Clinical Value and Operational Risks of MRI in ICU patients - A Retrospective Analysis Performed at a University Medical Center.

PURPOSE: Intensive care unit (ICU) patients have a high risk of developing complications when leaving the ICU for diagnostic procedures or therapeutic interventions. Our study examined the frequency of adverse events associated with magnetic resonance imaging (MRI) of intensive care patients and the extent of changes in therapy due to the MRI scan to weigh the risks associated with the scan against the potential benefits of an MR scan, using a change in therapy as an indicator of benefit. MATERIALS AND METHODS: 4434 ICU patients (January to December 2015) were identified by Hospital Information System (SAP-R/3 IS-H, Walldorf, Germany), ICU patient data management system Metavision (iMDsoft, Israel), and Radiology Information System (Nexus.medRIS, Version 8.42, Nexus, Germany). All intensive care and medical records (HIS) and MRI reports (RIS) were matched and further evaluated in a retrospective case-to-case analysis for biometric data, mechanical ventilation, ICU requirements, planned postoperative vs. emergency diagnostic requirements, complications and impact on further diagnosis or therapy. RESULTS: Out of 4434 ICU patients, 322 ICU patients (7.3 %) underwent a total of 385 MRI examinations. 167 patients needed a total of 215 emergency scans, while 155 patients underwent 170 planned postoperative MRI exams. 158 (94.6 %) out of 167 emergency scan patients were ventilated under continuous intravenous medication and monitoring. In the planned postoperative group, only 6 (3.9 %) out of 155 were ventilated, but a total of 38 (24.5 %) were under continuous medication. 111 patients were accompanied by nurses only during MRI. Only one severe adverse event (0.3 %) was noted and was attributed to study preparation (n = 385). In 8 MRI examinations (2.1 %), the examination was interrupted or cancelled due to the patients' condition. While all MRI examinations in the planned group were completed (n = 170, 100 %) (e. g., postoperative controls), only 207 out of 215 (96.3 %) could be performed for emergency diagnostic reasons. MRI influenced the clinical course with a change in diagnosis or therapy in 74 (19.2 %) of all 385 MRI examinations performed, and in the emergency diagnostic group it was 31.2 % (n = 67/215). CONCLUSION: Nearly 20 % of MRI examinations of ICU patients resulted in a change of therapy. With only one potentially life-threatening adverse event (0.3 %) during transport and the MRI examination, the risk seems to be outweighed by the diagnostic benefit. KEY POINTS: · The risk of adverse events associated with MRI scans in ICU patients is low.. · The rate of premature termination of ICU patients' MRI scans is low.. · Almost 20 % of ICU patients' MRI scans lead to a change of therapy..

Mortality on extracorporeal membrane oxygenation: Evaluation of independent risk factors and causes of death during venoarterial and venovenous support.

INTRODUCTION: Most patients on extracorporeal membrane oxygenation (ECMO) decease during therapy on the system. However, the actual causes of death have not been studied sufficiently. This study analyses the etiology, prevalence, and risk factors for the outcome variable death during ongoing ECMO for all patients and divided according to venoarterial (VA) or venovenous (VV) support. METHODS: We retrospectively analysed all patients receiving ECMO support at our institution between March 2006 to January 2021. Only the patients deceased during ongoing support were included. RESULTS: 2016 patients were placed on VA (n = 1168; 58%) or VV (n = 848; 42%) ECMO; 759 patients (37.7%) deceased on support. The causes of death differed between the support types: VA ECMO patients mostly died from cerebral ischemia (34%), low-cardiac output (LCO; 24.1%) and multi-organ failure (MOF; 21.6%), whereas in VV ECMO cases, refractory respiratory failure (28.2%), and sepsis (20.4%) dominated. Multivariate regression analysis revealed cardiopulmonary resuscitation (CPR) and acidosis prior to ECMO as risk factors for dying on VA ECMO, while high inotropic doses pre-ECMO, a high fraction of inspired oxygen on day 1, elevated lactate dehydrogenase, and international normalized ratio levels lead to an unfavourable outcome in VV ECMO patients. CONCLUSION: Even in highly experienced centers, ECMO mortality remains high and occurs mainly on support or 24 h after its termination. The causes of death differ between VV and VA ECMO, depending on the underlying diseases responsible for the need of extracorporeal support.

Trajectories of quality of life, return to work, psychopathology, and disability in survivors of the acute respiratory distress syndrome (ARDS): A three-year prospective cohort study (DACAPO).

