Swiss Sepsis National Action Plan: A coordinated national action plan to stop sepsis-related preventable deaths and to improve the support of people affected by sepsis in Switzerland.

Background: Sepsis is a devastating disease which causes yearly over 10 million deaths worldwide. In 2017, the World Health Organization (WHO) issued a resolution prompting member states to improve the prevention, recognition, and management of sepsis. The 2021 European Sepsis Report revealed that-contrary to other European countries-Switzerland had not yet actioned the sepsis resolution. Methods: A panel of experts convened at a policy workshop to address how to improve awareness, prevention, and treatment of sepsis in Switzerland. Goal of the workshop was to formulate a set of consensus recommendations toward creating a Swiss Sepsis National Action Plan (SSNAP). In a first part, stakeholders presented existing international sepsis quality improvement programs and national health programs relevant for sepsis. Thereafter, the participants were allocated into three working groups to identify opportunities, barriers, and solutions on (i) prevention and awareness, (ii) early detection and treatment, and (iii) support for sepsis survivors. Finally, the entire panel summarized the findings from the working groups and identified priorities and strategies for the SSNAP. All discussions during the workshop were transcribed into the present document. All workshop participants and key experts reviewed the document. Results: The panel formulated 14 recommendations to address sepsis in Switzerland. These focused on four domains, including (i) raising awareness in the community, (ii) improving healthcare workforce training on sepsis recognition and sepsis management; (iii) establishing standards for rapid detection, treatment and follow-up in sepsis patients across all age groups; and (iv) promoting sepsis research with particular focus on diagnostic and interventional trials. Conclusion: There is urgency to tackle sepsis. Switzerland has a unique opportunity to leverage from lessons learnt during the COVID-19 pandemic to address sepsis as the major infection-related threat to society. This report details consensus recommendations, the rationale thereof, and key discussion points made by the stakeholders on the workshop day. The report presents a coordinated national action plan to prevent, measure, and sustainably reduce the personal, financial and societal burden, death and disability arising from sepsis in Switzerland.

The Impact of the Society of Critical Care Medicine's Flagship Journal: Critical Care Medicine: Reflections of Critical Care Pioneers.

On the 50th anniversary of the Society of Critical Care Medicine's journal Critical Care Medicine, critical care pioneers reflect on the importance of the journal to their careers and to the development of the field of adult and pediatric critical care.

Trunk muscle function and its association with functional limitations in sedentary occupation workers with and without chronic nonspecific low back pain.

BACKGROUND: The function of trunk muscles in chronic nonspecific low back pain (CNLBP) is controversially discussed, and trunk muscle function in sedentary occupation workers is poorly understood. OBJECTIVE: To investigate whether muscle function differs between sedentary occupation workers with and without CNLBP and to determine the association between functional limitations and muscle function. METHODS: This study included 32 sedentary occupation workers (16 workers with CNLBP and 16 age- and sex-matched workers without CNLBP). Group differences in isokinetic trunk flexion-extension strength, muscle cocontraction, endurance time (Biering-Sorensen test) and electromyographic muscle fatigue were assessed. The association of these parameters and Oswestry Disability Index (ODI) score were examined in the CNLBP group. RESULTS: Participants with CNLBP had lower trunk extensor (-20%) and flexor (-18%) strength and less cocontraction (-22%) than participants without CNLBP, but due to large variability in both groups these differences were not statistically significant. Trunk muscle endurance and fatigue were comparable between groups. Variance in endurance time explained 28% of variance in the ODI-score in the CNLBP group (R2= 0.277). CONCLUSIONS: In patients with CNLBP, greater functional disability was associated with lower endurance. Further evidence is necessary to elucidate whether specifically training endurance performance may be beneficial for sedentary occupation workers.

Erste Evaluation eines Programms zur Frührehabilitation von Langzeitintensivpatient_innen.

First evaluation of an early rehabilitation programm for chronically critically ill patients Abstract. Introduction: Chronically critically ill patients are an increasing challenge for teams in intensive care units due to the burden of symptoms and the consumption of resources. Structured multimodal concepts are recommended for nursing care and treatment. A local, interprofessional program for early rehabilitation aims to provide optimal care for patients through a systematic, proactive and holistic treatment process with a rehabilitative focus. The program consists of specific assessments and systematic coordination of interprofessional early rehabilitation. Problem and objective: Interprofessional collaboration requires mutual acceptance and good communication from those involved. The functioning of selected processes as well as the satisfaction of the professionals are topics of a first formative evaluation. Methods: The team evaluated descriptive quality data as well as self-generated structured questionnaires. Results: Specific adjustments were made to the treatment plan for 52 of 112 patients in the program. The assessments are easy to carry out and support systematic early rehabilitation. From the perspective of the professionals involved, both the interprofessional collaboration and their understanding for the patients improved. Discussion and transfer: The program optimizes treatment and promotes good interprofessional collaboration. The formative evaluation provides valuable information for future process changes such as the inclusion of patients as well as further disciplines and program development beyond the boundaries of the intensive care unit.

