14:30 Uhr
P01:
Fluid Overload is associated with Mortality in Adult Intensive Care Patients – a systematic Review and Meta-Analysis
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Autor:innen:
Anna Messmer (Bern | CH)
Carina Zingg (Bern | CH)
Martin Müller (Bern | CH)
Joel Gerber (Bern | CH)
Joerg Schefold (Bern | CH)
Carmen Pfortmüller (Bern | CH)
Background: Fluid overload (FO) in critically ill patients is one of the hot topics in critical care, as recent research points towards an increased morbidity and mortality in critical ill patients who have received large volumes of fluids (1-4). Here, we systematically reviewed and synthesized the evidence on fluid overload and mortality in critically ill patients and have performed a meta-analysis of available data.
Data Sources: We performed a systematic search on PubMed, EmBase, and the Cochrane Library databases.
Study Selection: Studies evaluating the impact of fluid overload (FO, defined by weight gain > 5%) or positive cumulative fluid balance (CFB) on mortality in adult critical care patients were eligible for analysis. We excluded animal studies and trials in pediatric populations (age < 16 years), pregnant women, non-critically ill patients, very specific subpopulations of critically ill patients, and on EGDT (Early Goal-Directed Therapy). Assessment followed the COCHRANE/MOOSE guidelines for systematic reviews.
Results: We included and analysed 31 observational and three randomized controlled trials (including 31,076 ICU patients). We included only observational studies in the meta-analysis. CFB and FO were both associated with pooled mortality: after 3 days of ICU stay, adjusted risk ratio (aRR) for CFB was 2.15 (95% CI 1.51 - 3.07), and for FO 8.83 (95% CI 4.03 - 19.33), at any time point during ICU stay, aRR for for CFB was 1.39 (95% CI 1.15 - 1.69), and for FO 2.79 (95%CI 1.55 - 5.00). CFB was linked to mortality in patients with sepsis (aRR 1.66; 95% CI 1.39 -1.98), AKI (aRR 2.63; 95% CI 1.30 - 5.30), and respiratory failure (aRR 1.19; 95% CI 1.03 - 1.43). FO was associated with mortality in patients with both acute kidney injury (AKI) (aRR 2.38; 95% CI 1.75 - 2.98) and surgery (aRR 6.17; 95% CI 4.81 - 7.97). The risk of mortality increased by a factor of 1.19 (95% CI 1.11 - 1.28) per liter increase in positive fluid balance
Conclusion: The adjusted risk estimates reported in this meta-analysis suggest an association of fluid overload and positive cumulative fluid balance with increased mortality in the general critical care population, as well as in defined subgroups.
14:35 Uhr
P02:
Physiological response of prone positioning in intubated adults with severe COVID-19 acute respiratory distress syndrome: a retrospective study
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Autor:innen:
Andrea Boffi (Lausanne | CH)
Maximilien Ravenel (Lausanne | CH)
Lupieri Ermes (Lausanne | CH)
Jean-Daniel Chiche (Lausanne | CH)
Lise Piquilloud Imboden (Lausanne | CH)
CONTEXT AND AIM
Prone positioning is recommended for COVID 19 moderate to severe acute respiratory distress syndrome (ARDS) in intubated patients, but few data are available. The study aim was to assess the effect of proning on gas exchanges, respiratory system compliance (CRS) and ventilatory ratio (VR).
MATERIAL AND METHOD
Retrospective analysis of the patients intubated and proned in the Lausanne Adult ICU for COVID 19 ARDS between March 06 and May 30 2020. Patients’ characteristics, blood gas analysis at admission and number and duration of the prone position sessions were recorded. Ventilator settings, gas exchanges, CRS and VR were recorded before proning and before returning to supine position. Response in term of oxygenation was defined as increase in PaO2/FiO2 > 20%. Treatment failure was defined as death or start of extracorporeal membrane oxygenation (ECMO). Results expressed as median (IQR).
