Jörg Brederlau

Whole-Body Multislice Computed Tomography as the First Line Diagnostic Tool in Patients With Multiple Injuries : The Focus on Time

OBJECTIVE Whole-body multislice helical computed tomography (MSCT) becomes increasingly important as a diagnostic tool in patients with multiple injuries. We describe time requirement of two different diagnostic approaches to multiple injuries one with whole-body-MSCT (MSCT Trauma-Protocol) as the sole radiologic procedure and one with conventional use of radiography, combined with abdominal ultrasound and organ focused CT (Conventional-Trauma-Protocol). METHODS Observational study with retrospective analysis of time requirements for resuscitation, diagnostic workup and transfer to definitive treatment after changing from conventional to MSCT Trauma-Protocol. Group I: data from trauma patients imaged with whole-body MSCT. Group II: data of trauma patients investigated with conventional trauma protocol before the introduction of MSCT-Trauma-Protocol. RESULTS The complete diagnostic workup in group I (n = 82) was finished after 23 minutes (17-33 minutes) [median; interquartile range (IQR)] and after 70 minutes (IQR, 56-85) in group II (n = 79). The definitive management plan based on a completed diagnostic workup was devised after 47 minutes (IQR, 37-59) in group I and after 82 minutes (IQR, 66-110) in group II. CONCLUSION A whole-body MSCT-based diagnostic approach to multiple injuries might shorten the time interval from arrival in the trauma emergency room until obtaining a final diagnosis and management plan in patients with multiple injuries and might, therefore, contribute to improvements in patient care.

Sonographic imaging of the sciatic nerve and its division in the popliteal fossa in children

Background:  High resolution ultrasound is a possible option for anesthetists to detect nerves. We tested the possibility of imaging the sciatic nerve and its division into the tibial and peroneal part using high resolution ultrasound in children.

Arteriovenous extracorporeal lung assist as integral part of a multimodal treatment concept : a retrospective analysis of 22 patients with ARDS refractory to standard care

Background and objectives: Pumpless arteriovenous extracorporeal lung assist is increasingly used as a rescue therapy in acute respiratory distress syndrome. Arteriovenous extracorporeal lung assist is highly efficient in eliminating carbon dioxide and allows the application of ventilator techniques that prioritize lung protection and aim to reduce ventilator‐induced lung injury and remote organ dysfunction. Methods: Retrospective data analysis performed in a 12‐bed university hospital ICU. In all, 22 patients with acute respiratory distress syndrome refractory to standard care were included. Arteriovenous extracorporeal lung assist as central part of a multimodal treatment concept was combined with tidal volume (VT) reduction below 4 mL kg−1 predicted body weight, a positive end‐expiratory pressure titrated to optimize oxygenation and continuous axial rotation. Results: Hypercapnia was reversed within 24 h in survivors (39 mmHg (35‐42) (median and interquartile range) vs. 65 mmHg (54‐72), P < 0.05) and non‐survivors (5.2 kPa (5.5‐6.0) vs. 10 kPa (6.9‐13.9), P < 0.05). Oxygenation was significantly improved in survivors after 24 h (PaO2/FiO2 ratio 20.7 kPa (17.4‐22.7) vs. 11.7 kPa (7.3‐20.8), P < 0.05). All patients required norepinephrine infusion and volume resuscitation. The overall complication rate was 23%, predominantly due to reversible lower limb ischaemia. One patient (5%) was permanently disabled due to amputation of a seriously injured lower leg 9 days after initiation of arteriovenous extracorporeal lung assist therapy; however, the patient survived without neurological deficits despite an initial oxygenation index of 4.4 kPa. The overall mortality rate was 27%. Conclusions: A multimodal treatment concept with arteriovenous extracorporeal lung assist as its central part provides reversal of hypercapnia and stabilization of oxygenation. In an attempt to maximize lung protection and potentially reduce ventilator‐induced lung injury, a further VT reduction below 4 mL kg−1predicted body weight combined with a high mean airway pressure and continuous axial rotation is safely possible.

Application of standard operating procedures accelerates the process of trauma care in patients with multiple injuries.

