Improving the quality of the intensive care follow-up of ventilated patients during a national registration program.

OBJECTIVES: The Belgian Public Health Organization is concerned with rates of hospital-acquired infections like ventilator-associated pneumonia (VAP). Implementing best practice guidelines for these nosocomial infections has variable success in the literature. This retrospective study was undertaken to see whether implementation of the evidence-based practices as a bundle was feasible, would influence compliance, and could reduce the rates of VAP. STUDY DESIGN: We utilized easily collectable data about regular care to rapidly assess whether interventions already in place were effectively successfully applied. This avoided cumbersome data collection and review. METHODS: Retrospective compliance rates and VAP ratios were compared using z tests with P-values < 0.05 considered statistically significant. This data review attempted to examine the impact of education campaigns, staff meetings, in-services, physician checklist, nurse checklist, charge nurse checklist implementation, systematic VAP bundle application, and systematic protocols for oral care and sedation protocols. Additionally, VAP ratio could be registered by the participating centers. RESULTS: A total of 10,211 intensive care unit (ICU) patients were included in the study which represents 66,817 ICU days under artificial ventilation with an endotracheal tube. The general compliance for VAP bundle raised from VAP was 61% in February 2012 and 74.16% in December 2012 (P < 0.001). The incidence rate of VAP went from 8.34 occurrences/1000 vent days in 2009 to 4.78 occurrences/1000 vent days in 2012 (P < 0.001-Pearson test). CONCLUSIONS: Efforts to improve physician and staff education, and checklist implementation resulted in an increase in compliance for VAP bundle and a decrease in VAP ratio. This study confirms the applicability of best practice guidelines about regular care but results on VAP incidence have to be confirmed.

[Conflicts between healthcare professionals and families of a multi-ethnic patient population in the intensive care unit]. / Conflict tussen zorgverleners en families van een multi-etnische patiëntenpopulatie op de IC.

OBJECTIVE: To investigate which factors contribute to conflicts between healthcare professionals and family members from ethnic minority groups during medically critical situations in hospital. DESIGN: Descriptive, ethnographic research. METHOD: Ethnographic fieldwork was carried out in one intensive care unit (ICU) of a multi-ethnic urban hospital in Belgium in the period January-June 2014. Data were collected by means of negotiated interactive observation, in-depth interviews with healthcare professionals and examining the patients' medical files. Data were analysed using grounded theory procedures. RESULTS: Conflicts were primarily related to the participants' different views on 'good care'. Healthcare providers' (HCPs') views on good care were primarily grounded on a biomedical care model, whereas families' views on good care were mainly inspired by a holistic care approach. According to HCPs, giving good care included fighting the disease efficiently with great scientific competence, but family members considered this rather as attending to the patient and giving bedside care, amongst other things. The HCPs' biomedical vision on good care was strengthened by the strict application of ward regulations, characterizing the ICU setting. The families' holistic views on good care were strengthened by specific ethno-familial characteristics, including their ethno-cultural background. However, ethno-cultural differences only contributed to conflict if the policy context on the ICU could provoke this conflict. CONCLUSION: Conflicts cannot be exclusively linked to ethno-cultural differences. Structural, functional characteristics of the ICU contribute substantially to conflict development. Effective conflict prevention should, therefore, not only focus on ethno-cultural differences but should also focus sufficiently on the structural context and ward policy.

Measuring resting energy expenditure during extracorporeal membrane oxygenation: preliminary clinical experience with a proposed theoretical model.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is increasingly used in patients with severe respiratory failure. Indirect calorimetry (IC) is a safe and non-invasive method for measuring resting energy expenditure (REE). No data exist on the use of IC in ECMO-treated patients as oxygen uptake and carbon dioxide elimination are divided between mechanical ventilation and the artificial lung. We report our preliminary clinical experience with a theoretical model that derives REE from IC measurements obtained separately on the ventilator and on the artificial lung. METHODS: A patient undergoing veno-venous ECMO for acute respiratory failure due to bilateral pneumonia was studied. The calorimeter was first connected to the ventilator and oxygen consumption (VO2 ) and carbon dioxide transport (VCO2 ) were measured until steady state was reached. Subsequently, the IC was connected to the membrane oxygenator and similar gas analysis was performed. VO2 and VCO2 values at the native and artificial lung were summed and incorporated in the Weir equation to obtain a REEcomposite . RESULTS: At the ventilator level, VO2 and VCO2 were 29.5 ml/min and 16 ml/min. VO2 and VCO2 at the artificial lung level were 213 ml/min and 187 ml/min. Based on these values, a REEcomposite of 1703 kcal/day was obtained. The Faisy-Fagon and Harris-Benedict equations calculated a REE of 1373 and 1563 kcal/day. CONCLUSION: We present IC-acquired gas analysis in ECMO patients. We propose to insert individually obtained IC measurements at the native and the artificial lung in the Weir equation for retrieving a measured REEcomposite .

