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SwissMedical Forum
Offizielles Fortbildungsorgan der FMHOrgane officiel de la FMH pour la formation continueBollettino ufficiale per la formazione della FMHOrgan da perfecziunament uffizial da la FMH www.medicalforum.ch
Supplementum 64ad Swiss Medical Forum
2016;38 (Online-Publikation)
21. September 2016
Gemeinsame Jahrestagung 2016
Schweizerische Gesellschaft für Intensivmedizin
Gesellschaft für klinische Ernährung der Schweiz
Schweizerische Gesellschaft für Pulmonale Hypertonie
Montreux (Switzerland), 21.–23. September 2016
SMF – FMS Schweizerisches Medizin-Forum – Forum Médical Suisse – Forum Medico Svizzero – Forum Medical Svizzer
Inhalt | Sommaire Seite |Page Freie Mitteilungen | Communications libres 2-‐‑18 FM 01 – FM 05 2–7 SGI Pflege | SSMI Soins
FM 06 – FM 11 8–14 SGI Ärzteschaft | SSMI Médecins FM 12 – FM 16 15–20 SGI Gemeinsam | SSMI Communes
Beste Arbeiten Nachdiplomstudium Intensivpflege | Meilleures travaux de diplôme des Etudes post-‐‑diplôme en soins intensifs D01 – D05 21-‐‑25
ePoster 26-‐‑68 Gruppen | Groupes Posterviewing SGI Pflege | SSMI Soins P01 -‐‑ P13 SGI Ärzteschaft | SSMI Médecins P14 -‐‑ P31 SGPH | SSPH P32 -‐‑ P35 GESKES | SSNC P36 -‐‑ P37
Autorenverzeichnis | Index des auteurs 69-‐‑70
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Freie Mitteilungen – SGI Pflege | Communications libres SSMI Soins FM 01 – FM 05 FM01 Fachangestellte Gesundheit auf der Intensivstation: Auswirkungen auf die interprofessionelle Zu-‐‑sammenarbeit M M Jeitziner [1, 2], M Shaha [1], B Jenni [1] [1] Universitätsklinik für Intensivmedizin, Inselspital, Bern, Switzerland [2] IUFRS, Universität Lausanne, Lausanne, Switzerland Einführung Seit 2001 besteht die Schweizer Berufslehre Fachangestellte Gesundheit (FaGe) mit eidgenössischem Fachausweis. Dieser Abschluss befähigt, Patienten in stabilen Situationen zu betreuen. Der Einsatz von FaGes wird zunehmend bei hochkomplexen Patienten und instabilen Situationen diskutiert. Auch Intensivstationen müssen deshalb über einen neuen Skill-‐‑ und Grademix, nachdenken. Für die Pflegeteams entstehen neue Herausforderungen in der interprofessionelle Zusammenarbeit in Bezug auf Delegation und Arbeitsteilung. Ziel Die Studie beschreibt, wie FaGes in den intensivmedizinischen Pflegealltag eingebunden werden können. Methode In dieser qualitativen Studie einer universitären Intensivstation wurden 2 FaGes und 20 Experten mit Nachdiplomstudium Höhere Fachschule Intensivpflege (NDS HF IP) in semistrukturierten Einzel-‐‑interviews befragt. Die Transkripte wurden mit ATLAS ti induktiv nach Mayring (2010) analysiert. Ergebnisse Die Herausforderungen in der Zusammenarbeit wurden folgenden Kategorien zugeordnet: • Strukturelle und personelle Rahmenbedingungen schaffen • Charakteristika der FaGes und der Experten NDS HF IP • Stress und Angst vor hoher Arbeitsbelastung und Verlust von Anerkennung • Kompetenzen kennen • Vertrauen in FaGes entwickeln Hochkomplexe und rasch wechselnde Patientensituationen, knappe Personalressourcen, hohe Arbeitsbelastung und verschiedene Funktionen der Experten NDS HF IP beeinflussen die Integration der FaGes. Offenheit gegenüber Neuem und strukturierte Rahmen-‐‑bedingungen fördern die Integration. Oft wird diese durch Stress in der Zusammenarbeit, sowie durch individuelle Stressfaktoren erschwert. Insbesondere das Delegieren fällt diplomierten Experten NDS HF IP schwer. „Kennen“ die Experten NDS HF IP die FaGe, kann sie unterstützend eingesetzt werden. Die Experten NDS HF IP stellen hohe Ansprüche an ihre eigenen Fähigkeiten, dadurch entstehen Mechanismen die sich in Kontrolle oder im Übergeben von Verantwortung an die FaGes ausdrücken. Basis für eine gute Zusammenarbeit ist Vertrauen, welches über korrekt ausgeführte Handlungen erlangt wird und das Delegieren ermöglicht. Schlussfolgerungen FaGes können auf Intensivstationen eingesetzt werden, wenn die Experten NDS HF IP den Herausforderungen vorausschauend begegnen. Die Zusammenarbeit verlangt strukturierte Rahmen-‐‑bedingungen, Stressmanagement, Delegieren können und hohe professionelle Fähigkeiten.
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FM02 Multiprofessionelle Kommunikationsschulung „Breaking Bad News“ Gemeinsam auf dem Weg zu einer besseren Kommunikationsqualität mit Familienmitgliedern von Brandverletzten Ch Rosch [1], J Plock [1], P Steiger [1], A Salerno [1], S Monteverde [1] [1] UniversitätsSpital Zürich, Zürich, Switzerland Ausgangslage Brandverletzte bleiben aufgrund des komplexen Verletzungsmusters und der langwierigen Wundbehandlung monatelang auf der Intensivstation. Eine intensive Kommunikation mit den Familien kann potentielle Konflikte reduzieren und das Vertrauensverhältnis stärken. Im Rahmen regelmässiger multiprofessioneller Familiengespräche treten Pflegende und Ärzte gemeinsam auf. Um die Rollenfindung zu erleichtern und eine gemeinsame Haltung zu etablieren, wurde entschieden, als multiprofessionelles Behandlungsteam gemeinsame Kommunikationsschulungen durchzuführen. Ziele Erstellung, Verabschiedung und Umsetzung eines Konzepts zur multiprofessionellen Kommunikations-‐‑schulung „Breaking Bad News“. Gemeinsame Kommunikationsschulungen für Intensivpflegende, Intensivmediziner und Plastische Chirurgen. Gewährleistung einer gleichbleibenden Informationsqualität und professionellen Haltung im Rahmen von regelmässigen multiprofessionellen Familiengesprächen. Methode Durch das Bildungszentrum des UniversitätsSpitals Zürich wurde ein eintägiger Fortbildungstag „Breaking Bad News“ entwickelt, der von Intensivpflegenden, Intensivmedizinern und Plastischen Chirurgen gemeinsam besucht wird. Neben der Vermittlung von auf ethischen Prinzipien basierender Kommunikationstheorie stehen praktische Übungen mit Schauspielern in multiprofessionellen Kleingruppen im Zentrum. Das direkte Feedback durch die Schauspieler und Teamkollegen ermöglicht reflektiertes Lernen. Ergebnisse Ende 2015 wurden die ersten Schulungen durchgeführt, gemeinsam evaluiert und mit geringfügigen Anpassungen im 2016 fortgeführt. Die Rückmeldungen der Teilnehmenden sind durchwegs positiv, insbesondere das direkte Feedback der Schauspieler wird als wertvoll empfunden. Die Mitglieder der Spitaldirektion sind informiert und unterstützen weitere Fortbildungstage. Schlussfolgerungen Insbesondere im Rahmen der praktischen Übungen werden die Ressourcen und Kompetenzen der Mitarbeitenden der anderen Berufsgruppen erkannt und deren Einfluss auf den Gesprächsverlauf wahrgenommen. Dies steigert die Wertschätzung und das Vertrauen im multiprofessionellen Team.
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FM03 Sitzen am Bettrand: Kinaesthetics und neue Sitzhilfe machen’s möglich W Stehlin [1], C Wesch [1], S Hübsch [1], F Mettler [1], U Barandun Schäfer [1] [1] Universitätsspital Basel, Basel, Switzerland Hintergrund Die positive Wirkung der frühen Mobilisation ist für Patienten von Intensivstationen in Publikationen belegt (Needham, 2008). Mobilisation fördert Wohlbefinden, Funktionalität und Selbständigkeit und beugt Komplikationen vor. Einige Faktoren wie Angst vor Schmerzen, Sturz und Komplikationen sowie Zeitmangel behindern die frühe Mobilisation. Die Evaluation von Memmolo & Richter (2014) belegt jedoch, dass Zwischenfälle wie Kreislaufeinbruch und unbeabsichtigte Extubation selten vorkommen. Methode Zur Förderung der Bewegungskompetenz setzen die Intensivstationen am Universitätsspital Basel (USB) seit Jahren erfolgreich auf Kinaesthetics (Asmussen, 2009), unterstützt durch Schulungen (u.a. Grundkurs für alle) und Begleitung im Praxisalltag. Zudem entwickelten Expertinnen eine Richtlinie zur Frühmobilisation. Bei wenig Rumpfstabilität ist das Sitzen am Bettrand sinnvoll. Patienten, die noch nicht aus eigener Kraft aufrecht sitzen können, müssen dabei häufig von Pflegenden unterstützt werden. Dies ist jedoch anstrengend und schränkt die Bewegung stark ein. Die Suche nach einem geeigneten Hilfsmittel blieb erfolglos. Ein Kinaesthetics-‐‑Trainer am USB entwickelte mit der Firma OBA eine Sitzhilfe zur Stütze von Rücken und Armen. Ein erster Prototyp übertraf bereits in der Testphase alle Erwartungen. Unterdessen wurden mehrere Exemplare angeschafft. Ergebnisse Die neue Sitzhilfe ist leicht zu handhaben, bietet sehr guten Halt und Stabilität, das Material ist gut zu reinigen und desinfizierbar und erfüllt die Anforderungen des Brandschutzes. Schlussfolgerungen Die Sitzhilfe erleichtert die Frühmobilisation für alle Beteiligten. Den Patienten bietet sie Komfort und Sicherheit. Durch die Bewegungsfreiheit des Kopfes können sie besser durchatmen, um sich schauen, sprechen und trinken. Die Pflegenden können sich dem Patienten von vorne zuwenden, haben beide Hände frei und belasten ihren Rücken nicht. Die Sitzhilfe vereinfacht die Mobilisation an den Bettrand, optimiert den personellen Aufwand und trägt damit auch zur Motivation für möglichst frühe Mobilisation bei. Langjährige Pflegende bezeichnen sie als die beste Innovation seit Langem. Mitte 2016 führen Pflegeexperten eine Evaluation bezüglich Häufigkeit und Dauer der Mobilisation durch. Literatur Memmolo, G. & Richter, H. Intensiv 2014:22:18 Needham, D.M. JAMA 2008:300:1685 Asmussen, M. Praxisbuch Kinaesthetics 2009 München: Urban & Fischer
Bemerkung: Die Entwicklung der Sitzhilfe ist für die Intensivstationen mit keinem finanziellen Vorteil verbunden.
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FM04 Le râle agonique : une voix de souffrance en fin de vie ? A Perret [1], B Ricou [1] [1] groupe EOL*, Soins intensifs HUG Genève, Genève, Switzerland * Groupe EOL « accompagnement de la fin de vie aux SI » Hôpitaux Universitaires de Geneve (Pr. B Ricou, A Perret, C Kervella, H Riggi, J-‐‑M Allet, S. Flatres, N-‐‑M Chijoli, O Waeterloot, A. Jeleff) Introduction Le râle agonique est un symptôme fréquent en fin de vie. La famille est affectée et les soignants se sentent frustrés de ne rien pouvoir faire tant est forte la culture interventionelle. Comment accompagner la famille avant et après l’extubation terminale du patient aux soins intensifs? Objectifs L’objectif premier est de savoir si le râle agonique induit un inconfort pour le patient et s’il existe des recommandations pour une prise en charge pharmacologique et/ou non pharmacologique pour ce symptôme. Le second consiste à préciser l’impact que peut avoir le râle sur les familles et les soignants et aider ces derniers à mieux le prendre en charge sur le plan psychologique et technique. Méthode La recherche des articles s’est déroulée sur la base de données en « evidence based practiced » (Cochrane Library) et sur les moteurs de recherches suivants : PubMed, CINAHL, Google Scholar et Google. 22 articles, dont 8 études et 4 revues de la littérature compris entre les années 1997 à nos jours ont été sélectionnés. Résultats En ce qui concerne l’inconfort du patient présentant un râle agonique, les avis divergent aussi bien dans la littérature que chez les experts interrogés. Il est difficile de savoir si le patient souffre ou non. Les études se rejoignent sur le fait que la plupart des proches sont affligés par sa présence. Celles concernant l’impact du râle sur le soignant montrent que le râle a aussi un impact négatif sur le personnel qui travaille auprès des patients mourants. La procédure d’extubation terminale peut donc s’avérer traumatisante et nécessite une parfaite compréhension des proches et un personnel paramédical préparé. Quant à un traitement éventuel, certains auteurs, avant l’extubation, prônent les aspirations et l’association d’antimuscariniques, quand d’autres préconisent l’injection de méthylprednisone. Cependant, dans une version de mise à jour de la revue Cochrane, les experts concluent qu’il n’y a aucune preuve que toute intervention, pharmacologique ou non, soit supérieure au placebo dans le traitement de la respiration. Conclusion Le râle du mourant est un symptôme souvent éprouvant à vivre pour la famille et il paraît important que toutes les personnes accompagnant le patient aient été préparé à l’extubation terminale et à la symptomatologie qui va en découler. Les médicaments n'ont montré qu'une efficacité de 50%. Se pose alors un dilemme éthique d'un traitement pour soulager l'inconfort des familles et ou des soignants. Bibliographie Société suisse de médecine palliative, Dyspnée., Bigorio : best practice, 2003 Prévost, A.-‐‑P., Vigneault, A. La fin de vie aux Soins Intensifs de la futilité à l’utilité, Le médecin du Québec, 2008, volume 43,
numéro 9. Kompanje, E.J.O, et al. Anticipation of distress after discontinuation of mechanical ventilation in the ICU at the end of life.
Intensive Care Med, 2008, 34, 1593–1599 Hacpille L. Soins palliatifs et le Soutien aux Familles. Rouen : Lamarre. Ed 2012 Mazzocato C., Laurent P. et al. Les râles agoniques, Palliative Flash, ARCOS, 2007 Vinay, P., et al. Soigner les râles terminaux. Médecine palliative -‐‑ Soins de support –Accompagnement -‐‑ Éthique, 2009, 9,
148-‐‑156 Fartoukh, M., Brun-‐‑Buisson, C., Lemaire, F. Terminal extubation in 5 end-‐‑ of-‐‑life patients in intensive care units. Presse
Médicale, 2005, 34(7), 495–501 Wee, B., Hillier, R. Interventions for noisy breathing in patients near to death, Cochrane Database of Systematic Reviews,
Oxford, 2012. Kompanje, E.J.O. Death rattle after withdrawal of mechanical ventilation: practical and ethical considerations. Intensive
and Critical Care Nursing, 2006,Vol. 22, Issue 4, 214-‐‑219 Watts, T., Jenkins, K. Palliative care nurses’ feelings about death rattle. Journal of Clinical Nursing, 1999, 8, 615-‐‑618 Hirsch, C., Marriott, J F., M Faul C. Influences on the decision to prescribe or administer anticholinergic drugs to treat
death rattle: A focus group study. Palliative Medicine, 2012, 27(8) 732–738
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Lokker, ME. , et al. , Prevalence, Impact, and treatment of death rattle: A systematic review, Journal of Pain Symptom Management, 2013 Morita, T., Hirai, K., Sakaguchi, Y., Tsuneto, S., Shima, Y. Family-‐‑perceived distress about appetite loss and bronchial
secretion in the terminal phase. Journal Pain SymptomManagement, 2004, 27, 98-‐‑99 Wee, BL., Coleman PG., Hillier R., Holgate SH. The sound of death rattle I: are relatives distressed by hearing this sound?
Palliative Medicine, 2006, 20(3), 171–175 Wee, BL., Coleman PG., Hillier R., Holgate SH. The sound of death rattle II: how do relatives interpret the sound? Palliative
Medicine, 2006, 20(3), 177–181 Azoulay, E., et al. Risk of Post-‐‑traumatic Stress Symptoms in Family Members of Intensive Care Unit Patients. American
journal of respiratory and critical care medicine, 2005, vol 171 Wee, BL., Coleman, PG., Hillier, R., Holgate, ST. Death rattle: its impact on staff andvolunteers in palliative care, Palliative
Medicine, 2008, 22(2), 173–176 Bradley, K., Wee, B., Aoun, S. Management of death rattle: what influences the decisionmaking of palliative medicine
doctors and clinical nurse specialists? Prog Palliat Care,2010, 18, 270-‐‑274 Hirsch, C., Marriott, J F., M Faul C. Influences on the decision to prescribe or administer anticholinergic drugs to treat
death rattle: A focus group study. Palliative Medicine, 2012, 27(8) 732–738 Ryan, L., Seymour, J.Death and dying in intensive care: emotional labour of nurses.End of Life Journal, 2013, Vol 3, N° 2 Ricou, B., Doll, S., Gardaz, V. Accompagnement de fin de vie aux soins intensifs. RevueMédicale Suisse, 2011, 7, 2440-‐‑2443. Ricou, B., Chevrolet, J.-‐‑C. Mourir aux Soins Intensifs. Revue Médicale Suisse, 2002, n°602,17-‐‑21 Baud, F., et al. Limitation et arrêt des traitements en réanimation adulte : Actualisation des Recommandations de la
Société de Réanimation de Langue Française, 2009 Guay, D., Michaud, C., Mathieu, L. Conditions facilitant « les bons soins » palliatifs aux Soins Intensifs selon la perspective
infirmière. Recherche en Soins infirmiers, 2013, n°112 Mazzocato C., Laurent P. et al, Les râles agoniques, Palliative Flash, ARCOS, 2007 Perkin, R.M., Resnik, D.B. The agony of agonal respiration: is the last gasp necessary? Journal Medicin Ethics, 2002, (28),
164-‐‑169. Mc Adam, J L., Puntillo, K. Symptoms experienced by family members of patients in intensive care units. American journal
of critical care, 2009, Volume 18, No. 3. Code civil Suisse, 2013 Watts, T., Jenkins, K., Back, I. Problem and management of noisy rattling breathing in dying patients. International
Journal Palliative Nurse, 1997, 3, 245-‐‑252. Vivier E. et al, Extubation de confort en réanimation, congrès SRLF Paris, Service de réanimation polyvalente, centre
hospitalier Saint-‐‑Joseph & AMP, Saint-‐‑Luc, Lyon, 2013 Stocker, R., et al. Mesures soins intensifs. Académie suisse des sciences médicales, 2013
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FM05 Verbesserte Lebensqualität und erhöhtes Wohlbefinden für Langzeitpatienten auf der Intensivstation mit dem Passy-‐‑Muir Sprechventil – eine Fallstudie E Liem [1], M Fröhlich [1] [1] USZ, Zürich, Switzerland Ausgangslage und Ziel Die Respiratorabhängigkeit ist ein Merkmal sogenannter Langzeitpatienten auf der Intensivstation. Häufig erfolgt die Einlage einer Trachealkanüle, welche die verbale Kommunikation verhindert und die physiologischen Prozesse beim Atmen und Schlucken beeinträchtigt. Mittels eines multiprofessionellen Praxisentwicklungsprojektes wurde das Passy-‐‑Muir Sprechventil (PMV) eingeführt, um Patienten die Möglichkeit zur verbalen Kommunikation am Respirator zu bieten und die durch die Trachealkanüle bedingten Effekte auf die pharyngo-‐‑laryngeale Funktion zu mindern. Methodik Fallvorstellung einer 45-‐‑jährigen Patientin mit Cystischer Fibrose und Status nach Lungentransplantation mit Darstellung der PMV-‐‑Anwendung und deren Auswirkungen. Resultate Die Patientin wurde postoperativ extubiert. Aufgrund einer pulmonalen Erschöpfung erfolgte die Reintubation mit Tracheotomie. In Absprache mit Intensivpflege, Ärzten und Physiotherapie kam das PMV ein bis zweimal täglich bis zur einer Stunde zur Anwendung. Die Patientin musste lernen, langsam zu sprechen, um gut verstanden werden zu können und um sich pulmonal nicht zu schnell zu erschöpfen. Sie äusserte einen Zugewinn an Lebensqualität und Wohlbefinden durch das PMV, da sie ihre Bedürfnisse verbal ausdrücken und trinken konnte. Im Verlauf verschlechterte sich der Gesamtzustand der Patientin aufgrund diverser Faktoren, so dass die PMV-‐‑Anwendung kontraindiziert war. Schliesslich wurde eine palliative Therapie eingeleitet. In dieser Phase kam das PMV wieder zum Einsatz und das Wohlbefinden der Patientin konnte durch die Ermöglichung von Essen und Trinken gesteigert werden. Sie war in der Lage, wichtige Anliegen wie die Testamentserstellung und Klärung von Familienangelegenheiten zu bewältigen. Die Patientin verstarb am 50. postoperativen Tag. Schlussfolgerungen Der vorgestellte Fall verdeutlicht die Wirksamkeit des PMV bei Langzeitpatienten auf der Intensivstation. Voraussetzung für eine bestmögliche Anwendung ist eine enge Kommunikation im multiprofessionellen Behandlungsteam. So können die Möglichkeiten der Patienten zur Erlangung individueller Lebensqualität und Wohlbefinden auch in der letzten Lebensphase gewährleistet werden.