Objective Objective of this study is to determine whether the formulation of standard operating procedures (SOPs) and their incorporation in a trauma pathway are associated with an improvement of trauma treatment process. Materials and methods A retrospective data analysis of traumatized patients treated before the introduction of the SOPs (group I) and after a SOP training period of 6 months (group II) was performed. The time required for resuscitation (period A), diagnostic workup (period B) and total stay in the emergency room (period C) was used as a marker of trauma team performance. Data are described as median and interquartile range. Mortality within the first 24 h and within 30 days was determined. Results Eighty-two patients in group I and 79 patients in group II were analysed. Period A took 13 (10–17) min in group I and 10 (8–15) min in group II, respectively (P<0.001). Period B was finished after 23 (17–33) min in group I and after 17 (13–21) min in group II (P<0.001). Period C took 47 (37–59) min in group I and 42 (34–53) min in group II, respectively (P<0.05). A difference in mortality was not observed. Conclusion SOP incorporation in a trauma pathway shortens the total stay in the emergency room, resuscitation time and the time to achieve definitive diagnosis in multiple trauma patients. Thus, it can be concluded that organization and timing of trauma treatment steps help in improving the quality of trauma treatment process.

Identification of Candida fabianii as a cause of lethal septicaemia.

Infections caused by rare fungal species of low pathogenic potential become increasingly common in hospital settings. The identification of these species presents a major challenge for the clinical mycology laboratory. We describe a case of fatal septicaemia caused by Candida fabianii. The use of common biochemical approaches led to misidentification of the isolate as Candida utilis. Sequencing of the internal transcribed spacer regions (ITS1 and ITS2) allowed unequivocal species identification.

Transnasal transesophageal echocardiography : A modified application mode for cardiac examination in ventilated patients

UNLABELLED In 42 endotracheally intubated patients, we examined the utility of a miniaturized monoplane probe for transnasal transesophageal echocardiography (TEE). Transnasal TEE was prospectively evaluated in 26 deeply and 16 mildly sedated patients receiving topical anesthesia with lidocaine jelly 2%. The patients with deep sedation were additionally examined with transoral monoplane and multiplane TEE. Transnasal esophageal insertion of the TEE probe was successfully performed in 90% of patients. Endotracheal malpositioning was corrected in two patients. Nasal bleeding required treatment in another patient. Topical anesthesia was adequate in 82% of mildly sedated patients. Left ventricular short- and four-chamber long-axis views of good quality were obtained with transnasal (transoral) monoplane TEE in 76% (81%) and 92% (96%) of patients (differences not significant). Compared with conventional multiplane TEE, transnasal monoplane TEE missed diagnoses in 19% of patients. The relative error (mean +/- SEM) of quantification with transnasal TEE was <9% +/- 2% for ventricular diameters and <7% +/- 2% for cross-sectional area measurements, with a bias of 0.5 +/- 3.8 cm2 and 0.1 +/- 2.4 cm2 (mean +/- 2 SD) for left ventricular end-diastolic and end-systolic short-axis areas. The relative error in measuring intracardiac flow velocities was >40%, but systolic to diastolic peak velocity ratios at the valvular site were determined with an error <4% +/- 3%. Transnasal monoplane TEE can be performed even in mildly sedated patients with an endotracheal tube without further need for analgesia or sedation. The technique is as useful as conventional transoral TEE to image standard tomographic planes for quantification, but it is less suited for comprehensive echocardiographic diagnosing. IMPLICATIONS Transnasal insertion of a miniaturized monoplane transesophageal echocardiography (TEE) probe was studied in endotracheally intubated patients. Nasal passage was well tolerated even by patients with only mild sedation. Imaging quality was similar to conventional transoral monoplane TEE with larger transducers, but technical restraints cause a deficit in complete cardiac diagnosing obtained with multiplane TEE.

ACUTE RESPIRATORY DISTRESS INDUCED BY REPEATED SALINE LAVAGE PROVIDES STABLE EXPERIMENTAL CONDITIONS FOR 24 HOURS IN PIGS

Surfactant depletion is most often used to study acute respiratory failure in animal models. Because model stability is often criticized, the authors tested the following hypotheses: Repeated pulmonary lavage with normal saline provides stable experimental conditions for 24 hours with a PaO2/FiO2 ratio < 300 mm Hg. Lung injury was induced by bilateral pulmonary lavages in 8 female pigs (51.5 ± 4.8 kg). The animals were ventilated for 24 hours (PEEP: 5 cm H2O; tidal volume: 6 mL/kg; respiratory rate: 30/min). After 24 hours the animals were euthanized. For histopathology slides from all pulmonary lobes were obtained. Supernatant of the bronchoalveolar fluid collected before induction of acute respiratory distress syndrome (ARDS) and after 24 hours was analyzed. A total of 19 ± 6 lavages were needed to induce ARDS. PaO2/FiO2 ratio and pulmonary shunt fraction remained significantly deteriorated compared to baseline values after 24 hours (P <. 01). Slight to moderate histopathologic changes were detected. Significant increases of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 were observed after 24 hours (P <. 01). The presented surfactant depletion–based lung injury model was associated with increased pulmonary inflammation and fulfilled the criteria of acute ling injury (ALI) for 24 hours.

