Search

Botulism is a very rare disease in Switzerland, with less than one case per year, an incidence of 0.01 cases for 100,000 inhabitants. Indeed, over the past ten years, 9 cases have been reported to Public Health registry. Foodborne botulism (FB) is caused by ingestion of preformed botulinum neurotoxin. Characteristic features should be rapidly recognized, and prompt treatment should be administered to avoid further progression towards respiratory failure and death. We report the case of a patient who developed gastrointestinal symptoms just after a sandwich consumption followed by rapidly progressive cranial nerve impairment, truncal muscle weakness in a descending pattern and respiratory failure requiring mechanical ventilation. The diagnosis of foodborne botulism was delayed due to differential diagnosis considerations. Specific antitoxin therapy was administered immediately after firm clinical conviction of botulism, without waiting for serologic results that later confirmed the diagnosis. As expected, muscle weakness recovery was slow, with persistent chronic deficits nine years later. This case highlights differential diagnosis issues of botulism. These include acute neuromuscular disorders such as myasthenia gravis, Guillain-Barré syndrome, or tick-borne encephalitis. The importance of careful medical history and repeated clinical evaluation to avoid misdiagnosis can be lifesaving. Our case highlights the typical warning signs.

Bei zahlreichen kritischen Erkrankungen ist ein zellularer Sauerstoffmangel von zentraler Bedeutung. Das Aufgabengebiet der Hohenmedizin und -physiologie umfasst die Mechanismen der Hypoxietoleranz und der entsprechenden Anpassungsprozesse. Zunehmende Evidenz deutet darauf hin, dass die physiologischen und pathophysiologischen Prozesse eines Bergsteigers in hypobarer Hypoxie denen ahneln, die bei kritisch kranken Patienten von Bedeutung sind. Wahrend in den vergangenen Jahren v. a. Mechanismen des Sauerstofftransports in die Peripherie untersucht wurden, liegt der Fokus in jungerer Vergangenheit insbesondere auf Veranderungen des zellularen Sauerstoffverbrauchs. In diesem Kapitel werden Parallelen zwischen der Hohenmedizin und der Intensivmedizin aufgezeigt und diskutiert.

Im alpinen Gelande werden Schmerzen oft nur unzureichend behandelt. Die Verwendung einer Schmerzskala und von Analgesieprotokollen ist sinnvoll. Training in der Schmerzerkennung und -behandlung sollte etabliert und die Wichtigkeit einer nichtpharmakologischen Therapie unterstrichen werden. Das perfekte Analgetikum gibt es nicht. Der Einsatz verschiedener Analgetika ist sinnvoll, jedoch sollte die Zahl der mitgefuhrten Analgetika auf ein Minimum reduziert werden. Analgetika, die uber diverse Applikationswege verabreicht werden konnen und eine hohe therapeutische Breite haben, sollten bevorzugt werden. Eine multimodale Analgesie kann Vorteile bieten. Ein starkes Opioid ist fur die Behandlung von moderaten und starken Schmerzen empfohlen. Ketamin hat den Vorteil einer hohen therapeutischen Breite, wobei eine Kombination mit Midazolam oder einem langer wirksamen Opioid sinnvoll ist. Regionalanasthesie kann besonders bei langeren Transporten eine Alternative zur systemischen Analgesie sein.

