Stephan Braune

Death after percutaneous dilatational tracheostomy: a systematic review and analysis of risk factors

IntroductionSince the introduction and widespread acceptance of percutaneous techniques in the intensive care unit (ICU) setting, the number of critically ill patients undergoing tracheostomy has steadily increased. However, this procedure can be associated with major complications, including death. The purpose of this study is to estimate the incidence and analyze the causes of lethal complications due to percutaneous dilatational tracheostomy (PDT).MethodsWe analyzed cases of lethal outcome due to complications from PDT including cases published between 1985 and April 2013. A systematic literature search was performed and unpublished cases from our own departmental records were retrospectively analyzed.ResultsA total of 71 cases of lethal outcome following PDT were identified including 68 published cases and 3 of our own patients. The incidence of lethal complications was calculated to be 0.17%. Of the fatal complications, 31.0% occurred during the procedure and 49.3% within seven days of the procedure. The main causes of death were: hemorrhage (38.0%), airway complications (29.6%), tracheal perforation (15.5%), and pneumothorax (5.6%). We found specific risk factors for complications in 73.2% of patients, 25.4% of patients had more than one risk factor. Bronchoscopic guidance was used in only 46.5% of cases.ConclusionsAccording to this analysis, PDT-related death occurs in 1 out of 600 patients receiving a PDT. Careful patient selection, bronchoscopic guidance, and securing the tracheal cannula with sutures are likely to reduce complication rates.

High-flow nasal cannula oxygen versus non-invasive ventilation in patients with acute hypoxaemic respiratory failure undergoing flexible bronchoscopy - a prospective randomised trial

IntroductionCritically ill patients with respiratory failure undergoing bronchoscopy have an increased risk of hypoxaemia-related complications. Previous studies have shown that in awake, hypoxaemic patients non-invasive ventilation (NIV) is helpful in preventing gas exchange deterioration during bronchoscopy. An alternative and increasingly used means of oxygen delivery is its application via high-flow nasal cannula (HFNC). This study was conducted to compare HFNC with NIV in patients with acute hypoxaemic respiratory failure undergoing flexible bronchoscopy.MethodsProspective randomised trial randomising 40 critically ill patients with hypoxaemic respiratory failure to receive either NIV or HFNC during bronchoscopy in the intensive care unit.ResultsAfter the initiation of NIV and HFNC, oxygen levels were significantly higher in the NIV group compared to the HFNC group. Two patients were unable to proceed to bronchoscopy after the institution of HFNC due to progressive hypoxaemia. During bronchoscopy, one patient on HFNC deteriorated due to intravenous sedation requiring non-invasive ventilatory support. Bronchoscopy was well tolerated in all other patients. There were no significant differences between the two groups regarding heart rate, mean arterial pressure and respiratory rate. Three patients in the NIV group and one patient in the HFNC group were intubated within 24 hours after the end of bronchoscopy (P = 0.29).ConclusionsThe application of NIV was superior to HFNC with regard to oxygenation before, during and after bronchoscopy in patients with moderate to severe hypoxaemia. In patients with stable oxygenation under HFNC, subsequent bronchoscopy was well tolerated.Trial registrationClinicalTrials.gov NCT01870765. Registered 30 May 2013.

Revisiting the white blood cell count: immature granulocytes count as a diagnostic marker to discriminate between SIRS and sepsis--a prospective, observational study.

BackgroundSepsis is a serious disease condition and a major cause of intensive care unit (ICU) admission. Its diagnosis in critically ill patients is complicated. To diagnose an infection rapidly, and to accurately differentiate systemic inflammatory response syndrome (SIRS) from sepsis, is challenging yet early diagnosis is vital for early induction of an appropriate therapy. The aim of this study was to evaluate whether the immature granulocyte (IG) count is a useful early diagnostic marker of sepsis compared to other markers. Therefore, a total of 70 consecutive surgical intensive care patients were assessed. IGs were measured from whole blood samples using an automated analyzer. C-reactive protein (CRP), lipopolysaccharide binding protein (LBP) and interleukin-6 (IL-6) concentrations were also determined. The observation period was a maximum of 21 days and ended with the patients’ discharge from ICU or death. Receiver operating characteristic (ROC) analyses were conducted and area under the curve (AUC) was calculated to determine sensitivities and specificities for the parameters.ResultsWe found that the IG count significantly discriminates between infected and non-infected patients (P < 0.0001) with a sensitivity of 89.2% and a specificity of 76.4%, particularly within the first 48 hours after SIRS onset. Regarding the discriminative power for infection, the IG count was more indicative than other clinical parameters such as CRP, LBP and IL-6, which had a sensitivity of less than 68%. Additionally, the highest diagnostic odds ratio (DOR) with 26.7 was calculated for the IG count within the first 48 hours. During the course of the disease ROC curve analyses showed a superior positive predictive value of the IG count compared to the other measured parameters during the first five days following the fulfillment of SIRS criteria. However, the number of IGs was not correlated with ICU mortality.ConclusionsThe total number of IG in peripheral blood from ICU patients is a good marker to discriminate infected and non-infected patients very early during SIRS. However, the IG count is not suitable as a prognostic marker for mortality. Routine and serial measurement of IGs may provide new possibilities for rapid screening of SIRS patients on ICU with suspected infections.

