[Comparison of current critical care information systems from the perspective of clinical users : Summary of the results of a German nationwide survey]. / Vergleich aktueller Patientendatenmanagementsysteme in der Intensivmedizin aus Sicht der klinischen Nutzer : Zusammenfassung der Ergebnisse einer deutschlandweiten Umfrage.

BACKGROUND: Critical care information systems (CCIS) are computer-based systems designed to process the growing amount of complex medical data in intensive care units (ICU). Previous studies have shown that CCICs can increase the quality of patient care by reducing errors and improving work efficiency; however, other studies have shown that CCISs can also cause harmful effects by disrupting workflow, facilitating medication errors or increasing charting time. The factors that decide whether a CCIS has a positive or negative impact on patient care are summarized under the term "usability". This article summarizes the results of three previously published papers on this topic. OBJECTIVE: The aim of the study was to identify which CCIS functions were considered useful by clinical ICU staff and how well these functions are implemented in the CCISs currently used in German ICUs. MATERIAL AND METHODS: An online survey was performed targeting nurses and physicians working in German ICUs using a previously validated questionnaire. The questionnaire included a list of functions (36 for physicians/31 for nurses) that were preselected by experts based on a comprehensive model of ICU work processes. Each of these functions was rated by the study participants on a Likert scale ranging from 0 (worst rating) to 5 (best rating) with respect to the usefulness to identify which functions of CCIS can truly be considered as useful by clinical ICU staff. Furthermore, the participants rated how well these functions were implemented in the CCIS currently in use on the ICU, also using a Likert scale of 0-5. Further questions were provided to rate specific technical usability aspects of the CCISs currently in use. In addition, to capture possible confounders the questionnaire recorded 18 individual and workspace characteristics which might influence the ratings. RESULTS: A total of 171 nurses and 741 physicians participated in the survey of which 535 used CCISs. Of the functions 33 were rated as useful for doctors and 28 functions for nurses with median scores between 4 and 5. Participants currently using CCISs gave higher ratings compared to participants not using CCISs. The quality of the functions was rated relatively lower than the usefulness and the availability. Furthermore, currently used CCISs in Germany differ greatly in their technical and task-specific usability. Of the CCISs investigated, the system ICUData had the best overall rating and technical usability followed by the systems ICM and MetaVision. The same three CCIS were rated best in task-specific functions without significant differences between them. CONCLUSION: Those functions that were identified as useful based on the ratings of clinical ICU staff should be implemented in current CCIS. The list of these functions might be regarded as a first step towards providing a catalog of functional requirements for CCISs. Furthermore, as the results show that the quality of the available functions was rated lower than the availability of the functions, manufacturers should shift more of the effort away from the development of new features and focus on improving the user-friendliness and quality of existing functions.

Infection control in german-speaking burn centres: results of an online survey.

To systematically evaluate which infection control measures are in place in burn units, we conducted an online survey among 43 German-speaking burn units. The 29 units that responded and agreed to publication represented more than 125 patient beds. All units were located in advanced care hospitals. A total of 14 units provided single rooms only, and 22 units had a nurse-to-patient ratio of at least 1:2. Infection control practices included pre-emptive barrier precautions (29 units), the use of sterile filters for tap water supply (29 units), and an antibiotic stewardship program (24 units). Microbial screening of the patients on admission (23 units), regular prevalence screening (26 units) and surveillance of nosocomial infections (21 units) were also widely used. The high reply rate to the survey indicates the special relevance of infection control for burn units. Our survey shows that great efforts and several measures are being undertaken to address infection control challenges in burn patient care, but it also underlines the need for increased interdisciplinary infection control and antibiotic stewardship activities.

Afin d'évaluer les mesures préventives des infections déployées, nous avons réalisé une enquête en ligne auprès de 43 Centres de Traitement des Brûlés germanophones. Les 29 CTB ayant répondu (et accepté la publication) représentent 125 lits. Tous les CTB étaient situés dans des hôpitaux de référence. Quatorze CTB n'avaient que des chambres seules, 22 avaient un ratio infirmière/patient de1/2. Les mesures préventives comprenaient les précautions barrière (29), des filtres aux points d'eau (29), un programme d'évaluation de l'antibiothérapie (24). La cartographie bactérienne à l'entrée (23), la surveillance de la prévalence des infections (26) et des infections nosocomiales (21) étaient aussi régulièrement déployées. Le taux de réponse élevé pour ce type d'étude montre l'intérêt porté à la prévention des infections en CTB. Cette étude montre que les CTB portent une attention particulière à la prévention et à la surveillance des infections. Elle démontre aussi l'intérêt d'une approche multidisciplinaire et de la mise en place de programmes d'évaluation de l'antibiothérapie.

