Julia Langgartner

Ischemic-like cholangiopathy with secondary sclerosing cholangitis in critically Ill patients

OBJECTIVES:Sclerosing cholangitis in critically ill patients (SC-CIP) is a newly described entity of severe biliary disease with progression to liver cirrhosis. The mechanisms leading to this form of cholangiopathy with stricture formation and complete obliteration of bile ducts are unknown.PATIENTS AND  METHODS:In the last 2 yr, sclerosing cholangitis was diagnosed in 26 patients during or after their stay on the intensive care unit by ERCP and/or liver histology. Complete patient records were available for 17 patients. Histological evaluations of liver biopsies and of four explanted livers, parameters of cardiovascular and respiratory conditions, treatment modalities, and accompanying infections were analyzed to find further hints for the pathomechanisms leading to SC-CIP.RESULTS:With the beginning of cholestasis, the earliest endoscopic findings were intrahepatic biliary casts with impairment of the biliary flow and subsequent biliary infection, in most cases with Enterococcus faecium. Liver biopsy confirmed cholangitis and histology of explanted livers revealed ulcerated biliary epithelium with hemorrhagic exudates in the bile ducts. In the further course, progressive sclerosis with formation of multiple strictures of the bile ducts was observed. All patients suffered severe respiratory insufficiency with the need for mechanical ventilation (40.7 ± 32.9 days). The PaO2/FiO2 ratio until beginning of cholestasis was 150.5 ± 43.1. Half of the patients (9/17) were treated with high-frequency oscillatory ventilation and 12/17 patients by intermittent prone positioning. All patients required catecholamines for hemodynamic stabilization.CONCLUSIONS:SC-CIP is a severe and in most cases rapidly progressive complication of intensive care patients. Ischemic injury of the biliary tree with the formation of biliary casts and subsequent ongoing biliary infection due to multiresistant bacteria seem to be major pathogenic mechanisms in the development of this new entity of sclerosing cholangitis.

Combined skin disinfection with chlorhexidine/propanol and aqueous povidone-iodine reduces bacterial colonisation of central venous catheters

ObjectiveCentral venous catheter (CVC)-related infections may be caused by micro-organisms introduced from the skin surface into deeper tissue at the time of CVC insertion. The optimal disinfection regimen to avoid catheter-related infections has not yet been defined. This study compares three different approaches.DesignProspective randomised trial.SettingA tertiary care hospital.Patients and participantsOne hundred nineteen patients scheduled electively to receive 140 CVCs.InterventionsSkin disinfection was performed with either povidone-iodine 10% (PVP-iodine), chlorhexidine 0.5%/propanol 70%, or chlorhexidine 0.5%/propanol 70% followed by PVP-iodine 10%. Prior to disinfection, a swab from the site of insertion was taken for culture. CVCs were removed if no longer needed or infection was suspected. All catheters were cultured quantitatively after removal.Measurement and resultsBacteria could be isolated from 20.7% of the catheter tips. Bacterial growth was found in 30.8% of the catheters placed after skin disinfection with povidone-iodine, in 24.4% after disinfection with propanol/chlorhexidine and in 4.7% after disinfection with propanol/chlorhexidine followed by povidone-iodine (p=0.006). In 15 cases, the same organism was isolated from the skin swab and the catheter tip. Ten of these paired isolates showed the same pattern in a pulsed-field gel electrophoresis analysis.ConclusionsSkin disinfection with propanol/chlorhexidine followed by PVP-iodine was superior in the prevention of microbial CVC colonisation compared to either of the regimens alone. These results support the concept that catheter infections can originate from bacterial translocation at the time of catheter insertion.

Abdominal ultrasound in the intensive care unit: a 3-year survey on 400 patients

ObjectiveThis study analyzed 400 ultrasound examinations in the ICU to assess the indications of this imaging modality.Design and settingRetrospective analysis on prospectively collected data on 400 patients in a tertiary care hospital.Patients and participantsThe observational, prospective, clinical study examined 400 bedside abdominal ultrasound examinations performed in the ICU, of which 2% were performed emergently, 56% urgently, and 42% electively.Measurements and resultsEnvironmental conditions impaired the examination slightly in 54%, moderately in 27%, and severely in 4%. Total time per study ranged from 1 to 45 min (median 10). New pathological findings were detected in 31% while 33% confirmed already known pathologies. In 53% there was no therapeutic consequence, in 27% treatment was continued based on the sonographic findings, in 10% an intervention was necessary, in 6% other therapeutic changes followed, and in 4% additional evaluation was deemed necessary. In 80% no other imaging test had to be performed.ConclusionsUltrasound studies are deemed sufficient in a large proportion of patients and help to avoid other, more elaborate imaging studies. However, more focused indications for studies may help to improve cost-effectiveness.

