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Background The burden of long-term symptoms (ie, long COVID) in patients after mild COVID-19 is debated. Within a cohort of healthcare workers (HCWs), frequency and risk factors for symptoms compatible with long COVID are assessed. Methods Participants answered baseline (August/September 2020) and weekly questionnaires on SARS-CoV-2 nasopharyngeal swab (NPS) results and acute disease symptoms. In January 2021, SARS-CoV-2 serology was performed; in March, symptoms compatible with long COVID (including psychometric scores) were asked and compared between HCWs with positive NPS, seropositive HCWs without positive NPS (presumable asymptomatic/pauci-symptomatic infections), and negative controls. The effect of time since diagnosis and quantitative anti-spike protein antibodies (anti-S) was evaluated. Poisson regression was used to identify risk factors for symptom occurrence. Results Of 3334 HCWs (median, 41 years; 80% female), 556 (17%) had a positive NPS and 228 (7%) were only seropositive. HCWs with positive NPS more frequently reported ≥1 symptom compared with controls (73% vs 52%, P 6 months ago; anti-S titers correlated with high symptom scores. Acute viral symptoms in weekly questionnaires best predicted long-COVID symptoms. Physical activity at baseline was negatively associated with neurocognitive impairment and fatigue scores. Conclusions Seropositive HCWs without positive NPS are only mildly affected by long COVID. Exhaustion/burnout is common, even in noninfected HCWs. Physical activity might be protective against neurocognitive impairment/fatigue symptoms after COVID-19.

While medical nutrition therapy is an essential part of the care for critically ill patients, uncertainty exists about the right form, dosage, timing and route in relation to the phases of critical illness. As enteral nutrition (EN) is often withheld or interrupted during the intensive care unit (ICU) stay, combined EN and parenteral nutrition (PN) may represent an effective and safe option to achieve energy and protein goals as recommended by international guidelines. We hypothesise that critically ill patients at high nutritional risk may benefit from such a combined approach during their stay on the ICU. Therefore, we aim to test if an early combination of EN and high-protein PN (EN+PN) is effective in reaching energy and protein goals in patients at high nutritional risk, while avoiding overfeeding. This approach will be tested in the here-presented EFFORTcombo trial. Nutritionally high-risk ICU patients will be randomised to either high (≥2·2 g/kg per d) or low protein (≤1·2 g/kg per d). In the high protein group, the patients will receive EN+PN; in the low protein group, patients will be given EN alone. EN will be started in accordance with international guidelines in both groups. Efforts will be made to reach nutrition goals within 48–96 h. The efficacy of the proposed nutritional strategy will be tested as an innovative approach by functional outcomes at ICU and hospital discharge, as well as at a 6-month follow-up.

BackgroundThe burden of long-term symptoms (i.e. long-COVID) in patients after mild COVID-19 is debated. Within a cohort of healthcare workers (HCW), frequency and risk factors for symptoms compatible with long-COVID are assessed.MethodsParticipants answered baseline (August/September 2020) and weekly questionnaires on SARS-CoV-2 nasopharyngeal swab (NPS) results and acute disease symptoms. In January 2021, SARS-CoV-2 serology was performed; in March, symptoms compatible with long-COVID (including psychometric scores) were asked and compared between HCW with positive NPS, seropositive HCW without positive NPS (presumable a-/pauci-symptomatic infections), and negative controls. Also, the effect of time since diagnosis and quantitative anti-S was evaluated. Poisson regression was used to identify risk factors for symptom occurrence.ResultsOf 3’334 HCW (median 41 years; 80% female), 556 (17%) had a positive NPS and 228 (7%) were only seropositive. HCW with positive NPS more frequently reported ≥1 symptom compared to controls (73%vs.52%, pvs.6%, pvs.10%, p=0.004) were more common. Exhaustion/burnout was reported by 24% of negative controls. Many symptoms remained elevated in those diagnosed >6 months ago; anti-S titers correlated with high symptom scores. Acute viral symptoms in weekly questionnaires best predicted long-COVID symptoms. Physical activity at baseline was negatively associated with neurocognitive impairment and fatigue scores.ConclusionsSeropositive HCW without positive NPS are only mildly affected by long-COVID. Exhaustion/burnout is common, even in non-infected HCW. Physical activity might be protective against neurocognitive impairment/fatigue symptoms after COVID-19.summaryIn this prospective healthcare worker cohort, participants with SARS-CoV-2-positive nasopharyngeal swab were most likely to report long-COVID symptoms, whereas seropositive participants without positive swab were only mildly affected. Physical activity at baseline was negatively associated with neurocognitive impairment and fatigue.

