Improving nutritional therapy of persistent critically ill patients by organisational measures: A before and after study.

BACKGROUND & AIMS: Critically ill patients requiring prolonged intensive care (ICU) treatment are at high risk of malnutrition, which latter contributes to worsening outcome. Having observed that despite the presence of a nutrition protocol and dieticians, the patients with persistent critical illness (PCI) had been underfed during their ICU stay and particularly during the first 10 days, the aim was to analyse the impact of the organisational changes that were proposed to prevent the observed malnutrition. METHODS: Before (Period A) and after (Period B) study enrolling critically ill patients consecutively admitted, requiring >10 days of ICU treatment. The intervention consisted in increasing the early morning interactions between dieticians, nurses, and physicians, while modifying the computer visualisation of the dietician proposals. The primary endpoint was a reduction in the cumulative energy balance in period B. The ICU stay was divided in early ICU stay (first 10 days) and late ICU stay (day 11 to day 30). Other variables: protein, glucose, and prealbumin. RESULTS: Altogether, 205 patients (150 and 55 in period A and B respectively) were enrolled in the PCI program. Patient characteristics were similar over both periods except for lower SAPSII score in period B. There was no difference in nutritional pattern in the first 10 days between periods. The cumulate energy balance was less negative from day 11-30 in period B than in A (-884 vs -1566 kcal; p = 0.033). There was a one-day reduction in the median duration of fasting in period B (p < 0.0001). Overall compliance with nutrition protocol improved in period B with an earlier first indirect calorimetry (p = 0.003) and prealbumin measurement (p < 0.001), the latter increasing significantly more during ICU stay. CONCLUSION: Organizational changes that allowed an early identification of patients at nutritional risk, an increased targeted dieticians intervention and a better inter-disciplinary work was associated with a reduction in undue fasting, and significantly improved energy balances.

Video fluoroscopy for pulmonary artery catheter insertion in high-risk situation of knotting or misplacement.

Pulmonary artery catheter (PAC) insertion in patients with severe pulmonary hypertension, right heart dilation and failure, is very challenging. Misplacement and knotting are rare but could be serious complications leading to a delay of the monitoring and sometimes an emergent not expected intervention. Here we report a case of a patient admitted to Intensive Care Unit (ICU) with an acute hypoxemic respiratory failure. She had a history of chronic respiratory failure with pulmonary hypertension and right heart failure. We decided to monitor her cardiac output and pulmonary pressure with a PAC. Repeated attempts to reach the pulmonary artery (PA) were unsuccessful and the PAC was knotted and blocked at the distal tip of the introducer. Under fluoroscopy the knot was released by radiologist. Few days later, a monitoring of PA pressure was needed to guide a PA vasodilator treatment. Under fluoroscopic guidance with the supervision of radiologist, the catheter was successfully placed in the PA at the first attempt. Despite some limitations (patient displacement and radiation), this technique is more accurate than waveform guidance. We suggest in specific situations (low cardiac output, severe pulmonary hypertension, and severe tricuspid regurgitation) to consider first fluoroscopy.

[Pulmonary metastatic calcification]. / Les calcifications pulmonaires métastatiques.

INTRODUCTION: The lung is the organ most frequently involved by metastatic calcification. This condition is probably under-diagnosed, the patients usually being asymptomatic. This article summarizes the current knowledge concerning pulmonary metastatic calcification. BACKGROUND: The pathogenesis of pulmonary metastatic calcification is not well known, but it involves phosphate-calcium balance, renal function and pH. The most frequently encountered aetiologies are hyperparathyroidism, neoplastic bony lesions, and renal failure. The definitive diagnosis is achieved by histology, radiological examinations being insensitive. The clinical manifestations are various and can include a pulmonary restrictive syndrome, diffusion abnormalities, hypoxaemia and respiratory failure. The latter can be severe and influence the prognosis adversely: 19 cases of fatal pulmonary metastatic calcification have been reported. The treatment is aetiological and symptomatic. VIEWPOINT: The prognostic factors for a poor outcome of this potentially lethal condition remain to be determined. The management of asymptomatic patients is also uncertain. CONCLUSIONS: Pulmonary metastatic calcification is a rare condition of complex pathogenesis. The clinical manifestations are varied, ranging from asymptomatic to severe, even fatal.

