[Overview of relevant clinical recommendations from the new S3 guidelines on acute and chronic pancreatitis]. / Überblick über relevante klinische Empfehlungen aus der neuen S3-Leitlinie "Akute und chronische Pankreatitis".

Acute pancreatitis is a primary sterile inflammation of the pancreas, which is characterized by an unphysiological enzyme activation. This leads to an inflammatory reaction with edema, vascular damage and cell decay. The first German interdisciplinary S3 guidelines on chronic pancreatitis were published in 2012. Under the auspices of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) and with the participation of various societies and patient representatives, the guidelines were recently revised and extended, Comprehensive S3 guidelines on acute and chronic pancreatitis were compiled and agreed by consensus. This article presents the important clinical aspects on acute pancreatitis from these guidelines in a compact form and the recommendations are justified.

Study protocol P-MAPS: microbiome as predictor of severity in acute pancreatitis-a prospective multicentre translational study.

BACKGROUND: Acute pancreatitis (AP) is an inflammatory disorder that causes a considerable economic health burden. While the overall mortality is low, around 20% of patients have a complicated course of disease resulting in increased morbidity and mortality. There is an emerging body of evidence that the microbiome exerts a crucial impact on the pathophysiology and course of AP. For several decades multiple clinical and laboratory parameters have been evaluated, and complex scoring systems were developed to predict the clinical course of AP upon admission. However, the majority of scoring systems are determined after several days and achieve a sensitivity around 70% for early prediction of severe AP. Thus, continued efforts are required to investigate reliable biomarkers for the early prediction of severity in order to guide early clinical management of AP patients. METHODS: We designed a multi-center, prospective clinical-translational study to test whether the orointestinal microbiome may serve as novel early predictor of the course, severity and outcome of patients with AP. We will recruit 400 AP patients and obtain buccal and rectal swabs within 72 h of admission to the hospital. Following DNA extraction, microbiome analysis will be performed using 3rd generation sequencing Oxford Nanopore Technologies (ONT) for 16S rRNA and metagenomic sequencing. Alpha- and beta-diversity will be determined and correlated to the revised Atlanta classification and additional clinical outcome parameters such as the length of hospital stay, number and type of complications, number of interventions and 30-day mortality. DISCUSSION: If AP patients show a distinct orointestinal microbiome dependent on the severity and course of the disease, microbiome sequencing could rapidly be implemented in the early clinical management of AP patients in the future. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04777812.

Comparison of fever treatments in the critically ill: a pilot study.

BACKGROUND: Fever in critically ill patients is often treated with antipyretics or physical cooling methods. Although fever is a host defense response that may benefit some critically ill patients, others may not tolerate the cardiovascular demands associated with fever. OBJECTIVES: To compare antipyretics and physical cooling for their effects on core body temperature and cardiovascular responses in critically ill patients. METHODS: The antipyretic administered was 650 mg of acetaminophen. Physical cooling was accomplished by anterior placement of a cooling blanket at 18 degrees C. Core temperature and cardiovascular responses were measured in 14 febrile (body temperature, 38.8 degrees C) critically ill patients at baseline before treatment and up to 3 hours after treatment. Patients able to receive acetaminophen were randomly assigned to receive either acetaminophen only (n = 5) or acetaminophen in combination with a cooling blanket (n = 3). Patients not able to receive acetaminophen were treated with physical cooling only (n = 6). RESULTS: Mean body temperature decreased minimally from baseline to 3 hours after treatment in the physical-cooling-only group (from 39.1 degrees C to 39.0 degrees C) and in the physical cooling and acetaminophen group (from 39.1 degrees C to 38.6 degrees C), but the mean body temperature increased in the acetaminophen-only group (from 39.2 degrees C to 39.4 degrees C). Other notable findings included a slight increase in systemic vascular resistance index in the physical-cooling-only group and in the physical-cooling-plus-acetaminophen group. CONCLUSIONS: Although the study included only 14 subjects, the findings will provide information for future studies in febrile critically ill patients.