High-Flow Nasal Cannula Versus Bag-Valve-Mask for Preoxygenation Before Intubation in Subjects With Hypoxemic Respiratory Failure

BACKGROUND: Critically ill patients with respiratory failure undergoing intubation have an increased risk of hypoxemia-related complications. Delivering oxygen via a high-flow nasal cannula (HFNC) has theoretical advantages and is increasingly used. This study was conducted to compare HFNC with bag-valve-mask (BVM) for preoxygenation and to assess oxygenation during intubation in subjects with hypoxemic respiratory failure. METHODS: This study was a randomized controlled trial including 40 critically ill subjects with hypoxemic respiratory failure who received either HFNC or BVM for preoxygenation before intubation in the ICU. The primary outcome was the mean lowest SpO2 during intubation. RESULTS: The mean lowest SpO2 during intubation was 89 ± 18% in the HFNC group and 86 ± 11% in the BVM group (P = .56). In subjects receiving HFNC, a significant increase in SpO2 after preoxygenation was only seen in those previously receiving low-flow oxygen (P = .007), whereas there was no significant difference in SpO2 in subjects previously receiving noninvasive ventilation or HFNC (P = .73). During the 1 min of apnea after the induction of anesthesia, SpO2 dropped significantly in the BVM group (P = .001), whereas there was no significant decrease in the HFNC group (P = .17). There were no significant differences between the 2 groups at any of the predefined time points before or after intubation concerning SpO2, PaO2/FIO2, and PaCO2. CONCLUSIONS: Preoxygenation using HFNC before intubation was feasible and safe compared with BVM in critically ill subjects with acute, mild to moderate hypoxemic respiratory failure. There was no significant difference in the mean lowest SpO2 during intubation between the HFNC and the BVM group. There was also no significant difference in SpO2 between the 2 groups at any of the predefined time points. However, on continuous monitoring, there was a significant decrease in SpO2 during the apnea phase before intubation in the BVM group, which was not seen in the HFNC group. (ClinicalTrials.gov registration NCT01994928.)

Clinical features of critically ill patients with Shiga toxin-induced hemolytic uremic syndrome.

Objective:In Spring 2011, an unprecedented outbreak of Shiga toxin–producing Escherichia coli serotype O104:H4–associated hemolytic uremic syndrome occurred in Northern Germany. The aim of this study was to describe the clinical characteristics, treatments, and outcomes of critically ill patients with Shiga toxin–producing E. coli–associated hemolytic uremic syndrome during this outbreak. Design, Setting, and Patients:Multicenter, retrospective, observational study of critically ill adult patients with Shiga toxin–producing E. coli–associated hemolytic uremic syndrome in six hospitals in Hamburg, Germany, between May 2011 and August 2011. Measurements and Main Results:During the study period, 106 patients with Shiga toxin–producing E. coli–associated hemolytic uremic syndrome were admitted to eight ICUs. The median age was 40 years (range, 18–83) with a female:male ratio of 3:1. The median time from onset of clinical symptoms to hospital admission was 3 days and from hospital to ICU admission an additional 3 days. A total of 101 patients (95.3%) had acute renal failure and 78 (73.6%) required renal replacement therapy. Intubation and mechanical ventilation were required in 38 patients (35.8%) and noninvasive ventilation was required in 17 patients (16.0%). The median duration of invasive ventilation was 7 days (range, 1–32 days) and the median ICU stay was 10 days (range, 1–45 days). Fifty-one patients (48.1%) developed sepsis; of these 51 patients, 27 (25.4%) developed septic shock. Seventy patients (66.0%) developed severe neurological symptoms. Ninety-seven patients (91.5%) were treated with plasma exchange and 50 patients (47.2%) received eculizumab (monoclonal anti-C5 antibody). The mortality rate was 4.7%. Mild residual neurological symptoms were present in 21.7% of patients at ICU discharge, and no patient required renal replacement therapy 6 months after ICU admission. Conclusions:During the 2011 Shiga toxin–producing E. coli–associated hemolytic uremic syndrome outbreak in Germany, critical illness developed rapidly after hospital admission, often in young women. The infection was associated with severe neurological and renal symptoms, requiring mechanical ventilation and renal replacement therapy in a substantial proportion of patients. Overall, recovery was much better than expected.