RESULTS
42 patients (71% of males) were included. Age 63 (57-62) years, SAPSII 41 (34-46) and SOFA 7 (6-8). At intubation, PaO2/FiO2 was 137 mmHg (118-172), alveolo-arterial gradient (AaO2) 255 mmHg (200-345), CRS 36.4 ml/CmH2O (29.3-42.5), VR 1.7 (1.3-2.2). 191 sessions of prone positioning were performed. Time from the first PaO2/FiO2 < 150mmHg with FiO2 > 0.6 to first proning was 16 (5-36) hours. Number of sessions per patient was 3 (2-6) and duration 17 (16-19) hours. For all proning sessions PaO2/FiO2 increased from 107 (90-129) to 180 (148-210) mmHg, FiO2 decreased from 0.6 (0.5-0.7) to 0.4 (0.35-0.5) (p < 0.0001 for both). PaO2/FiO2 increase > 20 % was found in 83 % of proning. AaO2 decreased from 275 (212-334) to 127 (92-176) (p < 0.0001). CRS increased from 32.3 (27.7-40.8) to 36.2 (30-41.7) (p = 0.003) and VR from 2.3 (1.9-2.8) to 2.4 (2.0-2.9) (p = 0.03). Two (5 %) patients needed ECMO support and survived. Ten patients died (24 %). Patients in treatment failure group were older (73 (61-78) vs 60 (56-69), p = 0.009) and had more often a BMI > 30 kg/m2 (47 vs 8 % p = 0.03).
CONCLUSION
Prone positioning improved PaO2/FiO2 and AaO2 gradient. CRS and VR only slightly increased suggesting that the main effect is improvement in ventilation/perfusion ratio.
14:40 Uhr
P03:
Improvement in oxygenation after the first awake pronation session is associated with lower intubation rate in patients with Sars-Cov-2 acute hypoxemic respiratory failure
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Autor:innen:
Ermes Lupieri (Lausanne | CH)
Andrea Boffi (Lausanne | CH)
Zied Ltaief (Lausanne | CH)
Antoine Schneider (Lausanne | CH)
Samia Abed-Maillard (Lausanne | CH)
Jean-Daniel Chiche (Lausanne | CH)
Lise Piquilloud Imboden (Lausanne | CH)
Context and objectives
Prone positioning in non-intubated patients with severe Covid-19 pneumonia could help improving oxygenation and reducing intubation rate but data are missing. The objectives of this study were to assess the feasibility and physiological effects of this procedure and to assess whether response to the first prone positioning could help predict intubation.
Material and Methods
We conducted a retrospective analysis of the patients hospitalized for severe Covid-19 pneumonia between March 13th and October 29th 2020 in the Lausanne Adult ICU for whom awake prone positioning was performed for at least 45 minutes. We collected and compared the respiratory and blood gas parameters before and after each pronation (T-test or Wicoxon test). It was also assessed whether the effects of the first session could predict the need for intubation.
Results
During the study period, 48 non-intubated patients (27.7 % of the admissions) were proned for more than 45 minutes. 29 of them were included in the analysis (17 denied consent for retrospective analysis and 2 had a “do not intubate order”). 21 were men (72.4%). Age was 60 ± 13. At ICU admission PaO2/FiO2 was 92 [74-110] mmHg. A total of 110 sessions were performed in the included patients (3 [1-6] per patient, range 1 to 12). No adverse events were reported. Complete data were available for 74 sessions (67.3%). Aa-O2 decreased from 335 ± 99 before pronation to 269 ± 128 mmHg (p = 0.002) after pronation. PaO2/FiO2 increased from 103 [80-127] to 140 [85-173] mmHg (p = 0.003). Ph, PaCO2, RR were not different. Complete data for the first session were available for 25 patients. During the first pronation session, Aa-O2 decreased from 362 ± 82 to 275 ± 128 mmHg (p = 0.001) and PaO2/FiO2 increased from 94 [78-100] to 141 [91-189] mmHg (p = 0.002). Among the 29 included patients, 10 were intubated (34.5%). Two died in the ICU (6.9%). For similar Aa-O2 and PaO2/FiO2 before the first pronation session, we found that Aa-O2 was lower and PaO2/FiO2 was higher after the first pronation session in patients who did not require intubation compared to patients who had to be intubated (p = 0.000 and p = 0.003 respectively).
