Forum Médical Suisse Forum Medico Svizzero Schweizerisches Medizin

Forum Médical Suisse
Forum Medico Svizzero
Schweizerisches Medizin-Forum
21.8.2013
Supplementum 61
ad Swiss Medical Forum
2013;13(34)
Swiss Medical Forum
Joint Annual Meeting
Swiss Society of Intensive Care Medicine SSICM
Swiss Society for Cardio and Thoracic Vascular Surgery SSCS
Swiss Society for Emergency and Rescue Medicine SSER
Guest:
Swiss Society for Nephrology SSN
Working Group Interventional Cardiology and Acute Coronary
Syndrome
4.–6.9.2013 Palexpo Geneva
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ta b l e o f c o n t e n t s
HOT ABSTRACTS
H1 – H4
F R E E C O M M U N I C AT I O N S 4
2S
F R E E C O M M U N I C AT I O N S 1
F1 – F5
8S
POSTERS
3S
P1 – P30
9S
INDEX OF FIRST AUTHORS
F R E E C O M M U N I C AT I O N S 2
F6 – F10
F16 – F20
18 S
4S
F R E E C O M M U N I C AT I O N S 3
F11 – F15
6S
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Schweiz Med Forum 2011;11(nn):1
1
h ot a b st r ac t s
H1
H3
Prognostic Factors and Value of Decompressive
Craniectomy in the Treatment of Intracranial Hypertension
A. Rogers1, V. Cousin1, A. Verdon1, A.S. Sarrafzadeh1, K. Schaller1,
Y. Gasche1
1University Hospital Geneva, Geneva, Switzerland
Background: Decompressive craniectomy (DC) is a now well
established surgical procedure for the treatment of refractory
intracranial hypertension after an unsuccessful medical management.
This intervention is known to carry a high load of complications, even
though some carefully identified patients may greatly benefit from this
procedure.
Methods: We retrospectively analyzed data from all the patients
(n = 196) who underwent DC in our institution (Geneva University
Hospital, Switzerland) between January 2007 and December 2012.
Variables available for analysis were clinical status at presentation,
known medical history, underlying lesion characteristics, surgical
interventions, complications, discharge outcome and long term outcome
with the glasgow outcome scale (GOS). We performed multivariate
analysis to identify factors associated with a bad outcome (GOS 1–3)
after decompressive craniectomy.
Results: n = 196 (mean age 43.9 ± 18.8) patients underwent unilateral
(n = 175) or bilateral (n = 21) decompressive craniectomy for intractable
intracranial hypertension. Of those, n = 101 presented with traumatic
brain injury (TBI), n = 40 with aneurysmal subarachnoid haemorrhage
(SAH), n = 39 withmalignant MCA stroke, and n = 17 with other
pathologies. Mortality was 34.7% in TBI group, 15.4% in the stroke
group, 50% in SAH. A bad outcome was found in 74% of patients
(Glasgow Outcome Scale 1–3). Factors associated with poor outcome
were: GCS lower than 8 on admission, male sex, known hypertension
or cardiovascular diseases, cardiac arrest and shock during
hospitalization, stroke and aneurysms on the first CT-Scan.
Conclusion: DC is grieved with a high rate of complications and a poor
postoperative outcome, though it may be life saving in carefully selected
patients. Further work should provide clear factors predicting
postoperative mortality and outcome.
How ICU experienced nurses maintain their integrity despite
moral distress: A hermeneutic phenomenological study
T.M.L. Sala Defilippis1
1SUPSI, Manno, Switzerland
Background: Switzerland is facing a serious problem concerning
nurses’ shortage. Moral distress seems to play an important role when
nurses decide to leave their profession. Indeed, moral distress can lead
to the loss of moral integrity with dramatic consequences, such as
burnout. However, it could be said that this phenomenon affects only
some nurses; in fact, the majority continues to work at the bedside,
flourishing and maintaining their integrity intact.
Aims: This study explored and analysed how much is known among
nurses about the term ‘moral integrity’ and which protective factors as
well as coping mechanisms and strategies play an important role when
facing moral distress in order to maintain their moral integrity.
Method: This study uses a hermeneutic phenomenological inquiry
method based on Heidegger’s and Gadamer’s theories. Interviews
were carried out with eight female nurses who had at least five years of
experience in an intensive care unit. The interviews were tape recorded
and later transcribed in order to carry out an analysis. The analysis
followed the method suggested by Fleming et al. (2003).
Findings: Being morally intact represents for nurses both a state of
grace characterised by harmony and inner peace, as well as a constant
exercise to maintain a balance between one’s own and the surrounding
world. Being morally intact implies a readiness to compromise. This
readiness is limited by the sense of responsibility nurses feel for their
patients. Common sense, professional identity and feeling of selfdetermination emerged as protective factors that prevent nurses from
developing chronic reactive moral distress. When these protective
factors are not enough to avoid moral distress, nurses use coping
strategies, such as interior dialogue, rationalisation and finding meaning
in order to face morally distressing situations.
Conclusions: In order to increase nurses’ retention arising awareness
about moral distress should become a priority among management,
nurses and nursing students. Additionally research efforts should
concentrate on deepening the understanding of successful protective
factors and coping strategies. This study has demonstrated that
experienced nurses have a valuable knowledge that can represent a
starting point for developing effective measures which aim to support
them when coping with distressing situations.
H2
Check-list “Patient Safety” in cardiac surgery:
two year experience
O. Dzemali1, K. Graves1, P. Fodor1, A. Häussler1, H. Löblein1,
M. Genoni1
1
University Heratcenter Zürich, Zürich, Switzerland; 2Dept.
of Anästhesiology, City Hospital Triemli, Zürich, Switzerland
Objective: In this study we evaluated whether our application of WHO’s
World-Alliance for Patent Safety Checklist “Safe Surgery Safes Lives”
(CL) since March 2011, has led to reduced medical related error in the
operating theatre and early postoperative care (ICU).
Methods: The results of SIGN IN (before skin incision), TIME OUT
(de-briefing), and SIGN OUT (before patient transfer to the ICU) in this
period (697 cases, 2011 n = 257, 2012 n = 440 ) were entered into a
database (Dendrite Clinical Systems, UK) for statistical evaluation.
Results: Incomplete preoperative documentation required for SIGN IN
(patient consent forms, medical checklists, blood group identification)
was observed in 45% (2011) and 12% (2012). Based on “de-briefing”
in TIME OUT surgical strategy was changed in 21% (2011) and 17%
(2012), 8% and 6% of changes respectively, required preoperative
adaptations by all team members. Additions made in SIGN OUT
(important diversions from routine postoperative protocol with special
information on the ICU) were 3% (2011) and 4% (2012). Final
instrument/needle counts were inconsistent in three and one case
respectively, three of which were resolved before patient transfer.
Negligence on the part of a team member to fully participate in SIGN
OUT occurred in 6% (2011) and 2% (2012). These findings have
generated a significant number of critical incident reports (CIRS) and
provided important themes for the departmental morbidity and mortality
conference.
Conclusion: Since the introduction of CL in our department we have
seen a definite decrease in potentially harmful errors and experienced
better communication between team members. Furthermore, the
consequent usage of CL has led to a significant reduction of overall
operating time.
H4
Use of lights and siren: is there room for improvement?
F. Dami1, P.-N. Carron1, M. Pasquier1
1CHUV, Lausanne, Switzerland
Objective: The objective of the study is to analyse the use of L&S
during transport to the hospital according to the prehospital severity
status of the patient (NACA score), and the time saved by the time of
the day.
Methods: We searched the Public Health Services data for the Swiss
state of Vaud from January 1 to December 31, 2010. The study excluded
secondary missions (inter-hospital transfers), HEMS missions, and
missions without patient transport (patient dead on site, missions
canceled by the dispatch centre or when there was no patient on site).
The data included the use of L&S and time of the return to the hospital
and the patient demographics (age and gender). Night missions were
defined as missions occurring between 10 pm and 7 am. The severity of
the condition was graded according to the National Advisory Committee
for Aeronautics (NACA) score, assigned by the paramedics and/or
emergency physician at the end of the mission.
Results: 24’506 ambulance transports met the inclusion criteria. L&S
were used 4’066 times, representing 16.6% of all missions. Forty
percent of these graded NACA <4. The mean total transport time back
to hospital was 11.09 min (CI 10.84–11.34) with L&S and 12.84 min (CI
12.72–12.96) without. The difference was 1.75 min (105 sec), which was
statistically significant (p <0.001). During nighttime, this mean difference
of transport duration was smaller (0.17 minutes or 10.2 sec), and did
not reached statistical significance (p = 0.27). The time saved with L&S
during nighttime was a mere 10.2 seconds.
Conclusions: The present procedures seem questionable given the
severity status and NACA score of transported patients. These results
should prompt the implementation of more specific regulations for the
use of L&S during transport to the hospital, taking into consideration
certain physiological criteria of the victim as well as time of the day of
transport.
Schweiz Med Forum 2013;13(Suppl. 61)
2s
f r e e c o m m u n i c at i o n s 1
F2
F1
Macronutrients utilization and balances during the first
week of hospitalization in ventilated critically ill children
C. Jotterand1, C. Moullet1, J. Depeyre1, M.H. Perez2, J. Cotting2
1Nutrition and Dietetics Department, University of Applied Sciences,
Geneva, Switzerland; 2Pediatric Intensive Care Unit, University
Hospital, Lausanne, Switzerland
Aim: In critically ill children, adequate nutritional support is associated
with decreased mortality and morbidity. Nutritional needs may be
influenced by the metabolic stress, treatments, fever, etc. which makes
difficult the acute determination of macronutrients needs. If energy
needs have been documented, substrate utilization during the stay
remains unknown. The aim of this study was to determine
macronutrients utilization and balances during the first week
of hospitalization in ventilated critically ill children.
Methods: Children with expected mechanical ventilation ≥72 hours
and a FiO2 ≤60% were consecutively included. Energy expenditure,
respiratory quotient (RQ) and substrate utilization were calculated
from the values of oxygen consumption and carbon dioxide production
measured by indirect calorimetry and from total urinary nitrogen
measured by chemoluminescence daily. A total of 328 measurements
were performed. Macronutrients intakes were recorded using a
computerized information system (MetaVision, Imdsoft). Macronutrients
balances were then calculated as the difference between oxidation and
intakes. The RQ was also compared with the RQ of the macronutrients
administered (RQmacr).
Results: We included 63 children, 34 boys and 29 girls with a median
age (IQR) of 21 (0-103) months. Energy, protein and lipids balances
remained negative during the first week of hospitalization while
carbohydrates balance was positive from the first day. On average,
energy expenditure was 54 ± 10 kcal/kg/d and energy balance was
–9 ± 16 kcal/kg/d. Protein, lipids and carbohydrate oxidation were 1.4 ±
0.4 g/kg/d, 3.1 ± 1.5 g/kg/d and 5.1 ± 2.8 g/kg/d, respectively. The mean
balance was –0.4 ± 0.6g/kg/d for proteins, –1.9 ± 1.8 g/kg/d for lipids
and +1.8 ± 3.1 g/kg/d for carbohydrates. RQ measured was lower than
RQmacr calculated (0.81 ± 0.06 versus 0.92 ± 0.05).
Conclusion: In our group of ventilated critically ill children, we
observed a slight lipolysis and catabolism during the first week of
hospitalization. The carbohydrate oxidation was insufficient, probably
due to a reduced oxidation capacity and insulin resistance in metabolic
stress conditions.
Ultra-low flow veno-venous extracorporeal CO2 removal
for acute hypercapnic respiratory failure
M.P. Hilty1, T. Riva1, S. Cottini1, E. Kleinert1, A. Maggiorini1,
M. Maggiorini1
1
Medical Intensive Care Unit, University Hospital of Zurich,
Zurich, Switzerland
Introduction: Ventilation with low tidal volume and airway pressure has
been shown to provide a survival benefit in ARDS patients [1]. There is
some evidence that avoiding mechanical ventilation may be beneficial
in other settings of acute respiratory failure [2]. Our hypothesis is:
ultra-low flow veno-venous extracorporeal CO2 removal (vv-ECCO2R)
enables maintenance of a lung protective ventilation strategy or
spontaneous ventilation despite severe hypercapnic respiratory failure
(HRF).
Methods: 20 consecutive patients with HRF were investigated while
being mechanically ventilated (n = 14) or breathing spontaneously close
to respiratory exhaustion (intubation) (n = 6) between 10-2009 and
03-2013. Vv-ECCO2R was performed using a hemoperfusion device
with a polypropylene gas-exchanger (Prolung) connected to a 13.5F
double lumen hemodialysis catheter inserted in the jugular vein. Blood
flow rates of 400 mL/min were targeted, heparin was used to target a
systemic Anti-FXa of 0.3–0.4. Systemic, pre- and post membrane blood
gas analysis was obtained every 4h. Coagulation was assessed daily.
Results: Causes of HRF were severe ARDS (11), COPD (4), chronic
lung transplant rejection (3), cystic fibrosis (2). Median (IQR) ECCO2R
treatment duration was 4(2-6)d, blood flow 350 (300–400) mL/min and
membrane lifetime 30 (21–48)h. During the first 6h of treatment, PaCO2
decreased from 10.6 (9.3–12.9) to 7.9 (7.3–9.3), p <0.001; pH increased
from 7.23 (7.09–7.40) to 7.36(7.27–7.41), p <0.05. Thereafter, steady state
could be maintained without increasing the invasiveness of mechanical
ventilation (tidal volume 4.7 (3.8–6.5 ) mL/kgPBW, peak inspiratory
pressure 28(27–30) cmH2O after 24h of treatment). During the first 48h
of treatment, platelets decreased by 52% (p <0.01), Fibrinogen by 38%
(p <0.05). Intubation could successfully be avoided in all spontaneously
breathing patients, 4/6 had to be upgraded to high blood flow
extracorporeal circulation (2–4 L/min) due to increased oxygen demand.
6/14 mechanically ventilated patients recovered from respiratory
support, 8 patients died due to treatment withdrawal.
Conclusions: Our results confirm that in mechanically ventilated
patients with HRF, vv-ECCO2R supports the maintenance of lung
protective ventilation. In selected awake patients with acute HRF, it may
be a novel treatment approach to avoid intubation and mechanical
ventilation, hence preventing ventilator- and sedation-associated
morbidity and mortality.
Reference
1 PMID 10793162 / 2 PMID 22268135.
F3
Non-invasive ventilation in patients suffering from
respiratory failure: comparison between old and new
generation turbine based ICU and home ventilators
Paratte1, Piquilloud1, Verhoeven1, Thévoz1, Belmondo1, Jolliet1, Revelly1
1
Soins intensifs adultes et centre des brûlés, Lausanne, Switzerland
Introduction: ICU and home turbine-based ventilators can be used to
deliver non invasive ventilation (NIV) to patients presenting respiratory
failure (RF). The clinical performances of these different machines have
not been extensively studied. Similarly, the impact of using a specific
turbine-based NIV ventilator on patient ventilator synchrony is poorly
known.
Objectives: To compare trigger delay (Td), pressurization capacity and
patient-ventilator synchrony between 4 turbine-based ventilators (old
and new generation home and ICU ventilators) in patients suffering from
RF.
Ventilator
Td
[ms]
PTP trigger
[s × cm H2O]
Patients and Methods: Four 20-minute NIV sessions (using initial
clinician’s settings of IPAP and EPAP for all ventilators) were delivered
in random order with the following devices: VPAP3®, Resmed (old home
ventilator), Stellar150®, Resmed (new home ventilator), BiPAP vision®,
Philips (old ICU ventilator) and V60®, Philips (new ICU ventilator).
Pressure-time and flow-time tracings were recorded by a flow sensor
placed within the ventilator circuit. Surface electromyogram of the
diaphragm (sEMG) was also recorded. Td, pressure-time product during
the triggering phase (PTPtrigger) and pressure-time product at 500 ms
(PTP500) were computed from the recorded curves. Mean respiratory
rate and the number of ineffective efforts during each NIV session were
also computed from the curves. Patient comfort was evaluated twice
during each NIV session using a visual analog scale graded from 0 to
10. Comparisons between ventilators were performed by ANOVA for
repeated measurements (post-hoc test: Newman-Keuls’s). P value
<0.05.
PTP500
[s × cm H2O]
Ineffective efforts
by minute
VPAP3®
148 ± 40 b,c,d
0.73 ± 0.26 d
2.9 ± 1.0 b, c, d
0.2 ± 0.3 c, d
Stellar15®0
129 ± 28 a, d
0.72 ± 0.20 d
3.7 ± 1.1 a, c, d
0.3 ± 0.4
BiPAP-vision®
113 ± 13 a, d
0.66 ± 0.20 d
4.1 ± 1.3 a, b
0.6 ± 0.5 a
V60
99 ± 14
0.58 ± 0.14
4.0 ± 1.0
0.6 ± 0.4 a
®
a,b,c
a,b,c
a, b
a: different from VPAP3; b: different from Stellar; c: different from BiPAP-vision; d: different from V60.
