Search

BACKGROUND As one of the most essential technical components of the intensive care unit (ICU), continuous monitoring of patients’ vital parameters has significantly improved patient safety by alerting staff through an alarm when a parameter deviates from the normal range. However, the vast amount of alarms regularly overwhelms staff, and induces alarm fatigue that endangers patients. OBJECTIVE This study focused on providing a complete and repeatable analysis of the alarm data of an ICU’s patient monitoring system. We aimed to develop do-it-yourself (DIY) instructions for technically versed ICU staff to analyse their monitoring data themselves, which is an essential element for developing efficient and effective alarm optimization strategies. METHODS This observational study was conducted using alarm log data extracted from the patient monitoring system of a 21-bed surgical ICU in 2019. DIY instructions were iteratively developed in informal interdisciplinary team meetings. The data analysis was grounded on a framework consisting of five dimensions, each with specific metrics: alarm load, ie, alarms per bed per day, alarm flood conditions, alarm per device and per criticality; avoidable alarms, ie, the amount of technical alarms; responsiveness and alarm handling, ie response time; sensing, ie, usage of the alarm pause function; and exposure, ie, alarms per room type. Results were visualized using the R package ggplot2 to provide detailed temporal insights into the ICU’s alarm situation. RESULTS We developed step by step DIY instructions for self-analysis of patient monitoring data, including the scripts for data preparation and analysis. The alarm load in the respective ICU was quantified by 152.5 alarms per bed per day on average (SD 42.2), and alarm flood conditions with on average 69.55 per day (SD 31.12) that both occurred mostly in the morning shifts. Most alarms were issued by the ventilator, invasive blood pressure device and electrocardiogram (ie, high and low blood pressure, high respiratory rate, low heart rate). In regard to avoidable alarms, technical alarms by the ECG were the most frequent (eg, lead fallen off). The median response time to alarms yielded 8s (range 0-600). The alarm pause function was applied 10.86 times per bed per day (SD 2.6), and in 91% (19,334/21,194) was not actively terminated, resulting in a proper pause to pause ratio of 0.09:1. The exposure to alarms per bed per day was higher in single rooms (26%, mean 172.9/137.2 alarms per day per bed). 69% of all alarms (2,199.9/3,202.4, SD 651.2) were on average issued by 7.6 of 21 beds per day (36%). CONCLUSIONS Analyzing ICU alarm log data provides valuable insights into the current alarm situation. Our results call for alarm management interventions that effectively reduce the number of alarms in order to ensure patient safety and ICU staff’s work satisfaction. We hope our DIY instructions encourage others to follow suit in analyzing and publishing their ICU alarm data. CLINICALTRIAL NCT04661735

The case is presented of a 72-year-old male patient suffering from active infective aortic prosthetic endocarditis two months after emergency surgery with aortic valve implantation, and who underwent aortic arch reconstruction using a Dacron patch, due to the spontaneous post-procedural migration of a transcatheter-implanted aortic valve. The heart team considered transcatheter valve implantation (TAVI) due to the increased operative risk demonstrated by a EuroSCORE II of 10.9%, including chronic obstructive pulmonary disease (GOLD 3), cirrhosis (Child-B), esophageal varicose stage 2, chronic renal failure stage 3, and reduced left ventricular ejection fraction. Subsequently, the EuroSCORE II was extremely high (76%) due to active infective prosthetic endocarditis and the aortic arch reoperation. A sutureless aortic valve was implanted and a pericardial patch repair of the aortic ascending and arch completed. Sternal re-stabilization was required postoperatively. The patient was discharged home after 42 days, and no recurrent endocarditis was diagnosed during follow up.

Objective: Unplanned readmission of hospitalized patients to an ICU is associated with an increased mortality and hospital length of stay. The ability to identify patients at risk, who would benefit from prolonged ICU treatment, is limited. The aim of this study is to validate a previously published numerical index named the Stability and Workload Index for Transfer in a heterogeneous group of ICU patients. Design: In this retrospective data analysis, the Stability and Workload Index for Transfer score was calculated for all patients, and the ability of the score to predict readmission was compared with the original publication. Setting: Four ICUs, one intermediate care unit, and one postanesthesia care unit of the department of anesthesia and intensive care of a university hospital. Patients: All consecutive patients treated in one of the units. Interventions: None. Measurements and Main Results: Unplanned ICU readmissions or unexpected death within 7 days of ICU discharge. The data of 7,175 patients were included in the analysis. Five hundred ninety-six patients were readmitted or died within 7 days of discharge. The patients who are readmitted to the ICU are significantly older and have significantly higher scores that define the severity of disease at the time of admission and discharge of their first ICU stay. The source of admission for the initial ICU stay did not differ (p = 0.055), and the last Glasgow Coma Scale and the last Pao(2)/Fio(2) ratio before discharge from the ICU were higher in patients who did not need a readmission to the ICU. The performance of the Stability and Workload Index for Transfer score is poor with an area under the receiver operator curve of 0.581 (95% CI, 0.556-0.605; p < 0.001). Conclusions: Based on the data from our patients, the proposed Stability and Workload Index for Transfer score by Gajic et al is not ideal in aiding the clinician in the decision, if a patient can be discharged safely from the ICU and further research is necessary to define the patients at risk for readmission.

