[Patient concerns and palliative psychology interventions within an inpatient palliative care service]. / Patientenseitige Anliegen und palliativpsychologische Interventionen im Rahmen eines stationären Palliativdienstes.

BACKGROUND: Multi-professional inpatient palliative care services are increasingly complementing palliative care in hospitals alongside palliative care units. The present study aims to investigate the nature and frequency of patient concerns and palliative psychological interventions in the context of palliative psychological work, as well as the perceived quality of outcomes in an inpatient palliative service. METHODS: Palliative psychological interventions for terminally ill patients at the inpatient palliative care service at Leipzig University Hospital were investigated in a prospective follow-up evaluation study. Psychological distress (distress thermometer) as well as the perceived quality of the results of the palliative psychological support (from the therapist`s perspective) were recorded. Patient concerns and psychological conversation topics and interventions were recorded. Descriptive and regression analytic procedures were used. RESULTS: Over a year, 355 patients in the inpatient palliative care service received psychological support, 304 participated in the study (mean age 63.8 years, 55% male, 89% oncological disease). An average of 3 palliative psychological interviews were conducted; 64% of patients reported high psychological distress (M=6.5). The most common patient concerns and topics within the interviews were dealing with emotions (87%), resources (83%), conflicting care and autonomy issues (77%) and hope (76%); significantly less common were spiritual concerns (2%) or the patient's legacy (9%). The most frequently used palliative psychological interventions included: support in illness processing and acceptance (74%) or in emotional-relieving interventions (98%) as in normalisation (75%), active listening (97%) or emotional containment (95%). Regression analysis showed that an oncological (vs. non-oncological) disease, a high number of palliative psychological interviews and interventions, comprehensive information regarding the palliative dimension of the diagnosis as well as undisturbed contact in the initial interview had a positive effect on the perceived outcome quality. CONCLUSION: The study results show that palliative psychologists play an important role in inpatient palliative care teams and should be involved as early as possible in the course of the disease. There is a need for improvement, especially in the palliative psychological care of non-oncological patients.

Parenteral nutrition in palliative care: single-centre observational study.

OBJECTIVE: Cachexia and nutritional problems play a major role in palliative care. Artificial nutrition such as parenteral nutrition is common but its role and indications in terminal patients remain controversial due to lack of data. Therefore, recommendations are vague. Benefits and risks of parenteral nutrition in palliative care as well as the clinical implementation of the guidelines have not been adequately studied yet. METHODS: In this single-centre observational study, 72 palliative care patients were followed for 1 month. Patients with and without parenteral nutrition were analysed regarding venous access complications, oedema, weight and health-related quality of life. RESULTS: 93% of all patients showed reduced food intake. 34 (47%) patients received parenteral nutrition. Parenteral nutrition reduced energy deficit but was not associated with quality of life. Complications with the venous accesses for parenteral nutrition were frequent. A relevant proportion of patients with planned parenteral nutrition received no or only a few days of parenteral nutrition. Moreover, patients with parenteral nutrition showed more frequent and pronounced oedema. CONCLUSION: The benefit-risk balance of palliative parenteral nutrition in end-of-life treatment seems to be questionable. In view of the identified risks, parenteral nutrition in end-of-life care should be initiated with caution.

The Influence of Positive End-Expiratory Pressure on Leakage and Oxygenation Using a Laryngeal Mask Airway: A Randomized Trial.

