[Quality management: protocols for reporting in-hospital emergencies. Comparison of two methods]. / Qualitätssicherung: Dokumentation von Notfallsituationen im Krankenhaus. Vergleich zweier Methoden.

BACKGROUND AND OBJECTIVE: 10-20% of hospitalized patients experience adverse events, becoming clinically relevant in emergency situations (ES). Many studies have confirmed deficits in both organizational and professional aspects of care when responding to acute illness. These may result in a worsening outcome. A detailed reporting of acute intervention is necessary to make possible the detailed analysis of such situations and thus optimize the management of ES. It was the aim oft this study to compare the precision achieved in documenting ES using an in-hospital emergency protocol (IHEP), specifically developed for documentation of ES, with that using a standard anesthesia protocol (SAP), to prove which format would reflect the facts of the ES in better detail. METHODS: All IHEP documented in hospital emergencies between 2005 and 2007 were retrospectively analysed in order to compare them with ES documented by SAP during the same period of time. RESULTS: 200 protocols (52 IHEP and 146 SAP were included. Due to a lack of adequate structuring the conventional anesthesia protocols reported most details of ES in plain text. In comparison IHEP documentation allowed a more detailed, precise and complete documentation of ES. CONCLUSION: IHEP, designed according to the well known DIVI out-of-hospital emergency protocol, seems to be superior to using an SAP. Using IHEP is practicable and results in well documented data of ES, both medical and legal aspects of documentation are regarded. Retrospective analysis to improve ES performance is quite feasible when using HIP.

Extracorporeal pumpless interventional lung assist in clinical practice: determinants of efficacy.

Respiratory acidosis can become a serious problem during protective ventilation of severe lung failure. A pumpless arteriovenous interventional lung assist (iLA) for extracorporeal carbon dioxide removal has been used increasingly to control critical respiratory situations. The present study sought to evaluate the factors determining the efficacy of iLA and calculate its contribution to gas exchange. In a cohort of 96 patients with severe acute respiratory distress syndrome, haemodynamic parameters, oxygen consumption and carbon dioxide production as well as gas transfer through the iLA were analysed. The measurements demonstrated a significant dependency of blood flow via the iLA device on cannula size (mean+/-sd 1.59+/-0.52 L x min(-1) for 15 French (Fr), 1.94+/-0.35 L x min(-1) for 17 Fr, and 2.22 +/-0.45 L x min(-1) for 19 Fr) and on mean arterial pressure. Oxygen transfer capacity averaged 41.7+/-20.8 mL x min(-1), carbon dioxide removal was 148.0+/-63.4 mL x min(-1). Within two hours of iLA treatment, arterial oxygen partial pressure/inspired oxygen fraction ratio increased significantly and a fast improvement in arterial carbon dioxide partial pressure and pH was observed. Interventional lung assist eliminates approximately 50% of calculated total carbon dioxide production with rapid normalisation of respiratory acidosis. Despite limited contribution to oxygen transfer it may allow a more protective ventilation in severe respiratory failure.

[Heparin-induced type II thrombocytopenia as the etiology of severe recurrent pulmonary embolism]. / Heparininduzierte Thrombozytopenie Typ II als Ursache eines schweren Rezidivs einer Lungenembolie.

Heparin-induced thrombocytopenia (HIT) is a rare complication of anticoagulative heparin therapy. The more severe HIT type II is defined by peripheral thrombocytopenia combined with thrombotic and thromboembolic events. We report the case of a 24 year old male patient who was admitted to our ICU with thromboembolic obstruction of the right central pulmonary artery, and deep venous thrombosis (DVT) of the right superficial femoral vein. Systemic thrombolytic therapy with urokinase for seven days resulted in nearly complete resolution of the thromboembolic material in the pulmonary arteries. Antithrombotic therapy with intravenous heparin and overlapping oral phenoprocoumon was continued on the regular ward. Six days later, the patient had to be readmitted to the ICU with evidence of hemodynamic compromise due to massive bilateral pulmonary thromboembolism that could be confirmed by CT scan--DVT had extended to the right iliacal vein. Additionally, peripheral thrombocyte counts had markedly declined from 112.000 to 35.000/microliter within 3 days, indicating the presence of a Hit type II. This was verified by positive ELISA testing for antibodies against platelet factor 4 (PF4)-heparin-complex. A filter device was temporarily implanted into the inferior vena cava. The patients condition stabilized upon reinitiated systemic thrombolysis and replacement of heparin therapy against recombinant hirudin. Pulmonary artery pressures normalized. Peripheral thrombocytopenia diminished within three days. HIT type II is a severe complication of anticoagulative therapy with heparin. Here we report a case, and discuss diagnostic procedures as well as differential diagnosis to HIT type I.

