Frank Wappler

The implementation of a perioperative checklist increases patients' perioperative safety and staff satisfaction

The implementation of the ‘Surgical Safety Checklist’ caused a significant reduction in the incidence of complications and mortality among patients undergoing surgery. The aim of the present study was to evaluate perioperative safety standards and the quality of interprofessional cooperation before and after the introduction of a safety checklist from staff members point of view.

Cardiac output monitoring

Purpose of review The primary goal of hemodynamic therapy is the prevention of inadequate tissue perfusion and inadequate oxygenation. Advanced cardiovascular monitoring is a prerequisite to optimize hemodynamic treatment in critically ill patients prone to cardiocirculatory failure. The most ideal cardiac output (CO) monitor should be reliable, continuous, noninvasive, operator-independent and cost-effective and should have a fast response time. Moreover, simultaneous measurement of cardiac preload enables the diagnosis of hypovolemia and hypervolemia. Recent findings Over recent years, a number of significant studies in the field of CO monitoring have been published. The available CO monitoring techniques can be divided into invasive techniques, minimally invasive techniques, and noninvasive techniques. Summary Minor invasive arterial thermodilution is the standard for the estimation of CO. Less invasive and continuous techniques such as pulse-contour CO and arterial waveform analysis are preferable. The accuracy of noncalibrated pulse-contour analysis is still a matter of discussion, although recent studies demonstrate acceptable accuracy compared with a standard technique. Doppler techniques are minimally invasive and offer a reasonable trend monitoring of CO. Noninvasive continuous techniques such as bioimpedance and bioreactance require further investigation.

Anesthesia for patients with a history of malignant hyperthermia.

Purpose of review Malignant hyperthermia-susceptible patients have an increased risk during anaesthesia. The aim of this review is to present current knowledge about pathophysiology and triggers of malignant hyperthermia as well as concepts for safe anaesthesiological management of these patients. Recent findings Trigger substances and mechanisms have been well defined to date. Anaesthesia can be safely performed with i.v. anaesthetics, nitrous oxide, nondepolarizing muscle relaxants, local anaesthetics as well as xenon. Attention must be directed to the preparation of the anaesthetic machine because modern workstations need longer cleansing times than their predecessors. Alternatively, activated charcoal might be beneficial for elimination of volatile anaesthetics. Day case surgery can be performed in malignant hyperthermia-susceptible patients, if all safety aspects are regarded. Whether there is an association between malignant hyperthermia susceptibility and other disorders is still a matter of debate. Summary The incidence of malignant hyperthermia is low, but the prevalence can be estimated as up to 1: 3000. Because malignant hyperthermia is potentially lethal, it is relevant to establish management concepts for perioperative care in susceptible patients. This includes preoperative genetic and in-vitro contracture testing, preparation of the anaesthetic workstation, use of nontriggering anaesthetics, adequate monitoring, availability of sufficient quantities of dantrolene and appropriate postoperative care. Taking these items into account, anaesthesia can be safely performed in susceptible patients.

One year ago not business as usual: Wound management, infection and psychoemotional control during tertiary medical care following the 2004 Tsunami disaster in southeast Asia

