Behavioral pain scale may not be reliable in awake non-verbal intensive care patients: a case control study.

BACKGROUND: The evaluation of pain in patients, unable of oral communication, often relies on behavioral assessment. However, some critically ill patients, while non-verbal, are awake and have some potential for self-reporting. The objective was to compare the results of a behavioral pain assessment with self-reporting in awake, non-verbal, critically ill patients unable to use low-tech augmentative and alternative communication tools. METHODS: Prospective cohort study of intubated or tracheotomized adult, ventilated patients with a RASS (Richmond Agitation Sedation Scale) of -1 to + 1 and inadequate non-verbal communication skills in a surgical intensive care unit of a tertiary care university hospital. For pain assessment, the Behavioral Pain Scale (BPS) was used. Self-reporting of pain was achieved by using an eye tracking device to evaluate the Numeric Rating Scale (NRS) and the pain/discomfort item of the EuroQol EQ-5D-5 L (EQ-Pain). All measurements were taken at rest. RESULTS: Data was collected from 75 patients. Neither the NRS nor the EQ-Pain (r < .15) correlated with the BPS. However, NRS and EQ-Pain were significantly correlated (r = .78, p = < 0.001), indicating the reliability of the self-reporting by these patients. Neither the duration of intubation/tracheostomy, nor cause for ICU treatment, nor BPS subcategories had an influence on these results. CONCLUSIONS: Behavioral pain assessment tools in non-verbal patients who are awake and not in delirium appear unreliable in estimating pain during rest. Before a behavioral assessment tool such as the BPS is used, the application of high-tech AACs should be strongly considered. TRIAL REGISTRATION: German Clinical Trials Register, Registration number: DRKS00021233. Registered 23 April 2020 - Retrospectively registered, https://drks.de/search/en/trial/DRKS00021233 .

Enhancing European Management of Analgesia, Sedation, and Delirium: A Multinational, Prospective, Interventional Before-After Trial.

BACKGROUND: The objective of this study was to analyze the impact of a structured educational intervention on the implementation of guideline-recommended pain, agitation, and delirium (PAD) assessment. METHODS: This was a prospective, multinational, interventional before-after trial conducted at 12 intensive care units from 10 centers in Germany, Austria, Switzerland, and the UK. Intensive care units underwent a 6-week structured educational program, comprising online lectures, instructional videos, educational handouts, and bedside teaching. Patient-level PAD assessment data were collected in three 1-day point-prevalence assessments before (T1), 6 weeks after (T2), and 1 year after (T3) the educational program. RESULTS: A total of 430 patients were included. The rate of patients who received all three PAD assessments changed from 55% (107/195) at T1 to 53% (68/129) at T2, but increased to 73% (77/106) at T3 (p = 0.003). The delirium screening rate increased from 64% (124/195) at T1 to 65% (84/129) at T2 and 77% (82/106) at T3 (p = 0.041). The pain assessment rate increased from 87% (170/195) at T1 to 92% (119/129) at T2 and 98% (104/106) at T3 (p = 0.005). The rate of sedation assessment showed no signficiant change. The proportion of patients who received nonpharmacological delirium prevention measures increased from 58% (114/195) at T1 to 80% (103/129) at T2 and 91% (96/106) at T3 (p < 0.001). Multivariable regression revealed that at T3, patients were more likely to receive a delirium assessment (odds ratio [OR] 2.138, 95% confidence interval [CI] 1.206-3.790; p = 0.009), sedation assessment (OR 4.131, 95% CI 1.372-12.438; p = 0.012), or all three PAD assessments (OR 2.295, 95% CI 1.349-3.903; p = 0.002) compared with T1. CONCLUSIONS: In routine care, many patients were not assessed for PAD. Assessment rates increased significantly 1 year after the intervention. Clinical trial registration ClinicalTrials.gov: NCT03553719.

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.

Sedation, sleep-promotion, and non-verbal and verbal communication techniques in critically ill intubated or tracheostomized patients: results of a survey.

BACKGROUND: The aim of this survey was to describe, on a patient basis, the current practice of sedation, pharmacologic and non-pharmacologic measures to promote sleep and facilitation of communication in critically ill patients oro-tracheally intubated or tracheostomized. METHODS: Cross-sectional online-survey evaluating sedation, sleep management and communication in oro-tracheally intubated (IP) or tracheostomized (TP) patients in intensive care units on a single point. RESULTS: Eighty-one intensive care units including 447 patients (IP: n = 320, TP: n = 127) participated. A score of ≤ -2 on the Richmond Agitation Sedation Scale (RASS) was prevalent in 58.2% (IP 70.7% vs. TP 26.8%). RASS -1/0 was present in 32.2% (IP 25.9% vs. TP 55.1%) of subjects. Propofol and alpha-2-agonist were the predominant sedatives used while benzodiazepines were applied in only 12.1% of patients. For sleep management, ear plugs and sleeping masks were rarely used (< 7%). In half of the participating intensive care units a technique for phonation was used in the tracheostomized patients. CONCLUSIONS: The overall rate of moderate and deep sedation appears high, particularly in oro-tracheally intubated patients. There is no uniform sleep management and ear plugs and sleeping masks are only rarely applied. The application of phonation techniques in tracheostomized patients during assisted breathing is low. More efforts should be directed towards improved guideline implementation. The enhancement of sleep promotion and communication techniques in non-verbal critically ill patients may be a focus of future guideline development.