Measured versus calculated resting energy expenditure in critically ill adult patients. Do mathematics match the gold standard?

BACKGROUND: Indirect calorimetry (IC) is considered to be the standard method for estimating energy requirements in intensive care unit (ICU) patients. Hence, most ICU clinicians still rely on various mathematical formulas to calculate caloric requirements in their patients. We assessed whether measurements obtained by IC reached agreement with the results of such commonly used equations. METHODS: Retrospective study in consecutively hospitalized patients in a mixed medico-surgical adult ICU. Resting energy expenditure (REE) was measured by IC in all patients as a standard procedure within our routine nutritional care planning and simultaneously calculated from 10 distinct predictive equations. IC was performed with the VmaxTM Encore 29n calorimeter (VIASYS Healthcare Inc, Yorba Linda, CA). Bland-Altman plots and regression analysis were used to assess agreement between measured and calculated REE. RESULTS: The study included 259 critically ill patients: 161 subjects (62%) met final analysis criteria (age 63 ± 16 years; 58% males). Measured REE was 1571 ± 423.5 kcal/24 h with VO2 0.23 ± 0.06 L/min and VCO2 0.18 ± 0.05 L/min. Calculated values correlated very weakly with IC-derived measurements. Only the Swinamer equation and the Penn State 2010 reached an R² > 0.5. Widely used formulas in daily ICU practice such as the adjusted Harris Benedict, Faisy-Fagon, and ESICM '98 statement equations, reached R² values of respectively only 0.44, 0.49, and 0.41. Calculation resulted in under- as well as overestimation of REE. Global formulas reached no acceptable correlation in elderly or obese critically ill patients. CONCLUSION: In critically ill adult patients, measured REE poorly correlated with calculated values, regardless what formula was used. Our findings underscore the important role of IC to adequately estimate energy requirements in this particularly frail population.

Intermittent subglottic secretion drainage may cause tracheal damage in patients with few oropharyngeal secretions.

OBJECTIVE: Injurious prolapse of tracheal mucosa into the suction port has been reported in up to 50% of intubated patients receiving continuous aspiration of subglottic secretions. We investigated whether similar injury could be inflicted by automated intermittent aspiration. METHODS: Six consecutive patients, intubated with the Mallinckrodt TaperGuard Evac™ endotracheal tube, were studied. A flow sensor was placed between the vacuum regulating system and the mucus collector. Intermittent suctioning was performed at a pressure of -125 mmHg with a 25s interval and duration of 15s. After 24h, a CT scan of the tracheal region was performed. RESULTS: Excessive negative suction pressure, a fast drop in aspiration flow to zero, and important "swinging" movements of secretions in the evacuation line were observed in all patients. Oral instillation of antiseptic mouthwash restored normal aspiration flow and secretion mobility. CT imaging showed marked entrapment of tracheal mucosa into the suction port in all patients. CONCLUSION: In patients with few oropharyngeal secretions, automated intermittent subglottic aspiration may result in significant and potential harmful invagination of tracheal mucosa into the suction lumen. A critical amount of fluid must be present in the oropharynx to assure adequate and safe aspiration.

Monitoring the safety of antiepileptic medication in a child with Brugada syndrome.

