Enhanced recovery after cesarean section (ERAC): Where are we in Austria?

OBJECTIVE: Enhanced recovery after surgery (ERAS) recommendations for cesarean section (ERAC), likely the most common reason for laparotomy in women, were issued in 2018-19. We examined how current perioperative management at cesarean section in Austrian hospitals aligns with ERAS recommendations. STUDY DESIGN: We surveyed the 21 largest public obstetric units in Austria for alignment with 20 of the 31 strong ERAS recommendations regarding perioperative maternal care at cesarean section. We also looked at how the German-language clinical guideline for cesarean section (AWMF Guideline Sectio caesarea) aligns with ERAS recommendations. RESULTS: The 21 obstetric units cared for about 51% of all births in Austria in 2019. Cesarean section rates ranged from 17.7% to 50.4%. All 21 units implemented the five strong recommendations regarding patient information and counselling, regional anesthesia, euvolemia and multimodal analgesia. The least implemented strong recommendation was the one for the use of pneumatic compression stockings to prevent thromboembolic disease (0/21 units). Overall, all 21 units implemented ≥11 and 13 (62%) implemented ≥15 (≥75%) of the 20 strong recommendations; no unit implemented all 20 strong recommendations. There were no differences in the implementation of strong recommendations according to hospital volume. CONCLUSIONS: Even in the absence of formal adoption of ERAS program for cesarean section many perioperative ERAS recommendations are already implemented in Austria. The least implemented recommendations were the use of pneumatic compression stockings (0 of 21 units) and immediate catheter removal (4 of 21 units). Only 10 of the 20 ERAS recommendations we looked at are included in the current German-language clinical guideline for cesarean section.

Mechanical ventilation with ten versus twenty breaths per minute during cardio-pulmonary resuscitation for out-of-hospital cardiac arrest: A randomised controlled trial.

AIM OF THE STUDY: This study sought to assess the effects of increasing the ventilatory rate from 10 min-1 to 20 min-1 using a mechanical ventilator during cardio-pulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) on ventilation, acid-base-status, and outcomes. METHODS: This was a randomised, controlled, single-centre trial in adult patients receiving CPR including advanced airway management and mechanical ventilation offered by staff of a prehospital physician response unit (PRU). Ventilation was conducted using a turbine-driven ventilator (volume-controlled ventilation, tidal volume 6 ml per kg of ideal body weight, positive end-expiratory pressure (PEEP) 0 mmHg, inspiratory oxygen fraction (FiO2) 100%), frequency was pre-set at either 10 or 20 breaths per minute according to week of randomisation. If possible, an arterial line was placed and blood gas analysis was performed. RESULTS: The study was terminated early due to slow recruitment. 46 patients (23 per group) were included. Patients in the 20 min-1 group received higher expiratory minute volumes [8.8 (6.8-9.9) vs. 4.9 (4.2-5.7) litres, p < 0.001] without higher mean airway pressures [11.6 (9.8-13.6) vs. 9.8 (8.5-12.0) mmHg, p = 0.496] or peak airway pressures [42.5 (36.5-45.9) vs. 41.4 (32.2-51.7) mmHg, p = 0.895]. Rates of ROSC [12 of 23 (52%) vs. 11 of 23 (48%), p = 0.768], median pH [6.83 (6.65-7.05) vs. 6.89 (6.80-6.97), p = 0.913], and median pCO2 [78 (51-105) vs. 86 (73-107) mmHg, p > 0.999] did not differ between groups. CONCLUSION: 20 instead of 10 mechanical ventilations during CPR increase ventilation volumes per minute, but do not improve CO2 washout, acidaemia, oxygenation, or rate of ROSC. CLINICALTRIALS: gov Identifier: NCT04657393.

Association of immediate versus delayed extubation of patients admitted to intensive care units postoperatively and outcomes: A retrospective study.