Schweiz Med Forum 2013;13(Suppl. 61)
3s
f r e e c o m m u n i c at i o n s 1
Results (mean ± SD): 20 patients were included, 7 known for chronic
pulmonary disease (5 COPD, 1 restrictive syndrome and 1 mixed
obstructive and restrictive syndrome). Age 66 ± 13 years, BMI 25 ±
7 kg/m2. At inclusion, respiratory rate was 24 ± 5 cycles/min, PaCO2
39 ± 8 mm Hg, PaO2 77 ± 22 mm Hg (with O2 supplementation between
2 and 10 l/min).
Mean respiratory rate and comfort were not different between the four
ventilators tested.
Conclusion: In ICU patients suffering from respiratory failure,
NIV delivered with turbine-based ICU-ventilators afforded better
pressurization and a shorter response time in comparison to homeventilators. However, respiratory comfort was similar for all ventilators.
Interestingly, as previously published (1), very few ineffective efforts
occurred with turbine-based ventilators especially with home ventilators.
Reference
1 Carteaux G, et al. Chest 2012;142(2):367–76.
F4
Advance care planning in major surgery: preliminary results
on prevalence and concordance in patients and relatives
F. Gigon2, P. Merlani3, B. Ricou1
1University Hospitals of Geneva, Geneva, Switzerland; 2University of
Geneva, Geneva, Switzerland; 3Ospedale regionale di Lugano, Lugano,
Switzerland
Introduction: Patients who undergo major cardiovascular surgery
experience a journey in ICU were important decisions may have to be
taken while they are temporarily incompetent. Advance directives (AD)
were developed to respect patients’ autonomy; the alternative resides in
the health care surrogate decision maker (HCS).
This study aimed to investigate the prevalence of AD and HCS in
patients planned for major cardiovascular surgery and the concordance
with their relative.
Methods: Patients and their relative were interviewed according to a
structured questionnaire separately before or after surgery. Patients’
characteristics were extracted from the chart.
Results: Out of 405 eligible patients, 361(89%) patients, 256 (71%)
with relatives and 105 (29%) without relatives answered the interview.
Male patients: 256 (71%). Age (mean ± SD): 68 ± 15 years. 215 (60%)
patients underwent valvular replacement, 92 (25%) coronary bypass
and 54 (15%) other major cardiovascular surgeries. SAPS II (mean ±
SD): 33 ± 15; ASA(mean ± SD): 3 ± 0.5.
16(4%) had AD, 8(2%) a HCS. At the end of the interview, 60(17%)
were interested in AD, 50(14%) in HCS, and 19(5%) in actually writing
AD. AD or HCS were considered very useful theoretically but not of
interest for themselves, maybe for others. Discomfort or reluctance in
study’s participation was surprisingly rarely noted by the investigators
despite such sensitive topics. Only 5(1%) patients had a DNR order in
their chart whereas they had no AD.
When the data from the 256 patients and from their relatives were
compared, 9 (4%) patients had AD, 6 (3%) a HCS whereas 4 (2%)
relatives said the patient had AD, 2 (1%) a HCS, but they were often
wrong. At the end of the interview, 48 (19%) patients were interested in
AD, 41 (16%) in HCS, and 12 (5%) in actually writing AD. 63 (25%) and
49 (19%) relatives said the patient would have an interest in AD and
HCS respectively but were wrong in 73 (29%, p = 0.008) and 64 (25%,
p = .03) cases. There was no significant difference between data from
patients with relatives and patients without relatives.
Conclusions: Very few patients had AD or HCS when planned to
undergo a major surgery. Interest to have AD or a HCS was not higher
than 17% and only 5% actually wrote AD. The reasons of the
discrepancy between the expressed usefulness of AD and HCS and the
reality towards such approaches need to be further analysed. Relatives
weren’t always aware their beloved having AD or a HCS.
The FNRS sustained the study(CR31I3_127135/1).
F5
Relationship between transcutaneous CO2 measurement
and PaCO2 during non invasive ventilation delivered in
hypercapnic acute respiratory failure
D. Thévoz1, L. Piquilloud1, P. Jolliet1, J.-.P Revelly1
1Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
Aim: Non invasive ventilation (NIV) is the first treatment in case
of acute hypercapnic respiratory failure (AHRF). NIV efficiency is
continuously monitored using clinical parameters and blood gas
analysis after 30 or 60 minutes of treatment to document the
improvement in respiratory acidosis and hypercapnia. A reliable
non-invasive technique to monitor PaCO2 during NIV could simplify the
evaluation of NIV efficiency and allow an earlier adaptation of ventilator
settings.
The aim of this study was to assess whether measuring transcutaneous
CO2 (TcCO2) during NIV for AHRF could be of interest for evaluating
PaCO2 and its time-course.
Material and method: ICU patients requiring NIV for AHRF (PaCO2
>42 mm Hg) were included in this prospective observational study.
TcCO2 was measured during a 60-minute NIV treatment using a
dedicated auricular sensor and the Sentec monitor (Sentec,
Switzerland), connected to the patient 15 minutes before the beginning
of NIV.
Blood gas analysis and TcCO2 were performed before initiating NIV and
after 30, 45 and 60 minutes of NIV. CO2 gradient (PaCO2-TcCO2) was
calculated for each pair of measures. The correlation between PaCO2
and TcCO2 was assessed by linear regression; the agreement between
both measurements techniques was assessed using the Bland and
Altmann method for repeated measurements.
Preliminary results (median, IQR): 6 patients (4 women and 2 men,
3 with obstructive pulmonary disease, 2 with mixed obstructive and
restrictive disease) were included in the study. Age 71 [63–81], SAPS II
score 43 [35–48]. At inclusion, PaCO2 was 55 [53-67] mm Hg, SaO2
was 92 [91–94] % and respiratory rate was 22 [19–25] /min. 3 patients
were receiving continuous infusion of noradrenaline (maximum 10 µg/
min) during the study protocol.
PaCO2 values ranged from 43 to 71 mm Hg whereas TcCO2 values
ranged from 42 to 69 mm Hg. The correlation coefficient R2 between
PaCO2 and TcCO2 values was 0.94. Bias and precision were –0.8 and
2.6 mm Hg respectively, and the limits of agreement ranged from
–5.1 to 4.2 mm Hg. Extreme measured CO2 differences were –3.8
and 6.2 mm Hg.
Conclusion: In this preliminary study, in 6 patients undergoing NIV for
acute hypercapnic respiratory failure we found a promising agreement
between TcCO2 and PaCO2, suggesting that CO2 transcutaneous
measurement could be of interest to evaluate PaCO2 evolution during
NIV.
f r e e c o m m u n i c at i o n s 2
F6
Ten-Year Clinical Follow-up After Sirolimus-Eluting Stent
Implantation
Nuno Palhais, Diego Arroyo, Sonja Lehmann, Mario Togni,
Urs Kaufmann, Jean-Christophe Stauffer, Jean-Jacques Goy,
Stéphane Cook
Background: Little is known on the “very” long-term incidence of major
adverse cardiac events (MACE), target-lesion revascularization (TLR),
target-vessel revascularization (TVR) and stent thrombosis (ST) after
sirolimus-eluting stent (SES) implantation. We present the first study to
provide a 10-year clinical follow-up in an unselected patient population
who underwent SES implantation.
Methods and results: We ran a systematic 10-year clinical follow-up
in a series of 200 consecutive patients treated with unrestricted SES
implantation between April 2002 and April 2003 in two Swiss hospitals.
Outcomes and follow-up were obtained in all 200 patients. The
cumulative 10-year MACE rate was 47% with all-cause death of 20%,
cardiac death of 9%, myocardial infarction of 7%, TLR and TVR of
8% and 11% respectively. ARC-defined “definite and probable” stent
thrombosis-rate was 2.5%. TLR risk was maximal between 3 to 6 years.
New lesion revascularization increased throughout the study period.
Conclusion: Incidence of TLR was maximal 3 to 6 years after SES
implantation and decreased thereafter. MACE and non-TLR
revascularization rates steadily increased during the complete follow-up
underlining the progression of coronary artery disease.
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Figure 1
Incidence of revascularisation through 10 years of follow-up. Kaplan-Meier cumulative estimates for target-lesion revascularisation (TLR, orange), target-vessel
revascularisation (TVR, blue), and revascularisation for a new coronary lesion (New lesion, purple) up to 10 years of follow-up, with a landmark set at 3 and 6 years.
F7
Nécroses cutanées étendues sous terlipressine
A. Vuilleumier1, R. Zürcher Zenklusen1
1
Hôpital neuchâtelois Pourtalès, Neuchâtel, Switzerland
Introduction: Un patient de 42 ans est admis aux soins intensifs
pour une décompensation ascitique sur cirrhose CHILD C d’origine
éthylique, dans un contexte d’anémie profonde à 50 g/l et de sepsis
sévère sans foyer identifié. L’insuffisance rénale aiguë observée à
l’admission (créatinine plasmatique à 270 µmol/l) se corrige en cinq
jours après restauration volémique, antibiothérapie empirique par
ceftriaxone et ponction de 2200 ml d’ascite non-infectée. Sans raison
évidente, l’insuffisance rénale récidive brutalement peu après, avec une
élévation de la créatininémie jusqu’à 310 µmol/l, laissant suspecter un
syndrome hépato-rénal de type 1; nous débutons un traitement de
terlipressine à la dose de 6 × 1 mg/j, avec augmentation progressive
jusqu’à 6 × 2 mg/j. Au huitième jour de prescription, le patient développe
un exanthème bulleux des avant-bras, des jambes et des flancs,
évoluant rapidement en de larges lésions nécrotiques, dont la biopsie
conclut à une origine vasculaire. L’évolution est lentement favorable sur
le plan cutané, ainsi que sur les plans hépatique et rénal. Le patient
rentre à domicile au terme de sept semaines d’hospitalisation.
Discussion: La terlipressine est bien connue pour son efficacité dans
le syndrome hépato-rénal de type 1, pour lequel une réponse est
obtenue dans environ 52% des cas, avec une baisse de la mortalité
atteignant jusqu’à 34%. Alors que sa longue demi-vie est avantageuse
en pratique clinique, son action est dirigée sur les récepteurs V1 du
muscle lisse avec une prédominance sur les vaisseaux splanchniques.
Sa toxicité systémique est habituellement mineure, avec notamment
des douleurs abdominales, des diarrhées et des céphalées; rarement
surviennent des événements cardio-vasculaires et exceptionnellement
des nécroses cutanées. Notre cas de nécrose épidermique étendue
n’étant que le quinzième décrit dans la littérature, les facteurs favorisant
ce type de toxicité ne sont pas connus à ce jour. Aucune association
entre la posologie et le degré d’atteinte ni le délai d’apparition des
lésions, décrit entre 48h et cinq jours, n’a pu être mise en évidence.
Dans notre cas, ce n’est qu’au huitième jour de traitement qu’ont été
notées les manifestations cutanées, tandis que la distribution des
lésions reste caractéristique, à savoir l’abdomen, les jambes et les
avant-bras.
Conclusion: La nécrose épidermique reste une complication rare et
peu connue de l’administration de la terlipressine, qu’il importe de
pouvoir identifier.
Références
1 Lu YY, Wei KC, Wu CS. Terlipressin-induced extensive skin necrosis: a case
report and published work review. J Dermatol. 2012 Oct.
2 Mégarbané H, Barete S, Khosrotehrani K, Izzedine H, Moguelet P, Chosidow O,
Frances C, Aractingi S. Two observations raising questions about risk factors of
cutaneous necrosis induced by terlipressin (Glypressin). Dermatology. 2009.
3 Oh JE, Ha JS, Cho DH, Yu GJ, Shim SG. A case of ischemic skin necrosis after
glypressin therapy in liver cirrhosis. Korean J Gastroenterol. 2008 Jun.
4 Cochrane Database Syst Rev 2006.
F8
The Outcome of Preoperative and Postoperative Use of High
Dose Statins on Inflammation in Off Pump Coronary Bypass
Surgery
H. Loeblein1, O. Dzemali1, A. Haeussler1, D. Odavic1, M. Genoni1
1Triemli, Zürich, Switzerland
Objective: There is evidence suggesting that statins have antiinflammatory properties. This study was underta-ken to evaluate the
anti-inflammatory property and overall outcome of high dose pravastatin
in pa-tients undergoing off pump coronary bypass surgery.
Methods: This is a randomized prospective study which recruited 136
patients undergoing of pump cardiac sur-gery to receive either 40 mg or
80 mg pravastatin one day before surgery and continue the intake until
3 month after surgery. The exclusion criteria consisted of the use of
anti-inflammatory medications, history of inflammatory disease, acute
infection, acute myocardial infarction, and use of antibiotics.
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Result: Out of 136 patients 97 were followed 3 month postoperatively.
44 patients received 40 mg and 53 patients 80 mg pravastatin. There
was no difference between the two groups in regard to gender, age,
diabetes, preoperative C reactive protein (CRP), troponin, creatine
kinase MB (CKMB), transaminase and cholesterol values. The was no
difference between the groups in Regard to surgical time, the amount
of norepinephrine used, intubation time and mortality. There was no
difference between the two groups in regards to CRP, white blood cell
count, D-dimer shortly postopertive and at 90 days. Intensive care unit
(ICU) stay was significantly longer in the 40 mg group (p = 0.038).
There was a significantly higher in CKMB on the second and fourth
postoperative day in the 80 mg group (p = 0.034, p = 0.032). At 90 days
there was a significantly higher in myoglobin value in the 80 mg group.
Conclusion: The use of high dose statins just before off pump coronary
bypass does not have any impact on inflammation. It increase
postoperative CKMB and myoglobin and may decrease the ICU stay.
F9
Les quasi-incidents, un outil intéressant pour la pratique,
mais sous-déclarés au quotidien: identifier et comprendre
les causes
V. Miauton1, C. Tschanz1, F. Taalba1, G. Sridharan1, H. Ksouri1
1Service des soins intensifs et continus, Hôpital cantonal de Fribourg,
Fribourg, Switzerland
Introduction: Le quasi-incidents (QI), défini comme incident qui aurait
pu causer un dommage, mais qui n’a pas atteint le patient car
intercepté à temps ou par chance, est utile pour l’amélioration des
pratiques. Dans notre expérience, malgré le bénéfice tiré de l’analyse
des QI, on note qu’ils sont sous-déclarés. La littérature rapporte,
comme cause, un manque de perception d’utilité (1).
Notre étude tente d’identifier et comprendre les causes sous jacentes
à la sous déclaration des QI.
Méthode: Enquête combinant un questionnaire auprès de 55 médecins
et infirmiers dans un service de soins intensifs et continus disposant
d’un système de déclaration d’incidents. Les questions ouvertes sont
destinées à évaluer: la connaissance de la définition d’un QI, la
démarche en cas de détection d’un QI et l’utilité perçue de la démarche.
Les questions fermées ciblent: l’aptitude à discerner les QI (situations
pratiques) et les obstacles à la démarche déclarative de QI.
Résultats: Bien que 75% des personnes perçoivent l’utilité de déclarer
les QI, on identifie 3 groupes (G) différents dans la démarche en cas
de QI détecté: G1 (32%): “action directe sans déclaration”, détecte, agit,
sans déclarer le QI.G2 (20%): “action, déclaration sans compréhension”,
détecte, agit et déclare sans utilité perçue. G3 (48%): “action,
déclaration avec compréhension”, détecte, agit, déclare et perçoit l’utilité.
En plus de cette disparité de démarche et perception, on note:
a) La méconnaissance de la définition usuelle reconnue par 62%
des soignants. b) La confusion des QI détectés tardivement avec des
incidents (<40% de réponse exacte).c) Des obstacles: organisationnel
[défaut d’information interne (60%)] et individuels [acte de délation
(70%), peu de débriefing lors d’un QI (53%)] à la déclaration.
Conclusion: Notre étude révèle que la déclaration des QI est tributaire
de la perception, la communication et l’information au sein de l’équipe.
Les QI sont plus déclarés quand leur potentiel de préjudice et
d’évitabilité est perçu (G3) alors que la perception de leur omniprésence
induit une sous-déclaration (G1).Dans une organisation apprenante,
l’équipe doit «soulever» les barrières par une meilleure communication
entre soignants lorsque des QI sont détectés et par la diffusion de
l’information tirée de leur analyse. Enfin, la définition optimale des QI
doit dépendre du contexte organisationnel.
Référence
1 Kousgaard MB, et al. Scand J Prim Health Care. 2012;30:199.
F10
Gender differences in secretion of adipokines off pump
coronary bypass surgery (OPCAB)
H. Loeblein1, O. Dzemali1, A. Haeussler1, C. Meier1, D. Odavic1,
M. Genoni1
1
Triemli Hospital, Zürich, Switzerland
Purpose: Previous studies have suggested that women have a less
favorable outcome after coronary bypass surgery when compared to
men. This study was undertaken to examine the postoperative time
course of serum inflammatory markers and anti-inflammatory responses
to off pump coronary bypass surgery stratified by gender.
