Swiss Sepsis National Action Plan: A coordinated national action plan to stop sepsis-related preventable deaths and to improve the support of people affected by sepsis in Switzerland.

Background: Sepsis is a devastating disease which causes yearly over 10 million deaths worldwide. In 2017, the World Health Organization (WHO) issued a resolution prompting member states to improve the prevention, recognition, and management of sepsis. The 2021 European Sepsis Report revealed that-contrary to other European countries-Switzerland had not yet actioned the sepsis resolution. Methods: A panel of experts convened at a policy workshop to address how to improve awareness, prevention, and treatment of sepsis in Switzerland. Goal of the workshop was to formulate a set of consensus recommendations toward creating a Swiss Sepsis National Action Plan (SSNAP). In a first part, stakeholders presented existing international sepsis quality improvement programs and national health programs relevant for sepsis. Thereafter, the participants were allocated into three working groups to identify opportunities, barriers, and solutions on (i) prevention and awareness, (ii) early detection and treatment, and (iii) support for sepsis survivors. Finally, the entire panel summarized the findings from the working groups and identified priorities and strategies for the SSNAP. All discussions during the workshop were transcribed into the present document. All workshop participants and key experts reviewed the document. Results: The panel formulated 14 recommendations to address sepsis in Switzerland. These focused on four domains, including (i) raising awareness in the community, (ii) improving healthcare workforce training on sepsis recognition and sepsis management; (iii) establishing standards for rapid detection, treatment and follow-up in sepsis patients across all age groups; and (iv) promoting sepsis research with particular focus on diagnostic and interventional trials. Conclusion: There is urgency to tackle sepsis. Switzerland has a unique opportunity to leverage from lessons learnt during the COVID-19 pandemic to address sepsis as the major infection-related threat to society. This report details consensus recommendations, the rationale thereof, and key discussion points made by the stakeholders on the workshop day. The report presents a coordinated national action plan to prevent, measure, and sustainably reduce the personal, financial and societal burden, death and disability arising from sepsis in Switzerland.

Atrial and brain natriuretic peptide concentrations and the response to inhaled nitric oxide in patients with acute respiratory distress syndrome.

PURPOSE: The response to inhaled nitric oxide (iNO) is inconsistent in patients with acute respiratory distress syndrome (ARDS). We sought to determine whether the response to iNO, defined as 20% Pao(2)/Fio(2) increase from baseline, depends on the level of cardiac natriuretic peptides. MATERIALS AND METHODS: This is a prospective cohort study including 11 consecutive patients with ARDS who were eligible to receive iNO. Measurements of plasma concentrations of atrial natriuretic peptide (ANP), N-Terminal-Pro-B-Type Natriuretic Peptide (NT-pro-BNP) and 3',5'-cyclic guanosine monophosphate were obtained before initiating iNO and 30 minutes later during iNO. Baseline cardiac peptides, oxygenation, and hemodynamic variables and their change during iNO were compared among responders and nonreponders to iNO. RESULTS: Baseline ANP and NT-pro-BNP concentrations were higher in patients that responded to iNO and tended to decrease during iNO in responders only. 3',5'-Cyclic guanosine monophosphate concentrations were not different among responders and nonresponders and were unchanged during iNO. Baseline ANP was strongly correlated with change in intrapulmonary shunt, and baseline NT-pro-BNP and its change were correlated with the change in cardiac output. CONCLUSIONS: High ANP and NT-pro-BNP concentrations are associated with the response to iNO. These data suggest that cardiac peptides have the potential to identify a subgroup of patients with ARDS who might derive clinical benefit from iNO.

Nebulised heparin: a new approach to the treatment of acute lung injury?

The administration of heparin by nebulisation has been proposed for the 'local' treatment of pulmonary coagulation disturbances in acute lung injury (ALI). Alveolar and lung micro-vascular fibrin accumulation and breakdown inhibition indeed play a central role in the development and clinical course of this disease. Preclinical studies provide some evidence of the beneficial effects of heparin inhalation in several animal models of ALI. Clinical investigations are sparse, and trials such as the one presented by Dixon and colleagues in a recent issue of Critical Care are welcome as they provide insight into the possible clinical use of nebulised heparin in this situation. This phase 1 trial involved 16 patients with early ALI, and showed the feasibility of the approach. In addition, non-significant changes in respiratory functions and systemic anticoagulant effects were documented with the four doses tested. The study of Dixon and colleagues adds to data that helps pave the way towards a possible clinical use of heparin by nebulisation in ALI. It remains to be clarified in which clinical situations, at what time points and with which dosages the best chances exist for a beneficial effect on the prognosis of these patients.