Peak pressure during volume history and pressure-volume curve measurement affects analysis.

A previous volume history should be established prior to pressure- volume (P-V) curve measurement, however the effect of the volume history and the peak inspiratory pressure (PIP) during the P-V measurement has not been explored. Lung injury was created by lavage in nine sheep (25-35 kg). After stabilization, four P-V curves were sequentially obtained with PIP of 40, 50, 60, and 40 cm H2O. Prior to each P-V measurement the PIP delivered for 1 min was the same as during P-V measurement. We compared the lower inflection point (Pflex), upper inflection point (UIP), compliance below Pflex (Cstart), compliance between Pflex and UIP (Cinf), and compliance between UIP and peak pressure (Cend) for the inflation limb, and the point of maximum curvature on the deflation limb (PMC), compliance between peak pressure and PMC (Ctop), and maximum compliance (Cdef) for the deflation limb. In two sheep, Pflex at PIP 40 cm H2O could not be identified but appeared when PIP was raised. Pflex, Cstart, Cend, and Ctop were not affected by the PIP. However, UIP, PMC, Cinf, and Cdef increased as the PIP increased. Volume history and the PIP during P-V curve measurements affect both the inflation and deflation P-V curves.

[Analgo-sedation in intensive care: a quantitative, EEG-based trial with propofol 1% and 2%]. / Analgosedierung auf der Intensivstation. Eine quantitative, EEG-gestützte Untersuchung mit Propofol 1% und 2%.

OBJECTIVE: The primary aim of this study was to find out whether adequate long-term sedation (> or = 72 h) can be achieved in critically ill patients with an EEG median frequency controlled closed-loop system for the application of propofol 1% and 2%. Moreover, we investigated the pharmacokinetics and pharmacodynamics of propofol with respect to possible tolerance and compared the quality of sedation of both propofol formulations and their lipid load. PATIENTS AND METHODS: After institutional approval and written consent, 16 ASA II-IV patients were included in this study. Main inclusion criterion was the necessity for prolonged sedation/analgesia for at least 72 h. Sedation was induced and maintained using continuous infusion of propofol 1% (n = 7) or 2% (n = 9). Analgesia was maintained with continuous infusion of alfentanil. The EEG was recorded from four leads (Fp1,2 and C3,4) and the EEG median frequency was obtained from the power spectrum (0.5-32 Hz). Propofol was administered computer-controlled with a median frequency setpoint depending on the depth of sedation which was assessed clinically using a modified Ramsay score. Alfentanil was applied as TCI. Arterial plasma concentrations were measured by HPLC (propofol) and RIA (alfentanil). Pharmacokinetics of propofol and alfentanil were derived using a three compartment model. RESULTS: All patients were successfully sedated for 77 +/- 9 h. The median EEG frequency during sedation was stable at 1.5 +/- 0.2 Hz. The sedation score increased from 1 in the first 12 h to values between 2 and 3 for the remaining sedation period. At the same time, propofol plasma concentrations increased from 0.7 +/- 0.3 microgram/ml to 1.8 +/- 1.3 micrograms/ml. The patients required an average of 2.5 mg/kg/h propofol and 0.030 mg/kg/h alfentanil. Pharmacokinetics of propofol 2% showed an increased volume of distribution when compared to propofol 1%. Alfentanil clearance was found to be reduced with four patients having extremely small clearance values (33 +/- 3 ml/min). Triglyceride values increased up to 4.5 +/- 1.2 mmol/l for patients receiving propofol 1% and remained within normal range for propofol 2%. CONCLUSIONS: The EEG median frequency can be used for closed-loop control of propofol even for long-term sedation in critically ill patients. EEG median frequencies were similarly low as in deeply anaesthetised patients. No differences in quality of sedation were seen between the two propofol formulations, but propofol 2% seems to be advantageous due to lower lipid load and triglyceride values. Increasing concentrations of propofol at unchanged sedation scores and EEG median frequencies may indicate development of tolerance.