Background In a prospective healthcare worker (HCW) cohort, we assessed the risk of SARS-CoV-2 infection according to baseline serostatus. Methods Baseline serologies were performed among HCW from 23 Swiss healthcare institutions between June and September 2020, before the second COVID-19 wave. Participants answered weekly electronic questionnaires covering information about nasopharyngeal swabs (PCR/rapid antigen tests) and symptoms compatible with coronavirus disease 2019 (COVID-19). Screening of symptomatic staff by nasopharyngeal swabs was routinely performed in participating facilities. We compared numbers of positive nasopharyngeal tests and occurrence of COVID-19 symptoms between HCW with and without anti-nucleocapsid antibodies. Results A total of 4812 HCW participated, wherein 144 (3%) were seropositive at baseline. We analyzed 107,807 questionnaires with a median follow-up of 7.9 months. Median number of answered questionnaires was similar (24 vs. 23 per person, P = 0.83) between those with and without positive baseline serology. Among 2712 HCW with ≥ 1 SARS-CoV-2 test during follow-up, 3/67 (4.5%) seropositive individuals reported a positive result (one of whom asymptomatic), compared to 547/2645 (20.7%) seronegative participants, 12 of whom asymptomatic (risk ratio [RR] 0.22; 95% confidence interval [CI] 0.07 to 0.66). Seropositive HCWs less frequently reported impaired olfaction/taste (6/144, 4.2% vs. 588/4674, 12.6%, RR 0.33, 95% CI 0.15–0.73), chills (19/144, 13.2% vs. 1040/4674, 22.3%, RR 0.59, 95% CI 0.39–0.90), and limb/muscle pain (28/144, 19.4% vs. 1335/4674, 28.6%, RR 0.68 95% CI 0.49–0.95). Impaired olfaction/taste and limb/muscle pain also discriminated best between positive and negative SARS-CoV-2 results. Conclusions Having SARS-CoV-2 anti-nucleocapsid antibodies provides almost 80% protection against SARS-CoV-2 re-infection for a period of at least 8 months.

BackgroundThere is insufficient evidence regarding the role of respirators in the prevention of SARS-CoV-2 infection. We analysed the impact of filtering facepiece class 2 (FFP2)vs. surgical masks on the risk of SARS-CoV-2 acquisition among Swiss healthcare workers (HCW).MethodsOur prospective multicentre cohort enrolled patient-facing HCWs from June to August 2020. Participants were asked about COVID-19 risk exposures/behaviours, including preferred mask type when caring for COVID-19 patients outside of aerosol-generating procedures (AGP). For those performing AGPs, we asked whether they used FFP2 irrespective of the patient’s COVID-19 status (i.e. universal use). The impact of FFP2 on i) self-reported SARS-CoV-2-positive nasopharyngeal PCR/rapid antigen tests captured during weekly surveys, and ii) SARS-CoV-2 seroconversion between baseline and January/February 2021 was assessed.ResultsWe enrolled 3’259 participants from nine healthcare institutions, whereof 716 (22%) preferentially used FFP2 respirators. Among these, 81/716 (11%) reported a SARS-CoV-2-positive swab, compared to 352/2543 (14%) surgical mask users (median follow-up 242 days); seroconversion was documented in 85/656 (13%) FFP2 and 426/2255 (19%) surgical mask users. Adjusted for baseline characteristics, COVID-19 exposure, and risk behaviour, FFP2 use was non-significantly associated with a decreased risk for SARS-CoV-2-positive swab (adjusted hazard ratio [aHR] 0·8, 95% CI 0·6-1·0, p=0·052) and seroconversion (adjusted odds ratio [aOR] 0·7, 95% CI 0·5-1·0, p=0·053); household exposure was the strongest risk factor (aHR for positive swab 10·1, p20 patients) COVID-19 exposure (aHR 0·7, pConclusionRespirators compared to surgical masks may convey additional protection from SARS-CoV-2 for HCW with frequent exposure to COVID-19 patients.FundingSwiss National Sciences Foundation, Federal Office of Public Health, Cantonal Health Department St.Gallen