Method: The time course of fasting level of tumour necrosis factor-α
(TNF-α), interleukin 8 (IL-8), soluble IL-1 type I receptor (sIL-1 RI),
soluble IL-1 type II receptor (sIL-1RII), c-reactive protein (CRP),
monocyte chemotactic protein-1 (MCP1), Interferon-gamma induced
protein (IP-10), vascular endothelial growth factor (VEGF) at baseline on
day 0 and at postoperative days 1,2,3,4,5,6,7 was measured on 65
consecutive patients undergoing elective off pump coronary bypass
surgery. The exclusion criteria consisted of the use of anti-inflammatory
medications, history of inflammatory disease, acute infection, acute
myocardial infarction, and use of antibiotics within two weeks of surgery.
Result: 11% were female. At baseline TNF-α was higher in women
compared to men (p = 0.008). Postoperative days 1 and 2 there were no
differences in adipokines secretion between the two genders.
Postoperative day 3–7 there was significantly higher sIL-1RI (p =
0.11,0.031, 0.041, 0.014, 0.004) and significantly higher value of TNF-α
(p = 0.021, 0.003, 0.052, 0.021,0.052) in the female gender .There was
no difference between the two groups in the time course of the serum
levels of IL-8, soluble , sIL-1RII, IP-10, CRP , VEGF and MCP1.
Conclusion: Off pump surgery in females produces significantly higher
inflammatory states as compared to males. Both TNF-α and sIL-1RI
production were higher in the female gender.
f r e e c o m m u n i c at i o n s 3
F11
Value of Preoperative B-Type Natriuretic Peptide
in Off Pump Coronary Bypass Surgery
H. Loeblein1, O. Dzemali1, D. Odavic1, A. Haeussler1, M. Genoni1
1
Triemli Hospital, Zurich, Switzerland
Background: B-type natriuretic peptide (BNP) a neurohormone
secreted in response to volume expansion and pressure overload. Few
reports discuss this peptide’s prognostic value in patients undergoing
off pump cardiopulmonary bypass (OPCAB).
Methods: The data of all patients who underwent OPCAB between
1/2005–12/2010 was analysed. We investigated how the preoperative
BNP level related to five postoperative endpoints: troponin, creatine
kinase MB (CK-MB), atrial fibrillation, blood transfusion, intubation time,
intensive care unit (ICU) and hospital days.
Results: 885 patients underwent OPCAB between 1/2005–12/2010.
16.7% were female, 41% had NYHA class II and 20% NYHA class III
symptoms. 82% had coronary 3-vessel, 42.4% had left main disease
and 9.5% were in a critical preoperative state. The average preoperative
values were: creatinine 83 mmol/L, C-reactive protein 10mg/L, Troponin
2.2 mcg/L, euroscore 5.2, ejection fraction 55%. The average
postoperative values were: day one Troponin 4.32 mcg/L, day one
CK-MB 23.44 IU/L, intubations time 15hours, ICU 2.7days, hospital
days 13. 15% had postoperative atrial fibrillation and mortality was 1.3%.
Preoperative BNP correlated significantly with preoperative ejection
fraction (correlation coefficient [CC], −0.448; p = .0001), age (CC =
0.305; p = .0001), preoperative serum creatinine level (CC = 0.82;
p = .015), haematocrit (CC = -0.390; p < .0001), CRP (CC = 0.358;
p <.0001), CKMB (CC = 0.160; p < .0001), troponin (CC = 0.416;
p < .0001), pulmonary systolic pressure (CC = 0.387; p < .0001),
euroscore (CC = 0.539; p < .0001). Although there was no correlation
between preoperative BNP and postoperative atrial fibrillation and
mortality. BNP level correlated significantly with postoperative ICU
days (CC = 0.303;
p < .0001), hospital days (CC = 0.131; p <.001), intubation time
(CC = 0.245; p < .0001) and bood transfusion(CC = 0.220; p < .0001).
BNP was found to be an indipendent risk factor for postoperative
troponin (p = 0.006) and ICU days (p <0.001).
Conclusions: Used in conjunction with other clinical information,
preoperative measurement of BNP helps predict the postoperative
outcomes, especially postoperative ischema and ICU days for patients
undergoing OPCAB.
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F12
F14
Visiting policies in Swiss Intensive Care Units (ISUs):
a multicenter survey
C.S. Speroni1, D.G. Gobbi1, R.S. Scarano1, P.M. Merlani2,
A.P. Pagnamenta1
1Ospedale Regionale, Mendrisio, Switzerland; 2Ospedale Regionale,
Lugano, Switzerland
Introduction: Most ICUs worldwide have restricted visiting policies
(1-5). The presence of family members and visitors in the ICU is usually
limited due to different reasons. Current knowledge shows that these
limitations are not necessary for the treatment of our patients. To our
knowledge no data on visiting policies in Swiss ICUs are available and
accordingly we conducted an observational study on this subject Aims:
1) To investigate visiting policies in Swiss ICUs, 2) To identify variables
that avoid liberalization of visiting policies
Methods: Questionnaire-based nationwide survey among all ICUs
recognized by the Swiss Society of Intensive Care Medicine. An
electronic version of the original questionnaire (1, 3) was sent in May
2012: to all head nurses of Swiss ICUs.
Results: Response rate was 97,8% (73/75). Only two ICUs (2,7%) had
an open visiting policy (24 h/die). Median daily visiting time was 8 hours
(interquartile range: 4 hours). Linguistic area significantly influenced
visiting policies: ICUs in German-speaking Switzerland had a longer
median daily visiting time (10 h) than the other Swiss ICUs (6.5 h/die for
French-speaking Switzerland and 8 h/die for Italian-speaking
Switzerland). None of Swiss ICUs required gowning procedures for
visitors; whereas hand disinfection was strictly recommended. Visits by
children under twelve were authorized in 95.8% ICUs (70/73). In 24,6%
ICUs (18/73) visits were permitted only to immediate family members.
Most ICUs (56,2%) allowed a maximum of two visitors at the same time.
In a multivariate logistic regression analysis we were not able to identify
variables independent associated with visiting times
Conclusions: Swiss ICUs have less restrictive visiting policies than
other European countries, nevertheless only 2/73 Swiss ICUs have an
open visiting policie. We could not identify objective barriers for
restricted visiting time. Accordingly it would be desirable to encourage
nationwide strategies for the implementation of an open-visiting-model
in Swiss ICUs.
Einführung pädiatrischer Simulation auf der Abteilung für
Neonatologie und Intensivmedizin des Kinderspitals Zürich
F. Ulmer1, B. Chorschew1
1University Children’s Hospital, Zurich, Switzerland
Hintergrund: In der Pädiatrischen Intensivmedizin (PI) werden kritisch
kranke Kinder mit wachsendem medizinischen, personellen und
technischen Aufwand therapiert. Herausforderungen bilden die
apparative Komplexität, die interprofessionelle und multidisziplinäre
Behandlung, die emotionale Belastung durch die Präsenz von Eltern,
sowie das Arbeiten unter akutem Zeitdruck. Herkömmliche Aus- und
Weiterbildungskonzepte zielen nicht auf interdisziplinäre Teamtrainings
ab. Simulationsbasiertes Training bietet die Möglichkeit realistisch,
sicher und reproduzierbar ein breites Spektrum klinischer und situativer
Gegebenheiten zu inszenieren.
Ziel: Wir beabsichtigten die Etablierung des Simulationsmediums als
Weiterbildungsinstrument mit dem Ziel der Vermittlung von
medizinischem Wissen und zur Förderung von nicht technischen
Fähigkeiten im Arbeitsalltag. Durch interdisziplinäre Simulationen soll
die Handlungsfähigkeit der Mitarbeiter in akutmedizinischen Situationen
gefestigt werden. Übergeordnetes Ziel ist die Verbesserung der
Behandlungsqualität, was eine Steigerung der Patientensicherheit
gewährleisten soll.
Methodik: Ab September 2012 wurden in situ Simulationen eingeführt.
Der Kindersimulationstrainer SimBaby™, wurde in einem mobilen
Säuglingsbett an einem Patientenplatz der Intensivstation aufgebaut.
Die Simulationsszenarien dauerten 10–20 Minuten, wurden auf Video
aufgezeichnet und endeten mit einem 45 minütigem Debriefing. Dieses
konzentrierte sich auf das Besprechen des medizinischen
Schwerpunktes und auf die Sensibilisierung und Festigung von
Teamkompetenzen und der Kommunikationsfähigkeit des
Teilnehmerteams. Danach wurden die Teilnehmer mittels
Evaluationsformular befragt.
Ergebnisse: Während 9 Monaten wurden 18 Simulationsszenarien
durchgeführt und 39 Ärzte – und 53 Pflege- Evaluationen ausgewertet.
Organisation, Lerninhalt und Relevanz für klinische Tätigkeit werden als
gut bis sehr gut bewertet. Realitätstreue und infrastrukturelle
Ausstattung werden als gut bewertet. Die angemerkten Kommentare
zeugen von Motivation zum vertieften Studium des medizinischen
Sachverhaltes und von Interesse hausinterne Merkblätter besser zu
kennen. Mitarbeiter beurteilen Simulation als besonders förderlich für
Kommunikation und Teamdynamik in medizinischen Akutsituationen.
100% der Simulationsteilnehmer empfehlen Simulationstraining weiter.
References:
1 Quinio P, et al. Intensive Care Med. 2002;28:1389.
2 Lee MD, et al. Crit Care Med. 2007;35:497.
3 Giannini A, et al. Intensive Care Med. 2008;34:1256.
4 Vandijck DM, et al. Heart Lung. 2010;39:137–46.
5 Spreen AE, Schuurmans MJ. Intensive Crit Care Nurs. 2011; 27.
F13
Risk factors and incidence for postoperative delirium
in patients undergoing cardiac surgery with cardiopulmonary
bypass support vs. beating heart (off pump) surgery
O. Dzemali1, A. Häussler1, K. Graves1, A. Rist2, H. Löblein1, M. Genoni1
1Univeristy Heartcenter Zürich, Zürich, Switzerland; 2Dept. of
Anesthesiology, City Hospital Triemli, Zürich, Switzerland
Objective: To determine the incidence and risk factors for delirium a
retrospective analysis on 454 patients undergoing cardiac surgery
with the support of cardiopulmonary bypass (CPB) versus off-pump
coronary artery bypass (OPCAB) was performed.
Methods: Risk parameters were identified for all patients. CAM ICU
assessment for delirium was performed post-operatively. The patients
were allocated into two groups: Group 1, 245 patients requiring CPB
support and Group 2, 175 patients receiving OPCAB procedures.
Micro-emboli activity was measured on CPB patients with the BCC200
Bubble Counter. 34 patients could not be allocated into these two
groups and were excluded from the group totals.
Results: The total incidence of delirium for all cardiac patients (454)
was 14.76% (65 pts), for Group 1 (CPB, 21.22%, 52 pts), and Group 2,
(OPCAB 7.43%, 13 pts). Significant risk factors for group 1 were age
(p = 0.0001), Euroscore (p = 0.0199), CPB time (p = 0.0033), aortic
clamp time (p = 0.0241), MES volume (p = 0.0103) and transfusion of
erythrocytes (p = 0.005). For group 2 risk factors were age (p = 0.0014),
Euroscore (p = 0.0261), Cell-Saver volume (p = 0.0146) and transfusion
of erythrocytes (p = <0.0001). Areas of postoperative morbidity for
delirium for patients of both groups were similar with increased
intubation time, pneumonia, new atrial fibrillation, ICU and hospital stay.
Conclusion: Increased age, blood transfusion and cardiopulmonary
bypass are significant risk factors for delirium. The volume of microemboli activity during CPB correlates strongly with delirium. Off pump
coronary artery bypass surgery significantly reduces the incidence of
postoperative delirium by avoiding the use of cardiopulmonary bypass.
F15
Activité d’une unité de soins intermédiaires couplée aux
soins intensifs: description à l’aide du minimal data set
(MDSi)
G. Sridharan1, H. Ksouri1, D. Crausaz1, M. Maus1, A.M. Khamsi1,
V. Ribordy1
1Hôpital fribourgeois, Soins Intensifs et continus, Fribourg, Switzerland
Introduction: En 2012 des directives suisses pour la reconnaissance
des unités de soins intermédiaires (intermediate care, IMC) ont été
validées. Deux modèles sont décrits, l’IMC couplé à une unité de soins
intensifs (USI) et l’IMC indépendant. Nous décrivons l’activité d’une
IMC (6 lits) couplée à une USI (10 lits). Les deux unités constituent un
service autonome et polyvalent qui dispose de deux équipes infirmières
distinctes et qui est géré par la même équipe médicale.
Méthode: La base de données MDSi des SI a été complétée en 2012
par une deuxième base pour l’ensemble des données des patients pris
en charge dans l’IMC. Des paramètres supplémentaires ont été
intégrés, notamment pour décrire les modalités de la ventilation et
documenter les équipements du patient. La saisie et la validation se
font online, par l’équipe médico-soignante et les cadres, en conformité
avec le règlement de la SSMI. Le personnel médico-soignant a été
formé préalablement.
Résultats: Pendant l’année 2012, l’IMC a accueilli 1045 patients (âge
moyen 64a, SAPS-2 moyen 24, durée de séjour moyenne 1.5j), l’USI
1040 patients (âge moyen 64a, SAPS-2 moyen 33, durée de séjour
moyenne 2.1j). 18% des patients ont été pris en charge dans les deux
unités, le plus souvent il s’agissait de transfert de l’USI vers l’IMC («step
down»), améliorant la continuité de la prise en charge. La répartition
des horaires selon la catégorie SSMI était pour l’IMC: Ia 1%, Ib 21%, II
42% et III 36%. Pour l’USI: Ia 21%, Ib 40%, II 30% et III 9%. Le
pourcentage des horaires de ventilation était 17% pour l’IMC (invasive
par trachéotomie: 3%, non-invasive: 14%), et 48% pour l’USI (invasive:
32%, non-invasive: 16%). Le pourcentage horaire sous traitement
vasopresseur était 5% pour l’IMC et 26% pour l’USI. Le taux de
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f r e e c o m m u n i c at i o n s 3
réadmission à l’IMC ou à l’USI est <5%. Ces données ont également
permis d’améliorer la documentation de l’activité et d’effectuer une
facturation précise.
Conclusion: Ce modèle d’IMC permet la prise en charge de patient de
gravité moyenne à importante avec un recours fréquent à la ventilation
et l’utilisation de vasopresseurs de manière efficace et sécuritaire. Ce
système permet une mutualisation des ressources, améliore le flux des
malades et l’accessibilité aux lits de soins intensifs. La présence de
l’intensiviste, ainsi que la formation du personnel sont des facteurs clefs
pour permettre le développement de ce modèle. Les enjeux financiers
qui en résultent sont importants.
f r e e c o m m u n i c at i o n s 4
F16
Ethische Leitlinien in der Praxis: Was fördert, was hemmt
ihre Anwendung?
B. Meyer-Zehnder1, H. Albisser Schleger 2, S. Tanner 2,
V. Schnurrer 2, J. Schürmann 2, S Reiter-Theil 2, H. Pargger 1
1
Dep. Anästhesie, Universitätsspital, Basel, Switzerland; 2Klinische
Ethik Support & Begleitforschung, Universitätsspital, Basel, Switzerland
Hintergrund und Fragestellung: Fördernde und hemmende Faktoren
bei der Implementierung von medizinischen Leitlinien sind gut
untersucht. In der Literatur wird empfohlen, solche Faktoren vor einer
Implementierung zu ermitteln, um die Strategie entsprechend planen
zu können. Aktuell gewinnen auch ethische Leitlinien in der Klinik an
Bedeutung, bei denen diese Faktoren aber bisher nicht untersucht
wurden. Die medizinethische Leitlinie METAP (Medizin, Ethik, Therapie,
Allokation, Prozess) wurde im Rahmen eines SNF-Projekts (Nr.
3200B0-113724 und 32003B_125122) entwickelt mit dem Ziel, klinische
Fachpersonen für einen ethisch angemessenen Therapieentscheid
in schwierigen Einzelfallsituationen zu unterstützen (1, 2). METAP
wurde in den Jahren 2009–2011 in vier Spitälern auf drei
intensivmedizinischen und zwei geriatrischen Abteilungen eingeführt
und evaluiert. Welche hemmenden und fördernden Faktoren
identifizierten die Anwender von METAP?
Methode: Leitfadengestützte Einzel- (EI) und Gruppeninterviews (GI)
mit Mitarbeitenden, die METAP regelmässig angewendet haben
(33 EI und 9 GI; n = 77 (44 Pflegende, 24 Ärzte, 9 andere
Berufsgruppe). Auswertung nach den Regeln der qualitativen
Inhaltanalyse
Resultate: In den EI und GI wurden (fördernde und hemmende)
Faktoren identifiziert, die sich in vier Gruppen einteilen lassen: METAP/
Ethik per se, Strukturen/Ressourcen, Kontext/Umgebungsvariable und
die individuelle Ebene. Die darunter zusammengefassten
Unterkategorien zeigen jeweils eine fördernde oder hemmende
Ausprägung. Am häufigsten (mind. vier der fünf Abteilungen) genannt
wurden folgende Faktoren: Zeit- und Personalmangel, engagierte
Mitarbeitende, bereits bestehende Sensibilisierung für ethische
Probleme, bestimmte klinische Situation (z.B. Häufigkeit von komplexen
Situationen) sowie die Unterstützung durch die ärztliche und
pflegerische Leitung. Andere Faktoren wurden nur in einzelnen
Stationen beobachtet wie die Konkurrenz durch parallel eingeführte
Projekte oder die Verfügbarkeit des Materials. Wenn sich eine Wirkung
beobachten lässt, wird METAP eher angewendet, als wenn dies nicht
der Fall ist.
