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BACKGROUND: Despite aneurysmal subarachnoid haemorrhage (aSAH) patients often experiencing physical and mental disabilities impacting their quality of life (QoL), routine assessment of long-term QoL data and predictive tools are limited. This study evaluates the newly developed "functional recovery expected after subarachnoid haemorrhage" (FRESH) scores with long-term outcomes and QoL in European aSAH patients. METHODS: FRESH, FRESH-cog, and FRESH-quol scores were retrospectively obtained from aSAH patients. Patients were contacted, and the modified Rankin Scale (mRS), extended short form-36 (SF-36), and telephone interview for cognitive status (TICS) were collected and performed. The prognostic and empirical outcomes were compared. RESULTS: Out of 374 patients, 171 patients (54.1%) completed the SF-36, and 154 patients completed the TICS. The SF-36 analysis showed that 32.7% had below-average physical component summary (PCS) scores, and 39.8% had below-average mental component summary (MCS) scores. There was no significant correlation between the FRESH score and PCS (p = 0.09736), MCS (p = 0.1796), TICS (p = 0.7484), or mRS 10-82 months (average 46 months) post bleeding (p = 0.024), respectively. There was also no significant correlation found for "FRESH-cog vs. TICS" (p = 0.0311), "FRESH-quol vs. PCS" (p = 0.0204), "FRESH-quol vs. MCS" (p = 0.1361) and "FRESH-quol vs. TICS" (p = 0.1608). CONCLUSIONS: This study found no correlation between FRESH scores and validated QoL tools in a European population of aSAH patients. The study highlights the complexity of reliable long-term QoL prognostication in aSAH patients and emphasises the need for further prospective research to also focus on QoL as an important outcome parameter.
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Hemorragia Subaracnóidea , Humanos , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/diagnóstico , Qualidade de Vida , Estudos Retrospectivos , Pacientes , Recuperação de Função FisiológicaRESUMO
A patient with oral squamous cell carcinoma (OSCC) underwent complex surgical tumor therapy, including the reconstruction of soft tissues using a radial forearm flap. Due to venous congestion that could only partly be resolved by revision surgery, leech therapy was started on the second postoperative day. The patient developed pneumonia and sepsis and died as a result of septic shock, despite having received targeted broad-spectrum antibiotic therapy since day 5. Aeromonas spp. were cultured from both the patient's specimens and unused leeches. Biochemical identification and matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) yielded inconsistent identification results. Finally, microbiological identification of Aeromonas spp. was performed via 16S rDNA sequencing and use of the basic local alignment search tool (BLAST), and strains from both the patient and the leeches were identified as Aeromonas veronii. Aeromonas spp. strains derived from the patient and leeches and independent laboratory strains were submitted to randomly amplified polymorphic DNA (RAPD) subtyping. RAPD of A. veronii strains from both sources revealed an identical pattern, strongly suggesting the transmission of A. veronii from the leeches to the patient. Physicians should be aware of the potential for severe lethal infections as a fatal side-effect of leech therapy in critically ill patients, which should be addressed using antibiotic prophylaxis.
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INTRODUCTION: The acute respiratory distress syndrome (ARDS) is a highly relevant entity in critical care with mortality rates of 40%. Despite extensive scientific efforts, outcome-relevant therapeutic measures are still insufficiently practised at the bedside. Thus, there is a clear need to adhere to early diagnosis and sufficient therapy in ARDS, assuring lower mortality and multiple organ failure. METHODS AND ANALYSIS: In this quality improvement strategy (QIS), a decision support system as a mobile application (ASIC app), which uses available clinical real-time data, is implemented to support physicians in timely diagnosis and improvement of adherence to established guidelines in the treatment of ARDS. ASIC is conducted on 31 intensive care units (ICUs) at 8 German university hospitals. It is designed as a multicentre stepped-wedge cluster randomised QIS. ICUs are combined into 12 clusters which are randomised in 12 steps. After preparation (18 months) and a control phase of 8 months for all clusters, the first cluster enters a roll-in phase (3 months) that is followed by the actual QIS phase. The remaining clusters follow in month wise steps. The coprimary key performance indicators (KPIs) consist of the ARDS diagnostic rate and guideline adherence regarding lung-protective ventilation. Secondary KPIs include the prevalence of organ dysfunction within 28 days after diagnosis or ICU discharge, the treatment duration on ICU and the hospital mortality. Furthermore, the user acceptance and usability of new technologies in medicine are examined. To show improvements in healthcare of patients with ARDS, differences in primary and secondary KPIs between control phase and QIS will be tested. ETHICS AND DISSEMINATION: Ethical approval was obtained from the independent Ethics Committee (EC) at the RWTH Aachen Faculty of Medicine (local EC reference number: EK 102/19) and the respective data protection officer in March 2019. The results of the ASIC QIS will be presented at conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: DRKS00014330.
