End-of-life practices in 11 German intensive care units : Results from the ETHICUS-2 study

BACKGROUND

End-of-life care is common in German intensive care units (ICUs) but little is known about daily practice.

OBJECTIVES

To study the practice of end-of-life care.

METHODS

Prospectively planned, secondary analysis comprising the German subset of the worldwide Ethicus‑2 Study (2015-2016) including consecutive ICU patients with limitation of life-sustaining therapy or who died.

RESULTS

Among 1092 (13.7%) of 7966 patients from 11 multidisciplinary ICUs, 967 (88.6%) had treatment limitations, 92 (8.4%) died with failed CPR, and 33 (3%) with brain death. Among patients with treatment limitations, 22.3% (216/967) patients were discharged alive from the ICU. More patients had treatments withdrawn than withheld (556 [57.5%] vs. 411 [42.5%], p < 0.001). Patients with treatment limitations were older (median 73 years [interquartile range (IQR) 61-80] vs. 68 years [IQR 54-77]) and more had mental decision-making capacity (12.9 vs. 0.8%), advance directives (28.6 vs. 11.2%), and information about treatment wishes (82.7 vs 33.3%, all p < 0.001). Physicians reported discussing treatment limitations with patients with mental decision-making capacity and families (91.3 and 82.6%, respectively). Patient wishes were unknown in 41.3% of patients. The major reason for decision-making was unresponsiveness to maximal therapy (34.6%).

CONCLUSIONS

Treatment limitations are common, based on information about patients' wishes and discussion between stakeholders, patients and families. However, our findings suggest that treatment preferences of nearly half the patients remain unknown which affects guidance for treatment decisions.

[Organ donation-Not only a responsibility of intensive care medicine]

Im Jahr 2019 starben in Deutschland 756 Menschen, während sie auf der Warteliste für ein Spenderorgan standen. Sowohl im Eurotransplant-Verbund als auch weltweit gehört Deutschland mit 10,8 Organspendern/Mio. Einwohner im Jahr 2019 zur Schlussgruppe. Sämtliche politischen Versuche, die Spenderzahlen zu steigern, scheinen bislang ohne Effekt geblieben zu sein. Darüber hinaus hat die durch das „severe acute respiratory syndrome coronavirus 2“ (SARS-CoV-2) ausgelöste Pandemie zum weiteren Rückgang der Spenderzahlen geführt. Der Intensivmedizinerin kommt im Prozess der Erkennung möglicher Spender sowie als erste Ansprechpartnerin für die Angehörigen eine zentrale Rolle zu. Jedoch existieren nicht nur in den gesellschaftlichen und medialen Diskussionen um das Thema Organspende viele Unklarheiten, sondern auch bei den intensivmedizinisch tätigen Ärzten. Viele Annahmen und Hypothesen, die mit den niedrigen Spenderzahlen in einen Zusammenhang gebracht werden, lassen sich wissenschaftlich jedoch nicht belegen und sollen in diesem Beitrag diskutiert werden.

[Comparison of current critical care information systems from the perspective of clinical users : Summary of the results of a German nationwide survey]

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.

[Non-beneficial therapy and emotional exhaustion in end-of-life care : Results of a survey among intensive care unit personnel]

BACKGROUND

End-of-life care (EOLC) in the intensive care unit (ICU) is becoming increasingly more common but ethical standards are compromised by growing economic pressure. It was previously found that perception of non-beneficial treatment (NBT) was independently associated with the core burnout dimension of emotional exhaustion. It is unknown whether factors of the work environment also play a role in the context of EOLC.

OBJECTIVE

Is the working environment associated with perception of NBT or clinician burnout?

MATERIAL AND METHODS

Physicians and nursing personnel from 11 German ICUs who took part in an international, longitudinal prospective observational study on EOLC in 2015-2016 were surveyed using validated instruments. Risk factors were obtained by multivariate multilevel analysis.