Nutrition therapy, by enteral, parenteral, or both routes combined, is a key component of the management of critically ill, surgical, burns, and oncology patients. Established evidence indicates overfeeding (provision of excessive calories) results in increased risk of infection, morbidity, and mortality. This has led to the practice of "permissive underfeeding" of calories; however, this can often lead to inadequate provision of guideline-recommended protein intakes. Acutely ill patients requiring nutritional therapy have high protein requirements, and studies demonstrate that provision of adequate protein can result in reduced mortality and improvement in quality of life. However, a significant challenge to adequate protein delivery is the current lack of concentrated protein solutions. Patients often have fluid administration restrictions and existing protein solutions are frequently not sufficiently concentrated to deliver a patient's protein requirements. This has led to the development of new enteral and parenteral nutrition solutions incorporating higher levels of protein in smaller volumes. This review article summarizes current evidence supporting the role of higher protein intakes, especially during the early phases of nutrition therapy in acute illness, methods for assessing protein requirements, as well as, the currently available high-protein enteral and parenteral nutrition solutions. There is sufficient evidence (albeit limited from true randomized, controlled studies) to indicate that earlier provision of guideline-recommended protein intakes may be key to improving patient outcomes and that nutritional therapy that tailors caloric and protein intake to the patients' needs should be considered a desired standard of care.

ObjectivesProtecting healthcare workers (HCW) from Coronavirus Disease-19 (COVID-19) is critical to preserve the functioning of healthcare systems. We therefore assessed seroprevalence and identified risk factors for Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) seropositivity in this population.MethodsBetween June 22nd and August 15th 2020, HCW from institutions in Northern/Eastern Switzerland were screened for SARS-CoV-2 antibodies. We recorded baseline characteristics, non-occupational and occupational risk factors. We used pairwise tests of associations and multivariable logistic regression to identify factors associated with seropositivity.ResultsAmong 4’664 HCW from 23 healthcare facilities, 139 (3%) were seropositive. Non-occupational exposures independently associated with seropositivity were contact with a COVID-19-positive household (adjusted OR=54, 95%-CI: 31-97) and stay in a COVID-19 hotspot (aOR=2.2, 95%-CI: 1.1-3.9). Blood group 0 vs. non-0 (aOR=0.4, 95%-CI: 0.3-0.7), active smoking (aOR=0.5, 95%-CI: 0.3-0.9) and living with children ConclusionsLiving with COVID-19-positive households showed by far the strongest association with SARS-CoV-2 seropositivity. We identified several potentially modifiable risk factors, which might allow mitigation of the COVID-19 risk among HCW. The lower risk among those living with children, even after correction for multiple confounders, is remarkable and merits further study.

Flussigkeitstherapien sollten keine Routine- oder Standardverordnung sein, sondern wie jede andere medikamentose Therapie immer nach sorgfaltiger Abwagung von Nutzen und Risiken erfolgen.

La therapie liquidienne ne devrait pas constituer une mesure de routine ou standard, mais toujours avoir lieu apres un examen attentif des benefices et des risques, comme pour tout traitement medicamenteux.

Die Coronapandemie hat die hohe Verletzlichkeit von Menschen in Pflegeeinrichtungen gezeigt. Medizinethikerinnen und Medizinethiker anerkennen die grosse Verantwortung von Behörden und Institutionen im Anordnen und Umsetzen von Schutzmassnahmen für diese Menschen. Sie heben gleichzeitig hervor, dass bei ihrer Umsetzung der Schutz des Lebens mit dem Schutz der Persönlichkeit und der Lebensqualität einhergehen muss., Schweizerische Ärztezeitung, 101 (2728)

Zusammenfassung. Die aktuellen und zukünftigen (ethischen) Herausforderungen in der Intensivmedizin werden stark durch die aktuellen Entwicklungen in der Demographie und in der digitalen Welt beeinflusst. Ersteres wird Herausforderungen verschärfen, die bereits heute bestehen. Die digitale Transformation wird zur wahrscheinlich fundamentalsten Veränderung führen, die die moderne Medizin je gesehen hat. Nebst der personalisierten Medizin wird das Medizinalpersonal gefordert, sich über das Wissen und Können hinaus wieder vermehrt mit der Medizin als Kunst zu befassen und der Interaktion mit dem Patienten bzw. auch seinen Angehörigen ein hohes Gewicht beizumessen.

