Jerome Defosse

Coagulation management of bleeding trauma patients is changing in German trauma centers: an analysis from the trauma registry of the German Society for Trauma Surgery.

BACKGROUND: Recent findings have emphasized the need for early and aggressive coagulation support in bleeding trauma patients. This study aimed to examine whether blood component transfusion and hemostatic drug administration during acute trauma care have changed in daily practice during the recent years. METHODS: The multicenter trauma registry of the German Society for Trauma was retrospectively analyzed for primarily admitted patients older than 16 years with an Injury Severity Score ≥16 who had received at least five red blood cell (RBC) units between emergency room arrival and intensive care unit admission. Administration of fresh frozen plasma and platelet units has been documented since 2002, and use of hemostatic drugs since 2005. RESULTS: From 2002 until 2009 (n = 2,813), the fresh frozen plasma:RBC ratio increased from 0.65 to 0.75 (p = 0.02) and the platelet:RBC ratio from 0.04 to 0.09 (p < 0.0001). A constant increase was also observed regarding the overall use of hemostatic drugs (n = 1,811; 2005–2009) as these were administered to 43.4% of the patients in 2005 and to 60.7% in 2009 (p < 0.0001). Especially, the administration of fibrinogen concentrate (2005: 17.0%, 2009: 45.6%; p < 0.0001) and recombinant factor VIIa (2005: 1.9%, 2009: 6.3%; p = 0.04) showed a marked increase. However, mortality rates remained unchanged during the 8-year study period. CONCLUSIONS: The therapy of bleeding trauma patients has changed in Germany during the recent years toward more aggressive coagulation support. This development continues although grades of evidence are still low regarding most of the changes reported in our study. Randomized controlled trials are needed with respect to blood component therapy using predefined ratios and to the administration of hemostatic drugs commonly used for the severely injured. LEVEL OF EVIDENCE: III, therapeutic study.

Anaesthetic management of patients with myopathies

: The anaesthetic management of patients with myopathies is challenging. Considering the low incidence and heterogeneity of these disorders, most anaesthetists are unfamiliar with key symptoms, associated co-morbidities and implications for anaesthesia. The pre-anaesthetic assessment aims at the detection of potentially undiagnosed myopathic patients and, in case of known or suspected muscular disease, on the quantification of disease progression. Ancillary testing (e.g. echocardiography, ECG, lung function testing etc.) is frequently indicated, even at a young patient age. One must differentiate between myopathies associated with malignant hyperthermia (MH) and those that are not, as this has significant impact on preoperative preparation of the anaesthesia workstation and pharmacologic management. Only few myopathies are clearly associated with MH. If a regional anaesthetic technique is not possible, total intravenous anaesthesia is considered the safest approach for most patients with myopathies to avoid anaesthesia-associated rhabdomyolysis. However, the use of propofol in patients with mitochondrial myopathies may be problematic, considering the risk for propofol-infusion syndrome. Succinylcholine is contra-indicated in all patients with myopathies. Following an individual risk/benefit evaluation, the use of volatile anaesthetics in several non-MH-linked myopathies (e.g. myotonic syndromes, mitochondrial myopathies) is considered to be well tolerated. Perioperative monitoring should specifically focus on the cardiopulmonary system, the level of muscular paralysis and core temperature. Given the high risk of respiratory compromise and other postoperative complications, patients need to be closely monitored postoperatively.

Severe sepsis caused by a linezolid-resistant Enterococcus faecium in a 10-year-old girl after multiple trauma

While infections caused by Enterococcus faecium resistant to vancomycin (VRE) are increasing, linezolid-resistant strains are still rare. We present the case of a 10-year-old girl with severe sepsis caused by a linezolid-resistant E. faecium (Van-B VRE) after multiple trauma and right-sided hemipelvectomy. The off-label use of a targeted antimicrobial therapy with daptomycin (350 mg/day; approximately 8 mg/kg) for 17 days resulted in rapid normalization of infection parameters and improved clinical status. No side effects were observed and the patient was successfully discharged from the intensive care unit.

Massive cerebral air embolism after blunt chest trauma with full neurological recovery.

Cerebral air embolism (CAE) is a common, often lethal, complication in blunt and penetrating chest trauma. The factors affecting the outcome of CAE patients are poorly understood, and there is no generally accepted treatment algorithm. In this report, we present the case of a 28-year-old male motorcyclist with a massive CAE, including bilateral internal carotid artery air on computed tomographic examination following blunt chest trauma. With prehospital intubation, oxygen, transfusion, and open laparotomy but without any specific treatment regarding the CAE, a follow-up computed tomography (CT) scan approximately 6 hours later showed resolution of the cerebrovascular air. Recovery was unremarkable, and the patient was discharged neurologically intact after 22 days.