Treatment of trauma-associated hypothermia in children: evidence-based practice.

BACKGROUND: Hypothermia is a serious immediate consequence of traumatic injury in children. Although numerous studies have addressed the treatment of hypothermia in adults after trauma or surgery, few have examined this issue in injured children. OBJECTIVES: To evaluate the research literature on when and how to treat hypothermia during emergency care of children with trauma and to apply these findings to clinical nursing practice. METHODS: Electronic literature searches conducted periodically for 3 years yielded more than 50 publications on hypothermia and its treatment in trauma and surgical patients. Publications were grouped by cause of hypothermia and by warming methods. Single case reports and publications related to submersion injuries were excluded. RESULTS: Three clinical trials of patients with head injuries included adolescents aged 15 years and older. One study compared peripheral and core warming methods used during operative management of infants and young children. Only one study evaluated core warming in children with trauma. DISCUSSION: The treatments examined in the few research-based studies on the treatment of hypothermia during emergency care of children with trauma were given low recommendations. Although the warming methods were successful in selected surgical and adult patients, the methods cannot be recommended for treating children with trauma because of the lack of evidence-based findings. CONCLUSIONS: Caution should be used when extrapolating published data on the treatment of hypothermia in injured adults to injured children. Ongoing clinical trials should evaluate in children with trauma those warming methods that have been used successfully in surgical patients.

The effect of cerebrospinal fluid drainage on cerebral perfusion in traumatic brain injured adults.

Cerebrospinal fluid drainage is a first line treatment used to manage severely elevated intracranial pressure (> or = 20 mm Hg) and improve outcomes in patients with acute head injury. There is no consensus regarding the optimal method of cerebrospinal fluid removal. The purpose of this investigation was to determine whether cerebrospinal fluid drainage decreases intracranial pressure and improves cerebral perfusion and to identify factors that impact treatment effectiveness. This study involved 31 severely head injured patients. Intracranial pressure and other indices of cerebral perfusion (cerebral perfusion pressure, cerebral blood flow velocity, and regional cerebral oximetry) were measured before, during, and after cerebrospinal fluid drainage. Arterial and jugular venous oxygen content was measured before and after cerebrospinal fluid drainage. Patients underwent three randomly ordered cerebrospinal fluid drainage protocols that varied in the volume of cerebrospinal fluid removed (1 mL, 2 mL, and 3 mL) for a total of 6 mL of cerebrospinal fluid removed. There was a significant change in the intracranial pressure from a mean at baseline of 26.1 mm Hg (SD = 4.4) to 22.1 mm Hg immediately after drainage. One third of patients experienced a decrease in the intracranial pressure below 20 mm Hg; in two patients the intracranial pressure dropped less than 1 mm Hg. The following factors predicted 61.5% of the variance in the responsiveness of intracranial pressure to drainage: vecuronium hypothermia, baseline cerebral perfusion pressure and acuity of illness. Cerebrospinal fluid drainage provides a transient decrease in intracranial pressure without a measurable improvement in other indices of cerebral perfusion.

Use of blood cultures in critically ill patients.

Infection, bacteremia, and sepsis are frequent complications in critically ill patients. Ideally, the infectious agent is readily identified to facilitate timely treatment to promote the patient's recovery. Use of blood cultures is one method of identifying the pathogen. Fever is the primary indicator for obtaining blood samples for culture, but other indicators may be considered, depending on the patient's medical history and condition. Use of appropriate techniques when collecting blood samples for culture will decrease contamination and improve the likelihood of identification of the infectious agent. One new technique being tested for the identification of pathogens that cause bacteremia involves genetic technology and the polymerase chain reaction. The polymerase chain reaction is used to identify the DNA of bacteria that are present in the blood. Blood cultures may not always result in identification of the pathogen because the organism may not grow once placed in culture medium. This new method that uses the polymerase chain reaction may be more sensitive than blood cultures because it requires only DNA from bacteria. Although early studies have not been conclusive in terms of the benefits of this new technology, additional research will improve methods for identification of pathogens in critically ill patients.