Schlussfolgerung: Die Kenntnis dieser hemmenden und fördernden
Faktoren kann für die Einführung künftiger Leitlinien-Projekte hilfreich
sein. Stationsspezifische Faktoren sind entsprechend zu
berücksichtigen.
F17
Epidemiology and injury patterns of patients consulting
following assault by nightclub security agents in a university
hospital emergency service and an associated specialised
forensic consultation
A.-S. Feiner2, N. Romain-Glassey1, M. Gut1
1
Unité de Médecine des Violences, CURML, Lausanne, Switzerland;
2Service des Urgences, CHUV, Lausanne, Switzerland
Introduction: The Violence Medical Unit (VMU), a specialised forensic
medical consultation, was created at the Lausanne university Hospital
in 2006. All patients consulting at the ED for interpersonal violencerelated injury are referred to the VMU, which provides forensic
documentation of the injury and referral to the relevant community
based victim-support organisations within 48 hours of the ED visit.
This frees the ED medical staff from forensic injury documentation and
legal/social referral, tasks for which they lack both time and training.
Among community violence, assaults by nightclub security agents
against patrons have increased from 6% to 10% between 2007 and
2009. We set out to characterise the demographics, assault
mechanisms, subsequent injuries, prior alcohol intake and ED & VMU
costs incurred by this group of patients.
Methods: We retrospectively included all patients consulting at the
VMU due to assault by nightclub security agents from January 2007 to
December 2009. Data was obtained from ED & VMU medical, nursing
and administrative records.
Results: Our sample included 70 patients, of which 64 were referred by
the CHUV ED. The victims were typically young (median age 29) males
(93%). 77% of assaults occurred on the weekend between 12 PM and 4
AM, and 73% of the victims were under the influence of alcohol. 83% of
the patients were punched, kicked and/or head-butted; 9% had been
struck with a blunt instrument. 80% of the injuries were in the head and
neck area and 19% of the victims sustained fractures. 21% of the
victims were prescribed medical leave. Total ED & VMU costs averaged
1048 SFr.
Conclusion: Medical staff treating this population of assault victims
must be aware of the assault mechanisms and injury patterns, in
particular the high probability of fractures, in order to provide adequate
diagnosis and care. Associated inebriation mandates liberal use of
radiology, as delayed or missed diagnosis may have medical, medicolegal and legal implications.
Emergency medical services play an important role in detecting and
reporting of such incidents. Centralised management of the forensic
documentation facilitates referral to victim support organisations and
epidemiological data collection. Magnitudes and trends of the different
types of violence can be determined, and this information can be then
impact public safety management policies.
F18
Dedicated pediatric cardiac intensive care embedded
into a general pediatric intensive care service
S. Pilgrim1, J.-P. Pfammatter2, B. Grädel1, A Kadner3, B Wagner1
1Department of Pediatric Intensive Care, University Childrens Hospital
Berne, Bern, Switzerland; 2Department of Pediatric Cardiology,
University Hospital Berne, Bern, Switzerland; 3Department of
Cardiothoracic Surgery, University Hospital Berne, Bern, Switzerland
Aim: To describe the organisation of our pediatric cardiac intensive care
service embedded into the general pediatric intensive care unit (PICU)
and to compare it with established principles for pediatric cardiac
intensive care programmes (1). Dedicated pediatric cardiac intensive
care units with specialised teams have an impact on research and
setting standards for improved patient outcomes. Separating cardiac
and general pediatric intensive care services may not be applicable
for many centers however.
Methods: To provide and ensure optimal pediatric cardiac intensive
care, mandatory principles must be achieved. We compare our
specialised cardiac service integrated in our general PICU with a
framework of essential elements for sustained success for pediatric
cardiac intensive care programs (2).
Results: Multidisciplinary collaboration within a dedicated team and
anticipatory care in an individualised approach within clinical practice
guidelines are mandatory key elements [1, 2]. In our service we have
a dedicated team of specialised PICU nurses, intensivists, cardiologists,
cardiothoracic surgeons and anesthesists. A structured faculty
development and continuous quality assessment amongst our PICU
team is established. The cardiac core team attains its required
competencies by attending regular teaching activities (lectures,
workshops, hands-on sessions, simulation) that are provided by various
specialists of our pediatric cardiac service. Additional external courses
(i.e. ECMO-course) complement the faculty development program.
Members of the cardiac core team have the duty to pass their expertise
on to the general PICU team and to compile guidelines by direct
bedside support, topic-focused workshops and lectures, guideline
discussions and practical sessions that are embedded within the
working day and the general PICU faculty development program. This
helps to ensure successful multidisciplinary teamwork. Further required
essential elements as service continuum, gradual transition, unit
Schweiz Med Forum 2013;13(Suppl. 61)
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f r e e c o m m u n i c at i o n s 4
coverage, technology utilisation, data analysis and quality management
are established in our general PICU.
Conclusion: The proposed essential elements for sustained success of
a paediatric cardiac intensive care program can be achieved in our
setting of a mixed paediatric intensive care unit.
F19
Impact of Streaming Fast-Track on Early Management
of STEMI Patients
Nuno Palhais, Sonja Lehmann, Mario Togni, Jean-Jacques Goy,
Gérard Baeriswyl, Linda Abrecht, Valérie Stolt, Vincent Ribordy,
Jean-Christophe Stauffer, Stéphane Cook
University & hospital, Fribourg
Introduction: Timely coronary reperfusion of patients suffering from
acute ST-elevation myocardial infarction (STEMI) is associated with
improved clinical outcome. We implemented a fast track managed
activation protocol for STEMI in 2008 at our institution. The fast-track
protocol includes early activation of the catheterization laboratory and
cardiology by a single-call system and direct admission from ambulance
to the catheterization laboratory. Repeated instruction to the general
population (talks, local radio broadcasting and newspaper articles), to
primary care physicians, emergency rooms physicians and staff are
organized routinely. Dedicated algorithms are transmitted as pocket
cards and are available on the internet since 2008, and as iPhone app
since 2011. The purpose of this study is to evaluate the evolvement of
the time-intervals from 2008 to 2011, and its impact on clinical
outcomes.
Methods & Results: All consecutive patients that underwent PCI for
acute STEMI (pain lasting <12 hours) from January 2008 to December
2011 were included. Time-intervals, patients, lesions and procedural
characteristics were prospectively collected. Clinical outcome was
assessed by phone call at 1 and 12 months. There were 198
consecutive patients (143 men, mean age 63 ± 9 y.o.) At admission,
chest pain was lasting <6 hours in 85% and 5% were in overt
cardiogenic shock. Over this 4-year period, the median door-to-needle
time decreased from 82 to 60 minutes (p <0.003) and the median
pain-to-revascularization time decreased from 280 to 256 minutes (p
<0.01). Consistently, intra-hospital mortality rate decreased from 6% to
3%, and the composite rate of major adverse cardiac events at 1 year
almost halved from 33% to 17% (p <0.001).
Conclusion: Implementation of a fast track protocol for STEMI patients
impacts the efficiency of acute management (as illustrated by improved
time intervals) and decreases in-hospital mortality and 1-year clinical
outcome.
F20
Strategic Steps to Reduce Spinal Cord Injury in Thoracoabdominal Aortic Aneurysm Repair
O. Dzemali1, I. Schwegler3, S. Matter2, K. Graves1, H. Loeblein1,
A. Häussler1, M. Genoni1
1University Heart Center, Zürich, Switzerland; 2Dept. for
Anaesthesiology, City Hospital Triemli, Zürich, Switzerland; 3Dept.
of Vascular Surgery, City Hospital Triemli, Zürich, Switzerland
Objective: Open surgical repair of a thoraco-abdominal aorticaneurysm (TAAAR) is a very invasive procedure associated with
potentially high morbidity and mortality. This implicates the need for
well-founded diagnostic tools, monitoring systems and a constructive
approach to surgery, all aimed at reducing perioperative neurologic
complications.
Method: Between June 2010 und December 2012 16 patients were
operated for TAAA. All underwent preoperative angiography to identify
a Adamkiewicz-artery and a spinal catheter was inserted for
cerebrospinal fluid drainage. Intraoperatively, in addition to routinely
used cardiac surgical monitoring, we installed specific neurological
monitoring devices in form of regional oxygen saturation
(INVOSTM,Troy,Mi,USA) and motor and sensory evoked potentials
(MEP/SEP). Selective intercostal reconstruction based on MEP/SEP
results was performed. Furthermore, we used partial extracorporeal
circulation (PECC) through atrio-femoral-bypass to support collateral
cord circulation.
Results: There were no mortalities and no cases of persistent
paraplegia or hemiparesis. Two patients suffered temporary paraplegia
without residuum. Four patients showed clinical signs of delirium. Spinal
fluid drainage pressure remained constant <14 mm H2O over three
days. We performed reconstruction or rebranching of spinal cord
intercostal artery guided by MEP/SEP in 38.7%. INVOSTM monitoring
was continued until extubation, episodes of desaturation were not
observed. None of the patients had neurologic abnormalities at the time
of discharge.
Conclusion: TAAR in PECC technique was performed with no mortality
and low morbidity in our patient cohort. PECC in correlation to MEP/
SEP helped to avoid paresis and spinal fluid drainage functioned as a
“pop off valve”. All these steps minimise the risks of this kind of invasive
surgical intervention.
Posters
P1
Effect of volume loading on left ventricular torsion in septic
shock
S. Blöchlinger1, P. Krähenmann1, D. Berger2, J. Bryner3, J. Wiegand2
1Departement of Cardiology, Bern University Hospital (Inselspital),
Bern, Switzerland; 2Departement of Intensive Care Medicine, Bern
University Hospital (Inselspital), Bern, Switzerland; 3Department of
Anesthesiology, Perioperative Medicine and General Intensive Care
Medicine, Salzburg General Hospital, Salzburg, Austria; 4Paracelsus
Private Medical University, Salzburg, Austria
Purpose: Ventricular torsion is an important component of cardiac
function. The effect of septic shock on left ventricular torsion is not
known. Since torsion is influenced by changes in preload, we compared
the effect of fluid loading on left ventricular torsion in septic shock with
the response in matched healthy controls.
Methods: We assessed left ventricular torsion parameters by
transthoracic echocardiography in eleven patients early during septic
shock and in eleven age- and gender-matched healthy volunteers
before and after rapid volume loading with 250 mL of a Ringer’s lactate
solution.
Results: Peak torsion and peak apical rotation were reduced in septic
shock (10.2 ± 5.2° and 5.6 ± 5.4°) as compared to healthy volunteers
(16.3 ± 4.5° and 9.6 ± 1.5°; p = 0.009 and p = 0.006 respectively). Basal
rotation was delayed and diastolic untwisting velocity reached its
maximum later during diastole in septic shock patients than in healthy
volunteers (104 ± 16% versus 111 ± 14% and 13 ± 5% versus 21 ± 10%;
p = 0.03 and p = 0.034 respectively). Fluid challenge increased peak
torsion in both groups (septic shock 10.2 ± 5.3° vs 12.6 ± 3.9°; healthy
volunteers 16.3 ± 4.5° vs 18.1 ± 6°; p = 0.01). Fluid challenge increased
left ventricular stroke volume in septic shock patients (p = 0.003).
Conclusions: Compared to healthy volunteers left ventricular torsion is
impaired in septic shock patients Fluid loading attenuates torsion
abnormalities in parallel with increasing stroke volume. Reduced
torsional motion may constitute a relevant component of septic
cardiomyopathy.
Schweiz Med Forum 2013;13(Suppl. 61)
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Posters
P2
P4
The preoperative characteristics and postoperative
outcome of women undergoing off pump aortocoronary
bypass
(OPCAB) in compared to men in Switzerland
H. Loeblein1, O. Dzemali1, A. Haeussler1, M. Gruszczynski1,
D. Odavic1, M. Genoni1
1Triemli Hospital, Zürich, Switzerland
Objective: The preoperative characteristics and the postoperative
outcome of women undergoing OCAP bypass have been in the past
investigated with different outcomes. Our study was undertaken to
evaluate the preoperative characteristics and postoperative outcome of
women undergoing OPCAB surgery compared to men in Switzerland.
Method: The data of all patients who underwent off OPCAB between
1/2005-12/2010 was analysed. The preoperative characteristics and
postoperative outcome of women compared to men were evaluated.
Result: 885 patients underwent OPCAB between 1/2005–12/2010.
17.8% were female. There were no difference in gender with regard to
COPD, diabetes and angina pectoris grading, critical preoperative state,
number of diseased vessels, left main disease. Women were older
(p = 0.000), more obese (p = 0.004), had lower preoperative
haematocrit values (p = 0.000), higher preoperative C- reactive protein
values (p = 0.11) and more likely to present with NYHA III-IV symptoms
(p = 0.000), higher BNP (0.001), higher ejection fraction (p = 0.07),
positive family history for coronary disease (p = 0.18), and history for
hypertension (p = 0.000). Women were less likely to have undergone
percutaneous intervention (p = 0.024) and to have a history of smoking
(p = 0.000). There was no gender difference in the postoperative
outcome with regard to troponin, atrial fibrillation, death and intensive
care unit days. Females were intubated (p = 0.001) and hospitalized
longer (p = 0.001) and were more likely to receive blood transfusions
(p = 0.000). Female gender was found to be an independent risk factor
for postoperative transfusions taking in account all other variables
including preoperative haematocrit (p = 0.000).
Conclusion: Women in Switzerland undergoing off pump coronary
bypass surgery are older and have higher BNP, CRP and NYHA
grading for dyspnoea, more likely to have hypertension and positive
family history less likely to have undergone percutaneous intervention
compared to males. Female gender was also found to be an
independent risk for postoperative blood transfusion.
Risk factors for sternal wound infection in patients
undergoing off pump coronary bypass surgery with BITA
H. Loeblein1, O. Dzemali1, K. Graves1, M. Gruszczynski1, D. Odavic1,
M. Genoni1
1Triemli, Zürich, Switzerland
Purpose: The use of bilateral internal thoracic artery (BITA) grafting has
shown to provide a better survival benefit compared to single internal
thoracic artery (SITA) grafting. Previous studies have provided
conflicting evidence as to whether an increased risk of sternal infection
is associated with the use of bilateral internal mammary artery as a
coronary bypass graft (CABG) in patients with diabetes, COPD and
obesity. This study was undertaken to evaluate the risk factors for
sternal wound infection in patients undergoing off pump ACBP with
BITA grafting.
Method: The data of all patients who underwent off pump CABG
between 1/2009-12/2010 was retrieved from our data bank. The
preoperative and postoperative risks that may predispose to sternal
wound infection were evaluated. Sternal wound infections were
classified according to the guidelines of the Centre of Disease Control
and Prevention
Result: 384 patients underwent off pump ACBP and of those 48.4%
received BITA grafting. 6.4% presternal wound infections and no
mediastinitis occurred in those who received BITA grafting. With BITA
grafting there was no correlation between presternal wound infections
and gender, age, body mass index, Euro Score, diabetes mellitus,
HbA1c, preoperative albumin, history of smoking, extra cardiac
arteriopathy, number of coronary vessel disease, left main disease,
re-operation, emergence/ urgent surgery, number of graft used, surgical
time, surgical room temperature and humidity, ICU days, postoperative
atrial fibrillation and blood transfusion. There was a significant
correlation between both deep seternal wound infection and COPD
(p = 0.003, CC0.017–0.019).
Conclusion: Our analysis shows that only patients with COPD are at
risk for developing presternal infection with off pump BITA grafting. All
other patients which are solely based on the risk of sternal infection
should not be denied from receiving off pump BITA grafting.
P3
Risk Factors for Delirium in Patients Undergoing Coronary
Bypass Surgery
H. Loeblein1, O. Dzemali1, A. Kostorz1, D. Odavic1, M. Genoni1
1Triemli, Zürich, Switzerland
Purpose: The risk factors on postoperative delirium following Coronary
Bypass Surgery (CABG) are not well defined. The current study was
undertaken to evaluate the independent preoperative and postoperative predictors for postoperative delirium in patients undergoing CABG.
Methods: The data of all patients who underwent CABG between
8/2006-08/2007 were retrieved from our data bank. Delirium was
assessed by the confusion assessment method.
Results: Out of 294 patients, 13% developed delirium. No correlation
was seen between delirium and in-tensive care days, intubation time,
platelets transfusion, postoperative myocardial infarction, atrial
fibrilla-tion, ejection fraction worsening, need for dobutamine, need for
intraaortic ballon pump, need for haemofiltration, infection,
gastrointestinal complications. Independent risk factor for postoperative
delirium were: Low preoperative haematocrit p = 0.009, female gender
p = 0.013, age p = 0.031, peripheral vascular disease p = 0.0479,
adipositas p = 0.006. There was a 20% increase in isk for developing
delirium in patients receiving more than 4 packed red blood cell
transfusion.