Ultrasound-guided cannulation of the internal jugular vein in critically ill patients positioned in 30° dorsal elevation

Background and objective: Catheterization of the internal jugular vein is traditionally performed with the patient lying flat or in the Trendelenburg position. This puts patients with elevated intracranial pressure at risk of cerebral herniation. The objective of this study was to assess the safety of real-time ultrasound-guided catheterization of the internal jugular vein in ventilated patients with the patient positioned in a 30° head-up position. Methods: This prospective, single-centre case series was performed in a 12-bed multi-disciplinary adult intensive care unit (ICU) in a 1500-bed university hospital. The cohort consisted of 64 ventilated ICU patients (14 female, 50 male) with a median age of 52 yr (range 18-85 yr), needing central venous cannulation for insertion of a central venous, haemodialysis or pulmonary artery catheter. The majority of patients presented with risk factors for a difficult cannulation. Catheterization was performed using real-time ultrasound guidance with all patients positioned in 30° dorsal elevation. Results: Ultrasound-guided cannulation of the internal jugular vein was successful in all patients. There was no evidence of air embolism. Despite a high incidence of anomalous anatomy (39%) no injury to the carotid artery occurred. Central venous access was established in less than 1 min in 75% of patients. Conclusion: Ultrasound-guided cannulation of the internal jugular vein in ventilated ICU patients can be performed successfully with the patient positioned in 30° dorsal elevation. Potentially deleterious position changes can thus be avoided in high-risk patients.

The contribution of arterio-venous extracorporeal lung assist to gas exchange in a porcine model of lavage-induced acute lung injury

This prospective large-animal study was performed to evaluate the contribution of arterio-venous extracorporeal lung assist (AV-ECLA) to pulmonary gas exchange in a porcine lavage-induced acute lung injury model. Fifteen healthy female pigs, weighing 50.39±3.8 kg (mean±SD), were included. After induction of general anaesthesia and controlled ventilation, an arterial line and a pulmonary artery catheter were inserted. Saline lung lavage was performed until the PaO2 decreased to 51±16 mmHg. After a stabilization period of 60 min, the femoral artery and vein were cannulated and a low-resistance membrane lung was interposed. Under apnoeic oxygenation, variations of sweep-gas flow were performed every 20 min in order to evaluate the membrane lungs efficacy, in terms of carbon dioxide (CO2) removal and oxygen (O2) uptake. Although AV-ECLA is highly effective in eliminating CO2, if combined with apnoeic oxygenation, normocapnia was not achievable. AV-ECLAs contribution to oxygenation during severe hypoxemia was antagonized by a significant increase in the pulmonary shunt fraction.

Extracorporeal lung assist might avoid invasive ventilation in exacerbation of COPD

To the Editors: Acute exacerbation of chronic obstructive pulmonary disease (COPD) requiring invasive mechanical ventilation (IMV) is associated with a very poor prognosis. Therefore noninvasive mechanical ventilation (NIV) with avoidance of endotracheal intubation should be preferred. However, NIV can fail and result in severe respiratory acidosis. If IMV becomes mandatory, the development of pulmonary dynamic hyperinflation with subsequent barotrauma and circulatory failure is the main pathophysiological alteration. Extracorporeal CO2 elimination, such as that provided by an arteriovenous extracorporeal lung assist system (avECLA), combined with NIV might be a therapeutic option in order to avoid IMV in patients with acute exacerbation of COPD (AECOPD). We present three cases with hypercapnic respiratory failure that were treated with NIV and extracorporeal lung assist for 2, 7 and 8 days, respectively. The combination of these two therapeutic approaches might be effective to prevent the potentially lethal side-effects of IMV in this group of multi-morbid patients. COPD affects 4–7% of the general population and is the fourth leading cause of death in developed countries [1]. If patients with AECOPD require mechanical ventilation (MV), the mortality rate is 17–30% [2]. MV is mandatory in patients with AECOPD if decompensated hypercapnic respiratory failure is evident. NIV via face mask or helmet has been the evidence-based treatment of choice in AECOPD patients with hypercapnia for more than 20 yrs [3]. NIV has been shown to improve gas exchange and outcome when compared with IMV. However, in some cases NIV fails to eliminate CO2 sufficiently and tracheal intubation and IMV are traditionally regarded as the last treatment option [4]. The prognosis of the affected patients still remains very …