Guideline on positioning and early mobilisation in the critically ill by an expert panel.

A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.

Perceptions of critically ill individuals with acute and chronic spinal cord injury requiring a tracheostomy tube.

STUDY DESIGN: Observational study. OBJECTIVES: To evaluate the perceptions of patients requiring a tracheostomy tube and to identify possible different perceptions in critically ill patients with tracheostomy tubes who have acute (ASCI) or chronic spinal cord injuries (CSCI). SETTING: Medical and surgical intensive care units (ICU) and intermediate care unit of the BG University Hospital Bergmannsheil Bochum, Germany. METHODS: Patients who met the inclusion criteria completed a 25-item questionnaire on two consecutive days regarding their experiences and perceptions in breathing, coughing, pain, speaking, swallowing, and comfort of the tracheostomy tube. RESULTS: A total of 51 persons with ASCI (n = 31) and CSCI (n = 20) were included with a mean age of 53 years. Individuals with ASCI reported significantly more frequent pain and swallowing problems as compared to individuals with CSCI (p ≤ 0.014) at initial assessment. There were no differences between ASCI and CSCI reported with respect to speaking and overall comfort. CONCLUSIONS: It is necessary to regularly assess the perceptions of critically ill patients with tracheostomy tubes with ASCI or CSCI in the daily ICU care routine. We were able to assess these perceptions in different categories. For the future, evaluating the perception of individuals with SCI and a tracheostomy should be implemented to their daily routine care. TRIAL REGISTRATION: DRKS00022073.

Behavioral pain scale may not be reliable in awake non-verbal intensive care patients: a case control study.

BACKGROUND: The evaluation of pain in patients, unable of oral communication, often relies on behavioral assessment. However, some critically ill patients, while non-verbal, are awake and have some potential for self-reporting. The objective was to compare the results of a behavioral pain assessment with self-reporting in awake, non-verbal, critically ill patients unable to use low-tech augmentative and alternative communication tools. METHODS: Prospective cohort study of intubated or tracheotomized adult, ventilated patients with a RASS (Richmond Agitation Sedation Scale) of -1 to + 1 and inadequate non-verbal communication skills in a surgical intensive care unit of a tertiary care university hospital. For pain assessment, the Behavioral Pain Scale (BPS) was used. Self-reporting of pain was achieved by using an eye tracking device to evaluate the Numeric Rating Scale (NRS) and the pain/discomfort item of the EuroQol EQ-5D-5 L (EQ-Pain). All measurements were taken at rest. RESULTS: Data was collected from 75 patients. Neither the NRS nor the EQ-Pain (r < .15) correlated with the BPS. However, NRS and EQ-Pain were significantly correlated (r = .78, p = < 0.001), indicating the reliability of the self-reporting by these patients. Neither the duration of intubation/tracheostomy, nor cause for ICU treatment, nor BPS subcategories had an influence on these results. CONCLUSIONS: Behavioral pain assessment tools in non-verbal patients who are awake and not in delirium appear unreliable in estimating pain during rest. Before a behavioral assessment tool such as the BPS is used, the application of high-tech AACs should be strongly considered. TRIAL REGISTRATION: German Clinical Trials Register, Registration number: DRKS00021233. Registered 23 April 2020 - Retrospectively registered, https://drks.de/search/en/trial/DRKS00021233 .

First experiences of communication with mechanically ventilated patients in the intensive care unit using eye-tracking technology.

INTRODUCTION: Eye-tracking (ET) may be a novel tool for communication with intubated and mechanically ventilated critically ill patients. We hypothesized that ET could be learned fast and be used successfully by intensive care unit (ICU) and intermediate care (IMC) patients with artificial airways for communication. METHODS: Including all patients with mechanical ventilation via oral intubation or tracheostomy, who were at least 18 years of age with a score of -1 to +1 points on the Richmond agitation-sedation scale and a history of ventilation for more than 48 h. A commercially available ET was used. The investigations were performed by a physician with the support of a psychologist following a standardized study protocol. RESULTS: During a 4-week period a total of 11 patients completed all of the five steps of our study protocol. The time to complete our study protocol was 64 ± 23.8 min (range 43-125 min) with a mean of 1.5 ± 0.9 sessions (range 1-4 sessions). Seven patients (63.6 %) could run through all of the five steps within their first session. All patients (100%) preferred the gaze fixation technique to control the ET to the wink control. CONCLUSION: Mechanically ventilated ICU and IMC patients are able to use ET in a very short time for communication to indicate their basic needs, answer rating scales and pain scores as well as questionnaires about quality of life and self-esteem.Implications for rehabilitationCOMFORT - The novel communication device improves the patients' ability to communicate with the attending physicians, physiotherapists and nurses in order to provide a tailored rehabilitation approach.COMPLIANCE - The use of the eye-tracking technology enables the patients to communicate special needs and fears during the course of the rehabilitation.COMPLICATIONS - The eye-tracking technology enables the attending rehabilitation team to earlier detect complications (e.g. pain, depression) during the course of the rehabilitation.