PURPOSE: Describe the long-term development of outcomes for survivors of the Acute Respiratory Distress Syndrome (ARDS). MATERIAL AND METHODS: A cohort study with N = 877 ARDS survivors was conducted. Health related quality of life (HRQoL, Physical and Mental Component Scale: PCS, MCS of the SF-12), return to work (RtW), panic disorder, depressive symptoms (PHQD), and post-traumatic-stress-disorder (PTSD, PTSS-14) were assessed at 3, 6, 12, 24, and 36 months after discharge from ICU. RESULTS: PCS, MCS, and RtW increased during the first 12 months [e.g. PCS: Md = 36 (IQR 31-43) at 3 months, Md = 42 (IQR 34-52) at 12 months; MCS: Md = 44 (IQR 32-54) at 3 months, Md = 47 (IQR 33-57) at 12 months, RtW = 23.2% at 3 months, 54.5% at 12 months], and remained relatively stable afterwards. Proportion of major depressive syndrome decreased from 3 (14.2%) to 36 months (8.9%). Proportions of panic disorder (5.3% to 7.4%) and PTSD (27.1% to 32.6%) varied only slightly. CONCLUSIONS: Most of recovery in HRQoL and RtW occur during the first 12 months, after which a plateau is reached, indicating a chronification for many patients. Contrary to this, however, psychopathological symptoms remain stable, except for depressive symptoms. [200 words].

Effects of Individualised High Positive End-Expiratory Pressure and Crystalloid Administration on Postoperative Pulmonary Function in Patients Undergoing Robotic-Assisted Radical Prostatectomy: A Prospective Randomised Single-Blinded Pilot Study.

OBJECTIVES: Robotic-assisted laparoscopic prostatectomy (RALP) is typically conducted in steep Trendelenburg position (STP). The aim of the study was to evaluate whether crystalloid administration and individual management of positive end-expiratory pressure (PEEP) improve peri- and post-operative pulmonary function in patients undergoing RALP. DESIGN: Prospective randomised single-centre single-blinded explorative study. SETTING: Patients were either allocated to a standard PEEP (5 cmH2O) group or an individualised high PEEP group. Furthermore, each group was divided into a liberal and a restrictive crystalloid group (8 vs. 4 mL/kg/h predicted body weight). Individualised PEEP levels were determined by means of preoperative recruitment manoeuvre and PEEP titration in STP. PARTICIPANTS: Informed consent was obtained from 98 patients scheduled for elective RALP. INTERVENTIONS: The following intraoperative parameters were analysed in each of the four study groups: ventilation setting (peak inspiratory pressure [PIP], plateau pressure, driving pressure [Pdriv], lung compliance [LC] and mechanical power [MP]) and postoperative pulmonary function (bed-side spirometry). The spirometric parameters Tiffeneau index (FEV1/FVC ratio) and mean forced expiratory flow (FEF25-75) were measured pre- and post-operatively. Data are shown as mean ± standard deviation (SD), and groups were compared with ANOVA. A p-value of <0.05 was considered significant. RESULTS: The two individualised high PEEP groups (mean PEEP 15.5 [±1.71 cmH2O]) showed intraoperative significantly higher PIP, plateau pressure and MP levels but significantly decreased Pdriv and increased LC. On the first and second postoperative day, patients with individualised high PEEP levels had a significantly higher mean Tiffeneau index and FEF25-75. Perioperative oxygenation and ventilation and postoperative spirometric parameters were not influenced by restrictive or liberal crystalloid infusion in either of the two respective PEEP groups. CONCLUSIONS: Individualised high PEEP levels (≥14 cmH2O) during RALP improved intraoperative blood oxygenation and resulted in more lung-protective ventilation. Furthermore, postoperative pulmonary function was improved for up to 48 h after surgery in the sum of the two individualised high PEEP groups. Restrictive crystalloid infusion during RALP seemed to have no effect on peri- and post-operative oxygenation and pulmonary function.

Association of analgosedation with psychiatric symptoms and health-related quality of life in ARDS survivors: Post hoc analyses of the DACAPO study.

BACKGROUND: The acute respiratory distress syndrome (ARDS) is a life-threatening condition with the risk of developing hypoxia and thus requires for invasive mechanical ventilation a long-term analgosedation. Yet, prolonged analgosedation may be a reason for declining health-related quality of life (HRQoL) and the development of psychiatric disorders. METHODS: We used data from the prospective observational nation­wide ARDS study across Germany (DACAPO) to investigate the influence of sedation and analgesia on HRQoL and the risk of psychiatric symptoms in ARDS survivors 3, 6 and 12 months after their discharge from the intensive care unit (ICU). HRQoL was measured with the Physical and Mental Component Scale of the Short­Form 12 Questionnaire (PCS­12, MCS­12). The prevalence of psychiatric symptoms (depression and post­traumatic stress disorder [PTSD]) was assessed using the Patient Health Questionnaire­9 and the Post­Traumatic Stress Syndrome­14. The associations of analgosedation with HRQoL and psychiatric symptoms were investigated by means of multivariable linear regression models. RESULTS: The data of 134 ARDS survivors (median age [IQR]: 55 [44-64], 67% men) did not show any significant association between analgosedation and physical or mental HRQoL up to 1 year after ICU discharge. Multivariable linear regression analysis (B [95%­CI]) yielded a significant association between symptoms of psychiatric disorders and increased cumulative doses of ketamine up to 6 months after ICU discharge (after 3 months: depression: 0.15 [0.05, 0.25]; after 6 months: depression: 0.13 [0.03, 0.24] and PTSD: 0.42 [0.04, 0.80)]). CONCLUSIONS: Up to 1 year after ICU discharge, analgosedation did not influence HRQoL of ARDS survivors. Prolonged administration of ketamine during ICU treatment, however, was positively associated with the risk of psychiatric symptoms. The administration of ketamine to ICU patients with ARDS should be with caution. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02637011 (Registered 15 December 2015, retrospectively registered).

