Approach to the basic needs in patients on invasive ventilation using eye-tracking devices for non-verbal communication.

PURPOSE: To analyze the feasibility of eye-tracking (ET) devices as a communicative approach to the basic needs (BN) of intensive care unit (ICU) and invasively ventilated nonverbal patients. METHODS: Prospective, monocentric, and observational study including all patients without delirium, with an endotracheal tube or tracheostomy tube, with a history of invasive ventilation for more than 48 h, and inadequate nonverbal communication skills. The investigation was performed with commercially available ET devices (Tobii Dynavox I-15+) to express BN of ICU patients following a standardized 30-item yes-or-no questionnaire. RESULTS: A total of 64 patients with a mean age of 58.6 years were included. The main diagnoses for ICU admission were major trauma (43.6%), sepsis (21.8%), and acute abdomen (15.6%). Pain during repositioning (69%), thirst (69%), sleep disorders (66%), fatigue (64%), and anxiety regarding the lifelong need for assistance (64%) were the main problems reported by the patients. However, most of the patients described expectations of health improvement (78%), good family support (66%), and an improvement in quality of life due to the use of ET devices (67%). CONCLUSION: The use of ET in selected ICU patients with impaired communication is feasible, allowing them to express their BN. Apart from knowing the patients' individual BN, the results of our BN questionnaire may provide guidance for improvement measures in the care of patients in the ICU who are unable to speak. We believe that ET is useful for inquiring about and expressing BN and, therefore, may be capable of improving patient-medical team interactions and patient satisfaction.

Pilot study: advanced haemodynamic monitoring after acute spinal cord injury-Keep the pressure up?

BACKGROUND: Although the use of vasopressors to maintain haemodynamic goals after acute spinal cord injury (SCI) is still recommended, evidence regarding the target values and possible risks of this practice is limited, and data on haemodynamic parameters unaffected by catecholamines are rare. In this pilot study, we show the haemodynamic profile of patients with acute SCI mainly unaffected by vasopressor use and other factors that influence the cardiovascular system. METHODS: From March 2018 to March 2020, we conducted a prospective, single-centre pilot study of 30 patients with acute SCI. Factors that could affect the cardiocirculatory system other than SCI (sepsis, pre-existing heart disease or multiple trauma) led to exclusion. A total of 417 measurements were performed using the PiCCO™ system. RESULTS: The mean systemic vascular resistance index (SVRI, 1447.23 ± 324.71 dyn*s*cm-5*m2), mean central venous pressure (CVP, 10.69 ± 3.16) and mean global end-diastolic volume index (GEDVI, 801.79 ± 158.95 ml/m2) deviated from the reference range, while the mean cardiac index (CI), mean stroke volume index (SVI), mean arterial pressure (MAP), and mean heart rate (HR) were within the reference range, as indicated in the literature. A mixed model analysis showed a significant negative relationship between norepinephrine treatment and MAP (83.97 vs. 73.69 mmHg, p < 0.001), SVRI (1463.40 vs. 1332.14 dyn*s*cm-5*m2, p = 0.001) and GEDVI (808.89 vs. 759.39 ml/m2, p = 0.001). CONCLUSION: These findings could lead to an adaptation of the target range for SVRI and MAP in patients with acute SCI and therefore reduce the use of vasopressors.

Cervical Spinal Cord Injury Shows Markedly Lower than Predicted Mortality (>72 Hours After Multiple Trauma) From Sepsis and Multiple Organ Failure.

BACKGROUND: Sepsis and multiple organ failure (MOF) remain one of the main causes of death after multiple trauma. Trauma- and infection-associated immune reactions play an important role in the pathomechanism of MOF, but the exact pathways remain unknown. Spinal cord injury (SCI) may lead to an altered immune response, and some studies suggest a prognostic advantage for such patients having sepsis or multiple trauma. Yet these findings need to be evaluated in larger cohorts of trauma patients. METHODS: Retrospective, multicenter study, using the data of the TraumaRegister DGU. Patients with and without SCI surviving the initial first 72 hours after trauma were matched according to injury pattern and age. Comparative analysis considered morbidity (sepsis, MOF) and hospital mortality. RESULTS: The study population included 800 matched pairs. As intended by the matching process, patients with cervical SCI had an otherwise comparable injury pattern but a higher severity of trauma (mean Injury Severity Score: 36 vs 29, mean number of diagnosis: 5.6 vs 4.4). They had a higher rate of sepsis (15.9% vs 10.9%, P = .005) and MOF (35.9% vs 24.1%, P < .001) while mortality revealed no significant difference (9.5% vs 9.9%, P = .866). CONCLUSIONS: Cervical SCI leads to an increased rate of sepsis and MOF but appears to be favorable with respect to outcome of sepsis and MOF following multiple trauma. Further research should focus on the pathomechanisms and the possible arising therapeutic options.