Zusammenfassung. Die überwiegende Mehrzahl der 20 000 pro Jahr in der Schweiz wegen Schädel-Hirn-Trauma hospitalisierten Patienten läuft unter dem Diagnose-Kontinuum mildes Schädel-Hirntrauma/Commotio cerebri. Glücklicherweise erholt sich die Mehrzahl dieser Patienten nach Tagen bis Wochen vollständig. Allerdings muss bei ca. 15 % dieser Patienten mit prolongierten bis hin zu persistierenden Beeinträchtigungen gerechnet werden, was u.U. erheblich negative Auswirkungen auf deren Lebensqualität hat. Dies trifft insbesondere auf Patienten zu, die sich wiederholte milde Hirnverletzungen (z.B. im Rahmen von Kontaktsport) zugezogen haben. Unglücklicherweise werden viele dieser Patienten nie richtig diagnostiziert und oft als Hypochonder oder Simulanten abgestempelt. Das verhindert eine adäquate Rehabilitation und Unterstützung. Diese Mini-Review hat zum Ziel, den aktuellen Stand des Wissens bezüglich pathophysiologischen und klinischen Auswirkungen des milden Schädel-Hirn-Traumas darzulegen und einige Informationen zur Diagnostik und Behandlung auf Basis bestehender Guidelines zu vermitteln.

Norepinephrine and corresponding intra- and interorgan pathways are of clinical pathophysiologic and pharmacologic importance as exaggerated activation needs to be reduced and insufficient activation must be supported to prevent further deterioration and therapy-induced organ damage. This is of high relevance in critically ill patients in whom various norepinephrine-influenced organ systems are simultaneousy affected with varying degrees of tolerability and resistance to norepinephrine-induced cell damage and finds its maximal challenge in patients suffering from severe traumatic brain injury (TBI). This comprehensive review describes complex pathophysiologic interactions, including hemodynamic, microcirculatory, hormonal, metabolic, inflammatory, and thrombocytic alterations overshadowed by differential consequences of commonly applied pharmacological interventions following TBI. Overall, investigations published to date suggest that receptor-dependent effects of norepinephrine might predispose to complex evolving deterioration especially during intensive care which is characterized by differentiated complication-driven changes and specific complication-dependent needs. In this context, thrombocytes and leukocytes with their adrenergic receptors and differential norepinephric functional regulation are ideal candidates to influence all organs at once. Despite its secure integration of norepinephrine in clinical routine, future emphasis must be directed at unmasking, monitoring, and controlling possible receptor-mediated detrimental influences which could offset anticipated organ protection.

Assess optimal equation to noninvasively estimate intracranial pressure (eICP) and cerebral perfusion pressure (eCPP) following severe traumatic brain injury (TBI) using transcranial color-coded duplex sonography (TCCDS). This is an observational clinical study in a university hospital. A total of 45 continuously sedated (BIS 35 mmHg), and non-febrile TBI patients. eICP and eCPP based on TCCDS-derived flow velocities and arterial blood pressure values using three different equations were compared to actually measured ICP and CPP in severe TBI patients subjected to standard treatment. Optimal equation was assessed by Bland–Altman analysis. The equations: $$ {\hbox{ICP}} = {1}0.{927} \times {\hbox{PI}}\left( {{\hbox{pulsatility}}\,{\hbox{index}}} \right) - {1}.{284} $$ and $$ {\hbox{CPP}} = {89}.{646} - {8}.{258} \times {\hbox{PI}} $$ resulted in eICP and eCPP similar to actually measured ICP and CPP with eICP 10.6 ± 4.8 vs. ICP 10.3 ± 2.8 and eCPP 81.1 ± 7.9 vs. CPP 80.9 ± 2.1 mmHg, respectively. The other two equations, $$ {\hbox{eCPP}} = \left( {{\hbox{MABP}} \times {\hbox{EDV}}} \right)/{\hbox{mFV}} + {14} $$ and $$ {\hbox{eCPP}} = \left[ {{\hbox{mFV}}/\left( {{\hbox{mFV}} - {\hbox{EDV}}} \right)} \right] \times \left( {{\hbox{MABP}} - {\hbox{RRdiast}}} \right) $$ , resulted in significantly decreased eCPP values: 72.9 ± 10.1 and 67 ± 19.5 mmHg, respectively. Superiority of the first equation was confirmed by Bland–Altman revealing a smallest standard deviations for eCPP and eICP. TCCDS-based equation $$ \left( {{\hbox{ICP}} = {1}0.{927} \times {\hbox{PI}} - {1}.{284}} \right) $$ allows to screen patients at risk of increased ICP and decreased CPP. However, adequate therapeutic interventions need to be based on continuously determined ICP and CPP values.