Purpose Combination of prone positioning (PrP) and extracorporeal membrane oxygenation (ECMO) might be beneficial in severe acute respiratory distress syndrome (ARDS), because both approaches are recommended. However, PrP during ECMO might be associated with complications such as dislocation of ECMO cannulae. We investigated complications and change of oxygenation effects of PrP during ECMO to identify “responders” and discuss our results considering different definitions of response in the literature. Methods Retrospective analysis of complications, gas exchange, and invasiveness of mechanical ventilation during first and second PrP on ECMO at specified time points (before, during, and after PrP). We used multivariate nonparametric analysis of longitudinal data (MANOVA) to compare changes of mechanical ventilation and hemodynamics associated with the first and second procedures. Results In 12 ECMO patients, 74 PrPs were performed (median ECMO duration: 10 days (IQR: 6.315.5 days)). No dislocations of intravascular catheters/cannulae, endotracheal tubes or chest tubes were observed. Two PrPs had to be interrupted (endotracheal tube obstruction, acute pulmonary embolism). PaO2/FiO2-ratio increased associated with the first and second PrP (p = 0.002) and lasted after PrP in 58% of these turning procedures (“responders”) without changes in ECMO blood flow, respiratory pressures, minute ventilation, portion of spontaneously triggered breathing, and compliance. Hemodynamics did not change with exception of increased mean pulmonary arterial pressure during PrP and decrease after PrP p≤0.001), while norepinephrine dosage decreased (p = 0.03) (MANOVA). Conclusions Prone position during ECMO is safe and improves oxygenation even after repositioning. This might ameliorate hypoxemia and reduce the harm from mechanical ventilation.

Volume management and vasopressor support remain the gold standard of critical care for patients with shock. However, prolonged therapy with catecholamines in high doses is associated with a negative patient outcome. The aim of the present study was to analyze the administered levels of catecholamines over time with respect to survival, and to identify a cut-off to allow a prediction of survival. Consecutively, 9,108 adult patients during 22 months were evaluated. This group included 1,543 patients treated with epinephrine and/or norepinephrine with any dose at any time. Time and dosages of the applied drugs, the sequential organ failure assessment and acute and chronic health evalutation II scores on admission and daily, the length of intensive care unit stay, and the outcomes were recorded. The non-survivors received higher doses of norepinephrine and epinephrine than the survivors (p

Introduction The development and implementation of practice guidelines might be an important tool to evaluate the different practices and to consider different local strategies. Methods A postal questionnaire with 37 questions was sent to the leading physicians of 80 intensive care units in Germany, treating patients after cardiothoracic surgery. The survey covered the same core questions on current practice of hemodynamic monitoring, volume replacement, inotropic/vasopressor support, and transfusions before and after the publication of an S3 guideline. Results A total of 77.5 % of the completed questionnaires were returned. Monitoring changed to increased use of central venous oxygen saturation (ScvO2) in 55.1% (2005: 20.9%), end-tidal CO2-monitoring 36.2% (2005: 24.3%), and decreased use of the left atrial pressure with 12.3% (2005: 23.3%) and pulmonary artery catheter 47.5% (2005: 58.2%). For volume therapy, there is a decreased use of Hydroxyethyl starch (HES) with 38.7% (2005: 63.4%) and an increased use of crystalloids 41.9% (2005: 22.4%). For inotropes, there is a trend to a decreased use of dopamine with 9.7% (2005: 29.1%, P = 0.074). The clinical relevance of the guidelines was judged ‘high’ by 43.5% and ‘medium’ by 50% of the responding physicians; however, change of treatments was reported by one quarter of respondents. Conclusion Despite ongoing variability in the use of monitoring devices, volume replacement and vasopressor/inotrope use in cardiac surgery patients, there have been some changes in the therapy of these patients after publication of the guidelines. Because the guideline has been considered as clinically relevant, further interdisciplinary development and implementation support should be considered.

Background: Medication errors occur in approximately one out of five doses in a typical hospital setting. Patients in the intensive care unit (ICU) are particularly susceptible to errors during the application of intravenous drugs as they receive numerous potent drugs applied by syringe pumps. Objective: The aim of this study was to analyse the effects on potential harmful medication errors and to address factors that have potential for improving medication safety after the introduction of a standardized drug library into syringe pumps with integrated decision support systems. Methods: A team of physicians and nurses developed a dataset that defined standardized drug concentrations, application rates and alert limits to prevent accidental overdosing of intravenous medications. This dataset was implemented in 100 syringe pumps with the ability to log programming errors, alerts, reprogramming events and overrides (‘smart pumps’). In this retrospective pilot study, all pump-related transaction data were obtained from the pump logs, by downloading the data from the pumps, covering 20 months of use between 1 April 2008 and 30 November 2009. Patient data were gathered from the electronic patient charts. The study was performed in a cardiothoracic ICU of the Charite University Hospital, Berlin, Germany. Results: A total of 7884 patient treatment days and 133601 infusion starts were evaluated. The drug library with the features of the dose rate was used in 92.8% of the syringe pump starts, in 1.5% of the starts a manual dosing mode without the use of the drug library was used and in 5.7% of the starts the mode ‘mL/h’, without any calculation features, was used. The most frequently used drugs were vasoactive drugs, followed by sedation medication. The user was alerted for a potentially harmful overdosing in 717 cases and in 66 cases the pumps were reprogrammed after the alert. During the early morning hours a higher rate of alarms was generated by the pumps, compared with the rest of the day. Conclusions: Syringe pumps with integrated safety features have the capacity to intercept medication errors. The structured evaluation of the bedside programming history in log recordings is an important benefit of smart pumps, as this enables the users to obtain an objective measurement of infusion practice, which can be used to provide team feedback and to optimize the programming of the pumps. Further research will show if the combination of these data with physiological data from ICU patients can improve the safety of pump-driven intravenous medication.