AIM OF THIS STUDY: This study seeks to investigate, whether extubation of tracheally intubated patients admitted to intensive care units (ICU) postoperatively either immediately at the day of admission (day 1) or delayed at the first postoperative day (day 2) is associated with differences in outcomes. MATERIALS AND METHODS: We performed a retrospective analysis of data from an Austrian ICU registry. Adult patients admitted between January 1st, 2012 and December 31st, 2019 following elective and emergency surgery, who were intubated at the day 1 and were extubated at day 1 or day 2, were included. We performed logistic regression analyses for in-hospital mortality and over-sedation or agitation following extubation. RESULTS: 52 982 patients constituted the main study population. 1 231 (3.3%) patients extubated at day 1 and 958 (5.9%) at day 2 died in hospital, 464 (1.3%) patients extubated at day 1 and 613 (3.8%) at day 2 demonstrated agitation or over-sedation after extubation during ICU stay; OR (95% CI) for in-hospital mortality were OR 1.17 (1.01-1.35, p = 0.031) and OR 2.15 (1.75-2.65, p<0.001) for agitation or over-sedation. CONCLUSIONS: We conclude that immediate extubation as soon as deemed feasible by clinicians is associated with favourable outcomes and may thus be considered preferable in tracheally intubated patients admitted to ICU postoperatively.

Evaluation of the usefulness of non-invasive serum haemoglobin measurement in a perioperative setting in a prospective observational study.

Patient Blood Management (PBM) programmes seek to reduce the number of missed anaemic patients in the run-up to surgery. The aim of this study was to evaluate the usefulness of haemoglobin (Hb) measured non-invasively (SpHb) in preoperative screening for anaemia. We conducted a prospective observational study in a preoperative clinic. Adult patients undergoing examination for surgery who had their Hb measured by laboratory means also had their Hb measured non-invasively by a trained health care provider. 1216 patients were recruited. A total of 109 (9.3%) patients (53 men and 56 women) was found to be anaemic by standard laboratory Hb measurement. Sensitivity for SpHb to detect anaemic patients was 0.50 (95% CI 0.37-0.63) in women and 0.30 (95% CI 0.18-0.43) in men. Specificity was 0.97 (95% CI 0.95-0.98) in men and 0.93 (95% CI 0.84-1.0) in women. The rate of correctly classified patients was 84.7% for men and 89.4% for women. Positive predictive value for SpHb was 0.50 (95% CI 0.35-0.65) in men and 0.40 (95% CI 0.31-0.50) in women; negative predictive value was 0.93 (95% CI 0.92-0.94) in men and 0.95 (95% CI 0.94-0.96) in women. We conclude that due to low sensitivity, SpHb is poorly suitable for detecting preoperative anaemia in both sexes under standard of care conditions.

Association of Acute Kidney Injury Receiving Kidney Replacement Therapy With Prognosis of Critically Ill Patients With and Without Cancer: A Retrospective Study.