Long-term follow-up and quality of life in patients receiving extracorporeal membrane oxygenation for pulmonary embolism and cardiogenic shock.

BACKGROUND: Since 2019, European guidelines recommend considering extracorporeal life support as salvage strategy for the treatment of acute high-risk pulmonary embolism (PE) with circulatory collapse or cardiac arrest. However, data on long-term survival, quality of life (QoL) and cardiopulmonary function after extracorporeal membrane oxygenation (ECMO) are lacking. METHODS: One hundred and nineteen patients with acute PE and severe cardiogenic shock or in need of mechanical resuscitation (CPR) received venoarterial or venovenous ECMO from 2007 to 2020. Long-term data were obtained from survivors by phone contact and personal interviews. Follow-up included a QoL analysis using the EQ-5D-5L questionnaire, echocardiography, pulmonary function testing and cardiopulmonary exercise testing. RESULTS: The majority of patients (n = 80, 67%) were placed on ECMO during or after CPR with returned spontaneous circulation. Overall survival to hospital discharge was 45.4% (54/119). Nine patients died during follow-up. At a median follow-up of 54.5 months (25-73; 56 ± 38 months), 34 patients answered the QoL questionnaire. QoL differed largely and was slightly reduced compared to a German reference population (EQ5D5L index 0.7 ± 0.3 vs. 0.9 ± 0.04; p < 0.01). 25 patients (73.5%) had no mobility limitations, 22 patients (65%) could handle their activities, while anxiety and depression were expressed by 10 patients (29.4%). Return-to-work status was 33.3% (average working hours: 36.2 ± 12.5 h/per week), 15 (45.4%) had retired from work early. 12 patients (35.3%) expressed limited exercise tolerance and dyspnea. 59% (20/34) received echocardiography and pulmonary function testing, 50% (17/34) cardiopulmonary exercise testing. No relevant impairment of right ventricular function and an only slightly reduced mean peak oxygen uptake (76.3% predicted) were noted. CONCLUSIONS: Survivors from severe intractable PE in cardiogenic shock or even under CPR with ECMO seem to recover well with acceptable QoL and only minor cardiopulmonary limitations in the long term. To underline these results, further research with larger study cohorts must be obtained.

Does cerebral near-infrared spectroscopy (NIRS) help to predict futile cannulation in extracorporeal cardiopulmonary resuscitation (ECPR)?

AIM OF THE STUDY: Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving technique to improve cardiopulmonary resuscitation (CPR) outcomes. Identifying a readily available tool helpful for predicting patient's outcome is warranted. The aim of the study was to evaluate the capability of cranial near-infrared spectroscopy (cNIRS) to identify non-survivors or patients with unfavorable neurologic outcome prior to cannulation for ECPR to avoid futile cannulations. METHODS: Retrospective analysis (2015-2021) of 97 patients requiring ECPR due to cardiac arrest with prior cNIRS measurement, which was performed immediately after ECPR team arrived on scene. Lowest possible regional cerebral oxygen saturation (rSO2) is 15%. RESULTS: Mortality was 72.1% (70/97). Survivors showed in 88.9% (24/27) good neurological outcome (Cerebral Performance Category (CPC) 1 + 2). rSO2 = 15% (11/97) prior to cannulation was only found in non-survivors. Among survivors, initial rSO2 was not associated with neurological outcome. Non-shockable initial rhythm was associated with higher mortality (44/50). In survivors, time to ECPR was shorter (p = 0.006), and initial lactate was significantly lower, whereas initial pH and hemoglobin levels were higher (p = 0.001). Survivors and those with favorable neurological outcome showed lower maximal NSE levels in the first 72 hours (p < 0.001; p = 0.041). CONCLUSION: In our patient cohort, rSO2 = 15% immediately prior to cannulation for ECPR did not result in any survivors, thus might be a marker for futile cannulation in ECPR. Higher rSO2 values were not associated with favorable neurologic outcome. Lower initial lactate and lower maximal NSE within the first 72 h after arrest were associated with favorable outcome.