Development of the Tracheostomy Well-Being Score in critically ill patients.

PURPOSE: Little attention has been given to understanding the experiences and perceptions of tracheostomized patients. This study aimed to measure the impact of tracheostomy on well-being in critically ill patients with the development of the Tracheostomy Well-Being Score (TWBS). METHODS: This is a prospective, monocentric, observational study including critically ill patients with a tracheostomy without delirium. A 25-item questionnaire with items from six categories (respiration, coughing, pain, speaking, swallowing, and comfort) was used to select the 12 best items (two per category) to form the TWBS score after testing on two consecutive days. Item selection secured (1) that there were no skewed response distributions, (2) high stability from day 1 to day 2, and (3) high prototypicality for the category in terms of item-total correlation. RESULTS: A total of 63 patients with a mean age of 56 years were included. The 12 items of the TWBS were characterized by a high retest reliability (τ = 0.67-0.93) and acceptable internal consistency. The overlap with the clinician rating was low, suggesting that acquiring self-report data is strongly warranted. CONCLUSION: With the TWBS, an instrument is available for the assessment of the subjective effects a tracheostomy has on in critically ill patients. The score potentially offers a chance to increase well-being of these patients. Additionally, this score could also increase their quality of life by improving tracheostomy and weaning management. CLINICAL TRIAL REGISTRATION: German Clinical Trials Register Identifier DRKS00022073 (2020/06/02).

Sedation, sleep-promotion, and non-verbal and verbal communication techniques in critically ill intubated or tracheostomized patients: results of a survey.

BACKGROUND: The aim of this survey was to describe, on a patient basis, the current practice of sedation, pharmacologic and non-pharmacologic measures to promote sleep and facilitation of communication in critically ill patients oro-tracheally intubated or tracheostomized. METHODS: Cross-sectional online-survey evaluating sedation, sleep management and communication in oro-tracheally intubated (IP) or tracheostomized (TP) patients in intensive care units on a single point. RESULTS: Eighty-one intensive care units including 447 patients (IP: n = 320, TP: n = 127) participated. A score of ≤ -2 on the Richmond Agitation Sedation Scale (RASS) was prevalent in 58.2% (IP 70.7% vs. TP 26.8%). RASS -1/0 was present in 32.2% (IP 25.9% vs. TP 55.1%) of subjects. Propofol and alpha-2-agonist were the predominant sedatives used while benzodiazepines were applied in only 12.1% of patients. For sleep management, ear plugs and sleeping masks were rarely used (< 7%). In half of the participating intensive care units a technique for phonation was used in the tracheostomized patients. CONCLUSIONS: The overall rate of moderate and deep sedation appears high, particularly in oro-tracheally intubated patients. There is no uniform sleep management and ear plugs and sleeping masks are only rarely applied. The application of phonation techniques in tracheostomized patients during assisted breathing is low. More efforts should be directed towards improved guideline implementation. The enhancement of sleep promotion and communication techniques in non-verbal critically ill patients may be a focus of future guideline development.

Pilot study: advanced haemodynamic monitoring after acute spinal cord injury-Keep the pressure up?

BACKGROUND: Although the use of vasopressors to maintain haemodynamic goals after acute spinal cord injury (SCI) is still recommended, evidence regarding the target values and possible risks of this practice is limited, and data on haemodynamic parameters unaffected by catecholamines are rare. In this pilot study, we show the haemodynamic profile of patients with acute SCI mainly unaffected by vasopressor use and other factors that influence the cardiovascular system. METHODS: From March 2018 to March 2020, we conducted a prospective, single-centre pilot study of 30 patients with acute SCI. Factors that could affect the cardiocirculatory system other than SCI (sepsis, pre-existing heart disease or multiple trauma) led to exclusion. A total of 417 measurements were performed using the PiCCO™ system. RESULTS: The mean systemic vascular resistance index (SVRI, 1447.23 ± 324.71 dyn*s*cm-5*m2), mean central venous pressure (CVP, 10.69 ± 3.16) and mean global end-diastolic volume index (GEDVI, 801.79 ± 158.95 ml/m2) deviated from the reference range, while the mean cardiac index (CI), mean stroke volume index (SVI), mean arterial pressure (MAP), and mean heart rate (HR) were within the reference range, as indicated in the literature. A mixed model analysis showed a significant negative relationship between norepinephrine treatment and MAP (83.97 vs. 73.69 mmHg, p < 0.001), SVRI (1463.40 vs. 1332.14 dyn*s*cm-5*m2, p = 0.001) and GEDVI (808.89 vs. 759.39 ml/m2, p = 0.001). CONCLUSION: These findings could lead to an adaptation of the target range for SVRI and MAP in patients with acute SCI and therefore reduce the use of vasopressors.