RESULTS

The participation rate was 49.8% of personnel working in the ICU at the time of the survey. Overall, 325 nursing personnel, 91 residents and 26 consulting physicians participated. Nurses perceived NBT more frequently than physicians. Predictors for the perception of NBT were profession, collaboration in the EOLC context, excessively high workload (each p ≤ 0.001) and the numbers of weekend working days per month (p = 0.012). Protective factors against burnout included intensive care specialization (p = 0.001) and emotional support within the team (p ≤ 0.001), while emotional exhaustion through contact with relatives at the end of life and a high workload were both increased (each p ≤ 0.001).

DISCUSSION

Using the example of EOLC, deficits in the work environment and stress factors were uncovered. Factors of the work environment are associated with perceived NBT. To reduce NBT and burnout, the quality of the work environment should be improved and intensive care specialization and emotional support within the team enhanced. Interprofessional decision-making among the ICU team and interprofessional collaboration should be improved by regular joint rounds and interprofessional case discussions. Mitigating stressful factors such as communication with relatives and high workload require allocation of respective resources.

Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI))

Practice guidelines are systematically developed statements and recommendations that assist the physicians and patients in making decisions about appropriate health care measures for specific clinical circumstances taking into account specific national health care structures. The 1^st revision of the S-2k guideline of the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information (results of controlled clinical trials and expert knowledge) on the effective and appropriate medical care (prevention, diagnosis, therapy and follow-up care) of critically ill patients with severe sepsis or septic shock. The guideline had been developed according to the “German Instrument for Methodological Guideline Appraisal” of the Association of the Scientific Medical Societies (AWMF). In view of the inevitable advancements in scientific knowledge and technical expertise, revisions, updates and amendments must be periodically initiated. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.

[Anonymous critical incident reporting system. Implementation in an intensive care unit]

In 2003 an anonymous reporting system for critical incidents was implemented in the Department of Anaesthesiology and Intensive Care Medicine of the University Hospital Dresden. This reporting system was modified to an intranet-based version and extended to the intensive care unit (ICU). During the first 18 months 70 anonymous reports originating from the ICU were registered. The most common errors involved fluid management, followed by errors in airway management, cardio-vascular management, neurological problems and errors in drug administration. The main causes were lack of attention, missing check of measures, work load of nurses, experience and communication deficits. The article discusses the incidence of errors in the ICU setting and their potential effects.

[Study protocol of the VISEP study. Response of the SepNet study group]

In the commentary by Zander et al. the authors appear concerned about the methods and results of our, at that time, unpublished sepsis trial evaluating hydroxyethyl starch (HES) and insulin therapy. Unfortunately, the authors' concerns are based on false assumptions about the design, conduct and modes of action of the compounds under investigation. For instance, in our study the HES solution was not used for maintenance of daily fluid requirements, so that the assumption of the authors that this colloid was used "exclusively" is wrong. Moreover, the manufacturer of Hemohes, the HES product we used, gives no cut-off value for creatinine, thus the assumption that this cut-off value was "doubled" in our study is also incorrect. Other claims by the authors such as that lactated solutions cause elevated lactate levels, iatrogenic hyperglycemia and increase O(2) consumption are unfounded. There is no randomized controlled trial supporting such a claim - this claim is neither consistent with our study data nor with any credible published sepsis guidelines or with routine practice worldwide. We fully support open scientific debate. Our study methods and results have now been published after a strict peer-reviewing process and this data is now open to critical and constructive reviewing. However, in our opinion this premature action based on wrong assumptions and containing comments by representatives of pharmaceutical companies does not contribute to a serious, unbiased scientific discourse.

[Therapy of hyperthermia in sepsis and septic shock. Necessary or injurious?]

