Survey on the Updated German S3 Guideline for Intensive Care in Cardiac Surgery Patients.

BACKGROUND: The German guideline on intensive care treatment of cardiac surgical patients provides evidence-based recommendations on management and monitoring. It remains unclear if, respectively, to which degree the guidelines are implemented into the daily practice. Therefore, this study aims to characterize the implementation of guideline recommendations in German cardiac surgical intensive care units (ICUs). METHODS: An internet-based online survey (42 questions, 9 topics) was sent to 158 German head physicians of cardiac surgical ICUs. To compare the effect over time, most questions were based on a previously performed survey (2013) after introduction of the last guideline update in 2008. RESULTS: A total of n = 65 (41.1%) questionnaires were included. Monitoring changed to increased provision of available transesophageal echocardiography specialists in 86% (2013: 72.6%), SvO2 measurement in 93.8% (2013: 55.1%), and electroencephalography in 58.5% (2013: 2.6%). The use of hydroxyethyl starch declined (9.4% vs. 2013: 38.7%), gelatin 4% presented the most administered colloid with 23.4% (2013: 17.4%). Low cardiac output syndrome was primarily treated with levosimendan (30.8%) and epinephrine (23.1%), while norepinephrine (44.6%) and dobutamine (16.9%) represented the most favored drug combination. The main way of distribution was web-based (50.9%), with increasing impact on therapy regimens (36.9% vs. 2013: 24%). CONCLUSION: Changes were found in all questioned sectors compared with the preceding survey, with persisting variability between ICUs. Recommendations of the updated guideline have increasingly entered clinical practice, with participants valuing the updated publication as clinically relevant.

Comparison of qSOFA score, SOFA score, and SIRS criteria for the prediction of infection and mortality among surgical intermediate and intensive care patients.

BACKGROUND: It is crucial to rapidly identify sepsis so that adequate treatment may be initiated. Accordingly, the Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) scores are used to evaluate intensive care unit (ICU) and non-ICU patients, respectively. As demand for ICU beds rises, the intermediate care unit (IMCU) carries greater importance as a bridge between the ICU and the regular ward. This study aimed to examine the ability of SOFA and qSOFA scores to predict suspected infection and mortality in IMCU patients. METHODS: Retrospective data analysis included 13,780 surgical patients treated at the IMCU, ICU, or both between January 01, 2012, and September 30, 2018. Patients were screened for suspected infection (i.e., the commencement of broad-spectrum antibiotics) and then evaluated for the SOFA score, qSOFA score, and the 1992 defined systemic inflammatory response syndrome (SIRS) criteria. RESULTS: Suspected infection was detected in 1306 (18.3%) of IMCU, 1365 (35.5%) of ICU, and 1734 (62.0%) of IMCU/ICU encounters. Overall, 458 (3.3%) patients died (IMCU 45 [0.6%]; ICU 250 [6.5%]; IMCU/ICU 163 [5.8%]). All investigated scores failed to predict suspected infection independently of the analyzed subgroup. Regarding mortality prediction, the qSOFA score performed sufficiently within the IMCU cohort (AUCROC SIRS 0.72 [0.71-0.72]; SOFA 0.52 [0.51-0.53]; qSOFA 0.82 [0.79-0.84]), while the SOFA score was predictive in patients of the IMCU/ICU cohort (AUCROC SIRS 0.54 [0.53-0.54]; SOFA 0.73 [0.70-0.77]; qSOFA 0.59 [0.58-0.59]). CONCLUSIONS: None of the assessed scores was sufficiently able to predict suspected infection in surgical ICU or IMCU patients. While the qSOFA score is appropriate for mortality prediction in IMCU patients, SOFA score prediction quality is increased in critically ill patients.

Evidence of Prolonged Monitoring of Trauma Patients Admitted via Trauma Resuscitation Unit without Primary Proof of Severe Injuries.