OBJECTIVES: To assess outcomes of cancer patients receiving kidney replacement therapy due to acute kidney injury in ICUs and compare these with other patient groups receiving kidney replacement therapy in ICUs. DESIGN: Retrospective registry analysis. SETTING: Prospectively collected database of 296,424 ICU patients. PATIENTS: Patients with and without solid cancer with acute kidney injury necessitating kidney replacement therapy were identified and compared with those without acute kidney injury necessitating kidney replacement therapy. INTERVENTIONS: Descriptive statistics were used to ascertain prevalence of acute kidney injury necessitating kidney replacement therapy and solid cancer in ICU patients. Association of acute kidney injury necessitating kidney replacement therapy and cancer with prognosis was assessed using logistic regression analysis. To compare the attributable mortality of acute kidney injury necessitating kidney replacement therapy, 20,154 noncancer patients and 2,411 cancer patients without acute kidney injury necessitating kidney replacement therapy were matched with 12,827 noncancer patients and 1,079 cancer patients with acute kidney injury necessitating kidney replacement therapy. MEASUREMENTS AND MAIN RESULTS: Thirty-five thousand three hundred fifty-six ICU patients (11.9%) had solid cancer. Acute kidney injury necessitating kidney replacement therapy was present in 1,408 (4.0%) cancer patients and 13,637 (5.2%) noncancer patients. Crude ICU and hospital mortality was higher in the cancer group (646 [45.9%] vs 4,674 [34.3%], p < 0.001, and 787 [55.9%] vs 5,935 [43.5%], p < 0.001). In multivariable logistic regression analyses, odds ratio (95% CI) for hospital mortality was 1.73 (1.62-1.85) for cancer compared with no cancer 3.57 (3.32-3.83) for acute kidney injury necessitating kidney replacement therapy and 1.07 (0.86-1.33) for their interaction. In the matched subcohort, attributable hospital mortality of acute kidney injury necessitating kidney replacement therapy was 56.7% in noncancer patients and 48.0% in cancer patients. CONCLUSIONS: Occurrence rate of acute kidney injury necessitating kidney replacement therapy and prognosis in ICU patients with solid cancer are comparable with other ICU patient groups. In cancer, acute kidney injury necessitating kidney replacement therapy is associated with higher crude hospital mortality. However, the specific attributable mortality conveyed by acute kidney injury necessitating kidney replacement therapy is actually lower in cancer patients than in noncancer patients. Diagnosis of cancer per se does not justify withholding kidney replacement therapy.

Factors associated with physician decision making on withholding cardiopulmonary resuscitation in prehospital medicine.

This study seeks to identify factors that are associated with decisions of prehospital physicians to start (continue, if ongoing) or withhold (terminate, if ongoing) CPR in patients with OHCA. We conducted a retrospective study using anonymised data from a prehospital physician response system. Data on patients attended for cardiac arrest between January 1st, 2010 and December 31st, 2018 except babies at birth were included. Logistic regression analysis with start of CPR by physicians as the dependent variable and possible associated factors as independent variables adjusted for anonymised physician identifiers was conducted. 1525 patient data sets were analysed. Obvious signs of death were present in 278 cases; in the remaining 1247, resuscitation was attempted in 920 (74%) and were withheld in 327 (26%). Factors significantly associated with higher likelihood of CPR by physicians (OR 95% CI) were resuscitation efforts by EMS before physician arrival (60.45, 19.89-184.29), first monitored heart rhythm (3.07, 1.21-7.79 for PEA; 29.25, 1.93-442. 51 for VF / pVT compared to asystole); advanced patient age (modelled using cubic splines), physician response time (0.92, 0.87-0.97 per minute) and malignancy (0.22, 0.05-0.92) were significantly associated with lower odds of CPR. We thus conclude that prehospital physicians make decisions to start or withhold resuscitation routinely and base those mostly on situational information and immediately available patient information known to impact outcomes.

Nonelective surgery at night and in-hospital mortality: Prospective observational data from the European Surgical Outcomes Study.

BACKGROUND: Evidence suggests that sleep deprivation associated with night-time working may adversely affect performance resulting in a reduction in the safety of surgery and anaesthesia. OBJECTIVE: Our primary objective was to evaluate an association between nonelective night-time surgery and in-hospital mortality. We hypothesised that urgent surgery performed during the night was associated with higher in-hospital mortality and also an increase in the duration of hospital stay and the number of admissions to critical care. DESIGN: A prospective cohort study. This is a secondary analysis of a large database related to perioperative care and outcome (European Surgical Outcome Study). SETTING: Four hundred and ninety-eight hospitals in 28 European countries. PATIENTS: Men and women older than 16 years who underwent nonelective, noncardiac surgery were included according to time of the procedure. INTERVENTION: None. MAIN OUTCOME MEASURES: Primary outcome was in-hospital mortality; the secondary outcome was the duration of hospital stay and critical care admission. RESULTS: Eleven thousand two hundred and ninety patients undergoing urgent surgery were included in the analysis with 636 in-hospital deaths (5.6%). Crude mortality odds ratios (ORs) increased sequentially from daytime [426 deaths (5.3%)] to evening [150 deaths (6.0%), OR 1.14; 95% confidence interval 0.94 to 1.38] to night-time [60 deaths (8.3%), OR 1.62; 95% confidence interval 1.22 to 2.14]. Following adjustment for confounding factors, surgery during the evening (OR 1.09; 95% confidence interval 0.91 to 1.31) and night (OR 1.20; 95% confidence interval 0.9 to 1.6) was not associated with an increased risk of postoperative death. Admittance rate to an ICU increased sequentially from daytime [891 (11.1%)], to evening [347 (13.8%)] to night time [149 (20.6%)]. CONCLUSION: In patients undergoing nonelective urgent noncardiac surgery, in-hospital mortality was associated with well known risk factors related to patients and surgery, but we did not identify any relationship with the time of day at which the procedure was performed. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01203605.