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Freie Mitteilungen SGI Ärzteschaft | Communications libres SSMI médecins FM 06 – FM 10 FM06 Dexmedetomidine provides effective pain modulation and rapid extubation during perioperative fast-‐‑track management in patients after off-‐‑pump coronary artery bypass grafting A Zientara [1], S Matter-‐‑Ensner [2], S Mariotti [2], B Seifert [3], K Graves [1], O Dzemali [1], M Genoni [1] [1] Triemli Hospital, Cardiac Surgery, Zürich, Switzerland [2] Triemli Hospital, Anesthesiology, Zürich, Switzerland [3] University of Zurich, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland Aims Dexmedetomidine (DEX) is a highly selective, shorter-‐‑acting alpha-‐‑2 agonist with 10-‐‑fold greater alpha-‐‑2 to alpha-‐‑1 receptor selectivity than clonidine. Many desirable effects of DEX, including analgesia, anxiolysis, improvement of hemodynamic stability, and potential myocardial and renal protection have been proven. The aim of this study was to retrospectively investigate the effect of dexmedetomidine on patients undergoing off-‐‑pump coronary artery bypass grafting (OPCAB). Methods From January 2012 till March 2015, 464 patients after OPCAB were included for retrospective analysis of early postoperative outcome. After propensity matching (1:1) to mitigate selection bias in DEX infusion, including cardiovascular risk factors, baseline laboratory values and operative strategy, two groups (DEX vs DISO, n=129) could be compared. DEX patients received immediatly after chest closure an infusion of dexmedetomidine (1µg/kg/h) while disoprivan was reduced and stopped in the OR. DISO patients were transferred with disoprivan to the ICU, routinely. Continuous and categorical variables were reported as mean ± SD or percentages, and compared with the chi-‐‑square test and the Man-‐‑Whitney test, respectively. Results In the DEX group less use of pain medication in the initial phase at ICU could be observed. During the first 2 hours, DEX patients received significantly more intravenous nicomorphine (DEX 8 mg ± 3.2 vs DISO 6 mg ± 4, p<0.001), while in the following two hours the pain medication was significantly reduced (DEX 3.2 mg ± 2.8 vs DISO 4.7 mg ± 3.3, p<0.001). After 12 hours there was no difference in both groups, although remifentanyl was stopped considerably earlier in the DEX group (DEX 238 min ± 209 vs DISO 353 min ± 266, p<0.001). Additionally, DEX led to earlier extubation (DEX 208 min ± 106 vs, DISO 307 min ± 230, p<0.001). Furthermore, there was a significant difference in the occurrence of postoperative atrial fibrillation, which was rarer after DEX application (p=0.01). Delirium occurred only once in the DEX group and five times in the DISO group, which was statistically not significant (p=0.098). There were no differences between both groups in postoperative CK, CKMB or TropT and in Creatinine. Conclusion Early postoperative application of DEX supports the fast-‐‑track strategy in OPCAB patients by rapid extubation, less need of pain medication, rarer occurrence of atrial fibrillation and a tendency to less delirium.
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FM07 Adverse drug reactions as a cause of admission to intensive care unit : a 4-‐‑month prospective cohort study D Renard [1], V Berthaut [2], MD Schaller [3], C Manzon [3], P Voirol [4], T Buclin [1], F Livio [1] [1] Division of clinical pharmacology, CHUV, Lausanne, Switzerland [2] School of pharmaceutical sciences, Geneva, Switzerland [3] Service of intensive care medicine, CHUV, Lausanne, Switzerland [4] Service of pharmacy, CHUV, Lausanne, Switzerland Aims Adverse drug reactions (ADR) are a significant cause of hospitalization, including in intensive care unit (ICU). The aim of the present study was to assess the frequency and preventability of ADR-‐‑related admission to ICU. Methods Design: prospective 4-‐‑months observational study. Patients: all adult patients admitted to the Centre Hospitalier Universitaire Vaudois ICU between February and June 2015. Data collection: patient’s age and gender, current drugs, Simplified Acute Physiology Score II (SAPS II), length of stay and clinical outcome. The causality between drugs and organ failure at admission was assessed for all patients by the principal investigator and two clinical pharmacologists using a standardized method. Drug abuses and suicide attempts were excluded. ADR preventability was assessed with standardized criteria. ICU patients admitted for ADR were compared to all others. Results A total of 615 admissions was recorded during the 4-‐‑months study period. Of these, 55 (8.9%) admissions were ADR-‐‑related. A total of 18 ADR (33%) was deemed preventable. Most frequent ADR (by affected organ) were infections (36%, n=20), CNS disorders (18%, n=10) and cardiac disorders (13%, n=7). Bleeding, any site, was common (n=14). Immunosuppressants, antithrombotics and beta blockers were the most frequent classes of drugs involved. Compared to control patients, those with ADR were more polymedicated (69% vs 20%), had higher SAPS II scores (48 vs 41) and hospital mortality (29% vs 13%). The mean length of ICU stay was 5 to 6 days in both groups. Only 1 out of those 55 ADR cases was spontaneously reported to the pharmacovigilance officer. Conclusion ADR represent a frequent cause of ICU admission ; frail polymedicated patients are at higher risk. A third of these ADR meets criteria of preventability. Better training in pharmacotherapy and awareness of drug-‐‑related risks among health professionals are important to limit the heavy human and financial burden associated with ADR.
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FM08 Neurologic injury with severe adult respiratory distress syndrome in patients undergoing extracorporeal membrane oxygenation S Klinzing [1], U Wenger [2], F Stretti [1, 3], P Steiger [1], JE Rushing [4], U Schwarz [5], M Maggiorini [2] [1] Surgical Surgical Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland [2] Medical Intensive Care Unit, University Hospital of Zurich, Zurich, Switzerland [3] Università degli Studi di Milano, Milano, Italy [4] Department of Neuropathology, University Hospital of Zurich, Zurich, Switzerland [5] Department of Neurology, University Hospital of Zurich, Zurich, Switzerland Objective This study was designed as a descriptive investigation of neurologic injury in patients undergoing extracorporeal membrane oxygenation (ECMO) for adult respiratory distress syndrome (ARDS) and includes a review of the literature. Design Data from all patients undergoing ECMO treatment for severe ARDS at the University Hospital of Zurich during the time period 01.01.2008 – 31.12.2013 were analyzed in this retrospective single center study. The incidence of neurologic injury diagnosed by cerebral imaging or autopsy was determined. Results Seventy-‐‑four patients underwent ECMO for severe ARDS during the study period. Overall survival in this study population was 57%. ECMO associated neurologic injury occurred in 8 patients (10.8%). Intracerebral bleeding was diagnosed in all cases with a survival probability of 13%. After ECMO initiation, patients were diagnosed at median 6 days (IQR 4-‐‑23). Conclusion Severe neurologic injury in patients undergoing ECMO therapy is associated with high mortality. More research directed towards prevention and early diagnosis of neurologic injury is warranted in this patient population.
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FM09 Unfavorable long-‐‑term outcome for elderly patients after traumatic brain injury: an epidemiological study R Erlebach [1], A Pagnamenta [2], F Stretti [3], U Ehlers [1], S Klinzing [1], S Cottini [1], P Steiger [1], G Brandi [1] [1] Surgical Intensive Care Unit, University Hospital of Zurich, Zurich, Switzerland [2] Unit of Clinical Epidemiology, Ente Ospedaliero Cantonale, Bellinzona, Switzerland [3] Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy Aim Incidence and mortality of traumatic brain injury (TBI) are stagnating in Europe despite centralized and intensified care. A change in epidemiology towards older people with co-‐‑morbidities requires new data about injury mechanisms and prognostic factors. This study aims to describe epidemiology, risk factors and long-‐‑term outcome of moderate to severe TBI-‐‑patients, in particularly in the elderly, in a Swiss trauma center. Methods We analyzed retrospectively 174 adults (≥15 years) with moderate to severe TBI, admitted to the intensive care unit (ICU) of the University Hospital Zurich between January 2012 and June 2015. A length of stay at the ICU (LOS) of at least 48 hours was chosen. Functional outcome, assessed 6 months after TBI with the Glasgow Outcome Scale (GOS), was defined “unfavorable” (<3) or “favorable”(≥ 4). Results Based on age distribution, 3 subgroups were identified with similar gender distribution: <40 (39,6%), 40-‐‑64 (31,6%) and ≥65 (28,8%) years. The elderly group had more diabetes mellitus (p<0.05), cardiovascular diseases (p<0.001) and use of anticoagulants (p<0.01). Alcohol and drug abuse (p<0.05) was more common in the middle-‐‑aged group. Overall, traffic accidents (40%) and falls (37%) were the most common causes of TBI. Indoor-‐‑traumas increased with age (p<0.05). The elderly group had a worse Head-‐‑Abbreviated Injury Scale than the youngest (p<0.05), despite initial Glasgow Coma Scale (GCS) was lower in the youngest group (p<0.05). Injury severity score (ISS), days of mechanical ventilation (MV) and ICU-‐‑LOS didn’t differ between groups. The elderly group received less decompressive craniectomy (p<0.05), monitoring of intracranial pressure (p<0.01), cerebral microdialysis (p<0.01) and brain tissue oxygenation (p<0.01). Overall ICU mortality was 14,9% and did not differ between groups. Six months after TBI 56,9% of all patients had unfavorable outcome and 80.0% within the elderly subgroup (p<0.01). In the multivariate model unfavorable outcome was associated with increasing age (p<0.01) and pupillary abnormalities on scene (p<0.05). Conclusions TBI affects all ages and causes a high rate of death and disability. Age and pupillary abnormalities influence unfavorable outcome. Prevention of falls and traffic accidents could reduce the burden of TBI. Despite same ISS, days of MV, ICU-‐‑ LOS and mortality, the elderly presented a worse long-‐‑term outcome. Management of age-‐‑related diseases represents a challenge to reduce unfavorable outcome References Peeters W et al. Acta Neurochir 2015:157(10):1683. Roozenbeek B et al. Nat Rev Neurol. 2013:9(4):231. Wilson JT et al. J Neurotrauma 1998:15(8):573. Committee on Medical Aspects of Automotive Safety. JAMA 1971:215:277.
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FM10 Donation after cardiac death (DCD): a medical practice with ethical and psychological implications. A pilot study on the feelings experienced by the nursing and medical staff in the adult intensive care unit (ICU) of the Geneva University Hospitals. A Zellweger [1], Y Gasche [1, 2], D Moretti [1], H Majmou [1], C Cedraschi [1, 2, 3] [1] Department of Anesthesiology, Pharmacology and Intensive Care Medicine, Geneva University Hospitals, Geneva, Switzerland [2] Faculty of Medicine, University of Geneva, Geneva, Switzerland [3] Multidisciplinary Pain Centre, Division of Clinical Pharmacology and Toxicology, Geneva, Switzerland Aim DCD is considered a viable solution to reduce organ shortage, but it raises serious ethical and psychological issues that cannot be ignored. Understanding what alters DCD acceptance by ICU caregivers is important to run a sustainable DCD program and to offer an adapted support for the personnel involved. The aim of our research was to shed new light on feelings experienced by caregivers potentially involved in DCD. Methods We conducted an exploratory qualitative study before the introduction of DCD to investigate how ICU caregivers at the Geneva University Hospitals perceive DCD and how they associate this practice to ethical interrogations. Our qualitative study was based on three semi-‐‑structured focus groups with a sample of twenty-‐‑four caregivers (nurses, physicians and care assistants). Results Our analysis of caregivers’ feelings toward DCD showed the presence of various stress factors which are perceived as potential barriers to DCD acceptance. The temporal proximity between therapeutic withdrawal decision and organ donation process introduces a sense of “conflict of duty” in caregivers. Brain death not being central in DCD, traditional landmarks in donation are lost, which makes caregivers uncomfortable with this procedure. Some ICU professionals are afraid of families’ and public’s judgment. Some of them may perceive incoherence between social desirability and individual values. Taking into account all these issues, we can also observe that the majority of caregivers are able to deal with these complexities; they do not reject DCD but on the contrary they made several suggestions which are intended to reduce psychological impact of DCD, such as a desire of objectivity regarding DCD criteria or the training of specialised professionals to achieve DCD process. They stated being in favour of organ donation and in addition, we also observed trust in the DCD program and a high level of support within ICU. Conclusion Our qualitative study highlights major psychological distress induced by DCD, that represents a potential barrier to DCD acceptance in ICU. However, we can also observe that caregivers are able to deal with DCD difficulties by proposing solutions which are intended to reduce its psychological impact. In view of our results, we can consider if the introduction of DCD in the ICU should be accompanied by a program of psychological support to help caregivers dealing with this new and demanding activity. Acknowledgments This study was financially supported by the Department of Anaesthesiology, Pharmacology and Intensive Care Medicine Research Fund. The Geneva University Hospital DCD program is financially supported by the Geneva University Hospitals Private Foundation. We also gratefully acknowledge the support of Dynèle Gautier and also all the adult iICU who has always been highly collaborative.
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FM11 Donation after cardiac death (DCD): a medical practice with ethical and psychological implications. A pilot study on DCD perceptions felt by the nursing and medical staff in adult intensive care unit (ICU) of Geneva University Hospitals and Lausanne University Hospital A Zellweger [1], P Eckert [4], O Karam [5], C Cedraschi [1, 2, 3], D Moretti [1], H Majmou [1], D Carre [4], V Ludwig [4], Y Gasche [1, 2] [1] Department of Anaesthesiology, Pharmacology and Intensive Care Medicine, Geneva University Hospitals, Geneva, Switzerland [2] Faculty of Medicine, University of Geneva, Geneva, Switzerland [3] Multidisciplinary Pain Centre, Division of Clinical Pharmacology and Toxicology, Geneva, Switzerland [4] Adult Intensive Care Unit and burns centre, Lausanne University Hospital Centre, Geneva, Switzerland [5] Pediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland Aim DCD is considered a viable solution to reduce organ shortage, but it raises serious ethical and psychological issues that cannot be ignored. Understanding what alters DCD acceptance by ICU caregivers is important to run a sustainable DCD program and to offer an adapted support for the personnel involved. The aim of our research was to shed new light on feelings experienced by caregivers regarding DCD. Methods We developed a questionnaire which aims to identify caregivers’ opinions concerning DCD. Our survey incorporates a list of questions to examine ethical issues regarding therapy withdrawal and organ donation. The sample includes ICU caregivers (physicians, nurses and care assistants) at the Geneva and Lausanne University Hospitals. Data were collected using LogiIC software and Survey Monkey and then analysed through Statistical Package for Social Sciences -‐‑SPSS V.22.0. In both hospitals, our research was conducted before the introduction of the DCD program. Results 106 ICU professionals responded, 66% nurses, 30% physicians and 4% care assistant. Analysis shows that the most crucial ethical issues concentrated around four main topics. 1) Presence of some doubts concerning the real reasons leading to withdrawal of life support: 42% of respondent think that withdrawal of life support decision was not always taken in the interest of the patient; 2) Satisfactory level of support within ICU during end-‐‑of-‐‑life care: 49% of ICU nurses feel being reasonably well supported and 47% feel rather well or very well supported; 3) Hastening of patient death because of palliative treatments isn’t a main source of concern: in Geneva respondents perceive that this acceleration rather gives them a sense of relieve (52%). Lausanne data also show that 80% of respondent claim that they do not feel any conflict of interest in this context; 4) Independence between the therapeutic withdrawal and the decision to donate is reasonably well preserved: 73% of caregivers do not feel any conflict of interest during DCD procedure. Finally, our survey demonstrate that ICU professional were in favour of organ donation not only in DBD context (97%) but also in DCD (94%). In addition, 70% of caregivers trust in DCD program development. Conclusions The introduction of DCD in the ICU, challenges the ethical values of caregivers. Nevertheless, our findings suggest that caregivers generally embrace DCD as a valid practice for patients who do not fulfil brain death criteria Acknowledgments This study was financially supported by the Department of Anaesthesiology, Pharmacology and Intensive Care Medicine Research Fund. The Geneva University Hospital DCD program is financially supported by the Geneva University Hospitals Private Foundation. We also gratefully acknowledge the support of Dr. Didier Tassaux, MD, PhD; Josette Simon and also all the ICU personnel who has always been highly collaborative
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Freie Mitteilungen Gemeinsam | Communications libres communes FM 012 – FM 16 FM12 Hyperoxia enhances exercise performance in pulmonary arterial and chronic thromboembolic pulmonary hypertension: randomized trial S Ulrich [1], E Hasler [1], S Saxer [1], M Furian [1], S Müller-‐‑Mottet [1], S Keusch [1], KE Bloch [1] [1] Clinic of Pulmonology, University Hospital Zurich, Zürich, Switzerland Background Pulmonary hypertension impairs cardiac output, oxygen delivery and thus exercise capacity. Aims To investigate whether hyperoxia improves exercise performance in patients with pulmonary arterial and chronic thromboembolic pulmonary hypertension (PAH/CTEPH). Methods 22 stable PAH/CTEPH patients (8 women, 61±14y, mPAP 35±10mmHg) underwent 4 bicycle ergospirometries to exhaustion on different days breathing oxygen enriched (FiO2 0.50) or ambient air (FiO2 0.21) and using progressively increased or constant load (75%Wmax, FiO2 0.21) protocols, respectively, according to a randomized, balanced cross-‐‑over design. ECG, pulmonary gas-‐‑exchange, oxygen saturation by pulse oximetry (SpO2), cerebral (CTO) and muscle (MTO) tissue oxygenation by near-‐‑infrared spectroscopy were monitored. Results In progressive ramp tests under FiO2 0.50, maximal work rate, oxygen uptake, SpO2, CTO and MTO exceed values during FiO2 0.21 at end-‐‑exercise (table), while ventilatory equivalent for CO2 and heart rate were reduced at isotime. In constant load tests with FiO2 0.50 endurance was increased by 210±223% vs. FiO2 0.21. Conclusions In patients with PAH/CTEPH, breathing oxygen enriched air increases exercise performance by improving ventilatory efficiency and arterial oxygenation thereby enhancing oxygen availability in muscles and brain. Therefore, hyperoxia holds promise to improve efficacy of exercise training in PAH/CTEPH patients undergoing rehabilitation.