IntroductionFollowing the 2004 tsunami disaster in southeast Asia severely injured tourists were repatriated via airlift to Germany. One cohort was triaged to the Cologne-Merheim Medical Center (Germany) for further medical care. We report on the tertiary medical care provided to this cohort of patients.MethodsThis study is an observational report on complex wound management, infection and psychoemotional control associated with the 2004 Tsunami disaster. The setting was an adult intensive care unit (ICU) of a level I trauma center and subjects included severely injured tsunami victims repatriated from the disaster area (19 to 68 years old; 10 females and 7 males with unknown co-morbidities).ResultsMultiple large flap lacerations (2 × 3 to 60 × 60 cm) at various body sites were characteristic. Lower extremities were mostly affected (88%), followed by upper extremities (29%), and head (18%). Two-thirds of patients presented with combined injuries to the thorax or fractures. Near-drowning involved the aspiration of immersion fluids, marine and soil debris into the respiratory tract and all patients displayed signs of pneumonitis and pneumonia upon arrival. Three patients presented with severe sinusitis. Microbiology identified a variety of common but also uncommon isolates that were often multi-resistant. Wound management included aggressive debridement together with vacuum-assisted closure in the interim between initial wound surgery and secondary closure. All patients received empiric anti-infective therapy using quinolones and clindamycin, later adapted to incoming results from microbiology and resistance patterns. This approach was effective in all but one patient who died due to severe fungal sepsis. All patients displayed severe signs of post-traumatic stress response.ConclusionIndividuals evacuated to our facility sustained traumatic injuries to head, chest, and limbs that were often contaminated with highly resistant bacteria. Transferred patients from disaster areas should be isolated until their microbial flora is identified as they may introduce new pathogens into an ICU. Successful wound management, including aggressive debridement combined with vacuum-assisted closure was effective. Initial anti-infective therapy using quinolones combined with clindamycin was a good first-line choice. Psychoemotional intervention alleviated severe post-traumatic stress response. For optimum treatment and care a multidisciplinary approach is mandatory.

Long-term effects of a perioperative safety checklist from the viewpoint of personnel

While positive short‐term effects of the use of safety checklists have previously been reported by personnel, it is unclear to which extent these effects are maintained for a long‐term period. The aim of the present study was to evaluate perioperative safety standards and the quality of interprofessional cooperation from the viewpoint of the involved personnel for up to 2 years following the introduction of a safety checklist.

Quality of post-operative patient handover in the post-anaesthesia care unit: a prospective analysis

Anaesthesiology plays a key role in promoting safe perioperative care. This includes the perioperative phase in the post‐anaesthesia care unit (PACU) where problems with incomplete information transfer may have a negative impact on patient safety and can lead to patient harm. The objective of this study was to analyse information transfer during post‐operative handovers in the PACU.

Factors influencing lengths of stay in the intensive care unit for surviving trauma patients: a retrospective analysis of 30,157 cases

IntroductionThere are many potential influencing factors that affect the duration of intensive care treatment for patients who have survived multiple trauma. Yet the respective factors’ relevance to ICU length of stay (LOS) has been rarely studied. Thus, the aim of the present study was to investigate to what extent specific factors influence ICU LOS in surviving trauma patients.MethodsWe retrospectively analyzed a dataset of 30,157 surviving trauma patients from the TraumaRegister DGU® who were older than six years of age and received subsequent intensive care treatment for more than one day, from 2002 to 2011. Univariate analysis and multiple linear regression analysis were used to examine 25 categorical pre- and post-trauma parameters.ResultsUnivariate analysis confirmed the impact of all analyzed factors. In subsequent multiple linear regression analyses, coefficients ranged from -1.3 to +8.2xa0days. The factors that influenced the prolongation of ICU LOS most were renal failure (+8.1xa0days), sepsis (+7.8xa0days) and respiratory failure (+4.9xa0days). Patients spent one additional day in the ICU for every 5 additional points on the Injury Severity Score (regression coefficient +0.2 per point). Furthermore, massive transfusion (+3.3xa0days), invasive ventilation (+3.1xa0days), and an initial Glasgow Coma Scale score ≤8 (+3.0xa0days) had a significant impact on ICU LOS. The coefficient of determination for the model was 44% (R2).ConclusionsTreatment regimens, as well as secondary effects and complications of trauma and intensive care treatment, prolong ICU LOS more than the mechanism of trauma or pre-trauma patient conditions. Successful prevention of complicated courses of illness, such as sepsis and renal and respiratory failure, could significantly abbreviate the ICU stay in trauma patients. Therefore, the staff’s attention should be focused on preventive strategies.

Influence of prone positioning on the measurement of transpulmonary thermodilution-derived variables in critically ill patients.

