Prevalence of tracheostomy in ICU patients. A nation-wide survey in Switzerland.

OBJECTIVE: To assess the frequency, timing and technique of tracheostomy and its variation between different intensive care units (ICUs) in Switzerland. DESIGN: Retrospective, descriptive prevalence study. SETTING: A questionnaire was sent to all intensive care units formally recognized by the Swiss Society of Intensive Care Medicine. Excluded were paediatric ICUs. A total of 48 ICUs (70 %) responded. PATIENTS: In 1995 and 1996 the participating units had admitted 90,412 patients for a total of 243,921 ICU days. RESULTS: Seventy percent of the contacted ICUs answered the questionnaire. The prevalence of tracheostomy was 10% in the long-term ventilated patients (defined as > 24 h), or 1.3 % of all patients. Most tracheostomies were performed during the 2nd week of ventilation. The frequency of tracheostomy varied widely (0-60 %) and was only slightly associated with the different language regions of our country and with the policy of hospitals to accept or refuse intubated patients on their normal wards. Most units offered either conventional surgical tracheostomy (69 %) and/or percutaneous procedures (57 %). The decision to perform a tracheostomy was made mostly by the intensivist and the procedure was more often performed in the ICU (65 %) than in the operating theatre (35 %). Units where the intensivist had exclusive control used only percutaneous techniques. An overall complication rate of 13 % was reported, bleeding and infections being at the top of the scale. Only 27 % of the units performed late follow-up protocols. CONCLUSIONS: Despite its frequency, tracheostomy in Swiss ICUs is far from being standardized with regard to indication, timing and choice of technique.

Improving time-sensitive processes in the intensive care unit: the example of 'door-to-needle time' in acute myocardial infarction.

OBJECTIVE: To assess and reduce delays in coronary thrombolysis in patients with acute myocardial infarction. DESIGN: Prospective, descriptive study using statistical process control. SETTING: Interdisciplinary intensive care unit of a 300-bed community hospital. SUBJECTS: Thirty-seven consecutive patients with acute myocardial infarction who were receiving thrombolytic therapy. INTERVENTIONS: To perform an interdisciplinary formal process analysis aimed at detecting delay-causing factors, review of existing house rules, generation and implementation of new practice guidelines. MAIN OUTCOME MEASURES: Comparison of 'door-to-needle times' of patients admitted before, during and after formal process analysis and implementation of new guidelines. RESULTS: Mean 'door-to-needle time' fell significantly from 57 minutes (+/-25.4) in 16 patients studied before, to 32 minutes (+/-9.0) in 16 patients studied after the formal process analysis and the implementation of new guidelines (P < 0.002). An even more pronounced but transient decrease to 24 minutes (+/-3.8) was observed in five patients studied during the phase of formal process analysis (P < 0.004). Delay-causing factors were identified in the areas 'communication', 'people' and 'methods/rules/guidelines'. Equipment failure was never responsible for delays. CONCLUSIONS: Formal process analysis, followed by implementation of revised guidelines resulted in a significant reduction of 'door-to-needle time'. An initial dramatic but transient reduction of 'door-to-needle time' was considered observational and must not be mistaken as the definite new level of performance. We conclude that formal process analysis techniques are suited to improve processes in the intensive care unit.

[Quality assurance in intensive care: the situation in Switzerland]. / Qualitätssicherung in der Intensivmedizin: die Situation in der Schweiz.

The movement for quality in medicine is starting to take on the dimensions of a crusade. Quite logically it has also reached the intensive care community. Due to their complex multidisciplinary functioning and because of the high costs involved, ICUs are model services reflecting the overall situation in our hospitals. The situation of Swiss intensive care is particularly interesting, because for over 25 years standards for design and staffing of Swiss ICUs have been in effect and were enforced via onsite visits by the Swiss Society of Intensive Care without government involvement. Swiss intensive care thus defined its structures long before the word "accreditation" had even been used in this context. While intensive care in Switzerland is practised in clearly defined, well equipped and adequately staffed units, much less is known about process quality and outcomes of these services. Statistics on admissions, length of stay and length of mechanical ventilation, as well as severity data based on a simple classification system, are collected nationwide and allow some limited insight into the overall process of care. Results of intensive care are not systematically assessed. In response to the constant threat of cost containment, Swiss ICUs should increasingly focus on process quality and results, while maintaining their existing good structures.