The purpose of this study was to retrospectively evaluate whether computed tomography (CT) findings have prognostic value for the prediction of mortality and severity of the clinical course in patients presenting with early stage of acute respiratory distress syndrome (ARDS) due to swine-origin influenza A (S-OIV).Chest CT (16-/64-row multidetector CT) of 23 patients (of whom 9 patients died) were retrospectively reviewed by three independent blinded observers. The CT findings were graded on a 3-point scale (1: normal attenuation, 2: ground-glass attenuation, 3: consolidation). The extent of each abnormality was determined by visually estimating the percentage (to the nearest 10%) of the affected lung parenchyma in each zone and multiplied by the CT-score described above.All patients presented with a mixture of bilateral patchy consolidations and ground glass opacities. Spearman rank correlation in evaluation of the presence and extent of lung abnormalities by the three different observers was good (correlation coefficient, 0.876-0.922; p0.001). The overall CT-score in survivors (mean, 96.0 (± 26.2); range, 53-158) was significantly lower than that in non-survivors (mean, 116.2 (± 14.0); range, 101-139). ROC analysis revealed an area under curve of 0.79 (p = 0.021) for the CT score with an optimal cutoff value of a CT-score of 100 for prediction of survival, with a sensitivity of 100% and a specificity of 64% (accuracy, 78%). For this optimal cutoff, Kaplan-Meier estimator showed a significant difference for the survival ratio (p = 0.011).In patients with severe ARDS due to S-OIV-infection, the CT-score has a prognostic value in the prediction of mortality.

Pneumonia accounts for almost half of intensive care unit (ICU) infections and nearly 60% of deaths from nosocomial infections. It increases hospital stay by 7-9 days, crude mortality by 70% and attributable mortality by 30%.Our purpose was to assess the impact of standard operating procedures adapted to the local resistance rates in the initial empirical treatment for pneumonia on duration of first pneumonia episode, duration of mechanical ventilation, and length of ICU stay.Prospective observational cohort study with retrospective expert audit.Five anesthesiologically managed ICUs at University hospital (one cardio-surgical, one neurosurgical, two interdisciplinary, and one intermediate care).Of 524 consecutive patients withor = 36 hr ICU treatment 131 patients with pneumonia on ICU were identified. Their first pneumonia episode was evaluated daily for adherence to standard operating procedures. Pneumonia was diagnosed according to the American Thoracic Society guidelines. Patients with70% compliance were assigned to high adherence group (HAG), patients withor = 70% to low adherence group (LAG).HAG consisted of 45 (49 first episode) patients, LAG of 86 (82 first episode) patients, respectively. Mean duration of treatment of the first pneumonia episode was 10.11 +/- 7.95 days in the LAG and 6.22 +/- 3.27 days in the HAG (p = 0.001). Duration of mechanical ventilation was 317.59 +/- 336.18 hrs in the LAG and 178.07 +/- 191.33 hrs in the HAG (p = 0.017). Length of ICU stay was 20.24 +/- 16.59 days in the LAG and 12.04 +/- 10.42 days in the HAG (p = 0.001).Barriers in compliance need further evaluation.Adherence to standard operating procedure is associated with a shorter duration of treatment of first pneumonia episode, a shorter duration of mechanical ventilation, and a shorter ICU stay.

Delirium is a common complication of critically ill patients and is often associated with metabolic disorders. One of the most frequent metabolic disorders in intensive care unit (ICU) patients is hyperglycaemia. The aim of this retrospective study of 196 adult ICU patients was to determine if there is an association between hyperactive delirium and blood glucose levels in ICU patients. Hyperactive delirium was diagnosed using the delirium detection score. Blood glucose levels were monitored by blood gas analysis every 4 h. Hyperactive delirium was detected in 55 (28%) patients. Delirious patients showed significantly higher blood glucose levels than non-delirious patients Higher overall complication rates, length of ventilation, ICU stay and mortality rates were seen in the delirium group. In a multivariate analysis, glucose level, alcohol abuse, APACHE II score, complication by hospital-acquired pneumonia and a diagnosis of polytrauma on-admission all significantly influenced the appearance of delirium.

Die Intensivmedizin der Charite wurde und wird einem umfangreichen Reorganisationsprojekt unterzogen. Ziel dieser Untersuchung war es zu evaluieren, ob die derzeit geschaffenen Strukturen dem Vergleich mit DRG-basierten Personalkosten standhalten konnen. Die medizinischen Personalkosten aller intensivmedizinischen Bereiche der „Erwachsenenmedizin“ der Charite: Intensivstationen, Uberwachungsstationen und „post-anaesthesia care units“ (PACUs), wurden mit den modularen Erlosen fur Personalkosten fur den Kostenstellenbereich „Intensivmedizin“, die sich aus der Summe aller effektiv erlosten DRGs der Falle uber 14 Lebensjahren der Charite des Jahres 2005 zusammensetzen, verglichen. Diese wurden in das G-DRG 4.0 des Jahres 2006 uberfuhrt. Der Vergleich beruht auf der aktuellen Personalkostenentwicklung an der Charite im Jahr 2006. Die ansteigenden Personalkosten wurden beziffert aufgrund der Tatsache, dass an der Charite unlangst ein Vorschalttarifvertrag fur die in der Krankenversorgung tatigen Mediziner und anderen Wissenschaftler geschlossen wurde. Fur die anderen Dienstarten wird ebenfalls eine Personalkostensteigerung erwartet, die sich derzeit aber nur ungefahr abschatzen lasst. Der Vergleich zeigt, dass die Personalkosten der universitaren Intensivmedizin an der Charite auf der Grundlage des bundeseinheitlichen Basisfallwerts von derzeit 2836 EUR eine Deckungslucke von nur 4,2% aufweisen. Allerdings zeigt der Vergleich aber auch, dass eine deutliche Angleichung der Personalkosten an die im DRG-System erzielbaren Erlosanteile als Ergebnis der Reorganisationsmasnahmen stattgefunden hat. Mit dem im Land Berlin fur das Jahr 2006 vereinbarten (gekappten) Basisfallwert von 2955 EUR wird eine Kostendeckung moglich sein. Mit Blick darauf, dass infolge des Projektes verbesserte Kostenstrukturen erst mit der Zeit wirksam werden, besteht an der Charite die begrundete Erwartung, spatestens im Jahr 2010 mit dem bundeseinheitlichen Basisfallwert von geschatzten 2949 EUR in der universitaren Intensivmedizin profitabel arbeiten zu konnen. Die Intensivmedizin an der Charite umfasst das maximale Spektrum der konservativen und operativen Medizin. Nach einer umfassenden Reorganisation ist diese Intensivmedizin unter den Bedingungen des 4.0 G-DRG-Systems im Hinblick auf die Personalkosten kostendeckend moglich. Durch konsequente strukturelle Reorganisationen lassen sich Skaleneffekte positiv nutzen; dies fuhrt in der Folge zu einer kostendeckenden Personalstruktur auch in der „High-end-Intensivmedizin“.