Keeping it simple: the value of mortality prediction after trauma with basic indices like the Reverse Shock Index multiplied by Glasgow Coma Scale.

BACKGROUND: Identification of trauma patients at significant risk of death in the prehospital setting is challenging. The prediction probability of basic indices like vital signs, Shock Index (SI), SI multiplied by age (SIA) or the GCS is limited and more complex scores are not feasible on-scene. The Reverse SI multiplied by GCS score (rSIG) has been proposed as a triage tool to identify trauma patients with an increased risk of dying at EDs. Age adjustment (rSIG/A) displayed no advantage.We aim to (1) validate the accuracy of the rSIG in predicting death or early transfusion in a large trauma registry population, and (2) determine if the rSIG is valid for evaluation of trauma patients in the prehospital setting. METHODS: 70 829 trauma patients were retrieved from the TraumaRegister DGU database (time period between 2008 and 2017). The area under the receiver operating characteristic curve (AUROC) was calculated to measure the ability of SI, SIA, rSIG and rSIG divided by age (rSIG/A) to predict in-hospital mortality from data at the time of hospital arrival and solely from prehospital data. RESULTS: The rSIG at time of hospital admission was not sufficiently predictive for clinical decision-making. However, rSIG calculated solely from prehospital data accurately predicted risk of death. Using prehospital data, the AUROC for mortality of rSIG/A was the highest (0.85; CI: 0.85 to 0.86), followed by rSIG (0.76; CI: 0.75 to 0.77), SIA (0.71; CI: 0.70 to 0.71) and SI (0.48; CI: 0.47 to 0.49). CONCLUSION: The prehospital rSIG/A can be a useful adjunct for the prehospital evaluation of trauma patients and their allocation to trauma centres or trauma team activation. However, we could not confirm that the rSIG at hospital admission is a reliable tool for risk stratification.

Yes- mind the gap!

We totally agree with Deana and Colleagues that missing intermediate care 1) might be an explanation for unexpected unfavorable outcome and 2) strengthening of intermediate care has the potential to lower this high rate of unfavorable outcome after ICU discharge. Yes- mind the gap!

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.

Mortality in severely injured patients: nearly one of five non-survivors have been already discharged alive from ICU.

BACKGROUND: Most trauma patients admitted to the hospital alive and die later on, decease during the initial care in the emergency department or the intensive care unit (ICU). However, a number of patients pass away after having been discharged from the ICU during the initial hospital stay. On first sight these cases could be seen as "failure to rescue" of potentially salvageable patients. A low rate of such patients might be a potential indicator of quality for trauma care on ICUs and surgical wards. METHODS: Retrospective analysis of the TraumaRegister DGU® with data from 2015 to 2017. Patients that died during the initial ICU stay were compared to those who were discharged from the initial ICU stay for at least 24 h but died later on. RESULTS: A total of 82,313 trauma patients were included in the TraumaRegister DGU®. In total, 6576 patients (8.0%) died during their hospital stay. Out of those, 5481 were admitted to the ICU alive and 972 patients (17.7%) were discharged from ICU and died later on. Those were older (mean age: 77 vs. 68 years), less severely injured (mean ISS: 23.1 vs. 30.0 points) and had a longer mean ICU length of stay (10 vs. 6 days). A limitation of life-sustaining therapy due to a documented living will was present in 46.1% of all patients who died during their initial ICU stay and in 59.9% of patients who died after discharge from their initial ICU stay. CONCLUSIONS: 17.7% of all non-surviving severely injured trauma patients died within the hospital after discharge from their initial ICU treatment. Their death can partially be explained by a limitation of therapy due to a living will. In conclusion, the rate of such late deaths may partially represent patients that died of potentially avoidable or treatable complications.

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.

Poor outcome of octogenarians admitted to ICU due to periprosthetic joint infections: a retrospective cohort study.

BACKGROUND: Even though surgical techniques and implants have evolved, periprosthetic joint infection (PJI) remains a serious complication leading to poor postoperative outcome and a high mortality. The literature is lacking in studies reporting the mortality of very elderly patients with periprosthetic joint infections, especially in cases when an intensive care unit (ICU) treatment was necessary. We therefore present the first study analyzing patients with an age 80 and higher suffering from a periprosthetic joint infection who had to be admitted to the ICU. METHODS: All patients aged 80 and higher who suffered from a PJI (acute and chronic) after THR or TKR and who have been admitted to the ICU have been included in this retrospective, observational, single-center study. RESULTS: A total of 57 patients met the inclusion criteria. The cohort consisted of 24 males and 33 females with a mean age of 84.49 (± 4.0) years. The mean SAPS II score was 27.05 (± 15.7), the mean CCI was 3.35 (± 2.28) and the most patient had an ASA score of 3 or higher. The PJI was located at the hip in 71.9% or at the knee in 24.6%. Two patients (3.5%) suffered from a PJI at both locations. Sixteen patients did not survive the ICU stay. Non-survivors showed significantly higher CCI (4.94 vs. 2.73; p = 0.02), higher SAPS II score (34.06 vs. 24.32; p = 0.03), significant more patients who underwent an invasive ventilation (132.7 vs. 28.1; p = 0.006) and significantly more patients who needed RRT (4.9% vs. 50%; p < 0.001). In multivariate analysis, RRT (odds ratio (OR) 15.4, CI 1.69-140.85; p = 0.015), invasive ventilation (OR 9.6, CI 1.28-71.9; p = 0.028) and CCI (OR 1.5, CI 1.004-2.12; p = 0.048) were independent risk factors for mortality. CONCLUSION: Very elderly patients with PJI who needs to be admitted to the ICU are at risk to suffer from a poor outcome. Several risk factors including a chronic infection, high SAPS II Score, high CCI, invasive ventilation and RRT might be associated with a poor outcome.

