Patient Safety – Was wir von der Aviation noch nicht gelernt haben

Habe heute eine äußerst interessanten Artikel gemailt bekommen. “What I learned about adverse eents from Captain Sully“. Lesenswert!

Viele von uns bekommen höheren Pulsschlag, wenn Sie über Patient Safety hören und die Aviation als Beispiel genannt wird: Simulationstraining, Checklists, etc. Wer kennt nicht das phantastische Buch von Atul Gawande “The Checklist Manifesto”. Und die sichere Landung eines havarierten Passagierflugzeugs im Hudson River durch Captain Sully gilt als Musterbeispiel, welches wir Mediziner häufig hören. Jeder kennt die die phantastische Geschichte von US Airway Flight 1549. Toll! …. oder doch eher, ich kann die Vergleiche nicht mehr hören?

Der oben zitierte Artikel ist in dieser Angelegenheit äußerst lesenswert, beschreibt er doch, dass Captain Sully und seine Crew, aber auch der Verantwortliche Fluglotse des Towers, nach dieser grandiosen Leistung mehr als ein Monat Arbeitsunfähig waren! Post-traumatic stress disorder! Und wer hat selbst schon einen Autounfall erlebt und ein Flashback verspürt, wenn er nur einen Schatten im Augenwinkel hatte.

In unserer täglichen Arbeit ist das aber alles kein Thema: Ob persönlich angegriffen oder bespuckt von einem Drogenabhängigen, ob erfolgreich oder nicht-erfolgreich in der täglichen Arbeit mit der hochfokussierten Anstrengung bei Notfällen fallen wir danach häufig in ein Loch … und arbeiten weiter. Haben keine Minute, keine Stunde, keinen Tag oder noch länger Pause und/oder leiden an posttraumatischem Stresssyndrom wie die Crew von Flight 1549. “Stellen Sie sich nicht so an! Da musste ich auch durch!” eine häufige Aussage von Verantwortlichen. Der Artikel thematisiert dies in wirklich herausragender Art und Weise und zeigt auf, weshalb stressige Dienste oft noch Tage nachwirken … und uns hindern die eigene Ruhe zu finden. Ich kann mich auch heute sehr wohl an fatale Verläufe erinnern, sie bleiben lebenslang zurück.

Zusammenfassend habe ich mal wieder meinen Blickwinkel und meine Einschätzung durch diesen Einblick in Ereignisse anderer Tätigkeitsfelder geändert. Es liegt an uns, Änderungen anzustoßen. Die nächsten Generationen werden uns dankbar sein ….

[REVISIÓN] “No se puede intubar, no se puede ventilar” (Parte 3 de 3)

Decisión para proceder a la vía aérea quirúrgica de emergencia La VAPE inmediata está indicada cuando los esfuerzos máximos de técnicas no invasivas fallan en aliviar la hipoxia severa. Desafortunadamente, la toma de decisiones en NINO es a menudo demorada. Los estudios retrospectivos de manejo pre-hospitalario de la vía aérea muestran que la mayoría de […]

La sala blanca

La imagen es de aquí
Te quitas la bata blanca y eres uno más ante la enfermedad; conviene no olvidar lo que se siente, tenerlo bien presente cuando te vistes de blanco. Por cierto: todo bien, afortunadamente…