Cardiac Arrest: Composition of Resuscitation Teams and Training Techniques: Results of a Hospital Survey in German-Speaking Countries

BACKGROUND The long-term outcome of patients requiring cardiopulmonary resuscitation depends heavily on swift and appropriate care. The aim of this study was to obtain data on the composition and training of resuscitation teams in specialist departments for internal medicine and anesthesiology. METHODS Between October 2006 and February 2007, 440 questionnaires were sent to departments for anesthesiology and internal medicine in Germany (hospitals with more than 300 beds) and to university hospitals in Switzerland and Austria. RESULTS The response rate was 38%. Of 166 participating hospitals, 152 have an emergency team. Resuscitation training (RT) takes place in 111 hospitals. Ninety-two hospitals (55%) hold a course more than once a year. Of those hospitals with RT, 86% use a simulation dummy, 77% conduct theoretical tutorials, and 65% follow a fixed algorithm. CONCLUSION The majority of hospitals that participated in this survey have an emergency team in place and organize resuscitation training for their medical personnel. The training varies greatly, however, in frequency, size of group, and qualification of the trainer. Implementation of standardized training for and management of in-hospital resuscitation measures might further hone staff skills and therefore improve the long-term outcome for the patients concerned.

Comparison of inpatient and outpatient upper gastrointestinal haemorrhage.

Background and aimsInpatients developing upper gastrointestinal (GI) haemorrhage are at increased risk of death. This study was performed to elucidate differences in inpatients and outpatients.Patients/methodsThree hundred and sixty-two patients who needed esophagogastroduodenoscopy for upper GI bleeding were identified from endoscopy charts. Patients’ characteristics, bleeding parameters, clinical presentation, pre-existing medication, and laboratory data were compared between patients who were admitted because of upper GI bleeding and patients who developed bleeding while in hospital for other reasons.Results/findingsHospital mortality was 39.0% in inpatients vs. 11.1% in outpatients (p<0.01). Death due to bleeding was observed in 9.5% of inpatients vs. 2.5% of outpatients (p<0.01). Whereas peptic ulcer was the most common source of bleeding in both, variceal bleeding was the most common cause of death because of haemorrhage in both. Recurrent bleeding was associated with mortality in outpatients (p<0.001), but not in inpatients (p=0.11). Rates of bleeding recurrence and need for surgery was similar in both groups. Inpatients suffered more often from renal disease, pulmonary disease, diabetes mellitus, coagulopathy, or immunosuppression, and were treated more frequently with acetylsalicylic acid, glucocorticoids and heparin. The frequency of pre-existing disease was higher in inpatients.Interpretation/conclusionHigher mortality after GI bleeding in inpatients than in outpatients is due to a generally higher prevalence of co-morbidity rather than a single or a few risk factors.

Volcano-like intermittent bleeding activity for seven years from an arterio-enteric fistula on a kidney graft site after pancreas-kidney transplantation: a case report

IntroductionWe report the first case of a patient who underwent simultaneous kidney and pancreas transplantation and who then suffered from repeated episodes of severe gastrointestinal bleeding over a period of seven years. Locating the site of gastrointestinal bleeding is a challenging task. This case illustrates that detection of an arterio-enteric fistula can be very difficult, especially in technically-challenging situations such as cases of severe intra-abdominal adhesions. It is important to consider the possibility of arterio-enteric fistulas in cases of intermittent bleeding episodes, especially in transplant patients.Case presentationA 40-year-old Caucasian man received a combined pancreas-kidney transplantation as a result of complications from diabetes mellitus type I. Thereafter, he suffered from intermittent clinically-relevant episodes of gastrointestinal bleeding. Repeat endoscopic, surgical, scintigraphic, and angiographic investigations during his episodes of acute bleeding could not locate the bleeding site. He finally died in hemorrhagic shock due to arterio-enteric bleeding at the kidney graft site, which was diagnosed post-mortem.ConclusionsIn accordance with the literature, we suggest considering the removal of any rejected transplant organs in situations where arterio-enteric fistulas seem likely but cannot be excluded by repeat conventional or computed tomography-angiographic methods. Arterio-enteric fistulas may intermittently bleed over many years.

