[Trace element issues in Switzerland and Europe]. / Oligoéléments en Suisse et en Europe.

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

Foodborne botulism, a forgotten yet life-threatening disease: a case report.

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

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.

Prevalence of hypophosphatemia in the ICU - Results of an international one-day point prevalence survey.

BACKGROUND & AIMS: Hypophosphatemia (HypoP) is associated with organ dysfunction and mortality. Despite its potential severe consequences, HypoP remains poorly characterized in terms of real prevalence and timing of onset. The primary objective was to determine the prevalence of HypoP defined as blood phosphate <0.8 and < 0.65 mmol/l on one particular day at international level. METHODS: One-day point prevalence survey conducted by the Section of Metabolism, Endocrinology and Nutrition (MEN) of the European Society of Intensive Care Medicine (ESICM) during week 11-2020. RESULTS: In total, 56 adult and 4 paediatric ICUs, from 22 countries participated: 41 ICUs were mixed medico surgical, the 19 others being cardiac, medical or surgical. Phosphate measurements were performed daily in 21 ICUs, and 1-3 times per week in 39 ICUs. On D-Day 909 patients (883 adults) were present and 668/883 (75.7%) had serum/plasma phosphate determined, revealing a HypoP in 103 (15.4%) patients aged 62 [18 to 85] years. Of those, 49 patients presented phosphate <0.65 mmol/l: cases of hypophosphatemia were detected at any time of patient's ICU stay. No HypoP was observed in children. A treatment protocol existed only in 41.1% of adult ICUs, independently of ICU type, or size. Only 41/98 of the HypoP patients (29/41 of patients with phosphate <0.65 mmol/l) were receiving phosphate. CONCLUSION: HypoP is present at least in 15.4% of ICU patients, and may occur at any time during the ICU stay. The absence of phosphate repletion protocols in 60% of participating ICUs is an unexpected finding, and confirms the necessity for the development of ICU phosphate protocols and guidelines. CLINICALTRIALS IDENTIFIER: NCT04201899.

No evidence for interstitial lung oedema by extensive pulmonary function testing at 4,559 m.

The aim of the present study was to better understand previously reported changes in lung function at high altitude. Comprehensive pulmonary function testing utilising body plethysmography and assessment of changes in closing volume were carried out at sea level and repeatedly over 2 days at high altitude (4,559 m) in 34 mountaineers. In subjects without high-altitude pulmonary oedema (HAPE), there was no significant difference in total lung capacity, forced vital capacity, closing volume and lung compliance between low and high altitude, whereas lung diffusing capacity for carbon monoxide increased at high altitude. Bronchoconstriction at high altitude could be excluded as the cause of changes in closing volume because there was no difference in airway resistance and bronchodilator responsiveness to salbutamol. There were no significant differences in these parameters between mountaineers with and without acute mountain sickness. Mild alveolar oedema on radiographs in HAPE was associated only with minor decreases in forced vital capacity, diffusing capacity and lung compliance and minor increases in closing volume. Comprehensive lung function testing provided no evidence of interstitial pulmonary oedema in mountaineers without HAPE during the first 2 days at 4,559 m. Data obtained in mountaineers with early mild HAPE suggest that these methods may not be sensitive enough for the detection of interstitial pulmonary fluid accumulation.

Acceptation of Folk Medicine and its "secrets" in a Swiss Burn Centre.

In Switzerland 'Secret' is a folk medicine called upon for burns. It has belonged to UNESCO's intangible cultural heritage since 2012. It is supposed to ease pain and accelerate the healing process of burns. As the practice is widely used in the population, this observational study investigated the opinion of caregivers and patients from the National Burn Center of Lausanne. Qualitative observational study based on a survey including ten questions aimed at identifying the professionals' perception of the phenomenon. Questions were developed from repeated encounters in the burn center. Data collection took five months. Thirty-six healthcare professionals (HP) and 12 selected patients (or parents for minors) discharged after burns were interviewed on a voluntary basis: all of the HPs knew about 'Secret' from the workplace, and 26 from home: 33 were convinced that it might be useful and reduce pain. The perceived efficiency of the practice (36 respondents) differs depending on professional category and personal experience. Only one HP considered the practice to be dangerous. The nurses and auxiliary nurses expressed that it should be used more widely. The 12 patients considered it as a complementary step, not a replacement for medical care. Health professionals globally considered this practice safe and helpful. The patients were interested in using parallel approaches and were careful about their expectations. This openness is probably an indication that HPs believe that acceptance of the culture and beliefs of patients and their families might positively affect response to treatment, whatever the burn size.

