Chapter 1. Introduction

Background

In December 2007, the European Society of Intensive Care Medicine established a Task Force to develop standard operating procedures (SOPs) for operating intensive care units (ICU) during an influenza epidemic or mass disaster.

Purpose

To provide direction for health care professionals in the preparation and management of emergency ICU situations during an influenza epidemic or mass disaster, standardize activities, and promote coordination and communication among the medical teams.

Methods

Based on a literature review and contributions of content experts, a list of essential categories for managing emergency situations in the ICU were identified. Based on three cycles of a modified Delphi process, consensus was achieved regarding the categories. A primary author along with an expert group drafted SOPs for each category.

Results

Based on the Delphi cycles, the following key topics were found to be important for emergency preparedness: triage, infrastructure, essential equipment, manpower, protection of staff and patients, medical procedures, hospital policy, coordination and collaboration with interface units, registration and reporting, administrative policies and education.

Conclusions

The draft SOPs serve as benchmarks for emergency preparedness and response of ICUs to emergencies or outbreak of pandemics.

     

Predictive factors for polypharmacy among child and adolescent psychiatry inpatients

Background

Aim was to determine the predictive factors for polypharmacy among inpatient children and adolescents with psychiatric disorders.

Methods

Blinded, case-note review of children and adolescents with ICD 10 diagnosis of psychiatric disorders on psychotropic medication was conducted. Data on demography, illness, and treatment was analyzed with univariate and multivariate techniques.

Results

Proscribing non-pharmacological interventions (OR = 4.7) and pro re nata medication (OR = 3.3), increased the risk of polypharmacy. Prescribing physical restraint reduced the risk of receiving multiple medications (OR = 0.3).

Conclusion

Proscribing non-pharmacological interventions, pro re nata medication and physical restraints increased polypharmacy.

     

Role of CT Imaging for Coronary and Non-coronary Interventions

Purpose of Review

Pre-procedural imaging is essential for successful planning and performance of several cardiac interventions. Cardiac computed tomography (CT) is a non-invasive imaging modality capable of providing precise information required for different coronary and non-coronary interventions. The role of cardiac CT for the guidance of different cardiac interventions will be described in this review.

Recent Findings

Contrast-enhanced computed tomography imaging is increasingly being used for guiding transcatheter cardiac interventions. Anatomical and functional information provided by CT helps in successful planning and performance of several cardiac interventions.

Summary

Over the last decade, the continuous growth of interventional cardiology has been associated with widespread acknowledgment that CT is particularly useful for pre-interventional imaging with increasing implementation in clinical routine.

     

Robotic ultrasound-guided facet joint insertion

Purpose

Facet joint insertion is a common treatment of chronic pain in the back and spine. This procedure is often performed under fluoroscopic guidance, where the staff’s repetitive radiation exposure remains an unsolved problem. Robotic ultrasound (rUS) has the potential to reduce or even eliminate the use of radiation by using ultrasound with a robotic-guided needle insertion. This work presents first clinical data of rUS-based needle insertions extending previous work of our group.

Methods

Our system implements an automatic US acquisition protocol combined with a calibrated needle targeting system. This approach assists the physician by positioning the needle holder on a trajectory selected in a 3D US volume of the spine.

Results

By the time of submission, nine facets were treated with our approach as first data from an ongoing clinical study. The insertion success rate was shown to be comparable to current clinical practice. Furthermore, US imaging offers additional anatomical context for needle trajectory planning.

Conclusion

This work shows first clinical data for robotic ultrasound-assisted facet joint insertion as a promising solution that can easily be incorporated into the clinical workflow. Presented results show the clinical value of such a system.

     

Does patient volume affect clinical outcomes in adult intensive care units?

Purpose

This systematic review assessed if outcomes in adult intensive care units (ICUs) are related to hospital and ICU patient volume.

Methods

A systematic search strategy was used to identify studies reporting on volume–outcome relationship in adult ICU patients till November 2010. Inclusion of articles was established through a predetermined protocol. Two reviewers assessed studies independently and data extraction was performed using standardized data extraction forms.