Specific burn outcome prediction scores such as the Abbreviated Burn Severity Index (ABSI), Ryan, Belgian Outcome of Burn Injury (BOBI) and revised Baux scores have been extensively studied. Validation studies of the critical care score SAPS II (Simplified Acute Physiology Score) have included burns patients but not addressed them as a cohort. The study aimed at comparing their performance in a Swiss burns intensive care unit (ICU) and to observe whether they were affected by a standardized definition of inhalation injury. We conducted a retrospective cohort study, including all consecutive ICU burn admissions (n=492) between 1996 and 2013: 5 epochs were defined by protocol changes. As required for SAPS II calculation, stays24h were excluded. Data were collected on age, gender, total body surface area burned (TBSA) and inhalation injury (systematic standardized diagnosis since 2006). Study epochs were compared (χ2 test, ANOVA). Score performance was assessed by receiver operating characteristic curve analysis. SAPS II performed well (AUC 0.89), particularly in burns40% TBSA (AUC 0.93). Revised Baux and ABSI scores were not affected by the standardized diagnosis of inhalation injury and showed the best performance (AUC 0.92 and 0.91 respectively). In contrast, the accuracy of the BOBI and Ryan scores was lower (AUC 0.84 and 0.81) and reduced after 2006. The excellent predictive performance of the classic scores (revised Baux score and ABSI) was confirmed. SAPS II was nearly as accurate, particularly in burns40% TBSA. Ryan and BOBI scores were least accurate, as they heavily weight inhalation injury.Les scores prédictifs de mortalité spécifiques aux brûlés comme l’ABSI, le Ryan, le BOBI, ainsi que le Baux révisé ont été très largement étudiés. Les études ayant validé le SAPS II ont certes inclus des brûlés, mais ils n’ont pas été étudiés en tant que sous-population. Cette étude rétrospective, réalisée dans une unité de réanimation de brûlés suisse, avait pour but de comparer les performances de ces scores et d’évaluer l’impact d’une définition standardisée des lésions d’inhalation. Elle a inclus 492 patients hospitalisés entre 1996 et 2013, répartis en 5 périodes définies par des modifications du protocole interne de prise en charge. L’âge, la surface brûlée et l’inhalation (définition standardisée depuis 2006) ont été recueillis. Les périodes ont été comparées par ANOVA et χ2. La performance des scores a été évaluée par analyse des courbes ROC. Le SAPS II a démontré une bonne performance (AUC 0,89), particulièrement en cas de brûlure40% SCT (AUC 0,93). L’ABSI et le Baux révisé étaient les plus performants (AUC 0,92 et 0,91) et sont avérés peu affectés par le changement de définition de l’inhalation. Le BOBI et le Ryan se sont révélés moins précis (AUC 0,84 et 0,81) avec des performances encore davantage dégradées après le changement de définition de l’inhalation. L’excellente valeur prédictive du Baux révisé et de l’ABSI est ainsi confirmée. Le SAPS II s’est montré presque aussi précis, en particulier pour des surfaces40%. Les scores Ryan et BOBI ont été les moins précis.

Les patients admis en reanimation sont particulierement fragiles et sensibles a la fois aux effets de la denutrition et de la suralimentation qui provoquent infections, ventilation prolongee et surmortalite. La definition precise de besoins energetiques devient d’autant plus importante: la calorimetrie indirecte reste a ce jour le seul outil fiable, bien qu’elle ne soit pas applicable a tout patient.

Erkrankungen der Atmungsorgane gehoren zu den wichtigsten Determinanten der perioperativen Morbiditat und Letalitat. Ernste respiratorische Komplikationen treten vor allem in der postoperativen Phase auf. Grose Bedeutung fur das Minimieren des pulmonalen Risikos kommt der perioperativen Evaluation der Lungenfunktion zu, die ein fruhzeitiges Erkennen patienten- sowie operationsassoziierter Risikofaktoren ermoglicht. Insbesondere die intraoperative Beurteilung respiratorischer Parameter hat als kostengunstiges und effektives Verfahren in den letzten Jahren an Bedeutung gewonnen. Der folgende Artikel stellt Moglichkeiten und Grenzen des perioperativen Monitorings der Lungenfunktion dar. Besondere Schwerpunkte liegen neben der praoperativen Evaluation der Lungenfunktion insbesondere in der intraoperativen Interpretation respiratorischer Druck-, Fluss- und Volumendarstellungen.