Incidence and complications of cannula changes in long-term tracheotomized patients: a prospective observational study.

STUDY DESIGN: Prospective, monocentric observational study. OBJECTIVE: Investigation of incidence and complication rate of cannula changes in long-term tracheotomized patients suffering spinal cord injury. SETTING: University hospital in Bochum, Germany. METHODS: Prospective data collection of all cannula changes between September 2016 and September 2017. Physicians recorded mechanical complications and techniques to solve them, and/or complications resulting in patient-threatening condition. RESULTS: There were 149 cannula changes during 3191 observation days. Overall, urgent cannula changes occurred 2.1 times per 100 observation days. Within the first 8 weeks after tracheostomy, urgent cannula changes were necessary four times per 100 observation days, and were mandatory less than two times per 100 observation days thereafter. Overall, mechanical complications occurred in 12% of cannula changes, and 8% of cannula changes were accompanied by patient-threatening complications. Accidental decannulation (AD) occurred in 0.97 of 100 observation days. Recannulation after AD was accompanied by 29% of mechanical complications during reinsertion, and 16% led to patient-threatening complications. The major risk factors for mechanical complications were the time lag between cannula change and tracheostomy, and the urgency of the procedure while the thyroid cartilage-jugular distance was significantly associated with patient-threatening complications. CONCLUSION: AD and the requirement for urgent cannula changes are common and often related with mechanical and patient-threatening complications. Even weeks after tracheostomy, caregivers need to be aware of serious events, and therefore provide monitoring, knowledge, and appropriate resources to handle these events.

Risk factors and outcome of patients with periprosthetic joint infection admitted to intensive care unit.

INTRODUCTION: Prosthetic joint infection (PJI) is a severe complication after total joint replacement surgery. The current study analyzes the outcome and mortality of patients admitted to an intensive care unit following PJI. METHODS: Retrospective analysis of all patients treated between 2012 and 2016 due to PJI in the surgical intensive care unit of a university hospital. RESULTS: A total of 124 patients were included. The mean age was 75 ± 11 years. Of those 124 patients, 85 patients (68.5%) suffered a prosthetic infection of the hip, 33 patients (27.3%) of the knee, six patients (4.8%) of hip and knee. 52 patients were male (40.9%). The assessed mean Simplified Acute Physiology Score II (SAPSII) was 29.6 ± 5.9. The mortality rate was 21% (26/124). Of surviving patients, 53.1% were discharged home, 25.5% were transferred to a nursing home, and 21.4% were transferred to a geriatric rehabilitation center. Comparing survivors to non-survivors, the non-survivor group showed a higher incidence of renal replacement therapy (46.1 vs 3.0%; p < 0.01), higher SAPSII on admission (35.7 vs. 29.0; p = 0.01) and higher Charlson Comorbidity Indices (CCI) (5.5 vs. 2.82; p < 0.01). The multivariate regression identified CCI (odds ratio 1.49; p < 0.01) and renal replacement therapy (odds ratio 12.4; p < 0.01) as independent risk factors for increased mortality. CONCLUSIONS: Admission to an intensive care unit was associated with a mortality rate of 21%. Factors associated with poor outcomes included renal replacement therapy, higher admission SAPII scores, and higher admission Charlson comorbidity index. These factors could be used for individual risk assessment on admission to the ICU.

Percutaneous Dilatational Tracheostomy in Ankylosing Spondylitis (Bechterew Disease) Is Feasible and Not Associated With Higher Complication Rates.