Keeping it simple: the value of mortality prediction after trauma with basic indices like the Reverse Shock Index multiplied by Glasgow Coma Scale.

BACKGROUND: Identification of trauma patients at significant risk of death in the prehospital setting is challenging. The prediction probability of basic indices like vital signs, Shock Index (SI), SI multiplied by age (SIA) or the GCS is limited and more complex scores are not feasible on-scene. The Reverse SI multiplied by GCS score (rSIG) has been proposed as a triage tool to identify trauma patients with an increased risk of dying at EDs. Age adjustment (rSIG/A) displayed no advantage.We aim to (1) validate the accuracy of the rSIG in predicting death or early transfusion in a large trauma registry population, and (2) determine if the rSIG is valid for evaluation of trauma patients in the prehospital setting. METHODS: 70 829 trauma patients were retrieved from the TraumaRegister DGU database (time period between 2008 and 2017). The area under the receiver operating characteristic curve (AUROC) was calculated to measure the ability of SI, SIA, rSIG and rSIG divided by age (rSIG/A) to predict in-hospital mortality from data at the time of hospital arrival and solely from prehospital data. RESULTS: The rSIG at time of hospital admission was not sufficiently predictive for clinical decision-making. However, rSIG calculated solely from prehospital data accurately predicted risk of death. Using prehospital data, the AUROC for mortality of rSIG/A was the highest (0.85; CI: 0.85 to 0.86), followed by rSIG (0.76; CI: 0.75 to 0.77), SIA (0.71; CI: 0.70 to 0.71) and SI (0.48; CI: 0.47 to 0.49). CONCLUSION: The prehospital rSIG/A can be a useful adjunct for the prehospital evaluation of trauma patients and their allocation to trauma centres or trauma team activation. However, we could not confirm that the rSIG at hospital admission is a reliable tool for risk stratification.

German S3 Guideline: Oxygen Therapy in the Acute Care of Adult Patients.

BACKGROUND: Oxygen (O2) is a drug with specific biochemical and physiological properties, a range of effective doses and may have side effects. In 2015, 14% of over 55,000 hospital patients in the UK were using oxygen. 42% of patients received this supplemental oxygen without a valid prescription. Health care professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS: A national S3 guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. A literature search was performed until February 1, 2021, to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of evidence and for grading guideline recommendation, and a formal consensus-building process was performed. RESULTS: The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are based depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION: This is the first national guideline on the use of oxygen in acute care. It addresses health care professionals using oxygen in acute out-of-hospital and in-hospital settings.

The use of predefined scales and scores with eye-tracking devices for symptom identification in critically ill nonverbal patients.

BACKGROUND: Eye tracking (ET) may be a novel tool to enable nonverbal communication. We hypothesized that ET could be used successfully by intensive care unit (ICU) patients with artificial airways to express their levels of pain and mood, quality of life, and self-esteem with predefined scales and scores. METHODS: Prospective, monocentric, observational study, including patients with an endotracheal tube or tracheostomy tube and a history of mechanical ventilation for more than 48 hours without delirium, and inadequate nonverbal communication skills. The ICU patients' pain was assessed with a numeric rating scale, their mood was tested with a smiley analog scale. Quality of life and self-esteem were measured with the European quality of life-5 dimensions-5 levels-score and the visual analog self-esteem scale. RESULTS: A total of 75 patients with a mean age of 58.3 years were included. Main diagnoses for ICU admission were major trauma (45.3%), nonabdominal sepsis (22.6%), and acute abdomen (13.3%). Patients showed moderate levels of pain and sadness with a median of 4 (interquartile range, 3-5.5) on the numeric rating scale and a median of 4 (interquartile range, 3-4) on the smiley analog scale. The general health status on the European quality of life-5 dimensions-5 levels-score was rated as poor. Reporting on the visual analog self-esteem scale, most of the included patients felt trapped (90.7%) and not confident (72%), were frustrated (64%) or did not feel understood (56%). However, despite their severe illness, many patients classified themselves as intelligent (30.6%), not mixed up (38.6%), outgoing (38.6%), and optimistic (44%). CONCLUSION: Eye tracking enables symptom identification in critically ill voiceless patients with impaired communication options. The results of our study may provide guidance for improvement measures in the care of voiceless ICU patients. We believe that ET is useful for symptom identification and therefore may be capable of improving patient-medical team interaction and patient satisfaction. LEVEL OF EVIDENCE: Diagnostic Test or Criteria, Level III.