In critically ill patients fever is associated with an increased morbidity and mortality rate. However, it remains unclear whether fever is an associated symptom of the underlying severe disease or a stimulator of specific pathophysiological cascades considered responsible for a deleterious outcome. Hyperthermia per se induces systemic changes like increased energy and oxygen demands, tachycardia, or fluid loss which might be harmful especially in septic patients due to congestion of the cardiovascular system. In this constellation a reduction of fever by antipyretic strategies might be indicated to decrease oxygen and energy demands. On the other hand the increasing body temperature obviously plays an important role in the inflammatory hemostasis during infections. Fever optimises humoral and cellular responses to infection and has some direct effects on bacteria and other microorganisms. Therefore, in severe sepsis or septic shock, fever reduction might impair the immune competency of the patients. According to the currently available evidence a body temperature higher than 40 degrees C is definitely harmful and should be treated in any case. A temperature range between 36 degrees C and 39 degrees C should be achieved for patients with severe sepsis and septic shock. At present there are no data showing the superiority of any of the different antipyrectic strategies in septic patients. Hence, external cooling with cold blankets or other devices may induce shivering of the muscles with a substantial increase of oxygen demand and is hardly tolerated in conscious patients. However, antipyretic therapy in patients with severe sepsis or septic shock should be indicated while considering the individual pathophysiology of every patient.

[Treatment of toxic epidermal necrolysis. Experience with 9 patients with consideration of intravenous immunoglobulin]

Toxic epidermal necrolysis (TEN) is the maximal variant of severe bullous drug reactions with a high mortality rate of 30-40%. Treatment should be interdisciplinary and is best provided in an intensive care setting. Since no specific therapy has been established, supportive intensive care and topical treatment are of crucial importance. Between 1995 and 2005, nine patients with TEN were treated in the anesthesiology intensive care unit in cooperation with dermatology in the University Hospital of Dresden. All patients initially received corticosteroids and five patients were additionally treated with intravenous immunoglobulins (IVIG). The overall mortality of 33% was underestimated by the SAPS II-Score, whereas it was overestimated by the TEN-specific SCORTEN. In more severely affected patients, other scoring systems in addition to SCORTEN should be used for prediction of prognosis and evaluation of therapy. The mortality rate of our IVIG treated patients was 20% vs. 50% compared to the non-IVIG-group. However, due to the small number of patients and contradictory results in the literature, IVIG cannot be generally recommended for the treatment of TEN, but should be considered in early stages of the disease.

[Diagnosis and therapy of sepsis]

A recent survey conducted by the publicly funded Competence Network Sepsis (Sep- Net) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approx. 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approx. 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organisation of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to according to the requirements of the Working Group of Scientific Medical Societies (AWMF).

[Hypertonic saline solution for reduction of intracranial pressure. Are there doubts?]

Osmotherapy, i.e. the intravenous administration of hyperosmolar solutions, is one of the mainstays of therapy for reduction of a pathologically increased intracranial pressure, in addition to analgosedation and raising the upper body of the patient. The administration of mannitol as a osmotherapeutic agent is, however, marred by considerable side-effects. A possible alternative is the use of hypertonic saline solution (NaCl). The advantages and disadvantages of this option are considered as well as points still in question.

[Therapeutic options to improve the microcirculation in sepsis and septic shock]

The severe impairment of the microcirculation plays a substantial role in the pathogenesis of severe sepsis and septic shock, and leads to multiple organ failure and death. Therapeutic strategies to resuscitate the microcirculatory blood flow and to improve the functional capillar density are therefore essential to surmount the microcirculatory pathology and to avoid tissue hypoxia. Based on reasonable scientific evidence, early fluid resuscitation directed by defined haemodynamic and metabolic goals (EGDT) as well as the application of activated protein C (rhAPC) according to the guidelines could be recommended. Dobutamine is the first choice to improve cardiac output and to overcome myocardial depression in septic shock whereas phosphodiesterase-III-inhibitors and levosimendane are still experimental options. Furthermore selective inhibitors of iNOS, nitroglycerol, as well as vasopressin have to be investigated relating to their specific effects on the microcirculation and their influence on survival in seevere sepsis and septic shock.

Mikrozirkulation bei Sepsis und septischem Schock

Die komplexe Dysregulation der Mikrozirkulation spielt eine zentrale Rolle in der Pathogenese von Sepsis und septischen Schock und führt, wenn sie nicht rechtzeitig beseitigt werden kann, zum Multiorganversagen (MOV) und Tod. Maßnahmen zur Wiederherstellung der mikrovaskulären Zirkulation (Rekrutierung von Kapillaren) sind daher logische Therapieansätze zur Überwindung der Gewebehypoxie und zur Verhinderung eines MOV.