OBJECTIVE: To systematically review the symptoms and types of laryngeal injuries resulting from endotracheal intubation in mechanically ventilated patients in the intensive care unit (ICU). DATA SOURCES: PubMed, Embase, CINAHL, and Cochrane Library from database inception to September 2017. STUDY SELECTION: Studies of adult patients who were endotracheally intubated with mechanical ventilation in the ICU and completed post-extubation laryngeal examinations with either direct or indirect visualization. DATA EXTRACTION: Independent, double-data extraction and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias assessment followed the Cochrane Collaboration’s criteria. DATA SYNTHESIS: Nine studies (7 cohort, 2 cross-sectional) representing 775 patients met eligibility criteria. The mean (standard deviation; 95% confidence interval) duration of intubation was 8.2 (6.0; 7.7–8.7) days. A high prevalence (83%) of laryngeal injury was found. Many of these were mild injuries, although moderate to severe injuries occurred in 13%−31% of patients across studies. The most frequently occurring clinical symptoms reported post-extubation were dysphonia (76%), pain (76%), hoarseness (63%), and dysphagia (49%) across studies. CONCLUSIONS: Laryngeal injury from intubation is common in the ICU setting. Guidelines for laryngeal assessment and post-extubation surveillance do not exist. A systematic approach to more robust investigations could increase knowledge of the association between particular injuries and corresponding functional impairments, improving understanding of both time course and prognosis for resolution of injury. Our findings identify targets for future research and highlight the long-known, but understudied, clinical outcomes from endotracheal intubation with mechanical ventilation in ICU.

The vast majority out of the 20 000 patients annually hospitalized after sustaining a head injury belong to the minor head injury/cerebral concussion continuum. Fortunately, most of the patients show full recovery after days to weeks. However, about 15 % of these patients suffer from prolonged up to permanent sequels potentially impairing their quality of life to a considerable extent. This especially holds true for those who suffer from recurrent minor head injuries (i.e. victims from contact sport accidents). Unfortunately, many of these patients are never diagnosed in an appropriate way and therefore looked at as hypochondriacs or simulants. This prevents adequate rehabilitation and support. This review aims to present current knowledge about pathophysiology and clinical features of minor head injuries and to give some information about diagnostics and treatment according to current guidelines.

Zweiter Beitrag zur funktionsspezifischen Organisation der Spital-Arzteschaft. Vorgestellt wird ein Modell, das klarere Gewaltentrennung und starkere Arbeitsteilung zwischen Professionen und Betriebseinheiten propagiert. Wichtige Elemente sind ein zentrales Medizinisches Qualitats- und Performance-Management sowie die Unterscheidung zwischen Medizinischen Service-Einheiten als Grundversorger im Spital und Medizinischen Spezialisten-Einheiten

Deuxieme article portant sur les possibilites des medecins hospitaliers a s’organiser selon leur fonction. Le modele presente plaide pour une separation plus claire des pouvoirs et pour une meilleure repartition du travail entre professions et unites d’exploitation.

De nombreux hopitaux sont confrontes aux exigences du lean management, du renouvellement des infrastructures ou du changement de leur forme juridique. L’organisation du corps medical est cependant trop peu consideree comme un facteur de succes. Prenant pour exemple le groupe Hirslanden, les auteurs montrent comment des medecins se sont organises de maniere specifique a leur fonction afin de retrouver une repartition du travail pertinente.

Viele Spitaler begegnen den aktuellen Herausforderungen mit Lean Management, Erneuerung der Spitalinfrastruktur oder Umwandlung der Rechtsform. Doch die Organisation der Spitalarzteschaft werde zu wenig als Erfolgsfaktor eines Spitals wahrgenommen. Hier wird am Beispiel der Hirslanden-Gruppe eine funktionsspezifische Organisation der Arzte geschildert. Ein Anliegen dabei ist der Weg zuruck zu sinnvoller Arbeitsteilung und eine Fusion des Chefarzt- und Belegarztsystems.