Results

A total of 254 articles were screened. Of these 25 were relevant to this study. After further evaluation a total of 13 studies including 596,259 patients across 1,068 ICUs met the inclusion criteria and were reviewed. All were observational cohort studies. Four of the studies included all admissions to ICU, five included mechanically ventilated patients, two reported on patients admitted with sepsis and one study each reported on patients admitted with medical diagnoses and post cardiac arrest patients admitted to ICU, respectively. There was a wide variability in the quantitative definition of volume and classification of hospitals and ICUs on this basis. Methodological heterogeneity amongst the studies precluded a formal meta-analysis. A trend towards favourable outcomes for high volume centres was observed in all studies. Risk-adjusted mortality rates revealed a survival advantage for a specific group of patients in high volume centres in ten studies but no significant difference in outcomes was evident in three studies.

Conclusions

The results indicate that outcomes of certain subsets of ICU patients—especially those on mechanical ventilation, high-risk patients, and patients with severe sepsis—are better in high volume centres within the constraints of risk adjustments.

     

Incidence,treatment, and outcome of severe sepsis in ICU-treated adults in Finland: the Finnsepsis study

Objective

To determine the incidence and outcome of severe sepsis in the adult Finnish population and to evaluate how treatment guidelines in severe sepsis are applied in clinical practice.

Study design

A prospective study in 24 closed multidisciplinary ICUs in 21 hospitals (4 university and 17 tertiary hospitals) in Finland.

Patients

All 4,500 consecutive ICU admission episodes were screened for severe sepsis during a 4-month period (1 November 2004 – 28 February 2005). The referral population was 3,743,225.

Results

The severe sepsis criteria were fulfilled in 470 patients, who had472 septic episodes. The incidence of severe sepsis in the ICUs in Finland was 0.38/1000 in the adult population (95% confidence interval 0.34–0.41). The mean ICU length of stay was 8.2?±?8.1?days. ICU, hospital, and 1-year mortality rates were 15.5%, 28.3%, and 40.9%, respectively. Respiratory failure requiring ventilation support was the most common organ failure (86.2%); septic shock was present in 77% and acute renal failure in 20.6% of cases. Activated protein C was given to only 15 of the 55 patients with indication (27%) and low-dose corticosteroids to 150 of 366 (41%) patients with septic shock.

Conclusions

This prospective study found the incidence of ICU-treated severe sepsis in Finland to be 0.38 per 1,000 of the population. The ICU and hospital mortalities were also lower than earlier reported in United States or Australia. Evidence-based sepsis therapies were not used as often as recommended.

     

Successful interventions on an organisational level to reduce violence and coercive interventions in in-patients with adjustment disorders and personality disorders

Background

Self-directed and other violence as well as subsequent coercive interventions occur in a substantial proportion of patients with personality disorders during in-patient treatment. Different strategies may be required to reduce coercive interventions for patients of different diagnostic groups.

Methods

We specialised one of our acute admission wards in the treatment of personality disorders and adjustment disorders (ICD-10 F4 and F6). Patients are not transferred to other acute wards in case of suicidal or violent behaviour. Violent behaviour and coercive interventions such as seclusion or restraint were recorded in the same way as in the rest of the hospital. We recorded the percentage of subjects affected by diagnostic group and average length of an intervention in the year before and after the change in organisational structure.

Results

The total number of coercive interventions decreased by 85% both among patients with an F4 and those with an F6 primary diagnosis. Violent behaviours decreased by about 50%, the proportion of involuntary committed patients decreased by 70%.

Conclusion

The organisational change turned out to be highly effective without any additional cost of personnel or other resources.

     

The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (≥ 80 years)

Purpose

Very old critical ill patients are a rapid expanding group in the ICU. Indications for admission, triage criteria and level of care are frequently discussed for such patients. However, most relevant outcome studies in this group frequently find an increased mortality and a reduced quality of life in survivors. The main objective was to study the impact of frailty compared with other variables with regards to short-term outcome in the very old ICU population.