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Síndrome do Desconforto Respiratório , Cuidados Críticos , Humanos , Unidades de Terapia Intensiva , Estudos Multicêntricos como Assunto , Melhoria de Qualidade , Respiração Artificial , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/terapiaRESUMO
BACKGROUND: Intraventricular hemorrhage (IVH) is often caused by irruption of intracerebral hemorrhage (ICH) of basal ganglia or thalamus into the ventricular system. Instillation of recombinant tissue plasminogen activator (rtPA) via an external ventricular drainage (EVD) has been shown to effectively decrease IVH volumes while the impact of rtPA instillation on ICH volumes remains unclear. In this series, we analyzed volumetric changes of ICH in patients with and without intrathecal lysis therapy. METHODS: Between 01/2013 and 01/2019, 36 patients with IVH caused by hemorrhage of basal ganglia, thalamus or brain stem were treated with rtPA via an EVD (Group A). Initial volumes were determined in the first available computed tomography (CT) scan, final volumes in the last CT scan before discharge. During the same period, 41 patients with ICH without relevant IVH were treated without intrathecal lysis therapy at our neurocritical care unit (Group B). Serial CT scans were evaluated separately for changes in ICH volumes for both cohorts using OsiriX DICOM viewer. The Wilcoxon signed-rank test was performed for statistical analysis in not normally distributed variables. RESULTS: Median initial volume of ICH for treatment Group A was 6.5 ml and was reduced to 5.0 ml after first instillation of rtPA (p < 0.01). Twenty-six patients received a second treatment with rtPA (ICH volume reduction 4.5 to 3.3 ml, p < 0.01) and of this cohort further 16 patients underwent a third treatment (ICH volume reduction 3.0 ml to 1.5 ml, p < 0.01). Comparison of first and last CT scan in Group A confirmed an overall median percentage reduction of 91.7% (n = 36, p < 0.01) of ICH volumes and hematoma resolution in Group A was significantly more effective compared to non-rtPA group, Group B (percentage reduction = 68%) independent of initial hematoma volume in the regression analysis (p = 0.07, mean 11.1, 95%CI 7.7-14.5). There were no adverse events in Group A related to rtPA instillation. CONCLUSION: Intrathecal lysis therapy leads to a significant reduction in the intraparenchymal hematoma volume with faster clot resolution compared to the spontaneous hematoma resorption. Furthermore, intrathecal rtPA application had no adverse effect on ICH volume.
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Hemorragia Cerebral , Ativador de Plasminogênio Tecidual , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/tratamento farmacológico , Ventrículos Cerebrais/diagnóstico por imagem , Humanos , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do TratamentoRESUMO
The author name Kerim Beseoglu has been corrected and the details given in this correction are correct.
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INTRODUCTION: Acute respiratory distress syndrome (ARDS) with concomitant impairment of oxygenation and decarboxylation represents a complex problem in patients with increased intracranial pressure (ICP). Permissive hypercapnia is not an option to obtain and maintain lung-protective ventilation in the presence of elevated ICP. Pumpless extracorporeal lung assist (pECLA) devices (iLA Membrane Ventilator; Novalung, Heilbronn, Germany) can improve decarboxylation without aggravation associated with invasive ventilation. In this pilot series, we analyzed the safety and efficacy of pECLA in patients with ARDS and elevated ICP after severe traumatic brain injury (TBI). METHODS: The medical records of ten patients (eight male, two female) with severe ARDS and severe TBI concurrently managed with external ventricular drainage in the neurointensive care unit (NICU) were retrospectively analyzed. The effect of pECLA on enabling lung-protective ventilation was evaluated using the difference between plateau pressure and positive end-expiratory pressure, defined as driving pressure (ΔP), during the 3 days preceding the implant of pECLA devices until 3 days afterward. The ICP threshold was set at 20 mmHg. To evaluate effects on ICP, the volume of daily cerebrospinal fluid (CSF) drainage needed to maintain the set ICP threshold was compared pre- and postimplant. RESULTS: The ΔP values after pECLA implantation decreased from a mean 17.1 ± 0.7 cm/H2O to 11.9±0.5 cm/H2O (p = 0.011). In spite of this improved lung-protective ventilation, carbon dioxide pressure decreased from 46.6 ± 3.9 mmHg to 39.7 ± 3.5 mmHg (p = 0.005). The volume of daily CSF drainage needed to maintain ICP at 20 mmHg decreased significantly from 141.5 ± 103.5 ml to 62.2 ± 68.1 ml (p = 0.037). CONCLUSIONS: For selected patients with concomitant severe TBI and ARDS, the application of pECLA is safe and effective. pECLA devices improve decarboxylation, thus enabling lung-protective ventilation. At the same time, potentially detrimental hypercapnia that may increase ICP is avoided. Larger prospective trials are warranted to further elucidate application of pECLA devices in NICU patients.
