Impact of MALDI-TOF-MS-based identification directly from positive blood cultures on patient management: a controlled clinical trial.

OBJECTIVES: Rapid identification of pathogens directly from positive blood cultures (BC) in combination with an antimicrobial stewardship programme (ASP) is associated with improved antibiotic treatment and outcomes, but the effect of each individual intervention is less clear. The current study investigated the impact of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF) versus conventional identification on antibiotic management in a setting with a well-established ASP and low resistance rates. METHODS: In this single-centre open label, controlled clinical trial 425 patients with positive BCs were allocated by weekday during a 1-year period to either MALDI-TOF directly from positive BCs or conventional processing. ASP was identical throughout the study period. The primary outcome was duration of intravenous antimicrobial therapy and was analysed in an intention-to-treat approach. RESULTS: In all, 368 patients were analysed (MALDI-TOF n = 168; conventional n = 200) with similar baseline characteristics. Mean duration of intravenous antimicrobial therapy (12.9 versus 13.2 days, p 0.9) and length of stay (16.1 versus 17.9 days, p 0.3) were comparable. In the clinically significant bloodstream infection subgroup (n = 242) mean time from Gram-stain to active treatment was significantly shorter (3.7 versus 6.7 h, p 0.003). Admission to the intensive care unit after bloodstream infection onset was less frequent in the MALDI-TOF group (23.1 versus 37.2%, p 0.02). CONCLUSIONS: Rapid identification of contaminated BCs (n = 126) resulted in a shorter duration of intravenous antimicrobial therapy (mean 4.8 versus 7.5 days, p 0.04). Rapid identification using MALDI-TOF directly from positive BCs did not impact on duration of intravenous antimicrobial therapy, but provided fast and reliable microbiological results and may improve treatment quality in the setting of an established ASP.

[Existential questions prior to elective surgery. Survey in a preoperative anesthesia consultation service]. / Existenzielle Fragen vor einer elektiven Operation. Patientenbefragung in einer präoperativen Anästhesiesprechstunde.

BACKGROUND: Existential questions concerning the limitation of treatment must be answered when a major complication occurs after an elective operation. In these situations, the patient himself/herself cannot be asked about his/her will. Therefore, medical professionals must attempt to determine the patient's presumed will either through an existing advance directive (AD) or by consulting with the patient's relatives. Only one-fifth of all patients create an AD in advance, and the relatives cannot always reliably reproduce the patient's presumed will. Thus, it is important to talk about issues such as do-not-resuscitate before a patient undergoes elective major surgery. However, such discussions may unsettle and frighten the patient. This study aimed to determine if patients are willing to talk about difficult questions such as resuscitation before major surgery. How many patients create an AD? Who should decide when patients themselves are no longer capable? OBJECTIVES: Between March 1 and October 30, 2014, patients who attended the preoperative anaesthesia consultation service received a one-page questionnaire. In addition to a few personal questions (e.g. sex, age, surgery, health status), the questionnaire included four questions that could be answered according to a four-point Likert scale, with a yes or no response, or a with a selection of answers. RESULTS: 272 men (45.5%) and 321 women (53.7%) with a mean age of 52.9 years (standard deviation: 17.8 years) completed a questionnaire. 312 patients (52.2%) claimed to be healthy, while 116 patients (19.4%) observed a minimal health restriction. 125 patients (19.4%) suffered from a chronic illness that markedly (n = 108) or strongly (n = 17) limited daily life. More than three-fourths of the respondents were very ready (377/63.0%) or ready (79 patients/13.2%) to talk about the treatment of severe complications after an elective operation. 12.7% of the patients would rather not to talk about this topic (n = 47) or refused (n = 37). 58 patients (9.7%) checked the box "I do not know" or gave no answer. There was no significant difference between men and women (p = 0.58). The patient's state of health did not significantly affect the patient's willingness to talk (p = 0.61). 110 patients (18.4%) had already completed an AD. The probability of having an AD is highly dependent on the age and state of health. The likelihood of having one increases by 4% for each year of life, and in health-impaired patients it is 73% higher than in healthy ones. If the patient could no longer decide for himself/herself, the following options were selected from multiple possible answers: a relative decides (n = 272), discussing this with a physician prior to surgery (n = 212), previously created AD (n = 198), the treatment team decides (n = 28), I do not know/not (n = 48). CONCLUSIONS: Although the majority of the respondents were willing to talk about difficult issues before an operation, it remains unclear to what extent these results can be generalized. However, the results justify efforts to carefully inquire about and document the will of sick patients prior to major surgery. Both the treatment team and the relatives are relieved if the patient's will is known when difficult decisions have to be made.