The ECMOnet score: a useful tool not to be taken absolutely

Dear Editor, We read with great interest the article by Pappalardo and colleagues [1], and very much appreciate their effort in identifying predictors of mortality in patients on ECMO with lung failure induced by H1N1-influenza-A using the newly developed ECMOnet score. We congratulate the authors and all participating centers on the achievement of a nationwide database for these patients, which opens up new approaches to collectively improving the outcome in these patients. Predicting the risk of mortality is important and desirable in guiding the use of restricted treatment resources such as ECMO. It is not an easy undertaking, as very high accuracy is needed to avoid the grave consequences of an incorrect decision. We agree with the authors that ventilatory and blood gas parameters before ECMO cannot sufficiently predict the final outcome in a patient on ECMO, which may be explained by the fact that the extracorporeal device will support and partly substitute for respiratory function. In our own cohort of 38 patients with H1N1influenza-A and the need for venovenous ECMO since 2009 (Table 1), in addition to common respiratory parameters we tested static compliance (CRS) and corrected expired volume per minute (VEcorr), because a recent post hoc analysis showed that either a CRS of 20 ml/cm H2O or less or a VEcorr of at least 13 l/min in combination with a PaO2/FiO2 of 100 mm Hg or less identifies a higher risk subgroup [2, 3]. However, this may not be true for patients on ECMO, as we could not see a difference in our small sample. Failure of extrapulmonary organs may be a more important predictor, which is mirrored in two parameters of the new ECMOnet score, bilirubin and creatinine. In addition, hospital length of stay before ECMO institution was found to be a predictor of death, which parallels information from the ELSO database, that length of ventilation before ECMO is associated with a worse outcome [4]. This parameter might be falsified, if H1N1 is acquired in hospital, as we have seen in several referred cases. Parameter 4 (hematocrit) and parameter 5 (mean arterial pressure) may be iatrogenically corrected by blood transfusions and vasopressors, and we wonder whether this was taken into account when calculating the score. In our cohort, further major contributors to a poor outcome were chronic

Qualitätsmanagement: Implementierung des In-Hospital -Notfallprotokolls in die klinische Praxis

ZusammenfassungHintergrund und Ziel:Die Überlebensrate nach einer stattgehabten Reanimation im Krankenhaus liegt nach wie vor bei nur 14–17%. Die Dokumentation dieser „In-Hospital“-Notfallsituation (IHN) erscheint dabei gerade im deutschsprachigen Raum lückenhaft und inhomogen. Eine Optimierung der IHN-Aufzeichnung könnte neben der Komplettierung der Informationen für die Patientenweiterversorgung auch helfen, mögliche organisatorische und strukturelle Probleme zu erkennen, um so ein verbessertes Patientenoutcome zu ermöglichen. Zielsetzung dieser Erhebung war es, nach Implementierung eines von den Autoren in enger Anlehnung an das DIVI-Notarztprotokoll (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) entwickelten IHN-Protokoll alle Einsätze des internistischen Notfallteams (NT) über einen Zeitraum von 40 Monaten auszuwerten. Dabei sollte geklärt werden, inwieweit diese Dokumentationsform die notwendigen Fakten der IHN adäquat widerspiegelt, wie die Akzeptanz dieser zusätzlichen Dokumentation ist und inwiefern eine Qualitätsverbesserung der IHN-Dokumentation verzeichnet werden kann.Methodik:Analyse aller verfügbaren Protokolle der NT-Einsätze zur IHN zwischen August 2004 und Dezember 2007 (n = 65) sowie Auswertung der Entlassarztbriefe (EB) der jeweiligen Patienten.Ergebnisse:In 65% aller NT-Einsätze fand eine Dokumentation mit Hilfe des IHN-Protokolls statt. Im Mittel wurden 80% der vorgegebenen Protokollinhalte dokumentiert, wobei die Medikamente, deren Dosierung und der Zusammenhang der Applikation im zeitlichen Verlauf der IHN nur unzureichend dokumentiert wurden (77% lückenhafte Angaben). 25% der EB enthielten keinerlei Angaben über die IHN.Schlussfolgerung:Der Einsatz des IHN-Protokolls erscheint geeignet, um die aus medizinischer und forensischer Sicht erforderlichen Daten der IHN adäquat zu dokumentieren. In Anbetracht der Tatsache, dass die IHN im EB eines Patienten teilweise gar nicht erwähnt wurde, verbesserten sich die hausinterne Qualität und Vollständigkeit der Dokumentation durch die Einführung des IHN-Protokolls deutlich. Das „Vorfinden“ eines solchen Protokolls in der Patientenakte sollte zukünftig zur vermehrten Erwähnung der IHN in der Entlassungsdokumentation führen.AbstractBackground and Purpose:Outcome after in-hospital resuscitation with survival rates between 14–17% still remains poor. Structured documentation of in-hospital cardiac arrest especially in Germany is rare and inhomogeneous. Documentation of in-hospital emergency situations (I-ES) may help to develop organizational structures, to collect information of treatment after resuscitation and therefore, improve patient’s outcome. The aim of this study was to evaluate the documentation quality and user’s acceptance after the implementation of an in-house emergency (IHE) protocol used by the authors’ internal medicine emergency team (ET).Methods:Analysis of IHE protocols and discharge letters of 65 patients between August 2004 and December 2007 at a university medical center.Results:The IHE protocol was used in 65% of all emergency calls with a completion rate of 80% of all available documentation categories. Especially documentation of drugs given, their dosage and the general course of action was incomplete. In 25% the discharge letters did not contain information about the I-ES.Conclusion:Implementation of the authors’ IHE protocol, designed in close accordance with the DIVI (German Interdisciplinary Association of Intensive Care and Emergency Medicine) out-of-hospital emergency protocol, helps to collect important data in I-ES. Usage of the protocol resulted in better documentation of emergency situations in contrast to the information found in discharge letters alone. Nevertheless, documentation of I-ES still needs to be improved, especially concerning the completeness of records.