Reducing ventilator-induced lung injury and other organ injury by the prone position.

Mechanical ventilation can cause structural and functional disturbances in the lung, as well as other vital organ dysfunctions. Apoptosis is thought to be a histological sign of distant organ damage in ventilator-induced lung injury (VILI). Nakos and colleagues observed a protective effect of prone positioning against VILI in normal sheep. Less alteration in the lung architecture and function and in liver transaminases, and lower indices for apoptosis in the liver, the diaphragm and the lung were noted in the prone position compared with the supine position. If confirmed, these data open a new hypothesis for pathogenesis and prevention of VILI and its extrapulmonary complications.

Intensive care and emergency medicine: progress over the past 25 years.

Over the last quarter of a century, intensive care medicine has developed into an established hospital specialty with its own unique identity and characteristics. Significant advances have occurred, mostly in a succession of small steps rather than any dramatic leap, with many being linked to advances in health care across other disciplines. In addition, many changes have resulted from the scientific identification of the detrimental effects of certain traditional practices once thought to be therapeutic. Here, in an attempt to learn from the past and offer guidance for future progress, we detail some of the key changes in various aspects of intensive care medicine including respiratory, cardiovascular, metabolic, and nutritional care, as well as sepsis, polytrauma, organization, and management.

Continuous cardiac output monitoring after cardiopulmonary bypass: a comparison with bolus thermodilution measurement.

OBJECTIVE: The interchangeability of continuous measurement of cardiac output (CO) with the traditional bolus method in patients after cardiopulmonary bypass (CPB) is uncertain. DESIGN: Prospective observational clinical study. SETTING: A 20-bed surgical ICU at a university hospital. PATIENTS: Fourteen deeply sedated, ventilated, post-cardiac surgery patients, all equipped with a pulmonary artery catheter. INTERVENTIONS: Six hours after the end of the CPB, 56 simultaneous bolus and continuous measurements were compared by a linear regression analysis and Bland-Altman analysis. Bolus CO was estimated by averaging triplicate injections of 10 ml room-temperature NaCl 0.9%, delivered randomly during the respiratory cycle. A stringent maximum difference of 0.55 l min(-1) (about 10% of the mean bolus measured) was considered as a clinically acceptable agreement between the two types of measurements. To be interchangeable the limits of agreement (+/-2 SD of the mean difference between the two methods) should not exceed the chosen acceptable difference. MEASUREMENTS AND RESULTS: Continuous was correlated with bolus CO, with a correlation coefficient of r(2)=0.68. (p<0.01). The Bland-Altman analysis demonstrated an objective mean bias of 0.33+/-0.6 l min(-1) (confidence interval of -0.87-1.58) with 34% of measured values falling outside of the clinically acceptable limits. CONCLUSION: Our results suggest that, in the first 6 h after CPB, continuous and bolus CO determinations are not interchangeable; one third of the values obtained by continuous CO fell outside the strict limits of clinically useful precision.

Misplacement of central vein catheters in patients with hemothorax: a new approach to resolve the problem.

BACKGROUND: In emergency and pre-hospital care, the verification of the correct position of a central venous catheter is based on the observation of blood color reflow as well as pressure changes with respiration. However, in trauma patient with hemothorax, these indices may not always be reliable signs as the catheter is in a blood-filled pleural space. METHODS: A review of reports published describing patients presenting hemothorax and equipped with central venous catheter wrongly assumed to be in the correct position was performed. RESULTS: Over 10 years, seven reports have been published and a last study was found in the references list of one of the reviews. CONCLUSION: In patients with hemothorax due to severe thoracic trauma or other causes, a delay in detection of incorrect placement of a central venous catheter may delay fluid resuscitation and decrease the chances of survival. In this situation, the use of portable ultrasound devices may be an useful method to increase success rate in catheter insertion.

Transcutaneous PCO2 monitoring in critically ill adults: clinical evaluation of a new sensor.

