Forum Médical Suisse Swiss Medical Forum Schweizerisches Medizin

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Forum Médical Suisse
Swiss Medical Forum
17.10.2012
Schweizerisches Medizin-Forum
Supplementum 59
Jubiläumstagung 2012
ad Swiss Medical Forum
2012;42(35)
60 Jahre Schweizerische Gesellschaft für Anästhesiologie
und Reanimation (SGAR)
40 Jahre Schweizerische Gesellschaft für Intensivmedizin (SGI)
Gemeinsam mit:
Schweizerische Interessengemeinschaft für Anästhesiepflege
(SIGA)
Schweizerische Gesellschaft für Notfall- und Rettungsmedizin
(SGNOR)
Basel, 15.–17. November 2012
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Schweiz Med Forum 2011;11(nn):1
1
H OT A B ST R AC T S
H1
Intraoperative cerebral perfusion, autoregulation and
tissue oxygenation: a comparison between elderly patients
with and without postoperative cognitive dysfunction
Rossi1, S. Burkhart2, U. Monsch3, Kern1, Czosnyka4, P. Strebel2,
A. Steiner1
1
Department of Anaesthesia, University Hospital Centre and University
of Lausanne, Lausanne, Switzerland; 2Department of Anaesthesia and
Intensive Care Medicine, University Hospital Basel, Basel, Switzerland;
3Memory Clinic, Department of Geriatrics, University Hospital Basel,
Basel, Switzerland; 4Department of Clinical Neurosciences,
Neurosurgery Unit, University of Cambridge, Cambridge, United
Kingdom
Introduction: Postoperative cognitive dysfunction (POCD) affects up
to 40% of patients >60 years 1 week after major non-cardiac surgery
and approximately 10% of all patients 3 months postoperatively.
Inadequate intraoperative cerebral perfusion is often suspected in
patients presenting postoperative cerebral complications. We compared
cerebral perfusion under general anesthesia in elderly patients with and
without POCD and hypothesized that cerebrovascular autoregulation
is less efficient and cerebral oxygenation lower in patients developing
POCD.
Methods: We investigated 86 patients aged >= 65 yrs undergoing
elective non-cardiac surgery under sevoflurane based general
anesthesia. Mean arterial pressure (MAP) was measured continuously
using a plethysmographic method. Intraoperative cerebral perfusion
was monitored with transcranial Doppler (mean cerebral blood flow
velocity (FVm) in the middle cerebral artery). Cerebrovascular
autoregulation was determined by calculating the Mx-index, which is
based on changes in FVm due to variations in MAP. Dysautoregulation
was defined as an Mx >=0.5. Cerebral oxygenation was measured
with near-infrared spectroscopy (NIRS) and expressed as a tissue
oxygenation index (TOI). Data were averaged over the whole procedure
excluding induction and emergence. Cognitive function was assessed
preoperatively, 7 days and 3 months postoperatively using the CERADNeuropsychological Assessment Battery. POCD was defined as a
postoperative decline >1 z-score in at least 2 cognitive domains.
Results: 47% of the patients presented with POCD 1 week after
surgery and 35% at 3 months. There was no difference regarding
FVm, TOI and Mx between the groups at 7 days, but significantly more
patients with dysautoregulation developed POCD. Patients with POCD
at 3 months had significantly higher intraoperative FVm and TOI than
those without POCD. Dysautoregulation did not have an influence on
the occurrence of POCD at 3 months.
See table 1.
Conclusions: In our data, high intraoperative FVm and cerebral
oxygenation are associated with the development of POCD at 3 months
but not at 7 days. It remains unclear whether a high FVm and TOI in
presence of a concentration of approximately 1 MAC of sevoflurane are
signs of impaired cerebrovascular reactivity or indeed an indicator that
intraoperative cerebral hyperperfusion could be associated with POCD.
Acknowledgements: Supported by SNF Grant 32003B-121956
Table 1
7 days
3 months
No POCD (n = 40)
POCD (n = 36)
p-value
No POCD (n = 22)
POCD (n = 12)
p-value
Age (yrs)
71 ± 6
75 ± 7
0.02
70 ± 5
71 ± 6
0.81
Education (yrs)
13 ± 3
12 ± 3
0.01
13 ± 3
13 ± 3
0.89
MAP (mm Hg)
75 ± 11
74 ± 11
0.79
70 ± 9
74 ± 9
0.23
FVm (cm/s)
39 ± 18
43 ± 15
0.24
36 ± 14
50 ± 15
0.009
Mx
0.46 ± 0.17
0.53 ± 0.16
0.08
0.50 ± 0.13
0.52 ± 0.13
0.79
TOI (%)
67 ± 5
67 ± 5
0.64
65 ± 4
70 ± 4
0.007
TOI min (%)
61 ± 7
61 ± 6
0.80
60 ± 5
63 ± 5
0.09
TOI max (%)
72 ± 5
72 ± 5
0.46
70 ± 4
75 ± 4
0.001
Desaturation (%)
9±8
8±6
0.51
10 ± 8
8±5
0.32
EtCO2 (kPa)
4.58 ± 0.33
4.59 ± 0.33
0.95
4.6 ± 0.27
4.7 ± 0.44
0.29
MACEQ
1.16 ± 0.17
1.18 ± 0.17
0.62
1.23 ± 0.16
1.28 ± 0.14
0.3
Dysautoregulation (n)
15
22
0.04
10
6
0.8
TOI min, TOI max: minimal and maximal TOI-value, respectively; Desaturation: % of desaturation from baseline; EtCO2: end-tidal CO2
MACEQ: age corrected MAC equivalents
H2
Effect of Genetic Background Variability in Malignant
Hyperthermia Families
O. Bandschapp1, A. Urwyler1, T. Girard1
1Department of Anaesthesia and Intensive Care Medicine,
University Hospital Basel, Basel, Switzerland
Background: The clinical presentation of pharmacogenetic diseases
such as malignant hyperthermia (MH) is influenced by genetic and
environmetal factors. In an analysis of data from 4 large unrelated
MH families we have shown evidence for genetic influences on the
variability of in vitro muscle contracture tests (1). Molecular genetic
investigations of MH families and identification of causative ryanodine
receptor type 1 (RYR1) mutations provides the possibility to separate
the influence of single RYR1 mutations from familial genetic
background.
Methods: Forty-seven subjects from four families with an MH-related
death and with at least five clinically MH-susceptible individuals per
family were included. We compared the strength of muscle contractures
to challenges of halothane, caffeine, or both and the effect of these two
drugs on twitch potentiation in response to supramaximal electrical
stimulation among the families. After identification of MH causative
RYR1 mutations within these families following a genetic screening
program (2), data were analyzed in relation to familial RYR1 mutations.
Results: In the 4 MH families, MH susceptibility was confirmed in 36
individuals, and 11 individuals were diagnosed as MH-negative. In all
families RYR1 mutations were found: in both family 1 and family 2:
p.Val2168Met, in family 3: p.Gly3006Arg; and in family 4 p.Asp544Tyr.
In MH-susceptible individuals, muscle contractures to the 2% halothane
challenge were significantly higher in family 1 (n = 15; 16.2 ± 2.9 mN,
mean ± standard error of the mean) and in family 4 (n = 5; 16.4 ± 5 mN)
than in family 2 (n = 9; 5.8 ± 1.5 mN) or family 3 (n = 7; 6.0 ± 1.1 mN).
Muscle contractures to the caffeine challenge (2 mM) were significantly
increased in family 1 (7.3 ± 1.4 mN) compared with those in family 3
(1.3 ± 1.0 mN). In addition, we found a dose-dependent twitch
potentiation to the halothane challenge in family 2 (P <0.01) and to the
caffeine challenge in families 2 (P <0.001) and 3 (P <0.01), whereas
there was no twitch potentiation in families 1 and 4.
Schweiz Med Forum 2012;12(Suppl. 59)
2S
Conclusions: The findings that muscle contractures and twitch
potentiation are significantly different between two families with the
same MH causative RYR1 mutation (p.Val2168Met) indicate that a
variety of additional genetically inherited factors may have a modulating
effect on muscle function in MH susceptible individuals.
References: 1. Anesthesiology 1994;80:1287–95 2. Hum Mutat.
2009;30:590–8.
H3
Volatile Anesthetics Improve Survival in a Cecal Ligation
and Puncture Model
I.K. Herrmann1, M. Castellon2, D.E. Schwartz2, M. Hasler1,
M. Urner1, G. Hu2, R.D. Minshall2, B. Beck-Schimmer1
1University and University Hospital Zurich, Zurich, Switzerland;
2
University of Illinois, Chicago, United States
Introduction: Sepsis remains a leading cause of death in intensive
care units. There is growing evidence that volatile anesthetics have
beneficial immunomodulatory effects in complex inflammation-mediated
conditions. We investigate the effect of volatile anesthetics as well as
the primary sevoflurane metabolite on the overall survival of mice in
a sepsis model of cecal ligation and puncture.
Methods: Mice were exposed to anesthetic concentrations of
desflurane, isoflurane and sevoflurane either during induction of sepsis
or when the mice showed pronounced symptoms of inflammation. In
an additional treatment group, the water-soluble primary sevoflurane
metabolite, hexafluoroisopropanol, was administered intravenously
and overall survival as well as organ function and inflammation were
compared to the cecal ligation and puncture group without intervention.
Results: With desflurane and sevoflurane conditioning (1.2 minimal
alveolar concentration (MAC) for 2 hours immediately following cecal
ligation and puncture, overall survival was 58% and 83% compared to
17% in the untreated cecal ligation and puncture group (desflurane:
p = 0.049, N = 12; sevoflurane: p = 0.0005, N = 12), respectively.
Equi-MAC isoflurane concentrations did not significantly ameliorate
outcome (overall survival 42%, p = 0.12, N = 12). Application of
sevoflurane 24 hours after sepsis induction improved overall survival
to 66% (p = 0.045, N = 12). Interestingly, the intravenously administered
primary metabolite of sevoflurane was also highly effective in
decreasing mortality rate in cecal ligation and puncture mice in a
conditioning setting (77% survival, p = 0.037, N = 12).
Conclusions: The administration of the volatile anesthetics (desflurane
and sevoflurane) as well as intravenous application of the primary
sevoflurane CF3-containing metabolite reduced cecal ligation and
puncture-induced mortality in murine septic peritonitis.
H4
Advance directives and communication skills among
doctors of different specialities
F. Gigon2, P. Merlani1, B. Ricou1
1University Hospitals of Geneva, Geneva, Switzerland;
2
University of Geneva, Geneva, Switzerland
Introduction: Intensivists have to take important decisions for
incompetent patients. Surrogates are often unavailable or unable to
decide. Advance Directives (AD) were developed to respect the patients’
autonomy. Very few patients have AD at ICU admission, even for major
elective surgeries. We sought to investigate the attitude towards AD
and the self-rated communication skills among physicians of different
specialities.
Methods: Self-administered questionnaire including Quality of
Communication Score (2 subscores, min/max:0/10)1 sent to physicians
potentially involved in care of patients planned for heart surgery.
Results: From 409 questionnaires, 172(42%) were returned and
164(40%) completed by 50(31%) general practitioners, 73(45%)
internists, 22(13) intensivists and 18(11%) cardiologists. 121(73%)
practitioners had a private activity. Their General Communication
score were of [median(min/max;IQR)]:9(5/10;2) and the End-of-life
communication score of 7(1/10;2). 138/162(85%) physicians thought AD
useful, women more frequently (p=.01), cardiologists the least (p=.007).
16/159(10%) physicians never talked about AD to their patients,
99(62%) did so with 1-10% of them, 20(12%) with 11–25%, 14(9%) with
26–50%, 7(4%) with 51–75% and 3(2%) with all patients. 32/159(20%)
physicians were not involved in any patient planned for heart surgery
during the previous year, 81(51%) were for 1–5, 17(11%) for 6–10
patients. 57/118(48%) physicians never talked about AD to these
patients, 45(38%) did so with 1-5, 7(6%) with 5–10. 66/159(42%)
physicians thought the generalists should speak about AD to such
patients, 40(25%) the cardiologists, 23(14%) the internists.
129/158(82%) physicians thought they should ask patients about AD,
101(64%) would ask for a copy, 81(51%) if AD are still accurate and
78(49%) who the holder is.
Conclusions: A great majority of physicians thought AD useful, but few
talked about AD, or with a minority of patients. 10% never talked about
AD with their patients. Generalists and cardiologists are seen as the
doctors who should talk about AD with patients planned for heart
surgery. Self-rated general communication skills were very good(9/10),
less so for end-of-life(7/10). Further studies are needed to explore how
intensivists could collaborate with prehospital doctors to increase the
prevalence of AD. Comparison with what patients or relative think is
awaited.
Grant: This study is sustained by the FNRS (CR31I3_127135/1).
1Engelberg R. e
H5
Matrix metalloproteinase expression and neuroinflammation
in mice treated with recombinant-tissue plasminogen
activator after transient middle cerebral artery occlusion
J.C. Copin1, S. Lenglet1, D. Denes2, G. Coutts2, E. Pinteaux2,
F. Montecucco1, F. Mach1, K. Schaller1, Y. Gasche1
1
University Hospitals of Geneva, Geneva, Switzerland;
2University of Manchester, Manchester, United Kingdom
Introduction: A growing body of evidence indicates that recombinanttissue plasminogen activator (r-tPA), the only approved thrombolytic
treatment of ischemic stroke, might be neurotoxic. We recently showed
that unidentified matrix metalloproteinases (MMPs) other than MMP-9
could play a role in r-tPA-mediated blood-brain barrier disruption after
middle cerebral artery occlusion (MCAo). Ischemic stroke initiates an
inflammatory response in the brain. Despite the fact that some
cytokines are potent inducers of MMPs and that r-tPA could increase
the expression of cytokines and chemokines, there is very few data on
the role of r-tPA in neuroinfammation.
Methods: Seventy-five mice were subjected to MCAo for 1h and treated
with 10 mg/kg r-tPA or saline. Following 6 h, 24 h and 72 h of cerebral
reperfusion, brain mRNAs and proteins related to the inflammatory
response were analyzed by real-time RT-PCR, ELISA and cytometric
bead array assays.
Results: Expressions of MMP-3, -12 and -13 were increased at the
RNA level as soon as 6 h after reperfusion. MMP-8 was increased after
24 h, while MMP-1, -7, -9 and -10 were increased at 72 h. There were
no statistical differences between animals treated with r-tPA or saline.
Expressions of the mRNA coding for the CCL2, CCL3 and CXCL1
chemokines were increased at 6 h and peaked at 24 h. Treatment with
r-tPA significantly increased the expression of CCL3 at 6 h. At the
protein level, CCL2, CCL3 and CXCL1 were increased in the ischemic
cerebral territory with a peak of detection at 24 h. Statistically higher
CCL3 and CXCL1 protein concentrations were observed at 6 h in
r-tPA-treated animals as compared to saline-treated animals.
Myeloperoxidase, a neutrophil marker, was progressively increased in
the ischemic territory over the 72 h of the study, and was statistically
higher in r-tPA treated animals 6 h after reperfusion.
Conclusions: While gene expressions of the eight MMPs investigated
in this study were not modified by r-tPA treatment after stroke, the effect
of r-tPA on chemokines synthesis, early after stroke, leading potentially
to a higher inflammatory cell recruitment could play a role in r-tPA
neurotoxicity. The inflammatory response should be further clarified and
the effect of r-tPA on MMPs would need to be investigated at the protein
level.
H6
Impact d’un programme de gestion de la douleur
aux soins intensifs adultes
M.J. Roulin1, W. Pacini Menoud1, J. Magnard1, V. Nocquet Boyer1,
N. Delieuvin1, R. Giraud1, D. Tassaux1
1Hôpitaux Universitaire de Genève, Genève, Switzerland
La gestion de la douleur reste problématique aux soins intensifs avec
une incidence pouvant atteindre 50% selon les études. Le service des
soins intensifs adultes a instauré en octobre 2010 un programme de
gestion de la douleur qui avait pour but d’optimiser sa prévention, sa
détection et son soulagement. Un modèle structuré de changement a
guidé la stratégie d’implantation qui comprenait l’introduction de
protocoles d’évaluation de la douleur et de traitement pharmacologique,
l’adaptation de la documentation et de la prescription, un programme
intensif de formation avec un soutien en situation. Une évaluation du
processus et de l’impact de ce programme a été réalisée avec un devis
de recherche de type avant-après. L’évaluation était multimodale.
3S
L’impact sur la douleur des patients a été suivi avec un audit mensuel
pendant 18 mois des valeurs de l’intensité de la douleur sur une échelle
numérique (EN) de 0 (pas de douleur) à 10 (la pire douleur imaginable).
La perception des soignants à propos des barrières à la bonne gestion
de la douleur a été évaluée via un questionnaire distribué avant et une
année après. L’adhésion au protocole de traitement de la douleur a été
évaluée à l’aide d’un audit de 20 dossiers patients avant et 20 dossiers
après. Les résultats montrent une augmentation linéaire et stable du
nombre d’évaluation de la douleur par jour (3,16 à 5,0, p <0,01).
Toutefois la proportion des valeurs supérieurs à 3 sur l’EN a diminué de
37% à 23% cinq mois après la mise en place du programme, mais s’est
finalement stabilisée vers 30% à une année. Au niveau de la perception
des barrières à la bonne gestion de la douleur par les soignants, seul
le «manque de connaissance» a évolué favorablement (Z = –2,780,
p = 0.005). L’audit des dossiers a mis en évidence une augmentation
des antalgiques reçus: paracétamol 0,94 mg/j vs 1,43 mg/j (p = 0,019)
et morphine 20,5 mg vs 39,3 (p = 0,056). En conclusion, ce projet
d’amélioration de la gestion de la douleur a permis d’obtenir un
changement durable des pratiques concernant l’évaluation de la
douleur. Son impact a par contre été modéré sur l’intensité de la
douleur des patients, les barrières à la bonne gestion de la douleur
et les modifications des pratiques touchant à l’usage des antalgiques.
Ceci démontre la difficulté qu’il y a à modifier durablement les pratiques
et l’importance de mesurer l’impact d’un tel projet sur la durée pour
s’assurer que les changements de pratique sont stabilisés.
F R E E C O M M U N I C AT I O N S 1 – G E N E R A L A N A E S T H E S I A I
F1
Randomized controlled trial of sevoflurane vs. propofol to
prevent myocardial ischemia in noncardiac surgery patients
G. Lurati Buse1, Ph. Schumacher3, W. Studer2, E. Seeberger1,
R. Schumann1, J. Fassl1, J. Kasper1, M. Filipovic4, D. Bolliger1,
M. Seeberger1
1University Hospital Basel, Basel, Switzerland; 2Kantonsspital Liestal,
Liestal, Switzerland; 3Bürgerspital, Solothurn, Switzerland;
4Kantonsspital St. Gallen, St. Gallen, Switzerland
Background: Volatile anesthetics provide myocardial preconditioning in
coronary surgery patients. We hypothesized that sevoflurane compared
to propofol reduces the incidence of myocardial ischemia in patients
undergoing major noncardiac surgery.
Methods and Results: We enrolled 385 patients at cardiovascular risk
in 3 centers. Patients were randomized to maintenance of anesthesia
with sevoflurane or propofol. We recorded continuous ECG (cECG)
for 48 hours perioperatively, measured troponin T and NT-proBNP on
postoperative days (POD) 1 and 2. At 6 and 12 months, we contacted
patients by phone to assess major adverse cardiac events (MACE).
The primary endpoint was a composite of myocardial ischemia detected
by cECG and/or troponin elevation. Patients and outcome assessors
were blinded. We tested dichotomous endpoints by chi-squared on an
intention-to-treat basis. Myocardial ischemia occurred in 75 patients
(40.8%) in the sevoflurane and 81 (40.3%) in the propofol group (RR,
1.01; 95% confidence interval [CI], 0.78–1.30). Within 12 months, 14
patients (7.6%) suffered a MACE after sevoflurane and 17 (8.5%)
after propofol (RR, 0.90; 95% CI, 0.43–1.87).
Conclusion: Compared to propofol, sevoflurane did not reduce the
incidence of myocardial ischemia in high-risk patients undergoing major
noncardiac surgery. The sevoflurane and propofol groups did not differ
in MACE at 1 year.
F2
Impact of sevoflurane vs. propofol on incident delirium
after noncardiac surgery – a randomized controlled trial
G. Lurati Buse1, E. Seeberger1, J. Kasper1, R. Schumann1,
Ph. Schumacher2, W. Studer3, M. Filipovic1, D. Bolliger1, M. Seeberger1
1University Hospital Basel, Basel, Switzerland; 2Bürgerspital, Solothurn,
Switzerland; 3Kantonsspital Liestal, Liestal, Switzerland; 4Kantonsspital
St. Gallen, St. Gallen, Switzerland
Introduction: Animal studies suggest neuroprotection by sevoflurane.
There is some evidence supporting this neuroprotective effect in
patients undergoing cardiac surgery. Our objective was to evaluate
if sevoflurane compared to propofol reduced the incidence of
postoperative delirium in patients undergoing major noncardiac surgery.
Methods: This is a secondary analysis of a randomized controlled trial
of sevoflurane vs. propofol to reduce perioperative ischemia. The
occurrence of delirium was a prespecified secondary endpoint. We
enrolled patients at cardiovascular risk in 3 centres between February
2006 and October 2010. Patients were randomized to maintenance of
anesthesia with sevoflurane or propofol. Research staff previously
trained by a neuropsychologist assessed the occurrence of delirium by
the Confusion Assessment Method (CAM) at baseline, on postoperative
day 1, 2 and day 7 or discharge day whatever occurred first.
Postoperative delirium was defined as a CAM suggestive of delirium
on postoperative day 1 or 2 or 7.
Results: We enrolled 385 patients; thereof 184 were allocated to
sevoflurane and 201 to propofol. The CAM was missing in 1 patient
(0.3%) on postoperative day 1, in 5 (1.3%) on day 2, and in 42 (11.1%)
on postoperative day 7. Delirium was diagnosed in 21 patients(11.4%)
after sevoflurane and 29 (14.4%) after propofol (p = 0.379). Delirium
decreased over time: 8.4% on day 1, 6.6% on day 2, and 2.1% on day 7.
Conclusion: Compared to propofol, sevoflurane did not reduce the
occurrence of postoperative delirium in patients undergoing major
noncardiac surgery.
Reference: Schoen J, Husemann L, Tiemeyer C, Lueloh A, SedemundAdib B, Berger KU, Hueppe M, Heringlake M. Cognitive function after
sevoflurane- vs propofol-based anaesthesia for on-pump cardiac
surgery: a randomized controlled trial. Br J Anaesth. 2011;106(6):
840–50.
F3
Automatic Assessment of Difficult Intubation from Video
P. Schoettker1, G. Cuendet2, J.P. Thiran2, M. Sorci3, A. Yuce2,
C. Perruchoud4
1Centre Hospitalier Universitaire Vaudois CHUV, Lausanne,
Switzerland; 2Ecole Polytechnique Fédérale EPFL, Lausanne,
Switzerland; 3nViso SàRL, Chavannes-près-Renens, Switzerland;
4Ensemble Hospitalier de la Côte EHC, Morges, Switzerland
Introduction: Difficult laryngoscopy and tracheal intubation represents
a significant source of morbidity and mortality in anesthetic practice.
No simple test can effectively predict difficult cases and combination
are needed to increase sensitivity and specificity. We describe a new
method using computer vision and machine learning techniques to
predict difficult intubation.
Methods: Patients presenting to the anesthetic consultation before an
elective surgery necessitating general anesthesia were enrolled. Video
recordings, photos and depth maps of the head and neck (lateral and
front views) were performed with two high-definition webcams and
a Kinect® (fig. 1). Computer vision techniques (Active Appearance
Models) were used to automatically extract morphological features
while patient’s weight, height, age, gender and Mallampati grades were
obtained. On the day of surgery, the details of the tracheal intubation
Figure 1
Recording setup.
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Figure 2
Decisional tree.
randomization, the trachea was intubated with either the Bonfils or
the SensaScope. Success was defined as tracheal intubation within
2 attempts. Time necessary was defined from picking up the device
until cuffing of the tube in the trachea.
Results: 12 staff anesthesiologists, experienced with both devices,
intubated 131 patients so far. Mouth opening decreased after neck
collar placement. There were no demographic differences between
groups and intubation success rate did not differ between the devices
(table 1). There was a significant impact of the anesthesiologist on
success despite supervised training and high experience (p = 0.008).
There were no serious adverse events and no periods of hypoxia
during intubation.
Conclusions: SensaScope and Bonfils are both equally successful for
managing the simulated difficult airway. Both devices did not reach the
95% success rate considered desirable for managing difficult airway
cases. Success rates differed between anesthesiologists despite
adequate training.
Table 1
Demographics & success rates comparing Bonfils and SensaScope.
Data in mean (SD) or number (%).
Demographics
Bonfils
N = 63
Females
27 (43)
27 (40)
0.71
Age (years)
51 (18)
49 (17)
0.45
Height (cm)
171 (10)
173 (9)
0.28
Weight (kg)
74 (15)
79 (15)
0.05
BMI (kg m )
20 (1.5)
20 (1.6)
0.12
Mouth opening with stiff collar
(mm)
23 (3)
22 (3)
0.52
–2
SensaScope
N = 68
p-value
Outcome
were reported by the anesthesiologist in charge. A classifier was then
trained based on the preoperative data to correctly classify the patients
in the different laryngoscopic grades.
Results: In the first three months of the study, 198 patients were
included. Laryngoscopy showed Cormack-Lehane grades I (75.3%),
IIa (16.5 %), IIb (5.1%) and III (3.5%) while no grade IV was observed.
Training a classifier with such unbalanced classes is difficult and
the classification is prone to overfitting. In order to keep the classes
balanced, analysis was restricted to twenty patients (grade I: 6, grade
IIa: 5, grade IIb: 5, grade III: 4, grade IV: 0). A decision tree using the
Mallampatti score, the body mass index and three morphological
features was built (fig. 2). The chosen morphological features were the
thyromental distance in neutral position, the width of the mouth and the
distance from the angle of the mandible to the tip of the chin. The two
first nodes of the hierarchical structure isolated most of the samples
from grade I and all the samples from grade III. Samples belonging
to extreme classes were classified first, while the subnodes further
in the tree classified samples belonging to intermediate classes.
Conclusions: This study presents encouraging results for a fully
automatic computer vision based system designed to assess the
difficulty of intubation. It needs further confrontation to a larger patient’s
dataset.
F4
Success rates of fiberoptic intubation stylets in a simulated
difficult airway scenario: Bonfils™ versus SensaScope™
S. Fröhlich, L. Theiler, M. Kleine-Brueggeney, N. Urwyler,
Christine Riggenbach-Studiger, R. Greif
Department of Anesthesiology and Pain Therapy,
University Hospital Inselspital and University of Bern, Switzerland
Introduction: The rigid stylet Bonfils™ (Karl Storz, Tuttligen, Germany)
and the semi-rigid stylet SensaScope™ (Acutronic, Hirzel, Switzerland) are two intubation devices to visualize the airway during the
management of a difficult airway. There are no prospective randomized
controlled trials available comparing both in patients. We evaluated
the intubation success of both devices using stiff extrication collars
to simulate a difficult airway scenario.
Methods: With IRB approval (ISRCTN14429285) and written informed
consent, we planned to enroll 200 patients without predictors for difficult
airway, scheduled for elective surgery. After standardized induction
of anesthesia, an extrication collar (Laerdal, Wappingers Falls, NY)
adjusted to the patient’s neck limited mouth opening and neck
movement to simulate a difficult airway situation. According
Success rate
54 (86%)
62 (91%)
0.33
Success – 1st attempt
43 (68%)
52 (74%)
0.29
Time – successful attempt
(sec)
47 (37)
35 (32)
0.08
Time – all attempts (sec)
71 (58)
55 (60)
0.14
F5
Nasal administration of remifentanil in stomatosurgery
Ladislav Hess1, Jiri Malek2, Zdenek Hruby1, Alice Kurzova2,
Karel Stein3
1Institute of Clinical and Experimental Medicine, Prague,
Czech Republic; 2Dept. of Anaesthesiology and ICM, 3rd Faculty
of Medicine, Charles University, Prague, and University Hospital
Praha Vinohrady, Czech Republic; 3Military Health Insurance
Company, Praha, Czech Republic
Introduction: Procedures in stomatology are accompanied by
discomfort of patients in spite of use of local anaesthesia (LA). For
this reason, various drugs are used to relieve anxiety and potentiate
analgesia. Remifentanil is ultrashort-acting opioid with unique
pharmacokinetic profile. It is used intravenously; there is only 1
study when remifentanil was used by nasal administration to facilitate
intubation in children [1]. We expected that nasal administration of
remifentanil would induce anxiolysis and synergic analgesic effect
with LA without significant adverse cardiorespiratory effects.
Method: After ethic committee approval and patients consent,
remifentanil 7 mcg/kg was administered to both nostrils using mucosal
atomization device MAD 300 before scheduled extraction of (semi)
retained wisdom tooth (VIII.). Onset of effect, reaction to administration
of local anaesthesia and duration of effect were noticed based on
subjective patient’s report. Non-invasive blood pressure and pulse
oximetry were measured. Psychomotor recovery was tested by modified
Romberg’s test. ANOVA test was used for analysis of cardiorespiratory
parameters, P value <0.05 was considered significant.
Results: Until now, there were total 15 patients aged 18–38 years of
both sex and BMI bellow 25 included. First sign of effect according to
patients’ report started in 2.8 ± 0.8 min, full effect (feeling of stupor,
enchantment and mental relaxation) was after 4.5 ± 1.2 min. Duration of
anxiolytic effect and sedation was 26.2 ± 6.9 min. All patients remained
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cooperative and calm, tolerability of administration of local anaesthesia
and surgical procedure was excellent according to a dentist in 14 cases
and good in 1 case. Changes of cardiorespiratory parameters compared
to pre-administration ones were non-significant. Total psychomotor
recovery was 20–30 minutes after administration.
Conclusions: This is the first study using nasal remifentanil for
analgesic sedation in adults. Nasal remifentanil 7 mcg/kg produces
significant anxiolysis and analgesia in patients with (semi)retained VIII.
Onset and recovery are rapid and there are no significant changes of
cardiorespiratory parameters.
Literature: 1) Verghese ST et al. The effect of intranasal administration
of remifentanil on intubating conditions and airway response after
sevoflurane induction of anesthesia in children. Anesth Analg
2008;107:1176–81.
Acknowledgements: The study was supported by grants IGA NT 2184
and VG20102015014
F R E E C O M M U N I C AT I O N S 2 – G E N E R A L A N A E S T H E S I A I I
F6
Perioperative IV administration of magnesium sulphate
and postoperative pain: a meta-analysis
Eric Albrecht1, Kyle R. Kirkham2, Spencer S. Liu3, Richard Brull4
1
Medical Doctor, Department of Anesthesia, CHUV, Lausanne,
Switzerland; 2Medical Doctor, Departments of Anesthesia, Toronto
Western Hospital and Women’s College Hospital, University of Toronto,
Toronto, Canada; 3Clinical Professor, Department of Anesthesiology,
Hospital for Special Surgery, New York, USA; 4Associate Professor,
Departments of Anesthesia, Toronto Western Hospital and Women’s
College Hospital, University of Toronto, Toronto, Canada
Introduction: Magnesium has been reported to improve postoperative
pain however the evidence is inconsistent. The objective of this
quantitative systematic review is to evaluate whether or not the
perioperative administration of intravenous magnesium can reduce
postoperative pain.
Methods: The authors searched the electronic databases MEDLINE,
EMBASE and the Cochrane Central Register of Controlled Clinical
Trials. Extracted trial characteristics included Jadad score, type of
surgery, type of surgical anaesthesia, mode and total dose of
administered magnesium, the use and type of multimodal analgesia.
The primary acute pain-related endpoint evaluated was cumulative
IV morphine consumption at 24 h postoperatively. Secondary acute
pain-related endpoints sought were pain scores at rest and on
movement measured at 24 h postoperatively, early postoperative
(0–6 h) IV morphine consumption, early postoperative (0–6 h) pain scores
at rest and on movement, time to first analgesic request, and incidences
of postoperative nausea, vomiting (PONV) and pruritus within the first
24 h postoperatively. Additional relevant endpoints evaluated were
magnesium-related adverse effects including hypotension, bradycardia,
and sedation. Meta-analyses were performed with the assistance of
“Review Manager” software (RevMan version 5.1.6). Data are presented
as mean difference or relative risk (RR) with 95% confidence intervals
(CI). A 2-sided p value <0.05 was considered significant.
Results: Table 1 presents the trial characteristics. Independent of the
mode of administration (bolus or continuous infusion), perioperative
magnesium reduced cumulative intravenous morphine consumption
by 24.4% (mean difference: 7.6 mg, 95% CI: –9.5, –5.8 mg; p <0.00001)
at 24 hours postoperatively. Numeric pain scores at rest and on
movement at 24 hours postoperatively were reduced by 4.2 (95% CI:
–6.3, –2.1; p <0.0001) and 9.2 (95% CI: –16.1, –2.3; p = 0.009) out
of 100, respectively. Table 2 presents the other secondary acute
pain-related endpoints. There were no significant differences in the
incidences of the magnesium-related adverse effects.
Conclusion: We conclude that perioperative intravenous magnesium
reduces opioid consumption, and to a lesser extent, pain scores in the
first 24 hours postoperatively without any reported adverse effects.
equipment check) were introduced and merged with the well-described
anaesthesia non-technical skills (ANTS). This training is compulsory for
any new staff member, independent from their hierarchical position and
their professional experience. For this study we asked if a standardized,
full scale simulation-based training for new anaesthesia staff members
increases the knowledge and use of core competences and the
application of non-technical skills in daily routine.
Method: With written informed consent new staff members were
observed during the induction of anaesthesia after the initial simulation
trading. The applications of technical and non-technical skills were
monitored using a checklist in the operation room, and a standardized
structured questionnaire asked about knowledge of emergency
procedures and demographics. These observations were compared
to the same in another anaesthesia department without a simulation
program.
Results: We observed 62 (78%) participants with simulation and
24 (28%) without.
F7
Which competences are improved after simulation training?
C.A.S. Christian Seidl1, T.M. Thomas Merkt1, C.K. Konrad2,
R.G. Greif1
1
University Department of Anaesthesiology and Pain Therapy,
Inselspital, University Hospital, Bern, Switzerland; 2Department
of Anaesthesiology, Intensive Care Medicine, Emergency Medicine
and Pain Therapy, Cantonal Hospital, Lucerne, Switzerland
Background: New anaesthesia staff members are trained in a
standardized full-scale simulation program during their 1st week of
work to foster patient safety. Departmental standards (e.g. difficult
airway algorithm, local defibrillator, oxygen supply failure, and
Conclusion: Surprisingly, technical competences were well performed
in both groups except for the anaesthesia machine check. No
correlation was found with the experience level. Task management,
teamwork and situational awareness improved significantly with the
simulation training. Interestingly decision making was more often seen
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F R E E C O M M U N I C AT I O N S 2 – G E N E R A L A N A E S T H E S I A I I
in the non-simulation group because of their intense briefing directly
before anaesthesia induction integrated in the local time-out procedure.
Traditional introduction of new staff members teaches as well as
simulation technical competencies. Standardized, simulation-based
training substantially increases the application of most of the ANTS.
Institutionalized briefing strengthens decision making.
F8
The analgesic efficacy and safety of neuraxial magnesium:
a quantitative review
Eric Albrecht1, Kyle R. Kirkham2, Spencer S. Liu3, Richard Brull4
1
Medical Doctor, Department of Anesthesia, CHUV, Lausanne,
Switzerland; 2Medical Doctor, Departments of Anesthesia, Toronto
Western Hospital and Women’s College Hospital, University of Toronto,
Toronto, Canada; 3Clinical Professor, Department of Anesthesiology,
Hospital for Special Surgery, New York, USA; 4Associate Professor,
Departments of Anesthesia, Toronto Western Hospital and Women’s
College Hospital, University of Toronto, Toronto, Canada
Introduction: Since the first publication of neuraxial magnesium as
a perioperative analgesic adjunct in 2002, more than 15 clinical studies
have been published with encouraging results. However, concurrent
animal studies have reported clinical and histological evidence of
neurological complications with similar weight-adjusted doses. The
dual objectives of this quantitative systematic review are to assess
the analgesic efficacy and safety of neuraxial magnesium.
Methods: The authors searched the electronic databases MEDLINE,
EMBASE and the Cochrane Central Register of Controlled Clinical
Trials. Specific acute pain-related endpoints sought from each
publication were: (1) onset time of sensory blockade, (2) regression
time of sensory blockade, (3) onset time of motor blockade, (4)
regression time of motor blockade, (5) time to first analgesic request
after neuraxial blockade, (6) IV morphine consumption at 24 h
postoperatively, (7) pain scores at rest and on movement measured
at 24 h postoperatively, (8) early postoperative (0–6 h) IV morphine
consumption, (9) early postoperative (0–6 h) pain scores at rest and
on movement, (10) incidence of postoperative nausea and vomiting
(PONV) at 24 h postoperatively, and (11) incidence of pruritus at 24 h
postoperatively. The safety-related endpoints sought included (1)
temporary and permanent neurological complications, (2) hypotension,
(3) bradycardia and (4) sedation. Meta-analyses were performed with
the assistance of “Review Manager” software. A 2-sided p value <0.05
was considered significant.
Results: Table 1 presents the trial characteristics. The time to first
analgesic request was increased by 11.1% following intrathecal
administration of magnesium (mean difference: 39.6 min; 95% CI:
16.30, 63.0 min; p = 0.0009), and by 72.2% after epidural administration
(mean difference: 109.5 min; 95% CI: 19.6, 199.3 min; p = 0.02). Table 2
presents the other acute pain-related endpoints. Only four trials (total
of 140 patients) explicitly described monitoring for signs of temporary
permanent neurological complications and one complication was
recorded (headache). There were no differences in the incidences of the
other safety-related endpoints.
Conclusions: We conclude that, despite promising perioperative
analgesic effect, the risk of neurological complications resulting from
neuraxial magnesium has not yet been adequately defined.
F9
Occurrence of death during anaesthesia for surgery
in Switzerland. The ADS project
Z. Schulthess1, J. Sansonnes1, V. Pittet1, V. Moret2, B. Burnand1,
for the ADS Study Group1
1
Institute of Social & Preventive Medicine, Lausanne, Switzerland;
2Service of anaesthesiology, Lausanne, Switzerland
Introduction: Deaths occurring during anaesthesia for surgery is very
rare and, therefore, seldom studied. Using the Anaesthesia Database
Switzerland (ADS), we aimed to estimate the incidence of deaths
occurring during anaesthesia for surgery in Switzerland, to describe
the correlates of thereof, and to compare the results with data from the
literature.
Methods: Using the ADS database, we analysed information
prospectively and routinely collected during all anaesthesia for surgery
in 28 Swiss hospitals from 1 January 2000 to 31 December 2009. We
checked data quality regarding deaths by asking for confirmation to
hospitals for each case. We used descriptive and stratified analyses.
Results: Among the 729’307 anaesthesias considered, 122 deaths
were recorded. The crude death rate was 1.67/10’000 cases (CI 95%
1.38–1.97/10’000). Among death cases, 62.3% were men (46.6% of
living patients). The number of deaths increased with age; the category
16–35 years of age were overrepresented. An ASA index >3 was found
in 70.3% of deceased patients. Surgery occurred during an emergency
intervention in 71.3% of patients who died vs. 18.5% of living patients.
Duration of anaesthesia and surgery were longer in patients who died.
Cases occurred predominantly during major general, vascular and
major cardiac surgery. Most of dead patients (94.3%) presented at least
one comorbidity, particularly cardiovascular (62.2%). Cardiovascular
complications occurring during anaesthesia were the most frequent,
in 82.6% of cases.
Discussion: This study shows that the observed trends and
associations were to be expected. This indicates that the majority of
deaths occurring during anaesthesia for surgery were mostly linked to
patient characteristics, case severity, comorbidities, and type of surgery.
The comparison with published data indicates a lower crude incidence
rate in the Swiss study, with similar correlates with potential
determinants of death. The main limitation of the study is the limited
number of cases to evaluate the risks and correlates of deaths
occurring during anaesthesia. Routinely collected data (i.e., the ADS
project) are useful to monitor quality of anaesthesia care.
F10
Effects of the sevoflurane primary metabolite on
inflammatory and hemodynamic responses in a rat model
of endotoxic shock
M. Urner1, I.K. Herrmann1, M. Hasler2, C. Booy1, B. Roth Z’Graggen1,
B. Beck-Schimmer2
1Institute of Physiology, University of Zurich, Zurich, Switzerland;
2Institute of Anesthesiology, University Hospital Zurich, Zurich,
Switzerland
Introduction: Sepsis with multiple organ failure remains a leading
cause of hospital morbidity and mortality on intensive care units
imparting tremendous financial costs. Recently, the primary metabolite
of sevoflurane, hexafluoro-2-propanol (HFIP), has been found to exert
immunomodulatory properties attenuating inflammatory response to
lipopolysaccharides (LPS) in vitro [1]. We investigated whether HFIP
attenuates inflammatory mediator and cytokine expression in a rat
model of endotoxic shock.
Methods: Thirty-two male wistar rats were anesthetized, mechanically
ventilated and randomly assigned to one of the following groups: I) LPS
group (n = 8), which received intravenous E. coli endotoxin (1 mg/kg); II)
LPS+HFIP group (n = 8), which was treated identically to the LPS group
with the additional administration of HFIP (67 mcg/kg over 30 min) after
LPS injection. Control groups received ringer’s lactate instead of LPS.
General anesthesia was maintained using propofol. Blood gases
were measured every hour; aterial blood pressure was measured
continuously. Animals were euthanized 6 hours after endotoxin injection.
Interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), and
high-mobility group protein B1 (HMGB1) concentrations were analyzed
in plasma and bronchoalveolar lavage fluid (BALF). Linear regression
was used to evaluate influence of HFIP on inflammatory mediator and
cytokine expression.
Results: Plasma IL-6 and MCP-1 protein levels assessed after LPS
injection were increased compared to baseline (+101 ng/mL, R2: 0.323,
p = 0.004; +5479 ng/mL, R2: 0.530, p <0.001). This increase in IL-6 and
MCP-1 protein levels was attenuated in the LPS+HFIP group (–54%,
R2: 0.323, p = 0.01; –17%, R2: 0.530, p = 0.004). Similar results were
found in BALF for MCP-1 (–45%, R2: 0.690, p0.028), but not for IL-6
protein. The LPS-induced increase in plasma HMGB1 was attenuated in
animals of the LPS+HFIP group (R2: 0.510, p = 0.003). LPS-stimulated
animals had a +12% higher mean arterial blood pressure after 6 hours
when treated with HFIP (R2 = 0.684, p = 0.035). No significant
differences in lactate levels were observed. HFIP attenuated base
deficit in LPS-stimulated animals by 1 mmol/L (R2 = 0.522, p = 0.034).
Conclusion: The results suggest that hexafluoro-2-propanol partly
inhibits inflammatory response and may ameliorate the hemodynamic
reaction during endotoxic shock in rats.
References: [1] Urner et al., Am J Respir Cell Mol Biol. 2011. pp.
617–624.
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F R E E C O M M U N I C AT I O N S 3 – PA E D I AT R I C A N A E S T H E S I A
F11
The acute effect of surgical repair of mitral valve
insufficiency on airway and respiratory tissue mechanics
and pulmonary hemodynamics in children
I. Malaspinas1, L. Chok2, M. Beghetti1, W. Habre1, F. Petak3
1
University Hospital of Geneva, Geneva, Switzerland; 2Medical School,
University of Geneva, Geneva, Switzerland; 3University of Szeged,
Szeged, Hungary
Rationale: Increased pulmonary blood flow and pressure were shown
to be responsible for the lung function impairment in children with
congenital heart diseases (Anesthesiology, 110: 1348-55, 2009).
We assessed whether mitral valve insufficiency (MVI) leading to
postcapillary pulmonary hypertension is reflected in the mechanical
properties of the respiratory system, and whether surgical repair of MVI
improves respiratory mechanics in children.
Methods: Airway resistance (Raw), respiratory tissue damping (G) and
elastance (H) were obtained by forced oscillations in 8 children aged 12
± 2 (Mean ± SD) years under general anaesthesia before and
immediately after surgical repair of the MVI. Concomitantly, pulmonary
arterial pressure (PAP) was directly measured in the pulmonary artery
before aortic cannulation and chest closure.
Preliminary results: Surgical repair of MVI led to strong tendency in
the mean PAP for a decrease (from 33.0 ± 12 to 27.7 ± 9.0 mm Hg, p =
0.054). These postoperative pulmonary haemodynamical changes were
associated with significant decreases in Raw (5.5 ± 1.7 to 4.4 ± 1.1
cmH2O.s/l, p = 0.008) with no significant effects on G (11.5 ± 5.2, 10.1 ±
3.1 cmH2O/l, p = 0.7) and H (60.2 ± 9.5, 65.2 ± 13.7 cmH2O/l, p = 0.2).
Postoperative changes in Raw and PAP exhibited no significant
correlation.
Conclusions: These findings demonstrate an immediate improvement
of airway function after surgical repair of MVI in children. Further
experiments are needed to clarify the role of the direct effect of the
postoperative decrease in postcapillary pulmonary hypertension and
vascular engorgement in this beneficial change.
Supported by SNSF grant 3200B0-118231
F12
Gastric pH and residual volume after 1 versus 2 hours
fasting time for clear fluids in children
Alexander Schmidt, Philipp Ruland, Luis J. Seglias, Thomas Stark,
Martin Studer, Barbara Brotschi, Ursula Hanke, Svenja Siegmund,
Melanie Frühauf, Tobias Renner, Carola Sabandal, Richard Klaghofer,
Markus Weiss, Achim Schmitz
Introduction: Preoperative fasting is often prolonged because of
organisational delay, leading to patient discomfort. MRI data from
volunteers [1, 2] indicate that fasting times for clear fluids shorter than
actually recommended [3, 4] may be in accordance with acceptable
gastric residual volumes. Aim of this prospective clinical trial is to
compare gastric pH and residual volume after 1 or 2 hours preoperative
clear fluid fasting.