Invasiveness of Treatment Is Gender Dependent in Intensive Care: Results From a Retrospective Analysis of 26,711 Cases.

BACKGROUND: Health care and outcome of critically ill patients are marked by gender-related differences. Several studies have shown that male patients in intensive care units (ICU) more often receive mechanical ventilation, dialysis, pulmonary arterial catheterization (PAC), and central venous catheterization (CVC). We investigated gender-related differences in ICU treatment and mortality. METHODS: This retrospective, single-center study analyzed adult ICU patients admitted to the University Medical Center Regensburg between January 2010 and December 2017. Illness severity was measured with the Simplified Acute Physiology Score II (SAPS II) at ICU admission. We evaluated the intensity of ICU treatment according to the implementation of tracheostomy and extracorporeal membrane oxygenation (ECMO). We then assessed gender-related differences in the duration of mechanical ventilation and other invasive monitoring (PAC) and treatment methods (CVC, endotracheal intubation rate, and dialysis). ICU treatment and mortality data were obtained from an electronic data capture system. After adjusting for age, reason for hospitalization, and SAPS II score, we assessed the influence of gender on the intensity of ICU treatment using multivariable logistic regression. Odds ratios (OR) for the logistic regression models and incidence rate ratios (IRR) for the negative binomial regression models were calculated as effect estimates together with the corresponding 95% confidence intervals (95% CI). A P value of <.05 was considered significant. RESULTS: The study analyzed 26,711 ICU patients (64.8% men). The ICU mortality rate was 8.8%. Illness severity, ICU, and hospital mortality did not differ by gender. Women were older than men (62.6 vs 61.3 years; P < .001) at ICU admission. After multivariable adjustment, men were more likely to undergo tracheostomy (OR = 1.39 [1.26-1.54]), ECMO (OR = 1.37 [1.02-1.83]), dialysis (OR = 1.29 [1.18-1.41]), and PAC insertion (OR = 1.81 [1.40-2.33]) and had a longer duration of mechanical ventilation than women (IRR = 1.07 [1.02-1.12]). The frequency of endotracheal intubation (OR = 1.04 [0.98-1.11]) and placement of CVC (OR = 1.05 [0.98-1.11]) showed no gender-specific differences. Of ICU nonsurvivors, men were more likely to undergo tracheostomy (20.1% vs 15.3%; P = .004) and dialysis (54% vs 46.4%; P < .001) than women and had a longer duration of mechanical ventilation (6.3 vs 5.4 days; P = .015). CONCLUSIONS: After adjustment for severity of disease and outcome, ICU treatment differs between men and women. Men were more likely than women to undergo tracheostomy and ECMO.

Pronounced haemodynamic changes during and after robotic-assisted laparoscopic prostatectomy: a prospective observational study.

OBJECTIVES: Robotic-assisted laparoscopic prostatectomy (RALP) is typically conducted in steep Trendelenburg position (STP). This study investigated the influence of permanent 45° STP and capnoperitoneum on haemodynamic parameters during and after RALP. DESIGN: Prospective observational study. SETTING: Haemodynamic changes were recorded with transpulmonary thermodilution and pulse contour analysis in men undergoing RALP under standardised anaesthesia. PARTICIPANTS: Informed consent was obtained from 51 patients scheduled for elective RALP in a University Medical Centre in Germany. INTERVENTIONS: Heart rate, mean arterial pressure, central venous pressure (CVP), Cardiac Index (CI), systemic vascular resistance (SVR), Global End-Diastolic Volume Index (GEDI), global ejection fraction (GEF), Cardiac Power Index (CPI) and stroke volume variation (SVV) were recorded at six time points: 20 min after induction of anaesthesia (T1), after insufflation of capnoperitoneum in supine position (T2), after 30 min in STP (T3), when controlling Santorini's plexus in STP (T4), before awakening in supine position (T5) and after 45 min in the recovery room (T6). Adverse cardiac events were registered intraoperatively and postoperatively. RESULTS: All haemodynamic parameters were significantly changed by capnoperitoneum and STP during RALP and partly normalised at T6. CI, GEF and CPI were highest at T6 (CI: 3.9 vs 2.2 L/min/m²; GEF: 26 vs 22%; CPI: 0.80 vs 0.39 W/m²; p<0.001). CVP was highest at T4 (31 vs 7 mm Hg, p<0.001) and GEDI at T6 (819 vs 724 mL/m², p=0.005). Mean SVR initially increased (T2) but had decreased by 24% at T6 (p<0.001). SVV was highest at T5 (12 vs 9%, p<0.001). Two of the patients developed cardiac arrhythmia during RALP and one patient suffered postoperative cardiac ischaemia. CONCLUSIONS: RALP led to pronounced perioperative haemodynamic changes. The combination of increased cardiac contractility and heart rate reflects a hyperdynamic situation during and after RALP. Anaesthesiologists should be aware of unnoticed pre-existing heart failure to worsen during STP in patients undergoing RALP.