Objective Important changes in administering total parenteral nutrition (PN) admixtures have occurred over the past decade. This study describes hospital pharmacists' practices in France (F), Switzerland (CH), and Belgium (B). Methods From the responses received using a standardized questionnaire, ( n = 378) we determined the origin, types of container used, and choice of PN formula (standard versus tailor-made) and the type of quality control and the existence of nutrition support teams. Results The mean response rates were 55.6% (CH), 30.5% (F), and 24.5% (B). Standard formulas were used mainly for adult patients (CH, 86%; F, 79%; B, 86%), whereas approximately 50% of tailor-made PN bags were used for children. Single-compartment or multicompartment bags or glass bottles contained standard formulas. Most standard formulas were provided by industry, apart from (B), where 50% of PN solutions were compounded by hospital pharmacies. Single-compartment bags contained generally tailor-made formulas produced exclusively by hospital pharmacies in (CH) and (B), whereas 33% were provided by industry in (F). Quality controls were mostly visual and occurred in 75% to 95% of hospitals. Nutrition support teams were present in 32% to 45% of hospitals. Conclusion The choice, origin, and type of container used for PN formulas were highly variable among countries. However, the use of standard formulas in bags was predominant in (CH) and (B). The function of nutrition support teams was similar in (F), (CH), and (B).

Objective: To assess the association of enteroviruses (EV) with ALS by applying a sensitive seminested reverse transcription (RT) PCR protocol to the detection of enteroviral RNA in a blinded set of archived tissues from ALS and control cases.Methods: The specimen set consisted of 24 frozen spinal cord samples from ALS cases, 17 frozen spinal cord samples from negative control (non-ALS) cases, and 5 frozen spinal cord positive control samples. The positive controls were two human spinal cord samples spiked with poliovirus (PV) and three spinal cords from PV-infected transgenic mice. A sensitive, EV-specific, seminested RT-PCR assay was used to detect EV genome in RNA extracted from the specimens and controls.Results: The assay detected EV RNA in a 10−5 dilution of infected mouse tissue. EV RNA was not detected in the ALS specimens or in specimens from control cases, despite the presence of amplifiable RNA as assessed by amplification with control primers, whereas all of the positive control specimens yielded the expected PV amplification product.Conclusion: The reported association between EV infection and ALS was not confirmed by testing this set of specimens with these sensitive methods.

Die Mangelernahrung beeinflusst auf ungunstige Weise den Krankheitsverlauf von Patienten im Spital, vermindert ihre Lebensqualitat und erhoht die Gesamtkosten der Hospitalisation. Die Pravalenz der krankheitsbedingten Unterernahrung bei Spitaleintritt variiert in den europaischen Staaten zwischen 20 und 50 %. Dies veranlasste eine Kommission des Europarats zu einer Umfrage bezuglich der Organisation und den Modalitaten der Ernahrung im Spital. Dieser Beitrag fasst die Ergebnisse dieser Untersuchung zusammen und beschreibt die Stellungnahme der Kommission. Die Hauptfaktoren, welche zur Mangelernahrung im Spital beitragen, werden analysiert, und gleichzeitig werden Empfehlungen zur Verbesserung der Situation formuliert. Malnutrition negatively influences the clinical evolution, hospital costs and quality of life of patients. The prevalence of malnutrition at hospital admission varies between 20 and 50 % in European countries. Therefore, a group of experts assigned by the Council of Europe performed a large survey on the organisation and modalities of hospital nutrition. The present paper summarises the conclusions of the survey and the position of the Council of Europe in regard to hospital nutrition. It reviews the principal factors causing insufficient nutritional monitoring in hospitals, and it presents recommendations for improving the situation.

The characteristics of critically ill burned patients follow the same trends as the general intensive care unit (ICU) patient population. The age of patients requiring ICU admission has increased in parallel with increased life expectancy in Western countries, and the mean age of patients in the ICU is now often close to 65 years. Age impacts on mortality rates after burn trauma: Already after 60 years, the risk of death increases, even with small burns [1]. Several factors explain this increased risk of death: Lower wound healing capacity [2], increased susceptibility to infections and metabolic complications, and the increased likelihood of suffering from multiple comorbidities, such as alterations in vital organ function. Moreover, in this ‘frail’ population, the likelihood of trauma increases, as shown by the WHO statistics [3].