Methods: Children with ASA class I or II scheduled for procedures
in general anaesthesia with tracheal intubation were randomized into
group A = 1 hour or B = 2 hours preoperative fluid fast. After intubation
gastric contents was sampled in supine, left and right lateral patient
position using an orogastric tube. Gastric pH and residual volume were
determined. To compare demographics and outcome variables of both
groups, T-test or chi-square-test were applied as feasible. Data are
presented as mean (± SD).
Group
A (n = 56)
B (n = 55)
p-value
Age (y)
8.0 (± 4.1)
8.9 (± 4.7)
0.29
Weight (kg)
29.2 (± 15.7)
33.0 (± 18.3)
0.24
Gender (m/f)
40/16
28/27
0.027
Volume of fluid
intake (ml/kg)
4.2 (± 1.1)
3.8 (± 1.6)
0.11
Time between fluid
intake and sampling
(min)
79 (± 11)
138 (± 10)
<0.001
Gastric pH
1.44 (± 0.27)
1.6 (± 0.73)
0.16
Gastric residual
volume (ml/kg)
0.67 (± 0.66)
0.50 (± 0.42)
0.12
Results: So far, 111 children aged 1.3–16.8 (median 7.6) years, have
been included. Age, weight and amount of last preoperative fluid intake
were similar in both groups. Although fasting times for clear fluids were
significantly shorter in group A there was no significant difference in
gastric pH or residual volume between both groups.
Conclusion: Shortened fasting time for clear fluids of about 1 hour do
not alter gastric residual volumes or gastric pH in children significantly
compared to children fasted for 2 hours.
1. Schmitz A, et al. Br J Anaesth. 2011;107:425–9.
2. Schmitz A, et al. Br J Anaesth. 2012;108:644–7.
3. Anesthesiology. 2011;114:495–511.
4. Smith I, et al. Eur J Anaesthesiol. 2011;28:556–69.
F13
Impact of intraoperative music application on
postoperative behaviour in children and adolescents
S.B. Buehrer1, N.S. Spielmann1, A.S. Schmitz1, B.L. Latal2,
M.W. Weiss1
1
Department of Anaesthesia, University Children’s Hospital, Zurich,
Switzerland; 2Department of Paediatrics, Child Development Centre,
University Children’s Hospital, Zurich, Switzerland
Introduction: Hospital stay and anaesthesia may considerably
affect children and adolescents and may lead to the manifestation of
new-onset maladaptive behaviour [1]. Newly occurring maladaptive
behaviour such as nighttime crying, separation anxiety, temper
tantrums, enuresis, general anxiety and poor appetite have been
described to occur up to 50% of children undergoing surgery [2].
Several positive influences of music application during surgery in adults
are known [3–5]. This study aimed to evaluate potential similar benefits
in children undergoing surgery.
Methods: Children with ASA classification I &II undergoing herniotomy
or circumcision were included and randomized in an intervention group
(I) and control group (C). Both children and parents were blinded, and
all patients brought their own music to the operating theatre. After
premedication with midazolam, anaesthesia was induced using
sevoflurane or propofol and maintained using sevoflurane. For
perioperative analgesia a caudal block was performed using
bupivacaine. While headphones were placed in both groups, music
was only applied in group I. Postoperative behaviour at home was
documented by the parents 7, 14 and 30 days after surgery using a
questionnaire adapted from the Post Hospitalization Questionnaire
(PHBQ). The questions focused on sleeping disorders, anxiety, eating
disorders and general maladaptive behaviours. Unpaired, two-sided
student T-test (p <0.05) was used for demographic data and QuiSquare for outcome data.
Results: So far 72 children 59 (82%) male and 13 (18%) female)
aged 4.1–15.9 (mean 7.5) years were enrolled. Demographic data were
similar in both groups. A trend for a benefit from intraoperative music
application was found for sleeping disorders (p = 0.07) and general
maladaptive behaviours (p = 0.06).
Conclusions: Our preliminary data suggest a positive effect of
intraoperative music application on new-onset maladaptive behaviour in
children. More patients are needed to corroborate these promising
preliminary findings.
1 Stargatt R, et al. Pediatric Anesthesia, 2006;16:846–59.
2 Kain ZN, et al. Arch Pediatr Adolesc Med. 1996;150:1238–45.
3 Nilsson U, et al. Anaesthesia. 2003;58:699–703.
4 Twiss E, et al. British Association of Critical Care Nurses, Nursing in
Critical Care, 2006;11(5):224–31.
5 Sendelbach SE, et al. Journal of Cardiovascular Nursing.
2006;21(3):194–200.
F14
Endotracheal tube tip position in orally intubated infants
and toddlers: Comparative assessment of the precision
of three clinical localisation techniques
J. Moll1, F.J. Frei1, T.O. Erb1
1University Children’s Hospital Basel, Basel, Switzerland
Introduction: Correct positioning of the tip of an endotracheal tube
(TET) is of great clinical relevance especially in children. Several
techniques are currently used to predict the position of a TET including
the use of brand-specific tube intubation depth marks (DMT), cuff
palpation technique (CPT) and auscultation technique after right main
stem intubation (RMT) [1–3]. The precision of these techniques is
unknown. Accordingly, the aim of the study was to determine the related
precision of the location of the TET within the trachea in children aged
0–48 months.
8S
F R E E C O M M U N I C AT I O N S 3 – PA E D I AT R I C A N A E S T H E S I A
Figure 1
TET to carina distance for the 3 techniques.
Methods: After obtaining IRB approval and consent, we enrolled
69 healthy children with normal airway anatomy undergoing elective
surgery. Oral intubation was performed with a high volume-low pressure
cuff tube (Microcuff, Kimberley-Clark Global Sales, LLC; Roswell, GA,
USA) using the recommended age-related sizes (ID 3.0 mm: 0–8
months, 3.5 mm: 8–24 months, 4.0 mm: 24–48 months). Intubation
depth was performed adjusting the imprinted position marks to the
level of the vocal cords. The distance from the TET to the carina was
measured fibreoptically, and the insertion depth was measured in
relation to the frontal incisors or midline alveolar ridge. Auscultation
after RMT or cuff palpation above the jugulum was performed in a
randomised fashion. ANOVA and Levene’s Test for homogeneity of
distance variance were used; resulting differences were further
analysed using a pairwise F-test with Bonferroni correction.
Results: 68 children were studied (mean age ID 3.0 mm: 2.9 (2.0)
months, 3.5 mm: 15.1 (4.5) months, ID 4.0 mm: 36.8 (7.0) months).
The observed median TET-carina distance [interquartile range] was
36.7 [29; 43] mm using the DMT, 18 [13; 23.5] mm with the CPT and
-2 [-5; 1.75] mm using the RMT.
Conclusion: RMT resulted in the highest precision compared with the
CPT and DMT. Nonetheless, with all techniques an adequate tube
placement could be achieved in all individuals, in case of RMT after
adjusted withdrawal.
Literature: 1. Br J Anaesth. 2005;94(1):80–7. 2. Anesth Analg.
1995;81(1):135–8. 3. Anesth Analg. 1999;88(6):1380–3.
F15
Sevoflurane Induced Sustained Skeletal Muscle
Hyperexcitability within a Knock-Out Mouse Model
of Myotonic Muscular Dystrophy
O. Bandschapp1, C.L. Soule2, P.A. Iaizzo2
1Department of Anesthesia and Intensive Care Medicine, University
Hospital Basel, Basel, Switzerland; 2Departments of Surgery,
Biomedical Engineering, and Integrative Biology and Physiology,
University of Minnesota, Minneapolis, USA
Introduction: In vitro, anesthetics have been reported to exhibit
differential effects within isolated myotonic skeletal muscle bundles [1].
In the present in-vivo follow-up study using a knock-out mouse model
for the muscleblind proteins (Mbnl1ΔE3/ΔE3), sustained myotonic
features (i.e., increased half-relaxation times) were observed associated
with the administration of sevoflurane. In contrast, while the animals
were anesthetized with either halothane or isoflurane, the characteristic
myotonic warm-up phenomenon was elicited [2]. Here, the
electromyographic (EMG) signals, recorded simultaneously during
these in-vivo force assessments, are presented.
Methods: The mice (n = 5) were anesthetized by the initial
administration of the volatile agent to be tested, and then positioned
in the force assessment apparatus. Hindlimb muscles were stimulated
noninvasively and a concentric needle recording electrode was placed
intramuscularly in the given hindlimb: i.e., in the region of the tibialis
anterior muscle for EMG recording. After ensuring optimal muscle
length-tension relationships, EMG signals were recorded according to
the following stimulation protocol (single, double, triple and quadruple
pulses; repeated three times) during sevoflurane (n = 10), isoflurane
(n = 10) or halothane (n = 10) anesthesia. Both legs from each animal
were tested and all data were included in the analyses.
Results: The recorded EMGs elicited characteristic afterdepolarizations (fig. 1). While the electrical hyperexcitability of the
myotonic muscle was sustained under sevoflurane anesthesia (as
represented by an increased area under the curve [AUC] of the
electrical signal), this was not the case when either isoflurane and
halothane were used. AUC of the EMG signal was significantly higher
while the animals were exposed to sevoflurane as compared to
isoflurane or halothane (P <0.05) (fig. 2): AUC of the EMG signals
during isoflurane and halothane anesthesias were the same.
Conclusion: Sustained myotonic features (i.e., both increased half
relaxation times and electrical after-activity) were observed during
sevoflurane anesthesia. This was not the case when isoflurane and
halothane were administered: with these agents typical warm-up
phenomenon were elicited.
References: 1 Anesthesiology. 2009;111(3):584–90. 2 Abstract ASA
2011.
Figure 1
Figure 2
9S
F R E E C O M M U N I C AT I O N S 4 – R E G I O N A L A N A E S T H E S I A
F16
Evaluation of 108 ultrasound guided paravertebral blocks in
elective breast cancer surgery: a simple technique with low
postoperative pain scores and seldom rescue morphine
administration
E. Mauermann1, V. Lesch1, V. Lucic1, P. Imboden1, R. Listyo1
1
Kantonsspital St. Gallen, St. Gallen, Switzerland
Introduction: In patients undergoing breast cancer surgery, the
implementation of a paravertebral block decreases postoperative pain
and morphine administration, which may influence the rate of relapse
and potentially survivorship.
Methods: Over the course of one year, 108 consecutive patients
receiving a paravertebral block in addition to propofol/remifentanil TCI
for elective breast cancer surgery were examined. Anesthesia was
conducted in accordance with a pre-existing internal standardized
procedure (an initial 20 ml bolus of ropivacaine 0.75%, followed by
another 10 ml bolus of ropivacaine 0.75% after 120 minutes, and upon
emergence ropivacaine 0.2% at a continuous rate of 8 ml/h for circa
48h). Postoperative pain scores using the visual analog scale (VAS)
and morphine administration were assessed.
Results: The median patient age was 51 years (range: 35–86 years).
24% of patients had a mastectomy and 76% a breast conserving
operation. One patient displayed signs of epidural catheter placement.
No pneumothoraces were observed. In 9 patients, a second, then
successful, catheter placement attempt was necessary, due to either
intravascular placement (4 patients) or problems advancing the catheter
(5 patients).
Surprisingly, 18% of patients exhibited severe postoperative pain.
A detailed examination of these patients revealed that 4 overt block
failures occurred (3.7% of all patients). Furthermore, of the patients
with severe pain, 83% had operations partially outside of blocked
dermatomes (e.g. axillary dissection), 50% had the last ropivacaine
bolus more than 60 minutes prior to emergence, and 61% did not
receive a local anesthetic bolus as part of pain management in the
recovery room.
Conclusion: Ultrasound guided paravertebral catheter placement is a
simple technique resulting in generally low pain scores and seldom
rescue morphine administration. Nonetheless, a great deal of attention
must also be paid to blocking all relevant dermatomes and applying
ropivacaine boli at the appropriate times. Based on these results, the
internal protocol was adapted.
Table 1
Highest VAS score and rescue morphine postoperative by times.
Time period
Highest VAS (cm) median
(interquartile range)
Distribution highest VAS in %
0–3 cm
low
4–6 cm
moderate
7–10 cm
severe
Rescue morphine
applied in % of
patients
Recovery room
3 (1.5–5)
55
29
18
8.3 (mean 9.6 mg)
First 24h on ward
2 (1–4)
73
22.5
4.5
5.6 (mean 3.8 mg)
Second 24h on ward
1 (0–2)
90
10
0
0
F17
F18
Ultrasound guided block of the superior cervical ganglion,
description of a novel ultrasound guided technique in human
cadavers
Siegenthaler Andreas1, Haug Matthias1, Eichenberger Urs1,
Suter Marc1, Moriggl Bernhard1
1Pain Center, Department of Anesthesiology, University Hospital
Center and University of Lausanne, Lausanne, Switzerland; 2University
Department of Anesthesiology and Pain Therapy, University of Bern,
Inselspital, Bern, Switzerland; 3University Department of Anesthesiology
and Pain Therapy, University of Bern, Inselspital, Bern, Switzerland,
Bern, Switzerland; 4Pain Center, Department of Anesthesiology,
University Hospital Center and University of Lausanne, Lausanne,
Switzerland; 5Department of Anatomy, Histology and Embryology,
Division of Clinical and Functional Anatomy, Innsbruck Medical
University, Innsbruck, Austria
Introduction: Injection of opioids to the superior cervical ganglion
(SCG) has been reported to provide pain relief in patients suffering from
different kinds of neuropathic facial pain conditions, such as trigeminal
neuralgia, postherpetic neuralgia and atypical facial pain. The classic
approach to the SCG is a transoral technique using a so called
“stopper” to prevent accidental carotid artery puncture. The main
disadvantage of this technique is that the needle tip is positioned distant
from the actual target, possibly impeding successful block of the SCG.
We hypothesized, that the SCG can be identified and blocked using
ultrasound imaging, potentially increasing precision of this frequently
performed intervention.
Methods: In this pilot study, 20 US-guided blocks of the SCG were
performed in 10 human cadavers, in order to determine the accuracy of
this novel block technique. After injection of 0.1 ml of dye, the cadavers
were dissected to evaluate the needle position and colouring of the
SCG.
Results: 19 of the 20 needle tips were located in or next to the SCG. In
17 cases, the SCG was completely coloured and in 2 cases, the caudal
half of the SCG was coloured with dye. This corresponded to a
simulated block success rate of 95% (95% CI: 85–100%).
Conclusions: The anatomical dissections confirmed that our new
ultrasound-guided approach to the SCG is accurate. Ultrasound could
become an attractive alternative to the ‘blind’ transoral technique of
SCG blocks.
Comparison between coiled catheters and stimulating
catheters for continuous femoral nerve block
C.L. Luyet1, P.C. Conroy2, P.M. McHardy2, S.C. Choi2, C.M. McCartney2
1Inselspital Bern, University Hospital, Department of Anaesthesiology
and Pain Therapy, Bern, Switzerland; 2University of Toronto,
Sunnybrook Health Sciences Centre, Department of Anaesthesia,
Toronto, Canada
Background and objectives: The benefit of ultrasound guidance to
precisely place needles adjacent to nerves is undisputed. Ultrasound,
however, is less helpful in accurately placing perineural catheters.
Indeed the final resting position of the catheter tip is unpredictable and
can be inadequate in 10–50% of cases. Recently a catheter has been
developed which coils up on insertion, resulting in the final resting
position of the catheter tip being beside the needle tip (SonoLong Curl;
Pajunk) – this allows the catheter to remain close to the confirmed
initial needle tip position. The aim of this study was to determine
the effectiveness of the new catheter in comparison to a standard
stimulating catheter for continuous femoral nerve block after total knee
arthroplasty.
Methods: 63 patients were enrolled in a double-blind, randomized,
controlled study. Patients were randomized to receive either the coiled
catheter or a stimulating catheter for continuous femoral block. The
block was evaluated at different time-points by a blinded assessor.
Outcome measures including pain on movement, PCA consumption,
and sensation in the femoral nerve distribution were evaluated.
Results: Three patients were excluded from analysis. Of the remaining
patients 29 received a stimulating- and 32 a coiled catheter. The coiled
catheter was easier to place (subjective difficulty; P = 0.024) with fewer
catheter passes (P = 0.006). There was no difference in primary block
success or secondary block failure rate.
Conclusion: Placement of the coiled catheter in comparison to a
stimulating catheter is easier. The primary and secondary block success
rates, furthermore, of both techniques are comparable.
10 S
F19
Radiological evaluation of thoracic paravertebral catheters:
a prospective observational clinical trial in adults after
thoracoscopic surgery
LC Luyet1, SA Siegenthaler1, ZS Szücs-Farkas2, HG Hummel1,
UE Eichenberger1, AV Vogt1
1
Inselspital Bern, University Hospital, Department of Anaesthesiology
and Pain Therapy, Bern, Switzerland; 2Department of Radiology,
Hospital Centre of Biel, Biel, Switzerland
Background and aims: Continuous paravertebral block is often
described as producing a variable degree of block with a limited extent
over a few segments only. This variability could be explained by a
discrepancy between the needle tip location and the final resting
position of the catheter tip once introduced through the needle. This
possibility has recently been studied in an imaging study in fixed human
cadavers. The aim of this prospective clinical trial was to evaluate the
location of paravertebral catheters placed using the classical landmark
puncture technique and to correlate the distribution of contrast dye
injected through the catheters with the extent of somatic block.
Methods: Paravertebral catheters were placed in 30 patients after
video-assisted thoracic surgery. A fluoroscopic examination in two
planes using contrast dye was followed by injection of local
anaesthetics and subsequent clinical testing of the extent of the
anaesthetized area.
Results: In 30% of the cases, contrast dye spread was not seen within
the paravertebral space as intended. Misplaced catheters were in the
epidural space (3 cases), in the erector spinae musculature (5 cases)
and in the pleural space (1 case). Seven patients had a clinically
insufficient block resulting in a 23% failure rate. There was a
discrepancy between the radiological findings and the observed
distribution of loss of sensation.
Conclusions: We can conclude that the paravertebral space is not
suitable for catheters in current use unless the catheters are placed
under direct vision by a surgeon. Further studies using an ultrasound
guided approach or different catheter material are mandatory. In the
meantime we would suggest using paravertebral block as single
injection technique or rather using an epidural block where appropriate.
F20
Single-shot or continuous infusion femoral nerve
blockade total knee arthroplasty? A randomized,
placebo-controlled, double-blind trial
1. Eric Albrecht, medical doctor, department of anesthesia,
CHUV, Lausanne, Switzerland. 2. Dorothea Morfey, medical doctor,
Nottingham University Hospitals NHS Trust, Nottingham, England.
3. Vincent Chan, Professor, department of anesthesia, Toronto Western
Hospital, Toronto, Canada. 4. Rajiv Gandhi, assistant professor, division
of orthopedic surgery, Toronto Western Hospital, Toronto, Canada.
5. Arkadiy Koshkin, medical doctor, department of anesthesia, Toronto
Western Hospital, Toronto, Canada. 6. Ki Jinn Chin, associate
prodessor, department of anesthesia, Toronto Western Hospital,
Toronto, Canada. 7. Sylvie Robinson, physiotherapist, division of
physiotherapy, Toronto Western Hospital, Toronto, Canada. 8. Philippe
Frascarolo, biologist PhD, department of anesthesia, CHUV, Lausanne,
Switzerland. 9. Richard Brull, associate professor, department of
anesthesia, Toronto Western Hospital, Toronto, Canada.
Background: Femoral nerve blockade (FNB) provides excellent
analgesia for patients with total knee arthroplasty (TKA) but impair
quadriceps muscle strength and mobility. The ideal local anesthetic
regime to balance pain relief and mobility is unknown. This randomized
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11 S
controlled double-blind trial examined the effect of varying the
concentration and volume of a fixed-dose continuous ropivacaine
infusion compared to a conventional single-shot FNB on early and
long-term functional outcomes following TKA.
Methods: Sixty-nine patients scheduled for TKA with US-guided
femoral catheter and spinal block were randomized in PACU into three
groups with different regimes of infusion after a defined bolus of
ropivacaine (R2, ropivacaine 0.2% 5 ml/h; R1, ropivacaine 0.1%
10 ml/h; NS, normal saline 1 ml/h). The maximal total dose per hour
in group R2 and R1 was deliberately equivalent. The clinically relevant
primary outcome measure was distance walked (m) on the morning of
POD 2 after catheter removal. Secondary outcomes measured twice
daily included opioid consumption, pain at rest and during
physiotherapy (VRS), incidence of opioid-related side effects, active and
passive knee flexion (degrees), manual quadriceps muscle strength
testing (pounds), as well as functional recovery at 6 weeks, 3 months,
12 months (WOMAC, SF36 scores) and duration of hospital stay (min).
Statistical analysis included the ANOVA and Pearson tests for
continuous and non-continuous data, respectively. Significance was
considered at p <0.05.
Results: The distance walked on the morning of POD 2 was similar
between groups (R2 41 ± 31, R1 37 ± 32, and NS 41 ± 28 m; p = 0.91).
No statistically significant differences of clinical interest were detected
between groups at any time during the course of the FNB infusion in
any of the secondary outcomes except for passive flexion in POD 1.
(table 1 and 2).
Conclusions: Based on our current results, we cannot recommend the
use of a continuous perineural catheter infusion over a conventional
single-shot bolus for FNB for analgesia following TKA.
F R E E C O M M U N I C AT I O N S 5 – S G I
F21
Bündel-Strategie gegen Ventilator-Assoziierte
Pneumonien “Best Practice” auf der Intensivstation
S. Rupp, RN, B. Zimmermann, RN, P. Vanek, MD, A. Wäckerlin, MD
Kantonsspital Graubünden, Interdisziplinäre Intensivstation, Chur,
Schweiz
Introduction: Ventilator-Assoziierte Pneumonien (VAP) ist eine
ernstzunehmende Komplikation der mechanischen Beatmung auf
Intensivstationen. Mit dem Einsatz von präventiven Massnahmen im
Sinne einer Bündel-Strategie, lässt sich die VAP-Inzidenz reduzieren.
Im klinischen Alltag lassen sich Bündelmassnahmen nur schwer
umsetzen. Nur so ist zu erklären, weshalb trotz besseren Wissens die
Präventionsmassnahmen nicht flächendeckend und konsequent
umgesetzt werden. Wir demonstrieren die Umsetzungsstrategie einer
Präventionskampagne gegen VAP, welche in unserer interdisziplinären
Intensivstation ab Juli 2011 lanciert wurde.
Methods: Das auf Strategien der Organisationsentwicklung basierende
Konzept bestand aus sechs Phasen, welche die Planung, Umsetzung,
Analyse und Anpassung der Kampagne umfasste. Der Umsetzung lag
eine umfassende Informationskampagne zugrunde sowie die
Dokumentation durch ärztliche wie pflegerische Mitarbeitende im
Patienten-Daten-Management-System. Prospektiv untersucht wurde der
Anteil umgesetzter Präventionsmassnahmen beim mechanisch
beatmeten Patientenkollektiv. Die Analyse machte schliesslich eine
zielgerichtete Anpassung des Interventionenkatalogs ab Juli 2012
möglich.
Results: Die Kampagne wurde auf der interdisziplinären Intensivstation
eines mittelgrossen Kantonsspitals im Zeitraum von Juli 2011 bis Juni
2012 durchgeführt. Der Interventionskatalog der Bündelstrategie
umfasste 8 Einzelmassnahmen. Die Analyse der 2847 dokumentierten
Beatmungsschichten (8h/Schicht) ergab folgende Umsetzungsrate:
Anteil dokumentierte Schichten/total Beatmungschichten 68%,
umfassende Händehygiene (HH) 99% ,Cuff-Druck im Zielbereich (CD)
98%, Oberkörperhochlagerung (OK) 91%, Chlorhexidin
100%
80%
Mundwaschungen (DH) 92%, Ulkus-Prophylaxe vermieden (UP) 45%,
Enterale Ernährung EE) 82%, Aufwachversuch erfolgt (SS) 81% sowie
Hb-Transfusionsgrenze von 70g/l (TT) 76% (fig. 1).
Conclusions: Gebündelte Präventionsmassnahmen gegen VAP sind
auf Intensivstationen umsetzbar. Zur Einführung und Aufrechterhaltung
der Compliance kommen Erkenntnisse aus dem Bereich der
Organisationsentwicklung zum Einsatz. Präventionskampagnen müssen
kontinuierlich begleitet und weiterentwickelt werden. Implementierung
einer VAP Präventionskampagne braucht deren Effekt durch Nachweis
einer Reduktion von VAP Inzidenz nicht zu erbringen, da dieser
Nachweis bereits besteht.
F22
La ventilation non invasive au cours de l’insuffisance
respiratoire aiguë hypercapnique: les essais contrôlés
sont ils transposables à la pratique de tous les jours?
M.E. Brunner1, A. Lyazidi1, E. Akoumianaki1, D. Matamis1,
N. Elia2, M. Tramer2, J.-C. M. Richard1, L. Brochard1
1Hôpital universitaire de Genève, Service des Soins Intensifs et
Université de Genève, Genève, Switzerland; 2Hôpital universitaire
de Genève, Service d’Anesthésie et Université de Genève, Genève,
Switzerland
Objectif: La ventilation non invasive (VNI) est le traitement de référence
en cas de décompensation de broncho pneumopathie chronique
obstructive (BPCO). Les résultats des études prospectives randomisées
(randomized controlled trials, RCT) servent à déterminer le niveau de
preuve d’un traitement. Les résultats des RCT pourraient être différents
par rapport à ceux observés dans les études observationnelles qui
représentent probablement mieux la pratique de tous les jours. Nous
avons comparé les résultats de la VNI des RCT à ceux des études
observationnelles.
Méthode: Recherche systématique (1990–2012) dans PubMed,
Embase et Cochrane des articles comprenant les mots-clés: pulmonary
disease chronic obstructive, positive pressure respiration, chronic
obstructive lung disease, intermittent positive pressure breathing. Ont
été exclues les études: 1) sans le pourcentage de mortalité ni le taux
d’échec de la VNI; 2) concernant la VNI chronique; 3) comparant la VNI
à l’intubation d’emblée; 4) incluant œdème pulmonaire, pneumonie. Les
articles sont classés en 2 groupes: 1) RCT, 2) Etudes observationnelles
rétrospectives ou prospectives, ou groupe contrôle historique. Nous
60%
RCT (20 études)
Observationelles
(16 études)
Groupe
(nb études)
VNI
(n = 20)
Traitement
médical
(n = 20)
VNI (n = 16)
Traitement
médical
(n = 4)
Nb patients
498
516
2924
1363
Age (années)
67 ± 4.6
69 ± 4.8
69 ± 5.0
65 ± 3
pH
7.31 ± 0.05
7.32 ± 0.06
7.29 ± 0.06
7.34 ±
0.06
PaCO2 (kPa)
8.7 ± 1.3
8.8 ± 1.2
9.1 ± 1.5
7.0 ± 0.7
40%
20%
0%
DH
HH
OK
CD
SS
UP
EE
TT
Figure 1
Anteil umgesetzter (schwarz) gegenüber nicht umgesetzter
Einzelmassnahmen im Rahmen eines gebündelten
Präventionskonzeptes.
12 S
La figure représente le pourcentage d’intubation et la mortalité sous
traitement par VNI selon le type d’étude (test de Mann Whitney).
Intubati
avons étudié: 1) le taux d’échec de la VNI (intubation ou présence de
critères d’intubation) et 2) la mortalité (soins intensifs ou hospitalière ou
à 28 jours).
Resultats: PubMed: 478 articles, dont 17 retenus. Embase: 289
articles, dont 3 retenus. Cochrane: 10 articles retenus. Six articles cités
dans les bibliographies ont été ajoutés. La table résume la classification
des études, le nombre de patients (Nb) et leurs caractéristiques.
Conclusions: Les taux d’intubation chez des patients avec BPCO
traités par VNI sont très proches dans les RCT et les études
observationnelles, mais la mortalité moyenne est inférieure dans les
RCT (RCT: 12%, observationnelle: 18%). La sélection des malades,
des durées d’observation et des techniques de VNI différentes dans
les deux types d’étude pourraient expliquer ces différences.
Mortalité (%)
F23
Clinical characteristics and outcome of patients admitted
to a medico-surgical ICU requiring non invasive ventilation
(NIV) for hypercapnic respiratory failure
T. Soccorosi1, L. Piquilloud2, P. Jolliet2, J.-P. Revelly2
1Faculty of Biology and Medicine, University of Lausanne, Lausanne,
Switzerland; 2Intensive Care and Burn Unit, University hospital of
Lausanne, Lausanne, Switzerland
Introduction: Because it decreases intubation rate and mortality,
NIV has become first-line treatment in case of hypercapnic respiratory
failure (HRF). Whether this approach is equally successful for all
categories of HRF patients is however debated. We assessed if any
clinical characteristics of HRF patients were associated with NIV
intensity, success, and outcome, in order to identify prognostic factors.
Methods: Retrospective analysis of the clinical database (clinical
information system and MDSi) of patients consecutively admitted to our
medico-surgical ICU, presenting with HRF (defined as PaCO2 >50 mm
Hg), and receiving NIV between January 2009 and December 2010.
Demographic data, medical diagnoses (including documented
chronic lung disease), reason for ICU hospitalization, recent surgical
interventions, SAPS II and McCabe scores were extracted from the
All patients
Intubated
database. Total duration of NIV and the need for tracheal intubation
during the 5 days following the first hypercapnia documentation, as
well as ICU and hospital mortality were recorded. Results are reported
as median [IQR]. Comparisons with Chi2 or Kruskal-Wallis tests,
p <0.05 (*).
Results: 164 patients were included, 45 (27.4%) of whom were
intubated after 10 [2-34] hours, after having received 7 [2-19] hours
of NIV. NIV successful patients received 15 [5-22] hours of NIV for up
to 5 days. Intubation was correlated with increased ICU (20% vs.
3%, p <0.001) and hospital (46.7% vs. 30.2, p >0.05) mortality.
Conclusions: A majority of patients requiring NIV for hypercapnic
respiratory failure in our ICU have no diagnosed chronic pulmonary
disease. These patients tend to have increased ICUand hospital
mortality. The majority of patients were non-surgical, a feature
correlated with increased hospital mortality. Beside usual predictors
of severity such as age and SAPS II, absence of diagnosed chronic
pulmonary disease and non-operative state appear to be associated
with increased mortality. Further studies should explore whether these
patients are indeed more prone to an adverse outcome and which
therapeutic strategies might contribute to alter this course.
ICU death
Yes
No
Yes
Hospital death
No
Yes
No
Number of patients
164
45
119
13
151
57
107
Age
70
[60–77]
71
[59–76]
70
[60–78]
71
[65–75]
70
[60–77]
74
[68–78] *
66
[59–76]
SAPS (pts)
40
[32–48]
43
[32–61]*
39
[31–46]
52
[41–63] *
39
[32–47]
45
[37–59] *
37
[32–44]
McCabe rapidly fatal
20.7%
28.9%
17.7%
53.9%*
17.9%
26.3%
17.8%
No recent surgery
58.6%
51.1%
61.3%
69.2%
57.6%
70.2%*
52.3%
No chronic pulmonary
disease
54.9%
64.4%
51.3%
76.9%
53.0%
64.9%
49.5%
F24
Electrical Impedance Tomography-Based Assessment
of Ventilation-Perfusion Relationships in a Porcine Lung
Lavage Model: A Feasibility Study
T. Riedel1, D. Gerber2, H.U. Rothen3, B. Eberle2, A. Vogt2
1
Division of Paediatric and Neonatal Intensive Care Medicine,
Department of Paediatrics, University Children’s Hospital and University
of Bern, Bern, Switzerland; 2Department of Anaesthesiology and Pain
Medicine, University Hospital and University of Bern, Bern, Switzerland;
3Department of Intensive Care Medicine, University Hospital and
University of Bern, Switzerland
Background: Electrical impedance tomography (EIT) is a non-invasive,
radiation free tool to assess regional differences in aeration changes
and ventilation based on changes of electrical properties of lung
parenchyma. Hardware and analysis software have substantially
improved over the last few years with increased sampling rates and
better signal to noise ratio. Recently several approaches to assess
perfusion have also been proposed.
Objective: We aimed to evaluate the feasibility of EIT measurements
with perfusion assessment to track changes in ventilation-perfusion
(V/Q) relationship in a short-term acute lung injury model.
13 S
Methods: With animal care committee approval 15 anaesthetised pigs
were studied in supine position. After induction and instrumentation,
EIT, shunt fraction and PaO2/FiO2-ratio measurements were performed
before induction of an acute lung injury (ALI) with saline lavage
(baseline), and every 15 minutes thereafter during 4 hours of
standardized ventilator and hemodynamic support. EIT data were
analysed with and without filtering for respiratory rate and heart rate,
respectively. Regions of pulmonary perfusion were identified and
matched to their corresponding ventilated region, in order to generate
V/Q related parameter maps for each EIT measurement (V/QEIT).
Consecutive V/QEIT during and after ALI induction were then compared
to their baseline (prior to ALI induction) for global and regional changes
over time. Correlation of global V/QEIT with conventional shunt fraction
and PaO2/FiO2-ratio was tested.
Statistics: Nonparametric ANOVA and Cuzick Trend Test for
changes over time and Spearman Rank test for correlations.
Results: After ALI induction, regional V/QEIT changes significantly
over time in the posterior (dependent; p <0.01) but not in the anterior
(non-dependent) regions of the lung (p = 0.67). Global V/QEIT shows
a significant decrease (p <0.01 for trend analysis) over the 4 hour
post intervention period. Global V/QEIT correlates with PaO2/FiO2-ratio
(p = 0.01) but not with conventional shunt fraction (p = 0.47).
Conclusion: EIT is capable to detect changes in ventilation-perfusion
relationship in a porcine lung injury model, which correlate well with
PaO2/FiO2-ratio changes. The regional inhomogeneities detected by
EIT are well compatible with gravity-dependent lavage of the supine
animals’ posterior lung regions.
F25
First description of reverse triggering
(respiratory entertainment) in critically ill adults
EA Akoumianaki1, AL Lyazidi2, NR Rey1, NPM Perez-Martinez1,
DM Matamis1, RG Giraud1, LB Brochard2, JCMR Richard2
1University Hospital of Geneva, Intensive Care Unit, Geneva,
Switzerland; 2University Hospital of Geneva, Intensive Care Unit
and University of Geneva, Geneva, Switzerland
Introduction: Respiratory entrainment refers to the establishment
of a fixed repetitive temporal relationship between the neural and the
mechanical respiratory cycle. It constitutes a form of patient-ventilator
interrelation described more than 30 years ago in animals and normal
humans. Reports of respiratory entrainment in critically ill adults,
however, are lacking.
Objectives: In light of an accidental observation we retrospectively
reviewed existing recordings of mechanically ventilated and deeply
sedated patients searching for entrainment events, defined as muscular
efforts apparently triggered by the ventilator. We detected whether the
patients were entrained with the ventilator, i.e. with a regular pattern
and, if so, which were the characteristics of this phenomenon.
Methods: Over a 3 month period all available recordings of airway flow,
airway pressure and esophageal pressure or EAdi in intubated patients,
ventilated with an assist control mode of ventilation were visually
inspected. In case of reverse triggering, the duration of phase locking,
entrainment ratio (the number of spontaneous efforts within each
ventilator breath) and phase difference (dP) were evaluated. The dP
was the time, in seconds, elapsing between the commencement of
ventilator and neural breath. The dP divided by the ventilator cycle
duration and multiplied by 3600 provided the phase angle (θ). The
standard deviation (SD) of the different θ around a mean value
expressed the strength of entrainment.
Results: 8 patients (P) examined entrained for a portion varying from
7% to 100% of their total recording time. They all had acute respiratory
distress syndrome (ARDS) with a mean Ritchmond Agitation and
Sedation Scale (RASS) of –4.5. 1:1 ratio was present in 7 pts and
persisted from 43 sec to as long as 24 minutes. Three patients also
exhibited 1:2 and 1.3 ratios. 1:2 ratios were short-lived, being disturbed
every 10–12 cycles, by non entrainment epochs. 1:3 ratio was detected
in one patient and lasted for 25 sec. Most neural efforts occurred
around the cycling phase, failing to trigger the ventilator. 1:2 entrained
periods had wider SD compared to 1:1 periods.
Conclusions: Respiratory entrainment of variable durations and ratios
was identified in eight sedated patients with ARDS and caused regular
reverse triggering. ‘Reverse triggered’ breaths leading, in most cases,
to isometric diaphragmatic contraction, illustrate a new form of
patient-ventilator asynchrony.
F26
Verbesserung der Medikamentensicherheit auf der
Intensivstation im Stadtspital Triemli
Anett Neubert cand. Pflegewirtin RN; Sandra Haubner cand.
MNS, RN; Miguel González cand. MHC, RN; René Alpiger, EMBA, RN
Hintergrund: Im Gesundheitswesen liegt die Hauptquelle der Fehler
im Medikamentenprozess (30 bis 50%). Das komplexe Tätigkeitsfeld
einer Intensivstation führt im Vergleich zu anderen Bereichen zu
einer ausserordentlich hohen Fehlerrate im Bereich des Medikamentenmanagements. Aufgrund dieser Tatsache wurde bereits 2002 ein
Fehlermeldesystem auf der Intensivstation des Stadtspitals Triemli
eingeführt. Seit 2009 wird dies durch eine Qualitätsbeauftragte betreut,
was zu einer vertieften Etablierung des Fehlermeldesystems im Team
führte. Zu dem ergaben die Auswertungen der Fehlermeldungen
von 2009 bis 2011, dass die häufigste Fehlerquelle im Medikamentenmanagement lag.
Zielsetzung: Sensibilisierung der Mitarbeiter durch die eingegangenen
Fehlermeldungen auf der Intensivstation und Fehlerreduktion im
Medikamenten-management.
Methode: Mit Hilfe der SWOT-Analyse wurden die eingegangenen
Fehlermeldungen von 2011 dargestellt und im interprofessionellen
Team (Pflegende, Fachangestellte Gesundheit, Ärzte) nach
geeigneten Lösungen gesucht. Um ein möglichst breites Spektrum
an Einschätzungen und Sichtweisen zu erhalten, führte die
Qualitätsbeauftragte sechs SWOT-Analysen durch. Diese SWOTAnalysen wurden evaluiert, die Ergebnisse verdichtet und in
übergeordneten Kategorien zusammengefasst. Anhand einer
Literaturrecherche wurde ein Coupon entwickelt, um weiterführende
Analysen zu Mediakmentenfehlern zu betreiben.
Ergebnisse: – Schulung des gesamten Pflegeteams im Workshop
über Medikamentensicherheit. – Die Leitlinie «Umgang mit dem
Verordnungsblatt» wurde überarbeitet und wird interdisziplinär geschult.
– Erhöhung der Sicherheit in der Medikamentenverordnung durch eine
interdisziplinär erstellte Generikaliste. – Sicherstellung einer ruhigen
und unterbrechungsfreien Medikamentenvorbereitung. – Konsequente
Beschriftung der Medikamente vom Vorbereiten bis zur Verabreichung.
– Prozessoptimierung bei der Vorbereitung von Medikamenten. –
Sofortige Dokumentation der verabreichten Medikamente direkt nach
der Gabe durch die durchführende Person. – Einführung eines Coupons
zur Erfassung von Fehlermeldungen.
Schlussfolgerung: Durch die Teamschulung über Medikamentensicherheit und Ergebnisse der SWOT-Analyse wird eine Sensibilisierung
der Mitarbeiter erreicht. Medikamentenfehler werden dadurch reduziert.
Der Einsatz der Coupons ermöglicht eine schnelle und vereinfachte
Erfassung der Ereignisse und ermöglicht genaue Rückschlüsse zur
Ursache des Medikamentenfehlers.
F27
Measurement of resident workload in paediatric
intensive care
B. Frey1, J.P. Hossle2, M. Seiler Sigrist2, V. Cannizzaro1
1
University Childrens’s Hospital, Department of Intensive Care and
Neonatology, Zürich, Switzerland; 2University Children’s Hospital,
Department of Informatics, Zürich, Switzerland
Objective: to measure the workload of residents in a paediatric
intensive care unit (PICU) and to compare this value with possible
explanatory variables such as “nine equivalents of nursing manpower
use score” (NEMS), length of stay (LOS), age and severity of illness
at admission.
Methods: This is a prospective study in a tertiary, interdisciplinary
neonatal-paediatric intensive care unit. In 2010 and 2011, residents had
14 S
to give twice a day (morning and night shift) an estimation of their
workload for each patient they looked for (minor workload 0–30 min,
medium 30–90 min, high >90 min). The following demographic and
illness severity parameters were also collected prospectively: age, LOS,
NEMS, Paediatric Index of Mortality (PIM2), and main diagnosis at
admission.
Results: There were 2513 admissions to intensive care. Independent
predictors of residents’ workload were LOS (coefficient in multiple
regression: 11.8, p <0.0001) and NEMS (coefficient 1.2, p <0.0001).
R squared of 0.935 indicated a strong overall relationship. Severity
of illness at PICU admission and patient age did not explain overall
workload for the whole patient stay in PICU.
Conclusions: Workload of residents depends mainly on LOS, that
is on routine procedures unrelated to the severity of illness (rounds,
discussions with parents, administrative tasks). In addition, NEMS,
a therapeutic intervention score, is also an independent predictor of
residents’ workload and may be used for physician manpower
calculations. A semi-quantitative recording of time spent for each
patient, as used in this study, may be a practicable tool for a more
precise estimation of physician manpower need in PICU.
F28
Transpulmonary thermodilution measurements
in patients with severe mitral valve regurgitation
M.P. Hilty1, D. Franzen1, D. Wyss1, P. Biaggi1,
Christian Schmied2, M. Maggiorini1
1Medical Intensive Care Unit, University Hospital of Zurich,
Zurich, Switzerland; 2Clinic for Cardiology, University Hospital
of Zurich, Zurich, Switzerland.
Introduction: The assessment of hemodynamic parameters is a crucial
step in managing critically ill patients. Transpulmonary thermodilution
(TPTD) is a readily available and minimally invasive method that is used
extensively in intensive care units. However, its validity in patients with
severe mitral regurgitation (MR) has to our knowledge never been
assessed in humans. Therefore we assessed the validity of TPTD
measurements in patients with severe MR by comparing them to right
heart catheterism (RHC), left ventricular angiography (LHC), and
echocardiography of the left ventricle.
Methods: Patients who were subjected to coronary angiography at the
University Hospital of Zurich from 07-2009 to 04-2012 with severe MR
were included. Additionally, patients without valvular disease, with an
ejection fraction (EF) >40% and without severe diastolic dysfunction
(E/e›<15) served as a control group. All patients underwent TPTD using
the PiCCO2 device, RHC, LHC and an echocardiography of the left
ventricle. Parameters derived from TPTD included cardiac index (CdI),
global end diastolic volume (GEDV) and extravascular lung water
(EVLW).
Results: 24 patients were included. Mean ± SD age was 62.79 ± 15.81
and 63.09 ± 7.64 in patients with MR (n = 10) and in the control group
(n = 14). Patients in the MR group were fairly well compensated with a
mean NYHA class of 2.6 ± 0.7, only 2 patients in the MR group had
crackles in clinical examination. There was no significant difference
between the MR and control groups in CdI measured either with TPTD
(2.85 ± 1.02 vs 2.98 ± 0.42 L/(min*cm2), p = 0.24), LHC (2.84 ± 1.53 vs
2.21 ± 0.82L/(min*cm2), p = 0.49) or echocardiography (2.4 ± 0.84 vs
1.92 ± 0.62 L/(min*cm2), p = 0.17). Patients with MR had higher EVLW
(25.6 ± 8.92 vs 19.23 ± 8.59 mL, p = 0.01), pulmonary artery occlusion
pressure (PAOP) (19.3 ± 9.51 vs 10.36 ± 5.34 mm Hg, p = 0.03) and
E/e› measured by tissue doppler imaging (18.64 ± 9.61 vs 9.82 ± 3.12,
p = 0.01). GEDV (1679 ± 415 vs 1495 ± 273 mL, p = 0.51) did not differ
significantly, while LVEDV measured using LHC (189.4 ± 50.24 vs
119.25 ± 50.58 mL, p = 0.06) and echocardiography (140.9 ± 38 vs
105.5 ± 38, p = 0.08) were close to significance.
Conclusions: Our data suggests that TPTD and its derived parameters
are valid and may be helpful in the management of patients with
diagnosed or undiagnosed severe MR when interpreted correctly.
Especially CdI and EVLW measurements appear to be of good use.
GEDV is less accurate than LHC and echocardiography for the
assessment of LVEDV.
F29
Severe Traumatic Brain Injury: A Population-based
Prospective Cohort Study in Switzerland
Mathias Zürcher1, Guy Haller2, Ezra Bottequin2, Patrick Schoettker3,
Patrick Ravussin4, Monika Brodmann5, John Stover6, Joseph
Osterwalder7, Alois Haller8, Adrian Wäckelin9, Christoph Haberthür10,
Javier Fandino11, Chiara Haller12, Bernhard Walder2
1
Department of Anaesthesia and Intensive Care Medicine, University
Hospital Basel; 2Division of Anesthesiology, University Hospitals
of Geneva; 3Department of Anesthesiology, University Hospital Centre
of Lausanne; 4Department of Anesthesiology, Hospital of Sion;
5Department of Emergency Medicine, Inselspital Bern; 6Division of
Surgical Intensive Care, University Hospital of Zurich; 7Emergency
Department, Kantonsspital St. Gallen; 8Division of Surgical Intensive
Care, Kantonsspital Winterthur; 9Division of Intensive Care,
Kantonsspital Graubünden; 10Division of Surgical Intensive Care,
Kantonsspital Luzern; 11Neurosurgery, Kantonsspital Aarau,
Switzerland; 12Department of Psychology, Harvard University, USA.