Conclusions
Awake pronation in spontaneously breathing patients is feasible, improves PaO2/FiO2 and reduce Aa-O2. Response to the first session was associated with lower intubation rate.
14:45 Uhr
P05:
Isoliert sein auf der Intensivstation
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Autor:in:
Janet Walter (Zürich | CH)
Die Zunahme multiresistenter Keime und die Anfälligkeit von Intensivstationen für Ausbrüche von Erregern machen zunehmend Isolationsmassnahmen bei der Pflege von Patienten*innen erforderlich.
Ziel ist es, aufzuzeigen, wie Patienten*innen die Isolation erleben und welche pflegerischen Behandlungsschwerpunkte und Unterstützungsmassnahmen sich daraus ergeben. Zur Bearbeitung der Fragestellung wurde eine Literaturrecherche durchgeführt, sowie Erfahrungen in der Betreuung eines isolierten Patienten eingebracht. Patienten*innen auf der Intensivstation sind aus ihrem gewohnten Umfeld herausgerissen und von ihrer Alltagswelt isoliert. Intensivtherapie und eine hygienisch induzierte Isolation lösen zusätzlich negative Empfindungen aus. Eine Isolation bedeutet weniger Besuchskontakte. Dies kann zu einem Gefühl der Einsamkeit führen. Patienten*innen berichten über ein Stigmatisierungserleben, das die Sicherheit und den Selbstwert der Identität gefährdet. Sie haben bis zu 50% weniger Kontakt mit dem therapeutischen Team. Neben der reduzierten Versorgung führt dies zu einer Desinformation. In der Wahrnehmung ist „isoliert sein“ eng mit der Erfahrung von Todesangst verknüpft. Es besteht ein doppelt so hohes Risiko, Wahnvorstellungen und Delirien zu erleiden und ein 40% höheres Risiko, an Depressionen zu erkranken. Patienten*innen, die gut über die Notwendigkeit der Massnahmen aufgeklärt sind, empfinden diese aber auch durchaus als Schutz. Um die Beeinträchtigungen einer Isolation zu reduzieren, sollten Pflegefachkräfte die Pflegeschwerpunkte erkennen. Aus den Pflegediagnosen Relokationsstresssyndrom, soziale Isolation und Stigma können pflegerische Massnahmen abgeleitet werden. Patienten*innen profitieren von umfassenden Informationen, Orientierungsgabe und Kontakt zu Bezugspersonen, persönlich und per Telefon. Sie miteinzubinden in einen Tagesplan gibt zusätzlich Unterstützung. Die Besuchszeit sollte möglichst ungestört genutzt werden können. Ein zuhörendes Gesprächsverhalten, damit Patient*innen sich aussprechen können, hilft, Stigmatisierung und damit verbundene Scham zu reduzieren.
Es gilt, die Situation isolierter Patienten*innen auf der Intensivstation besser zu verstehen und ihnen die Adaption an veränderte Umstände zu erleichtern.