The treatment of infections is one of the central elements in post-operative intensive care and contributes significantly to outcome. Measures of quality of antibiotic therapy include survival, duration of ICU or in-patient stay and rates of organ failure, antibiotic resistance or nosocomial infection. The pre-requisites for antibiotic prescribing in the intensive care unit are as follows: the treatment has to be started early, the antibiotic must be effective against probable causative organisms, the patient's risk factors for infection with multi-drug resistant organisms must be taken into account, local patterns of resistance must be known, an effective dosage must be used and the duration of therapy should be adjusted to the patient's risk factors and probable causative organisms. The multiplicity of factors which must be taken into account when determining timely empirical therapy and the fact that this must be possible at any time of the day, make local standard operating procedures for antibiotic prescribing imperative. These standards should reflect local resistance patterns and should be regularly reviewed. The aim of this educational article is to portray a selection of the pre-requisites and strategies available in the treatment of infections with antibiotics in intensive care medicine.

We studied the influence of sequential involvement of the gastrointestinal (GI) tract on the development of multiple organ dysfunction (MOD) after cardiopulmonary bypass (CPB). One hundred and forty-six patients undergoing elective cardiac surgery were included in this prospective observational study. Standardized oral inert-sugar tests (sucrose, lactulose, mannitol, sucralose) were performed before and after CPB in different patients. Enzyme-linked immunosorbent assay of plasma levels of endotoxin core antibodies (EndoCAb) were performed peri-operatively. The functional mucosal surface was calculated from the amount of mannitol absorbed from the GI tract. Lower urine concentrations of absorbed mannitol were observed pre-operatively in patients developing MOD. In binary logistic regression this was an independent parameter. Decreased plasma concentrations of EndoCAb after surgery were seen in every patient, but were more significant in patients developing MOD. A reduced pre-operative functional mucosal surface may predict the early occurrence of MOD after surgery.

Monoplane hemodynamic TEE (hTEE) monitoring (ImaCor(®) ClariTEE(®)) might be a useful alternative to continuously evaluate cardiovascular function and we aimed to investigate the feasibility and influence of hTEE monitoring on postoperative management in cardiac surgery patients. After IRB approval we reviewed the electronic data of cardiac surgery patients admitted to our intensive care between 01/01/2012 and 30/06/2013 in a case-controlled matched-pairs design. Patients were eligible for the study when they presented a sustained hemodynamic instability postoperatively with the clinical need of an extended hemodynamic monitoring: (a) hTEE (hTEE group, n = 18), or (b) transpulmonary thermodilution (control group, n = 18). hTEE was performed by ICU residents after receiving an approximately 6-h hTEE training session. For hTEE guided hemodynamic optimization an institutional algorithm was used. The hTEE probe was blindly inserted at the first attempt in all patients and image quality was at least judged to be adequate. The frequency of hemodynamic examinations was higher (ten complete hTEE examinations every 2.6 h) in contrast to the control group (one examination every 8 h). hTEE findings, including five unexpected right heart failure and one pericardial tamponade, led to a change of current therapy in 89% of patients. The cumulative dose of epinephrine was significantly reduced (p = 0.034) and levosimendan administration was significantly increased (p = 0.047) in the hTEE group. hTEE was non-inferior to the control group in guiding norepinephrine treatment (p = 0.038). hTEE monitoring performed by ICU residents was feasible and beneficially influenced the postoperative management of cardiac surgery patients.

Nowadays 40-50 % of the patients receive inappropriate antibiotic treatment. Evidence based recommendations are not considered and there is an increasing burden of resistant pathogens. Therefore, standard operating procedures (SOPs) should be implemented considering guidelines and resistant species in the specific ICU. The authors developed algorithms and generated a user friendly computer program available for all ICU physicians all the time.

Background: Previous studies have shown that 20% of all patients admitted to the hospital abuse alcohol and have increased morbidity after surgery. Long-term alcoholic patients are shown to suffer from immune alterations, which might be critical for adequate postoperative performance. Cardiac surgery with cardiopulmonary bypass (CPB) also leads to pronounced immune alteration, which might be linked with patients’ ability to combat infections. Therefore, the aim of our study was to investigate the perioperative levels of TNF-alpha, interleukin-6, interleukin-10, and cortisol in long-term alcoholic and nonalcoholic patients undergoing cardiac surgery to elucidate a possible association with postoperative infections. Methods: Forty-four patients undergoing elective cardiac surgery were included in this prospective study. Long-term alcoholic patients (n= 10) were defined as having a daily ethanol consumption of at least 60 g and fulfilling the Diagnostic and Statistical Manual of Mental Disorders for alcohol abuse. The nonalcoholic patients (n= 34) were defined as drinking less than 20 g ethanol per day. Blood samples were obtained to analyze the immune status upon admission to hospital, the morning before surgery and on admission to the ICU, the morning of days one and three after surgery. Results: Basic characteristics of patients did not differ between groups. Long-term alcoholics had a fourfold increase in postsurgery infection rate and prolonged need for ICU treatment and mechanical ventilation. Postoperative levels of interleukin-10 and cortisol were significantly increased in long-term alcoholic patients compared with nonalcoholic patients. These observations were in line with postoperative interleukin-10 being predictive for postoperative infectious complications. Conclusions: The increased infection rate in long-term alcoholics strengthens the urgent need for interventional approaches providing modulation of the perioperative immune and HPA response in these high-risk patients to counteract their postoperative immune suppression.