Introductio: Although management of severely injured patients in the Trauma Resuscitation Unit (TRU) follows evidence-based guidelines, algorithms for treatment of the slightly injured are limited. METHODS: All trauma patients in a period of eight months in a Level I trauma center were followed. Retrospective analysis was performed only in patients ≥18 years with primary TRU admission, Abbreviated Injury Scale (AIS) ≤ 1, Maximum Abbreviated Injury Scale (MAIS) ≤ 1 and Injury Severity Score (ISS) ≤3 after treatment completion and ≥24 h monitoring in the units. Cochran's Q-test was used for the statistical evaluation of AIS and ISS changes in units. RESULTS: One hundred and twelve patients were enrolled in the study. Twenty-one patients (18.75%) reported new complaints after treatment completion in the TRU. AIS rose from the Intermediate Care Unit (IMC) to Normal Care Unit (NCU) 6.2% and ISS 6.9%. MAIS did not increase >2, and no intervention was necessary for any patient. No correlation was found between computed tomography (CT) diagnostics in TRU and AIS change. CONCLUSIONS: The data suggest that AIS, MAIS and ISS did not increase significantly in patients without a severe injury during inpatient treatment, regardless of the type of CT diagnostics performed in the TRU, suggesting that monitoring of these patients may be unnecessary.

Generating Surveillance Data for Nosocomial Infections from Routine Charting in Intensive Care Units.

The University Hospital of Giessen and Marburg (UKGM), Giessen, Germany participates in a country wide nosocomial infections surveillance project on intensive care units (ICU) called KISS. KISS data must be gathered daily and is comprised of detailed clinical data like patient movements, ward utilization, presence of central venous and urinary catheters and types of artificial respiration. This happens for all of the 10 ICU's at UKGM Giessen and proved to be very tedious and time consuming for the institute for hospital hygiene. The goal of this project was the automated generation of the KISS reports from routinely collected data in the patient data management system (PDMS). The results show that this is largely feasible without changing the documentation habits of physicians and nurses.

StudyAlert: From eCharts to Modern Messengers.

We developed a tool to detect patients possibly elegible for clinical studies by analysing the HL7-message-stream of the patient management system and notifying study investigators by email or a common messenger service via secured communication channels.

Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study.

BACKGROUND: Long-term ventilation in intensive care units (ICUs) is associated with several problems such as increased mortality, increased rates of ventilator-associated pneumonia (VAP), and prolonged time of hospitalization, and thus leads to enormous healthcare expenditure. While the influence of tracheostomy on VAP incidence, duration of ventilation, and time of hospitalization has already been analyzed in several studies, the timing of the tracheostomy procedure on patient's mortality is still controversial. The aim of our study was to investigate whether early tracheostomy improved outcome in critically ill patients. MATERIALS AND METHODS: Within 2 years, 100 critically ill, predominantly surgical patients entered this prospective randomized study. A percutaneous dilatational tracheostomy was performed either early (≤4 days, 2.8 days median) or late (≥6 days, 8.1 days median) after intubation. RESULTS: We could demonstrate that mortality was not significantly reduced in the early tracheostomy (ET) group in contrast to the late tracheostomy (LT) group. ET was associated with decreased VAP incidence (ET 38% vs. LT 64%), decreased duration of ventilation (ET 367.5 h vs LT 507.5 h), and shorter time of hospitalization both in hospital (ET 31.5 days vs LT 68 days) and in ICU (ET 21.5 days vs LT 27 days). CONCLUSION: Despite many advantages like reduced time of ventilation and hospitalization, early tracheostomy is not associated with decreased mortality in critically ill patients.

Response of proopiomelanocortin and gonado- or lactotroph systems to in-vitro fertilisation procedures stress.