Patients with respiratory failure undergoing prone positioning (PP) are often monitored by the transpulmonary thermodilution (TPTD) technique. However, it remains unclear whether the measurement of TPTD‐derived variables is influenced by PP. We investigated the effects of 135° PP on the accuracy of TPTD‐derived variables and their changes over an 8–10u2009h period of time.

Change of initial and ICU treatment over time in trauma patients. An analysis from the TraumaRegister DGU

BackgroundClinical guidelines have been standardized for pre- and in-hospital trauma management in the last decades. Therefore, it is known that prehospital management has changed significantly. Furthermore, in-hospital course may be altered to reduce complications and length of stay (LOS). However, the development of trauma patient in-hospital management as well as LOS in the intensive care unit (ICU) has not been investigated systematically over a long-term period in Germany. Aim of our study is to examine the changes in in-hospital management and LOS in the ICU in moderately and severely injured patients.MethodsPatients documented in the TraumaRegister DGU® (TR-DGU) of the German Trauma Society from 2000 to 2011 and admitted to ICU were included in this study. Demographic data, the pattern of injury, injury severity, duration of mechanical ventilation, LOS in the ICU, hospital LOS, and discharge destination were evaluated. The mean values and the standard deviations are shown. The constant variables were calculated with changes over time analyzed by linear regression analysis, and categorical variables were calculated with the chi-square test.ResultsA total of 18,048 patients were analyzed. The rate of patients being intubated at the time of ICU admission decreased from 86.8xa0% in 2000 to 60.0xa0% in 2011 (pu2009<u20090.001). The time of mechanical ventilation decreased from 7.5u2009±u200910.5 to 4.7u2009±u20098.7xa0days. The intensive care unit LOS was reduced from 11.7u2009±u200912.8 to 9.0u2009±u200911.3xa0days and the length of hospital stay from 27.9u2009±u200928.7 to 21.1u2009±u200920.4xa0days (both pu2009<u20090.01). The ICU LOS remained stable in the subgroup of mechanically ventilated patients (12.7u2009±u200913.2xa0day in 2000, 12,6u2009±u200912.9 in 2011, pu2009=u20090.6), whereas it was reduced in non-mechanically ventilated patients (5.5u2009±u20096.8xa0days in 2000, 3.6u2009±u20094.5xa0days in 2011; pu2009<u20090.001).ConclusionsThe reduction LOS in the analyzed dataset is mainly explained by the relevantly reduced rate of patients being intubated at the time of ICU admission. Our data demonstrate that trauma patients’ in-hospital course is influenced by reduced intubation rate at the time of ICU admission.

Successful treatment of severe Clostridium difficile infection by administration of crushed fidaxomicin via a nasogastric tube in a critically ill patient

OBJECTIVEnTo report the successful use of crushed fidaxomicin via a nasogastric tube for treatment of a severe Clostridium difficile infection in a critically ill patient.nnnDATA SOURCESnClinical observation of a patient, images of abdominal computed tomography, antimicrobial therapy and course of infection parameters.nnnDATA EXTRACTIONnRelevant information contained in the medical observation of the patient and selection of image and laboratory parameters performed in the patient.nnnDATA SYNTHESISnWe report a case of a 79-year old patient who developed septic shock with an increasing need for norepinephrine and acute renal failure due to a severe Clostridium difficile infection. Antimicrobial therapy with vancomycin via a nasogastric tube and metronidazole i.v. did not lead to improvement, infection parameters further increased, and the clinical condition became increasingly impaired. After 10 days, antimicrobial therapy was changed to fidaxomicin, crushed and administered via nasogastric tube. Within 24hours, infection parameters decreased. Further diarrhoea ceased and stool samples were negative for Clostridium difficile antigen.nnnCONCLUSIONSnOur case confirms that administration of fidaxomicin via a nasogastric tube was safe and effective in this patient. Further studies are needed to evaluate the efficacy of this strategy in critically ill patients systematically.