Extracorporeal membrane oxygenation (ECMO) is increasingly applied as rescue-therapy for patients with severe acute respiratory distress syndrome (ARDS). Here, we evaluate the effect of different configuration strategies (venovenous vs. venoarterial vs. veno-venoarterial) on the outcome. From 2006 to 2008, 30 patients received ECMO for severe ARDS. Patients were divided into three groups according to the configuration: veno-venous (vv; n = 11), venoarterial (va; n=8) or veno-venoarterial (vva; n = 11). Data were prospectively collected and endpoint was 30-day mortality. To identify independent risk factors, univariate analysis was performed for clinical parameters, such as age, body mass index, gender, configuration, low-pH, oxygenation index (pO(2)/FiO(2)) and underlying disease. Thirty-day mortality was 53% (n = 16) for all comers: 63% (n = 7) died in the vv-group, 75% (n = 6) in the va-group and 27% (n = 3) in the vva-group. Although univariate analysis could not rule out a significant predictor for the outcome, there was a trend visible to decreased mortality in the vva-group when compared to vv- and va-groups (27% vs. 63% vs. 75%; P = 0.057). ECMO provides a survival benefit in patients when considering a predicted mortality rate of 80% in ARDS. The configuration mode appears to impact the outcome as the veno-venoarterial appears to further improve the survival in this subset of patients.

Background.The Molecular Adsorbent Recirculating System (MARS) has been shown to clear albumin-bound toxins from patients with liver failure but might cause bleeding complications potentially obscuring survival benefits. We hypothesized that monitoring clotting parameters and bed-side thromboelastography allows to reduce bleeding complications.Methods. Retrospective analysis of 25 MARS sessions during which clotting parameters were monitored by a standardized protocol.Results. During MARS therapy median INR increased significantly from 1.7 to 1.9 platelet count and fibrinogen content decreased significantly from 57 fL−1to 42 fL−1and 2.1 g/L to 1.5 g/L. Nine relevant complications occurred: the MARS system clotted 6 times 3 times we observed hemorrhages. Absent thrombocytopenia and elevated plasma fibrinogen predicted clotting of the MARS system (ROC 0.94 and 0.82). Fibrinolysis, detected by thromboelastography, uniquely predicted bleeding events.Conclusion. Bed-side thromboelastography and close monitoring of coagulation parameters can predict and, therefore, help prevent bleeding complications during MARS therapy.

This study was undertaken as the first national single-center analysis to assess the impact of the new Swiss transplantation law on patient selection, intensive care unit (ICU) complications, outcome, and, in particular, costs in liver transplant recipients treated in our surgical ICU. The first 35 consecutive liver transplant recipients following the new act were compared with the last 35 liver transplant recipients preceding July 1, 2007. Following execution of the new law, recipients were in poorer condition, reflected by significant higher Model for End-Stage Liver Disease (MELD) scores (12 vs. 22; p = 0.006). Furthermore, the MELD group obtained more renal replacement therapies (40.0% vs. 14.3%; p = 0.015). Cumulative one-yr patient survival was comparable in both groups (91.4% vs. 80.1%, p = 0.22). Finally, the additional costs per single case increased 27 000 Euros after the adoption of the new law. Our data serve as an example that political decisions influence patient's selection, and, in turn, complications, finally leading to higher costs of medical treatment. Liver graft allocation according to the MELD system may save lives at the price of increased intensive care efforts.

With the development of a new generation of hydroxyethyl starches (HES), there has been renewed interest in their clinical potential. High doses of first- and second-generation HES were associated with adverse effects on renal function, coagulation, and tissue storage, thereby limiting their clinical applicability. Newer HES products have lower molar substitution and in vivo molecular weight, resulting in more rapid metabolism and clearance. In this review article, the differences between HES generations are highlighted, with particular emphasis on the improved safety profile of the third generation products. These improvements have been achieved with no loss of efficacy, and they contradict the assumption that efficacy of HES solutions is directly linked to plasma concentration. The impact of source material on structure and pharmacokinetics is highlighted, and the role of the carrier solution is critically assessed.

P. Michel , M. Arnold, H.-J. Hungerbuhler, F. Muller, C. Staedler, R. W. Baumgartner, D. Georgiadis, P. Lyrer, H. P. Mattle, R. Sztajzel, B. Weder, B. Tettenborn, K. Nedeltchev, S. Engelter, S. A. Weber, R. Basciani, J. Fandino, F. Fluri, R. Stocker, E. Keller, M. Wasner, M. Hanggi, Y. Gasche, R. Paganoni, L. Regli, for the Swiss Working Group of Cerebrovascular Diseases with the Swiss Society of Neurosurgery and the Swiss Society of Intensive Care Medicine

Critically ill patients commonly show a decrease in hemoglobin concentration during their stay in the intensive care unit. The purpose of the present study was to evaluate whether nonbleeding patients with acute coronary syndrome (ACS) show a similar decrease of hemoglobin, and thereby furnish reference values and analyze possible mechanisms. In this retrospective, descriptive study, the charts of all patients with ACS hospitalized between January 2004 and September 2005 were screened with regard to patient characteristics, time course of hemoglobin, as well as clinical parameters, concomitant drug therapy, and fluid balances. One hundred three nonbleeding patients with ACS were analyzed. They showed an average hemoglobin decrease of 1.27 +/- 1.00 g/dl (p