Streamlining the medication process improves safety in the intensive care unit.

BACKGROUND: Multiple interventions were made to optimize the medication process in our intensive care unit (ICU). 1 Transcriptions from the medical order form to the administration plan were eliminated by merging both into a single document; 2 the new form was built in a logical sequence and was highly structured to promote completeness and standardization of information; 3 frequently used drug names, approved units, and fixed routes were pre-printed; 4 physicians and nurses were trained with regard to the correct use of the new form. This study was aimed at evaluating the impact of these interventions on clinically significant types of medication errors. METHODS: Eight types of medication errors were measured by a prospective chart review before and after the interventions in the ICU of a public tertiary care hospital. We used an interrupted time-series design to control the secular trends. RESULTS: Over 85 days, 9298 lines of drug prescription and/or administration to 294 patients, corresponding to 754 patient-days were collected and analysed for the three series before and three series following the intervention. Global error rate decreased from 4.95 to 2.14% (-56.8%, P < 0.001). CONCLUSIONS: The safety of the medication process in our ICU was improved by simple and inexpensive interventions. In addition to the optimization of the prescription writing process, the documentation of intravenous preparation, and the scheduling of administration, the elimination of the transcription in combination with the training of users contributed to reducing errors and carried an interesting potential to increase safety.

[Medication errors on intensive care units: don't underestimate the risks due to transcription]. / Erreurs médicamenteuses aux soins intensifs: ne pas sous-estimer les risques dôs aux transcriptions.

UNLABELLED: INTRODUCTION; Medication errors [ME] can harm patients and increase costs. ME are frequent in the intensive care units (ICU], where patients are critically ill and therefore more vulnerable. Publications about ME in the critical care setting are rare. The differences between settings, the lack of standardized definitions and the use of different methods do not allow transposing published results to a specific ICU. The goal of this observational study is to analyse our local situation in relation to the literature findings and determine improvement opportunities. OUTCOMES: Rates of actual medication error [AME] and potential medication error [PME] per line of drug, and per patient-day. Distribution of errors among eight types considered clinically significant. CONTEXT: Intensive care unit, in a tertiary care hospital. METHOD: Error detection was based on the comparison between the prescriptions, the scheduling of the administrations [PME] and the actual medication administrations [AME). RESULTS: 229 lines with an AME were detected in 4636 lines of drugs administered to 144 patients during 373 patient-days. AME rate per line of drug was 5%. PME rate per line of drug was 17%. AME rate per patient-day was 61%. Dose omissions and not discontinued administrations accounted altogether for more than 50% of the total of AME. CONCLUSIONS: The literature does not consider the transcription stage as a priority target for error reduction, but this work shows that, depending on the context, transcriptions can significantly increase opportunities for errors. As transcription does not add any value, its suppression seems therefore to be an interesting target for medication safety improvement.

[Latin organ donation programme (LODP): an effective initiative to increase organ donation in Switzerland]. / Programme latin de don d'organes (PLDO): une initiative efficace pour augmenter les dons d'organes en Suisse.

The 1st federal transplant law was enforced in July 2007 with the obligation to promote quality and efficiency in the procedures for organ and tissue donation for transplantation. The Latin organ donation programme (LODP) created in 2008 aims to develop organ donation in 17 public hospitals in 7 Latin cantons, covering 2.2 million people; 29% of the Swiss population. The implementation of various effective measures by the LODP enabled the increase in the number of donors by 70% between 2008 and 2010, with four organs procured per donor; greatly exceeding the European average of three. The results show that LODP has successfully professionalised the system and we can only hope that similar organisations will be put into place throughout Switzerland.