Influence of quality of intensive care on quality of life/return to work in survivors of the acute respiratory distress syndrome: prospective observational patient cohort study (DACAPO).

BACKGROUND: Significant long-term reduction in health-related quality of life (HRQoL) is often observed in survivors of the acute respiratory distress syndrome (ARDS), and return to work (RtW) is limited. There is a paucity of data regarding the relationship between the quality of care (QoC) in the intensive care unit (ICU) and both HRQoL and RtW in ARDS survivors. Therefore, the aim of our study was to investigate associations between indicators of QoC and HRQoL and RtW in a cohort of survivors of ARDS. METHODS: To determine the influence of QoC on HRQoL and RtW 1 year after ICU-discharge, ARDS patients were recruited into a prospective multi-centre patient cohort study and followed up regularly after discharge. Patients were asked to complete self-report questionnaires on HRQoL (Short Form 12 physical component scale (PCS) and mental component scale (MCS)) and RtW. Indicators of QoC pertaining to volume, structural and process quality, and general characteristics were recorded on ICU level. Associations between QoC indicators and HrQoL and RtW were investigated by multivariable linear and Cox regression modelling, respectively. B values and hazard ratios (HRs) are reported with corresponding 95% confidence intervals (CIs). RESULTS: 877 (of initially 1225 enrolled) people with ARDS formed the DACAPO survivor cohort, 396 were finally followed up to 1 year after discharge. The twelve-month survivors were characterized by a reduced HRQoL with a greater impairment in the physical component (Md 41.2 IQR [34-52]) compared to the mental component (Md 47.3 IQR [33-57]). Overall, 50% of the patients returned to work. The proportion of ventilated ICU patients showed significant negative associations with both 12 months PCS (B = - 11.22, CI -20.71; - 1,74) and RtW (HR = 0,18, CI 0,04;0,80). All other QoC indicators were not significantly related to outcome. CONCLUSIONS: Associations between ICU QoC and long-term HrQoL and RtW were weak and largely non-significant. Residual confounding by case mix, treatment variables before or during ICU stay and variables pertaining to the post intensive care period (e.g. rehabilitation) cannot be ruled out. TRIAL REGISTRATION: Clinicaltrials.govNCT02637011. (December 22, 2015, retrospectively registered).

Tracheostomy in patients with acute respiratory distress syndrome is not related to quality of life, symptoms of psychiatric disorders or return-to-work: the prospective DACAPO cohort study.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is a life-threatening condition that often requires prolonged mechanical ventilation. Tracheostomy is a common procedure with some risks, on the other hand with potential advantages over orotracheal intubation in critically ill patients. This study investigated the association of tracheostomy with health-related quality of life (HRQoL), symptoms of psychiatric disorders and return-to-work of ARDS survivors. METHODS: Data were collected in the context of the prospective observational German-wide DACAPO study. Clinical and demographic patient data and treatment characteristics were obtained from the participating intensive care units (ICU). HRQoL and return-to-work were assessed using patient-reported questionnaires 3, 6 and 12 months after ICU discharge. HRQoL was measured with the Physical and Mental Component Scale of the Short-Form 12 Questionnaire (PCS-12, MCS-12). The prevalence of psychiatric symptoms (depression and post-traumatic stress disorder [PTSD]) was assessed using the Patient Health Questionnaire-9 and the Post-Traumatic Stress Syndrome-14. Physician-diagnosed anxiety and obsessive-compulsive disorder were recorded by patient self-report in the follow-up questionnaires. The associations of tracheostomy with HRQoL, psychiatric symptoms and return-to-work after 12 months were investigated by means of multivariable linear and logistic regression models. RESULTS: Primary 877 ARDS patients (mean ± standard deviation: 54 ± 16 years, 68% male) survived and were discharged from ICU. Out of these patients, 478 (54.5%) were tracheotomised during ICU treatment. After 12 months, patient-reported outcomes could be analysed of 388 (44.2%) respondents, 205 with tracheostomy and 183 without. One year after ICU discharge, tracheostomy showed no significant association with physical or mental health-related quality of life (PCS-12: - 0.73 [- 3.96, 2.51]; MCS-12: - 0.71 [- 4.92, 3.49]), symptoms of psychiatric disorders (depression: 0.10 [- 1.43, 1.64]; PTSD: 3.31 [- 1.81, 8.43]; anxiety: 1.26 [0.41, 3.86]; obsessive-compulsive disorder: 0.59 [0.05, 6.68]) or return-to-work (0.71 [0.31, 1.64]) in the multivariable analysis (OR [95%-CI]). CONCLUSIONS: Up to 1 year after ICU discharge, neither HRQoL nor symptoms of psychiatric disorders nor return-to-work was affected by tracheostomy. Trial registration NCT02637011 (ClinicalTrials.gov, Registered 15 December 2015, retrospectively registered).