Conclusions: Independent predictors for postoperative delirium are
female gender, age, obesity, peripher-al vascular disease and
preoperative haematocrit level. Postoperative blood transfusion is a
strong predic-tor for postoperative delirium
P5
Early postoperative changes in left-ventricular torsion
after aortic valve replacement for severe aortic stenosis:
a prospective clinical study
S.Blöchlinger1, F. Schwitz1, D. Berger1, J. Bryner1, E. Roost1,
S. Jakob1, M. Dünser1, J. Takkala1
1Department of Intensiv Care Medicine, Inselspital, University Hospital
Bern and University of Bern, Bern, Switzerland; 2Department of
Cardiology, Inselspital, University Hospital Bern and University of Bern,
Bern, Switzerland; 3Department of Cardiovascular Surgery, Inselspital,
University Hospital Bern and Univerity of Bern, Bern, Switzerland;
4Department of Anaestesiology, Perioperative andGeneral Intensiv Care
Medicine, Salzburg General Hospital and Paracelsus Privat Medical
Universitiy, Salzburg, Austria
Background: In patients with aortic stenosis, left ventricular systolic
torsion is increased to overcome excessive afterload. It is unknown how
torsion, which is dependent on preload, afterload and contractility, is
changed in the immediate postoperative period following aortic valve
replacement and whether it is responsive to fluid loading.
Methods: 12 patients undergoing routine aortic valve replacement for
aortic stenosis were assessed. Echocardiographic examination was
performed on the day before surgery and within 18 hours following
surgery including a 250 ml volume challenge.
Results: Peak torsion decreased postoperatively by 21.2% (23.4 ± 5.6°
to 18.4 ± 6.9°; p = 0.01), whereas the remaining torsion indices were
unaffected by aortic valve replacement. The fluid challenge increased
central venous pressure (8 ± 4 mm Hg to 11 ± 4 mm Hg; p = 0.003) and
reduced peak systolic torsion velocity (132.6 ± 41.7 °/s to 121.3 ± 32°/s;
p = 0.03). Peak torsion decreased in three patients and increased in
eight patients following fluid loading. Patients, whose peak torsion
increased, had higher early mitral inflow velocity postoperatively (p =
0.04) than those with decreasing peak torsion. Patients with reduced
peak torsion following fluid loading received more fluids (p = 0.04) and
had a higher positive fluid balance during the intensive care unit stay
(p = 0.03). Peak torsion following fluid loading correlated with total fluid
input (p = 0.001) and cumulative fluid balance (p = 0.002).
Conclusions: Left ventricular systolic torsion decreases early following
aortic valve replacement but remains elevated despite elimination of
aortic stenosis. In the majority of patients systolic torsion is augmented
by fluid loading whereas peak systolic torsion velocity is reduced.
Schweiz Med Forum 2013;13(Suppl. 61)
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Posters
P6
Impact of duty-hour reform and physician shortage on the
performance of a university medico-surgical adult intensive
care unit (ICU)
M.D. Schaller1, J.P. Revelly1, P. Eggimann1, P. Jolliet1, Y.A. Que1,
J.L. Pagani1
1
CHUV, Service de Médecine Intensive Adulte, Lausanne, Switzerland
Introduction: Since 2005, the federal labor act limits duty hours for
fellows (F) and residents (R) at a maximum of 50h weekly (maximum
consecutive hours: daily 12.5, nightly 12). The merging of the medical
and surgical ICUs into one multidisciplinary unit allowed a precise
definition of the requirements necessary to guarantee continuity of
medical care in our 34-bed medico-surgical ICU. We had to organise
the shifts and limit the hours accordingly. The optimal medical workflow
requires: (i) 5 F, 5 R and 4 attendings (A) during working days; (ii) 4 F,
2 R and 2 A during the weekends and public holidays; and (iii) 2 F, 2 R
on the ICU and 2 A on call during the night shifts.
Methods (data collections): Retrospective and prospective analysis
over the april 2011-october 2013 period. The work schedules were
planned by one dedicated R and validated by an A. Since January 2013,
the schedule is made only by the dedicated A. The number of F and R
was recorded. We observed difficulties to recrute R. The periods of
shortage were recorded prospectively. In situation of F and R shortage,
senior physicians perform direct patient management on top of their
others tasks (teaching, education, administration, research).
Results: Depending on the fellow recruitment shortage and on our
work organization requiring 2 R each night (730 nights per year), the
impact on workload for R and A has significantly increased. During this
study period, the number of R attributed by our institution was never
attained. Concomittantly to the decrease of R recruitment, a significant
increase in direct clinical work by A ensued. A median R activity of 10
days per month (IQR 0-29) is displaced on the A during working days.
Including the weekend period and public holidays, the real median R
activity displaced on the A increases to a median of 28 days per month
(IQR 16-55).
Conclusion: After implementation of the 2005-swiss labor law with
major duty hours reforms and 5 years after the creation of the «Service
de Médecine Intensive Adulte», a severe shortage in recruitment of
residents is observed. 730 nightshifts, 208 weekend-periods have to be
assumed by fellows and residents. The lack of physicians in this field of
specialization in Switzerland leads to a displacement of the clinical
activity overload on the senior specialist physicians. This could
influence well-being, increase stress symptoms or burn-out in this field
of acute medicine.
P7
Fine-tuning heparinisation with the Sonoclot analyzer
during extracorporeal membrane oxygenation
R. Behr1, K. Graves1, O. Dzemali1, M. Genoni1
1City Hospital Triemli Zürich, Zürich, Switzerland
Background: Extracorporeal membrane oxygenation (ECMO),
especially in the post cardiotomy setting, is often associated with acute
coagulation deficiencies. Differentiation between clotting abnormalities
and surgical bleeding is complex. The point of restarting heparin
postoperatively is difficult to determine and often guided by a fear of
device thrombosis. Measurement of activated clotting time (ACT) or
activated partial thromboplastin time (APTT) alone can be inadequate
to effectively control anticoagulation without causing fluctuations
towards bleeding or thrombo-embolism. We introduced the Sonoclot
analyzer in our institution as a point of care anticoagulation assay to
monitor residual heparin effect and the recovery of haemostasis
postoperatively, as well as heparin dosage response.
Methods: From patient whole blood samples we measured Sonoclot
ACT (activator kaolin) and the rate of fibrin polymerization using a
parallel analysis of Sonoclot gbACT (activator glass beads) and
Sonoclot HgbACT (activator glass beads plus heparinase). The latter
two assays provided a qualitative graph and quantitative ratio (gb/Hgb
clot rate ratio [CRr]) of fibrin polymerization. CRr results were plotted
against ACT, APPT and heparin dosage.
Results: Sonoclot CRr analysis visualized the impact of clotting factor
substitution, any residual heparin effect and heparin dosage response.
When heparin was initially withheld to aid postoperative haemostasis,
recovery of fibrin polymerization could be closely depicted and the point
of restarting heparin administration clearly defined. According to the
underlying pathology necessitating ECMO treatment, we specified a
target Sonoclot CRr between 0.5 and 0.8. This produced ACT values
which remained stable (± 15 sec.) and equidistant to APPT values as
heparin dosage increased (100 to 1000 IE/hr) with recovering patient
liver function. Bleeding was markedly reduced and we observed no
device related thrombotic complications.
Conclusion: Measurement of Sonoclot CRr is easy, delivers prompt
results at the bedside and allows determination of an individualized
patient target ACT/APTT during ECMO.
P8
Recurrent clotting of the right ventricular assist device –
repeated thrombolysis with two different protocols
A.M. Schuerner1, M.J. Wilhelm2, V. Falk2, F. Ruschitzka3, D. Bettex1,
A. Rudiger1
1
Institute of Anesthesiology, University Hospital Zurich, Zurich,
Switzerland; 2Clinic for Cardiovascular Surgery, University Hospital
Zurich, Zurich, Switzerland; 3Department of Cardiology, University
Hospital Zurich, Zurich, Switzerland
Background: Mechanical circulatory support with a ventricular assist
device (VAD) is increasingly used for the treatment of end-stage heart
failure. Thromboembolism, bleeding, infections and mechanical failure
are the major causes of morbidity and mortality. Pump dysfunction due
to clot formation in particular can become a life-threatening
complication and requires urgent therapeutic action.
Case report: A 48-year-old male patient received a left and right VAD
(HeartWare®, Framingham, MA) due to refractory biventricular heart
failure after acute myocardial infarction. Despite therapeutic
anticoagulation with heparin (anti-Xa activity 0.3–0.7 IU/ml) and
antiaggregation therapy with aspirin 100 mg/d, increasing power
requirements of the pump combined with elevated liver enzymes raised
the suspicion of right VAD thrombosis 14 and 20 days after deviceimplantation, respectively. In the first occasion, a normal pump function
was restored within 3 hours after iv administration of a 10 mg bolus of
recombinant tissue-type plasminogen activator (rt-PA; Actilyse®) [1]
followed by a infusion of 90 mg over 2 hours. Five days later a recurrent
in-pump clot formation was successfully treated with urokinase-type
plasminogen activator (Streptokinase®) 100'000E/h for 24 hours
administered through the central venous catheter. No major
haemorrhages were noticed during both interventions. In due course,
the anticoagulation management was changed from heparin to warfarin
(INR 2.5–3.5). Under this anticoagulation the patient developed a fatal
intra-cerebral haemorrhage 11 days after the last thrombolysis.
Conclusion: This case highlights that thrombolysis with high dose rt-PA
can quickly restore normal pump function in an acute life threatening
right VAD thrombus. Subacute thrombus formation can successfully be
treated with continuous intravenous urokinase administration resulting
in thrombus resolution within 24 hours. Further technical development of
the HeartWare® pump with respect to the right heart circulation will
hopefully reduce the risk of thrombus formation.
Reference
1 M. S. Kiernan, et al. J Thorac Cardiovasc Surg. 2011;142:71.
P9
Lactic acidosis, epilepsy and congestive heart failure
M. Lang1, A. Müller1, M. Maggiorini1
1University Hospital Zurich, Intensiv Care Medicine, Zurich, Switzerland
Introduction: Lactic acidosis, epilepsy and congestive heart failure are
frequently encountered in the intensive care unit, however if all of them
present in the same patient, this should alert you.
Case report: The 49 year old patient was admitted by the general
practitioner (GP) because of a history of nausea, vomiting, and cough
since three weeks. Symptoms progressively worsened and eventually
respiratory distress, delirium and apathy developed.
From the age of 30, the patient had developed progressive hearing
loss, ptosis, and proximal muscle weakness. Later, stroke-like episodes
developed with transient hemiparesis and epileptiform potentials in
the EEG. Because of a 3-fold increase in levetiracepam blood levels,
GP initial diagnosis was levetiracepam overdose.
On admission Hf was 87/min and BP 108/76 mm Hg. Clinical
examination revealed signs of impaired microcirculation. AST was 1496
U/L, ALT 1134 U/L, hs-Troponin-T 0.112 mcg/L, CK 1190 U/L,
NTproBNP 6868 ng/L, creatinine 111 mcmol/L and lactate 4.6 mmol/L.
Transthoracic echocardiography showed a dilated right and left
ventricle. LV-EF was 23% and RV-FAC was 18% (norm. >25%). Severe
tricuspid and moderate mitral regurgitation was documented. The
clinical suspicion of low cardiac output syndrome could be confirmed by
right heart catheterization.
We started levosimendan for inotropic support and a diuretic therapy
was begun because of elevated filling pressures. The clinically apparent
Schweiz Med Forum 2013;13(Suppl. 61)
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Posters
disturbance of microcirculation improved and elevated liver enzymes
and renal parameters were diminishing. Still, lactate levels didn’t show
complete normalization.
Retrospectively we found that, by the age of 44, when stroke-like
episodes first happened, the patient was diagnosed with MELAS
(mitochondrial encephalomyopathy, lactic acidosis with stroke-like
episodes) syndrome. Most common cardiac manifestations reported are
dilated or hypertrophic cardiomyopathy, Wolff-Parkinson-White
syndrome and atrioventricular heart block.
Conclusion: The diagnosis of MELAS syndrome should be considered
in the young patient that presents with heart insufficiency, especially
when accompanied by other clinical features such as stroke, seizures,
encephalopathy, lactic acidosis and muscle weakness.
P10
Implementation of a multidisciplinary care program
to develop percutaneous tracheotomy in an adult ICU
C. Massebiaux1, F. Hof1, X. Gonin1, P. Dulguerov1, JC. Richard1
1
Hôptaux Universitaires de Genève, Health Care Directorate;Genève,
Switzerland; 2Hôptaux Universitaires de Genève, Division of Intensive
Care,Genève, Switzerland; 3Hôptaux Universitaires de Genève,
Division of ENT and Head- and-Neck Surgery, Genève, Switzerland
Introduction: A medical and surgical multidisciplinary team introduced
percutaneous tracheotomy in our adult ICU in 2012. The aim was to
develop percutaneous tracheotomy, when indicated, in complement of
traditional surgical procedure. To prevent complications and optimize
nursing care in this context, two clinical nurse specialist (CNS)
collaborated with physicians to develop local standards and monitor
the introduction of percutaneous tracheotomy in our daily practice.
Aim: Describe the different steps of this project.
Method: At first a multidisciplinary group developed standards of care
that included organizational elements, procedures and check lists.
In addition, a comparative table was produced to allow nurses and
physicians to visualize the main differences between the two
techniques, the required monitoring and care. Furthermore, the
electronic spread sheet was formatted to include the appropriate care
plan. The information was disseminated through several means:
personalized electronic messages, in-services and written supports.
Percutaneous procedures were initially performed by surgeons in the
presence of intensivistes and then the roles were inverted. The CNS
supervised the procedures and coordinated the follow up in the ICU
and in to the ward.
Results: The first percutaneous procedure was performed during
January 2012. During the following year, 42 tracheotmies (19
percutaneous, 23 surgical) were performed. In one case, the
percutaneous procedure was converted to surgical due to hemorrhagic
complication. The procedure has been adjusted to define the
assignment of each protagonist according to the different steps of the
protocol. All health care professionals adhered to the new standards
of care.
Conclusion: The introduction of this multidisciplinary specific care
program in the ICU supervised by the CNS permitted fine adjustments
to take place. However the follow up of these patients continues after
their discharge from ICU. In our institution, a CNS dedicated to
tracheotomy patients contributes to the continuity of care and staff
education in general wards.
P11
Chronically Critical Illness (CCI): Möglichkeiten
der Aktivierung und Bewegung sogenannter
«Langzeitintensivpatienten»
S. Haubner1, M. Fröhlich2, O. Rohrer3
1Stadtspital Triemli, Zürich, Switzerland; 2Universitätsspital Zürich,
Zürich, Switzerland; 3Inselspital, Bern, Switzerland
Hintergrund/Fragestellung: Von den Intensivpatienten leiden 5 bis
10% an einem Chronical Critical Illness-Syndrom (CCI), was sich
durch eine prolongierte Abhängigkeit und erschwertes Weaning
vom Respirator, ausgeprägte Fatigue und Polyneuropathien oder
-myopathien kennzeichnet. Durch die Kommission Praxisentwicklung
Pflege der SGI/SSMI wurden Pflegeschwerpunkte für diese
sogenannten Langzeitintensivpatienten identifiziert. In diesem
Zusammenhang soll untersucht werden, welche pflegerischen
Massnahmen die Aktivität und Bewegung beeinflussen und welche
Wirksamkeit sie besitzen.
Methode: In den Datenbanken Pubmed, Cinahl und Cochrane Library
wurde nach deutsch- oder englischsprachigen Artikeln im Zeitraum
2000–2012 zu CCI, Intensivpflege, Aktivität, Bewegung und Mobilisation
gesucht. Identifizierte Publikationen wurden hinsichtlich ihrer Eignung
zur Beantwortung der Forschungsfrage und ihrer Praxisrelevanz kritisch
beurteilt.
Resultate: Es wurden 55 Studien gefunden, von denen 24
eingeschlossen wurden. Die Evidenzlage für Patienten mit CCI war
schwach, so dass Pflegeinterventionen für alle Intensivpatienten
berücksichtigt wurden. Die Stufen der Aktivierungs- und
Bewegungsmöglichkeiten reichen von der passiven Durchbewegung
und Umlagerung über aktive Übungen im Bett, die Mobilisation an
Bettrand oder in den Stuhl bis hin zu Gehversuchen und Lauftraining,
auch mit beatmeten Patien-ten. Daneben werden alternative
Möglichkeiten wie neuromuskuläre Stimulation beschrieben. Die
Massnahmen zeigen Wirksamkeit, indem sie Mobilisationseinbussen
und den Muskelabbau minimieren und die funktionale Unabhängigkeit
maximieren. Komplikationen werden reduziert, die
Beatmungsentwöhnung unterstützt, wodurch eine Verkürzung des
Aufenthaltes auf der IPS und im Spital erreicht werden kann.