We report the case of an 8 year old boy presenting with episodes of decreased consciousness. As the boy's father died of a sudden cardiac death (SCD) at the age of 31 years, among other causes a Brugada syndrome (BS) was suspected. The boy was further examined at the UZ Brussels Heart Rhythm Management Center. The intravenous administration of ajmaline confirmed a BS without ventricular arrhythmias. Syncope in children can be an imminent sign of BS. BS is a life threatening condition that can deteriorate into SCD. The boy presented with episodes of lowered consciousness, transpiration and paleness. Readmission for further investigation was required. Clinical observation and continuous registered EEG during sleep showed multiple epileptical incidents. Hence the child was diagnosed with new onset epilepsy. For initiation of antiepileptic therapy, the patient was admitted at the pediatric intensive care unit (PICU). Close clinical observation and cardiovascular monitoring with continuous 12-lead ECG registration were performed during orally administered sodium valproic acid. During this anticonvulsive treatment in a child with documented BS no significant alterations in ECG-findings were observed. In this particular patient sodium valproic acid treatment can be estimated as a safe anticonvulsive therapy.

Diagnostic markers of sepsis in the emergency department.

Sepsis is defined as the systemic inflammatory response to infection. However, changes in body temperature, heart and respiratory rate and white cell count (the "SIRS" criteria) are not specific enough to identify infected patients in the emergency department. Among many biological parameters, measurement of lactate, central venous oxygen saturation (ScvO2), C-reactive protein (CRP) and procalcitonin (PCT) are of particular interest. Early (within 6h) and goal-directed (ScvO2 > 70%) resuscitation increases survival in severe sepsis and septic shock, particularly in patients with high lactate clearances. CRP and PCT are both useful markers of sepsis but PCT increases earlier, better differentiates infective from non-infective causes of inflammation, more closely correlates with sepsis severity in terms of shock and organ dysfunction and better predicts outcome when followed in time. However, PCT measurement is more costly, time-consuming, and not widespread available. New markers for rapid diagnosis of sepsis (e.g. TREM-1) are under investigation.

Postischemic mild hypothermia reduces neurotransmitter release and astroglial cell proliferation during reperfusion after asphyxial cardiac arrest in rats.

The present study investigated whether postischemic mild hypothermia attenuates the ischemia-induced striatal glutamate (GLU) and dopamine (DA) release, as well as astroglial cell proliferation in the brain. Anesthetized rats were exposed to 8 min of asphyxiation, including 5 min of cardiac arrest. The cardiac arrest was reversed to restoration of spontaneous circulation (ROSC), by brief external heart massage and ventilation within a period of 2 min. After the insult and during reperfusion, the extracellular glutamate and dopamine overflow increased to, respectively, 3000% and 5000% compared with the baseline values in the normothermic group and resulted in brain damage, ischemic neurons and gliosis. However, when hypothermia was induced for a period of 60 min after the insult and restoration of spontaneous circulation, the glutamate and dopamine overflows were not significantly different from that in the sham group. Histological analysis of the brain showed that postischemic mild hypothermia reduced brain damage, ischemic neurons, as well as astroglial cell proliferation. Thus, postischemic mild hypothermia reduces the excitotoxic process, brain damage, as well as astroglial cell proliferation during reperfusion. Moreover, these results emphasize the trigger effect of dopamine on the excitotoxic pathway.

Mild hypothermia induced by a helmet device: a clinical feasibility study.

STUDY OBJECTIVE: To test the feasibility and the speed of a helmet device to achieve the target temperature of 34 degrees C in unconscious after out of hospital cardiac arrest (CA). METHODS: Patients with cardiac arrest due to asystole or pulseless electrical activity (PEA) who remained unconscious after restoration of spontaneous circulation (ROSC) were enrolled in the study and randomised into two groups: a normothermic group (NG) and a hypothermic group (HG). Bladder and tympanic temperature were monitored every 15 min. A helmet device was used to induce mild hypothermia in the HG. Later on, the effect of mild hypothermia on the haemodynamics, electrolytes, lactate, arterial pH, CaO2, CvO2 and O2 extraction ratio were analysed and compared to the values obtained from the NG. RESULTS: Thirty patients were eligible for the study, 16 were randomised into the HG and 14 were randomised into the NG. The median tympanic temperature at admission in both groups was 35.5 degrees C (range: 33.3-38.5 degrees C) and the median tympanic temperature after haemodynamic stabilisation was 35.7 degrees C (range: 33.6-38.2 degrees C). In the HG, the core and the central target temperature of 34 degrees C were achieved after a median time of 180 and 60 min, respectively after ROSC. At the start of the study, no significant differences between the NG and HG were seen. At the end of the study, lactate concentration and O2 extraction ratio were significantly lower in the HG; however the CvO2 was significantly lower in the NG. CONCLUSIONS: Mild hypothermia induced by a helmet device was feasible, easy to perform, inexpensive and effective, with no increase in complications.