Sleep-wake disturbances (SWD) are common after traumatic brain injury (TBI). In acute TBI, we recently found decreased CSF levels of hypocretin-1, a wake-promoting neurotransmitter. In the present study, we aimed to delineate the frequency and clinical characteristics of post-traumatic SWD, to assess CSF hypocretin-1 levels 6 months after TBI, and to identify risk factors for posttraumatic SWD. A total of 96 consecutive patients were enrolled within the first 4 days after TBI. Six months later, out of 76 TBI patients, who did not die and who did not move to foreign countries, we included 65 patients (86%, 53 males, mean age 39 years) in our study. Patients were examined using interviews, questionnaires, clinical examinations, computed tomography of the brain, laboratory tests (including CSF hypocretin-1 levels, and HLA typing), conventional polysomnography, maintenance of wakefulness and multiple sleep latency tests (MSLT) and actigraphy. Potential causes of post-traumatic SWD were assessed according to international criteria. New-onset sleep-wake disturbances following TBI were found in 47 patients (72%): subjective excessive daytime sleepiness (EDS; defined by the Epworth Sleepiness Scaleor = 10) was found in 18 (28%), objective EDS (as defined by mean sleep latency5 min on MSLT) in 16 (25%), fatigue (daytime tiredness without signs of subjective or objective EDS) in 11 (17%), post-traumatic hypersomnia 'sensu strictu' (increased sleep need ofor = 2 h per 24 h compared to pre-TBI) in 14 (22%) patients and insomnia in 3 patients (5%). In 28 patients (43% of the study population), we could not identify a specific cause of the post-traumatic SWD other than TBI. Low CSF hypocretin-1 levels were found in 4 of 21 patients 6 months after TBI, as compared to 25 of 27 patients in the first days after TBI. Hypocretin levels 6 months after TBI were significantly lower in patients with post-traumatic EDS. There were no associations between post-traumatic SWD and severity or localization of TBI, general clinical outcome, gender, pathological neurological findings and HLA typing. However, post-traumatic SWD correlated with impaired quality of life. These results suggest that sleep-wake disturbances, particularly EDS, fatigue and hypersomnia are common after TBI, and significantly impair quality of life. In almost one out of two patients, post-traumatic SWD appear to be directly related to the TBI. An involvement of the hypocretin system in the pathophysiology of post-traumatic SWD appears possible. Other risk factors predisposing towards the development of post-traumatic SWD were not identified.

BACKGROUND: Numerous, mostly uncontrolled, observations suggest that artificial liver support with the Molecular Adsorbent Recirculating System (MARS) improves pathophysiologic sequelae and outcome of acute and acute-on-chronic liver failure. MARS is felt to be safe, but extracorporeal circuits may activate coagulation. OBJECTIVE: To assess the frequency of and risk factors for activation of coagulation during MARS treatment. PATIENTS/METHODS: Retrospective analysis of coagulopathy/bleeding complications observed during 83 consecutive MARS sessions in 21 patients (11 men; median age 46 years; median three sessions per patient; median duration of session 8 h). RESULTS: Nine clinically relevant episodes of coagulopathy/bleeding were observed in eight patients, forced to premature cessation of MARS in seven and ended lethal in four. Four complications occurred during the first, five during later (third to seventh) MARS sessions and two bleeders tolerated further sessions without complications. Coagulation parameters worsened significantly also during MARS sessions not associated with bleeding (P< or =0.004). In univariate analysis, patient's age, vasopressor therapy, pretreatment INR, fibrin D-dimer and fibrinogen concentrations, but not severity of underlying disease (MELD, Child-Pugh, SAPS II scores), were significantly associated with coagulopathy (P