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End of progressive ramp End of constant load FiO2 0.21 FiO2 0.50 FiO2 0.21 FiO2 0.50 Endurance, s 552 ± 111 645 ± 136* 617 ± 440 1257 ± 503*
Work rate, watts 113 ± 38 132 ± 48* 85 ± 29 85 ± 29
V’O2, l/min 1.4±0.4 2.2±0.5* 1.4 ± 0.4 1.8 ± 0.5*
Heart rate, 1/min 130±18 137±21* 138 ± 17 132 ± 16
V‘E, l/min 62±17 65±18* 65 ± 19 60 ± 14
V’E/V’CO2 41±9 37±7* 46 ± 9 40 ± 7*
SpO2, % 90±6 98±2* 89 ± 7 99 ± 1*
CTO, % 61±9 71±7* 62 ± 9 69 ± 8*
MTO, % 61±8 65±11* 61 ± 9 66 ± 10*
Borg CR10, dyspnea 6 ± 2 5 ± 2 6 ± 2 4±2*
Mean±SD values during final 30 sec of exercise; * P<0.05 vs. FiO2 0.21; V’O2: oxygen uptake; V’E: minute ventilation; V’E/V’CO2: ventilatory equivalent for CO2; SpO2, CTO and MTO: arterial, cerebral and muscle tissue oxygenation End of progressive ramp End of constant load FiO2 0.21 FiO2 0.50 FiO2 0.21 FiO2 0.50 Endurance, s 552 ± 111 645 ± 136* 617 ± 440 1257 ±
503* Work rate, watts 113 ± 38 132 ± 48* 85 ± 29 85 ± 29 V’O2, l/min 1.4±0.4 2.2±0.5* 1.4 ± 0.4 1.8 ± 0.5* Heart rate, 1/min 130±18 137±21* 138 ± 17 132 ± 16 V‘E, l/min 62±17 65±18* 65 ± 19 60 ± 14 V’E/V’CO2 41±9 37±7* 46 ± 9 40 ± 7* SpO2, % 90±6 98±2* 89 ± 7 99 ± 1* CTO, % 61±9 71±7* 62 ± 9 69 ± 8* MTO, % 61±8 65±11* 61 ± 9 66 ± 10* Borg CR10, dyspnea 6 ± 2 5 ± 2 6 ± 2 4±2* Mean±SD values during final 30 sec of exercise; * P<0.05 vs. FiO2 0.21; V’O2: oxygen uptake; V’E: minute ventilation; V’E/V’CO2: ventilatory equivalent for CO2; SpO2, CTO and MTO: arterial, cerebral and muscle tissue oxygenation
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FM13 Dexamethasone reduces pulmonary artery pressure in lowlanders with COPD travelling to 3200m. Randomized, placebo-‐‑controlled trial. M Lichtblau [1], M Furian [1], S Aeschbacher [1], M Bisang [1], S Hartmann [2], St Ulrich [1], T Latshang [1], A Aldashev [3], E Mirrakhimov [4], T Soronbaev [4], KE Bloch [1], S Ulrich [1] [1] Pulmonary Division and Sleep Disorders Center, University Hospital of Zurich, Zurich, Switzerland [2] Departments of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada [3] Research Institute for Molecular Biology and Medicine, Bishkek, Kyrgyzstan [4] National Centers for Cardiology and Internal Medicine, Bishkek, Kyrgyzstan Background COPD is associated with increased pulmonary artery pressure (PAP) at lowlands and affected patients may be at risk of symptomatic pulmonary hypertension when travelling to altitude. Since dexamethasone prevents pulmonary edema due to excessive rise of PAP in susceptible subjects at high altitude1 we performed a randomized, placebo-‐‑controlled trial evaluating the hypothesis that preventive treatment with dexamethasone mitigates the altitude-‐‑induced PAP rise in COPD patients. Methods Consecutive non-‐‑hypoxemic patients with COPD Gold grade 1-‐‑2 living below 800m, SpO2 >93%, in stable condition were invited to participate in the trial. Participants were randomized to receive dexamethasone (4mg tablets, bid) or placebo one day before ascent from Bishkek (760m) and during a 3-‐‑stay sojourn at Tuja Ashu high altitude clinic (3200m), Kyrgyz Republic. Echocardiography was performed at 760m and after the first night at 3200m. The main outcome was the tricuspid pressure gradient (TPG). Results: 109 patients were randomized (mean±SD age 56±9, BMI 26±4 kg/m2, FEV1 89±21%pred, SpO2 95±2%). The TPG and systolic PAP increased from 760 to 3200m, dexamethasone mitigated the altitude-‐‑induced increase in TPG vs. placebo while the increase in cardiac output mediated by both a higher heart rate and stroke volume was similar with dexamethasone and placebo. The more moderate increase in TPG with dexamethasone was associated with a higher oxygen saturation (SpO2) at peak walk test. Regression analysis confirmed that dexamethasone was associated with a reduced altitude-‐‑induced increase in TPG even when controlled for age and COPD-‐‑severity reflected by FEV1%pred (R2=0.58, P=0.02). Conclusion In lowlanders with COPD, GOLD grade 1-‐‑2, travelling to 3200m induces mild pulmonary hypertension. Dexamethasone mitigates this altitude-‐‑induced increase in PAP while maintaining cardiac output with a favorable effect on the pressure/flow ratio at rest and on oxygenation during exercise. Reference Maggiorini M, Brunner-‐‑La Rocca HP, Peth S, Fischler M, Bohm T, Bernheim A, Kiencke S, Bloch KE, Dehnert C, Naeije R, Lehmann T, Bartsch P, Mairbaurl H. Both tadalafil and dexamethasone may reduce the incidence of high-‐‑altitude pulmonary edema: a randomized trial. Ann Intern Med 2006;145(7):497-‐‑506. Dexamethasone (n=58) Placebo (n=51) Treatment effect Bishkek
(760m) Tuja Ashu (3200m)
Bishkek (760m)
Tuja Ashu (3200m)
TPG, mmHg 18 ± 5 26 ± 6* 20 ± 5 31 ± 9* 4 (2; 7) ## Systolic PAP, mmHg 31 ± 6 39 ± 8* 32 ± 6 45 ± 11* -‐‑5 (-‐‑8; -‐‑1) ## HR, bpm 67 ± 9 77 ± 11* 69 ± 9 73 ± 10* -‐2.2 (-‐6.4; 2.0)# SV, ml 71 ± 12 80 ± 12** 73 ± 12 77 ± 12** 4.4 (-‐0.2; 9.0) CO, l/min 4.7 ± 0.9 5.7 ± 1.0** 4.9 ± 0.7 5.7 ± 1.1** 0.1 (-‐0.3; 0.6) Pressure/Flow ratio, mmHg/l/m
4.0 ± 1.2 4.6 ± 1.1** 4.1 ± 1.1 5.6 ± 1.6 -‐1.0 (-‐1.5; -‐0.5) ##
6 MWT, m 500 ± 76 486 ± 93 502 ± 77 483 ± 84 -‐20.0 (-‐42.4; 2.4) SpO2 peak walk, % 95.0 ± 1.5 87.9 ± 3.1* 95.0 ± 2.5 85.1 ± 4.2* 2.9 (1.5;4.3) # TPG = tricuspid pressure gradient, PAP = pulmonary artery pressure, HR = heart rate, SV = stroke volume, CO = cardiac output, 6MWD = 6 minute walk distance, * p<.05 resp. **<.01 altitude vs. lowland, #p<.05, ##p<.01 dexamethasone vs. placebo
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FM14 Effect of Diagnosis Related Groups Implementation on the Intensive Care Unit of a Swiss Tertiary Hospital: a Cohort Study L Chok [1], E Bachli [2], P Steiger [1], D Bettex [1], S Cottini [1], E Keller [1], M Maggiorini [1], R A Schuepbach [1] [1] University Hosptial Zurich, Zurich, Switzerland [2] Hospital Uster, Uster, Switzerland Background In 2013 the Swiss Diagnosis Related Groups ((Swiss)-‐‑DRG)) was implemented in Intensive Care Units (ICU). Its impact on hospitalizations has not yet been thoroughly examined. We compared the number of ICU admissions according to clinical severity and referring institution, screened whether implementation of SwissDRG affected admission policy, ICU length-‐‑of-‐‑stay (LOS) or ICU mortality. Methods Retrospective single center cohort study conducted at the University Hospital Zurich, Switzerland between January 2009 and end of 2013. Demographic and clinical data were retrieved from a quality assurance data base. Results Admissions (17231) before introduction of SwissDRG were used to model expected admissions after DRG and compared to admissions observed. Forecasting matched observations in patients with a high clinical severity admitted from internal units and external hospitals (admitted / predicted: 709 / 703, [95% CI, 658-‐‑748] and 302 / 332, [95% CI, 269-‐‑365] respectively). In low severity of disease patients in-‐‑house admissions become more frequent than expected whereas external admission were less frequent (admitted / predicted: 1972 / 1910, [95% CI, 1898-‐‑1940] and 436 / 518, [95% CI, 482-‐‑554] respectively). In regard to LOS and ICU mortality DRG could not be linked to make significant changes. Conclusions DRG introduction had not affected ICU admissions policy, except for an increase of in-‐‑house patients with a low clinical severity of disease. DRG had neither affect ICU mortality nor ICU LOS.
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FM15 An acetate buffered crystalloid solute versus 0.9% saline and hemodynamic stability in patients receiving renal transplantation: a prospective, randomized, controlled trial CA Pfortmueller [1, 2], GC Funk [3], E Potura [2], C Reitere [2], F Luf [2], B Kabon [2], W Druml [4], E Fleischmann [2], G Lindner [5] [1] Department of Intensive Care Medicine, Bern University Hospital, Bern, Switzerland [2] Department of General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria [3] Department of Respiratory and Critical Care Medicine, Otto Wagner Hospital Vienna and Ludwig-‐‑Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria [4] Department of Nephrology, Medical University of Vienna, Vienna, Austria [5] Department of Emergency Medicine, Hirslanden – Klinik Im Park, Zurich, Switzerland Background Infusion therapy is one of the most often prescribed medications in hospitalized patients. Currently used crystalloid solutes have a variable composition and may therefore influence acid-‐‑base status, intra-‐‑ and extracellular water content and plasma electrolyte compositions and have a major impact on organ function and outcome. The aim of our study was to investigate whether use of acetate based balanced crystalloids leads to better hemodynamic stability compared to 0.9% saline. Methods We performed a subanalysis of a prospective, randomized, controlled trial comparing effects of 0.9% saline or an acetate-‐‑buffered, balanced crystalloid during the perioperative period in patients with end-‐‑stage renal disease undergoing cadaveric renal transplantation. Need for catecholamine therapy and blood pressure were the primary measures. Results A total of 150 patients were included in the study. 76 were randomized to 0.9% saline while 74 received an acetate-‐‑buffered balanced crystalloid. Noradrenaline for cardiocirculatory support during surgery was significantly more often administered in the normal saline group, given earlier and with a higher cumulative dose compared to patients receiving an acetate-‐‑buffered balanced crystalloid (30% versus 15%, p=0.027; 68 ±45 versus 75 ±60, p= 0.0055; respectively 0.000492 mcg/kgBW/min, ±0.002311 versus 0.000107mcg/kgBW/min, ±0.00039, p=0.04). Mean minimum arterial blood pressure was significantly lower in patients randomized to 0.9% saline than in patients receiving the balanced infusion solution (57.2 [SD 8.7] versus 60.3 [SD 10.2] mmHg; p=0.024). Conclusions The use of an acetate-‐‑buffered, balanced infusion solution results in reduced need for use of catecholamines and cumulative catecholamine dose for hemodynamic support and in less occurrence of arterial hypotension in the perioperative period. Further research in the field is strongly encouraged.
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FM16 Influence of nutritional parameters on clinical outcomes in patients with acute myeloid leukemia undergoing hematopoietic stem cell transplantation A Baumgartner [1], N Zueger [1, 3], A Bargetzi [1, 3], Z Stanga [2], M Bargetzi [1], B Mueller [1], P Schuetz [1] [1] Kantonsspital Aarau, Aarau, Switzerland [2] Inselspital, Bern, Switzerland [3] Universtitätsspital Basel, Basel, Switzerland Introduction In acute myeloid leukemia (AML) patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT), there is uncertainty about the influence of nutritional parameters on clinical outcomes. Herein, we investigated associations of initial body mass index (BMI) and weight loss during HSCT on clinical outcomes in a well-‐‑characterised cohort of AML patients. Methods We analysed data of the Basel stem-‐‑cell transplantation registry (KMT Kohorte) including all patients with AML undergoing first allogeneic HSCT from 01/2003 to 01/2014. We used multivariable regression models adjusted for prognostic indicators (European Group for Blood and Marrow Transplantation (EBMT) risk score and cytogenetics). Results Mortality in the 156 AML patients (46% female, mean age 46 years) over the 10-‐‑years of follow-‐‑up was 57%. Compared to patients with a baseline BMI (kg/m2) of 20-‐‑25, a low BMI<20 was associated with higher long-‐‑term mortality (70% vs 49%, adjusted hazard ratio (HR) 1.97 (95%CI 1.04 to 3.71), p=0.036). A more pronounced weight loss during HSCT (>7% vs. <2%) was associated with higher risk for bacterial infections (52% vs 28%, odds ratio (OR) 2.8 (95%CI 0.96 to 8.18), p=0.059) and fungal infections (48% vs 23%, OR 3.37 (95%CI 1.11 to 10.19), p=0.032), and longer hospital stays (64 vs 38 days, adjusted mean difference 25.6 days (15.7 to 35.5), p<0.001). Conclusion In patients with AML, low initial BMI and a more pronounced weight loss during HSCT are strong prognostic indicators associated with lower survival and worse disease outcomes. Intervention research is needed to investigate whether nutritional therapy can reverse these associations.
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Beste Arbeiten Nachdiplomstudium Intensivpflege | Meilleures travaux de diplôme des Etudes post-‐‑diplôme en soins intensifs D01 Prévention de la douleur induite aux Soins Intensifs de Pédiatrie par l’hypnoanalgésie C Tournaire [1] [1] Soins Intensifs de Pédiatrie et de Néonatologie -‐‑ Hôpitaux Universitaires de Genève Contexte La douleur induite est omniprésente dans les contextes de soins aigus. Les données épidémiologiques montrent que les patients y sont confrontés au quotidien. De nombreux moyens pharmacologiques existent et sont utilisés. Une insatisfaction demeure particulièrement dans un milieu de soins pédiatriques. Considérant les alternatives thérapeutiques non-‐‑pharmacologiques existantes, je me suis demandée dans quelle mesure l’hypnoanalgésie a-‐‑t-‐‑elle sa place pour prévenir la douleur induite aux Soins Intensifs de Pédiatrie chez l’enfant sans assistance respiratoire. Méthode Ma recherche documentaire est orientée vers trois concepts: les soins intensifs, la douleur induite, l’hypnose. Des ouvrages spécifiques à l’hypnose et la pédiatrie ainsi que des articles entre 1997 et 2014 ont étayé cette investigation. Les recommandations et référentiels de différentes Sociétés Savantes ont été exploités. Les bases de données essentiellement utilisées sont PubMed et Science Direct. La synthèse d’un entretien d’expert permet d’apporter les applications, la mise en pratique et les limites de l’hypnose. Résultats L’hypnose agit sur la composante sensorielle et émotionnelle de la douleur, en modulant son intensité. Des études par imagerie ont prouvé son action sur une partie précise du cerveau. La pharmacologie seule ne peut l’atteindre. Cette méthode apparaît comme une technique complémentaire, parfaitement adaptée à l’enfant qui possède une grande capacité à s’évader dans son imaginaire. L’enfant est replacé au centre de sa prise en charge, accompagné par ses parents et les soignants. Le rôle propre de l’infirmier(e) prend toute sa dimension, en développant une communication optimale, une relation d’aide et de l’empathie, dans un contexte de Soins Intensifs. Conclusion Ainsi deux axes prioritaires se dégagent. Il s’agira de sensibiliser les soignants au choix des mots lors de soins douloureux, et aux principes d’une communication « thérapeutique » et d’optimiser la prise en charge de la douleur induite, gage de la qualité des soins, par l’intermédiaire d’un projet de déploiement des techniques d’hypnoanalgésie à l’hôpital des enfants et plus particulièrement aux soins intensifs de pédiatrie. Cela implique du dialogue avec les professionnels médicaux et infirmiers pour expliquer et créer de l’adhésion, ainsi que de la formation en hypnoanalgésie pour permettre la généralisation de cette pratique.
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D02 Angehörige auf der Intensivstation – Bedeutung, Belastungen und Bedürfnisse der Angehörigen N Bustamante [1] [1] Kantonsspital St. Gallen, St. Gallen, Switzerland Auf die Intensivstation treten Patienten mit schweren bis lebensbedrohlichen Erkrankungen ein, die intensivmedizinisch überwacht und therapiert werden. Der Fokus aller Disziplinen richtet sich dabei hauptsächlich dem Wohlergehen des Patienten. Die kritische Erkrankung bedeutet aber nicht nur eine Bedrohung für den Patienten selbst, sondern für das gesamte Familiensystem. Eine Aufnahme auf die Intensivstation löst bei Angehörigen Gefühle von Angst, Unsicherheit und Hilflosigkeit aus. Wie sie die schwere Zeit erleben ist sehr individuell. Jeder reagiert anders darauf und fordert daher die Pflegefachperson in unterschiedlichster Weise. Gelegentlich werden Angehörige zudem als zusätzliche Belastung im ohnehin schon strengen Alltag angesehen. Zu Beginn der Diplomarbeit wird eine konkrete Situation beschrieben, die mir meine eigene Unsicherheit im Umgang mit Angehörigen verdeutlicht. Sie motivierte mich dazu, mich differenziert mit der Lage und Perspektive der Angehörigen auseinander zu setzen. Aufgrund der beschriebenen Situation, Ausgangslage sowie zuvor formulierten Arbeitshypothese leitete ich folgende Fragestellungen ab: Welche Bedeutung haben Angehörige für den Patienten? Worin liegen die Bedürfnisse der Angehörigen von Intensivpatienten? Wie könne Angehörige durch Pflegefachpersonen unterstützt werden? Zur Erstellung der Arbeit wurde eine breite Literaturrecherche in Fachbüchern und Fachzeitschriften durchgeführt sowie Studien in deutscher Sprache integriert. Ein Praxistransfer ermöglicht es, die empfohlenen Massnahmen auf deren Durchführung zu evaluieren und kritisch auf deren Machbarkeit zu hinterfragen. Die Arbeit gibt Einblick in Erfahrungen, die Patienten mit Besuchen machen und trägt dazu bei, ein Verständnis dafür zu schaffen, warum vertrauten Personen eine grosse Bedeutung zukommt. Um Angehörige angemessen zu unterstützen, ist es zentral, ihre Bedürfnisse zu kennen. Nähe, Zusicherung und Information gehören dabei zu den wesentlichen Anliegen. Konkrete Massnahmen zur Unterstützung der Angehörigen werden anhand einer Behandlungssituation oder Krisensituation erklärt. Bereits die Erkenntnis über die Bedeutung, Belastungen und Bedürfnisse der Angehörigen hilft im Umgang mit ihnen. Sie lässt die Pflegefachperson dadurch häufig instinktiv richtig handeln. Zudem zeigt die Überprüfung der empfohlenen Unterstützungsmassnahmen, dass sie durchaus in der Praxis anwendbar sind.
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D03 Libéralisation des horaires de visites aux SIA : Quels sont les impacts sur les soignants? AL Roussel/Rohee [1] [1] HUG centre de formation, Genève, Switzerland Contexte La présence des familles au chevet du patient peut être difficile à accepter pour les soignants. De plus en plus sensibilisé à l’intérêt bénéfique de la famille sur le patient, le soignant doit intégrer cette donnée dans la prise en charge globale. Mais dans un environnement « hyper-‐‑technique », la présence permanente des familles peut-‐‑elle entrainer des difficultés pour le soignant ? Méthode 8 articles et un livre spécifiques aux politiques de visites des SIA détaillant les expériences des soignants ont été retenus. Pour compléter la réflexion, un entretien d’expert et l’observation d’un service « ouvert », ont été effectués. Résultats Les études démontrent des disparités concernant les ressentis des soignants. Pour certains, la présence régulière des familles perturbe ; ils décrivent un manque de formation en communication, une contrainte dans l’exécution des soins. Pour d’autres, l’ouverture 24h/24h apporte un bénéfice aux patients sans réel profit pour les proches ou le soignant. Enfin, certains voient dans la libéralisation des horaires de visites, des bienfaits. Une relation de confiance améliorée au sein de la triade proches / soignants / patients, ainsi que la diminution de l’anxiété des familles, apportent au soignant un environnement de travail plus calme et moins stressant. Pour les institutions qui ont laissé le choix des horaires de visites aux proches, une nette amélioration des relations proches-‐‑soignants a été identifiée. Pour ces services, le retour en arrière sur des restrictions d’horaires parait inconcevable… Discussion Il a été identifié l’importance d’une méthodologie pour mener à bien un projet d’ouverture 24h/24h. Il faut rassurer les équipes par la mise en place d’outils, de méthode. Il faut prendre en considération leurs expériences, leurs avis et leurs doutes concernant le changement de politique de visite tout en plaçant le patient au centre de la démarche. Conclusion Dans le principe de bien évaluer pour bien évoluer, l’objectif est de proposer, après une présentation des résultats du travail à l’équipe, et une enquête auprès des soignants, la constitution d’un « groupe projet » au sein des SIA des hôpitaux universitaires de Genève. La libéralisation des horaires de visites pourrait alors ne plus être seulement un sujet de mémoire, mais plutôt un vrai projet d’équipe pour l’amélioration globale de la qualité de soin.
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D04 Weaningprotokolle – Ein "must" oder nur "nice to have"? M Reinitzer [1] [1] Universitätsspital Basel, Basel, Switzerland Einleitung Als Studierender und Neuling auf einer Intensivstation (IS) stand ich vor der Herausforderung, wie man im Arbeitsalltag die relevanten Strategien, Kriterien und Standards rund um intubierte und beatmete Patienten schnell und übersichtlich zur Verfügung haben kann. Im Zusammenhang mit dieser Lernfrage habe ich von anderen Studierenden erfahren, dass einige IS Weaningprotokolle (WP) verwenden. Weiter zeigte sich, dass Pflegende unterschiedliche Rollen und Kompetenzen im Zusammenhang mit der Beatmungsentwöhnung haben. Aus diesem Grund habe ich mich im Rahmen der Diplomarbeit mit der Frage befasst, ob ein systematisches bzw. protokollgestütztes Vorgehen bei der Beatmungsentwöhnung einen Vorteil in Bezug auf die Outcomefakoren Gesamtbeatmungsdauer, Dauer des Weaningprozess, Aufenthaltsdauer auf der IS, Gesamtaufenthaltsdauer im Spital, erfolgreiche Extubation, Reintubationsrate, Pneumonierate und Mortalität hat. Fragestellung Gibt es Evidenz, welche belegt, dass sich das Patientenoutcome signifikant verbessert, wenn ein WP eingesetzt wird? Methode/Design Fokussierte Literaturarbeit Resultate und Schlussfolgerungen/Empfehlungen Trotz uneinheitlicher Definitionen, Kriterien und einer heterogenen Weaningpraxis zeigt sich, dass das systematische Vorgehen bei der Beatmungsentwöhnung mit einem WP einen Vorteil in Bezug auf die definierten Outcomefaktoren haben kann. Eine generelle Aussage über den potentiellen Nutzen eines WP ist jedoch schwierig, da die einzelnen Studien teils unterschiedlich aufgebaut sind und die institutionsspezifischen Gegebenheiten und Einflussfaktoren welche die Outcomefaktoren beeinflussen können, nicht ausreichend beschrieben werden. Das systematische Vorgehen im Weaningprozess kann die Aufmerksamkeit der Beteiligten erhöhen. Cheklisten und Protokolle können unerfahrenen helfen alle relevanten Punkte im Weanigprozess zu berücksichtigen und können bei hoher Arbeitsbelastung eine wertvolle Gedankenstütze sein. Intubierte und beatmete Patienten lassen sich im Hinblick auf die Beatmungsentwöhnung in drei Kategorien unterteilen. In der Kategorie 1 (einfach) empfiehlt sich eine Weaning-‐‑Checkliste. In den Kategorien 2 (schwierig) und 3 (prolongiert) kann der Einsatz eines WP geprüft werden. Standardisierte pflegerische Massnahmen-‐‑Bündel zeigen eine deutliche Verbesserung des Patientenoutcomes. Deshalb sollte deren Berücksichtigung bei WP und Cheklisten diskutiert werden. Quellen Blackwood, B., Burns, KEA., Cardwell, CR. & O’Halloran, P. (2014). Protocolized versus non-‐‑protocolized weaning for
reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database of Systematic Reviews 2014, Issue11, Art. No.: CD006904. DOI: 10.1002/14651858.CD006904.pub3.