The quality of acute intensive care and the incidence of critical events have an impact on health-related quality of life in survivors of the acute respiratory distress syndrome - a nationwide prospective multicenter observational study.

Background: Initial treatment (ventilator settings, rescue therapy, supportive measures), and prevention of critical events improve survival in ARDS patients, but little data exists on its effect on health-related quality of life (HRQOL) and return to work (RtW) in survivors. We analyzed the association of the intensity of treatment at ARDS onset and the incidence of critical events on HRQOL and RtW a year after ICU discharge. Methods: In a prospective multi-centre cohort study, the intensity of treatment and the incidence of critical events were determined at 61 ICUs in Germany. At 3, 6, and 12 months, 396 survivors reported their HRQOL (Short-Form 12) and RtW. The parameters of the intensity of acute management (lung protective ventilation, prone position, hemodynamic stabilization, neuromuscular blocking agents), and critical events (hypoxemia, hypoglycemia, hypotension) were associated with HRQOL and RtW. Results: Patients ventilated at ARDS onset with a low tidal volume (VT≤7 ml/kg) had higher arterial carbon dioxide levels (PaCO2=57.5±17 mmHg) compared to patients ventilated with VT>7ml/kg (45.7±12, p=0.001). In a multivariate adjusted dichotomized analysis, a better mental 3-month SF-12 was observed in the higher VT-group (mean 43.1±12) compared to the lower VT-group (39.5±9, p=0.042), while a dichotomized analysis for driving pressures (≤14 mbar vs >14 mbar) did not show any difference neither in PaCO2 levels nor in HRQOL parameters. A decrease in the mental (6-month: 40.0±11 vs 44.8±13, p=0.038) and physical SF-12 (12-month: 38.3±11 vs 43.0±13, p=0.015) was reported from patients with hypoglycemia (blood glucose <70 mg/dl) compared to those without hypoglycemic episodes. More frequent vasopressor use with mean arterial pressure ≥65 mmHg was associated with an impaired physical SF-12 (6-month: 38.8±10) compared to less vasopressor use (43.0±11, p=0.019). Conclusions: In acute management of ARDS, a lower VT strategy associated with hypercapnia, as well as the frequent usage of catecholamines and the management of blood glucose may influence short-term HRQOL of survivors. The awareness of these findings is of clinical importance for the acute and post-ICU care.

Stressors and strains of next of kin of patients with ARDS in intensive care: A qualitative interview study using a stress-strain approach.

OBJECTIVES: This study aims to explore and analyse the stressors and strains of next of kin of acute respiratory distress syndrome (ARDS) patients during their stay in the intensive care unit utilising the stressors and strain approach as a theoretical framework. METHODS: Data collection was performed as semi-standardised qualitative interviews. 35 families of patients with ARDS were approached when visiting the intensive care unit. Participants were recruited until thematic saturation was reached; finally, 17 persons (age ranging from 26 to 71 years, nine women) took part. Systematic content analysis was conducted on the theoretical foundations of the stressors and strain approach. FINDINGS: Numerous stressors were identified; they can be divided into three main categories: in relation to organising the visit, occurring during the visit and arising at home. These stressors were reported highly consistently throughout participants. However, the strains resulting from these stressors were varying in manifestation and level. CONCLUSIONS: This study explores the manifold stressors and strains of next of kin of a critically ill patient. Some stressors are inherent to the life-threatening condition of a family member; others arise from the health care system and could be modified. The level of strain experienced depends on social support, individual coping skills and life circumstances.

Ambulatory and stationary healthcare use in survivors of ARDS during the first year after discharge from ICU: findings from the DACAPO cohort.

BACKGROUND: For many survivors of acute respiratory distress syndrome (ARDS), the process from discharge from intensive care unit (ICU) to recovery is long and difficult. However, healthcare use after discharge from ICU has received only little attention by research. This study sets out to investigate the extent of ambulatory and stationary healthcare use among survivors of ARDS in Germany (multicenter DACAPO cohort) and to analyze predictors of stationary healthcare use. RESULTS: A total of 396 survivors of ARDS provided data at 1 year after discharge from ICU. Fifty percent of 1-year survivors were hospitalized for 48 days or longer after discharge from ICU, with 10% spending more than six out of 12 months in stationary care. The duration of hospitalization increased significantly by the length of the initial ICU stay. All participants reported at least one outpatient visit (including visits to general practitioners), and 50% contacted four or more different medical specialties within the first year after discharge from ICU. CONCLUSIONS: For most of the patients, the first year after ARDS is characterized by an extensive amount of healthcare utilization, especially with regard to stationary health care. These findings shed light on the substantial morbidity of patients after ARDS and contribute to a better understanding of the situation of patients following discharge from ICU.