Hb Iraq-Halabja beta10 (A7) Ala-->Val (GCC-->GTC): a new beta-chain silent variant in a family with multiple Hb disorders.

A patient originating from Iraq was referred to our laboratory upon suspicion of a hemoglobinopathy. Routine hematological tests revealed a microcytic and slightly anemic phenotype with an elevated HbA2 suggestive of beta-thalassemia. Samples were obtained for several members of the family which upon examination revealed highly heterogeneous phenotypes that prompted us to investigate the case further. Sequencing of the beta-globin gene and alpha cluster mapping in the propositus and his brother showed a previously undescribed beta-globin variant:Hb Iraq-Halabja, beta10(A7) Ala-->Val (GCC-->GTC), associated with beta0-thalassemia IVS-2 nt1 G-->A and either alpha-thal-2-3.7 kb deletion (brother), or alpha-globin gene triplication anti-3.7 kb type (propositus). Detailed functional studies of the variant gave a normal oxygenation curve, a normal heterotopic action of 2,3 DPG, and normal heat stability and isopropanol precipitation tests. The variant shows a clear difference in migration properties compared to normal beta-chain only when run on PAGE urea Triton. As expected, alpha/beta-globin mRNA ratios were influenced by the concomitant presence of an alpha-globin gene pathology and the beta0 thalassemia and not by the presence of the beta-globin variant which apparently is clinically silent.

Acute colonic pseudoobstruction (Ogilvie's syndrome) in two patients receiving high dose clonidine for delirium tremens.

We describe two cases of severe colonic pseudo-obstruction (Ogilvie's Syndrome) after high dose clonidine i.v. infusions for delirium tremens. The first symptoms occurred 36 h and 5 days, respectively, after institution of therapy. The diagnosis of colonic pseudo-obstruction (CPO) was confirmed during emergency laparotomy in both cases. While other known risk factors may have been present, we propose that clonidine had a major parasympatholytic effect on the large bowel of these patients and was therefore responsible, either alone or in combination with these other factors, for the development of CPO. We conclude that the therapy of delirium tremens with high i.v. doses of clonidine carries the risk of provoking severe CPO, especially when other contributing factors are present. While therapy of the alcohol withdrawal syndrome with clonidine appears to be an attractive alternative to conventional treatment, ICU physicians should be alerted to this potentially serious complication.

[The trauma patient: open hospital choice?]. / Der Unfallpatient: Freie Spitalwahl?

Victims of trauma have usually no choice regarding the physician or hospital they are admitted to. In order to deliver the best possible trauma care it is crucial that trauma victims first receive competent on site primary care before being admitted directly to a hospital that is sufficiently equipped and qualified to take care of their injuries. Recent literature suggests that individual outcomes, but also per-case costs of trauma patients clearly improve, when prehospital care, triage and admission to specially designed trauma centres are coordinated within regional trauma systems. This provides supporting evidence for the recent proposals by the Swiss Medical Association (FMH) in 1996 who formulated 12 statements regarding rescue services in Switzerland. In order to optimise rescue and trauma care there is an urgent need for restructuring existing systems nation-wide. Trauma patients may thus to some degree lose their freedom in choosing their preferred physician or hospital.

Process quality in the intensive care unit.

This review describes general principles of quality control and focuses on the issue of process quality in intensive care units. Process quality of a service organisation mostly involves the factors timing and communications. Management tools for improving and enhancing process quality are mainly edition and enforcement of practice guidelines, but also the setting of performance standards and regular audits of process quality by selected indicators. Implementation of these concepts into the practice of Intensive Care is discussed and recommendations are made.

The automatic selection of ventilation parameters during the initial phase of mechanical ventilation.