Braun, J.-‐‑P. (2014). Protokolle in der Intensivmedizin – Sinnvolle Hilfe oder zusätzliche Last. In: Deutsche Akademie für Anästhesiologische Fortbildung (Hrsg.), Aktuelles Wissen für Anästhesisten, Refresher Course Nr. 40. Ebelsbach: Aktiv Druck & Verlag GmbH, (S. 101-‐‑107).
Moerer, O. (2013). Respiratorentwöhnung – Welche Verfahren sind geeignet? AINS – Anästhesiologie – Intensivmedizin – Notfallmedizin – Schmerztherapie, 48, 640-‐‑646.
Sunder, K. (2014). Evidenzbasierte Pflege «Rund um maschinell beatmete Patienten». Unterrichtsunterlagen. Modul IP 4. Nachdiplomstudiengang HF Intensivpflege, Universitätsspital Basel.
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D05 Vom Warteplatz bis zum Intensivpflegebett Erstkontakt mit Angehörigen von lebensbedrohlich erkrankten/ verletzten Intensivpatienten D Nussbaumer [1] [1] Universitätsspital Zürich, Zürich, Switzerland Einleitung Auf Intensivstationen werden Patienten in lebensbedrohlichen Situationen betreut. Den Erstkontakt mit den Angehörigen wird durch die Pflegenden zusätzlich durchgeführt, was eine optimale Angehörigen-‐‑betreuung erschwert. Fragestellung Wie gestalte ich den Erstkontakt mit Angehörigen von lebensbedrohlich erkrankten/ verletzten Patienten, um meinen Bedürfnissen und deren der Angehörigen gerecht zu werden? Wie überwinde ich meine Unsicherheit, in den ersten Sekunden, beim Erstkontakt mit Angehörigen von lebensbedrohlich erkrankten/ verletzten Intensivpatienten? Methodik Diese Arbeit beruht auf aktueller Literatur und ist mit einem Praxisbeispiel ergänzt, um die wichtigsten Aspekte aufzuzeigen. Ergebnisse Die Ausgangslage, in welcher sich die Angehörigen befinden, wird als Ausnahmesituation oder Krisensituation beschrieben. Hier herrschen Gefühle wie Stress, Angst und Unsicherheit vor. Pflegende müssen davon ausgehen, dass Angehörige völlig unvorbereitet auf der Intensivstation eintreffen. Das Warten ist für die Angehörigen eine Qual. Um diese Wartezeit zu überbrücken, sollten Angehörige regelmässig über die aktuelle Situation informiert werden. Der Erstkontakt ist hier von sehr grosser Bedeutung um eine vertrauensvolle Beziehung zwischen den Angehörigen und Pflegenden zu schaffen. Die Anwesenheit von Angehörigen am Intensivpflegebett wird von Pflegenden oft als störend, anstrengend und nervend empfunden. Hier sind die Pflegenden einer Doppelbelastung ausgesetzt und können dieser nur bedingt nachkommen. Schlussfolgerung Die Literatur geht davon aus, dass die Pflegenden die Zeit haben ihre volle Aufmerksamkeit den Angehörigen zu widmen. In der Realität müssen Pflegende jedoch den Erstkontakt neben der Betreuung eines Intensivpatienten durchführen. Hier gibt es zwei mögliche Varianten, um meinen Bedürfnissen und denen der Angehörigen nachzukommen. Bei der ersten Variante werden die Angehörigen zeitnah zum Eintreffen begrüsst und an das Bett begleitet. Sie dürfen kurz bleiben und werden danach wieder hinausgebeten, damit sich die Pflege uneingeschränkt dem Patienten widmen kann. Bei der zweiten Variante wird bei fehlender Kapazität seitens Pflegenden, das Care Team als Betreuungsteam für die Angehörigen hinzugezogen. Beide Varianten tragen zu einer optimalen Angehörigen-‐‑ und Patienten-‐‑betreuung bei.
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ePosters P01 Comment améliorer l’observance des mesures spécifiques contacts à travers un visuel de rappel ? F Dumoulin [1] [1] Hôpitaux Universitaires de Genève (HUG) Contexte et objet de réflexion Le non respect des mesures spécifiques contact (MSC) et des désaccords concernant l’emploi de la signalétique de rappel utilisée en situation de soins ont été les facteurs déclenchant de mon questionnement et de ma recherche documentaire. L’identification des critères de qualité des visuels de rappel ainsi que les éléments d’aide à la sensibilisation des soignants au pied du lit pour le respect des MSC ont été des objectifs prioritaires de ce travail. Méthode de la recherche documentaire Trois axes de recherche ont pu être dégagés : les MSC, les conséquences d’un écart aux MSC, et les recommandations quant au visuel de rappel pour diffuser les messages et favoriser l’adhésion aux mesures. J’ai recherché ces trois thèmes dans chacune des parties de mon travail : la recherche exploratrice, la recherche documentaire (six articles), deux entretiens d’expert, avec un spécialiste de la prévention de l’infection et avec une graphiste experte dans les visuels, afin de tout mettre en discussion. Résultats Les MSC sont définies par un organisme de référence, les «Centers of Disease Contrôle » (CDC). Elles sont comparativement assez semblables dans les différents pays, sauf en ce qui concerne les indications de leur mise en place. Les écarts des MSC sont mesurés de façon individuelle, n’ont pas d’impacts visibles, et sont peu documentés dans la littérature. Cependant trois catégories de conséquences reviennent dans ma recherche documentaire et sont complétées lors de mon entretien d’expert : les conséquences sur le patient, sur les autres patients et sur le soignant. Les freins comportementaux au respect des MSC, eux sont bien décrits et sont un guide pour comprendre pourquoi nous ne respectons pas ces mesures. Il n’existe pas de manuel de la signalétique mais la couleur, la forme, la taille, l’emplacement du visuel de rappel sont des critères à essayer d’assembler afin d’obtenir un message fort et efficace.
Propositions d’améliorations L’axe prioritaire d’amélioration est la signalétique :
- l’emplacement unique - le contraste des couleurs - la couleur - la forme du support - les écrits et pictrogrammes - et les mesures spécifiques qui nécessitent une prise de conscience particulière (selon le germe
associé).
Expliquer les raisons d’un changement de signalétique aux collaborateurs, et mettre en visibilité les conséquences encourues lors du non respect des MSC.
Former les équipes soignantes à l’utilisation des nouveaux visuels de rappel afin de favoriser l’adhésion de l’équipe soignante à ce projet.
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P02 45 plus − «Wir sind doch die Zukunft!» Erleben des Arbeitsalltags von Pflegenden auf der Intensivstation: eine qualitative Studie C Karde [1], R Spirig [1], D Bettex [1] [1] Universität Basel, Basel, Switzerland [2] Universitätsspital Zürich, Zürich, Switzerland Abstract ICU nurses over the age of 45 are an important resource for the future of healthcare services. This qualitative study investigated how ICU nurses experience daily nursing practice at the University Hospital Zurich and identified possible support. Interviews with twelve ICU nurses were interpreted using qualitative content analysis. The results revealed a fundamental tension between nurses’ personal expectations and the demands from their work environment. Nurses perceived aging as a natural part of life but were fearful about the reduction of their physical endurance and uncertain about future job security. They wished to see their employers to address the topic of aging. The study showed that nurses increasingly expect support from their employers in order to meet the workload requirements in intensive care inspite of increasing age. Key words ICU nurses over 45 years of age, Intensive Care Unit (ICU), work environment, qualitative research Zusammenfassung Intensivpflegende im Alter ab 45 Jahren stellen eine wichtige Ressource der zukünftigen Gesundheits-‐‑versorgung dar. Diese qualitative Studie untersuchte das Erleben des Arbeits-‐‑alltags von Pflegenden ab 45 Jahren auf den Intensivstationen des Universitätsspitals Zürich und explorierte Unterstützungs-‐‑möglichkeiten. Inhaltsanalytisch ausgewertete Einzel-‐‑interviews mit zwölf Intensivpflegenden zeigten ein Spannungsfeld zwischen dem eigenen Anspruch der Pflegenden und den Anforderungen ihrer Arbeitsumgebung. Das Älterwerden beschrieben die Befragten als zum Lebenszyklus gehörig. Jedoch bestanden Ängste hinsichtlich der geringeren körperlichen Belastbarkeit und der Arbeitszukunft. Der Wunsch nach Thematisierung des Altersaspektes durch den Arbeitgeber war groß. Die Ergebnisse machen deutlich, dass Pflegende vermehrt Unterstützung durch ihren Arbeitgeber erwarten, um auch zukünftig professionell pflegen zu können und den Arbeitsbedingungen mit zunehmendem Alter weiterhin gewachsen zu sein.
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P03 Pflegerische Betreuung von Patienten mit ECMO / ECLS -‐‑ Verfahren –Gewährleistung der Patientensicherheit durch strukturierte Einführung und Begleitung C Keim [1] [1] Universitätsspital Zürich, Zürich, Switzerland Ausgangslage Im Intensivpflegebereich des UniversitätsSpitals Zürich (USZ) wurden im Jahr 2015 117 Patienten mit einem Extracorporeal Membrane Oxygenation oder Extracorporeal Life Support -‐‑ Verfahren (ECMO / ECLS) betreut. Die Anwendung dieses Therapieverfahrens ist anspruchsvoll und mit potentiellen Gefahren verbunden, zum Beispiel Kanülendislokationen. Intensivpflegende dürfen diese Patienten frühestens sechs Monate nach Stellenantritt sowie nach erfolgter theoretischer und praktischer Einführung selbstständig betreuen. Durch Personalwechsel müssen Wissen und Können auf dem aktuellen Stand gehalten werden, um die Patientensicherheit jederzeit gewährleisten zu können. Ziel Es werden Rahmenbedingungen geschaffen, die durch eine professionelle Arbeitsweise der Intensiv-‐‑pflegenden höchste Patientensicherheit gewährleisten. Methode Vorstellung des ECMO / ECLS -‐‑ Konzeptes für die Einarbeitung und nachfolgende Begleitung der Intensivpflegenden am USZ. Ergebnisse Das Konzept umfasst theoretische und praktische Schulungen im interdisziplinären Setting von Intensivpflege und Kardiotechnik. Dabei beziehen sich die theoretischen Inhalte auf die Pathophysiologie von Herz, Lunge und das Gerinnungssystem. In einer praktischen Sequenz besteht die Möglichkeit, das Gerät mit allen Funktionen kennenzulernen und Notfallsituationen zu üben. Erst anschliessend erfolgt eine klinische Einführung der Intensivpflegenden am Patientenbett. Im Spitalalltag stehen dem interdisziplinären Team ein Standard Operation Procedere (SOP) mit definierten Verantwortlichkeiten, Checklisten und Merkblätter, zum Bespiel für das Ausmessen und die Bilddokumentation der Kanülenlage, zur Verfügung. Diskussion/Schlussfolgerung Die Kombination von Theorie-‐‑ und Praxistag zur Einführung hat sich bewährt. Damit sollen die Fachkompetenz und das interdisziplinäre Arbeiten der Intensivpflegenden weiter gefestigt werden. Klar definierte Rollen und Aufgaben in der Betreuung dieser komplexen, zum Teil wachen Patienten geben Pflegenden Transparenz und Sicherheitsgefühl, welches sich auf die Patientensicherheit auswirkt. Rückmeldungen aus dem Team bestätigen dies. Für die Zukunft sind ergänzende Refresher -‐‑ Veranstaltungen geplant, um gezielt Fragen zu beantworten und Problemstellungen zu diskutieren.
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P04 Praktische Umsetzung der Bezugspflege auf der Intensivstation Eine Analyse mit dem REPVAD – Modell* *REPVAD steht für: Reasoning, Evidence, Procedures, Values, Attitudes, Defense J Maier [1], E Liem [1], D Knuppe [1], I Penker [1] [1] UniversitätsSpital, Zürich, Switzerland Hintergrund Vor sechs Jahren wurde auf den Intensivstationen im USZ die Bezugspflege eingeführt und kurz darauf evaluiert. Ein Konzept wurde erstellt, in dem die wichtigsten Punkte verbindlich festgehalten sind. In der Praxis ist jedoch zu beobachten, dass das Bezugspflegekonzept nicht oder nur teilweise umgesetzt wird. Die Gründe sind sehr vielschichtig und betreffen mehrere Ebenen: Personalmangel, Skill-‐‑Grade-‐‑Mix, verschiedene Prioritäten in der Zuteilung der Patienten (Studierende, Einführungen, hochspezialisierte Geräte, kurzfristige Schichtwechsel, etc.): Eine nicht nutzerfreundliche Pflegeprozessdokumentation und mangelndes Wissen darüber hemmt Pflegefachpersonen, sich als Bezugspflegende einzutragen. Die „Überwachung“ der Zuteilung von Bezugspflege durch Kaderpersonen findet selten statt. Eine kürzlich durchgeführte Evaluation ergab zudem, dass nur knapp die Hälfte der Patienten und Patienten eine Bezugspflegeperson zugeteilt hatten und dass diese nicht kontinuierlich „ihre“ Patienten/Patientinnen betreut hatten. Ziel Optimale Umsetzung des Bezugspflegekonzeptes auf der Intensivstation. Methode/Massnahmen Analyse mit dem REPVAD – Modell und Erstellung eines Massnahmenplans in einer Arbeitsgruppe aus zwei Pflegeexperten, einer Abteilungsleitung und einer Bildungsverantwortlichen. Der Austausch über die einzelnen Schritte des REPVAD -‐‑ Modells finden über eine virtuelle Plattform statt. Ergebnisse Der Analyseprozess ist erst Anfang Juni 2016 abgeschlossen. Durch die verschiedenen Sichtweisen der AG (Management, Bildung und Fach) zeichnet sich aber jetzt schon die Vielschichtigkeit der Problematik ab, die nur mit einem gemeinsamen Massnahmenplan gelöst werden kann. Diskussion Der relativ aufwändige Weg des virtuellen Austausches über die einzelnen Schritte des REPVAD – Modelles lohnt sich für die Bearbeitung einer komplexen Problemstellung wie die der Bezugspflegeumsetzung sehr, da verschiedene Dimensionen eines Problems beleuchtet werden können und so ein komplettes Gesamtbild davon entsteht. Lösungen können so breit gestützt erarbeitet werden und in einen Massnahmenplan einfliessen.
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P05 Ein Fachgremium macht sich auf den Weg Neustrukturierung des Pflegeforums* der Intensivstationen (*Bestehend aus acht Pflegeexperten/Pflegeexpertinnen) auf Stufe 5 & 6 nach dem Laufbahnmodell des UniversitätsSpitals Zürich (USZ) J Maier [1], P Massarotto [1] [1] UniversitätsSpital, Zürich , Switzerland Hintergrund Im USZ existieren sechs dezentral geführte Intensivstationen (IPS) mit insgesamt 64 Bettplätzen und rund 350 Pflegefachpersonen. Auf jeder IPS ist eine Pflegeexpertin / ein Pflegeexperte (PE) beschäftigt, die wiederum von einem fachführenden PE unterstützt werden. Die PE treffen sich wöchentlich für zwei Stunden zum fachlichen Austausch. Die Treffen dienen vorwiegend zum Informationsaustausch und unterliegen keiner festgelegten Struktur. Mehrere PE – Wechsel in der Vergangenheit, unterschiedliche Abschlüsse der PE, verschiedene Bedürfnisse der einzelnen IPS und ein fehlendes Konzept führen zu einer heterogenen Zusammenarbeit. Methode Mit der Schaffung und Besetzung einer zweiten fachführenden PE – Stelle wurde die Umorganisation des Pflegeforums beschlossen. Zunächst wurden das Rollenverständnis und die Erwartungen aller Mitglieder geklärt sowie die Wichtigkeit des gegenseitigen Vertrauens als Notwendigkeit herausgearbeitet. Daraus hat sich eine neue Sitzungsstruktur abgeleitet, um den Bedürfnissen besser gerecht zu werden. Neu sind die Sitzungen unterteilt in einen Arbeits-‐‑ und einen Fortbildungsteil. Die Sitzungen werden mit einer Austauschrunde begonnen, denn Störungen haben Vorrang. Die vorgegebenen Zeiten werden durch die Sitzungsleitung und allen PE eingehalten. Eine Feedbackrunde am Ende der Sitzung ermöglicht die Reflexion der Sitzung. Die Kommunikationsregeln wurden schriftlich festgehalten und stehen allen zur Verfügung. In einer Planungsliste sind An-‐‑ und Abwesenheiten sowie die zu bearbeitenden Jahresthemen mit den entsprechenden Verantwortlichen ersichtlich. Ergänzt wird die Liste durch fünf alternierende Themen für den Fortbildungsteil (Journalclub, Fachinput, Aktionslernen, Jahresziele und externe Gäste). Ergebnisse Da die Umstrukturierung erst im März gestartet hat, können derzeit nur wenige Ergebnisse dargelegt werden. Es zeichnet sich aber jetzt schon ab, dass die vorgegebene Struktur positive Auswirkungen auf den Ablauf und den Inhalt der Sitzungen haben. Auch konnten schon drei Fortbildungsteile erfolgreich durchgeführt werden. Diskussion Herausfordernd ist die strikte Einhaltung der zeitlichen Vorgaben und der aufgestellten Regeln. Die ersten Erfahrungen mit der neuen Struktur lassen jedoch darauf schliessen, dass diese in hohem Masse zu einem erfolgreichen Sitzungsablauf beiträgt und dass v.a. der Fortbildungsteil die Qualität erhöht und zu einer positiven Gruppendynamik beiträgt.
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P06 Miniaudits als Praxis-‐‑ und Qualitätssicherungsinstrument auf Intensivstationen L Weibel [1], C Wesch [1], U Barandun Schäfer [1] [1] Universitätsspital, Basel, Switzerland Einleitung Seit 2011 werden unter der Leitung des Vereins für Qualitätsentwicklung in Spitälern und Kliniken (ANQ) in der Schweiz flächendeckende Qualitätsmessungen durchgeführt. ANQ-‐‑Mitglieder sind der Spitalverband H+, santésuisse, die Kantone und die Eidgenössischen Sozialversicherer. An einem Stichtag im Jahr werden bestimmte Qualitätsindikatoren auf allen Abteilungen erfasst. Die Messergebnisse werden zentral aufgearbeitet und anschliessend veröffentlicht. Die Resultate ermöglichen einen transparenten nationalen Vergleich. Aufgrund der Erkenntnisse können Spitäler und Kliniken gezielt Massnahmen zur Verbesserung ihrer Qualität entwickeln. Für die einzelnen Stationen bietet jedoch die einmal jährlich durchgeführte ANQ-‐‑Erhebung nur ein begrenzt aussagekräftiges Resultat. Bei diesen Qualitätserhebungen sind gezielte Massnahmen zur direkten Reflektion und Qualitätsverbesserung nicht vorgesehen. Wir sind der Meinung, solche Datenerhebungen sollten auch dafür genutzt werden, mit den Pflegenden unterstützend reflektieren zu können und damit direktes Lernen im Alltag zu ermöglichen. Fragestellung Welche Erfahrungen machen wir mit mehrmals jährlich durchgeführten Miniaudits zu diversen Qualitätsindikatoren auf den Intensivstationen? Methode/Design Ein Erfahrungsbericht Resultate Auf den Intensivstationen eines Universitätsspitals werden bei den Themen Delir-‐‑, Haut-‐‑ und Wund-‐‑ und Schmerzmanagement bis fünf Mal jährlich sogenannte Miniaudits durchgeführt. Die zu erhebenden Daten wurden unter anderem in Anlehnung an die ANQ-‐‑Erhebung zusammengestellt. Die Daten werden von Ressourcenpflegenden erhoben. Sie besprechen die Befunde mit den zuständigen Pflegenden, Behandlungsoptionen werden diskutiert und umgesetzt. Anschliessend übertragen die Pflegeexperten die Daten ins SPSS und wertet sie aus. Schlussfolgerungen/Empfehlungen Die Miniaudits werden von den Pflegenden geschätzt, weil sie in einem wohlwollenden Klima durchgeführt werden. Die Möglichkeit eines fachlichen Austausches mit Mitarbeiterinnen mit erweiterten Kompetenzen wird als gewinnbringend taxiert. Die Miniaudits ermöglichen eine engere Verlaufsabbildung von pflegerelevanten Qualitätsmerkmalen. Der Jahresdurchschnitt aus 5-‐‑6 Erhebungen ist aussagekräftiger als die einmalige ANQ-‐‑Erhebung. Die Themen können entsprechend den thematischen Schwerpunkten der Station frei gewählt werden. Wir erleben die Miniaudits als geeignetes Praxisentwicklungs-‐‑ und Qualitätssicherungsinstrument.