Home return 6 months after an intensive care unit admission for elderly patients.

BACKGROUND: Home return after critical care is very important not only to patients and families. To move back home, patients have to fulfill two conditions: survive, and have a relatively good functional status. In addition, home return could be considered a low-cost outcome because of the reduced permanent healthcare costs. METHODS: To determine the factors influencing the home-return probability of critically ill elderly patients 6 months after an intensive care unit (ICU) admission, we analyzed a cohort of patients aged 65 years or older admitted to an ICU. Demographic and social parameters, as well as admission diagnosis, underlying diseases, severity scores, ICU stay parameters, and complications were recorded. The final outcome was the place of stay (or death) 180 days after ICU admission. RESULTS: Of 526 patients, 72% of the cohort and 93% of hospital survivors were able to return to their homes. Among the variables used in the multivariate logistic regression, advanced age, length of hospital stay before ICU admission, severity of acute illness, diagnosis category, and complications, as well as certain comorbidities, such as chronic heart failure or a neoplasia, were independently negatively associated with a home return. CONCLUSION: Some interesting factors were identified in this single-center study. They could be considered for a multicenter study to build a universal prediction model for home return. Home return could be used for elderly patients as a surrogate for outcomes that are very important to the elderly but also to health politics.

Antibiotic use: is appropriateness expensive?

Antibiotics are prone to misuse. In this study, 37% of 600 antibiotic prescriptions in three hospitals were considered unnecessary. When antibiotic therapy was indicated, 45% were considered to be inadequate. In multivariate analyses, the indicated treatments were found to be more expensive than the unjustified ones, probably because the latter were more often oral regimens. However, for indicated treatments, the cost of adequate and inadequate treatments did not differ significantly.

[Are hospital network interesting for intensive care medicine?]. / Réseaux hospitaliers: quel intérêt en médecine intensive?

In critical care medicine, collaborative networks are well-developped for clinical research. This model is equally interesting for care, education and management. For example, in a network, an intensivist can be easily sent to another hospital in order to deliver specialized care. In French and Italian part of Switzerland, a critical care network was recently founded and it implements now several collaborative projects. Networks are very interesting for their members because they allows some small ICUs to survive and avoid very expensive costs related to restructuration of the larger ones. Thus, this model will certainly develop during the next years.

[Latin program for organ donation: the intensivists are networking]. / Programme latin de don d'organes: les intensivistes se mettent en réseau.

The new Swiss federal law on organ and transplantation strengthens the responsibilities of the intensive care units. In Italian and French speaking parts of Switzerland, the Programme Latin pour le Don d'Organe (PLDO) has been launched to foster a wider collaboration between intensivists and donation coordinators. The PLDO aims at optimising knowledge and expertise in organ donation through improvements in identification, notification and management of organ donors and their next of kin. The PLDO dispenses education to all professionals involved. Such organisation should allow increasing the number of organs available, while improving healthcare professionals experience and next of kin emotion throughout the donation process.

[Merging of two intensive care units: preliminary observations]. / Fusion de deux services de médecine intensive: quelques observations préliminaires.

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

Pharmacokinetics and dosage adaptation of meropenem during continuous venovenous hemodiafiltration in critically ill patients.