Introduction: Severe traumatic brain injury (TBI) is a high burden for
society. There are few published studies describing the epidemiology
of severe TBI in developed countries.
Objective: to describe characteristics and outcomes of patients with
severe TBI in Switzerland.
Methods: This study included all adult patients with blunt or penetrating
trauma with an Abbreviated Injury Severity Scale (ISS) score of the
head (AISH) >3, who presented to all the French or German speaking
trauma centres in Switzerland from May 2007 through April 2010. All
surviving patients had follow-up for 1 year. Outcome measures were
mortality, Glasgow Coma Scale (GCS) at 14 days, Extended Glasgow
Outcome Score (GOSE) as well as Neurobehavioral Rating ScaleRevised (NBRS-R) at 3, 6, and 12 months. Data were analysed with
descriptive statistics (Median, [25th,75th quartiles]).
Results: Of the 1012 patients screened for inclusion, 922 fulfilled the
inclusion criteria. The incidence rate was 8.5 per 100’000 population.
74% were men. Median age for all patients was 55 years [33, 71] with
two age peaks (20–30 & 60–70 years). Median GCS on scene was 9
[4, 14] versus 5 [3, 14] at the emergency department (ED). Both pupils
were reactive in 74% on scene versus 72% at the ED. ISS was 25 [20,
34]. Blunt trauma caused 96% of TBI. 31% of patients had multiple
trauma. Accident mechanisms included falls (53%), road traffic
accidents (32%), and others (15%). Median arrival time (hh:min) at the
trauma center for direct admission was 00:46 [00:35, 01:01] and 03:12
[02:15, 04:20] for indirect admission. 44% were intubated on scene.
Intracranial hematoma evacuation was performed in 24%,
intraventricular drainage in 8%, and intracranial monitoring in 19%.
Median ICU stay was 9 days [4, 20] and hospital stay was 11 days
[6, 21]. SAPS 2 Score was 44 [29, 57]. The death rate was 30%. Median
time to death was 2 days [1,6]. Median GCS of survivors at 14 days was
15 [14, 15]. Median GOSE of survivors was 5 [3, 7] at 3 months, 6 [4, 8]
at 6 months and 7 [5, 8] at 12 months. Median NBRS-R of survivors
was 32 [29, 37] at 3 months, 31 [28, 35] at 6 months, and 30 [27, 35]
at 12 months.
Conclusions: This population-based, prospective, cohort study,
investigating severe TBI in Switzerland showed an increased age and a
higher incidence of falls as accident mechanism than earlier studies in
other European countries. Most survivors were conscious at 14 days.
The GOSE increased slightly over a period of 1 year.
F30
Endotoxin activity in sepsis and septic shock
M.P. Hilty1, B. Eberle1, M Maggiorini1
1Medical Intensive Care Unit, University Hospital of Zurich, Zurich,
Switzerland
Introduction: Despite advances in critical care medicine, sepsis
continues to have a high mortality [1]. The identification of modifiable
factors which influence outcome in a favorable way is a great challenge.
One such candidate is bacterial endotoxin. Previous data suggests that
high endotoxin activity (EA) is related to worse outcome [2]. Our aim is
to assess and monitor EA in patients with severe sepsis and septic
shock. Our hypothesis is that the incidence of high EA (EA >0.6) is low,
and that EA is equivalent to SAPS2 and SOFA score in predicting
mortality.
Methods: Patients treated at the Medical ICU at the University Hospital
of Zurich from 09-2011 to 05-2012 with severe sepsis or septic shock
were included. The highest EA level within the first 24 hours after ICU
admission, followed by EA at 48 and 72 hours, were noted alongside
physiological parameters and inflammatory markers. All patients
received standard care according to the surviving sepsis guidelines [1].
EA was measured using the EAA™ Endotoxin Activity Assay. We
present our preliminary results.
Results: 54 patients were included. Mean ± SD SAPS2 was 59 ± 23,
SOFA at ICU admission 13 ± 5. EA measured within the first 24 hours
was 0.52 ± 0.20, with no significant differences for gram status and
infection focus. The most prevalent infection focus was pulmonary,
followed by soft tissue and bones, and abdominal. 19 (35%) patients
presented with an EA >0.6 within the first 24 hours. In these patients,
compared to those with an EA <0.6, the fall in EA over the first 72 hours
15 S
Figure 1
Prediction of ICU mortality by EA measured within the first 24 hours,
SAPS2 and SOFA at ICU admission.
was significantly larger (0.17 ± 0.19 vs 0.02 ± 0.13, p = 0.009, CI
0.03–0.24). Overall ICU mortality was 25%. EA measured within the
first 24 hours was significantly higher in ICU non-survivors versus
survivors (0.64 ± 0.26 vs 0.45 ± 0.20, p = 0.03, CI 0.01–0.34). Receiver
Operating Characteristic (ROC) analysis for ICU mortality yields an
AUC of 0.72 (CI 0.55–0.89) for EA measured within the first 24 hours,
0.81 (CI 0.69–0.94) for SAPS2 and 0.85 (CI 0.73–0.97) for SOFA at
ICU admission. EA measured within the first 24 hours does not
correlate well with SAPS2 (r = 0.27, p = 0.05), SOFA at ICU admission
(r = 0.24, p = 0.14) and IL-6 (r = 0.26, p = 0.07).
Conclusion: In unselected septic patients variability of EA at ICU
admission is high and independent of bacterial strain. Incidence of
EA >0.6 measured within the first 24 hours is low, but predicts poor
outcome. Measurement of EA is warranted because it does not
correlate well with SAPS2, SOFA and IL-6.
F31
Relation between physical / pharmacological
restraint in the ICU and adverse events
Perren A.1, Corbella D.2, Iapichino E.3, Di Bernardo V.4,
Leonardi A.1, Di Nicolantonio R.4, Buschbeck C.1, Boegli L.5,
Pagnamenta A.5, Malacrida R.4
1ICU, Ospedale Regionale Bellinzona e Valli, 6500 Bellinzona;
2 Anaesthesia Dept, Ospedali Riuniti di Bergamo, Bergamo, Italy;
3
Clinical Psycologist, Ospedale San Paolo, Milano, Italy; 4 ICU,
Ospedale Civico, 6900 Lugano; 5 ICU, Ospedale Beata Vergine,
6850 Mendrisio
Introduction: Analgesic and sedative medications are widely used in
intensive care units (ICU) to achieve patient comfort and tolerance to
the environment, and to eliminate various forms of distress. Yet, their
excessive use is associated with increased physical and psychological
morbidity and mortality. On the other hand, an inadequate reduction of
sedation or the presence of delirium may induce patients to cause
harmful events. Thus, pharmacological and/or physical restraint may be
applied in order to protect both patients and caregivers. The aim of this
study was to analyse the relationship between the presence of physical
/ pharmacological restraint and occurrence of adverse events
(e.g. self-extubation, device removal).
Methods: A prospective, observational and multicentric study was
carried out. Inclusion criteria 25 hours after admission were: age ≥18
years, NEMS ≥21, SAPS II ≥32 and informed consent (patient or next
of kin), whereas patients with acute psychosis or presumed/confirmed
major cerebral damages were excluded. The following data were
prospectively registered: 1) at recruitment and discharge: general
patient characteristics, diagnoses, comorbidities, pre-existing
psychiatric medications; 2) for every nurse shift (8hrs): adverse events,
level of sedation (SAS), change in analgo-sedation, NEMS, SAPS II,
presence of physical restraint. Categorical variables were evaluated
with the Fisher exact test.
Results: 120 patients with a mean (±SD) age of 66.3 ± 15.7 yrs and a
preceding Karnofsky score of 75.5 ± 22.7 were included. Other relevant
patient characteristics were: SAPS II 52.0 ± 19.0, NEMS at admission
31.5 ± 7.4, lenght of ICU (hospital) stay 12 ± 11,1 (30.9 ± 23.2). Mortality
was 19%; 32% of patients were transferred to another hospital and 49%
discharged home. 23 patients (19%; 256 shifts) were never physically
restrained, 29 (24%; 744 shifts) had a minor (bedrails) and 68 (57%;
2296 shifts) a major physical restraint. A total of 86 adverse events were
observed (see table 1); no association was found between adverse
events and physical restraint (p = 0.137) or analgo-sedation (p = 0.523;
2.6% of shifts with an adverse event for both, sedated and not sedated
patients).
Table 1
Association between physical restraint and adverse events for all nurse shifts.
Physical restraint
Ø Physical restraint
Adverse events
SAS 1-4
SAS>=5
P
SAS 1-4
SAS>=5
P
No
2820
396
<0.001
2810
395
<0.001
Auto-extubation
1
1
10
0
Removal CVC
0
0
5
0
Removal NGT
6
9
20
12
Removal AC
1
5
4
3
Removal other drainages
1
2
1
5
SAS: sedation agitation scale; CVC: central venous catheter; NGT: naso gastric tube; AC: arterial catheter.
16 S
Conclusions: In about half of all shifts some kind of physical restraint
could be observed. There is a trend towards more adverse events in
not physically restrained patients. Adverse events occurred in agitated
and physically restrained patients, or in the contrary, in quiet and not
restrained patients. This latter fact may suggest a certain
underestimation of the patient’s real condition. Surprisingly no effect
of sedation on adverse events was observed.
F32
Die Intensive Care Delirium Screening Checklist (ICDSC)
und der Behandlungsalgorithmus im klinischen Alltag –
eine qualitative Evaluation auf einer Medizinischen
Intensivstation
Weibel Lukas1, Massarotto Paola1
1
Universitätsspital, Basel, Switzerland
Einleitung: Delirien sind auf den Intensivstationen weltweit eine
häufig auftretende Komplikation (Devlin et al., 2008). Patienten und
Patientinnen, welche ein Delir erleiden, haben eine längere
Beatmungszeit, eine erhöhte Mortalität und Morbitität (Ely et al., 2004).
Die Erfassung und Behandlung eines Delirs soll systematisch und
anhand eines medikamentösen Algorithmus durchgeführt werden.
Auf den Intensivstatonen des Universitätsspitals wurde im 2009,
im Rahmen des interprofessionellen Delirkonzepts, die Intensive
Care Delirium Screening Checklist (ICDSC) eingeführt und ein
medikamentöser Algorithmus festgelegt. Im Verlauf zeigte sich,
dass die ICDSC teilweise nur ungenügend angewendet und der
medikamentöse Algorhitmus nicht konsequent umgesetzt wurde.
Ziel: Mittels Fokusgruppeninterview sollen Erfahrungen mit der
täglichen Anwendung der ICDSC auf der Medizinischen Intensivstation besprochen werden. Positive oder negative Aspekte des
medikamentösen Algorithmus eruiert werden.
Methode: Zwei Fokusgruppeninterviews zu je 60 Minuten wurden
mit jeweils fünf Teilnehmenden geführt. Eine Analyse der
Anwendungsquantität und -qualität anhand des elektronischen
Patienten Dokumentationssystems ermöglichte eine gleichmässige
Durchmischung der Fokusgruppen. Die Gespräche wurden auf Tonband
aufgenommen und anschliessend transkribiert. Die Inhaltsanalyse
erfolgte nach Mayring (1983).
Resultate: Mittels der transkribierten Interviews wurden 35 Codes
erzielt. Diese Codes konnten sieben Gruppen zugeteilt werden. Aus
den sieben Gruppen wurden die Hauptthemen «Menschliche
Faktoren», «Wissen» und «Instrument» entwickelt. Acht konstruktive
Lösungsvorschläge wurden benannt. Die Lösungsvorschläge wurden
umgesetzt und prägen den täglichen Praxissupport durch das
Praxisentwicklungsteam.
Schlussfolgerungen: Diese qualitative Evaluation ermöglichte
einen vertieften Einblick und Austausch in Bezug auf die Anwendung
der ICDSC und des medikamentösen Algorithmus aus Sicht der
Pflegenden. Der qualitative Zugang ermöglichte ein vertieftes
Verständnis zu den Schwierigkeiten in der Anwendung und den
Kontextfaktoren. Daraus konnten passende konstruktive
Lösungsvorschläge für den Alltag abgeleitet werden.
F33
Le raisonnement clinique infirmier lors de l’évaluation
de la douleur chez les patients intubés, sédatés et non
communicants aux soins intensifs
A. Gerber1, Thévoz1, Ramelet1
1
Institut universitaire de formation et de recherche en soins,
Haute Ecole de Santé Vaud (HESAV), Lausanne, Switzerland
Introduction: l’objectif de cette étude observationnelle était de décrire
les indicateurs influençant le raisonnement clinique de l’infirmière
experte lors de l’évaluation de la douleur chez les patients intubés,
sédatés et non communicants aux soins intensifs. Les résultats
produisent une meilleure compréhension entre l’évaluation et la
gestion de la douleur en pratique et finalement participent à
augmenter la qualité de l’évaluation et de la gestion de la douleur.
Méthode: un échantillon de sept infirmières expertes (>5 ans
d’expérience professionnelle et reconnues par les pairs) travaillant
dans une unité de soins intensifs d’un hôpital universitaire de Suisse
Romande a participé à cette étude. Les données ont été récoltées
en situation réelle lors de l’évaluation de la douleur de sept patients
en utilisant la méthode du «think aloud», par une observation non
participative et par un entretien semi-structuré. Les données ont été
analysées en utilisant une méthode d’analyse de contenu déductive
sur la base d’un modèle de raisonnement clinique, comprenant les
catégories suivantes: le contexte, la situation du patient, la génération
d’hypothèse, les actions infirmières et l’évaluation de l’action.
Résultat: la médiane d’expérience des infirmières participantes est de
14 ans (étendue 15) en soins et de 6 ans (étendue 5) en soins intensifs.
Les patients étaient intubés, sédatés et non communicants ayant une
moyenne de score APACHE II de 19. Les résultats montrent que les
infirmières se basent principalement sur des indicateurs physiologiques
pour évaluer la douleur. Elles cherchent à prévenir la douleur pour le
patient. Elles se référent régulièrement à des situations déjà vécues
(pattern). Elles mobilisent leurs connaissances pour pondérer l’agitation
liée à la douleur ou d’autres causes en générant des hypothèses puis
réalisent un test antalgique pour confirmer ou infirmer l’hypothèse
retenue.
Conclusion: le contexte clinique joue un rôle important par rapport au
raisonnement clinique de l’infirmière et la gestion de la douleur. Pour
faciliter cette tâche difficile, l’évaluation de la douleur doit être combinée
avec l’évaluation de la situation clinique du patient et du niveau de
sédation des patients de soins intensifs.
F34
Kognitive Beeinträchtigungen bei Chronically Critically Ill
Patients («Langzeitintensivpatienten»): Was kann die Pflege
zur Prophylaxe, Früherkennung und Behandlung beitragen?
S. Jäger1, B. Eberhard1
1Interdisziplinäre Intensivstationen Bürgerspital Solothurn und
Kantonsspital Olten, Solothurner Spitäler AG, Solothurn, Switzerland;
2
Zentrum für Intensivmedizin (ZIM), Kantonsspital Winterthur,
Winterthur, Switzerland
Hintergrund: Durch die Zunahme von Patientinnen und Patienten
die eine akut lebensbedrohliche Erkrankung überleben, werden wir
immer mehr mit den Langzeitkomplikationen konfrontiert, insbesondere
bei den sogenannten «Langzeitintensivpatienten». Eine häufige
Komplikation ist mit einer Prävalenz bis 80% ein Delir. Dies führt zu
einer verlängerten Beatmungsdauer, einem verlängerten Aufenthalt
auf der Intensivstation (IS) und im Spital sowie zu höherer
Mortalität. Des Weiteren werden negative Auswirkungen auf den
Rehabilitationsprozess, bleibende kognitive Beeinträchtigungen
in verschiedenen Schweregraden, eine höhere Pflegeberdürftigkeit,
vermehrte Einweisungen in Institutionen und eine niedrigere
Lebensqualität Monate bis Jahre nach der Entlassung beschrieben.
Beispielsweise zeigte ein Viertel von ARDS-Überlebenden nach sechs
Jahren milde bis mittelschwere kognitive Defizite.
Ziel: Erarbeitung und Darstellung möglicher Pflegeinterventionen
zur Prophylaxe, Früherkennung und Behandlung kognitiver Defizite.
Methode: Im Rahmen der SGI Kommission Praxisentwicklung
Intensivpflege wurde eine Literaturübersicht zu kognitiven Defiziten
bei Chronically Critically Ill Patients mit Fokus auf Delir, Auswirkungen
auf den Rehabilitationsprozess, bleibende Defizite, Lebensqualität
und mögliche Pflegeinterventionen erstellt.
Ergebnisse: Delir auf der IS ist mit kognitiven Defiziten nach der
Spitalentlassung assoziiert. Oft verbessern sich kognitive Defizite im
Verlauf des ersten Jahres. Aber 46–79% dieser Patientengruppe leiden
nach einem Jahr noch an kognitiven Beeinträchtigungen. Dies sind
Defizite des Gedächtnisses, der Aufmerksamkeit und der exekutiven
Funktionen. Als Risikofaktoren werden Hypoglykämie, Hypoxämie,
Hypotension, Sedation und fehlende Erinnerung an den Aufenthalt auf
der IS angegeben. Um kognitiven Beeinträchtigungen vorzubeugen
wird Delirscreening, Prävention und Frühbehandlung empfohlen. Durch
gezieltes Pflegeassessment und fokussierte Pflegeinterventionen z. B.
in den Bereichen Kommunikation, Wahrnehmung/Orientierung, Schlaf/
Ruhe, Aktivität/Bewegung unterstützt die Pflege Prophylaxe und
Frühbehandlung des Delirs.
Schlussfolgerungen: Die Pflegefachpersonen auf IS nehmen eine
wichtige Rolle im interprofessionellen/interdisziplinären
Behandlungsteam ein. Durch ihre Präsenz bei den Patientinnen und
Patienten können sie frühzeitig Delir-Symptome und deren Fluktuation
erkennen. Dadurch unterstützen sie den Diagnoseprozess und die
Frühbehandlung des Delirs.
F35
Standortbestimmung der Praxisentwicklung der
Operativen Intensivbehandlung nach den ersten
fünf Jahren
U. Barandun Schäfer1, W. Schyboll1, C. Spychiger1,
C. Wesch1, M. Wehrli1
1
OIB Universitätsspital Basel, Basel, Switzerland
Hintergrund: Seit 2007 ist Praxisentwicklung auf der Operativen
Intensivbehandlung OIB (22 Betten) ein strategisches Ziel. Erster Schritt
war die Ausarbeitung eines Portfolios (Schubert et al., 2009). Die
Umsetzung dieser Strategie wird im Führungsgremium diskutiert und
17 S
entschieden. Seit 2007 arbeiten PflegeexpertInnen auf der OIB mit. Sie
unterstützen Pflegefachpersonen in komplexen Patientensituationen,
führen Pflegevisiten durch, erarbeiten evidenz-basierte Konzepte,
arbeiten mit in Fort- und Weiterbildungen, unterstützen die Reflexion
durch Fallbesprechungen und leiten ethische
Entscheidungsfindungsgespräche. Innovationen werden in temporären
Projekt- und kontinuierlichen Arbeitsgruppen entwickelt. In jeder Gruppe
wirken je eine Fach- und eine Führungsbeauftragte mit. Für diese
Gruppen sind Ziele, Aufgaben und Erfolgsindikatoren auf der Basis des
Qualitätsmanagement nach EFQM formuliert.
Methode: Analyse der bisherige Entwicklungsarbeit anhand des
PARISH-Modells zur Etablierung einer Evidenz-basierten Pflegepraxis
(Rycroft-Malone et al., 2004) mit Kriterien zu den Dimensionen Evidenz,
Kontext und Befähigung zu Veränderung. Die Daten wurden mittels
Fokusgruppeninterviews mit Führungs-, Fach- und Bildungsbeauftragten sowie Pflegenden erfasst. Die Resultate wurden im Führungsteam kritisch reflektiert.
Wichtigste Ergebnisse: In der Dimension «Evidenz» heben
Führungsverantwortliche hervor, dass die fachlichen Richtlinien heute
stärker auf belegtem Fachwissen basieren als früher. Pflegeexpertinnen
betonen, dass die Evidenzquelle Expertise noch intensiver eingebracht
werden muss. In der Dimension «Kontext» erlebt die Führung
einen Spagat zwischen Weiterentwicklung und Dienstleitung, die
PflegeexpertInnen heben das Spannungsfeld zwischen Neuerungen
und Nachhaltigkeit hervor. In der Dimension «zu Veränderungen
befähigen» zeigt sich, dass Pflegende, die aktiv im Entwicklungsprozess eingebunden sind, auch bei der Umsetzung anderer
Innovationen engagierter sind. Mitarbeitende der Teams melden kritisch
zurück, dass sie den Überblick über die vielen Vorhaben verlieren und
dass nicht alle Projekte gut evaluiert werden. Sie schätzen die klaren
fachlichen Vorgaben und das Fortbildungsprogramm. Die fachliche
Unterstützung durch PflegeexpertInnen wird geschätzt, wenn auch
manche Mitarbeitenden befürchten, die eigene Fachkompetenz könne
darunter leiden.
Schlussfolgerungen: Es werden konkrete Empfehlungen für die
weitere Praxisentwicklung abgeleitet.
P1
Protective effects of volatile agents against
bronchoconstriction induced by an allergic reaction
in sensitized rabbit pups
Lele Enikő1, Belin Xavier1, Carnesecchi Stéphanie1,
Peták Ferenc1, Habre Walid1
1Anaesthesiological Investigation Unit, Department of Anaesthesiology,
Pharmacology and Intensive Care, University Hospitals of Geneva,
Geneva, Switzerland; 2Division of Anaesthesiological Investigations,
University of Geneva, Faculty of Medicine, Geneva, Switzerland;
3Department of Pathology, University of Geneva, Faculty of Medicine,
Geneva, Switzerland; 4Department of Medical Physics and Informatics,
University of Szeged, Faculty of Medicine, Szeged, Hungary
Background and Goal of Study: Volatile agents exert a differential
protective effect on the airways and lung periphery following cholinergic
stimulation [1]. We hypothesize that they may also have different
abilities to inhibit the lung response to an allergic reaction particularly in
the presence of bronchial hyperresponsiveness (BHR). We investigated
the ability of isoflurane (Iso), sevoflurane (Sevo) and desflurane (Des)
to prevent lung constriction induced by an allergic reaction in a model
of BHR.
Materials and Methods: Low-frequency respiratory input impedance
data (Zrs) were collected in ovalbumin (OVA)-sensitized five-week old
rabbit pups. Measurements were performed at baseline condition in
control (Group C, n = 10) and during inhalation of 1 MAC Isoflurane
(Group Iso, n = 12), Sevoflurane (Group Sevo, n = 9) or Desflurane
(Group Des, n = 9). After 1 mg intravenous OVA, respiratory airway
resistance (Raw), tissue damping (G), and elastance (H) were
obtained from Zrs by model fitting in each minute for 15 min.
Results: Respiratory mechanics were comparable in all groups
at baseline conditions. Raw was markedly increased following
administration of intravenous OVA (fig. 1) with significant attenuation
after 3 minutes in animals under sevoflurane. There was a parallel and
significant elevation in G (208 ± 63%, 280 ± 90%, 331 ± 57% (mean ±
SE%) in group C, Sevo, Iso, respectively, p <0.05), with a more
pronounced deterioration in animals of group Des (510 ± 122%,
p <0.05).
Conclusions: Commonly used volatile agents failed to inhibit the most
severe acute phase of the anaphylactic constrictor response both in the
central airways and lung periphery. However, recovery from the acute
response was faster when anaesthesia was maintained with
sevoflurane, while desflurane worsened the ventilation heterogeneities
that develop after allergen exposure.
References: 1. Myers CF et al. Can J Anaesth. 2011; 58(11):1007–15.
Supported by Swiss National Science Foundation Grant No 3200B0118231
Keywords: volatile agent, allergic lung response, ovalbumin, forced
oscillatory technique, respiratory mechanics
P2
PEEP-induced volume changes assessed by CT imaging
and multiple-breath washout technique in a rabbit model
of acute lung injury
Gergely Albu1, Tristan Zand2, Ferenc Petak3, Walid Habre4
1Department of Anesthesiology, University Hospitals of Geneva,
Geneva, Switzerland; 2Department of Radiology, University Hospitals
of Geneva, Geneva, Switzerland; 3Department of Medical Physics and
Informatics and Engineering, University of Szeged, Szeged, Hungary;
4Geneva Children’s Hospital, University Hospitals of Geneva and
Geneva University, Geneva, Switzerland
Assessing lung volume in clinical practice is crucial to adapt ventilation
strategy under different lung conditions. We aimed to compare lung
volume changes assessed with multiple-breath washout technique
with those calculated by CT scan imaging under different PEEP before
and after surfactant depletion with whole lung lavage (BAL). After
institutional ethical and animal Welfare Committee approval, 8 rabbits
were anaesthetized, tracheotomized and ventilated with volume
controlled ventilation with a tidal volume of 7 ml/kg and a respiratory
rate of 30/min. End-expiratory lung volume were determined by
multiple-breath helium wash-out technique (EELVHe) consecutively at
PEEP levels of 3, 0 and 9 cmH2O. Concomitantly, CT scan imaging of
the chest was performed to determine the end-expiratory lung volume
normalized by the lung density (EELVCT) in order to exclude all
non-aerated zones (with a density > -80HU). These measurements
were repeated following BAL with subsequent maintenance of PEEP
at 3, 0, and 9 cmH2O. Increasing PEEP to 9 cmH2O led to similar
increases in EELVHe and EELVCT (26.2 ± 4.8 to 86.7 ± 9.7 and 24.1 ±
5.9 to 92.4 ± 20.7 ml respectively p <0.0001) While both techniques
were sensitive to follow the lung volume changes with PEEP, the
multiple-breath washout technique was more sensitive than the CT
imaging to detect the deleterious effect of BAL on lung volumes at
18 S
different end-expiratory pressures (p <0.001). There was a strong
correlation between EELVHe and EELVCT with r2 = 0.85 at control
conditions, r2 = 0.69 after BAL and r2 = 0.77 for the pooled data obtained
under both conditions, respectively. The strong associations between
the changes in the indices obtained from CT imaging and the multiplebreath wash-out maneuvers with helium suggest that the latter bedside
technique appeared to be sensitive to detect changes in the endexpiratory lung volume following PEEP changes in normal lungs and
in the presence of acute lung injury. Thus, EELVHe can be used in
clinical practice as bedside parameter to follow lung volume changes
when different ventilation strategies are applied.
P3
Route of epinephrine administration in cardiopulmonary
resuscitation: Comparison of intravenous versus
intramuscular injection in piglets
J. Mauch1, S. Ringer2, N. Spielmann1, M. Weiss1
1Department of Anaesthesia, University Children’s Hospital Zurich,
Zurich, Switzerland; 2Section Anesthesiology, Equine Department,
Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
Introduction: Intravenous (iv) epinephrine is the drug of first choice in
cardiopulmonary resuscitation (CPR). Early epinephrine administration
seems to be advantageous to achieve return of spontaneous circulation
(ROSC). But in cardiac arrest, iv or intraosseous vascular access is not
always immediately available. The study aims to compare efficacy of
early / delayed iv versus early intramuscular (im) epinephrine injection
with regard to ROSC and survival in cardiac arrest model.
Methods: Piglets were randomized into three groups, anesthetized with
sevoflurane, their trachea intubated and the lungs artificially ventilated.
To induce cardiac arrest ropivacaine was continuously infused by a
syringe infusion pump through a central venous line at rate of 2 mg/kg/
min until circulatory arrest occurred. (pulseless electric activity (PEA)
was defined as mean arterial pressure (MAP) 25% of initial value,
corresponding to 12–13 mm Hg). Then, ropivacaine infusion and
sevoflurane were stopped, chest compression was started and the pigs
were ventilated with 100% oxygen. One minute later epinephrine iv (10
µg/kg, group IV) or epinephrine im (100 µg/kg, group IM) or normal
saline (group NS) were applied. If required, further doses of iv
epinephrine were given every 4 minutes in group IV or im epinephrine
after 10 minutes in group IM. Twenty-one minutes after circulatory arrest
iv epinephrine was given to all animals, if required. ROSC was defined
as MAP >40% of initial value. Chest compressions and ventilation were
stopped after 30 minutes if there was no ROSC. Primary outcome was
survival. Secondary outcome was time to ROSC. Results are given as
median (interquartile range).
Results: Twenty-four pigs (3x8), aged 19.5 (16–22) days, weighing 5.4
(5.0–5.7) kg were investigated. Total amount of ropivacaine
administered was 9.1 mg/kg (8.2–10.0) in group IV, 10.0 mg/kg
(8.2–12.4) in group IM and 8.5 mg/kg (6.7–9.2) in group NS. Rhythm
before starting CPR, surviving pigs and time to ROSC (surviving pigs
only #):
Conclusions: Early im epinephrine provided simlar survival compared
to early iv epinephrine and was superior to delayed (21 minutes after
arrest) epinephrine administration. Further animal studies using other
models of cardiac arrest are needed to confirm these preliminary
results.
P4
Electrocardiographic and blood pressure alterations
caused by intravenous injection of ropivacaine test dose
J. Mauch1, S. Ringer2, N. Spielmann1, M. Weiss1
1Department of Anesthesia, University Children’s Hospital Zurich,
Zurich, Switzerland; 2Section Anesthesiology, Equine Department,
Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
Introduction: Objective signs to detect inadvertent intravascular
injection of local anesthetics are essential in the anesthetized pediatric
patient. For intravenously injected bupivacaine it was shown that only
an epinephrine containing test dose reliably provoked T-wave
alterations, changes in heart rate and blood pressure [1, 2]. This study
aimed to investigate electrocardiographic (ECG) alterations caused by
intravenous ropivacaine.
Methods: Twenty-four pigs (median weight 5.4 kg, median age 19.5
days), were anesthetized with sevoflurane and the trachea intubated
and ventilated. For test dose application, they were randomized into
two groups: Group R received plain ropivacaine 0.2%, group RA
received ropivacaine 0.2% + epinephrine 1:200’000. Under stable
cardiopulmonary and anesthesia conditions 0.2 ml/kg of the test
solutions were injected through a cannulated ear vein. Fifteen minutes
later, 0.4 ml/kg were applied. Heart rate (HR), mean arterial pressure
(MAP) and ECG trace were recorded and analyzed. A positive effect
was defined as followed: HR increase >= 10 bpm, MAP increase
>=15 mm Hg, T increase >=25% base line [3].
Results: Results are given as median (range).
Test dose 0.2 ml/kg
Group R (n = 12)
Group RA (n = 12)
HR increase (bpm)
0 (0 to 0)
86 (47 to 117)
HR decrease (bpm)
–8 (–3 to –18)
–4.5 (–1 to –11)
Group IV
Group IM
Group NS
MAP increase (mm Hg)
1 (0 to 4)
52.5 (45 to 77)
Arrest rhythm
PEA / Asystole
5/3
5/3
5/3
MAP decrease (mm Hg)
–2 (0 to –5)
–1 (0 to –11)
Surviving pigs
8
7
4
HR increase (yes/no)
0/12
12/0
Time to ROSC
(min)
2 (2–5.5)
4 (4–8) #
19.5 (12.3–28)#
MAP increase (yes/no)
0/12
12/0
T elevation (yes/no)
5/7
12/0
19 S
Test dose 0.4 ml/kg
Group R (n = 12)
Group RA (n = 12)
HR increase (bpm)
0 (0 to 9)
94 (55 to 119)
HR decrease (bpm)
–13.5 (–6 to –29)
–5.5 (–2 to –10)
MAP increase (mm Hg)
1 (0 to 9)
70.5 (59 to 83)
MAP decrease (mm Hg)
–5.5 (–2 to –8)
–0.5 (0 to –1)
HR increase (yes/no)
0/12
12/0
MAP increase (yes/no)
0/12
12/0
T-elevation (yes/no)
5/7
12/0
Conclusions: In this animal model, an epinephrine containing common
test dose of ropivacaine reliably provoked T-wave elevations and
considerable increases in HR and MAP. In contrast to bupivacaine, plain
ropivacaine caused T elevations in a remarkable percentage (42%) of
animals.
References: 1 Mauch J, et al. Br J Anaesth. 2010;104:94–7; 2 Mauch J,
et al. Br J Anaesth. 2012;108:283–9. 3 Tobias JD. Anesth Analg.
2001;93:1156–61.
P5
Myocardial effects of isoflurane, sevoflurane and
desflurane on right ventricular function in senescent rats
G. Blaudszun1, D.R. Morel1
1Hôpitaux Universitaires Genève, Genève, Switzerland
Background: Aging is associated with left ventricular systolic and
diastolic dysfunction. Moreover, myocardial response to halogenated
anaesthetics can be altered through the aging process. The effects of
senescence on the right ventricle (RV) are less well studied.
Methods: Eight adult (4-month-old [4MO]; mean weight ± SD: 475 g
± 22) and seven senescent (22-month-old [22MO]; mean weight ± SD:
578 g ± 46) male Wistar rats were anaesthetized, instrumented with
a RV conductance catheter and underwent well-controlled doseresponses to isoflurane, desflurane and sevoflurane inhalation
(minimum alveolar concentration [MAC] 0.5, 1.0, 1.5). Steady-state
and classical dynamic pressure-volume loops were recorded, as well
as RV function parameters and systemic haemodynamics.
Results: Aging was associated with an impairment of the RV diastolic
relaxation (dP/dtmin, P = 0.0017), whereas the RV systolic function was
unaltered (dP/dtmax, P = 0.3820; preload-adjusted dP/dtmax [PAdP/
dtmax], P = 0.9425; preload-recruitable stroke work [PRSW],
P = 0.1624), as was the RV cardiac output (P = 0.1550). Senescent
rats were globally characterized by a greater inter-individual variability.
In both age groups, RV contractility remained stable under increasing
desflurane inhalation (P value of the 4MO and 22MO, respectively:
dP/dtmax, P = 0.4757 and P = 0.6340; PAdP/dtmax, P = 0.0748 and
P = 0.8575; PRSW, P = 0.5266 and P = 0.6073), while it was the
most decreased by sevoflurane exposure (dP/dtmax, P <0.0001 and
P <0.0001; PAdP/dtmax, P <0.0001 and P = 0.0003; PRSW, P <0.0001
and P = 0.0386; NS between age groups). Isoflurane produced
intermediate alterations. Sevoflurane inhalation also impaired diastolic
function (dP/dtmin, P <0.0001 and P = 0.0147); this was not observed
under desflurane or isoflurane inhalation.
Conclusions: In rats, RV dysfunction occurring with advanced age
results from impairment of diastolic relaxation. Because sevoflurane not
only profoundly alters RV systolic function but also diastolic relaxation,
this halogenated anaesthetic should not routinely be used in an older
population group. On the other hand, desflurane, more than isoflurane,
is devoid of any major systolic or diastolic RV dysfunction and should be
regarded as safe in senescent individuals.
P6
In vitro lung model to assess gas exchange by multiple
inert gas elimination technique (MIGET) using micropore
membrane inlet mass spectrometry (MMIMS)
B. Varadarajan1, J. Consiglio2, B. Mayr2, St. Vandenberghe4,
V. Hartwich1, H.U. Rothen3, B. Eberle1, A. Vogt1
1
University Department of Anaesthesiology and Pain Therapy,
University Hospital Bern, Inselspital, Bern, Switzerland; 2University
Department of Cardiovascular Surgery, University Hospital Bern,
Inselspital, Bern, Switzerland; 3University Department of Intensive Care
Medicine, University Hospital Bern, Inselspital, Bern, Switzerland;
4
University Department of ARTORG Cardiovascular Engineering,
University Hospital Bern, Inselspital, Bern, Switzerland
Introduction: MIGET by MMIMS provides a rapid and direct method
to determine the inert gas concentrations from small blood sample
volumes [1]. Hollow fibre diffusion membrane oxygenators have been
used as a gas exchange model to describe nitric oxide and carbon
monoxide transfer [2]. MIGET by MMIMS has not been tested in such
a setup to evaluate predefined ventilation perfusion (VA/Q) distributions.
We aimed (I) to design an in vitro lung model (IVLM) including 5 gas
exchange compart-ments and (II), to compare shunt fractions derived
from MMIMS-MIGET (MM-S) with preset reference shunt fractions of
the IVLM (IVLM-S).
Methods: Five oxygenators (QUADROX-iD Pediatric; MAQUET/D)
switched in parallel within a closed extracorporeal circuit were ventilated
in total with 2.5 l min-1 sweep gas at an FIO2 of 0.21, and perfused
using a micro-diagonal pump (DeltaStream DP-II; Medos/D) with human
blood at a rate of 2.5 l min-1 via 2 mixing chambers situated up- and
downstream (representing arterial and venous vascular beds) to the
parallel gas exchange compartments. Inert gas solution1 (six
solubilities) was infused at a rate of 1.5 ml min-1. Model shunt (IVLM-S)
fractions were set to the range of 0, 20, 40, 60 and 80% by bypassing
blood flow to either 0, 1, 2, 3 or 4 oxygenators and measured by in-line
flow meters (Levitronix, Zurich, CH). Duplicate blood samples (3 ml)
were taken at each IVLM-S fraction simultaneously from the mixing
chambers up- and downstream of the gas exchange assembly. The
samples were analyzed to determine MM-S from retention data using
MIMMS by MIGET [3].
Results: The IVLM performed well, allowing stable control of
compartmental blood and gas flows, as well as reproducible inert gas
transfer. Coefficient of variation for replicated IVLM-S was 0.4%. and for
MM-S, 6.1%. Ten pairs of IVLM-S (0 to 91.2%) and MM-S (0.0 to 42.8%)
were taken for analysis. Linear regression was MS = 0.43*IVLM-S+2.4
(P <0.0001, r2 = 0.99). Mean bias (±2 SD) was –30.7% (±39.2%) by
Bland-Altman analysis.
Conclusions: MM-S reflects IVLM-S qualitatively and reproducibly,
however, with a systematic underestimation. The IVLM may become a
convenient system to validate and test MIGET systems and underlying
assumptions by means of preset VA/Q rela-tionships.
References: 1 Dünges B. A&A 109: 1831. 2 Svitek R.G. Ann Biomed
Eng 36:992. 3 Wagner PD. J Clin Invest 59:203.
Funded by SNF 320030_133046
P7
Comparison of plasmatic concentrations after conjunctival
and nasal administrations of midazolam in rabbits
L. Hess1, J. Malek2, A. Kurzova2, M. Jacek3, E. Matejckova3,
M. Votava4, Z. Simunkova1
1Institute of Clinical and Experimental Medicine, Prague, Praha,
Czech Republic; 23rd Faculty of Medicine, Charles University, Prague
and University Hospital Praha Vinohrady, Czech Republic, Dept. of
Anaesthesiology and Resuscitation, Praha, Czech Republic; 33rd
Faculty of Medicine, Charles University, Prague, Department of
Biochemistry, Cell and Molecular Biology – Division of Biochemistry,
Praha, Czech Republic; 43rd Faculty of Medicine, Charles University,
Prague Dept. of Pharmacology, Praha, Czech Republic
Introduction: Delivering drugs via nasal and/or conjunctival application
could provide a rapid and convenient way of administration. We
attempted to determine whether conjunctival administration of
midazolam could produce the same plasmatic levels and clinical
effect as nasal administration.
Method: After ethic committee approval, 20 chinchilla rabbits were
administered midazolam 1 mg/kg either conjunctivally (group C, 10
animals) or nasally (group N, 10 animals). Measured parameters were
SpO2, blood pressure and heart rate before administration and in
1 minute intervals and immobilisation time (loss of righting reflex).
The measurements were performed for 20 minutes. Blood samples
for measurement of plasmatic concentrations by gas chromatography
were taken from auricular vein just after immobilisation, 10 minutes
after immobilisation and 30 minutes after administration. Plasmatic
concentrations were measured twice from each sample. Nitrogenphosphorus detector for Shimadzu GC-17A was used for the analysis to
increase significantly the sensitivity of determination of low anaesthetic
concentrations in a limited volume of biological samples from small
laboratory animals. Signs of conjunctival irritation were observed
using modified technical standards ČSN EN ISO 10993-10. Wilcoxon’s,
Mann-Whitney and ANOVA tests were used for statistical analysis.
P value <0.05 was considered significant.
Results: Results are produced as average (standard deviation (SD).
Onset of effect (s) was comparable in both groups: group C 80.5 (18.6)
s, group N: 109.5 (49.2) s. Heart rate, SpO2 and blood pressure were
stable and without significant differences from pre-administration values
20 S
or between groups. Plasmatic concentrations (ng/ml) were similar in
both groups (blood samples just after onset of effect, 10 min. after onset
of effect and 30 min. after administration): group C: 250(88), 143(56), 97
(40), group N: 177(97), 139(73), 84(49). There were no signs of
conjunctival irritation in C group.
Conclusions: This is the first study comparing plasmatic concentration
of midazolam after conjunctival and nasal administration. Conjunctival
midazolam 1 mg/kg in rabbits produced rapid onset of effect and
plasmatic concentrations comparable with nasal midazolam 1 mg/kg.
The study was supported by grant IGA NT 11284 and VG20102015014
P8
Readdressing of Spinal Glial Glutamate Transporter in
Experimental Neuropathic Pain: Investigation of Culprit
PKC Isoforms
R.D. Gosselin1, P. Meylan1, I. Decosterd1
1CHUV, Lausanne, Switzerland
Astrocytic excitatory amino-acid transporters (EAAT) and γ-aminobutyric acid (GABA) transporters (GAT) are thought to play an important
role in neuropathic pain. In particular, regulations of EAAT and GAT
subcellular addressing via protein kinase C (PKC) are paramount in
transporter function. However, the specific PKC isoforms accountable
are poorly investigated, and the available data remain controversial. We
therefore explored the spinal glial EAAT and GAT subcellular
readdressing in vivo following peripheral nerve injury, and explored ex
vivo the relative importance of the different PKC isoforms on such
regulation. Spared nerve injury (SNI) was performed in male SpragueDawley rats (200–250 g). Seven days post injury, spinal cords were
collected, separated into ipsi- and contralateral dorsal quadrants,
homogenized and submitted to subcellular fractionation (14 fractions)
by ultracentrifugation on sucrose gradient (15–50%) and analyzed by
western-blot. In another series of rats, immunofluorescence was
performed after transaortic perfusion (paraformaldehyde 4%). Primary
cultures of astrocytes were from rat pups (post natal day 1-2). Confluent
cells were shaken (250 rpm) to remove microglia and pharmacologically
treated with PKC activators or inhibitors. Immunolabeling or subcellular
fractionation/western-blots were performed on cell extracts. Subcellular
fractionation reveals that SNI generates an ipsilateral shift of EAAT from
fractions enriched in NaK-ATPase (general marker for plasma
membrane) toward fractions containing caveolin-1 (plasmalemmal
caveolae microdomains). We found that PKC-θ, δ and ξ undergo
marked spinal ipsilateral phosphorylation, as opposed to PKC-α/β and ε.
Immunofluorescence shows that phospho-PKC-δ is exclusively present
in astrocytes, ζ is mainly astroglial, whereas θ is only neuronal. No PKC
activation could be found in micoglia. In primary cultures of astrocytes,
PMA triggered PKC-δ activation and a concomitant re-addressing of
EAAT-1 to caveolin-1-enriched fractions. This EAAT-1 regulation was
fully inhibited by the PKC-δ inhibitor rottlerin, but not the PKC-ζ
inhibitory peptide (ZIP). These data complete the former paradigm
that solely focused on EAAT overall synthesis in the maintenance of
hypersensitivity. We suggest that PKC-controlled EAAT trafficking might
be an important regulatory mechanism in chronic pain, offering new
avenues for more refined therapeutical strategies.
P9
Modulation of nociceptin receptor mRNA expression
via multiple mitogen-activated protein kinase signaling
pathways
Lan Zhang1, Frank Stuber1, Ulrike M. Stamer1
1Inselspital, University of Bern, Bern, Switzerland
Introduction: The nociceptin receptor (NOP) with its endogenous
agonist nociceptin is involved in immune response and pain processing.
NOP expression is modulated in patients with inflammatory diseases
and pain, however, mechanisms contributing to this regulation in human
peripheral blood are still unknown. The aim of the present investigation
was to study the modulation of NOP expression in human Mono Mac 6
(MM6) cells under inflammatory conditions and to elucidate possible
mechanisms involved in its regulation.
Methods: MM6 cells were cultured with or without different
concentrations (0.1–100 ng/ml) of phorbol-12-myristate-13-acetate
(PMA), a potent inflammatory and tumor promoting compound, for up
to 72 hrs. mRNA expression of NOP was measured by quantitative
RT-PCR. Subsequently, signalling pathways of mitogen-activated protein
kinase kinase (MAPKK/MEK), p38, c-Jun N-terminal kinase (JNK) and
nuclear factor kappa B (NF-kB) were investigated to evaluate their
contribution to the regulation of NOP. MM6 cells were cultured with PMA
10 ng/ml for 6 hrs after pre-treatment with the kinase inhibitors PD98509
(30 μM), SB203580 (10 μM), SP600125 (10 μM) or Bay11-7821 (3 μM)
for 1 hr. In addition, levels of intracellular phosphorylated extracellular
regulated protein kinases (pERK), pJNK, pp38 and pNF-κB were
measured by flow cytometry using specific anti-phospho antibodies.