OBJECTIVE: To analyse for the first time the response of the corticotroph-type and the melanotroph-type pituitary proopiomelanocortin (POMC) system with regard to in-vitro fertilisation (IVF) treatment using self-developed highly specific non-cross-reacting radioimmunoassay. SETTING: University hospital. patients: A total of 28 patients undergoing IVF oocyte retrieval. Cross sectional exploratory study, one factorial design with repeated measurements on one factor, non-parametric tests. Blood was collected before anaesthesia (t(A)) (n=28) and immediately after oocyte retrieval (t(B)) (n=28). MAIN OUTCOME MEASURE(S): beta-endorphin immunoreactive material (IRM), acetyl-N-beta-endorphin IRM, beta-lipotropin IRM, ACTH, cortisol, estradiol, progesterone, prolactin, luteinizing hormone, and follicle-stimulating hormone. For determination of authentic beta-endorphin [beta-endorphin (1-31)] a highly specific two-site fluid phase immunoprecipitation radioimmunoassay was developed, which did not cross-react with any beta-endorphin derivative or any other opioid peptide tested. RESULTS: No response of acetyl-N-beta-endorphin IRM and of authentic beta-endorphin (1-31) was observed to oocyte retrieval in contrast to a significant increase of corticotroph-type proopiomelanocortin derivatives. A significant rise in prolactin plasma concentration indicates a pronounced lactotroph response to oocyte retrieval stress. No significant correlation between POMC derivates and prolactin and between POMC derivatives and gonadotropins or sexual steroids except for ACTH and progesterone and for beta-endorphin IRM and estradiol was observed. CONCLUSION: IVF treatment stress led to significant corticotroph-type POMC and lactotroph responses, but not to responses of authentic beta-endorphin or melanotroph-type POMC in women undergoing oocyte retrieval.

Corrected incidences of co-morbidities - a statistical approach for risk-assessment in anesthesia using an AIMS.

OBJECTIVE: In anesthesia and intensive care logistic regression analysis are often used to generate predictive models for risk assessment. Strictly seen only independent variables should be represented in such prognostic models. Using anesthesia-information-management-systems a lot of (depending) information is stored in a database during the preoperative ward round. The objective of this study was to evaluate a statistical algorithm to process the different dependent variables without losing the information of each variable on patient's conditions. METHOD: Based on data about prognostic models in anesthesia an iterative statistical algorithm was initiated to summarize dependent variables to subscores. Seven subscores out of several preoperative variables were calculated corresponding to the proper incidence and the correlation to the occurrence of intraoperative cardiovascular events was evaluated. After that first step logistic regression was used to build a predictive model out of the seven subscores, 10 patient-related, and two surgery-related variables. Performance of the prognostic model was assessed using analysis of discrimination and calibration. RESULT: Four out of seven subscores together with age, type and urgency of surgery are represented in the prognostic model to predict the occurrence of intraoperative cardiovascular events. The prognostic model demonstrated good discriminative power with an area under the ROC curve (AUC) of 0.734. CONCLUSION: Due to reduced calibration, the clinical use of the prediction model is limited.

Automatic calculation of the nine equivalents of nursing manpower use score (NEMS) using a patient data management system.

OBJECTIVE: The most recent approach to estimate nursing resources consumption has led to the generation of the Nine Equivalents of Nursing Manpower use Score (NEMS). The objective of this prospective study was to establish a completely automatically generated calculation of the NEMS using a patient data management system (PDMS) database and to validate this approach by comparing the results with those of the conventional manual method. DESIGN: Prospective study. SETTING: Operative intensive care unit of a university hospital. PATIENTS: Patients admitted to the ICU between 24 July 2002 and 22 August 2002. Patients under the age of 16 years, and patients undergoing cardiovascular surgery or with burn injuries were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The NEMS of all patients was calculated automatically with a PDMS and manually by a physician in parallel. The results of the two methods were compared using the Bland and Altman approach, the interclass correlation coefficient (ICC), and the kappa-statistic. On 20 consecutive working days, the NEMS was calculated in 204 cases. The Bland Altman analysis did not show significant differences in NEMS scoring between the two methods. The ICC (95% confidence intervals) 0.87 (0.84-0.90) revealed a high inter-rater agreement between the PDMS and the physician. The kappa-statistic showed good results (kappa>0.55) for all NEMS items apart from the item "supplementary ventilatory care". CONCLUSION: This study demonstrates that automatical calculation of the NEMS is possible with high accuracy by means of a PDMS. This may lead to a decrease in consumption of nursing resources.