Evidence-based practice: fever-related interventions.

Fever is a common phenomenon in critically ill patients. Ideally, all decisions about treatment of fever would be based on results of well-developed research studies. Instead, some research questions related to treatment of fever have been studied more extensively than others. This article is an evaluation of the usefulness of the research studies related to treatment of fever in the critically ill. Two questions are addressed: when is treatment of fever most beneficial to a critically ill patient, and how is fever most effectively treated in the critically ill? Evidence related to the treatment of fever is evaluated by using the recommendation levels of the research-based practice protocols of the American Association of Critical-Care Nurses.

Perceived stress, physiologic stress arousal, and premenstrual symptoms: group differences and intra-individual patterns.

The purpose of this study was to examine evidence for perceived stress, hypothalamic-pituitary-adrenal, and autonomic nervous system involvement in premenstrual symptoms. Women with a low severity (LS, n = 40), premenstrual syndrome (PMS, n = 22), and premenstrual magnification symptom patterns (PMM, n = 26) rated perceived stress, turmoil, and fluid retention symptoms for one entire cycle. Daily late afternoon urine samples were assayed for epinephrine, norepinephrine, and cortisol. Using multivariate analysis of variance analyses, we found significant group and cycle phase and group by phase interaction effects for perceived stress. There were no group or cycle phase differences in cortisol, epinephrine, and norepinephrine. Intraindividual analyses using cross-correlation techniques revealed a positive time lagged relationship between perceived stress and norepinephrine and cortisol levels across all groups. Only women with a PMS pattern demonstrated perceived stress leading epinephrine levels. Cortisol, epinephrine, and norepinephrine levels led symptoms for all groups with one exception: there was no cross-correlation between epinephrine and turmoil for the PMS group. Perceived stress led both types of symptoms, regardless of group, and symptoms also led stress. The results provide evidence for a unique relationship between epinephrine, perceived stress, and symptoms for women with PMS, and for a reciprocal relationship between stress and symptoms for each of the groups.

Comparison of brain temperature with bladder and rectal temperatures in adults with severe head injury.

OBJECTIVE: The purpose of this study was to compare brain temperature (Tbr) with conventional indicators of core body temperature (i.e., rectal temperature [Tre] and bladder temperature [Tbl]), in adults with severe head injury. METHODS: The relationships between Tbr and Tbl and between Tbr and Tre are described in terms of differences in temperature in eight patients with severe head injury. INSTRUMENTATION: Brain tissue temperature was measured every minute, with a thermocouple embedded 2 cm from the tip of a ventriculostomy catheter used to measure intracranial pressure. Tbl was measured with a thermistor embedded in a bladder catheter, and Tre was measured with a thermistor in a rectal probe. RESULTS: Tbr was usually greater than Tbl and Tre. The average difference between Tbr and Tbl for each patient ranged from 0.32 to 1.9 degrees C, with standard deviations of the difference ranging from 0.30 to 0.80 degrees C. The average difference between Tbr and Tre for each patient ranged from 0.1 to 2.0 degrees C, with standard deviations of the difference ranging from 0.32 to 1.08 degrees C. In the majority of patients, the differences (Tbr - Tbl and Tbr - Tre) were greater at temperatures outside of the normal temperature range (Tbr < or =36 degrees C and >38 degrees C). CONCLUSION: Tbl and Tre often underrepresent Tbr after traumatic brain injury, particularly when the patient is hypo- or hyperthermic.

Fever.

Fever is a host defense response that provides a sign of an ongoing process related to infection, inflammation, drug reactions, neoplasms, autoimmune diseases, and vascular disorders. The most frequent causes of fever in acutely ill patients are infection and inflammation, but fever may be caused by one or more of a long list of pathophysiologic processes.