Results: NOP was constitutively expressed in human MM6 cells
(median (1st/3rd quartile) 0.10 (0.03/0.12) arbitrary unit). PMA
modulated NOP mRNA expression dose-dependently. The expression
was significantly down-regulated after the cells were cultured with PMA
10 ng/ml for 6 hrs compared to controls without any treatment: 0.007
(0.004/0.009) vs. 0.06 (0.04/0.08), p = 0.005. Pretreatment of cells with
the kinase inhibitors PD98509 or SP600125 partially prevented the
suppressing effect of PMA (both p <0.05). NOP mRNA levels were 3.9
and 6.1 times higher compared to the PMA treated group, respectively.
Intracellular phospho-flow cytometry analysis showed that both pERK
and pJNK were significantly induced after MM6 cells were cultured with
PMA. This increase was inhibited when the cells were pretreated with
the respective anti-phospho antibodies.
Conclusions: PMA modulates NOP mRNA expression in human MM6
cells. MAPKK/MEKs and JNK-dependent signal pathways seem to be
involved in the regulation on NOP expression under inflammatory
conditions.
P10
Near-Real Time Pulmonary Shunt Measurement With
Multiple Inert Gas Elimination Technique (MIGET) by
Micropore Membrane Inlet Mass Spectrometry (MMIMS)
in Porcine Lung Injury
B. Varadarajan1, D. Gerber1, L. Häller1, V. Hartwich1,
St. Vandenberghe3, B. Eberle1, H.U. Rothen2, A. Vogt1
1University Department of Anaesthesiology and Pain Therapy,
University Hospital Bern, Inselspital, Bern, Switzerland; 2University
Department of Intensive Care Medicine, University Hospital Bern,
Inselspital, Bern, Switzerland; 3University Department of ARTORG
Cardiovascular Engineering, University Hospital Bern, Inselspital,
Bern, Switzerland
Introduction: The multiple inert gas elimination technique (MIGET)
using gas chromatography (GC) is the reference method to determine
ventilation/perfusion (VA/Q) distributions, but is time-consuming and
demands a high level of technical expertise. MIGET by micropore inlet
mass spectrometry (MMIMS) significantly reduces the analysis
complexity compared to GC (1,2). MMIMS-MIGET shunt (MM-S)
correlate well with Riley shunt (R-S) in a porcine lavage lung model 1.
This study aimed to evaluate MIGET by multi-pore MMIMS and
compare MM-S with R-S at a high temporal resolution in porcine
lavage acute lung injury (ALI) model.
Method: With animal care committee approval, 15 anaesthetized
pigs (24 ± 1 kg) were studied. After induction and instrumentation,
a dissolved inert gas (IG) mixture (sulphur hexafluoride, krypton,
desflurane, enflurane, diethyl ether, acetone) was infused at a rate of
8 ml kg-1 h-1. Arterial, mixed venous and mixed expired samples were
collected at baseline (T1) and after lung injury induction in 15 minutes
intervals (T2-T15). Samples were analyzed for IG partial pressures
using the multi-pore MMIMS system (Oscillogy LLC, Folsom PA). The
resulting retention data were transformed to VA/Q distributions (3).
As compartments of interest (fig. 1), MM-S fraction was determined
as VA/Q <0.005, and R-S by using conventional blood gas analysis.
Results: As indicator of experimental error, the MMIMS dataset had a
residual sum of squares (RSS) <5.3 in 87.2%, RSS <10.6 in 94.0% and
RSS <16.8 in 97.2%. Data pairs (n = 218) were obtained for MMIMSMIGET shunt (range, 0% to 27.6%) and Riley shunt (range, 5% to
72.0%). Both MM-S (P = 0.009) and R-S (P = 0.02) showed the
expected increase after ALI induction with slow recovery towards T15).
Time course of R-S fraction was consistently reflected by MM-S.
Correlation between RS and MS yielded r2 = 0.67 (P <0.0001).
M-S underestimated R-S (mean bias ± 2SD = –11.1 % ± 9.0%).
Conclusion: MMIMS enhances temporal resolution of the MIGET
methodology to a near-real time VA/Q distribution analysis technique,
but underestimates R-S systematically. This provides new insights into
short-term changes of VA/Q mismatch during acute lung injury and may
become useful for clinical decision making.
References: 1 Baumgardner J. J Appl Physiol 89:1699.
2 Duenges B. A & A 109:1831. 3 Wagner PD. J Clin Invest 59:203.
SNF Grant 320030_133046.
21 S
P11
Impact of sevoflurane vs. Propofol on NT-PROBNP release
G. Lurati Buse1, Ph. Schumacher2, W. Studer3, E. Seeberger1,
R. Schumann1, J. Fassl1, J. Kasper1, M. Filipovic4, D. Bolliger1,
M. Seeberger1
1
University Hospital Basel, Basel, Switzerland; 2Bürgerspital,
Solothurn, Switzerland; 3Kantonsspital Liestal, Liestal, Switzerland;
4
Kantonsspital St. Gallen, St. Gallen, Switzerland
Introduction: Animal studies suggest cardioprotection by sevoflurane.
There is evidence supporting this cardioprotective effect in patients
undergoing cardiac surgery [1, 2]. Our objective was to evaluate if
sevoflurane compared to propofol reduces postoperative NT-proBNP
release in patients undergoing noncardiac surgery.
Methods: This is a secondary analysis of a randomized controlled
trial of sevoflurane vs. propofol to reduce perioperative ischemia.
Postoperative NT-proBNP concentrations were prespecified secondary
endpoints. We enrolled patients at cardiovascular risk in 3 centres
between February 2006 and October 2010. Patients were randomized
to maintenance with sevoflurane or propofol. We measured NT-proBNP
on postoperative day 1 and 2. Patients and laboratory staff were
blinded. The distributions of NT-proBNP concentration on both
postoperative days were skewed; as such, we tested for differences
in the distribution of postoperative NT-proBNP concentrations (day 1
and day 2) of patients allocated to sevoflurane and to propofol by
Mann-Whitney-test.
Results: We enrolled 385 patients, 184 patients received sevoflurane
and 201 patients propofol. The NT-proBNP concentration was missing
in 5.7% (22/385) on day 1 and in 4.1% (16/385) on day 2. The median
NT-proBNP concentration on postoperative day 1 was 526 (interquartile
range 257-1031.5) after sevoflurane and 559 pg/mL (IQR 238–1,235.5)
after propofol (p = 0.709). On postoperative day 2, the median NTproBNP concentrations was 932.5 pg/mL (IQR 450.5–1670.5) and
928.5 pg/mL (IQR 417.75–2068.5) after sevoflurane and after propofol
(p = 0.766), respectively.
Conclusion: Compared to propofol, sevoflurane did not affect
postoperative NT-proBNP release in patients undergoing major
noncardiac surgery.
References: 1. Yu CH, Beattie WS. The effects of volatile anesthetics on
cardiac ischemic complications and mortality in CABG: a meta-analysis.
Can J Anaesth. 2006;53(9):906–18.
2. Yao YT, Li LH. Sevoflurane versus propofol for myocardial protection
in patients undergoing coronary artery bypass grafting surgery:
a meta-analysis of randomized controlled trials. Chin Med Sci J.
2009;24(3):133–41.
P12
Influence of epidural mixture and surgery on bladder
function after open renal surgery: A randomized clinical
trial
P.Y. Wuethrich1, T. Metzger2, L. Mordasini2, F. Burkhard2, M. Curatolo1
1
Department of Anesthesiology and Pain Therapy, University Hospital
Bern, Bern, Switzerland; 2Department of Urology, University Hospital
Bern, Bern, Switzerland
Introduction: In a previous study we found, contrary to our hypothesis,
that thoracic epidural analgesia (TEA) after open renal surgery impairs
voiding function. The goal of this study is to exclude surgery itself as a
cause and determine which epidurally administered drugs (bupivacaine
or bupivacaine/fentanyl) are behind the changes in lower urinary tract
function.
Methods: In a randomized, controlled, double blinded, single center
study, 40 patients with no pre-existing lower urinary tract symptoms
were equally randomized to receive an epidural regimen with
bupivacaine 0.125% or bupivacaine 0.125% with fentanyl 2 mcg/ml. All
patients underwent urodynamic investigations before placement of the
epidural catheter at level T8/9, after activating the TEA before surgery
and 2 days after open renal surgery under TEA with a segmental
blockade from T4 to T12. Primary outcome was the difference in
postvoid residual (PVR) between the bupivacaine group and
bupivacaine-fentanyl group after surgery. All urodynamic parameters of
storage and voiding phases were assessed according to the guidelines
of the International Continence Society.
Results: In both group a significant increase in PVRs from 15 ml
[range: 0–95] to 200ml [0-695], P <0.001 in the bupivacaine group and
from 20 ml [0-90] to 450 ml [70-850], P <0.001 in the bupivacaine/
fentanyl group was observed after activation of the TEA. This was more
pronounced in the group receiving fentanyl (P = 0.041). These changes
did not differ significantly before and after surgery. Maximum detrusor
pressure, detrusor pressure at maximum flow rate and maximum flow
rate were significantly reduced in both groups but did not worsen after
surgery.
Conclusions: Thoracic epidurally administrated bupivacaine with a
segmental blockade T4 to T12 resulted in clinically relevant PVRs on the
basis of impaired detrusor function. The addition of fentanyl enhanced
this effect without generating greater PVRs. After surgery, the voiding
phase was not further impaired, however bladder compliance was
decreased. Based on this observation removal of the transurethral
catheter in patients with TEA warrants close monitoring of the postvoid
residual.
P13
Efficacy of sugammadex for the reversal of moderate
and deep rocuronium-induced neuromuscular block
in patients pre-treated with magnesium sulphate –
randomised study
C. Czarnetzki, C. Lysakowski, N. Elia, M.R. Tramèr
Background and Goal: Sugammadex, a modified gamma cyclodextrin,
is a selective binding agent specifically designed to encapsulate
the neuromuscular blocking agent rocuronium. Pre-treatment with
intravenous magnesium sulphate (MgSO4) prolongs spontaneous
recovery time after a single intubation dose of rocuronium by about 25%
[1]. Our hypothesis was that after pre-treatment with MgSO4, the time
to reverse a moderate and a deep neuromuscular block induced by an
intubation dose of rocuronium with standard doses of sugammadex
was significantly prolonged.
Methods: Thirty-two men (18–65 years) were randomly allocated to
receive MgSO4 60 mg kg–1 or matching placebo (saline) in a doubleblinded manner. Study drugs were given intravenously for 15 min before
induction of anaesthesia with propofol, sufentanil and rocuronium 0.6
mg kg–1. Anaesthesia was maintained with a target-controlled propofol
infusion. Neuromuscular transmission was measured using train-offour (TOF)-Watch SX acceleromyography. In part I of the study,
sugammadex 2 mg kg–1 was administered in 16 patients (8 MgSO4 and
8 placebo) at reappearance of the second twitch (“moderate” block).
In part II, sugammadex 4 mg kg–1 was administered in 16 patients
(8 MgSO4 and 8 placebo) at post-tetanic count 1–2 (“deep” block).
The primary endpoint was the time in seconds from injection of
sugammadex to a T4/T1 ratio ≥0.9.
Results: Data from all 32 randomised patients could be analysed. In
part I (moderate block), time from injection of sugammadex to a T4/T1
ratio ≥0.9 was on average 72 [SD = 19] seconds with MgSO4 and was
74 [30] seconds with saline (P = 0.874). In part II (deep block), time
was 74 [27] seconds with MgSO4 and was 75 [17] seconds with saline
(P = 0.922).
Conclusion: Pre-treatment with intravenous MgSO4 has no impact on
the efficacy of recommended doses of sugammadex for the reversal of
moderate and deep rocuronium-induced neuromuscular block.
1. Czarnetzki C et al. Time course of rocuronium-induced neuromuscular
block after pre-treatment with magnesium sulphate: a randomised study.
Acta Anaesthesiol Scand. 2010;54:299–306.
P14
Impact of sevoflurane vs. propofol on patients’ satisfaction
G. Lurati Buse1, E. Seeberger1, J. Kasper1, R. Schumann1,
Ph. Schumacher2, W. Studer1, M. Filipovic1, D. Bolliger1,
M. Seeberger1
1University Hospital Basel, Basel, Switzerland; 2Bürgerspital, Solothurn,
Switzerland; 3Kantonsspital Liestal, Liestal, Switzerland; 4Kantonsspital
St. Gallen, St. Gallen, Switzerland
Introduction: The aim was to evaluate the effect of sevoflurane
compared to propofol on the incidence of PONV, headache, and vertigo
after major noncardiac surgery. We further assessed patients’
satisfaction.
Method: This is a secondary analysis of a multicenter randomized
controlled trial of sevoflurane vs. propofol to reduce perioperative
ischaemia in patients at cardiovascular risk. PONV, headache, vertigo,
and patients’ satisfaction were prespecified tertiary endpoints and was
collected systematically onpostoperative day 1, 2 and 7. Patients’
satifaction was quantified by a numarical ratings scale (NRS) in 2
centres. The scale ranged from 0 to 10 with low values indicating low
satisfaction. We tested for dichotomous variables by chi-squared or
Fisher’s exact test, as appropriate. We tested for differences in the NRS
distribution across treatment groups by Mann-Whitney U test. The big
22 S
majority (97%) of the patients was enrolled in one of the centres;
therefore, we did not stratify the satisfaction analysis by centre.
Results: We analysed 385 patients, 199 patients in the sevoflurane and
201 patients in the propofol group.
Table 1 shows the results on the incidence of PONV, headaches,
vertigo and on patients’ satisfactio.
PONV
Headache
Vertigo
Median NRS
(IQR)
Sevoflurane
Propofol
P-value
day 1
29 (16%)
18 (9%)
0.042
day 2
17 (9%)
15 (8%)
0.544
day 7
6 (4%)
6 (4%)
0.983
day 1
7 (4%)
4 (2%)
0.288
day 2
5 (3%)
7 (4%)
0.655
day 7
4 (2%)
4 (2%)
1
day 1
7 (4%)
4 (2%)
0.288
day 2
6 (3%)
6 (3%)
0.888
day 7
3(2%)
7 (4%)
0.336
day 1
7 (5-8)
7 (5-8)
0.173
day 2
7 (5-8)
7 (5-8)
0.734
day 7
8 (6-9)
7 (5-9)
0.122
Table 2
Management and outcomes.
Sedation
%
(n)
Vasopressor
Convers
LA→GA
Mortality
intraproc.
Extubat.
post-proc.
ICU
postproc.
DEX
21%
(61)
69%
(42)
8%
(5)
0%
(0)
97%
(59)
6.6%
(4)
No DEX
79%
(226)
65%
(146)
7%
(16)
1.3%
(3)
96%
(217)
8.4%
(19)
n.s.
n.s.
n.s.
p-value
–
n.s.
n.s.
treatment. Data are mean ± SD. Groups were compared by Students
t-test and chi-square test (alpha set at 5%).
Results: The first 61 patients undergoing procedural sedation with DEX
for TF-AVI were analyzed. Results were compared to the other 226 LA
cases from the registry without DEX treatment. No patient was excluded
from the analysis. Patient’s baseline characteristics are shown in table 1.
Mean DEX induction dose was 53 ± 42 micrograms, cumulative dose
122 ± 66 micrograms. Anesthesia management and outcomes are
summarized in table 2.
Conclusions: Procedural sedation with DEX for transcatheter aortic
valve implantation was comparable to the results of sedation without
DEX with respect to procedural outcomes. Nearly all patients can be
transferred to a step-down immediately after the procedure.
Conclusion: Sevoflurane compared to propofol resulted in a higher
incidence of PONV on postoeprative day 1. This effect however, did not
persist until day 2. The incidence of headache, of vertigo, and patients’
satisfaction were not affected by the choice of sevoflurane vs. propofol.
P15
Procedural Sedation with Dexmedetomidine
for Transcatheter Aortic Valve Implantation
R.M. Basciani1, G. Erdös1, P. Wenaweser2, B. Eberle1
1Department of Anesthesiology and Pain Medicine, University Hospital
Bern, Inselspital, Bern, Switzerland; 2Department of Cardiology,
University Hospital Bern, Inselspital, Bern, Switzerland
Introduction: Transfemoral Aortic Valve Implantation (TF-AVI) in
patients with severe aortic valve stenosis can be performed under
sedation and local anesthesia. Different sedatives and opioids are
used by various groups (e.g., propofol, midazolam, piritramide, fentanyl,
remifentanil, and ketamine). Dexmedetomidine (DEX) is a centrally
acting alpha-2 adrenergic agonist used for intensive care and
procedural sedation. So far, no report about its use for conscious
sedation in TF-AVI exists. We report our first experience with the
use of DEX for sedation in TF-AVI patients.
Methods: With written informed consent to be included into a
prospective TAVI registry database, and IRB approval, patients with
severe symptomatic aortic valve stenosis undergoing transfemoral TAVI
receive local anesthesia and sedation as per clinical routine. Starting
from July 2011, patients were sedated with DEX (loading dose,
1 mcg*kg–1 over 20 minutes, followed by infusion of 0.3–0.7 mcg*kg
–1*min–1) to achieve a sedation level correlating to a Ramsay Scale of
4 at the discretion of the attending anesthesiologist. Results of DEX
group were compared to the LA group from our registry without DEX
Table 1
Patients baseline characteristics.
DEX (n = 61)
No DEX (n = 226)
p-value
Age, years
82 ± 6
83 ± 4.4
n.s.
Male, n, (%)
27/35
84/142
n.s.
BMI, kg*m2
29.7 ± 6.8
26.1 ± 4.9
<0.001
AVA, cm2
0.6 ± 0.21
0.6 ± 0.33
n.s.
LVEF, %
54 ± 13
53 ± 15
n.s.
Log Euroscore, %
25 ± 11
23 ± 14
n.s.
P16
Local or general anesthesia for transcatheter aortic valve
implantation: single-center results from a 400 patient series
R.M. Basciani1, G. Erdös1, S. Stortecky2, K. Ariakuddy1,
P. Wenaweser2, T. Carrel3, S. Windecker2, B. Eberle1
1
Department of Anesthesiology and Pain Medicine, University Hospital
Bern, Inselspital, Bern, Switzerland; 2Department of Cardiology,
University Hospital Bern, Inselspital, Bern, Switzerland; 3Department
of Cardiovascular Surgery, University Hospital Bern, Inselspital, Bern,
Switzerland
Introduction: Transcatheter Aortic Valve Implantation (TAVI) via femoral
or transapical access is a treatment option for high-risk patients with
aortic valve stenosis. Whether for TAVI, local anesthesia with sedation
(LAS) or general anesthesia (GA) is preferable as a routine is still
controversial. We report anesthetic technique and outcomes of 402
patients performed at our institution.
Methods: With written informed consent to be included into a
prospective TAVR registry database, and IRB approval, 402 consecutive
patients with severe symptomatic aortic valve stenosis were treated by
transfemoral, transapical or transsubclavian TAVI (2007–2011).
Transapical/-subclavian TAVI was performed under GA, transfemoral
TAVI either under LAS or GA. Events were assessed according to Valve
Academic Research Consortium (VARC) criteria. Data are mean ± SD.
Groups were compared by Students t-test and chi-square test as
appropriate (alpha set at 5%).
Results: Patients (n = 402) age was 83 ± 6 years, aortic valve area
0.6 cm2, left ventricular ejection fraction 52 ± 15%, logistic EuroSCORE
24 ± 14, and STS Score 6.8 ± 5%. Patients were analyzed according
to their preprocedural allocation to GA or LAS; none was excluded. TAVI
procedure was started in 157 (39%) under GA, and in 245 (61%) under
LAS. With LAS, unplanned conversion to GA was necessary in 17
patients (6.9%). Occurrence of intraprocedural CPR and mortality, as
well as all-cause 30d-mortality were not significantly different between
LAS and GA. The intensive care unit was bypassed by 92% of patients
after LAS compared to 33% after GA. The table summarizes
management and outcomes.
Conclusions: Both GA and LA appear as acceptable and safe
strategies for TAVI, if indications are followed correctly, with an all-cause
30-day mortality as low as 6.5%. Immediately after TAVI about 90%
of patients can be managed without mechanical ventilation. After GA,
the majority can be extubated on the table. Following successful LAS,
nearly all patients can be transferred to a step-down unit immediately
after the procedure.
23 S
P17
Value of international normalized ration (INR) testing
after major cardiac surgery
D. Bolliger1, D. Freiermuth1, U. Zenklusen1, M. Gregor1,
P. Matt2, F. Eckstein2, J. Fassl1, M.D. Seeberger1
1University Hospital Basel, Department of Anaesthesia and Intensive
Care Medicine, Basel, Switzerland; 2University Hospital Basel,
Clinic for Cardiac Surgery, Basel, Switzerland
Introduction: Patients with an international normalized ratio (INR)
value of 1.5 or more after surgery are regarded as at risk for bleeding. In
this study, we evaluated whether high INR values in patients after major
cardiac surgery are associated with increased bleeding and transfusion
of allogeneic blood products.
Methods: With ethical approval, we retrospectively analyzed 177
patients undergoing proximal aortic surgery with induced hypothermic
cardiac arrest from January 2009 through December 2011.
Thromboelastometric analyses and a treatment algorithm aiming to
optimize the fibrinogen-based clot formation were used in all patients.
The first postoperative measurement of INR was used to divide the
patients into groups with normal and high INR (equal or more than 1.5).
We compared postoperative blood loss, transfusion of allogeneic blood
products and the use of coagulation factor concentrates in all patients
and in the subgroups without transfusion of fresh frozen plasma (FFP).
Data are given as mean [SD], median [interquartile range] or number
(percentage), and were compared by Student’s t test, Mann Whitney U
test, and Chi Square test.
Results: We found high INR values in 67 patients (38%). There was
no difference in gender, weight and height between the groups (all
P >0.05), but patients with high INR were older (60 [12] vs. 64 [10] years;
P = 0.022). Postoperative bleeding were comparable (450 [270-610] ml
vs. 510 [280-740] ml; P = 0.274), as was the number of patients with
revision surgery or/and bleeding volumes >1000 ml/24h (P = 0.105).
Erythrocyte concentrates (EC) were transfused in 34 patients (31%;
0 [0–1] units) with normal INR and in 32 patients (48%; 0 [0–2] units)
with high INR (P = 0.025). FFP was transfused in 14 patients (13%;
0 [0–0] units) with normal INR and in 20 patients (30%; 0 [0–2] units)
with high INR (P = 0.005). No differences in platelet transfusions and
the administration of coagulation factor concentrates were found
between the two groups (all P >0.05). In the subgroups of patients
without FFP transfusion, no significant differences in bleeding and
transfusion of hemostatic products or EC were found (P values between
0.364 and 0.605).
Conclusions: Markedly increased INR values are frequently found after
major cardiac surgery. They are associated with increased postoperative
transfusions of FFP and EC. However, many patients with increased
INR values do not need FFP which questions high INR as single trigger
for FFP transfusion.
P18
Effects of implementation of a standard perioperative
care pathway (Enhanced Recovery After Surgery: ERAS)
in elective colo-rectal surgery
S.G. Gander1, D.R. Roulin1, A.D. Donadini1, P.F. Frascarolo1,
L.S. Steiner1, C.K. Kern1, N.D. Demartines1, C.B. Blanc1
1
University Hospital, Lausanne, Switzerland
Introduction: Enhanced Recovery After Surgery (ERAS) is a
multimodal and multidisciplinary perioperative care pathway designed
to achieve early recovery by attenuating the stress response.
20 evidence-based interventions are supposed to be implemented
during the patients’ hospitalisation and notably include preoperative
counselling, provision of clear carbohydrate beverages until 2h before
surgery, standard anaesthetic and peri- and post-operative fluid
management techniques, nausea and vomiting prophylaxis, optimized
analgesia as well as early postoperative feeding and mobilization. The
purpose of the study was to quantify the efficiency of ERAS in elective
colo-rectal surgery, by comparing outcomes of patients before and after
implementation of ERAS.
Methods: 127 patients completed the ERAS pathway (ERAS group) in
2011 and 2012 and were compared to 50 patients who were operated
in 2010 before introduction of the ERAS protocol (control). Compliance
to the ERAS pathway was defined as the number of ERAS interventions
applied in each patient divided by the total number of possible ERAS
interventions. Perioperative iv fluids, primary length of stay (LOS) and
complications were compared.
Results: The compliance to the ERAS pathway was 40% in the control
group and 72% in the ERAS group (p <0.001). Groups were similar
regarding age (p = 0.57), gender (p = 0.74), body-mass index
(p = 0.90), and ASA physical status score (p = 0.11). Intravenous
Table 1
Results of total iv fluids peroperative and on day 0, and LOS.
Control group
n = 50
ERAS group
n = 127
p-value
Total iv per-op
crystalloids (ml)
mean ± SD
2449 ± 750
1488 ± 701
<.0001
Total iv per-op Colloids
(ml) mean ± SD
747 ± 509
658 ± 457
0.19
Total iv fluids post-op
Day 0(ml) mean ± SD
1806 ± 733
960 ± 435
<.0001
Primary LOS (median;
Interquartile 25–75%)
10 [7–28]
7 [4-9]
<.0001
per-operative and post-operative fluids administration on the day of
surgery, as well as primary LOS were significantly lower in the ERAS
group. Results are shown in table 1. Post-operative nausea and vomiting
were 26% in the control group and 15% in the ERAS group (p = 0.10)
The readmissions rate within 30 postoperative days was 2 versus 7 in
the control and ERAS group respectively (p = 1.00). The number of
patients with major complications (Grade III–V according to the Dindo
and Clavien classification1) up to 30 post-operative days was 11 (22%)
and 11 (9%) (p = 0.57) in the control and ERAS groups respectively.
Conclusions: Successful implementation of a standard perioperative
care pathway in elective colo-rectal surgery, significantly reduced iv fluid
administration in the perioperative period and the length of stay without
increasing the readmission rate within 30 days.
1. Dindo D, et al. Ann Surg. 2004;240:205.
P19
Cerebral oxygenation using near infrared spectroscopy
for shoulder surgery in beach chair position: regional
anesthesia with sedation compared to general anesthesia for
neurobehavioral outcome
1
José A. Aguirre, MD, MSc; 1Tina Trachsel, cand. med.;
1Sarah Schneider, cand. med.; 1Corinne Wanner, MD;
2PD Werner Baulig, MD; 1Prof. Alain Borgeat, MD
1Division of Anesthesiology, Balgrist University Hospital, Forchstrasse
340, 8008 Zurich, CH; 2Department of Anesthesiology and Intensive
care, Klinik im Park, Seestrasse 220, 8027 Zurich, CH
Objectives: Cerebral hypoperfusion is related to beach chair position
and controlled hypotension. Near-infrared spectroscopy (NIRS)
measures cerebral oxygen saturation (rScO2) showing impact in
cerebral function recovery. NIRS changes and outcome comparing
both anesthesia techniques in beach chair position are needed.
Methods: Eighty patients scheduled for shoulder surgery are divided
in 2 groups: 40 patients in the regional (R-) group and 40 patients in
the general (G-) anesthesia group (propofol target controlled infusion).
Anesthesiologists are blinded to the rScO2 values. Baseline data the
day before surgery include neurological and neurobehavioral tests
repeated the first day after surgery. The baseline data for NIRS /
bispectral index (BIS) / pCO2, invasive blood pressure at heart and
meatus level and cerebral blood flow (CBF) using doppler of the carotid
and vertebral arteries are taken prior anesthesia, then after beach chair
positioning and all 20 minutes after start of surgery until discharge.
Results: Patients in the R-group show more stable values of rScO2,
blood pressure and cerebral blood flow with similar neurobehavioral test
results after surgery compared to patients in the G-group. (Preliminary
data).
Conclusions: Regional anesthesia offers more stable cardiovascular
conditions for shoulder surgery in beach chair position compared to
general anesthesia.
P20
Propofol-induced respiratory depression during
sedation before and during colonoscopy
Danny Mann, Volker Hartwich, C.N.R.A, Peter M Schumacher,
M.Sc., Ph.D., Antonello Caruso, Martin Luginbühl, M.D.,Ph.D.
Department of Anesthesiology, University Hospital Bern, Switzerland
Background: Models of propofol-induced respiratory depression
(e.g. Bouillon et al. [1]) have been developed from data of unstimulated
volunteers. Using a modified Bouillon-model [2] replacing arterial with
24 S
transcutaneous PCO2 (PtcCO2) we compared propofol-induced
PtcCO2 increase before and during colonoscopy.
Methods: After local ethics committee approval, written informed
consent was obtained from 20 patients scheduled for elective
colonoscopy. A propofol-infusion was given at an effect site target
concentration [3] (Ce-t) of 2.5 mcg/ml before colonoscopy until the
PtcCO2 had stabilized. Then the Ce-t was set to 0, until the patient was
awake and the PtcCO2 had reached baseline. The Ce-t was again set to
2.5 mcg/ml for colonoscopy and was adjusted according to the patients’
needs. Upon termination of colonoscopy the infusion was stopped.
Oxygen was administered by face mask throughout the study. Vital
signs, BIS, transcutanous CO2 (SenTecTM) were recorded continuously,
the OAAS-Score every 5 min. The predicted PtcCO2 was calculated
according to Caruso [2] and Hartwich [4]. The prediction error (PE (%))
of the PtcCO2 increase over baseline before infusion stop was
determined for the two sedation periods (median performance
error, MDPE and median absolute performance error, MDAPE) [5].
Results: The mean (SD) age was 55 (13), and the BMI 26 (6).
The ratio male/female was 11/9 and ASA I / II was 7/13.
Conclusions: The OAAS-Score was lower and the maximal Ce-t
propofol was higher during colonoscopy compared to sedation before.
The measured increase of the PtcCO2 was lower than predicted in both
periods. The accuracy of the prediction was acceptable in the nonstimulated period but not during colonoscopy. Colonoscopy may
decrease propofol-induced respiratory depression.
References
1 Bouillon TW, et al. Anesthesiology. 2004;100:240–50.
2 Caruso AL, et al. IEEE Conference Proceedings. 2007, SaA07.6
3 Schnider TW, et al. Anesthesiology. 1999;90:1502–16.
4 Hartwich, et al. Anesthesiology 2009; Anesthesiology. 2009; A1469
5 Varvel JR, et al. J Pharmacokinet Biopharm. 1992;20:63–94.
The results are presented in table 1:
End of precolonoscopy
sedation
End of
Colonoscopy
P Value
17.8 (4.9)
37.0 (15.4)
<0.001
OAAS-Score*
2.7 (1.8)
1.6 (2.0)
0.03
BIS°X
65.5 (11.1)
65.2 (11.0)
0.95
Predicted Prop Ce (mcg/ml)*
2.46 (0.1)
2.44 (0.5)
0.78
Predicted max Prop Ce (mcg/ml) during sedation period
2.57 (0.1)
2.9 (0.4)
0.001
Mean Baseline PtCO2 (mm Hg) before start of infusion
36.5 (4.3)
36.4 (2.4)
0.18
Measured PtcCO2 (mm Hg)*
42.7 (5.0)
41.4 (4.2)
0.09
Predicted PtcCO2 (mm Hg)*
48.7 (0.2)
48.7 (2.0)
0.60
MDPE (Bias, %)*
–29.8 (29.5)
–41.5 (42.7)
0.29
MDAPE (Accuracy, %)*
30.8 (28.4)
50.4 (29.4)
0.042
Duration (Min.) of sedation period
Data are mean (SD), paired t-test or Wilcoxon rank test as appropriate. * = values from the last 60 seconds of
propofol infusion.
P21
Pulmonary Artery Catheter Insertion: a close-up
Look Using Visible Heart ® Methodologies
O. Bandschapp1, R. Goff2, G. Mallin2, M. Loushin3, P.A. Iaizzo2
1
Department of Anaesthesia and Intensive Care Medicine, University
Hospital Basel, Basel, Switzerland; 2Departments of Surgery,
Biomedical Engineering, and Integrative Biology and Physiology,
University of Minnesota, Minneapolis, United States; 3Department of
Anesthesiology, University of Minnesota, Minneapolis, United States
Introduction: Pulmonary artery (PA) pressure sensing catheters are
placed into the pulmonary circulation, via the right heart, aided by an
inflatable balloon at its tip: they are typically navigated into the lungs
without the use of fluoroscopy.
Methods: We employed Visible Heart® methodologies to reanimate a
human heart (male, 45 years) with a clear perfusate, and then created
educational videos demonstrating the steps of proper pulmonary artery
catheter placement [1]. As of today, our laboratory has reanimated 51
human hearts and developed a free access website displaying these
observed functional anatomies: http://www.vhlab.umn.edu/atlas/. During
the PA catheter placement, the heart was functioning in a four-chamber
working mode while eliciting a normal sinus rhythm and cardiac output
ranged between 3–5 l/min. Further, estimated ejection fractions elicited
by such reanimated hearts can be within similar ranges to these
non-viable donor hearts relative to pre-recovery hemodynamics: it
should be noted that in vitro functioning can also be augmented by
administration of catecholamines and/or calcium.
Results: Employment of this technique has led to this insightful
catheter placement video, which allows one to visualize what is
happening during each step of this clinical procedure (see fig. 1 & 2) [2].
Developed videos successfully provide a novel visual perspective of the
critical events that occur while inserting a pulmonary artery catheter
and show the resistant yet fragile intracardiac structures that these
catheters need to be navigated through. The videos’ educational values
were augmented by inlaid pressure curves; showing morphological
changes that occur when the catheters move through the valves (fig. 2).
Further, a high quality computer animation and fluoroscopy of a
pulmonary artery catheter filled with contrast are synced with the
endocardial footage to aid the viewer.
Figure 1
25 S
(95%CI): 1.6(1.4/1.7) versus 2.2(2.1/2.3); p <0.001). Pain scores at rest
and mobilization did not differ between genotypes and patients’
satisfaction was comparable to the piritramide group.
Conclusions: CYP2D6 genotype influences oxycodone metabolism.
PM could compensate their higher analgesic consumption via additional
PCA demands.
P23
Figure 2
Conclusion: From a design perspective, the developed videos clearly
demonstrate that PA balloon guided catheters function to: guide such
catheters with the flow of blood (perfusate), avoid damage to
endocardial anatomical structures, and thus these catheter can
normally be navigated through the right heart without the need for
fluoroscopy.
References: (1) Quill JL, Laske TG, Hill AJ, Bonhoeffer P, Iaizzo PA.
Circulation. 2007;116:e548. (2) Bandschapp O, Goff R, Mallin G,
Loushin M, Iaizzo PA. American Journal of Respiratory and Critical Care
Medicine 2012 (in press).
P22
Postoperative Oxycodone Analgesia and CYP2D6
Genotype
U.M. Stamer1, L. Zhang3, M. Book1, L.-E. Lehmann1, I. Wilhelm1,
F. Stüber1, F. Musshoff2
1
Department of Anaesthesiology and Pain Medicine, Inselspital,
University of Bern, Bern, Switzerland; 2Department of Forensic
Medicine, University of Bonn, Bonn, Germany; 3Department of
Anaesthesiology and Intensive Care Medicine, Bonn, Germany
Introduction: The μ-opioid receptor agonist oxycodone is metabolized
by polymorphic cytochrome P450 enzymes (CYPs). An impact of
CYP2D6 and CYP3A genetic variants is discussed, however, clinical
data from postoperative settings are sparse.
Methods: After approval of the local ethics committee and written
informed consent, patients scheduled for major surgery were included
in this prospective, genetic association study. 246 patients received
oxycodone 0.05 mg/kg or the comparator piritramide 0.08 mg/kg before
emergence of anesthesia and subsequent patient-controlled analgesia
(PCA). Plasma concentrations of oxycodone and its metabolites
oxymorphone, noroxycodone and noroxymorphone were measured
and CYP2D6 and CYP3A genetic variants possibly influencing
pharmacokinetics, analgesic consumption and efficacy were analyzed.
For CYP2D6 4 genotype groups were differentiated: PM (poor
metabolizers, no active CYP2D6 allele, no enzyme activity), IM/HZ
(intermediate metabolizers / heterozygous with decreased CYP2D6
activity); EM (extensive metabolizers, wild-types, normal CYP2D6
activity), UM (ultrarapid metabolizers, increased CYP2D6 activity).
Primary endpoint was a comparison of genotype dependent plasma
concentrations of oxycodone and its metabolites. The secondary
endpoint was defined by oxycodone consumption compared to
piritramide.
Results: Oxymorphone plasma concentrations were related to CYP2D6
genotype dependent enzyme activity, with highest measures in PM:
AUC mean (95%CI): 56.0 (5.4/22.4) versus 41.8(38.2/45.4) ng•h/ml)
in patients with at least one wild-type allele. In contrast, plasma
concentrations of the metabolite oxymorphone were lowest in PM
compared to patients with CYP2D6 activity (3.4(0.5/6.5) versus
7.7(7.0/8.4) ng•h/ml)). There was no correlation of plasma
concentrations to CYP3A genotype. The cumulative oxycodone
consumption up to 12 hours was highest in PM (25.3 ± 8.1 mg)
compared to EM (18.3 ± 10.0 mg; p <0.01). Equianalgesic dose ratios
of piritramide:oxycodone differed between PM and EM + UM (mean
Intubation success with fiberoptic intubation stylets:
influence of anesthesiologists’ experience
L. Theiler, M. Kleine-Brueggeney, N. Urwyler,
Christine Riggenbach-Studiger, R. Greif
Department of Anesthesiology and Pain Therapy, University
Hospital Inselspital and University of Bern, Switzerland
Introduction: There is conflicting data about the influence of providers’
experience on learning curves for intubation stylets: the rigid Bonfils™
(Karl Storz, Tuttligen, Germany) and the semi-rigid SensaScope™
(Acutronic, Hirzel, Switzerland). We expected attendings would need
fewer attempts and were faster at tracheal intubation compared with
novice residents without fiberoptic experience.
Methods: With IRB approval (ISRCTN14429285) and patients’ written
informed consent 10 novice residents participated in this study. After 5
supervised trials on a manikin, each resident intubated 20 patients
(without predictors for difficult airway, scheduled for elective surgery).
According randomization, either the Bonfils™ or the SensaScope™
was used. Success was defined as tracheal intubation within 5 attempts
limited to 120 seconds each. Time necessary was defined from picking
up the device until cuffing of the tube in the trachea. Residents’ data
were compared with data from 15 attendings intubating 20 patients
each.
Results: 500 patients were enrolled. There were no differences
between attendings and residents regarding intubation success rates
and times necessary until success. No difference was found between
devices for the attendings, but residents were significantly faster with
the Bonfils (table 1). Over the 10 trials, both residents and attendings
decreased the necessary time until success by less than 2 seconds.
There were no serious adverse events and no periods of hypoxia during
intubation.
Conclusions: We found no influence of providers’ experience on
intubation success rates for both SensaScope™ and Bonfils™.
Residents tend to be faster with the Bonfils™ compared with the
SensaScope™. The decrease in intubation times for both groups
indicates a learning curve of negligible clinical relevance.
Table 1
Demographics and success rates comparing Bonfils™ and
SensaScope™. Data in mean (SD) or number/total (%); A = Attending,
R = Resident; *A vs. R
Outcome
Success
rate
Success 1st
Attempt
Bonfils™
SensaScope™
p-value
A
148/150 (99%)
148/150 (99%)
0.99
R
96/100 (96%)
97/100 (97%)
0.70
p-value*
0.18
0.36
A
121/150 (81%)
107/150 (71%)
0.05
R
76/100 (76%)
70/100 (70%)
0.26
p-value*
0.38
0.76
Time of
successful
attempt
(sec)
A
46 (21)
45 (21)
0.55
R
42 (26)
50 (27)
<0.01
p-value*
0.12
0.08
Overall time
(sec)
A
75 (70)
87 (78)
0.17
R
72 (70)
97 (91)
<0.01
p-value*
0.73
0.35
A
1.4 (p = 0.046)
1.6 (p <0.01)
R
0.7 (p = 0.40)
1.9 (p = 0.03)
Time
decreased
per trial
over the
first 10 trials
(sec)
26 S
P24
In-hospital cardiac arrest after leaving a monitored bed –
do we transfer patients too early?
Harm F., Ummenhofer W., Luethy M., Zuercher M.
Department of Anaesthesia and Intensive Care Medicine,
University Hospital Basel, Switzerland
Introduction: In-hospital resuscitation at the University Hospital Basel
is a well-established service performed by a “Rapid Response Team”
(RRT) staffed by intensive care unit (ICU) and anaesthesia personnel.
Accompanying implementation of new structural features of Basic Life
Support interventions for first responders as well as an improved alarm
system for the RRT, close prospective monitoring of mission
characteristics was initiated. In patients suffering from in-hospital
cardiac arrest, beside demographics, locations and outcomes, we were
interested in the 24-hour in-hospital-pathway before cardiac arrest.
Methods: Consecutive collection of a standardised data set (extended
in-hospital Utstein template) of all RRT interventions at the University
Hospital Basel, Switzerland, from December 1, 2010 – May 31, 2012.
Data were entered in Microsoft Excel and analysed using IBM SPSS
Statistics 19.0. Data are presented as descriptive statistics and mean
± SD.
Results: During the study period, the RRT was called to 137 patients
in a potentially life-threatening state; of these, 70 patients (51%)
suffered from cardiac arrest. Mean age was 70 ± 14.9 years, 20 (29%)
were female. For location and corresponding outcome (survival to
discharge rate and Cerebral Performance Category (CPC)), see figure
1. Twenty-five of all cardiac arrests (36%, mean age 68 ± 17.0 years)
occurred within 24 hours after patient transfer from ICU (12), emergency
department (ED) (10) or operating room (OR) (3). Of
these, 13 arrests (52%, mean age 69 ± 19.1 years) occurred on
non-monitored ward beds (6 of 12 from the ICU; 4 of 10 from the ED
and 3 of 3 from the OR). Comparing non-monitored vs. monitored
cardiac arrests, 3 of 13 (23%) vs. 7 of 12 patients (58%) survived
to discharge, and 3 of 3 (100%) vs. 6 of 7 (86%) had a favourable
outcome (CPC 1-2).
Conclusions: Close to 20% of patients (13 of 70) with in-hospital
cardiac arrest had been recently (within the last 24 hours) transferred
from a monitored to a non-monitored area of the hospital (i.e., from
intensive, intermediate care, the ED or the OR to the general ward).
Obviously, survival chances of cardiac arrests are considerably higher
in a monitored state. As organisational and economic pressures on
turn-over rates for monitored care patients increase, these figures may
be important.
P25
Mortality and causes of death for elective and non-elective
surgery after stay in post anaesthesia care unit
C. de Lorenzi1, M. Borgeaud1, N. Wickboldt1, B. Walder1
1
Division of Anaesthesiology, Department Anaesthesiology,
Intensive Care and Clinical Pharmacology, University Hospitals
of Geneva, Geneva, Switzerland
Introduction: The causes of post-operative death after stay in the
post-anaesthesia care unit(PACU) were rarely investigated. The quality
of care in the PACU has an impact on the post-operative mortality(1);
therefore, identification of causes of death after PACU stay can be the
basis of future quality improvement programs. The primary aim of this
study was to investigate the causes of death post-PACU. Secondary
aim was to determine the time interval between PACU stay and death.
Methods: The design of the study was retrospective. The study was
performed in the PACU with intermediate care facilities (IMC) of the
University Hospitals of Geneva (HUG). We included all patients with
PACU stay and post-operative, in-hospital death during the period of
July 2008 to June 2011. We searched in the computerized patient data
system of the HUG for pre-operative (age, physiological score of the
American society of Anaesthesiology (ASA), oncological disease),
intra- and post-operative parameters.
Results: Two-hundred seventeen patients who died after their PACU
stay were included; 66 patients (30.6%) were operated electively and
150 (69.4%) non-electively. Median age was 78 years (range from 29 to
99 years); ASA distribution was ASA 2: 16 (7.4%), ASA 3: 139 (64.1%),
ASA 4: 61 (28.1%), ASA 5: 1 (0.5%); 129 patients (59.4%) had
oncological pathologies. The causes of death were cardiac [60 (27.6%)],
respiratory [68 (31.3%)], digestive [18 (8.3%)], cerebral [15 (6.9%)],
renal [14 (6.5%)], infectious [52 (24%)], oncological [36 (16.6%)],
haemorrhagic [13 (6%)], not established [10 (4.6%)]; for 9 patients no
information was available. The median survival time after discharge
from PACU was 6 days (in median 7 days for elective surgery and 5
days for emergency). Forty-one patients (18.9%) died within 48 hours
post-PACU; for these patients the median age was 83 years (range from
44 to 95 years), the ASA distribution was ASA 3: 56.1%, ASA 4: 43.9%;
56.1% were suffering from oncological diseases and 73.2% had an
emergency surgery. These patients died principally from cardiac (39%)
and respiratory (31.7%) causes.
Conclusions: Major causes of death after PACU stay are respiratory,
cardiac and infectious. The majority of deceased patients was operated
in emergency and their death was several days after PACU discharge.
Strategies improving the emergency pathway including regular
post-operative checks for vital signs and infections may decrease
in-hospital mortality after PACU stay.
P26
Quality of care in post anaesthesia care unit of
a university hospital
V. Léchappé1, T. Laroche1, B. Walder1, F. Bajaj1, A.C. Rae1,
P. Chopard1, P. Francis1
1Geneva university, Geneva, Switzerland
Introduction: Optimal postoperative care is important to avoid
complications which increase the length of hospital stay and/or risk of
mortality. The Post Anaesthesia Care Unit (PACU) is a key element in
postoperative care, in particular, if patients stay for a prolonged period
(within a PACU offering intermediate care facilities). Few studies have
been performed investigating patients’ opinion on care within such a
PACU. The aim of this survey was to estimate the quality of care,
from a patient’s point of view.
Methods: A survey with a predefined questionnaire after discharge
from PACU at Geneva University Hospitals was performed between
April 19th and July 22th 2011. This PACU treated 9600 patients in 2011.
Inclusion criteria: Stay in PACU >6 hours, knowledge of the French
language, absence of cognitive dysfunction, absence of reduced
consciousness and willingness to respond to a questionnaire. Exclusion
criteria: Patients classed ASA 5. The questionnaire included the
following domains: demographic data, data related to anaesthesia and
surgery, patient’s preoperative PACU advice, general care in PACU,
staff-patient relationship, pain and patient’s comfort. An estimated
summary per domain was calculated by addition of answers in a
specific domain. All analyses of data were descriptive.