Essential trace elements are inorganic metalloid substances: insufficient intakes cause predictable biological and clinical alterations. Numerous factors contribute to the alterations of iron, iodine, selenium, and zinc status, such as low soil content resulting in low food content, malabsorption, or biological fluid losses. Age categories at high risk of deficit in the general population include children, pregnant and lactating women, and elderly; critical illness is a specific condition. Substitution and supplementation studies that respect physiological nutritional doses result in significant clinical benefits: improved immunity and cognitive functions, better wound healing. Supplementation with supra-nutritional doses in subjects or patients with adequate status may result in deleterious cancer and cardiovascular consequences due to their potential toxicity.

Cardiovascular disease is a major cause of morbidity and mortality in Western countries, being responsible for a large number of admissions to intensive care units (ICU), after acute myocardial infarction, cardiac surgery, or acute cardiomyopathies. Moreover, the prevalence of cardiovascular diseases is high in patients admitted for primary non-cardiac conditions, since a growing proportion of patients is over 65 years, and chronic cardiac heart failure has a prevalence of 30–130 individuals per 1000 in this age category [1].

Burn injuries are very frequent, most being trifle cases. Nevertheless every year about 200 patients need to be treated in one of the two specialised Swiss burns centres. Admission criteria are burns15% body surface or burns to critical areas (face neck, hands, genitalia, joints) and electrical injuries. The paper reviews the physiophathology of the burn wound which differs depending on the thermal or electrical aetiology. The airway may be threatened due to true inhalation, but also to burns to the face or neck. In major burns20% body surface in adults, or10% in children, fluid resuscitation will be required; oral hydration is generally sufficient by smaller burns. Surgical treatment of 2nd and 3rd degree burns starts within the first 24 days after injury. While complex treatment is generally available in peace time, a major accident such as a disco-fire that can generate hundreds casualties in a few minutes, can threaten our system and force the adoption of triage rules, and simplified treatments. Attitudes to adopt in such conditions are discussed.

The toxic epidermal necrolysis (TEN) is an immunologic reaction in the skin with apoptosis of kératinocytes: most cases are reactions against drugs. The main features of this reaction are a separation of the epidermis and erosions of the mucus membranes, associated with a reduction of the general condition with kidney and liver failure. This leads to problems similar to those observed in severely burned patients. The mortality high of patients with TEN can be reduced, if the responsible drug is immediately withdrawn and if the patient is treated in a specialized burns intensive care unit. The medical treatment to stop the chain reaction of apoptosis is still under discussion. Through a case report, this article will focus on the complexity of the treatment of patients with TEN and will point out the importance of a multidisciplinary approach.

Malnutrition is common in critically ill patients with acute renal failure. The aim of this review is to describe the basis for nutritional support during renal replacement therapy.Review of the literature.Techniques of nutritional support and nutritional requirements are described.Early aggressive enteral, parenteral or combine nutritional support is required in critically ill patients on replacement therapy.

The merging of two intensive care units is a time of profound change, and constitutes a risk of mishaps. We report some aspects of such a project in our institution. The evaluation of various indicators reflecting the activity, patient's hospital pathways, mortality, as well as the use of specific techniques, has shown that no particular problem was observed during the first 9 months. Improvements in performance or productivity have not been demonstrated so far. The follow-up will permit to demonstrate long-term benefits. We believe that these observations may be of interest for other departmental or hospital reorganisations.

Background/Aims: Malnutrition is common in critically ill patients with acute renal failure. The aim of this review is to describe the basis for nutritional support during renal replacement therapy.

Respiratory diseases contribute significantly to perioperative morbidity and mortality. Severe pulmonary complications usually emerge postoperatively. To minimise pulmonary risk, the perioperative evaluation of lung function is of major significance, allowing the identification of patient and surgery-related risk factors. In particular, the significance of the intraoperative assessment of lung function has gained in importance over the last few years. The following article describes the possibilities and frontiers of the perioperative assessment of lung function, and focuses especially on the significance of preoperative pulmonary function tests and the intraoperative interpretation of respiratory pressure, flow, and volume loops.