[Ethical case discussions in the intensive care unit : from testing to routine]. / Ethische Fallbesprechungen auf der Intensivstation : Vom Versuch zur Routine.

BACKGROUND: The daily work of many healthcare professionals has become more complex and demanding in recent years. Apart from purely medical issues, ethical questions and problems arise quite often. Managing these problems requires ethical knowledge. Questions about the usefulness of a therapy and treatment occur especially at the end of life. So-called medical futility, a useless futile therapy, is often perceived by nurses and physicians in intensive care units who themselves often develop symptoms of depression or burnout. The clinical ethical model METAP (acronym from module, ethics, therapy decision, allocation and process) provides methods and criteria that allow the clinical team to treat and solve ethical issues according to a solution-oriented approach. The ethical decision-making of this model addresses these issues according to a series of sequential stages in the form of a so-called escalation model. When it is not possible to tackle and solve an ethical problem or dilemma in one stage, one moves to the next. The implementation of this approach in everyday practice requires the commitment of all team members in addition to certain basic conditions. MATERIAL AND METHODS: In a surgical intensive care unit a fixed date in the schedule is reserved for ethical case discussions (level 3 of the escalation model). At this level a team member who has been specified according to a quarterly plan is responsible for the organization and performance of the discussion. All protocols of the 44 ethical case discussions in 41 patients between January 2011 and July 2012 were collected and summarized. A short questionnaire to all participants recorded their assessment of the benefits for the patient and the team as well as their perception of personal stress reduction. Also queried was the impact of this method on the collaboration between nurses and physicians and the ethical competence. RESULTS: Ethical case discussions among the care team took place regularly (44 case discussions between January 2011 and June 2012). The duration of these discussions ranged from 30 to 60 min. On average 6.2 persons took part, including 2.7 nurses and 3.2 physicians. Of the 41 patients (16 female, 25 male) for whom a discussion was carried out, 23 died during the continued hospital stay. The respondents (response rate 52 %) assessed the benefit for patients and team as high (slightly higher benefit for physicians than nurses) and 55 % of physicians and 71 % of nurses perceived a reduction in the burden of decision-making in difficult cases due to the case discussions. All physicians and 66 % of the nurses reported an improvement in the cooperation between the professional groups and 80 % of the nurses and more than half of the physicians noticed an increase in their own ethical competence. CONCLUSION: A methodically structured ethical decision-making process can and should be integrated into the clinical routine. This process requires a fixed place in everyday practice and the defined responsibility for the actual organization and performance. Support by medical and nursing management personnel is also essential for the implementation. The regular occurrence of ethical case discussions among the care team relieves the participants and improves collaboration between nurses and physicians.

Evaluation of treatment outcomes for Stenotrophomonas maltophilia bacteraemia.

OBJECTIVE: The goal of this study was to retrospectively collect data about treatment outcomes in patients diagnosed with Stenotrophomonas maltophilia bacteraemia over a period of 20 years and evaluate these data with respect to the efficacy of treatment options. METHODS: The setting was a 700-bed tertiary care hospital in a large urban area. Hospital databases and medical records provided information about episodes of S. maltophilia, patient characteristics and treatment outcomes. Patients with at least one positive blood culture for S. maltophilia were included in the study. Data were analysed with respect to clinical improvement and mortality ≤30 days after the onset of infection. We compared patient characteristics, laboratory values and treatments by using the Chi-square or Fisher's exact tests and the Mann-Whitney test. RESULTS: We investigated 27 patients with S. maltophilia bacteraemia. The focus of infection was a central venous catheter in 18 (67 %) cases. The 30-day mortality rate was 11 %. All patients who were treated with an antibiotic that was effective in vitro against the pathogen recovered clinically and survived ≥30 days after the onset of infection. The most frequently used antibiotic was trimethoprim-sulfamethoxazole administered alone or in combination with a fluoroquinolone. CONCLUSIONS: Despite the fact that S. maltophilia is resistant to multiple antibiotics, the prognosis for patients with S. maltophilia bacteraemia is good when they are treated with antibiotics that are effective against this pathogen in vitro.