BACKGROUND: The value of positive end-expiratory pressure (PEEP) in maintaining oxygenation during ventilation with a laryngeal mask airway (LMA) mask is unclear. To clarify the potential benefit or harm to PEEP application during positive pressure ventilation with a ProSeal LMA® mask, we compared the effect of PEEP versus zero end-expiratory pressure (ZEEP) on gas leakage and oxygenation. We hypothesized that a PEEP of 8 mbar (8.2 cm H 2 O) would be associated with an increased incidence of gas leakage compared to ZEEP. METHODS: We designed a prospective, controlled, randomized, single-blinded, multicenter clinical trial. Patients >18 years of age with an American Society of Anesthesiologists (ASA) physical status I/II without increased risk of aspiration were enrolled if they were scheduled for elective surgery under general anesthesia with an LMA mask. Patients were randomized to a control group managed with ZEEP or an intervention group managed with a PEEP of 8 mbar. Both groups received positive pressure ventilation. The primary end point was the occurrence of gas leakage. The Student t test and χ 2 test were used for statistical analysis. RESULTS: A total of 174 patients were enrolled in the ZEEP group, and 208 were enrolled in the PEEP group. The incidence of gas leakage did not differ between the 2 groups (ZEEP: 23/174, 13.2%; PEEP: 42/208, 20.2%; P = .071; odds ratio [OR], 1.611; 95% confidence interval [CI], 0.954-2.891). However, more patients required reseating of the LMA mask in the PEEP group (ZEEP: 5/174, 2.9%; PEEP: 18/208, 8.7%; P = .018; OR, 3.202; 95% CI, 1.164-8.812). The need for endotracheal intubation did not differ between groups (ZEEP: 2/174, 1.1%; PEEP: 7/208, 3.4%; P = .190; OR, 2.995; 95% CI, 0.614-14.608). After positive pressure ventilation for 25 minutes, the mean peripheral oxygen saturation (Sp o2 ) was higher in the PEEP than in the ZEEP group (98.5 [1.9]% vs 98.0 [1.4]%; P = .01). Peak inspiratory pressure (PIP; 16 [2] vs 12 [4] mbar; P < .001) and dynamic compliance (57 [14] vs 49 [14] mL/mbar; P < .001) were both higher in the PEEP group than in the ZEEP group. CONCLUSIONS: Use of PEEP did not affect the overall incidence of gas leakage. However, PEEP did result in a higher incidence of attempts to reseat the LMA mask compared to ZEEP, whereas the incidence of rescue intubation did not differ between groups. We concluded that a PEEP of 8 mbar did not increase overall gas leakage during positive pressure ventilation with an LMA mask, but it did slightly improve gas exchange and compliance. Overall, our study does not provide strong arguments for using PEEP during ventilation with an LMA mask in elective surgery.

Extracorporeal Membrane Oxygenation and Perfluorocarbon in a Therapy Refractory Case of Acute Respiratory Distress Syndrome.

Perfluorocarbons are oxygen-carrying, dense liquids initially intended for the use in partial or total liquid ventilation of patients with severe acute respiratory distress syndrome but which did not show beneficial effects in clinical studies. However, perfluorocarbons may be used for lung lavage in severe alveolar proteinosis. In acute respiratory distress syndrome, oxygenation may be so severely compromised that the use of nonoxygenated perfluorocarbons may not be possible. We report a case of severe, nonresolving acute respiratory distress syndrome treated with extracorporeal membrane oxygenation to secure oxygenation, using perfluorocarbon in a single instillation to aid the clearance of debris and proteinacous edema.

Non-medical risk factors associated with postponing elective surgery: a prospective observational study.

BACKGROUND: Operation room (OR) planning is a complex process, especially in large hospitals with high rates of unplanned emergency procedures. Postponing elective surgery in order to provide capacity for emergency operations is inevitable at times. Elderly patients, residents of nursing homes, women, patients with low socioeconomic status and ethnic minorities are at risk for undertreatment in other contexts, as suggested by reports in the medical literature. We hypothesized that specific patient groups could be at higher risk for having their elective surgery rescheduled for non-medical reasons. METHODS: In this single center, prospective observational trial, we analysed 2519 patients undergoing elective surgery from October 2018 to May 2019. A 14-item questionnaire was handed out to illicit patient details. Additional characteristics were collected using electronic patient records. Information on the timely performance of the scheduled surgery was obtained using the OR's patient data management system. 6.45% of all planned procedures analysed were postponed. Association of specific variables with postponement rates were analysed using the Mann-Whitney U test and Fisher's exact test/χ2-test. RESULTS: Significantly higher rates of postponing elective surgery were found in elderly patients. No significant differences in postponing rates were found for the variables gender, nationality (Germany, EU, non-EU), native language, professional medical background and level of education. Significantly lower rescheduling rates were found in patients with ties to hospital staff and in patients with a private health insurer. CONCLUSIONS: Elderly patients, retirees and nursing home residents seem to be at higher risk for having their elective surgery rescheduled. However, owing to the study design, causality could not be proven. Our findings raise concern about possible undertreatment of these patient groups and provide data on short-term postponement of elective surgery. Trial registration DRKS00015836. Retrospectively registered.