Aufgrund guter wissenschaftlicher Evidenz kann für den klinischen Einsatz bezüglich der Restitution der Mikrozirkulation bei schwerer Sepsis und septischen Schock die frühzeitige und an hämodynamischen und metabolischen Zielen ausgerichtete Volumenersatztherapie EGDT. (early goal directed therapy) sowie die Applikation von rhAPC entsprechend der EU-Zulassungsindikationen empfohlen werden. Für die Behandlung der septisch induzierten Kardiomyopathie ist Dobutamin das Mittel der ersten Wahl, während Phosphodiesterase-III-Inhibitoren oder Levosimendan noch experimentelle Therapieoptionen darstellen. Inwieweit die direkten Effekte von Dobutamin und rhAPC auf die Mikrozirkulation klinisch relevant sind sollte in weiteren Studien geprüft werden.

[Diagnosis and therapy of sepsis. Guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine]

A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).

[Diagnosis and therapy of sepsis: guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine]

A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).

Reduktion der Aggressivität der Beatmung nach Therapie eines Ölsäure-induzierten Lungenversagens durch Inhalation von Perfluorhexan

INTRODUCTION

The application of perfluorohexane (PFH) vapor led to an improvement of oxygenation and mechanical lung function in a model of oleic acid-induced ARDS in sheep. The aim of this study was to investigate the effects of PFH on gas exchange over an extended time period and to reduce the invasiveness of ventilation.

METHOD

ARDS was induced in sheep ( n=12) by injecting 0.1 ml/kg body weight oleic acid intravenously. Six sheep were treated for 30 min with 18 vol.% PFH (PFH-Tx) and followed up over a time period of 240 min while untreated sheep ( n=6) served as controls. Subsequently the F(I)O(2) was reduced to generate a p(a)O(2) between 100-140 mmHg. Gas exchange, respiratory and hemodynamic data were collected at regular intervals. Data were analysed using covariance analysis.

RESULTS

PFH treatment led to an improvement in oxygenation ( p<0.01) and in mechanical lung function ( p<0.01). Furthermore, mean pulmonary artery pressure ( p<0.01) and shunt ( p<0.01) were lower in PFH-Tx. F(I)O(2) could be reduced in all PFH-treated animals ( p<0.01).

CONCLUSION

Treatment of oleic acid-induced lung injury with PFH vapor improved oxygenation and mechanical lung function over a extended time period allowing a reduction in the invasiveness of ventilation.

Fatal intracerebral hemorrhage due to leptospirosis

Intracerebral hemorrhage in leptospirosis is a rare event. We report on a fatal case of intracerebral hemorrhage complicating leptospirosis in a 47-year-old sewage drain worker. Since substantial thrombocytopenia was observed during the course of the disease, postmortem autopsy was performed to further elucidate the genesis of platelet destruction. Due to immunohistological findings, immunologically mediated thrombolysis was considered responsible for thrombocytopenia, whereas no signs of disseminated intravasal coagulopathy or deranged platelet production in the bone marrow were detected.

Impact of n-3 fatty acid supplemented parenteral nutrition on haemostasis patterns after major abdominal surgery