14:50 Uhr
P06:
Routinemässiges Anspülen bei endotrachealen Absaugen – ja oder nein – ein Praxisbeispiel
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Autor:innen:
Annina Jakob (Zürich | CH)
Sarah Naji (Zürich | CH)
Yvonne Kröger (Zürich | CH)
Einleitung: Das endotracheale Absaugen ist ein häufiger und invasiver Vorgang, der bei intubierten, beatmeten Patienten auf der pädiatrischen Intensivstation (PICU) notwendig ist. Durch das Entfernen von Sekret, kann die Lunge mehr Volumen pro Atemzug aufnehmen und die Oxygenierung und Ventilation positiv begünstigen. Studien und der Austausch mit Fachexperten zeigen, dass ein endotracheales Absaugen mit routinemässigem Anspülen mit NaCl 0.9% nur durchgeführt werden soll, wenn Zeichen für Sekret, welches die Atemwege verlegt, vorhanden ist. Aufgrund dieser Datenlage wurde auf der PICU das Vorgehen beim endotrachealen Absaugen entsprechend angepasst. In der Umsetzung kam es bei mehreren Patienten auf der PICU zu Tubusobstruktionen mit kritischem Reanimationsereignis.
Methode: Die Patientendaten wurden analysiert, um zusammen mit einer weiteren Literaturrecherche Hauptsymptome zu identifizieren, von welchen Kriterien zur Indikation des endotrachealen Absaugens abgeleitet werden können.
Ergebnisse: Die Analyse der aufgezeichneten Patientendaten hat gezeigt, dass es bereits mehrere Stunden vor einem kritischen Ereignis Trends für eine unzureichende Belüftung gab. Von einem routinemässigen Absaugen und dem Anspülen mit NaCl 0,9% wird in der Literatur abgeraten. Es wird jedoch empfohlen, die Entscheidung anhand von klaren Kriterien und Assessments zu treffen. Um die Patientenversorgung zu verbessern und lebensbedrohende Ereignisse zu vermeiden, werden auf der PICU Assessments getestet. Diese sollen Pflegefachpersonen in ihren klinischen Überlegungen und der Entscheidung zum endotrachealen Absaugen, mit oder ohne anspülen, unterstützen. Die Assessments sollen unter dem Fokus der Beurteilung der Atemwegssituation und unter Einbezug der Beatmungswerte und dem Krankheitsbild angewendet werden.
Schlussfolgerungen: Der routinemässige Einsatz eines sensiblen und hochspezifischen Assessments zur Beurteilung der individuellen Patientensituation in Bezug auf das endotracheale Absaugen ist auf der PICU unerlässlich, damit Leitsymptome für ein kritisches Ereignis frühzeitig erkannt werden und die pflegerische Handlung für die Patienten sicher durchgeführt werden kann.
14:55 Uhr
P07:
Neue Ansätze zur Früherkennung und Prophylaxe des akuten Nierenversagens
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Autor:innen:
Farid Temori (München | DE)
Peter B. Luppa (München | DE)
Zielstellung: Das akute Nierenversagen (ANV) stellt eine schwere Erkrankung mit tödlichem Potenzial dar. Seit Jahren bestehen hohe Prävalenzen und entsprechende Therapiekosten sowie Mortalitätsraten. Die Diagnostik eines ANV erfolgt in den Klassifikationen RIFLE (risk, injury, loss, end stage) und AKIN (akute kidney injury network) auf Basis der Urinausscheidung und des Serumkreatinins. Beide Verfahren haben eingeschränkte Aussagekraft. Zudem hat weder RIFLE noch AKIN die Fähigkeit, bei fehlenden Basis-Kreatinin-Werten ein ANV von einem chronischen Nierenversagen (CNV) zu trennen. Unsere Studie hatte es zum Ziel, mögliche Vorteile der Biomarker Harnstoff, Cystatin C, TIMP-2 (tissue inhibitor of metalloproteinases 2) und IGFBP-7 (insulin-like growth factor binding protein 7) gegenüber Serumkreatinin hinsichtlich der Detektion des ANV aufzuzeigen. Insbesondere sollte die Wertigkeit der Biomarker in Bezug auf die Prädiktion von Ereignissen wie Mortalität und Auftreten eines ANV untersucht werden.