Procedural times in early non-intubated VATS program - a propensity score analysis.

BACKGROUND: Non-intubated video-assisted thoracic surgery (NiVATS) has been introduced to surgical medicine in order to reduce the invasiveness of anesthetic procedures and avoid adverse effects of intubation and one-lung ventilation (OLV). The aim of this study is to determine the time effectiveness of a NiVATS program compared to conventional OLV. METHODS: This retrospective analysis included all patients in Leipzig University Hospital that needed minor VATS surgery between November 2016 and October 2019 constituting a NiVATS (n = 67) and an OLV (n = 36) group. Perioperative data was matched via propensity score analysis, identifying two comparable groups with 23 patients. Matched pairs were compared via t-Test. RESULTS: Patients in NiVATS and OLV group show no significant differences other than the type of surgical procedure performed. Wedge resection was performed significantly more often under NiVATS conditions than with OLV (p = 0,043). Recovery time was significantly reduced by 7 min (p = 0,000) in the NiVATS group. There was no significant difference in the time for induction of anesthesia, duration of surgical procedure or overall procedural time. CONCLUSIONS: Recovery time was significantly shorter in NiVATS, but this effect disappeared when extrapolated to total procedural time. Even during the implementation phase of NiVATS programs, no extension of procedural times occurs.

Tetrahydroporphyrin-tetratosylate (THPTS)-based photodynamic inactivation of critical multidrug-resistant bacteria in vitro.

BACKGROUND: Photodynamic inactivation (PDI) is a promising approach to treat multidrug-resistant infections. However, effectiveness of PDI is limited, particularly in Gram-negative bacteria. The use of photosensitizer (PS) 3,3',3'',3'''-(7,8,17,18-tetrahydro-21H,23H-porphyrine-5,10,15,20-tetrayl)tetrakis[1-methyl-pyridinium]tetratosylate (THPTS) and laser light has led to very promising results. This study focuses on the effects of THPTS in various critical multidrug-resistant bacterial strains and explores the possibility of light-emitting diode (LED)-based activation as a clinically more feasible alternative to laser light. METHODS: THPTS was further chemically characterized and in vitro testing of PDI of different multidrug-resistant bacterial strains was performed under various experimental conditions, including varying drug concentration, incubation time, light source (laser and LED) and light intensity, by determination of viable bacteria after treatment. The effect of hyaluronic acid as an adjuvant for medical applications was also evaluated. RESULTS: Bacterial density of all investigated bacterial strains was reduced by several orders of magnitude, irrespective of multidrug-resistance or hyaluronic acid addition. The effect was less intense in Gram-negative strains (disinfection), and more pronounced in Gram-positive strains (sterilization), even at reduced THPTS concentrations or decreased light treatment intensity. Controls without THPTS or without light treatment did not indicate reduced bacterial density. CONCLUSIONS: PDI with THPTS and laser light was effective in all investigated bacterial strains. Gram-negative strains were less, but sufficiently, susceptible to PDI. Adding hyaluronic acid did not reduce the antibacterial treatment effect. LED-based PDI is equally effective when illumination duration is increased to compensate for reduced light intensity.

Laryngeal tube suction II or endotracheal intubation for laparoscopic radical prostatectomy in a head down position: A randomised controlled trial.