Levosimendan is a recently developed drug which is not yet approved for clinical routine use in Germany. The clinical use is limited to a few selected cases and it has been used as a salvage therapy in patients with severe heart insufficiency. As a potent inodilator it has been given to patients with severe heart failure, when all other therapeutic options have failed. However, in some European countries levosimendan is used in clinical routine situations and the European Society of Cardiologists has included the drug in their guidelines for treatment of acute heart failure. The following article describes the main pharmacological characteristics of levosimendan and summarises the indications for this new drug for physicians working in the field of anaesthesia or intensive care.

Background: The law regarding transfusions ‘Transfusionsgesetz’ of July 7th, 1998 requires all health-care facilities to implement a quality assurance system concerning the usage of

Background: Heparin-induced thrombocytopenia type II (HIT II) is a rare but potentially life-threatening complication of heparin therapy. Hitherto, only few reports on HIT II in infants and children have been published. In particular, infants and children who have to be operated under cardiopulmonary bypass are at risk as an alternative anticoagulation is required. Case Presentation: We report on an infant with a congenital heart defect who was scheduled for cardiac surgery (Damus Kaye-Stansel procedure) with cardiopulmonary bypass. In the intensive care unit, an HIT II was diagnosed. Before surgery, the infant was pretreated with epoprostenol sodium (incrementally increasing up to a maximum dose of 30 ng/kg/min) before heparin was administered shortly after sternotomy. Mean arterial pressure was kept stable with an infusion of norepinephrine and the course of the cardiopulmonary bypass showed no signs of thrombosis. Drainage loss in the postoperative period was moderate. Conclusion: In HIT II infants, pretreatment with epoprostenol sodium before reexposure to heparin may offer a safe and effective anticoagulation for cardiopulmonary bypass.

OBJECTIVE The objective of this study was to evaluate computed tomography (CT) findings in patients with sepsis with unknown inflammatory focus and acute respiratory distress syndrome. METHODS Acute respiratory distress syndrome findings on CT of 36 patients with sepsis were graded on a 6-point scale, and the percentage of affected lung was estimated. Resulting CT scores were correlated to intensive care scores and survival. RESULTS Forty-four percent of the patients died, revealing a significantly higher CT score than survivors (P = 0.01). Survivors showed larger areas of unaffected lung (P < 0.001), whereas patients with fatal outcome had more ground-glass opacities (P = 0.002; sensitivity, 73%; specificity, 57%) and traction bronchiectasis (P = 0.009; sensitivity, 54%; specificity, 68%). Pulmonary findings on CT did not allow discriminating between a pulmonary and extrapulmonary focus. No significant coherence between CT score and intensive care scores could be revealed. CONCLUSIONS A CT scoring system based on pulmonary findings in patients with sepsis with acute respiratory distress syndrome comprises prognostic implications in terms of the patients' survival.

Standardised drug syringe labelling may reduce drug errors, but data on drug syringe labelling use in European anaesthesiology departments are lacking.Survey investigating if standardised drug syringe labelling is used, and if there are geographical, demographic and professional differences in hospitals with and without use of drug syringe labelling.Structured, web-based anonymised questionnaire.European anaesthesia departments.Members of the European Society of Anaesthesiology.Online survey from 2 February to 12 April 2011.Standardised drug syringe labelling use and, if yes, drug syringe labelling for insulin and norepinephrine.Descriptive and comparative analyses of users and nonusers of standardised drug syringe labelling.One thousand and sixty-four of 4163 members (25.6%) from 72 countries participated, among whom 660 (62.0%) used standardised drug syringe labelling; in Northern and Western Europe, there were 428 users of drug syringe labelling and 112 nonusers, and in Southern and Eastern Europe, there were 184 users and 255 nonusers (P 0.001). Three hundred and ninety-four (37%) respondents used standardised drug syringe labelling hospital-wide; 202 (30.1%) used International Organisation of Standardisation-based standardised drug syringe labelling, 101 (15.1%) used similar systems, 278 (41.5%) used other systems and 89 (13.3%) used labels supplied by drug manufacturers. The label colour for insulin was reported as white or 'none' in 519 (76.7%) answers and another colour in 158 (23.3%). The label colour for norepinephrine was reported as violet in 206 (30.4%) answers, white or 'none' in 226 (33.3%), red in 114 (16.8%) and another colour in 132 (19.5%). A standardised drug syringe labelling system supplied by the pharmaceutical industry was supported by 819 (76.9%) respondents, and not supported by 227 (21.3%).A majority of European anaesthesiology departments used standardised drug syringe labelling, with regional differences and mostly without following an international standard. Thus, there are options for quality improvement in drug syringe labelling.

