Advance Care Planning in Switzerland: Chances and challenges of delivering high-quality ACP in a small high-income, multilingual, federally organized country.

We describe the development of ACP in Switzerland during the last decade in the German- and French-speaking cantons and on the national level. In 2013, a revision of the Swiss civil law came into force, declaring advance directives (ADs) as binding. Since then, ACP has been researched and implemented primarily by universities and university hospitals. Despite the foundation of the national association "ACP Swiss" in 2020, several national initiatives, and a roadmap for a national implementation, many challenges and barriers still remain. There is, however, reasonable hope to implement high-quality ACP throughout Switzerland within the next ten years.

Continuous Estimation of Cardiac Output in Critical Care: A Noninvasive Method Based on Pulse Wave Transit Time Compared with Transpulmonary Thermodilution.

PURPOSE: Estimation of cardiac output (CO) and evaluation of change in CO as a result of therapeutic interventions are essential in critical care medicine. Whether noninvasive tools estimating CO, such as continuous cardiac output (esCCOTM) methods, are sufficiently accurate and precise to guide therapy needs further evaluation. We compared esCCOTM with an established method, namely, transpulmonary thermodilution (TPTD). Patients and Methods. In a single center mixed ICU, esCCOTM was compared with the TPTD method in 38 patients. The primary endpoint was accuracy and precision. The cardiac output was assessed by two investigators at baseline and after eight hours. RESULTS: In 38 critically ill patients, the two methods correlated significantly (r = 0.742). The Bland-Altman analysis showed a bias of 1.6 l/min with limits of agreement of -1.76 l/min and +4.98 l/min. The percentage error for COesCCO was 47%. The correlation of trends in cardiac output after eight hours was significant (r = 0.442), with a concordance of 74%. The performance of COesCCO could not be linked to the patient's condition. CONCLUSION: The accuracy and precision of the esCCOTM method were not clinically acceptable for our critical patients. EsCCOTM also failed to reliably detect changes in cardiac output.

Renal cell carcinoma in kidney transplant recipients: descriptive analysis and overview of a major German transplant center.

Aim: Elevated risk of malignancy-related death after renal transplantation is reported and renal malignancy was ranked as the third most frequent site of malignancy-related death. However, there is a lack of data characterizing renal cell carcinoma associated with end-stage renal disease and kidney transplantation. Patients & methods: We retrospectively identified 5250 patients who underwent kidney transplantation at the Hannover Medical School since 1970. Results: 124 patients with renal cell carcinoma (incidence 2.36%) were identified. Among all patients, metastatic recurrence was noted in 4.8%. In multivariate analysis, tumor stage and hemoglobin were identified as independent prognostic markers of OS, while tumor grading was predictive for disease recurrence. Conclusion: Apart from showing the prognostic value of tumor staging and hemoglobin, our data suggest that a risk adapted approach for early transplantation is feasible.

A case report: a 22-year-old septic patient with central venous pO2 of 198 mmHg.

BACKGROUND: Central venous saturation and central venous pressure can be determined with central venous catheters. Therefore, the tip of the catheter should be located in the superior vena cava. The location can be monitored by electrocardiography or X-ray. The central venous pressure curve is displayed on the monitor. The reference value of central venous saturation is >70%. Venous pO2 is normally 35-45 mmHg and central venous pressure 1-9 mmHg. CASE SUMMARY: We treated a 22-year-old patient with septic shock. Central venous saturation was 100% with a pO2 of 198 mmHg. The arterial blood gas analysis was comparatively low with saturation of 98% and pO2 of 111 mmHg. On chest X-ray, the central venous catheter tip appeared on the left side of the heart. On echocardiography, aortic positioning was not evident. On the monitor, a 'venous pressure-like' curve was seen, that did not stand in exact correlation to the electrocardiogram curve. The computed tomography (CT) image showed placement of the catheter in the upper left pulmonary vein. The patient had a partial anomalous pulmonary venous return. DISCUSSION: The C-wave of the central venous pressure curve normally occurs after the R-wave of the electrocardiogram. If C-waves appeared before R-waves, the central venous catheter placement is not central venous and must be checked. In our case, the apparent 'venous' pO2 in blood gas examination was higher than arterial pO2. The catheter position had to be in an oxygenated vessel proximal to the left ventricle. A vascular anomaly was a possible diagnosis and was confirmed on CT imaging.

Low Level of Vegetative State After Traumatic Brain Injury in a Swiss Academic Hospital.