Soluble fiber reduces the incidence of diarrhea in septic patients receiving total enteral nutrition: a prospective, double-blind, randomized, and controlled trial.

BACKGROUND AND AIMS: Attempts to control enteral nutrition associated diarrhea in the critically ill tube-fed patient by implementing feeding formulas enriched with fiber were mostly unsuccessful. Recently, it was shown that enteral feeding containing soluble partially hydrolyzed guar decreased the incidence of diarrhea in a cohort of non-critically ill medicosurgical patients. We investigated whether this type of enteral feed could also influence stool production in patients with severe sepsis, a population at risk for developing diarrhea. METHODS: The study was double-blind. Patients with severe sepsis and septic shock were consecutively enrolled and at random received either an enteral formula supplemented with 22 g/l partially hydrolyzed guar or an isocaloric isonitrogenous control feed without fiber. All patients were mechanically ventilated and treated with catecholamines and antibiotics. Enteral feeding was provided through a nasogastric tube for a minimum of 6 days. A semiquantitative score based on stool volume and consistency was used for daily assessment of diarrhea. RESULTS: 25 patients fulfilled the criteria for data analysis. Soluble fiber was administered in 13 of them. The two groups were well-matched for gender, age, disease severity, cause of sepsis, laboratory parameters, total feeding days and time to reach nutritional goals. The mean frequency of diarrhea days was significantly lower in patients receiving fiber than in those on standard alimentation (8.8+/-10.0 % vs 32.0+/-15.3 %; P=0.001). The whole group of fiber-fed patients had less days with diarrhea per total feeding days (16/148 days (10.8%) vs 46/146 days (31.5%); P<0.001) and a lower mean diarrhea score (4.8+/-6.4 vs 9.4+/-10.2; P<0.001). The type of enteral diet did not influence sepsis-related mortality and duration of stay in the intensive care unit. CONCLUSION: Total enteral nutrition supplemented with soluble fiber is beneficial in reducing the incidence of diarrhea in tube-fed full-resuscitated and mechanically ventilated septic patients.

The effect of mild hypothermia and induced hypertension on long term survival rate and neurological outcome after asphyxial cardiac arrest in rats.

STUDY OBJECTIVE: we studied the long-term effect of a combined treatment with resuscitative mild hypothermia and induced hypertension on survival rate and neurological outcome after asphyxial cardiac arrest (CA) in rats. METHODS: 36 male Wistar rats, were randomised into three groups: Group I (n=10): anaesthetised with halothane and N(2)O/O(2) (70/30%) had vessel cannulation but no asphyxial CA; mechanical ventilation was continued to 1 h. Group II (n=13): under the same anaesthetic conditions and vessel cannulation, was subjected to asphyxial CA of 8 min, reversed by brief external heart massage and followed by mechanical ventilation to 1 h post restoration of spontaneous circulation (ROSC). Group III (n=13): received the same insult and resuscitation as described in group II, but in contrast to the previous group, a combination treatment of hypothermia (34 degrees C) and induced hypertension was started immediately after ROSC and maintained for 60 min ROSC. Survival rate and neurological deficit (ND) scores were determined before arrest, at 2 and 24 h, and each 24-h up to 4 weeks after ROSC. RESULTS: Baseline variables were the same in the three groups. Comparison of the asphyxial CA groups (groups II and III), showed an increased, although not statistically significant, survival rate at 72 h after ROSC in group III, and it became highly significant at 4 weeks after ROSC. The ND scores were the same in both asphyxial CA groups (groups II and III). CONCLUSIONS: Resuscitative mild hypothermia and induced hypertension after asphyxial CA in rats is associated with a better survival rate. This beneficial effect persisted for 4 weeks after ROSC.