BACKGROUND: The laryngeal tube suction II (LTS II) is a supraglottic airway device (SAD) with a gastric drainage tube and enhanced seal properties as compared with other SADs. Therefore, its use has been proposed in situations with an elevated risk of aspiration. OBJECTIVES: To compare the safety and efficacy of airway management and controlled mechanical ventilation when using either an LTS II or an endotracheal tube for laparoscopic radical prostatectomy. DESIGN: Randomised, controlled, blinded and single-centre study. SETTING: Academic tertiary care centre in Leipzig from April 2014 to May 2015. PATIENTS: It was planned to include 100 patients but the study was stopped after 50 patients following an interim analysis. These 50 patients were randomised to either the LTS II group or the endotracheal tube group. All male patients aged more than 18 years for elective laparoscopic radical prostatectomy were eligible. Exclusion criteria included a BMI more than 30, American Society of Anesthesiologists class III or greater, a history of gastroesophageal reflux or other factors known to increase the risk of aspiration and a known difficult airway. INTERVENTIONS: All patients received general anaesthesia. Airway management was with either a LTS II or an endotracheal tube, according to the randomisation. MAIN OUTCOME MEASURES: The primary endpoint was successful insertion of the particular airway device during anaesthesia for laparoscopic radical prostatectomy. RESULTS: In 15 of the 28 patients randomised to LTS II, the device had to be removed and an endotracheal tube inserted, mainly because of an airway leak (n = 10) or swelling of the tongue (n = 3). Ventilation was successful in all patients (n = 22) randomised to endotracheal tube. Quality of ventilation was rated better in the endotracheal tube group. CONCLUSION: Our data suggest that LTS II should not be the preferred method of airway management in patients undergoing laparoscopic radical prostatectomy. TRIAL REGISTRATION: DRKS00008985 (German Clinical Trials Register).

Distributive shock, cardiac arrhythmias and multiple organ failure following surgery of a fourth ventricular epidermoid.

A 33-years-old male patient presented with cardiac arrhythmias, acute shock and multiple organ dysfunction after the surgical removal of a massive epidermoid posterior to the brainstem. The patient initially presented with paraesthesia along the right C6 dermatome due to a big tumour at the brain stem. Surgical removal was performed without adverse events and he was transferred to our intensive care unit (ICU) immediately after the operation. Though initially showing a stable postsurgical course he developed cardiac arrhythmias and a state of acute distributive shock with consecutive multi organ failure. Extensive diagnostic measures could not identify a specific cause for this rapid deterioration. However, under carefully monitored symptomatic therapy the patient improved quickly, was extubated 72 h after admission and discharged from the ICU 6 days later. The follow-up did not show any persisting neurological deficits and no evidence of a residual tumour in the MRI-study.

Acute respiratory failure after aspiration of activated charcoal with recurrent deposition and release from an intrapulmonary cavern.

OBJECTIVE: To report on the recurrent release of charcoal from an intrapulmonary cavern in a case of acute respiratory failure after charcoal aspiration. DESIGN: Case report. SETTING: Anaesthesiological ICU, university hospital. PATIENT: An 18-year-old ethanol intoxicated comatose patient regurgitated and aspirated activated charcoal during orotracheal intubation. TREATMENT: After 2 days of mechanical ventilation, the patient was transferred to a tertiary care university hospital. On admission, acute respiratory distress syndrome with bilateral pulmonary infiltrations was diagnosed. The patient's recovery was hampered by recurrent release of charcoal from an intrapulmonary cavern. Sophisticated ventilatory support, prone positioning, secretolytics, repetitive bronchoscopy, and antibiotic therapy may have facilitated bronchoalveolar clearance and weaning after 18 days. CONCLUSION: Aspiration may be a dramatic complication if charcoal is administered in comatose patients without airway protection. In this case report, advanced intensive care measures were necessary to tackle the special feature of charcoal release from an intrapulmonary cavern.

[The significance of perioperative immunonutrition]. / Stellenwert der perioperativen Immunonutrition.

Perioperative immunonutrition is aiming at modulating altered immunological and metabolic functions in the context of major surgery. It is defined as the supplementation of constitutionally essential substrates such as glutamine, arginine, omega-3-fatty acids or nucleotides. The application of such formula is recommended for patients undergoing major abdominal-surgical procedures and tumour surgery in the head neck area. The substitution should be given 5-7 days before and after the intervention.

Endothelin-1 influences the efficacy of inhaled nitric oxide in experimental acute lung injury.