Ausserdem wird deutlich, dass sie sicher und machbar sind und kein
vermehrtes Risiko für den Patienten mit sich bringen. Die
Verantwortlichkeit liegt je nach kulturellem Kontext im Bereich der
Pflege und/oder der Physiotherapie.
Schlussfolgerung: In der Literatur beschriebene Massnahmen für
Intensivpatienten zur Verbesserung von Aktivität und Bewegung sind
auch bei Patienten mit CCI anwendbar. Dabei ist die frühestmögliche
Mobilisation von grösster Bedeutung. Sie sollte mit Begleitkonzepten
wie täglichen Aufwachversuchen, einem Delir- und AnalgosedationsManagement und Ernährungsstrategien gekoppelt sein, um in ihrer
Gesamtheit die Genesung dieser Patientengruppe positiv zu
beeinflussen.
P12
Schmerzerfassung bei nicht kommunikationsfähigen
Patienten auf der Intensivstation – Unterschiede in der
Anwendung und Anwenderfreundlichkeit der Behavioral Pain
Scale (BPS) und des Zurich Observation Pain Assessment
(ZOPA)
S. Gemperle1, J. Maier1
1Kantonsspital, Winterthur, Switzerland; 2Universitätsspital, Zürich,
Switzerland
Einleitung: Ungefähr 75% der intensivpflichtigen Patienten berichten
während ihrer Behandlung über starke bis sehr starke Schmerzen,
während die Behandelnden zu ca. 80% die Schmerztherapie als
adäquat einstufen. Ein Grund für diese Diskrepanz könnte der fehlende
Einsatz von Fremdeinschätzungsinstrumenten für Schmerzen sein. Da
Schmerzen negative körperliche und psychische Auswirkungen auf
Menschen haben, ist die Erfassung und Behandlung von Schmerzen
ein wichtiges Behandlungsziel auf Intensivstationen. Auf der Suche
nach geeigneten Instrumenten auf Intensivstationen im Kanton Zürich,
fanden sich die “Behavioral Pain Scale” (BPS) und das “Zurich
Observation Pain Assessment” (ZOPA).
Fragestellung: Worin liegen die Unterschiede in der Anwendung
und der Anwenderfreundlichkeit von BPS und ZOPA bei der
Schmerzerfassung von sedierten und maschinell beatmeten
erwachsenen Patienten auf der Intensivstation des Kantonsspitals
Winterthur?
Methode: Im Zuge einer Abschlussarbeit zum NDS HF Intensivpflege
wurde eine Literturrecherche zu Schmerzassessments, zu
Anwenderfreundlichkeit sowie zu maschinell beatmeten, sedierten
Intensivpatienten durchgeführt. Begleitend gab es eine Testreihe zur
Anwendung von BPS und ZOPA im Praxisalltag und eine Evaluation der
Anwenderfreundlichkeit beider Instrumente anhand vorher aufgestellter
Kriterien.
Ergebnisse: Je 18 Einschätzungen mit BPS und ZOPA wurden
erhoben. Beide erwiesen sich in der Praxis als anwenderfreundliche
Instrumente zur Einschätzung von Schmerzen bei maschinell
beatmeten Patienten.
Die Evaluation ergab, dass die Erfassung mit der BPS weniger Zeit
erforderte als mit ZOPA. In den anderen Kategorien überzeugte das
ZOPA, da die insgesamt 13 mit Definitionen hinterlegten
Verhaltensmerkmale eine umfassende Einschätzung von Schmerzen
ermöglichen. Hinzu kommt, dass im Gegensatz zur BPS beim ZOPA
auch physikalische Indikatoren berücksichtigt werden.
Diskussion: Der Einsatz beider Instrumente ermöglichte eine
umfassende und differenzierte Schmerzeinschätzung. Dies unterstützte
die Einleitung schmerzlindernder Massnahmen und machte diese
nachvollziehbarer. Die Dokumentation des gesamten
Schmerzmanagements gewann an Klarheit und Struktur, die
Zusammenarbeit im multiprofessionellen Team wurde leichter. Obwohl
das BPS weniger Zeit in Anspruch nimmt, wird der Einsatz von ZOPA
priorisiert, da es eine differenziertere Schmerzerfassung ermöglicht und
sich als anwenderfreundlicher präsentiert hat.
Schweiz Med Forum 2013;13(Suppl. 61)
12 s
Posters
P13
Fatal West Nile Virus Meningoencephalitis –
first case reported in Switzerland
L. Röllin1, F. Hillgärtner1, B. Preiswerk1, O. Engler2
1Department of Internal Medicine, Stadtspital Triemli Zürich, Zürich,
Switzerland; 2Labor Spiez, BABS (federal office for population
protection), Spiez / Bern, Switzerland; 3Department of Infectiology,
Stadtspital Triemli Zürich
Background: First reported case of a fatal meningoencephalitis caused
by a West Nile Virus in Switzerland
Case report: In September 2012, a 78-year-old man was transferred
to our intensive care unit with rapidly progressive disturbance of
consciousness. One week prior to admission the patient was treated in
a kosovar hospital for a suspected infection with high temperature and
fatique with rehydration and empiric antibiotic therapy. His medical
history was significant for a B-cell-lymphoma diagnosed in 2009 and
treated in curative intention with a combination chemotherapy
(R-CHOP) without signs of recurrence since. He was admitted to the
ICU due to a progressive encephalitic syndrome with high fever, rapidly
decreasing mental status and confusion despite broad-spectrum
antibiotic therapy (piperacillin/tazobactam) started 2 days prior to his
hospital admission. A thoracic/abdominal CT scan ruled out any source
of infection and an echocardiogram showed no evidence of
endocarditis. Blood cultures were negative. A CT scan of the head
showed no signs of elevated intracranial pressure. The CSF showed a
leukocytosis with 1888/ml white blood cells (WBC) and elevated total
protein. Despite high dose ceftriaxone, ampicillin and acyclovir in an
ICU setting, the patient’s mental status continued to deteriorate and
he was intubated.
Repetitive CT scans demonstrated no brain edema, intracerebral
hemorrhage or signs of an ischemia. A MRI of the brain showed no
pathological findings, particullary no recurrent lymphoma. All serological
testing were negative except for West Nile-Virus with a 5.6-fold increase
of the serum IgM titer. PCR testing of CSF and serum confirmed the
results.
The patient’s comatose state persisted. Two EEG`s showed generalized
deceleration of basic activity without signs of an epileptic state. High
dose steroid therapy did not affect the patient’s mental status. A brain
biopsy was not performed. After 24 days in the ICU without neurological
improvement therapeutic interventions were discontinued, and the
patient subsequently died. A request for an autopsy was denied.
Discussion: West Nile Virus (WNV) is an arthropod (mosquitoe)-borne
single-stranded RNA virus in the family of Flaviviridae. Less than 1% of
WNV infections manifest as severe neuroinvasive disease, such as
meningoencephalitis.
Conclusion: In West Nile Virus meningoencephalitis, therapy is limited
to supportive care and is usually fatal. This was the first such reported
case in Switzerland.
P14
Multi Organ Dysfunction Syndrome caused by Miliary
Tuberculosis in a Patient with HIV– a Death Sentence?
C. Flothmann1, B. Preiswerk2, M. Genoni3, R. Behr3, R. Buonomano4,
M. Suhner5, P. Fodor5, S. Frick1
1Dept of Internal Medicine; Stadtspital Triemli, Zürich, Switzerland;
2Dept of Infectious Diseases and Hospital Epidemiology, Stadtspital
Triemli, Zürich, Switzerland; 3Dept of Cardic Surgery, Stadtspital Triemli,
Zürich, Switzerland; 4Depts of Internal Medicine and Infectious
diseases, Limmattalspital, Schlieren, Switzerland; 5Dept of
Anaesthesiology and Intensive Care, Stadtspital Triemli, Zürich,
Switzerland
Background: Multi-organ-dysfunction syndrome (MODS) is a rare but
mostly fatal complication of miliary tuberculosis (Tbc) with a mortality of
up to 100%.
Case report: A 33-year old female patient, hospitalized for suspected
cholezystits, abdominal organomegaly and lymphadenopathy, was
found to be positive for HIV-infection. Radiographically, miliary Tbc was
suspected. Before any diagnostic procedure could be performed, acute
respiratory distress syndrome (ARDS) necessitating emergency
intubation and multi-organ failure developed (pancytopenia, anemia,
acute renal failure and severe hemodynamic instability). Despite
maximal ventilatory support, oxygenation remained insufficient (pO2
9.34 kPa, pCO2 7.43, SO2 80%, pH 7.01, HCO3 13.5 mmol/l, Lactat 1.4
mmol/l; Oxygenation index = 70). Rapid implantation of extracorporal
membrane oxygenation (ECMO)-support at a district hospital by our
team of cardiac surgeons, perfusionists and anesthestetists and
consecutive transport in a tertiary center was organized.
Bronchoalveolar lavage yielded acid fast bacilli, real-time-pcr showed
Mycobacterium tuberculosis. Rifampicin, Isoniazid, Ethambutol and
Pyrazinamid were started immediately. Together with maximal intensive
care therapy and steroids, the patient improved. ECMO was explanted
on day 7, antiretroviral therapy (ART) was started 4 weeks later. The
patient was discharged with residual renal impairment and critical
illness neuromyopathy.
Discussion: Miliary tuberculosis as a first manifestation of a HIVinfection is rarely reported and has a mortality up to 90% percent.
The mortality of severe ARDS requiring ECMO-support is up to 70%.
The additional negative impact of advanced HIV-infection on the course
of Tbc and vice versa add to the somber picture of our patient.
To our knowledge, this is the first report of a HIV-positive patient
surviving ARDS and severe multi-organ-failure due to miliary
tuberculosis using a multidisciplinary approach with ECMO, intensive
care support, Tbc treatment, steroids and ART.
Conclusion: Despite the lack of therapeutic evidence and a low
probability of survival at presentation, our patient survived. Even though
the use of such extensive and expensive treatment can be questioned,
this example stands for encouragement of an aggressive approach in a
young patient, even in situations of multiple diagnosis with limited
prognosis like HIV infection, miliary Tbc and severe ARDS.
Reference
LEE PL, Eur Resp J. 2003;22:141.
P15
Left main artery thrombus complicating heart
transplantation in a patient with heparin-induced
thrombocytopenia
A.P. Pazhenkottil1, A. Rudiger1, S. Jacobs1, V. Falk1, F. Enseleit1,
F. Ruschitzka1, D Bettex1
1University Hospital Zürich, Zürich, Switzerland
Introduction: Heparin-induced thrombocytopenia (HIT) is an antibodymediated adverse drug reaction to heparin and can cause lifethreatening venous and arterial thrombosis.1 Affected patients require
alternative anticoagulants and heparin must be strictly avoided.
However, only few studies have investigated anticoagulation strategies
for patients with HIT undergoing cardiac surgery. We describe a patient
with HIT undergoing heart transplantation, which was complicated by a
thrombus in the left main artery (LMA) immediately after graft
implantation.
Case report: A 62 years old man suffering from ischemic
cardiomyopathy (EF 15%) after an anteroseptal myocardial infarction
(occluded left anterior descending (LAD) with consecutive scar) and
subsequent implantation of a CRT-ICD device two years ago, was
admitted to the ICU due to recurrent ventricular tachyarrhythmia with
adequate shock deliveries from his ICD. While all antiarrhythmic
therapies were ineffective an extra-corporal membrane oxygenation
(ECMO) was implanted as bridge to decision. Anticoagulation was
established with heparin. As the heart did not recover, a left ventricular
assist device was implanted as bridge to transplant. On the 5th
postoperative day the patient developed a drop in platelet count from
138 G/l (preoperatively) to 24 G/l. Positive antibodies confirmed the
diagnosis of HIT. Heparin was stopped and anticoagulation was
established with bivalirudin (Angiox®). Sixty days after HIT diagnosis,
the patient was scheduled for heart transplantation. Surgery was
performed under bivaluridin therapy without difficulty. However, a severe
left ventricular dysfunction was diagnosed immediately after going off
bypass. An occlusion of the LAD was suspected by transoesophageal
echocardiography and the patient transferred to the hybrid operation
theatre for coronary angiography. This confirmed a large thrombus in
the LMA, which was aspirated in the same session resulting in a rapid
improvement of ventricular pump function.
Discussion: To our knowledge, this is the first case of a heart-recipient
with HIT under bivalirudin in which the heart transplantation was
complicated by a thrombus in the LMA immediately after graft
implantation. Heparin administration to the organ donor might have
been an important risk factor for this. Further studies are needed to
establish the optimal anticoagulation management of HIT patients
during cardiac surgery.
References:
1 Warkentin TE. Br J Haematol. 2003;121:535–55.
Schweiz Med Forum 2013;13(Suppl. 61)
13 s
Posters
P16
Severe hyponatremia after methamphetamine
consumption
B. Henzi1, R. Bühler2, A. Klarer3
1Bürgerspital Solothurn, Clinic for Internal Medicine, Solothurn,
Switzerland; 2Bürgerspital Solothurn, Neurology, Solothurn,
Switzerland; 3Bürgerspital Solothurn, Interdisciplinary Intensive Care
Unit, Solothurn, Switzerland
Background: Hyponatremia is associated with a high morbidity and
mortality.
There are numerous causes of hyponatremia, which have to be
categorized by the associated volume status.
Methamphetamine (“crystal meth”) is related to other amphetamines,
but its effects are much stronger. Amphetamines provoke among other
things euphoria and suppress hunger and thirst.
Case report: A 25 years old man was admitted to the emergency room
in a comatose state of unknown etiology. He showed numerous bruises
and blisters on his feet. A CT scan revealed moderate signs of brain
edema. Laboratory analysis disclosed severe hyponatremia of 116
mmol/L with a serum osmolality of 248 mmol/L. A urine analysis
screened positive for methamphetamine.
We interpreted these findings as a severe hypotonic hyponatremia with
consecutive coma. The patient was thereafter admitted to the intensive
care unit. Concerning the severe clinical state and the assumed rapid
development of the hyponatremia a rapid correction of the serum
sodium value was aimed. According to guidelines a bolus (100 mL)
of 3% sodium chloride solution as well as a continuous drip of 0.9%
sodium chloride were administered. To prevent osmotic demyelination
syndrome (central pontine myelinolysis) the correction rate should not
rise above 8 mmol/L per day. However, despite replacement of the
sodium chloride solution with glucosaline solution and administration
of desmopressin a spontaneous correction of the hyponatremia with
polyuria and a serum sodium of 136 mmol/L after 16 hours was
observed. Fortunately, 48 hours after admission the patient gained
consciousness, did not present any neurologic deficits and was
dismissed 2 days later. The patient affirmed to have consumed
methamphetamine and recalled having drunk excessive amounts of
water. We conclude that this patient suffered from a substance-induced
potomania with consecutive severe hyponatremia. Literature shows only
rare cases of methamphetamine associated hyponatremia (1) following
the same pathophysiological mechanism of the development of the
hyponatremia (2) as in our case.
Conclusions: Methamphetamines bear life-threatening effects. This
widely available and addictive drug has dangerous effects even in
one-time users. In otherwise unexplained hyponatremia, doctors should
think of amphetamine-induced potomania as the causative source.
1. White SR. Semin Respir Crit Care Med. 2002;23:27–36.
2. Boulanger-Gobeil C, et al. J Med Toxicol. 2012;8:59–61.
P17
Impact of blood loss in perioperativ outcome of cardiac
surgery patients
A.K. Haeussler1, O. Dzemali1, M. Yilmaz1, D. Odavic1, K. Graves1,
M. Genoni1
1Unit Cardiac Surgery Citiy Hospital Zurich, Zurich, Switzerland;
2Unit, Switzerland
Introduction: Cell salvage (CS) is used during cardiac surgery to
reduce or avoid blood transfusion . It has also been claimed to improve
impact for clinical outcome and decrease the risk of stroke and
neurocognitive dysfunction. The aim of this study was to evaluate the
effect of CS in perioperativ outcome of cardiac surgery patients.
Methods: We assessed quantitatively the autologous blood volume in
CS retrospectively in unselcted Patients during cardiac surgery. Patients
were matched in three groups. Group I with blood volume 0–499ml in
CS, Group II with 500–999 ml in CS and Group III 1000–4000 ml in CS.
Primary endpoints were need of blood products, need of factor
replacements and mortality. Second endpoints were neurological
symptoms, drainage volume of thoracal tubes and need of reexploration.
Results: Group I with the lowest bleeding rate showed lowest mortality
rate of 1.65%. Group II had with 4.58% a significant higher mortality and
group III with 11.5% highest. This correlated significant with the
substitution of blood products, autolouge and allogeneic erythrocyte
concentrates (p = 0.0023. In all groups the need of blood products
increased significant. Additional there was significant difference in early
clinical outcome between the groups.
Conclusion: The perioperative coagulation management in patients
undergoing cardiac surgery should aim blood loss, especially of less
then 1000 ml in CS. Perioperative morbidity and mortality can be
affected by the use of CS system with loss of more than 1000 ml blood.