[Clinical everyday ethics-support in handling moral distress? : Evaluation of an ethical decision-making model for interprofessional clinical teams]. / Klinische Alltagsethik - Unterstützung im Umgang mit moralischem Disstress? : Evaluation eines ethischen Entscheidungsfindungsmodells für interprofessionelle klinische Teams.

BACKGROUND: High-tech medicine and cost rationing provoke moral distress up to burnout syndromes. The consequences are severe, not only for those directly involved but also for the quality of patient care and the institutions. The multimodal model METAP (Modular, Ethical, Treatment, Allocation, Process) was developed as clinical everyday ethics to support the interprofessional ethical decision-making process. The distinctive feature of the model lays in education concerning ethics competence in dealing with difficult treatment decisions. METAP has been evaluated for quality testing. METHODS: The research question of interest was whether METAP supports the handling of moral distress. The evaluation included 3 intensive care units and 3 geriatric units. In all, 33 single and 9 group interviews were held with 24 physicians, 44 nurses, and 9 persons from other disciplines. An additional questionnaire was completed by 122 persons (return rate 57%). RESULTS: Two-thirds of the interview answers and 55% of the questionnaire findings show that clinical everyday ethics supports the handling of moral distress, especially for interdisciplinary communication and collaboration and for the explanation and evaluation of treatment goals. METAP does not provide support for persons who are rarely confronted with ethical problems or have not applied the model long enough yet. CONCLUSION: To a certain degree, moral distress is unavoidable and must be addressed as an interprofessional problem. Herein, clinical everyday ethics may provide targeted support for ethical decision-making competence.

Effect of n-3 fatty acids on markers of brain injury and incidence of sepsis-associated delirium in septic patients.

BACKGROUND: Data regarding immunomodulatory effects of parenteral n-3 fatty acids in sepsis are conflicting. In this study, the effect of administration of parenteral n-3 fatty acids on markers of brain injury, incidence of sepsis-associated delirium, and inflammatory mediators in septic patients was investigated. METHODS: Fifty patients with sepsis were randomized to receive either 2 ml/kg/day of a lipid emulsion containing highly refined fish oil (equivalent to n-3 fatty acids 0.12 mg/kg/day) during 7 days after admission to the intensive care unit or standard treatment. Markers of brain injury and inflammatory mediators were measured on days 1, 2, 3 and 7. Assessment for sepsis-associated delirium was performed daily. The primary outcome was the difference in S-100ß from baseline to peak level between both the intervention and the control group, compared by t-test. Changes of all markers over time were explored in both groups, fitting a generalized estimating equations model. RESULTS: Mean difference in change of S-100ß from baseline to peak level was 0.34 (95% CI: -0.18-0.85) between the intervention and control group, respectively (P = 0.19). We found no difference in plasma levels of S-100ß, neuron-specific enolase, interleukin (IL)-6, IL-8, IL-10, and C-reactive protein between groups over time. Incidence of sepsis-associated delirium was 75% in the intervention and 71% in the control groups (risk difference 4%, 95% CI -24-31%, P = 0.796). CONCLUSION: Administration of n-3 fatty acids did not affect markers of brain injury, incidence of sepsis-associated delirium, and inflammatory mediators in septic patients.

Outcome in polytraumatized patients with and without brain injury.

BACKGROUND: To investigate the long-term outcome in polytrauma victims with traumatic brain injury (TBI) and without traumatic brain injury (NTBI). METHODS: Cohort study based on prospectively collected data. Evaluation of functional outcome and quality of life at least 2 years (median 2.5) following trauma in 111 survivors [39.5 ± 20.9 years; injury severity score (ISS) 27.9 ± 8.2; TBI: n = 45; NTBI: n = 66] out of a total of 211 consecutive multiply-injured patients with an ISS > 16, all primarily admitted to the intensive care unit. RESULTS: Significantly fewer TBI patients lived independently compared with NTBI patients (71% vs. 95%; P < 0.001). TBI patients showed a higher decrease in their capacity to work compared with NTBI patients (P < 0.002). Both study groups experienced a significantly reduced long-term outcome in comparison with pre-injury level in all dimensions of the short form (SF)-36. Following stepwise logistic regression, the mental sum component of the SF-36 and the Nottingham Health Profile discriminated independently between TBI and NTBI patients (R(2) = 0.219; P < 0.001). CONCLUSION: More than 2 years after injury, polytraumatized patients with and without TBI suffer from a reduction in functional outcome and quality of life, but TBI patients are doing importantly worse. Any comparison of trauma patient cohorts should consider these differences between TBI and NTBI patients. Given their discriminatory potential, the sensitivity of self-reported measures needs further affirmation with neuropsychological assessments.

