteral diclofenac infusion.ConclusionsParenteral diclofenac infusion after aSAH effectively reduces body temperature, but may lead to CPP decrease and brain-tissue hypoxia, which were both associated with poor outcome after aSAH.

The “Coagulation Box” and a New Hemoglobin-Driven Algorithm for Bleeding Control in Patients With Severe Multiple Traumas

BackgroundExtensive hemorrhage is the leading cause of death in the first few hours following multiple traumas. Therefore, early and aggressive treatment of clotting disorders could reduce mortality. Unfortunately, the availability of results from commonly performed blood coagulation studies are often delayed whereas hemoglobin (Hb) levels are quickly available.ObjectivesIn this study, we evaluated the use of initial hemoglobin (Hb) levels as a guide line for the initial treatment of clotting disorders in multiple trauma patients.Patients and MethodsWe have developed an Hb-driven algorithm to initiate the initial clotting therapy. The algorithm contains three different steps for aggressive clotting therapy depending on the first Hb value measured in the shock trauma room, (SR) and utilizes fibrinogen, prothrombin complex concentrate (PCC), factor VIIa, tranexamic acid and desmopressin. The above-mentioned drugs were stored in a special “coagulation box” in the hospital pharmacy, and this box could be immediately brought to the SR or operating room (OR) upon request. Despite the use of clotting factors, transfusions using red blood cells (RBC) and fresh frozen plasma (FFP) were performed at an RBC-to-FFP ratio of 2:1 to 1:1.ResultsOver a 12-month investigation period, 123 severe multiple trauma patients needing intensive care therapy were admitted to our trauma center (mean age 48 years, mean ISS (injury severity score) 30). Fourteen (11%) patients died; 25 (mean age 51.5 years, mean ISS 53) of the 123 patients were treated using the “coagulation box,” and 17 patients required massive transfusions. Patients treated with the “coagulation box” required an average dose of 16.3 RBC and 12.9 FFP, whereas 17 of the 25 patients required an average dose of 3.6 platelet packs. According to the algorithm, 25 patients received fibrinogen (average dose of 8.25 g), 24 (96%) received PCC (3000 IU.), 14 (56%) received desmopressin (36.6 µg), 13 (52%) received tranexamic acid (2.88 g), and 11 (44%) received factor VIIa (3.7 mg). The clotting parameters markedly improved between SR admission and ICU admission. Of the 25 patients, 16 (64%) survived. The revised injury severity classification (RISC) predicted a survival rate of 41%, which corresponds to a standardized mortality ratio (SMR) of 0.62, which implies a higher survival rate than predicted.ConclusionsAn Hb-driven algorithm, in combination with the “coagulation box” and the early use of clotting factors, could be a simple and effective tool for improving coagulopathy in multiple trauma patients.