Results: 220 of 341 invited patients (65%) participated in this survey.
Median age (range) was 63 (18-90), 202 patients were classed ASA 2/3
(93%), 149 patients declared themselves as being in good health
(68%). 189 patients had general surgical, orthopaedic or cardiovascular
interventions (86%); 150 patients (68%) were elective and 184 patients
(84%) had a surgical risk class of 2/3. Overall, general care and
staff-patient relationship was estimated as adequate in 85%,
preoperative PACU advice in 58%, pain treatment in 64% and comfort
in 65%. Domains with low adequacy were: 60 patients had no prior
information on the duration in PACU before surgery (27%); 64 patients
reported feeling ignored during their stay in PACU (29%); 67 reported
an absence of a surgical visit (30%), and only 140 (64%) always
received a personal introduction from staff.70 were disturbed by noise
(36%) and only 102 (46%) received visits from relatives or friends
(54%). 89 patients experienced intense pain on admission (40%).
Conclusions: The overall care in PACU was estimated as adequate
according to most patients. This questionnaire identified domains which
can be improved.
27 S
threatening state; for 3 patients (2%), records were missing. See figures
1 and 2 for destinations and causes of the life-threatening
RRT interventions (mean age 69 ± 13.9 years; 52 (38%) female).
Characteristics for the 70 patients suffering from cardiac arrest were
as follows: Mean age 70 ± 14.9 years; the initial rhythm was: 12 (17%)
ventricular fibrillation (VF) / ventricular tachycardia (VT), 27 (39%)
asystole, 30 (43%) pulseless electrical activity (PEA) and 1 (1%)
unknown. Return of an at least transient perfusing rhythm was achieved
in 49 cases (70%): 11 of 12 with initial VF/VT, 16 of 27 with initial
asystole, and 21 of 30 with initial PEA. Of the 70 patients with cardiac
arrest, 29 (41%) were discharged alive, 23 of them (79%, mean hospital
days 14 ± 10.6) with a Cerebral Performance Category (CPC) of 1 or 2.
The initial rhythm of the 23 cases with favourable CPC was:
7 (30%) VF/VT, 10 (44%) PEA, 5 (22%) asystole and 1 (4%) unknown.
Conclusions: With 86% of calls being activated for patients with
life-threatening conditions, our in-hospital resuscitation system seems
to be initiated appropriately and accurately. With 51% of these patients
in serious condition having cardiac arrest and 34% being respiratory
distressed, team composition with staff from the Medical Intensive Care
Unit and from the Department of Anaesthesia appears to be adequate.
After reviewing the literature available, outcome after in-hospital cardiac
arrest in our institution seems to be good.
P27
In-hospital resuscitation calls – prospective follow-up
of cause, locations and outcome
Harm F., Ummenhofer W., Luethy M., Zuercher M.
Department of Anaesthesia and Intensive Care Medicine,
University Hospital Basel, Switzerland
Introduction: In-hospital resuscitation at the University Hospital Basel
is a well-established service performed by a “Rapid Response Team”
(RRT) staffed by ICU (leadership) and Anaesthesia personnel (airway
management). Accompanying implementation of new structural features
of Basic Life Support interventions for first responders as well as an
improved alarm system for the RRT, close prospective monitoring of
mission characteristics was initiated. Follow-up of the first 18 months
addresses causes of emergency calls and outcome after in-hospital
cardiac arrest.
Methods: Consecutive collection of a standardised data set (extended
in-hospital Utstein template) of all interventions of the RRT at the
University Hospital Basel, Switzerland, from December 1, 2010 – May
31, 2012. Data were entered in Microsoft Excel and analysed using IBM
SPSS Statistics 19.0.
Results: The RRT was activated for 160 patients. Of these, 137 (86%)
were found in a potentially life-threatening and 20 (12%) in a non-life-
P28
Comparison of the single-use Ambu aScope2 ® versus
the fibreoptic bronchoscope for tracheal intubation
in patients with cervical spine immobilization
P. Schoettker1, V. Krugel1, P. Frascarolo1, I. Bathory1
1University Hospital CHUV, Lausanne, Switzerland
Introduction: Despite the emergence of new videoscopes, fibreoptic
intubation remains a key technique for difficult airway management.
Standard reusable bronchoscopes offer high quality vision but are
expensive to purchase, in addition to maintenance. Recently, a
single-use flexible videoscope has been developed with an updated
device being commercialised (Ambu aScope2®) integrating a better
quality optical system.
Aim: We planned a prospective randomized controlled clinical study
to compare the Ambu aScope2® to a standard fibreoptic bronchoscope
for tracheal intubation in 100 patients with a simulated difficult airway.
Methods: 100 patients (ASA 1 or 2 undergoing elective surgery with
oro-tracheal intubation) were randomly assigned to group “aScope2®”
or “fiberoptic bronchoscope”. After standardized induction of general
anesthesia and neuromuscular blockade, the neck was immobilized
with an appropriately sized semi-rigid Philadelphia Patriot® cervical
collar and intubation performed by the same anaesthetist.
Quality of vision
Demographics, time to indentify the carina, time to intubate, time to
railroad the tube, intubation success, quality of vision as well as ease
of intubation were recorded.
Results: Both groups were similar in terms of gender, ASA, weight,
height and no statistically significant difference was noted in factors
predictive of difficult intubation (MP, TMD and neck circumference).
All patients were successfully intubated in both groups. The time was
significantly shorter and the quality of vision significantly better in the
standard fibreoptic bronchoscope group. Four patients necessitated two
attempts in the aScope2® group (secretions that lead to removal of the
scope and lens cleaning), compared to eight with the fibrescope
(p = 0.22) due to secretions (1 patient), malpositionning of the
Ovassapian split airway (2 patients) and accidental withdrawal of
fibrescope during manipulation (5 patients).
Conclusions: Evolution of technology has led to the design and
commercialisation of a single-use flexible optic device. In simulated
difficult airway patients, oro-tracheal intubation was always possible with
this device, although with less quality of vision and longer time
comparing to a standard fibreoptic bronchoscope. It might represent an
alternative in cases of non-available expensive fibreoptic
bronchoscopes or specific institutional situations.
Ease of intubation
Time [s]
Excellent
Acceptable
Unacceptable
Easy
Intermediate
Difficult
To see carina
To intubate
Fibrescope
49*
1*
O
38
7
5
14.5 [11.8; 22.0]*
49.5 [40.0; 59.3]*
aScope2
24*
22*
4
30
12
8
27.5 [22.0; 45.8]*
69.5 [54.8; 97.3]*
®
*: significant difference (p <0.05)
28 S
P29
Hypnosis before medical procedures – A systematic review
N. Cheseaux1, A. Juillet de Saint Lager1, B. Walder1
1
Hôpitaux Universitaires de Genève, Genève, Switzerland
Background and goal: There is a controversy if hypnosis is effective
when performed before medical procedure. This systematic review of
randomised controlled trials (RCTs) aimed to estimate the efficacy of
hypnosis before diagnostic or therapeutic medical procedures.
Materials and methods: Medline, Psycinfo, Embase, Cinhahl, and the
Cochrane Central Registrar of Controlled Trials databases were
searched to identify RCTs comparing hypnosis against active or
inactive control interventions before medical procedures. All RCTs had
to report about pain and anxiety. Three reviewers independently
selected RCTs; the quality of the included RCTs was investigated with
two different scores. Characteristics of RCTs were abstracted by 2
investigators and crosschecked by another one. The data were not
pooled because heterogeneous outcome measures were observed.
Results and discussion: Nineteen RCTs with 1037 patients were
included; study size was 20 to 200 patients (1 RCT >100 patients).
These RCTs included 479 patients with hypnosis, 494 with control
interventions and 64 without group attribution; 11 RCTs had active
controls, 5 RCTs inactive controls and 3 RCTs both. Fifteen RCTs
included 899 adults (mean age 23 to 63 years), 4 RCTs 138 children
(mean age 8 to 14 years). Five of 15 RCTs with adults included 410
females only (mean age 25 to 49 years). Ten of 19 RCTs (52.6%)
had major quality limitations. Duration of hypnosis was 3 to 30 minutes;
5 RCTs used audiotapes; 6 had more than one session, 3 tested
hypnotic susceptibility. Thirteen RCTs reported on pain and 12 on
anxiety. Ten of 13 RCTs on pain reported on quantitative data, eight
of 10 RCTs favoured hypnosis; of these 8 RCTs, 5 had large postinterventional pain intensity variability and 3 did not report variability. Six
of 8 RCTs reported on significant difference for post-interventional pain.
Nine of 12 RCTs on anxiety reported on quantitative data and 6 on
post-interventional anxiety; all RCTs favoured hypnosis; of these 6
RCTs 2 had large post-interventional anxiety intensity variability, 1 did
not report variability and 3 had low variability. Four of 6 RCTs reported
on significant difference for post-interventional anxiety.
Conclusions: Hypnosis before medical procedures estimated with
post-interventional pain and anxiety may be efficient; however, majority
of included RCTs had major methodological limitations. Large,
well-conducted RCTs with a standardised hypnosis and assessments
are needed.
P30
Early postoperative change of double-lumen to
single-lumen tube after thoracoabdominal aortic surgery
R.M. Basciani1, G. Erdös1, G. Jermann1, J. Schmidli2, B. Eberle1
1Department of Anesthesiology and Pain Medicine, University
Hospital Bern, Bern, Switzerland; 2Department of Cardiovascular
Surgery, University Hospital Bern, Bern, Switzerland
Introduction: Double-lumen tube (DLT) and one-lung ventilation
are necessary to facilitate thoracoabdominal aortic aneurysm (TAAA)
surgery. Early postoperative (p.op.) change of DLT to a single-lumen
tube (SLT) may facilitate bronchial toilet and avoid DLT malposition (1).
However, persistent lung bleeding, impaired oxygenation and airway
swelling may impede safe airway management. No evidence exists
about optimal tube exchange timing, but current ACCF/AHA guidelines
(1) discourage routine exchange at the end of TAAA repairs (Class III).
Our study aim was to determine feasibility and safety of immediate
p.op. change of DLT to SLT following TAAA surgery.
Methods: With IRB approval for this retrospective single-center
observational study, records of all patients undergoing TAAA repair
at our institution between April 2008 and May 2010 were reviewed.
Data are mean ± SD.
Results: Sixty-nine patients (male, 46; female, 23; age, 64 ± 12 y; body
mass index, 25 ± 4 kg/m2) were analyzed, none was excluded. TAAA
were asymptomatic, symp-tomatic, and ruptured in 41 (59%), 20 (29%),
and 8 (12%). Surgery was performed elective, emergent, and urgent in
57 (82%), 6 (9%), and 6 (9%). Duration of surgery and distal aortic
perfusion were 461 ± 114 and 192 ± 66 min, respectively. All but 2
patients (persistent pulmonary hemorrhage) had their DLT changed
to SLT immedi-ately p.op. in the OR by the attending anesthesiologist.
No change maneuver failed. There were no change-related airway
complications. The table summarizes management and outcomes:
Conclusions: With careful airway evaluation and difficult airway
equipment at hand, we regard immediate p.op. change of DLT to SLT
by anesthesiologists after TAAA surgery as feasible and safe, with
Airway management
% of cohort
Size of DLT: 35/37/39/41
5/23/45/27
Type of DLT: left/right
95/5
Immediate p.op. DLT exchange
97
Use of laryngoscopy for exchange
94
Use of airway exchange catheter
6
Failed exchange intubation
0
Blood gas results
before
after exchange
PaO2, mm Hg
223 ± 94
171 ± 73
PaCO2, mm Hg
44 ± 9
34 ± 6
Pulmonary outcomes
% of cohort
Pulmonary complications (overall)
30
Persistent p.op. lung bleeding
3
ARDS
5
Pneumonia
7
Pleural effusion
11
Pneumothorax
3
Pulmonary embolism
3
Tracheostomy
10
Length of ICU stay (d)
5.8 ± 9
expected failure/complication rates of <5%. Current guidelines should
be adapted with regard to this aspect of TAAA anesthesia.
Reference: Anesth Analg 2010;111:279.
P31
Comparing Performance and Impact of First Responders on
Outcome in Prehospital Emergency Medicine in Switzerland
J. Schoenhofer1, L. Theiler2, B. Kaempfen3, C. Stave4, R. Greif1,
N. Urwyler1
University Hospital of Bern, Bern, Switzerland, Bern, Switzerland;
2University of Miami Miller School of Medicine, Miami, United States;
3
Department of Anaesthesiology, Spitalzentrum Oberwallis, Visp,
Switzerland, Visp, Switzerland; 4Lane Medical Library & Knowledge
Management Center, Stanford University School of Medicine, Stanford,
California, USA, Stanford, United States
Background: Despite a decades-long evolution of emergency medical
services, there is no consensus on the effectiveness of prehospital first
responders. The aim of this study was to evaluate performance and
impact on outcome of first responders. We hypothesized that
emergency physicians are more accurate in spite of contradictory
results reported in the medical literature.
Methods: In a retrospective cohort study we compared the accuracy
of diagnoses and the assessment of severity of cases by emergency
physicians, paramedics, and general practitioners in prehospital
emergency medicine. A board of certified emergency physicians
compared the diagnoses made in a prehospital emergency situation to
those at discharge of the hospital. We included all patients rescued by a
land based emergency system admitted to a Level III Trauma Center in
the alpine region of Switzerland within one year. Primary outcome was
the impact on mortality. Secondary outcomes were: time spent by the
patient in the field, time of hospitalization as well as the influence of
clinical experience and postgraduate training on accuracy of diagnoses.
Results: We evaluated the accuracy of 1,241 diagnoses. Patient with
a possibly life threatening injury or disease (NACA Score ≥4) admitted
with a wrong or missing diagnosis had an increased risk to die (odds
ratio 1.9; CI 1.04–3.34). The time spent with the patient in the
prehospital emergency situation did not increase if diagnosis was
correct. Hospital stays of patients with a correct compared to a wrong
or missing diagnosis were significantly shorter. This finding was
independent of the NACA Score. The three groups made diagnoses
with similar accuracy (p = 0.139). Emergency physicians showed a
significant increase in accuracy correlated to their clinical experience
29 S
(p <0.001). After postgraduate year six they reached a level of
diagnostic accuracy >95%. This effect could not be shown for the other
groups. Paramedics and general practitioners underestimated the
severity of cases more often than emergency physicians (p <0.001).
Conclusion: A correct diagnosis in prehospital emergency medicine
reduces mortality and length of hospital stay. Trained and certified
emergency physicians make diagnoses and severity assessments
with a higher degree of accuracy compared to paramedics or general
practitioners. Therefore, they should be increasingly integrated into
prehospital emergency medicine, particularly for more severe cases.
P32
Study of the mice motor activity in pain conditions
G. Kirschmann, A. Paraschiv-Ionescu, M.R. Suter, P. Kloucek,
I. Decosterd
Introduction: Animal pain models have substantially improved the
understanding of pain mechanisms. A major limitation is the absence
of mathematically quantifiable outcomes pertaining to the differences
between humans and rodents. Based on previous studies using
multivariate measures of physical activity in humans we performed
studies of the motor activity in mice under pain conditions.
Methods: We used and improved the ActivMeter system (Bioseb) to
quantify measurements of motor activity in mice under neuropathic pain
condition and after administration of analgesics. The home-cage of the
mice was placed on the testing platform and activity was recorded for
24 hours with a 12/12h light/dark cycle. The ActivMeter allows the
discrimination between rapid and slow movement, motionless activity
and immobility. In the first experiment we used the spared nerve injury
(SNI) model of neuropathic pain. Activity was recorded before surgery
(Baseline) and 7 and 25 days after SNI (n = 12). In the second set of
experiment we administrated validated analgesic drugs (assessed with
a classical mechanical allodynia-like method) to evaluate their effect on
mice activity. Six naïve animals were tested every week in a cross-over
design and received either no injection or intraperitoneal injection of
NaCl 0.9%, rufinamide 25 and 50 mg/kg or amitriptyline 10 mg/kg.
Animals’ activity was recorded for 24 hours just after injections.
Results: Using a standard analysis of activity parameters (mean
durations) we have observed the expected variation of activity of the
mice during the circadian cycle, with a pic of activity during the dark
phase. Mice demonstrated the same pattern of activity compared to
baseline after SNI. Rufinamide decreased average activity per hour
from 25 minutes to 5 minutes and also average distance per hour from
45 m to 10 m during the pic of dark phase. Amitriptyline provoked a
small decrease in the locomotor activity but mainly delayed the pic of
activity from 9 pm to 1 am.
Conclusions: Using standard analysis we could point out an effect of
both analgesics but no difference was seen from neuropathic pain itself.
Ongoing work is dedicated to the analysis and quantification of the
temporal structure of animals’ motor activity. Such analysis allow us to
better understand pain-related behavioral aspects in animal’s models, to
find objective and measurable parameters to analyze the consequence
of pain and its treatment on animals beyond testing only evoked-pain
paradigm.
P33
Temporal characterization of microglia reactivity
in the SNI neuropathic pain model
N.P. Piller1, I.D. Decosterd1, M.R.S. Suter1
1Centre Hospitalier Universitaire Vaudois, Pain Center,
Department of Anesthesiology, Lausanne, Switzerland
Background: After peripheral nerve injury, a reaction of microglia (CNS
macrophage-related cells) occurs in the spinal cord and participates in
neuropathic pain. This activation evolves with the course of time but
virtually no studies explored its temporal phenotypic characterization.
Methods: As a pilot study, we investigated the transcriptional
regulation, after spared nerve injury (SNI), of a panel of genes, chosen
among potential phenotype biomarkers of macrophages attempting to
liaise current theories about macrophages differentiation. To determine
relevant time points we quantifyied transcribed Iba1 and CD11b, two
markers of reactive microglia, at day 2, 4, 7, 10, 14 and 21 after SNI in
rat spinal cord dorsal horn. To normalize RT-PCR data the three most
stable reference genes were validated using geNorm and strict controls
of an eventual genomic contamination were performed. RT2 Profiler
PCR Arrays (SABiosciences, Qiagen Switzerland) permitted to analyze
84 transcribed genes at 4 time points with a high inter- and intra-arrays
reproducibility and specificity. Data analysis was performed on PCR
Array Data Analysis Web Portal from Qiagen with the delta-deltaCT
method.
Results: Arrays were analysed at day 2 (early microglial reaction), day
4 (peak), day 10 (transition phase) and at day 21 (resolution phase)
according to observations in regulation of Iba1 and CD11b. We could
confirm some previous studies results, notably the large and sustained
up-regulation of complement components after nerve injury along the
entire time course. Interestingly, beside previously described TLR2 and
TLR4 upregulation, TLR1 showed the largest and most sustained
increase among TLRs, which was never described in spinal cord to our
knowledge. Chemokines and cytokines were difficult to trustfully study
due to low expression levels and wide variation within the groups.
Conclusion: PCR arrays permitted to quantify only a focused panel of
transcripts with the high-throughput approach of an array. Regarding
our working hypothesis, some results might reflect the existence of a
time-dependent phenotypic switch, such as the early induction of
pro-inflammatory chemokines and cytokines and the late induction of
the prototypic anti-inflammatory IL-10. Finally, although the increase of
TLR1 expression was described after a peripheral nerve injury it had
never been shown in the central nervous system. These regulations
and their downstream implications have to be further studied.
P34
Evaluation of a Newly Developed Esketamine Nasal
Spray in a Human Pain Model
C. Bitter1, M. Haschke2, O. Bandschapp3, W. Ruppen3,
W. Ummenhofer3, K. Suter1, S. Deuster1, C. Surber1
1Hospital Pharmacy, University Hospital Basel, Basel, Switzerland;
2
Pharmacology and Toxicology, University Hospital Basel, Basel,
Switzerland; 3Anaesthesia and Intensive Care Medicine, University
Hospital Basel, Basel, Switzerland
Introduction: Ketamine is an analgesic, sedative and anesthetic agent,
which is used in critical care medicine, pediatrics and for special pain
situations. It is mainly administered by the intravenous or intramuscular
route. Nasal application is an additional alternative. However, only
moderate bioavailability (BA) of about 30% has been reported for
nasal ketamine. Further, kinetic and dynamic data of nasal ketamine
is lacking. The aim of this study was to compare a newly developed
mucoadhesive esketamine nasal spray formulation with intravenously
(i.v.) or intramuscularly (i.m.) administered esketamine, in a clinical
study for pharmacokinetics (PK), pharmacodynamics, adverse effects,
and nasal tolerance.
Methods: A randomized and double-blind study (NCT00847418) was
performed after ethic’s approval. Eight healthy, non-smoking male
volunteers received 20 mg esketamine nasal/i.v./i.m. in a triple-dummy
design on three separate study days. Intense PK-sampling and an
experimental pain test with repeated and continuous intradermal
electrical stimulation were performed. Vital signs, adverse effects
(muscle tone, sialorrhoe, nausea, nystagm, and dizziness), and
tolerance of the application modes were monitored. Additionally,
coordination, fatigue, crankiness, and medication effect were noted
with visual analog scales. Psychic effects were assessed with validated
psychometric questionnaires.
Results: Clinical effective plasma-levels of esketamine (BA 71%) were
reached in comparable time with the developed nasal formulation as for
i.m. application. All tested application modes showed no significant
differences in pain reduction for the first hour. Maximal pain reduction
was reached first and was slightly more pronounced for i.v. application,
followed by i.m. and nasal application. Adverse effects and increase
of blood pressure and heart rate were comparable after nasal and i.m.
application and more pronounced after i.v. application. Psychotomimetic
and dissociative adverse effects of esketamine were detected (most
prominent for i.v. application). All effects were transient and self-limiting.
Conclusion: The developed esketamine nasal spray is an effective,
needle-free, and easy to use alternative application mode of ketamine
for patients suffering from acute pain.
30 S
P35
Normative values of electrical pain and reflex thresholds
in pain-free population
A.Y. Neziri1, P. Scaramozzino2, O.K. Andersen3, B. Radanov4,
A.H. Dickenson5, L Arendt-Nielsen3, M. Curatolo1
University Hospital of Bern, Inselspital, Bern, Switzerland; 2DeFiMS,
SOAS, University of London, London, Switzerland
3
Center for Sensory-Motor Interaction, Department of Health Science
and Technology, Aalborg University, Aalborg, Switzerland; 4Pain Unit,
Clinic Wilhelm Schulthess, Zürich, Switzerland; 5Department of
Pharmacology, University College London, London, Switzerland
Aim: The aim of this study was to provide percentile normative values
of spinal nociceptive reflex thresholds and subjective pain thresholds
(to single and repeated electrical stimulation) and of the area of the
reflex receptive fields.
Methods: 300 controls (150 males, 150 females, 18–80 y.) were studied
in a previous investigation (Neziri et al., Eur J Pain. 2010;14:134–41).
Nociceptive withdrawal reflex thresholds (tibialis anterior muscle evoked
by stimulation of the foot sole), pain thresholds to single and repeated
electrical stimulation (stimulated on the nervus suralis innervations
area), and the area of reflex receptive fields (RRF area) were assessed.
The RRF area was defined as the skin area of the foot sole from which
a NWR could be evoked in the tibialis anterior muscle, expressed as
proportion of the total foot sole area. The influences of gender, age,
height, weight, body mass index, body side of testing, depression,
anxiety, catastrophizing and parameters of Short-Form 36 were
analysed. Estimates of quantile regressions with a variance-covariance
matrix were generated. 5th, 10th and 25th percentiles (p5, p10, p25) for
single electrical stimulation and temporal summation were computed.
For RRF area, 75th, 90th and 95th percentiles (p75, p90, p95) were
computed, since sensitization is reflected by increased values of RRF
area.
Results: Age had a significant impact on the pain threshold to single
electrical stimuli. The reflex threshold to single electrical stimuli was
lower on the dominant compared to the non-dominant side. Values
lower than p5, p10, p25 for single electrical stimulation and temporal
summation, and higher than p75, p90 and p95 for RRF area, reflect
different degrees of central hypersensitivity. The percentile normative
values (p5, p10, p25) for pain threshold to single electrical stimulation
were: 9, 9 and 10 mA for age ≤49, and 6, 7 and 8 mA for age ≥50;
for single electrical stimulation reflex threshold: 10, 11 and 14 mA for
dominant body side, and 10, 12 and 15 for non-dominant body side;
for temporal summation pain detection: 6, 6 and 7 mA; for temporal
summation reflex threshold: 6, 6, and 7 mA. Normative values for RRF
area were: 0.62, 0.90 and 1.00 (p75, p90, p95).
Conclusions: Estimates of critical normative values for electrical pain
test in a pain-free population were determined. These values can be
used in clinical practice for the assessment of widespread central
hypersensitivity in individual patients.
P36
Epidemiology of widespread pain hypersensitivity
to mechanical and electrical stimuli in chronic pain patients
J. Schliessbach1, Y. Ghamri1, A. Ashraf1, A. Neziri1, O.K. Andersen2,
L. Arendt-Nielsen2, M. Curatolo1
1University Department of Anesthesiology and Pain Therapy,
Inselspital, Bern, Switzerland; 2Laboratory for Experimental Pain
Research, University of Aalborg, Aalborg, Denmark
Aim: Generalized hypersensitivity to painful stimuli is frequent in
chronic pain and due to sensitization of brain and spinal cord. Studies
suggest that 18–36% of chronic pain patients show generalized
hypersensitivity to pressure pain tolerance thresholds (PPTT). The
current study examines its prevalence using pressure pain detection
threshold (PPDT), electrical pain detection threshold (EPDT) and
electrical nociceptive withdrawal reflex threshold (NWR).
Methods: Consecutive patients with pain >3 months were enrolled with
no current pain, vascular or neurological disorders of the extremities or
conditions affecting neurological function (diabetes, alcohol abuse, etc.).
PPDT was measured by pressure algometry at the 2nd toe. 25ms
train-of-five square wave stimuli were applied distal to the lateral
malleolus with increasing current intensity until a pain sensation (EPDT)
and a biceps femoris reflex (NWR) were evoked. The mean values were
compared to the 5th, 10th and 25th percentile of gender- and ageadjusted normative values. Preliminary data are presented.
Results: 253 patients (147 ♀, 106 ♂) were tested. Results for PPDT:
13 patients (5.1%) below the 5th percentile (♀:10 or 6.8%, ♂:3 or 2.8%);
16 patients (6.3%) below the 10th percentile (♀:13 or 8.8%, ♂:3 or
2.8%); 42 patients (16.6%) below the 25th percentile (♀:28 or 19%,
♂:14 or 13.2%). EPDT results: 151 patients (59.7%) below the 5th
percentile (♀:92 or 62.6%, ♂:59 or 55.7%); 171 patients (67.6%) below
the 10th percentile (♀:103 or 70%, ♂:68 or 64%); 194 patients (76.7%)
below the 25th percentile (♀:117 or 80%, ♂:77 or 73%). NWR results:
70 patients (28%) had intolerable pain before the reflex threshold was
reached. Of the remaining 183 patients, 113 (62%) were below the 5th
percentile (♀:71 or 67%, ♂:42 or 55%); 128 (70%) were below the 10th
percentile (♀:79 or 75%, ♂:49 or 64%); 157 (86%) were below the 25th
percentile (♀:94 or 89%, ♂:63 or 82%).
Conclusions: Fewer patients than expected had PPDT below the 10th
and 25th percentiles of normative values, thus no widespread central
hypersensitivity to PPDT was found. This is in contrast to a study with
18–36% prevalence assessed by PPTT. PPDT seems to be not
sensitive to detect widespread central hypersensitivity, whereas
electrical measurements may be particularly sensitive. This indicates
that central sensitization processes are detected to extremely variable
extent by different testing modalities, stressing the need for multimodal
assessments.
P37
Ranking of central hypersensitivity parameters according
to their discriminative ability in chronic neck pain
A.Y. Neziri1, A. Limacher2, B. Radanov3, O.K. Andersen4,
L. Arendt-Nielsen4, P. Jüni2, M. Curatolo1
1University Department of Anaesthesiology and Pain Therapy, Bern
University Hospital, Inselspital, Bern, Switzerland; 2Division of Clinical
Epidemiology and Biostatistics, Institute of Social and Preventive
Medicine (ISPM) University of Bern and CTU Bern, Bern University
Hospital, Inselspital, Bern, Switzerland; 3Pain Unit, Clinic Wilhelm
Schulthess, Zürich, Switzerland; 4Center for Sensory-Motor Interaction,
Department of Health Science and Technology, Aalborg University,
Aalborg, Denmark
Aim of Investigation: It is well known that chronic pain is associated
with plasticity changes and hypersensitivity of the central nervous
system. Central hypersensitivity can be assessed by various modalities
of experimental pain tests (quantitative sensory tests). However,
comparative performance of quantitative sensory tests for diagnostic
purposes is unclear. The aim of present case-control study was to
explore the discriminative ability of different quantitative sensory tests
in distinguishing between cases with chronic neck pain and pain-free
controls, and to rank these tests according to the extent of their
association with chronic pain.
Methods: 40 cases with chronic neck pain and 300 pain-free controls
were recruited and tested. Gender, age, height, weight, body mass
index and psychological measures were recorded as potential
confounders. 26 quantitative sensory tests, including different modalities
of pressure, heat, cold and electrical stimulation were used. As
measures of discrimination, we estimated the area under receiver
operating characteristics (area under ROC).
Results: In order of their discriminative ability, six tests appeared
useful: 1. pressure pain detection threshold at the site of most severe
pain (fitted area under the ROC curve 0.92, 95% CI 0.86–0.98),
2. single electrical stimulation reflex threshold (0.90, 0.84–0.95),
3. single electrical stimulation pain detection threshold (0.89, 0.82–
0.95), 4. temporal summation pain detection threshold (0.87, 0.80–
0.94), 5. pressure pain tolerance threshold at the site of most severe
pain (0.86, 0.77–0.95), and 6. cold pain detection threshold at lateral
aspect of leg (0.81, 0.70–0.91).
Conclusions: Pressure and electrical pain modalities appeared most
promising measures to distinguish between cases with chronic neck
pain and pain-free controls. They may be most promising for future
diagnostic and prognostic purposes.
Acknowledgments: This work was funded by the Swiss Science
National Foundation, the Danish Research Council for Technology and
Production and the Scientific Funds of the University Department of
Anesthesiology and Pain Therapy of the University of Bern.
31 S
P38
Do central hypersensititvity and altered pain modulation
predict the course of chronic low back and neck pain?
S. Mlekusch1, J. Schliessbach1, R. Cámara2, L. Arendt-Nielsen3,
P. Jüni2, M. Curatolo1
1Department of Anaesthesiology and Pain Therapy, Inselspital –
University Hospital of Bern, Bern, Switzerland; 2Division of Clinical
Epidemiology and Biostatistics, Institute of Social and Preventive
Medicine (ISPM) University of Bern, Bern, Switzerland; 3Center for
Sensory-Motor Interaction, Department of Health Science and
Technology, University of Aalborg, Aalborg, Denmark
Aim of Investigation: Widespread central hypersensitivity and altered
conditioned pain modulation (CPM) may contribute to symptoms of
chronic pain. Information on their prognostic values is limited. We tested
the hypothesis that widespread central hypersensitivity and altered
CPM, when assessed during the chronic phase of low back and neck
pain, predict poor outcome.
Methods: Consecutive patients with chronic low back and neck pain
referred to our Pain Clinic during one year were enrolled. Demographic
variables, Multidimensional Pain Inventory, Beck Depression Inventory
(BDI), Catastrophizing Scale of the Coping Strategies Questionnaire
and pain medication were recorded. Pressure pain tolerance threshold
at the 2nd toe and tolerance time during cold pressor test were
recorded as parameters of widespread central hypersensitivity. CPM
was measured by the change in pressure pain tolerance threshold
(test stimulus) after cold pressor test applied to the hand (conditioning
stimulus). A structured telephone interview was performed 12–15
months after, whereby numeric rating scale for pain intensity, painrelated interference with sleep, performed treatments and current pain
medication were recorded. Average and maximum pain intensity of the
last 24h at follow-up were the endpoints. Univariable and multivariable
linear regression models were used to analyze the prognostic value of
widespread central hypersensitivity and CPM. The analyses were crude
and adjusted in multivariable analyses including the following
independent variables: gender, age, catastrophizing scale, BDI, pain
duration, intake of opioids, and type of pain syndrome (low back or
neck).
Results: We included 169 patients. For both low back and neck pain,
statistically significant reductions from baseline to follow-up were
observed in pain intensity, pain-related interference with sleep and
drug consumption (p <0.001). Uni- and multivariate analyses used to
investigate the prognostic value of widespread central hypersensitivity
and CPM did not reveal statistically significant associations.
Conclusions: In this exploratory study, assessments of widespread
pain sensitivity and CPM by pressure algometry and cold pressor test
did not predict the course of chronic low back and neck pain. The
question of whether other test modalities have a predictive value is still
open.
P39
Expectations of general practitioners referring patients
to an ambulatory university pain clinic – A survey to improve
the collaboration between external practicing physicians and
university center
K. Streitberger1, S. Joos3, V. Piguet2, C. Oehler1, M. Curatolo1
1University Department of Anesthesiology and Pain Therapy, Inselspital,
Bern, Switzerland; 2Multidisciplinary Pain Centre, University Hospital,
Geneva, Switzerland; 3Department of General Practice and Health
Services Research, University Hospital, Heidelberg, Germany
Introduction: Collaboration of different physicians treating the same
patient is important to improve quality of the treatment. Knowledge on
the expectations of the referring doctors is important to improve the
collaboration between them and tertiary care centers. We performed
a survey to evaluate the expectations of general practitioners (GPs)
referring patients to ambulatory university pain clinics.
Methods: The choice of questions was based on a pilot survey where
the GPs were asked what they expect from a referral of their patients
to the university pain center. The answers were compared and weighted
for inclusion into the new questionnaire. The questionnaire included
statements about expectations on pain reduction, waiting time,
treatment modalities, and communication. The GPs scored their
agreement to the statements on a 5 point scale, whereby 1 = definitely
not and 5 = very much. A statement was considered as a relevant
expectancy if a median of 4 or 5 was achieved and if more than 50% of
GPs scored more than 3. The questionnaire was sent to 100
consecutive GPs referring patients to the ambulatory pain clinic of the
university hospital of Bern.
Results: The response rate was 61%. The most important expectancies
with a median of 5 were information in written form (95% scored >3),
information after last consultation (92%), and support in the treatment
of complex patients (87%). Further important expectancies with a
median of 4 were short waiting time to first consultation (80%), at least
50% pain reduction by the treatment in the pain unit (63%), offers of
training education from the pain unit (63%), and cost effective therapies
(54%). Among the less important expectancies with a median of 3 were
follow-ups by the pain unit (48%), use of the newest therapies (41%),
information by mouth (38%), restriction to patient evaluation and
advisory service for the GP (34%), information after every consultation
(33%), taking over the complete therapy in complex situations (31%),
and information after the first consultation (28%). The lowest median
was 2 for the expectation to take over the complete therapy (16.4%).
Conclusions: Our study showed that GPs very much expect
information in written form after the last consultation and a support in
the treatment of complex patients, but most do not expect that the
complete therapy has to be taken over. Considering those issues could
improve the collaboration between GP and the university pain centers.
P40
Outpatient continuous regional analgesia after
orthopaedic foot surgery: economical considerations
1Andrea Saporito, MD; 2Evelina Sturini, MD; 3John Petri, MD;
4
Prof. Alain Borgeat, MD; 4José Aguirre, MD, Msc
1Anesthesiology Dept., Regional and Ambulatory Anesthesia Unit,
Bellinzona Regional Hospital, 6500 Bellinzona, Switzerland (andera.
saporito@eoc.ch); 2Anesthesiology Dept., St. Chiara Clinic, Via Stefano
Franscini 4, 6600 Locarno, Switzerland; 3Orthopedic Department,
Bellinzona Regional Hospital, 6500 Bellinzona, Switzerland; 4Division of
Anesthesiology, Balgrist University Hospital, Forchstrasse 340, 8008
Zurich, CH
Background: Continuous regional anesthesia for home pain therapy
after limb ambulant surgery is established. However, safety and
cost-effectiveness of this ambulant management must be assessed.
Methods: After approval by the ethical committee and written informed
consent 168 patients scheduled for elective foot surgery were allocated
into the outpatient or into the inpatient treatment group. All patients
received a continuous popliteal block for surgery. Continuous regional
anesthesia for 48 hours using an elastomeric pump delivering 5 ml
ropivacaine 0.2% was performed for all patients. Outpatients were
discharged the day of surgery and followed with telephone interviews.
Block quality, patient satisfaction and impact of both treatments on
direct and indirect costs were analysed.
Results: There was no difference in pain and the incidence of PONV.
Persistent motor block was equal in both groups. There was no
difference in unscheduled ambulatory visits or readmissions.
Readmissions related costs were 720.10 USD per outpatient patient
and 410.50 USD for inpatients. Additional ambulatory visits costs were
8.10 USD per outpatient and 6.9 USD in controls. Total costs were
2195.22 USD vs. 13502.94 USD in controls.
Conclusions: Outpatient continuous regional analgesia is highly
cost-effective, offers an excellent pain therapy and is well accepted by
patients.
P41
The effects of continuous ropivacaine 0.3% for peripheral
regional anesthesia compared to ropivacaine 0.2%
1José A. Aguirre, MD, MSc; 1Sandra Guzzella, cand. med.;
1
Prof. Alain Borgeat, MD
1Division of Anesthesiology, Balgrist University Hospital,
Forchstrasse 340, 8008 Zurich, CH
Objectives: Continuous regional anesthesia is clearly superior to
systemic analgesia after orthopedic surgery. However, the most effective
local anesthetic concentration for continuous regional anesthesia using
ropivacaine is still controversial.
Methods: In a retrospective study 200 postoperative orthopedic
patients with regional continuous anesthesia for 48 hours (interscalene,
infraclavicular, femoral and popliteal catheters) using ropivacaine
0.2% were compared with 200 postoperative orthopedic patients using
ropivacaine 0.3% for the same indications. Pain at rest and with motion,
analgesia demand, motor block duration and side effects were
compared.
Results: Ropivacaine 0.3% offers a better pain control reducing use
of additional analgesics and improving pain with motion. Motor block
duration was not significantly longer compared to ropivacaine 0.2%
32 S
and side effects of the different catheters were comparable between
the groups. Sensory block in both groups were comparable and the
incidence of stumbling or falling was not higher in the ropivacaine
0.3% group.
Conclusions: Continuous regional anesthesia using ropivacaine
0.3% offers better analgesia with movement compared with ropivacaine
0.2% without increasing motor and sensory block duration or side
effects. These results must be verified in further prospective randomized
studies.
P42
Evaluation of a modified coracoid approach
for the brachial plexus block
1José A. Aguirre, MD, MSc; 1Sandra Guzzella, cand. med.;
2
PD Georg Feigl, MD; 1Prof. Alain Borgeat, MD
1
Division of Anesthesiology, Balgrist University Hospital, Forchstrasse
340, 8008 Zurich, CH; 2Institute of Anatomy, Medical University of Graz,
Harrachgasse 21; 8010 Graz, Austria
Background: Different techniques have been described to perform a
neurostimulation-based brachial plexus block at the infraclavicular level.
However, the block of the musculocutaneous nerve is challenging and
often asks for a double stimulation technique. After a preliminary
anatomy study on 29 cadaver axilla, we developed a new technique
combining landmarks and the respective advantages of two established
techniques.
Methods: Forty patients scheduled for elective, monolateral hand
surgery are included and regional anesthesia is performed using the
modified coracoid approach (MC-). Twenty patients receive a single
shot block and twenty a catheter placement both using nerve
stimulation and sonographic control. Block quality (surgical anesthesia,
nerves blocked), technical feasibility, complications (vascular puncture,
pneumothorax) and patient satisfaction are evaluated. Twelve patients
of the catheter group receive an MRI to assess catheter tip placement
and local anesthetic spread.
Results: Preliminary results confirm a high success rate of 98% within
20 in the single shot and 97% in the catheter group. No technical
difficulties, no complications and an excellent patient satisfaction are
reported.
Conclusions: According to our preliminary anatomy and clinical results
the new modified coracoid approach offers an alternative for single shot
and catheter placement in the infraclavicular region using
neurostimulation.
P43
P44
Evolution of anaesthesia practice, demography and
complications in Switzerland: results of a 15-years
routine data collection
V. Pittet1, C. Perret1, V. Moret2, B. Burnand1, for the ADS Study Group1
1
Institute of Social & Preventive Medicine, Lausanne, Switzerland;
2Service of anaesthesiology, Lausanne, Switzerland
Background: Quality and safety in anaesthesiology request continuous
monitoring. Currently, anaesthesia is used more often in older, high risk
patients. Anaesthesia Database Switzerland (ADS) is a data registry
implemented in almost 25% of all Swiss hospitals. Its main goal is to
foster quality improvement by providing anaesthesia departments with
benchmark comparisons and incidents analysis. We present the
evolution of the anaesthetic practice in Switzerland for 1996–2010.
Methods: ADS includes three modules: 1) “Minimal data set” includes
basic anaesthesia- (type, chronology, operations, emergency) and
patient variables (age, gender, ASA index); 2) “Management and
techniques” gathers variables on operating rooms, supervisors,
anaesthesia techniques; 3) “Quality” gathers variables on per-/
post-anaesthesia incidents and their severity, and patients’
comorbidities. Each hospital is responsible for its data collection and
control. Anonymous data extracts are regularly sent to a data centre for
validation and analyses purposes.
Results: In 2010, 37 hospitals were participating in at least one module
and 21 were collecting data related to quality. Since 1996, a total of
2’158’735 anaesthetic procedures have been included in the central
database. Among the 1’739’794 documented procedures related to
surgery, 63% were general, 29% loco-regional and 8% combined
anaesthesia; about 19% of cases were emergencies. Among patients
receiving surgical anaesthesia, 53% were women, and mean age (SD)
was 48 (23). A linear increase in the percentage of patients‘ age was
observed over time > 50, with a maximum in the 50–64 category
(coefficient (c) = 0.49; p <0.001). Overall, 80% of patients had an ASA
score of 1 or 2; a linear decrease in the percentage of ASA 1 was
observed over time (c = –1.25; p <0.001) and an increase of ASA 2
(c = 0.842; p <0.001) or ASA 3 (c = 0.33; p <0.001). The prominent
comorbidities were hypertension (21%), allergy (15%), smoking (16%)
and obesity (12%). A total of 154’036 incidents were recorded between
1996 and 2010, among the 15% of all anaesthesia with a recorded
complication: 30% were cardiovascular, 6% respiratory, 32% specific to
anaesthesia and 18% general.
Conclusion: Trends in anaesthesia healthcare observed in Switzerland
over the last 15 years are: ageing of population receiving surgical
anaesthesia and an increase in the severity of pathologies. ADS enable
hospitals to monitor their own activity and allows benchmarking among
participants.
Inter-Professional Hybrid Simulation to teach nontechnical skills in the delivery room: A BeSiC Training
Program for Midwife Students and Anesthesia Residents
Th. Arnold*, M. Jordi*, I. Uhr#, R. Greif*
*Department of Anesthesiology and Pain Therapy, BeSiC – Bern
Simulation and CPR-Center, University Hospital Inselspital and
University of Bern, Switzerland; #Bern University of Applied Sciences,
Section Health, Bachelor of Science in Midwifery Program, Bern,
Switzerland
Introduction: Midwives and anesthetists work together during
pain-relief interventions in the delivery room. Despite different views
of the labor both professional groups are treating the same patient.
Cooperation and communication are based on a mutual understanding
of care for women giving birth. Despite proper skill training taught
separately by both institutions this inter-professional cooperation relying
mostly on non-technical skills (NTS) is rarely trained in that setting.
Therefore we developed a special inter-professional training program
for midwife students and anesthesia residents integrating simulated
patients (SP) and hybrid simulation for delivery room interventions.
Methods: With written informed consent, midwife students and
anesthesia residents participated in different scenarios (e.g. epidural
catheter placement for labor pain relief, anaphylactic reaction, high
epidural/ spinal analgesia, unilateral analgesia after intervention).
Midwives and obstetric anesthetists developed the cases based on
the needs of the learners. Needed special equipment like a pregnancy
simulator with the baby, a cardiotocograph, and an epidural puncture
training device were organized by their institutions. SP were trained to
act according to a predefined script. Teaching personnel acted as family
members or care givers during the scenarios. Anesthesia residents
punctured an epidural training set that was strapped on the back of
the SP covered by surgical drapes. The simulation room was furnished
similar to a local delivery room. All scenarios were videotaped for later
debriefing.
Results: The scenarios were judged as clinically relevant by both
professional groups and reflected daily practice. We were able to run the
developed scenarios according to the previously defined learning aims.
The anesthesia residents experienced the epidural hybrid simulator as
real. The video debriefing focused on NTS and increased awareness
about the different points of interests and views between the
participants. Discussions about ethics during life threatening situations
was broadened by the integration of the inside view of the SPs as the
women giving birth.
Conclusions: This special inter-professional training program was
applicable for different experienced learners, the SP-hybrid simulation
was technically feasible and easy to integrate in the common simulator
environment, and interdisciplinary discussions lead to deeper
understanding of the different professional attitudes.
33 S
P45
Differences and similarities in the assessment of a joint
task and its influence on communication and performance
in anesthesia teams
Dr. med. Gisin S., Affiliation1, Presenting Author, Dr. phil. Burtscher
M.J.2, Dr. Sevdalis N.3, Prof. Dr. Manser T.4, Prof. Dr. med. Ummenhofer
W.1, Prof. Dr. med. Scheidegger D.1
1Simulation Basel, Department of Anesthesia, University Hospital
Basel, Switzerland; 2Department of Psychology, University of Zurich,
Switzerland; 3Imperial College London, United Kingdom; 4Department
of Psychology, University of Fribourg, Switzerland
Induction: In the last decade several studies pointed out the
importance of teamwork for safe and efficient patient care (1).