Methods

A transnational prospective cohort study from October 2016 to May 2017 with 30 days follow-up was set up by the European Society of Intensive Care Medicine. In total 311 ICUs from 21 European countries participated. The ICUs included the first consecutive 20 very old (≥ 80 years) patients admitted to the ICU within a 3-month inclusion period. Frailty, SOFA score and therapeutic procedures were registered, in addition to limitations of care. For measurement of frailty the Clinical Frailty Scale was used at ICU admission. The main outcomes were ICU and 30-day mortality and survival at 30 days.

Results

A total of 5021 patients with a median age of 84 years (IQR 81–86 years) were included in the final analysis, 2404 (47.9%) were women. Admission was classified as acute in 4215 (83.9%) of the patients. Overall ICU and 30-day mortality rates were 22.1% and 32.6%. During ICU stay 23.8% of the patients did not receive specific ICU procedures: ventilation, vasoactive drugs or renal replacement therapy. Frailty (values ≥ 5) was found in 43.1% and was independently related to 30-day survival (HR 1.54; 95% CI 1.38–1.73) for frail versus non-frail.

Conclusions

Among very old patients (≥ 80 years) admitted to the ICU, the consecutive classes in Clinical Frailty Scale were inversely associated with short-term survival. The scale had a very low number of missing data. These findings provide support to add frailty to the clinical assessment in this patient group.

Trial registration

ClinicalTrials.gov (ID: NCT03134807).

     

Increasing evidence-based interventions in patients with acute infections in a resource-limited setting: a before-and-after feasibility trial in Gitwe,Rwanda

Objective

To evaluate whether a focused education program and implementation of a treatment bundle increases the rate of early evidence-based interventions in patients with acute infections.

Design

Single-center, prospective, before-and-after feasibility trial.

Setting

Emergency department of a sub-Saharan African district hospital.

Patients

Patients >?28 days of life admitted to the study hospital for an acute infection.

Interventions

The trial had three phases (each of 4 months). Interventions took place during the second (educational program followed by implementation of the treatment bundle) and third (provision of resources to implement treatment bundle) phases.

Measurements and main results

Demographic, clinical, and laboratory data were collected at study enrollment; 24, 48, and 72 h after hospital admission; and at discharge. A total of 1594 patients were enrolled (pre-intervention, n?=?661; intervention I, n?=?531; intervention II, n?=?402). The rate of early evidence-based interventions per patient during Intervention Phase I was greater than during the pre-intervention phase (74?±?17 vs. 79?±?15%, p?<?0.001). No difference was detected when data were compared between Intervention Phases I and II (79?±?15 vs. 80?±?15%, p?=?0.58). No differences in the incidence of blood transfusion (pre-intervention, 6%; intervention I, 7%; intervention II, 7%) or severe adverse events in the first 24 h (allergic reactions: pre-intervention, 0.2%; intervention I, 0%; intervention II, 0%; respiratory failure: pre-intervention, 2%; intervention I, 2%; intervention II, 2%; acute renal failure: pre-intervention, 2%; intervention I, 2%; intervention II, 1%) were observed.

Conclusions

Our results indicate that a focused education program and implementation of an infection treatment bundle in clinical practice increased the rate of early evidence-based interventions in patients with acute infections (mostly malaria) admitted to a sub-Saharan African district hospital. Provision of material resources did not further increase this rate. While no safety issues were detected, this could be related to the very low disease severity of the enrolled patient population (http://www.clinicaltrials.gov: NCT02697513).

     

Context region discovery for automatic motion compensation in fluoroscopy

Purpose

Image-based tracking for motion compensation is an important topic in image-guided interventions, as it enables physicians to operate in a less complex space. In this paper, we propose an automatic motion compensation scheme to boost image guidence power in transcatheter aortic valve implantation (TAVI).

Methods

The proposed tracking algorithm automatically discovers reliable regions that correlate strongly with the target. These discovered regions can assist to estimate target motion under severe occlusion, even if target tracker fails.