Approach to the basic needs in patients on invasive ventilation using eye-tracking devices for non-verbal communication.

PURPOSE: To analyze the feasibility of eye-tracking (ET) devices as a communicative approach to the basic needs (BN) of intensive care unit (ICU) and invasively ventilated nonverbal patients. METHODS: Prospective, monocentric, and observational study including all patients without delirium, with an endotracheal tube or tracheostomy tube, with a history of invasive ventilation for more than 48 h, and inadequate nonverbal communication skills. The investigation was performed with commercially available ET devices (Tobii Dynavox I-15+) to express BN of ICU patients following a standardized 30-item yes-or-no questionnaire. RESULTS: A total of 64 patients with a mean age of 58.6 years were included. The main diagnoses for ICU admission were major trauma (43.6%), sepsis (21.8%), and acute abdomen (15.6%). Pain during repositioning (69%), thirst (69%), sleep disorders (66%), fatigue (64%), and anxiety regarding the lifelong need for assistance (64%) were the main problems reported by the patients. However, most of the patients described expectations of health improvement (78%), good family support (66%), and an improvement in quality of life due to the use of ET devices (67%). CONCLUSION: The use of ET in selected ICU patients with impaired communication is feasible, allowing them to express their BN. Apart from knowing the patients' individual BN, the results of our BN questionnaire may provide guidance for improvement measures in the care of patients in the ICU who are unable to speak. We believe that ET is useful for inquiring about and expressing BN and, therefore, may be capable of improving patient-medical team interactions and patient satisfaction.

Trauma patients with SARS-CoV-2 in German ICUs during the 2nd wave of the COVID-19 pandemic.

PURPOSE: In January and February 2021, about 4000 severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) positive patients were treated daily in German intensive care units (ICUs). The number of SARS-CoV-2-positive ICU patients with trauma, however, is not known and neither whether the trauma itself or COVID-19 causes the critical illness. METHODS: A total of 173 German ICUs, representing 3068 ICU beds, participated in a survey developed by the Trauma Section of the German Interdisciplinary Association of Intensive Care Medicine (DIVI). RESULTS: Participating ICUs reported an overall 1-day prevalence of 20 and an overall 7-day prevalence of 35 SARS-CoV-2-positive trauma patients in the ICU. Critical illness was triggered by trauma alone in 50% of cases and by the combination of trauma and COVID-19 in 49% of cases; 70% of patients were older than 65 years and suffered from a single injury, predominantly proximal femur fractures. The distribution of patients was comparable regarding the level of care of the trauma centre (local, regional, and supra-regional). CONCLUSION: The proportion of trauma patients of all SARS-CoV-2-positive critically ill patients is small (~ 1%) but relevant. There is no concentration of these patients at Level 1 trauma centres. However, the traumatic insult is the most relevant cause for ICU treatment in most of these patients. Regarding a new wave of the pandemic, adequate trauma dedicated resources and perioperative structures and expertise have to be provided for COVID-19 trauma patients.

[Oxygen in the acute care of adults : Short version of the German S3 guideline]. / Sauerstoff in der Akuttherapie beim Erwachsenen : Kurzversion der S3-Leitlinie.