OBJECTIVE: In critically ill patients, arterial blood gas analysis is the gold standard for evaluating systemic oxygenation and carbon dioxide partial pressure. A new miniaturized carbon dioxide tension Pco2-Spo2 single sensor (TOSCA, Linde Medical Sensors AG, Basel, Switzerland) continuously and noninvasively (transcutaneously) monitors both Paco2 and oxygen saturation by pulse oximetry (Spo2). The present study was designed to investigate the usability and the accuracy of this device in critically ill patients. DESIGN: Prospective clinical investigation. SETTING: A 20-bed, university-affiliated, surgical intensive care unit. PATIENTS: Patients admitted after major surgery, multiple trauma, or septic shock equipped with an arterial catheter. INTERVENTIONS: The heated (42 degrees C) sensor was fixed at the earlobe using an attachment clip. Transcutaneous Pco2 (TcPco2) measurements were correlated with Paco2 values (measured using a blood gas analyzer). In addition, the differences between Paco2 and TcPco2 values were evaluated using the method of Bland-Altman. MEASUREMENTS AND MAIN RESULTS: We studied 55 patients, aged 18-80 (mean 57 +/- 15) yrs. A total of 417 paired measurements were compared. Correlation between TcPco2 and Paco2 was r = .86 (p < .01) in the Paco2 range of 24-101 mm Hg. Mean bias (+/-sd) between the two methods of measurement (Bland-Altman analysis) was 1.2 +/- 6.0 mm Hg with TcPco2 slightly overestimating arterial carbon dioxide tension. Nineteen percent of the measured values were outside of the acceptable clinical range of agreement of +/-7.5 mm Hg. CONCLUSIONS: The present study suggests that Paco2 can be acceptably assessed by measuring TcPco2 using the TOSCA Pco2-Spo2 sensor.

Does continuous positive airway pressure by face mask improve patients with acute cardiogenic pulmonary edema due to left ventricular diastolic dysfunction?

OBJECTIVE: Continuous positive airway pressure (CPAP) by face mask is an effective method of treating severe cardiogenic pulmonary edema (CPE). However, to our knowledge, no study has provided a precise evaluation of the effects of CPAP on cardiac function in patients presenting with CPE and preserved left ventricular (LV) function. DESIGN: Prospective observational clinical study. SETTING: A 14-bed, medical ICU at a university hospital. PATIENTS: Nine consecutive patients presenting with hypoxemic acute CPE. INTERVENTIONS: All patients were selected for 30 min of CPAP with 10 cm H(2)O by mask with fraction of inspired oxygen adjusted for a cutaneous saturation > 90%. Doppler echocardiography was performed before CPAP application and during the last 10 min of breathing with CPAP. Two-tailed, paired t-tests were used to compare data recorded at baseline (oxygen alone) and after CPAP. MEASUREMENTS AND RESULTS: Four patients presented CPE with preserved left ventricular (LV) function (a preserved LV ejection fraction [LVEF] > 45%, and/or aortic velocity time integral > 17 cm in the absence of aortic stenosis or hypertrophic cardiomyopathy). Oxygenation and ventilatory parameters were improved by CPAP in all patients. Hemodynamic monitoring and Doppler echocardiographic analysis demonstrated that in patients with preserved LV systolic function, mean arterial pressure and LV end-diastolic volume were decreased significantly by CPAP (p < 0.04). In patients with LV systolic dysfunction, CPAP improved LVEF (p < 0.05) and decreased LV end-diastolic volume (p = 0.001) significantly. CONCLUSION: CPAP improves oxygenation and ventilatory parameters in all kinds of CPE. In patients with preserved LV contractility, the hemodynamic benefit of CPAP results from a decrease in LV end-diastolic volume (preload).

[Continuous Svo2 measurements and co-oximetry are not interchangeable immediately after cardiopulmonary bypass]. / Après circulation extra-corporelle, la mesure continue de la Svo2 et la co-oxymétrie du sang mêlé ne sont pas interchangeables.

OBJECTIVE: To determine the accuracy of continuous (in vivo) measurement of mixed venous oxygen saturation (SvO(2)), using a fibreoptic catheter, in patients having had cardiopulmonary bypass (CPB). METHODS: Using a pulmonary arterial catheter, we prospectively studied 14 patients (age 64 +/- 8) having had cardiopulmonary bypass. Mean hematocrit was 30 +/- 4%. The catheter was calibrated in vitro and in vivo, according to the manufacturer's instructions. Fifty-six simultaneous measurements of continuous SvO(2) (CSvO(2)) and measured SvO(2) (MSvO(2)) were taken with a co-oxymeter and the paired values were analyzed by the linear regression method. To make the two sets of measurements interchangeable, we established, a priori, a maximum limit of 3% (approximately 5% of the measurement), as being an acceptable difference between the two types of measurements. RESULTS: All the measurements were obtained within four hours of the placement of the catheter. CSvO(2) was weakly correlated with MSvO(2), with a correlation coefficient of r(2) = 0.49 (P < 0.001). The Bland-Altman analysis demonstrates an objective mean bias of 0.8 +/- 3%, with 36% of the values measured falling outside clinically acceptable limits. For values of CSvO(2)

The respiratory change in preejection period: a new method to predict fluid responsiveness.