Results

We evaluate the proposed method for pigtail tracking during TAVI. We obtain significant improvement (12 %) over the baseline in a clinical dataset. Calcification regions are automatically discovered during tracking, which would aid TAVI processes.

Conclusion

In this work, we open a new paradigm to provide dynamic real-time guidance for TAVI without user interventions, specially in case of severe occlusion where conventional tracking methods are challenged.

     

Withholding or withdrawing of life-sustaining therapy in older adults (≥ 80 years) admitted to the intensive care unit

Purpose

To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU.

Methods

This prospective study included intensive care patients aged?≥?80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up.

Results

LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32–7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78–2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12–1.34) and SOFA score [OR of 1.07 (95% CI 1.05–1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries.

Conclusions

The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country.

Trial registration

ClinicalTrials.gov (ID: NTC03134807).

     

Olanzapine vs haloperidol: treating delirium in a critical care setting

Objective

To compare the safety and estimate the response profile of olanzapine, a second-generation antipsychotic, to haloperidol in the treatment of delirium in the critical care setting.

Design

Prospective randomized trial

Setting

Tertiary care university affiliated critical care unit.

Patients

All admissions to a medical and surgical intensive care unit with a diagnosis of delirium.

Interventions

Patients were randomized to receive either enteral olanzapine or haloperidol.

Measurements

Patient’s delirium severity and benzodiazepine use were monitored over 5 days after the diagnosis of delirium.

Main results

Delirium Index decreased over time in both groups, as did the administered dose of benzodiazepines. Clinical improvement was similar in both treatment arms. No side effects were noted in the olanzapine group, whereas the use of haloperidol was associated with extrapyramidal side effects.

Conclusions

Olanzapine is a safe alternative to haloperidol in delirious critical care patients, and may be of particular interest in patients in whom haloperidol is contraindicated.

     

Diagnosis and management of skin and soft tissue infections in the intensive care unit: a review

Purpose

To review the salient features of the diagnosis and management of the most common skin and soft tissue infections (SSTI). This review focuses on severe SSTIs that require care in an intensive care unit (ICU), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis.

Methods

Guidelines, expert opinion, and local institutional policies were reviewed.

Results

Severe SSTIs are common and their management complex due to regional variation in predominant pathogens and antimicrobial resistance patterns, as well as variations in host immune responses. Unique aspects of care for SSTIs in the ICU are discussed, including the role of prosthetic devices, risk factors for bacteremia, and the need for surgical consultation. SSTI mimetics, the role of dermatologic consultation, and the unique features of SSTIs in immunocompromised hosts are also described.

Conclusions

We provide recommendations for clinicians regarding optimal SSTI management in the ICU setting.

     

Offene Arthrolyse des Kniegelenks

Background

Loss of range of motion of the knee joint causes significant disability. Surgical treatment should include arthroscopic as well as open arthrolysis procedures.

Objectives

Impairments of extension and flexion can have capsular or extra-articular origins in the musculature. The techniques of open capsulotomy and interventions on the proximal and distal extension apparatus are presented.

Methods

Discussion on the indications and surgical techniques for open arthrolysis of the knee joint are presented based on own results and the available literature.

Results

The established surgical techniques can significantly improve the range of motion considering the severity of this case group.

Conclusions

An exact analysis of the cause of knee stiffness is necessary. Only intra-articular problems can be arthroscopically treated and open techniques are indicated when the stiffness is caused by an extra-articular pathology. The techniques are established and reproducible.

     

Erythromycin versus metoclopramide for post-pyloric spiral nasoenteric tube placement: a randomized non-inferiority trial

Purpose

To determine whether erythromycin is non-inferior to metoclopramide in facilitating post-pyloric placement of self-propelled spiral nasoenteric tubes (NETs) in critically ill patients.