Methode: Die Kreatinin-Verläufe von 53 Intensivpatienten wurden per Ex-Post Methode auf ANV und CNV geprüft. Bei allen Patienten wurden zu fünf Messzeiten T0, T4-6h, T12h, T24h und T48h ab ICU-Aufnahme je auf die Größen Kreatinin, Cystatin C, Harnstoff im Serum, die Biomarker TIMP-2 und IGFBP-7 im Urin untersucht. Die Bestimmung der klinischen Parameter fand im Labor statt. Die neuen Biomarker wurden im Urin mit dem POCT-Verfahren Nephrocheck® (Astute Medical USA) gemessen.
Ergebnisse: Mit der Ex-Post Methode wiesen doppelt so viele Patienten ANV auf als nach RIFLE und AKIN. Zu allen Messzeiten reagierten die Biomarker Cystatin C, TIMP-2 und IGFBP-7 sehr sensibel auf akute Einschränkung der Nierenfunktion und wiesen hohe Korrelationen auf. Bezüglich der Prädiktion der ICU-Mortalität schnitten die beiden Kenngrößen TIMP-2 und IGFBP-7 zu allen Messzeiten am besten ab (AUC 0,732). Betreffend die Prädiktion eines ANV war die Aussagekraft der Serummarker Kreatinin und Cystatin C zu allen Messzeiten ähnlich gut wie die Urinmarker IGFBP-7 und TIMP-2.
Schlussfolgerungen: Das engmaschige Monitoring von Kreatinin, Cystatin C im Serum, sowie von TIMP-2 und IGFBP-7 im Urin, bietet eine Möglichkeit ANV-Patienten von solchen mit CNV bei fehlenden Kreatinin-Basiswerten im kurzfristigen Verlauf besser zu trennen. Bezüglich der ICU-Mortalität könnte die hohe Prädiktion der Biomarker TIMP-2 und IGFBP-7 dabei helfen das Outcome der Intensivpatienten mit ANV zu verbessern.
15:00 Uhr
P08:
Pathologic fractures in pediatric intensive care patients – an underestimated complication of chronic critically ill children; two case reports and a literature review
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Autor:innen:
Vanja Zivkovic (Zürich | CH)
Barbara Brotschi Aufdenblatten (Zürich | CH)
Janet Kelly-Geyer (Zürich | CH)
Kevin Schmid (Zürich | CH)
Eva Kühlwein (Zürich | CH)
Background
While risk factors for developing osteopenia and fractures in chronically ill children (1) are well described and routinely addressed, there is little awareness of these risk factors in critically ill children.
Methods: 2 case reports and a literature review
Results
Case A
A preterm boy was born with a median congenital diaphragmatic hernia and several other malformations resulting in chronic respiratory failure and a severe malassimilation syndrome needing continuous intensive care from birth. Due to several episodes of acute kidney injury, he developed a secondary Fanconi syndrome and secondary hyperparathyroidism resulting in severe osteopenia. At the age of 7 months 8 long bone fractures were diagnosed within a few days.
Case B
A late preterm girl born with a tricuspid atresia type 1b was admitted at 3 months of age for an elective cardiac catheterization. She had a highly complicative course resulting in severe chronic cardiac failure requiring respiratory support, diuretics and jejunal feeds. Chronic furosemide medication caused hypercalcuria. The patient developed a secondary hyperparathyroidism resulting in a pathologic humerus fracture and two additional asymptomatic vertebral fractures after 5.5 months of intensive care.
Comparing these two cases with the literature, both cases exhibit several known risk factors for osteopenia.
Discussion
Studies analyzing osteopenia in pediatric critically ill patients (2-4) conclude that risk factors known from chronic illness (e.g. renal insufficiency, loop diuretics, prolonged immobilization) as well as additional risk factors including age < 2 years, respiratory diagnosis, illness severity and length of hospitalization put critically ill children at risk.
Having 2 or more risk factors considerably increases the risk of children sustaining pathologic fractures of which many go unrecognized (2). Implementing a protocol increasing awareness of osteopenia, recognition and management of at-risk children can lower the risk of fractures (2).