[Quality management: implementation of the "in-hospital" emergency protocol into clinical routine].

ZusammenfassungHintergrund und Ziel:Die Überlebensrate nach einer stattgehabten Reanimation im Krankenhaus liegt nach wie vor bei nur 14–17%. Die Dokumentation dieser „In-Hospital“-Notfallsituation (IHN) erscheint dabei gerade im deutschsprachigen Raum lückenhaft und inhomogen. Eine Optimierung der IHN-Aufzeichnung könnte neben der Komplettierung der Informationen für die Patientenweiterversorgung auch helfen, mögliche organisatorische und strukturelle Probleme zu erkennen, um so ein verbessertes Patientenoutcome zu ermöglichen. Zielsetzung dieser Erhebung war es, nach Implementierung eines von den Autoren in enger Anlehnung an das DIVI-Notarztprotokoll (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) entwickelten IHN-Protokoll alle Einsätze des internistischen Notfallteams (NT) über einen Zeitraum von 40 Monaten auszuwerten. Dabei sollte geklärt werden, inwieweit diese Dokumentationsform die notwendigen Fakten der IHN adäquat widerspiegelt, wie die Akzeptanz dieser zusätzlichen Dokumentation ist und inwiefern eine Qualitätsverbesserung der IHN-Dokumentation verzeichnet werden kann.Methodik:Analyse aller verfügbaren Protokolle der NT-Einsätze zur IHN zwischen August 2004 und Dezember 2007 (n = 65) sowie Auswertung der Entlassarztbriefe (EB) der jeweiligen Patienten.Ergebnisse:In 65% aller NT-Einsätze fand eine Dokumentation mit Hilfe des IHN-Protokolls statt. Im Mittel wurden 80% der vorgegebenen Protokollinhalte dokumentiert, wobei die Medikamente, deren Dosierung und der Zusammenhang der Applikation im zeitlichen Verlauf der IHN nur unzureichend dokumentiert wurden (77% lückenhafte Angaben). 25% der EB enthielten keinerlei Angaben über die IHN.Schlussfolgerung:Der Einsatz des IHN-Protokolls erscheint geeignet, um die aus medizinischer und forensischer Sicht erforderlichen Daten der IHN adäquat zu dokumentieren. In Anbetracht der Tatsache, dass die IHN im EB eines Patienten teilweise gar nicht erwähnt wurde, verbesserten sich die hausinterne Qualität und Vollständigkeit der Dokumentation durch die Einführung des IHN-Protokolls deutlich. Das „Vorfinden“ eines solchen Protokolls in der Patientenakte sollte zukünftig zur vermehrten Erwähnung der IHN in der Entlassungsdokumentation führen.AbstractBackground and Purpose:Outcome after in-hospital resuscitation with survival rates between 14–17% still remains poor. Structured documentation of in-hospital cardiac arrest especially in Germany is rare and inhomogeneous. Documentation of in-hospital emergency situations (I-ES) may help to develop organizational structures, to collect information of treatment after resuscitation and therefore, improve patient’s outcome. The aim of this study was to evaluate the documentation quality and user’s acceptance after the implementation of an in-house emergency (IHE) protocol used by the authors’ internal medicine emergency team (ET).Methods:Analysis of IHE protocols and discharge letters of 65 patients between August 2004 and December 2007 at a university medical center.Results:The IHE protocol was used in 65% of all emergency calls with a completion rate of 80% of all available documentation categories. Especially documentation of drugs given, their dosage and the general course of action was incomplete. In 25% the discharge letters did not contain information about the I-ES.Conclusion:Implementation of the authors’ IHE protocol, designed in close accordance with the DIVI (German Interdisciplinary Association of Intensive Care and Emergency Medicine) out-of-hospital emergency protocol, helps to collect important data in I-ES. Usage of the protocol resulted in better documentation of emergency situations in contrast to the information found in discharge letters alone. Nevertheless, documentation of I-ES still needs to be improved, especially concerning the completeness of records.