LA SALA BLANCA

Esta parece ser una mañana tranquila. A pesar de ello, a través de la puerta abierta veo transitar batas blancas, uniformes azules y camas empujadas por celadores.  La sala, otras veces concurrida, está hoy solo ocupada por una mujer mayor, encamada, de mirada inquieta y asustada. Su brazo izquierdo conectado a un equipo de suero es lo único que asoma entre las sábanas además de un rostro moreno coronado por una cabellera blanca. No tiene mal aspecto. 
La otra pobladora de la sala de paredes blancas soy yo. Me acerco inquieta al umbral de la puerta a la espera de noticias. Mi mirada se cruza un instante con la suya y sonrío levemente. Algo nos decimos, algo compartimos: la incertidumbre. Y el  miedo.  Me acerco al borde de su cama y sin que yo abra la boca, empieza a hablar. Lo hace de forma pausada, solo su lengua que acaricia de vez en cuando el borde de los labios traduce la inquietud que esconden las palabras. Me cuenta que lleva meses pachucha y que no le encuentran los motivos. Le han hecho muchas, muchas pruebas; parece que esta de hoy es dura porque le tienen que dormir…Suspira, su marido parece que se ha despistado: el hombre ya es mayor, rebasa los 80, y últimamente se le olvidan las cosas. Había quedado en que llegaría a tiempo de acompañarla, pero…Igual el autobús…Tal vez esté tomándose un café en el mismo hospital…
Claro- le digo- Seguro que aparece apresurado, no se preocupe usted, no andará lejos.
 Viven en una población que dista lo suyo del hospital, y no tienen coche.
 ¿Tiene hijos?- me pregunta.
Sí, dos, ya mayores- le digo.
¡Qué suerte!- responde con algo parecido a la tristeza.
Lo es- afirmo con la cabeza, segura de ello.
Nosotros, no tenemos- murmura ladeando la cabeza - Ya estamos mayores…No se crea, me dice, voy a cumplir 79.
 ¿Sí? Pues no parece - le digo- Tiene usted una piel estupenda. Y es verdad.
Es porque estoy morena - asegura. Del balcón, porque ya casi no salgo… ¿Tiene ascensor? -  me pregunta.
-  le digo.
Esa es otra ventaja -  afirma y yo con ella.
Suspira de nuevo, preocupada. ¡Ay, este hombre…! -  dice. Chasquea la lengua con un deje de impaciencia.
 ¿Usted cree que tardarán mucho en hacerme la prueba?- me pregunta preocupada
 No lo creo, parece que hoy andan ligeros - le digo. Ya verá, le dormirán un poquito y en breve estará en su habitación, a ver si hay suerte y está pronto en casa.
 El hospital es triste - me dice resignada.
Pues sí…se está mejor en casa -  apunto yo más que segura.
 Pero cuando hace falta…dice ella con más resignación.
 Claro, claro, no hay otra…le digo cómplice.
Alisa las sábanas con su mano presa, como si fuera muy importante que su superficie blanca no acogiera arrugas. La vida no es plana, pienso yo…
Advierto que alguien se acerca a nuestra sala; no me trae malas noticias, tampoco son del todo buenas. Pero me doy por satisfecha. Mañana será otro día.

Y aparco la tristeza, me acerco hasta su cama y le cojo la mano un momentito, le sonrío, aprieto sus dedos suave unos segundos; su marido no ha llegado, andará el hombre despistado…La enfermera nos mira y espera  paciente, también sonríe levemente. Le digo adiós y le deseo suerte, de corazón. Y me mira con el miedo allí emboscado, con su carita morena, su boca dibujando una medio sonrisa que agradezco. Y la sala blanca, de aspecto inocente, queda vacía de historias a la espera de otras parecidas. 

The World of Emotions

Hola a tod@s, my dear friends.

Today I want to share 3 interviews I have received recently and really loved them, because they refer to things that normally we don't like to talk: the world of emotions.



The first, an interview published recently in El Mundo to Dr. Christina Puchalski, whose headline is irresistible to me: 'Physicians to connect with the patient are needed'.

The second was sent to me a few days ago by Elena Lorente (Bringing colour to nursing): an interview with neurologist and neuroscientist of the Favarolo University Facundo Mames, who thinks that "optimism is a cerebral protection factor".

And the third, Dr. Jorge Campamà, intensivist in Barcelona, talks about transcendence and accompanying at death. And concludes: "Good doctors are distinguished in their struggle to become a good human being."

All of them are really interesting, I leave tasks if you want a break for you and know these incredible people.

Happy Friday

Gabi

Cardiac arrest, add antibiotics to the kitchen sink?

Clinical scenario:
You get a page out for a 55 yo M in cardiac arrest, EMS reports PEA on their arrival, patient has received 3 rounds of epi prior to arrival, patient achieves return of spontaneous circulation (ROSC) after 5 minutes of ACLS while in the ED. When family arrives they report the patient had been feeling unwell for several days and had a significant cough.  No obvious infiltrate was seen on initial chest xray.  The patient's BP is stable on an epi infusion. You admit the patient to the ICU. Your attending requests drawing blood cultures and starting the patient on broad spectrum antibiotics, and cites data stating antibiotics improves mortality in out of hospital cardiac arrest. You perform a brief literature review. 

Literature Review:
Out of hospital cardiac arrest (OHCA) has a very high mortality rate, where approximately only 23% make it to the hospital alive, and 7.6% survive to hospital discharge. (1) The most common etiology of out of hospital cardiac arrest is presumed to be myocardial in origin. However, several retrospective studies indicate that sepsis and bacteremia may also be a significant contributing factor to OHCA. A study by Coba et al in published in 2014 performed a prospective study to identify the incidence of bacteremia in OHCA patients. They enrolled 173 patients, where all patients had two sets of blood cultures drawn, 77 patients met exclusion criteria (trauma, pregnant, pediatric, single positive culture of skin flora). The overall incidence of bacteremia was 37% (65 patients). The most common bacterial species cultured were streptococcus and staphylococcus and Ecoli and klebsiella for gram positive and gram negative bacteria respectively. Bacteremic OHCA patient had significantly higher lactates, lower pH, and more frequent use of vasopressors. Notably the ED survival was significantly lower in the bacteremic patients (25%) compared to nonbacteremic patients (40%). However, 28 day mortality difference was insignificant in bacteremic vs nonbacteremic patients (93.8 vs 92.6%). The figure below by Coba et al lays out the proposed inter-relationships between bacteremia and sudden cardiac arrest. (1)
Proposed association between bacteremic infection and sudden cardiac arrest. From Coba et al.