In modern intensive care, enteral nutrition is the route recommended to provide artificial nutrition. The advantages of enteral nutrition are numerous, although not definitely proven [1]. The most important claimed advantages include: Maintenance of the gut mucosal barrier function, with concomitant reduction of endotoxin and bacteria translocation [2]; reduction of nosocomial infection [3]; increased tolerance to carbohydrates; and reduced acute phase response to inflammation or infection [4].

The micronutriment requirements, whether trace elements (inorganic) or vitamins (organic), are tightly linked to the carbohydrate, lipid and protein metabolism, since they are involved in all metabolic pathways as cofactors. The micronutriments also have major immunological, endocrinological and antioxydant functions. Especially in the surgical patient, individual requirements may vary considerably and will be particularly increased in case of prior deficiency, anabolic states, or increased losses (burns, diarrhoea, gastric aspiration, intestinal fistulae, alcoholism, use of renal replacement techniques). In some of these settings, the micronutriment requirements will be independent from the macronutriments: this has been demonstrated for burns and intestinal fistulae. In the case of depletion prior to surgery, an isolated supplementation may be required without starting a proper nutrition. In general, micronutriment supplements will have to be started upon initiation of any artificial nutrition. After elective surgery and in absence of specific losses, the micronutriment requirements will be linked to the metabolic state of the patient and to the energy-protein intakes. This is most striking for the vitamin B group, where the requirements are indicated in mg per 1000 kcal. Vitamins A and E are also at risk in the surgical patient. Recommended micronutriment supplements have been revised in 1994. Some trace element deficiencies (Se, Cr, Mo) can initiate very serious complications and will require special caution in the perioperative period. Other deficiencies (Cu, Zn) result in more slowly evolving clinical pictures, with lesser life-threatening potential, resulting in infections and prolonged wound healing. In such cases, multi-elementary supplements are inadequate, and single element solutions supplements are required. All the micronutriments are characterized by a dose-response curve. The quantity avoiding biochemical dysfunctioning in human pathological situations has not yet been established, and it is unsatisfactory to merely compensate for the losses. This notion of biochemical dysfunctioning phase preceeding the clinical deficiency syndrome is in investigation for many nutriments, especially as the importance of some micronutriments, such as Se and vitamin E, in maintaining antioxidant defences is clearly established. The potential for preventing free radical induced overproduction of cytokines by means of nutritional strategy and enhanced antioxidant defences clearly exists, and is only at an early phase of investigation in patients. The future will be marked by the development of nutritional pharmacology based on pathology-specific micronutriment supplements.

Because Cu, Se, and Zn are involved in immune and antioxidative defense mechanisms and tissue repair, deficiencies might aggravate complications classically observed with burns. After measuring massive cutaneous trace element losses in 10 burn patients, our aim in this study was to determine whether large intravenous intakes of Cu, Zn, and Se can modify serum trace element levels and recovery after major burns. Ten patients, aged 34 +/- 6 yr (mean +/- SD), admitted to the burns center of a Swiss university hospital with thermal burns on 41 +/- 9% of their body surface were studied prospectively, with trace element balance studies from day 1 (D1) to D7 postinjury. Urine and blood samples were also collected on D10, D15, D20, and D25. The patients were divided into two groups of five and received either standard (group 1, control) or greatly increased (group 2, treatment: 4.5 mg Cu, 190 micrograms Se, and 40 mg Zn/day) trace element intakes. Energy and protein intake and wound treatment were similar in both groups. The treatment group was characterized by improved Cu, Se, and Zn status (increase in serum levels and various protein indicators), a much larger leukocyte increase between D4 and D14 (mainly neutrophils), and shorter hospital stay (45 days) compared with the untreated group (57 days). Grafting requirements were more extensive in group 1. Although severity of injury and wound treatment were similar in the groups, the duration of hospitalization was lower in the treated group. Further studies are required to determine whether this is related to trace element supplementation.