Il existe en Suisse une médecine traditionnelle dénommée « secret ¼ dédiée aux brûlures (supposée avoir des effets analgésiques et cicatrisants) inscrite au patrimoine immatériel de l'UNESCO depuis 2012. Dans la mesure où elle est très largement utilisée, nous avons conduit une étude observationnelle sur l'opinion qu'en ont les soignants et les patients du CTB national de Lausanne. Nous avons utilisé un questionnaire à dix items, développé après des entretiens plus informels. Trente six professionnels et 12 patients (ou parents quand le patient était mineur), interrogés après leur sortie, ont volontairement participé à l'étude. Tous les professionnels avaient entendu parler de « secret ¼ soit au travail soit chez eux (26). Trente trois étaient persuadés de son utilité analgésique, 1 seul le considérant comme dangereux. Cette opinion varie selon la catégorie professionnelle et l'expérience personnelle, les infirmières et aide- soignantes estimant qu'il devrait être plus largement utilisé. Les patients estimaient que « secret ¼ était un adjuvant ne devant pas remplacer la prise en charge médicalisée. Les professionnels considéraient que « secret ¼ est simple et utile. Les patients étaient intéressée par cette approche parallèle, tout en gardant une certaine retenue quant à ce qu'ils pouvaient en attendre. Cette ouverture d'esprit suggère que les professionnels pensent que la prise en compte de la culture et des croyances des patients et de leur famille peut promouvoir l'efficacité du traitement conventionnel, quelle que soit la surface brûlée.

Disposition of valganciclovir during continuous renal replacement therapy in two lung transplant recipients.

OBJECTIVES: To determine whether valganciclovir 450 mg every 48 h for cytomegalovirus (CMV) prophylaxis provides appropriate ganciclovir exposure in solid organ transplant recipients during continuous renal replacement therapy (CRRT). PATIENTS AND METHODS: Ganciclovir pharmacokinetics was intensively studied in two lung transplant recipients under valganciclovir 450 mg every 48 h over one dosing interval. In vitro experiments using blank whole blood spiked with ganciclovir further investigated exchanges between plasma and erythrocytes. RESULTS: Ganciclovir disposition was characterized by apparent total body clearance of 3.3 and 5.8 L/h, terminal half-life of 16.9 and 14.1 h, and apparent volume of distribution of 60.3 and 104.9 L in Patients 1 and 2, respectively. The observed sieving coefficient was 1.05 and 0.96, and the haemofiltration clearance was 3.3 and 3.1 L/h. In vitro experiments confirmed rapid efflux of ganciclovir from red blood cells into plasma, increasing the apparent efficacy of haemofiltration. CONCLUSIONS: A valganciclovir dosage of 450 mg every 48 h appears adequate for patients under CRRT requiring prophylaxis for CMV infection, providing concentration levels in the range reported for 900 mg once daily dosing outside renal failure.

Fish oil after abdominal aorta aneurysm surgery.

OBJECTIVE: Fish oil (FO) may attenuate the inflammatory response after major surgery such as abdominal aortic aneurysm (AAA) surgery. We aimed at evaluating the clinical impact and safety aspects of a FO containing parenteral nutrition (PN) after AAA surgery. METHODS: Intervention consisted in 4 days of either standard (STD: Lipofundin medium-chain triglyceride (MCT): long-chain triglyceride (LCT)50%-MCT50%) or FO containing PN (FO: Lipoplus: LCT40%-MCT50%-FO10%). Energy target were set at 1.3 times the preoperative resting energy expenditure by indirect calorimetry. Blood sampling on days 0, 2, 3 and 4. Glucose turnover by the (2)H(2)-glucose method. Muscle microdialysis. CLINICAL DATA: maximal daily T degrees, intensive care unit (ICU) and hospital stay. RESULTS: Both solutions were clinically well tolerated, without any differences in laboratory safety parameters, inflammatory, metabolic data, or in organ failures. Plasma tocopherol increased similarly; with FO, docosahexaenoic and eicosapentaenoic acid increased significantly by day 4 versus baseline or STD. To increased postoperatively, with a trend to lower values in FO group (P=0.09). After FO, a trend toward shorter ICU stay (1.6+/-0.4 versus 2.3+/-0.4), and hospital stay (9.9+/-2.4 versus 11.3+/-2.7 days: P=0.19) was observed. CONCLUSIONS: Both lipid emulsions were well tolerated. FO-PN enhanced the plasma n-3 polyunsaturated fatty acid content, and was associated with trends to lower body temperature and shorter length of stay.

[Burns--from trifle case to mass casualty]. / Verbrennungen--Von der Bagatelle zur Katastrophe.