Seeking worldwide professional consensus on the principles of end-of-life care for the critically ill. The Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) study.

Great differences in end-of-life practices in treating the critically ill around the world warrant agreement regarding the major ethical principles. This analysis determines the extent of worldwide consensus for end-of-life practices, delineates where there is and is not consensus, and analyzes reasons for lack of consensus. Critical care societies worldwide were invited to participate. Country coordinators were identified and draft statements were developed for major end-of-life issues and translated into six languages. Multidisciplinary responses using a web-based survey assessed agreement or disagreement with definitions and statements linked to anonymous demographic information. Consensus was prospectively defined as >80% agreement. Definitions and statements not obtaining consensus were revised based on comments of respondents, and then translated and redistributed. Of the initial 1,283 responses from 32 countries, consensus was found for 66 (81%) of the 81 definitions and statements; 26 (32%) had >90% agreement. With 83 additional responses to the original questionnaire (1,366 total) and 604 responses to the revised statements, consensus could be obtained for another 11 of the 15 statements. Consensus was obtained for informed consent, withholding and withdrawing life-sustaining treatment, legal requirements, intensive care unit therapies, cardiopulmonary resuscitation, shared decision making, medical and nursing consensus, brain death, and palliative care. Consensus was obtained for 77 of 81 (95%) statements. Worldwide consensus could be developed for the majority of definitions and statements about end-of-life practices. Statements achieving consensus provide standards of practice for end-of-life care; statements without consensus identify important areas for future research.

Mortality after surgery in Europe: a 7 day cohort study.

BACKGROUND: Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfirmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe. METHODS: We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ(2) and Fisher's exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Significance was set at p<0·05. We constructed multilevel logistic regression models to adjust for the differences in mortality rates between countries. FINDINGS: We included 46,539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients were admitted to critical care after surgery with a median length of stay of 1·2 days (IQR 0·9-3·6). 1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude mortality rates varied widely between countries (from 1·2% [95% CI 0·0-3·0] for Iceland to 21·5% [16·9-26·2] for Latvia). After adjustment for confounding variables, important differences remained between countries when compared with the UK, the country with the largest dataset (OR range from 0·44 [95% CI 0·19-1·05; p=0·06] for Finland to 6·92 [2·37-20·27; p=0·0004] for Poland). INTERPRETATION: The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients. FUNDING: European Society of Intensive Care Medicine, European Society of Anaesthesiology.

Epidemiology and outcome following post-surgical admission to critical care.