Although there is very little data examining pre-existing bacteremia in OHCA, there has been a significant amount of research studying infection following ROSC in OHCA. The most commonly cited sources of post ROSC infection are lung possibly from aspiration during arrest, or gut likely from translocation of flora secondary to low flow state during arrest.  Davis et al performed a retrospective analysis on 138 patients admitted to the ICU following OHCA, and showed that 97.8% had at least one positive mark of infection within 72 hours (positive blood culture, consolidation on cxr, CRP greater than 100 or wbc greater than 11 or less than 4 x10^9 ). In this study approximately 38.4% of patients received antibiotics during the first 7 days of their ICU stay. The authors showed that mortality was significantly lower among those receiving antibiotics versus those not receiving antibiotics (56.6% versus 75.3%). However, highest mortality was within the first three days, and for patients who survived to day 3, there was no difference in mortality between those who received antibiotics already and those who had not. (2)

Take home points:
OHCA is typically presumed to be a primary myocardial event, however there is some data to suggest that sepsis is potentially a significantly under reported cause. Furthermore, there is also data to suggest that following ROSC, infection is quite common, and antibiotics may reduce early mortality. However, caution must be taken, as of yet there are no RTC's comparing prophylactic antibiotics versus placebo in OHCA.

Expert Commentary:

Dr. Holthaus one of our own critical care and sepsis guru's was nice enough to provide some of his own thoughts on this topic, and cardiac arrest in general. 

Things we'd like to see examined in future cardiac arrest RCTs:
1) Antibiotics during arrest - push dose, timing, coverage.
2) Propofol - control for this or exclude as a variable since it has been shown to cause some mitochondrial dysfunction and may be thwarting potential resuscitation benefits.
3) Epi dosing - frequency, continue 1mg push dose vs lower dose vs maximum that is less likely to cause or further exacerbate either ischemic or post-inflammatory cardiomyopathy.
4) Vasopressin-Steroid-Epi- for ED arrest. Link to VSE study in JAMA . VSE (vasopresson-steroids-epi) better than Epi alone for in-hospital arrest Vasopressin (20u, q 3-5min, max 100u, w 1 mg epi pushes)-Methypred (40mg IV x1) w better ROSC (84% vs 66%) and better CPC1/2 survival (14% vs 5%).  Major caveat is time to ACLS was very low at 2 min for both which is way faster than many we see in the ED that are frequently >10 min downtime before EMS.  Hypothesis generating, re-hinting at potential beneficial role of vasopressin and steroids for shock (like sepsis). 
5) ED ECMO for cardiac arrest or refractory/severe shock
6) Remote ischemic conditioning immediately after ROSC- 5 min thigh BP tourniquet to >20mmHg above SBP then deflate, repeat 3-4 times, reportedly induces systemic circulation of a protein that blocks CNS/cardiac opening of the "mitochondrial permeability transition pore" which is the final common pathway for ischemic reperfusion injury).  On recent ED ECMO podcast (Shiner-Bellezo) Link to podcast Remote ischemic conditioning 

Personally since everything (ACLS) isn't getting much results, if I can remember to I will do Vasopressin-Methypred-Epi dosing, I am less excited about a lot of epi (ie 3 pushes tells me if they're trending toward making it or not), I've pushed zosyn and then hung vancomycin in a code (after learning about Coba study). I have generally avoided propofol in past because of known myocardial suppression, and now with concern for mitochondrial insult, I just use fentanyl/versed. In addition I  will try thigh remote ischemic reconditioning, and continue targeted temperature management to 33-36C while hoping for ED ECMO (which I think will be the biggest game changer)  

Submitted and Edited by Louis Jamtgaard PGY-3 @Lgaard
Faculty Review by Chris Holthaus

References

 1) Coba V et al. The incidence and significance of bacteremia in out of hospital cardiac arrest.
Resuscitation. 2014 Feb;85(2):196-202. d

2)Davies K et al. Early antibiotics improve survival following out-of hospital cardiac arrest.Resuscitation 2013 May; 84 (5) : 616-9.