Qualitätsmanagement: Implementierung des „In-Hospital“-Notfallprotokolls in die klinische Praxis@@@Quality Management: Implementation of the „In-Hospital“ Emergency Protocol into Clinical Routine

ZusammenfassungHintergrund und Ziel:Die Überlebensrate nach einer stattgehabten Reanimation im Krankenhaus liegt nach wie vor bei nur 14–17%. Die Dokumentation dieser „In-Hospital“-Notfallsituation (IHN) erscheint dabei gerade im deutschsprachigen Raum lückenhaft und inhomogen. Eine Optimierung der IHN-Aufzeichnung könnte neben der Komplettierung der Informationen für die Patientenweiterversorgung auch helfen, mögliche organisatorische und strukturelle Probleme zu erkennen, um so ein verbessertes Patientenoutcome zu ermöglichen. Zielsetzung dieser Erhebung war es, nach Implementierung eines von den Autoren in enger Anlehnung an das DIVI-Notarztprotokoll (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) entwickelten IHN-Protokoll alle Einsätze des internistischen Notfallteams (NT) über einen Zeitraum von 40 Monaten auszuwerten. Dabei sollte geklärt werden, inwieweit diese Dokumentationsform die notwendigen Fakten der IHN adäquat widerspiegelt, wie die Akzeptanz dieser zusätzlichen Dokumentation ist und inwiefern eine Qualitätsverbesserung der IHN-Dokumentation verzeichnet werden kann.Methodik:Analyse aller verfügbaren Protokolle der NT-Einsätze zur IHN zwischen August 2004 und Dezember 2007 (n = 65) sowie Auswertung der Entlassarztbriefe (EB) der jeweiligen Patienten.Ergebnisse:In 65% aller NT-Einsätze fand eine Dokumentation mit Hilfe des IHN-Protokolls statt. Im Mittel wurden 80% der vorgegebenen Protokollinhalte dokumentiert, wobei die Medikamente, deren Dosierung und der Zusammenhang der Applikation im zeitlichen Verlauf der IHN nur unzureichend dokumentiert wurden (77% lückenhafte Angaben). 25% der EB enthielten keinerlei Angaben über die IHN.Schlussfolgerung:Der Einsatz des IHN-Protokolls erscheint geeignet, um die aus medizinischer und forensischer Sicht erforderlichen Daten der IHN adäquat zu dokumentieren. In Anbetracht der Tatsache, dass die IHN im EB eines Patienten teilweise gar nicht erwähnt wurde, verbesserten sich die hausinterne Qualität und Vollständigkeit der Dokumentation durch die Einführung des IHN-Protokolls deutlich. Das „Vorfinden“ eines solchen Protokolls in der Patientenakte sollte zukünftig zur vermehrten Erwähnung der IHN in der Entlassungsdokumentation führen.AbstractBackground and Purpose:Outcome after in-hospital resuscitation with survival rates between 14–17% still remains poor. Structured documentation of in-hospital cardiac arrest especially in Germany is rare and inhomogeneous. Documentation of in-hospital emergency situations (I-ES) may help to develop organizational structures, to collect information of treatment after resuscitation and therefore, improve patient’s outcome. The aim of this study was to evaluate the documentation quality and user’s acceptance after the implementation of an in-house emergency (IHE) protocol used by the authors’ internal medicine emergency team (ET).Methods:Analysis of IHE protocols and discharge letters of 65 patients between August 2004 and December 2007 at a university medical center.Results:The IHE protocol was used in 65% of all emergency calls with a completion rate of 80% of all available documentation categories. Especially documentation of drugs given, their dosage and the general course of action was incomplete. In 25% the discharge letters did not contain information about the I-ES.Conclusion:Implementation of the authors’ IHE protocol, designed in close accordance with the DIVI (German Interdisciplinary Association of Intensive Care and Emergency Medicine) out-of-hospital emergency protocol, helps to collect important data in I-ES. Usage of the protocol resulted in better documentation of emergency situations in contrast to the information found in discharge letters alone. Nevertheless, documentation of I-ES still needs to be improved, especially concerning the completeness of records.