The effect of administered crystalloid fluid temperature on aural temperature of moderately and severely injured children.

OBJECTIVE: Warm intravenous fluid (W-IVF) administration is the standard of care to prevent hypothermia in injured adults. It is argued that such administration may not be helpful for treating injured children, because children often do not require as much intravenous fluid (i.v.f.) as adults. The purpose of this study was to compare the effects of W-i.v.f. to room temperature intravenous fluid (RT-i.v.f.) administration on aural temperature (Ta) in injured children during the first hour of trauma resuscitation. DESIGN: A randomized, controlled repeated-measures trial. SETTING: Emergency department, intensive care unit, and diagnostic areas in a level I pediatric trauma center. SAMPLE: Thirty moderately or severely injured children, ranging in age from 2 to 17 years (mean age = 8.9 years; SD = 4.4). METHODS: Eligible children were randomly assigned to receive either W-i.v.f. or RT-i.v.f. on ED arrival. Warmed IVF was administered with the Hotline fluid warmer (SIMS Level 1, Rockland, Mass). Aural temperatures were measured on arrival and every 10 minutes for 1 hour with a Core-Check Tympanic Thermometer (IVAC Medical Systems, San Diego, Calif). The level of significance for hypothesis testing was set at 0.05 (two-tailed). RESULTS: Groups were comparable in age, gender, weight, amount of infused i.v.f., Revised Trauma Score, room temperature, and baseline Ta. On average, Ta for the W-i.v.f. group increased by 0.25 degree C from baseline to final Ta, whereas Ta for the RT-i.v.f. group decreased by 0.32 degree C from baseline to final Ta. Repeated-measures analysis of covariance, treating baseline Ta as a covariate, demonstrated that Ta response profiles were similar (p = 0.06). CONCLUSIONS: When comparing the changes between baseline and final Ta for the W-i.v.f. and RT-i.v.f. groups, the standardized difference in temperature change was 0.62. Although results of the repeated measures analysis of covariance were not statistically significant, the standardized difference in temperature changes was large enough to warrant administration of W-i.v.f., even at slow flow rates, to prevent hypothermia in injured children.

Analgesic prescription and administration to adolescents admitted to an adult versus pediatric trauma center.

OBJECTIVE: To compare the prescription and administration practices for narcotic and non-narcotic analgesics given to injured adolescents admitted to an adult versus pediatric trauma center. METHODS: A retrospective chart review of 45 medical records for documentation of prescribed and administered analgesics in the first 48 hours of hospitalization. RESULTS: Adolescents treated at the adult trauma center had significantly more narcotics ordered in the first 24 hours of admission compared to adolescents in the pediatric trauma center. However, when controlling for injury severity, there was no difference between the narcotic administration at the two trauma centers. There were no differences in the types or numbers of doses of non-narcotic analgesics prescribed or administered. CONCLUSION: There were no differences in the prescription or administration of narcotic and non-narcotic analgesics to injured adolescents in an adult versus a pediatric trauma center. Future research should focus on the prospective enrollment of injured adolescents at additional trauma centers and a larger sample size to validate or refute these findings.

A comparison of aural and rectal temperature measurements in children with moderate and severe injuries.

OBJECTIVE: The purpose of this study was to compare initial rectal and aural (i.e., ear-based) temperature measurements in children with moderate and severe injuries during their trauma care in the emergency department. DESIGN: A cross-sectional, prospective design was used to compare aural temperature and rectal temperatures in injured children. SAMPLE/SETTING: A convenience sample of 40 children who met the study inclusion criteria were enrolled at the level I pediatric regional resource trauma center in western Pennsylvania. METHODS: Aural temperature was measured by infrared technology (IVAC Corporation, San Diego, Calif.), and rectal temperatures were measured with a thermistor (IVAC Corporation). RESULTS: The subjects (N = 40) ranged in age from 1 to 14 years (mean 6.9 years; SD = 4.4 years). The mean difference between rectal and aural temperature measurements (mean = -0.3 degree C; SD = 0.76 degree C) was statistically significant when compared with a paired t test (p < 0.05). The Pearson product-moment correlation coefficient between aural and rectal temperature measurements was moderate to high (r = 0.85). CONCLUSION: The moderate to high correlation between the two methods shows promise for use of aural infrared temperature measurements as a screening measure for children with moderate and severe injuries.