PURPOSE: To describe the factors related to outcome in patients admitted to the intensive care unit (ICU) after major surgery at a national level (in Austria). METHODS: Analysis of a prospectively collected database of ICU admissions over an 11-year period. Factors associated with mortality and how this changed with time were explored using logistic multilevel modelling. RESULTS: A total of 88,504 surgical patients had a mean ICU length of stay of 6.5 days and total hospital stay of 31.3 days. They had an ICU mortality of 7.6% and a hospital mortality of 11.8%. Factors associated with hospital mortality included age (odds ratio (OR) 1.42 per 10 years of age), urgency of operation (2.02 for emergency when compared to elective), SAPS II score (OR 1.09), reason for admission being a medical cause and the specific nature of the surgery itself: thoracic (OR 1.81), cardiovascular (OR 1.25), trauma (OR 1.22) or gastrointestinal surgery (OR 1.71). In addition patients who had pre-existing chronic renal (OR 1.40), respiratory (OR 1.20) or cardiac failure (OR 1.29), cirrhosis (OR 2.50), alcoholism (OR 1.42), acute kidney injury (OR 1.88) and/or non-metastatic cancer (OR 1.20) were associated with higher hospital mortality than patients without this co-morbidity. There was a reduction in the OR for death over the whole 11-year period. This improved outcome remained valid even after adjusting for the identified risk factors for mortality (OR per year 0.96). CONCLUSIONS: This study has shown the high level of demand for critical care for this patient group and an improving rate of survival.

Jejunal tube placement in critically ill patients: A prospective, randomized trial comparing the endoscopic technique with the electromagnetically visualized method.

OBJECTIVE: Head-to-head comparison of the success rate of jejunal placement of a new electromagnetically visualized jejunal tube with that of the endoscopic technique in critically ill patients. DESIGN: : Prospective, randomized clinical trial. SETTING: Two intensive care units at a university hospital. PATIENTS: : A total of 66 critically ill patients not tolerating intragastric nutrition. INTERVENTIONS: Patients were randomly assigned (2:1 ratio) to receive an electromagnetically visualized jejunal feeding tube or an endoscopically placed jejunal tube. The success rate of correct jejunal placement after 24 hrs was the main outcome parameter. MEASUREMENTS AND MAIN RESULTS: The correct jejunal tube position was reached in 21 of 22 patients using the endoscopic technique and in 40 of 44 patients using the electromagnetically visualized jejunal tube (95% vs. 91%; relative risk 0.9524, confidence interval 0.804-1.127, p = .571). In the remaining four patients, successful endoscopic jejunal tube placement was performed subsequently. The implantation times, times in the right position, and occurrences of nose bleeding were not different between the two groups. The electromagnetically visualized technique resulted in the correct jejunal position more often at the first attempt. Factors associated with successful placement at the first attempt of the electromagnetically visualized jejunal tube seem to be a higher body mass index and absence of emesis. This trial is registered at ClinicalTrials.gov, number NCT00500851. CONCLUSIONS: In a head-to-head comparison correct jejunal tube placement using the new electromagnetically visualized method was as fast, safe, and successful as the endoscopic method in a comparative intensive care unit patient population.

[Disturbances of gastrointestinal motility in intensive care units]. / Gastrointestinale Motilitätsstörungen auf der Intensivstation - Ursachen, Konsequenzen und Therapie.

Maintaining regular function of the intestinal tract is an important prerequisite for successful outcomes in critical illness. Disturbances of gastrointestinal motility are frequently caused by drugs, excessive fluid load, mechanical ventilation, surgical or ischemic damage, and occur frequently in sepsis and SIRS. Impaired gastrointestinal motility may give rise to a vitious circle of enteral nutrition intolerance, edema, and may eventually result in a breakdown of the gastrointestinal barrier. Early diagnosis, patient-adapted treatment and a focus on prophylactic measures are necessary prerequisites to maintain gut function in critically ill patients.

Impact of nosocomial infections on clinical outcome and resource consumption in critically ill patients.

