Thomas Wurmb

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.

Prolonged heparin-free extracorporeal membrane oxygenation in multiple injured acute respiratory distress syndrome patients with traumatic brain injury.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) can be used as an “ultima ratio” strategy in multiple injured patients with severe thoracic trauma. However, systemic anticoagulation during ECMO is recommended and thus traumatic brain injury (TBI) and intracranial bleeding are well-accepted contraindications for ECMO therapy. METHODS: This report describes three cases of prolonged heparin-free venovenous ECMO in multiple injured acute respiratory distress syndrome patients with severe TBI failing conventional mechanical ventilation. RESULTS: Using this strategy, neither ECMO-associated bleeding nor clotting of the extracorporeal circuit occurred. All patients survived. CONCLUSIONS: Based on our experience, we recommend the use of heparin-free ECMO in multiple injured patients with pulmonary failure that is not successfully controlled by lung-protective ventilation even if severe TBI is present. LEVEL OF EVIDENCE: IV, therapeutic study.

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.

Combination of positioning therapy and venovenous extracorporeal membrane oxygenation in ARDS patients

Positioning therapy may improve lung recruitment and oxygenation and is part of the standard care in severe acute respiratory distress syndrome (ARDS). Venovenous extracorporeal membrane oxygenation (vvECMO) is a rescue strategy that may ensure sufficient gas exchange in ARDS patients failing conventional therapy. The aim of this case series was to describe the feasibility and pitfalls of combining positioning therapy and vvECMO in patients with severe ARDS. A retrospective cohort of nine patients is described. The patients received 20 (15–86) hours (median, 25th and 75th percentile) of positioning therapy while being treated with vvECMO. The initial PaO2/FiO2 index was 64 (51–67) mmHg and the arterial carbon dioxide tension was 60 (50–71) mmHg. Positioning therapy included 135 degrees prone, prone positioning and continuous lateral rotational therapy. During the first three days, the oxygenation index improved from 47 (41–47) to 12 (11–14) cmH2O/mmHg. The lung compliance improved from 20 (17–28) to 42 (27–43) ml/cmH2O. Complications related to positioning therapy were facial oedema (n=9); complications related to vvECMO were entrance of air (n=1) and pump failure (n=1). However, investigation of root causes revealed no association with the positioning therapy and had no documented effect on the outcome. The reported cases suggest that positioning therapy can be performed safely in ARDS patients treated with vvECMO, providing appropriate precautions are in place and a very experienced team is present.

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.

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 …

Extrakorporale Membranoxygenierung und schweres Schädel-Hirn-Trauma

Veno-venous extracorporeal membrane oxygenation (ECMO) may be lifesaving in multiple injured patients with acute respiratory distress syndrome (ARDS) due to chest trauma. To prevent circuit thrombosis or thromboembolic complications during ECMO systemic anticoagulation is recommended. Therefore, ECMO treatment is contraindicated in patients with intracranial bleeding. The management of veno-venous ECMO without systemic anticoagulation in a patient suffering from traumatic lung failure and severe traumatic brain injury is reported.ZusammenfassungDie venovenöse extrakorporale Membranoxygenierung (vv-ECMO) kann bei polytraumatisierten Patienten mit „acute respiratory distress syndrome“ (ARDS) zur Sicherung des Gasaustausches bei Versagen von konventionellen Beatmungsstrategien eingesetzt werden. Da eine systemische Antikoagulation zur Vermeidung von thrombembolischen Komplikationen empfohlen wird, ist die ECMO bei Patienten mit intrakraniellen Blutungen kontraindiziert. Es wird über den mehrtägigen Einsatz einer vv-ECMO ohne systemische Antikoagulation zur Sicherstellung eines suffizienten Gasaustausches bei einem polytraumatisierten ARDS-Patienten mit schwerem Schädel-Hirn-Trauma (SHT) berichtet.AbstractVeno-venous extracorporeal membrane oxygenation (ECMO) may be lifesaving in multiple injured patients with acute respiratory distress syndrome (ARDS) due to chest trauma. To prevent circuit thrombosis or thrombembolic complications during ECMO systemic anticoagulation is recommended. Therefore, ECMO treatment is contraindicated in patients with intracranial bleeding. The management of veno-venous ECMO without systemic anticoagulation in a patient suffering from traumatic lung failure and severe traumatic brain injury is reported.

Akutes Lungenversagen und septische Kardiomyopathie

A 30-year-old patient was admitted to hospital with fever and respiratory insufficiency due to community acquired pneumonia. Within a few days the patient developed septic cardiomyopathy and severe acute respiratory distress syndrome (ARDS) which deteriorated under conventional mechanical ventilation. Peripheral venoarterial extracorporeal membrane oxygenation (va-ECMO) was initiated by the retrieval team of an ARDS/ECMO centre at a paO2/FIO2 ratio of 73 mmHg and a left ventricular ejection fraction (EF) of 10 %. After 12 h va-ECMO was converted to veno-venoarterial ECMO (vva-ECMO) for improvement of pulmonary and systemic oxygenation. Left ventricular function improved (EF 45 %) 36 h after starting ECMO and the patient was weaned from vva-ECMO and converted to vv-ECMO. The patient was weaned successfully from vv-ECMO after 5 additional days and transferred back to the referring hospital for weaning from the ventilator.

In-vivo-Diagnostik einer malignen-Hyperthermie-Disposition

BACKGROUND In malignant hyperthermia (MH), volatile anesthetics induce hypermetabolism, lactic acidosis and rhabdomyolysis in predisposed patients. The authors hypothesized that intramuscular caffeine and halothane application would increase local lactate concentration in MH susceptible (MHS) individuals more than in non-susceptible (MHN) subjects without initiating the full MH syndrome. METHODS In 14 MHS, 12 MHN and 7 control individuals, microdialysis probes were placed in the rectus femoris muscle and perfused with Ringers solution at 1 microl/min. After equilibration, 250 microl caffeine (80 mM) was injected through the first microdialysis probe, halothane 10 vol% dissolved in soybean oil was perfused through a second microdialysis probe and a third probe was used for control measurements. Dialysate samples were analyzed for lactate spectrophotometrically. Systemic hemodynamic and metabolic parameters were measured. Data are presented as median and quartiles. RESULTS Intramuscular caffeine and halothane significantly increased local peak concentrations of lactate in MHS probands [5.0 mM (3.4-8.1 mM) and 3.7 mM (2.6-5.0 mM), respectively] compared to MHN [1.6 mM (1.3-2.0 mM) and 1.9 mM (1.6-2.0 mM)] or control individuals [2.1 mM (1.9-2.3 mM) and 2.0 mM (1.6-2.1 mM)]. This was accompanied by a higher serum creatine kinase level in the MHS group. Hemodynamic and metabolic parameters were normal in the investigated groups. CONCLUSION Intramuscular caffeine and halothane application induces a temporary and abnormal increase of local lactate in MHS individuals. No serious systemic side effects occurred. This study presents evidence that metabolic monitoring with local stimulation by caffeine and halothane may allow a minimally invasive diagnosis of MH susceptibility.