Conclusion
Children requiring a prolonged intensive care stay are often at risk for osteopenia with subsequent pathologic fractures due to their underlying disease and the necessary treatments. More awareness of this rare but important complication is required.
15:05 Uhr
P09:
Renal tubular acidosis in pregnant Covid-19 patients
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Autor:innen:
Simona Humbel (Zufikon | CH)
Simone Unseld (Zürich | CH)
Pedro David Wendel Garcia (Zürich | CH)
Sascha David (Zürich | CH)
Rea Andermatt (Zürich | CH)
Background and Objectives: Metabolic acidosis is a common problem in critically ill patients and often a consequence of acute kidney injury or lactic acidosis. With normal renal function and normal anion gap (AG), the diagnostic approach involves a urine analysis and the differential diagnosis are more complex. Renal tubular acidosis (RTA) is a rare disorder (10 in 100,000) in which, despite a well-preserved glomerular filtration rate (GFR), metabolic acidosis develops because of either a defect in the secretion of H+ (Type I) or the inability to reabsorb bicarbonate (Type II) 1]. RTA has not been reported in Covid-19 patients, but single cases have been associated with pregnancy [2].
We have observed a high percentage of normal AG (hyperchloremic) metabolic acidosis in pregnant critically ill Covid-19 patients and systematically analyzed the prevalence, etiology and clinical course.
Methods: Retrospective analysis from patient data monitoring system and chart review.
Results: From February 2020 to April 2021 321 Covid-19 patients were admitted to the intensive care units (ICU) of the University Hospital Zurich. Ninety-five (29.5%) were women and 8 were either pregnant or just had C-section before admission to the ICU (age 24 to 42 years, 32 ± 2.7 gestational week). Seven women had symptomatic Covid-19 and were included in the study. Despite a normal renal function (eGFR 137 ± 17 ml/min/m2 BSA), 6 out of these 7 patients (85.7%) either presented themselves on admission or during ICU-stay with an AG negative metabolic acidosis (pH 7.27 ± 0.1, min HCO3- 15.6 ± 3.1 mmol/l, pCO2 3.8 ± 1.0). Despite the generally rare incidence of RTA, we found that 3 of these 6 acidotic women fulfilled diagnostic criteria for RTA. Sodium bicarbonate was given over 2.3 ± 0.5 days in 43% of them. All women recovered from RTA within less than 7 days.
Conclusions: Here we report for the first time that metabolic acidosis might be very common (85%) in critically ill pregnant Covid-19 patients and further half of the women had evidence of an extremely rare tubulopathy. We want to point out that the diagnosis of RTA was not made in all of these patients during their ICU stay, but only afterwards, which underlines the relevance of our findings for raising awareness among intensivists treating (pregnant) Covid-19 patients. It remains to be demonstrated if this observation is an indirect epiphenomenon or a putative direct viral effect on the tubular epithelium.
15:10 Uhr
P10:
Nasogastric tube placement: can the tracheal etCO2 and gastric pH measurements reduce the misplacement?
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Autor:innen:
Simone Dell'Era (Bellinzona | CH)
Andrea Glotta (Lugano | CH)
Maira Biggiogero (Lugano | CH)
Giovanni Bona (Lugano | CH)
Edoardo Tasciotti (Bellinzona | CH)
Francesco Ruggiero (Lugano | CH)
Christoph Kronemberg (Bellinzona | CH)
Andrea Saporito (Bellinzona | CH)
Samuele Ceruti (Lugano | CH)
Introduction: nasogastric tube (NGT) placement is a common procedure performed in critical care setting. Chest X-Ray is the diagnostic gold-standard to confirm correct placement, with the downsides of both the need for critical care patients’ mobilization and intrinsic actinic risk. Other potential methods to confirm NGT placement have shown a lower accuracy compared to chest X-ray; ETCO2 and pH analysis have singularly yet investigated as an alternative to the gold standard. Aim of this study was to determine eventual thresholds in combine measurements of ETCO2 and pH values, at which correct NGT positioning can be confirmed with the highest accuracy.