Methods

A prospective, multicenter, open-label, parallel, and non-inferiority randomized controlled trial was conducted comparing erythromycin with metoclopramide in facilitating post-pyloric placement of spiral NETs in critically ill patients admitted to intensive care units (ICUs) of eight tertiary hospitals in China. The primary outcome was procedure success defined as post-pyloric placement (spiral NETs reached the first portion of the duodenum or beyond confirmed by abdominal radiography 24 h after tube insertion).

Results

A total of 5688 patients were admitted to the ICUs. Of these, in 355 patients there was a plan to insert a nasoenteric feeding tube, of whom 332 were randomized, with 167 patients assigned to the erythromycin group and 165 patients assigned to the metoclopramide group. The success rate of post-pyloric placement was 57.5% (96/167) in the erythromycin group, as compared with 50.3% (83/165) in the metoclopramide group (a difference of 7.2%, 95% CI ??3.5% to 17.9%), in the intention-to-treat analysis, not including the prespecified margin of ??10% for non-inferiority. The success rates of post-D1 (reaching the second portion of the duodenum or beyond), post-D2 (reaching the third portion of the duodenum or beyond), post-D3 (reaching the fourth portion of the duodenum or beyond), and proximal jejunum placement and the incidence of any adverse events were not significantly different between the groups.

Conclusions

Erythromycin is non-inferior to metoclopramide in facilitating post-pyloric placement of spiral NETs in critically ill patients. The success rates of post-D1, post-D2, post-D3, and proximal jejunum placement were not significantly different.

     

Estimating needle tip deflection in biological tissue from a single transverse ultrasound image: application to brachytherapy

Purpose

This paper proposes a method to predict the deflection of a flexible needle inserted into soft tissue based on the observation of deflection at a single point along the needle shaft.

Methods

We model the needle-tissue as a discretized structure composed of several virtual, weightless, rigid links connected by virtual helical springs whose stiffness coefficient is found using a pattern search algorithm that only requires the force applied at the needle tip during insertion and the needle deflection measured at an arbitrary insertion depth. Needle tip deflections can then be predicted for different insertion depths.

Results

Verification of the proposed method in synthetic and biological tissue shows a deflection estimation error of \(<\)2 mm for images acquired at 35 % or more of the maximum insertion depth, and decreases to 1 mm for images acquired closer to the final insertion depth. We also demonstrate the utility of the model for prostate brachytherapy, where in vivo needle deflection measurements obtained during early stages of insertion are used to predict the needle deflection further along the insertion process.

Conclusion

The method can predict needle deflection based on the observation of deflection at a single point. The ultrasound probe can be maintained at the same position during insertion of the needle, which avoids complications of tissue deformation caused by the motion of the ultrasound probe.

     

Sekundäre Steife der Schulter

Background

In addition to idiopathic shoulder stiffness, secondary shoulder stiffness in particular is often associated with extra-articular subacromial adhesions between the rotator cuff and the surrounding anatomical structures.

Objective

The aim of this article is to present clinical results and complications as well as the surgical technique of extra-articular release in the context of secondary shoulder stiffness.

Material and Methods

Selective review of the literature and presentation of own clinical experience.

Results

Intra-articular and extra-articular release are related to a high patient satisfaction and an improved range of motion. Exact knowledge of the extra-articular anatomy is necessary to prevent iatrogenic lesions of vessels, nerves and the rotator cuff. Compared to patients with a primary stiff shoulder, patients suffering from posttraumatic stiff shoulder benefit more from arthroscopic interventions with intracapsular and extracapsular release.

Conclusion

Restrictions in range of motion of the shoulder can be related to extra-articular adhesions. These adhesions need to be specifically addressed during arthroscopic treatment of stiff shoulders.

     

Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions

Purpose

To compare the attitudes of physicians towards withholding and withdrawing life-sustaining treatments in intensive care units (ICUs) in low-middle-income Asian countries and regions with those in high-income ones, and to explore differences in the role of families and surrogates, legal risks, and financial considerations between these countries and regions.

Methods

Questionnaire study conducted in May–December 2012 on 847 physicians from 255 ICUs in 10 low-middle-income countries and regions according to the World Bank’s classification, and 618 physicians from 211 ICUs in six high-income countries and regions.