Meropenem, a carbapenem broad-spectrum antibiotic, is regularly used in patients undergoing continuous venovenous hemodiafiltration (CVVHDF). Its disposition was studied over one dosage interval in 15 patients under CVVHDF on a steady regimen of 500 or 1000 mg every 8 to 12 hours. Meropenem levels were measured in plasma and filtrate-dialysate by high-performance liquid chromatography (HPLC) with UV detection. The mean CVVHDF flow rates were 7.1 +/- 0.9 L/h for blood (mean +/- SD), 0.5 +/- 0.3 L/h for predilution solution, 1.2 +/- 0.3 L/h for countercurrent dialysate, and 1.8 +/- 0.5 L/h for the total filtrate-dialysate. The pharmacokinetic analysis was based both on a noncompartmental approach and on a four-compartment modeling. The mean (coefficient of variation [CV]) total body clearance, volume of distribution at steady state, and mean residence time were, respectively, 5.0 L/h (46%), 14.3 L (29%), and 4.8 h (36%). The hemodiafiltration clearances calculated from plasma data alone and plasma with filtrate-dialysate data were 1.2 L/h (26%) and 1.6 L/h (39%), respectively. The compartmental model was used to optimize the therapeutic schedule of meropenem, considering reference minimal inhibitory concentration (MIC) of sensitive strains (4 mg/L). The results indicate that two different therapeutic schedules of meropenem are equally applicable to patients receiving CVVHD: either 750 mg tid or 1500 bid.

Determination of meropenem in plasma and filtrate-dialysate from patients under continuous veno-venous haemodiafiltration by SPE-LC.

Meropenem, a carbapenem antibiotic displaying a broad spectrum of antibacterial activity, is administered in Medical Intensive Care Unit to critically ill patients undergoing continuous veno-venous haemodiafiltration (CVVHDF). However, there are limited data available to substantial rational dosing decisions in this condition. In an attempt to refine our knowledge and propose a rationally designed dosage regimen, we have developed a HPLC method to determine meropenem after solid-phase extraction (SPE) of plasma and dialysate fluids obtained from patients under CVVHDF. The assay comprises the simultaneous measurement of meropenem's open-ring metabolite UK-1a, whose fate has never been studied in CVVHDF patients. The clean-up procedure involved a SPE on C18 cartridge. Matrix components were eliminated with phosphate buffer pH 7.4 followed by 15:85 MeOH-phosphate buffer pH 7.4. Meropenem and UK-1a were subsequently desorbed with MeOH. The eluates were evaporated under nitrogen at room temperature (RT) and reconstituted in phosphate buffer pH 7.4. Separation was performed at RT on a Nucleosil 100-5 microm C18 AB cartridge column (125 x 4 mm I.D.) equipped with a guard column (8 x 4 mm I.D.) with UV-DAD detection set at 208 nm. The mobile phase was 1 ml min(-1), using a step-wise gradient elution program: %MeOH/0.005 M tetrabutylammonium chloride pH 7.4; 10/90-50/50 in 27 min. Over the range of 5-100 microg ml(-1), the regression coefficient of the calibration curves (plasma and dialysate) were >0.998. The absolute extraction recoveries of meropenem and UK-1a in plasma and filtrate-dialysate were stable and ranged from 88-93 to 72-77% for meropenem, and from 95-104 to 75-82% for UK-1a. In plasma and filtrate-dialysate, respectively, the mean intra-assay precision was 4.1 and 2.6% for meropenem and 4.2 and 3.7% for UK-1a. The inter-assay variability was 2.8 and 3.6% for meropenem and 2.3 and 2.8% for UK-1a. The accuracy was satisfactory for both meropenem and UK-1a with deviation never exceeding 9.0% of the nominal concentrations. The stability of meropenem, studied in biological samples left at RT and at +4 degrees C, was satisfactory with < 5% degradation after 1.5 h in blood but reached 22% in filtrate-dialysate samples stored at RT for 8 h, precluding accurate measurements of meropenem excreted unchanged in the filtrate-dialysate left at RT during the CVVHDF procedure. The method reported here enables accurate measurements of meropenem in critically ill patients under CVVHDF, making dosage individualisation possible in such patients. The levels of the metabolite UK-1a encountered in this population of patients were higher than those observed in healthy volunteers but was similar to those observed in patients with renal impairment under hemodialysis.

[Coronary artery bypass by mini-thoracotomy: noticeable benefits with clinical experience of the treatment team]. / Pontages coronariens par mini-thoracotomie: bénéfices visibles avec l'expérience croissante de l'équipe traitante.