Use of a Weighted, Automated Analysis of the Differential Blood Count to Differentiate Sepsis from Non-Infectious Systemic Inflammation: The Intensive Care Infection Score (ICIS)

INTRODUCTION Rapid and accurate diagnosis and immediate treatment of sepsis are of crucial importance. However, differentiating sepsis from Systemic Inflammatory Response Syndrome (SIRS) is a difficult challenge. Many diagnostic approaches based on clinical chemistry surrogate markers have not improved the situation. MATERIAL AND METHODS The ICIS score was established in a cohort of 70 consecutive patients with SIRS. The score includes five parameters involved in the early innate immune response: mature neutrophils count, immature neutrophils count, antibody-secreting cells count, detection of neutrophils and monocytes/macrophages activation. The score can be provided in real-time without sample preparation and is independent from inter-observer variability. RESULTS Each ICIS score parameter itself is highly correlated with the occurrence of infection. A mean ICIS value of < 5 (lower cut-off level) indicated the absence of infection whereas the score did not fall below a value of 6 in infected patients throughout the observation time. The area under curve to detect infection for ICIS was found to be highest compared to CRP, LBP, EPO, IL-6 and TNF-α (AUC=0.851, P < 0.0001). CONCLUSION Cut-off values for ICIS as a marker of infection were defined by this pilot study. The superior discriminative power of ICIS compared to CRP, LBP, EPO, IL-6 and TNF-α is underlined by its high positive and negative predictive value, particularly within the first 48 hours (PPV=79.7%, NPV=74.5%). The ICIS score provides promising potential for reliably and swiftly discriminating sepsis from SIRS in the first critical hours.

Rescue bedside laparotomy in the intensive care unit in patients too unstable for transport to the operating room.

IntroductionThe prognoses of critically ill patients with a requirement for emergency laparotomy and severe respiratory and/or hemodynamic instability precluding transport to the operating room (OR) are often fatal without surgery. Attempting emergency surgery at the bedside might equally result in an adverse outcome. However, risk factors and predictors that could support clinical decision making have not been identified so far. This study describes the clinical characteristics, indicative pathophysiology and outcomes in patients undergoing resuscitative laparotomy in the intensive care unit (ICU).MethodsThis was a retrospective observational study of all critically ill adult patients undergoing resuscitative laparotomy in the ICUs of a German university hospital from January 2005 to July 2013. Clinical characteristics, risk factors, and treatments were compared between survivors and non-survivors. The primary endpoint was 28-day survival.ResultsA total of 41 patients with a median age of 64 (21 to 83) were included. The most frequent reasons for ICU admission were sepsis, pneumonia, and pancreatic surgery. All patients were mechanically ventilated, receiving vasopressors, and were in multiple organ failure. Twenty-nine patients (70.7%) were on renal replacement therapy and two patients (4.9%) on extracorporeal membrane oxygenation. The main reasons for surgery were suspected intra-abdominal bleeding (39.0%), suspected intestinal ischemia (24.4%) or abdominal compartment syndrome (24.4%). Twenty-eight-day, ICU and hospital mortalities were 75.6%, 80.5%, and 82.9%, respectively. In six out of ten patients (60%) who survived surgery for more than 28 days, bedside laparotomy was rated as a life-saving procedure by an interdisciplinary group of the investigators.ConclusionsThese findings suggest that in selected critically ill patients with a vital indication for emergency laparotomy and severe cardiopulmonary instability precluding transport to the OR, a bedside resuscitative laparotomy in the ICU can be considered as a rescue procedure, even though very high mortality is to be expected.