BACKGROUND: Ankylosing spondylitis (AS) is a common disease with an incidence of approximately 0.5% in Europe, causing severe limitations of axial spine mobility and cervical kyphosis. Deformities of the cervical spine and the temporomandibular joints could increase the risk of complications while performing an intubation or tracheostomy. The percutaneous dilatational tracheostomy (PDT) is a standard procedure in intensive care medicine. However, the combination of cervical kyphosis and osteoporosis makes patient positioning challenging. Therefore, one could conclude that patients with AS are not candidates for PDT, but neither studies nor case reports yet reported about feasibility of this procedure in AS. METHODS: Retrospective analysis at a level 1 trauma center of patient records from 2002 to 2016, assessing all patients with AS and PDT. RESULTS: A total of 31 patients with AS have been subjected to PDT. All PDTs were performed using the modified Ciaglia single-step dilatational technique. Neither cardiopulmonary nor surgical complications occurred during the procedure. One patient received a change of the existing airway prior to the procedure; a small nasal tube was changed for a laryngeal mask. CONCLUSION: Although head positioning may be challenging, PDT should be taken into consideration for patients with AS. In the hands of an experienced doctor, it is safe and feasible.

Extracorporeal membrane oxygenation in spina bifida and (H1N1)-induced acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is characterized as an acute hypoxemic and/or hypercapnic respiratory failure seen in critically ill patients and is still, although decreased over the past few years, associated with high mortality. Furthermore, ARDS may be a life-threatening complication of H1N1 pneumonia. We report on a 45-year-old spina bifida patient with confirmed H1N1 influenza virus infection causing acute respiratory failure, who was successfully weaned from 42-day veno-venous extracorporeal membrane oxygenation (vv-ECMO) treatment with an excellent outcome. Due to the physical constitution of spina bifida patients, we experienced challenges concerning cannula positioning and mechanical ventilation settings during weaning.

Against the odds: what to expect in rehabilitation of chronic spinal cord injury with a neurologically controlled Hybrid Assistive Limb exoskeleton. A subgroup analysis of 55 patients according to age and lesion level.

Objective Age and lesion level are believed to represent outcome predictors in rehabilitation of patients with chronic spinal cord injury (SCI). The Hybrid Assistive Limb (HAL) exoskeleton enables patients to perform a voluntary controlled gait pattern via an electromyography-triggered neuromuscular feedback system, and has been introduced as a temporary gait training tool in patients with SCI. The aim of this prospective pre- and postintervention study was to examine functional outcomes as a function of age and lesion level in patients with chronic incomplete SCI (iSCI) or chronic complete SCI (cSCI) with zones of partial preservation (ZPP) by using the HAL as a temporary training tool. Methods Fifty-five participants with chronic iSCI or cSCI (mean time since injury 6.85 ± 5.12 years) were classified according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) and divided by age (< 50 or ≥ 50 years), independent of lesion level, and also into 4 homogeneous groups according to lesion level. The subgroups were as follows: Subgroup 1, tetraplegic iSCI (n = 13) (C2-8, AIS C [n = 8] and AIS D [n = 5]); Subgroup 2, paraplegic iSCI with spastic motor behavior (n = 15) (T2-12, AIS C [n = 8] and AIS D [n = 7]); Subgroup 3, paraplegic cSCI with complete motor paraplegia and absence of spastic motor behavior (n = 18) (T11-L4 [AIS A], and ZPP from L-3 to S-1); and Subgroup 4, paraplegic iSCI with absence of spastic motor behavior (n = 9) (T12-L3, AIS C [n = 8] and AIS D [n = 1]). The training paradigm consisted of 12 weeks of HAL-assisted treadmill training (5 times/week). Baseline status was documented prior to intervention by using the AIS grade, Walking Index for SCI II (WISCI II) score, the 10-meter walk test (10MWT), and the 6-minute walk test (6MinWT). Training effects were assessed after 6 and 12 weeks of therapy, without HAL assistance. Results Overall, a time reduction of 47% in the 10MWT, self-selected speed (10MWTsss) (< 50 years = 56% vs ≥ 50 years = 37%) and an increase of 50% in the 6MinWT were documented. The WISCI II scores showed a mean gain of 1.69 levels. At the end of the study, 24 of 55 patients (43.6%) were less dependent on walking aids. Age had a nonsignificant negative influence on the 10MWTsss. Despite a few nonsignificant subgroup differences, participants improved across all tests. Namely, patients with iSCI who had spastic motor behavior improved to a nonsignificant, lesser extent in the 6MinWT. Conclusions The HAL-assisted treadmill training leads to functional improvements in chronic iSCI or cSCI, both in and out of the exoskeleton. An improvement of approximately 50% in the 10MWTsss and in gait endurance (6MinWT) can be expected from such training. The influences of SCI lesion level and age on functional outcome were nonsignificant in the present study. Older age (≥ 50 years) may be associated with smaller improvements in the 10MWTsss. An iSCI in paraplegic patients with spastic motor behavior may be a nonsignificant negative predictor in gait endurance improvements. Clinical trial registration no.: DRKS00010250 ( https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_DE.do ).