Particularly communication plays an important role with regard to
teamwork. There was shown that 82% of errors occurring in anesthesia
can be attributed at least to some extent to misunderstanding and
deficient communication (2). A further study made the correlation
between information transfer and patient safety; the less information
transfer in surgical teams in the operation theatre was observed, the
higher was the probability for incidence of complications, morbidity and
even mortality (3). But it remains unclear which supporting measures
could have a positive impact on team-communication. Our study
investigated, if a common understanding for an assigned task (“shared
mental model”) can play a decisive role in this context. Therefore teams
of the anesthesia department of the University Hospital Basel, each
composed by an anesthesia resident and an anesthesia nurse, were
interrogated before and after accomplishment of a general anesthesia.
The two custom-designed questionnaires focused on teamwork and
coordination in anaesthesia, particularly during induction, with the aim
to identify factors for improvement in teamwork.
Methods: This study was approved by the Ethics Committee of Basel.
Our survey was conducted as a pre-/post correlation study with two
different measuring times. The first measurement point was before
starting induction of general anesthesia, the second after completion
of anesthesia and handing over the patient to the post anesthesia care
unit. The two questionnaires used for this study were specially designed
for our scientific objectives in cooperation with experts in psychology
and human factors. Statistical analyses was carried out using
regression analysis following the work by Crocker & Algina (1986).
Power analysis assessed the number of 48 teams as sufficient to
provide solid evidence for our research objectives.
Results: Data collection was completed in May 2012, but detailed
analysis is still in progress and will be finished by August 2012.
Nevertheless preliminary results indicate a positive correlation between
a common sense for the upcoming tasks and the quality of
communication (r = 0.51, p <0.01). Ongoing analyses shall clarify these
issues to further details and explore further coherences (e.g. perceived
pressure of work).
Summary: With our study we expect to show a correlation between
the degree of compliance in the assessment of a common task and
accurate communication. Therefore we just started with the analyses
of the pre and post questionnaires filled out by 48 mixed anesthesia
teams. As preliminary results suggest a positive correlation between
a common sense for the upcoming tasks and the quality of
communication, we are very much looking forward to further and more
detailed analysis to confirm these promising tendencies possibly till the
end of this summer.
References:
1 Burtscher MJ, et al. Managing non-routine events in anesthesia:
the role of adaptive coordination. Human Factors. 2010;52(2):282–94.
2 Cooper JB, et al. Preventable anesthesia mishaps: a study of human
factors. Quality and Safety in Health Care. 2002;11(3):277–82.
3 Mazzocco K, et al. Surgical team behaviors and patient outcomes.
Am J Surg. 2009;197(5):678–85.
P46
A Survey of Standardized Drug Syringe Label Use in
Anaesthesiology
N. Wickboldt1, F. Balzer2, J. Goncerut1, P.A. Michel3, S. Staender4,
R. Kinnaer5, W. Boemke2, M. Kastrup2, C. Spies2, B. Walder1
1
Division of Anaesthesiology, Department Anaesthesiology, Intensive
Care and Clinical Pharmacology, University Hospitals of Geneva,
Geneva, Switzerland; 2Department of Anaesthesiology and Surgical
Intensive Care, Charité, Universitymedicine Berlin, Berlin, Germany;
3
IT Administrator, Division of Anaesthesiology, University Hospitals of
Geneva, Geneva, Switzerland; 4Chairman, EBA/ESA patient safety task
force, Division of Anaesthesiology and Intensive Care, Hospital
Männedorf, Männedorf, Switzerland; 5IT Administrator, ESA Secretariat,
Brussels, Belgium
Introduction: The European Board of Anaesthesiology (EBA) and the
European Society of Anaesthesiology (ESA) patient safety task force
stated that drug errors are avoidable and impair patient safety.
Standardized drug syringe labelling (DSL) may reduce drug errors, but
data on DSL use in European anaesthesia departments are lacking.
Therefore, the primary aim of this survey was to investigate if
standardized DSL is used in European anaesthesia departments; and
if there are geographic, demographic and differences in hospitals
with and without use of DSL. Secondary aims were to determine
the currently used types of standards for DSL within Europe, the
standardized DSL for two specific drugs (insulin and norepinephrine),
and if users expect that standardized DSL should be delivered by the
pharmaceutical industry.
Methods: This investigation was supported by the Taskforce Patient
safety of EBA and ESA. A prospective survey was performed using a
structured, web-based, and anonymized questionnaire in English for
ESA members from 2nd February to 12th April 2011. Descriptive and
comparative analyses of users and non-users of standardized DSL
were performed.
Results: One-thousand-and-sixty-four of 4163 ESA members (25.6%)
from 72 countries participated, among whom 660 (62.0%) used
standardized DSL; in Northern and Western Europe were 428 (79.3%)
users of DSL and 112 (20.7%) non-users, in Southern and Eastern
Europe 184 (45.1%) users and 255 (54.9%) non-users (p <0.001).
Three-hundred-and-ninety-four (37.0%) respondents used standardized
DSL hospital-wide; 202 (30.1%) used ISO (International Organisation of
Standardization) based standardized DSL, 101 (15.1%) ISO-norm-like,
278 (41.5%) other systems and 89 (13.3%) manufactory delivered.
Label colour for insulin was reported as white or “none” in 519 (76.7%)
answers, another colour in 158 (23.3%). Label colour for norepinephrine
was reported as violet in 206 (30.4%) answers, white or “none” in 226
(33.3%), red in 114 (16.8%), another colour in 132 (19.5%). In favour of
a standardized DSL delivered by pharmaceutical industries were 819
(76.9%) respondents, against 227 (21.3%).
Conclusions: A majority of European anaesthesiology departments
applied standardized DSL, with significant regional differences and
mainly without following an international norm. Thus, there are options
for quality improvement in DSL via a potential for increased use of DSL
and for a homogeneous DSL in Europe.
P47
Controlled Rapid Sequence Induction –
An analysis of 1001 children
D. Neuhaus1, A. Schmitz1, A.C. Gerber1, M. Weiss1
1
Department of Anaesthesia, University Children’s Hospital,
Zürich, Switzerland
Introduction: Classical rapid sequence induction (RSI) with apnoea
prior to intubation and sellick manoeuvre puts paediatric patients at risk
for respiratory deterioration and traumatic intubation [1]. A controlled
RSI (cRSI) with gentle facemask ventilation prior to intubation and
omitting cricoid pressure seems to be a safer and more appropriate
approach in paediatric patients [2–4]. Aim of this study was to analyse
benefits and complications of cRSI in a thousand children.
Methods: Retrospective cohort analysis of all patients between 2007
and 2011 in a tertiary paediatric hospital undergoing cRSI according to
the standardized institutional protocol. By means of electronic patient
data management system vital sign data were reviewed for respiratory
parameters, intubation difficulties (Cormack and Lehane grade) as well
as adverse respiratory events during induction, intubation and further
course of anaesthesia.
Results: A total of 1001 patients with cRSI were analyzed. Moderate
hypoxaemia (SpO2 80–89%) during cRSI intubation occurred in 0.6%
(n = 6) and severe hypoxaemia (SpO2 <80%) in 0.3% (n = 3) of patients
(1.1 years (0.1–13.3), ASA 3 [1–4]). None of these patients developed
bradycardia. Gastric regurgitation without pulmonary aspiration was
reported in 0.1% of patients (n = 1). No pulmonary aspiration was
observed. Intubation (C/L° 1=85%, 2 = 11%, 3n = 0%, 4 = 0.1%) was
documented as “difficult” in 0.5% of patients (n = 5), two of them were
expected “difficult airways” and required fiberoptic intubation. Further
course of anaesthesia as well as respiratory conditions after extubation
did not reveal evidence for “silent aspiration” during cRSI.
Conclusion: Controlled RSI-intubation using gentle facemask
ventilation prior to intubation supports stable conditions for securing the
airway in children with a suspected full stomach without increasing the
risk for pulmonary aspiration.
1 Gencorelli, F.J., R.G. Fields, and R.S. Litman. Complications
during rapid sequence induction of general anaesthesia in children:
a benchmark study. Paediatr Anaesth. 2010;20(5):421–4.
34 S
2 Johr M. Anaesthesia for the child with a full stomach. Curr Opin
Anaesthesiol. 2007;20(3):201–3.
3 Weiss, M. and A.C. Gerber. Rapid sequence induction in children –
it’s not a matter of time! Paediatr Anaesth. 2008;18(2):97–9.
4 Becke, K. and J. Schmidt. Rapid Sequence Induction in Childhood.
Intensivmed Notfallmed Schmerzther. 2007;9:624–30.
P48
Pain and physical performance in adolescents:
A cross-sectional study in Swiss school children
I. Wilhelm1, T. Radtke2, M. Wilhelm2, U. Stamer1
1
Department of Anaesthesiology and Pain Medicine, University Hospital
Bern, Bern, Switzerland; 2Department of Cardiology, University Hospital
Bern, Bern, Switzerland
Introduction: The prevalence of chronic pain in adolescents is
increasing in industrialized countries. We examined the prevalence
of pain in Swiss school children to determine the impact of pain on
physical activity, performance and quality of life.
Methods: After ethic approval and parents’ written informed consent,
adolescents of a school in Olten participated in a study of
cardiovascular health. Pain was assessed by a standardized pain
questionnaire including the P-PDI (pediatric pain disability index). The
students were stratified into 3 groups according to their frequency of
pain. GI: no pain, GII: pain <1x/week, GIII: ≥ 1x/week pain. Physical
activity was recorded with an accelerometer for 8 days. Physical
performance was assessed by a spiroergometric test. Primary end
point was exercise capacity. Data were corrected for gender.
Results: 52 adolescents (14.5 ± 0.7 years, 28 girls) were enrolled. 43
questionnaires (83%) were returned, and 39 subjects with complete
data could be analyzed. The groups comprised of n = 12 in GI, n = 19 in
GII, and n = 12 in GIII, respectively. Thus, 31 students (72%), including
13 girls (42%), reported of regular episodes of pain. Body mass index
and pubertal status did not differ between the groups. Regular pain
medication was reported in 45% of adolescents. Location of major pain
was head in 42%, back in 32%, and abdomen and periphery in 13%,
respectively. Severity of major pain in the last 3 months was similar in
the groups GII and GIII (NRS 4.6 ± 1.4 vs. 5.3 ± 1.4; p = 0.163).
Compared to GII, in GIII, the impairment of daily life by pain in the last
3 months was significantly higher (P-PDI (median, IQR) 27.5 (6) vs. 17
(10); p = 0.002). This was especially apparent at school (p = 0.004) and
during unpleasant tasks (p = 0.02), less for hobbies, homework and
sports. The groups did not differ in physical activity (min/day: GI = 211 ±
36, GII = 204 ± 55; GIII = 197 ± 53). An increase in frequency of pain
was associated with a decrease in exercise capacity (watt/lean body
mass: GI = 5.1 ± 0.4, GII = 4.7 ± 0.6; GIII = 4.4 ± 0.6; p = 0.04).
Conclusions: Pain is a common problem in adolescents. Pain
frequency and localization are comparable with international crosssectional studies. A new aspect of this study is the association of pain
with a reduced exercise capacity in otherwise healthy school children.
Thus, early diagnosis and therapy are useful in order to prevent
chronicity.
P49
Does the pre-anesthetic consultation effectively
reduce parental and children’s anxiety?
J. Scemama-Clergue1, C. Osso1, N. Favez1, W. Habre1
1
HUG, Genève, Switzerland; 2Université de Genève,
Faculté de Psychologie, Genève, Switzerland
Introduction: Children’s anxiety is often linked to parental anxiety
and has been shown to promote negative post-operative outcomes.
Induction of anesthesia is known to be the most stressful moment
during the preoperative period. Although pre-anesthetic consultation
(PAC) has been advocated as an important step in the management of
anxiety in children and parents, it has not yet been shown as effective in
reducing parental and children’s anxiety. Our research explores parental
and children’s anxiety before and after the PAC as well as an index of
preoperative anxiety.
Methods: Following Ethics committee approval and parental/children’s
informed consent, we included 48 children aged 6 to 12 yrs and
scheduled for elective outpatient surgery. Prior to the consultation, a
psychologist assessed parental anxiety with the Faces Pain ScaleRevised (FPS-pre) and conducted a semi-structured interview with the
children in addition to the evaluation of the degree of anxiety by the
mean of two well validated tools: the Venham Picture Test (VPT-pre) and
a Visual Analog Scale (VAS-pre). The same assessment took place
after the PAC both in parents (FPS-post) and children (VPT-post and
VAS-post). In order to assess the effect of the PAC on the stress
induced by anesthesia induction, children were also asked to evaluate
on a VAS their anxiety in the case surgery would have to take
immediately after the PAC (VAS-now). Nonparametric analyses were
performed using Wilcoxon paired test for comparisons within groups
and Mann-Whitney test for comparisons between groups.
Results: A good correlation was observed between parental and
children’s anxiety after the PAC and between FPS-post and VAS-now
values (p <0.01). PAC had a significant effect on parental anxiety with a
significant decrease in FPS scores following the consultation (p <0.01).
In children, there was a discrepancy between the tools used to assess
their anxiety with VAS decreasing significantly after PAC (p <0.001)
while no change was observed when using the VPT scores. Their
semi-structured interview revealed that the VAS-pre scores were
predicted by the expression of a pre-consultation fear (p <0.001.
Interestingly, the anxiety expressed by the VAS-now was significantly
higher than both VAS-pre and VAS-post values (p = 0.002 and p <0.001,
respectively).
Conclusion: Our results demonstrate that despite a reduction in
parenta.
P50
Anesthesiologist’s medical experience does not affect
the effectiveness of the preoperative anesthetic consultation
on parents’ and children’s anxiety
J. Scemama-Clergue, C. Osso, N. Favez, W. Habre
Introduction: Induction of anesthesia is the most stressful moment for
a child in the preoperative period. Thus, pre-operative interventions
such as the pre-anesthetic consultation should aim at reducing anxiety
related to this moment. We investigated whether more experienced
anesthesiologists would be more effective than Registrars in alleviating
preoperative anxiety in children and parents after the pre-anesthetic
consultation (PAC).
Methods: After approval by our Institutional ethics committee and
obtaining parents’ and children’s consent, we evaluated children’s and
parental anxiety in 48 consecutive PAC including children aged 6 to 12
yrs scheduled for outpatient surgery. 26 PAC were held by Registrars,
13 by Consultant registrars and 9 by Senior anesthetists. Parental
anxiety was assessed by the Faces Pain Scale-Revised (FSP) before
and after PAC. In children, anxiety was evaluated using the Venham
Picture Test (VPT) and s Visual Analog Scale (VAS-pre and VAS-post).
In addition, after the PAC, children were asked to evaluate on a VAS
their anxiety in the case surgery would have to take place now
(VAS-now) as an indication for their preoperative anxiety. Comparison
between groups was made using the Kruskall-Wallis test.
Results: There was a discrepancy between the VAS and the VPT
scores in detecting the reduction in children’s anxiety. However, PAC led
to a significant decrease both in parents’ (p <0.01) and children’s anxiety
(evaluated by the VAS, p <0.001). When looking at the level of
experience, our results showed a significant decrease in children’s
anxiety only in the Registrars group, when evaluated by the VAS
(p = 0.002) despite a longer consultation in the Consultant group. In this
latter group, there was a trend towards a decrease in children’s anxiety,
both when measured by the VAS (p = 0.057) and the VPT (p = 0.054).
Interestingly, the Registrars failed to reduce VAS-now even in children
who decreased their anxiety after PAC. We were able to detect a
significant decrease in parental anxiety in the Registrars and the
Consultants groups if the needs of the parents were considered as an
independent variable.
Conclusion: Unexpectedly, Registrars were the more efficient in
decreasing children’s anxiety after PAC. However, only the most
experienced anesthesiologists achieved a reduction of the anxiety
linked to the fear of surgery in children. No difference in parental
reduction of anxiety was observed between the three groups of
anesthesiologists.
P51
Changes in respiratory mechanics following surgical
repair of mitral valve insufficiency in children
I. Malaspinas1, A.L. Martin1, A. Perrin2, M. Beghetti1, F. Petak3,
W. Habre1
1
University Hospital of Geneva, Geneva, Switzerland; 2Medical School,
University of Geneva, Geneva, Switzerland; 3University of Szeged,
Szeged, Hungary
Rationale: Postcapillary pulmonary hypertension (PHT) such as
observed with mitral valve insufficiency (MVI) is associated with lung
function impairment. We assessed airway resistance (Raw) and total
respiratory elastance (Ers) before and after surgical repair of MVI in
35 S
children to verify whether vascular engorgement is responsible for
the increase in airway tone and stiffness of the respiratory tissues.
Methods: The input impedance of the respiratory system during
spontaneous breathing was measured in 16 children, aged 12.3 ± 2.5
years (mean ± SD), with congenital or post rheumatic mitral valve
insufficiency preoperatively, and within 5 days and 3 weeks after mitral
valve repair surgery. Raw was estimated by calculating the average
resistance values between 4 and 26 Hz, while Ers was assessed from
the respiratory reactance data by model fitting.
Preliminary results: Raw decreased significantly 5 days after the
surgery (5.5 ± 1.6 to 4.3 ± 1.0 cmH2O.s/l, p <0.001). It remained lowered
3 weeks later in 8 children (4.5 ± 1.4 cmH2O.s/l, p = 0.003). Conversely,
Ers exhibited no significant changes postoperatively (70 ± 10, 58 ±
6 and 77 ± 9 cmH2O/l, before and 5 and 21 days after the surgery,
respectively, p = 0.4)
Conclusions: Decreasing vascular engorgement after surgical
reparation of MVI in children results in a fast and sustained
improvement in airway function. The lack of concomitant beneficial
changes in the Ers suggests that mechanical interdependence between
the airways and pulmonary vasculature is responsible for this finding.
Supported by SNSF grant 3200B0-118231
P52
P53
Interdisciplinary Management of an Openly Ruptured
Iliac Artery Aneurysm – a case report
S. Krebs1, L. Theiler1, M. Kleine Brueggeney1, R. Greif1,
A. Stellmes2, N. Urwyler1
1Department of Anesthesiology and Pain Therapy, University
Hospital of Bern, Bern, Switzerland; 2Department of Cardiovascular
Surgery, University Hospital of Bern, Bern, Switzerland
Introduction: The reported mortality rate for patients who undergo
surgery for ruptured iliac artery aneurysm is about 70%. Survival
depends on correct clinical assessment and immediate action of
all involved practitioners from different disciplines. This case report
describes such a collaboration on one patient who survived an openly
ruptured iliac artery aneurysm without subsequent disabilities.
Case Report: The prehospital emergency physician found a conscious,
pale 68-year-old male patient in hypovolemic shock and made the
clinical diagnosis of a ruptured abdominal aneurysm. The patient
was transported by helicopter to the University-based Emergency
Department (ED) where an abdominal sonogram was performed,
confirming the prehospital emergency physician’s clinical diagnosis.
Due to the deterioration of the patient the team in the ED decided to
waive further diagnostics, called the vascular surgeon and rushed to
the operating room. The anesthesiologist expected the patient to go into
cardiac arrest either with the induction of anesthesia or with laparotomy,
therefore actions of everyone present were quickly reviewed and
coordinated during the team briefing in advance of the start of the
procedure. After induction of anesthesia, laparotomy showed a gushing
arterial bleeding and the patient went into pulseless electrical activity
(PEA). The team immediately and effectively resuscitated the patient
as previously planned. The surgeon was able to clamp the abdominal
aorta. The patient lost about 6L of blood but could be stabilized with
blood products. A Y-prosthesis was placed infrarenally onto the ruptured
iliac artery. After surgery the patient was admitted to ICU and was
extubated 15 hours after leaving the operating room. He showed no
neurologic impairment and left the hospital 8 days after surgery without
having any other complications.
Discussion: The correct diagnosis of a ruptured abdominal aneurysm
by the prehospital emergency physician led to a fast response by the
in-hospital team. The rapidly deteriorating patient condition led us to
waive further diagnostic procedures in order to save the patient’s life. A
briefing prior to surgery established good communications between the
anesthesia and surgical teams and a plan for resuscitation, resulting in
immediate, successful resuscitation when the patient went into PEA.
This patient survived without disabilities due to a correct clinical
diagnosis and good premeditated teamwork.
Thrombelastography in traumatic placental abruption with
Disseminated Intravascular Coagulation – a case report
Jakobea Benz-Wörner1, Romedi Benz1, Anita Gähler2,
Christoph Haberthür1, Christoph Konrad1
1Klinik für Anästhesie, chirurgische Intensivmedizin, Rettungsmedizin
und Schmerztherapie, Luzerner Kantonsspital, 6000 Luzern 16,
Schweiz; 2Hämatologisches Zentrallabor und Abteilung Hämatologie,
Luzerner Kantonsspital, 6000 Luzern 16, Schweiz
Case Report:
Introduction: With a foetal mortality of up to 75% and a maternal one
of 1%, the traumatic placental abruption is a severe emergency [1]. The
serious consequences of this disease – massive intrauterine bleeding
and Disseminated intravascular Coagulopathy (DIC) – need to be
recognized and treated immediately. Thrombelastography provides a
rapid assistance in differential diagnosis and goal directed treatment.
Method: We report the case of a pregnant women involved in a
car-crash presenting with traumatic placental abruption in the 26th week
of gestation. Due to foetal impairment an urgent caesarean section was
performed. Blood loss was moderate but followed by oozing bleeding.
Thrombelastography was implemented to help in the differentiation
of depletional coagulopathy from DIC, to focus the application of
coagulation products and to monitor their effect.
Results: Thrombelastography showed a massive depletion of
fibrinogen and coagulation factors (s. fig. 2). In the situation of moderate
blood loss and stable hemodynamic parameters, DIC was suspected
[2]. Conventional laboratory findings analysed by international scores
confirmed later on the diagnosis of DIC. Immediately a target oriented
treatment with 4 g of fibrinogen, 1250 IE factor XIII, 2000IE PPSB
(factor II, VII, IX, X) and administration of 2 g of tranexamic acid to
36 S
prevent hyperfibrinolysis was applied. Thanks to the elimination of the
trigger factors of DIC by the removal of placenta and amniotic fluid and
thanks to the fast correction of coagulation deficits, the oozing bleeding
stopped and the thrombelastographic control showed a stabilization
of coagulation parameters.
Conclusion: DIC leads to rapid and massive deficits in coagulation
that are assessed with important delay by standard laboratory exams.
Thrombelastography records the time dependant course of clot
formation and stabilisation (s. fig. 1). These characteristics are of great
help for rapid differential diagnosis and focused treatment of
thrombocytopenia, hypofibrinogenemia, coagulation factor deficits and
hyperfibrinolysis [3].
Bibliography
1 Hall D. Abruptio placentae and disseminated intravascular
coagulopathy. Semin Perinatol. 2009;33:189–95.
2 Heindl B. (2008) Gerinnungsmanagement beim perioperativen
Blutungsnotfall. UNI-MED Verlag AG, Bremen.
3 Sharma P. A novel thromboelastographic score to identify overt
disseminated intravascular coagulation resulting in a hypocoagulable
state. Am J Clin Pathol 2010;134:97–102.
P54
Exchange transfusion as an adjunctive therapy in severe,
complicated Malaria – a Case Report
Babic Daniela1, Klarer Alexander2, Arn Kornelius3, Yuen Bernd1
1
Interdisciplinary Intensive Care Unit, Hospital Bülach, 8180 Bülach;
2
Medical Intensive Care Unit, University Hospital Zürich, 8091 Zürich;
3
Division of hematology, University Hospital Zürich, 8091 Zürich
Introduction: Malaria is a leading infectious disease worldwide, with
Plasmodium falciparum as the one species with the potential for rapidly
progressive severe disease. Severe malaria is associated with multiple
organ dysfunction and goes along with significant morbidity and
mortality. The most important therapy in severe malaria is immediate
initiation of parenteral treatment. Exchange transfusion (ET) as
adjunctive therapy must be considered in patients with parasitemia
higher than 10% or if complications such as cerebral malaria, diffuse
intravascular coagulation, ARDS or acute renal failure occur.
Case report: A 68 year-old caucasian woman turned unconscious,
hypotonic and cyanotic on a flight from Mombasa (Kenia) to Zurich. On
physical examination in the emergency departement the patient was
markedly somnolent and febrile with a temperature of 38.7 °C. She
was in distributive shock with a blood pressure of 70/46 mm Hg and
a heart rate of 130/min. Her oxygen saturation while breathing 10 lt/
minute of oxygen was 86%. She had petechiae over both lower legs
and an obvious meningism. Blood gases and laboratory tests showed
a metabolic acidosis (pH 7.27, BE –19.3 mmol/l, Lactate 9.9 mmol/l),
a renal insufficiency (Creatinine 431 μmol/l), thrombocytopenia and
hypoglycaemia. The peripheral blood smear showed numerous
intraerythrocytic ring forms of P. falciparum and the parasitemia was
37 S
quantified at 37%. According to the clinical findings and investigations
the diagnosis of severe and complicated malaria with organ involvement
and shock was made. The patient was initially treated with quininehydrochloride and clindamycin. Given the concerning neurologic status
and very high parasitemia, ET was considered, so that the patient
was transferred to the University hospital of Zurich, where a therapy
with parenteral artesunate and doxycycline was initiated. Because of
persistently high parasitemia a single exchange transfusion (1.0 of total
patient’s blood volume) was performed. The post procedure parasitemia
was reduced to 5% and became undetectable under continuing drug
therapy. After three weeks of intensive care treatment the clinical course
finally was favourable with full recovery of the patient.
Conclusion: Timely recognition and initiation of appropriate parenteral
antimalarial treatment is crucial. Exchange transfusion for a more rapid
parasite clearance may be associated with a beneficial effect on
survival in severe malaria. Therefore, we suggest that clinicians should
consider ET as a adjunct therapy in severe malaria, although data of
prospective, randomized trials are lacking.
P55
A wolf in sheep’s clothing: Panton-Valentine leukocidin
positive Staphylococcus aureus Sepsis
Chr. Caduff1, B. Eberle1, B. Preiswerk2, A. Weber3, M. Maggiorinr1
1Medical Intensive Care Unit, University Hospital of Zurich, Zurich,
Switzerland; 2Division of Infectious Diseases and Hospital
Epidemiology, University Hospital of Zurich, Zurich, Switzerland;
3Institute of Surgical Pathology, University Hospital of Zurich, Zurich,
Switzerland
Introduction: Sepsis by Panton-Valentine leukocidin (PVL)-secreting
Staphylococcus aureus (S. aureus) is an infection with severe morbidity
and high mortality. We present two surviving patients in order to
sensitize for this highly lethal infection.
Case: The first patient was a 51-year old man, who was treated for
a arthritis of the left knee due to a Methicillin-susceptible (MSSA)
S. aureus. He developed a septic shock, ARDS, multiple lung
abscesses and severe pyomyositis of all 4 extremities needing surgical
debridement. The second patient was a 53-year old diabetic man with
an influenza-like syndrome presented with a community-acquired
pneumonia due to a Methicillin-resistant (MRSA) S. aureus. The
patient developed a septic shock, ARDS and severe microcirculationdisturbance with necrosis of both feet, which needed amputation. In
both patients the blood cultures revealed a S. aureus. The PCR assays
detected Panton-Valentine leukocidin toxin genes in the MSSA and the
MRSA. They were successfully treated with antitoxin antibiotics and
by veno-venous extracorporeal membrane oxygenation (ECMO) for
several days because of severe ARDS.
Discussion: Infection with PVL-secreting S. aureus is rare and mainly
affects healthy children and young adults. S. aureus harbors many
virulence factors. One of these factors is the PVL toxin, which acts as
an exotoxin that causes leukocyte destruction and tissue necrosis
explaining the course of disease in affected patients. Interestingly, the
two patients presented were older and they showed a different course
of disease. The second patient showed the typical course of disease
starting with influenza-like symptoms rapidly followed by septic shock
and severe respiratory failure, whereas the first patients presentation
with pyomyositis was atypical for PVL-secreting S. aureus. To our
knowledge, there is only one case report in the literature with severe
pyomyositis caused by PVL-secreting S. aureus.
Conclusion: Patients in severe septic shock in whom S. aureus is
considered as a possible infective agent, it is important to identify
PVL-secreting strains and include antitoxin antibiotics in the initial
empirical treatment and cover MRSA in patients at risk. Veno-venous
ECMO assured oxygenation in this multi-organ failure setting.
P56
Elevated ScvO2 – not always an indicator of
distributive shock
D. Franzen1, K. Auinger1, M. Maggiorini1
1
University Hospital, Medical ICU, Zurich, Switzerland
Background: ScvO2 measurement is recommended to estimate
patient’s oxygen delivery (DO2) in septic shock. However its value is still
debated. ScvO2 is an estimate of oxygen extraction (O2E) and depends
upon DO2 and oxygen consumption (VO2). We present a case with
sepsis and an unexpected high ScvO2.
Case report: An 84 year old male with known metformin treated
diabetes type 2 and newly diagnosed bullous pemphigoid developed a
septic shock due to an infected hip prosthesis. ScvO2 and arterial O2
saturation was 95% and 96%, respectively. The patient was oligo-anuric
and serum creatinin was 300 µmol/l. Arterial blood gas analysis
revealed compensated lactic acidosis (pH 7.37, pCO2 3.21 kPa, HCO3
– 13.7 mmol/l, Lactate 7.0 mmol/l). During the following 24 hours, lactate
plasma levels normalized, but the ScvO2 remained unchanged.
Echocardiography showed a LV-EF of 35%, a systolic pulmonary artery
pressure of 48 mm Hg, a normal function of a slightly hypertrophic right
ventricle and no evidence for a right-left shunt. Metformin plasma level
was 4.45 ng/l (normal <1). Malposition of the central-venous (CV-)
catheter was excluded by the recording of a formal correct CV-pressure
curve. In this setting, excessively elevated ScvO2 could be either due
to a distributive shock, an impaired mitochondrial respiration with
abnormally low VO2 in metformin-induced lactic acidosis or an
anomalous termination of pulmonary veins into the superior vena cava
(SVC). Using a pulmonary artery catheter (PAC), venous oxygen
saturation was measured in the high SVC, inferior vena cava, right
atrium and pulmonary artery. The oximetry run revealed a significant
step-up of the oxygen saturation in the middle SVC. VO2, DO2 and O2E
were 456 ml/min, 1312 ml/min, and 35%, respectively. The diagnosis
of a partial anomalous pulmonary venous return of the right upper
pulmonary vein into SVC was made. Unfortunately, the patient died two
days later because of the septic shock. At autopsy, our clinical diagnosis
of anomalous insertion of the right pulmonary veins into SVC was
confirmed.
Conclusion: ScvO2 >90% is likely caused by anomalous termination
of pulmonary veins into the SVC. However, distributive shock and/or
depressed VO2 following metformin intoxication may have contributed
to lactic acidosis in our patient. A PAC or imaging techniques are of
value establishing the correct diagnosis.
P57
Implantation of veno-venous extracorporeal membrane
oxygenation (ECMO) to enable interhospital transfer of
a patient with severe acute respiratory distress syndrome
(ARDS)
Schaer C.1, Klarer A.2, Starck C.3, Yuen B.1
1Interdisciplinary Intensive Care Unit, Hospital Bülach; 2Medical
Intensive Care Unit and 3Division of Cardiac and Vascular Surgery,
University Hospital Zürich, Switzerland
Case report: A 41-year-old woman presented at our emergency
department with constant left flank pain. She was diagnosed with
pyelonephritis due to a proximal 4 mm ureteral stone. After two days she
developed sever urosepsis and secondary ARDS and was transferred
to the intensive care unit (ICU). At first, oxygen saturation could be
maintained with nasal oxygen delivery. Within the following 16 hours,
oxygen content had to be increased continuously and 18 hours after
ICU admission endotracheal intubation was necessary because of
refractory hypoxemic and hypercapnic respiratory failure. Mechanical
ventilation was difficult because of severely limited pulmonary
compliance. Despite optimization of the ventilator settings lung
protective ventilation could not be achieved within twelve hours after
intubation and we planned to refer our patient to a tertiary ECMO
centre. It was foreseen to transfer her by air ambulance (REGA) but
the air transportation had to be cancelled because it was impossible
to oxygenate and ventilate the patient sufficiently with the transport
ventilator of the air ambulance. The heart surgery team (cardiac
surgeon and perfusionist) of the tertiary care hospital was called in to
install a veno-venous ECMO at our institution. Within 90 minutes the
heart surgery team arrived and the ECMO was successfully installed
so that the patient could safely be transported by road to the tertiary
centre. Our patient remained on ECMO for seven days and was
extubated after 11 days. She fully recovered from the ARDS and was
sent to a rehabilitation centre.
Conclusion: Conventional transportation, either by air or by road, of
instable ARDS patients may not always be safely possible. In such
cases ECMO implantation should be considered as a means of
enabling safe transportation. A 5-year experience of ECMOimplantation at the referral hospital showed that use of veno-venous
ECMO enables safe road transportation of severe ARDS patients to
tertiary care institutions with a very low rate of complications. This mode
of transport allows more advanced care of these patients and probably
may even improve survival [1]. Our case shows that an ECMO can
successfully be implanted at a referring regional hospital and the patient
then safely transported even by road.
1 Isgrò S, et al. Extracorporeal membrane oxygenation for interhospital
transfer of severe acute respiratory distress syndrome patients: a 5-year
experience. Int J Artif Organs 2011;34(11):1052–60.
38 S
P58
P60
A rare cause of acute respiratory failure
H.L. Lederer1, K.A. Auinger1, M.M. Maggiorini1
1
Universitätsspital Zürich, Zürich, Switzerland
Background: Since acute respiratory failure is frequent in the ICU, rare
causes may be missed. Potassium is an important intracellular cation.
Na+, K+- ATPase pump actively regulates the ratio of intracellular (IC)
to extracellular (EC) potassium concentration which determines the
resting membrane potential. This is fundamental for normal
neuromuscular function. In hypokalemia, an increased IC potassium/EC
potassium quotient leads to reduced electrical excitability which can
cause acute respiratory failure due to muscle paralysis if severe
enough. We present a case of acute respiratory failure in conjunction
with hypokalemic tetra paresis due to Gitelman Syndrome. Gitelman
syndrome is an autosomal recessive genetic disorder with mutations
in the Na-Cl-cotransporter gene in the distal tubule. It causes volume
deficit with hypotension, potassium and magnesium wasting and
metabolic alkalosis associated with secondary hyperaldosteronism.
Case report: A 35 year-old caucasian man was diagnosed with
Gitelman Syndrome in 2005. Despite appropriate therapy with
spironolactone and oral substitution of electrolytes he was repeatedly
admitted because of worsening hypokalemia with general weakness.
Aggravating factors so far were alimentary changes and diarrhea.
Currently he was admitted with almost complete paralysis that led to
respiratory failure after he was prescribed 500 mg of steroids
(Prednisone) by a neurologist to treat symptoms that resembled a flare
of multiple sclerosis. Laboratory analysis on admission revealed severe
hypokalemia of 1.3 mmol/L (3.3–4.5 mmol/L) and hypophosphatemia of
0.17 mmol/L (0.87–1.45 mmol/L), the electrocardiogram (ECG) showed
the classical signs of severe hypokalemia. Arterial blood gas analysis
showed a paO2 of 7.36 kPa and a pCO2 of 6.37 kPa. Respiratory failure
due to involvement of the respiratory muscles and subsequently
hypoventilation had to be treated with noninvasive ventilation. With
substitution of potassium, phosphate and magnesium his potassium
levels raised and his neurological symptoms completely resolved within
hours.
Conclusion: Extensive hypokalemia as a consequence of an
underlying congenital defect can lead to acute but transient tetra paresis
and hypoventilation leading to acute respiratory failure. Non-invasive
mechanical ventilation revealed useful as a bridge to symptoms
resolution.
Plasmacortisol zur Diagnose einer relativen
Nebennierenrindeninsuffizienz?
K. Wollmann1, C. Conrad1, U. Denzler1, B. Schmid1, R. Savoca1
1Universitätsspital Zürich, Zürich, Switzerland; 2Spitäler Schaffhausen,
Schaffhausen, Switzerland
Einleitung: Eine relative Nebennierenrindeninsuffizienz (NNRI) geht
mit einem nicht adäquaten Anstieg des Plasmacortisols relativ zur
Krankheitsschwere einher. Untersuchungen haben gezeigt, dass das
Plasmacortisol bei schwersten Erkrankungen meist über 690 nmol/l
liegt. Demzufolge wurde dieser Grenzwert zur Diagnose einer relativen
NNRI vorgeschlagen. Diese Arbeit überprüft das Plasmacortisol
hinsichtlich seiner diagnostischen Aussagekraft in Bezug auf diesen
Grenzwert bei relativer NNRI.
Methoden: Plasmacortisol wurde prospektiv bei 80 Patienten der
interdisziplinären Intensivstation des Kantonspitals Schaffhausen
erfasst, die dort im Zeitraum von Januar 2010 bis Juni 2011
hospitalisiert waren. Alle Patienten waren aufgrund des klinischen
Verdachts auf eine relative NNRI mit Hydrocortison gemäss den
aktuellen Leitlinien behandelt worden. Als klinische Kriterien einer
relativen NNRI galten ein therapierefraktärer Schock mit erhöhtem
Katecholaminbedarf und starker Plusbilanz. Gemäss dem
Plasmacortisol wurden die Patienten in 2 Gruppen aufgeteilt, eine mit
Plasmacortisol >= 690 nmol/l und eine mit <690 nmol/l. Anhand dieser
beiden Gruppen wurde verglichen, ob sich ein Unterschied im
Behandlungserfolg bei relativer NNRI zeigte.
Resultate: Aufgrund des Plasmacortisols wurden 13 Patienten in die
Gruppe >= 690 nmol/l und 67 Patienten in die Gruppe <690 nmol/l
eingeteilt. Hinsichtlich des Therapieerfolges mit Hydrocortison zeigte
sich in beiden Gruppen eine hoch signifikante Besserung der klinischen
Parameter einer relativen NNRI. Zudem konnte gezeigt werden, dass
der SAPS-Score als auch der anfängliche Katecholaminbedarf in der
Gruppe >= 690 nmol/l signifikant höher waren als in der Gruppe mit
niedrigen Cortisolwerten waren.
Schlussfolgerung: Beide Gruppen verbessern sich signifikant nach
Cortisol-Gabe. Im Gegensatz zur Literatur, profitierten auch die
Patienten mit einem Cortisolwerte >= 690 nmol/l. Diese Resultate
könnten auf einem pharmakologischen Cortisol-Effekt, unabhängig von
einer NNRI, einem Spontanverlauf oder einem fehlenden cut-off des
Serumcortisols beruhen. Die Kriterien zur Erkennung einer relativen
NNRI bleiben somit weiterhin unklar und bedürfen weiterer Studien.
P59
A rare non-pulmonary infection with Legionella
pneumophila
S. Hermatschweiler1, Y. Achermann1, C. Colombo1, A. Bürgel1,
G. Senn1, L. Aceto1, S. Jacobs1, D. Bettex1, H. Sax1, A. Rudiger1
1University Hospital Zurich, Zurich, Switzerland
Introduction: Legionella-induced pneumonia is a common finding, but
reports of non-pulmonary infections are rare. We describe herein the
first case of a hospital-acquired, biopsy-proven Legionella pneumophila
infection causing sternal wound infection, cellulitis, and an abscess in
the same patient.
Case report: A 71-year old male presented with an aortic dissection
type A. He underwent emergency replacement of the supracoronary
ascending aorta. One week after initial surgery he was transferred to
another hospital, where a sternal wound infection was diagnosed. After
readmission to our hospital, antibiotic treatment was empirically
changed to imipenem, vancomycin and clindamycin. Revision surgery
confirmed a severe mediastinitis with a left flank cellulitis and abscess.
Because of negative sternal tissue cultures, a broad-range PCR was
performed revealing Legionella pneumophila. Legionella urine antigen
and specific PCR from other sternal and abdominal samples but not
from respiratory secretions were positive. Cultures grew Legionella
pneumophila serogroup 1. The patient fully recovered after 6 months of
antibiotic treatment with rifampicin and levofloxacin. Our postoperative
wound management includes wound covering with a transparent
dressing (OpSite; Smith & Nephew), which is normally left unchanged
for 5 days postoperatively. Antiseptic single-use wipes (Octenisan,
Schülke & Mayr) are used for skin hygiene. According to nurse
documentation, the dressings in this particular patient had to be
changed several times during the first 7 days because of excess wound
secretions. Repeated Legionella cultures in the ICU (hot water and
aerator swabs) remained negative. Therefore, the hypothesis of tab
water transmitted infection could not be confirmed in this case.
Conclusions: This rare case of non-pulmonary postoperative wound
infection with L. pneumophila sg 1 is the first documented nosocomial
legionellosis in our hospital since 2005. Importantly, a single case of
non-pulmonary legionellosis warrants instant investigations.
P61
Uncalibrated pulse contour cardiac output measurement
devices overestimate effective cardiac output
K. Auinger1, M. Hilty1, Ch. Caduff1, F. auf der Maur1,
E.-M. Kleinert1, M. Maggiorini1
Introduction: The measurement of cardiac output (CO) in the
hemodynamic unstable critically ill patient is recommended to guide
therapy. Uncalibrated cardiac output measurement devices, because
minimally invasive, are increasingly advertised. The aim of our study
was to test accuracy of uncalibrated devices in the critically ill patient.
Methods: A LiDCO-rapid (LR) and a PulsioFlex (PF) cardiac output
monitoring device was simultaneously connected to the arterial line
of 10 hemodynamically unstable patients monitored with a continous
CO (CCO) pulmonary artery catheter. Both systems allow manual
calibration of the pulse-contour algorithm assessed CO. After 3
simultaneously recorded CO values, 30 min apart each, both systems
were calibrated with the CO value shown by the CCO-device. Thereafter
hemodynamic values were recorded after 5 minutes, 1, 5 and 10 hours.
Accuracy of both systems was assessed using non-parametric statistic
tests.
Results: Baseline hemodynamics (mean ± SD) of the 10 patients were:
heart rate 91 ± 25 bpm, mean arterial pressure 77 ± 7 mm Hg, pulse
pressure 55 ± 13 mm Hg, CCO 6.4 ± 2.6 l/min and CCO-stroke volume
70 ± 18 ml. Before calibration the CO value indicated by the LR was on
average 8.9 ± 4.9 l/min (p = 0.02 vs CCO) and by the PF was 7.6 ± 3.4
l/min (p = 0.11 vs. CCO). Five minutes and 1, 5 and 10 hours after
calibration the CO values indicated by the LR and the PF differed from
the CCO by 0.09 ± 0.46, 0.13 ± 1.00, 0.09 ± 0.95, 0.03 ± 0.82 l/min
(p = 0.66) and 0.04 ± 0.55, 0.22 ± 1.00, 0.38 ± 0.98, 0.03 ± 0.95 l/min
(p = 0.81), respectively. Although before calibration PP was almost
identical between LR, PF and CCO, LR indicated a SV of 94 ± 25 ml
(p = 0.03 vs CCO) and PF a SV of 81 ± 21 (p = 0.11 vs CCO). Before
calibration the correlation coefficient between LR and CCO and PF and
CCO was r = 0.77 (p = 0.01) and r = 0.73 (p = 0.02) respectively.
39 S
Conclusions: The results of our study indicate that assessment of CO
and SV by uncalibrated pulse contour CO measurement devices
overestimates real cardiac output by 20–30%. However after calibration
they correctly reflect effective CO without need of recalibration for up to
10 hours. Thus calibration of pulse contour CO measurement devices is
warranted.
P62
Preoperative platelet aggregation inhibition due to aspirin
therapy: an exploratory prospective study
L. Theiler2, C. Stave3, J.L. Zehnder1, M. Kleine Brueggeney2,
N. Urwyler1
1
Department of Pathology, Stanford University School of Medicine,
Stanford, CA, USA, Stanford, United States; 2Department of
Anesthesiology, University Hospital of Bern, Bern, Switzerland, Bern,
Switzerland; 3Lane Medical Library & Knowledge Management Center,
Stanford University School of Medicine, Stanford, CA, USA, Stanford,
United States; 4Department of Anesthesiology, University of Miami,
School of Medicine, Miami, FL, USA, Miami, United States
Background: Although patients suffering from cardiovascular disease
are commonly treated with aspirin, actual measured platelet function in
patients on aspirin therapy remains mostly ignored in the published
literature. Recent studies analyzing information taken from patients’
medical records have shown a benefit if aspirin is not discontinued
preoperatively. However, it is not clear whether data on aspirin therapy
taken from patients’ medical records accurately reflect platelet
aggregation inhibition.
Methods: In this exploratory observational study on a small number of
patients we compared assumed platelet aggregation inhibition due to
aspirin therapy as reported in the medical records to actual measured
platelet function. We measured preoperative platelet function using a
point-of-care platelet function analyzer (Multiplate® Verum Diagnostica
GmbH, Munich, Germany) in 39 patients undergoing cardic surgery.
Results: Information retrieved from the medical record on aspirin
therapy and the assumed presence or absence of platelet aggregation
inhibition was inaccurate in 14 out of 39 cases (36%). Of the 30 patients
on aspirin only 21 (70%) showed a therapeutic level of platelet
aggregation inhibition. Significantly more patients showed a therapeutic
effect if aspirin was discontinued 0–1 day preoperatively (17, 89%)
versus 2–7 days (4, 36%, p <0.01). Patients with a preoperative
therapeutic platelet aggregation inhibition had an elevated odds ratio to
receive platelets (5.3, 95% CI = 1.27–22.2) and showed a trend towards
negative outcome.