BACKGROUND: Oxygen is a drug with specific properties, a defined dose-effect range and side effects. In 2015, in a sample of UK hospital patients, 14% were treated with oxygen, of which only 42% had a prescription. Health care workers are often uncertain about the relevance of hypoxemia, and there is limited awareness of the risks of hyperoxemia. Numerous randomized controlled trials on oxygen therapy have recently been published. METHODS: As part of the guideline program of the Working Group of Scientific Medical Societies e. V. (AWMF), this S3 guideline was developed with the participation of 10 medical societies on the basis of a literature search up to 02/01/2021. The system of the Oxford Centre for Evidence-Based Medicine (CEBM) (The Oxford 2011 Levels of Evidence) was used to evaluate the literature. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE), and a formal consensus process of recommendations was performed. RESULTS: The guideline contains 34 evidence-based recommendations on the indication, prescription, monitoring, and discontinuation of oxygen therapy in acute care. The indication for oxygen is mainly hypoxemia. Hypoxemia and hyperoxemia should be avoided, since both increase mortality. The guideline recommends target ranges of oxygen saturation for acute oxygen therapy without differentiating between different diagnoses. Target areas depend on the risk for hypercapnia and ventilation status. The guideline provides an overview of available oxygen delivery systems and contains recommendations for their selection based on patient safety and comfort. CONCLUSION: This is the first German guideline on the use of oxygen in acute care. It is aimed at medical professionals who use oxygen in and outside hospitals and is valid until June 30th, 2024.

[German S3 Guideline - Oxygen Therapy in the Acute Care of Adult Patients]. / S3-Leitlinie Sauerstoff in der Akuttherapie beim Erwachsenen.

BACKGROUND: Oxygen (O2) is a drug with specific biochemical and physiologic properties, a range of effective doses and may have side effects. In 2015, 14 % of over 55 000 hospital patients in the UK were using oxygen. 42 % of patients received this supplemental oxygen without a valid prescription. Healthcare professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS: A S3-guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. Literature search was performed until Feb 1st 2021 to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used and for assessing the quality of evidence and for grading guideline recommendation and a formal consensus-building process was performed. RESULTS: The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION: This is the first national guideline on the use of oxygen in acute care. It addresses healthcare professionals using oxygen in acute out-of-hospital and in-hospital settings. The guideline will be valid for 3 years until June 30, 2024.

Distinct Behavior of Traumatic versus Nontraumatic Intracerebral Hematomas: Different Biology or Impact of Age?

BACKGROUND AND STUDY AIMS: Patients with large intracerebral hematomas (ICH) may demonstrate different demographics and underlying brain and systemic diseases, as well as different radiologic courses and distinct outcomes. It remains unclear whether their different behavior attributes to a different biology of the ICH or to the asymmetric characteristics of the two populations. To analyze and adjust for potential sources of selection and treatment bias, our study compared age-matched patients with traumatic and nontraumatic ICH in a single cohort diagnosed and treated in the same surgical department. MATERIAL AND METHODS: We analyzed 135 consecutive patients with traumatic (n = 90) or spontaneous ICH (n = 45) undergoing treatment at a surgical intensive care unit of an urban university hospital. We documented their differences before and after adjustment for age in terms of demographics, the therapies applied, their radiologic (i.e., volume and rate of ICH expansion [HE]) and clinical (patients' outcome at 30 days) course, the length of hospital and ICU stay, as well as the hospital costs. RESULTS: Patients with traumatic ICH demonstrated more favorable clinical and radiologic characteristics at admission, that is, higher Glasgow Coma Scale score (p < 0.001), less frequently dilated pupil (p = 0.028), lower Charlson Comorbidity Index (p < 0.001), smaller ICH volume (p < 0.001), noneloquent (p < 0.001) or nonintraventricular (p = 0.003) ICH locations, as well as underwent fewer neurosurgical interventions (p < 0.001) and showed a better outcome (p = 0.041), defined as Glasgow Outcome Scale 4 and 5. After adjustment for age, no different outcomes were observed. Of note, elderly patients on novel oral anticoagulants (NOACs) were more likely to develop an HE compared with those on vitamin K antagonists (VKAs, p = 0.05) after traumatic brain injury (TBI) but not after spontaneous ICH. CONCLUSION: Our data reveal a significant heterogeneity within the traumatic series. Whereas younger patients show an excellent outcome, the elderly population of the traumatic cases demonstrates a poor outcome similar to that of the nontraumatic cohort. HE under NOACs rather than under VKAs is more likely in the elderly after TBI. Larger prospective trials are warranted to elucidate the potential individual underlying molecular mechanisms for the development of an ICH and HE in these diseases.

ISS alone, is not sufficient to correctly assign patients post hoc to trauma team requirement.