First experiences of communication with mechanically ventilated patients in the intensive care unit using eye-tracking technology.

INTRODUCTION: Eye-tracking (ET) may be a novel tool for communication with intubated and mechanically ventilated critically ill patients. We hypothesized that ET could be learned fast and be used successfully by intensive care unit (ICU) and intermediate care (IMC) patients with artificial airways for communication. METHODS: Including all patients with mechanical ventilation via oral intubation or tracheostomy, who were at least 18 years of age with a score of -1 to +1 points on the Richmond agitation-sedation scale and a history of ventilation for more than 48 h. A commercially available ET was used. The investigations were performed by a physician with the support of a psychologist following a standardized study protocol. RESULTS: During a 4-week period a total of 11 patients completed all of the five steps of our study protocol. The time to complete our study protocol was 64 ± 23.8 min (range 43-125 min) with a mean of 1.5 ± 0.9 sessions (range 1-4 sessions). Seven patients (63.6 %) could run through all of the five steps within their first session. All patients (100%) preferred the gaze fixation technique to control the ET to the wink control. CONCLUSION: Mechanically ventilated ICU and IMC patients are able to use ET in a very short time for communication to indicate their basic needs, answer rating scales and pain scores as well as questionnaires about quality of life and self-esteem.Implications for rehabilitationCOMFORT - The novel communication device improves the patients' ability to communicate with the attending physicians, physiotherapists and nurses in order to provide a tailored rehabilitation approach.COMPLIANCE - The use of the eye-tracking technology enables the patients to communicate special needs and fears during the course of the rehabilitation.COMPLICATIONS - The eye-tracking technology enables the attending rehabilitation team to earlier detect complications (e.g. pain, depression) during the course of the rehabilitation.

Feasibility, safety, and functional outcomes using the neurological controlled Hybrid Assistive Limb exoskeleton (HAL®) following acute incomplete and complete spinal cord injury - Results of 50 patients.

OBJECTIVE: Recent studies reveal that Hybrid Assistive Limb (HAL®) locomotion training in paraplegic patients suffering from chronic spinal cord injury (SCI) induces improvements in functional and ambulatory mobility. The purpose of this study was to determine the safety, feasibility, and functional effectiveness of HAL® locomotion training in the initial rehabilitation of acute SCI patients. This clinical trial represents the first systematic intervention worldwide for acute SCI patients using a neurologically controlled exoskeleton. DESIGN: Single center, prospective study. SETTING: BG University Hospital Bergmannsheil, Bochum, Germany. PARTICIPANTS: Fifty acute SCI patients (14 women, 36 men). INTERVENTIONS: All participants received a daily (5 times/week) HAL® exoskeleton supported training for 12 weeks (mean amount of training sessions 60.4 ± 30.08). OUTCOME MEASURES: Functional outcome for overground walking was monitored using the 10-m-walk test (10 MWT) combined with the WISCI II score, 6-minute-walk test (6 MWT) and the timed-up and go test (TUG test). Treadmill-related parameters (speed, distance and walking time) and the Lower Extremity Motor Score (LEMS) were recorded separately. RESULTS: Significant improvements were observed for HAL®-associated (walking time, distance and speed) and for functional outcomes (10 MWT, 6 MWT and TUG-test). WISCI-II-Score and the LEMS increased significantly compared with the status prior to training. CONCLUSION: HAL® locomotion training is feasible and safe in the rehabilitation of acute SCI patients. The HAL® exoskeleton enables the patient to perform effective treadmill training and leads to improvements in functional and ambulatory mobility. However, spontaneous recovery vs training-related effects remain unclear and findings should not be extrapolated beyond the acute in-patient rehabilitation setting.Trial registration: German Clinical Trials Register identifier: DRKS00010250..