P18
Perioperative Extracorporal Membrane Oxygenation
Support Reduce the Operative Risk for Post Infraction
Ventricular Septal Defect
O. Dzemali1, R. Behr1, A. Hauessler1, P. Fodor2, H. Loeblein1,
D. Odavic1, M. Genoni1
1
University Heart Center, Zürich, Switzerland; 2Dept. for
Anaesthesiology, City Hospital Triemli, Zürich, Switzerland
Aim: Mechanical complications after acute myocardial infraction, such
as post-infarction ventricular-defects (PI-VSD) is still an uncommon
complication and it is one of most frequent causes of sudden cardiac
death. This case report describes the peri-operativ management of
55-year-old man with subacute PI-VSD.
Case report: A 55 year old male visited our emergency department
after 3 day of crescendo chest pain. He presented with a tachycardia,
sinusrythm and ST elevation in I and AVL ECG. Cardiac enzymes
confirmed the diagnosis of posterior infarction. High frequency levine
V/VI holosystolic murmur was mainly audible in left parasternal lesion.
Echocardiography revealed dysfunction of left ventricle, dilatation of
right ventricle and a large posterior PI-VSD. Despite inotropes and
vasoconstrictor there was hemodynamic instability. Therefore, the
percutaneous venoarterial extracorporeal membrane oxygenation
(ECMO) was elective setup using the right subclavian artery and right
femoral vein. After this intervention patient was extubated and we
obtained the stabilization of the patient and improvement of the clinical
conditions.
We arranged the operation on post infraction day 11 to reduce operative
risk. Under more stable condition, the patient underwent coronary
angiography before the operation that shows the proximal occlusion of
RCA and RCX. Then he underwent elective surgery, namely, VSD patch
repair and coronary artery bypass grafting. The ECMO duration after
surgery was 3 days and patient was discharged from hospital 41 days
after the operation in good condition.
Conclusion: Perioperative instability and early PI-VSD carry a grave
prognosis. Achieving haemodynamic stability prior to surgery reduce
operative risk. This suggests that ECMO support is reliable before and
after definitive surgery in PI-VSD.
P19
Tagebücher bei kritisch kranken Patienten der
Intensivstation
Béatrice Moser, BScN cand. MScN, Marie-Madlen Jeitziner, MNS
Inselspital, Universitätsklinik für Intensivmedizin, Bern
Hintergrund/Zielsetzungen: Patienten der Intensivstation (ICU)
durchlaufen im Zusammenhang mit einer lebensbedrohlichen
Erkrankung oder einem schweren Unfall mehrere, zeitlich kurz
aufeinanderfolgende invasive Interventionen. Oft müssen kritisch
Kranke für diese Behandlung intubiert, sediert und mechanisch
beatmet werden. Häufige Folgen dieses Therapieregimes sind fehlende
oder fragmentierte Erinnerungen, wobei letztere verhältnismässig oft zu
wahnhaften Erlebnissen wie Albträumen und Halluzinationen führt.
Der Literatur ist zu entnehmen, dass rund 40% der ICU-Überlebenden
während der Rekonvaleszenz psychische Probleme wie Angst,
Depressionen oder gar ein Posttraumatisches Belastungssyndrom
(PTBS) entwickeln, wodurch die Lebensqualität der Betroffenen deutlich
eingeschränkt wird. Um ein höheres Mass an faktischen Erinnerungen
zu erreichen wird das Führen von Tagebüchern empfohlen
Fragestellung: Wie beeinflusst das Führen von Tagebüchern den
psychischen Outcome eines erwachsenen kritisch kranken Patienten
der Intensivstation?
Methode: Es wurde eine Literaturrecherche in den Datenbanken
PubMed, Cinhal, Web of Knowledge und der Cochrane Library mit dem
Suchterm “intensive care diary” durchgeführt. Zusätzlich wurden
Wissenschaftlerinnen und Wissenschaftler per E-Mail kontaktiert, die
bereits mehrere Arbeiten zur Thematik veröffentlicht hatten. Die initiale
Literaturliste konnte dadurch optimal ergänzt werden.
Resultate: Insgesamt konnten acht Studien einer detaillierten Analyse
unterzogen werden. Tagebücher reduzieren Angst, Depression,
PTBS-Symptome und verbessern zudem die gesundheitsbezogene
Lebensqualität. Dabei gibt es keine homogene Patientengruppe die
besonders von der Intervention profitieren könnte. Während Pflege- bzw.
Schweiz Med Forum 2013;13(Suppl. 61)
14 s
Posters
Arztberichte meist auf Organe reduziert, fragmentiert und für Laien
unverständlich sind, erzählt das Tagebuch, das sowohl von
medizinischem Personal sowie von Angehörigen verfasst wird, die
persönliche ICU-Geschichte eines Patienten. Erfahrungen von
Patienten zeigen, dass durch Tagebücher eine Differenzierung
zwischen Realität und Träumen erreicht werden kann. Zudem fördert ein
Tagebuch das Verständnis für eine lange Rehabilitationsphase. Durch
die Einträge der Besucher wurde den Patienten ausserdem bewusst,
wie viel Bestärkung sie von nahen Angehörigen erfuhren. Das
Tagebuch wurde den Patienten zwei bis acht Wochen post-ICU durch
Ärzte oder Pflegefachpersonen an einer Follow-Up Visite abgegeben.
Schlussfolgerungen: Tagebücher sind eine wirksame und
kostengünstige Intervention zur Verbesserung des psychischen
Outcomes von erwachsenen kritisch kranken Patienten der
Intensivstation, unabhängig von der Diagnose.
P20
Diagnostic d’une cardiomyopathie par non compaction
au cours d’une cardiomyopathie du péripartum
L. Hergafi1, V. Stolt2, V. Stolt3, G. Sridharan1, N. Ben Ali4, V. Ribordy1
1
Soins intensifs et continus-Hôpital cantonal Fribourg, Fribourg,
Switzerland; 2Service de cardiologie Hôpital de Payerne, Payerne,
Switzerland; 3Service de cardiologie Hôpital cantonal de Fribourg,
Fribourg, Switzerland; 4Service de Gynécologie-Obstétrique Hôpital
cantonal de Fribourg, Fribourg, Switzerland
Introduction: La cardiomyopathie du péripartum (CMPP) est une
maladie rare, mais grave, qui peut survenir pendant le dernier mois de
la grossesse et/ou les cinq mois suivant l’accouchement.
La cardiomyopathie par non compaction (CMNC) est une pathologie
congénitale, qui est (très) rare. Ces deux entités sont souvent sousdiagnostiquées en raison de leur faible incidence et leur
symptomatologie peu spécifique. Le premier traitement est
médicamenteux (symptomatique) dans les deux cas. Le potentiel de
récupération cardiaque est possible dans la CMPP, par contre il est
quasi nul dans les cas de CMNC rapportés.
Nous rapportons le cas d’une CMNC de découverte fortuite lors d’une
CMPP décompensée.
Cas: Une patiente âgée de 28 ans développe, à terme d’une grossesse
gémellaire, une insuffisance respiratoire aiguë motivant l’admission aux
soins intensifs. Le diagnostic initial de pré-éclampsie et de pneumonie
hypoxémiante est retenu. Un traitement anti-hypertenseur ainsi qu’une
antibiothérapie sont débutés et une césarienne est réalisée en urgence.
En postopératoire et en raison d’une aggravation respiratoire, le
diagnostic est revu grâce à l’échocardiographie aux soins intensifs
permettant de retenir une insuffisance cardiaque globale congestive
avec tableau d’œdème aigu des poumons suggestif d’une CMPP.
L’échocardiographie de contrôle confirme une dysfonction systolique à
prédominance gauche majeure avec une fraction d’éjection ventriculaire
gauche (FEVG) à 15%. L’aspect du myocarde est typique d’une CMNC.
L’évolution clinique est favorable sous un traitement médicamenteux
d’insuffisance cardiaque et anticoagulation.
Une IRM cardiaque faite à distance confirme le diagnostic de CMNC.
L’évolution échocardiographique à trois mois témoigne d’une
amélioration de la FEVG à 50%.
Conclusion: A l’issue de ce cas, nous attribuons le tableau
d’insuffisance cardiaque aiguë, plutôt, à la CMPP vu la récupération de
la fonction cardiaque. Il nous paraît judicieux de rappeler l’intérêt de
l’échocardiographie précoce devant toute insuffisance respiratoire aiguë
durant le péripartum et en réanimation de façon générale. Il est aussi
important de souligner l’originalité du cas avec l’association de deux
pathologies rares et dont le diagnostic est difficile. Nous proposons une
discussion et une revue sur le sujet.
P21
Chronic Critical Illness (CCI): Empfehlungen für die
Informationsvermittlung bei «Langzeitintensivpatienten»
L. Weibel1, G. Stoffel1
1
Universitätsspital, Basel, Switzerland; 2Kinderspital, Zürich,
Switzerland
Ausgangslage: Auf Intensivpflegestation werden zunehmend Patienten
mit chronisch kritischer Erkrankung (chronic critical Illness = CCI)
betreut. Besonders beim Übergang von einer akuten in eine chronische
Erkrankung ist die Kommunikation mit den Patienten oft ungenügend.
Verschiedenste Gründe, wie prolongierte Beatmung mit erschwerter
Kommunikation, stellen die Betreuenden vor grosse Herausforderungen.
Ziel der Arbeit ist, literaturbasierte Empfehlungen zu erstellen.
Methode: In den Datenbanken Pubmed, Cinahl und Cochrane wurde
mit den Stichwörtern “chronically critically ill”, “intensive care”,
“information” und “knowledge” deutsch- und englischsprachige Artikel
gesucht.
Resultate: Acht Studien konnten eingeschlossen, dies zeigt eine
knappe wissenschaftliche Datenlage.
In der Literatur finden sich unterschiedliche Definition für CCI Patienten.
In der Phase nach der Extubation und Stabilisierung der Erkrankung
besteht ein erhöhter Bedarf an Informationen über das Geschehene
und das Bedürfnis, die erlebten Ereignisse zusammenfügen (piecing
togehter). Reorientierung sowie Beruhigung und Bestätigung stellen
zentrale Konstanten dar. Durch konsistente Informationen verstehen die
Patienten, was geschieht und werden bei der Stressbewältigung
unterstützt. Die Informationsvermittlung sollte verständlich und ehrlich
sein sowie Verlauf, Prognose – Outcome – Chance zur Erholung
aufzeigen. Pflegende nehmen bei der Kommunikation zwischen
Angehörigen und dem multiprofessionellen Team eine Schlüsselrolle
ein. Ein Kommunikationskonzept für CCI Patienten und deren
Angehörigen werden für Intensivpflegestationen mit einer umfassenden
Schulung der Betreuenden bestehend aus der Erhebung der
individuellen Bedürfnisse (“Needs-Assessment”) der Patienten und
Angehörigen, offenen Besuchszeiten, Bezugspersonensysteme mit
Familienmeetings empfohlen und sollten im Sinne eines “Care bundles”
gemeinsam umgesetzt werden. Schriftliche Informationen wie
Broschüren stellen eine weitere wichtige Komponente dar.
Intensivstationen wird empfohlen, eine Informationsstrategie zu
definieren und anzuwenden.
Schlussfolgerungen: Die Literatur zeigt wichtige Aspekte der
Informationsvermittlung für CCI Patienten und deren Angehörige auf,
wie die Erfassung der Informationsbedürfnisse, die Definition der
Informationsinhalte mit schriftlichen Informationen, der Festlegung einer
Informationsstrategie mit familienzentriertem Fokus und einem
definierten Informationsfluss im Behandlungsteam.
Referenzen:
Azoulay E, et al. Am J Respir Crit Care Med. 2002;165(4):438–42.
Carson SS, et al. Crit Care Med. 2012;40(1):73-78.
Henneman EA, Cardin S. Crit Care Nurs Clin North Am. 1992;4(4):615–21.
Hofhuis JG, et al. Intensive Crit Care Nurs. 2008;24(5):300–13.
Hupcey JE, Zimmerman H. E. Am J Crit Care. 2000;9(3):192–8.
Nelson JE, et al. J Crit Care. 2005;20(1):79–89.
Nelson JE, et al. Arch Intern Med. 2007;167(22):2509–15.
Zaforteza C, et al. Int J Nurs Stud. 2005;42(2):135–45.
P22
Braucht es auf einer pädiatrischen Intensivstation mehr
als nur intensivpflegerisches Grundlagenwissen?
Der Aufbau einer spezialisierten interdisziplinären Fachgruppe
zur Betreuung und Behandlung von kardiologischen und
kardiochirurgischen Neugeborenen und Kindern – ein
Praxisentwicklungsprojekt
D. Berger1, M. Braunwalder1, A. Scholl1, S. Pilgrim1, B. Grädel1
1
Abteilung für pädiatrische Intensivbehandlung, Universitätskinderklinik,
Bern, Switzerland
Hintergrund: In den letzten Jahren verbesserten sich die Möglichkeiten
zur Diagnostik und Therapie von Kindern mit angeborenen Herzvitien
massiv. Damit stiegen die Anforderungen an die Pflegefachpersonen
und die Ärzte der allgemeinen pädiatrischen Intensivstation. Neues
Fachwissen und neue, vor allem technische Fertigkeiten mussten
erlernt und vertieft werden.
Methode: Um die Behandlung der Patienten zu verbessern, wurde
ein interdisziplinäres Praxisentwicklungsprojekt gestartet. Wichtig
war die Interdisziplinarität, nicht nur im Sinne von verschiedenen
Professionen wie Ärzten und Pflegefachpersonen, sondern auch der
verschiedenen Fachgebiete wie z.B. die pädiatrischen Kardiologen,
Kinderherzchirurgen, Kinderherzanästhesisten und den
Kardiotechnikern.
Eine Fachgruppe aus Pflegefachpersonen und einer Oberärztin
wurde gebildet. Zusammen mit der Pflegeexpertin organisierten die
Projektleiterin und die Oberärztin die Arbeitsgruppentage. Zuerst ging
es darum den Pflegefachpersonen der Kardiofachgruppe und den
Ärzten der Intensivstation mehr Wissen, durch die jeweiligen
Spezialisten zu vermitteln.
Eine weitere Aufgabe der Kardiofachgruppe war es Skripte und
Richtlinien zu verfassen, um das Gelernte dem ganzen Team
zugänglich machen zu können.
Resultate: Die Organisation der Referenten aus den verschiedenen
Fachgebieten gestaltete sich nicht ganz problemlos. Die
Pflegefachpersonen erhielten Arbeitsgruppentage zu ihrer theoretischen
und praktischen Schulung. Für die Spezialisten hatte der klinische Alltag
Schweiz Med Forum 2013;13(Suppl. 61)
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Posters
Vorrang, so dass die Referate an den Randstunden geplant werden
mussten und man sich nie ganz sicher war, ob der Referent auch
erscheinen würde.
Allen Beteiligten war aber wichtig, dass die Behandlung der Patienten
verbessert wird. So halfen gegenseitige Toleranz und eine hohe
Einsatzbereitschaft von allen sowie ab und zu ein gemeinsames Essen
etwaige Misstöne zu überwinden.
Schlussfolgerung: Nach einem Jahr Projekt-Phase konnte die
Kardiofachgruppe in die Linie überführt werden. Es hatte sich eine
Fachgruppe mit grossem Know-how und spezifischen Fertigkeiten in
der Betreuung der schwer herzkranken Patienten gebildet. Es sind
einige Richtlinien und Skripte entstanden welche den
Pflegefachpersonen ausserhalb der Kardiofachgruppe helfen die
Patienten adäquat zu betreuen. Die Mitglieder bieten sich als
Ressourcen für ihre Kolleginnen an. Weiter hat die Kardiofachgruppe
einen ECMO-Kurs für ihre Kolleginnen und die Ärzte der pädiatrischen
Intensivstation entwickelt.
Sicherheit von Patient und medizinischem Personal gewährleistet
werden?
Methode: Im Zuge eines Praxisentwicklungsprojektes wurde eine
QMS – Richtlinie erstellt sowie ein verbindliches Schulungsprogramm
entwickelt.
Beteiligt waren Pflegende und Ärzte der Neurochirurgischen
Intensivstation sowie der leitende Physiker und eine MTRA der
Radiologie.
Ergebnisse: Die Transporte und Untersuchungen im MRI konnten
unter Beibehaltung des Behandlungsstandards der Intensivstation und
ohne Gefährdung von Patient und medizinischem Personal
durchgeführt werden.
Diskussion: Medizintechnische und logistische Neuerungen fordern
häufig ein spontanes Reagieren. Im Falle der MRI – Untersuchungen
waren sehr viele vor allem sicherheitstechnische Aspekte auf mehreren
Ebenen zu klären. Die dafür benötigten personellen und zeitlichen
Ressourcen haben sich jedoch gelohnt: eine effiziente und sichere MRI
– Untersuchung von beatmeten Patienten wurde ermöglicht.