The accuracy and clinical utility of preload indexes as bedside indicators of fluid responsiveness in patients after cardiac surgery is controversial. This study evaluates whether respiratory changes (Delta) in the preejection period (PEP; DeltaPEP) predict fluid responsiveness in mechanically ventilated patients. Sixteen postcoronary artery bypass surgery patients, deeply sedated under mechanical ventilation, were enrolled. PEP was defined as the time interval between the beginning of the Q wave on the electrocardiogram and the upstroke of the radial arterial pressure. DeltaPEP (%) was defined as the difference between expiratory and inspiratory PEP measured over one respiratory cycle. We also measured cardiac output, stroke volume index, right atrial pressure, pulmonary arterial occlusion pressure, respiratory change in pulse pressure, systolic pressure variation, and the Deltadown component of SPV. Data were measured without positive end-expiratory pressure (PEEP) and after application of a PEEP of 10 cmH2O (PEEP10). When PEEP10 induced a decrease of >15% in mean arterial pressure value, then measurements were re-performed before and after volume expansion. Volume loading was done in eight patients. Right atrial pressure and pulmonary arterial occlusion pressure before volume expansion did not correlate with the change in stroke volume index after the fluid challenge. Systolic pressure variation, DeltaPEP, Deltadown, and change in pulse pressure before volume expansion correlated with stroke volume index change after fluid challenge (r2 = 0.52, 0.57, 0.68, and 0.83, respectively). In deeply sedated, mechanically ventilated patients after cardiac surgery, DeltaPEP, a new method, can be used to predict fluid responsiveness and hemodynamic response to PEEP10.

Transcranial Doppler: an early predictor of ischemic stroke after cardiac arrest?

UNLABELLED: A 69-yr-old woman was admitted to the intensive care unit after cardiac surgery. Immediately after the discontinuation of cardiopulmonary bypass, she had a circulatory arrest. A 13-min open-chest cardiac massage was followed by 70 min of cardiopulmonary bypass. Right hemiplegia and right extensor plantar reflex were noted after the patient awakened. She had been included in a prospective study protocol measuring, before and after surgery, cerebral blood flow with transcranial Doppler (TCD). The data were retrospectively analyzed, and it was established that the TCD had recorded cerebral perfusion defects. This is the first case of acute ischemic stroke after cardiac arrest with retrospective documentation of asymmetrical cerebral blood flow by a systematic postoperative TCD recording. IMPLICATIONS: Clinical neurological examination is often of limited value in deeply sedated patients. This case report describes the early diagnosis of an ischemic stroke by using transcranial Doppler after cardiac surgery. Thus, transcranial Doppler could be used systematically for cerebral perfusion monitoring in patients who have undergone major hemodynamic instabilities.

Systematic review of the prevention of delayed ischemic neurological deficits with hypertension, hypervolemia, and hemodilution therapy following subarachnoid hemorrhage.

OBJECT: There is uncertainty about the efficacy of hypertension, hypervolemia, and hemodilution (triple-H) therapy in reducing the occurrence of delayed ischemic neurological deficits (DINDs) and death after subarachnoid hemorrhage. The authors therefore conducted a systematic review to evaluate the efficacy of triple-H prevention in decreasing the rate of clinical vasospasm, DINDs, and death. METHODS: The authors systematically reviewed studies identified based on a MEDLINE, EMBASE, and COCHRANE Register search of articles published between 1966 and 2001, and reference lists of identified articles. An independent assessment of each study's methodological quality, population, intervention, and outcomes (rates of symptomatic vasospasm, DINDs, and death) was performed. Summary relative risk estimates were calculated for the main outcomes using fixed- or random-effect models, as appropriate. Only four prospective, comparative studies with a total of 488 patients were identified. The median internal validity score was 0.5 (range 0-2); the median external validity score was 3 (range 2-6). Compared with no prevention, triple-H therapy was associated with a reduced risk of symptomatic vasospasm (relative risk [RR] 0.45, 95% confidence interval [CI] 0.32-0.65), but not DIND (RR 0.54, 95% CI 0.2-1.49). The risk of death was higher (RR 0.68, 95% CI 0.53-0.87). Sensitivity analyses including only randomized, controlled trials showed no evidence of statistically significant results for these major end points. CONCLUSIONS: The paucity of information and important limitations in the design of the studies analyzed preclude evaluation of the efficacy of triple-H prevention and formulation of any recommendations regarding its use for the prevention of cerebral vasospasm.