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Lesões Encefálicas/terapia , Descarboxilação/fisiologia , Circulação Extracorpórea/métodos , Pressão Intracraniana/fisiologia , Respiração com Pressão Positiva/métodos , Síndrome do Desconforto Respiratório/terapia , Adolescente , Adulto , Lesões Encefálicas/complicações , Circulação Extracorpórea/instrumentação , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Humanos , Hipertensão Intracraniana/complicações , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Síndrome do Desconforto Respiratório/fisiopatologia , Estudos Retrospectivos , Ventiladores Mecânicos/estatística & dados numéricosRESUMO
Acute kidney injury requiring renal replacement therapy occurs in up to 10% of all intensive care unit patients. Those who are hemodynamically unstable are often treated with continuous renal replacement therapy requiring continuous anticoagulation of the extracorporeal circuit. This is usually achieved by infusion of unfractionated heparin, which subsequently increases the risk of bleeding. To avoid systemic anticoagulation for continuous renal replacement therapy, regional anticoagulation with citrate has been introduced. We studied safety and efficacy of regional citrate anticoagulation for continuous venovenous hemodialysis in surgical patients requiring high dialysis doses. This was an observational prospective study in a 40-bed surgical intensive care unit at a university hospital. During a 12-month study period, all consecutive critically ill patients with high risk of bleeding requiring continuous renal replacement therapy continuous renal replacement therapy were treated with citrate anticoagulation for continuous venovenous hemodialysis. Prescribed dialysis dose was 45 mL/kg per h with a 10% increase for expected downtime. We studied filter lifetime, delivered dialysis dose, control of acid-base status, bleeding episodes, and adverse effects, that is, citrate intolerance. The total number of filters analyzed in 75 patients was 100. Mean (± standard deviation) filter running time was 78 ± 25 h. Fifty-one circuits had to be renewed because of extended filter running time (96 ± 18 h), 33 discontinued for reasons not related to renal replacement therapy (62 ± 19 h), and 13 due to filter clotting (58 ± 18 h). The mean dialysis dose during the first 72 h was 49 ± 14 mL/kg per h. Overall, acid-base status after 72 h was well controlled in 62% of patients, metabolic alkalosis (pH > 7.45) occurred in 29%, and metabolic acidosis (pH < 7.35) in 9%. In one patient, treatment was stopped because of citrate accumulation. Citrate intoxication or overt bleeding episodes were not observed. Regional citrate anticoagulation for continuous venovenous hemodialysis is a safe and effective method to deliver a high dialysis dose in critically ill patients with a high risk of bleeding. Filter patency was excellent, acid-base status was well controlled, and clinically relevant adverse effects were not observed. Therefore, citrate anticoagulated continuous venovenous hemodialysis is a useful treatment option for patients with acute kidney injury requiring high dialysis doses and at risk of bleeding.
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Injúria Renal Aguda/terapia , Anticoagulantes/administração & dosagem , Ácido Cítrico/administração & dosagem , Diálise Renal/métodos , Equilíbrio Ácido-Base , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Ácido Cítrico/efeitos adversos , Feminino , Hemorragia/epidemiologia , Hemorragia/etiologia , Hospitais Universitários , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Fatores de TempoAssuntos
Temperatura Baixa/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Parada Cardíaca/cirurgia , Afogamento Iminente/cirurgia , Edema Pulmonar/cirurgia , Esternotomia/métodos , Criança , Parada Cardíaca/diagnóstico , Parada Cardíaca/etiologia , Humanos , Masculino , Afogamento Iminente/complicações , Afogamento Iminente/diagnóstico , Edema Pulmonar/diagnóstico , Edema Pulmonar/etiologiaRESUMO
Mycoplasma hominis and Ureaplasma parvum are rare causes of severe and fatal infections. The diagnosis of infection with mycoplasma is dependent on clinical suspicion and microbiological diagnosis, and often relies on molecular methods that do not readily detect antibiotic resistance. This may be of increasing importance as illustrated in the case below.