Mortality Risk Stratification After Traumatic Brain Injury and Hazard of Death With Titrated Hypothermia in the Eurotherm3235Trial.

OBJECTIVES: Hypothermia reduces intracranial hypertension in patients with traumatic brain injury but was associated with harm in the Eurotherm3235Trial. We stratified trial patients by International Mission for Prognosis and Analysis of Clinical Trials in [Traumatic Brain Injury] (IMPACT) extended model sum scores to determine where the balance of risks lay with the intervention. DESIGN: The Eurotherm3235Trial was a randomized controlled trial, with standardized and blinded outcome assessment. Patients in the trial were split into risk tertiles by IMPACT extended model sum scores. A proportional hazard analysis for death between randomization and 6 months was performed by intervention and IMPACT extended model sum scores tertiles in both the intention-to-treat and the per-protocol populations of the Eurotherm3235Trial. SETTING: Forty-seven neurologic critical care units in 18 countries. PATIENTS: Adult traumatic brain injury patients admitted to intensive care who had suffered a primary, closed traumatic brain injury; increased intracranial pressure; an initial head injury less than 10 days earlier; a core temperature at least 36°C; and an abnormal brain CT. INTERVENTION: Titrated Hypothermia in the range 32-35°C as the primary intervention to reduce raised intracranial pressure. MEASUREMENTS AND MAIN RESULTS: Three hundred eighty-six patients were available for analysis in the intention-to-treat and 257 in the per-protocol population. The proportional hazard analysis (intention-to-treat and per-protocol populations) showed that the treatment effect behaves similarly across all risk stratums. However, there is a trend that indicates that patients in the low-risk group could be at greater risk of suffering harm due to hypothermia. CONCLUSIONS: Hypothermia as a first line measure to reduce intracranial pressure to less than 20 mm Hg is harmful in patients with a lower severity of injury and no clear benefit exists in patients with more severe injuries.

Atrial and brain natriuretic peptide concentrations and the response to inhaled nitric oxide in patients with acute respiratory distress syndrome.

PURPOSE: The response to inhaled nitric oxide (iNO) is inconsistent in patients with acute respiratory distress syndrome (ARDS). We sought to determine whether the response to iNO, defined as 20% Pao(2)/Fio(2) increase from baseline, depends on the level of cardiac natriuretic peptides. MATERIALS AND METHODS: This is a prospective cohort study including 11 consecutive patients with ARDS who were eligible to receive iNO. Measurements of plasma concentrations of atrial natriuretic peptide (ANP), N-Terminal-Pro-B-Type Natriuretic Peptide (NT-pro-BNP) and 3',5'-cyclic guanosine monophosphate were obtained before initiating iNO and 30 minutes later during iNO. Baseline cardiac peptides, oxygenation, and hemodynamic variables and their change during iNO were compared among responders and nonreponders to iNO. RESULTS: Baseline ANP and NT-pro-BNP concentrations were higher in patients that responded to iNO and tended to decrease during iNO in responders only. 3',5'-Cyclic guanosine monophosphate concentrations were not different among responders and nonresponders and were unchanged during iNO. Baseline ANP was strongly correlated with change in intrapulmonary shunt, and baseline NT-pro-BNP and its change were correlated with the change in cardiac output. CONCLUSIONS: High ANP and NT-pro-BNP concentrations are associated with the response to iNO. These data suggest that cardiac peptides have the potential to identify a subgroup of patients with ARDS who might derive clinical benefit from iNO.

Nebulised heparin: a new approach to the treatment of acute lung injury?

The administration of heparin by nebulisation has been proposed for the 'local' treatment of pulmonary coagulation disturbances in acute lung injury (ALI). Alveolar and lung micro-vascular fibrin accumulation and breakdown inhibition indeed play a central role in the development and clinical course of this disease. Preclinical studies provide some evidence of the beneficial effects of heparin inhalation in several animal models of ALI. Clinical investigations are sparse, and trials such as the one presented by Dixon and colleagues in a recent issue of Critical Care are welcome as they provide insight into the possible clinical use of nebulised heparin in this situation. This phase 1 trial involved 16 patients with early ALI, and showed the feasibility of the approach. In addition, non-significant changes in respiratory functions and systemic anticoagulant effects were documented with the four doses tested. The study of Dixon and colleagues adds to data that helps pave the way towards a possible clinical use of heparin by nebulisation in ALI. It remains to be clarified in which clinical situations, at what time points and with which dosages the best chances exist for a beneficial effect on the prognosis of these patients.

Treating sensitive cervical areas with ozone. A prospective controlled clinical trial.