A prospective, open, single blind, randomized study comparing four analgesics in the treatment of peripheral injury in the emergency department.

The efficacy of four analgesics, distinct concerning analgesic power and mechanism of action, was evaluated for pain relief in patients suffering from single peripheral injury. Patients were randomly allocated to receive either propacetamol (the pro-drug of paracetamol) 20 mg/kg i.v., piritramide 0.25 mg/kg i.m., tramadol 1 mg/kg i.v. or diclofenac 1 mg/kg i.v. Pain scores were measured by the patient using the visual analogue scale (VAS) and by an observer using a 4-point verbal rating scale (VRS). Cardiorespiratory variables and side effects were recorded. One hundred and sixty patients were included, 131 completed the study. Groups matched for demography and baseline pain levels. In general pain scores decreased with time. No significant differences were found between groups at any particular time point. VAS scores were significantly (p < 0.02) lower than baseline scores 30 minutes after injection in all treatment groups except for the piritramide group where significance (p < 0.01) was reached after 60 minutes. VRS score analysis showed a similar trend although significances differed. In the piritramide group significantly more side effects were noted than in the other groups (p < 0.05). We conclude that intravenous propacetamol, tramadol and diclofenac are equally efficacious for emergency analgesic treatment of single peripheral trauma.

Cardiac troponins I and T are biological markers of left ventricular dysfunction in septic shock.

BACKGROUND: Cardiac depression in severe sepsis and septic shock is characterized by left ventricular (LV) failure. To date, it is unclear whether clinically unrecognized myocardial cell injury accompanies, causes, or results from this decreased cardiac performance. We therefore studied the relationship between cardiac troponin I (cTnI) and T (cTnT) and LV dysfunction in early septic shock. METHODS: Forty-six patients were consecutively enrolled, fluid-resuscitated, and treated with catecholamines. Cardiac markers were measured at study entry and after 24 and 48 h. LV function was assessed by two-dimensional transesophageal echocardiography. RESULTS: Increased plasma concentrations of cTnI (>/=0.4 microgram/L) and cTnT (>/=0.1 microgram/L) were found in 50% and 36%, respectively, of the patients at one or more time points. cTnI and cTnT were significantly correlated (r = 0.847; P <0.0001). Compared with cTnI-negative patients, cTnI-positive subjects were older, presented higher Acute Physiology and Chronic Health Evaluation II scores at diagnosis, and tended to have a worse survival rate and a more frequent history of arterial hypertension or previous myocardial infarction. In contrast, the two groups did not differ in type of infection or pathogen, or in dose and type of catecholamine administered. Continuous electrocardiographic monitoring in all patients and autopsy in 12 nonsurvivors did not disclose the occurrence of acute ischemia during the first 48 h of observation. LV dysfunction was strongly associated with cTnI positivity (78% vs 9% in cTnI-negative patients; P <0.001). In multiple regression analysis, both cTnI and cTnT were exclusively associated with LV dysfunction (P <0.0001). CONCLUSIONS: These findings suggest that in septic shock, clinically unrecognized myocardial cell injury is a marker of LV dysfunction. The latter condition tends to occur more often in severely ill older patients with underlying cardiovascular disease. Further studies are needed to determine the extent to which myocardial damage is a cause or a consequence of LV dysfunction.

Liver perfusion and hepatocellular inflammatory response in sepsis.

Sepsis is characterized by disturbances in liver perfusion and alterations in intrahepatic cellular functions and interactions. This provokes structural and functional liver damage as well as hepatocellular activation that is believed to perpetuate the immuno-inflammatory response. Changes in hepatic perfusion during sepsis are still poorly understood due to the heterogeneity of septic animal models and the difficult accessibility of the hepatic circulation in humans. Sinusoidal blood flow is severely compromised during sepsis due to a decline in perfused sinusoidal area in association with a decrease in sinusoidal flow velocity. Imbalances in the production of nitric oxide may account for these (micro) circulatory disorders. Interactions between liver macrophages, activated endothelial cells and hepatocytes determine the intensity of inflammation and contribute to initial liver damage. Hepatocellular injury is then enhanced by attracted and invading neutrophils. The management of hepatic dysfunction during sepsis is largely supportive and based on prevention and vigorous resuscitation including early nutritional support and adequate oxygenation. Interestingly, experimental studies suggest that pharmacological interventions with significant hemodynamic effects, such as dobutamine and nitric oxide synthase inhibitors, may adversely affect the liver during the septic process.