Conclusion: Platelet aggregation inhibition cannot be assumed based
on information taken from medical records; it must be obtained through
measurements. Preoperative aspirin therapy resulting in a therapeutic
platelet aggregation inhibition increases the need for transfusion of
platelets. Whether the benefit of preoperative aspirin therapy outweighs
the risks needs to be re-evaluated in concert with measured
preoperative platelet aggregation inhibition.
P63
Efficacy and safety of Vernakalant for new onset
atrial fibrillation after cardiac surgery
A. Rudiger1, A. Breitenstein1, S. Salzberg1, D. Bettex1
Introduction: Vernakalant (Brinavess®) is an atrium specific
multichannel blocker that is licenced in Switzerland for the treatment of
new onset atrial fibrillation (AF). This study investigates the suitability,
safety and efficacy of this novel antiarrhythmic drug in selected
postoperative cardiac surgery patients.
Methods: The study was performed in the cardio-surgical intensive
care unit (ICU) of our institution. All patients with new AF were screened
for in- and exclusion criteria according to the manufacturers’
recommendations. Included patients were treated with 3 mg/kg of
Vernakalant over 10 min and, if unsuccessful, a second dose of 2 mg/
kg. Serial heart rhythm/rate and blood pressure were monitored
according to a protocol until 2 hours after treatment. Results are given
as numbers or means (± standard deviation), a p-value <0.05 is
considered significant.
Results: A total of 105 patients with new onset AF were screened,
of these 92 were excluded due to haemodynamic instability (n = 62),
self-limiting AF (n = 14), chronic AF (n = 10), atrial flutter (n = 8),
intra-venous amiodarone treatment (n = 6), long QT (n = 4), and
myocardial infarction (n = 3). Vernakalant was administered to 13
patients with the following baseline characteristics: Age 74 (±9) years,
men n = 9, SAPS 39 (±12), bypass surgery n = 9, valve surgery n = 6,
vascular surgery n = 3, left ventricular ejection fraction 55 (±8) %, heart
rate 110 (±28) /min to 123 (±31) /min, potassium 4.9 (±0.2) mmol/l,
magnesium 0.96 (±0.11) mmol/l, CRP 170 (±86) mg/l. All but 2 patients
required a second dose. Mean arterial blood pressure at baseline was
74 (±9) mm Hg and did not decrease significantly during the 120
minutes observation period. Lactate and ScvO2 were 1.2 (±0.4) mmol/l
and 62 (±6) %, respectively, and did not deteriorate significantly during
the follow up. Adverse events included nausea (n = 1), bradycardia
(n = 1) and hypotension (n = 1). Six patients converted to sinus rhythm
within 6 hours, but 3 of them had a relapse of AF during the ICU stay.
Conclusions: Applying the strict in- and exclusion criteria provided by
the manufacturer, only a minority of postoperative ICU patients with
new onset AF qualified for Vernakalant. The drug was well tolerated,
but converted patients to sinus rhythm only in a moderate number of
patients. Future research is needed to identify the ideal candidates for
Vernakalant.
P64
Physical and pharmacological restraint in the ICU –
clinical settings
Perren A.1, Corbella D.2, Iapichino E.3,Di Bernardo V.4,
Leonardi A.1, Di Nicolantonio R.4, Buschbeck C.1, Boegli L.5,
Pagnamenta A.5, Malacrida R.4
1
ICU, Ospedale Regionale Bellinzona e Valli, 6500 Bellinzona;
2Anaesthesia Dept, Ospedali Riuniti di Bergamo, Bergamo, Italy;
3Clinical Psycologist, Ospedale San Paolo, Milano, Italy; 4ICU,
Ospedale Civico, 6900 Lugano; 5ICU, Ospedale Beata Vergine,
6850 Mendrisio
Introduction: Analgesic and sedative medications are widely used in
intensive care units (ICU) to achieve patient comfort and tolerance of
the environment, and to eliminate various forms of distress. Yet, their
excessive use is associated with increased morbidity (physical and
psycological) and mortality. On the other hand, an inadequate reduction
of sedation or the presence of delirium may induce patients to cause
harmful events. Thus, pharmacological and/or physical restraint may be
applied in order to protect both patients and caregivers. The aim of this
study was to depict the clinical scenario of restraint practice and,
secondarily, of sedation.
Methods: A prospective, observational and multicentric study was
carried out. Inclusion criteria 25 hours after admission were: age
≥18 years, NEMS ≥21, SAPS II ≥32 and informed consent, whereas
patients with acute psychosis or presumed/confirmed major cerebral
damages were excluded. The following data were prospectively
registered: 1) at recruitment and discharge: general patient
characteristics, diagnoses, comorbidities, pre-existing psychiatric
medications; 2) for every nurse shift (8hrs): level of sedation (SAS),
change in analgo-sedation, NEMS, SAPS II, presence of physical
restraint. A logistic analysis of all relevant determinants of physical
restraint and sedation with stepwise procedure was performed.
Results: 120 patients with a mean (±SD) age of 66.3 ± 15.7 yrs and a
preceding Karnofsky score of 75.5 ± 22.7 were included. Other relevant
patient characteristics were: SAPS II 52.0 ± 19.0, NEMS at admission
31.46 ± 7.41, lenght of ICU (hospital) stay 12 ± 11,1 (30.9 ± 23.2).
Mortality was 19%, 32% were transferred to another hospital and 49%
discharged home. In 43% of all nurse shifts (1411 of 3296) some kind
of physical restraint was applied and 79.8% had a pharmacological
sedation. Physical restraint was positively associated with a SAS≥6
(OR 14.2 ± 6.5), a reduction in analgo-sedation (OR 2.7 ± 0.8) and an
40 S
admission from another ICU (OR 2.3 ± 0.6). There was a negative
association between physical restraint and NEMS and SAPS II.
However, the most discriminating variable was the treating ICU (centre
A: OR 1; centre B: OR 0.06 ± 0.01 and centre C: OR 0.32 ± 0.06)
whereas this variable had no effect on the presence of sedation. Other
determinants, positively associated with sedation, were male gender,
NEMS, target of sedation and a too awake patient (judgment of nurse
or physician). On the contrary, an observed SAS <3 and the nurse’s
judgment of a too profound sedation were negatively associated.
Conclusions: Physical restraint is generally applied in patients
perceived as too awake or agitated. Frequently, this phenomenon
concerns the almost recovered patient. The most important variable
associated with physical restraint is the treating ICU, whereas
pharmacological restraint is extremely frequent among all ICUs. These
data suggest an important role of local clinical practice for physical
restraint but not for pharmacological sedation.
P65
Epidemiology of widespread mechanical hypersensitivity
and altered conditioned pain modulation in chronic pain
in a tertiary care pain center
Y. Ghamri1, S. Mlekusch1, J. Schliessbach1, R. J-A. Cámara2,
P. Jüni2, L. Arendt-Nielsen3, M. Curatolo1
1Inselspital, Bern University Hospital, Bern, Switzerland; 2Institute of
Social and Preventive Medicine, University of Bern, Clinical Trials Unit,
Bern, Switzerland; 3Center for Sensory-Motor Interaction, Aalborg
University, Aalborg, Denmark
Introduction: Knowledge on prevalence and contributing factors are
important to determine the clinical relevance of central sensitization
and altered conditioned pain modulation (CPM).
The present study was conducted to examine the epidemiology of
widespread central sensitization with an easy to use bed-side test.
Methods: Consecutive patients referred to the pain clinic between
January 2010 and May 2011 were enrolled. Exclusion criteria were:
pain, vascular or neurological disorders at the foot or hand to be tested,
diabetes and alcohol abuse. Demographic and psychosocial variables
were recorded. Pressure pain detection threshold (PPDT) as test
stimulus was measured on the second toe of the non- or less painful
body side before and after a conditioning cold pressor test applied to
the contralateral hand. Widespread mechanical hypersensitivity was
defined as a value of PPDT lower than the normative values previously
defined in a study on 300 pain-free volunteers (Neziri et al, Eur J Pain
2010). The difference between PPDT before and after the cold pressor
test was the measure for CPM. Altered CPM was defined as no change
or decrease in PPDT after cold pressor test.
Results: Here we present an initial analysis of the results. 652 patients
have completed the study. 357 (55%) were females and 295 (45%)
were males. 13 (2%) were under the 5th percentile of normative values
for PPDT. Altered CPM was present in 167 Patients (26%). PPDT were
significantly lower in the altered CPM group, compared with the rest
of the sample (284 kPa vs 358 kPa, p <0.01).
Conclusion: Unlike our previous study (Schliessbach et al. submitted,
using pressure pain tolerance threshold), only 2% of the patients had
PPDT below the 5th percentile of the normal values. Therefore, it seems
that PPDT is not sensitive to detect widespread mechanical
hypersensitivity. The prevalence of 26% of altered CPM reproduces
the results of the previous study. Thus, PPDT in combination with cold
pressor test could be a less painful alternative to tolerance thresholds
for the assessment of CPM. Altered CPM is associated with lower
PPDT values and reciprocally, suggesting that altered CPM and central
sensitization may be interrelated phenomena.
Aim: The aim of this prospective pilot study was, using IP and PDR,
1) to quantify individual level of pain in comatose/sedated mechanically
ventilated ICU patients and 2) to analyze the effect of incremental
boluses of analgesics on PDR.
Methods: Patient population consisted of hemodynamically stable
comatose/sedated mechanically ventilated ICU patients, requiring
analgesia (fentanyl 50–100 mcg/h) as part of standard ICU care. The
IP NeuroLight Algiscan® (IDMED, Marseille, France) was used. Baseline
level of pain was first quantified by measuring PDR following a
moderate noxious electrical stimulation (10–20 mA), applied to the ulnar
nerve. Second, we tested the effect of an incremental dose of fentanyl
(50, 100 mcg i.v. boluses) on PDR following a fixed 20 mA electrical
stimulation.
Results: A total of 42 tests were performed on 11 patients. The median
baseline PDR to noxious stimulation was 33%, with a wide range from
13 to 131%, indicating highly variable individual level of pain within our
patient cohort. No correlation was found between the previous 24 h
cumulative dose of fentanyl and the PDR (Pearson r = 0.11, p = 0.46;
fig. 1). Bolus analgesia with fentanyl was associated with a significant
reduction of PDR from baseline 27 ± 18% to 15 ± 7% (p = 0.05) with
fentanyl boluses (fig. 2).
Conclusions: Infrared pupillometry quantified variable individual levels
of pain across comatose/sedated ICU mechanically ventilated patients,
despite standardized analgesia. Fentanyl boluses were associated with
a significant decrease of pain, as assessed by a reduction in pupillary
dilatation response. Our preliminary data suggests infrared pupillometry
may optimize the management of analgesia individually in ICU patients.
MO is supported by Grants from the Swiss National Science Foundation
(FN 320030_138191) and The European Critical Care Research
Network (ECCRN).
Figure 1
P66
Infrared Pupillometry for the Management of Analgesia
in Sedated Mechanically Ventilated ICU Patients
SUYS1, SALA1, ODDO1
1
CHUV, Lausanne, Switzerland
Background: Analgesia is an essential component of critical care.
Recent evidence demonstrates that pain assessment is still underused
in the ICU and that improving pain assessment might reduce morbidity
and ICU related costs. Assessment of pain is based on subjective
scales that require a conscious interacting patient, and are therefore
less suitable for comatose/sedated mechanically ventilated ICU
patients. Infrared pupillometry (IP) enables the quantification of pain
by measuring pupillary dilatation in response to a noxious stimulus
(PDR) and is emerging as a new technique to optimize analgesia in
the operative room. Whether IP might improve the management of
analgesia in the ICU is still unknown.
Figure 2
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P67
The effects of proportional modes of ventilation during
lower limbs exercise in critically ill ventilated patients.
Preliminary results
E.A. Akoumianaki1, N.D. Dousse1, S.G. Graf1, A.L. Lyazidi2,
J.C.L. Lefebvre1, N.A. Abidi1, F.B. Boroli1, M.E.B. Brunner1,
J.C.M.R. Richard2, L.B. Brochard2
Switzerland; 2University Hospital of Geneva, Intensive Care Unit
and University of Geneva, Geneva, Switzerland
Introduction: Early exercise of critically ill patients has beneficial
effects on muscle strength, mass preservation and on systemic
inflammatory suppression. The type of assisted mechanical ventilation
(MV) may significantly affect exercise performance. In pressure support
ventilation (PSV), assistance remains fixed for every breath. Therefore,
a mismatch between demand and assist could induce increased work
of breathing, limiting exercise. Modes of MV that provide assistance
proportional to patient’s instantaneous effort (Proportional Assist
Ventilation, PAV+ and Neurally Adjusted Ventilatory Assist, NAVA)
should efficiently track the dynamic changes of ventilator demand
during exercise and adequately unload respiratory muscles leading
to increased exercise tolerance.
Methods: Critically ill patients requiring mechanical ventilation for more
than 48 hrs were prospectively enrolled. At day 1 the patients underwent
an incremental workload test on a cycloergometer to determine the
maximum resistance level capacity. The next day, two 15 minutes
exercise periods, reproducing 60% of the maximum resistance, were
performed. During each session patients were ventilated with PSV and
a proportional mode in random order. The type of proportional mode
(PAV+ or NAVA) was randomly selected. VO2 was measured through
indirect calorimetry. Dyspnea and limb fatigue were evaluated through
a modified Borg dyspnea scale score and a Borg limb discomfort scale.
The change in VO2 (%) between baseline and the final 5 minutes of
each exercise session (ΔVO2) has been computed. The distance
performed as well as the difference in dyspnea, limb fatigue and
respiratory rate per minute (ΔRR) were also recorded. A statistical
comparison was done by the non parametric test of Wilcoxon signed
rank.
Results: 6 patients were tested, 3 in each group. Median (range) age,
APACHE II score, days on ICU and days on MV at the time of the study
were 57.5 years (53 to 72), 24 (13 to 42), 16.5 days (6–54) and 16.5
days (6–54) respectively. ΔVO2 (%) was significantly higher during PSV
in comparison to proportional modes (PROP) (table).
Conclusions: These preliminary results demonstrate that patients
ventilated with proportional modes exhibited less increase in VO2
during exercise than those ventilated with PSV. No significant
differences were found with regard to other outcomes.
P68
Effects of different levels of synchronization during
pressure targeted ventilation on lung protection and
variability
E.A. Akoumianaki1, A.L. Lyazidi2, S.M. Mortaza3, S.D. Draghi4,
J.C.L. Lefebvre1, SD Dimassi1, G.F.S.P. Sferazza Papa1,
D.T. Tassaux1, A.M. Mercat3, L.B. Brochard2, J.C.M. Richard2
Switzerland; 2University Hospital of Geneva, Intensive Care Unit and
University of Geneva, Geneva, Switzerland; 3University Hospital of
Angers, Intensive Care Unit, Angers, France; 4University of Rouen,
Rouen, France
Introduction: Pressure targeted modes of ventilation can be classified
into three categories according to the different levels of synchronization,
i.e., capability of spontaneous efforts to trigger the ventilator: 1. non
synchronized modes (e.g., APRV), 2. partially synchronized modes
(e.g., BIPAP, BIPAP, BiLevel, DUOPAP etc) and 3. fully synchronized
modes (e.g., PAC, BIPAP assist). We hypothesized that the degree of
synchronization affect the control of tidal volume (VT) and breathing
variability. Using an active lung model simulator we compared the
impact of synchronization level on VT and transpulmonary pressure
swings (Ptp).
Methods: All available pressure targeted modes of 5 ventilators (Evita
XL, Dräger; Servo-I, Maquet; PB 840, Covidien; Engstrom, General
Electric; and G5, Hamilton Medical) were tested with the active
breathing simulator (ASL-5000, Ingmar) in which spontaneous breaths
had a muscular pressure (Pmus) of –10 cmH2O and a respiratory rate
(RR) of 20/min with compliance and resistance of 30 mL/cmH2O and
5 cmH2O/L/s. Ventilator settings were as follows: PressureHIGH
30 cmH2O, PEEP 15 cmH2O, ventilator frequency 15 breaths/min
and inspiratory to expiratory ratio (I:E) of 1:3. Partially synchronous
modes were tested with and without pressure support (PS) for efforts
occurring at PEEP. Resulting VT and Ptp swings and their coefficient of
variation (CV), calculated as the standard deviation (sd) divided by the
mean value, were assessed.
Results: Among the different pressure targeted modes we found that,
as the level of synchronization increased, the VT and Ptp increased
while their variability decreased (table).
Conclusion: In the presence of spontaneous breathing, different
VT and Ptp swings can be encountered during pressure targeted
ventilation, depending on the level of synchronization with the ventilator.
The higher is the synchronization of SB with the ventilator, the larger
the Ptp swings and VT recorded and the lower is the variability
suggesting that synchronization might potentially be harmful. These
results require clinical validation.
P69
Evaluation des systèmes à Pression Positive Continue
(CPAP) sur banc d’essai
A.L. Lyazidi2, C.D. Draghi3, E.A. Akoumianaki1, M.M. Marechal1,
J.M.G. Granier1, D.M. Matamis1, C.L. Leemann1, D.T. Tassaux2,
L.B. Brochard2, J.C.M.R. Richard2
1Hopitaux Universitaires de Genève, Unité des Soins Intensifs,,
Genève, Switzerland; 2Hopitaux Universitaires de Genève, Unité
des Soins Intensifs; Université de Genève, Genève, Switzerland;
3Université de Rouen, Rouen, France
Introduction: La pression positive continue (CPAP) est une des
techniques de support respiratoire de l’insuffisance respiratoire aiguë.
Plusieurs dispositifs sont disponibles pour pratiquer cette technique
avec des conceptions différentes (venturi, jet, turbine, etc) et peuvent
donc avoir des performances inégales. Nous avons évalué les
performances de six modèles de CPAP en termes de travail respiratoire
lié au système (circuit+CPAP), de volume courant (Vt) généré, d’effort
inspiratoire nécessaire pour obtenir un Vt cible et de résistances
expiratoires.
Matériel et Méthode: Six systèmes (Boussignac, Vygon; Evita XL,
Dräger; Mercury, Mercury Medical ; O-Two, O-Two Medical
Technologies Inc; Pulmodyne, Pulmodyne®; Vivo 40, Breas Medical) ont
été testés à 5 et 10 cmH2O. Les CPAP ont été branchés sur un poumon
test actif (ASL5000, Ingmar Medical) simulant des efforts respiratoires
avec une résistance de 5 cmH2O/L/s et une compliance de 60 ml/
cmH2O. Trois séquences de tests ont été réalisées où les systèmes de
CPAP ont été soumis: 1) au même effort inspiratoire; 2) à des efforts
différents pour générer le même Vt; 3) à différents débits dont 60L/min
pour mesurer les résistances expiratoires.
Résultats: –Pour un effort inspiratoire identique, les Vt mobilisés
étaient très différents variant de 250 ml (Pulmodyne) à 480 mL (Evita
XL). – Pour générer le même Vt des efforts inspiratoires plus ou moins
intenses étaient nécessaires et le travail respiratoire lié au système
était variable (figure). – Les résistances expiratoires à 60L/min étaient
variables: 9.8, 9.4, 8.1 et 7 cmH2O/L/s respectivement pour Pulmodyne,
O-Two, Mercury et Boussignac.
Conclusion: Les résultats des tests ont montré des performances
variables entre les différents systèmes de CPAP qui peuvent s’expliquer
par les différences de conception technologique.
P70
Amino acids intake in critically ill children on nutritional
support
C.M. Moullet1, N.J. Jornod1, J.D. Depeyre1, C.J. Jotterand1,
M.O.R. Ranson2, M.H.P. Perez3, J.C. Cotting3
1
Nutrition and Dietetics Department, University of Applied Sciences
Western (HES-SO), Geneva, Switzerland; 2Clinical Nutrition Unit,
University Hospital (CHUV), Lausanne, Switzerland; 3Pediatric
Intensive Care Unit, University Hospital (CHUV), Lausanne,
Switzerland
Rationale: In critically ill children, proteins in nutritional support are
very important, especially to preserve skeletal muscle mass. However,
proteins can only be used optimally if amino acids meet the qualitative
and quantitative needs for the organism. Currently no recommendation
exists for this population. The aim of this observational study was to
assess essential amino acids (EAAs) and nonessential amino acids
(ENAAs) intakes in critically ill children.
Methods: Children with a nutritional support and length of stay in the
Pediatric Intensive Care Unit ≥72 hours were consecutively included.
Energy, protein and amino acids intakes were recorded daily using a
clinical information system. In the absence of recommendations for
42 S
critically ill children, EAAs were compared to the Dietary References
Intakes for healthy children (DRI, 2005). For NEAAs, we used breast
milk in young children (0–12 months) and mixed muscle protein content
in older children (1–18 years) as reference values. Protein intake was
also compared to the DRI.
Results: Thirteen children, 10 boys and 3 girls, with a median age
[IQR)] of 2.5 [1–7] years were included in the study. 114 days were
analyzed. Twelve children received enteral nutrition and only one
received mixed nutrition. Two children received mother’s milk, 3 received
infant formulas, 7 received enteral solutions for children and 1 for adults.
Mean (±SD) protein intake was 1.0 ± 0.5 g/kg/d and 31% of children
reached the recommended protein intake. EAAs intake exceeded the
DRI, especially for isoleucine (194% ± 74% of DRI), tryptophane (173%
± 79 of DRI) and threonine (169% ± 66 of DRI). The NEAAs intake was
lower or higher than the reference values. Infant formulas and enteral
solutions are low in glutamine and taurine but rich in cysteine and
tyrosine. In an expected way, EEAs and NEAAs intake were close to
the reference values for children fed with breast milk.
Conclusion: Although protein intake was lower than the
recommendations in this group of critically ill children, EAAs intake
exceeded the reference values whereas NEAAs varied considerably.
Further studies are needed to determine amino acids requirements in
this population and to assess the risk of toxicity.
P72
Analysis of 120 consecutive episodes of bacteremia
occurring over one year in a large mixed ICU
E. Oppliger1, D.H. Tsai2, J.P. Revelly1, Y.A. Que1,
I. Guessous2, P. Eggimann1
1CHUV, Lausanne, Switzerland; 2IUMSP, Lausanne, Switzerland
Introduction: Bacteremia are among the leading form of severe
infection requiring ICU management, and have been reported to be
associated with important morbidity and mortality.
Methods: We analyzed all consecutive episodes of bacteremia
occurring in patients hospitalized in our mixed 32-bed ICU over a 12
month period (01.10.09–30.09.10). Chi-square tests were used for the
P71
Antioxidant micronutrients supplementation in ventilated
critically ill children: an observational study
C. Jotterand2, J. Depeyre2, C. Moullet2, M.-H. Perez1, J. Cotting1
1Pediatric Intensive Care Unit, University Hospital (CHUV), Lausanne,
Switzerland; 2Nutrition and Dietetics Department, University of Applied
Sciences Western Switzerland (HES-SO), Geneva, Switzerland
Rationale: Antioxidant micronutrients may have an important role
in the fight against oxidative stress in critically ill patients. In adults,
supplementations have been associated with reduction of mortality.
In children, the actual needs are unknown and a systematic
supplementation has not been yet recommended. The aim of this
observational study was to assess antioxidant micronutrients intakes
in children receiving or not supplementation.
Methods: Children with expected mechanical ventilation >= 72 hours
were consecutively included. Antioxidant micronutrients: vitamins C
and E, copper, zinc and selenium, were recorded daily using a clinical
information system. Intakes were compared to the recommendations:
the Dietary References Intakes for healthy children (DRI, 2001) for
patients on enteral nutrition and the guidelines of the European Society
for Pediatric Gastroenterology, Hepatology and Nutrition for children on
parenteral nutrition were used, respectively. Energy balance was
calculated as the difference between energy intake and energy
expenditure measured by indirect calorimetry.
Results: Forty-nine children, 25 boys and 24 girls, were included. The
median age [IQR)] was 22 [4–40] months. 409 days were analyzed and
236 indirect calorimetry measurements performed. All children had
enteral nutrition and 3 also had parenteral nutrition. 31 children were
supplemented with vitamins; 3 with trace elements; 6 with vitamins and
trace elements and 9 children had no supplementation. Most children
with supplementation had a mean intake for the studied period that
reached the recommendations: 82% of children for vitamin C, 77%
for vitamin E, 56% for zinc, 78% for copper and 89% for selenium. In
contrast, only few children without supplementation reached the
recommendations: 50% for vitamin C, 10% for vitamin E, 40% for zinc,
40% for copper and 5% for selenium. In children with supplementation,
the recommendations were reached on average the day after admission
while they were reached after 4–11 days in the other group. Mean
energy balance was –8 ± 16 kcal/kg/d in supplemented children
(n = 40) and –20 ± 11 kcal/kg/d in non-supplemented children (n = 9),
respectively (p = 0.042).
Conclusion: Supplementing critically ill children with vitamins and trace
elements is necessary in order to reach at least the recommendations
in antioxidant micronutrients for healthy children. Further studies are
needed to determine their actual needs.
43 S
categorical variables and ANOVA tests were used for the continuous
variables.
Results: We found 120 episodes of bacteremia for an incidence-density
of 57.5 episodes/1000 admissions or 12.8 episodes per 1000 patientdays. The source of bactreremia differs considerably according to their
origin (table 1). Among nosocomial episodes, 34% were related to
vascular accesses, including two thirds acquired outside of the ICU.
Among health-care associated episodes, 63% originated from the
urinary tract. In contrast, a respiratory origin was found in 37% of
community-acquired episodes. The overall mortality was 34% as
compared to 7.9% and 13.6% for the overall ICU and hospital mortality
of other patients over the same period, respectively (table 2). In a
multivariate model, age (1.06 [1.02–1.11]) and septic shock (3.47
[1.38–8.7]) were significantly associated with a fatal outcome, whereas
severe sepsis (0.17 [0.04–0.8]) and more than 3 antibiotics (0.77
[0.58–1.00]) were protective.
Conclusions: Two-third of bacteremia documented among ICU
patients were nosocomial and in contrast to those community-acquired,
Gram-negatives represented the majority of them. Community-acquired
bacteremia were associated with a higher proportion of septic shock
and a significantly higher death rate.
Discussion – Conclusion: Des modifications importantes de
l’utilisation des agents anti-infectieux sont observées sur la période
concernée. Les raisons de ces modifications méritent d’être
investiguées. Il pourrait s’agir d’une évolution du profil de résistance des
souches isolées, d’un simple changement dans les pratiques locales,
ou encore de raisons économiques. Les résistances aux antibiotiques
augmentant non seulement au sein de la population générale mais
aussi au sein de la population brûlée, une utilisation plus restrictive des
antibiotiques pourrait être évaluée sans pour autant priver cette
population à hauts risques de traitements vitaux. Dans cette optique, un
suivi thérapeutique étroit des médicaments chez ce type de patients
pourrait s’avérer judicieux.
Tableau 1
Résumé des molécules dont l’utilisation a changé entre 2007 et 2011.
Amoxicilline –
acide clavulanique
P73
Evolution de l’utilisation des thérapies anti-infectieuses
chez les patients hospitalisés pour brûlures dans un
Centre suisse de référence
A. Henry1, P. Eggimann2, M.M. Berger2, A. Pannatier1, P. Voirol1,
Y.A. Que2
1Service de Pharmacie, Centre hospitalier universitaire vaudois
(CHUV), Lausanne, Switzerland; 2Service de Médecine Intensive
Adulte, Centre hospitalier universitaire vaudois (CHUV), Lausanne,
Switzerland
Introduction: Les anti-infectieux occupent une place essentielle dans
le traitement des patients brûlés, ces derniers présentant de multiples
facteurs les prédisposant aux infections sévères. Dans ce contexte,
l’utilisation de ces molécules doit être rigoureusement contrôlée afin
d’atteindre les objectifs thérapeutiques tout en minimisant le risque de
développement et dissémination de résistances. L’objectif du présent
travail était d’évaluer l’évolution de la prescription des anti-infectieux
chez les patients brûlés hospitalisés au Centre des Brûlés (CB) de
notre hôpital.
Méthode: Etude rétrospective incluant tous les patients brûlés admis
au CB de 2007 à 2011. Les données des traitements anti-infectieux ont
été extraites du dossier patient informatisé (Metavision), par année et
par patient. Les outcomes analysés étaient le nombre de jours de
traitement, le nombre de cures reçues et la dose administrée cumulée.
Les anti-infectieux présentant des modifications importantes de leur
fréquence d’utilisation ont ensuite été analysés plus en détail. Les
patients n’ayant pas reçu d’anti-infectieux systémiques au cours de
leur séjour ont été exclus.
Résultats: Le CB a accueilli 182 patients brûlés durant les années
2007 à 2011, dont 125 ont reçu des anti-infectieux (tab. 1). Les
molécules dont l’utilisation a fortement augmenté sont la caspofungine,
la ceftazidime, le colistiméthate, le fluconazole et le meropenem (fig. 1).
En revanche, l’utilisation de la céfazoline, de la ciprofloxacine et de
l’imipenem-cilastine a diminué. Pour l’amoxicilline-acide clavulanique,
la céfépime, la pipéracilline-tazobactam et la vancomycine, aucune
évolution franche n’a été mise en évidence.
Molécules dont l'utilisation augmente de 2007 à 2011
Céfazoline
Céfépime
Ceftazidime
Colistiméthate
Ciprofloxacine
Fluconazole
Imipenem – cilastine
0.5
Nombre de cures par patient
Caspofungine
0.4
Caspofungine
0.3
Ceftazidime
Colistiméthate
0.2
Meropenem
Fluconazole
Meropenem
0.1
0
2007
2008
2009
2010
2011
Figure 1
Molécules dont l’utilisation augmente de 2007 à 2011.
Piperacilline
– tazobactam
2007
2008
2009
2010
2011
dose cumulée / nb patients
[grammes]
15.01
11.39
14.71
9.01
13.03
nb cures / nb patients
0.51
0.42
0.46
0.42
0.54
durée des ttt cumulés /
nb patients [jours]
3.37
2.39
2.54
2.00
2.74
[grammes]
0.00
0.01
0.09
0.05
0.08
0.00
0.03
0.11
0.05
0.20
nb patients [jours]
0.00
0.27
1.74
0.95
1.51
[grammes]
1.22
0.48
1.31
0.66
0.54
0.61
0.33
0.49
0.29
0.14
nb patients [jours]
0.83
0.36
0.71
0.47
0.31
[grammes]
0.00
0.00
2.23
5.79
0.57
0.00
0.00
0.03
0.11
0.03
nb patients [jours]
0.00
0.00
0.40
1.42
0.14
[grammes]
0.00
0.00
0.54
1.89
3.20
0.00
0.00
0.06
0.03
0.09
nb patients [jours]
0.00
0.00
0.23
0.34
0.63
[grammes]
0.00
1.15
0.00
2.89
13.26
0.00
0.03
0.00
0.08
0.11
nb patients [jours]
0.00
0.52
0.00
0.58
2.17
[grammes]
0.41
0.68
0.68
0.53
0.26
0.07
0.09
0.17
0.08
0.06
durée des ttt cumulés / nb
patients [jours]
0.34
1.24
1.14
0.74
0.49
[grammes]
0.60
0.82
0.89
0.05
0.88
0.17
0.06
0.11
0.11
0.26
nb patients [jours]
1.73
2.09
2.20
0.18
2.94
[grammes]
5.60
0.85
1.98
2.63
1.96
0.37
0.06
0.17
0.11
0.06
nb patients [jours]
2.49
0.33
1.14
1.18
0.60
[grammes]
3.24
10.41
7.50
7.16
10.02
0.17
0.36
0.26
0.45
0.40
nb patients [jours]
1.07
2.42
2.29
2.63
3.46
dose cumulée /
nb patients [grammes]
38.09
30.95
38.83
29.37
36.38
0.24
0.27
0.43
0.34
0.51
nb patients [jours]
2.39
2.36
3.17
2.50
3.97
Légende: Molécules dont l’utilisation augmente; molécules dont l’utilisation diminue
44 S
P O ST E R S G I : I C U M A N AG E M E N T
P74
Agreement between nurses’ and brain injured patients’
assessment of pain
M.J. Roulin1, A.S. Ramelet1
1Institute of Higher Education and Nursing Research University of
Lausanne, Lausanne, Switzerland; 2University Hospitals of Geneva,
Geneva, Switzerland; 3HECVSanté, University of Applied Sciences
of Western Switzerland, Lausanne, Switzerland
Pain in critically ill patients in the intensive care unit (ICU) is common.
However, pain assessment in critically ill patients may be complicated
when patients are unable to self report their pain. A study by Ahlers et
al. (2008) found a significant correlation between the Numerical Rating
Scale (NRS) scored by medical and surgical ICU patients (the gold
standard) and the NRS scored by nurses. This study aimed to verify this
correlation in critically ill patients and ICU nurses at rest (no pain) and
during a noxious procedure (turning). A prospective observational study
was performed in 40 critically ill brain injured patients with a mean
Glasgow score of 13.7 (± 1.7). Patients who were unable to use the
NRS were asked to self-report the presence/absence of pain with a
“yes” or “no” answer to the question “Do you have pain?”. Patients (when
possible) and their attending nurses, blinded to patient answers, were
asked to assess independently pain intensity with a NRS. The NRS is
based on a scale from 0 to 10; 0 represents no pain and 10 represents
the worst possible pain. Eighteen patients (45%) reported the presence
of pain at rest and 25 (62.5%) during the noxious procedure with a
statistically significant difference [chi-square test (1, N = 40) = 15.105,
p = 0,000]. Twenty-nine patients (72.5%) were able to self-report their
pain intensity at rest (Mdn = 0, IQR = 3) and during the noxious
stimulation (Mdn = 2, IQR = 5). However the difference between these
two measurements was not statistically significant (Z = –1.434, p =
0.152). The attending nurses median score was 0 (IQR = 4) at rest? and
2 (IQR = 3) during the noxious stimulation. The difference between
the nurses’ assessments at rest and during a noxious stimulation were
statistically significant (Z = –1.959, p = 0.05). The agreement between
the patient and the attending nurses’ assessment was high with an
intra-class correlation at rest of 0.768 (CI 0.573–0.885) and during
noxious stimulation of 0.745 (CI 0.540–0.867). These results show that
pain remains problematic in ICU brain injured patients, even for those
able to self-report. We also found a good agreement between patient’s
self-report of pain and the attending nurse’s assessment, suggesting
that this latter may be considered as a proxy measure for patients
unable to self-report. However, as the sample is small and limited to
brain injured patients, there is a need to confirm these results in a larger
sample of patients before generalizing to all ICU patients.
P75
SwissScoring – Survey of SAPS II assessing practices
A .Perren, M .Previsdomini, I. Perren, B. Cerutti, P. Massarrotto,
M. Kaufmann, P. Merlani, H.U. Rothen
Introduction: The simplified acute physiology score II (SAPS II) is
probably still the most commonly used score in Europe to asses the
severity of acute disease in the critically ill adult patient. In Switzerland,
it is also a key-component to define hospital reimbursement for patients
admitted to a certified intensive care unit (ICU). However, nothing is
known about how SAPS II is documented for the individual patient.
Accordingly, the primary aim of this study was to evaluate actually
used practices to implement and score SAPS II.
Methods: An online survey (April – June 2012) was carried out among
all physician heads (PH) of the 78 Swiss certified adult ICUs. Using a
questionnaire, we asked how SAPS II scoring was implemented in the
ICU (e.g. training of personnel, validation of scoring). Furthermore, we
collected information on organizational characteristics of the ICU.
Results: Sixty-three of 78 (81%) PH participated. 45 (72%) were
Swiss-Germans, 14 (22%) Swiss-Romands and 4 (6%) Swiss-Italians.
Median (IQR) time spent for responding was 6.6 min (4.7–9.6 min). PH
are men in 82%, their age is <45 yrs (16%), 46–55 yrs (61%) or >56 yrs
(23%). Swiss ICU are hierarchically independent in 65% of cases, the
others are mainly integrated in a department of internal medicine (50%)
or anaesthesia (42%). Apart from the primary specialization, PH are
also board certified in anaesthesia (48%) or internal medicine (42%).
21% of PH have an additional qualification in management. Major
features regarding the SAPS II assessing practices are listed in table 1.
64% of all ICUs are provided with a “reminder” for missing SAPS II
scoring, activated after 24 hrs (16%), the next day (18%) or later (66%).
22% of those without “reminder” report that SAPS II scoring may be
neglected even during a prolonged period of time. In 31% of ICUs there
is a patient data management system allowing for semi-automatic
SAPS II scoring.
Conclusions: In this online survey, an excellent response rate was
observed. About two thirds of Swiss ICUs are hierarchically independent
organizations. PH are generally motivated to assure timely and validated
scoring. Nevertheless, our data suggest that some aspects (structured
teaching and systematic quality control) should be further promoted.
Table 1
Characteristics of SAPS II assessing practices.
%
Proper ICU
doctor
SAPS scored
by
Instruction by
Evening shift
68
Night shift
51
%
Quality control
SAPS
Manual
scoring by
Every week
39
Every month
12
67
Occasionally
19
Senior doctor
17
Never
7
Nurse
11
Others
5
Who controls
Senior doctor
83
Head nurse
11
Colleague
71
Quality officer
5
Structured training
25
Others
1
Others
4
Yes
89
No
11
Manual
75
Semi-automatic
23
Automatic
2
Research of all data
76
Memory recall &
research
24
Kind of feedback
Quality control
group
Significance
of SAPS
22
Junior doctor
Feedback after
control
Kind of
scoring
Every day
Individual
71
Team meeting
14
Others
15
No
29
Important for
SwissDRG
45
Yes, ICU based
64
Internal evaluation
18
Yes, external
7
Generally
interesting
24
Others
13
45 S
P76
P77
SwissScoring – Survey of NEMS assessing practices
A. Perren, M. Previsdomini, I. Perren, B. Cerutti, P. Massarotto,
M. Kaufmann, P. Merlani, H.U. Rothen
Introduction: The nine equivalents of nursing manpower use score
(NEMS) is frequently used to quantify, evaluate and allocate nursing
workload at the Intensive Care Unit level. In Switzerland, it is also a
key-component to define hospital reimbursement for critically ill patients.
However, nothing is known about how NEMS is documented for the
individual patient. Accordingly, the primary aim of this study was to
evaluate actually used practices to implement and score NEMS.
Methods: An online survey (April – June 2012) was carried out among
all head-nurses (HN) of the 78 Swiss certified adult intensive care units
(ICUs). Using a questionnaire, we asked how NEMS scoring was
implemented in the ICU (e.g. training of personnel, validation of
scoring). Furthermore, we collected information on organizational
characteristics of the ICU.
Results: Sixty-four of 78 (82%) HN participated. 46 (72%) were
Swiss-German, 13 (20%) Swiss-Romand and 5 (8%) Swiss-Italian.
Median (IQR) time spent for responding was 6.7 min (4.4–10.8 min).
HN are women in 51%, their age is <45 yrs (45%), 46–55 yrs (45%)
or >56 yrs (10%). Specific ICU specialization is Swiss in 94%, and 86%
of HN have a further certification (nurse management 45%, MAS 10%,
others 31%). Major features regarding the NEMS assessing practices
are listed in table 1. 69% of all ICU are provided with a “reminder” for
missing NEMS scoring, activated after every shift (48%), the next day
(31%) or later (21%). 42% of those without “reminder” reported that
NEMS scoring may be neglected even during a prolonged period of
time. In 33% of ICU there is a Patient Data Management System
permitting semi-automatic NEMS scoring.
Do the DRG change admission characteristics
to a large ICU?
K.H. Homburg1, P.F. Fodor1, S.B. Blumenthal1
1Stadtspital Triemli, Zürich, Switzerland
Introduction: The new Swiss financing system by means of Diagnosis
Related Groups (DRG), effective since 1.1.2012, forms the basis of a
performance-based system to reimburse general hospital services. With
the introduction of the DRGs we expect (1) the number of admissions
from external hospitals to a large intensive care unit (ICU) to increase
and (2) the severity of illness of the assigned patients to rise.
Methods: The ICU of the city hospital Triemli in Zurich has an
interdisciplinary organisation with surgical and internal medical patients
with a maximum occupancy of 18 beds and a center function for the
surrounding hospitals. In this ongoing prospective observational study,
we collect and analyse the anonymised data of all patients assigned to
our ICU from an external hospital during defined periods prior and after
the introduction of the DRGs. Exclusion criteria are admission via
emergency department and internal relocations. The primary endpoint
is the number of admissions from an external hospital to our ICU. The
secondary endpoint is the severity of illness of the assigned patients,
detected by the scoring systems SAPS II and APACHE II.
Results: We present preliminary data of a 8 months period, 4 months
prior and 4 months after the introduction of the DRGs. The analysis
was performed with 162 and 210 datasets, respectively. We found an
increase of 32% of admitted patients from external hospitals to our ICU
(144 vs 191). The ratio of accepted vs refused patients was unchanged
prior and after the introduction of the DRGs (90% accepted vs 10%
refused). The severity of illness of the accepted patients is comparable
before and after the introduction of the DRG (table 1).
Table 1
Characteristics of NEMS assessing practices.
%
Who scores
Instruction
by
Manual
scoring by
14 (5 – 41)
13 (4 – 42)
APACHE II
34
Data are expressed as median and range.
16
Every week
30
14
Every month
8
Occasionally
21
Specialized nurse
Others
Colleague
64
Structured training
35
1
Quality control NEMS
Never
Who controls
7
Head nurse
60
Senior doctor
21
Research of all data
32
Clinical specialist 12
Memory recall
15
Quality officer
Combination of both
53
Every month
45
Occasionally
27
Never
27
Significance Important for
of NEMS
SwissDRG
21 (6 – 79)
%
70
Feedback after control
Survey of
data
with DRG
24 (6 – 70)
Every day
ICU nurse
Others
before DRG
SAPS II
Kind of feedback
8
Yes
78
No
22
Individual
48
Team meeting
29
55
Specific meeting
Internal evaluation
22
Others
14
Generally interesting
13
Others
10
No
28
Yes, ICU based
64
Quality control group
Yes, external
7
8
Conclusions: Excellent adherence towards this online questionnaire
was observed. Most HN of Swiss ICU have an additional qualification in
nursing management and are generally motivated in appropriate
scoring and corresponding validation. Nevertheless, our data suggest
that there is some margin for improvement in teaching and quality
control.
Conclusion: The introduction of the DRG in Switzerland increases the
number of admission to a large ICU with a center function. Further data
analysis has to be performed.
P78
Do the DRG influence patient characteristics at the time
of discharge from a large ICU?
G.Z. Ziltener1, P.F. Fodor1, S.B. Blumenthal1
1
Stadtspital Triemli, Zürich, Switzerland
Introduction: The new Swiss financing system by means of Diagnosis
Related Groups (DRG), effective since 1.1.2012, forms the basis of a
performance-based system to reimburse general hospital ser-vices. The
influence of this new system on patients discharge characteristics from
a large inten-sive care unit (ICU) is not known. With the introduction of
the DRGs we expect patients to be discharged (1) after a shorter length
of ICU stay and (2) with higher severity of illness-score.
Methods: The ICU of the city hospital Triemli in Zurich has an
interdisciplinary organisation with surgical and internal medical patients
with a maximum occupancy of 18 beds and a center function for the
surrounding hospitals. In this ongoing prospective observational study,
we collect and analyse the anonymised data of all patients discharged
from our ICU during defined periods prior and after the introduction of
the DRGs. There are no exclusion criteria. The primary endpoint is the
length of ICU stay in hours. The secondary endpoint is the severity of
illness of the patients at the time of discharge, detected by the scoring
system SAPS II.
Results: We present preliminary data of a 10 months period, 5 months
prior and 5 months after the intro-duction of the DRGs. Data of 823 and
884 patients were analysed, respectively. We found comparable length
of stays in our ICU with a mean ±SD of 51.5 ± 3.6 h and 51 ± 3.9h.
The SAPS II scores at the time of discharge from the ICU were also
comparable before and after the intro-duction of the DRGs with 28.3 ±
13 and 27.9 ± 12.7.
Conclusion: Beside a higher caseload, up to now the introduction
of the DRG system in Switzerland has no impact on discharge
characteristics from a large ICU with a center function. Further data
analy-sis has to be performed.
46 S
P79
SIPHAROM: un groupe de travail interdisciplinaire
en Suisse latine sur l’utilisation des médicaments
en soins intensifs
P. Voirol1, L. Gattlen1, T. Fumeaux2, P. Eckert3
1CHUV, Lausanne, Switzerland; 2GHOL – Hôpital de Nyon,
Nyon, Switzerland; 3Hôpital du Valais (RSV), Sion, Switzerland
Introduction: La présence de pharmaciens cliniciens en soins intensifs
est reconnue comme efficiente. Les préoccupations quant à la gestion
et l’administration des médicaments sont communes à tous les
hôpitaux: du fait du transfert fréquent des patients d’un hôpital vers
un autre, et de la migration du personnel soignant des soins intensifs
(médecins ou infirmiers) durant le cursus professionnel, la mise en
commun des problèmes et solutions au sein d’un réseau pourrait
permettre à la fois un meilleur retour d’expérience, un partage des
compétences, et une harmonisation raisonnable des pratiques. Dans
ce but, un groupe de travail interdisciplinaire (SIPHAROM) a vu le jour
en Suisse Romande en 2007, et s’est étendu à toute la Suisse Latine,
avec comme but la mise en place d’un tel réseau.