PURPOSE: To determine whether the treatment of hypersensitive teeth with gaseous ozone (Healozone, KaVo 1600 ppm) for 60 seconds reduces pain immediately after treatment and in the longer term. METHODS: In three private practices in Switzerland, 31 subjects suffering from hypersensitive teeth were treated with gaseous ozone over a period of 54 weeks (one test and one control tooth in each subject). A cross-over design was chosen. The pain level was measured with a Visual Analogue Scale before and after the treatment. RESULTS: The subjects' pain level was reduced by 55% +/- 5.5% immediately after the ozone treatment. Over time, the pain level decreased significantly in all groups: The pain level in the test teeth was significantly reduced in Weeks 0-22 (treatment group, P < 0.001) compared to the pain level before treatment. The pain level in the control group was also reduced significantly over time in Weeks 0-22 (no-treatment, P = 0.025) and in Weeks 22-54 (treatment group, P = 0.0065). Comparing test and control teeth over time, there was no statistically significant difference in pain reduction (P = 0.58).

Reducing ventilator-induced lung injury and other organ injury by the prone position.

Mechanical ventilation can cause structural and functional disturbances in the lung, as well as other vital organ dysfunctions. Apoptosis is thought to be a histological sign of distant organ damage in ventilator-induced lung injury (VILI). Nakos and colleagues observed a protective effect of prone positioning against VILI in normal sheep. Less alteration in the lung architecture and function and in liver transaminases, and lower indices for apoptosis in the liver, the diaphragm and the lung were noted in the prone position compared with the supine position. If confirmed, these data open a new hypothesis for pathogenesis and prevention of VILI and its extrapulmonary complications.

Intensive care and emergency medicine: progress over the past 25 years.

Over the last quarter of a century, intensive care medicine has developed into an established hospital specialty with its own unique identity and characteristics. Significant advances have occurred, mostly in a succession of small steps rather than any dramatic leap, with many being linked to advances in health care across other disciplines. In addition, many changes have resulted from the scientific identification of the detrimental effects of certain traditional practices once thought to be therapeutic. Here, in an attempt to learn from the past and offer guidance for future progress, we detail some of the key changes in various aspects of intensive care medicine including respiratory, cardiovascular, metabolic, and nutritional care, as well as sepsis, polytrauma, organization, and management.

Continuous cardiac output monitoring after cardiopulmonary bypass: a comparison with bolus thermodilution measurement.

OBJECTIVE: The interchangeability of continuous measurement of cardiac output (CO) with the traditional bolus method in patients after cardiopulmonary bypass (CPB) is uncertain. DESIGN: Prospective observational clinical study. SETTING: A 20-bed surgical ICU at a university hospital. PATIENTS: Fourteen deeply sedated, ventilated, post-cardiac surgery patients, all equipped with a pulmonary artery catheter. INTERVENTIONS: Six hours after the end of the CPB, 56 simultaneous bolus and continuous measurements were compared by a linear regression analysis and Bland-Altman analysis. Bolus CO was estimated by averaging triplicate injections of 10 ml room-temperature NaCl 0.9%, delivered randomly during the respiratory cycle. A stringent maximum difference of 0.55 l min(-1) (about 10% of the mean bolus measured) was considered as a clinically acceptable agreement between the two types of measurements. To be interchangeable the limits of agreement (+/-2 SD of the mean difference between the two methods) should not exceed the chosen acceptable difference. MEASUREMENTS AND RESULTS: Continuous was correlated with bolus CO, with a correlation coefficient of r(2)=0.68. (p<0.01). The Bland-Altman analysis demonstrated an objective mean bias of 0.33+/-0.6 l min(-1) (confidence interval of -0.87-1.58) with 34% of measured values falling outside of the clinically acceptable limits. CONCLUSION: Our results suggest that, in the first 6 h after CPB, continuous and bolus CO determinations are not interchangeable; one third of the values obtained by continuous CO fell outside the strict limits of clinically useful precision.

Misplacement of central vein catheters in patients with hemothorax: a new approach to resolve the problem.

BACKGROUND: In emergency and pre-hospital care, the verification of the correct position of a central venous catheter is based on the observation of blood color reflow as well as pressure changes with respiration. However, in trauma patient with hemothorax, these indices may not always be reliable signs as the catheter is in a blood-filled pleural space. METHODS: A review of reports published describing patients presenting hemothorax and equipped with central venous catheter wrongly assumed to be in the correct position was performed. RESULTS: Over 10 years, seven reports have been published and a last study was found in the references list of one of the reviews. CONCLUSION: In patients with hemothorax due to severe thoracic trauma or other causes, a delay in detection of incorrect placement of a central venous catheter may delay fluid resuscitation and decrease the chances of survival. In this situation, the use of portable ultrasound devices may be an useful method to increase success rate in catheter insertion.