BACKGROUND: No standards exist regarding decision making for comatose patients, especially concerning life-saving treatments. The aim of this retrospective, single-center study was to analyze outcomes and the decision-making process at the end of life (EOL) in patients with traumatic brain injury (TBI) in a Swiss academic tertiary care hospital. METHODS: Consecutive admissions to the surgical intensive care unit (ICU) with stays of at least 48 hours between January 1, 2012 and June 30, 2015 in patients with moderate to severe TBI and with fatality within 6 months after trauma were included. Descriptive statistics were used. RESULTS: Of 994 ICU admissions with TBI in the study period, 182 had an initial Glasgow Coma Scale <13 and a length of stay in the ICU >48 hours. For 174 of them, a 6-month outcome assessment based on the Glasgow Outcome Scale (GOS) was available: 43.1% (36.0%-50.5%) had favorable outcomes (GOS 4 or 5), 28.7% (22.5%-35.9%) a severe disability (GOS 3), 0.6% (0%-3.2%) a vegetative state (GOS 2), and 27.6% (21.5%-34.7%) died (GOS 1). Among the GOS 1 individuals, 45 patients had a complete dataset (73% men; median age, 67 years; interquartile range, 43-79 years). Life-prolonging therapies were limited in 95.6% (85.2%-99.2%) of the cases after interdisciplinary prognostication and involvement of the surrogate decision maker (SDM) to respect the patient's documented or presumed will. In 97.7% (87.9%-99.9%) of the cases, a next of kin was the SDM and was involved in the EOL decision and process in 100% (96.3%-100.0%) of the cases. Written advance directives (ADs) were available for 14.0% (6.6%-27.3%) of the patients, and 34.9% (22.4%-49.8%) of the patients had shared their EOL will with relatives before trauma. In the other cases, each patient's presumed will was acknowledged after a meeting with the SDM and was binding for the EOL decision. CONCLUSIONS: At our institution, the majority of deaths after TBI follow a decision to limit life-prolonging therapies. The frequency of patients in vegetative state 6 months after TBI is lower than expected; this could be due to the high prevalence of limitation of life-prolonging therapies. EOL decision making follows a standardized process, based on patients' will documented in the ADs or on preferences assumed by the SDM. The prevalence of ADs was low and should be encouraged.

Pretransplant dyslipidaemia influences primary graft dysfunction after lung transplantation.

OBJECTIVES: Primary graft dysfunction (PGD) is a major cause of mortality within the first year following lung transplantation. Pulmonary hypertension, elevated body mass index (BMI), prolonged ischaemic time of the graft, intraoperative blood transfusions >1000 ml and the use of cardiopulmonary bypass or extracorporeal membrane oxygenation increase the risk for PGD. We aimed to evaluate whether dyslipidaemia is an additional risk factor for the development of PGD. METHODS: We retrospectively analysed demographic and clinical data of 264 patients who received their first bilateral lung transplantation between March 2000 and October 2013 at our institution. The endpoint was PGD grade 3 at any time, defined according to the International Society for Heart and Lung Transplantation (ISHLT) criteria. Fasting lipid profiles at listing time or just before transplantation (baseline) were documented and dyslipidaemia was defined as any of the parameters being out of range. Comparisons of continuous variables between patients with PGD grade 3 and patients without were performed with the Mann-Whitney U-test, whereas proportions were compared with the χ(2) test. Continuous variables were presented as arithmetic means with standard deviation for ease of comparison, but levels of statistical significance were computed using the appropriate non-parametric statistical test. To identify PGD risk factors, a forward stepwise logistic regression model was used. RESULTS: PGD occurred in 63 recipients (24%). Pretransplant dyslipidaemia was documented in 153 recipients (58%) and was significantly more prevalent among recipients developing PGD (45 vs 108, P < 0.013). Despite various underlying pulmonary pathologies, higher triglyceride (TG) levels (1.41 ± 0.78 vs 1.16 ± 0.78, P < 0.012), lower high-density lipoprotein-cholesterol (HDL-C) concentrations (1.24 ± 0.55 vs 1.57 ± 0.71, P < 0.0005) and higher cholesterol/HDL-C values (3.80 ± 2.02 vs 3.00 ± 0.92, P < 0.0005) were associated with a lower incidence of PGD. Patients with PGD had significantly longer ischaemic time (350 ± 89 vs 322 ± 91, P = 0.017) and higher BMI (23 ± 5 vs 21 ± 4.4, P < 0.007). CONCLUSIONS: Dyslipidaemia seems to be an independent risk factor for PGD after lung transplantation: low circulating levels of HDL-C and hypertriglyceridaemia increase the incidence of PGD. Even if HDL-C levels are difficult to alter today, triglyceride and cholesterol levels can be addressed therapeutically and may have a positive influence on the development of PGD.

Hemodynamics during an ambulance flight.

Transportation of patients may present challenges, especially if they need intensive care, require mechanical ventilation, or are hemodynamically unstable. In the reported case study, Picco-based measurements were used to track hemodynamic changes in a patient throughout the duration of a transfer, which included an air ambulance transport. If air medical transport is indicated, several additional physical and chemical considerations require awareness during the trip, planning, and pretransport patient preparation: first, that decreasing atmospheric pressure leads to reduced blood oxygenation, and second, that intracorporeal volume shifts may occur during takeoff and landing. To our knowledge, our findings represent the first measurements with a Picco system during interhospital patient transport that included an air medical flight.