Neurological complications in critically ill patients; septic encephalopathy, critical illness polyneuropathy.

Septic encephalopathy and critical illness polyneuropathy are two syndromes, appearing at different stages in critically ill patients. Their aetiology is unclear, but many arguments seem to associate them with respiratory insufficiency in a context of systemic inflammatory response syndrome (S.I.R.S.) and multiple organ dysfunction syndrome (M.O.D.S.). Septic encephalopathy appears early in the course of sepsis, diagnosis is based on clinical picture and electro-encephalogram. The exact pathogenesis is unclear. Prognosis is related to the underlying pathology, and treatment is supportive. Critical illness polyneuropathy is a predominantly motor axonal dysfunction, occurring in a setting of respiratory insufficiency, S.I.R.S., and M.O.D.S. A weaning problem often indicates the presence of critical illness polyneuropathy. Diagnosis is made on history, clinical picture and electromyographic studies. Indeed, motor and sensory conduction studies show a reduction of the amplitude of action potentials. In a later stage fibrillations and positive sharp waves emerge, with a further reduction of action potentials. Follow-up examinations reveal signs of axonal regeneration. The exact aetiology is unknown, but may be related to sepsis and M.O.D.S. Sepsis and M.O.D.S. are associated with the release of "mediator" substances, and somewhere in this cascade, there might be a toxin, influencing the nerve. A differential diagnosis with myopathy and neuromuscular transmission defects has to be made. Specific treatment is absent, and prognosis is related to the underlying pathology.

Does N-acetyl-L-cysteine influence cytokine response during early human septic shock?

STUDY OBJECTIVE: To assess the effects of adjunctive treatment with N-acetyl-L-cysteine (NAC) on hemodynamics, oxygen transport variables, and plasma levels of cytokines in patients with septic shock. DESIGN: Prospective, randomized, double-blind, placebo-controlled study. SETTING: A 24-bed medicosurgical ICU in a university hospital. PATIENTS: Twenty-two patients included within 4 h of diagnosis of septic shock. INTERVENTIONS: Patients were randomly allocated to receive either NAC (150 mg/kg bolus, followed by a continuous infusion of 50 mg/kg over 4 h; n= 12) or placebo (n=10) in addition to standard therapy. MEASUREMENTS: Plasma concentrations of tumor necrosis factor-alpha (TNF), interleukin (IL)-6, IL-8, IL-10, and soluble tumor necrosis factor-alpha receptor-p55 (sTNFR-p55) were measured by sensitive immunoassays at 0, 2, 4, 6 and 24 h. Pulmonary artery catheter-derived hemodynamics, blood gases, hemoglobin, and arterial lactate were measured at baseline, after infusion (4 h), and at 24 h. RESULTS: NAC improved oxygenation (PaO2/FIO2 ratio, 214+/-97 vs 123+/-86; p<0.05) and static lung compliance (44+/-11 vs 31+/-6 L/cm H2O; p<0.05) at 24 h. NAC had no significant effects on plasma TNF, IL-6, or IL-10 levels, but acutely decreased IL-8 and sTNFR-p55 levels. The administration of NAC had no significant effect on systemic and pulmonary hemodynamics, oxygen delivery, and oxygen consumption. Mortality was similar in both groups (control, 40%; NAC, 42%) but survivors who received NAC had shorter ventilator requirement (7+/-2 days vs 20+/-7 days; p<0.05) and were discharged earlier from the ICU (13+/-2 days vs 32+/-9 days; p<0.05). CONCLUSION: In this small cohort of patients with early septic shock, short-term IV infusion of NAC was well-tolerated, improved respiratory function, and shortened ICU stay in survivors. The attenuated production of IL-8, a potential mediator of septic lung injury, may have contributed to the lung-protective effects of NAC.