[Application of a sponaneous ventilation protocol. Experiences from a weaning center for neurological diseases]. / Anwendung eines standardisierten Spontanatmungsprotokolls. Erfahrungen in einem Weaning-Zentrum mit neurologischem Schwerpunkt.

OBJECTIVE: The aim of this study was to investigate a novel standardized protocol in this neurological weaning unit in order to optimize the weaning process for patients subjected to prolonged mechanical ventilation. Of primary interest were the frequency of and reasons for deviating from the protocol as well as risk factors for weaning failure and mortality. PATIENTS AND METHODS: All patients admitted to the weaning unit were enrolled in this prospective observational study. The weaning protocol consisted of 22 discrete weaning steps. An individual weaning approach was only begun if the standardized protocol failed. Variables for risk analysis included age, body mass index, APACHE II score, reason for initiating mechanical ventilation, total duration of inpatient stay before admission to the weaning unit, extent of mechanical ventilation period before admission, chronic pulmonary diseases and dialysis. RESULTS: Between October 2007 and December 2008 a total of 644 consecutively admitted patients were enrolled in the study. The mean age was 67.6 ± 12.3 years, the mean inpatient stay before admission was 45.8 ± 34.9 days and the mean duration of mechanical ventilation before admission to the unit was 38.1 ± 28.7 days. The mean APACHE II score was 19.0 ± 7.2, 68 % of the patients were male, 98.6 % had a tracheotomy tube, 30.9 % had a history of chronic pulmonary disease and 13.7 % required dialysis. Reasons for initiating ventilation were cerebral 33.1 %, pulmonary 28.7 %, cardiovascular 31.5 %, neuropathic 2.8 %, myopathic 0.9 %, spinal cord injuries 1.9 % and 1.1 % were unclear. Weaning was successful in 77.3 % (498 patients) of all cases with a mean duration of 22.0 ± 33.9 days. Of those successfully weaned, a total of 85.9 % (n = 428) were weaned according to the standard protocol. The weaning process was also shorter (20.8 ± 35.6 versus 29.0 ± 19.9 days) for those patients weaned according to the protocol compared to those patients where the protocol failed. Protocol failure was normally due to complications during the weaning process. Among the patients where the protocol failed, chronic pulmonary disease (41.4 versus 28.3 %; p < 0.02), a longer duration of ventilation (42.3 ± 22.8 versus 35.9 ± 25.3 days; p < 0.01) and a longer in-hospital stay (52.7 ± 41.4 versus 42.4 ± 30.1 days; p < 0.01) prior to admission were significantly more common. A total of 23.0 % (n = 148) of the patients died and 9.8 % (n = 63) of the patients were discharged into a home care ventilation program. Chronic pulmonary disease and the duration of inpatient stay prior to admission were predictors of weaning failure. The APACHE II score, age and acute renal failure with concomitant need for dialysis were the factors best predicting mortality. CONCLUSIONS: The majority of patients receiving prolonged mechanical ventilation can be successfully weaned using a standardized protocol. Failures of standardized weaning per protocol occurred most often in patients with chronic pulmonary disease and following longer inpatient stay. These patients also had a higher risk of final weaning failure.

[Weaning from prolonged mechanical ventilation in neurological weaning units: an evaluation of the German Working Group for early Neurorehabilitation]. / Beatmungsentwöhnung in neurologischen Weaningzentren : Eine Bestandsaufnahme der Arbeitsgemeinschaft Neurologisch-neurochirurgische Frührehabilitation.

BACKGROUND: A significant proportion of patients with long-term mechanical ventilation (MV) and difficult or prolonged weaning suffer from primary or secondary neurological conditions and concomitant functional disorders, in addition to respiratory problems. Therefore, these patients are treated in neurological weaning departments. MATERIAL AND METHODS: Using a questionnaire members of the German Working Group for early neurorehabilitation were interviewed with respect to the structure of weaning facilities, weaning strategies, patient characteristics and treatment outcome of patients admitted for weaning in 2009. RESULTS: In the year 2009 a total of 1,486 patients were admitted to 7 participating neurological weaning units. The primary diagnosis was a neurological condition in 97.5% of the patients. In 62.9% of the patients the neurological condition was considered to be primarily responsible for the MV, 22.8% demonstrated pulmonary factors and for 3.0% a cardiac condition was determined to be decisive. In 5.0% of the patients it was not possible to ascertain a single cause or factor. Weaning was successful in 69.8% of all cases, 64.9% (965 patients) were released from the facility without MV, 274 patients (18.4%) were released with MV, 61.3% of these (168 patients) were referred to other rehabilitation facilities or into the care of the family physician and 38.7% (106 patients) were transferred to other hospitals due to special medical problems. The total mortality rate was 16.6% (247 patients deceased). CONCLUSIONS: In this first comprehensive evaluation of German neurological weaning centers for patients with long-term MV, structures and treatment outcomes were compared with recent results from the literature.