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P07 Qualité de prise en soins des Patients Long Séjour aux Soins Intensifs : Enquête sur la Check-‐‑List M Takyi [1], M Desarmenien [1], AL Blanchard-‐‑Courtois [1], N Abidi [1], B Ricou [1] [1] Hôpitaux Universitaires de Geneve, Genève, Switzerland Introduction Les progrès de la Médecine intensive permettent la survie de patients gravement atteints. Il en résulte une augmentation d’une population survivant dans une situation critique chronique, citée comme « Chronic Critical Ill » dans la littérature anglo saxonne* . Les patients hospitalisés plus de 7 jours sont définis « Patients Long Séjour (PLS) » dans les soins intensifs (SI) de Genève. Les PLS requièrent des soins médico-‐‑infirmiers particuliers, différents de ceux prodigués aux patients de phase aiguë. Depuis 2005, un groupe multidisciplinaire, nommé groupe PLS, dédié à assurer leur prise en charge et suivi a acquis une expertise sur ces malades chroniques de soins intensifs. Le groupe PLS a implémenté des outils de monitorage spécifiques aux PLS. Parmi eux, une Check List (CL) qui permet de répertorier les problèmes potentiels propres à ces malades. La CL est intégrée dans le dossier informatisé spécifique aux SI à J7 (Clinisoft) et est planifiée aux 24h jusqu’à la sortie définitive du service. Aims Evaluer le ressenti des soignants vis-‐‑à-‐‑vis de cet outil. Connaitre le taux d’utilisation de la CL par les infirmiers. Estimer la pertinence de sa programmation et sa fréquence. Apprécier le bénéfice de la CL dans l’identification des problèmes et la prise en soins des PLS. Méthods L’enquête a été menée auprès des infirmiers des SI en janvier 2015. Elle a été réalisée via un questionnaire en ligne (Survey Monkey®). Elle interrogeait les infirmiers sur différents points:
• Les données démographiques telles le profil du soignant (infirmier certifié ou non). • Le degré d’utilisation de l’outil CL. • La pertinence du moment de sa mise en place et de son contenu. • La programmation de la CL. • Les bénéfices ressentis par le soignant. • L’impact de l’utilisation de la CL dans une prise en soins des PLS.
Results 102 questionnaires ont été complétés soit un taux de réponses de 48%. 82 % des réponses venaient des infirmiers certifiés, 18 % de non certifiés. Le taux d’utilisation est très bon : plus de 90% des répondants utilisent cet outil. L’équipe est en accord à 67 % avec la pertinence d’introduction de la CL à J7. Conclusions Suite à cette enquête, le groupe PLS a été conforté dans l’utilité de la CL. Il n’a pas jugé utile d’y apporter des modifications. Cette enquête sera répétée dans un an afin d’évaluer l’utilité de modifications éventuelles. Littérature * Nelson J, Cox C, Hope A. Chronic Critical Illness, Am J Respir Crit Care Med, 2010;182:446
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P08 Hilfreiche Interventionen zur Reduktion von Moral Distress (=moralischem Stress) bei Intensivpflegepersonen. K Engi [1] [1] UniversitätsSpital Zürich, Pflege Intensivpflege Neurochirurgie, Zürich, Switzerland Thema Handeln Intensivpflegefachpersonen aufgrund äusserer Umstände entgegen ihren persönlichen und beruflichen Wertevorstellungen, entsteht als Folge dieser Werte-‐‑konflikte Moral Distress. Dies hat Auswirkungen auf die Pflegequalität und die Arbeitsmotivation der Betroffenen. Langfristig kann Moral Distress zu Burnout und Ab-‐‑wanderung aus dem Beruf führen. Fragestellung Welche literaturgestützten Möglichkeiten haben Intensivpflegefachpersonen zur erfolgreichen Bewältigung von moralischen Wertekonflikten in ihrem Berufsalltag? Methode Zur Beantwortung der Fragestellung wurde mittels einer systematisierten Literatur-‐‑recherche auf wissenschaftlichen Datenbanken sowie der Literaturverzeichnisse verschiedener Fachartikel nach Publikationen gesucht. Die eruierten Daten wurden hiernach kritisch beurteilt und diskutiert. Ergebnisse Bis anhin sind wenige Studien publiziert worden, welche konkrete Interventionen im Umgang mit Moral Distress untersuchten. Ethik-‐‑Schulungen, ethische Fallbesprechungen sowie eine Guideline wurden als mögliche Strategien zur Reduktion von Moral Distress identifiziert. Sie unterstützen die kritische Selbstreflexion und fördern die moralische Resilienz von Intensivpflegefachpersonen. Schlussfolgerung Die kognitive Auseinandersetzung mit den persönlichen und fremden Wertevorstellungen senkt die Belastung durch Moral Distress.
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P09 Le Score de Glasgow : Vers une mise à jour des pratiques ? JP Miroz [1], P Delbarre [1] [1] CHUV, Lausanne, Switzerland Introduction Le score de Glasgow est un indicateur de l’état de conscience, réalisée quotidiennement chez tout patient aux soins intensifs. Il permet le suivi des patients présentant des troubles sévères de la vigilance et d’orienter sa prise en charge. Malgré sa reproductibilité, il existe des variations dans sa réalisation au sein d'un même service, selon les techniques utilisées, les connaissances et les appréhensions de chacun. Le but de notre projet est d’améliorer et d’harmoniser cette pratique, afin de réduire les écarts entre les évaluations des soignants, et d’anticiper les soins et surveillances en situation critique. Méthode Un questionnaire proposé aux collègues permet d’identifier la diversité des techniques ainsi que les doutes et craintes dans la réalisation du score, notamment en lien à la stimulation douloureuse du patient. Il confirme le besoin d’apprentissage des infirmiers (ères). Résultats/Discussion En collaboration avec un Professeur du service spécialisé en neuro-‐‑réanimation, de nouvelles recommandations sont consultés. Ils aboutissent à un nouveau protocole de service. Le changement des pratiques est accompagné par la mise en place d’ateliers pratiques dans la réalisation du Score de Glasgow auprès des soignants de chaque unité. Adoptée par l’ensemble des infirmiers (ères) du service il permettra une évaluation plus précise de l’état de vigilance du patient, et ce quelque soit l’expérience du soignant. Il permettra également une anticipation des complications ainsi que des interventions plus rapides en situation aigu et complexe. Conclusions Le nouveau protocole contribue indéniablement à l’amélioration des connaissances en matière de soins et surveillance du patient en soins intensifs. Il ne garantit pas une amélioration du pronostic du patient, mais favorise une évaluation clinique neurologique optimale. Bibliographie : Chan, MF. Matter I. Investigating nurses’ knowledge, attitudes and self-‐‑confidence patterns to perform the conscious
level assessment: a cluster analysis. (2013) (Wiley publishing Asia Pty Ltd) (pp 351-‐‑359). Waterhouse C. British Journal of Neuroscience Nursing 4(10): 492-‐‑9. (2009) An audit of nurses’ conduct and recording of
observations using the Glasgow Coma Scale. Waterhouse C. British Journal of Neuroscience Nursing (Br J Nuerosci Nurs) 5(5): 209-‐‑14. (2009). The use of paintful
stimulus in relation to Glasgow Coma Scale observation.
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P10 Etude de l’impact des Soins Intensifs sur les Patients Long Séjour: Evaluation rétrospective à 6 mois. AL Blanchard-‐‑Courtois [1], N Abidi [1], M Desarmenien [1], B Ricou [1] [1] hôpitaux universitaires de Genève, Geneve, Switzerland Introduction Les Patients Long Séjour (PLS) sont des patients hospitalisés plus de 7 jours aux soins intensifs. En 2012, ils représentaient 22 % des admissions. Ces patients développent des besoins spécifiques durant l’hospitalisation prolongée. Ils ont une qualité de vie préoccupante après les SI*. Ils présentent non seulement une diminution physique, mais souffrent aussi de douleurs et des troubles psychosociaux importants. Aims Réaliser une analyse quantitative des besoins ressentis durant l’hospitalisation. Connaitre les conséquences sur le fonctionnement familial et social, 6 mois après un long séjour aux SI. Evaluer l’impact du journal de bord sur le patient et les proches. Découvrir l’outcome des patients et leur qualité de vie. Effectuer différentes mesures concernant la satisfaction des familles. Evaluer l’impact psychique de l’hospitalisation d’un proche. Explorer de potentielles mesures d’amélioration dans le service. Méthods Les patients et leurs familles ont été abordés durant le séjour à l’hôpital pour les informer de l’étude. Ils ont été appelés 6 mois après la sortie des SI pour obtenir leur accord afin d’envoyer le questionnaire anonyme. Les mesures ont été réalisables grâce à l’utilisation des trois outils: Critical Care Family Inventory (CCFNI), EuroQol, et Trauma Screening Questionnaire. Compte tenu de la densité des résultats, les données présentées concernent uniquement les patients. Leur questionnaire comportait 45 questions. Results Sur 70 questionnaires envoyés aux patients, il y a eu 32 réponses. Les questions évaluaient l’importance accordée aux besoins suivant pendant l’hospitalisation du patient, le ressenti à la lecture du journal de bord, le vécu actuel, la relation avec le conjoint, l’état de santé des répondants au moment du questionnaire, l’état psychologique. Conclusions Cette étude a permis de mettre en relief l’importance des besoins et des attentes des patients PLS pendant leur séjour.Après leur hospitalisation, ils manifestent des troubles qui altèrent lourdement leurs relations socioprofessionnelles et leur qualité de vie. Les manifestations psychologiques à 6 mois de l’hospitalisation sont parfois très sévères. Bibliographie : *Friedrich JO, Wilson G, Chant C et al. Long-‐‑term outcomes and clinical predictors of hospital mortality in very long stay
intensive care unit patients: a cohort study, Crit Care, 2006;10:R59
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P12 L’électrode qui remet en question nos pratiques! C Joseph [1], J-‐‑D Gaillard [1], V Plouhinec [1], A Fishman [1] [1] Service de médecine intensive adulte. CHUV, Lausanne, Switzerland Contexte En 2012, suite à des résultats d’hygiène hospitalière montrant la colonisation des siphons par des Pseudomonas, un changement de pratique a été instauré pour l’hygiène des patients. La toilette (eau/savon) a été abandonnée au profit de lingettes nettoyantes et hydratantes. Pour garantir une efficacité optimale du produit, il est demandé de ne pas l’essuyer. Septembre 2014, introduction des lingettes à la Chlorhexidine(Chx). Fin 2014, l’apparition de réactions cutanées sous les électrodes a conduit à un recensement de cet événement indésirable. En 4 jours, 134 observations, 18,4 % étaient porteur de lésions (n= 25), réparties en 4 types : irritation [réaction disparaît en 6h (n=9)], rougeur [réaction toujours présente le lendemain (n= 12)], phlyctène séreuse (n=3) et phlyctène purulente (n=1)]. Une analyse, selon le diagramme d’Ichikawa, a permis de prendre des mesures correctrices immédiates. Notamment : Le changement quotidien des électrodes suite à la toilette, l’importance de bien sécher la peau avant la pose, l’interdiction d’utiliser des produits irritant pour enlever les résidus de colle, la modification du stockage du matériel, la révision des câbles ECG. Afin d’évaluer les mesures correctrices mises en place, un nouveau recensement a été effectué pendant 1 mois (1-‐‑ 30 avril 2016) : 377 observations, 24% étaient porteur de lésions (n=91), répartie en 2 types : irritation (n=73) et rougeur (n=18) ce dernier point a montré que le taux de lésions cutanées n’a pas diminué. Suite à notre changement de pratique pour la toilette, nous émettons l’hypothèse que l’utilisation des lingettes à la Chx pour la toilette du patient provoquerait ce type de réaction. Méthodologie Etude observationnelle prospective, avec un partage du service en 2 groupes de patients : 1 groupe (U4-‐‑5) toilette avec lingettes à la Chx 2 groupe (U1-‐‑2) toilette avec des lingettes sans Chx. La procédure pour le changement des électrodes reste la même dans tout le service. Recensement sur un mois (1-‐‑31 mai) des réactions cutanées : évaluation écrite quotidienne du patient, selon la méthode utilisée pour le relevé et l’évaluation. Résultats Les résultats intermédiaires (12 mai) ne montrent pas de différence significative entre les 2 groupes (résultat final sera publié au congrès). Conclusion Au vu des résultats intermédiaires, il ne semble pas que la Chx soit la cause des lésions, la question se pose de l’utilisation quotidienne de la lingette pour la toilette.
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P13 L'intégration des nouveaux infirmiers aux soins intensifs un défi pour les praticiens formateurs du CHUV. E Scolari [1], L Soncini [1], J Becquet [1], A Fasoglio [1], N Gross [1], C Schneiter [1], M Musset [1], A Fishman [1] [1] CHUV, Lausanne, Switzerland Contexte Un séminaire d’intégration a été élaboré en 2001 par les praticiens formateurs des soins intensifs (néonatologie, pédiatrique et adulte). Durant ce séminaire de 9 jours, ils dispensent des cours théoriques et pratiques (ventilation mécanique, système cardiaque,…)qui visent à favoriser l’intégration de leur nouveau personnel dans ces services hautement spécialisés. Problématique Le séminaire a été adapté au fil des années en fonction des nouvelles obligations et besoins. Si le service de néonatologie a fortement diminué sa participation, les Soins Intensifs adultes et pédiatriques collaborent étroitement. Les Praticiens Formateurs constatent cependant que les attentes et exigences des deux services tendent à diverger. Méthodes : Le séminaire a été évalué à l’aide d’un questionnaire soumis aux participants après chaque journée de cours et à l'aide d'un questionnaire soumis aux infirmiers chefs d'unité de soins et à leurs remplaçants. Résultats Le séminaire s’avère moins spécifique et moins adapté aux besoins lorsque les deux populations infirmière, pédiatrique et adultes, se retrouvent ensemble pour les cours. Actuellement, ils recueillent l’avis des ICUS. Conclusion Au vu des résultats, une restructuration sur le fond et la forme de ce séminaire s'impose pour qu'il continue de répondre aux besoins des nouveaux collaborateurs et du terrain.
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P14 Case Report: Repeated membrane clogging under CiCa dialysis with reduced serum albumin. A Klapproth [1], U Eriksson [1] [1] GZO Spital, Wetzikon, Switzerland Aim Hypothesis generating case report illustrating a potential effect of albumin substitution in preventing filter clotting in hypalbuminemic patients under CiCa dialysis. Case report We present a case of a 69-‐‑year-‐‑old patient with severe sepsis, acute renal failure, and respiratory failure on mechanical ventilation and continuous hemodialysis. Renal replacement therapy was instituted instituted utilising Fresenius Multifiltrate and Ci-‐‑Ca-‐‑Dialysate K2 according to manufacturer specifications.Three cycles of hemodialysis were applied. Only 12h after starting the fourth and the following cycles filter clotting occurred. Filter pressures rised shortly after beginning of each cycle and increased exponentially thereafter. Even heparin administration did not prevent filter clotting. Filter clotting tendency was paralleled by decreasing serum albumin levels. Removed filters showed significant clots in capillaries. Referring to a publication of Unger et al.1 100ml albumin (HA) 20% were infused as a bolus and then provided as a 12.5 ml / h continuous infusion upstream of the filter. Albumin substitution resulted immediately in reduced filter pressures and delayed filter clotting significantly. Unger was able to show that by missing the second-‐‑layer to the destruction of red blood cells to the capillary holes and thus for continuous Hb Waste Clotten comes in the capillaries. Conclusion Albumin substitution upstream of hemofiltration filters prevented filter clotting in a patient with significant hypalbuminemia. Reduced serum albumin levels are associated with reduced biocompatibility of the filter membrane. The potential association between filter clotting and serum albumin should be further addressed in ICU patients undergoing hemodiafiltration. Reference Unger, J. K. (2008). Membrane-‐‑Clogging bei intensivmedizinisch angewandten Aphereseverfahren: Identifizierung der atiologischen Trias mit Strategieentwicklung zur First-‐‑Level Pravention von Filterblockade und Gerinnungsaktivierung. [Membrane clogging in apheresis-‐‑filters used in intensive care medicine – Identification of the etiological triad and concept for first level prevention].
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P15 A First Evaluation of Omni®, a new Device for Renal Replacement Therapy P Schläpfer [1], JD Durovray [1], V Plouhinec [1], C Chiappa [1], R Bellomo [1, 2], A Schneider [1] [1] Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland [2] Royal Melbourne University, Melbourne, Australia Aims Several generations of devices have gradually improved the safety and feasibility of continuous renal replacement therapy (CRRT) to support critically ill patients with acute kidney injury (AKI). Omni® (B. Braun, Melsungen, Germany), a new third generation CRRT device has been designed with the aim of improving therapy accuracy and fluid balance management. Such improvements are thought to facilitate the achievement of the target renal dose and net fluid removal. Accordingly, we sought to evaluate the safety and feasibility of providing CRRT with Omni® in critically ill patients with acute kidney injury. Methods In a tertiary university affiliated hospital, we used Omni® to provide CRRT in ten critically ill patients. RRT was provided in CVVH mode with heparin anticoagulation or CVVHD mode with regional citrate anticoagulation. We collected patients’ characteristics, filter life time, circuit pressures, interruption of therapy duration and reasons (alarm types), achieved and targeted renal dose, metabolic parameters (serum creatinine and potassium levels and arterial base excess). In addition, we administered a survey to all nurses providing the therapy to assess the ease of use and user interface of the device. Results RRT was applied using Omni® in CVVH-‐‑heparin mode in six patients (total duration 365.5 hours) and in CVVHD-‐‑citrate mode in four (total duration 249.7 hours). No major adverse events were observed and no therapy needed to be discontinued for safety concerns. Mean filter life was 22.8 hours (SD 14.2) in CVVH-‐‑heparin mode and 33.5 (SD 22.2) in CVVHD-‐‑citrate mode. Recirculation mode was successfully attempted in five patients (total duration 12.7 hours). Therapy interruption due to alarms corresponded to a total of 25.5 hrs (7% of total therapy time) in CVVH-‐‑heparin mode and 11.9 hours (4% of total therapy time) in CVVHD-‐‑citrate mode. Mean achieved renal dose was 26.3 ml/kg/hr corresponding to 96% of the targeted dose in CVVH-‐‑heparin mode and 29.8 ml/kg/hr corresponding to 98% of the targeted dose in CVVHD-‐‑citrate mode. In both RRT modes, excellent metabolic control and adequate fluid balance were achieved. Overall, the interface, design and ease of use were evaluated by users as excellent. Conclusions CRRT in both CVVH and CVVHD modes could be provided using Omni® in a safe and efficient way in ten critically ill patients. Users provided positive feedback regarding therapy setup, management and user interface.
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P16 ICU Training: Filling in the Gaps S Doll [1], H Ksouri [1], G Sridharan [1] [1] Intensive Care Unit, Hôpital fribourgeois, Fribourg, Switzerland Background In Switzerland, junior physicians working at the intensive care unit (ICU) present a wide heterogeneity in post-‐‑graduate backgrounds. Most come to the ICU for a limited amount of time, typically ranging from 3 to 6 months, in order to complete their specialty training requirements (usually in internal medicine, anesthesia, or surgery). Few come with the goal of completing an ICU fellowship. Such rotations take place at various times in their curriculum, which results in significant differences in practical, theoretical and cultural experiences among interns and fellows. Aims Investigate practical tools aimed at identifying junior physicians’ specific needs during an ICU rotation. Methods We conducted a survey using a self-‐‑administered online questionnaire at the end of an 18 months observation period (November 2014-‐‑April 2016). All junior physicians having completed at least 3 consecutive months were included. Answers were reported on a 4-‐‑points Likert scale. Paired sample t-‐‑tests were performed to evaluate the significance of junior physicians’ variations in needs before and after their rotation. Results Response rate was 83% (26 out of 31). Medical education had been completed in Switzerland in 63% of the cases. The majority came from internal medicine (38%), with the rest evenly spread between ICU, anesthesia, and surgery. Only 32% were pursuing an ICU specialization. Approaches to identify specific needs and respectively customize training are presented in Figure 1. All tools to identify specific needs were judged appropriate, except the FMH E-‐‑logbook. Among our approaches to transmit knowledge, run-‐‑in introduction courses for newcomers at the beginning of each rotation and weekly practical workshops got the highest ranking. Junior physicians’ self-‐‑reported needs prior and after completion of their ICU rotation are presented in Figure 2. Several objectives were considered attained by the end of the rotation, although the need for mastering ultrasound imagery remained high. Conclusion Our study presents simple, readily-‐‑implementable multi-‐‑modal approaches to identify junior collaborators’ specific strengths, needs, and expectations. This is crucial in order to implement customized training as early as possible, allocate resources appropriately, increase efficiency and security, and bolster satisfaction.