AIM OF THE STUDY: Minimally invasive coronary artery bypass surgery is fundamentally different as compared to open sternal approach under cardiopulmonary bypass. Modifications of the surgical, anesthesiologic and post-operative techniques are necessary before evaluation of its real benefit. We analyze the potential effect of a learning period on the short term results of this technique. METHODS: From July 1997 to February 1999, 20 patients were operated using this method. We compare the results of the first 10 patients (group 1: 8M/2F, 59.6 +/- 13.8 years) to those of the last 10 patients (group 2: 8M/2F; age = 63.2 +/- 6.1 years). DISCUSSION: Progress between the two groups is striking. Left anterior descending coronary clamping time could be reduced from 28.5 +/- 2.4 min. in group 1 to 22.2 +/- 1.8 min. in group 2 (p < 0.05), and operative time was reduced from 125 +/- 4 min. to 97 +/- 5 min. (p < 0.005). The post-operative atrial fibrillation rate diminished from 4/10 in group 1 to 1/10 in group 2.3/10 patients in group 1 suffered a post-operative pneumonia whereas none in group 2 had pulmonary complication. The stay in the intensive care unit could be reduced from 2.3 +/- 0.3 days to 1.4 +/- 0.2 days (p < 0.05) and the total post-operative stay diminished from 8.5 +/- 0.9 days to 4.7 +/- 0.5 days (p < 0.005). CONCLUSION: There are evidence for a learning period in minimally invasive cardiac surgery. Short term benefits of this technique are then evident as demonstrated by a reduction in the ICU stay and the hospital stay.

Permissive hypercapnia impairs pulmonary gas exchange in the acute respiratory distress syndrome.

Current recommendations for mechanical ventilation in the acute respiratory distress syndrome (ARDS) include the use of small tidal volumes (VT), even at the cost of respiratory acidosis. We evaluated the effects of this permissive hypercapnia on pulmonary gas exchange with the multiple inert gas elimination technique (MIGET) in eight patients with ARDS. After making baseline measurements, we induced permissive hypercapnia by reducing VT from 10 +/- 2 ml/kg to 6 +/- 1 ml/kg (mean +/- SEM) at constant positive end-expiratory pressure. After restoration of initial VT, we infused dobutamine to increase cardiac output (Q) by the same amount as with hypercapnia. Permissive hypercapnia increased Q by an average of 1.4 L. min(-)(1). m(2), decreased arterial oxygen tension from 109 +/- 10 mm Hg to 92 +/- 11 mm Hg (p < 0.05), markedly increased true shunt (Q S/Q T), from 32 +/- 6% to 48 +/- 5% (p < 0.0001), and had no effect on the dispersion of VA/Q.VA/Q. On reinstatement of baseline V T with maintenance of a high Q, Q S/Q T remained increased, to 38 +/- 6% (p < 0.05), and Pa(O(2 ))remained decreased, to 93 +/- 4 mm Hg (p < 0. 05). These results agreed with effects of changes in VT and Q predicted by the mathematical lung model of the MIGET. We conclude that permissive hypercapnia increases pulmonary shunt, and that deterioration in gas exchange is explained by the combined effects of increased Q and decreased alveolar ventilation.

Tissue oxygenation and hemodynamic response to NO synthase inhibition in septic shock.

