[Inadequate ICU-admissions : A 12-month prospective cohort study at a German University Hospital]. / Nicht indizierte Aufnahmen auf der Intensivstation : 12-Monats-Observationsstudie an einem Universitätsklinikum.

BACKGROUND: Intensive care medicine (ICM) is increasingly utilized by a growing number of critically ill patients worldwide. The reasons for this are an increasingly ageing and multimorbid population and technological improvements in ICM. Inappropriate patient admissions to the intensive care unit (ICU) can be a threat to rational resource allocation and to patient autonomy. OBJECTIVES: In this study, the incidence, characteristics, and resource utilization of patients inappropriately admitted to ICUs are studied. METHODS: This prospective study included all consecutive patients admitted from 01 September 2012 to 31 August 2013 to the Department of Intensive Care Medicine of a German university hospital comprised of 10 ICUs and 120 beds. Inappropriate admission was defined according to category 4B of the recommendations of the Society of Critical Care Medicine (SCCM; "futility of ICU treatment" or "ICU declined by patient") and was determined in each suspected case by structured group discussions between the study team and all involved care givers including the referring team. RESULTS: In all, 66 of 6452 ICU admissions (1 %) were suspected to have been inappropriate on retrospective evaluation the day after admission. In 50 patients (0.8 %), an interdisciplinary consensus was reached on the inappropriateness of the ICU admission. Of these 50 patients, 41 (82 %) had previously declined ICU treatment in principle. This information was based on the patient's presumed wish as expressed by next of kin (56 %) or in a written advanced directive (26 %). In 9 patients (18 %), ICU treatment was considered futile. In all cases, a lack of information regarding a patient's wishes or clinical prognosis was the reason for inappropriate ICU admission. CONCLUSION: In this study, patients were regularly admitted to the ICU despite their contrary wish/directive or an unfavorable clinical condition. Although this was registered in only 1 % of all admissions, optimizing preICU admission information flow with regard to relevant exclusion criteria not only helps respect patient autonomy but also allows for more adequate resource allocation.

Extracorporeal lung support in patients with chronic obstructive pulmonary disease.

When patients with chronic obstructive lung disease (COPD) and acute on chronic respiratory insufficiency fail non-invasive ventilation (NIV) they are commonly intubated and treated with invasive mechanical ventilation (IMV) to ensure adequate gas exchange. However, IMV itself is associated with considerable complications which can aggravate any pre-existing lung disease and contribute to morbidity and mortality. When lung protective ventilation fails or cannot be maintained, full or partial extracorporeal lung assist (ECLA) is increasingly used to provide oxygenation and/or carbon dioxide removal. This can rescue patients' lives, help resting their lungs until recovery or transplantation or even avoiding intubation and IMV in the first place. Recent technological improvements of extracorporeal devices have made ECLA more efficient and safe. This article discusses different types of ECLA, their potential indications in patients with COPD as well as the preliminary clinical evidence for their effectiveness and safety.

Comparison of three different commercial PCR assays for the detection of pathogens in critically ill sepsis patients.

INTRODUCTION: The high mortality rate associated with sepsis necessitates a timely identification of the causative organism in order to optimize antimicrobial therapy. PCR assays are increasingly being used for this purpose. The aim of this study was to compare three commercially available PCR systems for the diagnosis of systemic infections. PATIENTS AND METHODS: In a prospective observational study, a broad-range (SepsiTest®; Molzym, Bremen, Germany) and two multiplex PCR assays (VYOO®; SIRS-Lab, Jena, Germany and LightCycler® SeptiFast; Roche, Mannheim, Germany) were compared to blood cultures with respect to the clinical course of 50 critically ill patients with sepsis, severe sepsis or septic shock. RESULTS: Pathogens were detected by PCR in 12 % (SepsiTest®), 10 % (VYOO®) and 14 % (LightCycler® SeptiFast) of samples and in 26 % by blood culture. Negative results were obtained using all four methods in 32 samples (64 %) and 3 (6 %) samples were positive in all tests. Upon consideration of additional diagnostic findings and the clinical course, eight (16 %) of the positive blood culture results were deemed clinically relevant. All three PCR assays could also identify the causative organism (or a specific gene thereof) in three of these eight positive blood cultures, whereas for five of the eight, all three PCR assays were negative. In one patient with a negative blood culture, the SepsiTest®, VYOO® and LightCycler® SeptiFast assays were positive for Streptococcus species. The PCR assays appeared to be less susceptible than blood cultures to false-positive results arising from contamination with coagulase-negative staphylococcal organisms. CONCLUSION: There was some variability between the three PCR assays tested and the corresponding blood cultures with regards to the type of pathogen detected. The three PCR assays appeared to be less susceptible to false-positive results than blood cultures.