Midregional pro-atrial natriuretic peptide and procalcitonin improve survival prediction in VAP.

Ventilator-associated pneumonia (VAP) affects mortality, morbidity and cost of critical care. Reliable risk estimation might improve end-of-life decisions, resource allocation and outcome. Several scoring systems for survival prediction have been established and optimised over the last decades. Recently, new biomarkers have gained interest in the prognostic field. We assessed whether midregional pro-atrial natriuretic peptide (MR-proANP) and procalcitonin (PCT) improve the predictive value of the Simplified Acute Physiologic Score (SAPS) II and Sequential Related Organ Failure Assessment (SOFA) in VAP. Specified end-points of a prospective multinational trial including 101 patients with VAP were analysed. Death <28 days after VAP onset was the primary end-point. MR-proANP and PCT were elevated at the onset of VAP in nonsurvivors compared with survivors (p = 0.003 and p = 0.017, respectively) and their slope of decline differed significantly (p = 0.018 and p = 0.039, respectively). Patients with the highest MR-proANP quartile at VAP onset were at increased risk for death (log rank p = 0.013). In a logistic regression model, MR-proANP was identified as the best predictor of survival. Adding MR-proANP and PCT to SAPS II and SOFA improved their predictive properties (area under the curve 0.895 and 0.880). We conclude that the combination of two biomarkers, MR-proANP and PCT, improve survival prediction of clinical severity scores in VAP.

Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia: a randomised study.

In patients with ventilator-associated pneumonia (VAP), guidelines recommend antibiotic therapy adjustment according to microbiology results after 72 h. Circulating procalcitonin levels may provide evidence that facilitates the reduction of antibiotic therapy. In a multicentre, randomised, controlled trial, 101 patients with VAP were assigned to an antibiotic discontinuation strategy according to guidelines (control group) or to serum procalcitonin concentrations (procalcitonin group) with an antibiotic regimen selected by the treating physician. The primary end-point was antibiotic-free days alive assessed 28 days after VAP onset and analysed on an intent-to-treat basis. Procalcitonin determination significantly increased the number of antibiotic free-days alive 28 days after VAP onset (13 (2-21) days versus 9.5 (1.5-17) days). This translated into a reduction in the overall duration of antibiotic therapy of 27% in the procalcitonin group (p = 0.038). After adjustment for age, microbiology and centre effect, the rate of antibiotic discontinuation on day 28 remained higher in the procalcitonin group compared with patients treated according to guidelines (hazard rate 1.6, 95% CI 1.02-2.71). The number of mechanical ventilation-free days alive, intensive care unit-free days alive, length of hospital stay and mortality rate on day 28 for the two groups were similar. Serum procalcitonin reduces antibiotic therapy exposure in patients with ventilator associated pneumonia.

Intracranial pressure in patients with sepsis.

INTRODUCTION: In sepsis the brain is frequently affected although there is no infection of the CNS (septic encephalopathy). One possible cause of septic encephalopathy is failure of the blood-brain barrier. Brain edema has been documented in animal models of sepsis. Aggressive fluid resuscitation in the early course of sepsis improves survival and is standard practice. We hypothesized that aggressive fluid administration will increase intracranial pressure (ICP) and may cause critical reductions in cerebral perfusion pressure (CPP). MATERIALS AND METHODS: Patients with sepsis were investigated daily on up to four consecutive days in the intensive care unit. Mean arterial blood pressure (MAP) and blood flow velocity in the middle cerebral artery were monitored for one hour each day. ICP was calculated non-invasively from MAP and flow velocity data. S-100beta was determined daily. FINDINGS: Fifty-two measurements were performed in 16 patients. ICP could be determined in 45 measurements in 15 patients. Seven patients had an ICP > 15 mmHg and 11 patients had a CPP < 60 mmHg on at least 1 day. We found no significant correlation between ICP and fluid administration, but low CPP was significantly correlated with elevated S-100beta (r = -0.47, p = 0.001). CONCLUSIONS: Further research is needed to determine the role of ICP/CPP monitoring in patients with sepsis.