Computed tomography for the identification of a potential infectious source in critically ill surgical patients

INTRODUCTION Computed tomography (CT) seems already to have an important role to identify an infectious source in the management of patients with sepsis. However, our daily clinical behavior in ordering CT imaging was never scrutinized. METHODS We conducted a retrospective single-center analysis of CT and its therapeutic consequences in an operative intensive care unit in a tertiary care hospital in Germany. All CTs of the abdomen and/or thorax between 1st January and 31st December 2012 were included. One hundred forty-four CT studies were enrolled: 60.4% visceral, 6.9% vascular, 17.4% thoracic, and 14.6% trauma surgical cases and in 0.7% other disciplines. RESULTS In 76 CT studies (52.8%), a source of infection was found and was associated with a change in treatment in 65 (85.5%) cases. In contrast, in patients without identification of an infectious source in the CT imaging, treatment was changed after CT imaging in 11 (16.2%) cases. Computed tomography provided positive findings predominantly in the organ or the region of the surgical field. CONCLUSIONS Computed tomographic imaging detected an infectious source in more than 50% of cases. Our data suggest that CT should be recommended to identify a source of infection in critically ill patients. Furthermore, prospective studies are needed to investigate the potential impact of CT imaging on outcome and to define criteria when to perform a CT imaging study.

New Approaches to Airway Management in Tracheal Resections—A Systematic Review and Meta-analysis

OBJECTIVES Although endotracheal intubation, surgical crossfield intubation, and jet ventilation are standard techniques for airway management in tracheal resections, there are also reports of new approaches, ranging from regional anesthesia to extracorporeal support. The objective was to outline the entire spectrum of new airway techniques. DESIGN The literature databases PubMed/Medline and the Cochrane Library were searched systematically for prospective and retrospective trials as well as case reports on tracheal resections. SETTING No restrictions applied to hospital types or settings. PARTICIPANTS Adult patients undergoing surgical resections of noncongenital tracheal stenoses with end-to-end anastomoses. INTERVENTIONS Airway management techniques were divided into conventional and new approaches and analyzed regarding their potential risks and benefits. MEASUREMENTS AND MAIN RESULTS A total of 59 publications (n = 797 patients) were included. The majority of publications (71.2%) describe conventional airway techniques. Endotracheal tube placement after induction of general anesthesia and surgical crossfield intubation after incision of the trachea were used most frequently without major complications. A total of 7 new approaches were identified, including 4 different regional anesthetic techniques (25 cases), supraglottic airways (4 cases), and new forms of extracorporeal support (25 cases). Overall failure rates of new techniques were low (1.8%). Details on patient selection and procedural specifics are provided. CONCLUSIONS New approaches have several theoretical benefits, yet further research is required to establish criteria for patient selection and evaluate procedural safety. Given the low level of evidence, it currently is impossible to compare methods of airway management regarding outcome-related risks and benefits.

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

OBJECTIVE To report the successful use of crushed fidaxomicin via a nasogastric tube for treatment of a severe Clostridium difficile infection in a critically ill patient. DATA SOURCES Clinical observation of a patient, images of abdominal computed tomography, antimicrobial therapy and course of infection parameters. DATA EXTRACTION Relevant information contained in the medical observation of the patient and selection of image and laboratory parameters performed in the patient. DATA SYNTHESIS We 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. CONCLUSIONS Our 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.

Validation of radial artery-based uncalibrated pulse contour method (pulsioflex) in critically ill patients: A observational study