Material & Methods: this was a prospective, multicenter, observational trial; a continuous cohort of eligible patients was allocated to two arms, to identify clear cut-off threshold able to detect correct NGT tip positioning with the maximal accuracy. Patients underwent general anesthesia and orotracheal intubation; in the first group difference between tracheal and esophageal ETCO2 values were assessed. In the second group difference between esophageal and gastric pH values were determined.
Results: from November 2020 to March 2021, 85 consecutive patients were enrolled: 40 in the ETCO2 group and 45 in the pH group. The ETCO2 ROC analysis for predicting NGT tracheal misplacement demonstrate an optimal ETCO2 cutoff value of 25.5 mmHg, where both sensitivity than specificity reach 1.0 (AUC 1.0, p < 0.001). The pH ROC analysis for predicting NGT correct gastric placement demonstrated the optimal pH cutoff value at 4.25, with a mild diagnostic accuracy (AUC 0.79, p < 0.001).
Discussion: A device capable of combining the presence of a negative marker with a positive marker could be accurate enough in identifying the correct NGTs positioning. Further studies are required to validate the reproducibility of these results by a specific device, whose accuracy also ought to be compared with standard chest X-ray.
15:15 Uhr
P11:
Emergency ABCDE management of status epilepticus: a prospective high-fidelity simulation study
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Autor:innen:
Paulina Kliem (Basel | CH)
Kai Tisljar (Basel | CH)
Sira Baumann (Basel | CH)
Pascale Grzonka (Basel | CH)
Gian Marco De Marchis (Basel | CH)
Stefano Bassetti (Basel | CH)
Roland Bingisser (Basel | CH)
Sabina Hunziker (Basel | CH)
Stephan Marsch (Basel | CH)
Raoul Sutter (Basel | CH)
Objectives: To investigate the frequency and order of correctly performed examination steps of the ABCDE (Airway-Breathing-Circulation-Disability-Exposure) approach by physicians confronted with a simulated scenario of a patient with status epilepticus (SE); to further analyze the compliance of SE treatment with the guidelines in relation to performed ABCDE examinations, and to identify risk factors for non-adherence to the ABCDE approach.
Methods: In this prospective trial at a Swiss academic simulator training center, physicians of different background/affiliations were confronted with a simulated SE. Primary outcomes were correctly performed examination steps "A"to"E", performance of all examination steps, and examinations in correct order.
Results: 74 physicians of different medical specialties recognized SE and performed a median of 4 of the 5 ABCDE checks (interquartile range 3-4). 5% performed complete assessments. Airways were checked within the recommended timeframe in 46%, breathing in 66%, circulation in 92%, and disability (neurologic examination) in 96%. Head-to-toe (exposure) examination was performed in 15% despite paramedics reporting a possible fall. Airways were protected on time in 14%, oxygen supplied in 69%, and antiseizure drugs administered in 99%. These treatments were performed more frequently if ABCDE checks were followed. Participants' neurologic affiliation was associated with performance of fewer checks (OR-0.49; p=0.015).
Conclusions: Adherence to the ABCDE approach in a simulated SE was infrequent but led to a more frequent protection of airways. This calls for intensive training of the ABCDE approach especially for neurologists as the lack of airway protection may increase mortality and promote treatment refractoriness of SE related to aspiration-pneumonia.
15:20 Uhr
P12:
Neuron-specific enolase (NSE) predicts long-term mortality in patients after cardiac arrest: Results from a prospective trial
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Autor:innen:
Jonas Müller (Basel | CH)
Benjamin Bissmann (Basel | CH)
Christoph Becker (Basel | CH)
Katharina Beck (Basel | CH)
Nina Loretz (Basel | CH)
Simon Amacher (Basel | CH)
Chantal Bohren (Basel | CH)
Hans Pargger (Basel | CH)
Kai Tisljar (Basel | CH)
Raoul Sutter (Basel | CH)
Stephan Marsch (Basel | CH)
Sabina Hunziker (Basel | CH)
Background and goals: Neuron-specific enolase (NSE) increases in response to brain injury and is recommended for outcome prediction at short term in cardiac arrest patients. There is, however, limited understanding of NSEs influence on long term outcomes. Our aim was to investigate whether NSE predicts long-term mortality and poor neurological outcome in cardiac arrest patients.