Pumpless extracorporeal lung assist and adult respiratory distress syndrome.

We report use of a pumpless extracorporeal lung assist-a safe and effective method in the management of severe acute respiratory failure that allows an extracorporal gas-exchange without the use of a pump.

Rapid effects of lipopolysaccharides on indocyanine green clearance in rat liver.

BACKGROUND: Lipopolysaccharides (LPSs) are thought to be one of the triggers of organ reactions to sepsis, which causes hepatocellular dysfunction. This dysfunction can be demonstrated by a reduction of organic anion transport. The aim of our study was to assess whether the transport of indocyanine green (ICG) is affected by LPS, and whether Kupffer cells are involved. METHODS: Single-pass liver perfusion with ICG at a concentration of 57.8 mg/kg/min was performed for 130 min. pH, oxygen tension and perfusion pressure were continuously measured in influent and effluent. Taurocholate was infused at 48.3 mg/kg/min to achieve a stable bile flow. LPS was added at concentrations of 0.45, 0.9 and 1.44 mg/kg/min for 30 min. ICG was determined photometrically in perfusate and bile. To depress the function of Kupffer cells male Wistar rats were treated with GdCl3 24 h in advance. Primary cultured hepatocytes were used for studying the direct effect of LPS on the uptake rate of ICG. RESULTS: Forty-five minutes after administration of LPS a significant dose-dependent decrease of ICG uptake was seen in animals treated with LPS. Livers of animals pretreated with GdCl3 did not show this decrease. LPS had no direct effect on the uptake of ICG into primary cultured hepatocytes, whereas treatment of these cells with 8-bromo-cGMP resulted in a significant increase of ICG uptake. CONCLUSION: LPS has a rapid dose-dependent effect on the detoxification properties of the liver for ICG. The rapid effect of LPS on ICG uptake in hepatocytes is mediated by Kupffer cells.

[Effects of restrictions on use of vancomycin in a German university hospital]. / Erfahrungen mit der Beschränkung des Einsatzes von Vancomycin an einem deutschen Universitätsklinikum.

BACKGROUND: Recently, increasing antibiotic resistance has been observed among gram-positive bacteria. However, only few isolates were found to be resistant against glycopeptides. Therefore, internationally accepted guidelines recommend a restricted use of vancomycin and other glycopeptide antibiotics in order to prevent the development of resistance against these clinically important antibiotics. In many countries, the hospital pharmacies play a key role in control and reinforcement of antibiotic formulary restrictions. In Germany, however, the hospital pharmacies usually do not take over such control functions, and most wards keep a stock of regularly used drugs including antibiotics, which makes reinforcement of restrictions difficult. METHODS: In an attempt to achieve a restriction of vancomycin use, the pharmacy of our university hospital was advised to deliver vancomycin to the wards only on request with a special order form signed by an attending, individually for every patient who should receive vancomycin. The efficacy of this restriction measure was evaluated in 3-month periods before and after the restriction became effective. RESULTS: Hospitalwide, this led to a 20.1% reduction of i.v. vancomycin and an 85.7% reduction of oral vancomycin use per 1000 patient days. If the hematology/oncology units were not considered, the reduction of i.v. vancomycin use was 41.8%, and the total use after the restriction 24.2 g per 1000 patient days. Microbiology results which justified the use of vancomycin decreased by 8.3% (10.9% hematology/oncology units not considered) between the 2 observation periods. Assuming a 7-day mean course of i.v. vancomycin therapy, the empirical use of i.v. vancomycin decreased from 39.9% to 8% after the restriction had been instituted. CONCLUSION: Allowing only experienced physicians (attendings) to decide on the use of vancomycin therapy, proved in our experience to be an effective measure to reduce unnecessary vancomycin use.