BACKGROUND Because of their simplicity, uncalibrated pulse contour (UPC) methods have been introduced into clinical practice in critical care but are often validated with a femoral arterial waveform. OBJECTIVE We aimed to test the accuracy of cardiac index (CI) measurements and trending ability from a radial artery with one UPC. DESIGN An observational study. SETTING Tertiary care mixed-surgical ICU. Data were obtained from April 2015 to July 2016. PATIENTS We studied 20 critically ill mechanically ventilated patients monitored by UPC (PulsioFlex; Pulsion Medical Systems SE, Feldkirchen, Germany). We used transpulmonary thermodilution (PiCCO2) as a reference. MAIN OUTCOME MEASURES Bland–Altman-analyses with percentage errors were calculated to assess the accuracy of CI values from radial pulse contour analysis (CIRAD), autocalibration (CIAC) and femoral pulse contour analysis (CIFEM). All were compared with a reference (CITD) at 4-h intervals for 24 h. Trending ability was assessed by polar-plots and four-quadrant-plots. CI is given in l min−1 m−2. RESULTS Bland–Altman-analyses: for CIRAD, the mean bias was −0.1 with limits of agreement (LOA) of −2.9 to 2.7 and a percentage error of 70%; for CIAC, the mean bias was 0 with LOA −2.8 to 2.7 and a percentage error of 70%; for CIFEM, the mean bias was 0 with LOA −1.2 to 1.2 and a percentage error of 30%, respectively. Polar plots for trending: for CIRAD, the angular bias was 12° with radial LOA of 39°, a polar concordance rate of 73% and a concordance rate of 67% in the four-quadrant-plot; for CIAC, the angular bias was 4° with radial LOA of 41°, polar concordance rate of 79% and a concordance rate of 74% in the four quadrant plot; for CIFEM, the angular bias was −2° with radial LOA of 50°, polar concordance rate of 74% and a concordance rate of 81%. CONCLUSION In critically ill patients, the PulsioFlex system connected to a radial arterial catheter is inaccurate for CI measurements and does not track changes in CI adequately. We therefore recommend using validated thermodilution techniques for monitoring in the critical care setting.BACKGROUND Because of their simplicity, uncalibrated pulse contour (UPC) methods have been introduced into clinical practice in critical care but are often validated with a femoral arterial waveform. OBJECTIVE We aimed to test the accuracy of cardiac index (CI) measurements and trending ability from a radial artery with one UPC. SETTING Tertiary care mixed-surgical ICU. Data were obtained from April 2015 to July 2016. PATIENTS We studied 20 critically ill mechanically ventilated patients monitored by UPC (PulsioFlex; Pulsion Medical Systems SE, Munich, Germany). We used transpulmonary thermodilution (PiCCO2) as a reference. MAIN OUTCOME MEASURES Bland-Altman-analyses with percentage errors were calculated to assess the accuracy of CI values from radial pulse contour analysis (CIRAD), autocalibration (CIAC) and femoral pulse contour analysis (CIFEM). All were compared with a reference (CITD) at 4-h intervals for 24 h. Trending ability was assessed by polar-plots and four-quadrant-plots. CI is given in l min m. RESULTS Bland-Altman-analyses: for CIRAD, the mean bias was -0.1 with limits of agreement (LOA) of -2.9 to 2.7 and a percentage error of 70%; for CIAC, the mean bias was 0 with LOA -2.8 to 2.7 and a percentage error of 70%; for CIFEM, the mean bias was 0 with LOA -1.2 to 1.2 and a percentage error of 30%, respectively. Polar plots for trending: for CIRAD, the angular bias was 12° with radial LOA of 39°, a polar concordance rate of 73% and a concordance rate of 67% in the four-quadrant-plot; for CIAC, the angular bias was 4° with radial LOA of 41°, polar concordance rate of 79% and a concordance rate of 74% in the four quadrant plot; for CIFEM, the angular bias was -2° with radial LOA of 50°, polar concordance rate of 74% and a concordance rate of 81%. CONCLUSION In critically ill patients, the PulsioFlex system connected to a radial arterial catheter is inaccurate for CI measurements and does not track changes in CI adequately. We therefore recommend using validated thermodilution techniques for monitoring in the critical care setting.

Usefulness of broad-range PCR plus sequencing for the diagnosis of bacteremia due to a lung abscess.

The early detection and treatment of sepsis in patients is essential for a positive outcome. Microbiological analysis of blood cultures, as the gold standard for diagnosis, is rather slow. However, more rapid methods like PCR have become available recently and are being evaluated clinically. We present data from the monitoring of a patient with sepsis who was on anti-infective treatment. The patient was positive for Streptococcus pneumoniae by broad-range PCR and sequence analysis in a blood sample and resected lung tissue specimen, the latter embedded in paraffin, while blood culture diagnostics remained negative.

Kasuistik – Luftembolie nach ZVK-Entfernung

Placement and removal of central venous catheters (CVC) are routine procedures in anesthesiology and on the intensive care unit. There are numerous possible complications associated with those interventions. Here, we report on a patient who developed respiratory failure immediately after removal of a CVC. The proof of air bubbles in echocardiography confirmed the diagnosis of air embolism. In this article we describe causes, symptoms and therapy of air embolism.