Materials & methods: Within this prospective observational study, we included consecutive adult patients after cardiac arrest admitted to the ICU. NSE was measured upon ICU-admission and on days 1, 2, 3, 5 and 7. We calculated Hazard-ratios using Cox-regression and logistic regression to study the associations of NSE levels with long term overall all-cause mortality and neurological outcome defined by Cerebral Performance Category (CPC) scale two years after cardiac arrest.
Results: From 403 patients, 176 (43.7%) survived with a median follow-up of 43.7 months (IQR 14.3 to 63.0 months). NSE on day 3 showed the highest prognostic performance for mortality compared to other days of measurement, with an AUC of 0.81 and an adjusted HR of 1.55 and 1.51. Subgroup analysis indicated that predictive value of NSE for mortality was significantly higher in younger patients < 54 years of age and showed excellent sensitivity and negative predictive value of 100%. Results were similar for poor neurological outcome, however there were no significant differences in subgroup analysis.
Conclusion: NSE measured three days after cardiac arrest is associated with long-term mortality and neurological outcome and may thus provide prognostic information that improves clinical decision-making, particularly in the subgroup of younger patients < 54 years, where NSE showed an excellent negative predictive value.
15:25 Uhr
P13:
Overmortality and disproportionate resource use during Covid-19 pandemic in the ICU
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Autor:innen:
Nora-Medea Messerich (St. Gallen | CH)
Gian-Reto Kleger (St. Gallen | CH)
Introduction: On March 11th, WHO declared SARS-CoV-2 infection as a pandemic. Switzerland was affected by a first wave (March to Jul) and a second wave (Oct-Dec) in 2020. A remarkable number of patients developed severe ARDS requiring intensive care unit (ICU) care and mostly invasive mechanical ventilation. ICU resources were severely strained due to high mortality, prolonged ICU length of stay (LOS), lack of ICU beds, need of specialized equipment, and specially trained ICU staff.
To assess the quality and performance of an ICU longitudinally, we regularly track two parameters: Standardized 28 d mortality rate (SMR) as an outcome parameter and standardized resource use (SRU) as a surrogate marker for effectiveness.
Objectives: Analysis of the outcome and effectiveness during the first and second waves of the Covid-19 pandemic in 2020 compared with previous years.
Methods: We analyzed prospectively obtained data of our quality assessment data set of our 12-bed medical ICU. SMR was calculated longitudinally (2012 to 2020) based on a recalibrated original SAPS II model. SRU was calculated longitudinally using the method of Rothen et al. [1], but using SAPS II. Both models were calibrated specifically to our ICU using pooled patient data from 2007 to 2013, generalized additive models (GAM), and a bootstrap sampling procedure.
Results: In 2020 we cared for 1’170 patients, including 137 with severe SARS-CoV-2 infection. 87 (64%) of these patients had been ventilated invasively and 22 (16%) had vv-ECMO. 38 (28%) patients died in the hospital and median ICU-LOS was 9 (IQR 3 to 18) days. This resulted in an SMR of 1.05 and SRU of 1.03, which is substantially higher than in previous years when we observed a steadily decreasing SMR and SRU (Fig. 1 and 2).
Conclusions: During the first Covid-19 pandemic year, the SMR in our ICU increased considerably compared with previous years, while resource use also increased. This reflects the high proportion of patients with Covid-19 who were hospitalized in the ICU during 2020. Mortality and resource consumption were disproportionally high in the first year of the Covid-19 pandemic.