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P17 Perioperative Irisin and Adipokine Levels as Surrogate Markers for the Metabolic Stress Response to Cardiac Surgery A Boltres [1], F Lanzi [1], E Nitschmann [2], T Mayer [1], E Mauermann [1], U Schurr [3], E Seeberger [1], L Wykes [2], H Pargger [1], A Kopp Lugli [1] [1] Department of Anesthesia & Surgical Intensive Care, University Hospital of Basel, Basel, Switzerland [2] School of Dietetics and Human Nutrition, McGill University, Montreal, Canada [3] Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland Aims The metabolic stress response induced by surgical injury causes a catabolic state including reduced insulin sensitivity. These alterations are comparable to metabolic derangements provoked by diabetes type 2 (DM2) and are related to marked perioperative morbidity and mortality rates. Adipose tissue and skeletal muscle play a pivotal role in the endocrine system, interacting with insulin sensitivity via adipokines and myokines, respectively.1,2 This explorative, prospective observational study aims to assess the perioperative levels of two adipokines (CXC-‐‑chemokine ligand 5 (CXCL5) and visfatin) and the myokine irisin. Methods One-‐‑hundred thirty patients hospitalized for elective on-‐‑pump cardiac surgery were consecutively recruited receiving standardized perioperative care. Serum adipokine and irisin concentrations were measured before induction of anesthesia (baseline values), upon arrival on the intensive care unit, and on postoperative day 1 (POD1) and 3 (POD3). Results Patient’s baseline characteristics are shown in Table 1. CXCL5 decreased during the early perioperative period and returned to baseline by POD3. Visfatin increased during surgery, showed a decrease by POD1, only to increase again by POD3. While there is no difference for visfatin between DM2 and non-‐‑DM2 patients, CXCL5 appears to be higher for diabetic subjects for all measured time points. Irisin seems to be higher at baseline and on POD3 in non-‐‑DM2 compared to DM2 patients but decreased to the same level in all patients during the early postoperative period and slightly increased in parallel on POD1. On POD3, irisin differed again, slightly displaying an increase in non-‐‑DM2 and a decrease in DM2 patients (Table 2). Conclusions The two pro-‐‑inflammatory adipokines displayed no uniform perioperative fluctuation proposing different impacts of the stress response to surgery or other metabolic influences. DM2 patients suffer from insulin resistance per se, which may explain the lower irisin levels before surgery and on POD3. The decrease in irisin concentrations of DM2 and non-‐‑DM2 patients to similar levels during the early postoperative phase may be due to the standardized insulin regimen in intensive care. Further trials investigating correlations between adipokine and myokine concentrations, insulin sensitivity, and surgical outcomes are encouraged to test their potential role as biomarkers. References Boström P et al. Nature 2012;481:463-‐‑8 2. Ouchi N et al. Nat Rev Immunol 2011;11:85-‐‑97
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References A. Kopp Lugli et al: Adipokines and the Metabolic Stress Response to Surgery: Perioperative Trends in CXCL5 and Visfatin
Concentrations A. Boltres et al: How the Stress Response to Cardiac Surgery Affects Irisin Levels and Insulin Resistance A. Kopp Lugli: Correlation of HbA1c and the Insulin Sensitivity Markers HOMA and QUICKI in Patients Undergoing
Cardiac Surgery
Variable( All(Patients((130)( Non5Diabetics((92)( Diabetics((38)(
Sex((M/F)( 95/35( 68/24( 27/11(
Age((yrs)( 65(±(12.3( 63.1(±(13.3( 69.4(±(8.2(
ASA((2/3/4)( 15/95/20( 11/74/7( 4/21/13(
BMI((kg/m2)( 27.2(±(4.5( 26.1(±(3.8( 29.9(±(4.8(
HbA1c((%)( 6.2(±(0.9( 5.8(±(0.4( 7.2(±(0.9(
EuroSCORE( 6.8(±(11.7( 5.9(±(11.7( 8.8(±(11.5(
SAPS(II(Score( 29.2(±(8.7( 28.3(±(8.8( 31.5(±(7.8(
Type(of(surgery(AKB/valve/multiple(( 48/44/38( 32/34/27( 16/10/11(
Duration(of(surgery((min)( 222.7(±(59.9( 220(±(62.4( 228.8(±(53.8(
Table(1.(Patient(characteristics(
(
Variable( (( Preop( Arrival(ICU( POD(1( POD(3(
CXCL5((pg/ml)( All((130)( 919(±(511( 615(±(392( 650(±(400( 826(±(516(
(( NonFDM2((92)( 866(±(472( 563(±(346( 609(±(345( 788(±(422(
(( DM2((38)( 1047(±(582( 748(±(471( 752(±(506( 916(±(685(
Visfatin((ng/ml)( All((130)( 5.3(±(3.3( 15.6(±(10.1( 9.4(±(7.4( 14.2(±(9(
(( NonFDM2((92)( 4.9(±(2.8( 14.8(±(8.5( 9(±(6.8( 13.7(±(7.7(
(( DM2((38)( 6.4(±(4( 17.6(±(13.4( 10.3(±(8.7( 15.6(±(11.4(
Irisin((µg/ml)((
All((130)( 2.9(±(1.4( 2.0(±(0.9( 2.3(±(1.1( 2.5(±(1.2(
( NonFDM2((92)( 3.1(±(1.4( 2.0(±(0.9( 2.3(±(1.2( 2.6(±(1.2(
( DM2((38)( 2.6(±(1.1( 2.1(±(0.9( 2.5(±(1.0( 2.3(±(1.1(
Table(2.(Values(for(CXCL5,(visfatin(and(irisin(
(
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P18 DNR does not mean doing nothing – End-‐‑of-‐‑life-‐‑decisions on a surgical ICU ward B Meyer-‐‑Zehnder [1], H Pargger [1] [1] University Hospital, Basel, Switzerland Aims Although intensive care units (ICU) save lives, many patients with severe injuries and diseases die in an ICU each year. More than a decade ago, the large multi-‐‑center Ethicus I study described end of life practices in 37 ICUs in 17 European countries (1). The frequency of end-‐‑of-‐‑life decisions (EOLD) varied by region according to religious affiliation. The Ethicus II follow-‐‑up study evaluates end-‐‑of-‐‑life practices in ICUs throughout the world and examines how they have changed in recent years. The results of a single surgical ICU ward are presented here. Methods This prospective, observational study included all patients with an end-‐‑of-‐‑life decision (withhold and/or withdraw) and/or dying on the ICU between 1 October 2015 and 31 March 2016. Results Eighty-‐‑two patients (40 women, 42 men) were included during the six-‐‑month observational period. The mean age was 74.98±13.46 years (31-‐‑100 years); the SAPS score were 23-‐‑110 (mean 59.69, SD 22.346). Four patients died after unsuccessful resuscitation and three were brain dead. The other 75 patients could be divided in three groups: Group A (n=28): only DNR and/or no intubation if needed Group B (n=23): DNR initially, changed to palliative care after some days Group C (n=24): concurrent DNR and change to palliative care Only one patient died in Group A, and 27 left the hospital (transfer to another hospital, a rehabilitation ward, or home). All patients died in Groups B and C. These included 36 patients on the ICU, 17 on another ward in the hospital, 2 after transfer to hospice care. For 24 patients (29.3%) the EOLD could be based on an advanced directive (AD). More patients from Group A had an AD (Group A: 14 patients, Groups B&C: 5 patients each). The mean SAPS score was highest in Group C (Group A 49.70 vs. B 51.48 vs. C 75.71). Conclusions At the observed ICU, patients with a DNR order are treated who later on can leave the hospital. The vast majority of the dying patients have an EOLD. References (1) Sprung CL, Cohen SL, Sjokvist P et al. JAMA 2003:290:790-‐‑797
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P19 To the limit of extreme malnutrition: Threating patients with Anorexia nervosa in the ICU. A Müller [1], M Maggiorini [1]
[1] Medical Intensive Care Unit, University Hospital Zurich and University of Zurich, Zurich, Switzerland Introduction Anorexia nervosa(AN)is a psychiatric disturbance that can result in serious and potentially deadly medical complications. Case reports A 21-‐‑year-‐‑old woman with a restrictive AN (BMI:9.6 kg/m2) and a 19-‐‑year-‐‑old woman with a binge-‐‑eating/purging type AN (BMI:10kg/m2) were admitted to the ICU for supervised refeeding and weight restoration. On examination their general conditions were extremely poor, both were bed-‐‑ridden as they couldn’t stand up due to orthostatic instability and muscle weakness. Initial workup revealed hypotension, sinus bradycardia, and hypothermia. Laboratory investigations revealed pancytopenia, elevated liver enzymes, dyselectrolytemia.Refeeding was carried out starting simultaneous parenteral and enteral refeeding at a maximum of 10-‐‑15 kcal/kg daily to minimize the risk for refeeding syndrome. Supplements of electrolyts, vitamins, minerals were provided according to plasma levels. The energy content in the diet was gradually increased over the period of days to a max.of 30-‐‑35 kcal/d. Cardiovascular dysfunction resolved within days, but pancytopenia took weeks to resolve upon refeeding. Fig.1 illustrates the relationship between GPT, prealbumine and caloric intake. Discussion Extreme malnutrition(BMI<12kg/m2)can cause significant medical complications. Pancytopenia could be explained by bone marrow atrophy or gelatinous marrow transformation, both findings related to starvation and seen in AN. That the pancytopenic state totally resolves upon refeeding in the absence of other causes, supports the starvation-‐‑induced mechanism. The markedly elevated aminotransferases at admission in case 1 is likely not related to refeeding, but may be explained by a combination of starvation-‐‑induced hepatocyte autophagy and by hepatic hypoxia.The rising liver enzymes in case 2 might be a direct result of refeeding, via dextrose deposition(steatosis)in the liver. A number of reversible alterations in cardiac structure and function have been recorded. A high proportion of sudden deaths have been proposed to ventricular arrhythmias(e.g torsade de pointes,QT interval dispersion).During refeeding electrolyte shifts caused by exuberant insulin release make patients suspectible to such arrhythmias. Conclusion Patients with the most severe cases of AN have a high prevalence of serious medical complications. The initial refeeding phase of these high-‐‑risk patients bears further potentially fatal complications and need therefore a close monitoring
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P20 High Prevalence of Severe Vitamin D Deficiency in Medical ICU patients -‐‑ a marker for ICU mortality? T Hauffe [1], M Hilty [1], EM Kleinert [1], M Maggiorini [1] [1] Division of Medical Intensive Care Unit, University Hospital Zurich, Zurich, Switzerland Background and Aims Vitamin D deficiency has a high prevalence in critical ill patients (Christopher 2015) and is associated with increased morbidity and mortality. Amrein et al. demonstrated that in patients with severe 25-‐‑OH-‐‑Vitamin D deficiency (≤12mcg/l) high dose Vitamin D substitution was associated with a lower in-‐‑hospital mortality (Amrein, Schnedl et al. 2014). The objective of our study is to investigate the prevalence of substantial Vitamin D deficiency in a tertiary medical intensive care unit, as well as its association with comorbidities and impact on ICU mortality. Methods We conducted a retrospective data analysis of all patients admitted to our intensive care unit from October 2015 – March 2016 (6 months). Patients with long duration ICU therapy (>7d), as well as patients with pre-‐‑existing malnutrition were assessed for Vitamin D (25-‐‑OH-‐‑Vitamin D) deficiency and substituted with 600 000 E of Colecalciferol orally in case of severe Vitamin D deficiency (≤12mcg/l). SAPSII score and Charlson-‐‑Comorbidity-‐‑Index were recorded concurrently with Vitamin D measurements, and ICU-‐‑ and hospital-‐‑mortality was assessed. Results Of 303 patients admitted to our intensive care unit, 91 patients were not included in the study due to missing consent for data research. Of the remaining 212 patients, 107 patients fulfilled the inclusion criteria. Mean age was 60.3 ± 15.8 years, Charlson-‐‑Index was 4.8 ± 2.5, SAPSII was 52.3 ± 17.7 and LOS-‐‑ICU 11.98 ± 12.7 days. Vitamin D levels were on average measured 3.97 ± 2.8 days after admission. Twenty-‐‑one (19.6%) patients had Vitamin D levels of > 20mcg/l, 20 (18.7%) between 12-‐‑20mcg/l and 66 (61.7%) of ≤ 12mcg/l (mean Vitamin D 34.9 ± 11.1 mcg/l, 16.26 ± 2.1 mcg/l, 6.6 ± 2.7mcg/l, respectively p< 0.05). Age, Charlson-‐‑Index and LOS were not significantly different between groups. Eighteen (17%) of our patients died of which 12 were in the ≤ 12mcg/l group. Patients dying in the ICU had significantly lower vitamin D levels (9.7 ± 6.6 vs. 14.8 ± 13.0 mcg/ml, p = 0.018) and where sicker on admission (SAPS II 61.3 ± 16.7 vs. 50.5 ± 17.4, 0.021). Conclusion Severe Vitamin D deficiency has a high prevalence in a medical ICU population. Patients with a Vitamin D level ≤ 12mcg/l are sicker on admission and have an increased mortality despite high dose substitution. References Christopher, KB. Current opinion in clinical nutrition and metabolic care, 2015. 18(2): p. 187-‐‑92. Amrein, K. et al. JAMA 2014; 312: 1520-‐‑153
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P21 Insuring succession: How do junior physicians perceive the specialty of intensive care medicine (ICM)? H Ksouri [1], S Doll [1], G Sridharan [1] [1] Intensive Care Unit, Hôpital fribourgeois, Fribourg, Switzerland Aims Data has emerged that the growing health-‐‑care needs of an aging population will outpace the future supply of ICU physicians. If current projections are correct, training programs will need to expand their capacity and encourage more residents to apply for critical care training. An adequate supply of ICU physicians will depend on an improved interest in intensive care medicine. We therefore evaluated our trainees’ perceptions of intensive care medicine (ICM) as compared to other specialties, and the influence of an ICU rotation on this perception. Methods We conducted a survey using a self-‐‑administered online questionnaire at the end of an 18 months’ observation period (November 2014-‐‑April 2016)). All trainees having completed at least 3 consecutive months in our ICU were included. The survey was organized into two sections. The first section requested to provide information on personal and demographic characteristics, career plans, and ICM experiences. In the second section, trainees were asked to compare their perceptions of ICM with other specialties before and after ICU rotation. A 5-‐‑point Likert scale was used to identify a range of responses. A Paired Sample T-‐‑Test was performed to determine a progression of perceptions before and after ICU rotation. Results The majority of trainees had worked in internal medicine before (38%), had no university experience (42%), and most came to the ICU for the first time (77%), (Table 1). Survey responses profiled the perceptions of ICM as compared with other specialties (Table 2). Trainees reported a positive perception regarding job satisfaction, intellectual stimulation and attractiveness. This perception was present before ICU rotation, and was almost unchanged afterwards. Other items were graded more negatively before the ICU rotation, i.e. those related to personal life-‐‑style (impact on private life, possibility to plan holidays) and to working conditions (level of stress, overtime work, hard conditions, possibility of part-‐‑time work). After ICU rotation we note a positive trend of these items although some were still graded in disfavor of ICM. Conclusion Despite some bias and limitations of our survey, results help to better understand the career interests and needs of young physicians and the potential barriers they perceive to entering fellowship training. Reflection and efforts are needed to promote interest in ICM training and attractiveness to avoid a negative impact on ICU resources in future.
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P23 Mortality of patients with chronic invasive home ventilation J Elsas [1], J Habermann [1], P Felleiter [1] [1] Swiss Paraplegic Centre, Nottwil, Switzerland Introduction Currently, 37% of the patients treated in Swiss intensive care units are ventilated. A small fraction of these patients remains dependent of invasive ventilation. After discharge from acute care and rehabilitation these patients may return home or they have to be cared for at nursing homes. We examined retrospectively the survival of patients dependent on invasive ventilation after their discharge from the Swiss Paraplegic Centre Nottwil. Methods From the data bases of our RespiCare Team (internal service for the care of ventilated patients) and our social service we identified all patients dependent on invasive ventilation that were discharged from 01.04.2005 to 01.04.2016 from the Swiss Paraplegic Centre Nottwil. We extracted the demographic data, diagnoses, discharge dates and discharge locations of these patients. Patients transferred to another hospital or suffering from ALS were excluded. The current status of all included patients was obtained using telephone interviews. Results We identified 92 patients requiring invasive ventilation. Four patients transferred to another hospital and 11 patients suffering from ALS were excluded. 41 patients (age 22-‐‑84 years, avg. 58 y; 31 m, 10 f) were transferred to nursing homes. 37 patients (11-‐‑80 years, avg. 42 y; 22 m, 14 f) returned to their homes. The Kaplan-‐‑Meier survival curves for both groups are shown in Figure 1. Discussion The Kaplan-‐‑Meier estimates for mortality differ between the two groups. It remains unclear whether both groups are comparable, e. g. the age distribution seems to be different. Nevertheless, mortality in the group of patients transferred to a nursing home differs already during the first year after discharge. At the end of the observation period of 52 months, mortality is doubled in this group. For a differentiated analysis of the underlying causes a prospective study would be necessary.
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P24 Heat stroke: a rare but life-‐‑ threatening condition associated with climate change. M Lepori [1], D Fadini [1], M Guigli-‐‑Poretti [1], R Spinelli [1], I Jermini-‐‑Gianinazzi [1], E Zamprogno [1] [1] Ente ospedaliero Cantonale, Bellinzona, Switzerland Background The increase in seasonal temperatures, due to global warming, has a potential influence on the health of the communities concerned. In Summer 2015, Switzerland, like the rest of Europe, recorded an unusually hot Summer, especially in the second half of July. Heatstroke is a rare but life-‐‑threatening clinical condition associated with the exposure to high temperature. Aim The purpose of this study is to describe the incidence of cases of heat stroke during the hottest week of summer 2015 observed in the emergency services in public hospitals of Ticino Canton (Ente Ospedaliero Cantonale, EOC). Methods We describe characteristics and clinical outcome of the 5 cases of heat stroke observed in our emergency services and ICU services from 20th to 31st July 2015. Results During the relevant period, 3393 primary admissions to the 4 emergency services studied. In five cases, severe heat strokes were observed. During this time in 2015 the average maximum temperature recorded was 31.9°C which was significantly higher than in the previous two years, 24.5°C and 26.8°C (p <0.01) respectively. Characteristics of patients and clinical issue are shown below : age (y) 67±20 T° 40.4±2.4 ICU admission 3/5 ICU stay n=3(d) 5.6±1.5 Ward stay (d) 9±6.3 MV (n) 2 pts Dialysis (n) 1 pt DIC (n) 3 pts Hepatic damage (n) 3 pts Deaths (n) 0 pts pt= patient Conclusions Incidence of heat stroke may increase during the period of persistent elevation of ambient temperature. As the climate change is evolving to more frequent and hot summer seasons, one important adaptive measure should be to associate prevention plans with hospital organization, in order to cope with these cases effectively.
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P25 Use of simulation-‐‑based training in Swiss pediatric health care institutions: A national survey F Ulmer [1], K Laine [1], M Stocker [1] [1] University Insel Hospital Berne, Berne, Switzerland Background Simulation-‐‑based medical training (SBMT) is a powerful tool for continuing medical education. Despite SBMT’s rising popularity over the past decade, best practices guidelines pertaining to design and implementation have yet to be established. The aim of this survey is to assess, describe and analyze the current state of SBMT in Swiss pediatric health care institutions. Methods A national survey designed by the authors was carried out with medical education representatives of every FMH recognized Swiss pediatric health care institution. SBMT was defined as any kind of training with a mannequin excluding national and/or international standardized courses. The survey reference day was May 31st 2015. Results Thirty Swiss pediatric health care institutions answered our survey (response rate 96.8%) with 66.6% offering SBMT. More than 90% of the institutions were conducting in-‐‑situ training and 62.5% were using high-‐‑fidelity mannequins. Technical skills, communication and leadership ranked among the top training priorities. All institutions catered to inter-‐‑professional participants. The vast majority conducted training that was neither embedded within a larger educational curriculum (79.2%) nor evaluated (66.6%) by its participants. Only 5 institutions (20.8%) extended their training to at least two thirds of their hospital staff (physicians, nursing staff). Conclusions Two thirds of Swiss pediatric health care institutions are offering SBMT: SBMT is exclusively inter-‐‑professional, mainly in-‐‑situ based, covering technical as well as non-‐‑technical skills and often employs high-‐‑fidelity mannequins. Despite the marked increase of SBMT in recent years in Swiss pediatric healthcare institutions, only a few are able to include two thirds or more of their inter-‐‑professional staff in SBMT. Only a fraction of the institutions apply systematic approaches to their training programs consisting of structured participant evaluations and research activities embedded within a larger educational curriculum. The German speaking region of Switzerland and the use of high-‐‑fidelity simulation are associated with a low penetration rate of SBMT for hospital staff. Needs assessment driven simulation programs tailored to meet the fidelity requirements of an institution’s health care providers may help extend SBMT to a larger portion of hospital staff.