Programme, projet: SIPHAROM est un groupe de travail du Réseau
Latin de Médecine Intensive. Il réunit un médecin, un infirmier et un
pharmacien issus de treize hôpitaux, et a pour buts:
• L’échange de données concernant l’administration de médicaments
aux soins intensifs,
• Le partage des connaissances et des compétences pour régler
ces problèmes identifiés
• L’établissement de standards «latins» pour l’administration des
médicaments de soins intensifs
Résultats: Les réunions semestrielles de SIPHAROM ont permis
de lancer divers projets, centrés sur quatre axes principaux:
• Harmonisation de la dilution et préparation de médicaments
intraveineux continus usuels: définition de 52 dilutions standards
en tenant compte des problèmes de compatibilités, de la littérature
et des données récoltés par les divers centres. Ce travail a permis des
collaborations avec l’industrie pour développer des substances prêtes
à l’emploi
• Harmonisation de l’étiquetage des médicaments injectables:
définition des éléments minimaux devant figurer sur les étiquettes
(d’après les recommandations et normes internationales disponibles)
• Echange de données critiques (messages d’alerte, problèmes de
stabilités ou de compatibilité)
• Rédaction de recommandations communes pour l’utilisation de
médicaments au sein du réseau
Discussion, conclusion: L’utilisation adéquate des médicaments dans
les soins intensifs requiert la mise en commun de diverses
compétences propres aux différentes professions impliquées dans la
prise en charge des malades (médecins, infirmiers et pharmaciens).
La mise en place d’un réseau est un moyen efficace d’augmenter
encore ce partage de compétences.
P80
Standardized drug labelling in intensive care: results
of an international survey among ESICM members
F. Balzer1, N. Wickboldt2, C. Spies1, B. Walder2, J. Goncerut2,
G. Citerio3, A. Rhodes4, M. Kastrup1, W. Boemke1
1Department of Anaesthesiology and Intensive Care Medicine,
Campus Charité Mitte and Charité Campus Virchow-Klinikum,
Charité-University Medicine Berlin, Berlin, Germany; 2Division of
Anaesthesiology, Department of Anaesthesiology, Intensive Care
and Clinical Pharmacology, University Hospitals of Geneva, Geneva,
Switzerland; 3Department of Anesthesia, Hospital San Gerardo, Monza,
Italy; 4Department of Intensive Care Medicine, St. George’s Healthcare
NHS Trust, St. Georges University of London, London, United Kingdom
Introduction: Standardized coloured drug labels may increase patient
safety in the intensive care unit (ICU). The rates of adherence to
standardized drug syringe labelling (DSL) in European and nonEuropean ICUs, and the standards applied are not known. The aim of
this survey among the members of the European Society of Intensive
Care Medicine (ESICM) was to assess if and what standardized DSL
is used, if the standards for DSL are similar internationally and if
intensivists expect that standardized DSL should be delivered by the
pharmaceutical industry.
Methods: The study was endorsed by ESICM. A structured, webbased, anonymized survey on standardized DSL was performed among
ESICM members from March to May 2011 (Clinicaltrials.gov identifier
NCT01232088). Descriptive data analysis was performed and Fisher’s
exact test was applied (p <0.05).
Results: Four-hundred-eighty two submissions from 61 countries were
analyzed (20% non-European). Thirty-five percent of the respondents
reported that standardized drug labelling was used hospital-wide, and
39% reported that standardized DSL was used in their ICU (Europe:
Northern 53%, Western 52%, Eastern 17%, Southern 22%). The
International Organization of Standardization (ISO) 26825 norm in its
original form was used by 30%, an adapted version by 19% and local
versions by 45%; 6% used labels that were included in the drug’s
packaging. Eighty percent wished that the pharmaceutical industry
supplied ISO 26825 norm labelling together with the drugs.
Conclusion: Standardized drug labelling is not widely applied in
European and non-European ICUs, and mostly does not adhere strictly
to the ISO norm. The frequency and quality of DSL differs to a great
extent between European regions. This leaves much room for
improvement. The pharmaceutical industry could be supportive by
supplying standardized drug labels together with the drugs.
P81
The number of drugs is independently associated
with mortality
T. Tritschler1, B. Frey1
1
Kinderspital Zürich, Zurich, Switzerland
Introduction: The possibility that more care may also cause harm
received little attention in the past. Therefore, it is important to detect
potential overtreatment and evaluate the reasons. In our study we
focused on number of drugs applied [1].
Methods: Prospectively collected data of 1009 sequential first
admissions in 2007 to a multidisciplinary, 19-bed paediatric intensive
care unit (PICU). Number of drugs applied in the first 24 hours was
retrospectively evaluated. We analysed possible explanatory parameters
for the number of drugs: severity of illness at admission (PIM2),
diagnosis, age, sex, foreign immigrant status, religious denomination
and socio-professional status of parents. We also analysed whether
PICU mortality is associated with the number of drugs. Non-parametric
tests and binary logistic regression analysis were used to evaluate
associations.
Results: The mean number of drugs for the whole sample was 5.8
(SE 0.1). The most common drugs were sedatives (692), paracetamol
(601), antibiotics (514) and pro-/anticoagulatory drugs (303). There
were significant correlations between number of drugs and severity
of illness (p <0.001), mortality (p = 0.015), age (p = 0.008), principal
diagnosis and religious denomination. Children with Christian
denomination received more drugs than children with other
denominations (p = 0.015). The variables independently predicting
“death in PICU” were PIM2 (OR 1.056, 95% CI 1.024–1.088), length
of stay (OR 1.048, 1.001–1.098) and number of drugs (OR 1.134,
1.010–1.273).
Conclusions: The association between number of drugs applied in
the first 24 hours of PICU admission and mortality urges intensivists for
caution regarding unlimited drug therapy. The mere availability of drugs
may lead intensivists and nurses to use them inappropriately. Patients
may be harmed by side effects and drug-drug-interactions. The
pharmaceutical industry may foster overtreatment. Overtreatment may
be a serious problem in intensive care.
1. Part of the data has been previously published: Tritschler T et al
(2011) Are immingrant children admitted to intensive care at increased
risk? Swiss Med Wkly 141:w13190.
P82
Patients who “leave without being seen” the Emergency
Department: the role of a fast-track way (Notfallpraxis)
M. Lepori1, M. Trobia1
1
Ospedale Regionale, Bellinzona, Switzerland
Background: The phenomenon of patients who leave without
being seen (LWBS) by a physician an emergency department (ED),
represents a failure of the system of take in charge of patients. Although
medical literature shows that the clinical evolution of LWBS patients
is practically always favourable, we have to undertake all the
possible efforts in order to reduce the amount of these cases.
Aim: The aim of this study is to evaluate the impact on the LWBS
patients phenomenon of the introduction of a fast track way
(Notfallpraxis), for the patients whose triage score – executed according
to the “Swiss Emergency Triage Scale” model – has determined their
redirection to this new care unit.
Methodology: We compared prospectively the LWBS patients’ rate of
the ED, analysing the data for the period March-May 2011 (before the
47 S
introduction of this new unit) and the period March-May 2012 (after its
opening).
Results: During the period March-May 2011 the number of patients
in the ED was of 5418, while during March-May 2012 it was of 5192
(P = NS). The percentage of LWBS patients was of 1.69% in year 2011
and of 0.84% in 2012 (1.27 %), (P <0.05) NS).
Conclusion: The introduction of a fast track way (Notfallpraxis) for the
least serious cases is a suitable instrument to reduce the amount of
LWBS patients in the ED.
P83
Institutionalisierte ethische Fallbesprechungen auf
einer chirurgischen Intensivstation – Eine Zwischenbilanz
Meyer-Zehnder Barbara1, Albisser Schleger Heidi2,
Barandun Schäfer Ursi1, Reiter-Theil Stella2, Pargger Hans1
1
Departement Anästhesie, Universitätsspital, Basel, Switzerland;
2
Klinische Ethik Support & Begleitforschung, UPK, Universitätsspital,
IBMB, Basel, Switzerland
Hintergrund und Fragestellung: Therapieentscheide wie die Frage,
ob eine begonnene Therapie bei stagnierendem Behandlungserfolg
weitergeführt werden soll oder nicht und wie bei nicht-urteilsfähigen
Patienten vorzugehen ist, können in einem Behandlungsteam
Unsicherheit, Belastung und Konflikte auslösen. Interprofessionelle
Fallbesprechungen können möglicherweise die Qualität der
Entscheidungen verbessern und die Beteiligten entlasten. Vor diesem
Hintergrund wurde die medizinethische Leitlinie METAP entwickelt,
die Grundlagen und Hilfsmittel für die ethische Entscheidungsfindung
zur Verfügung stellt. Sie bietet ein mehrstufiges Entscheidungsmodell
(Eskalationsmodell), welches als 3. Stufe eine ethische
Fallbesprechung im Behandlungsteam beinhaltet. Diese
Fallbesprechungen, die einem definierten Ablauf folgen, finden auf
einer chirurgischen Intensivstation seit Mitte 2010 regelmässig statt.
Dafür ist ein fester Termin im Wochenablauf reserviert, der in Anspruch
genommen wir, wenn eine Indikation für ein Gespräch besteht. Die
Gespräche werden von einer Gruppe geschulter Mitarbeitender, einer
«Steuergruppe» aus Pflegenden und Ärzten, organisiert und moderiert.
Dabei wird in einem Halbjahresplan ein Verantwortlicher aus der
Gruppe definiert. Haben ethische Fallbesprechungen zur Unterstützung
der Entscheidungsfindung im Alltag Platz?
Methode: Alle ethischen Fallbesprechungen, die zwischen dem
1. Januar 2011 und dem 14. Mai 2012 stattfanden, wurden erfasst und
ausgewertet. Neben Alter, Geschlecht, Grunderkrankung und SAPS
der besprochenen Patienten wurden statistische Angaben zu den
Teilnehmenden und das Outcome erfasst.
Resultate: Im Beobachtungszeitraum fanden 40 ethische
Fallbesprechungen bei 38 Patienten (23 Männer, 15 Frauen;
Durchschnittsalter 68 Jahre) statt. Das entspricht gemittelt einer
Besprechung pro 12 Tage. Im Mittel nahmen 6 Mitarbeitende daran teil
(3 Ärzte/3 Pflegende). Eine Fallbesprechung dauerte zwischen 30 und
60 Minuten. 19 Patienten (12 Männer, 7 Frauen) sind in der Folge
verstorben.
Schlussfolgerung und Ausblick: Ethische Fallbesprechungen finden
in unserem Modell ca. alle 2 Wochen statt. Das in METAP
vorgeschlagene Verfahren ist demnach im klinischen Alltag anwendbar;
die Bestimmung einer verantwortlichen Person für die Organisation
hat sich bewährt. Ein fester Termin garantiert die regelmässige
Durchführung. Aktuell wird daran gearbeitet, die Vernetzung mit
den zuweisenden Klinikern zu verbessern und deren Teilnahme zu
unterstützen.
P84
Zufriedenheit bei Schichtübergaben:
Die akkurate Wahrnehmung des Gegenübers ist wichtig
Ch. Nick1, P.L. Klumb1
1University of Fribourg, Fribourg, Switzerland
Für die gute Kommunikation bei Schichtübergaben von Ärzten sind die
Bedürfnisse des Gegenübers ein wichtiger Einflussfaktor. Ziel der
vorliegenden Studie war es zu zeigen, inwieweit die korrekte
Einschätzung des Gegenübers (operationalisiert durch Abweichungen
zwischen Fremd- und Selbsteinschätzung des positiven (PA) oder
negativen (NA) Affekts) sich auf die Zufriedenheit des Partners in der
Übergabedyade auswirkt. Eine akkurate Einschätzung des Affekts wird
dabei als Manifestation sozialer Kompetenz betrachtet. Dies ist für die
Verbesserung der Übergaben relevant und bislang liegt wenig
empirische Evidenz dazu vor. Um die Abweichung in der Einschätzung
des Befindens zu messen, wurden über einen Zeitraum von vier
Wochen mit Hilfe von computergestützten Ereignisstichproben jeweils
unmittelbar nach den Schichtübergaben Daten zu Befinden und
Zufriedenhit von Assistenzärzten der Intensivstationen von fünf
Schweizer Krankenhäusern gesammelt. Die Stichprobe besteht aus
32 Ärzten (47,1% Frauen, 52,9% Männer; Durchschnittsalter 33,59
Jahre), die im Untersuchungszeitraum 213 Übergaben absolvierten.
Die Auswertung erfolgte mit Mehrebenenanalysen (HLM). Je akkurater
der ausscheidende Arzt das Befinden seines Gegenübers einschätzte,
desto zufriedener war der ankommende (und Informationen
empfangende) Arzt mit der Übergabe. Signifikant war der Effekt jedoch
nur hinsichtlich NA (b = –.35; p < .001). Theoretische und praktische
Implikationen dieser Ergebnisse werden diskutiert.
POSTER SGI PFLEGE
P85
Symptombelastung bei Chronically Critical Illness (CCI) –
sogenannten «Langzeitintensivpatienten»
M.M. Jeitziner1, U. Barandun Schäfer1, P. Massarotto1
1SGI Kommission Praxisentwicklung Intensivpflege, Bern,
Switzerland
Einleitung: Patienten und Patientinnen mit Chronically Critical Illness
(CCI), sogenannte «Langzeitintensivpatienten», sind Menschen, die
nach einer lebensbedrohlichen Ereignis einen prolongierten Verlauf
erleben und lange maschinelle Beatmung benötigen. Diese
Patientengruppe beansprucht bis zu 20–25% der Pflegetage auf
Intensivstationen (IS). Für die Betroffenen und ihre Angehörigen
bedeutet es grosses Leid. Durch die medizinischen Fortschritte
wird ihre Anzahl weiter steigen. Die SGUI/SSMI Kommission
Praxisentwicklung Intensivpflege ist daran, das aktuelle Wissen zu
mehreren Aspekten von CCI zusammenzufassen und zur Verfügung
zu stellen. Diese Arbeit gibt einen Überblick über Symptombelastung,
Bewältigung und Massnahmen zur Reduktion der Belastung bei CCI.
Methode: In den Datenbanken MedLine und CINAHL wurde nach
Texten zu Symptomen, Bewältigung (Coping) und Massnahmen zur
Unterstützung von CCI Betroffenen auf der IS gesucht. Die relevanten
Artikel wurden systematisch beurteilt und zusammengefasst.
Resultate: CCI Betroffene leiden an vielen Symptomen. Sie erfahren
körperliche Symptome wie Durst, Schmerz, Atemnot, Polyneuro- und
Polymyopathie, Appetitmangel, Gewichtsverlust und Energielosigkeit.
Typische psychische Symptome sind depressive Verstimmung,
Antriebslosigkeit und Angst. Im Bereich Kognition leiden viele
Betroffene an Delirium, Denk- und/oder Gedächtnisstörungen.
Kommunikationsschwierigkeiten behindern den Kontakt zur Familie
und zu den Fachpersonen. Zudem belasten Sorgen um Finanzen und
die Berufstätigkeit sowie veränderte familiäre Rollen. CCI Patienten
verfügen über unterschiedliche Strategien, zur Bewältigung der
belastenden Situation, u.a. Anpassung an die Stressoren. Zu den
Frühmassnahmen zählen Symptom- und Bedürfnisassessment,
Prävention und Management akuter organischer Störungen,
zielgerichtete Behandlungsstrategien (z.B. zu Weaning und Ernährung),
Frühmobilisation, Einbezug der Familie und Kommunikationsstrategien.
Spätmassnahmen sind z. B. Beschäftigungsangebote, Umgang mit
Leiden sowie körperliche und psychische Rehabilitation.
Schlussfolgerung: Die systematische individuelle Symptom- und
Bedürfniserfassung trägt dazu bei, gezielt Massnahmen gegen die
hohe Belastung der Betroffenen zu ergreifen. Das Identifizieren und
Unterstützen vorhandener Copingstrategien sowie der Einsatz gezielter
Massnahmen können den Aufenthalt auf der IS und seine Folgen für
CCI Betroffene günstig beeinflussen.
48 S
POSTER SGI PFLEGE
P86
Augenpflege auf der Intensivstation –
«Kann man da nicht mal ein Auge zudrücken?»
O. Röpke1
1Zuercher Hochschule für angewandte Wissenschaften,
Winterthur, Switzerland
Introduction: Sedierte und bewusstseinsveränderte Patienten
auf Intensivstationen benötigen eine spezielle Augenpflege zur
Verhinderung von Keratopathien. Die Inzidenz der Keratopathien wurde
in früheren Untersuchungen mit 42–60% angegeben. Die Fachliteratur
beschreibt das Thema meist nur sehr kurz und die Augenpflege wird
häufig als wenig prioritär eingestuft. Die vorliegende Untersuchung
versucht die Frage zu beantworten, welche Massnahmen der
Augenpflege zur Verhinderung von Keratopathien bei sedierten
und bewusstseinsveränderten Patienten auf Intensivstationen die
wirkungsvollsten sind.
Methods: Zur Beantwortung der Fragestellung fand eine systematische
Literatursuche in den Datenbanken Pubmed und CINAHL statt, die
sieben quantitative Studien und eine Metaanalyse hervorbrachte. Die
Auswertung dieser Studien fand anhand anerkannter Gütekriterien
und unter Berücksichtigung der Evidenzstufen statt.
Results: Die am häufigsten untersuchten Interventionen in den
quantitativen Studien waren die Behandlung mit Augensalbe und die
Anwendung von Polyethylenverbänden als feuchte Kammer. Statistisch
signifikante Ergebnisse wurden in drei der sieben Studien und
der Metaanalyse zugunsten der Polyethylenverbände gefunden.
Conclusions: Um die Kornea der untersuchten Population sicher vor
Keratopathien zu bewahren, reicht die alleinige Salbung der Augen
bei exponierter Kornea wahrscheinlich nicht aus. Die Anwendung von
Polyethylenverbänden erwies sich in den untersuchten Studien als
sichere Massnahme zur Verhinderung von Keratopathien. Allerdings
sollten aufgrund von potentiellen Komplikationen, z.B. der
Infektionsgefahr, Polyethylenverbände aber nur mit Vorsicht
angewendet werden und in weiteren Studien insbesondere auf diese
Komplikationen untersucht werden.
P87
Patientenorientierter Einbezug von Angehörigen
auf der Intensivstation
C. Wesch1, U. Barandun Schäfer1, M. Wehrli1
1OIB Universitätsspital Basel, Basel, Switzerland
Hintergrund: Angehörige sind für Patienten und Personal auf
Intensivstationen eine wichtige Ressource und ihr Einbezug in
Entscheidungen und Pflegetätigkeiten ist für alle Beteiligten ein
Gewinn. Gleichzeitig befinden sie sich selbst in einer sehr belastenden
Situation. Die Umsetzung ist ressourcenabhängig (zeitlich, fachlich,
kommunikativ). Unterschiedliches Vorgehen führt zu Verunsicherung
und Konflikten. Im Rahmen der formulierten Strategie (Portfolio) wurde
auf der Station ein Praxisentwicklungsprojekt durchgeführt. Ziel war die
Erarbeitung eines Konzeptes zur Nutzung der Ressourcen der
Angehörigen für die Patienten. Die Ergebnisse der Literaturrecherche
und das geplante Vorgehen wurden am SGI/SSMI Kongress 2011
vorgestellt.
Methode: Die Projektarbeit begann mit einer systematischen
Literaturübersicht und einer Ist-Erhebung (Befragung von 20 Patienten
und 13 Angehörigen). Eine interprofessionelle Projektgruppe entwickelte
unter der Leitung eines Pflegeexperten konkrete Massnahmen in
Anlehnung an die Methode der Aktionsforschung (Datenanalyse
zum Ist-Zustand, Erstellung eines Aktionsplanes, Umsetzung der
Massnahmen durch Projektgruppe und Evaluation in mehreren Zyklen).
Fokussiert wurden der Betreuungsauftrag gegenüber den Angehörigen,
die Informationsübermittlung sowie die praktische Unterstützung bei der
Arbeit mit Angehörigen. Nach Genehmigung durch die Führung erfolgte
die Implementierung mittels Schulungen und Begleitung im Alltag.
Ergebnisse: Die Massnahmen zur Informationsübermittlung umfassen
die Regelung des Informationsaustausches mit dem Sekretariat und die
Erstellung einer Informationsbroschüre für Angehörige. Zur Förderung
ihres Einbezuges werden Angehörige unter Berücksichtigung der
individuellen Situation und der Ressourcen eingeladen, bei
Pflegemassnahmen im Zimmer zu bleiben und aktiv mitzuarbeiten.
Zudem sprechen Pflegende mit Angehörigen über deren Erleben
dieser Zusammenarbeit. In schwierigen Situationen wenden die
Pflegeexperten bei Gesprächen mit Angehörigen leitfadengestützt
ausgewählte Aspekte der Familienzentrierten Pflege von Wright und
Leahey (2005) an.
Schlussfolgerungen: Die Ergebnisse einer ersten Zwischenevaluation
aus Sicht von Patienten, Angehörigen und Pflegenden zeigen: Viele
Angehörige nehmen Angebote zum Einbezug gerne an. Die Patienten
fühlen sich dadurch unterstützt. Voraussetzung für einen
patientenorientierten Einbezug der Angehörigen sind ein klares
Commitment der Führung, fachliche Begleitung.
P88
Lärm auf der Intensivstation und dessen Auswirkungen
auf Patienten und Personal
Daniela Lang-Eberle, UniversitätsSpital Zürich
Einleitung: Tagtäglich sind wir Geräuschkulissen ausgesetzt, die wir
mehr oder weniger beeinflussen können. Aufgrund von Beschwerden
seitens der Patienten und des Personals wurde nach Rücksprache mit
der Arbeitsmedizin eine Lärmmessung auf unserer Intensivstation
veranlasst.
Fragestellung: Ist es möglich mit einfachen Interventionen eine
signifikante Lärmreduktion auf einer Intensivstation zu erreichen?
Methodik: Die Arbeitsgruppe Basale Stimulation AIO IPS Hof B
hat durch die Arbeitsmedizin des UniversitätsSpital Zürich eine
Lärmmessung veranlasst. Gleichzeitig stellte die Arbeitsmedizin
Literatur zur Verfügung, damit die Interventionen aufgrund der
Auswirkungen von Lärm auf Patienten und Personal abgeleitet werden
konnte. Die Interventionen wurden schrittweise umgesetzt und nach
einem Jahr erfolgte eine Kontrollmessung.
Ergebnis: Die Lärmemissionen gingen um ca. 25% zurück. Das Thema
Lärm war präsent und vor allem wurde das Personal sensibilisiert
lärmverursachende Faktoren auszuschalten.
Schlussfolgerung: Die Lärmmessung nach den Interventionen hat
deutlich gezeigt, dass die Sensibilisierung des Personals und die
Umsetzung der Interventionen zu einer Lärmminderung führten. Wir
müssen dieses Thema jedoch weiterhin präsent halten, damit wir bei
hohem Arbeitsanfall nicht in alte Muster zurückfallen.
P89
Chronically Critically Ill Patients: Herausforderungen
bei der Pflege von sogenannten «Langzeitintensivpatienten»
– Überblick
U. Barandun Schäfer1, M.R. Fröhlich1, S. Haubner1, E. Liem1
1SGI/SSMI Kommission Praxisentwicklung Intensivpflege, Basel,
Switzerland
Hintergrund: Durch Fortschritte in der Intensivmedizin überleben
immer mehr Menschen akute, lebensbedrohliche Erkrankungen. Neben
vielen Patientinnen und Patienten, die nur kurze intensivmedizinische
Betreuung benötigen, gibt es eine Patientengruppe, die durch eine
lange Aufenthaltsdauer mit prolongierter Abhängigkeit von maschineller
Beatmung auffällt. Diese «Langzeitintensivpatienten» werden als
Chronically Critically Ill (CCI) Patients bezeichnet. Sie beanspruchen
20 bis 25% der Intensivpflegetage. Zur Pflege dieser Patientengruppe
besteht ein grosses Wissensdefizit.
Ziel: Erarbeitung und Darstellung des aktuellen Wissens über
Chronically Chritical Illness (CCI).
Methode: Literaturübersicht zu CCI mit Fokus auf Merkmalen,
Pathophysiologie und pflegerelevanten Phänomenen.
Ergebnisse: Als Chronically Critical Ill gelten Patientinnen und
Patienten, welche längere Zeit (je nach Quelle ab 2 Tagen bis ab 4
Wochen) beatmet sind oder bei denen eine Tracheotomie durchgeführt
wurde, weil sie nicht vom Respirator entwöhnt werden können. CCI
geht mit komplexen pathophysiologischen Veränderungen im gesamten
Organismus einher, insbesondere mit metabolischen, endokrinen und
immunologischen Störungen. Aktivierte Stress- und Entzündungsmediatoren, kataboler Stoffwechsel, rezidivierende Infekte sowie
deren Folgen verzögern die Genesung und Massnahmen zur (Früh-)
Rehabilitation. Die pflegerelevanten Phänomene werden gemäss der
internationalen Pflegeklassifikation NNN1 in Aktivitäten des täglichen
Lebens eingeteilt. Am folgenschwersten für die Betroffenen und
ihre Angehörigen sind kognitive Defizite, Schlafstörungen,
Polyneuropathien/-myopathien, Erschöpfung und depressive
Verstimmung während des Aufenthalts sowie auch nach Austritt
von der Intensivstation und dem Spital.
Schlussfolgerungen: Zunehmend mehr Menschen sind von CCI
betroffen. CCI hat grosse Auswirkungen für die Betroffenen und ihre
Angehörigen. Ärztliche, pflegerische und therapeutische Teams von
Intensivstationen und nachbetreuenden Einrichtungen sind gefordert,
wirksame Interventionen zur Prävention und Linderung des Leidens
sowie zur erfolgreichen Bewältigung und Frührehabilitation zu ergreifen.
Mitglieder der SGI Kommission Praxisentwicklung Intensivpflege werten
die aktuelle Literatur zu folgenden Teilbereichen aus: Symptome/
Bewältigung; Atmung/Beatmung/Weaning; Kognition/kognitive Defizite;
Bewegung/Frühmobilisation. Erste Resultate werden am SGI/SSMI
Kongress 2012 präsentiert.
49 S
POSTER SGI PFLEGE
P90
L’utilisation de séquences filmées dans l’organisation
du travail: l’activité réelle aux soins intensifs de Fribourg
F.T. Taalba1, M.M. Meuwly1
1Hôpital cantonal HFR, Fribourg, Switzerland
Introduction: Dans le cadre d’un projet de formation aux soins
intensifs à l’Hôpital fribourgeois, un prototype d’aide à l’action a été
conçu et testé. (Wisner et de Montmollin, 1960). Il consiste en des
boucles itératives d’analyse à partir de séquences filmées de l’activité
réelle de soignants sur la place de travail. Ce dispositif consiste en une
recherche-action reposant sur une approche d’ergonomie de langue
française.
Méthode: L’étude consiste en l’analyse des séquences filmées, axées
sur trois activités aux soins intensifs: la transmission orale lors de la
prise de poste; le tour du lit du patient; la visite médicale. L’échantillon
comprend: 2 cliniciennes, 1 responsable de la formation pratique,
3 formateurs cliniques, 1 infirmière certifiée et 2 étudiants. L’analyse
comporte cinq phases. La première consiste à filmer l’activité du
soignant, sur une matinée de soins. La deuxième s’organise sous la
forme d’un entretien d’autoconfrontation, d’une heure. La troisième
permet de formaliser l’activité du soignant en règles d’action (Pastré,
1997). La quatrième comporte un entretien d’autoconfrontation
analytique (Theureau, 1992), d’une heure, où le chercheur confronte
le soignant à la formalisation de ses règles d’action. La cinquième
consiste en une séance collective de discussion des résultats avec
tous les soignants.
Résultats: Douze films ont été réalisés. Les résultats obtenus montrent:
1) des modalités opératoires différentes chez tous les collaborateurs;
2) la construction de systématiques transitoires chez les étudiants;
3) des émotions, des préoccupations fortes chez les étudiants, reliées
à la sécurité du patient et à la leur, ainsi qu’à la mise en visibilité de leur
non maîtrise du cas clinique à autrui.
Conclusion: Cette étude met en évidence des prises de consciences
individuelles et collectives sur l’activité professionnelle engendrant un
développement potentiel de la pratique. Les résultats permettent de:
a) diminuer les conflits entre collaborateurs; b) acquérir et développer
des compétences visant la performance; c) revisiter les procédures et
processus qualité; d) effectuer des bilans de progression; e) concevoir
des dispositifs de formation innovant sur la base d’un principe
d’alternance intégrative; f) concevoir des espaces d’activité déontique
(Dejours, 2009). Notre étude est prometteuse en termes de gestion des
ressources humaines, de formation et de recherche.
P91
Quand l’ergonomie joue un tour à la toilette!
C. Joseph1, V. Plouhinec1, L. Gattlen1, M.J. Thévenin1,
P. Eggimann1, P. Maravic1
1CHUV, Lausanne, Switzerland
Introduction: Moment privilégié de la relation patient – soignant, la
toilette permet de rafraichir, d’observer, d’évaluer, et de communiquer
avec le patient. Une architecture défavorable des boxes (1 lavabo par
chambre de 2 à 3 lits) et les pratiques actuelles (cuvette, savon, lavette)
compliquent sa réalisation et favorisent le risque de transmission de
microorganismes (eau contaminée, éclaboussures, va-et-vient). Selon
la littérature, les lingettes permet une réduction de la transmission
croisée des microorganismes entre les patients. Nous avons évalué des
gants et lingettes à usage unique, dans la perspective d’abandonner
des toilettes traditionnelles.
Methode: Evaluation de plusieurs marques de lingettes (incontinence)
et gants (toilette) à usage unique (dont les paquets sont réchauffés
au micro-onde avant usage)au moyen d’un questionnaire standardisé,
complété d’une analyse médico-économique. Un suivi des infections
nosocomiales et des journées d’isolements permet de quantifier la
réduction des transmissions nosocomiales.
Resultats: 165 toilettes (1/3 par des aides soignants et 2/3 par des
infirmiers) ont été évaluées (tableau). Les lignettes et gants à usage
unique permettent: 1) de simplifier et d’optimiser les toilettes (nettoyer,
hydrater, observer et stimuler en un seul geste); 2) de diminuer les va
et vient au lavabo; 2) un gain de temps de 10 min par patient (plus de
rinçage, de séchage, et de produit hydratant); 3) un meilleur respect
des principes d’hygiène; 4) d’éviter les dangers d’éclaboussure et
de glissade. Le coût des lingettes est équivalent à celui de l’addition
des coûts directs (savon, crème) et indirects (service de lingerie et
blanchisserie). Suite à cet essai, dans l’attente des réallocations
financières nécessaires, nous sommes revenus aux toilettes
traditionnelles, ce qui a suscité de vives réactions des soignants
désormais acquis à ce nouveau paradigme.
Conclusions: Les préjugés sur «une toilette sans eau» sont tombés au
vu des autres avantages (rapidité, simplicité, hygiène, confort
d’utilisation) et le personnel est acquis au principe des lingettes et gants
à usage unique. Le coût étant équivalent, au vu des bénéfices attendus
en termes d’hygiène hospitalière, nous préconisons l’abandon des
toilettes traditionnelles et l’introduction des lingettes et gants à usage
unique.
P92
Das Care Team: Begleitung am Lebensende auf der
neonatologischen und pädiatrischen Intensivstation
Sarah Naji, Claudia Dobbert
Auf den Intensivstationen des Kinderspitals Zürich sterben jährlich
35–50 Kinder. Ein Grossteil dieser Patienten wird notfallmässig
hospitalisiert. Es handelt sich dabei um Neu- und Frühgeborene mit
perinatalen Adaptationsstörungen, angeborenen Fehlbildungen und
Stoffwechselerkrankungen, Kinder nach Unfällen, mit schweren
Krankheiten u.a. Tumorleiden, kardiologischen Erkrankungen, aber
auch Kinder mit Intoxikationen oder Folgen von Misshandlungen.
Diese kritisch kranken oder sterbenden Kinder benötigen eine intensive
medizinische und pflegerische Betreuung durch das Behandlungsteam.
Dabei bleibt vielfach nicht genügend Zeit für die Begleitung der
Angehörigen, welche oft unerwartet mit dem unfassbaren Ereignis
konfrontiert sind. Eltern haben in dieser Zeit unterschiedliche
Bedürfnisse, die zum einen ihre Rolle und zum anderen ihre grosse
Belastung betreffen. Die aktive Teilnahme in Entscheidungsprozessen,
regelmässige offen und ehrlich geführte Gespräche über den Zustand
des Kindes und eine Einbeziehung in die Betreuung und Pflege
ihres Kindes bis zum Tod sind notwendig, damit die Elternrolle
wahrgenommen werden und der Trauerprozess beginnen kann.
Vor 10 Jahren wurde das Care Team aufgebaut, um Betroffenen eine
Begleitung und Unterstützung anzubieten, die den psycho-emotionalen
Bedürfnissen im Kontext verschiedener Kultur- und Glaubensrichtungen
gerecht wird. Die Mitarbeiterinnen und Mitarbeiter entlasten das
Behandlungsteam und begleiten sterbende Kinder und ihre
Angehörigen. Erlebnisse während der Zeit des Abschiednehmens
beeinflussen den Trauerverlauf der Eltern und Geschwister stark. Die
Rückmeldungen von Betroffenen und Fachpersonen bestätigen, dass
die Begleitung durch das Care Team wertvoll und hilfreich ist. Auch
nach dem Tod sind Angebote für die Trauerbegleitung erforderlich, die
vom Care Team nur zum Teil geleistet werden können. Allerding wurden
im Verlauf des Projektes einzelne Massnahmen zur Nachbetreuung
implementiert. So sind inzwischen Nachgespräche, Trauerkarten,
Gedenkbuch oder das Angebot zur Trauerbegleitung durch eine
Psychologin selbstverständlich geworden. Ebenso wurde das Care
Team als Teilprojekt dem Kompetenzzentrum für pädiatrische Palliative
Care angegliedert. In einem nächsten Schritt wird eine qualitative
Befragung von Fachpersonen und betroffenen Familien zur Evaluation
stattfinden. Die Kosten für das Projekt werden aus Drittmitteln finanziert.
Die positiven Reaktionen von Betroffenen und Fachpersonen zeigen,
dass es wünschenswert ist, auf allen neonatologischen und
pädiatrischen Intensivstationen eine vertiefte und auf die Bedürfnisse
der Angehörigen angepasste Begleitung am Lebensende anzubieten.
50 S
POSTER SGI PFLEGE
P93
Pflegevisite auf der Intensivstation – «Eine
Unterstüzungsmassnahme für Bezugspflegende»
J. Maier1, C. Rosch1
1UniverstitätsSpital, Zürich, Switzerland
Vor drei Jahren wurde auf den Intensivstationen des UniverstiätsSpitals
Zürich das Bezugspflegesystem eingeführt. Bei der Evaluation konnte
festgestellt werden, dass die strukturiere Erfassung von
Pflegeproblemen sowie die gezielte Planung von individuellen
Pflegeinterventionen für Bezugspflegepersonen eine grosse
Herausforderung darstellte. Zudem zeigten die jährlich stattfindenden
Evaluationen der Pflegedokumentationen, dass eine Überpfüfung der
geplanten und geleisteten Pflege kaum stattfand. Eine Möglichkeit, dies
anzugehen stellt die Pflegevisite dar. Deshalb wurde diese im Zuge
eines Praxisentwicklungsprojektes für die Intensivstationen geplant.
Zielsetzungen:
– strukturierte Benennung der Hauptpflegeprobleme in Pflegediagnosen
– verbindliche Planung individueller Pflegeinterventionen
– eine Überprüfung der geleisteten Pflege
– die Förderung von Fachdiskussionen im Team
– die Verbesserung der Pflegequalität
In einem Pilotprojekt wird ab Juli 2012 auf zwei Intensivstationen die
Wirkung der Pflegevisite im Hinblick auf die oben genannte Zielsetzung
getestet. Die Moderation und die Patientenauswahl obliegt der in der
Praxis tätigen Pflegeexpertin. Nebst ihr nehmen die Bezugspflegeperson sowie optional noch eine bis maximal zwei weitere Pflegepersonen teil. Als Struktur wurde ein adaptiertes Raster des ePA-AC
(ergebnisorientiertes PflegeAssessment Acute Care)geählt, das dieses
aktuell im UniverstiätsSpital Zürich eingeführt wird. Als Ergebnis werden
nebst eine strukturierteren Pflegedokumentation und einer daraus
resultierenden Steigerung der Pflegequalität auch die Etablierung von
Fachdiskussionen über Pflege erwartet sowie eine Stärkung der Rolle
der Bezugspflegepersonen.
P94
Regelmässiges interprofessionelles Gespräch
auf der Intensivstation für Brandverletzte des USZ
Christine Rosch, Pflegeexpertin
USZ, NUK D 102, Rämistr. 100, 8091 Zürich, christine.rosch@usz.ch
Ausgangslage: Im Rahmen der Erstellung eines Behandlungspfads
wurden Ziele und Schlüsselelemente der Versorgung Brandverletzter
definiert. Dies erfolgte evidenzbasiert durch systematische Literaturrecherche und mit Hilfe von Mitarbeitenden- und Patienteninterviews.
Zu den Schlüsselelementen des Behandlungspfades zählen
Kommunikation, Koordination von Rollen sowie Planung der Aktivitäten
des multiprofessionellen Teams, der Patienten1 und Angehörigen.
Ziele: Wir wollen Kommunikationssicherheit für das gesamte
Behandlungsteam erreichen und verbessern. Hierdurch werden
diagnostische und therapeutische Prozesse optimiert und das Risiko
für Behandlungsfehler vermindert. Verlegungen erfolgen koordiniert,
erhöhte Mitarbeiterzufriedenheit und hohe Patienten-/ Angehörigenzufriedenheit sind die Folge.
Methode: Seit Januar 2012 haben wir ein wöchentliches
interprofessionelles Gespräch implementiert, das uns Klarheit
über erfolgte und geplante Interventionen sämtlicher beteiligter
Berufsgruppen gibt und so Prozessoptimierung und qualitativ
hochstehende Versorgung Brandverletzter erleichtert. Jeden
Mittwochmorgen treffen wir uns für 30 min., um über sämtliche
Patienten der IPS zu sprechen. Anwesend sind Intensivmediziner,
Chirurgen, Pflegende IPS und Bettenabteilung, Physio-/ Ergotherapie,
Ernährungsberatung, Psychiater, Klinische Ethik, Sozialarbeit,
Abteilungskoordination. Nach der Vorstellung des Patienten diskutieren
alle Berufsgruppen erfolgte und geplante Interventionen. Anschliessend
dokumentiert die Pflegeexpertin Inhalte und Beschlüsse im
Klinikinformationssystem. Bei Bedarf kann ein weiterführendes
Gespräch sofort organisiert werden.
Ergebnisse: Das interprofessionelle Gespräch liess sich problemlos
in die bestehende Visite integrieren, es verläuft strukturiert und klar
geleitet. Die Mitarbeitenden der Berufsgruppen nehmen mit hoher
Verbindlichkeit aktiv daran teil. Die Koordination und der routinemässige
Austausch erleichtern und beschleunigen den Patientenprozess. Das
Ziel koordinierter Verlegungen wurde bei der Mehrzahl der Patienten
bereits erreicht. Ausserdem sind Verständnis und Vertrauen unter den
Mitarbeitenden der Berufsgruppen gewachsen, was Kommunikation
und Zusammenarbeit erleichtert.
Fazit: Wir befinden uns auf dem richtigen Weg, das interprofessionelle
Gespräch wird von allen Teilnehmenden angenommen und als sinnvoll
bewertet. Wir werden es mit Fokusgruppeninterviews evaluieren und
ggf. Anpassungen vornehmen. Es ist geplant, das Gespräch auf die
Bettenabteilung auszuweiten.
1 Die im Dokument verwendete männliche Form gilt immer auch für das weibliche
Geschlecht
P95
Waschen ohne Wasser WoW
Forschungsanwendung auf der Intensivstation:
Waschen mit Einmalwaschtüchern oder der traditionellen
Waschmethode?
Weidner Evelyn1, Rohrer Ottilia1, Jeitziner Marie-Madlen1
1Klinik für Intensivmedizin, Inselspital, Bern, Switzerland
Einführung: Bei allen Tätigkeiten der Körperpflege während der
stationären Pflege im Spital sind Infektionsrisiken dokumentiert.
Aufgrund eines Nachweises von Burkholderia Cepacia in
Pflegeprodukten wurde nach einer vorbeugenden Hautreinigung
gesucht. WoW heissen spezielle Einwegtücher, bei deren Einsatz sich
Seife, Wasser und Emulsionen erübrigen. Damit das Komfortgefühl
für die Patienten erhalten bleibt, sind diese Tücher aus weichem Vlies
hergestellt. Studien zeigen, dass die Patienten die Pflege mit WoWEinwegtüchern als weniger schmerzhaft oder weniger anstrengend
empfinden als mit den konventionellen Waschtüchern. Zudem
vermindert der Einsatz der Wow-Einwegtücher deutlich sowohl die
körperliche als auch die zeitliche Belastung der Pflegenden. Auch die
Wäschereduktion der Institution fällt ins Gewicht.
Methode: In der Zeitspanne von August 2010 bis November 2010
wurde WoW auf der interdisziplinären Intensivstation getestet.
Schulungen der Pflegenden und eine Multiplikatorengruppe begleiteten
den Test des neuen Angebots. Während der Testphase wurde mit
strukturierten Interviews und Fragebögen bei Patienten und Pflegenden
das Angebot WoW evaluiert. Folgende Aspekte wurden dabei
berücksichtigt: das Wohlbefinden der Patienten, die Anwenderfreundlichkeit, die Qualität des Produktes, die Effektivität der
Körperpflege, der Reinigungseffekt, die Auswirkungen auf die Haut
und mögliche Nebeneffekte. Zudem wurden mögliche finanzielle und
zeitliche Einsparungen überprüft.
Ergebnisse: Insgesamt konnten 57 Fragebögen von Pflegenden
evaluiert werden und 20 Patienten wurden befragt. WoW wurde von
45 (79%) der Pflegenden als ein effektives und anwender-freundliches
Angebot beschrieben. Verschmutzungen liessen sich in 43 (75%) Fällen
ent-fernen und die Haut wurde gepflegt. Die meisten Patienten erlebten
WoW als angenehm und wohltuend: sie fühlten sich erfrischt. Zeit
sparten die Pflegenden vorwiegend bei der Vorbereitung der
Körperpflege und beim Entsorgen der Waschutensilien. Zudem konnte
ein Rückgang beim Wäscheverbrauch sowie beim konventionellen
Waschprodukteverbrauch beobachtet werden. Das neue Angebot
konnte gut in die Konzepte der Basalen Stimulation® und Kinästhetik
integriert werden.
Schlussfolgerungen: WoW ist ein innovatives Angebot, das die
Patienten und die Pflegenden als Erweiterung in die Körperpflege
integrieren können. Dabei gilt es jedoch, den individuellen
Körperpflegebedürfnissen der Patienten Rechnung zu tragen.
51 S
E R S TAU T O R E N V E R Z E I C H N I S
Aguirre JA 24 S, 32 S, 33 S
Akoumianaki EA 14 S, 42 S
Albrecht E 6 S, 7 S, 11 S
Albu G 18 S
Arnold Th 33 S
Auinger K 39 S
Babic D 37 S
Balzer F 47 S
Bandschapp O 2 S, 9 S, 25 S
Barandun Schäfer U 17 S, 49 S
Basciani RM 23 S, 29 S
Benz-Wörner J 36 S
Bitter C 30 S
Blaudszun G 20 S
Bolliger D 24 S
Brunner ME 12 S
Buehrer SB 8 S
Caduff Chr 38 S
Cheseaux N 29 S
Copin JC 3 S
Czarnetzki C 22 S
de Lorenzi C 27 S
Franzen D 38 S
Frey B 14 S
Fröhlich S 5 S
Gander SG 24 S
Gerber A 17 S
Ghamri Y 41 S
Gigon F 3 S
Gisin S 34 S
Gosselin RD 21 S
Harm F 27 S, 28 S
Henry A 44 S
Herrmann IK 3 S
Hermatschweiler S 39 S
Hess L 5 S, 20 S
Hilty MP 15 S
Homburg KH 46 S
Jäger S 17 S
Jeitziner MM 48 S
Joseph C 50 S
Jotterand C 43 S
Kirschmann G 30 S
Krebs S 36 S
Lang-Eberle D 49 S
Léchappé V 27 S
Lederer HL 39 S
Lele Eniko S 18
Lepori M 47 S
Lurati Buse G 4 S, 22 S
Luyet CL 10 S, 11 S
Lyazidi AL 42 S
Maier J 51 S
Malaspinas I 8 S, 35 S
Mann D 24 S
Mauch J 19 S
Mauermann E 10 S
Meyer-Zehnder B 48 S
Mlekusch S 32 S
Moll J 8 S
Moullet CM 42 S
Naji S 50 S
Neubert A 14 S
Neuhaus D 34 S
Neziri AY 30 S, 31 S
Nick Ch 48 S
Oppliger E 43 S
Perren A 16 S, 40 S, 45 S, 46 S
Piller NP 30 S
Pittet V 33 S
Riedel T 13 S
Rossi 2 S
Roulin MJ 3 S
Röpke O 49 S
Rosch C 51 S
Roulin MJ 45 S
Rudiger A 40 S
Rupp S 12 S
Saporito A 32 S
Scemama-Clergue J 35 S
Schaer C 38 S
Schliessbach J 31 S
Schmidt A 8 S
Schoenhofer J 29 S
Schoettker P 4 S, 28 S
Schulthess Z 7 S
Seidl C 6 S
Siegenthaler A 10 S
Soccorosi T 13 S
Stamer UM 26 S
Streitberger K 32 S
Suys 41 S
Taalba FT 50 S
Theiler L 26 S, 40 S
Tritschler T 47 S
Urner M 7 S
Varadarajan B 20 S, 21 S
Voirol P 47 S
Weibel L 17 S
Weidner E 51 S
Wesch C 49 S
Wickboldt N 34 S
Wilhelm I 35 S
Wollmann K 39 S
Wuethrich PY 22 S
Zhang L 21 S
Ziltener GZ 46 S
Zürcher M 15 S
52 S

Forum Médical Suisse Swiss Medical Forum Schweizerisches Medizin

Transcription

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