Ziele: Evaluation der pulmonalen Veranderungen septischer Patienten mit ‘acute respiratory distress syndrome' (ARDS) und Differenzierung zwischen pumonalem und extrapulmonalem infektiosen Fokus sowie Patientenmanagement und -uberleben. Methode: 36 Ganzkorper-CTs septischer Patienten mit unbekanntem Fokus und ARDS wurden von zwei erfahrenen Radiologen im Konsensus hinsichtlich septischer Ursache und in Abgleich mit den Patientenakten ausgewertet. Das ARDS-Stadium wurde in der CT unter Berucksichtigung der Ausdehnung und des Ausmasses der pulmonalen Veranderungen in einer 6-Stufen-Skala eingeteilt. Die CT-Ergebnisse wurden mit den klinischen Daten und dem Patientenuberleben korreliert. Ergebnis: 44% der Patienten starben innerhalb des Krankheitsverlaufes. Diese Patienten zeigten einen signifikant hoheren CT-Score als die Uberlebenden (p=0,010). ARDS-typische pulmonale Veranderungen wurden bei allen Patienten beobachtet, die Uberlebensgruppe zeigte jedoch grosere Areale nicht betroffenen Lugenparenchmyms (p

Evidence-based medicine is often inadequately implemented in intensive care units (ICU); the aim of this study was to improve its implementation via a technical feedback system, using key performance indicators (KPI). The study evaluated 205 patients treated in a cardiac surgical ICU over a 6-month period (3 months before and 3 months after implementation of the feedback system). KPI adherence rates for sedation, delirium and pain monitoring, and completion of a weaning protocol before and after the implementation of the feedback system, were compared. Adherence rates for pain and delirium monitoring, and implementation of the weaning protocol, were significantly increased by the intervention. Adherence to KPIs for sedation, which were high at baseline, could not be further improved. Daily display of KPI implementation had a positive effect on adherence to standard operating procedures. Adherence to guidelines may be improved by using this feedback system as part of the clinical routine.

A 26-year-old man with osteogenesis imperfecta and severe aortic regurgitation was scheduled for aortic valve replacement. As previously described by other authors the operation was difficult owing to the friability and weakness of the tissues. Mean blood losses of 153 mL per hour during the first 7 postoperative hours were observed. Despite normal coagulation indicators the bleeding did not stop and recombinant factor VIIa was applied at 40 μg/kg. Bleeding was successfully stopped after this single application.

Standardised coloured drug labels may increase patient safety in the intensive care unit (ICU). The rates of adherence to standardised drug syringe labelling (DSL) in European and non-European ICUs, and the standards applied are not known. The aim of this survey among ESICM members was to assess if and what standardised drug syringe labelling is used, if the standards for drug syringe labelling are similar internationally and if intensivists expect that standardised DSL should be delivered by the pharmaceutical industry. A structured, web-based, anonymised survey on standardised DSL, performed among ESICM members (March-May 2011; Clinicaltrials.gov NCT01232088). Descriptive data analysis was performed and Fisher's exact test was applied where applicable. Four hundred eighty-two submissions were analysed (20 % non-European). Thirty-five percent of the respondents reported that standardised drug labelling was used hospital-wide, and 39 % reported that standardised DSL was used in their ICU (Europe: Northern 53 %, Western 52 %, Eastern 17 %, Southern 22 %). The International Organization of Standardization (ISO) 26825 norm in its original form was used by 30 %, an adapted version by 19 % and local versions by 45 %; 6 % used labels that were included in the drug's packaging. Eighty percent wished that the pharmaceutical industry supplied ISO 26825 norm labelling together with the drugs. Standardised DSL is not widely applied in European and non-European ICUs and mostly does not adhere strictly to the ISO norm. The frequency and quality of DSL differs to a great extent among European regions. This leaves much room for improvement

Das hamodynamische Monitoring und die Differenzialtherapie mittels adaquater Volumensubstitution sowie positiv-inotroper und vasoaktiver Substanzen sind die Grundpfeiler der postoperativen intensivmedizinischen Behandlung von kardiochirurgischen Patienten. Ziel der S3-Leitlinie ist es, die Empfehlungen zum Monitoring und zur Therapie evidenzbasiert zu prufen sowie Zielkriterien hierfur festzulegen. Die Bewertung erhobener Messparameter im Zusammenhang mit der klinischen Gesamtsituation des Patienten erlaubt die Entwicklung eines weiterfuhrenden Therapiekonzepts und die Festlegung von Zielkriterien zur Kontrolle des Behandlungserfolgs. Bislang existieren Leitlinien und Empfehlungen lediglich fur Teilbereiche der kardiochirurgischen Intensivmedizin. So bestehen Leitlinien fur den Einsatz des Pulmonalarterienkatheters und der transosophagealen Echokardiographie fur diesen speziellen Bereich der postoperativen Patientenversorgung. Die Deutsche Gesellschaft fur Thorax-, Herz- und Gefaschirurgie (DGTHG) und die Deutsche Gesellschaft fur Anasthesiologie und Intensivmedizin (DGAI) haben sich daher zum Ziel gesetzt, einen nationalen Ansatz zur Sicherung und Verbesserung der Qualitat der postoperativen kardiochirurgischen Intensivmedizin mit der vorliegenden evidenzbasierten S3-Konsensusleitlinie zu schaffen. Ziel dieser Leitlinie ist eine Bewertung der verfugbaren Monitoringverfahren im Hinblick auf Indikationen, Vorgehen, Aussagen, Limitationen, Kontraindikationen und Risiken; weiterhin die Differenzialtherapie mit Volumenersatzlosungen vs. positiv inotropen und vasoaktiven Substanzen, die differenzierte Katecholamintherapie einschlieslich der Inodilatoren und Kalziumsensitizer sowie die Einsatzkriterien der intraaortalen Ballonpumpe. Die Leitlinie ist in einem standardisierten Prozess nach Vorgaben der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) erstellt worden. Die Verabschiedung der Kernaussagen der Leitlinie erfolgte in zwei Konsensusverfahren unter Moderation der AWMF.