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Comments To the best of our knowledge, this is the only national survey that has comparatively analyzed the state of medical Simulation in Swiss PICUs and NICUs covering 97% of FMH recognized pediatric hospitals. It allows to compare established and successfully operating medical simulation programs and elucidates current gaps. The knowledge shall serve as a guide for designing, improving and implementing future interprofessional simulation programs throughout Switzerland and stimulate discussion and co-‐‑operation between institutional and national stakeholders of pediatric resuscitation education.
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1 Mountain Clinic Davos 2 Delemont 3 Locarno 4 Lugano 5 Meyrin 6 Morges 7 Nyon 8 Payerne 9 Visp 10 Yverdon-les-Bains11 Neonatology Unit, University Hospital Zurich
Category 2 12 Aigle 13 Baden 14 Belinzona 15 Biel 16 Fribourg 17 Münsterlingen 18 Neuchatel 19 Vevey 20 Triemli Hospital Zurich
Category 3 21 Aarau22 Chur23 Lucerne24 Sion25 Winterthur
Category 4 26 Basel27 Bern28 Geneva29 Lausanne30 St. Gallen31 Children’s Hospital Zurich
Figure 1
Categories of hospitals
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P26 A febrile illness complicated by ophthalmoplegia, impaired consciousness and cytoalbuminologic dissociation: «Bickerstaff brainstem encephalitis» R Gähwiler [1], R Baldinger [2], U Schwarz [3], B Yuen [1] [1] Interdisciplinary Intensive Care Unit, Spital Bülach, Bülach, Switzerland [2] Division of Neurology, Spital Bülach, Bülach, Switzerland [3] Department of Neurology, University Hospital Zürich, Zürich, Switzerland We report the case of a 56-‐‑year-‐‑old, otherwise healthy female patient who presented with an acute febrile illness with generalized myalgias, and repeated vomiting since three days. The first clinical examination was unremarkable except of a marked somnolence . The next day she was confused and disorientated and developed an upbeat nystagmus and external ophthalmoplegia. Meningism or other focal neurological deficits were not present. The only abnormal laboratory test at presentation was a slight thrombo-‐‑cytopenia of 107’000/µl. CRP and leucocyte count was within the normal range. Because of progressive loss of consciousness (GCS 4), hypoxemic respiratory failure and loss of swallowing reflex the patient was transferred to the Intensive Care Unit where she was intubated. The next diagnostic steps comprised of lumbar puncture, brain MRI, EEG, ENMG, thoracoabdominal CT-‐‑Scan and serologic testing. Cerebrospinal fluid analysis indicated cytoalbuminologic dissociation with 13 mononuclear cells/µl (<5) and a protein concentration of 1506mg/l. Brain MRI revealed several small bilateral pontine DWI positive and FLAIR hyperintense lesions. EEG showed no evidence of non-‐‑convulsive status epilepticus and ENMG was without signs of demyelinating or axonal neuropathy. With the diagnosis of acute rhombencephalitis we started empirical therapy with Acyclovir until HSV-‐‑PCR was negative. Due to suspected immune mediated pathogenesis, we started a high dose corticosteroid pulse therapy followed by intravenous immunglobulines, unfortunately without clinical improvement during the next two weeks. Altough all autoantibodies, including anti-‐‑GQ1b IgG antibody remained negative, we assumed a parainfectious autoimmune etiology summarized under the term “Bickerstaff-‐‑encephalitis” as the cause of the acute rhombencephalitis with external ophthalmoplegia, altered consciousness and typical MRI and cerebrospinal fluid findings. Finally the clinical course was favourable and the patient regained consciousness. After four weeks she was transferred to neurorehablilitation without cognitive impairment but persistent paraplegia and mild bilateral arm paresis. In the presentation we will discuss the diagnosis and differential diagnosis of Bickerstaff brainstem encephalitis.
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P27 Fat in the head – what’s wrong? ME Kajdi [1], A Wäckerlin [1], C Nauer [1], I Broger [1], P Ahlborn [1], S Morf [1] [1] Kantonsspital Graubünden, Chur, Switzerland Aim Our aim was to describe the migration of fat into the intracranial subarachnoidal space in an extensively polytraumatized patient after operative treatment of his fractured sacral spine. Methods We retrospectively reviewed the patients chart focusing on injury pattern, operative treatment, clinical and radiologic findings. Results A 50-‐‑year old male patient was admitted to our hospital after a bike accident. Injury pattern consisted of thoracic, abdominal and pelvic injuries with an overall ISS of 41 points. Initial computed tomography (CT) of the head was within normal limits. CT trauma-‐‑scan revealed completely unstable bilateral pelvic ring injury, including complex fractures of the sacrum with neuroforaminal involvement. Treatment was operatively and consisted of open repositioning with lumbopelvic fixation. 9 days later the patient underwent CT of head and neck, showing hypodense lesions suspicious for fat tissue in the subarachnoid space. Examination was extended to brain magnet resonance imaging showing hyperintense signals in the T1-‐‑weighted sequences corresponding to fat deposits in the basal and prepontine cisterns. Clinical course was complicated by meningoencephalitis, partial loss of vision, ventilator-‐‑associated pneumonia with septic shock and multi organ dysfunction syndrome. 4 months after discharge, the patient’s vision remained compromised. Conclusions In contrast to fat embolism syndrome, which is caused by fat migration through blood stream, we suspect direct migration of fatty bone marrow from the fracture site into the sacral subarachnoid space with subsequent migration into the intracranial ventricles in our patient. Regarding the literature only one similar case has been described before(1). The presence of intraventricular fat is rare and can be associated with rupture of intradural dermoid cysts or postoperative course after removal of dermoid tumors, is the result of traumatic rupture of Tarlov cysts, ruptured teratomas or surgical treatment of CSF leakage. Whether fat migration might have promoted the patient’s vision loss remains unclear. However, deterioration of vision, vision loss and cranial nerve palsies in patients with intraventricular fat deposits have been described before (2-‐‑4). References 1)Lyo I. et al. J Korean Neurosurg Soc 2008; 44:95 2)Gallman W. et al. J Neuroimaging 2011; 21:287 3)Ludwig CA. et al. International Journal of Surgery Case Reports 2015; 7:1 4)Uff C. et al. J. Neurosurg Spine 2005; 3:390
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P28 An unusual usual suspect ME Kajdi [1], S Hofer-‐‑Strebel [1], M Furrer [1], A Wäckerlin [1], P Vanek [1] [1] Kantonsspital Graubünden, Chur, Switzerland Aim To describe the course of a critically ill patient presenting with clinical signs of shock originating from an unusual diagnosis. Methods Retrospective analysis of our patient’s data and charts focusing on clinical presentation, diagnostics and radiologic findings combined with review of current literature. Results A 64-‐‑year old male was referred to our hospital with suspected diagnosis of non-‐‑ST-‐‑elevation myocardial infarction after syncope. 2 weeks prior to admission a large (17x8x9 cm) abdominal aortic aneurysm (AAA) had been found by his general practitioner. At that time the patient had decided to postpone his decision on the suggested invasive treatment. Due to a syncope that led to the current admission, the referring hospital ruled out AAA rupture by contrast-‐‑enhanced CT scan but found positive markers for acute coronary heart disease. The angiography of coronary arteries was uneventful and showed no evidence of acute infarction. At admission to our Intensive Care Unit the patient was hemodynamically stable with significant tachycardia. After receiving intravenous betablockers he deteriorated within minutes, presenting with clinical signs of congestive heart failure and finally cardiogenic shock with multiorgan dysfunction syndrome. Aetiology of the acute hemodynamic failure was unclear, as the advanced diagnostics revealed contradictory findings: another (non contrast-‐‑enhanced) CT scan showed no signs of AAA rupture, transthoracic echocardiography revealed hyperdynamic state and hemodynamic monitoring by PiCCO-‐‑technology demonstrated unconclusive data. Patient management remained empiric and symptomatic, but still “successful” so that he slowly stabilized. A contrast-‐‑enhanced CT scan at day 10 finally revealed spontaneous aortocaval fistula (ACF) that hadn’t been documented before. Endovascular aortic aneurysm repair was performed successfully the following day and the patient transferred to the ward 2 days later. Conclusions Massive arteriovenous shunting in our patient led to hemodynamic collaps, probably precipitated by use of betablockers. Current literature confirms that Primary ACF is a rare but potentially life-‐‑threatening complication of AAAs which is often overseen initially. gold standard for diagnosis is contrast-‐‑enhanced CT scan, which should be performed immediately in spite of compromised kidney function.
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P29 Fatal hyperammonemia in an immunocompromized patient with systemic cryptococcosis F Furrer [1], A Müller [1], N Corti [2], M Maggiorini [1] [1] Medical Intensive Care Unit, University Hospital Zurich and University of Zurich, Zurich, Switzerland [2] Department of Pharmacology and Toxicology, University Hospital Zurich and University of Zurich, Zurich, Switzerland Aim To report the adverse effects of an antifungal and antiviral treatment with flucytosine and brivudine in a patient with systemic cryptococcosis and suspected HSV-‐‑1-‐‑reactivation receiving continuous renal replacement therapy and dying from refractory hyperammonemia. We hypothesize a rare drug-‐‑drug interaction is the case of lethal hyperammonemia in our patient. Case Report A 56 year old male with a generalized infection with Cryptococcus neoformans was admitted to the ICU in septic shock with later evidence of Enterobacter aerogenes in blood cultures. Because of dilative cardiomyopathy the patient had a heart transplant and was under immunosuppressive therapy with mycophenolic acid and prednisolone. In addition the patient was treated with the nucleosid analogon brivudine, because of a suspected HSV-‐‑1-‐‑reactivation one week prior to his admission. After initiation of an antimycotic regimen with flucytosine and amphotericine B the patient developed a severe and refractory and lethal hyperammonemia (peak 749 ɥmol/l) despite high dose hemodiafiltration and pharmaceutical therapy. The patient died form generalized cerebral edema. Discussion Flucytosine, a prodrug that is converted into 5-‐‑FU once taken up into the fungal cell, which after a further conversion inhibits fungal RNA and DNA synthesis. Since mammalian cells do not express cytosine-‐‑deaminase, selective toxicity to fungal cells should be granted. However, flucytosine is known to cumulate with renal dysfunction and that CRRT does not protect from accumulation. Thus, increasing flucytosine plasma concentration may have lead, via the action of the intestinal microflora, to toxic 5-‐‑FU plasma concentrations in our patient. In addition our patient got treated with brivudine. The main metabolite of brivudine, bromvinyluracil, is known to cause irreversible inhibition of the enzyme dihydropyrimidine-‐‑deaminase leading to an additional accumulation of 5-‐‑FU, via inactivation of 5-‐‑FU degradation. Deadly hyperammonemia has been described as a rare adverse effect of 5-‐‑FU treatment in cancer patients. Conclusion Drug induced hyperammonemia is an important differential diagnosis in a comatose patient in the ICU. Does your patient on CRRT receive flucytosine and brivudine be aware, because this may be the cause of hyperammonemia due to excessive accumulation of the toxic 5-‐‑FU.
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P30 Human Pooled Immunoglobulin Blocked Streptokinase-‐‑Mediated Virulence in Necrotizing Fasciitis by Streptococcus Disgalactiae Subspecies Equisimilis F Ugolini [1], F Andreoni [1], N Keller [1], A Neff [1], E Marques Maggio [1], A Zinkernagel [1], R A Schuepbach [1] [1] University Hospital Zurich, Zurich, Switzerland Streptococcus dysgalactiae subsp. equisimilis (SDSE or Group C and G streptococci) cause a wide spectrum of human diseases ranging from superficial to invasive infections, particularly in patients with underlying chronic disease or immunodeficiency. Invasive streptococcal infections such as necrotizing fasciitis (NF) have predominantly been associated with group A Streptococcus (GAS or S. pyogenes), however recent studies show SDSE as an emerging cause of serious disease, making improved understanding of SDSE virulence essential. We observed a fulminant case of NF caused by SDSE in which the bacteria produced high levels of streptokinase and the patient lacked of streptokinase-‐‑blocking antibodies. Passive immunotherapy with exogenous commercial pooled human intravenous immunoglobulin (Ex-‐‑IgGs) efficiently blocked streptokinase-‐‑mediated fibrinolysis caused by bacterial supernatants. Confirming an important role of streptokinase in SDSE virulence, we found that a streptokinase-‐‑deficient mutant of the clinical isolate lost virulence in a murine NF model. Likewise, clinical severity in the murine NF model was equally attenuated by administration of Ex-‐‑IgGs. In conclusion our data support a major role of streptokinase in SDSE-‐‑associated invasive infection, linking susceptibility to lack of endogenous streptokinase-‐‑blocking antibodies providing a rationale for Ex-‐‑IgGs therapy as a potentially useful adjunction to antibiotics.
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P31 Catastrophic tumor lysis syndrome after induction chemotherapy for acute myeloid leukemia D Stark [1], S Balabanov [2], M Maggiorini [1], Ch Ganter [1], U Wenger [1] [1] Medical Intensive Care Unit, University Hospital Zurich, Switzerland [2] Clinic for Hematology, Univesity Hospital Zurich, Switzerland Introduction To learn more about early signs of tumor lysis syndrome (TLS) and possible treatment options, we present a case of a 34-‐‑year old man with severe lethal tumor lysis syndrome causing multiple organ failure syndrome after initiation of chemotherapy for acute myeloid leukemia (AML). Case Report The patient presented with dyspnea, fever and recurrent upper respiratory tract infections since 3 months. The peripheral blood and bone marrow sample were diagnostic for an AML. An induction chemotherapy with idarubicin and cytarabin was started 2 days after hospital admission. As intermediate risk for TLS was anticipated (leucocyte count 91 G/l, (1)), the patient was treated with fluid and rasburicase. The patient was admitted to our ICU because of acute respiratory failure. Chest-‐‑CT-‐‑scan revealed bilateral pulmonary infiltrates. We applied non-‐‑invasive mechanical ventilation. Thirty-‐‑six hours after admission to the ICU an electrolyte (hyperkalemia, hyperphosphatemia, hypocalcemia) and cytokines storm (IL-‐‑6 max. 30’046 ng/l) with consecutive hypercapnic respiratory failure, inotrope resistant cardiogenic shock, acute renal and liver failure and severe disseminated intravascular coagulation developed. Despite full mechanical support of the heart, the lung and the kidney, and a cytokine adsorber (Cytosorb®) the patient died 5 days after induction chemotherapy. Discussion Hematologic malignancies with high tumor burden have a high risk of developing TLS. Risk stratification as suggested by Cairo et. al. (1) and guidelines in treatment TLS (2) guide prophylactic therapy and treatment. In our patient an intermediate risk for TLS was prognosticated, suggesting an underestimation of the risk. The normal prophylactic measurements did not prevent the catastrophic course. Rising the question whether other adjuncts like cytokine adsorbtion or steroids might mitigate the inflammatory reaction. Conclusion In AML patients the assessment of the risk for TLS is crucial. Cairo’s risk classification seems to underestimate this risk. New options for the mitigation of the cytokine storm in this kind of patient are necessary to prevent catastrophic TLS. References 1) MS Cairo and M Bishop. British Journal of Haematology 2004, 127: 3-‐‑11 2) GL Jones et al. British Journal of Haematology 2015, 169 (5): 661-‐‑71
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P32 Exercise pulmonary hemodynamics predict outcome in patients with systemic sclerosis A Stamm [1], S Saxer [1], M Lichtblau [1], E Hasler [1], S Jordan [2], L Huber [1], K Bloch [1], O Distler [2], S Ulrich [1] [1] UniversityHospital Zurich, Pulmonology, Zürich, Switzerland [2] UniversityHospital Zurich,Division of Rheumatology, Zürich, Switzerland Objectives To investigate the prognostic value of exercise hemodynamics measured during right heart catheterization (RHC) in patients with systemic sclerosis (SSc) referred for evaluation of pulmonary hypertension (PH). Methods Patients with SSc undergoing RHC at rest and during maximal supine incremental cycle exercise were grouped into those with resting precapillary PH (restPH = mean pulmonary artery pressure (mPAP) ≥25mmHg, pulmonary artery wedge pressure <15mmHg), exercise-‐‑induced PH (exPH = mPAP ≥30mmHg and mPAP/cardiac output >3mmHg/l/min at maximal exercise), and without PH (noPH). Patients’ characteristics, hemodynamics and follow up data were compared between groups. Results 72 patients with SSc were followed for median (quartiles) 33 (15;55) months. Mean (95%CI) survival without transplantation estimated by Kaplan Meyer analysis was 4.4 (0.8 to 2.9) yrs in restPH (n=17), 5.2 (4.4 to 6.1) yrs in exPH (n=28) and 9.5 (8.4 to 10.6) yrs in noPH (n=27, p<0.05 vs. others). In cox regression models, the exercise-‐‑induced increase in mPAP (hazard ratio 1.097, 95%CI 1.002 to 1.200) and the coefficient of pulmonary vascular distensibility (alpha) (hazard ratio 0.100, 95%CI 0.012 to 0.871) controlled for age, but not resting hemodynamics predicted transplant-‐‑free survival. Conclusions Among patients with SSc and normal mPAP at rest, an excessive increase in mPAP during exercise and an impaired vascular distensibility may indicate an early stage of pulmonary vasculopathy that is associated with reduced survival similar to that in patients with resting PH.
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P33 Severity of pulmonary hypertension correlates with daily physical activity of the patients S Saxer [1], E Hasler [1], K Bloch [1], S Ulrich [1] [1] UniversityHospital Zurich, Pulmonology, Zürich, Switzerland Background/Aim Strenuous activity and exercise training were until recently prohibited in patients with precapillary pulmonary hypertension (PH) in fear of exacerbated right ventricular failure. The aim of this study is to analyze daily physical activity in incident PH-‐‑patients and to correlate it with pulmonary hemodynamics. To find out whether the patients with more severe PH are already less active when they got the diagnosis. Methods Incident patients with arterial and chronic thromboembolic PH (PAH and CTEPH) had hemodynamics assessed by right heart catheterization (RHC) and activity parameters by SenseWear®. The 6 minute walking distance (6MWD) and WHO functional class were assessed. Pearson Correlations and regression analysis between activity parameters and hemodynamics were calculated. Results Seventeen patients (10 females, 57(40;69)years, mPAP 52(35;56)mmHg, cardiac output (CO) 4.7(3.2;5.4)l/min, 6MWD 450(273;597)m were included. Nine of the patients had a sedentary lifestyle (<5000 steps/day) and eight were somewhat active (5000-‐‑10’000 steps/day). Several hemodynamics parameters correlated with activity parameters (Table). There were no correlations between NYHA functional class and activity. The regression analysis showed that the cardiac output significantly influences the activity parameters corrected for age. Conclusion Patients with more severe PH are less active than those with mild PH at the time of diagnosis. SensWear® is a promising tool to assess exercise performance of PH patients in daily life during long-‐‑term care. Since activity recording reflect hemodynamics, without an influence of age, they might have the potential to serve as monitors of changes in hemodynamics in the spontaneous course of disease or in response to treatment. Table&
Pearson(correlations(between(activity(parameters(and(hemodynamics((n(=(17).(
! Energy!expend+iture!
Average!METs!
Low!(>3METs)!
Moderate!(3+6METs)!
High!(6+9METs)!
Steps/!day! Active!Energy!expend+iture/!day!
6MWD! !0.374! !0.608*! +0.506*! !0.540*! +0.039! !0.845**! !0.391!
mPAP! +0.365! +0.365! !0.373! +0.351! +0.333! +0.032! +0.426!PAWP! +0.524*! +0.511*! !0.431! +0.565*! +0.171! +0.356! +0.516*!
CO! !0.592*! !0.451! +0.524*! !0.461! !0.521*! !0.262! !0.631**!CI! !0.440! !0.431! +0.424! !0.367! !0.611**! !0.249! !0.509*!
Abbreviations:!6MWD:!6!minute!walking!distanceV!mPAP:!mean!pulmonary!arterial!pressureV!PAWP:!pulmonary!arterial!wedge!pressureV!CO:!Cardiac!outputV!CI:!cardiac!indexV!MET:!Metabolic!equivalent!units!(1MET!is!3.5ml!O2/kg/min)V!*p<0.05,!**p<0.01.(!