Burn injuries are very frequent, most being trifle cases. Nevertheless every year about 200 patients need to be treated in one of the two specialised Swiss burns centres. Admission criteria are burns > 15% body surface or burns to critical areas (face neck, hands, genitalia, joints) and electrical injuries. The paper reviews the physiophathology of the burn wound which differs depending on the thermal or electrical aetiology. The airway may be threatened due to true inhalation, but also to burns to the face or neck. In major burns >20% body surface in adults, or > 10% in children, fluid resuscitation will be required; oral hydration is generally sufficient by smaller burns. Surgical treatment of 2nd and 3rd degree burns starts within the first 24 days after injury. While complex treatment is generally available in peace time, a major accident such as a disco-fire that can generate hundreds casualties in a few minutes, can threaten our system and force the adoption of triage rules, and simplified treatments. Attitudes to adopt in such conditions are discussed.

[Toxic epidermal necrolysis]. / Epidermolyse nécrosante suraiguë de Lyell ou toxic epidermal necrolysis.

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

Does the type of parenteral lipids matter? A clinical hint in critical illness.

BACKGROUND & AIMS: An altered lipid profile is common among intensive care unit (ICU) patients, but evidence regarding the impact of different fatty acid (FA) emulsions administered to patients requiring parenteral nutrition (PN) is scarce. This study aimed to compare the plasma triglycerides (TG) response to two types of commercial lipid emulsions: a structured mixture of long- and medium-chain triglycerides (LCT/MCT) or LCTs with n-9 FA (LCT+) in ICU patients. METHODS: In this retrospective observational study conducted in a multidisciplinary ICU: two groups were defined by the type of emulsion used. Inclusion criteria were: consecutive patients on PN staying ≥4 days with one TG determination before commencing PN and at least one during PN. Recorded variables included energy intake, amount and type of nutritional lipids, propofol dose, glucose and protein intake, laboratory parameters, and all drugs received. Hypertriglyceridemia (hyperTG) was defined as TG >2 mmol/L. RESULTS: The dynamic impact of the emulsion was analyzed in 187/757 patients completing the inclusion criteria (112 LCT/MCT and 75 LCT+). The demographic variables, severity indices, diagnostic categories, and outcomes did not differ between the two groups. Seventy-seven patients (41%) presented hyperTG. Both groups received similar daily energy (1604 versus 1511 kcal/day), lipids (60 versus 61 g/day), and glucose intake (233 versus 197 g/day). There was no increase of TG concentration in those receiving the LCT/MCT emulsion compared to those receiving the LCT+ emulsion (0 and 0.2 mmol/L, respectively, p < 0.05). CONCLUSION: LCT/MCT emulsions are associated with a less pronounced increase of plasma TG levels than LCT+ emulsions.

Impact of the reduction of the recommended energy target in the ICU on protein delivery and clinical outcomes.

BACKGROUND & AIMS: Energy targets are a matter of debate for intensive care (ICU) patients. As the guidelines have evolved, energy targets have been reduced, while the protein intake objectives have increased. The impact of these changes remains largely unknown. This quality study aimed at investigating the clinical impact of these changes in patients with an ICU stay >3 days. METHODS: Observational cohort study over two 3 months periods (A, B), with distinct prevailing nutrition recommendations in patients admitted consecutively to a multidisciplinary ICU. Inclusion criterion: ICU stay >3 days. Recorded variables: severity scores, energy target and delivery, protein delivery, feeding route, length of stay (ICU, hospital) and hospital outcome. Data as mean, SD and IQR. RESULTS: The analysis included 389 patients, and 3920 observation days. Except for patient age (A versus B: 57.8 and 62.3 years; p = 0.010) and NRS (4.3 vs 3.9 respectively p = 0.002), the cohorts were similar. Compared to A, the mean prescribed energy target decreased by 125 kcal (1947 kcal/d vs. 1822 kcal*day-1 respectively), resulting in lower energy delivery (1353 kcal*day-1 vs. 1238 kcal*day-1; p < 0.0001), and reduced protein delivery (81 g*day-1 vs. 65 g*day-1: p < 0.0001). These differences were associated in survivors with prolonged mechanical ventilation (5.0 days vs. 6.7 days; p = 0.004), extended ICU stay (8.5 vs. 9.9 days; p = 0.0036), and longer hospital stay (23.4 vs. 26.4 days respectively; p = 0.028). Mortality was unchanged. CONCLUSIONS: A linear reduction in energy target recommendation without changing the feed composition led to an unplanned and significant reduction in protein delivery, which was associated with a prolonged duration of ventilation and an extended hospital stay.

ESPEN Guidelines on Enteral Nutrition: Intensive care.

Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma.

[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.

Comparison of mortality prediction models and validation of SAPS II in critically ill burns patients.