The impact of obesity on pulmonary deterioration in patients undergoing robotic-assisted laparoscopic prostatectomy.

Obesity affects respiratory and hemodynamic function in anesthetized patients. The aim of this study was to evaluate the influence of the body mass index (BMI) on pulmonary changes in a permanent 45° steep Trendelenburg position (STP) during robotic-assisted laparoscopic prostatectomy (RALP). 51 patients undergoing RALP under standardized anesthesia were included. Perioperative pulmonary function and oxygenation were measured in awake patients (T0), 20 min after the induction of anesthesia (T1), after insufflation of the abdomen in supine position (T2), after 30 min in STP (T3), when controlling Santorini's plexus in STP (T4), before awakening while supine (T5), and after 45 min in the recovery room (T6). Patient-specific and time-dependent factor on ventilation and predicted peak inspiratory pressure (PIP), driving pressure (Pdriv) and lung compliance (LC) in a linear regression model were calculated. PIP and Pdriv increased significantly after induction of capnoperitoneum (T2-4) (p < 0.0001). In univariate mixed effects models, BMI was found to be a significant predictor for PIP and Pdriv increase and LC decrease. Obese patients a BMI > 31 kg/m2 reached critical PIP values ≥ 35 cmH2O. Postoperative oxygenation represented by the PaO2/FiO2 ratio was significantly decreased compared to T0 (p < 0.0001). Obesity in combination with STP and capnoperitoneum during RALP has a profound effect on pulmonary function. Increased PIP and Pdriv and decreased LC are directly correlated with a high BMI. Changes in PIP, Pdriv and LC during RALP may be predicted in relation to patient's BMI for consideration in the preoperative setting. Trial registration number Z-2014-0387-6. Registered on 8 July 2014.

Acceptability of a German multicentre healthcare research study: a survey of research personnels' attitudes, experiences and work load.

OBJECTIVES: The DACAPO study as a multicentre nationwide observational healthcare research study investigates the influence of quality of care on the quality of life in patients with acute respiratory distress syndrome. The aim of this study was to investigate the acceptability to the participating research personnels by assessing attitudes, experiences and workload associated with the conduct of the DACAPO study. DESIGN, SETTING AND PARTICIPANTS: A prospective anonymous online survey was sent via email account to 169 participants in 65 study centres. The questionnaire included six different domains: (1) training for performing the study; (2) obtaining informed consent; (3) data collection; (4) data entry using the online documentation system; (5) opinion towards the study and (6) personal data. Descriptive data analysis was carried out. RESULTS: A total of 78 participants took part (46%) in the survey, 75 questionnaires (44%) could be evaluated. 51% were senior medical specialists. 95% considered the time frame of the training as appropriate and the presentation was rated by 93% as good or very good. Time effort for obtaining consent, data collection and entry was considered by 41% as a burden. Support from the coordinating study centre was rated as good or very good by more than 90% of respondents. While the DACAPO study was seen as scientifically relevant by 81%, only 45% considered the study results valuable for improving patient care significantly. CONCLUSION: Collecting feedback on the acceptability of a large multicentre healthcare research study provided important insights. Recruitment and data acquisition was mainly performed by physicians and often regarded as additional time burden in clinical practice. Reducing the amount of data collection and simplifying data entry could facilitate the conduct of healthcare research studies and could improve motivation of researchers in intensive care medicine. TRIAL REGISTRATION NUMBER: NCT02637011; Pre-results.

German-wide prospective DACAPO cohort of survivors of the acute respiratory distress syndrome (ARDS): a cohort profile.