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P34 Targeting the prostacyclin pathway in the treatment of connective tissue disease associated pulmonary arterial hypertension (PAH): Insights from the randomized controlled GRIPHON trial with selexipag F Lador [1], S Gaine [2], R Channick [3], L Di Scala [4], N Galiè [5], HA Ghofrani [6, 7], MM Hoeper [8], I Lang [9], V McLaughlin [10], R Preiss [4], LJ Rubin [11], G Simonneau [12], O Sitbon [12], VF Tapson [13], K Chin [14] [1] Service de Pneumologie, Programme Hypertension Pulmonaire, Hôpitaux Universitaires de Genève et Faculté de Médecine, Genève, Switzerland [2] National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland [3] Massachusetts General Hospital, Boston, MA, United States [4] Actelion Pharmaceuticals Ltd, Allschwil, Switzerland [5] Istituto di Malattie dell'Apparato Cardiovascolare, University of Bologna, Bologna, Italy [6] University of Giessen and Marburg Lung Center (UGMLC), member of the German Center of Lung Research (DZL), Giessen, Germany [7] Department of Medicine, Imperial College London, London, United Kingdom [8] Department of Respiratory Medicine, Hannover Medical School and German Center of Lung Research, Hannover, Germany [9] Medical University of Vienna, Dept of Internal Medicine II, Division of Cardiology, Allgemeines Krankenhaus, Vienna, Austria [10] University of Michigan Health System Division of Cardiovascular Medicine, Ann Arbor, MI, United States [11] Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA, United States [12] Hôpital Universitaire de Bicêtre, Université Paris-‐‑Sud, Le Kremlin Bicêtre, France [13] Cedars-‐‑Sinai Medical Center, Los Angeles CA, United States [14] UT Southwestern Medical Center, Dallas, TX, United States Aims Despite available therapies, patients with connective tissue disease-‐‑associated PAH (PAH-‐‑CTD) have a poor prognosis. The global phase III GRIPHON study (NCT01106014) enrolled 1,156 patients, including 334 with PAH-‐‑CTD. Compared with placebo, selexipag reduced the risk of the primary composite outcome of morbidity/mortality up to end of treatment by 41% (hazard ratio [HR] 0.59; 99% CI: 0.37–0.96) among patients with PAH-‐‑CTD. We examined the effect of selexipag vs placebo in the PAH-‐‑CTD subgroups: PAH associated with systemic sclerosis (PAH-‐‑SSc), systemic lupus erythematous (PAH-‐‑SLE) and mixed CTD (PAH-‐‑MCTD). Methods Patients (aged 18–75 years) were randomised 1:1 to placebo or selexipag. HRs (95% CI) were calculated using Cox regression models to determine the effect of selexipag vs placebo on morbidity/mortality. Results Of the 334 patients enrolled with PAH-‐‑CTD, 170 had PAH-‐‑SSc, 82 PAH-‐‑SLE and 47 PAH-‐‑MCTD; CTD sub-‐‑classification was not reported in 35 patients. Across the subgroups, the majority of patients were female (84–99%) and were receiving an endothelin receptor antagonist, a phosphodiesterase type-‐‑5 inhibitor or both at baseline (73–83%). In the PAH-‐‑SSc, PAH-‐‑SLE and PAH-‐‑MCTD groups, the mean (SD) age was 60.0 (10.6), 39.0 (11.3) and 48 (14.7) years, respectively, and 65%, 33% and 45% were in WHO functional class III, respectively. Selexipag reduced the risk of morbidity/mortality events by 44% (HR 0.56; 95% CI 0.34–0.91) in PAH-‐‑SSc, by 34% (HR 0.66; 95% CI 0.30–1.48) in PAH-‐‑SLE, and by 53% (HR 0.47; 95% CI 0.15–1.48) in PAH-‐‑MCTD patients (Figure). The treatment effect was consistent across the PAH-‐‑CTD subgroups (interaction test indicated no heterogeneity; p=0.6737). By the end of study, 22 PAH-‐‑SSc, 7 PAH-‐‑SLE and 3 PAH-‐‑MCTD patients in the placebo, and 17 PAH-‐‑SSc, 4 PAH-‐‑SLE, 8 PAH-‐‑MCTD patients in the selexipag group had died. Common prostacyclin-‐‑associated side effects observed with selexipag in PAH-‐‑CTD patients (e.g. headache, diarrhea, nausea) generally occurred at a similar incidence to PAH-‐‑non-‐‑CTD patients and within the PAH-‐‑CTD subgroups.
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Conclusion The GRIPHON study included the largest randomized cohort of patients with PAH-‐‑CTD to date. The treatment effect of selexipag on the time to first morbidity/mortality event was consistent across the PAH-‐‑SSc, PAH-‐‑SLE and PAH-‐‑MCTD subgroups. These data suggest that targeting the prostacyclin pathway with selexipag is an effective therapeutic option in these difficult-‐‑to-‐‑treat patients.
Acknowledgements Study funded by Actelion Pharmaceuticals Ltd. Medical writing support provided by NSPM Ltd, Cheshire, UK, funded by Actelion Pharmaceuticals Ltd.
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P35 Using the antecubital vein as a safe approach for right heart catheterization in patient with suspected or confirmed pulmonary hypertension F Rey [1], F Lador [1], S Noble [1] [1] Hôpitaux Universitaire de Genève, Genève, Switzerland Aims Vascular access for right heart catheterization (RHC) procedures is usually performed using proximal venous access sites such as the common femoral vein or the internal jugular vein. While these routes are relatively low risk for patients, significant complications can occur such as large hematomas, pseudoaneurysms, and arterio-‐‑venous fistula formation, especially in patients treated with anticoagulants. Using the antecubital vein approach for RHC is safe and reduces procedural and fluoroscopy time as previously described. Methods We retrospectively analyzed data on thirty-‐‑eight patients with suspected or confirmed pulmonary hypertension of varied origins, who underwent RHC between January 2012 and April 2016. Data was collected from procedures performed at rest and/or with effort using the antecubital vein approach. A Terumo Slender 7F in 6F introducer was inserted and over a Terumo 0.025” J-‐‑tipped wire a 7-‐‑F Swan ganz catheter was introduced. Procedural time and successful access, complications such as hematomas, pseudoaneurysms, arterio-‐‑venous fistula, neurological complications, and fluoroscopy time were assessed. Results Patient mean age was 62 ± 14 years-‐‑old. 32 % had chronic thromboembolic hypertension, 16% had valvulopathy, 13% had severe chronic pulmonary disease, 13% had restrictive pulmonary syndrome, 13% had dilated cardiomyopathy, 8% had systemic disease and 5% had idiopathic pulmonary hypertension. 40% of patients had anticoagulation therapy and mean INR value was 1.3± 0.4. Once the introducer was inserted, access to the pulmonary artery was successful in all patients. The rate of complications was 0%. 84% of patients had left catheterization and when pulmonary pressures were normal at rest, 21% had RHC with effort (cycling). Mean fluoroscopy time for right catheterization only was 2.3 minutes. Mean fluoroscopy time for right and left catheterization +/-‐‑ coronary angiography was 9.6 minutes. The mean of the mean pulmonary artery pressure at rest was 30.7 ± 16.5 mmHg, for the mean wedge pressure was 12.7 ± 8.2 mmHg and for the indexed cardiac output was 2.4± 0.7 L/min/m2. One patient had pulmonary hypertension with effort. Conclusion Using the antecubital vein permits evaluation of pulmonary pressures at rest and during effort in patients with suspected or confirmed pulmonary hypertension of different origins. Procedures are short and safe.
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P36 Medicines Shortages and Globally Disrupted Supply Chains – A Threat for Delivery of Patient Care in Switzerland H Jenzer [1], S Büsser [1], F Scheidegger-‐‑Balmer [1], M Silva [1], L Sadeghi [1] [1] Bern University of Applied Sciences, Health Division, aR&D Nutrition & Dietetics, Bern, Switzerland Aims Medicines shortages have become a global phenomenon and a problem that has grown to become a crisis in terms of delivering patient care. Shortages induce bad clinical outcomes and additional costs for public health.[1-‐‑4] The aim of this contribution is to evaluate the Swiss medicines shortages situation in early summer 2016 and to raise the delegates’ awareness for the coping COST Action 15105. Method This work arises from COST Action CA 15105 European Medicines Shortages Research Network -‐‑addressing supply problems to patients (Medicines Shortages) and refers to previously screened references (http://wwwwhitehouse.gov/the-‐‑press-‐‑office/2011/10/31, http://www.ispe.org/drugshortagespreventionplan.pdf), surveys (www.eahp.eu, www.spitalpharmazie-‐‑basel.ch) and databases (www.drugshortage.ch, www.ema.europa.eu, www.accessdata.fda.gov/scripts/shortages, http://www.nutritioncare.org, www.drugshortages.ca, www.bfarm.de). Results In Switzerland, in April and Mai 2016, shortages were increasing from 221 to 239 within a month. Initially 44 and later 54 new alerts were notified within the latest 7 days, demonstrat-‐‑ing a worsening problem on national and international markets, making optional importation impossible. Among unavailable products, six injectable micronutrient additives for both adults and chil-‐‑dren could be found. Alternatives were lacking. Disruptions arise from stocks permanently kept small to reduce bound capital and from manufacturing quality issues. Conclusions Regulation revealed to be one of the driving forces for supply chain disruptions. More rigidity in regulation for pharma as compared to food industry provokes escape and “fight-‐‑or-‐‑flight” behaviours, whereas a less rigid regulatory frame as for food industry is likely to facilitate an undisrupted supply chain. The bigger number of independent production sites for nutrients all over the world as compared to pharmaceuticals (such as after merger situations), might be an explanation for why less nutrients will be affected by shortages than medicines. Round table negotiations within COST Action CA 15105 gathering all stakeholders will con-‐‑tribute to prevent supply chain disruptions. References [1] McLaughlin M. JMCP 2013;19(9):783-‐‑788. [2] McLaughlin M. HospPharmacy 2013;48(8): 617-‐‑618. [3] Jenzer H, Fenton-‐‑May V. In: Practical Pharmaceutics, Springer International 2015:25-‐‑50. [4] Huys I, Simoens S IntJPharmacyPractice 2013;21(1):1-‐‑2. Acknowledgement This article is based upon work from COST Action CA 15105 European Medicines Short-‐‑ages Research Network -‐‑ addressing supply problems to patients (Medicines Shortag-‐‑es), supported by COST (European Cooperation in Science and Technology) (http://www.cost.eu/COST_Actions/ca/CA15105).
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P37 Nutritional Support Practices in Hematopoietic Stem Cell Transplantation Centers: A nationwide Comparison A Baumgartner [1], M Bargetzi [1], A Bargetzi [1], N Zueger [1], Ph Schuetz [1] [1] Kantonsspital Aarau, Aarau, Switzerland Introduction In 2009, international nutritional societies in Europe and the United States published practice guidelines on screening and nutritional support of patients undergoing stem cell transplantation. Little is known about how these guidelines are implemented in routine clinical practice. We performed a nationwide survey involving all transplantation centers with the aim of better understanding current practice patterns, differences between clinical practice and international recommandations as well as possible barriers to the use of nutritional therapy. Hopefully, the knowledge gained from this survey will contribute to the development of national practice guidelines in Switzerland. Methods We performed a qualitative survey including all clinical centers across Switzerland that offer allogeneic (n=3) or autologous (n=7) stem cell transplantation. We focused on in-‐‑house protocols pertaining to malnutrition screening, indications to initiate nutritional support, types of nutritional therapy available and provided, and recommendations regarding neutropenic diets. Results All centers offering allogeneic transplantation, and most of the centers offering autologous transplantation, had a malnutrition screening-‐‑tool in place, mainly the Nutritional Risk Screening (NRS 2002) tool. All centers provided nutritional support for patients. There is wide variation regarding start and stop of nutritional therapy as well as route of delivery, with 5 centers recommending parenteral nutrition (PN) and 5 centers recommending enteral nutrition (EN) as a first step. Although all centers offering allogeneic transplantation and about every other autologous transplant center used a neutropenic diet, the specific recommendations regarding the type of food and food handling showed significant variation. Discussion This Swiss nationwide practice survey found wide variation in the use of nutritional therapy in patients undergoing stem cell transplantation, with low adherence overall to current practice guidelines. Understanding and reducing barriers to guideline implementation in clinical practice may improve clinical outcomes. Close collaboration of centers will facilitate future research needed to improve current practice and ensure high quality of treatment. Furthermore, homogeneity of recommendations will improve patient’s confidence and, enhance the credibility of caregiver recommendations
Table 1. Comparison of guideline recommendations on nutritional risk screening of HSCT patients and routine practices at Swiss transplant centers Recommendations by
ASPEN Recommendations by ESPEN
Practices at centers offering allo-HSCT (n=3)
Practices at centers offering auto-HSCT (n=7)
Screening Routine screening indicated Routine screening indicated • Performed at all centers on admission • 3/7 screened on admission • Other centers screen individually
Screening parameters
No specific tools recommended
No specific tools recommended
• 2/3 centers use NRS • 1/3 centers use an individual algorithm
(includes indirect calorimetry, bioelectrical impedance, height, weight, 24h-diet recall, physical activity in addition to other parameters)
• 5/7 centers use NRS • 2/7 center do not screen
Screening for vitamin or trace element deficiencies
No recommendation No recommendation • 1/3 centers performs screening • Other centers do not screen
• 1/7 centers performs screening • Other centers do not screen
Routine use of a multivitamin
No recommendation No recommendation • 2/3 routinely use multivitamin • Other center does not
• 1/7 centers uses multivitamins • Other centers do not
allo-HSCT= allogeneic stem cell transplantation, auto-HSCT=autologous stem cell transplantation, NRS=Nutritional risk screening tool
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Table 2. Comparison of guideline recommendations on nutritional support for HSCT patients and routine practices at Swiss transplant centers Recommendations by
ASPEN Recommendations by ESPEN
Practices at centers offering allo-HSCT (n=3)
Practices at centers offering auto-HSCT (n=7)
Primary nutritional support
EN EN • 2/3 PN • 1/3 EN
• 3/7 PN • 3/7 EN • 1/7 no nutritional support
Indication of primary nutritional support
Apparent malnutrition or anticipated insufficient oral intake for 7-14 days but functioning GIT and absence of neutropenia
Apparent malnutrition or insufficient oral intake (< 60% or daily needs) and mucositis </= Grade 2
• 3 different recommendations • 1/3 NRS • 1/3 oral intake • 1/3 no quantitative parameter
• 7 different recommendations, 7 different parameters used • 2/7 centers use oral intake to
different extents • 1/7 uses either NRS or weight loss
(not quantified) • 1/7 combination of NRS, weight
loss and oral intake • 1/7 combination of mucositis and
weight loss (not quantified) • 1/7 no quantitative parameters • 1/7 no nutritional support
Criteria for discontinuation
Neutrophil engraftment and sufficient oral intake (no quantitative recommendation)
Tolerance of 50% daily needs orally
• 2/3 oral intake >60% of daily needs • 1/3 oral intake >50% of daily needs
• 2/7 oral intake >60% of daily needs • 2/7 oral intake >75% of daily needs • 1/7 oral intake >25-50% of daily needs • 1/7 recovery from mucositis • 1/7 no nutritional support
Dosage No recommendation Kcal: 20-25/kg/d (bedridden) Kcal: 25-30/kg/d (ambulatory) Protein: 1-2g/kg/d
• 2/3 estimate caloric requirements with Harris-Benedict-Formula (or adapted version BASA-ROT)
• 1/3 according to ESPEN guidelines
• 2/7 Harris-Benedict-Formula • 2/7 ESPEN guidelines • 1/7 Kcal: 30-35/kg/d • 1/7 individual decision • 1/7 no nutritional support
Secondary nutritional support
PN if apparent malnutrition or anticipated insufficient oral intake for 7-14 days but non-functioning GIT or neutropenia/ thrombopenia
PN if insufficient oral intake AND mucositis Grade 3-4, ileus, or intractable vomiting
• 2/3 EN • 1/3 PN if severe gut insufficiency
• 3/7 PN if severe gut insufficiency and intolerance of EN
• 4/7 no further recommendations
GIT=gastrointestinal tract!
Table 3. Comparison of guideline recommendations on the use of glutamine, neutropenic diets, and nutritional support in patients with GvHD by international societies and routine practices at Swiss transplant centers Recommendations by
ASPEN Recommendations by ESPEN
Centers offering allo-HSCT (n=3) Centers offering auto-HSCT (n=7)
Use of Glutamine parenterally Indication Indication given despite
weak evidence No further recommendations
Indication given No further recommendations
• 1/3 if severe diarrhoea • 1/3 if no oral intake • 1/3 centers does not use glutamine
• 2/7 centers use glutamine • 1/7 centers sees indication in severe diarrhoea • 1/7 centers no objective indication criteria • 5/7 centers do not use glutamine
Dosage No recommendations 0.6 g/kg/d • 1/3 1.5ml/kg/d • 1/3 no information • 1/3 centers does not use glutamine
• 1/7 1.5ml/kg/d • 1/7 no further information • 5/7 centers do not use glutamine
Neutropenic diet Indication Given despite weak
evidence No recommendations • Used in all centers • 3/7 centers use ND
Parameters for discontinuation
Neutrophil recovery No recommendations • 1/3 neutrophil recovery • 1/3 discontinuation of amphotericine • 1/3 clinical decision
• 2/7 neutrophil recovery • 1/7 clinical decision • 4/7 centers do not use ND
Restrictions for RIC-allo-HSCT
No recommendations No recommendations • 1/3 alike MAC-allo-HSCT until neutrophil recovery
• 1/3 separate guidelines • 1/3 alike MAC-allo-HSCT
• Not relevant
Nutritional support in GvHD Indication Moderate to severe
GvHD with insufficient oral intake or significant malabsorption
No recommendations • 2/3 NRS >3 • 1/3 severe diarrhoea (not quantified)
•
Primary nutritional support
PN No recommendations • PN in all centers •
ND=Neutropenic diet, MAC=Myeloablative conditioning, RIC=Reduced-intensity conditioning, GvHD=Graft-versus-host disease
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Table 4. Comparison of adherence to general recommendations on neutropenic diets among Swiss transplant centers offering allo-HSCT General recommendations Center 1 Center 2 Center 3
Type of recommendation • For in-patients • For out-patients • For nursery staff
• For in-patients • For out-patients • For nursery staff
• For out-hospital patients
Differentiation between populations and recommendations
1. According to extent of immunosuppression and acuity of GvHD
2. According to conditioning regime 3. Inpatients and ambulatory patients
1. According to conditioning regime 2. Inpatients and ambulatory patients
1. None
Recommendations on food hygiene
• Very detailed description for out-hospital patients (personal hygiene, storage, kitchen supplies, temperatures for cooking, washing raw products)
• Routine consultation by nutritionist before discharge
• Detailed description for out-hospital patient (personal hygiene, storage, kitchen supplies, temperatures for cooking, washing raw products)
• Routine consultation by nutritionist before discharge
• Detailed description for out-patients (personal hygiene, storage, kitchen supplies, temperatures for cooking)
General food consumption • Reheating not recommended • Allowed if heated > 70°C • Consume tea within 24h • No recommendation on cooled food • No recommendation on prepared fruit
• Reheating not recommended • Allowed if heated up "properly" • Consume warm tea within 12h • Consume cooled food within 6h • Consume prepared fruit (peeled and
sliced) within 2h
• No reheating • No refreezing • Consume self-prepared meals <24h • No recommendation on cooled food • No raw fruit consumption allowed
Convenience food • Only small packages • Consume within 24h
• Only small packages • Consume within 24h
• Only small packages • Consume within 24h
Return to normal nutrition • If no immunosuppression or no active GvHD
• After recontamination (= discontinuation of Ampho-Moronal)
• No later than D+100
• According to individual decision
allo-HSCT= allogeneic stem cell transplantation !
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Autorenverzeichnis Name des Erstautors | Nom du premier auteur Baumgartner A FM16; P37 Blanchard-‐‑Courtois AL P10 Boltres A P17 Bustamante N D2 Chok L FM14 Doll S P16 Dumoulin F P01 Elsas J P23 Engi K P08 Erlebach R FM09 Furrer F P29 Gähwiler R P26 Hauffe T P20 Jeitziner M M FM01 Joseph C P12 Jenzer H P36 Kajdi ME P27; 28 Karde C P02 Keim C P03 Klinzing S FM08 Klapproth A P14 Ksouri H P21 Lador F P34 Lepori M P24 Lichtblau M FM13 Liem E FM05 Maier J P04; P05 Meyer-‐‑Zehnder B P18 Miroz JP P09 Müller A P19 Nussbaumer D D5 Reinitzer M D4 Renard D FM07 Rey F P35 Rosch Ch FM02 Rousse AL D3 Perret A FM04 Pfortmueller CA FM15 Saxer S E P33 Scolari P13 Schläpfer P P15 Stamm A P32 Stark D P31 Stehlin W FM03 Takyi M P07 Tournaire C D1 Ugolini F P30 Ulmer F P25 Ulrich S FM12 Weibel L P06 Zellweger A FM10; F11 Zientara A FM06
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