OBJECTIVE: Nosocomial infections still present a major problem in intensive care units (ICUs), accounting for prolonged ICU and hospital stays and worsened outcomes. There exist differences in the literature regarding the impact of nosocomial infections on attributable mortality and resource consumption. The aim of this study was to observe these effects in a large cohort of critically ill patients. PATIENTS AND SETTINGS: Thirty-four Austrian ICUs participated in the study by documenting all nosocomial infections from 1 June to 30 November 2003 according to the Hospital in Europe Link for Infection Control through Surveillance (HELICS) protocol. MEASUREMENTS AND RESULTS: Of 2,392 patients with a length-of-stay (LOS) >2 days, 683 (28.6%) developed at least one nosocomial infection. The most common infection was pneumonia (n = 456), followed by central venous catheter (CVC) infections (n = 101). Risk-adjusted mortality rates (standardized mortality ratios) were significantly increased for infected patients [0.91 (0.83-0.99) vs. 0.68 (0.61-0.74)]. Significant attributable risk-adjusted mortality was found for patients with pneumonia, combined infections (both 32%) and CVC-related infections (26%). LOS in the ICU increased significantly for all infections. CONCLUSIONS: We conclude that significant attributable mortality for several nosocomial infections exists in a large cohort of critically ill patients, with the highest impact occurring in those with microbiologically diagnosed pneumonia and combined infections. All infections were associated with an increased resource consumption. Effective infection control measures could improve both clinical outcome and proper and effective use of ICU resources.

Predictors of early recovery of health status after intensive care.

OBJECTIVE: To identify factors predictive of good or poor recovery of health status and health-related quality of life (HRQOL) 90 days after admission to an intensive care unit (ICU). DESIGN AND SETTING: Prospective international multicentre study in 19 ICUs participating in the HRQOL substudy of the SAPS 3 project. INTERVENTION: The EuroQol questionnaire (EQ) was administered to discharged ICU patients 90 days after admission. A question to compare present health status with that 3 months before ICU admission (same/better/worse) was added. PATIENTS: Six hundred and eighteen patients who spent >24h in an ICU and survived for 90 days. EQ data and health comparison were available in 559 (90.5%) of them. MEASUREMENTS AND RESULTS: Patients reported their general level of health to be better (33.8%), the same (31.1%), or worse (35.1%) in comparison with baseline. Recovery was considered to be good for answers "better" or "the same". Regression analysis showed that transplantation surgery [odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01-0.63], coronary artery bypass surgery without valvular repair (OR 0.39, 95% CI 0.17-0.92) and being admitted to the ICU from a ward or other location (OR 0.55, 95% CI 0.31-0.95) predicted good recovery of health. Predictors of poor recovery (all present at the time of ICU admission) were unplanned ICU admission, hypothermia, serum creatinine level >or=2mg/dl, pH

Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study.

OBJECTIVE: To assess on a multinational level the prevalence and corresponding factors of selected unintended events that compromise patient safety (sentinel events) in intensive care units (ICUs). DESIGN: An observational, 24-h cross-sectional study of incidents in five representative categories. SETTING: 205 ICUs worldwide MEASUREMENTS: Events were reported by intensive care unit staff members with the use of a structured questionnaire. Both ICU- and patient-related factors were assessed. RESULTS: In 1,913 adult patients a total of 584 events affecting 391 patients were reported. During 24 h multiple errors related to medication occurred in 136 patients; unplanned dislodgement or inappropriate disconnection of lines, catheters, and drains in 158; equipment failure in 112; loss, obstruction or leakage of artificial airway in 47; and inappropriate turn-off of alarms in 17. Per 100 patient days, 38.8 (95% confidence interval 34.7-42.9) events were observed. In a multiple logistic regression with ICU as a random component, the following were associated with elevated odds for experiencing a sentinel event: any organ failure (odds ratio 1.13, 95% confidence interval 1.00-1.28), a higher intensity in level of care (odds ratio 1.62, 95% confidence interval 1.18-2.22), and time of exposure (odds ratio 1.06, 95% confidence interval 1.04-1.08). CONCLUSIONS: Sentinel events related to medication, indwelling lines, airway, and equipment failure in ICUs occur with considerable frequency. Although patient safety is recognised as a serious issue in many ICUs, there is an urgent need for development and implementation of strategies for prevention and early detection of errors.