P23
ARDS as the presenting manifestation of undiagnosed
acute monocytic leukemia
K. Auinger1, A. Klarer1, M. Maggiorini1
1
Medical Intensive Care Unit, Zürich, Switzerland;
2
Interdisciplinary Intensive Care Unit, Solothurn, Switzerland
Background: Cases of ARDS as the presenting manifestation of
undiagnosed acute monocytic leukemia are rarely described in the
literature. ARDS is attributed to leukemic pulmonary involvement from
leukostasis or leukemic infiltration after more common causes of ARDS
have been ruled out. However, establishing the diagnosis of leukemic
pulmonary involvement is challenging since various criteria are of
limited diagnostic value; changes on chest imaging are nonspecific and
heterogeneous, the retrieval of leukemic cells by bronchoalveolar
lavage (BAL) has a low negative predictive value and the presence of
blast cells in BAL fluid in patients with alveolar hemorrhage is difficult to
interpret. Last, the proposed criterion of a blast cell count above 40% to
suspect leukemic pulmonary infiltration is of little value since there are
patients described in the literature with blast cell counts below 40%.
Case report: A 17 year old woman was addmited with ARDS. An
ovarian teratoma has been successfully treated one year before.
Laboratory analyses on admission revealed anemia of 110 G/L,
thrombocytopenia 64G/L and leukozytosis of 14.5 G/L with no blasts on
peripheral blood smear. Coagulation was activated with INR of 1.7,
prothrombin time 39%, fibrinogen of 3.4 G/L and D-Dimers of 5.9 mg/L.
LDH was 8452 U/L, CRP 234 mg/L and PCT 26.5 ug/L. A BAL was
performed that revealed bloody fluid but no alveolar hemorrhage and
atypical cells that could not be further classified. A tumor was ruled out
by normal CT scan.
During the course on the ICU, high-dose steroids where administered
empirically besides broad spectrum antibiotics. After extensive
investigation, the cause of ARDS remained unclear. The patient could
be transferred to the normal ward on day 12. Bone marrow punction
was performed 11 days later because of persisting severe
thrombocytopenia and worsening DIC despite stabilization of the
patient’s condition and revealed AML M5 with 60% of blast cell
infiltration. Rescue chemotherapy was started despite massive tumor
lysis (LDH 18712 U/L) and fulminant DIC. The patient developed severe
alveolar hemorrhage and died on the fourth day after institution of
chemotherapy despite maximal treatment with ECMO.
Conclusion: Leukemic pulmonary involvement leading to ARDS may
be the presenting symptom of AML M5. Since diagnosis in the absence
of blast cells on peripheral blood smear is challenging, a high index of
suspicion may lead to the right diagnosis.
P25
Pronged survival after surgical resection of a primary
mitral valve sarcoma
H. Loeblein1, O. Dzemali1, K. Graves1, A. Haeussler1, D. Odavic1,
M. Genoni1
1
Triemli, Zurich, Switzerland
Introduction: Primary sarcoma of the mitral valve is rare. A complete
surgical resection should be attempted even though the accessibility
and location of the tumour may provide surgical challenges. The
prognosis of patients with a primary cardiac sarcoma is very poor
because of their resistance to therapy. This report describes a 48-yearold gentleman who underwent Mitral valve sarcoma resection and has
been tumour free for two years.
Case: In 1994 a 47-year-old ship captain initially presented a cardiac
murmur. Then in 1998, because of a work required physical exam, an
echocardiography was performed which showed a mitral valve tumour
(22 u15 mm) with a moderate mitral insufficiency, which was assumed
to be a myxoma. A six (6) month follow up echocardiography revealed
an increase in tumour size (32 u18 mm) which obstructed the mitral
flow. On 01.03.2010 the intraoperative histopathological analysis
revealed a cellular spindle proliferation confirming the diagnosis of
sarcoma. The tumour, including the mitral leaflets, was removed and a
biological prosthetic inserted. The final histology revealed a high grade
Sarcoma, FNCLCC (Fédération Nationale des Centres deLutte Contre
le Cancer classification) 5 and no tumour free border. Postoperative the
patient received a combination of radio and chemotherapy with: with
30 × 2 Gy = 60 Gy from 20.04.2010 to 02.06.2010 and weekly
chemotherapy of Adriblastin with a total of 7 applications. His the last
follow up on January 2012 which included blood work, computer
tomography chest and abdomen showed no sign of metastasis.
Echocardiography am 29.01.2010, CT 29.01.2010.
P24
Der klinikinterne Transport und die MRI – Untersuchung
mit beatmeten Patienten: Eine multiprofessionelle
Herausforderung
J. Maier1, H. Giray1, M. Lorenz1, E. Keller1
1Universitätsspital Zürich, Zürich, Switzerland
Einleitung: Der klinikinterne Transport beatmeter Patienten zum
Magnetresonanztomogramm (MRI) und die dortige Untersuchung nam
in den letzten Monaten auf der Neurochirurgischen Intensivstation aus
diversen Gründen zu.
Jeder Transport klinisch Kranker stellt eine grosse Gefährdung dar.
Die Morbidität und die Mortalität lassen sich durch sorgfältige Planung
von Transport und Untersuchung minimieren.
Fragestellung: Wie kann während eines klinikinternen Transportes
und einer Untersuchung im MRI bei beatmeten Patienten der
Behandlungsstandard der Intensivstation aufrechterhalten sowie die
Tumor, New Valve.
Schweiz Med Forum 2013;13(Suppl. 61)
16 s
Posters
P26
P28
Case Report Of Operative Treatment Of Giant
Aneurysms Of The Coronary Arteries
A.K. Haeussler1, O. Dzemali1, D. Odavic1, M. Yilmaz1, M. Genoni1
1Unit Cardiac Surgery Citiy Hospital Zurich, Zurich, Switzerland
Introduction: Coronary aneurysm of the left and the right coronary
arteries are very rare with an incidence of less than 0.1%. Different
reasons like vasculitis, trauma, genetic disorder, mycotic and iatrogenic
are described for this illness in literature.
Most common complication is myocardial infarction (mi).
In case of mi myocardial revascularisation, exclusion and resection of
these aneurysms are described. Mandatory also is oral anticoagulation.
Case Report: 60-year-old man suffered of mi of the right coronary
artery (rca) system with right heart failure, mitral and tricuspid
insufficiency.
Evaluation illustrated three sequential aneurysms of the rca (7 u 4 cm,
6 u 3.4 cm and 4 u 2.5 cm) an on at circumflex branch with an
diameter of 3.6 u 2.3 cm. Additional there was an asymptomatic
infrarenal aneurysm (6.7 u 5 cm).
After clinical recompensation cardiopulmonary bypass and cardioplegic
arrest was performed in mild hypothermia. Patient underwent coronary
bypass grafting starting with reversed greater saphenous vein to the
posterior interventricular artery and two marginal arteries of rca.
Second reversed greater saphenous vein graft was placed on the distal
third of circumflex branch and an obtuse marginal branch. Left internal
thoracic artery was placed to diagonal branch of left anterior
descendens and to left anterior descendens at distal third. The
aneurysms were excluded via aortotomy by sutures of both ostiums.
Distal they were ligated by a ligation with silk. Mitral valve was replaced
by an mechanical valve.
Postoperative course was prolonged with vasoplegia and an open
chest. Thorax was closed after 10 days. Histologic pathology showed
now diagnosis. Surgical pathology confirmed artheromatous coronary
artery aneurysms.
Conclusion: This patient showed calcified coronary artery aneurysms,
which can occur in patients with calcifications of their coronary arteries.
Clinical presentation is the mi maybe caused by embolization. Therapy
is the exclusion and bypass grafting.
Mediastinal Mass reveals as a Giant Aneurysm of the
Saphenous Vein Graft: Presentation of Two Uncommon
Cases and Surgical Management
A. Zientara1, O. Dzemali1, D. Odavic1, M. Genoni1
1Universitäres Herzzentrum, Zürich, Switzerland
Background: Saphenous vein graft aneurysms (SVGAs) are a rare
complication after coronary artery bypass grafting (CABG) occuring
10–20 years after the procedure mainly as incidental findings. SVGAs
may correlate with mechanical complications and require an individual
management.
Case Description: Two patients with giant SVGAs were operated by
means of cardiopulmonary bypass (CPB). In one patient the aneurysm
ruptured and the operation was savely continued as a beating-heart
procedure.
Conclusion: Concerning better follow-up and longer life expectancy a
growing number of SVGA-related complications will continue to be
identified. Our experience confirms surgery by means of CPB as a save
management reducing the risk of hemorrhages.
P27
Aspergillose broncho-invasive sous ventilation
mécanique: à propos de 2 cas
D. Crausaz1, V. Erard2, Ph. Dumont3, M. Maus1, G. Sridharan1
1Soins intensifs, Fribourg, Switzerland; 2Infectiologie, Fribourg,
Switzerland; 3Pneumologie, Fribourg, Switzerland
L’aspergillose broncho-invasive (ABI), pathologie se limitant à la trachée
et/ou à l’arbre bronchique, ne représente qu’une proportion mineure
des aspergilloses pulmonaires. Nous rapportons 2 cas d’ABI survenue
sous ventilation mécanique, dans le contexte d’un ARDS (cas n° 1 sur
choc septique avec défaillance multi-organique; cas n° 2 sur pneumonie
virale à Influenza H1N1). L'ABI, contrairement à l’aspergillose angioinvasive, présente un aspect endobronchique suggestif, caractérisé par
des dépôts membranaires d’aspect cireux recouvrant une muqueuse
ulcérée. Cette entité se traduit radiologiquement par la présence diffuse
de condensations nodulaires péri-bronchiques, histologiquement par
l’invasion nécrosante de la muqueuse par des éléments mycéliens.
L’issue a été fatale, malgré l’initiation d’un traitement antifongique et en
l’absence d’immuno-suppression. La survenue en un mois dans la
même unité d’une pathologie infectieuse rare des voies aériennes a fait
rechercher une éventuelle contamination fongique des différents
composants du système de ventilation, contenant dans les 2 cas un
humidificateur à air chaud (cascade). Les cultures effectuées sur la
cassette expiratoire du ventilateur d’un des patients, ainsi que sur le
matériel de ventilation (tuyaux, filtre, eau stérile pour la cascade) issu
du même lot que celui utilisé par les patients affectés, n’ont pas révélé
de croissance fongique. La germination de spores aspergillaires,
colonisant au préalable l’arbre bronchique, pourrait avoir été favorisée
par l’environnement humide du système de ventilation et avoir ainsi
contribué à une auto-infestation fongique de l’arbre trachéo-bronchique.
Bien que nous ne puissions ni prouver ni exclure l’implication de
l’humidificateur à air chaud dans l'ABI de ces 2 patients, le bénéfice de
ce dernier (réduction de l’hypercapnie grâce au retrait du filtre
humidifiant et antibactérien responsable d’un petit espace mort)
l’emporte sur le risque infectieux potentiel lié à une éventuelle
croissance de spores fongiques. L'ABI reste une entité exceptionnelle,
mais doit être évoquée lors de ventilation d’un patient avec
pneumopathie, même en l’absence d’immuno-suppression.
P29
The risk of body packing: a case of a fatal cocaine
overdose
S. Ritter1, B. Zoller2, C.A. Meier3
1
Intensive Care Unit, Department of Internal Medicine, Stadtspital
Triemli, Zurich, Switzerland; 2Surgical Intensive Care, University
Hospital, Zurich, Switzerland; 3Department of Internal Medicine,
Stadtspital Triemli, Zurich, Switzerland
Background: Generally, a good prognosis of hospitalized cocaine
body packers is observed. In case of intraluminal rupture of a packet,
however, severe cocaine intoxication can occur with cardiovascular and
neurological complications. A fatal case of accidental cocaine overdose
associated with prolonged epileptic activity and refractory vasoplegic
and cardiogenic shock is reported.
Case presentation: A 28-year-old man had a generalized seizure and
a subsequent short period of cardiac arrest before admission. He was
unconscious and presented with bilateral mydriasis, a blood pressure of
80/25 mm Hg, heart rate of 75/min, and temperature of 36.6 °C. Arterial
blood gas analysis revealed severe lactic acidosis (pH 6.46, lactate
27 mmol/L). Computed tomography (CT) scan of the head was normal
and a CT scan of the abdomen showed six foreign bodies in the rectum
and distal sigmoid. All packets, of which one was damaged with visible
leakage, were safely removed by endoscopy shortly after admission.
However, the patient remained comatose. Electroencephalography
demonstrated a nonconvulsive status epilepticus; despite antiepileptic
therapy and total colectomy for ischemic colitis, the patient died from
combined vasoplegic and cardiogenic shock with multiple organ failure,
including severe rhabdomyolysis and liver failure, only 38 hours after
admission. Forensic toxicological analysis of blood samples revealed
lethal concentrations of cocaine (2’800 mcg/L) and its metabolite
benzoylecgonine (6’200 mcg/L).
Discussion: Cocaine acts via the blockade of the presynaptic reuptake
of biogenic amines, leading to both adrenergic crisis and proconvulsive
effects. In addition to close monitoring, management of symptomatic
cocaine poisoning includes the administration of benzodiazepines for
agitation and seizures, and the administration of phentolamine for
severe hypertension. Internal concealment of illicit drugs can lead to
massive and rapid cocaine intoxication in case of package leakage or
rupture. Immediate removal of the packets is warranted, generally by
surgery. Low output heart failure can result not only from septic
cardiomyopathy, but also from negative inotropic effects of high doses
of cocaine following adrenergic receptor desensitization induced by
chronic cocaine administration.
Conclusions: Body packing and systemic cocaine toxicity from a
ruptured packet should be considered in patients with sustained
seizures or unexplained shock.
Schweiz Med Forum 2013;13(Suppl. 61)
17 s
Posters
P30
Correlation of IM-complex treatment code between GDRG
and SwissDRG: the pediatric calibration study
M.L. Losa1, A. Limacher2, H.U. Rothen1
1Tarifkommission SGI, Switzerland; 2CTU, University of Bern, Bern,
Switzerland
Introduction: The new Swiss hospital financing system (SwissDRG)
was introduced in January 2012 and is based on the German model
(G-DRG). The allocation of ICU patients to a DRG-group is very
important. In Germany, this is assured using the OPS-Code 8-98d. This
code is divided into several sub-codes, using a clinical complexity score
(daily sum of 25 items). For Switzerland, resource use is documented
using several variables of the Swiss Minimal Dataset for ICUs (MDSi).
Use of MDSi is mandatory for all certified Swiss ICUs and has thus
been widely used for several years. Accordingly, SGI proposed to use
variables from MDSi also for DRG coding (CHOP 89.13.6: PIM2 + Σ
daily NEMS). The aim of this study was to assess agreement between
the German and the Swiss model and to indentify the influence of
cofactors.
Methods: The study was conducted in four pediatric ICUs. All patients
admitted between 01.11.2010 and3 1.5.2011 with an age between 28
days and 16 years were included in the study. The German complexity
score was collected manually on a daily basis by a study coordinator
who also checked for plausibility, the Swiss-score was extracted from
data collected for MDSi. Thereafter, data were forwarded in anonymous
form for further analysis to the Clinical Trials Unit (CTU) of the
University of Bern.
Results: A total of 570 records were sent for pre-analysis. 18 datasets
were excluded as they did not fulfill the inclusion criteria and four
additional because total NEMS >2400. A linear model was fitted:
German-score = 0.542 * Swiss-score (95% prediction interval: ± 114,
Pearson correlation: 0.94). In a multivariable model, several cofactors
have a significant influence (gender, age, readmission, mode of
admission, and ventilation and their interactions with the Swiss score)
and improve the prediction of the German score. However, the
improvement is relatively small with a 95% prediction interval of ± 103
German score points.
Conclusion: The relationship between the German and the Swiss
Score for the complexity score for the allocation of patients to a
DRG-group and therefore for the calculation of the yield can be
described by a simple linear regression model. A fractional polynomial
function does not improve the correlation. The model can be improved
by the inclusion of cofactors however the improvement is relatively
small and the real impact (financing) probably negligible. These results
confirm the results of a previous similar study in adults.
i n D e x o f f i r s t au t h o r s
Auinger K 16 S
Jotterand C 3 S
Behr R 11 S
Berger D 15 S
Blöchlinger S 9 S, 10 S
Lang M 11 S
Loeblein H 5 S, 6 S, 10 S, 16 S
Losa ML 18 S
Crausaz D 17 S
Maier J 16 S
Massebiaux C 12 S
Meyer-Zehnder B 8 S
Miauton V 6 S
Moser B 14 S
Thévoz D 4 S
Palhais N 4 S, 9 S
Paratte 3 S
Pazhenkottil AP 13 S
Pilgrim S 8 S
Weibel L 15 S
Dami F 2 S
Dzemali O 2 S, 7 S, 9 S, 14 S
Feiner A-S 8 S
Flothmann C 13 S
Gemperle S 12 S
Gigon F 4 S
Haeussler AK 14 S, 17 S
Haubner S 12 S
Henzi B 14 S
Hergafi L 15 S
Hilty MP 3 S
Sala Defilippis TML 2 S
Schaller MD 11 S
Schuerner AM 11 S
Speroni CS 7 S
Sridharan G 7 S
Ulmer F 7 S
Vuilleumier A 5 S
Zientara A 17 S
Ritter S 17 S
Rogers A 2 S
Röllin L 13 S
Schweiz Med Forum 2013;13(Suppl. 61)
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