The objective of the study was to evaluate the tissue oxygenation and hemodynamic effects of NOS inhibition in clinical severe septic shock. Eight patients with septic shock refractory to volume loading and high level of adrenergic support were prospectively enrolled in the study. Increasing doses of NOS inhibitors [N(G)-nitro-L-arginine-methyl ester (L-NAME) or N(G)-monomethyl-L-arginine (L-NMMA)] were administered as i.v. bolus until a peak effect = 10 mmHg on mean blood pressure was obtained or until side effects occurred. If deemed clinically appropriate, a continuous infusion of L-NAME was instituted and adrenergic support weaning attempted. The bolus administration of NOS inhibitors transiently increased mean blood pressure by 10 mm Hg in all patients. Seven out of eight patients received an L-NAME infusion, associated over 24 h with a progressive decline in cardiac index (P < 0.001) and an increase in systemic vascular resistance (P < 0.01). Partial or total adrenergic support weaning was rapidly possible in 6/8 patients. Oxygen transport decreased (P < 0.001), but oxygen consumption remained unchanged in those patients in whom it could be measured by indirect calorimetry (5/8). Blood lactate and the difference between tonometric gastric and arterial PCO2 remained unchanged. There were 4/8 ICU survivors. We conclude that nitric oxide synthase inhibition in severe septic shock was followed with a progressive correction of the vasoplegic hemodynamic disturbances with finally normalization of cardiac output and systemic vascular resistances without any demonstrable deterioration in tissue oxygenation.

Comparison of models used for UV index calculations.

Eighteen radiative transfer models in use for calculation of UV index are compared with respect to their results for more that 100 cloud-free atmospheres, which describe present, possible future and extreme conditions. The comparison includes six multiple-scattering spectral models, eight fast spectral models and four empirical models. Averages of the results of the six participating multiple-scattering spectral models are taken as a basis for assessment. The agreement among the multiple-scattering models is within +/- 0.5 UV index values for more than 80% of chosen atmospheric parameters. The fast spectral models have very different agreement, between +/- 1 and up to 12 UV index values. The results of the empirical models agree reasonably well with the reference models but only for the atmospheres for which they have been developed. The data to describe the atmospheric conditions, which are used for the comparison, together with the individual results of all participating models and model descriptions are available on the Internet: http://www.meteo.physik.uni-muenchen.de/++ +strahlung/cost/.

Tumor necrosis factor-alpha is expressed by monocytes/macrophages following cardiac microembolization and is antagonized by cyclosporine.

The time course of expression of TNF-alpha in myocardial wound healing following ischemic injury was investigated in the porcine heart. Microembolization was used to induce focal ischemia and necrosis in hearts of 39 adult pigs. The animals were sacrificed after 3, 6, 12, 24 h, 3 and 7 days, and after 4 weeks, and the myocardial tissue was studied by immunofluorescence using specific antibodies. TNF-alpha containing cells were identified as monocytes/macrophages by double staining with a muramidase antibody. Monocytes/macrophages were the only source of TNF-alpha. Microembolization caused multiple necrotic foci with loss of myocytes in the left ventricular myocardium. These foci contained numerous monocytes/macrophages and showed an inflammatory reaction typical of wound healing followed by replacement with scar tissue. The number of TNF-alpha positive cells increased after 24 h, peaked between 3-7 days and slowly decreased thereafter. Expression of TNF-alpha in monocytes/macrophages was significantly reduced after pretreatment of pigs with cyclosporine or dexamethasone. It is concluded that 1.) in myocardial tissue monocytes/macrophages are the only cell type expressing TNF-alpha, 2.) TNF-alpha is involved in wound healing after ischemia, and 3.) synthesis of TNF-alpha and inflammatory angiogenesis can be inhibited be treatment with either cyclosporine or dexamethasone.

[Simulation of in vivo study conditions for comparing the possibilities and limits of mammography in various breast implants]. / Simulation von In-vivo-Untersuchungsbedingungen zum Vergleich der Möglichkeiten und Grenzen der Mammographie bei verschiedenen Brustimplantaten.

Especially in breast reconstruction after mastectomy, subcutaneous mastectomy, or extensive lumpectomy, the radiological properties of breast implants play an important role. Mammography is still the gold standard for follow-up diagnostics as well as for preventive diagnostics, and the interpretation of these films is greatly influenced by the type of the implant filler material. In this study, in vivo conditions are simulated, and standard mammography techniques applied to examine the effects of various types of implants on the readability of mammography films using semiquantitative measurements as well as subjective judgement by independent radiologists.