OBJECTIVE: To test a method that allows automatic set-up of the ventilator controls at the onset of ventilation. DESIGN: Prospective randomized crossover study. SETTING: ICUs in one adult and one children's hospital in Switzerland. PATIENTS: Thirty intubated stable, critically ill patients (20 adults and 10 children). INTERVENTIONS: The patients were ventilated during two 20-min periods using a modified Hamilton AMADEUS ventilator. During the control period the ventilator settings were chosen immediately prior to the study. During the other period individual settings were automatically determined by the ventilatior (AutoInit). MEASUREMENTS AND RESULTS: Pressure, flow, and instantaneous CO2 concentration were measured at the airway opening. From these measurements, series dead space (V(DS)), expiratory time constant (RC), tidal volume (VT, total respiratory frequency (f(tot), minute ventilation (MV), and maximal and mean airway pressure (Paw, max and Paw, mean) were calculated. Arterial blood gases were analyzed at the end of each period. Paw, max was significantly less with the AutoInit ventilator settings while f(tot) was significantly greater (P < 0.05). The other values were not statistically significant. CONCLUSIONS: The AutoInit ventilator settings, which were automatically derived, were acceptable for all patients for a period of 20 min and were not found to be inferior to the control ventilator settings. This makes the AutoInit method potentially useful as an automatic start-up procedure for mechanical ventilation.

Severe skiing injuries: a retrospective analysis of 361 patients including mechanism of trauma, severity of injury, and mortality.

All ski accident patients requiring an inhospital treatment at our institute from 1984 to 1992 (n = 2,053) were analyzed retrospectively. The incidence, pattern, and severity of the injuries, as well as the 30-day mortality comparing two time slots (1984 to 1988 and 1989 to 1992) were analyzed for the 361 cases classified as "serious" injuries according to the following definitions and groupings: group 1, multiple trauma (Injury Severity Score > or = 18) and patients with multiple fractures (n = 179; group 2, abdominal or thoracic single trauma (Abbreviated Injury Scale (AIS) score > or = 2, n = 58); and group 3, isolated head injuries (AIS score > or = 2, n = 124). Serious injuries were observed in 19% in the first period compared to 16% in the second period (not significant). Two hundred thirty-eight of 361 patients injured themselves by just falling, while 117 collided with some sort of obstacle like other skiers (45), trees or rocks (27), posts, pylons, barriers (20), and moving objects (25) such as piste machines, ski lifts, automobiles, and in one case a helicopter. Six skiers were caught on the ski run by an avalanche. Comparing the two time periods, trauma circumstances did not change significantly. The number of most severe head injuries (AIS score > or = 4) increased from 11.6 to 19.3% (p < 0.05). The overall mortality increased from 2 to 7% (p < 0.05). Group 2 had the best prognosis with no mortality, while group 3 was rated worst with 8%. Skiing remains a major source of serious trauma in winter resort areas.(ABSTRACT TRUNCATED AT 250 WORDS)

Late outcome of percutaneous dilatational tracheostomy in intensive care patients.

OBJECTIVE: Percutaneous dilatational tracheostomy is increasingly practiced in intensive care units and has a low incidence of early complications. The late effects of this procedure are still poorly known and were the focus of this study. DESIGN: Prospective descriptive clinical study. SETTING: Interdisciplinary intensive care unit in a 300-bed teaching hospital. PATIENTS: A consecutive group of critically ill patients who underwent percutaneous tracheostomy between Nov. 90 and March 93, surviving at least 2 months after decannulation. MEASUREMENTS AND RESULTS: There were 17 patients fulfilling the inclusion criteria and 16 of them were seen and examined. The follow-up protocol required a formal standardized patient interview, a physical examination of the stoma site and a fiberoptic laryngotracheoscopy. Results of these sub-tests and overall outcome rating were standardized and expressed as good, moderate or poor. Subjective rating was good in all patients. All denied suffering from any side effects of their tracheostomy. Clinical examination revealed neither stridor nor hoarseness in any of the patients. Most of the scars were whitish and less than 1 cm in length, a few were sunken in, none had adhesions. In 15 patients the clinical result was good and in one, moderate (whitish, sunken-in scar, longer than 2 cm). Ten patients underwent tracheoscopy, while 6 did not. There were no signs of significant stenosis or tracheomalacia. In 8 patients with minor findings results were scored as good, while 2 were classified as moderate (combination of swelling and scar formation of a string-like membrane). The overall rating was good in 13 patients (81%) and moderate in 3 patients (19%). There were no poor outcomes. CONCLUSIONS: Late outcome of percutaneous dilatational tracheostomy in critically ill patients is mostly good. Pending further studies, the use of this technique in intensive care units appears justified.