Results

After we accounted for personal, ICU, and hospital characteristics on multivariable analyses using generalised linear mixed models, physicians from low-middle-income countries and regions were less likely to limit cardiopulmonary resuscitation, mechanical ventilation, vasopressors and inotropes, tracheostomy and haemodialysis than those from high-income countries and regions. They were more likely to involve families in end-of-life care discussions and to perceive legal risks with limitation of life-sustaining treatments and do-not-resuscitate orders. Nonetheless, they were also more likely to accede to families’ requests to withdraw life-sustaining treatments in a patient with an otherwise reasonable chance of survival on financial grounds in a case scenario (adjusted odds ratio 5.05, 95 % confidence interval 2.69–9.51, P < 0.001).

Conclusions

Significant differences in ICU physicians’ self-reported practice of limiting life-sustaining treatments, the role of families and surrogates, perception of legal risks and financial considerations exist between low-middle-income and high-income Asian countries and regions.

     

Adverse drug reactions and deliberate self-poisoning as cause of admission to the intensive care unit: a 1-year prospective observational cohort study

Objective

The aim of the present study was (1) to determine the prevalence of intensive care unit (ICU) admissions due to an adverse drug reaction (ADR), and (2) to compare affected patients with patients admitted to the ICU for the treatment of deliberate self-poisoning using medical drugs.

Design

Prospective observational cohort study.

Setting

Fourteen bed medical ICU including an integrated intermediate care (IMC) section at a tertiary referral center.

Patients

A total of 1,554 patients admitted on 1 January 2003 to 31 December 2003.

Results

Ninety-nine patients were admitted to the ICU with a diagnosis of ADR (6.4% of all admissions), 269 admissions (17.3%) were caused by deliberate self-poisoning. Patients admitted for treatment of ADR had a significantly higher age, a longer treatment duration in the ICU, a higher SAPS II score, and a higher 6-month mortality than those with deliberate self-poisoning. Most patients (71.7%) suffering from ADR required advanced supportive care in the ICU while the majority of patients (90.7%) with deliberate self-poisoning could be sufficiently treated in the IMC area. All diagnostic and therapeutic procedures in the ICU except mechanical ventilation were significantly more often performed in patients with ADR.

Conclusions

This study provides further evidence that ADR is a frequent cause of admission to medical ICUs resulting in a considerable use of ICU capacities. In the present setting patients with ADR required longer and more intense medical treatment in the ICU than those with deliberate self-poisoning.

     

Comparison of European ICU patients in 2012 (ICON) versus 2002 (SOAP)

Purpose

To evaluate differences in the characteristics and outcomes of intensive care unit (ICU) patients over time.

Methods

We reviewed all epidemiological data, including comorbidities, types and severity of organ failure, interventions, lengths of stay and outcome, for patients from the Sepsis Occurrence in Acutely ill Patients (SOAP) study, an observational study conducted in European intensive care units in 2002, and the Intensive Care Over Nations (ICON) audit, a survey of intensive care unit patients conducted in 2012.

Results

We compared the 3147 patients from the SOAP study with the 4852 patients from the ICON audit admitted to intensive care units in the same countries as those in the SOAP study. The ICON patients were older (62.5 ± 17.0 vs. 60.6 ± 17.4 years) and had higher severity scores than the SOAP patients. The proportion of patients with sepsis at any time during the intensive care unit stay was slightly higher in the ICON study (31.9 vs. 29.6%, p = 0.03). In multilevel analysis, the adjusted odds of ICU mortality were significantly lower for ICON patients than for SOAP patients, particularly in patients with sepsis [OR 0.45 (0.35–0.59), p < 0.001].

Conclusions

Over the 10-year period between 2002 and 2012, the proportion of patients with sepsis admitted to European ICUs remained relatively stable, but the severity of disease increased. In multilevel analysis, the odds of ICU mortality were lower in our 2012 cohort compared to our 2002 cohort, particularly in patients with sepsis.