Rescue Therapy With a Pumpless Extracorporeal Lung Assist Device in a Patient With Acute Interstitial Lung Disease and Severe Refractory Hypercapnia

Idiopathic interstitial pneumonia frequently causes severe pulmonary restriction that in turn makes mechanical ventilation difficult. We report the case of a 44-year-old woman who developed a refractory severe hypercapnic respiratory failure (PaCO2 281 mm Hg, pH 6.77) despite mechanical ventilation with high inspiratory pressure and PEEP. A pumpless extracorporeal lung assist device, Novalung, was used as rescue therapy for carbon dioxide removal, enabling lung-protective ventilation and normalization of life-threatening acidosis. Open lung biopsy revealed an idiopathic interstitial pneumonia with histological features of a nonspecific interstitial pneumonia. Corticosteroid therapy led to progressive improvement of pulmonary function, soon permitting cessation of mechanical ventilation and extracorporeal therapy. The patient was discharged from the intensive care unit after 20 days. This case demonstrates the successful use of pumpless extracorporeal lung assist as an alternative device to pump-driven extracorporeal membrane oxygenation in severe hypercapnic respiratory failure secondary to nonspecific interstitial pneumonia.

Population pharmacokinetics and dosing simulations of ceftazidime in critically ill patients receiving sustained low-efficiency dialysis

Objectives To describe the population PKs of ceftazidime in critically ill patients receiving sustained low-efficiency dialysis (SLED). Patients and methods This study was performed in ICUs of a university hospital. We collected blood samples during three consecutive days of SLED sessions in patients receiving ceftazidime. Concentration versus time curves were analysed using a population PKs approach with Pmetrics ® . Monte Carlo simulation for the first 24 h including a 6 h SLED session was performed with the final model. The fractional target attainment against the MIC of Pseudomonas aeruginosa was executed using targets of 50 and 100% fT  >   MIC . Results In total, 211 blood samples of 16 critically ill patients under SLED were collected. SLED treatments were 299.3 (68.4) min in duration. A two-compartment linear population PK model was most appropriate. The mean (SD) CL of ceftazidime on SLED, and off SLED were 5.32 (3.2), 1.06 (1.0) L/h respectively. The PTA for 50% fT  >   MIC for a dose of 1 g intravenously every 8 h was 98%. Assuming a target of 100% fT  >   MIC a dose of 2 g every 12 h covers isolates with MIC ≤8 mg/L with a PTA of 96%. Conclusion In critically ill patients receiving SLED, ceftazidime 1 g every 8 h and ceftazidime 2 g every 12 h appear to be sufficient for achieving traditional (50% fT  >   MIC ) and aggressive PD targets (100% fT  >   MIC ) for susceptible isolates (MIC ≤8 mg/L), respectively.

Value of Computed Tomography of the Chest in Subjects With ARDS: A Retrospective Observational Study

BACKGROUND: The value of computed tomography (CT) of the chest in the management of patients with ARDS is poorly defined. The aim of this study was to assess the clinical utility of thoracic CT scans in subjects with ARDS using the Berlin definition. METHODS: This was a retrospective, observational study in a university hospital ARDS center on all subjects with ARDS in whom a CT scan of the chest was performed immediately before or during an ICU stay between January 1, 2007 and June 30, 2013. RESULTS: During the study period, a total of 1,781 thoracic CT scans were performed, of which 204 cases met inclusion criteria. The most common pathologic findings of the lung parenchyma were consolidations (94.1% of cases) and ground glass opacities (85.3%). Furthermore, CT scans showed pleural effusions (80.4%), mediastinal lymphadenopathy (66.7%), signs of right ventricular strain and pulmonary hypertension (53.9%), pericardial effusion (37.3%), emphysema of the chest wall (12.3%), pneumothorax (11.8%), emphysema of the mediastinum (7.4%), and pulmonary embolism (2.5%). Results of CT scans led to changes in management in 26.5% of cases. Mortality was significantly increased in subjects with involvement of lung parenchyma of >80% (P = .004). Intrahospital transport was associated with critical incidents in 8.3% of cases. CONCLUSIONS: Systematic evaluation of thoracic CT scans yielded information useful for making a diagnosis, predicting prognosis, and recognizing concomitant disorders requiring therapeutic interventions. Results obtained from CT scans led to changes in management in 26.5% of cases.