Beneficial effects of inhaled nitric oxide (iNO) on arterial oxygenation in acute lung injury (ALI) suggest the presence of vasoconstriction in ventilated lung regions and this may be influenced by endothelin-1 (ET-1). We studied a possible interaction between ET-1 and iNO in experimental ALI. Sixteen piglets were anesthetized and mechanically ventilated (inspired O2 fraction, 1.0). After induction of ALI by surfactant depletion, animals were randomly assigned to either inhale 30 ppm NO (iNO group, n = 8), or to receive no further intervention (controls, n = 8). Measurements were performed during the following 4 hrs. In all animals, induction of ALI significantly decreased arterial oxygen tension (PaO2) from 569 +/- 15 (prelavage) to 58 +/- 3 mm Hg. Inhaled NO significantly increased PaO2 when compared with controls (iNO group: 265 +/- 51 mm Hg; controls: 50 +/- 4 mm Hg, values at 4 hrs, P < 0.01). Prelavage ET-1 plasma levels were comparable between groups (iNO: 0.74 +/- 0.03, controls: 0.71 +/- 0.03 fmol/ml, NS). During the protocol, the ET-1 levels increased and were different at 3 hrs (iNO: 0.93 +/- 0.06, controls: 1.25 +/- 0.09 fmol/ml; P < 0.05). PaO2 changes induced by iNO revealed a moderate and significant correlation with ET-1 plasma levels (R = 0.548, P = 0.001). Our data suggest that endogenous ET-1 production influences the efficacy of iNO in ALI. Furthermore, iNO reduced ET-1 plasma levels, possibly indicating anti-inflammatory properties of iNO in the early phase of ALI.

Comparison between instillation of bupivacaine versus caudal analgesia for postoperative analgesia following inguinal herniotomy in children.

BACKGROUND: In this study we compare the postoperative pain relief for inguinal herniotomy in children provided by instillation of bupivacaine into the wound with that provided by a caudal block. METHODS: Fifty-eight children aged 0-5 years having elective unilateral hernia repair were studied in this prospective, randomized, single-blind study. Anaesthesia was induced and maintained with oxygen, nitrous oxide, sevoflurane and propofol. Patients were randomly assigned to receive caudal analgesia with 1.0 ml.kg-1 body weight (BW) bupivacaine 0.25% or wound instillation with 0.2 ml.kg-1 BW bupivacaine 0.5% at the end of surgery. Pain was assessed over 24 h using a modified 10-point objective pain scale. During the first postoperative hour in the postanaesthesia care unit (PACU), intravenous (i.v.) piritramide (0.05 mg.kg-1) was administered to any child scoring 5 or more points on the pain scale. On the ward, rectal acetaminophen was administered by a staff nurse when considered necessary. RESULTS: Thirty children in the caudal group and 28 children in the wound instillation group were studied. There were no statistically significant differences between the groups regarding need for i.v. opioids, discharge time from the PACU and administration of acetaminophen. No statistically significant differences in postoperative pain score were observed in 16 of a total of 17 postoperative observations. No complications and no adverse effects were observed. CONCLUSION: Instillation of bupivacaine into a wound provides postoperative pain relief following hernia repair, which is as effective as that provided by a postoperative caudal block.

Immunologic and hemodynamic effects of "low-dose" hydrocortisone in septic shock: a double-blind, randomized, placebo-controlled, crossover study.

Within the last few years, increasing evidence of relative adrenal insufficiency in septic shock evoked a reassessment of hydrocortisone therapy. To evaluate the effects of hydrocortisone on the balance between proinflammatory and antiinflammation, 40 patients with septic shock were randomized in a double-blind crossover study to receive either the first 100 mg of hydrocortisone as a loading dose and 10 mg per hour until Day 3 (n = 20) or placebo (n = 20), followed by the opposite medication until Day 6. Hydrocortisone infusion induced an increase of mean arterial pressure, systemic vascular resistance, and a decline of heart rate, cardiac index, and norepinephrine requirement. A reduction of plasma nitrite/nitrate indicated inhibition of nitric oxide formation and correlated with a reduction of vasopressor support. The inflammatory response (interleukin-6 and interleukin-8), endothelial (soluble E-selectin) and neutrophil activation (expression of CD11b, CD64), and antiinflammatory response (soluble tumor necrosis factor receptors I and II and interleukin-10) were attenuated. In peripheral blood monocytes, human leukocyte antigen-DR expression was only slightly depressed, whereas in vitro phagocytosis and the monocyte-activating cytokine interleukin-12 increased. Hydrocortisone withdrawal induced hemodynamic and immunologic rebound effects. In conclusion, hydrocortisone therapy restored hemodynamic stability and differentially modulated the immunologic response to stress in a way of antiinflammation rather than immunosuppression.