Use of non-invasive-stimulated muscle force assessment in long-term critically ill patients: a future standard in the intensive care unit?

BACKGROUND: This study's main purpose was to test the feasibility of employing a non-invasive-stimulated muscle force assessment approach in long-term critically ill patients. METHODS: A case series was performed over a 4-year period in the intensive care unit (ICU). Of the 25 patients initially recruited, eight patients required long-time mechanical ventilation for a median of 3.8 weeks (range 2-10 weeks) and were immobilized for 5 weeks (range 2-10 weeks). With a previously tested non-invasive measuring device, we weekly assessed peak torques and rates of force development and relaxation of patients' ankle dorsiflexor contractile responses, induced via peroneal nerve stimulation. Subsequently, we derived each patient's time course of observed progressive weakness and/or recovery. RESULTS: During their critical illnesses, seven out of eight patients elicited significant decreases in measured peak torques. In survivors (n = 6) during their recovery periods, torques gradually recovered. In the two patients who died, their strengths decreased continuously until death. The rate of force development data elicited similar trends as peak torque responses, whereas relative relaxation rates differed more widely between individuals. CONCLUSION: This approach of non-invasive-stimulated muscle force assessment can be used in long-term critically ill patients and may eventually become a standard in the intensive care unit, e.g. for assessing recovery. This method is easy to employ, reproducible, provides important phenotypic quantification of skeletal muscle contractile function, and can be used for long-term outcomes assessment.

Assessment of three different mortality prediction models in four well-defined critical care patient groups at two points in time: a prospective cohort study.

BACKGROUND AND OBJECTIVE: Mortality prediction systems have been calculated and validated from large mixed ICU populations. However, in daily practice it is often more important to know how a model performs in a patient subgroup at a specific ICU. Thus, we assessed the performance of three mortality prediction models in four well-defined patient groups in one centre. METHODS: A total of 960 consecutive adult patients with either severe head injury (n = 299), multiple injuries (n = 208), abdominal aortic aneurysm (n = 267) or spontaneous subarachnoid haemorrhage (n = 186) were included. Calibration, discrimination and standardized mortality ratios were determined for Simplified Acute Physiology Score II, Mortality Probability Model II (at 0 and 24 h) and Injury Severity Score. Effective mortality was assessed at hospital discharge and after 1 yr. RESULTS: Eight hundred and fifty-five (89%) patients survived until hospital discharge. Over all four patient groups, Mortality Probability Model II (24 h) had the best predictive accuracy (standardized mortality ratio 0.62) and discrimination (area under the receiver operating characteristic curve 0.9), but Simplified Acute Physiology Score II performed well for patients with subarachnoid haemorrhage. Overall calibration was poor for all models (Hosmer-Lemeshow Type C-values between 20 and 26). Injury Severity Score had the worst discrimination in trauma patients. All models over-estimated hospital mortality in all four patient groups, and these estimates were more like the mortality after 1 yr. CONCLUSIONS: In our surgical ICU, Mortality Probability Model II (24 h) performed slightly better than Simplified Acute Physiology Score II in terms of overall mortality prediction and discrimination; Injury Severity Score was the worst model for mortality prediction in trauma patients.

Fulminant neuroleptic malignant syndrome after perioperative withdrawal of antiParkinsonian medication.

Neuroleptic malignant syndrome is a rare complication when using neuroleptic drugs. We report the case of a patient with severe Parkinson's disease who developed neuroleptic malignant syndrome after withdrawal of his antiParkinsonian medication for elective coronary artery bypass grafting. Sodium dantrolene may be a therapeutic option in severe cases.

[Volume therapy in hypotensive trauma patients]. / Volumentherapie bei hypotensiven Traumapatienten.