[Blessings of technology? The severely injured skier--a result of technical equipment on the ski slope]. / Segen der Technik? Der schwerverletzte Skifahrer infolge technischer Einrichtungen auf der Skipiste.

In a retrospective manner we studied the injury pattern of 2053 patients following a skiing accident that required hospital admission in the year 1984-1992. Of these 361 or 18% were categorised as severely injured according to the AIS/ISS scoring system. 31% of these 361 skiers were injured by colliding at considerable speed with either a moving object (other skier, snow cat, ski-lift, etc) or fixed obstacles (trees, rocks, pilons, etc) along the ski slopes. As the most extensive injuries seem to result from collisions with the latter, fixed obstacles, it should be requested that more protective measures are being taken to prevent such severe accidents.

Automatic selection of tidal volume, respiratory frequency and minute ventilation in intubated ICU patients as start up procedure for closed-loop controlled ventilation.

OBJECTIVE: Before a patient can be connected to a mechanical ventilator, the controls of the apparatus need to be set up appropriately. Today, this is done by the intensive care professional. With the advent of closed loop controlled mechanical ventilation, methods will be needed to select appropriate start up settings automatically. The objective of our study was to test such a computerized method which could eventually be used as a start-up procedure (first 5-10 minutes of ventilation) for closed-loop controlled ventilation. DESIGN: Prospective Study. SETTINGS: ICU's in two adult and one children's hospital. PATIENTS: 25 critically ill adult patients (age > or = 15 y) and 17 critically ill children selected at random were studied. INTERVENTIONS: To stimulate 'initial connection', the patients were disconnected from their ventilator and transiently connected to a modified Hamilton AMADEUS ventilator for maximally one minute. During that time they were ventilated with a fixed and standardized breath pattern (Test Breaths) based on pressure controlled synchronized intermittent mandatory ventilation (PCSIMV). MEASUREMENTS AND MAIN RESULTS: Measurements of airway flow, airway pressure and instantaneous CO2 concentration using a mainstream CO2 analyzer were made at the mouth during application of the Test-Breaths. Test-Breaths were analyzed in terms of tidal volume, expiratory time constant and series dead space. Using this data an initial ventilation pattern consisting of respiratory frequency and tidal volume was calculated. This ventilation pattern was compared to the one measured prior to the onset of the study using a two-tailed paired t-test. Additionally, it was compared to a conventional method for setting up ventilators. The computer-proposed ventilation pattern did not differ significantly from the actual pattern (p > 0.05), while the conventional method did. However the scatter was large and in 6 cases deviations in the minute ventilation of more than 50% were observed. CONCLUSIONS: The analysis of standardized Test Breaths allows automatic determination of an initial ventilation pattern for intubated ICU patients. While this pattern does not seem to be superior to the one chosen by the conventional method, it is derived fully automatically and without need for manual patient data entry such as weight or height. This makes the method potentially useful as a start up procedure for closed-loop controlled ventilation.

Computerized blood gas interpretation as tool for classroom and ICU.

OBJECTIVE: To describe structure and function of a PC based blood gas interpretation program (ABG-consultant) developed for nurses and physicians, and to test educational impact and user acceptance. DESIGN: Prospective, blinded study SETTING: Interdisciplinary ICU of a county hospital in Switzerland PARTICIPANTS: Nurses specialized in intensive care INTERVENTIONS: Exposure to the ABG-consultant program MEASUREMENT AND RESULTS: A first group of nurses was subjected to a written examination, then the ABG-consultant was made available for them for 2 months, and finally the same examination was taken again. Additionally, they completed a questionnaire related to the performance of the ABG-consultant. A second group of nurses took the same sequence of examinations but had no access to the ABG-consultant. The score of the examinations increased by 4.8 points in the first group (p < 0.0001) and by 1.3 points (p < 0.16) in the second group. More than 400 consultations were conducted over a period of 2 months and the users themselves stated that the system was of help and easy to use. CONCLUSION: The results have shown that exposure to the ABG-consultant has increased the blood gas knowledge of the ICU nurses. It therefore appears desirable and worthwhile to address other areas of clinical medicine by a similar teaching-consulting approach.