PURPOSE: While most research focuses on the association between medical characteristics and residual morbidity of survivors of the acute respiratory distress syndrome (ARDS), little is known about the relation between potentially modifiable intensive care unit (ICU) features and the course of health-related quality of life (HRQoL). Accordingly, the DACAPO study was set up to elucidate the influence of quality of intensive care on HRQoL and return to work (RtW) in survivors of ARDS. The continued follow-up of these former ICU patients leads to the establishment of the DACAPO (survivor) cohort. PARTICIPANTS: Sixty-one ICUs all over Germany recruited patients with ARDS between September 2014 and April 2016. Inclusion criteria were: (1) age older than 18 years and (2) ARDS diagnosis according to the 'Berlin definition'. No further inclusion or exclusion criteria were applied. 1225 patients with ARDS could be included in the DACAPO ICU sample. Subsequently, the 876 survivors at ICU discharge form the actual DACAPO cohort. FINDINGS TO DATE: The recruitment of the participants of the DACAPO cohort and the baseline data collection has been completed. The care-related data of the DACAPO cohort reveal a high proportion of adverse events (in particular, hypoglycaemia and reintubation). However, evidence-based supportive measures were applied frequently. FUTURE PLANS: Three months, 6 months and 1 year after ICU admission a follow-up assessment is conducted. The instruments of the follow-up questionnaires comprise the domains: (A) HRQoL, (B) RtW, (C) general disability, (D) psychiatric symptoms and (E) social support. Additionally, an annual follow-up of the DACAPO cohort focusing on HRQoL, psychiatric symptoms and healthcare utilisation will be conducted. Furthermore, several add-on projects affecting medical issues are envisaged. TRIAL REGISTRATION NUMBER: NCT02637011.

Quality of inter-hospital transportation in 431 transport survivor patients suffering from acute respiratory distress syndrome referred to specialist centers.

BACKGROUND: The acute respiratory distress syndrome (ARDS) is a life-threatening condition. In special situations, these critically ill patients must be transferred to specialized centers for escalating treatment. The aim of this study was to evaluate the quality of inter-hospital transport (IHT) of ARDS patients. METHODS: We evaluated medical and organizational aspects of structural and procedural quality relating to IHT of patients with ARDS in a prospective nationwide ARDS study. The qualification of emergency staff, the organizational aspects and the occurrence of critical events during transport were analyzed. RESULTS: Out of 1234 ARDS patients, 431 (34.9%) were transported, and 52 of these (12.1%) treated with extracorporeal membrane oxygenation. 63.1% of transferred patients were male, median age was 54 years, and 26.8% of patients were obese. All patients were mechanically ventilated during IHT. Pressure-controlled ventilation was the preferred mode (92.1%). Median duration to organize the IHT was 165 min. Median distance for IHT was 58 km, and median duration of IHT 60 min. Forty-two patient-related and 8 technology-related critical events (11.6%, 50 of 431 patients) were observed. When a critical event occurred, the PaO2/FiO2 ratio before transport was significant lower (68 vs. 80 mmHg, p = 0.017). 69.8% of physicians and 86.7% of paramedics confirmed all transfer qualifications according to requirements of the German faculty guidelines (DIVI). CONCLUSIONS: The transport of critically ill patients is associated with potential risks. In our study the rate of patient- and technology-related critical events was relatively low. A severe ARDS with a PaO2/FiO2 ratio < 70 mmHg seems to be a risk factor for the appearance of critical events during IHT. The majority of transport staff was well qualified. Time span for organization of IHT was relatively short. ECMO is an option to transport patients with a severe ARDS safely to specialized centers. Trial registration NCT02637011 (ClinicalTrials.gov, Registered 15 December 2015, retrospectively registered).

Characteristics and provision of care of patients with the acute respiratory distress syndrome: descriptive findings from the DACAPO cohort baseline and comparison with international findings.

BACKGROUND: Little is known about the characteristics and real world life circumstances of ARDS (acute respiratory distress syndrome) patient populations. This knowledge is essential for transferring evidence-based therapy into routine healthcare. The aim of this study was to report socio-demographic and clinical characteristics in an unselected population of ARDS patients and to compare these results to findings from other large ARDS cohorts. METHODS: A German based cross-sectional observational study was carried out. A total of 700 ARDS patients were recruited in 59 study sites between September 2014 and January 2016. Socio-demographic, disease and care related variables were recorded. Additionally, characteristics of other large ARDS cohorts identified by a systematic literature search were extracted into evidence tables. RESULTS: Median age of ARDS patients was 58 years, 69% were male. Sixty percent had no employment, predominantly due to retirement. Seventy-one percent lived with a partner. The main cause of ARDS was a pulmonary 'direct' origin (79%). The distribution of severity was as follows: mild (14%), moderate (48%), severe (38%). Overall ICU mortality was calculated to be 34%. The observed prevalence of critical events (hypoxemia, hypoglycemia, re-intubation) was 47%. Supportive measures during ICU-treatment were applied to 60% of the patients. Other ARDS cohorts revealed a high heterogeneity in reported concomitant diseases, but sepsis and pneumonia were most frequently reported. Mean age ranged from 54 to 71 years and most patients were male. Other socio-demographic factors have been almost neglected. CONCLUSIONS: The proportion of patients suffering of mild ARDS was lower compared to the only study identified, which also applied the Berlin definition. The frequency of critical events during ICU treatment was high and the implementation of evidence-based therapy (prone positioning, neuro-muscular blockers) was limited. More evidence on socio-demographic characteristics and further studies applying the current diagnostic criteria are desirable.