Evaluation of four methods of warming intravenous fluids.

OBJECTIVE: The purpose of this in vitro study was to compare four methods of warming intravenous fluid (IVF) with a control of unwarmed IVF at flow rates of 200, 400, 600, 800, and 1000 ml/hr. DESIGN: A 5 x 5 factorial experimental design was used to evaluate the methods of warming IVF and the control at varied flow rates. METHODS: The methods of warming IVF in this study included the following: (1) the Level 1 System 250 fluid warmer with D-60HL tubing (Level 1 Technologies, Inc., Rockland, Mass.); (2) the Level 1 System 250 fluid warmer with D-50 tubing (Level 1 Technologies, Inc.); (3) the Hotline fluid warmer with L-70 tubing (Level 1 Technologies, Inc.); and (4) the Baxter DW 1000 D blood fluid warmer with blood cuff set tubing (Baxter Healthcare Corporation, Valencia, Calif.). The IVF temperatures were measured with thermocouples at three points: (1) in the intravenous solution bag, (2) in the tubing after the infusion pump, and (3) 2 cm proximal to the end of the tubing. Ambient temperature and the temperature at the three measurement points were recorded when the temperature at the point 2 cm proximal to the end of the tubing was stable for 3 minutes. RESULTS: With single-lumen tubing, fluids flowing at low rates (e.g., 200 ml/hr) were barely warm at the end of the tubing. In contrast, fluid warmed with triple-lumen technology was consistently kept warm throughout the tubing.

Comparison of peripheral temperature measurements with core temperature.

The authors' objective of this study was to identify a peripheral method of measuring body temperature that approximates core body temperature. A cross-sectional design was used to compare peripheral measures of body temperature with core temperature. Peripheral temperatures were measured in the ear using two infrared thermometers, in the mouth using a mercury in glass thermometer, electronic thermometer, and chemical indicator thermometer, in the axilla using a mercury in glass thermometer, electronic thermometer, and chemical indicator thermometer, and in the rectum using a mercury in glass thermometer and electronic thermometer. A statistically significant difference was found between peripheral temperature measures and core temperature, except for the axillary chemical indicator temperature and both aural temperatures. Pearson correlation coefficients of > or = 0.79 were found for the association of pulmonary artery temperatures with oral mercury, oral electronic, axillary electronic, rectal mercury, and rectal electronic temperatures. Correlation coefficients were less than 0.20 between pulmonary artery and aural temperatures measured by both devices. Based on results from this study, there is no perfect instrument for approximating core temperature, although the electronic thermometer used orally has a low mean difference (0.18 degree C), low standard deviation of the difference (0.24 degree C), and a correlation coefficient of 0.79.

Understanding the febrile state according to an individual adaptation framework.

Fever is a common problem in the critically ill that is often treated by nurses. Decisions regarding treatment of fever would be more informed if based upon research related to fever. The authors, in this article, present an individual adaptation framework for conceptualizing the components of the febrile state important to practice, and review some of the existing research related to development, assessment, and treatment of fever.

Cardiac assist devices as a bridge to cardiac transplant.

The number of heart transplants being performed in the United States over the last decade has increased significantly. The supply of human donor hearts has not kept up with the demand. This situation has led to the development of means to support patient's cardiac function until a human donor heart can be obtained. Methods to support the patient include use of ventricular assist devices and the total artificial heart. Integration of caring and technology in patients receiving cardiac assist devices (CADs) provides a challenge for critical care nurses. Nursing care of the patient with a CAD involves identification and prevention of complications, familiarization with new technology, and development of a caring environment.