Recommended trace element doses during parenteral nutrition have been revised many times and increased, especially in surgical patients. Blood products are known to provide significant amounts of trace elements under certain circumstances. In intensive care patients crystalloids and colloids are also given in large amounts. This study aimed at determining the magnitude of the unrecognized trace element administrations after major burns and/or trauma. Fifteen patients burnt 36 +/- 11% (mean +/- SD) of body surface area, aged 34 +/- 8 years, admitted to the Burns Centre and 11 trauma patients with an Injury Severity Score of 29 +/- 6 points, aged 40 +/- 13 years, admitted to the surgical Intensive Care Unit in a Swiss University Hospital. Prospective study of intakes and urinary excretion from the first post-injury day (D1) to D7. Copper and zinc were analyzed by flame atomic absorption spectrophotometry, and selenium by fluorimetry. The actual trace element administrations were much larger than those prescribed in the 3 groups of patients, and were significantly above the most recent parenteral recommended daily allowance = RDA (2.3 times RDA for copper, 5 times for selenium and zinc in Group 2, which received the largest i.v. supplements). There greatest provision of the 3 elements was by the blood products (packed red cells and frozen plasma) and by the albumin solutions (0.5 mg.L-1 Cu, 90 micrograms.L-1 Se and 2.1 mg.L-1 Zn in the 20% solutions). During the resuscitation phase, crystalloids provided a significant amount of copper (0.14 mg.L-1 NaCl 0.9%, none in dextrose) and zinc (0.3 mg.L-1 of any crystalloid), whereas selenium was not detected.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of omeprazole, an inhibitor of the parietal cell H+-K+-ATPase, on pepsin and acid secretion was studied in an in vitro perfused whole mouse stomach model. Omeprazole inhibited basal and dibutyryl cAMP (DBcAMP)- and histamine-stimulated acid secretion in a dose-dependent fashion with a maximally effective dose of 10(-4) M. At the same time, omeprazole induced a dose-dependent increase of unstimulated pepsin release. This increase was not affected by pretreatment with 10(-3) M atropine or 10(-4) M cimetidine. It was, however, inhibited by preincubation with 10(-4) M carbonyl cyanide m-chlorophenylhydrazone (CCCP). Pepsin secretion after maximally effective doses of histamine or DBcAMP was not affected by 10(-4) M omeprazole. In a concentration of 10(-5) M, the effect of omeprazole was additive to the effect of submaximal concentrations of carbachol and histamine. NaSCN and imidazole mimicked the effect of omeprazole on acid secretion, but pepsin release was only stimulated with 10(-2) M imidazole. Another weak base, benzylamine, stimulated acid and pepsin in parallel. Luminal perfusion with solutions of high K+ concentration did not enhance basal pepsin release. The dissociated response of acid and pepsin secretion indicates that omeprazole does not act selectively on the parietal cell. The stimulation of pepsin secretion might be related to the weak base properties of the compound.

Summary Background & aims Since the publications of the ESPEN guidelines on enteral and parenteral nutrition in ICU, numerous studies have added information to assist the nutritional management of critically ill patients regarding the recognition of the right population to feed, the energy-protein targeting, the route and the timing to start. Methods We reviewed and discussed the literature related to nutrition in the ICU from 2006 until October 2013. Results To identify safe, minimal and maximal amounts for the different nutrients and at the different stages of the acute illness is necessary. These amounts might be specific for different phases in the time course of the patient's illness. The best approach is to target the energy goal defined by indirect calorimetry. High protein intake (1.5 g/kg/d) is recommended during the early phase of the ICU stay, regardless of the simultaneous calorie intake. This recommendation can reduce catabolism. Later on, high protein intake remains recommended, likely combined with a sufficient amount of energy to avoid proteolysis. Conclusions Pragmatic recommendations are proposed to practically optimize nutritional therapy based on recent publications. However, on some issues, there is insufficient evidence to make expert recommendations.