Expert panel consensus was used to develop evidence-based process indicators that were independent risk factors for the main clinical outcome parameters of length of stay in the intensive care unit (ICU) and mortality. In a retrospective, matched data analysis of patients from five ICUs at a tertiary university hospital, agreed process indicators (sedation monitoring, pain monitoring, mean arterial pressure [MAP] ≥ 60 mmHg, tidal volume [TV] ≤ 6 ml/kg body weight, peak inspiratory pressure [PIP] ≤ 35 cmH2O and blood glucose [BG] ≥ 80 and ≤ 130 mg/dl) were validated using a prospective dataset of 4445 consecutive patients. After matching for age, sex and ICU, 634 patients were analysed. Logistic regression of the 634 patients showed that monitoring analgesia and sedation, MAP ≥ 60 mmHg and BG ≥ 80 mg/dl were relevant for survival. Linear regression of the 634 patients showed that analgesia monitoring, PIP ≤ 35 cmH2O and TV ≤ 6 ml/kg were associated with reduced length of ICU stay. Linear regression on all 4445 patients showed analgesia, sedation monitoring, MAP ≥ 60 mmHg, BG ≥ 80 mg/dl and ≤ 130 mg/dl, PIP ≤ 35 cmH2O and TV ≤ 6 ml/kg were associated with reduced length of ICU stay, indicating that adherence to evidence-based key process indicators may reduce mortality and length of ICU stay.

This study evaluated the correlation and agreement between the Bispectral Index (BIS) or A-line Autoregressive Index (AAI) and a clinical scoring system, the Ramsay Sedation Scale (RSS), in 40 patients after elective cardiac surgery and admission to the intensive care unit. All patients received sedation with propofol according to the study protocol. BIS, AAI and RSS were documented at two different levels of sedation: deep sedation RSS 4–6; and slight sedation/extubation RSS 2–3. Both the BIS and AAI agreed well with the RSS (η-coefficients of 0.902 and 0.836, respectively, for mean overall RSS stages). The systems agreed well among each other (overall intra-class correlations of 0.670 for consistency and 0.676 for absolute agreement). There was significant discrimination between RSS 2–3 and RSS 4–6 with BIS and AAI (BIS mean difference of 24.73, 95% confidence intervals [CI] 21.08–28.37; AAI mean difference of 20.90, 95% CI 14.64–27.16). In conclusion, BIS and AAI correlated well with RSS overall and also at different levels of sedation.

Elderly patients account for 42–52% of intensive care unit (ICU) admissions and for almost 60% of all ICU days in the USA and up to 50% receive inappropriate antibiotic treatment. The aim of this study was to evaluate whether adherence to Standard Operating Procedures (SOPs) reduced ICU mortality in an elderly population. The study included consecutive patients ( n = 228) aged ≤ 60 years with an ICU stay of > 72 h. SOPs were based on evidence-based medicine guidelines for diagnosis and treatment of infections, and on local resistance rates. According to preset indicators of quality management standards and assessment of different degrees of adherence, an implementation rate > 70% was considered adherent (high adherence group [HAG]) and ≤ 70% was considered non-adherent (low adherence group [LAG]). Patients in the HAG ( n = 137) had significantly reduced mortality compared with LAG patients ( n = 91): 5.8% versus 19.8%, respectively. It was concluded that adherence to SOPs based on evidence-based medicine that consider local resistance rates for antibiotic treatment in elderly ICU patients is associated with a lower mortality rate.

The treatment of infections is one of the central elements in post-operative intensive care and contributes significantly to outcome. Measures of quality of antibiotic therapy include survival, duration of ICU or in-patient stay and rates of organ failure, antibiotic resistance or nosocomial infection. The pre-requisites for antibiotic prescribing in the intensive care unit are as follows: the treatment has to be started early, the antibiotic must be effective against probable causative organisms, the patient's risk factors for infection with multi-drug resistant organisms must be taken into account, local patterns of resistance must be known, an effective dosage must be used and the duration of therapy should be adjusted to the patient's risk factors and probable causative organisms. The multiplicity of factors which must be taken into account when determining timely empirical therapy and the fact that this must be possible at any time of the day, make local standard operating procedures for antibiotic prescribing imperative. These standards should reflect local resistance patterns and should be regularly reviewed. The aim of this educational article is to portray a selection of the pre-requisites and strategies available in the treatment of infections with antibiotics in intensive care medicine.

The aim of this study was to assess the effects on postoperative outcome of levosimendan with respect to timing of its administration in cardiac surgery patients.Levosimendan administration was triggered by a severely reduced left ventricular systolic function (left ventricular ejection fraction,35%) and/or signs of a low cardiac output syndrome. A total of 159 patients were retrospectively assigned depending on an early (perioperatively up to the first hour after intensive care unit [ICU] admission) vs late (later than the first hour after ICU admission) start of treatment.Patients receiving levosimendan after the first hour of ICU admission (n = 89) had a significantly increased inhospital (P = .004) and 1-year (P = .027) mortality. Duration of mechanical ventilation (P = .002), incidence of renal dysfunction (P = .002), and need of renal replacement therapy (P = .032) were significantly increased in the late start group. A late start of levosimendan treatment was associated with an odds ratio of 2.258 (95% confidence interval, 1.139-4.550; P = .021) for inhospital mortality and an adjusted hazard ratio of 1.827 (95% confidence interval, 1.155-2.890; P = .010) for 1-year survival.Findings of this retrospective analysis favor an "early," that is, intraoperatively up to the first hour after ICU admission, start of perioperative levosimendan treatment to maximize its ability to reduce mortality and morbidity.