Specific burn outcome prediction scores such as the Abbreviated Burn Severity Index (ABSI), Ryan, Belgian Outcome of Burn Injury (BOBI) and revised Baux scores have been extensively studied. Validation studies of the critical care score SAPS II (Simplified Acute Physiology Score) have included burns patients but not addressed them as a cohort. The study aimed at comparing their performance in a Swiss burns intensive care unit (ICU) and to observe whether they were affected by a standardized definition of inhalation injury. We conducted a retrospective cohort study, including all consecutive ICU burn admissions (n=492) between 1996 and 2013: 5 epochs were defined by protocol changes. As required for SAPS II calculation, stays <24h were excluded. Data were collected on age, gender, total body surface area burned (TBSA) and inhalation injury (systematic standardized diagnosis since 2006). Study epochs were compared (χ2 test, ANOVA). Score performance was assessed by receiver operating characteristic curve analysis. SAPS II performed well (AUC 0.89), particularly in burns <40% TBSA (AUC 0.93). Revised Baux and ABSI scores were not affected by the standardized diagnosis of inhalation injury and showed the best performance (AUC 0.92 and 0.91 respectively). In contrast, the accuracy of the BOBI and Ryan scores was lower (AUC 0.84 and 0.81) and reduced after 2006. The excellent predictive performance of the classic scores (revised Baux score and ABSI) was confirmed. SAPS II was nearly as accurate, particularly in burns <40% TBSA. Ryan and BOBI scores were least accurate, as they heavily weight inhalation injury.

Les scores prédictifs de mortalité spécifiques aux brûlés comme l'ABSI, le Ryan, le BOBI, ainsi que le Baux révisé ont été très largement étudiés. Les études ayant validé le SAPS II ont certes inclus des brûlés, mais ils n'ont pas été étudiés en tant que sous-population. Cette étude rétrospective, réalisée dans une unité de réanimation de brûlés suisse, avait pour but de comparer les performances de ces scores et d'évaluer l'impact d'une définition standardisée des lésions d'inhalation. Elle a inclus 492 patients hospitalisés entre 1996 et 2013, répartis en 5 périodes définies par des modifications du protocole interne de prise en charge. L'âge, la surface brûlée et l'inhalation (définition standardisée depuis 2006) ont été recueillis. Les périodes ont été comparées par ANOVA et χ2. La performance des scores a été évaluée par analyse des courbes ROC. Le SAPS II a démontré une bonne performance (AUC 0,89), particulièrement en cas de brûlure <40% SCT (AUC 0,93). L'ABSI et le Baux révisé étaient les plus performants (AUC 0,92 et 0,91) et sont avérés peu affectés par le changement de définition de l'inhalation. Le BOBI et le Ryan se sont révélés moins précis (AUC 0,84 et 0,81) avec des performances encore davantage dégradées après le changement de définition de l'inhalation. L'excellente valeur prédictive du Baux révisé et de l'ABSI est ainsi confirmée. Le SAPS II s'est montré presque aussi précis, en particulier pour des surfaces <40%. Les scores Ryan et BOBI ont été les moins précis.

New genotyping method discovers sustained nosocomial Pseudomonas aeruginosa outbreak in an intensive care burn unit.

BACKGROUND: Pseudomonas aeruginosa is a leading cause of healthcare-associated infections in the intensive care unit (ICU). AIM: To investigate an unexplained increase in the incidence of P. aeruginosa recovered from clinical samples in the ICU over a two-year period. METHODS: After unsuccessful epidemiological investigation by conventional tools, P. aeruginosa clinical isolates of all patients hospitalized between January 2010 and July 2012 were typed by a novel double-locus sequence typing (DLST) method and compared to environmental isolates recovered during the investigation period. FINDINGS: In total, 509 clinical isolates from 218 patients and 91 environmental isolates were typed. Thirty-five different genotypic clusters were found in 154 out of 218 patients (71%). The largest cluster, DLST 1-18, included 23 patients who were mostly hospitalized during overlapping periods in the burn unit. Genotype DLST 1-18 was also recovered from floor traps, shower trolleys and the shower mattress in the hydrotherapy rooms, suggesting environmental contamination of the burn unit as the source of the outbreak. After implementation of appropriate infection control measures, this genotype was recovered only once in a clinical sample from a burned patient and twice in the environment, but never thereafter during a 12-month follow-up period. CONCLUSION: The use of a novel DLST method allowed the genotyping of a large number of clinical and environmental isolates, leading to the identification of the environmental source of a large unrecognized outbreak in the burn unit. Eradication of the outbreak was confirmed after implementation of a continuous epidemiological surveillance of P. aeruginosa clones in the ICU.