Background Underreporting of intraoperative events in anaesthesia is well-known and compromises quality documentation. The reasons for such omissions remain unclear. We conducted a questionnaire-based survey of anaesthesia staff to explore perceived barriers to reliable documentation during anaesthesia. Methods Participants anonymously completed a paper-based questionnaire. Predefined answers referred to potential barriers. Additional written comments were encouraged. Differences between physician and nurse anaesthetists were tested with t-tests and chi-square tests. Results Twenty-five physician and 30 nurse anaesthetists (81% of total staff) completed the survey. The reported problems referred to three main categories: (I) potential influences related to working conditions and practices of data collection, such as premature entry of the data (indicated by 85% of the respondents), competing duties (87%), and interfering interruptions or noise (67%); (II) problems referring to institutional management of the data, for example lacking feedback on the results (95%) and lacking knowledge about what the data are used for (75%); (III) problems related to specific attitudes, e.g., considering these data not useful for quality improvement (47%). Physicians were more sceptical than nurses regarding the relevance of these data for quality and patient safety. Conclusions The common perceived difficulties reported by physician and nurse anaesthetists resemble established barriers to incident reporting and may similarly act as barriers to quality documentation during anaesthesia. Further studies should investigate if these perceived obstacles have a causal impact on quality reporting in anaesthesia. Trial registration ClinicalTrials.gov identifier is NCT01524484. Registration date: January 21, 2012. Electronic supplementary material The online version of this article (doi:10.1186/1471-2253-15-13) contains supplementary material, which is available to authorized users.

We present a short overview on what is state of the art in mechanical ventilation with emphasis on acute lung injury and acute respiratory distress syndrome as well as on some newer trends for weaning of the patients from mechanical ventilation.

Background and Purpose:: The study reports experience with the recently commercially available V.A.C.® Abdominal Dressing System, a system designed for a temporary closure of an open abdomen situation under negative pressure. The method allows a late primary fascial closure after laparotomy in case of damage control, abdominal compartment syndrome or severe intra-abdominal spesis and facilitates delayed reconstruction of a large ventral hernia. Patients and Methods:: 18 patients with an open abdomen after laparotomy were managed between February 2002 and September 2004. Results:: Twelve patients after primary, one patient after secondary fascial closure and one patient with partially primary closure and resorbable mesh for abdominal wall reconstruction were free of wound infection or dehiscence of the abdominal wall. Evisceration or enteric fistulas were not observed. Five patients died in consequence of severe injury, a multiple organ failure or septic complications. Conclusion:: V.A.C.® Abdominal Dressing System is an effective temporary closure technique for open abdomen in critically ill patients which makes a late primary fascial closure up to 2 months after initial laparotomy possible either in trauma patients or in case of severe intraabdominal infection. The technique is simple and easily mastered

Despite the envisioned breakthrough prophesied for the end of the past century in healing brain injured patients, both clinicians and basic scientists are still struggling with this burden. In the past decades, intensive research has brought forward a plethora of different targets which—in part—have already been integrated in clinical routine directed at detailed monitoring, therapeutic interventions, and prevention of secondary deterioration. While intracellular targets remain obscure alterations on a larger scale as e. g., measured intracranial pressure (ICP), calculated cerebral perfusion pressure (CPP), and various imaging techniques are fundamental components of our present clinical understanding. At bedside, comprehension of pathophysiological loops and circuits of a given value (e. g., ICP) depends on individual knowledge, interpretation, and availability of additional diagnostic steps. As stated in the guidelines brought forward by the American Association of Neurological Surgeons and evaluated in various reports by the Cochrane Library we are still lacking prospective, randomized trials for the majority of the proposed diagnostic and therapeutic interventions. In this context, a recent meta-analysis even questioned the importance of ICP monitoring as we are lacking data from randomized controlled trials clarifying the role of ICP monitoring. The present review is to give an overview of various diagnostic and therapeutic possibilities based on reports published in the past 5 years to strengthen current approaches and nourish future well-designed investigations how to avoid and treat intracranial hypertension.

PURPOSE OF REVIEW This article defines the indication for airway-securing measures and describes the actual state of knowledge about the available techniques. Various modes of ventilation and their rationale are presented. RECENT FINDINGS New techniques in airway management and ventilation strategy are presented, explained and evaluated. SUMMARY Respiratory failure is a major confounding factor of morbidity and mortality in critical care patients and contributes considerably to prolonged intensive-care unit stay. When respiratory impairment is acute, rapid assessment of essential respiratory functions such as airway patency, gas exchange, and cough function have the highest priority in patients in life-threatening conditions. Securing the airway is a basic and vital procedure that has to be applied either in an elective or an emergency situation. Various levels of difficulty in laryngoscopy, intubation and maintaining oxygenation can occur and require standardized protocols, an adequate level of expertise and appropriate equipment. In intubated patients as well as in patients without secured airway, ventilatory assistance of various degrees and invasivities may be required. In this article all clinically applied forms of ventilation, their advantages and disadvantages as well as the relevant settings are extensively presented and discussed.