In various diseases n-3 fatty acids exert anti-inflammatory properties. These effects seem to be related to the uptake and incorporation of eicosapentaenoic acid (EPA) into the cellular substrate pool after dietary intake of EPA, which is contained in fish oils (FO). In the state of inflammation EPA is released to compete with arachidonic acid (AA) for metabolism at the cyclo-oxygenase and the 5-lipoxygenase level. The metabolites of EPA have less inflammatory and chemotactic potency than the substances derived from AA. In addition to positive effects, early studies pointed towards prolonged bleeding times after dietary intake of n-3 fatty acids. This study was undertaken to address the issue of potential coagulation disturbances associated with postoperative parenteral FO administration. This was a prospective, randomised, double blinded clinical trial, carried out in two operative intensive care units (13 and 16 beds) in a university hospital. Forty-four patients undergoing elective major abdominal surgery participated in the trial. Patients were randomly assigned to receive total parenteral nutrition (TPN) supplemented with either soybean oil (SO, Lipovenoess 10% PLR; 1.0 g/kgBW per day; n = 20) for five days or with a combination of FO and SO (FO, Omegaven; 0.2 g/kgBW per day plus SO, Lipovenoes 10% PLR; 0.8 g/kgBW per day, n = 24), respectively. Blood samples were taken preoperatively (day -1), prior to (day 1) during (days 2-5) and after TPN (day 6). The coagulation parameters thromboplastin time (Quick), activated partial thromboplastin time (aPTT), fibrinogen and antithrombin III were measured. To differentially assess activation levels of extrinsic and intrinsic coagulation pathway, factors VIIa and XIIa were quantified. Moreover platelet function was determined by resonance thrombography. Baseline values of coagulation and platelet function were comparable in both groups, but coagulation activity dropped after surgery. Over the observation period of 6 days, however, physiological levels were regained. No clinically significant differences were observed between the SO- and SO + FO- group. These findings suggest that infusion of fish oil in doses up to 0.2 g/kgBW per day is safe regarding coagulation and platelet function.

Effects of inhalation of perfluorocarbon aerosol on oxygenation and pulmonary function compared to PGI2 inhalation in a sheep model of oleic acid-induced lung injury

OBJECTIVE

To evaluate the effects of PFC aerosol compared to PGI2 aerosol and NaCl aerosol on gas exchange and lung mechanics in oleic acid-induced acute lung injury.

DESIGN

A prospective, controlled, randomised, in vivo animal laboratory study.

SETTING

Research laboratory at an university hospital.

SUBJECTS

Twenty one (n = 21) adult sheep of either gender weighing 26.8+/-6.4 kg.

INTERVENTIONS

The animals were randomised to three groups: PFC aerosol (perfluorooctane), PFC group; prostacyclin aerosol (Flolan), PGI2 group; and NaCl aerosol (0.9% sodium chloride solution), control group. After induction of anaesthesia and placement of vascular catheters, lung injury was induced with 0.12 ml x kg(-1) oleic acid. Aerosols were continuously administered for 2 h using a jet nebuliser. Gas exchange, pulmonary mechanic, and haemodynamic parameters were obtained at regular intervals.

MEASUREMENTS AND MAIN RESULTS

PFC aerosol increased oxygenation (PaO2) 15 min after the initiation of treatment up to 120 min (P < 0.05). Transpulmonary shunt improved in the PFC group (P < 0.05) while it did not change in the two other groups. PFC aerosol reduced maximum airway pressure (Pmax) (median) significantly from (median) 38 mbar to 32 mbar (P < 0.05). Static compliance improved significantly in the PFC group (P < 0.05).

CONCLUSION

The inhalation of a PFC aerosol led to a significant improvement in pulmonary mechanics and gas exchange, which was not observed in the other two groups. These data suggest that a small dose of perfluorocarbon will have beneficial effects on gas exchange and respiratory mechanics. Therefore, the non-invasive aerosol application technique seems to be a reasonable alternative to administer perfluorocarbons in severe lung injury.

Perfluorohexane attenuates proinflammatory and procoagulatory response of activated monocytes and alveolar macrophages

BACKGROUND

A number of studies have demonstrated the effectiveness of liquid ventilation with perfluorocarbons in improving pulmonary function in acute respiratory distress syndrome. Although it is known that perfluorocarbon-associated gas exchange facilitates lung mechanics and oxygenation, the complete mechanism by which perfluorocarbons exert their beneficial effects in acute lung injury still remains unclear. Possibly, an influence of perfluorocarbons on proinflammatory and procoagulant features of monocytic cells present in the alveolar space, such as alveolar macrophages (AMs), may be involved. Therefore, we examined in an in vitro model the effects of perfluorocarbon on both activated mononuclear blood cells (MBCs) and AMs by monitoring the expression of interleukin (IL)-1 beta, tumor necrosis factor (TNF)alpha, and tissue factor (TF).