[Temporary balloon catheter occlusion for control of bleeding of a blunt injury of the proximal axillary artery. Case report and review of the literature]. / Temporäre Ballonkatheterokklusion zur Blutungskontrolle einer stumpfen Verletzung der proximalen A. axillaris. Fallbeschreibung und Literaturübersicht.

We describe the successful placement of an intra-arterial balloon catheter by a femoral approach in order to occlude the proximal arterial end and to control massive bleeding in a patient with rupture of the left axillary artery after blunt scapulo-thoracic dissociation. To our knowledge this technique has so far not been reported in Europe. It allows rapid control of bleeding, minimizes blood loss and markedly facilitates pre- and perioperative management in selected cases. The authors review the relevant literature dealing with this topic.

Five years' follow-up of severely injured ICU patients.

We conducted a 5-year follow-up study of a group of 461 consecutive trauma patients treated in our Intensive Care Unit from 1980 to 1983. The entry criteria (initial survival and severe injury: ISS greater than or equal to 18) were fulfilled by 233 patients with a mean ISS of 29.3 and mean age of 35.6 years. Data on prehospital care, type and timing of surgery, and hospital and ICU stay were recorded during hospital discharge. The protocol strictly asked for a personal interview and a physical examination. Mailed questionnaires or phone interviews were not allowed. The areas of medical sequelae, aftercare, missed injuries, occupation, insurance, social integration, economics, legal aspects, and traffic involvement were covered. We were able to gather final information from 223 (95.6%) of the 233 cases. Forty-three patients (18.4%) died in the hospital, 13 patients (5.6%) died later, and 167 (76.5%) were eventually seen. Only 10 patients (4.4%) were lost to follow-up. Outcome was judged using the Glasgow Outcome Scale (GOS), which was compared with a GOS value given prospectively at the time of hospital discharge. Eighty-nine percent of the survivors were healthy or slightly disabled (GOS 5 and 4), 9% were severely disabled, and only 2% were in a persistent vegetative state. Outcome after 5 years was better than tentatively prognosed at the time of hospital discharge. Ninety-one patients with severe head injuries (AIS 4-5) were additionally tested using the Mini Mental State instrument. This test revealed normal mental functions in 77% and dementia, mostly of a minor degree, in 23% of the head-injured patients. Almost all the early deaths and two thirds of the late deaths were related to severe head injury. Seventy-nine percent of the survivors were working after 5 years. During the post-trauma period, patients experienced reduced social well-being and also changed professional and recreational activities. There appears to be extensive room for improvement in the posthospital recovery phase. We conclude that survivors of critical trauma have a very good chance, after 5 years, of regaining a high quality of life. All efforts at improving trauma survival and quality of trauma care are therefore worthwhile and deserve high priority.

Lightning injury with lung bleeding in a tracheotomized patient.

A 68-year-old man, who had undergone laryngectomy six months earlier, was struck by lightning and developed pulmonary hemorrhage. This was attributed to pulmonary barotrauma due to a lightning blast via his tracheostoma.

[Serial rib fractures: a differentiated treatment concept, illustrated by 59 severely injured intensive care patients]. / Rippenserienfrakturen: ein differenziertes Behandlungskonzept, dargestellt an 59 schwerverletzten Intensivpatienten.

In a group of 59 consecutive ICU trauma patients with blunt chest injury and considerable injury severity (ISS = 29) a three-staged therapeutic approach was followed, depending seriousness of chest injury, overall injury severity and age. Stage 1: i.v. analgesia and conventional respiratory therapy. Stage 2: continuous epidural analgesia (local anesthetics and opiates) and intermittent CPAP (continuous positive airway pressure) by face mask. Stage 3: Endotracheal intubation and internal pneumatic stabilization of the chest, preferably spontaneous breathing. Only 44% of the patients needed intubation, and none died. The authors recommend this three-step approach towards blunt chest injury and serial rib fractures.