PURPOSE: An injury severity score (ISS) ≥ 16 alone, is commonly used post hoc to define the correct activation of a trauma team. However, abnormal vital functions and the requirement of life-saving procedures may also have a role in defining trauma team requirement post hoc. The aim of this study was to describe their prevalence and mortality in severely injured patients and to estimate their potential additional value in the definition of trauma team requirement as compared to the definition based on ISS alone. METHODS: Retrospective analysis of a trauma registry including patients with trauma team activation from the years 2009 until 2015, who were 16 years of age or older and were brought to the trauma center directly from the scene. Patients were divided into a group with an ISS ≥ 16 vs. ISS < 16. For analysis a predefined list of abnormal vital functions and life-saving interventions was used. RESULTS: 58,723 patients were included in the study (N = 32,653 with ISS ≥ 16; N = 26,070 with ISS < 16). From the total number of patients that required life-saving procedures or presented with abnormal vital functions 29.1% were found in the ISS < 16 group. From the ISS < 16 group, 36.7% of patients required life-saving procedures or presented with abnormal vital signs. The mortality of those was 8.1%. CONCLUSIONS: Defining the true requirement of trauma team activation post hoc by using ISS ≥ 16 alone does miss a considerable number of subjects who require life-saving interventions or present with abnormal vital functions. Therefore, life-saving interventions and abnormal vital functions should be included in the definitions for trauma team requirement. Further studies have to evaluate, which life-saving procedures and abnormal vital functions are most relevant.

Major trauma due to suicide attempt: increased workload but not mortality.

INTRODUCTION: Suicide attempt is a common cause for major trauma. Due to the underlying psychiatric disease, patients` compliance or even prognosis may be reduced. Modalities of discharge after surgical acute care might differ. METHODS: Retrospective study including trauma patients of two urban level 1 trauma centers between 2013 and 2017. Data originally collected for quality management using the German trauma registry were supplemented after review of medical charts with details on psychiatric disease and discharge modalities. RESULTS: We included 2118 consecutive patients of which 108 (5%) attempted suicide. Most common psychiatric diagnosis were depression (38%) and schizophrenia (25.9%). Comparing patients after suicide attempt with others, suicide attempt was associated with a younger age (42.3 vs. 49.0 years), a higher injury severity (mean ISS 24.7 vs. 16.8) and consecutively, a higher expected mortality (risk-adjusted prognosis for mortality 18.0 vs. 8.1%), while observed mortality was lower than expected in both groups (16.7 vs. 6.4%). Survivors after suicide attempt had a longer stay on ICU (mean days on ICU 17 vs. 7). 56% were transferred to psychiatric facilities and only 4% could be discharged home after acute surgical care. CONCLUSION: Incidence of suicide attempts among major trauma patients is high. Mean injury severity is higher than in unintended trauma and associated with a prolonged stay on intensive care unit even after adjustment for injury severity and age. Risk-adjusted mortality is not increased. Proportion of patients discharged home or to out-patient rehabilitation is very low. Specialized institutions who offer both, musculoskeletal rehabilitation and psychiatric care are required for rehabilitative treatment after the acute surgical care.

Incidence, impact and risk factors for multidrug-resistant organisms (MDRO) in patients with major trauma: a European Multicenter Cohort Study.

INTRODUCTION: The burden of MDRO in health systems is a global issue, and a growing problem. We conducted a European multicenter cohort study to assess the incidence, impact and risk factors for multidrug-resistant organisms in patients with major trauma. We conducted this study because the predictive factors and effects of MDRO in severely injured patients are not yet described. Our hypothesis is that positive detection of MDRO in severely injured patients is associated with a less favorable outcome. METHODS: Retrospective study of four level-1 trauma centers including all patients after major trauma with an injury severity score (ISS) ≥ 9 admitted to an intensive care unit (ICU) between 2013 and 2017. Outcome was measured using the Glasgow outcome scale (GOS). RESULTS: Of 4131 included patients, 95 (2.3%) had a positive screening for MDRO. Risk factors for MDRO were male gender (OR 1.73 [95% CI 1.04-2.89]), ISS (OR 1.01 [95% CI 1.00-1.03]), PRBC's given (OR 1.73 [95% CI 1.09-2.78]), ICU stay > 48 h (OR 4.01 [95% CI 2.06-7.81]) and mechanical ventilation (OR 1.85 [95% CI 1.01-3.38]). A positive MDRO infection correlates with worse outcome. MDRO positive cases GOS: good recovery = 0.6%, moderate disability = 2.1%, severe disability = 5.6%, vegetative state = 5.7% (p < 0.001). CONCLUSIONS: MDRO in severely injured patients are rare but associated with a worse outcome at hospital discharge. We identified potential risk factors for MDRO in severely injured patients. Based on our results, we recommend a standardized screening procedure for major trauma patients.