METHODS

Mononuclear blood cells, obtained from peripheral blood of healthy volunteers, or AMs from diagnostic bronchoalveolar lavage were stimulated by incubation with lipopolysaccharide in the presence of different amounts of perfluorohexane, which was devoid of cytotoxicity.

RESULTS

Using both video-enhanced contrast and electron microscopy, the authors observed that perfluorohexane droplets were phagocytosed by activated monocytes as well as by in vitro--cultured AMs within 1--3 h. After lipopolysaccharide stimulation of monocytes or AMs, we observed a down-regulation of TF mRNA and a significant inhibition (P < 0.05) of cellular TF antigen by perfluorohexane. In addition, the concentration of both IL-1 beta and TNF alpha in the supernatant of lipopolysaccharide-stimulated MBC was significantly decreased (P < 0.01) by perfluorohexane compared with controls without perfluorohexane. By preincubation of lipopolysaccharide-containing medium with perfluorohexane, the authors could exclude that the inhibitory effect of perfluorohexane was caused by binding or sequestering limited amounts of lipopolysaccharide.

CONCLUSION

Taken together, our results demonstrate an interference of perfluorohexane with the expression of the procoagulant protein TF on monocytes and AMs as well as with the release of proinflammatory cytokines by MBCs. These effects may contribute to the protective role of liquid ventilation with perfluorocarbons in injuries associated with local activation of inflammatory processes.

Electroencephalogram silence ratio for early outcome prognosis in severe head trauma

OBJECTIVE

To introduce the electroencephalogram silence-ratio (ESR) as a variable derived from mathematically processed electroencephalogram for early outcome prognosis in patients with severe head trauma and to comparatively assess sensitivity, specificity and predictive value vs. somatosensory evoked potentials and brainstem auditory evoked potentials.

DESIGN

Prospective, interventional study.

SETTING

Intensive care unit of a university hospital.

PATIENTS

A total of 32 adults with severe acute head trauma (Glasgow Coma Scale score < or = 8).

METHODS AND MAIN RESULTS

In all patients, electroencephalographic recording was continuously performed by frontomastoid electrode montage for 24-96 hrs after admission to the ICU. The data were subsequently computed by fast Fourier analysis and the ESR (intervals of suppression as periods >240 msecs during which the electroencephalographic voltage did not exceed 5 microV) was displayed and recorded on a computer for further evaluation. Somatosensory evoked potentials and brainstem auditory evoked potentials were elicited during the first 2 days after admission. Outcome evaluation was performed 6 months after trauma using the Glasgow Outcome Scale and the Rappaport Disability Rating Scale. After careful artifact exclusion, the ESR depicted the highest sensitivity, specificity, and positive predictive value compared with evoked potentials. Even a highly significant correlation between outcome and ESR was found (p < .0001).

CONCLUSION

The ESR is a valuable variable showing a high reliability with respect to outcome prediction in severe head trauma with a higher predictive value than short latency somatosensory evoked potentials. Evidence exists that the ESR provides at least partial information regarding adequate cerebral oxygen delivery.

Epidural abscess after epidural catheter for pain release during pancreatitis

BACKGROUND

Despite knowledge about compromised host defence in the course of diabetes mellitus and pancreatitis, epidural analgesia (EA) is recommended for pain management during pancreatitis.

CASE REPORT

We present the case of a diabetic patient with pancreatitis who developed an epidural abscess after 3 days with an epidural catheter. Natural killer and T-helper cell counts were distinctively reduced in the absence of HIV serology. Furthermore, a synthesis failure of the liver was observed and evidenced by low cholinesterase, low whole protein fraction and low antithrombin III in the peripheral blood.

CONCLUSION

We suggest that the combination of pancreatitis, diabetes and compromised immunity might be a contraindication to epidural analgesia.