[Critical illness polyneuropathy und polymyopathy. How certain is the clinical diagnosis in patients with weaning failure?]. / Critical-illness-Polyneuropathie und -Polymyopathie. Wie sicher ist die klinische Diagnose bei Patienten mit Weaning-Versagen?

A frequent cause of weaning failure and the resultant long-term artificial ventilation is the generalized weakness syndrome in the sense of critical illness polyneuropathy or polymyopathy. However, hardly any information is presently available regarding the necessary intensity of the diagnostic workup for reaching or excluding a diagnosis with certainty in the neurological examination or regarding the additional diagnostic value of electrophysiological studies in patients receiving long-term acute care suspected of having critical illness polyneuropathy and polymyopathy. Therefore, the goal of this investigation was to address these questions. A total of 280 patients with complicated weaning were included in the study. All patients underwent clinical examination by a specialist in neurology and electrophysiological workup performed by another specialist. Among the patients studied, the greatest possible certainty of the diagnosis (positive predictive value) of the clinical examination was 97.9% [95% confidence interval (CI) 69.4-99.9] and the best certainty of excluding the diagnosis (negative predictive value) was 88.9% (95% CI 82.7-93.0). Thus, in difficult-to-wean patients who were considered to probably have the diagnosis of critical illness polyneuropathy or polymyopathy as assessed by a specialist, little additional information is gained from an electrophysiological study, which is hence dispensable in these cases.

Ethical and legal aspects of enteral nutrition.

European ethical and legal positions with regard to EN vary slightly from country to country but are based on a common tradition derived from Graeco Roman ideas, religious thought and events of the 20th century. The Hippocratic tradition is based on 'beneficience' (do good) and 'non-maleficience' (do no harm). Religious thinking is based upon the presumption of providing food and drink by whatever means unless burden outweighs benefit. The concept of 'autonomy' (the patients right to decide) arose following in the decades after the Second World War and is enshrined in Human Rights law. The competent patient has the right to participate in decision making and to refuse treatment although the doctor is not obliged to give treatment which he or she considers futile or against the patient's interests. The incompetent patient is protected by law. The fourth principle is that of 'justice' i.e. equal access to healthcare for all. The law regards withholding and withdrawing treatment as the same. It also defines the provision of food and drink by mouth as basic care and feeding by artificial means as a medical treatment. It requires doctors to act in the best interests of the patient.

[Color-coded duplex ultrasound and contrast medium enhanced duplex ultrasound in deep venous thrombosis]. / Farbkodierte Duplexsonographie und kontrastmittelverstärkte Duplexsonographie bei tiefer Beinvenenthrombose.

Even with highly developed ultrasound systems, diagnosis of deep leg vein thrombosis is difficult in lower leg veins and in the area of the adductor channel. In order to evaluate color duplex-sonography, contrast media duplex-sonography and phlebography in comparison, 79 patients (38 men and 40 women aged 54 to 89) with deep leg vein thrombosis were examined. As a result, patients suffering from thrombosis were characterized by a vein-artery quotient of > 2.0 (p < 0.01). In color Doppler duplex-sonography false negative findings occurred in 12 cases of lower leg vein thrombosis and in 3 cases of thrombosis within the adductor channel. By contrast media duplex-sonography the diagnostic reliability could be increased to a sensitivity of over 95 per cent.

[Experiences in the use of color-coded intracranial duplex ultrasound]. / Erfahrungen bei der Anwendung der farbkodierten intrakraniellen Duplexsonographie.

Thirty patients (12 men and 4 women over 60, and 8 men and 6 women under 60 years) with angiographically intact brain vessels were examined by intracranial Duplex Sonography. The flow velocity within the Arteria cerebri media was found to show normal values. In order to examine the connection between the degree of seriousness of a one-sided internal carotid stenosis and the resulting flow velocity in both medial cerebral arteries, 74 patients (36 over and 38 under 60 years) with temporary neurologic deficits or transitory ischemic attacks were examined. One to three weeks after angiography, intracranial Duplex Sonography was carried out. The group of patients over 60 years with a one-sided 50 percent internal carotid stenosis showed significantly lower maximum low velocity values of the homolateral Arteria cerebri media in comparison with the control group. The group of patients under 60 years also presented with significantly lower flow velocity values of the homolateral A. cerebri media, but only in the cases with filiform stenoses or occlusions. The advantages and disadvantages of this ultrasound method are discusses.

[Value of color-coded duplex sonography in diagnosis of extracranial vascular changes]. / Wertigkeit der farbkodierten Duplex-Sonographie bei der Diagnostik extrakranieller Gefässveränderungen.

72 patients at the age of 44 to 76 years with transitory ischaemic attacks which happened and for a short time reversible deficits, respectively, were diagnosed both conventionally duplex-sonographically and with the colour-coded duplex sonography under the question of vascular stenotic process in the region of the cervical vessels. After the ultrasound examination within two weeks an angiography was performed. As a result was shown that in 10 patients with an angiogram without pathological findings by means of the colour-coded duplex sonography in 3 cases plaque formations could be proved which could be clearly diagnosed only by colour marking.