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.

A Consensus-Based Criterion Standard for the Requirement of a Trauma Team.

BACKGROUND: Trauma team activation (TTA) represents a considerable expenditure of trauma centre resources. It is mainly triggered by field triage criteria. The overall quality of the criteria may be evaluated based on the rate of over- and undertriage. However, there is no gold standard that defines which adult patients truly require a trauma team. The objective of this study was to develop consensus-based criteria defining the necessity for a trauma team. METHODS: A consensus group was formed by trauma specialists experienced in emergency and trauma care with a specific interest in field triage and having previously participated in guideline development. A literature search was conducted to identify criteria that have already been used or suggested. The initial list of criteria was discussed in two Delphi round and two consensus conferences. The entire process of discussion and voting was highly standardized and extensively documented, resulting in a final list of criteria. RESULTS: Initially 95 criteria were identified. This was subsequently reduced to 20 final criteria to appropriately indicate the requirement for attendance of a trauma team. The criteria address aspects related to injury severity, admission to an intensive care unit, death within 24 h, need for specified invasive procedures, need for surgical and/or interventional radiological procedures, and abnormal vital signs within a defined time period. CONCLUSIONS: The selected criteria may be applied as a tool for research and quality control concerning TTA. However, future studies are necessary to further evaluate for possible redundancy in criteria that may allow for further reduction in criteria.

Correction to: Inhalative sedation with small tidal volumes under venovenous ECMO.

In the original publication, the affiliations of fourth and fifth authors were published incorrectly. The corrected affiliations are given in this correction.

Inhalative sedation with small tidal volumes under venovenous ECMO.

BACKGROUND: Inhalative sedation is an emerging method for long-term sedation in intensive care therapy. There is evidence that it is easy to control and may be beneficial compared to intravenous sedation. Yet little is known about the use in patients with compromised lung function. In this retrospective analysis, we searched files of patients receiving inhalative sedation under venovenous extracorporeal membrane oxygenator (vv-ECMO) support due to lung failure. METHODS: After ethical approval, we performed a retrospective analysis of patients receiving vv-ECMO support and inhalative sedation in the surgical ICU in 2015. Isoflurane was administered via the AnaConDa®-system. Sedation was tested using Richmond Agitation and Sedation scale (RASS). RESULTS: 7 patients were identified. Median age was 50 years (26/70 years). All were male. Median ECMO runtime was 129 h (37/1008 h) and the survival rate was 57.9%. Dose of isoflurane was 1.7 ml/h (0.8 / 4.0 ml/h) resulting in expiratory concentrations of 0.8 Vol% (0.3/1.8 Vol%), inspiratory of 0.6 Vol% (0.1/1.4 Vol%). Higher concentrations of isoflurane were associated with increased depth of sedation (expiratory p = 0.016; inspiratory p = 0.027; averaged p = 0.015). With tidal volume below 350 ml, association was still present for expiratory and averaged concentrations of isoflurane (expiratory p = 0.031; inspiratory p = 0.082; average p = 0.039). CONCLUSIONS: This is the first study that shows that inhalative concentrations of isoflurane are associated with depth of sedation in patients with lung failure. We were able to show that even with major impacts in lung mechanics and function targeted sedation with volatile anaesthetics is feasible and dose-response relationship appears to exist.

[Benefits of medical emergency teams : Mortality on normal wards and readmission to intensive care wards]. / Nutzen von "medical emergency teams" : Sterblichkeit auf Normalstationen und Rückverlegungsrate auf Intensivstationen.

Medical emergency teams (MET) were implemented in many hospitals worldwide in order to identify patients at risk on normal wards and to initiate diagnostics and therapy without delay. Ideally, the implementation leads to prevention of cardiac arrests and unexpected deaths on normal wards, reduced rates of admissions to intensive care units and hospital mortality. Various track and trigger systems are available to identify such patients and for them to be assessed and treated within 30-45 min by the MET. The ideal personnel composition of METs has not yet been established. Whether the implementation of an MET generally leads to an improvement of treatment on normal wards or to a reduction in mortality in hospitals has not been finally clarified. Mortality and morbitidy (M&M) conferences can help to analyze if an individual clinic is likely to profit from the introduction of a MET.