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Artrite Infecciosa/microbiologia , Infecções por Mycoplasma/microbiologia , Mycoplasma hominis , Infecções por Ureaplasma/microbiologia , Artrite Infecciosa/diagnóstico , Artrite Infecciosa/tratamento farmacológico , Artroplastia de Quadril/efeitos adversos , Infecção Hospitalar/diagnóstico , Infecção Hospitalar/microbiologia , Evolução Fatal , Humanos , Hospedeiro Imunocomprometido , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Infecções por Mycoplasma/diagnóstico , Infecções por Mycoplasma/tratamento farmacológico , Mycoplasma hominis/efeitos dos fármacos , Mycoplasma hominis/genética , Mycoplasma hominis/isolamento & purificação , Infecções por Ureaplasma/diagnóstico , Infecções por Ureaplasma/tratamento farmacológicoRESUMO
We report a patient with severe hypercalcemia and acute kidney failure, in whom citrate anticoagulation was used not only for anticoagulation but also to correct ionized hypercalcemia (1.77 mmol/L). In this patient, after a complicated surgical procedure, septic shock led to acute kidney failure. We started continuous venovenous hemodialysis with citrate anticoagulation. By almost stopping the calcium substitution during the first hours, elevated systemic ionized calcium decreased into the normal range within 8 hours. Although calcium substitution was then increased, serum ionized calcium decreased to a nadir of 0.86 mmol/L and then stabilized within the normal range within the next 24 hours. To correct the imbalance in systemic ionized calcium concentration, the calcium substitution was varied over a wide range of 0.1-3.0 mmol/L of generated effluent. The time delay between adjustment in calcium infusion rate and the first detectable change in ionized calcium level was below 4 hours. However, the full response to a change of the calcium substitution was found after 8-12 hours.
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Anticoagulantes/uso terapêutico , Cálcio/administração & dosagem , Citratos/administração & dosagem , Soluções para Hemodiálise/química , Hipercalcemia/terapia , Diálise Renal , Idoso , Algoritmos , Cálcio/sangue , Neoplasias do Colo/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Humanos , Masculino , Diálise Renal/métodos , Insuficiência Renal/complicações , Sepse/complicaçõesRESUMO
PURPOSE OF REVIEW: This review summarizes the knowledge of error and of critical incident reporting systems in general and especially in emergency medicine. RECENT FINDINGS: Medicine is a high-risk area and emergency medicine in particular needs consequent use of critical incident reporting systems. We need a safety culture to learn from our mistakes and we need to discuss all mistakes regardless of hierarchical structures in medicine. SUMMARY: The first step in avoiding fatalities in emergency medicine is to accept that errors do occur. The next question is how to prevent errors in medicine and not to search for personal mistakes. We need a culture of error and not a culture of blame. Critical incidents occur in all ranges of medical hierarchical structures. We have to accept the presence of mistakes and we need to recognize them every day to protect our patients.
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Medicina de Emergência , Erros Médicos/prevenção & controle , Gestão de Riscos/métodos , Humanos , Erros Médicos/estatística & dados numéricos , Garantia da Qualidade dos Cuidados de SaúdeRESUMO
The efficiency of hemodialysis treatments depends on catheter performance and, consequently, on effective blood flow that can be achieved at maximum extracorporeal pressures. Differences in effective and displayed flow were determined with ultrasound dilution technology, and a mathematical correction function for the MultiFiltrate hemodialysis machine was developed. This algorithm was used to calculate effective blood flow during treatment from displayed flow and arterial pressure. To assess catheter performance over time, we measured effective blood flow as function of extracorporeal pressure in 11 uncuffed, tunneled hemodialysis catheters with shotgun design. Pressure and flow profiles of the catheters were determined, and pressure symmetry was measured. To assess flow resistance over time, pressure trends of the catheters at different blood flow rates were measured for each patient over a mean period of 6.1 +/- 3.0 days. Increases in flow resistance during the study period were found to be small. Mean arterial pressure decreased from -185 mm Hg to -200 mm Hg, and mean venous pressure increased from 197 mm Hg to 215 mm Hg. Effective flow did not change significantly during the study. In conclusion, all catheters investigated easily provided effective flows above 450 mL/min over the study period at maximum extracorporeal pressures below +/-300 mm Hg.