Background: In Germany, more than 100,000 patients are monitored and treated in 80 intensive care units (ICUs) following cardiac surgery each year. The controversies concerning the different methods of hemodynamic monitoring and the appropriate agents for volume therapy and inotropic support are well known. However, little is known about how monitoring and treatment are currently performed. Methods: A questionnaire with 39 questions was sent to the leading physicians of 80 ICUs in Germany, treating patients after cardiac surgery. The questions to be answered covered the current practice of hemodynamic monitoring, volume replacement, inotropic/vasopressor support and transfusions in patients after cardiac surgery. Results: Sixty-nine per cent of the questionnaires were completed and returned. All ICUs used basic monitoring as recommended by the societies. The use of advanced hemodynamic monitoring included the pulmonary artery catheter (58.2%), transesophageal echocardiography (38.1%) and transpulmonary dilution techniques (13%). Crystalloids (21.2%) and colloids (73%) were used for volume replacement. Epinephrine (41.8%) and dobutamine (30.9%) were the first-choice inotropic drugs for the treatment of low cardiac output syndrome, followed by phosphodiesterase inhibitors (14.5%). Second-choice drugs for the treatment of low cardiac output syndrome were enoximone (29%), milrinone (25%) and dobutamine (25%). A written transfusion protocol and a transfusion threshold for red blood cells existed in 59% and 79% of ICUs, respectively. Conclusion: Hemodynamic monitoring and the variability in clinical practice with regard to volume replacement, transfusion triggers and the use of vasopressors/inotropes in cardiac surgery patients tend to follow the results of traditional experience rather than current scientific knowledge. Guidelines are therefore necessary to help to improve the standards of intensive care after cardiac surgery and thus the outcome of patients.

Nowadays 40-50 % of the patients receive inappropriate antibiotic treatment. Evidence based recommendations are not considered and there is an increasing burden of resistant pathogens. Therefore, standard operating procedures (SOPs) should be implemented considering guidelines and resistant species in the specific ICU. The authors developed algorithms and generated a user friendly computer program available for all ICU physicians all the time.

Objective: Analysis of safety and efficacy of recombinant activated factor VII (rFVIIa) used as the last resort for refractory bleeding after cardiac surgery. Design: Retrospective cohort analysis and matched pairs analysis with historic controls were performed. In the rFVIIa group, which also received conventional hemostatic therapy, data were collected for a median of 14 hrs from admission to the intensive care unit (ICU) to the administration of rFVIIa and for the following 24 hrs. In the control group, which received only conventional hemostatic therapy, data were collected for 14 and then for 24 hrs after admission to the ICU. Setting: University hospital. Patients: Twenty-four patients matched with historic controls. Interventions: None. Measurements and Main Results: No thromboembolic complications were observed in the rFVIIa group. Blood loss and transfusion requirements were significantly reduced in the period after the administration of rFVIIa. However, in the 24-hr period after rFVIIa administration, blood loss (p = .140) and transfusion of packed red blood cells (p = .442) and fresh frozen plasma (p = .063) were not different between the rFVIIa and control groups. Platelet concentrates (p = .004) were transfused less in the control group. Mortality and 6-month survival rates were not different between the groups. Conclusions: When used as a last resort, rFVIIa was safe but not incrementally efficacious over conventional hemostatic therapy.

Background: Citrate anticoagulation is an excellent alternative to heparin anticoagulation for patients at high risk of bleeding requiring continuous renal replacement therapy. However, citrate anticoagulation has some potential adverse effects such as metabolic alkalosis and acidosis, hypernatremia, hypo- and hypercalcemia. Thus, most citrate anticoagulation protocols use specially designed dialysis fluids to compensate for most of these disarrangements. This study aimed at establishing a citrate anticoagulation protocol designed for a dialysate flow rate of about 2 l/h. Methods: Based on theoretical considerations we composed a dialysis fluid suitable for a 2 l/h dialysis flow rate. The dialysate contained 133 mmol/l sodium, 2 mmol/l potassium, 1.1 mmol/l magnesium, 25 mmol/l lactate, and 112.2 mmol/l chloride. Results: Twenty-three patients were included in the study. During the treatments minor flow rate adaptations were needed and the treatments were well tolerated. Filter life was appropriate (51.3 ± 24.6 h). Thirteen patients developed a mild metabolic alkalosis (pH > 7.45 plus BE > +3) which was easily counteracted by increasing the dialysis fluid flow (by increments of 500 ml). Acid-base values returned to normal within 24 h after increasing the dialysate flow. The maximum dialysate flow was 3,000 ml/h. Hypernatremia and hypocalcemia were not observed. The systemic ionized calcium concentration was successfully controlled by adjustments of a continuous calcium infusion made with respect to the results of 6-hourly measurements. Conclusion: The analyzed citrate anticoagulation protocol was well tolerated and filter lifetime was appropriate. Regional anticoagulation with trisodium citrate in combination with a customized calcium-free dialysate is a safe and effective alternative to a heparin-based anticoagulation regimen.

An infant, 2 months old, underwent cardiac surgery because of congenital heart defects and pulmonary hypertension. Surgery was performed in hypothermia and cardiac standstill. On the second day after surgery the infant had to be resuscitated due to a combination of acute left-ventricular failure, pulmonary vascular hypertension and a slight right-to-left-shunt. A breakthrough in the treatment was achieved by using levosimendan to improve left-ventricular function and to decrease vascular resistance.

Introduction Most case series suggest that less than half of the patients receiving a mechanical cardiac assist device as a bridge to recovery due to severe post-cardiotomy heart failure survive to hospital discharge. Levosimendan is the only inotropic substance known to improve medium term survival in patients suffering from severe heart failure.