In trauma patients it is mandatory to establish the exact reason for their hypotension. If hypovolaemia is most probably responsible for the hypotension, fluid resuscitation should be initiated. The therapy of choice is infusion of sugarless, isotonic crystalloids with a physiologic serum electrolyte composition. In patients with brain injuries a decrease in serum osmolality is not advisable and hypertonic fluids may therefore be considered. Human albumin preparations are no longer indicated, but synthetic colloids may be an adjunct to a pure crystalloid regime. Hydroxyethyl starch preparations with a molecular weight in the mean range are reasonable choices considering the individual advantages and disadvantages of the various colloids. Larger blood losses must be treated with blood components such as packed red cells, fresh frozen plasma and thrombocyte concentrates as indicated. There are no widely accepted values for laboratory or monitoring parameters in starting or stopping a given fluid therapy; these values are unquestionably influenced, among other things, by the patient history and the pattern of the injuries. Initial resuscitation (when to start, who should administer the fluid and how much) also remains a focus of heated controversy.

Transthoracic echocardiography for perioperative haemodynamic monitoring.

Transoesophageal echocardiography (TOE) is valuable for perioperative monitoring in patients at risk from haemodynamic disturbance. However, its use is not practicable in patients undergoing surgical procedures under regional anaesthesia. We describe two cases showing that transthoracic echocardiography (TTE) has the same advantages as TOE and thus may be valuable for monitoring awake patients. TTE should be considered when extended perioperative haemodynamic monitoring is needed but TOE is not possible.

Gastric intramucosal pH as a monitor of gut perfusion after thrombosis of the superior mesenteric vein.

Gastric intramucosal pH (pHi) when measured by a tonometer is a simple and minimally invasive method to determine gut ischemia. In a case of severe mesenteric venous thrombosis, we measured pHi intra- and postoperatively over a period of five days. The goal was to monitor improvement or deterioration of gastrointestinal perfusion in the intensive care unit and to perform a second-look laparotomy if the condition worsened. We observed that gastric pHi is a more sensitive parameter for detecting intestinal ischemia than parameters such as arterial pH, base excess, or lactate. This patient's pHi rose continuously, which allowed us to proceed in a conservative way without any further invasive diagnostic interventions. Thus, the application of a gastric tonometer in cases of mesenteric venous thrombosis may help to reduce costs by preventing unnecessary postoperative diagnostic maneuvers such as angiography, computed tomography, or even second-look laparotomy.

Gastric intramucosal pH-guided therapy in patients after elective repair of infrarenal abdominal aneurysms: is it beneficial?

OBJECTIVE: To determine if gastric intramucosal pH (pHi)-guided therapy reduces the number of complications and length of stay in the intensive care unit (ICU) or the hospital after elective repair of infrarenal abdominal aortic aneurysms. DESIGN: Prospective, randomized study. SETTING: Surgical intensive care unit (SICU) of a University Hospital. PATIENTS: Fifty-five consecutive patients randomized to group 1 (pHi-guided therapy) or to group 2 (control). INTERVENTIONS: Patients of group 1 with a pHi of lower than 7.32 were treated by means of a prospective protocol in order to increase their pHi to 7.32 or more. MEASUREMENTS AND RESULTS: pHi was determined in both groups on admission to the SICU and thereafter at 6-h intervals. In group 2, the treating physicians were blinded for the pHi values. Complications, APACHE II scores, duration of endotracheal intubation, fluid and vasoactive drug treatment, treatment with vasoactive drugs, length of stay in the SICU and in the hospital and hospital mortality were recorded. There were no differences between groups in terms of the incidence of complications. We found no differences in APACHE II scores on admission, the duration of intubation, SICU or hospital stay, or hospital mortality. In the two groups the incidence of pHi values lower than 7.32 on admission to the SICU was comparable (41% and 42% in groups 1 and 2, respectively). Patients with pHi lower than 7.32 had more major complications during SICU stay (p < 0.05), and periods more than 10 h of persistently low pHi values (< 7.32) were associated with a higher incidence of SICU complications (p < 0.01). CONCLUSIONS: Low pHi values (< 7.32) and their persistence are predictors of major complications. Treatment to elevate low pHi values does not improve postoperative outcome. Based on these data, we cannot recommend the routine use of gastric tonometers for pHi-guided therapy in these patients. Further studies are warranted to determine adequate treatment of low pHi values that results in beneficial effects on the patient's postoperative course and outcome.